SOME RARE CLINICAL OBSERVATIONS 
IN 
OBSTETRIC PRACTICE. 
BY 
SAMUEL 0. BUSEY, M.D., 
Washington, D. C. 
[Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XX., September, 1887.] 
NEW YORK : 
WILLIAM WOOD & 00., PUBLISHERS, 
56 & 58 Lafayette Place. 
1887. SOME RARE CLINICAL OBSERVATIONS 
IN 
OBSTETRIC PRACTICE. 
BY 
SAMUEL 0. BUSEY, 
Washington, D. C. 
[Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XX., September, 1887.] 
NEW YORK: 
WILLIAM WOOD & CO., PUBLISHERS, 
56 & 58 Lafayette Place. 
1887. Some Rare Clinical Observations in Obstetric Practice.' 
The title of an essay should indicate the subject-matter of 
discussion. In this important requisite, the above title is en- 
tirely wanting. It would have been impossible to have grouped 
together the following reports under one common heading other 
than some general statement that they were clinical observations 
in obstetric practice. They are presented for your consideration, 
not as unique cases, but as illustrations of some surprises which 
have caused me much embarrassment and some anxiety, and 
may contribute something as aids in the diagnosis and manage- 
ment of uncommon and unexpected complications of pregnancy 
and labor. 
Case I.-A Caul-Sac Obstructing the Diagnosis of Position in 
Head Presentation. 
Mrs. E., pregnant for the third time, commenced to feel very 
slight pains during the early morning of July 13th (1879), but 
they were so trifling as not to attract serious attention. She had 
not expected to be confined prior to August 1st. At 10 a.m., the 
os only admitted the end of the index finger; the fetus was too 
high for the recognition of the presentation without the introduc- 
tion of the hand into the vagina, which was not done. At 7 p.m., 
the os was dilated to about the size of a silver half-dollar. At this 
time the diagnosis of head presentation in L. 0. A. position was 
made. At 11.30 p.m., the os had dilated to the size of a silver 
dollar and was dilatable. The bag of waters had formed and was 
protruding; the membranes felt thick and tough; and the pains 
were not vigorous. An hour later, the amniotic sac was 
ruptured and a free and copious discharge of fluid followed. To 
accomplish this I had, during an intermission of pain, passed the 
right index finger through the os and posteriorly (the patient 
lying on her left side) between the membranes and inner surface 
of the uterine wall, just far enough to feel the head, and at the 
moment of greatest tension of the sac the sharp edge of the finger 
1 Read before the Washington Obstetrical and Gynecological Society, 
March 18th, 1887. 4 
Busey : Some Rare Clinical 
nail was suddenly thrust against it by extending the partially 
flexed finger. The perforation was made directly opposite the 
anterior fontanelle. Immediately after the escape of the " waters," 
I could feel the fontanelle, follow the course of the sagittal suture, 
but could only reach the posterior fontanelle high in the left 
anterior direction. Flexion had not taken place, but the head 
being small and the pelvis roomy, interference was not deemed 
necessary, as I believed that as soon as the expulsive pains were 
sufficiently powerful the vertex would descend and rotate under 
the arch of the pubis. The pains changed in character and 
speedily increased in force. Soon after the exploration just refer- 
red to I discovered the condition which I have called a caul-sac. 
The index finger being introduced through the dilated os, came 
in contact with a sac extending from the posterior margin of the 
anterior fontanelle laterally around the parietal protuberances 
and backwards over the vertex concealing the posterior fontanelle. 
