from distension from within, and from the action of the gastric juice and ingesta upon its internal surface. There would, moreover, be a risk of exciting fatal inflammation, to which I should not feel justified in subjecting the patient. Palliative measures, such as are at present adopted, may succeed in further reducing the size of the opening, and, at all events, render the patient's existence more

comfortable.

ARTICLE II.-Case of Difficult Labour, in consequence of Twins joined by the Breast. By CHARLES STUART, M.D., Chirnside, Berwickshire.

THE following case is an additional instance of unforeseen difficulty occurring in the course of a labour, in which no certain rules of practice can be laid down, and shows what an amount of obstruction may be overcome, when sufficient time has elapsed for complete dilatation of the maternal passages.

I was called, on the morning of Thursday the 10th of October last, at seven o'clock, to attend Mrs E., æt. 22, residing in the village of Chirnside, who was in her first labour. On my arrival I found the pains regular, and of good strength. On examination, the os uteri was felt dilated to about the size of a shilling, soft and cushiony, the head presenting in the first cranial position, the vagina well lubricated; and, in short, everything was going on quite favourably. The pains continued steadily to increase, and after a space of four hours the os uteri was well expanded, and the pains began to have a bearing-down character, till about two o'clock P.M., when they recurred only at long intervals. Shortly after three o'clock the pains returned with considerable violence and frequency; but little or no change had taken place in the position of the head, and there seemed to be great difficulty in its passage through the brim into the cavity of the pelvis. I found that by allowing my patient to lie down the strength of the pains was most materially decreased, so I determined to keep her moving about as long as was prudent. I never recollect noticing this to such an extent in any other case, when the pains were so violent. The cranium advanced with extreme slowness, considering the strong nature of the pains; and it was only after the most severe straining that the head began to press on the perineum, and after a very tedious passage was born about seven o'clock P.M. The pains previous to this were of the most frightful description, and they were now, if it was possible, increased. Some apparently insurmountable obstacle seeming at this stage to oppose the further exit of the infant, I tried by every means in my power to discover the cause of delay, but from the extreme tightness of the parts it was impossible to ascertain its nature. I dreaded, from the enormous straining, that the uterus would speedily rupture, unless

delivery was immediately effected, so accordingly I applied at first gentle traction; but, when I found that unavailing, I was forced to increase it to what previously I would have considered a most unwarrantable degree, and succeeded in delivering the shoulders, when for the first time I discovered something unusual. I continued, however, my traction as my only hope of getting the woman delivered; and, after using the greatest force, I was in no small degree astonished when another head came down, with the face considerably flattened. This second head lay twisted round upon the back of the first delivered infant. After farther perseverance, I succeeded in extracting two males, still-born, and intimately joined from the sternum to the umbilicus, into which an umbilical cord, common to both, was inserted. The placenta speedily followed, and was not larger than is usually seen in cases of twins. The umbilical cord was rather thicker than usual. About an hour elapsed from the time the head was born till the delivery was completed. The pains during that period were of the most agonising and alarming character, and made me regret exceedingly having no chloroform. After a careful examination of the external parts, I was very glad to find no perineal laceration, which I feared very much from the passage of such a mass. The twins were at the full time, and fifteen inches long. The band of connection extended from the upper part of the sternum to the umbilicus, and was seven inches broad and three long; and the diameter of the twins, when laid together, was six and a-half inches. They were perfectly and fully formed in other respects, but the head that presented first was the larger of the two. I failed in obtaining permission to make any more particular examination.

When we consider the breadth of the connecting band between the two children in the above case, we see more clearly how the head of the second child could assume the position that it did, and to what an extent the connecting band must have been stretched to have allowed of its being placed at the back of the shoulders of the other child when delivered.

My patient is a woman of slender figure, but well formed, and of good constitution. During her pregnancy she enjoyed excellent health, which in some measure strengthened her for the extreme trial she had to undergo, and which she endured with the greatest fortitude.

She has made a most excellent recovery, and is now quite strong. No doubt the long delay before the head was born, in a great degree saved her from the danger of perineal laceration, as there was ample time for complete dilatation, which was so essential for the safe passage of such a mass as had to follow.

ALLANTON, 18th November 1850.

ARTICLE III.-Rare Case of Complicated Parturition. By JAMES GRAY, M.D., Perth.

THE following instance of the protrusion of the hand of the child through the walls of the vagina and rectum (without injury to the perineum), in a case of common head presentation, is so rare, if not unique, in its occurrence, as to deserve being placed upon record :

On the evening of the 26th February 1850, I was summoned to attend Mrs Y. in her first confinement. She resided at a distance of twelve miles from my residence in Perth. I found her in bed suffering from a severe expulsive pain. The cry which escaped her led me at once to make an examination. In doing so I discovered, as I thought, the head of the child partly born, and covered, as is not unfrequently the case, by the membranes. After the pain subsided, I had time to make a more careful examination. The os externum was found to be thrust forwards and upwards to the front of the pelvis; the perineum greatly distended; the orifice of the rectum dilated considerably,— exposing its mucous surface to the extent of an inch. The head presented in the second position; the membranes were entire. On introducing the index finger of the right hand into the rectum, I found that one of the child's hands lay upon the right cheek. Another pain soon followed, more fully stretching the perineum and opening the anus; without, at the same time, affecting the outlet of the vagina. To prevent the perineum from being injured, I placed the palm of my right hand over the anus and perineum, carrying my fingers into the vagina, so as to prevent the too sudden expulsion of the child. While thus engaged, I felt that something had given way; a gush of fluid followed, and a pressure of something solid against the palm of my hand. This I found to be one of the hands of the child, which had protruded itself through the walls of the vagina and rectum a little above the verge of the anus. The pain returning, I expected every moment, from the state of the parts, and from the powerful efforts made, that the perineum would give way. This was prevented by still carefully supporting the parts, retarding by counter-pressure the progress of the child-and thus giving time for the external parts to relax, which, in the course of half an hour, took place. The head, consequently, was gradually expelled, and as it emerged under the arch of the pelvis, the hand also descended through the opening in the walls of the vagina and rectum, as de