CASES IN  MIDWIFERY,
Slitfr $ltmaris.
THOMAS F. COCK,  M.D..
     PIIA'SICIAN TO TUB XEW YORK HOSPITAL.
[Re-printed from the New York Journal of Medicine,
      ■ 3i70:i:--
       NEW^YORK:
SAMUEL S. & W. WOOD.
         1855.
^ 
 
CASES  IN  MIDWIFEKY.
The following cases are published, not from any novelty or
peculiar interest that  they possess,—for such are occurring
every day in a crowded city—but from a conviction that it
is the  duty of every one  to present the experience he has
been enabled to gather, in order that some industrious com-
piler of statistics may use his little  store of materials to»
benefit the profession.  In a  department like midwifery,
where statistics are so readily obtainable,  and where prece-
dents are of so much value in directing practice, there is less
excuse for neglecting to record cases, than in other depart-
ments, where a doubt  in diagnosis, or perplexity in choosing
the proper means of  relief,  would deter from committing
results to writing.
   Fifteen  years of professional experience have enabled me
to collect the accompanying cases.
   Face Presentations.—Face presentations were met with
eight times.   In four cases,  complications existed which
invalidated the life  of the child; viz.: twice the foetus was
anencephalous, once rupture of the uterus existed, and once
the funis presented with  the face,  and as much  delay had 
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occurred through previous manipulation, perforation was
employed as the best  mode  of relieving  the mother.  Re-
garding these as necessarily fatal to the child, the results
were:  to the mother, favorable  in  all except the case  of
ruptured uterus; to  the  child, favorable in  four cases ;
necessarily dead, four.  Mode of delivery.—Unassisted,  six
cases;  by perforation, two  cases.   Length of labor.—The
longest wTas fourteen hours; the shortest  four hours.  Pre-
sentation.—Noted in  four cases,  three of which were left
mento-iliac, one right mento-iliac.
  Presentations of  Inferior Extremities.—Under this
head are included presentations of breech, knees, and feet,
as no  difference in the plan of treating such varieties was
deemed necessary.
  The total of cases noted  is twenty-seven.   Of these, there
occurred, as single births, twenty; while seven  were in con-
nection with twTins.
  Results.—No fatal  result to mother occurred.   Of the
children, twelve are recorded as still-born,  of which two
were putrid  and two others  premature.   Deducting these,
eight births  out of twTenty-seven were still.   Of the still-
born, three are noted as muciparous, four  as primiparous.
Sex.—Eleven girls to twelve boys are noted; in the other
cases not noticed.  Recurrence.—In  one case, all the births
(four) were by the breech; in another, all (five) were breech;
in one  there were two  breech deliveries out of eight labors.
The only case worthy of special record is as follows :
  Case 3.—Patient primipara, aged  32 years.    The foetus
presented by the breech,  its abdomen  being  toward the
abdomen of the mother.  The body of the child was rotated
so as to bring the face toward the sacrum after the delivery
of the  arms, but all manual efforts  for the delivery of the
head failed, though assisted by ergot.  It was then suspected
that the head might be hydrocephalic, and accordingly a
puncture was made through  the  orbit with a trocar, which
was the only instrument at command.  Delivery was then
readily effected.   This  was an unusual complication of diffi- 
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culties, the position was the worst of the breech presentation,
and the diagnosis of hydrocephalus was but problematical,
as no fluctuating point could be reached.   It was  noticed
that immediately on ceasing tractive efforts the head receded,
but the true state of the case was only suspected until con-
firmed by the effect of puncturing the cranium.  The long
continued efforts (thirty-two hours) resulted in vesico-vaginal
fistula.   This  patient  was under my observation  as  an
hospital nurse for fifteen years, and managed to  perform her
duties without exciting suspicion of her condition.
  Presentations  of  the  Superior Extremities and
Cases of Version.  Case L.—Seen in consultation.   Right
hand  of a premature foetus presented.   Delivery effected
readily by version.
  Case 2.—A multipara pregnant with her third child.
Before the membranes ruptured, a presenting part was detect-
ed through the partially dilated os, which was supposed to
be the elbow, but when the  waters escaped, this was found
to be the right foot.   In the expectation that labor would
progress  without  serious difficulty,  time was  allowed  for
further development; but it was ascertained that instead of
the foot descending, a hand was substituted.   Action being
non-avoidable, the hand was passed  into the uterus, a foot
seized, and by it version was effected.   The child, a male,
was resuscitated with difficulty.   Phlegmasia dolens super-
vened during the second week after delivery, but the patient
eventually recovered.
  Case 3.—Multipara, aged  25.  The  physician in attend-
ance came for me four hours after the rupture of the mem-
branes.   The right  hand was found presenting.  Version
was readily effected ;  but there  was no pulsation in the
cord,  and the child, a male, was still-born.
  Case 4.—Multipara with fourth conception.   Ten days
before labor  commenced  she  had hemorrhage, but it  did
not recur at the time of labor.   The patient was seen twelve
hours after the commencement of pains, and the right arm
was found protruding from the vulva much swollen.  As  the 
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pregnancy had not advanced to full  term, the possibility  of
spontaneous evolution suggested itself;  but it was  deemed
more advisable to turn.   Considerable difficulty was experi-
enced in effecting version;  the small size  of the  limb pre-
vented a  firm  grasp,  and powerful uterine contractions
produced much  annoyance in manipulating.  Success was
finally obtained by passing the hand over the breech in utero
and steady traction.
  CaSe 5.— Version.—Referred to as tenth case of twins.  The
first child having been delivered  by forceps, in consequence
of convulsions, the second was turned.
  Case 6.—A multipara  in her  third labor.    The  child
presented with  both hands.  In ineffectual efforts to turn,
her attendant had exhausted his  strength, and solicited
assistance.   The right foot was found in the vagina with a
fillet upon it, the left foot higher up, both  hands posteriorly
much swollen, and finally a loop of the cord not  pulsating.
By the aid of chloroform, version was effected with consider-
able exertion, and the body delivered as far as the shoulders ;
with these much difficulty was experienced, as the  arms were
greatly  swollen.   This done,  the body of the  foetus was
turned strongly over the mother's abdomen, and the head
easily delivered.  Child dead.
  Case 7.—A multipara,  aged 29, with her tenth concep-
tion, and in the seventh month.  The child  presented by the
right elbow.  Version was effected without difficulty,  and a
living female child delivered.
  Case 8.—Referred  to  as  Case 13  of twins.  The second
child  presented with cord, hand and foot.   Version was
attempted  without  chloroform, but though the foot was
brought externally, the uterus prevented turning, until  re-
laxed by chloroform.  The child, a male, was still-born.
  Case  9.—A primipara.  About nine hours after the com-
mencement of labor, she was  found with  a hand and head
presentation.  Delay was advised, in hopes of natural de-
livery ;  but, after five hours, no progress being  made, the
application  of  forceps was commenced.   Immediately  on 
5
passing in the hand the head receded, and the foetal hand
descended.  No alternative was left but version, which was
effected without much difficulty.   The child, a girl, gasped
but once.
   Case 10.—A multipara, aged 23,  with her second  con-
ception.  The child presented by the right elbow.   Version
was easily accomplished; but the child, a male, was  still-
born.
   Case 11.—A  multipara in her fourth labor.   She had
been under the care of a  student, who,  on  ascertaining the
presentation to be of the  superior extremity, sent for assist-
ance.  The previous labor had been tedious.   The right arm
was found protruding from the vulva, and the uterine con-
tractions  energetic.   Chloroform was administered  with
happy  effect, in  relieving  the  contractions,  and  version
commenced.  The right  hand was first tried, and came
immediately in contact with a very salient sacral promon-
tory ; the cord did not pulsate.   The child lay with the
abdomen to the mother's abdomen, the right arm being
extruded.   With  my right  hand the  foot  could  not  be
reached, but on substituting the left,  version was easily
produced.  No delay was experienced until the head engaged,
when owing to the diminution of the antero-posterior diame-
ter, by tjie projecting promontory, the head became arrested
and required much exertion to free  it.   The child, a boy,
was dead before the operation.
   Case 12.—A  multipara, set. 27 years, in her third labor.
The presentation was funis with the right hand.  Version was
effected readily under  the influence of chloroform, and a
male child born in an asphyxiated condition.   It was resus-
citated.
   Case 13.—A  multipara, aged 40 years, with her fifth con-
ception.  Case referred to  as fifth of rupture of uterus.  The
patient was in an apparently desperate condition, but version
seemed the most feasible means for a fa\rorable issue.   No
trouble was experienced in finding the feet or in delivering.
The foot  was lifted over the distinct edge of a rent in the 
6
right side of the uterus.  The child, a male, was dead before
beginning.  The mother recovered.
   Remarks.—Thirteen cases are given in which version was
required for delivery, of which the results were to the mother
favorable in all, to the child favorable in only three instances.
Of these one was premature, and five were certainly dead
before the operation was commenced.  The sex of the chil-
dren is given in nine cases, of which seven were male and
two female.
   In performing  version, no effort has been made to grasp
both feet, but a selection of the foot opposite to the present-
ing hand has been attempted, and this experience proves to
be the most satisfactory mode of manipulating.  In cases
where one foot has been brought externally, and delay has
occurred in producing  turning,  it  has been  thought that
benefit has ensued from passing the hand beyond the breech,
while traction is made on the foot  in the vagina, and thus,
by the double purchase, some refractory cases have yielded.
