12

at three A.M., on the day before Dr. Davis was called, whichwas at half-past ten A.M. Now, had this woman been seen bya practitioner eight or ten hours after the commencement oflabour who was acquainted with the common means used forthe removal of obstructions in such cases, her delivery, fromwhat is stated of the case, would in all probability have beeneffected naturally and safely in about fourteen or fifteenhours. Even when Dr. Davis was called, it does not appearthat he used any means either to remove the obstructions or to increase the expulsive efforts of the uterus, but at onceproceeded to bring down one of the legs, which he accom-plished. To any one attempting to bring down the leg of achild similarly circumstanced as this one was, the difficultywill be found to be very considerable. I once made an effortto do this, but soon desisted from my mad attempt-usedmeans for the removal of the causes of delay, when the childwas expelled in a short time afterwards by the natural efforts.The third case was a woman twenty-five years of age, of

good health and conformation, and at her full period.Dr. Davis was called to this case at six P.M., and labour painshad commenced at half past eleven of the previous even-ing. The Doctor found the orifice of the uterus one-thirdshort of its full dilatation, parts cool, the pelvis of averagedimensions. At this distant period from the commencementof labour, the doctor left his patient without a single prescrip-tion for her relief, only hoping everything would do wellwithout constitutional treatment. It has been repeatedlyshown by me that no woman in labour, of the descriptionunder consideration, will continue many hours undelivered,unless from obstructing causes which are remediable, and theremedies have also been clearly stated, as well as the mode ofusing them. Yet we see that this poor woman was left with-out an attempt to relieve or shorten her woful, ineffectual,suffering. At midnight, when Dr. Davis again called, hefound the pains frequent and strong, the head still at thebrim of the pelvis, pulse firm and full. He again left thepatient, but now he advised bleeding under certain circum-stances. At six A.M. he was again summoned, the patient hadbeen bled to sixteen ounces; the head was now immovable inthe pelvic brim. The doctor called again at one P.M., whenconsiderable protrusion of the scalp had taken place, still, hesays, the bony part of the head had not descended lower thanat his previous visit. Eighteen ounces or more blood weretaken.Up to this stage of the proceedings, bleeding was the only

means of relief used, and yet the reader is not put in possessionof those distinctive symptoms necessary to be known in orderto enable him to judge even of the propriety or impropriety ofthe course pursued. However, it is quite certain, that insome protracted cases of a somewhat similar description,bleeding is not the remedy required; and in other labours,although bleeding is absolutely necessary, yet it will provequite inadequate of itself to remove the obstructions to theadvancement of the child. It is stated, that about half-pasttwo P.M., on account of peculiar symptoms, the labour wasterminated by the operation of craniotomy. Such a revoltingtermination to a case apparently so simple and remediable inits early stages, ought truly to thrill the sensible parts of man, Iand rouse his mental energies to arrest a procedure so lethargicand apparently so uncalled for.The remaining cases are of so similar a description, are so

similarly treated, and consequently their oneness of resultwith the preceding ones, render it unnecessary to occupy timeand space in repeating what has already been said.

It is stated that one of the children was large, and that thesacro-pubic diameter of the pelvic brim did not exceed threeand a half inches. Dr. Burns, in his " Dlidwifery," seventhedition, page 431, states that it is the opinion of high authority,and with which he agrees, that if the dimensions of the pelviswere certainly under three inches, a living child could not beborn; yet, in the next page, he refers to a case by Baude-locque, when a living child, by the use of the forceps, wasdelivered, when the pelvis, in its conjugate diameter, did notmeasure more than three inches. Now were the obstructingcauses to delivery removed early with a pelvis of the dimen-sions of three aud a half inches, it is my belief, that, by theaction of the uterus alone, a living child would be born.Although I have selected the foregoing cases as exhibitingthe practice pursued by two eminent metropolitan obstetri-cians, and although their practice, according to my experience,is fraught with the evils of severe, unnecessary, protractedsuffering, great danger, both to the mother and the child, andnot unfrequently, as we have seen in various instances, withthe lamentable loss of life; yet from all the research whichI have made for several years up to the present time, it seems