To the sense of touch the sac seemed to be filled with fluid. It 
became very tense during the pains, and during the intermissions 
was sufficiently so to prevent recognition of the sutures, bony 
margins, or posterior fontanelle; and had I not known that I had 
ruptured the amniotic sac, and discharged a considerable amount 
of fluid, I might have punctured a sect nd time; but relying upon 
this fact I avoided any violence. No caput succedaneum could be 
felt; nor did the sac feel like the scalp distended with hydro- 
cephalic fluid. The head was small and the labor was progressing 
satisfactorily. The vertex descended, rotated under the arch of 
pubis, and at 3 A.M. (14th) the head passed the vulva. Then the 
nature of the difficulty was discovered to be a hood consisting of 
a portion of the membranes which covered the entire vertex, ex- 
tending laterally and posteriorly, as previously described, be- 
tween which and the underlying scalp was interposed a quantity 
of amniotic fluid. This hood I removed before the trunk of the 
child was delivered. At what stage of the progress of the head 
through the maternal passage the caul separated from the 
remaining portion of the secundines I cannot determine; but the 
secondary sac was recognized during the passage of the head 
through the parturient outlet, and was not understood until after 
the head had escaped and was examined in situ. 
The formation of the secondary sac was undoubtedly due to 
the location of the puncture in the amniotic sac. As a rule, 
spontaneous rupture of the membranes takes place in the part 
protruding through the os, most frequently at or about the 
most dependent part or apex of the bag of waters, because at 
this point the pressure force of the compressed liquid is greatest 
and the resistance least. I have never witnessed the expulsion of 
an ovum " at term " with the membranes intact; nor would I 
permit such a delivery to occur, if avoidable. I have, how- Observations in Obstetric Practice. 
5 
ever, very often encountered persistent membranes which 
delayed delivery. When to interfere in such cases is a very 
important question. Too early evacuation of the liquor amnii 
retards dilatation of the os, prolongs labor, intensities the suffering 
of the woman, increases the risks of the fetus, and augments the 
difficulties and dangers of efforts to correct transverse and other 
abnormal presentations. Protracted persistence of the mem- 
branes wastes uterine power, lessens its propulsive force, delays 
retraction of the cervix, and may prevent the engagement of 
the presenting part in and its escape through even a softened 
and dilatable os. The tensile strength of the membranes 
(Duncan) varies from four to thirty-seven and a half pounds. 
The propulsive force which bursts the bag of membranes is 
frequently, in natural labors, quite sufficient to complete delivery; 
lienee it is obvious (Duncan) that in many such labors the ovum 
would be expelled with membranes entire if artificial rupture 
had not been accomplished. In those cases of persistent mem- 
branes where the tensile strength is at or near its maxim am, or 
even above the average, it is equally obvious that delivery is 
delayed, and there is an unnecessary expenditure of uterine 
force with consequent exhaustion, which is proportionate to the 
duration of the persistence of the bag of waters and condition 
of the patient. In no case ought the bag be permitted to ad- 
vance in its integrity beyond the external surface, and in many 
cases an earlier discharge of the waters will be expedient. The 
puncture of the bag should always be made at or as near as may 
be convenient to the centre of the convex portion. The tear 
does not, however, even when spontaneous, always take place 
at the most dependent part in the vaginal pouch, or even ex- 
ternal to the os. When located high within the os, there may 
be persistence of the bag of waters notwithstanding the gradual 
discharge of the liquor amnii. Spontaneous rupture usually 
occurs at the beginning of the second stage of labor. 
Case II.-An Elongated and Protruding Bag of Waters Ob- 
structing Diagnosis of Presentation. 
Mrs. D. was delivered of her second child April 13th, 1873. 
At my first visit, I did not make a diagnosis of the presentation, 
but simply satisfied myself that labor had begun. At my second 
visit, made several hours later, I was astonished to find, protrud- 
ing from the vulva, an elongated and tense sac terminating in an 
irregularly shaped enlargement. This bag. of waters I could 
trace up to and within the os uteri, where it was again expanded 6 
Busey : Some Rare Clinical 
into a roundish and larger tube. Between this point and the 
distal and protruding extremity its calibre was much smaller. 
The os was dilated to about the size of a silver dollar and dilat- 
able. I knew the pouch was the bag of waters, but I could not 
determine the cause of its peculiar shape. I did not attempt to 
make a diagnosis of the presentation by the introduction of the 
finger into the uterus, because I feared to prematurely rupture 
the membranous bag, and could not, either by inspection or pal- 
pation, ascertain its contents beyond the fact that it was fluid. 
