CIHM Microfiche Series (i\/lonographs) ICIVIH Collection de microfiches (monographles) Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques QO/I r Tl C( sriques Technical and Bibliographic Notes / Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. □ n n n Coloured covers/ Couverture de couleur Covers damaged/ Couverture endommagee Covers restored and/or laminated/ Couverture restcuree et/ou pelliculee Cover title missing/ Le titre de couverture manque Coloured maps/ Cartes geographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relie avec d'ajtres documents Tight binding may cause shadows or distortion along interior margin/ La reliure serree peut causer de I 'ombre ou de la distorsion le long de la marge interieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajoutees lors d'une restauration apparaissent dans le texte, mais, lorsque ce(a etait possible, ces pages n'ont pas ete f >lmees. L'lnsiitut a microfilme le meilleur exemplaire qu'il lui a ete possible de se procurer. Les details de cet exemplaire qui sont peut-£tre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite. ou qui peuvent exiger une modification dans la methode normale de f ilmage sont indiques ci-dessous. □ Coloured pages/ Pages de couleur □ Pages damaged/ Pages endommagees □ Pages restored and/or laminated/ Pages restaurees et/ou pelliculees Pages discoloured, stained or foxed/ Pages decolorees, tachetees ou piquees □ Pages detached/ Pages detachees 0Showth rough/ Transparence □ Quality of print varies/ Qualite inegale de I'i impression □ Com Pagin n nuous pagination/ Pagination continue Includes index(es)/ Comprend un (des) index Title on header taken from;/ Le titre de I'en-t^te provient: issue/ la livraison ^ Additional comments:/ Coinmentaires supplementaires: □ Title page of iss Page de titre de □ Caption of issue/ Titre de depart de la livraison n Pagination is as follows: [l]-8, 1-6, 15-22 p. Masthead/ Generique (periodiques) de la livraison This item is filmed at ths reduction ratio checked below/ Ce document est filme au taux de reduction indique ci-dessous. 10X 14X 18X 22X 26X 30X J 12X 16X 20X 24X 28 X 32 X The copy filmed here has been reproduced thanks to the generosity of: National Library of Canada L'exemplaire film6 fut reproduit grdce d la g6n6rosit6 de: Bibliothdque nationale du Canada The images appearing here are the best quality possible considering the condition and legibility cf the original copy and in keeping with the filminq contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page vith a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol —►(meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les images suivantes ont 6t6 reproduites avec le plus grand soin, compte tenu de la condition et de la nettetd de l'exemplaire filmd, et en conformity avec les conditions du contrat de filmage. Les exemplaires originaux dont la couverture en papier est imprim6e sont film6s en commenpant par le premier plat et en terminant soit par ia dernidre page qui comporte une empreinte d'impression ou d'illustration, soit par le second plat, selon le cas. Tous les autres exemplaires originaux sont film6s en commenpant par la premidre page qui comporte une empreinte d'impression ou d'illustration et en terminant par la dernidre page qui comporte une telle empreinte. Un des symboles suivants apparaitra sur la dernidre image de cheque microfiche, selon le cas: le symbole — ► signifie "A SUIVRE", le symbole V signifie "FIN ". Les cartes, planches, tableaux, etc., peuvent Stre film^s d des taux de reduction diffdrents. Lorsque le document est trop grand pour Stre reproduit en un seul clich6, il est filmd d partir de Tangle sup6rieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images n6cessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 MICROCOPY RESOLUTION TEST CHART (ANSI and ISO TEST CHART No. 2) 1.0 1.25 12.8 1^ m mil 2.2 Ii 1^ '""= If 1^ 2.0 i& II — i-i=S ■- u K.'..u 1.8 1.4 L6 ^ APPLIED IIVMGE 1653 Ec • Main Slreel Rochester, New Ycrk 14609 USA (716) 482 -0300- Phone (7ie) 288 - 018" - i^n. ( If IV.: I /^. I / K STA.TISTTCS OF THE UNIVERSITY I.YJNa-IN HOSPITAL, 7 I^rONTRKAL. AKCIIIJ'.ALI) HALL, M.I)., K., L.U.C.S.E. iTivsiriAN-ArcoL-ciEn; TO Tin; sAMi;; nioi k.<,-,o.: of miduifeuv /m, tii:: m.sea^f. "!■ WOMK.V ANN CIIILDHD.V, rXIVEnSITV ni- .vi;iI,L fOI.I.KdK; PIIESIDKVT nr TIIK COM-Kni: OF J'I1V.= ICIA.\S AM) I^C;ilr,EOX.S W I.OWKIt CAXAI.A : noNoiiAitv FEr.r.on- ok the onsTETRiCAr, soriRiv of i.oxdov : iO\<ri.TIN'; I'UVSICIAN .MO.VmKAL liEXKRAr. rio=riTAI. : ETC, ETC , ETC. (From ili( Briliah Amrnani Jiwnidl.) Jttoutic;il : PTITXTRD V>Y .TOITX LOYELL, ST. XTCTTOLAS STKKKT. 1860. m r^^?fe^ ** <* i4(<fr ;i ART, YIU.— Statistics of the University Lying-in Hospital, Montreal. By Archibald Hall, M.D., PhyHieian Accouclieur to the same ; Professor of Midwifery, &c. University of McGill College ; President of the College of Physicians and Surgeons of Lower Canada ; Honorary Fellow of the Ob- stetrical Society of London, &c., &c. The importance of Statistics is now acknowledged in the different Medical Sciences, and they have been happily brought to bear upon the settlement of many disputed points. But in none is their influence of such moment as in Midwifery, as they have established with a degree of precision which cannot bo questioned, many highly important principles, if they can be so called, which lie at the foundation of its science and practice, and it is here, far more than in Medicine or Surgery, that their great influence must be chiefly confessed. Nature always operates by laws which we are enabled to appreciate only by this means, while at the same time, we become enabled by the same means to estimate the slightest deviation from them. The greater the amount of statistical informa- tion, therefore, which can be brought to bear upon certain given points, the more surely will these become established as principles or laws, and it is with the view of contributing to the mass of information which we already possess OB many interesting subjects connected with midwifery, that I throw the follow- ing results into the common fund ; but, before entering directly upon the more immediate subject of this paper, it may be well to premise a few remarks on the history of the Institution, whose operation has furnished them, by way of shew- ing its advantages as a means of studying obstetrics practically. The first Lying in-Hospital established in Montreal, was founded by the lat« Dr. MacNider, in the year 1841, and went into very successful operation. In consequence, however, of a refusal to allow the students of the University access to it on account of the practical advantages which it was thought capable of affording, (Dr. MacNider at that time being a lecturer on midwifery in tho Montreal School of Medicine,) it was deemed proper about a couple of years afterwards by the Professors in the University of McGill College, ; found one in couuectiou with the University, and to place its professional control in the hands of the Professor of Midwifery, intimately associating it with the chair. 2 > Tho practical nJvantnfjcs thus accruing to the students nt tho Univerflity by this arran-^oment arc obvious. Shortly after tho decease of Dr. MacNider, an event whieii took phico in tho year 1840, lii.s Hospital was closed and has not since been re-opened. At the present moment there arc two Lying-in-IIospitals in Montreal. One is tlio Ilopital do St. lVlat,'io, a lloman Catholic Institution, admitting Protestants, however. It is under the eeonomic manaf,'ement of the Sisters of St. Pehifrie, and the professional char<j;e of Dr. Trudelle, the present Lecturer on Midwifery in the Montreal School of Medicine. It admits a considerable number of patient - during the year, and the students of that school have, as I have understood, access to it. Tho other is the University Lyin--in-IIospital, which was opened in November, 1843, as well for charitable purposes, as for the instruction of the students in the Faculty of Medicine of JlcOiil C<.lle,i,'e in practical midwifery, an object which it has carried out as successfully as its opportunities permitted. For the first ten years of its existence, the Hospital was under the able superintendence of the late much lamented Dr. MeCulloch, then the Professor of Midwifery in tho University, and since that Kcntlennui's decease by Asiatic Cholera during the last visitation of that epidemic in 1854, it has been under the charge of the present Professor of that branch ; tho other members of the Medical