   Convulsions.—Cases of eclampsia only have been placed
on record, though several more have been visited. In some,
a single visit,  perhaps, has been made, and the history not
obtained, with the requisite minuteness to warrant any deduc-
tions from them.  Of the seven cases the following particulars
are recorded. Variety of convulsion.—Insix,epileptiforni;inone,
hysterical.  Time of occurrence.—During labor,  in all, seven ;
continued aftenvard in four cases.  Number of labors.—All were
primiparous except one, the hysterical case. Number of convul-
sions.—hi two, four ; in one, eight; in one, fourteen ;  in one,
eighteen ; in one, a single hysterical paroxysm ; and in one, fif-
teen.  Number of children.—One was a case of twins; all the rest
were single births. State oftheurine.—Noted in five cases,in all
of which albumen was found. Premonitory symptoms.—In three,
only pain in the head was spoken of.  (Edema was a promi-
nent symptom in all except the  hysterical case, and in this
the feet alone  were oedematous.  Mode of treatment.—In all
but one venesection was used;  chloroform was employed in
four cases ; tartar emetic in two cases ;  enemata, sinapisms, 
7
and cups were used, but not noticed, in all. Mode of delivery.
—In three cases natural efforts effected expulsion;  in four,
forceps were used; and for the second twin, version was
employed, the only case.   Results.—Favorable to mother in
five  cases, two  deaths.  Of children four  were saved, and
four were still-born, both twins being dead.
  Of these cases the most worthy of record was the tAvin-
birth.   When seen, the woman  appeared past all  hope of
recovery.  She had had fifteen convulsions,  was perfectly
insensible, the pulse being feeble and very rapid.  Delivery
was attempted rather  from  a consciousness  of duty than
with any hope of beneficial effect, and was produced, the
first child by forceps, the  second by version.   It was pre-
sumed on leaving the patient that she would soon die ;  but
on  meeting  her attendant,  some little time after, he in-
formed me that she had  recovered,—an exemplification of
a cardinal rule  in  midwifery, not to suffer a woman to die
undelivered.
  Hemorrhage.—No record has been kept of hemorrhage,
in connection with  abortion.  Twenty-eight cases of differ-
ent varieties  of flooding have been met with, in some instan-
ces slight, in others  serious, and in  one  only (Case  3rd of
placenta praevia) has there been a fatal issue. •  The instances
enumerated as slight have been mostly where bleeding occur-
red with  retained placenta, and, with these exceptions, no
case has been deemed worthy of record as one  of flooding,
unless  some obvious general effect  upon the patient was
produced.
  Causes.—Six cases of unavoidable  hemorrhage are given
under  the head of placenta praevia.   Six  are  recorded with
retained placenta.  Two with "uterine hydatids."   Two of
placental apoplexy.   Of the remainder, inertia of the uterus
was the cause in four cases; detached placenta in one, and
in five no reason is specified.
  Time of occurrence.—Before labor in fourteen cases. During
labor in ten.   Before the delivery of the placenta  in four-
teen ; (the cases of  placenta  praevia  are reckoned under all 
8
these heads.)  After the delivery of placenta in six.  Second-
ary hemorrhage is noticed in one instance.
  The number of cases  of flooding  is apparently large, yet
special efforts to prevent this accident have always been
made.  A uniform practice was  early commenced, and has
been  constantly adhered to, of placing  one  hand over  the
fundus uteri as soon  as the head was delivered, and main-
taining steady pressure as the child was expelled, which was
only personally remitted during  the necessary  attention to
the child, until the  placenta was delivered.  An attendant's
services  have—while engaged in tying the cord,  and then
only—been  substituted for my own compression.  During
the last two or three years, as a means of preventing flooding
after delivery, a  small book wrapped in a napkin  has been
placed over the uterus and the binder tightly applied.
  With all these precautions there have been some instances
where more blood  was  lost  than was  desirable.   In such
cases reliance has been placed on ergot, which has proved so
far, a satisfactory anti-hemorrhagic.  This drug has  also been
given when flooding was anticipated from its occurrence in
former labors.  In the special cases  as those of unavoidable
hemorrhage, etc., the treatment is given under the  appropri-
ate heads.
  As a means of preventing a  return of flooding, manual
compression has  been most relied on even in preference to,
though not to the exclusion of, the use of cold in its various
forms.  In the severest  case of flooding from inertia, pres-
sure was  maintained  by my own hands for  five hours  con-
secutively, a service correctly appreciated only by those who
have been similarly employed.   Nevertheless, it seemed at
the time  the only measure that prolonged life.   As a tem-
porizing measure in flooding before labor or  before delivery,
the alum plug has been relied on with much confidence, and
in no ordinary case has it disappointed; but its use is attended
with one serious inconvenience in  cases where  operative
measures become necessary.  So great a corrugation of the
vagina is produced, and such dry and obscuring coagula are 
9
formed, that no slight embarrassment in manipulating occurs.
With this objection, however, it is a remedy of value, and in
hemorrhages connected  with  abortion it  has  been found
peculiarly useful.
   The  following   cases  are,  perhaps,  worthy  of special
record :—
   Case 1.—While  visiting  Bellevue Hospital wards,  my
attention was called to a woman who had just been delivered
of a male child, after a natural labor followed by spontaneous
expulsion of the placenta.  NotAvithstanding that the uterus
appeared to be well contracted, blood continued  to flow.
On examining, there was found projecting  from the vulva a
tumor of fleshy consistence, and about two inches  broad,
which on being traced up,.was found to be attached to  the
anterior  lip  of the os uteri, so that its length was about four
inches.  From the  bed at least a quart of clotted blood was
removed.  Pressure aided by  ergot failing to  control this
bleeding, a hand was passed  into the uterus and a clot
removed.  The stimulus  of the  hand together with  strong
external  pressure,  seemed to  be efficient  in checking  the
flooding.  Subsequently ergot was given more rapidly, and
there was no further flow.  About four weeks after confine-
ment an  examination was made with the speculum, and on
the anterior lip was a projection about one inch long, half
an inch wide, and about one quarter of an inch raised above
the surface.   The os uteri presented  an excoriated surface
from which  a bloody purulent fluid was oozing.
   Case 2.—The following case was published in the Ar. Y.
Med. Tunes for August, 1854, from which an abbreviation is
now made.  A multipara, aged 40 years, about 6i months
advanced in pregnancy, had been exerting herself during  the
morning, and while conversing in the afternoon she became
pale and  faint.  She was assisted to bed, and soon became
nauseated, and complained of distressing distention of the
abdomen. Previous to this occurrence her abdomen had been
quite small for the supposed time of pregnancy; now, how-
ever, the  increase in size not only attracted her own attention 
10
but became manifest to bystanders.   Both bowels and blad-
der had been evacuated during the day.  When seen about
three hours after this attack the patient was pale and faint,
with a cool surface, feeble, compressible, rather slow pulse,
disposed  to  gape and to vomit.   The  principal complaint
was of the  sense of distention, which she  spoke of as  a
" feeling  like bursting."  On examining  the abdomen  the
uterus was found distended to the size of full term of preg-
nancy, the portion of the organ in the right hypochondrium
appeared to be more elevated than the rest, and there was an
obscure sense of fluctuation in this region.  Percussion de-
tected flatus in the epigastric region, while,  by the ear,
neither foetal pulsation nor placental murmur could be dis-
covered.   Vaginal examination discovered no hemorrhage,
and the cervix uteri was undeveloped. During the next after-
noon labor commenced, and a  small  quantity of dark fluid-
blood was discharged.  About nine hours  after this, the os
being well dilated, the membranes were ruptured manually,
a large quantity of liquor amnii escaped, and the  next  con-
traction expelled the foetus with  the placenta, and a large
quantity of clotted blood,  in amount, as was subsequently
ascertained,  at least two quarts. The placenta was unbroken
on its foetal  surface, but the maternal aspect bore evidences
of  detachment over fully three-quarters of its  extent.  The
patient recoverd.
   Another instance of this  form of hemorrhage presented it-
self some years since.  In this case the labor was progress-
ing satisfactorily, when the patient became faint, sick at the
stomach, restless, and exclaimed that she was going to die.
No blood escaped from the vagina.   After a momentary lull
of  contraction, pains came on vigorously, the liquor amnii
Avas discharged, uncolored, but with the placenta  several
large clots of blood were  expelled.   This woman also  re-
covered.
   Case 3.—Secondary Hemorrhage.—A primipara was deliver-
ed on the 12th  of May.   She had  a slow  getting up, and
while engaged in washing, June 1st, had some bloody dis- 
11
charge. On the 4th of June, twenty-three days after delivery,
while at church, and standing at  the  baptism of her child,
flooding came on.  She continued to stand until she became
faint, and was carried home.   By the  application of ice and
a bandage the flooding was  checked.   Two  days after, on
visiting her, she was found on the floor, pale  and faint, and
with some recurrence of bleeding;  she was very imprudent
in exertion, but recovered after a tedious convalescence.
   In one other case hemorrhage,  to a considerable  extent,
occurred on the 10th day.
   Placenta  Previa.  Case 1 .—Multipara pregnant with
her  eleventh  child.   Five days  before delivery noticed  a
slight  discharge of blood  accompanied by slight pain.  By
vaginal examination  the  os uteri was thick  and patulous,
but  no presentation  could be distinguished.  The next day
but  one after, she lost a large  quantity of  bright blood by
gushes, accompanied by pain, for  restraining  which  pills of
lead and opium sufficed.   On the succeeding day small losses
of blood continued.  In the  evening a small  portion of the
placenta  could  be detected  over the os, but as the labor
advanced the hemorrhage gradually  ceased, and no inter-
ference was deemed  necessary, for the membranes ruptured
spontaneously, and with the next contraction the head, was
expelled.  The  child, a boy,  was apparently lifeless when
born, but was resuscitated.   Convalescence was protracted
and  precarious.   The patient suffered from fecal  accumula-
tion, complicating the  effects of  loss of blood so as closely
to resemble puerperal fever.