After waiting some time, perhaps an hour, and no change having 
taken place, I punctured the membranes, and then, to my great 
surprise, discovered that I was dealing with a presentation of the 
right foot. The other foot was brought down and delivery ac- 
complished as usual. 
This observation suggested the inquiry into the diagnostic 
value of the size and contour of the bag of waters in the de- 
termination of the presentation. I pursued this investigation 
for a while, but it did not promise much beyond the general 
statement that its size and shape were as much dependent upon 
the condition of the os, amount of liquor amnii, tensile strength 
of the membranes, and power of uterine contraction as upon 
the presenting part of the fetus. In head and breech presenta- 
tions the membranous bag is more or less hemispherical, and 
more or less regular in contour, according to the presence and 
extent of lacerations of the cervix and shape of the os. In 
breech cases, the bag is usually less tense but more voluminous 
than in head presentations, because of the imperfect closure of 
the lower uterine segment; and when the os is rigid, it may be 
elongated. In cases of extension of an extremity with persist- 
ence of the membranes, there would be an elongation of the 
pouch, and the shape of the most dependent part might indicate 
the presence of a hand or foot. Madame Lachapelle declared 
she was never anxious when " the flat sac " was present, thereby 
meaning, says Cazeaux, that any " very great protrusion of 
it nearly always announces an unfavorable position." 
Case III.- Vesical Distention Mistaken for Puerperal Peri- 
tonitis. 
This case was seen in consultation the seventh day of the 
puerperium. Multipara. Fever with abdominal pain and swelling 
began on the fourth day and ranged very high, notwith- 
standing the free employment of quinine. At the time of the 
consultation the temperature was above 104°; the pulse was very 
frequent and feeble, barely perceptible. There was considerable- Observations in Obstetric Practice. 
7 
tremor of hand and subsultus. The delirium was mild: the 
general aspect of the patient indicated speedy death. 
The abdominal swelling had continuously increased from its 
beginning. The area of percussion flatness corresponded with 
the contour of a greatly distended bladder; beyond its limits the 
percussion note was tympanitic. Fluctuation was very distinct 
within the borders of the dull area. There was no pain or ten- 
derness on pressure in any part of the abdomen. The nurse in- 
sisted that the patient had regularly passed water in sufficient 
quantity, and the attending physician had accepted her statements 
without suspicion of error. There was a strong urinous odor 
about the bed and person, probably attributable to the constant 
dribbling from an over-filled bladder. I drew off two quarts of 
high-colored, turbid, aminoniacal urine. After the evacuation 
of the bladder the abdominal walls were relaxed and flabby. The 
patient continued to sink and died during the succeeding night. 
The title of this case is the expression of my own conviction 
of its nature. I believe the retention of urine had continued, 
from her confinement, and that she died of acute toxemia. 
The enlargement of the abdomen had been observed, but had 
been supposed by the attending physician to be tympanitic dis- 
tention. A careful inspection, percussion, and palpation would 
have made the diagnosis perfectly clear. 
Case IV.-Labor Pains Mistaken for the Pain of Vesical 
Repletion. 
In describing the case of "fecal impaction obstructing labor'* 
(Amer. Journ. Obst., vol. XIX., p. 1,093) which I reported to 
this Society April 2d, 1886, I referred to the mistake of the pa- 
tient in ascribing her distress and pains to inability to pass 
water when in fact she was in labor. I drew off four ounces 
of muddy urine, and, suspecting that I had not emptied the 
bladder, endeavored to ascertain the cause of the failure by vagi- 
nal examination, when I discovered the fecal mass filling the pel- 
vis, and the dilated os with the bag of waters above the symphy- 
sis pubis. The recognition of these conditions absorbed my 
attention, and I did not again employ the catheter or attempt by 
palpation to verify or disprove the statement of the patient that 
she was suffering from retention of urine. I assumed, without 
consideration, that she was mistaken, and proceeded to break up 
and dislodge the fecal mass. When this was accomplished, the 
womb descended into the pelvis and labor progressed speedily to 
completion. About one hour afterwards she passed a very large 
quantity of urine, thus proving that I had failed to empty the 
bladder. This failure was due to the upward and forward dis- 
placement of that viscus and the impingement of the gravid 
uterus, which had been lifted out of the pelvis by the very large 
fecal mass which occupied it. 8 
Busey : Some Rare Clinical 
Her satisfactory recovery does not exclude the possibility of 
danger from vesical distention during labor. After having 
freed the rectum of the fecal accumulation, and the womb had 
descended into the pelvis, the condition of the bladder should 
have been ascertained either by catheterization or abdominal 
palpation. I recall your attention to this case because of the 
novel relation of the fecal mass in the rectum to the displaced 
parturient womb, and to the elevated and distended bladder, by 
which micturition was impeded and labor obstructed. 