Faculty of the University, liaving always constituted a Board of consulting Physicians. It is supported partly by voluntary subscription, and partly by an annual Legislative grant, increased during tho last two or three years to £75 per annum. Tho amount received from the former source is very limited, but in consequence of strictness in collecting from pay patients and the ex- tremely prudent economic management of its matron and resident midwife, Mrs, Hope, who is thoroughly instructed in midwifery, and has received the license of the College of Physicians and Surgeons, the Hospital has not only a sufficiency to meet its annual expenditure, but has been enabled to li(iuidate a considerable debt, which oppressed it a few years ago. A kind benefactress, the late Mrs. Maria A. Monk, becjueathed to it at her decease in 1853, the generous amount of £2G2 10s., which was immediately invested in Bank stock, and having been increased from time to time as circumstances allowed, the Hospital has now, to its credit, the sum of £300, which is reserved as a fhnd for the erection of a suitable building at a future day. The premises which it now occupies are by no means adapted to the purposes to which they are applied, but no better can at present be obtained. The Ho.spital is, however, conveniently situated, being close to the lecture rooms and the Montreal General Hospital, and of easy access to the students. A minute record is kept of every case. As soon as a patient enters, the fol- lowing particulars are noted in regard to her— the date of admission,— her name, —her age— and the country of her birth ; and, when the accouchement has been completed, the following additional details are recorded,— the kind of labour— the nature of the presenting part— the duration of the labour— the time before the delivery at which the membranes ruptured— the sex of the infant,— its kngthand its weight,— the weight of the Placenta,— the length of the umbilical c«id, the number of days since the last catamenial period— the condition in ^1 '■? .1 . i 8 >. . v:i <•. r * .1 . i which the child wns born, whether living', still, or dond, — whcthor the cnsc in a first, second or tliinl, &c. j,'c,Htiition, and liistly tiio date of her dischiir;.'o from the Hospital, and after a catoj^orical reply to all these ((uestions, any peculiari- ties in the labour are finally detailed under an appropriate headini;. All these particulars are entered by the student in attemlance on the case, immediately after the termination of the aceouelienient, so that in time a truly valuable amount of statistical information will be obtainable. Tlio Hospital lias now been in operation sixteen years, audit is the results which during that time have accu- mulated, which furnish the f;roundwork of this paper.* It appears tiiat duriiif^ this period of time I'.KiH women have been admitted as patients, beinj; an annual averaftc of about 1213, Of these five were cases of Abortion, which reiiuire to be deducted from our calculations. It is necessary to remark that the total number f^iven includes a list of 747 cases of which tt very minute portion only of their details has been preserved, viz. : their admis- sion and coiifiiienicnt. I will only use these in a jreneral way. Every endea- vour has been made to discover where these records are, but without avail. It is exceedingly to be regretted that any portion of them whatever has been lost. The suflBciently large number of 1210, however, yet remain whose details have been preserved in their comparative cntireness. It must be further observed, that it is sometimes impossible to fill up answers to all the (juestions ; and I may exemplify this remark by the well known difiiculty in determining the number of days intervening between the cessation of the catanienia and the commencement of labour, but in all cases in which the results have been obtained from numbers less than the total, the precise number will be stated. I propo.se to enumerate at first general details ; and I will reserve to the con- clusion of the paper, the narrative of such peculiarities in the labours as have been specially noticed in the records. Of the 19G0 women admitted, besides deducting the five cases of abortion already noticed, we have further to add to this latter number, 14, who either left the Hospital before delivery or were expelled for bad conduct. These deductions reduce the total number to 1949. Of the 1949 patients 17 have died, the causes of the deaths having been the fol- lowing : — five from puerperal fever ; six from peritonitie and metritic affections; one from epilepsy complicating the labd':, uid ending in cerebral congestion ; and five from puerperal convulsions. This proportion yields a ratio of mortality in the cases, of 1 to 114.G labours, thus exhibiting a highly favourable ratio. Of this number there arc only 1208 entries in the register, which can be ren- dered tributary to the purposes of this paper, the record containing nothing •In the British American Journal of February, 184Y, the late Dr. McCulloch contri- buted an interesting paper on the statistics of the Hospital based upon 3S4 cases, which had up to that period of time been admitted. Tliese cases which furnished the ground worlc of his deductions are among the 1\1, whose details are now all lost except there- cord of their admission and confinement. I will therefore avail myself of his labours when- ever I fird them suiting my purpose. More lately. Dr. Fenwick, with my permission, has given, in the Medical Chronicle for September, 1857, the particulars of 1009 accouchements. ^> > whatever, of the lalanoo of 747, with few oxcoptionH, except their name, date of entry, conflnc.uent and religion. It appcarn, however, that the 120H ptve birth to 122:} chiLInn, ofwlH.,,, (W7 were hc^M. and f,5C were Ki.Is, and adding tho HtatLstaN of Dr. MeCuiloeh, of the im which he reported, wo have tho follow- inK nunibcrH, 845 boyn and 7;J2 nirls. Tho BKi-Hof i:i01 are ^ivun, and after classification they appear as follow •— from 30 to M .85 from ,'{5 to 40 43 from 40 to 4£i 3 from 45 to 50 1 recorded by Dr. McCiilh.cli in his 1 5 ycurH of n-ic and under, 1 from 15 to 20 2.'{5 from 20 to 25 B8G from 25 to .'tO 347 Tho a^'e of the youiif,'e,st ndmittod ?■ paper. It wa.s 14 year« „ml 7 months. In this case the presentation wa.s a posterior occipito-iliae. The labour lasted seven hours, and tho child weighed MX pound-x. The a^'o of tin, oldest was 47. Ca.mlfle.onuy the hIr/hs.-Ont of tho whole nun.ber of casualties nmonR the b.rth.s, I find that 42 were born dead, and lU children were .till born. Of th, so last the Hlatisties are as follow: of the 34 infants, there were 21 males and 13 temales. Of the males, attempts at resuscitation were successful in 17 eases and unsuccessful in 4. Of the fen.ales, atten.pts at resuscitation were successful in 10 and unsuccessful in 3, exhibiting a total of 27 to 7, or thrccfourths of casca of sti 1-born children, in which the eflorts for resuscitation have been crowned with the most complete success. la all the eases which have occurred since 1854 the application of the stethoscope, and tho evidence furnished by it alone, as to the action of the infant's heart, prompted the perseverance in the efforts for resuscita- tion, which were frcjuently attended with success under the most unpromising circumstances. And on tlii.s point I may remark, tluit experience has served to convince me, that on, 10 account whatever, should the means for rcsu.scitation be disc.mt.nued unt. that instrument, and that Instrument only, furnishes in- conte;Uible proof of the cessation of the action of the heart. With regard to the particular gestation in which the dor-ths and still-births occurred, I g!e.m the followin,^ : of the 42 born dead, 27 were males and 16 were females. the n,ales 20 died in the first accouchement, 4 in the second, and 3 in the third and subseciuent ones. Of the females 9 died in the first accouchement, 2 in the second, and 4 in the tliird and subsequent ones. Of tho still-b.r hs tliere were 21 males and 13 females. Of the males, 12 Btill-births occurred in the first, G in the second, and 3 in the third and subsequent ac- couckments ; and of the females, 9 occurred in the first accouchement, 3 in the second and 1 in the third or subsequent one. These figures strongly corro- borate 1 rof Simpson's views as to the influence of the male offspring in the induction of difhculties. The following general averages are deducible from the foregoing: that the deaths of the infants were to the whole births as 1 to 46.4 ; that the still-births were to the whole births, as 1 to G0.90, and that the recoveries in the still-births were to the deaths in the same as 27 to 7, or nearly as 4 to 1 Duration oflabour.