   Case 2.—A Multipara  with her fourth  conception, was
delivered after a labor of fifteen hours.  The first evidence
of labor was  hemorrhage, and on examination, her attend-
ant  discovered a small portion of placenta over the os uteri.
At the time of my visit, the patient was considerably blanch-
ed and restless, the pulse  being feeble.  The os was nearly
dilated, and each pain  caused an increased flow.  The indi-
cation seemed to be  to  effect delivery by the  contractions of
the  uterus itself, instead of by forceps, and  for this purpose 
12
ergot was given with good effect.  Its influence was kept
up until delivery was completed, by the expulsion of the
placenta with a large gush of fluid blood.  The  child was
still-born.
  Case 3.—Referred to as Case 14 of forceps.  Hemorrhage
came on at the seventh month of gestation, and  continued
with some intervals until delivery, there being no pain, and
the os undilated.  Only temporizing measures were used.
At the time of my visit, the patient was perfectly pallid,
but  the uterine efforts were regular, and producing some
effect. Nature  was making a last rally.   Stimulants and
ergot failed to effect expulsion, and, as a last resort, forceps
were used readily, and a still-born child extracted.  The
placenta was delivered soon after, but the  exhaustion had
been too great, and death occurred in less than two hours.
  Case 4.—Multipara,  get. 34.  When  about five  months
advanced she was  jolted in a carriage, and on the following
day a colored mucous discharge occurred, which  continued
more or  less for some time.  About six weeks  after this,
Avhile quiet in  bed,  a  gush of blood occurred, about four
ounces in amount,  and without pain.  The os  was patulous
and no presentation appreciable.   The flooding recurred  on
the following night while  dropping asleep.   An alum plug
suppressed the hemorrhage for four days.  On this day hemor-
rhage returned and labor commenced, and during the day the
bleeding was considerable and accompanying the pains. Alum
again moderated the flow, and acet. plumb, was given with
untoward effect, for  nausea  and  faintness followed its use.
By examination the placenta was centrically implanted.
The alum  had  produced constriction and coagula impeding
attempts  at  version.  The  placenta  was  now detached
manually and the hemorrhage ceased.   Very soon after the
detachment, the faintness which had required stimulants was
relieved.   The  pains  ceasing,  ergot  was used for their
renewal, and, after an interval of about an hour, contractions
became ergotic and delivery was effected.
   Case 5.—A multipara, aet 22, with her second conception. 
13
While quiet  in  bed,  about three a.m.,  the  patient was
seized with flooding, and on my arrival she was in a pool of
blood.  The os uteri was of the size of half a dollar, and on
the right side soft, pulpy, and loose.   The woman  was not
conscious of the commencement of labor, but the examination
seemed to develop contraction, and that quite actively.  At
each pain hemorrhage occurred with a gush and labor, advanced
rapidly.  The membranes were ruptured, and the flooding
ceased.  A few pains sufficed to  deliver the child, but it was
perfectly lifeless.
   Case 6.—Multipara with her  second  child.  Four days
before my visit, flooding occurred without pain, the woman
being at full term of gestation.   The tampon was used satis-
factorily until to-day.   On the recurrence of the  bleeding,
the placenta was found partially over the os, the head being
beyond.   Ergot  was advised.   On my  arrival, labor was
found to be actively progressing, and the hemorrhage had
ceased.  No interference was deemed necessary, and delivery
of a dead male child was  soon  accomplished,  the  detached
placenta following very soon. The patient was much blanched
from  loss of blood, but  recovered slowly.
   Remarks.—Six cases  are given, one of which proved fatal
to the mother,  while  of the children only one was saved.
Two cases occurred at the seventh month of pregnancy.  The
amount of placenta detectable was partial in all except one
case,  (No. 4,) where it was centrical.   The mode of delivery
was by uterine efforts,  aided more or less  by ergot, in four
of the cases; by forceps in one case (fatal); and by detaching
the placenta in one case.  Rupturing the membranes was of
service in three cases.  Case fourth is  the only one in which
the practice so ably advocated by Prof. Simpson, has been
seen,  and in this the effect of detaching  the placenta com-
pletely was  so satisfactory as to warrant a repetition of the
practice under similar  circumstances.  Almost immediately
after detachment, the system seemed to rally as if nature ap-
preciated the relief from a fatal drain, and from that moment
the patient's condition, before alarming, improved. 
14
   Retained Placenta.   Case 1.—Multipara delivered of
her ninth conception without professional assistance.   About
eighty hours after delivery my attendance was requested to
deliver the placenta, which was found to be in utero.  Ergot
to the extent of two drachms was given with the effect of ex-
pelling the mass  which seemed to have been recently at-
tached over about one-third of its surface.   Subsequently
she wras purged severely, and as was supposed, by anomalous
action of the ergot.
   Case 2. — Placenta  retained by  adhesion.  A  primipara,
aged 20, delivered after an ordinary labor of seven hours
duration.   The uterus was well contracted, and a portion of
the placenta was found in the upper portion of the vagina ;
this was hooked down,  but the placenta was now ascertained
to be adherent.  Hemorrhage,  to considerable extent, occur-
red, and the placenta was detached and removed in portions.
A binder and compress, with ergot, sufficed to restrain  the
flooding.  On the fourth  day a portion of placenta came
away,  which proved to be final, and  the patient recovered,
'though slowly, having  been considerably exhausted by loss
of blood.
   CV/se 3.— The  same  patient, in labor with  her  second
child.   From its  previous occurrence,  adhesion was  antici-
pated in this case, and, to  avoid it, firm  pressure was kept
over the uterus from the time  of the expulsion of the head.
After the child was expelled, the uterus could be felt enlarg-
ing beneath the  hand, the patient became tremulous  and
agitated ;  suddenly the abdomen subsided with a gush, which
was supposed to be the placenta passing.   Examination,
however, detected the placental mass partially detached, and
in the vagina,  while about half was  attached within  the
uterus.  This was detached manually, and expelled  by va-
ginal contraction.  No unpleasant  consequences followed.
In a subsequent labor this complication did not occur.
   Case 4.—Multipara,  aged 33, in labor with  eighth  con-
ception.  The labor was of twenty-four hours duration, and
the expulsion of the  shoulders was delayed.    After  the 
15
delivery of the child, hemorrhage came on and the placenta
was found attached over one-half its extent.   It was detached
manually, and the flooding ceased.
   Case 5.—Multipara, aged 33, in labor with her sixth con-
ception.  After a severe labor of twelve hours the placenta
was found to be retained by adhesion and irregular contrac-
tion.  It was  delivered by detaching and then removing it.
   Case G.—Referred to  as sixth case of forceps.   An adhe-
sion, of about two inches in diameter, detained the placenta,
and some hemorrhage occurred. Detached manually.
   Case  7.—Hourglass Contraction.— A primipara, aged 28.
The body of the child was violently extruded.   Observing
some hemorrhage, the hand was  introduced, and found  a
sort of chamber on the right side of the uterus, whence
the placenta was manually detached over a small space and
uterine contraction expelled both hand and placenta.
   Case  8.—Adhesion.—A multipara, aet. 30, about six and
a half months advanced, in her fifth pregnancy, was subjected
to  violence which induced flooding and premature  labor.
After the expulsion of the child the placenta remained, not-
withstanding severe expulsive efforts on the woman's part.
The hand being introduced, found firm adhesion over about
three-fourths of  the  placenta  which was  detached, and  a
contraction expelled the whole.
   Case  9.—Adhesion.—A  primipara was  delivered after an
ordinary labor of five or six hours duration.  After the ex-
pulsion of the foetus  the  placenta was found in  the vagina,
and the insertion of  the  cord was plainly distinguishable.
On attempting to hook down the  placenta with the  finger,
a  small, narrow strip was found very firmly adherent with
the os uteri.  In manipulating to detach this, the narrow
isthmus  gave Avay, leaving a small portion of the placenta
still attached.   It was  thought more prudent to leave the
separation  of this portion  to  time and the natural  efforts,
than to grope about with the hand, and without a guide in
a firmly contracted uterus, and thus manually to injure the
organ.   The patient progressed favorably up to the tenth 
                           16

day when she had considerable irritative fever, and a dark and
fetid discharge.  She recovered.   In a subsequent labor ad-
hesion did not occur.
  Case 10.—Adhesion.—A primipara was  delivered after a
labor of more than ninety hours.   After the expulsion of the
child (Avhich was born alive) the placenta was not cast off.
As there was no hemorrhage, and the expulsive  efforts were
strong, no interference Avas attempted for half an hour.  De-
livery was then effected by introducing the  hand and  de-
taching the placenta over about half its surface.
  Case 11.—Adhesion.—Case  ninth  of embryotomy.   Pla-
centa required manual delivery.
  Case  12.—Irregular  Contraction.—Case eleventh  of em-
bryotomy.   After  instrumental delivery,  the placenta was
detained by irregular  contraction,  and  was  found by  the
hand in a separate  compartment of the uterus.
   Case 13.—Adhesion. — The woman had been delivered
after an easy labor, but the  placenta was retained.  At  my
visit, four and a half hours after the expulsion of the foetus,
the placenta was found partly in the vagina.  On tracing it
up, a strong adhesion  existed to  the uterus  within the os,
which was firmly contracted.  Two fingers were used satis-
factorily in detaching the adhesion, and then  the whole was
forcibly expelled with a gush of blood.
