rise to the belief that the intestine has been returned, some omentum alone remaining. The previous history of the case, as regards the prior reducibility of the tumour and the amount of persistent tension, must be our chief guides as to whether strangulation still persists, requiring the operation; and in doubtful cases a purgative may assist the diagnosis. On the other hand, a thickened state of the surrounding parts, the consequence of inflammation or fatty deposition, may lead the young practitioner to believe that reduction which is real has not taken place. The diminution in size and the absence of tension are the chief diagnostic signs. As to the objection which has been raised to the forced taxis, that in the event of its not succeeding and the operation becoming necessary, the patient is exposed to more danger in consequence of the contusion the parts have undergone, it is not confirmed by M. Gosselin's observation. In the cases of 6 patients upon whom it had been practised from thirty to forty-five minutes, and who were subsequently operated upon, 1 death and 5 recoveries took place. It is true that, as is the author's practice, the operation was performed immediately after the taxis had failed, so as not to give time for inflammation to become developed as a consequence of the contusion. A more temporizing procedure would probably be attended with less favourable results.

VII. On In-growing Toe-nail. By Drs. PORTER and LORINSER.

Dr. Porter (American Journal of Med. Science, Jan., p. 124) describes the treatment of this affection as it occurred in his own person. He dwells upon the following three points: 1. The importance of removing all pressure from the affected part, which in his own case was accomplished by the following procedure. "After a loose stocking had been drawn on the foot, a friend was requested-having pulled its extreme end forward-to stitch a seam partly across it in front of all the toes except the large one, thereby hanging or resting the stocking on the second and third toes, leaving the affected phalanx in a sulcus." A circular piece of leather from a partly worn boot was also removed directly over the affected nail. 2. The nail is not incurvated, as it is sometimes said to be, the disease being really in the soft parts and induced by pressure. If the corner of the nail can be skilfully removed, the suffering ceases, when the inflammation is but slight, or even when suppuration has occurred, provided that all future pressure be prevented -the affection, in the author's opinion, being indeed originally produced by the pressure of too short a boot. 3. When granulations conceal the edge of the nail which is irritating the swollen integuments, fomentations and poultices must be applied to allay the inflammation, in order to admit of the removal of a portion of the nail. When this end is not attained, the knife or caustic must be resorted to, and in the author's case both had to be employed, for he had let the malady gain a considerable height before he yielded to it. The cure was accomplished in the end by taking off all pressure through the contrivance in the stocking above described, and pencilling the granulations with saturated solution of alum, which was applied as hot as it could be borne, this increasing its efficacy. Small pledgets of lint wetted with it were left on for twenty-four hours, covered with oiled silk. Dry lint was next substituted, wet and dry applications alternating. Under this treatment, which was not painful, the granulations flaked off or were absorbed, and at the end of three days the macerated corner of the nail was easily removed. The hot saturated solution of alum is an admirable application for granulations or ulcers about the nails, the salt being deposited on cooling in a state of impalpable powder.

Dr. Lorinser (Boston Journal, Dec. 15th, from the Oesterr. Zeitschrift für

Heilkunde) takes a different view of this affection to that usually held. Examining it at an early stage, pressing the granulations to one side with a flat probe, the edge of the nail is found to be undermined for a short distance, and is hollow, and the granulations which furnish the pus exist also beneath it, and on the lateral border of its matrix. "Since the ulcerated portion of the matrix is covered by the nail, so that only that portion of the pus next to the edge can be pressed out, while the rest remains collected underneath, the ulceration assumes all the characters of a fistula, and if left undisturbed can only with difficulty, or not at all, be cured, because the conditions under which the healing of a fistula is usually accomplished are wanting. Then, again, the sharp edge of the nail is pressed by treading against the granulations which surround it acting as a foreign body and increasing the growth of these. But if this pressure of the nail existed alone, without the fistulous condition below just alluded to, prolonged rest would be sufficient to produce a cure, which is not the case. Moreover, at first the nail has generally undergone no change in shape, and the affection may exist with a completely normal one, while persons having very distorted nails may never suffer from it. Again, the agency of the shoe is doubtful in many cases. After describing the further progress of the affection, Dr. Lorinser concludes-1. That the affection originates in an inflammation and ulceration of a part of the matrix, and that paronychia maligna is nothing more than such ulceration of greater extent and more rapidly destructive; 2. That the names onyxis, in-growing nail, onychia, are wholly inappropriate and confusing, since the nail does not grow into the skin, but the granulations springing from the skin and from the matrix cover over and embrace the edge of the nail, without the shape of the latter being necessarily abnormal.

In accordance with these views, the treatment should not be directed so much to the nail as to the fistulous ulceration beneath the matrix, the indication being to expose this, so as to convert it into an open wound, prevent the accumulation of pus, and promote cicatrization.

