æther-inhalation during labour, and so far it is, I believe, destined to form the commencement of a new and important epoch in obstetric practice. But secondly, the case appeared to me to be one of great moment as an apposite illustration of views which I had been previously led to entertain, as to the possibility and propriety of substituting, in some instances, extraction by the feet for extraction by the crotchet the delivery of the infant by the hand of the accoucheur instead of its delivery by instruments-the lateral compression of the child's head by the contracted sides of the pelvis, instead of its more dangerous oblique or longitudinal compression by the long forceps,-and, above all, the transient and not necessarily fatal, depression of the flexible skull of the fætus, for the destructive and necessarily deadly perforation of it. It is in this second or latter point of view that I propose to consider the preceding and other analogous cases in the present memoir. In directing the attention of the Obstetric Society in January last, to the case which I have stated above, and its relations to the question of turning, I took occasion to state that I had practised the same operation as an alternative for craniotomy and the long forceps, in other instances in which the head had been morbidly detained at the brim, from the existence of disproportion between the two; and that I believed it to present the following advantages over embryulcio:-It gave the child a chance of life; it was more safe to the mother, because it could be performed earlier in labour and more speedily; it enabled us to adjust and extract the head of the child through the imperfect pelvic brim in the most advantageous form and direction, the head flattening laterally under the traction; the neck (if the child were living or only lately dead,) was so strong as to allow us to exert such a degree of traction upon the obstructed head, that the sides of the cranium might become very greatly compressed, or indented under it, and that without necessarily destroying the child; and lastly, it was a practice which could be followed when proper instruments were not at hand, and the avoidance of instruments was generally desirable, when it was possible. even These observations were published in the March number of the "Monthly Journal of Medical Science," (p. 718.*) In a later number of the same Journal, in describing a case of delivery through a pelvis extremely deformed by maalacosteon, I took occasion to discuss, in brief terms, the different means of treatment required in contracted pelves of different dimensions; and I repeated in the same words the above advantages of turning in comparison with embryulcio. At the same time I stated in addition, in relation to the theory of the practice, that "I believed that when the child presents by the feet, and thus the apex, instead of the I had previously stated the details of the case at page 639, and again at page 721, vertex or base of the cone, formed by the head and body of the fœtus, comes first, it may make its transit without embryulcio, through a pelvis, the smallness of which would otherwise have necessitated mutilation or the operation of craniotomy." The essay from which I make this extract appeared in the No. of the Journal that was published on the 1st July, 1847. A few weeks subsequently,-viz., in the Provincial Medical and Surgical Journal for July 28, Dr. Radford, of Manchester, engaged in the investigation of the question, by publishing a communication "On Turning in Labours rendered Difficult by Distortion of the Pelvis." In this communication Dr. Radford avoids all allusion, by name or reference at least, to the previous observations which I had ventured to offer to the profession on the subject, and he propounds the practice to his readers as if it were a new and original suggestion on his own part, as far as British midwifery is concerned. At the same time, in a spirit of true humanity, which does him high honour, he strongly declares, that “whatever practice can safely supersede the murderous operation,-craniotomy,-should be adopted." "The records of operative midwifery ought not (he observes,) to be stained with so barbarous a procedure, which, according to the present recognized principles of practice, is so unconditionally and so unhesitatingly performed." And, he adds, "It cannot be a matter of surprise that I should, entertaining opinions that craniotomy ought to be considered an operation of necessity, and not of election, hail with delight any measure which only promises to lessen the number of these destructive operations." Afterwards, Dr. Radford proceeds to offer some remarks which evidently shew that he has mistaken alike in its principles and in most of its details, the alternative operation which I had proposed to substitute for instrumental delivery; the fault, however, is, I believe, chiefly or entirely, my own, and is a natural result of the brevity and imperfections of my previous notices on the subject. Indeed, I have reason to know, that Dr. Radford's misconceptions of the proposed practice are, on this very account, shared in by many others. It is with the anxious view of remedying this defect that I draw up the present communication, and I trust that the great practical importance of the questions discussed in it, will stand as some apology for the otherwise unwarrantable prolixity and repetitions that may possibly be observed in the discussion. In following out the object I have indicated, I will treat severally and successively of the kind of cases which gave rise to the suggestions of the proposed practice; of the theory, principles, or mechanism of the practice; and of its advantages in relation to the curtailment of the duration of labour. I will then answer the objections which I have heard raised against it, in relation to the safety of the infant, and the safety H TURNING IN DEFORMITY OF THE PELVIS. of the mother; and I will, lastly, consider the classes of cases best adapted for the practice, and the conditions requisite for its success. SECT. II. EVIDENCE SUGGESTIVE OF THE PRACTICE. In studying in their more minute details, the obstetric histories of recorded cases of morbid contractions of the pelvis, I have been often forcibly struck with the circumstance, that apparently when the child presented præternaturally, and in consequence, ultimately passed with the feet or pelvic extremity first, the labour seemed frequently both easier and safer to the mother and infant, than when, in other labours in the same patients, the head of the fœtus happened to form the presenting part. In this way, mothers who had 675 in which the child was extracted footling, in consequence of its presenting transversely, or with the upper extremity. CASE II. To a woman "who had suffered very much in her former labours from the pelvis being distorted," Dr. Smellie was called, and found the breech of the child presenting. The extraction of the head required considerable management, but the child was saved. (Collect. 