The following case presents vesical repletion in an equally 
novel but entirely different aspect. 
Case V.-Cystocolpocele1 Complicating Pregnancy. 
During the early morning of November 24th, 1886, I received 
a note from a gentleman informing me that his wife was in 
labor, and requesting my immediate attendance. I found the 
lady, who was expecting to be confined the latter part of Decem- 
ber, in great suffering, the pains seeming to be continuous with 
quickly recurring exacerbations. She insisted that they were 
labor pains. Proceeding to make a vaginal examination, the 
finger passed the ostium vaginae and with some force entered a 
tense, resilient pouch, apparently lined with a smooth, moist, 
mucous surface, the walls of which could be displaced by the 
movements of the finger to a limited extent laterally, upwards, 
and backwards (the patient lying upon her back), but always 
closing around the finger. I could not find the os, cervix, nor a 
presenting part; nor could I feel a cicatrix, a line of adhesion, or 
a point of induration. My suspicion was that the vagina had 
been obliterated by inflammatory adhesions. It was not an am- 
niotic sac because of its uniform tenseness, the absence of hemi- 
spherical or elongated shape, and the impossibility of defining its 
contour by forcing the finger between it and the vaginal walls. 
December 21st, 1886. 
'"Mv Dear Doctor:-The term cystocele vaginalis has been in use 
thirty or forty years, but it is objectionable as bringing a Greek and Latin 
term together. Cystocele is, of course, Greek -nvOris the bladder, and 
nyX?], a tumor; but vaginalis is simply Latin. Nevertheless, it must be 
admitted that cystocele is a Latinized form, and so the offence is pal- 
liated. I think it would be better to substitute for vaginalis the ac- 
cepted Greek equivalent, noXnos, which is commonly employed to 
signify the genital passage in the female. The term might be cystocol- 
pocele or colpocystocele, the latter being more euphonious, but the first 
being more correct pathologically. 
It is very common to preserve the kappa in words compounded with 
ncXitoS, as kolporrhaphy, but I think if the Latinized form of c is used 
for and uyXy it would be inconistent to spell the new comer 
with a K. Very truly yours, Robert Fletcher." Observations in Obstetric Practice. 
9 
After a careful and prolonged exploration, the patient all the 
time asserting that I was causing her increased pain, I desisted 
completely baffled. I knew that she had given birth to a male 
child two years before, and believed that she was now far ad- 
vanced in her second pregnancy. She had always enjoyed good 
health, and neither she nor her husband had ever called my at- 
tention to any pelvic trouble. To gain time for reflection I 
walked the floor, talked with the nurse, and made many irrelevant 
inquiries of the patient. During this time I elicited the informa- 
tion that she had, during the previous day, three loose move- 
ments from her bowels, but had not passed water since the pre- 
vious early afternoon, and I called to mind the methods of 
exploration by the rectum and abdomino-vaginal palpation. Thus 
reassured, I resumed the examination by the introduction of the 
index and middle fingers. The blind pouch, formed by the 
pressure of the fingers against the cyst, remained persistent and 
inexplicable. Then turning the palmar surfaces of the examin- 
ing fingers towards the bladder, and gently tapping with the un- 
employed hand the abdomen above the pubis, within the area of 
vesical distention, I felt distinctly the wave of fluctuation 
against the fingers in the blind pouch, and the thought flashed 
through my mind that I was dealing with a distended bladder, 
prolapsed into and filling the pelvic cavity, obliterating the 
vagina and interposing a column of fluid within its tense walls, 
between the cervix uteri and ostium vaginae. I immediately di- 
rected the nurse to assist the patient to the commode, and then 
retired to the adjoining room to await the result. Upon my re- 
turn, the nurse informed me that the patient had passed a very 
large quantity of urine, which had been emptied into the closet. 