  Case 14.—Adhesion.—A primapara  had been delived af-
ter a tedious labor, but after waiting an hour her attendant
could not  deliver the placenta.   The placenta was  found
completely adherent.   Chloroform was used to  quiet the
patient, who was very restive, but it was not deemed expedi-
ent to produce its full effect, as  a consequence, instead of
facilitating, it embarrassed the operation.   The effects wTere
allowed to pass away, and then with much difficulty the  pla-
centa was detached and removed.                ,
   Case 15.—Partial  Adhesion.—A primipara was  delivered
after an easy labor of six hours.  A portion of the placenta
descended  into the vagina.   On  passing  the hand into the
uterus,  the  remainder of the placenta was found firmly at- 
17
tached  near the fundus.   With  one hand supporting the
uterus,  and the  other  manipulating inside, detachment was
easily effected.
   Case  16.—Adhesion  and Irregular Contraction.—A primi-
para  delivered with forceps (Case 28.) for eclampsia.   The
placenta was found adherent firmly over about three-quarters
of its superficies, and in a chamber formed by irregular  con-
traction.   It was detached with some difficulty.
   Rcynarlis.—Of the sixteen cases given, the cause of retention
was in fourteen cases from adhesion, and two from irregular
contraction.  In no case was inertia the cause of delay—a
result attributable, it  is thought, to the  practice of firmly
compressing the uterus with my own hand, from the time of
the expulsion of the head to the severing of the cord. By pur-
suing this method, and firmly compressing the  uterus after-
wards, the placenta is  usually found in the vagina.  If not so
found,  there  is  usually  adhesion,  which, if  flooding co-
exists, will require prompt detachment.  In eight of the six-
teen cases, hemorrhage occurred; in seven it was not present
to any  amount.   In all the cases the result was favorable.
In manipulating for the detachment of the placenta, it has
been found greatly preferable to use one hand externally, to
support  the uterus, while the other is engaged internally,
than to  trust to even an experienced assistant.  The manoeu-
vre, easily accomplishable in the one method, has been found
difficult by the other.
  Funis Presentations.—Presentations of the cord have oc-
curred in five cases.  Number of labor.—Mostly multipara,
one only being a primipara.  Duration of  labor ^varied  from
four hours to two days.  Complication.—In one  case the face
presented with the  cord, in one the hand and cord came
down together, and one was a premature birth.   Sex of chil-
dren in  all Avas male.  Mode of delivery.—The  simple cases
were left to nature, except the case of two days  duration,
Avhich was perforated.  Embryotomy was also performed
where the face presented; the third complicated  with the
arm suggested version, and in this only was the child saved. 
18
Results.—Mothers all saved.   To the child, embryotomy was
fatal tAvice ; once the birth was premature ;  twice compres-
sion of the cord caused death; and one was saved by turning.
  Twins.  Case 1.—A multipara, in her  tenth parturition,
was delivered, after three hours labor, of two girls.   No de-
lay  occurred  between the births;  both presented by the
head.  Two placenta?.
  Case 2.—Multipara, delivered of two girls after a labor of
twenty-four hours, both presentations being vertex.   The
patient was completely unmanageable, and  during the ex-
pulsion of the second foetus, tossed off the coverings com-
pletely, so as to expose the foetus in its passage.  The foetus
was expelled, together with the placenta, the membrane not
being ruptured.  Single placental mass.
  Case 3.—Multipara, about  six months  and three weeks
advanced in pregnancy, confined with  two girls, the first
presenting by the vertex,  the  second by the breech.  The
children  died on the day after birth.
  Case 4.—Primipara, delivered  of  a boy after a labor of
eight  hours, vertex presentation. Uterine efforts now ceased,
and were not renewed until forty-eight hours after the birth
of the first child, when a girl was  expelled also by vertex
presentation.   Both children were born alive.
  Case 5.—Multipara,  delivered of  her  third  conception
after a labor of nine hours.  Two girls, both vertex presen-
tation.
  Case 6.—Primipara, delivered  of  two  girls  after a labor
of forty-eight hours ; both vertex ; single placenta.
  Case 7.—Multipara, delivered of  her  ninth  conception
after  about one hour of  labor.  The children  were  both
females.  The presentation of the first was unknown, having
been  born before my arrival; the second was breech ; two
placentae.
  Case 8.—A  primipara,  anasarcous for  two months, had
complained of headache and occasional dimness of vision for
some  time; urine highly albuminous; both  children pre-
sented footling, and were delivered with an interval of seven- 
19
teen hours ; both lifeless.   The  mother died on  the third
day, with granular degeneration of the kidney, as confirmed
by  the autopsy.   No convulsions occurred;  single placen-
tal mass.
  Case 9.—A  primipara, delivered of two boys after a labor
of fourteen hours; both children presented by the breech,
and  both were in sacro-anterior positions; there was  but
one placental  mass.
  Case  10.—A primipara, delivered, by forceps and  by
version, of two  girls, both  still-born.   When seen, she was
quite  comatose,  having had fifteen  convulsions ;  the  first
child was delivered by forceps, the  second by turning; the
woman was  quite pulseless,  and appeared moribund,  but
eventually recovered.
  Case 11.—The first foetus presented with hand, cord,  and
foot.   Delivery was  effected by  version twenty-one hours
after the commencement of labor.  Pains then ceased, and
were renewed, with partial effect, under the use of ergot;
the soft parts  became heated, and, as the foetus seemed dead,
perforation and  speedy delivery  seemed desirable; but this
opinion was overruled, and after a delay of thirty-two hours
more,  a dead foetus was expelled.
  Case 12.—A primipara, aet. 22.  The  first child presented
in the right-occipito-anterior position ; the  second by the
breech.  Both were females, and born alive.
  Case 13.—A multipara, with  her third conception,  was
in labor about four days.  The first child presented right-oc-
cipito-anterior, and was born alive ;  the second presented by
hand, cord, and  foot, and required to be turned; both were
boys, the second being still-born;  there were two placentae.
  Case 14.—A multipara, in her sixth  labor, was delivered
twro hours before my visit, of a living male child.   Friction
had  been maintained, but labor did not progress.   The
membranes were ruptured, and with the second pain after, a
female child was expelled,  also alive.   Both presentations
were cephalic; the children were full-sized; the two  pla-
centae  were very heavy. 
20
   Case 15.—A primipara,  aged 33  years.  Her labor had
 been of about forty-eight hours duration Avhen seen  by me,
 and the head of the child, though small and quite movable,
 had not made perceptible progress for nearly twenty hours.
 There appeared to her attendant no special cause for delay,
 for the pains had been sufficiently energetic to effect delivery.
 The size and shape of the abdomen dreAV attention, and in-
 quiry was made as to the possible existence of tAvins,  as a
 cause of delay. After waiting to see the effect of contraction,
 it was decided to assist with the forceps, which was accord-
 ingly done, and a living male child delivered under a moderate
 influence of chloroform and ether mixed.  Another child was
 discovered,  also presenting by the head ; but the uterine
 energies seemed  to have been  so much  impaired as to  be
 unable to expel the foetus.   Ergot AA-as given, and produced
 some effect.  About three and  a half hours after the expul-
 sion of the first child, a female living  child was born without
 instrumental aid.  There was but a single placental mass.
 This case is referred  to as Case 29 of Forceps Deliveries.
   Remarks.—Number of Labors.—Of  the  fifteen cases, se\Ten
 occurred with multiparae,  and seven with primiparae, one
 being unrecorded.  Sex.—Noted in twelve labors ; of these,
 two boys occurred twice, two girls seven times, a male and
 female in three instances.   When the sexes have been oppo-
 site, the male has been the first born. Presentations.—Noted in
fourteen cases; of these, two cephalic presentations occurred
seven times, two breeches twice, one head and one  breech
three times, and  twice with  the second  twin,  a hand, the
cord, and a foot presented.  Residts.—Living births for  both
twins occurred eleven times ;  both  were still-born  twice;
and twice only one of the children was dead.   One mother
 died from albuminuria.  Interval.—In one case, forty-eight
hours elapsed between the two births, once thirty-two hours,
 once seventeen hours, and once three hours ; in the others,
 ;he second labor came on so rapidly as not to require notice.
 Number of Placenta.—Recorded in nine cases.  Of these, a
 single mass was delivered five times, and in four cases two
placentae were expelled. 
21
   Rupture  of Uterus.  Case 1.—Was seen after about
 two days labor.   For thirty-six hours after the  rupture of
 the membranes, there was little or no pain ; the pains then
 became satisfactory, and the attendant supposed the labor
 would soon terminate; but the pains ceased, vomiting ensued,
 the skin became cool and clammy, and the pulse feeble, but
 the head did not recede, nor had any sudden, sharp pain, been
 noticed.   These symptoms had occurred about seven hours
 before my visit.  When seen, the patient was cool and
 clammy, pulse almost imperceptible and very rapid, vomit-
 ing frequent; over  the hypogastrium  a soft  fluctuating
 tumor, which was supposed to  be the  bladder, but was
 proved not so by the catheter; per vaginam could be felt
 the forehead, the right orbit being at the right acetabulum.
 Forceps  were tried, to save the child if possible; but the soft
 fluctuating feel created a suspicion of the nature of the case.
 The instrument, though locked pretty readily, slipped from
 the head.   The perforator was then used, and a large quantity
 of bloody serum escaped, and  the cranium collapsed and was
 readily removed by  the  crotchet.   Care  was exercised to
 produce  uterine  contraction,  and  stimulants freely used.