that the above crude and irrational mode of procedure stillcontinues to prevail over the whole civilized world.Just after the above observations were finished, THE LANCET

for March 28th, 1846, was handed to me, and in it I observedfurther contributions to midwifery, by Dr. Hall Davis. Ishall only briefly notice the first case mentioned.The patient was aged forty-two, of stout habit and firm

fibre, and in labour of her first child; she had enjoyed goodhealth. Dr. Davis was sent for on Dec. 18th, 1845, at four P.M.True pains had first set in at 3 A.M. on the previous day,(Wednesday.) At two P.M. of the same day, the orifice of theuterus had become fully obliterated. "The pains entirely lefther at one P.M., (Thursday,) three hours before my visit, butnot suddenly, having latterly gradually lessened in force andfrequency. I found (says Dr. Davis) the expression of coun-tenance good, the face congested from the effects of previousefforts, skin moist and hot, pulse 100 and soft, no heat ofvagina, a puffy protuberance of scalp, the head impacted, thebones felt slightly overlapping," &c. Under these circum.stances, and after the evacuation of the bladder, delivery bythe crotchet was effected. Had I been present when Dr.Davis proposed destroying the child by the crotchet, myquestion to him would have been, "For what reason willyou take the life of the poor hapless babe ? Your enu-

merated symptoms as regards the woman are all favour-able ; and it is only the impacted condition of the child’shead which seems to actuate you to deprive it of life 1"The acknowledged congested state of the woman’s faceshowed clearly the nature of her case ; her "stout habit andfirm fibre," subjected to long, unnecessary, severe pains, pro-duced not only congestion and torpor of circulation in theface, but in every part of her body; and this condition of themother occasioned the same state in the child-namely, agorging with blood, and an increase of size of its whole body,and especially its head, forming the principal cause of im-paction. A labour like the present, left without suitabletreatment, is the principal cause of impaction, and a fertilesource of excuse for destroying infantine life. The extractionof a sufficient quantity of blood in this case would, at thesame instant, have lessened the congested state and bulk of

! the child, as well as the congested and swollen parts of themother, which, along with the other usual and necessary

! means, would have given more room for the passage of thechild, while the very common rigidity of the perinasum met

with in such cases would have been relaxed, so as to haveL allowed the child to pass alive by the natural efforts of themother.

Paisley, May, 1846. _________________

ON LIGATURE OF VEINS.

By WALTER YATES, Esq., Surgeon, Nottingham.I HAD occasion a little while ago to ligature a vein-the

particulars of the case are these:Ann C-, aged thirty-three, a very stout person, was

coming carelessly down stairs with a chamber-pot in herhand, and happening to tread on her dress, she fell all her length to the bottom; the chamber utensil was broken into avery many fragments, from some of which she sustained asevere injury of the arm. She immediately got up, and foundher dress to be almost completely besprinkled with blood; astream of the same fluid was also flowing down her arm.Assistance happening most luckily to be at hand, her armwas bound tightly up with six or seven handkerchiefs. Sheconsiders the loss of blood in this short time to have been not

less than two quarts. (?) She feels faint, is very pale, anddreadfully alarmed lest she shall lose her arm. Having athand everything necessary for the purpose of effectuallysecuring any vessel or vessels that might be wounded, Iremoved the handkerchiefs, immediately upon which a terrificgush of blood followed, which I was unable to arrest by thefirmest pressure of a bandage, being obliged to have recourseto the tourniquet. Having thus temporarily prevented thehaemorrhage, I then searched the wound-which was deep,and was directed horizontally across the front of the elbow-joint, the incision being about three inches in length. Idiscovered a large vessel, which I at first took to be thehumeral artery, but which afterwards turned out to be thecommon basilic vein. The incision proceeding as it didthrough three-fourths of its calibre only, allowed the vesselto gape very considerably, hence the tremendous escape ofblood. Without further loss of time I then passed a tena-culum through the vein, above the place where it was injured,and a second one through it below the same place, and directlydivided the remaining portion of the tube, disconnecting very