32, Case 10.) CASE III.-Dr. Smellie's assistance was requested for a patient with "the breech presenting, and the pelvis distorted." The midwife told him "that the woman's former labours had been very difficult and tedious, but now as the breech presented she was afraid the difficulty would be greater." He "saved this child also, although a good deal of force was used to deliver the head." (Ibid, Case 2.) CASE IV.-A woman, with the " pelvis narrow," and "who formerly was used to have tedious labours," had a breech presentation. Dr. Smellie brought down the legs, "as the breech did not advance with the assistance of the strong pains." The child was delivered with difficulty, but alive. (Ibid, Case 13.) always suffered under very severe and instrumental labours, when their children presented with the head foremost, were, I found, not unfrequently fortunate enough to escape far more easily, when, at other times, the infant chanced either to present originally with the feet, or had the feet artificially brought down during the labour in consequence of the infant lying transversely with the arm or shoulder constituting the CASE V. A woman, with "the pelvis distorted and presenting part;-nay, the history of some few cases awry, from the right ilium being much higher than the incidentally but strongly showed, that when the other," was three times pregnant. The first labour distortion and obstruction in the maternal passages was terminated by craniotomy. The child in the were so great as to have invariably necessitated in all second labour was premature, and presented by the the previous labours the death of the infant by the arm. It was brought away alive by turning. In her operation of craniotomy, a living child was occasion-third labour the child reached the full time, presented ally at last happily born alive, when it happened to by the head, was turned, and lost. (Ibid, 34, No. 2, Case 1.) pass or to be brought through the contracted pelves as an original or artificial footling presentation. In such instances the presentation of a hand or foot, when first discovered at the commencement of labour, has been regarded as an undoubted source of increased danger and difficulty, but it has at last more frequently proved a source of increased safety to the mother, and the indirect means of the preservation of the infant. As an illustration of these remarks I might appeal to the evidence of many different cases observed and recorded by different authors, without any view to such a question as that which forms the subject of the present memoir. But to avoid superfluity of proof, I will in the mean time restrict the evidence to a very abridged statement of the cases of the kind. recorded by one or two authors; and for this purpose, I first select the work of Dr. Smellie, believing, as I sincerely do, that his writings are not less remarkable for the strong thoughts and singular practical sagacity which they display, than for the spirit of candour and truthfulness with which all his facts are reported. In his volumes, Dr. Smellie has recorded an unusual number of contracted and distorted pelves; among them I find the following cases illustrative of the remarks which I have ventured to offer in the preceding paragraphs. The three first cases relate to natural pelvic presentations; the two last are instances CASE VI.-A woman, with "a narrow and distorted pelvis, from the three lowest vertebræ of the loins bending forward," four times reached the full period of pregnancy. In her first and third labours the child required to be mutilated by craniotomy before delivery could be accomplished. The infant in the second labour was small, and "with the greatest difficulty saved, by the assistance of the forceps." At the fourth confinement the right shoulder of the child presented. Dr. Smellie first tried cephalic version, but failed. He then seized one leg, turned the child, brought out the body and extremities, and ultimately, after much exertion, extracted the head. The child was alive. The mother recovered better than in any of her preceding labours. (Ibid, No. 5, Case 2.) In his "Clinical Midwifery," Dr. Lee reports the following case as one probably similar to those which first suggested the propriety of the artificial induction of premature labour : CASE. The patient had been five times preg< nant. She was delivered of her first child by craniotomy. Dr. Lee employed the same operation to deliver her at her fourth confinement. "At the end of the seventh month of her second pregnancy labour came on spontaneously, and the child was born alive without artificial assistance, and has been reared." Her third pregnancy was terminated by labour coming on at the commencement of the eighth month. "The nates presented, and the child was also extracted alive." "Dr. H. Davies induced premature labour at the seventh and a half month of her fifth pregnancy, and the child was born alive, but died soon after in convulsions." the ninth month of pregnancy; a foot presented, and the child was extracted dead, without craniotomy." YE These, I repeat, and similar instances, (and I shall have occasion to quote cases still more striking in the sequel,) appear to me to point evidently to this probable Occurrences similar to what happened in the pre- conclusion,-that in particular forms and instances ceding case must, observes Dr. Lee, "originally have at least, of distorted