The pain had ceased and the blind pouch had disappeared. The 
os and cervix could easily be reached. Labor had not begun. I 
advised the patient to go to sleep and forget the suffering of the 
four previous hours, and I reclined for the coming hour in 
peaceful relaxation upon a comfortable lounge. 
This is to me an unique observation. Prolapse of the bladder 
during labor has been quite frequently witnessed. Such a 
complication may be caused by a pre-existing cystocele, pre- 
vious protracted and difficult labors, inflammatory adhesions, 
habitual retention of urine, pressure of the head during the 
early period of labor upon the fundus or middle of the bladder 
when it is partially filled with urine, and constriction of the 
urethra from unusual elongation. Such descent of the bladder 
has been mistaken for a hydrocephalic head, a persistent amni- 
otic sac, and an ovarian cyst; and in several instances it has 
either been incised or punctured, thus establishing a vesico- 
vaginal fistula. 10 
Busey : Some Rare Clinical 
It thus appears that in its diagnostic aspects I was dealing 
with a very grave complication. 1 supposed the patient was 
in labor, and if I had concluded the vesical prolapse to have 
been either of the conditions for which it has been mistaken 
I might have committed a very grave mistake and seriously in- 
jured the patient. 
The case here reported differs from the cases of cystocolpo- 
cele complicating labor, in that it occurred a month previous 
to the labor and did not exhibit the usual subjective symptoms 
of that condition. It was characterized by pains not unlike 
labor pains and therefore the more deceptive, and by absence 
of the usual sensation of fulness and dragging, and constant 
painful desire with inability to pass water; tenesmus and 
dysuria were not only absent, but there was not even an in- 
clination to urinate; und the bladder was evacuated with facil- 
ity and ease when the patient was assisted to the commode. 
The negative symptoms were calculated to entice one into the 
errors that have been committed in somewhat similar cases. 
The history of retention of urine, with tenesmus and dys- 
uria, an abdominal tumor in the region of the bladder, and 
the detection of a fluctuating tumor in the vagina painful to 
pressure, and that can be evacuated by the urethra, constitute 
the essential signs of a correct diagnosis. With a knowledge 
of the possibility of such a displacement of the bladderan d 
method of diagnosis no mistake would be excusable. It may 
happen, however, that an accumulation may take place without 
any vesical intumescence above the pubis. In that event, the 
discovery of a soft, fluctuating, and elastic tumor in the cavity 
of the pelvis, and its evacuation by the urethra, must be relied 
upon for a diagnosis. The condition of the bladder must be 
definitely ascertained. 
Case VI.-Puncture into the Pelvis of a Fetus with a 
Blunt Hook. 
Madam X. was taken in labor June 20th, 1886. She had been 
in ill health for several years and was greatly distressed by the 
accidental death of her elder son. The labor progressed slowly, 
due to her feeble condition, constant apprehension of danger, the 
absence of efficient uterine contraction, and to a breech present- 
ation. In consequence of the delay and supervening exhaustion, I 
determined to resort to artificial delivery under anesthesia, and 
invited Dr. Charles E. Hagner to assist me. 
The breech presented, with extremities reflected on the trunks Observations in Obstetric Practice. 
11 
in right dorso-anterior position. After a futile attempt by traction 
with the finger over the fold of the right thigh, we decided to make 
an effort with the blunt hook. I passed the instrument from 
within out, with point towards the pelvis, over the fold of the 
right or pubic thigh and felt the end on the outer pelvic side. 