1. At an early stage of the affection the exposure of the ulceration may be effected by inserting a small pledget of lint between the edge of the nail and the granulations, and then destroying these with nitrate of silver. The pledget should at first consist only of a few threads of lint, not longer than the edge of the nail, pushed carefully and deeply in with a flat probe. It should be changed at least twice a day, its thickness being gradually increased. If there is much tenderness, cold compresses should be applied over the lint, and when the suppuration is abundant, a cold foot-bath should be employed before the dressing. After a few days, the edge of the nail having become free, the pledget can be pushed under the undermined portion, so as to absorb the pus as secreted, prevent the springing up of granulations, and hinder the contact of the nail with surrounding parts. In this way, in the milder forms, healthy granulations form at the bottom of the ulceration, and as the pus escapes freely, healing soon follows. When, however, the granulations have formed into a high ridge, partly covered with skin, and the edge of the nail is soft and deeply undermined, the fungous growth must be seized with a forceps, and enough of it removed by a crescent-shaped incision to expose the edge of the nail, the soft and ragged portion of which is to be cut away as far as possible without injury to the matrix, thus laying open the ulceration of the latter. Lint may now be pushed under any overhanging portion of the nail as before.

2. When the edge of the nail is still undermined, and there is a disposition to the production of flabby granulations, sheet lead may be advantageously applied.

QUARTERLY REPORT ON MIDWIFERY.

BY ROBERT BARNES, M.D., F.R.C.P.

Physician to the Royal Maternity Charity, Assistant Obstetric Physician to the London Hospital, &c.

The Uterine Dilator.

By HORATIO R. STORER, M.D. (Amer. Journ. of Med. Science, July, 1859.)

DR. STORER advocates fluid pressure as the best means of artificially dilating the cervix uteri; and describes an apparatus he has contrived for the purpose. The instrument consists of three portions: a distensible sac, made in preference of goldbeater's skin, the dilating medium; a hollow staff for support, and as a channel of communication to and from the sac; and an external source of supply, for which Higginson's elastic pump is best adapted. As the membranous sac becomes distended with water, it assumes first a fusiform, then a globular shape. An advantage insisted upon by Dr. Storer is, that the pressure operates, more Naturæ, from above downwards. He relates a case in which the cervix was by this means rapidly dilated; reflex action was remarkably excited, especially by suddenly evacuating the sac. He also makes the incidental observation that, upon presenting the central mass of the elastic pump to the stethoscope, the continuity of the column of water remaining unbroken by the stopcock, the sounds of the foetal heart were rendered more distinctly audible. He remarks that this is a further development of the principle of foetal auscultation described by Dr. Keiller, of Edinburgh. [It may be said, in like manner, that the plan of dilating the cervix by fluid pressure is a further development of the colpeurynter of Braun.-REP.]

II. LABOUR.

1. Cases of Obstructed Labour:-1. From extensive Hard Cicatrix of the Vulva. 2. From Malformation of the Pelvis. By L. J. MARTIN. (Australian Med. Journ., Oct., 1859.)

2. On the Use of the Forceps in Face Presentations. By Dr. VON HELLY, Teacher of Obstetrics at the University of Prague. (Vierteljahrschr., 1859.)

3. Experience in Face Presentations. By SPAETH. (Est. Zeitschr. f. Prakt. Heilkunde, Nos. 26, 27, 1859.)

4. Observations on External Turning. By Dr. CARL ESTERLE. (Schmidt's Jahrb., No. 10, 1859.)

5. Placental Adhesion as a Cause of Hour-glass Contraction and Protracted Labours. By JOHN MARTIN, M.D., New York. (Amer. Med. Monthly, Oct., 1859.)

1. Mr. Martin, of Melbourne, describes a case of obstructed labour from occlusion of the vagina, which had occurred after destruction of the labia, clitoris, &c., by a burn when the patient was a child. The vulva was occupied by a very dense and extensive cicatrix, the only opening through which was a small ring-like aperture, admitting the tip of the little finger, and situated in the posterior part of the cicatrix close to the anus. Division of the cicatrix was performed, and closure counteracted by bougies. She became pregnant. There was great obstruction when the head came to the vulva; incisions were made and delivery effected.

Case 2.-We refer to the second case on account of the recovery of the child after injury during birth. The antero-posterior diameter was not more

than three inches. The head presented in first position. Under chloroform the long forceps was applied. Great and protracted efforts were made to extract. The child, a female, when born, showed scarcely any sign of life; the head exhibited an extensive radiated and depressed fracture of the left parietal bone, near the anterior fontanelle, which had evidently been caused by the pressure of the projecting bone as the head was drawn through the brim. By the "ready method" and otherwise the child was restored, and a month afterwards was alive and well. The fractured surface appeared to be gradually rising.

[This case is especially interesting, as illustrating the extent of compression and even of violent injury from which a child may recover. It is an encouragement to resort to the long forceps or turning in preference to craniotomy in cases of contracted pelvis. Contrary to the opinion of the author, we believe that turning in this case would have been attended with less injury to the skull.-REP.]