 The placenta was  found in the  vagina, and removed.  The
 patient lived four hours after delivery, and about eleven hours
 after the supposed time of rupture.  Post mortem.—On open-
 ing the abdomen, about half a pint of  fluid blood was found.
 The peritoneal coat did not exhibit a rupture positively, but
 was supposed to be torn in the removal; for in the vicinity
 of the rent, the uterine tissue was softened.  Upon the uterus,
 in spots,  was a slight deposit of lymph, and some pus was
 found  betvyeen the bladder and  pubes.   On opening the
 uterus, which was large, dark, and somewhat softened, a
 rent Avas discovered on the right side, anteriorly and near the
 neck ;  the vagina was intact.
  Case 2.—A woman, aet. 20  years, who had had one abor-
tion previously, and one seATere labor, in  which  the child
was still-born, was seized with labor-pains  about forty-eight
 hours before my seeing her. Labor had progressed favorably 
22
until the head had  descended to  the cavity of the pelvis.
About this time the contractions ceased, but abdominal pain
was present, and  also vomiting.   Her attendant attempted
the application of the forceps, but the head receded on the
introduction of the second blade.  When seen, the patient
was pale, livid, and distressed, tossing and complaining when
the abdomen was  touched, vomiting a yellow fluid, the pulse
over 150.  Through the abdominal walls the form of the
foetus was abnormally distinct.  A perforation existed in the
perineum, and a band was found in the vagina, the results
of the former labor.  The finger detected the head above the
pubes.  Forceps and embryotomy not being applicable, the
question of  gastrotomy was  mooted, but decided against-
The patient died ten hours after the  supposed time of  rup-
ture,  and three hours after the consultation.   Autopsy seven-
teen hours after death.—On opening the abdomen, some bloody
serum was found, and the foetus,  entirely escaped from the
uterus, was  lying in about the first  obstetric  position.  In
the flexure of the knee  a knuckle of intestine rose up in-
tensely  reddened and covered with a  film of fibrin.   The
omentum and parietal  peritoneum  also showed marks of
inflammation.   The child being removed, the placenta could
be seen extruded from the uterus, while  the uterus itself was
in the right iliac  region, measuring six  inches in length by
four and a half in breadth.  The  os uteri was not torn,  but
an inch above it, and on the anterior aspect,  a large trans-
verse rupture was found.  The anterior vaginal wall was also
extensively lacerated.  The dimensions  of the pelvis were :
superior strait, antero-posterior diameter four inches, trans-
verse four and a half; inferior strait, transverse three  and
a  quarter, antero-posterior four and a half.  The pubic arch
resembled that of a male pelvis.   The ilio-pectinal eminence
on the right side  was quite sharp.
   Case  3.—A multipara, aet. 35, in labor with her  sixth
child.  Her previous labors had been easy and natural, with
the exception of the first, which was tedious.  For  about
thirteen hours the present labor progressed slowly,  with 
23
weak and inefficient contractions.  About this time the pains
ceased ; there was no sudden pain, no outcry or sensation
of tearing, and the head, -which had presented in the left
occipito-anterior-position, did not recede.  About seven hours
after the cessation of the pains, she was visited and found
lying on her back, with a sunken, haggard, and pale coun-
tenance, tossing to and fro, complaining of pain over the
whole  abdomen, right shoulder, and legs, the surface cool
and moist, the pulse feeble and  about 160.   On examining
the abdomen,  portions of the foetus could be  distinctly felt
on the left side, but on the right they could not be distin-
guished ; the head  had  not receded.  After passing th%
catheter, by which bloody fluid escaped, delivery with the
forceps was attempted.  The instrument used was of bad
workmanship,  and the blades  yielded when delivery was
nearly effected.   Perforation then became necessary, and
after removal of several pieces  of bone, a male  foetus was
delivered.  The woman lived one hour and a half.   No au-
topsy could be obtained.
   Case 4.—Was seen Avith Dr. Metcalfe, by  whom it has
been published in theN. Y. Medical Times, Nov., 1854.  This
patient recovered.
   Case 5.—This case was  reported by Dr.  J. S.  Monell, in
the N. Y. Medical  Times, Oct.,  1S54.  The  patient present-
ed herself at  my office about a year after in apparent good
health.
  The following case did not occur in my practice, but as it
has never been published, it is now  presented, somewhat
compressed  from the statement of Dr.  E. W. Owen,  by
whom  it was furnished at my  request.  A woman,  aged
thirty-seven years, in her  seventh  confinement, of good
health, spare habit and nervo-sanguineous temperament, had
suffered no more pain before labor than is usual.   Labor com-
menced about noon; was summoned to, and saw the patient,
at seven p.m.   On examination, found the  membranes pro-
truding,  the pains, having a true expulsive character, recur-
ring at regular intervals, and having  a good  duration, the 
24
presentation perfectly natural, the parts dilatable, well lubri-
cated and cool.  At one  and a half,  a.m., during a  strong
contraction, the patient complained of acute pain in the back
and abdomen,  running up in the direction of the umbilicus.
The contractions ceased suddenly.  The patient, during the
pain, remarked that she felt as if she should burst.  Made an
examination during the pain, there was no recession  of the
head, no  alteration in the form of the abdominal tumor, no
perceptible hemorrhage.  The patient desired to sit  on the
chamber, and I retired.  She had no sooner got upon her feet
than she  fainted.  I was  hastily summoned, and found the
countenance pale and sharp, surface cold and clammy, pulse
rapid, wiry, and fluttering;  made an examination, found the
head had not  receded;  vomiting shortly occurred of dark,
red fluid; assistance was summoned ;  forceps were applied,
and a still-born foetus delivered, followed by two or three
quarts of blood.   The child weighed between  twelve and
thirteen pounds.  During my absence for aid, a change in the
form of the uterine tumor had taken place, the uterus having
broken away and occupying the right  upper abdomen, the
foetus, the lower and left, the head not receded.   Death en-
sued in less than two hours after the  rupture.   P.M.—No
clots, no inflammation;   the  uterus  was excessively large
and firm.  The  rupture was a bilateral  one,  two  and  a
half inches in extent of the vagina and cervix uteri at its pos-
terior lip where it forms the cul de  sac.  On incising the
uterus from the rent up to the fundus, the walls were found
more than double their usual thickness.  From this  we in-
ferred that such immense muscular power exerting its force
from above, together with the large size of the  foetus, was
the cause of this unfortunate occurrence.
   Autopsy of a Case of Ruptured  Uterus.—This case was seen
only after death.  At the autopsy, the following history was
given.  The patient, about  thirty years of age,  had had one
instrumental labor ; the  second natural, and the third the
fatal  one.  Labor  pains  began  on the  morning  before
death,  but no presentation  could be  distinguished;   later in 
25
 the afternoon the labor seemed nearer its close, but suddenly
 the contractions ceased, and pain in the epigastric region was
 complained of with dyspnoea.   Forceps were used with great
 difficulty, and proving ineffectual to deliver, the perforator
 was used, and with much effort the head drawn down.   A
 handkerchief was now tied about the neck of the foetus, and
 three operators, by successive efforts, drew down and delivered
 the foetus.  The woman died in an hour.   The fundus uteri
 extended to  the umbilicus.  Large  clots  were found in the
 abdomen, and also some fluid blood.   A laceration existed on
 the anterior aspect at the junction of the vagina and uterus
 about three inches long, transverse in direction, with ragged
 edges and greatly ecchymosed.   The antero-posterior diame-
 ter of the superior strait measured  three and a half inches,
■ the transverse five inches, the  promontory was very pro-
 jecting.
    Case Simulating Rupture.—A multipara, aet 31 years, in her
 seventh labor;  for some time the labor progressed slowly ;
 suddenly, after a severer pain than she had experienced, she
 began  to  complain of  pain in the epigastric region, which
 she compared to a " foot sticking in there," and she exclaim-
 ed that she."should  burst."  As she was ordinarily a quiet
 Avoman in her labors, some apprehension of rupture was felt.
 She felt weaker, but the pains continued.   The membranes
 were ruptured,  and in about an hour the foetus was expelled
 alive.   As the uterus contracted two distinct indentations or
 depressions were felt in the fundus.  Four days after some
 fever developed, and the  pulse ran  over  one  hundred  and
 twenty, but in about four days she was able to sit up.
   Remarks.—Six  cases of rupture are given as having been
 seen by myself, one furnished by Dr. E. W. Owen, and  of
 one the autopsy only  was witnessed.  For the sake of con-
 venience the  result of  the Avhole are tabulated.  Results.—
 Of the eight cases, six proved fatal to the mother, and two re-
 covered ; to the child all were fatal.  Number of labors.—All
 were multiparas  Cause of rupture.—Hydrocephalus  of the
 foetus in one case, contracted pelvis in  two  cases,- and  in
i 
26
one case an abnormally thick muscular uterus, with a large
child, was supposed to have been the cause.  In  one case
there was reason to presume that mal-adroit attempts to de-
liver had produced a laceration.   Duration of labor.—Two
days or more in two cases.  Cessation of the pains.—Occurred in
four cases,  vomiting noticed in four cases.   Presentation—All
were head.  Mode of delivery.—By perforation in four  cases, by
forceps  once, by  turning once.   Died undelivered  one.
Lived after rupture.—Recovered two.  Death in eleven hours
one, in ten  hours one, in twenty-one hours one, in two hours
one.  Seat of rupture.—Anteriorly near neck in three  cases;
posteriorly one case, on right side in one case.