-ln 1094 cases of accouchement, the mean duration of the labour was found to be 7 hears 3" minute.-,. The longest labour lasted ik » •• ^ > 84 hours ; a Inhour of wich duration occurrod twice ; in both cnsoH malcH Were born, in one iiiNtanco liviiif.'. in the other dead. The duration of tiio filiortest labour was 12 minutes. 'I'ho time hero meant in the completion of the two flmt stugoH of the labour or the birth of the child. I lind the comiiarativo duration of the labours as iiillowrt : — Under 1 hour 2t From 1 to 5 hours 291 " 5 to 10 " " 10 to 15 " 3'J4 254 15 to 20 " 82 from 45 to 60 hours 11 1 3 1 2 2 50 to 55 55 to 00 fiO to 05 05 to 70 70 to 75 75 to 80 80 to 85 85 to 90 " 20 to 25 " 78 " 25to;J0 " 29 «« 30 to;{5 " 1) " 35 to 40 " 8 "40 to 45 " 2 In 1192 labours. Titne between the rupture of the membranes and birth of child, — The period of time intcrveiiin;:!; between the rupture of the membranes and the birth of the child is recorded in 740 out uf the 1!H9 labours, and the mean time wa.s ascer- tained to be 2 hours 48 minutes. The longest period was 71 hours ; the shortest, contemporaneous with, or shortly after the birth of the child. Dundiun (f gestation, — With regard to the number of days during which gestation progressed, the greatest pains were taken to ensure accuracy, and out of the whole number of patients admitted, there arc only 714 cases who.se infor- mation can bo considered at all reliable. Tiie period taken is the time inter- vening between the last day of the last catamenial flow, and that at which labour commenced. Every one in practice knows the difliculty that exists in ascertaining this period with precision. Tliese difficulties are enhanced in Hospital practice, where there exists every motive for deception on the part of the pat lent. Retain iug for the calculation all whose statements seemed probable, and rejecting all which bore even the seeming of improbability, we have then 714 cases for the basis of our statistics on this point ; and it will be observed that the results, given below, bear out with singular exactitude the conclusions drawn from 150 gestations, and long ago published by Merrinian on the same subject, and subse- quently quoted, I believe, by Churchill. The following are the results obtained in the U. L. Hospital, of 714 women, at different ages. 4 were delivered in the 37th week; i. e., from the 252nd to the 259th day 37 (( (1 (( 38 K If II 259 If 266 127 « If l( 39 If If II 266 ff 273 265 (C « (1 40 l( If If 273 II 280 157 (( l( (( 41 If (f It 280 II 287 85 (( (( l( 42 If If II 287 If 294 29 (( (( (( 43 If (1 II •lU If 301 10 (( (( l( 44 If II II 301 it 308 I now notice the singular circumstance, singular, if the statements made by the scvcirtil paticuts could bc iiupllcitly rcIicd OQ, that the register cuuiuCfatos a it It 6 two cases whoso gestation lasted onlv 0^7 i in 22, on the 270th day; i„ 44 on the 27^^ l T'"' ^"^""' commenced «nd in 17 on the 281st day. Then o„fo ■ ^' ^" ^^ °" ^'''^ ^SOth day -von days, f^n the 282„d'to the 288th both "ff "°™"''^ '^'^^''^ ^'^ -' folWng each other in the following order ' "fT^/: "'''^^" --''-« number treated at their diffe ent g tadl l/1°"'"^' '^'"^^^ ^^--nt the on ire truthfulness of the statenS ' i^^f? ^.^ '^ *^--" upon the have been known to falsify their truo 1 I ""* ^^'^^ unmarried women Hospital, to avoid the operation ^V^T^'t-""'' '""''^'^ "f entering" possible, that unmarried females shJ ll ''^ '' "''"<^d °nt as strictTv Z gw-e.e.doftl.r.tehild.l...^.^_„,^ «6 « r f ' " 9 " " 37 « ^^'^ " « , ^^« "«^^'^o/^/.e/,/„„,,_Thcwei.d>tnA. ■/ " 12 " exclusive of the twin and JVJ^ °^ *'"" ^"^^nts is given in lisr; ^^lbs.3o. TheheavS^a^^ir-. ,' '"? *^'--» --g w^ <S ^ boy, who weighed, at term I^ 4Tb 1 1'"^, V, ^^^^ ^^ ^ ^ the" light: 1 1 ,' anddid well.-lt was his mother ' tll^^ ' T'^'^' '^'^^^^^^ 17 inlhes dimmutive weight to the severivoJ hi ''''^'^''-''^^^> ^ho attributed S fiother was very intemperate WherH. ",'"' ^'"' ^'^^ undergone tII Th:^ei:!::^^^^^^^^^^^ - ?-" "^ '" ^-^ '-'--^ - ^^ --" ::r?- :^r^^^^"^^:^^^ 5;^ ^-?-^ - -^y i„ .t^rent «g« weight is 7 Ibs'.^ '■' "' " ''' United States, according to B ef It ^ In the 13 tw' o '" ^ecK, the aver- -nymalesasferalerreZtrw^^^^^^ have record, which yielded as the females 6 lbs fira n, i • *"' "^^''^ ma es was Clh« n / , the greater T I ' /n ' '°^"^- *^'« average wei-dit nf M i '" °'- """^ "^ fertater. ihe following is the loUiU-n ? /^'o'lt of the girls to be sli<rhtlv whch occurred. No. 1, 5 lbs. 8 tV^'lt 1 "" *"P'^^« - "- only c^I Itsaverage wei..f,f ^ ^«f«— Ihe weight of the Placenta ,\ rn„ .1 ^ • fee weight was ascertained to !,<. 1 ii. a " recorded in 835 casps 1 oz. and occurred only once Pi ! ^^^ ^ '''~^^' heaviest weighed 4 11 ' 1 •• i y '..' I ,y * 1 < ■ ) ■> l|!) <-"' I « . children doing well. It might be supposed that this apparent hypertrophy (if it may be so called) was of a morbid nature. There is nothing in the record to favour any such idea. The lightest one weighed 10 oz. It occurred also once and m a primiparous woman, who al-o with her child, at term, did well. This one also shewed no signs of disease. A placenta weighing 11 oz. also occurred once, and cases in which they weighed 12 oz. were noticed 6 times. With two exceptions these were also met with in primiparous women. The wei-ht of the Placentas in the case of the triplets, to be hereafter mentioned, was e'lbs. 8oz Battledore placentas were noticed 18 times, being onse in 46.3 labours Length of the umbilical corcl-Tho length of the umbilical cord, was mea- sured in 1180 cases ; Its mean length was ascertained to be 19.5 inches The longest measured 47 inches. It occurred only once, and was four times encircled round the infant's neck. The shortest measured 5 inches, and was nine times noticed. Between the extremes of 47 and 5 inches, the record furnishes examples of all the mtermediato lengths, some of course more prevalent than others. I subjoin a table shewing the comparative frequency : From 1 to 5 inches long, there were 11 5 to 10 10 to 15 15 to 20 20 to 25 25 to 30 30 to 35 35 to 40 40 to 45 45 to 50 61 235 377 326 113 41 12 3 1 The foregoing table excludes the twin and triplet cases. The mean length of the umbilical cord in these cases was ascertained to be 18.5 inches. Length of the in/ant.— The length of the infant is given in 815 cases It ranged between 14 and 27 inches ; 14 inches was the shortest, nine of the infants born having measured this length; 27 inches was the length of the longest of which there were only three examples. The mean average length estimated from the whole number of cases is 20.3 inches. The relative prevalence of the lengths will be seen by reference to the following table.* 10 21 33 67 100 139 9 infants measured 14 inches. 221 infants measured 21 inches. 15 16 17 18 19 20 142 45 18 4 2 3 « 22 23 24 25 26 27 Caseaux, m his adrn'rable work "A Theoretical and Practical Treatise on Midwife! of dCZr T f f '°"' ^«S°' '^'^^'^ th« fallowing remark, in alluding to the iuduction of dystochml labours by excessive volume of the foetus: "That the largest children are ne.er rnoro than twenty-thrcc inches from vertex to heel." The foregoing table Zm^:^:: "'""* ""^^^ ^*° '^ P^^^^*^- ^•^^^^ ^^^ ^-^^ proportions ? oToi 815 infants whose measurements exceeded that length. -.r 8 JZot! '"''""' '*'''"""' "' "^''^' *^ "^^^ *^° ^°"°-"S S-eral The mortality of the mothers was aa 1 to 114-G admissions The mortahty of the infants was to the whole births as 1 to 46-4 Ihe still-births were to the whole birtlis as 1 to 60-9 The recoveries in the still-births were to the deaths as 4 to 1 TW T TH^S'^l """""^ *^' '^''^'''' '"'''"'^ chiefly in primiparous women That the still-b.rths occurred chiefly with male offspring. Ihat the chief mortality occurred also with the same That the average duration of labour was 7 hours, 35 minutes. That the average time intervening between the rupture of the membranes and the delivery of the child, was 2 hours 48 minutes ^ That upon the whole, the labours lasted longer with male than with female infants and that the principal difficulties occurred chiefly with the fZer Ihat by far the largest proportion of women were confined in their 40th week iTw :7oX:s:' ^-^ ''''' '-'' ''- -'-'--^ ^'^'^-^^ -^-^ -^^ That the average weight of the infants was 7 lbs. 3 oz That the average length of the infants was 20-3 inches That the average length of the umbilical cord was 19-5 inches And that the average weight of the placenta was 1 lb 4 oz In an ensuing paper I propose to analyse the labours, specifying the presen sTrhoft ^''^"^"f'.