2. Dr. Von Helly presents a valuable analysis of the mechanism and treatment of face presentations. Starting from the familiar fact, that these are more tedious than labours in which the vertex presents, he says the reason lies in the circumference with which the head enters the pelvis, and in the unusual relations which the peculiar position of the fœtus induces. The head of a fœtus born by the vertex, is lengthened in the longest or diagonal diameter-i.e., from chin to vertex; the vertex is the highest point, towards which the roof of the skull forms a gradually inclined plane from the forehead. The diagonal diameter surpasses the straight one, from forehead to vertex, by an inch, so that the two diameters form two lines which, when the head is looked at in profile, form an irregular triangle. The occiput of a head born by face-presentation appears drawn out or lengthened in the direction of the straight diameter; the roof is but slightly arched, is flat, and ends in a sharper angle at the forehead. The difference between the straight and diagonal diameters disappears, so that the two lines, one drawn from forehead to vertex, the other from chin to vertex, form a nearly isosceles triangle. Measurements have been made in reference to this point in 32 cases; these give:

The straight diameter was longer than the diagonal in 2 cases.

equal to
shorter

The head finds, from the arching of the roof and occiput towards the opposing side of the pelvis, an obstruction to its descent, whence, through protracted uterine contractions, the neck is more stretched, the occiput approaches the back, and the forehead from having been the lowest part is drawn back. When the skull is flattened, and the head has in this manner lost in height, its vertical diameter decreases in length, and so finds room in the pelvic brim, the chin sinking backwards to be on same level as the forehead. When the face approaches the outlet, the chin immediately leaves the side of the pelvis, draws forward near the symphysis, and the neck places itself against the posterior surface of the anterior wall of the pelvis. Most frequently this change from the diagonal to the antero-posterior diameter is effected at the floor of the pelvis. The skull thus enters the cavity of the sacrum; the chin is gradually driven forward under the symphysis pubis, and the face becomes visible between the labia pudendi. Forehead, roof, and occiput roll over the perinæum, whilst the head, by revolving on its horizontal axis, is brought nearer to the breast.

Dr. Von Helly cites the well-known experience of L. J. Böer, as proving the efficacy of nature in bringing these cases to an end; and says, that in 58 cases

which have occurred in the last few years in the Prague Lying-in Hospital, perforation was performed twice under urgent circumstances, the child being dead, and in two instances the forceps was used.

Dr. Von Helly deprecates attempts to alter the presentation by changing the face for the occiput, or by turning. In the 58 cases of the Prague Hospital there was a proportion of 18-19 per cent. of dead-born children, calculated in this wise: 2 were delivered after perforation, 1 was born putrid; these three being subtracted, there remained 55 births. Of these 10 gave dead children. The cause of this unfavourable result to the child lies in the compression which the skull and brain undergo; in the obstruction to the circulation of the brain, caused by the diminution of the calibre of the vessels of the neck under the great stretching produced; and, above all, by the long continuance of these dangerous conditions occasioned by the unusual protraction of the labour. Injury of the spinal marrow he looks upon as theoretical, and says he has found few opportunities of observing in the autopsies cerebral apoplexy, although there may be congestion of the brain and membranes.

Before the dilatation of the os uteri, the author deprecates interference. In cases where the necessity for aid arises, and the os is open, the question, he says, is in what relation the forceps is to be applied to the face-presentation, and how it is to be applied so as to entail no bad result for mother or child. The long forceps ought not to be applied when the head is still high; at this stage the circumference and resistance of the head are still great; the operation is very difficult, the prospect of the child's life very small; whilst danger is incurred by the mother from the liability of the instrument to slip. Above the brim the double-curved forceps must be applied in the transverse diameter; one blade will lay on the forehead and crown, but the other can get no secure hold on the face and neck without so compressing the latter part as to destroy it. If urgent circumstances call for delivery when the child is undoubtedly dead, perforation is to be resorted to.

When auscultation declares that the child is alive, nothing but accidents threatening the mother can justify tentative applications of the forceps; and as soon as conviction is obtained that further force is dangerous for the mother, perforation is indicated. The author agrees with Mittermaier and the greater number of obstetric practitioners in deciding in favour of perforation even when the child may still be alive, rather than with those who would wait until the lives of both mother and child are imperilled. But when the face has descended into the lower part of the pelvic cavity, the relations are so changed as to be more favourable for the forceps: one blade can be laid in opposition to the sacro-iliac synchondrosis, the other to the foramen ovale. If the chin be at the symphysis, the application of the forceps is of course still easier.

The following two cases are important:

CASE I-A woman who had borne eight children was in labour on the 9th of September at term; the liquor amnii had escaped. Pains first came on next day, weak, and rare. Accustomed to quick labours, and getting anxious, she pressed the midwife to apply the forceps. This was done on the 11th, and abandoned after fruitless attempts. Another and a third attempt was made on the following day by several physicians, which were equally fruitless; and the patient was brought to hospital. The countenance was blanched, the features sunk, extremities cold, pulse scarcely felt, abdomen painful and meteoric, uterus unevenly distended, the lips of the os uteri swollen, hanging flaccid in the vagina. The head was in the brim, face presenting in the transverse diameter, the forehead to the right and lower down. The presenting eye was hanging out of its socket; the epidermis came off the face în shreds. The patient was a little revived from her state of exhaustion by hot wine and musk. The trepan-perforator was applied, and a large putrid child extracted