  Inversion of  the Uterus.—The only case in Avhich this
accident occurred was seen in connection with  Dr. M. D. Van
Pelt, by Avhom  a  report was  made in the N.  Y. Medical
Times,  for February, 1853.   The case was one of interest in
a medico-legal point of view, and also from the peculiar mode
in which the inversion, or rather eversion occurred.   The
uterus  was not indented from  the fundus, but  the inferior
portion seemed to have turned out, giving a sort of trumpet
shape to the loAver part of the organ.  Restitution was read-
ily effected, and  the woman recovered.   Dr. V. P. has given
the particulars of the case.
  Monstrosities.   Casel.—Anencephalous Foetus.—A multi-
para, aged 28, pregnant with her third  conception, Avas pre-
maturely seized  with labor pains resulting  from  domestic
calamity.  At the first examination no presenting part could
be discovered, the vagina being filled with the bag of waters.
Some abnormity was suspected, and the membranes alloAved
to rupture  spontaneously.  The presentation  of  the  face
could  be then made  out but from the deficiency of frontal
bone an anencephalous foetus was inferred.   At each pain,
liq. amnii continued to gush, so that the bed was saturated,
and  a  large puddle formed on the uncarpeted floor.   Great
exertion on the woman's  part  was necessary  to  deliver the
shoulders, which were firm and  brawny   The foetus just
before  expulsion gave a convulsive start, but was born dead. 
27
  Case 2.—Multipara with  her  fourth conception.   During
gestation she had had much domestic annoyance.  On exami-
nation the face was found presenting, and the sharp edge  of
the frontal  bone  toward the right acetabulum, and  beyond
this a soft mass could be felt.  The previous case  led me to
anticipate a similar foetus.   There was no  profuse gush  of
waters, and no abnormal development of the body.  The foetus
was a male and was born alive.  It cried, passed urine, and
faeces,  and lived  fifty hours.
  Hydrocephalus.—Three cases  have occurred, in all  of
which perforation was employed as the means of relief, and
the cases will  be found under that head.
  The risks attending  this complication are  illustrated by
twro of the  cases.  In the first, which was a breech presenta-
tion, vesico-vaginal fistula resulted from the pressure which
would not have occurred  under more enlightened advice.
With another case, rupture of the uterus  took place Avith
fatal issue.  In  the remaining  case the diagnosis  Avas  so
obscure, that three intelligent accoucheurs (one a Professor
of Midwifery,) did  not suspect the complication, until the
perforator revealed the truth by  a gush of serous fluid.
  Vesicular  Mole.  Case 1.—A primipara, in about the
seventh month of conception, had some hemorrhage, for which
my attendance was requested under the supposition of pla-
centa  praevia.   An  expelled  mass was  shown, which on
examination proved to  be a conglomeration of vesicles,
many of them being as large as a hazel-nut.   Some similar
bodies protruded from  the os uteri which were removed.
On inquiring into  the  history of the case  the patient said,
that for five months after supposed conception, she enlarged
rapidly, less so after that.   No motion had been felt.   The
areola Avas well marked.   Ergot was  advised  to complete
the expulsion of the "mole," but proved of little avail.   On
the next day  another portion was spontaneously expelled,
after which she  left the asylum.
   Case 2.—A multipara, in her second  gestation.   For
three months the ordinary signs of pregnancy Avere present, 
28
but about this time the nausea became more persistent and
distressing, and severe neuralgia of the head occurred.  Sub-
sequently there was  some slight hemorrhage, which lasted
until visited a few days before the development of the case.
After about eight hours of pretty severe pains, the  os uteri
became sufficiently dilated to admit tAVO fingers, with which
about a pint of " hydatids" were scooped out. Considerable
hemorrhage took  place during this process, and stimulants
became necessary. Convalescence was slow, and on several
occasions a few  vesicles escaped with some  hemorrhage.
Neuralgic pains also, were severe, for which tonics were freely
given.  She recovered.
  Forceps Cases.   Case 1.—A primipara, having been for
twenty-eight hours in labor, was delivered of a boy by means
of forceps.  The  child was alive.  In  this case the mem-
branes had been ruptured for thirteen  hours, and the head
on  the perineum  for about eight hours.  The soft  parts
becoming hot and painful, with diminishing pains, delivery
was deemed necessary.
    Case 2.—A primipara,  aet. 30.   At the first examina-
tion the membranes were found to have been ruptured, and
the os uteri of the size of a quarter dollar.  Severe pains for
nineteen  hours proving ineffectual to  deliver, forceps were
used, and a male child born alive.  For  some time  after-
wards  the patient complained of pain,  and  difficulty  of
moving the right leg.
  In this case chloroform was used, and it was  supposed to
be the first case in which that anaesthetic was  employed in
midwifery in this city. The date was January,  1848.
   Case 3.—A  primipara, aet.  37.   Membranes ruptured
before examination, and the os uteri about one inch in diame-
ter. In the course of four hours  the os tincae was  dilated,
and the head at the inferior strait in the right occipito-ante-
rior position, but no progress beyond  was made for eleven
hours.  The  pubic arch was contracted.   By the aid of for-
ceps a female child  was  delivered almost lifeless, but  was
resuscitated.   In delivering  the placenta it was found to be 
29
 in a chamber, (as it were) of the uterus, produced by irregu-
 lar contraction.  Chloroform relieved this stricture, and deli-
 very was readily completed.
   Case 4.—A multipara, aet.  26, was delivered of her third
 conception, a girl,  by forceps, after a labor of twenty hours.
   Case 5.—The instrument  used for  the delivery of the
 head of the first twin, as referred  to  Case 17, of breech, and
 Case 9, of twins.
   Case 6.—A primipara, act.  24 years, delivered after  a
 severe  labor of forty-eight hours duration, of a  living girl.
 Dilatation of the os proceeded but slowly, and after its com-
 pletion the pains were not effective for delivery.   The con-
 tractions  commenced with apparent  force,  but, before pro-
 ducing expulsive effect,  violent pain  through the  hips and
 down the  thighs occurred, which seemed to cut  short all
 bearing down effort.   For this it  was supposed that chLDro-
 form might be serviceable, but its use was overruled. Opium
 seemed to control it temporarily.   Venesection  was  also
 used.   As a final resort forceps were employed, and delivery
 easily effected.   An  adhesion of the placenta about two
 inches in  diameter, presented the  expulsion of the placenta,
 and required detachment manually.  This  patient was at-
 tacked  with puerperal fever on the third day after  delivery,
 and lingered until the seventeenth day when she died.
   Case 7.—Referred  to  as  Case 10,  of  twins.  Protracted
 convulsions rendered delivery necessary, and as  the head
 was in the pelvic cavity forceps were applied.
   Case S.—Referred  to  as  Case 1,  of  rupture of uterus.
 Forceps applied but slipped from the yielding of the head—
 the foetus being hydrocephalic.
   Case  9.—Referred to as Case 3, of rupture of the uterus.
 The  blades of  the forceps sprung during traction, which
 was not severe.
   Case 10.—Primipara, aet.  33.   The membranes ruptured
tAvelve  hours  after the  commencement of labor, and slow
progress was made  for two hours, when the caput  succeda-
neum was almost at the vulva.  No progress was now made 
30
for eight hours, and forceps were used.   A living male child
Avas born.
   Case 11.—A multipara, ast.  23, in her third labor.   Her
attendant stated  that  the head had occupied  the inferior
strait for twelve hours without advancing.  Four hours more
were  permitted  to  elapse before proceeding  to delivery.
This was  readily effected by the  short forceps ; child lived.
   Case 12.—A primipara, aged 20, was  delivered by forceps
of a male  child (living), after a severe labor of thirty hours.
For about thirteen hours there was no  advance of the head,
though the contractions were energetic.
   Case 13.—A primipara, aged 27, was  seized with eclamp-
sia, on the day but one previous to visit, and  at the time of
delivery  she had  had fourteen convulsions.  No foetal pulsa-
sation could be  heard; but the use of forceps was deemed
preferable to perforation.  A still-born male child, weighing
nine pounds and three-quarters, was delivered.  The woman
died of puerperal  fever, which  was prevalent at  the time.
   Case 14.—Case 3 of Placenta Praevia.   A primipara,  aged
29, was seized with  flooding,  during the seventh month of
gestation, which  continued for a fortnight before my visit.
Natural efforts, though seconded by ergot, failed to deliver.
The  forceps were easily applied,  and  delivery quickly ef-
fected ; but  the hemorrhage had been too long continued,
and the patient survived only an hour and a half.
   Case  15.—A primipara, aged  24 years.  After a  slow
progress of labor for  seven  hours,  the head in the right-
occipito-anterior  position reach the  perineum ; here it re-
mained stationary until forceps were used, twenty-nine hours
after the commencement.   In the meanwhile, she took some
sour milk, which  soon purged her freely, Avith borborygmus
and pain.  The use of instruments was advised,  but rejected
some  hours  before delivery.   At the time of delivery the
labia  were oedematous, with a yellowish vaginal  discharge,
and pulse 130.   The  child, a female, was still-born.  The
patient had  a protracted  convalescence.
   Case 16.—A primipara, aged 30.  Had  three convulsions 
31
before delivery, which was  effected  by forceps, and subse-
quently one more.  The child, a male, was still-born.   Al-
buminuria existed.
   Case 17.—A primipara, aged 33.   At the time of visit she
had been in labor  about forty-eight hours, the membranes
having  ruptured about thirty hours.  No progress had been
made by the head for eight hours. The child, a girl, Avas born
living, but lived only for a short time.