At my request, Dr. H. examined the adjustment of tha 
instrument and, with the statement that it was all right, 
surrendered the handle to me. After continuing the traction 
for a while, only during the feeble pains, I felt a sudden jerk as 
if something had given way and heard an indistinct thud. Sup- 
posing I had fractured the thigh I reversed the hook and resumed 
the effort of traction, with a finger against the point between the 
thighs. Failing in these efforts, I brought down the legs and speed- 
ily completed the delivery. The child was born asphyxiated, but 
was resuscitated after considerable effort. The injury inflicted by 
the blunt hook consisted of a puncture through the abdominal 
wall above the ramus of the pubis, midway between the symphysis 
and inferior spinous process of the right ilium, penetrating the 
pelvis to the depth of three-fourths of an inch. The edges of 
the transverse slit through the integument were brought together 
by a suture and the wound was dressed antiseptically with a 
pledget of absorbent cotton dusted with iodoform. On the third 
day some pus oozed from the wound. The suture was cut out, 
the wound cleansed and dressed with dry absorbent cotton. The 
next day Dr. J. Ford Thompson saw the child and advised dress- 
ing daily with a narrow strip of iodoform gauze gently inserted 
into the wound and covered with a pledget of absorbent cotton. 
This treatment was followed with great care for two weeks with- 
out any apparent improvement. I then concluded that the 
method of dressing, which necessitated the frequent extension of 
the thigh, prevented reparation by gaping the wound, and sub- 
stituted for it daily cleansing of the surface and a thin layer of 
dry absorbent cotton, with direction to the nurse to avoid any 
manipulation which might extend the thigh and open the wound. 
At the expiration of another week the wound was entirely healed, 
leaving only a linear cicatrix. 
When discovered I regarded the injury as fatal and so informed 
the father who replied, if that was so I ought to discontinue my 
efforts at resuscitation which I declined. From its birth to the 
completion of the cure the child never'exhibited the slightest 
symptom or, in fact, any evidence of the reception of such an in- 
jury. The apprehension of injury to the bladder or rectum was 
dispelled by the absence, at the expiration of twenty-four hours, 
of any sign of damage to either of these organs. 
This accident was the result of over-caution on my part. The 
displacement of the instrument must have occurred daring the 
transfer from Dr. H. to me. I should either not have extended 
to my colleague the courtesy of an examination or, having done 12 
Busey: Some Rare Clinical 
so, should have requested him to proceed with the efforts at 
traction or, having resumed control of the instrument, should 
have re-examined the adjustment before proceeding. 
This case was also complicated with adhesion of the placenta, 
which was delivered by Dr. II. The hemorrhage was controlled 
by hot-water intrauterine injections. Mother made a good 
recovery. 
Case VII.-Four Drachms of the Fluid Extract of Cascara 
given for an equal quantity of the Fluid. Extract of Ergot. 
At 11 p.m. Feb., 1882, I was invited by the late Dr. Beale to 
assist him in a case of protracted and difficult labor. The patient, 
a short, dumpy primipara, had been in active labor about twelve 
hours. The head presented in L. 0. A. position and seemed to 
be arrested at the brim in the biparietal diameter. With the 
forceps the head was drawn into the cavity of the pelvis, but 
■could not be delivered through the inferior outlet. After several 
ineffectual efforts with the forceps, I lifted the head from the 
pelvis, seized the feet, and attempted to accomplish delivery by 
version. I could not, however, force the liead through the pelvic 
outlet by traction on the lower extremities, combined with supra- 
pubic pressure and a finger in the mouth of the child. Forceps 
to the after-coming head were equally futile. I then passed the 
blunt hooked end of one blade of Hodge's forceps into the mouth 
of the child, and thus with traction on the extremities and the 
blade of the forceps completed delivery. The child was as- 
phyxiated and could not be resuscitated. The expulsion of the 
placenta was followed by a profuse hemorrhage. A second drachm, 
the first having been given immediately after the delivery of the 
placenta, of the fluid supposed to be ergot, was promptly ad- 
ministered by Dr. Beale, and I grasped and firmly held the uterus. 