^^^l^ ^^- -^^*- Fovalence all condude S a of I f^Tf'T'" ''''''''''^ '" '^' "^°«* ''"P°'-t'^"t ca3c« of parturition of wh ch the books of the Hospital contain a record, whether occurrin" i^ mv own time or in that of my predecessor. occurring m my Montreal, January 30th, 1860. I •Jl »g general IS women. ranes and h female ler. 'th week, >y to the presen- with a turition in my (2.) In my first paper on the Statistics of flie University Lyin--in Ilospita], pub- lished in the second number of the British American Journal, I considered in detail all the circumstances connected with the cases treated in it as far as the records permitted, with the exception of the labours themselves and their pecu- liarities. These I reserve for a future occasion, and it is to these that I pur- pose now to address myself; but before doing so I desire briefly to supply an omission in not having alluded to the monstrosities observed during the currency of the practice as more immediately appertaining to the subject of that paper. Monstrosities, or the efl!'ects of imperfect development on the one hand, or of superfluous development on the other, have been noticed six times since the'cstab- lishment of the Hospital. Two infants were born anoucephalic, one of them having had only a single nostril. Both lived a few minutes after birth. Another infant was born wanting all the ribs from the second to the seventh on the left side, thus exhibiting at each expiratory eflFort a deep soft sulcus through which the heart's action could be distinctly perceived and felt. Superadded'^to these defficiencies in the osseous organization of this infant, a like absence occurred in the spinous processes of all the vertebras from the second or third cervical to the last lumbar, constituting a Spina Bifida of no ordinary character. Thii infant, strangely, imperfectly organized as it was, lived about twenty-four hours. The fourth w.-s born with six fingers on the left hand, and a correspond- ing number of toes on the left foot, these supernumerary appendages having been removed by ligation shortly after its birth. The fifth one had Spina Bifida" the posterior part of the third Lumbar vertebra being wanting. And the last one presented a v^ry unusual appearance. " The parietal bones were separated by a sagittal suture, 2^ inches in width. Attached to the integument were two tu- mours one above the other, the one next to the cranium was smaller than the one above it, and the deciduous membrane and amnion which enclosed the pro- duct of conception extended to these tumours by a cord-like process and envel- oped them." The patient who bore this child stated that she had received a blow from a cudgel during her pregnancy on the left side of the abdomen ; the woman, however, bore her child the full term of gestation, but it was still born, and died soon after its birth.- It presented by the feet. To proceed now with the more immediate subject of this paper. Out of the 1949 entries in the books of the Hospital, I can only find 849 of which a record of the peculiarities of the labour remains j and if to this number ^l 2 wc add tlio 354, whose statistics were f;ivcn in a vorj- n;cncral manner by the late Dr. McCulloch in the British yimeriaui Journal of 18-47, and wliicli 1 now pro- pose to make use of to the extent they permit, we liavo then the number of 1203 cases as the basis of our present statistical observations. An inspection of tlie register will disclose the fact that the classification of the labours adopted was the old one of " Natural, I'retematural, Laborious and Com- plex," an excellent enouL^h one for ordinary purposes, but scarcely precise enough for statistical uses. With the exception of tlie .35-1 cases which furnished the basis of Dr. McCulloch's observations, whoso division in that paper I adopt as suitable to my present purposes, I have carefully examined the details of the re- maining 849 labours, exclusive of the multiple pregnancies of which I have the record, and have reduced them to Naegele's system of classification, the one which seems to me the simple and at the same time the most scientific and truthful, Following, then, this system of classification, ^^e have the following numbers of each of his four principal varieties of presentation : Occipito-Iliac, II53 Sacro-Iliac, 33 Mento-Iliac 10 Cephalo-Iliac, 7 1203 Following up these four principal divisions, I find the following varieties in the presentations : 1 Occipito-Illiac. — 1st Position 1101 cases 2nd " 28 " 3rd " 8 " 4th " 9 '< 5th " 3 '< 6th " 4 « 1153 2 Sacro-Iliac — Anterior 30 " Posterior 2 " Left Transverse 1 " 3.] 3 Mento-Iliac— Anterior 8 " Posterior 2 " 10 4 Cephalo-Iliac — Left lateral plane 5 " llight lateral plane 2 " 7 Total cases— 1203 While the Occipito-Iliac presentations are thus shown to exhibit the larwe preponderance of about 9G per cent, of the whole accouchements, the other forms of presentation show the following ratios : the Sacro-Iliac presen;: ,ns, 1 in every 3G.45 labours or 2.7 per cent. ; the Mento-Iiiao proseuiatiuus 1 iu every 120.3 labours or 0,8 per cent ; and the Cephalo-Iliac prct-entations, 1 in every 171.8 labours or 0.4 per cent. Bosiaes these cases wo have to enumenitc nineteen cases oF twins whicli in- L'ludu tl;o,sc ciiunienitea by tlie hitc Dr. McCulioeh and one case of Triijlets. The results of tiicso labours may be thus briefly noticed. The offspring from the twin cases was 20 boys and 18 girls ; and with regard to their mode of iiresoniation Ifmd that24 presented by the vertex and 14 by" the breech or feet, and of the whole number, only one, a boy, was lost. Tlie pro- portion of twins to the whole births bears a ratio of 1 to every ()3.;j labours. TI;o relative wei-hts of the males as compared with the females in tiicsc cases were detailed in my previous paper. The triplet case allude^' to produced two boys and one girl ; of whom one a boy was still born but afterwards die;!, although every effort was made to resus- citate it. In this case the first presouted by the breech, and the otlicr two by the vertex. The ratio of Triplet cases to the whole is as 1 to IUGS. Alluding to niultiple pregnancies, Churchill furuishes the following comparative ratios froin Hritish, German, an 1 French practice, that of twins 1 to 77;| cases, and that of triplets as 1 to 5840 cases. After these prefatory remarks let us examine the complications wliich have been manifested in the different labours. Among the Occipito-Iliac presentations I find the vertex complicated with a collateral descent of one hand eigiit times; and with that of both hands once. In seven of these cases the right hand was the one wliich descended along with" the head, the hand most commonly placed near the ear. lu one case only"was it the left hand. All these cases terminated favorably with one exception in which tho child was still born, but was afterwards resuscitated by the usual appliances. This latter case was additionally complicated with an cntortillcmentof the cord around the child's neck. There was no appeal to operative assistance in any of these cases. There were four cases in which the presentation of the vertex became compli- cated with a Prolapsus of the Funis to a greater or less extent. In two of these cases the prolai^sed cord was returned and maintained above the brim of the Pelvis, the infants having been born vigorously alive ; in a third case under like circumstances the child wms still born, yet every effort at resuscitation was fruit- less; and in the fourth case, the child had been dead for at least twenty-four hours, as afterwards ascertained. But in this ease the vertex presented in the ;5rd position, and although the funis was returned, it became necessary to resort to the long forceps as the head had not become engaged in the cavity of the Pelvis. This infant was of course brought into the world dead. One Oceipito-Iliac case was complicated with mania, which declared itself four days before the accouchement. Nothing pecuhar transpired in regard to this €vent, nevertheless the maniacal symptoms continued for seventeen" days after- wards, when she was di-charged without much amelioration of her condition, and placed under the care of her friends, as the case had become no longer suited to the Hospital. Another case of this cla,ss