13

slightly, and with the point of the scalpel, the vein from itscellular investment both upwards and downwards, so as toadmit of a ligature being placed around its two extremitieswithout any stretching of its coats, or of the nervous filamentsconnected with the coats. This operation occasioned veryacute pain, which abated, however, in the space of a fewminutes. All danger from immediate haemorrhage beingnow at an end, I leisurely, but carefully, examined the wound,in order to ascertain the exact nature of the injury. Therebeing no pulsation of either of the two ligatured ends of thevessel, I placed my finger in the wound, and felt distinctlythe brachial artery pulsating directly under the finger, andimmediatelv under the divided vein. It was this want ofpulsation which at once led me to suppose that the humeralartery had escaped injury, and that the vessel injured was alarge vein, that vein being, of course, the common basilic.The edges of the wound were brought together by a singlesuture, and by straps of adhesive plaster, a dossil of warmwetted lint being placed over all. The fore-arm, placed atright angles with the humerus, was then lightly bandagedwith a roller thoroughly soaked in warm water, the wholelimb being supported and kept in its position by a longpasteboard splint, nicely adapted to the occasion. She was

put to bed, and kept on low diet; directions were given thatthe whole arm should be kept continually moist with warmwater. She was placed under the action of a saline antimo-nial mixture, having first had a draught containing fortyminims of the tincture of opium.One ligature came away on the ninth day, and the second

on the eleventh day ; and the entire wound healed kindly inthe short space of a fortnight.Remarks.-During the progress of this case, not one single

untoward symptom appeared-a circumstance that to manymay perhaps seem to be remarkable, since the application ofa ligature to so large a vein as the common basilic at the bendof the elbow is for the most part looked upon as an actfraught with danger; the result, as is supposed, of the greattendency there is in veins when ligatured to become inflamed,and to produce symptoms of the most threatening kind-inshort, those of phlebitis. It seems to me, however, that thedanger is exaggerated, because in several other instanceswhich I have seen, as well as in this, where veins of con-siderable size and importance have been ruptured in conse-quence of accidental injury, either in the course of surgicaloperations or by ordinary accident no dangerous symptomshave come on. It should be known, however, that in all thesuccessful cases of this kind falling under my notice, theVessel in each instance has been completely divided before theapplication of the ligature. I believe that the experience ofmen engaged in practice where these cases chiefly occur willbear me out in this statement. I am of opinion, also, that itwill confirm another assertion-viz., that ligature of varicoseveins by means of pins and silk, or other material, is liable toinduce dangerous symptoms, the result of some local or

general phlebitic action. The reason of this is not so appa-rent as is the actual fact: in the few cases of varicose veincoming under my observation, where this plan of treatmenthas been adopted, local phlebitic action, at least, has been theconsequence.

The only conclusion, then, that can reasonably be drawnfrom these facts is, that in those cases of complete division ofa vein the vessel may be ligatured, not with impunity to besure, but with as much, and perhaps more, chance of successthan ligature of an artery under like conditions.

In both cases a diminution of the calibre and a retractionwithin the cellular investment or sheath of the vein follow ;but in the other kind of case-ligature without division-neither the one nor the other act can take place; hence areason of the success of the one operation, and of the failureand danger of the other.Nottingham, May, 1846.

EMPLOYMENT OF ELECTRO-MAGNETISM INPARALYSIS.