   Case 18.—A  primipara,  aged about 30, strong and ple-
thoric.   About  three  hours after  the  commencement of
labor, the water escaped.  Her attendant  had made attempts
to dilate the os manually, and supposing that he had suc-
ceeded, was desirous that forceps should be used.  At my
first visit the  os uteri  was about one and  a half inches in
diameter, with a thick hard undilatable margin.   Opium
was advised, and this failing, chloroform  was to to be given.
In the afternoon she was again visited, her attendant stating
that he had again "used manual dilatation, and with  good
effect;"  that chloroform had been used, and the os was fully
dilated.  On examination the os uteri was about three inches
in diameter, and rigid in the whole circumference.  Vene-
section was advised.  At the next visit, the  os Avas  fully
dilated, and forceps were used, and a  dead male child de-
livered, weighing ten and a quarter pounds.
   Case  19.—Referred  to  as  Case  11, embryotomy.  For-
ceps were used prior to the perforator.   A primipara,  aged
30.   Length of labor four days.
   Case  20.—A  primipara,  aged 30.   Position  right-occi-
pito-anterior.   Labor tedious and  with much  pain poste-
riorly, even while the  head Avas  at  the  superior strait.  A
chill  had occurred, and her attendant  had deemed delivery
advisable.   Forceps were readily applied, and  delivery ef-
fected.   There was no pulsation in the cord around the neck,
and the child, a boy, was  still-born.
   Case 21.—A primipara, aged 23 years,  had been in  labor
for fifty hours.  At the time of my  visit  the head was low
in the pelvis, but uterine efforts did not ad\rance it.  After 
32
watching for an hour, forceps were used and a male child
Avas born living.
  Case oo _A multipara, aged over 35 years, with her nltn
conception.   On two  occasions previously, instruments had
been used.   She had been  in  labor thirty-eight hours, and
though the  pains were  strong, no progress was made  to
delivery.  Chlorofo rm having been premised forceps were
used, and, with severe exertion, a boy extracted still-born.
   Case 23.—A primipara, aet.  about 23.   She was said  to
have been in labor for two days.   No progress having been
made for  some hours, forceps were used.  The delay was
owing to the position, left occipito-posterior.  A living male
child was delivered.
   Case 24.—Refer to  Case  11, embryotomy.  The forceps
were readily applied,  but traction did not cause the head to
descend ; and as the foetus was dead, the perforator was pre-
ferred to the use of more violent exertion with the forceps.
The patient was a primipara, aet. 27.   The child a female.
    Case 25.—A primipara,  aet. 28 years, had been in labor
four days.   The child, a  male, was born alive.
   Case 26.—A multipara, ast. 43 years, with her  eighth
child.   In the absence of her attendant, this patient was
seen  about  midnight.  Her  labor  commenced with rup-
ture  of the  membranes; and about twelve hours after, her
 attendant gave her ergot, and left with  the belief that the
 os uteri was fully dilated.   On examination the os was about
 the size of a half dollar.  The pains were ergotic, " crampy,"
 continuous, and very distressing.   In about four hours the
 os became  dilated, except the anterior  lip.   About twelve
 hours after, as no progress was made, forceps were used, and
 after severe traction,  a male child, weighing  twelve pounds,
 was extracted alive.
   Case 27.—A primipara,  aet. 22 years, had been in labor
 about two days, and attempts made to deliver with forceps.
 On examination, deep and extensive lacerations of the labia
 were  found, the  result  of the previous manipulations.  No
 difficulty was experienced in locking the forceps, and deliver- 
33
ing a still-born male child, of rather more than ordinary size
and weight.
   Case  28.—A primipara,  aet.  25 years,  strong, plethoric,
and  anasarcous,  was  taken with  convulsions  during the
dilatation of the os uteri.  For this she was bled. When seen,
she had had seven more fits, and  was lying in the coma of
the last.  On examination, the head was found in the cavity
of the pelvis in the left occipito-anterior position.  The urine
had accumulated, and was  removed  by catheter;  it was
strongly albuminous to heat and nitric  acid.   The child was
believed to be dead; nevertheless, forceps seemed advisable,
and the event proved them to be the proper instruments.   A
living male child, weighing ten and a half pounds, was readily
extracted.  The placenta adhered, (Case 16.)
   Case 29.—Referred to as Case  15 of twins.   A  primi-
para, aet. 33  years,  being unable to  expel  the  first twin,
after forty-eight hours exertion, forceps were used, and  a
living male child delivered.
   Remarks.—The most striking circumstance in  connection
with these  cases  is, the  preponderance  of primiparous
patients.   Of twenty-six  cases,  in Avhich the number of
births is noticed, five only were  multipara?,—twenty-one
primiparae.   In the multiparas, the  reason for the use of  the
instruments was, in one, rupture of the uterus;  in one, con-
tracted pelvis, which had on a previous occasion necessitated
their use; and in one, the imprudent use of ergot, with a very
large child, had exhausted the uterine energies.  In four cases,
the forceps were used for convulsions, in only one of which
the child was born alive ; and one mother died of subsequent
puerperal fever.   The duration of labor varied from nineteen
hours, the shortest period, to four days, the longest recorded.
The time elapsing during the second stage of labor without
progress, has been the criterion for the necessity of using
instruments ;  and  in  reflecting  on  these  cases,  in two
instances only has subsequent experience convinced me that
nature  would have equally  well  accomplished  delivery.
In some cases, the application has been too long postponed,
and unpleasant consequences ensued.  Of the two cases just
                      3 
34
referred to, one was a head detained after a breech delivery,
where proper manipulation would have secured extraction.
The other was  a simply delayed labor,  where the short
forceps were used.  In all, except this case, the long forceps
with a double curve have been used, and proved serviceable.
It is often said that the hand that uses is of more consequence
than the instrument to be used, a remark generally true,
though not always so.   On several occasions, my own forceps
have succeeded where other instruments have failed; and in
one case in particular, a pair of forceps yielded so much, in
the course of extraction, as to permit the head to slip through,
though the blades were correctly applied.
  Results.—Of  twenty-four  children, fourteen  have been
born alive, nine are recorded as still-born.   Of these nine,
two heads were  subsequently perforated, two  were born in
eclampsia, one died during unavoidable hemorrhage.   Three
mothers have died, two of fever and one of placenta praevia.
Sex.—Recorded  in  twenty cases,  of  which fourteen were
females.
  The ages of mothers have ranged from 23 to 43 years, the
majority being over 30.
  Embryotomy.   Case 1.—Was performed to  deliver  a
large foetal head.  Though occurring in a public institution,
no  instruments were to be had for any operation, and in this
case the perforator used was an ordinary pocket-knife.
   Case •£.—Referred to as Case 3 of breech labors.   In  the
same institution, no instruments being procurable, a  trocar
was used,  and  the opening made through the orbit.
   Case 3.—The perforator used for an hydrocephalic child,
the forceps having failed.
   Case 4.—Also  an  hydrocephalic child.  Forceps readily
applied, but slipped.   Referred to as Case 1 of rupture of
uterus.
   Case  5.—Referred  to as Case 3  of rupture of  uterus.
The perforator used after the failure of forceps.
   Case  6.—Case 4 of rupture of uterus.
   Case 7.—A  primipara.   Duration  of labor twenty-nine
hours.  No foetal pulsation could be detected, and there was 
35
 a fetid odor from vaginal examination.  After delivery by the
 craniotomy forceps, there was some hemorrhage.  Recovery
 was tedious.  Male foetus.
   Case 8.—A multipara, four days in labor with her second
 conception.  When seen,  a  fetid odor was perceptible  on
 vaginal examination, the soft parts hot and dry.   This woman
 died of peritonitis.
   Case 9.—A  primipara, aet. 26,  had been  in labor for
 five days  before visit.   Vaginal examination gave ample
 evidences  of decomposition.   In delivering the foetus, the
 bones of the head came away separately, as also the clavicle
 and some ribs.  The remnants of the foetus without the brain
 and bones  weighed eight and  three-fourth pounds.  The
 patient lived only two days.
   Case 10.—A primipara,  aet.  18, was delivered, after a
 labor of two  days.  The cord  prolapsed by  the head, and
 was pulseless for twenty-four hours.   Delivery was readily
 effected.  The woman died.
   Case 11.—A  primipara, ast. 32 years, had been  in labor
 when seen for two  days, during  which time ergot had  been
 given, and attempts made to  deliver with the forceps. When
 visited, the caput  succedaneum was found distending the
 vulva, but delivery was impeded by the narrowness of the
 bis-ischiatic diameter, which was not more than three inches.
 At the request of the attendants, an  attempt  was made to
 apply forceps, but it proved,  as was  anticipated, unavailing.
 The perforator was then used, and even after the brain was
 evacuated, much difficulty was experienced in delivering the
 head.   No  less trouble was  experienced in delivering the
 body.   The cuticle peeled readily, showing the death of the
 foetus before perforation.  The uterus contracted irregularly,
 and the hand  was passed to effect the  detachment of the
 placenta.
   Case 12.—This case  had been under the charge  of two
 different practitioners; the first of whom said he had found
an arm presenting, which he had returned, and  then resigned
the case to the second, who found the cord prolapsed and
the face presenting in the left mento-iliac position.  He had 
36
tried forceps ineffectually-   On visiting the case, about a
foot of the funis was found prolapsed,  the  face was  at the
superior strait, looking to the left side, the chin being poste-
rior.   The cord being pulseless for a long time, the child was
presumed to be dead, and cephalotomy the proper means of
delivery.  The  perforator was pushed through  the scalp-
tumor which had formed on the right frontal bone, and after
breaking up the  brain, delivery was effected by craniotomy
forceps and the crotchet.  As the head was being delivered,
the occiput rotated upon the crotchet as a pivot from right
to left, into the hollow of the sacrum, and was thus delivered,
the chin being under the pubes; restitution occurred toward
the left thigh.  The shoulders were delivered manually, and
the placenta passed without assistance; child, a male.