was complicated with epilepsy, to which the patient had been subject for several years previously. In this case, tl-, pro- eentation was natural, but in consequence of the supervention of an attack in- 1 1 mediiite delivery was nocessitated. The child was bora dciul, and the woaian died tivo hours after the accouchement had been completed. In another case, the patient had been brought *o the Hospital comatose, and had boon so lor fourteen liours previously, the coma having resulted from puer- peral convulsions, of which no less than seventeen fits had occurred before her admission ; it does not appear that the woman liad received any treatment prior to her admission. The forceps wore used in this case, — the child was born dead, but the mother recovered and was discharged on the fifteenth day afterwards. In another instance, convulsions threatened after the delivery of the child and before that of the placenta. The timely employment of the lancet, and imme- diate extraction of the after-birth arrested the further progress of the symptoms. Another case was complicated with extensive redema of the labia majora. After labour had commenced, the labia were punctured, which cifectually removed any obstacle to the delivery which might have been afforded by this condition of the vulvar aperture. It was this patient's first child. A rather singular complication was exhibited in another patient. After ad- mission she became affected with jaundice which necssitated lier removal to the Montreal General Hospital, where shortly after her entraiice severe cerebral symp- toms manifested themselves accompanied with violent delirium. This condition terminated in puerperal convulsions wliich continued until her death, which took place a few hours after her delivery, which was effected by Dr. Craik, the house sur- geon of that Institution, artificially. The child in this instance Wiis born dead. I was informed that at t''0 autopsy which took place, the liver was found very much atrophied. As apparently connectcu .vith this case, I may incidentally remark that one or two cases of a somewhat similar character occurred in private practice about the same time. I saw one of these cases with Prof. Holmes. Siie was married and in the sixth month of her second pregnancy. She was taken ill on a Friday with the premonitory symptoms of jaundice, which declared itself more and more unmistakably until she was first seen on the following Thursday by Dr. Holmes. On the Iriilowing day severe delirium set in succeeded by coma, at which period I saw her. She died early on the following day. At the postruiortem examina- tion of this case, the liver was also found considerably atrophied, especially the left lobe, of an intensely yellow colour, and so soft as to break down readily un- der the finger. This case furnished the material for an important monograph from the pen of Dr. Holmes, which appeared in the Montreal Medical Chronicle for Jaimary 1856. One case occurred in which the vertex presented, complicated with additional presentations of the left hand, right foot and Funis. This very rare complica- tion ,as reported in the same Journal for June 1855, by the gentleman in attendance upon it, and I will allude to it more particularly hereafter. One case of laceration of the perineum occurred, and in a rather singular man- ner. The presentation was normal, but complicated by severe, occasional spasmo- dic rigidity of the lower extremities. These liaving been considered as not in- voluntary, the patient was cautioned very emphatiealiy not to perniil them. Not- withstanding this caution, she closed her thighs on the head of die fcetus when i !( it was pressing on tlie perineum, and tlie opclpiit bcL^inninc- to emerf^e. This forced the face violently against tlie perineum, and notwithstniiding every exer- tion on the purt of the gentleman in attendance to prevent it, the perineum yield- ed, and a considerable laceration took place, which was afterwards treated in the usual manner. Cases of Placenta ProBvia occurred three times: in two of these intanees the placenta was only partially implanted over the os uteri, and in the other case, completely. I will notice this latter case on a future page. Rigidity of the os externum uteri was frequently observed, but very seldom as offering any serious impediment to the progress of the labour. Eight cases are on record however, in which this condition of that part very materially pro- tracted the labour, and became in fat the real obstacle, demaiuliiig the employ- ment of energetic moans ta subdue it. In one case I find tliat Belladonna inuntions had been resorted to without the slightest apparent effect ; and after several hours had elapsed, it was finally subdued by the exhibition of twenty minims of Vin. Ipecac, every hour. The ordinary method pursued now in these annoying cases, which, while it rapidly subdues the rigidity, at the same time saves the time and anxiety of the attendant, is the administration of one grain doses of Tartar Emetic given every lialf hour. I have rarely been eompcll d to administer more than two such doses, while in the large majority of cases, 1 have usually found it to yield in the course of twenty or twenty-five minutes aftei the exhibition of the first dose. In one case the child was dead born at full term, covered thickly with the copper coloured rash of tert.ary Syphilis. The infant had not been long dead, as the skin evinced few of the signs of maceration. It occurred in tlio case of a married woman, who does not appear to have ever .suffered frum any ofthi; primary symptoms of that affection, although occasionally hereelf covered with a rash for which she could not account, but which had yielded to the medical treatment adopted from time to time as it appeared. Nineteen cases of Puerperal fever occurred in the Hospital at different periods since its establishment, and in every instance necessitating its temjwrary closure. One of these eases, although I place it und r this head, was an uuiuistakable, and well marked c ise of Uterine Piilebitis, in which the formation of .secondary abscesses took place in the joints of the elbow and wrist. This woman recovered. Of these cases seven terminated fatally, and the fortunate issue in the remaining is chiefly attributable to the very prompt treatment to which the patients wcic sub- mitted after the existence of the disease in the Hospital had been too emphatically realized. Seven severe cases of Uterine IToemorrhage occurred, five before the delivery of the placenta, and two after. The Hmuorrhage in all these CJises was control- led by the usual means, no ulterior bad consef|uences having resulted. As a matter of curiosity I now record the following circumstance which is certainly curious, if true, and there does not seem to exist any good or sufficient ground for doubting the woman's veracity, as she could have gained or secured nothing by the falsehood whatever, if one. This patient, a respectable looking married womm, 40 years of age, and the mother of four previous children. decl:irc(l that she liad not perceived any catainenial flow whatever, since tlio birth of iior fourth child, tlion six years of a-o. I think this may be set down as another instance of the vagaries, sometimes cxliibited by Dame Nature lu the performance of this function. Ecjually Hin;j;uhir anomalies are on record. The forceps were employed in nineteen in-<tanees, the sliort forceps seventeen times, and the long forceps twice. One case in which the latter was used has been already alluded to, and the other was one in which contraction of the antero-pos- terior diameter of the brim existed, and the attempt to deliver having been in- effectually made by this instrument, it was afterward effected by version. Tlu- chief features of this case will be detailed afterwards. In the seventeen short forceps cases, the child was extracted dead in two instances, the bodies having exhibited the ordinary signs of death having taken place some days previously. In one of these cases the child was not only dead, but both it and the placenta wen- very considerably decomposed. In the other two cases, the infants wero born 'still.' To both the usual means of resuscitation were applied, but only in one case with success. In the remaining thirteen cases the infants were living when born. In only one case was the issue unfavorable to tlie mother. I will give an ab- stract of this case also shortly. Podalic version was performed six timoF-.. In five of these cases the pre- sentations were some portions