By WILLIAM PRETTY, Esq., M.R.C.S.E., London.THE communication of Dr. Golding Bird to THE LANCET ofJune 13th, upon the employment of electro-magnetic currentsin the treatment of paralysis, has been read by me with feel-ings of much interest and satisfaction. I gladly give mytestimony in conformation of the beneficial results of electro-magnetism, more especially in the case of the lady with whommyname is mentioned. My chief object just now is to bringto the remembrance of the doctor, or at least to detail to

the readers of THE LANCET, a prominent and important featurein that case-viz., an almost incessantly painful condition ofthe limb (the left arm) which accompanied the paralysis.All attempts at motion, whether made voluntarily, or by thea.ssistance of others, increased the suffering. This exaltedstate of sensibility, a morbid condition of the sentient nerves,rendered it for a moment doubtful if the remedy could beborne by the patient. Very weak currents were first em-ployed, and for a short time only. These were graduallyincreased in strength, and also in duration of employment,and, in a short time, something like an equilibrium of thenervous energy (if I may be allowed the term) was establishedbetween the sentient and motor nerves ; the limb graduallyregained its power, and the pain as gradually diminished, tillperfect recovery ensued.

I can add another case which came under my care afew years since. _ A delicate single lady, had been oftenattacked with ph risy in the subacute form during the winterand spring month:, of several successive years, and, moreover,had to bear up aga. st much mental disquietude, and, for thecure of her bodily co nplaint, usually required one, and some-times two small bleco. gs, in addition to other means. She be-came much reduced in. =°ength, and enervated ; she was twiceaffected with numbness of the fingers; could not feel distinctlya pin placed between her finger and thumb; great weaknessin her arms, rendered them, comparatively speaking, useless,and accompanied with much pain. Each attack she recoveredfrom, under the employment of galvanism, but I am some-what ashamed to say, not administered under my own imme-diate direction. The profession must feel obliged to Dr.Golding Bird for the information he has given relative to thecheapness of the apparatus, and the utility of its applicationin several forms of paralysis. I will revert to the presenceof severe pain in these cases, in the absence of all attempts atmotion, as going far to distinguish them from the ordinaryattacks of paralysis, the result of disease in the nervouscentres. The absence or presence of pain, however, will notforbid the employment of electro-magnetic currents in thecases of palsy dependent upon a disordered condition of thenervous system, induced by exhaustion and enervation. Iwill only further observe, as an inducement for medical mento supply themselves with an electro-magnetic apparatus, thatits most decidedly beneficial agency has been reported in somecases of midwifery where a more active contraction of theuterus was deemed all but necessary for the preservation ofthe patient’s life.

, June, 1846. __

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.JUNE 23.—DR. CHAMBERS IN THE CHAIR.

ON THE INTERNAL STRUCTURE OF THE HUMAN KIDNEY, AND ALLTHE CHANGES WHICH ITS SEVERAL COMPOUND PARTS UNDERGO

IN "BRIGHT’S DISEASE." By JOSEPH TOYNBEE, Esq., SeniorSurgeon to St. George’s and St. James’ General Dispensary.

Tars paper contains the result of the author’s.researches intothe structure and into the nature of Bright’s disease of thekidney, since 1838, during between two and three years hewas engaged in pursuing investigations in conjunction withDr. Bright, but as a variety of circumstances prevented thepublication of a work, the result of their joint labours, theauthor details but the principal facts which have been elicited.Feeling how much is due to the assistance and cooperation ofDr. Bright, at whose expence the greater part of the extendedseries of drawings elucidating the paper were made, the authorstates, that it is not without some degree of diffidence that heprefixes his name to the communication.

In the division of the paper on the " Anatomy of the Kid-ney," the author successively describes minutely the result ofthis examination into the parenchyma, the tubuli uriniferi,the arteries, veins, and nerves of the organ, in each of whichdepartments views are advanced, varying considerably fromthose of modern and former anatomists.

In the pathological observations, the author adheres to theopinion advanced by Dr. Bright, and lately so ably advocatedby Dr. G. Robinson, that a congested condition of the organprecedes the important changes which subsequently occur inthe three stages of disease. The author then proceeds todemonstrate that the arteries first become diseased and thatthe tubuli veins and parenchyma of the organ follow.The three stages of the disease are illustrated by an elaborate

series of drawings, in which the various successive changes areindicated, and the paper concludes by pointing to the variousplans which should be carried out for the prevention of thisdisease at present so formidable in all classes of society. -