As soon as it could be obtained, a hot-water intrauterine injection 
was employed. The contraction which followed soon remitted 
and the hemorrhage returned. A third and a fourth drachm of 
the fluid extract was given, and the hot-water injections were 
repeated a second and a third time, but the temporary con- 
tractions of the womb were speedily succeeded by complete relax- 
ation and recurrence of the hemorrhage. An hour or more 
elapsed during these ineffectual efforts to secure persistent uterine 
contraction when, worn out by the continuous stooping posture, 
with one hand grasping the womb and the other holding the 
nozzle of the syringe, 1 insisted that Dr. Beale had made a 
mistake or else the ergot was worthless. He replied that he had 
purchased it himself and that it was Squibb's preparation. Not 
satisfied, a messenger was dispatched to a druggist for Squibb's 
fluid extract of ergot. This was obtained and administered and 
soon permanent contraction was secured. The patient was made 
as comfortable as possible, and the necessary instructions were 
given to the nurse. When about to leave the house, Dr. Beale Observations in Obstetric Practice. 
13 
discovered the bottle of ergot he had purchased in his overcoat 
pocket. He had given four drachms of the fluid extract of cas- 
cara within the period of one and a half hours. After a brief con- 
ference, it was decided that he should remain in the house during 
the remainder of the night and await developments. The con- 
valescence of the patient was not disturbed by any of the ordinary 
discomforts of the puerperal period. Her bowels moved naturally 
on the third day and her recovery was speedy and complete. 
This patient had a prolonged and difficult labor ; was subjected 
to several ineffectual efforts at delivery with the forceps ; then 
the head was lifted from the pelvis; the child was turned; de- 
livery of the after-coming head by traction on the extremities 
combined with supra-pubic pressure failed, as did also the effort 
with the forceps to the after-coming head combined with trac- 
tion by the extremities. Finally, delivery was accomplished by 
traction with the blunt hooked end of the blade of the forceps 
in the mouth of the child combined with supra-pubic pressure. 
Then followed a profuse and persistent hemorrhage, and the in- 
effectual efforts to secure permanent contraction of the uterus, 
during which four drachms of the fluid extract of cascara were 
administered; nevertheless, her convalescence was uninter- 
rupted and recovery complete. 
The usual rapid and satisfactory convalescence of lying-in 
women, upon whom the employment of hot-water intrauterine 
irrigation has been provoked by some grave complication of 
labor, has impressed me with the conviction that thorough 
washing out of the cavity of the womb after labor is the most 
effective preventive of certain puerperal disorders. I would 
not advocate it as a routine practice ; nevertheless, I am so fully 
convinced of its value that I would advise it in every case of 
manual or instrumental delivery. 
Traction with the blunt hook in the child's mouth is a novel 
procedure. I examined the condition of the mouth of the child 
very carefully, and could not detect any injury. It might have 
been otherwise in a living child. At the time the instrument 
was employed, I believed the child was dead, for considerable 
time had been expended in the previous futile efforts. 
Case VIII.-A drachm of MonseVs Solution given instead of 
an equal quantity of the Fluid Extract of Ergot. 
In November last, Madam X. miscarried during the sixth month 
of her third pregnancy. Directions were given to the nurse to ad- 
minister a drachm of the fluid extract of ergot at 9 p.m., if neces- 14 
Busey : Observations in Obstetric Practice. 
ary. Very soon after that hour I was hastily summoned by the 
nformation that the nurse had given a drachm of Monseks solu- 
>tion. The patient recognized the mistake immediately, and the 
nurse promptly administered a large potation of water. I found 
the patient perfectly calm, but complaining of a sense of weight 
and scalding in the stomach, with frequent very acid eructations, 
and a sharp taste of vinegar. Her pulse, temperature, and general 
condition were entirely satisfactory. I ordered hourly doses of a 
half ounce each of a solution of the bicarbonate of soda (prepared 
by dissolving one drachm in an ordinary goblet of water) until the 
acid eructation ceased; gum arabic water ad libitum; and, in the 
event of any disturbace of the bowels, one or more drachm doses 
of paregoric. Several hours after the solution of iron had been 
taken the patient vomited freely, and in quick succession had two 
copious liquid stools. The catharsis was checked by paregoric. 
No further trouble occurred. At my visit the next day the con- 
dition of the patient was in every way satisfactory. Her con- 
valescence was uninterrupted.