of the intant's lateral planes. In the sixtli case, it was performed to convert a vertex into a footling case, and effect the delivery through a contracted brim, which did not appear possible in any man- ner, except by means of craniotomy. I have briefly alluded to this case in the last' paragraph. In one instance of arm presentation, the late Dr. ]\IcCulloch succeeded'' by means of external minipulttion, (a practice again lately urged ibr adoption more generally,) in bringing the head to the brim of the pelvis, thus avoiding the hazard of this operation. No cases have as yet occurred in the Hospital, reriuiring the performance of any of the other obstetrical operations, a matter of some congratulation. A word lastly as to the general employment of chloroform. During the at- tendance of the late Dr. MoCuUoeh, as well as since I have had charge of the Hospital, chloroform has been but sparingly used ; its general use is pi-ohibited in all ordinary labours ; but it is employed whenevcjr anything untoward occurs which demands an artificial assistance. It has accordingly been employed in all the cases of version, and in forceps cases, after the blades of the instrument have been introduced and locked. Such are the cases to which its employment has been as yet restricted, because no others have as yet occurred to require it. I will conclude the.«e statistics, by giving in as short detail as possible, the par- ticulars of some of the principal and most important cases which have occurred in the Hospital since it was opened; and to render these observations as complete as possible, I will place under contribution Dr. McCulloch's commu- nication in a former series of this Journal, previously alluded to, as also that of Dr. Fenwick. MoNTHEAi., April 25th. 1860. \ l-l \ (3.) 1 will now coucluJo these observations by reporting as briefly as possible the leading features of some of tJie more important cases which have occurred in the Hospital since its establishment. Case I.— Ca^c of twins. Concealed ddivcri/ of one child. This important case, of which I propose to give merely an abstract, was reported at length by Br. S. C. Sewell, in whose practice it occurred, in the 2nd Vol. of the old series of the British American Journal, for 181G. Tt possesses important medico- legal bearings. On the Kjth November 1845, Dr. Sewell was requested by a gentleman, a patient of his, to visit his servant woman, Bridget Cloono, aged 40, who 'he stated, was suffering from colic and pain in the back. After arrival at' the house. Dr. Sewell was Induced to suspect a pregnancy, which was confirmed by vaginal examination. He estimated the gestation to have been about seven or eight months. Upon being charged with it, the woman indignantly denied the impeachment, but admitted, that " if there was anything inside her it was no child." She was immediately removed to the U. L. Hospital, where on examination, one hour afterwards, Dr. S. found the os uteri dilated and the membranes protruding, indicating a conceakd labor in progress. He then detected what appeared to be a funis lying coiled in the upper part of the vagina, on pulling which, a free extremity came down but not to the vulvar aperture. Dr. Sewoll left, and on returning shortly afterwards, he found Dr. McCulloch in attendance, a child having been just delivered by the feet, and the woman still persisting that there was no child. It is necessary now to notice that the extremity of the free funis presented every appearance of having been cut by a pair of scissor.s or knife. Information of the circum- stances was lodged at the Police Office, and on examining her trunk of clothing at the house of her master, the body of i> male child was found underneath the clothes which it contained, these having been carefully smoothed over it. Without entering further into detail, it will suffice to enumerate the con- clusions arrived at by Drs. McCulloch and Sewell after a post movtan examina- tion, performed by order of the Coroner : " 1. That the child had breathed freely. •■' 2nd. The marks of injury on the right breast and neck were inflicted during life. " 3rd. They were in all probability caused by the left hand of an adult grasping the neck of the infant. AJf M 16 " 4th. The protrusion of the tongue and the position of tlie hands arc pro- bably referable to strangulation. " 5th. Death was not cau.scd by liccuiorrliage from the cord ; and " 6th. The child was between seven and eight months of utero-gcstation." To conclude this case using Dr. Sewcll's own words when narrating it ; " the rest of the evidence went to shew that she had been a widow for .some " years ; that she had carefully concealed lur pregnancy ; that she had taken " powerful cmmenagoguc medicines prescribed by an irregular practitioner up " to the day of delivery, and that she was seen half an hour before Dr. ScweU's " arrival at the house, to get out of bed, stand by its side, take a pair of scissors '• from underneath the pillow and rut wmething under the bed chthcs." There seems to be an incongruity in the latter part of this statement, the italics of which are my own. The cord could not have been divided under the bed clothes, she standing at the time by the bed side, as the shortness of the cord lying in the vagina, evidently indicates it to have been severed close to her own person, furthermore proved by the length of the cord attached to the infant wliich was found to be nine inches. I cannot explain this apparent discrepancy. The result however of the case was, that the coroner's Jury returned a verdict " of wilful murder " and she was immediately put under arrest. The bill of indictment founded upon this verdict was afterwards thrown out by the Grand Jury. The woman was then indicted for concealing the birth of an illegitimate child, convicted, and sentenced to six months' imprison- ment. It is not only unnecessary, but out of place here, to consider the im- iwrtant medico-legal bearings of this case. Case 2. — Turning hi/ external mam'puhition In a trunk prcmentation. Mrs. McM. was admitted on the 24th July 1852, and labour set in on the following day. The membranes had not ruptured, but on vaginal examination a hand was detected presenting at the os uteri. Dr. McCulloch was notified of the circumstance and was in prompt attendance. The right liand was now diagnosed to be the presenting one ; and by careful examination, the head of the foetus was distinctly felt in the right iliac fossa. Instead of turning the child, he determined to attempt to bring the head to the superior strait. By a series of well managed external manipulations he eventually succeeded in displacing it from the right iliac fossa, and lodging it over the brim of the pelvis where it fortunately remained. A rupture of the membranes, with the consequent increase in the force of the uterine contractions, maintained it in its po.sition, and it advanced along with the hand, which it was found impossible to return. The shoulder became pressed under the chin, and the forearm and hand became extended along the face and parietal bone. The child was born alive but died thirty hours afterwards. The parietal bone was found to be distinctly indented by the hand and fingers of the infiint at the time of its birth. I think there can be no doubt that version performed by external manipula- tion, may be far more frequently resorted to than it is, and that this means of converting an unfavourable presentation into a favourable one has been to a very great extent lost sight of. It is scarcely taught in the schools, and rarely alluded ^■s »V L 17 to even in obstetric : works, but it is an operative procedure of great merit uu.l should bo nttempteu in nil eascH, mho accoucheur is fortunate enough to sec his patient before the membranes have ruptured, some portion of the infant's lateral piano prcscntmg, the head not very remotely placed from the centre of the bri n of the pelvis, and at the same time no unfavourable complications existing which may demand a prompter termination of the labour than this method affords whethrr for the sake of the mother or the child. Under such circumstances, 'this me- thod should be adopted in preference to submitting the mother and her infant to the hazards necessarily encountered -•.) the performance of podalic version, Acaseocourre'i in my own private practice about three months since, which exhi- bits the feasibility of the operation, and the comparative ease with which at least in this instance, it was performed. Mrs. McH , whom I had twice pre- viously attended in her aecouehements, .