   Case 13.—A primipara,  aged 30, had been in labor four
days before my visit.  The pulse was 122, with no abdominal
soreness; the bladder was distended.  Per vaginam the head
Avas pressing upon the soft parts, the sutures sharp and bones
overlapping.  There was no uterine  contraction, and had
been none for five hours.  The catheter was passed.   After
an unsatisfactory attempt with the forceps, the scissors were
used.  By the crotchet the cranium was pulled away piece-
meal, and, with much difficulty, the remnant of the head and
body were  delivered, a great explosion of fetid gas follow-
ing the expulsion.  The placenta  was found enclosed in  a
chamber ; and was delivered manually.
   Case 14.—A primipara,  aged 27, had been in  labor for
three days prior to my seeing her, the membranes having rup-
tured within seven hours  after  the commencement.  Per
vaginam, the scalp was found turned,  and  the edges of the
bones sharp, the presentation being right occipito-anterior. The
inferior strait was  contracted, the pubic arch being like that
of a male pelvis.   The abdomen presented two tumors, di-
vided by a  sulcus, which appearance was  quite deceptive,
as the catheter was stated to have been  recently  passed.
This proved to be an error, for on the  delivery of  the head,
urine gushed out very freely.  Forceps were first tried, and
though easily applied, produced no effect, and the perforator 
37
 was then resorted to.  Severe traction was requisite, but de-
 livery was finally effected, and the woman recovered^
   Rlmarks.-Oi the fourteen cases, one only occurred in my
 own practice, viz.: the breech case, in which hydrocephalus
 caused the delay in expelling the head.   In no case has a
 living child been sacrificed, a circumstance  attributable to
 the natural repugnance every conscientious practitioner feels
 to destroying life, even in emergencies.  As, with the one ex-
 ception, all the cases were seen in consultation, much delay
 had occurred in seeking advice, and there has been no ground
 for hesitating as to the  mode  of delivery.   Evidences  of
 fetal death have been, in all cases, manifest.   So much  has
 this been the case,  that it has materially influenced the re-
 sult to  the  mother;  for out of the fourteen cases, no less
 than five women have died.   Of these, one death was from
 rupture of the uterus, and four from  fever.  Of ten cases
 recorded, only one  occurred in a multipara.  The reason for
 operating is  noticed in eight cases, three were for  ruptured
 uterus;  three children were hydrocephalic;  twice the funis
 was prolapsed and pulseless.
    Unclassified Cases.  Case  1. — Presentation  Occipito
 Pubic—A German woman,  get. 36 years,  pregnant with
 her sixth  child,  was delivered, after a very tedious labor
 of twenty hours.  Her previous  labors had been easy and
 rapid.  In this, though the contractions were sufficiently en-
 ergetic,  but  little progress was made, owing to the position
 of the child.  At the  superior strait, the presentation was
 easily made  out by the occipital and  sagittal sutures.  The
 latter occupied the antero-posterior diameter of the superior
 strait, and the head was with difficulty expelled in  this posi-
 tion.
   Case 2.—Labor with Disease of Heart.—Death.—A multi-
 para, in  her  seventh pregnancy, began to complain about two
 months before term.   Irritability of stomach, deficient secre-
 tion of bile, scanty and high-colored urine, the pulse full
and bounding, were prominent manifestations.  Venesection
relieved the symptoms temporarily.  A week later she was
troubled with cough and slight hemoptysis, for which no 
38
pulmonary cause could  be found.  On consultation, the
venesection was repeated, and antimonials used, with good
effect.  The cough subsided, and the urine became copious,
having no albumen in it.   A careful examination of the heart
now discovered hypertrophy, with a systolic murmur, having
its intensity over the aortic valves.  The improvement lasted
about a fortnight, and the patient suffered more than before.
The respiration was difficult, and  she could  not lie down ;
the sputa were streaked with blood.  A different consultant
was called in, who advised enemata of turpentine and a solid
diet, in order to relieve flatulence.    These measures did
not relieve.   The  pulse was tense, strong,  and bounding,
causing the radial and ulnar arteries to start, with the violence
of the pulsations; the cough was frequent, and expectoration
bloody.  A small bleeding was ventured, but the force  of
the pulse was broken at once, and the arm tied up.  On re-
newed consultation, it was determined  to anticipate labor;
and, to induce premature contraction, compressed sponge
was inserted within the cervix,  and  the vagina plugged.
These measures seemed to coincide with labor, though the
patient was not conscious of it; for in about four hours the
os  uteri  had dilated  to  two inches in diameter, and the
membranes had ruptured spontaneously.  No relief was ob-
tained by the evacuation of the liquor amnii.  While I was
in an adjoining apartment, she arose to the close  stool, and
when called, I found the head had  emerged while in  that
position.   The patient was placed in  bed, and soon the body
of a female child was expelled living.  The placenta remained
partly within and partly without  the os uteri, strong pres-
sure being kept up over the fundus uteri; but there was  no
flooding.   After some effort on the woman's part, and the
ineffectual use of ergot, the placenta was delivered manually
and with less than the usual  loss of blood, and the  uterus
contracted well.  The patient  could not be kept recumbent,
but tossed around violently, gasping for breath, but no flood-
ing occurred.  Stimulants were actively given  for more than
an hour, when she started up wildly, gasped, and  died.
  Case 3. — Dyspnoea after  labor  threatening  dissolution.— 
39
 A multipara, aged 30 years, with an obscure cardiac affec-
 tion (hypertrophy)  was troubled with dyspnoea during the
 latter months of gestation, which precluded exertion even to
 a moderate extent.  The labor was  short, the pains being
 lengthened and  efficient, but all outcry was stifled by self-
 control.  No hemorrhage succeeded delivery, but almost im-
 mediately after the difficulty of breathing became very alarm-
 ing, the face became lurid, the nails purple, the pulse weak,
 irregular and intermittent, and she was compelled to sit up
 in order to breathe.   Stimulants were freely used by mouth,
 and to the nose, and a sinapism laid between the shoulders.
 Relief gradually ensued,  and she recovered without  return
 of the distress.
   Case 4.—Was  requested to see, in consultation with two
 practitioners, a primipara, aet. 30, who had been in labor
 for two days, the membranes having ruptured early, and the
 subsequent progress being slow.  Her attendant was  sitting
 by the bedside, and stated, that about three hours before, the
 pains had been active and delivery seemed imminent, but
 suddenly the pains had ceased.  The head, he said, Avas im-
 pacted,  and the  catheter would not pass.  The pulse was
 100, the skin cool but not clammy.  On examining the ab-
 domen, the bladder Avas much distended.   On attempting to
 pass into the vagina,  the head was found delivered, the scalp
 emphysematous,  and the bones loose.  Her attendant was
 much surprised.  He was requested to complete the delivery,
 and with some trouble, owing to the putrid state of the foe-
 tus, did so.  Immediately on the expulsion, an explosion of
 fetid gas occurred, and the bladder was  evacuated spontane-
 ously.  The woman subsequently died.
   Granting her accoucheur's account to  be strictly correct as
 to the cessation of pain, and his subsequent examination find-
 ing the head still under the pelvis, what effected  the  deliv-
 ery ? Was it the development of gas by decomposition that
 silently extended  the head ?
   Case 5.—Elongated anterior lip of cervix.—A multipara with
her second child.  On making the usual vaginal examination,
the os was found about two-thirds dilated, and a teatlike pro- 
40
jection attached to the anterior lip. After sometime she rose
from her bed to go to stool,  and was found upon her hands
and knees, the child being on the floor, and having lost con-
siderable  blood.  The cord was divided, and as the woman
continued to lose blood, she was replaced in bed before deliv-
ering  the placenta.  This having been done, firm pressure
was made over the uterus, which caused the escape of blood
andcoagula.  Per vaginan were found clots, and another sub-
stance which was supposed  at first to be  a clot firmer  than
the rest.   On tracing it up, however, it was found to be the
anterior lip of the uterus, elongated sufficiently to protrude
from the vulva, about one inch wide at its apex, and gradual-
ly widening to  its base.  This was not interfered with.  A
similar case had been related to me a few days  previous by
Dr. Beadle.
   Case 6.—Good effects of chloroform.—A primipara, the wife
of a  medical  gentleman, had  been in  labor  when seen,
for several hours, the os being  dilated, and the pains slow
and inefficient; simple delay was advised.  The next  day,
as no  progress had been made, ergot was suggested,  but no
good effects were obtained from it.   Her husband had also
used chloroform.  In the night it wras thought  advisable to
use forceps, as the labor had  continued about forty-three
hours, the head occupying, for a long time, the inferior strait
without advancing for several hours.   As a preparatory step
chloroform was used, and as soon as the  full effect was ob-
tained, the operation was commenced.  On attempting  the
passage of the first blade the head was found descending, and
of course the natural efforts  were allowed to complete the
delivery.  The child, a boy,  was born  asphyxiated, but re-
covered.   In this case  two causes had acted to  impede
labor, first the pains  were inefficient, while the second and
principal cause was great sensitiveness of the external parts.
Chloroform  acted  kindly in relieving this hyperaesthesia,
and then the uterine efforts sufficed to expel the foetus through
a vulva, relaxed also  probably^by the anaesthetic.
  New York, 64 East Twelfth-st., Sep. 25.