«ont for me in her fifth. In the fourtli labour the infant presented by the breach, but beyond this all went well in the prceeding ones. She was tall, and rather slenderly built, but well proportion^ Ihc labour liad been in progress about a couple of hours before I arrived at her house, and on examination, I found the os uteri dilated to about tlic size of a crown, the membranes protruding to a slight extent, and enclosing, what after some difficulty I made out to be an elbow. The globular form of tho foetal head was distinctly enough traceable in tho left iliac region. Bearing in mind the success obtained in the exsc above reported, I resolved, as the uterine action was not urgent, and intervals of several minutes occurred between the pains to attempt to bring the head to the superior strait by means of external manipula- tion. Placing one hand on that portion of the abdomen opposite the child's head, and the other on th'j part opposite its nates, by gentle pushes and im- pulses, I felt the head, after about twenty minutes manoeuvering, gradually receding from its position ; and at an ensuing vaginal examination, I had the satisfaction of feeling tho vertex, the elbow having completely disappeared. By this time the pains had become more rapid and efficient, and were fast losing their primitive character. A severe bearing down pain soon came on during which the membranes ruptured, and in the course of about an hour afterwards the vertex presented at the vulvar aperture in the first position. I am fully of opi- nion that this procedure may be more frequently resorted to than it is. After the membranes have ruptured, this operation becomes impossible. Case 3.— Presentation of tie vertex, comjiUcatcd with prolapsus of the funis, left hand, right foot, and left latiral plane. This case occurred since my connection with the Hospital and was reported in the Montreal Medical Chronicle for June 1855, by Mr. (now Dr.) Kollmyer the gentleman who was in attendance upon it; I will therefore give a risumi of it Bridget B. aged 28, married, strong and healthy, applied for admission into the U. L. H. on tho 23rd March 1855. Tho present is her fourth pregnancy nothing untoward having occurred in her previous aecouehements. Labour supervened about 10 A.M. on the morning of the 22nd AprU and having been summoned, Mr. is., found on examination, the os uteri thiok mosit 18 cool, and yitil<Ui|. tk pauw c, , inued, aud the ii„ mbrauee ruptured about 1 , I', M. when a tw^ forge <|uoatity t,i li.juor aranii cscoped, On cXOMlMtfM Imtnediitcly nller this cvenr. a loop of tltf' Bnif»ilical cord prcdcnfod itwlf exiiirnally, but uo other proMcntitif,' pint could bo reached by fh(i firi-er. TMiniVmg u .1 case for ver»io» a /lose of opium was adiuiniKtcrcd, ami I wuM s«,i Sor, On my nrrival at the hoH{,it»l, after introducitif; a con- Kiderablo portion ».f llm /,Hn/f: I detected the occiput presenUi above the brim, and inclined tcvards fae luotiht-r's ri^ht sacro-iliac nynchondroMH, but so much M.) ii.s to imprcHs me with tho idea that the labour mi-ht terminate spontane- ously, if no other (ibstaele intervened. A little to the left of the occiput a careful examination still further detecte.l a f„ot, which was diagnosed to 'bo the ri-ht one, and u little hi-her up a hand, which turned out to be tho left one, while stretched across the brim of the pelvis l»y the child's left lateral plane, and the umbilical cord still pulsatin- was prolapsed. J{y th.; application of the stethoscope the pulsations of the fcetal hearl were heard, and counted at 4I» in tlKMuinute, thus indicating the extreme dan,t,'er in which the child was placed r at lirst inmi;ined that 1 had to deal with a case of multiple prc-nancy but m carefully cxaminin- the fact wiw ascertained that the funis, fijot occiput and hand all appertained to the same child. An attempt was made to return the prolapsed funis, and j.ush up tho inferior extremity and body m as to permit a more complete en-a-emcnt of the occiput, but the powerful uterine jBtioi -^ich was goin- on utterly precluded this mananivrc. By this time Hi., pulsations in t!u« cord liad ceasc.l. Havin- resolved upon the immcd.ute operation of version, chloroform was administered, and when its amcsthetic influence had been secured, I proceeded to its accom- plishment, by seizing the right foot, and bringing it into tho vagina, where it was secured by a fillet ; with some difliculty I next succeeded in seizing tho other foot, and the labour then progressed as usual until the delivery of the arms. With very great difficulty tho posterior or sacral arm was made to effect its curve over the child's chest, but all attempts to perform the same ope- ration with the anterior or pubic one proved unavailing. This arm was found to have become crossed behind the child's neck and rested on the brim of the pelvis. This difficulty necessitated a rccour.se to the blunt hook. This instru- ment was passed upwards along tho back of the child, and fastened upon the shoulder, which was brought by careful traction into the cavity of the pelvis where afterwards manual interference effected tho disengagement of tho arm! The head was finally extracted after considerable exertion. Tho child, which was born dead, was unusually large. It weighed 10 lbs i oz., and measmed 26 inches in length. The funis was also unusually long having been about 28 inches in length. The duration of the labor was about 5^ hours, and the mother recovered well. Case 'i.— Presentation oj ' c V,'.Hex, complicated hj projection of the Pro tmntory of Sacrum; rigiHty . i :• uteri, >^ orifice; ineffectual attempts at delivery by the long forcep<i ; ^oe^i'.i i...'r-.>,«. successful Mrs. EJiza Fceny, a manioc? ;>.< ;ar, stout and /-roiis, aged 37 years, in her second pregnancy, was ad^.Uwd ,; k.. the TJ. L. iiospital, at 10 a. m. of the i^\ vi^ * fi* 1' 19 r„i„';!; •""''■• '"'"■ "■■'■ '■'"'"'• ^"■■"' — "■' «•■' ...... .ha. ».. Immodiutcly after her udmittaneo a copious ,t .hariro of I. . .- . place AtU.„.la„..eon thi.s ea.., havin, flJle: iJ JZ :M '(ITw ' nynKlwu,.. that Kcntlon.a,. was inunedia.ely M.n.na.ned In . ii tl " rV ^ hav ni,' been seen bv liim sl... ,.»...» i • i """"'"ca. m a httlo while after "U.-i„e action. The ioHowin. was tiie n.ixture ""''^"™ "' *'" Antim ct Potassa) Tartrat, irr. vi. Morpliino Mur. J>!oIut. (I'h. E.) 3 i. Aquao 5 vi M, Capiat 5 j. (jiuKjue (,uarta parte hora-. By the ti.ue ,.he had taken three do.es of the niedicine, I arrived at the Ho. contuinzng a drachn. of the solution of the n.uriate"? ml 'was e.tZ. internally. It was now about 5 p. ni ■ .md »nAor ih exhibited uterine aetion would beeon.e moi/r " ulai „d eff L 'T'""" '^'' '^' gained forward a loop of the PuL whieh it Z fm.nl u "" "' '' thus additionally eom^plieating the eak'tuLZ felt in ,t. On consultation it was now deemed advisable to ha recout^^^^^^^^^^ long forceps, wh.cl, were repeatedly applied by myself, and arrw^ds bv Dr Holmes, but which as often slipped off the head It w.. 1! ? 7 to have recourse to version Thn n«f;« . T 1' ""^ '""'"^^'''^ "Pon now exhausted. I request"'! J)- f-b _ ' """. ""'^"^"as the other, but w«. af.r powcrf. i^^U.e' *;- T^ j'':;:-^"' ^S t I 20 was born dead, but the mother, notwithstanding the severity of her labour, made an excellent recovery, and was discharged from the hospital on the 7th ^T&ld in the remarks on this case in the ward-book of the hospital, that the biparietal diameter of the child's head measured 4^ inches, and that the antero- posterior diameter of the brim of the pelvis, ascertained by digital measure- ment, was only three inches. The following additional peculiarities in regard to the child are on record: Its length was 24 inches; its weight 101b. 8 oz; and the length of the funis umbilicalis was 45 inches. It is worthy of remark that her accouchement, two years previously, was only of two hours duration, that child was then living, nothing unfavourable having occurred. _ Case G.-Vertex presentation in the left Transverse position, compli- cated with generally contracted diameters of the brim of the pelvis, and an exostosis of the Right Sacro-iliac Synchondrosis. Forceps. M N. G., an unmarried primipara, aged 30 years, of short stature, stout and active was admitted into the U. L. Hospital on the 22nd January, 1855, and abour came on the 18th March at G a.m. As soon as possible aft.r this was known the gentleman to whose charge this case fell was sent for. This party confident in his own powers, and too proud to consult the matron with whom he had had an altercation some time previously, was resolved to manage it exclusively him- self, which the matron, grossly neglecting her duty, permitted him todo In fact he stated that he had enjoyed an extensive midwifery practice in Upper Canada in the place where he resided, and was therefore competent to any emer- gencies which might arise. The unfortunate result of this case proclaims how shamefully he violated his obvious duties. He arrived at the hospital at about ^ From this time till about 11 a.m., the pains were light with considerable in- tervals between them, but they now began to be more active and efficient. An examination was made, which satisfied him that the infant was presenting by the vertex. The os uteri became nearly fully dilated about 3 p.m., when the pL changed to the ordinary bearing down ones. Matters continued in this stat« with the exception of increasing intensity m the pains, and but littken- .agement of the head in the cavity of the pelvis until 6 o clock the »«*«>«"»»?; Ihen he at last deemed it his duty to send for me. I arrived at the hospital at 7 am and on careful examination discovered a transverse presentation of the vertex a very large caput succedaneum, and marked heat and tenderness throughout the whole length of the vagina, especially about the os uteri The h^tttr however, was well dilated, and the head had become very considerably ent^d within the brim of the pelvis, but closely impacted. The apparent con- dition of the patient was by no means promising. Her countenance was expres- sive of anxiety and very much flushed, the pulse was quick and hard, the pains powerfully bearing down, with very short intervals. There was no other Ele but the immediate application of the forceps. The head was low fTTLn to permit the use of the short pair, which were therefore used. With considerable difficulty 1 succeeded in applying them, an^ro-posvenor.y un the 'hild's head, and after considerable tractive force, the head was withdrawn. •T- < * TN <) ' < I > T •0 21 The child was still born, and small, weighing only 6 lbs. 8 oz. ■ and although at- tempts at resuscitation were made, and continued perseveringly for nearly an hour, they proved fruitless, the heart's action ceasing in the course of three quarters of an hour. The mother progressed favourably until the fourth day, when symptoms of pelvic cellulitis began to manifest themselves. In consequence of this she was removed to the Montreal General Hospital. An extensive abscess formed within the cavity of the pelvis on the left side, which was opened through the vaginal wall, permitting the escape of an immense amount of intensely foetid pus She died, however, on the 23rd of April. The pelvis forms a specimen in the patho- logical museum of the Faculty of Medicine of McGill College. It presents some sight obliquity; the internal plane of the Ischium on the left side .shews evi- dent traces of caries. There is a considerable exostosis on the left Sacro-Iliac Synchondrosis, and a thorough anchylosis of this articulation on both sides. Ihe anteroposterior orconjugatediamcter of the brim measures .3,3, i„ches and the transverse 4j\ inches. ' There can be no doubt that this unfortunate creature would have survived her accouchement had a more timely assistance been afforded. Ca.ses 7-U.-.Vertexj>resentations complicated with rigidity of the Os Uteri These selected cases are of no further moment than as tending to establish the value of a practice suggested by myself in the December number, 1850, of the old series of the BnUsh American Journal, in which there appeared a paper confirmatory of the utility of Tartar Emetic, exhibited in such cases in one grain doses, given every half hour. This practice was at the time supported by the effects witnessed in four cases of parturition, complicated with excessive ngidity of some part of the uterine orifice, and these selected. I deem it unne- cessary to enter into the peculiarities of these cases, as their phenomena were nearly aU alike. K.gidity of the Os Uteri presents nearly the same phenomena in all cases; except that the rigidity maybe partial or complete, involving one portion or another of the uterine orifice. The above, however, are cases in which the labour wa.s prolonged by rigidity of the whole external orifice, which acted as a tight band upon the vertex, prohibiting^ its advance. .VII these cases were managed in accordance with the principles contained in the paper to which I have adverted, viz : the exhibition of grain doses of the Tar- tar emetic, exhibited every half hour. In no instance was it necessary to repeat the Tartar emetic more than twice ; one dose most commonly sufficing. It is my opinion that the value of exhibiting the remedy in the way indicated over bleeding, Belladonna, or the same medicine given every four hours in smaller doses as commonly advised, is unquestionable, and I adduce these cases as addi- tional ones confirmatory of the fact. mT V^7^f«'^J«i'''-^*'«; ^"i^"^ ^P^loion of the u-holc uterine contents. Hn!l' y fTt k" "^'^ ^^' "PP"'*^ '' "^^ '' ^ ^^™i*^d into the U. L. Hospital, about the beginning of December, 1846. I„ consequence of puerperal lTA""^'"•"l^*^'^'^'^*'>^I-''^"^-» «* this period, admittance ^... .enxcu, bu., at the same time, the promise of a.ssistance was extend- ed to her in her own house, when the appointed time arrived. From the ? oo 3 , ,1 i I it answers returned to my questions at this time, I expected that the case would turn out one of Placenta Prsevia, a suspicion which was afterwards confirmed. Symptoms of labour set in on the 17th of the same montli, and licr husband called at my house to notify me of the fact at a.m. of that day. I immediately placed her in the charge of Mr. (now Dr. D. T, Robertson), a most intelligent pupil of my own,who immediately accompanied the husband. I should now remark that, within a few minutes after having been notified of the case, I was sum- moned to attend upon a lady who had engaged my services some months pre- viously, and as the house in which Mrs. T. lived was but little out of my road to that of my own patient, T ventured to pay her u short visit, to assure myself of the state of affairs, and to assist Mr. 11., if necessary, to the fullest extent my own limited time permitted. Mrs. T. was a short stout woman, in her sixth gesta- tion, her previous ones having been all ordinary. On examining lier, after entering the house, I found the os uteri dilated to nearly the size of half a crown, soft and dilatable, the pains active, but not very efficient, the placental mass completely blocking up the orifice. There was, of course, the usual hsBmorrhage, but it was by no means profuse. In fact her pulse was scarcely affected by what she had lost, and was losing. The case admitted of some delay, and as my own time was very limited, not permitting me the application of the stethoscope, to ascertain the condition of the child, or the extent and nature of the placental engagement, I advised 31r. R. to send for Dr. Fcnwick, then Registrar of the Hospital, and in the mean time to apply the tampon to moderate the haemorrhage. That gentleman was accordingly sent for, and as he has re- ported the case in the Medical Chronich for 1847. T quote the conclusion as detailed by him : " I saw the woman shortly afterwards. On examination I found the placenta almost wholly detached, and bulging out though the os, which was dilated. The pains were lingering, and by no means severe. With each pain there was a slight gu.sh of blood, but the quantity lost was so trifling as not to have affected the circulating system. I explained to her husband that manual interference was necessary, and while preparing myself for the immediate performance of version the patient was seized with a prolonged smd vigorous pain, and as I passed my-hand beneath the bed-clothes, the placenta was shot out with considerable force over my knuckles, and the child immediately followed. The uterus contracted firmly, and all was well as regards the mother. The child, however, was dead." Nothing requires to bo said about the other two cases of Placenta Proevia, both of which were " partial." The ordinary management was adopted, and in both cases the infants born were living. The foregoing is a sketch of some of the more important cases which have occurred in the Hospital, from its establishment to the present period. I have given them as an appendix to the two papers previously published. Montreal, 1st July, I860. ^ 7^ (.' V f -" ..# l r A ^^ V } < I A- Wf^i