pelves, the passage of the child suggested the idea of bringing on premature labour by the feet or pelvic extremity, affords to it and the artificially in cases of distorted pelvis, and probably mother some special facility of transit which is wanting led, in 1756, to that consultation of the most eminent when the head or cephalic extremity forms the prepractitioners in London, at which the practice was senting part. And we have thus placed before us this approved of, and soon after successfully carried into problem,-upon what does this greater facility and effect by Dr. Macaulay;"* and by a similar study of safety of footling, as compared with head presentations, the modes of delivery occasionally adopted by nature in such cases, depend? Let us proceed to the conin the same cases of distorted pelvis, we have, I think,sideration of this point, and attempt to ascertain how suggested to us likewise the propriety of artificially this result is obtained. turning and extracting the infant as a footling presentation. I shall cite only one other case from the same writer, shewing the degree of difficulty in con Clinical Midwifery, Case 81, p. 39. (To be continued.) tracted pelvis to be less when the child passes by a pelvic or footling presentation, than when it presents THE HISTORY OF AN EPIDEMIC CONTINUED and passes by the cephalic extremity. CASE VII-A patient, with the outlet and brim of the pelvis, both considerably contracted, was delivered of her first child by craniotomy, after being more than forty-eight hours in labour, and extremely exhausted. "The difficulty," Dr. Lee remarks, "experienced in extracting the head with the crochet, after it was opened, proved that delivery could not have been completed by any other method." At her third labour she was again delivered by craniotomy, after the labour had endured for some time, and four fits of convulsion had supervened. "I found her," says Dr. Lee, "completely insensible, with dilated pupils and constant convulsive movements of the muscles of the face. The pains continued with such violence, and recurred at such short intervals, that I dreaded rupture of the uterus. * The small size of the pelvis, the impossibility of applying the forceps to the head, the imminent risk of rupture of the uterus, with the result of the former labour, were the circumstances which made me to determine to open the head" At her fourth confinement, the child's head was again perforated. Labour had commenced on the 2nd of December; the liquor amnii escaped soon after; the pains continued strong and regular during the whole night. On the morning of the FEVER, AS IT OCCURRED IN THE PARISH OF GREAT FINBOROUGH, SUFFOLK, IN THE AUTUMN OF 1846; RELATED MORE PARTICULARLY AS ILLUSTRATIVE OF THE DOCTRINE OF CONTAGION. By C. R. BREE, M.R.C.S., Stowmarket. It is not my intention to write a treatise upon fever; or to frighten my brother associates with a lengthened disquisition upon disputed points, connected with what Dr. Graves has termed, the most intensely interesting of all subjects connected with medical science. My object in the following remarks is to state broadly, clearly, and I trust concisely, some of what I think will be found not uninteresting facts, connected with the all-absorbing subject of continued fever. The parish of Great Finborough is situated upon rather high ground, three miles in a south-westerly direction from Stowmarket, on the road to Hadleigh, Like almost every other rural village in the county of Suffolk, it is distinguished by stagnant ditches, neglected horse-ponds, and ill-arranged cess-pools, which are more or less to be discovered surrounding the thin, cold, damp, confined, lath-and-plaster-built cottages, which are allotted as residences to our labouring poor. Its geological characters are simple and easily described. head was still wedged in the brim, the abdomen Fifty, sixty, or seventy feet of alternating blue and tense, the patient occasionally delirious, &c., crani-yellow diluvial clay, or drift as it is termed, with the chalk formation at the bottom, and from four to ten otomy was performed. The patient was thus delivered feet of heavy loamy soil at the top. by embryulcio in her first, third, and fourth labours. The history of her second confinement is this,-"I proposed to induce premature labour on the 21st of July, 1835, when she was seven months and a half pregnant; but she would not consent to this. Labour 8th, (six days after labour "had commenced,") the came on spontaneously at the commencement of Clinical Midwifery," p. 62, I will not say that any of the above points had anything to do with my first case of fever, as I was not able to trace it to contagion. It will be found that with most of the other cases there was no difficulty in settling this point. For convenience, I have drawn a rough diagram of the parish, numbering the infected houses corresponding to the cases in the order in which they occurred. EPIDEMIC CONTINUED FEVER, The first case which occurred in the parish was on the 25th of August, 1846, at least, this is the date of my first visit. As the symptoms in all the cases were as similar as could be expected from the same disease affecting different individuals of various ages, I will content myself with briefly describing this case, which will do as a type of the rest. Ex uno disce omnes. 677 But my patient had a long convalescence; although after the 5th of September she was safe from the imminent danger which had threatened her, and from which she had been snatched by the all-powerful agency of port-wine, she had yet to encounter the effects of disease. Emaciation, great debility, irritability of mind, are, I find, the prominent features of my notes of September 11th, and it was some weeks before nourishing diet and suitable tonic remedial agents had restored her to health. CASE 2.-On the 21st of September, Susan Pegg, the woman who had nursed the above case, told me during my visit that she felt ill. I detected the premonitory symptoms of fever, and sent her home. CASE 1.-A. Garrad, the wife of a labouring man residing in the cottage marked below, No. 1, sent for me on the 25th of August, 1846. She had, I found, been drooping as it is emphatically termed, for several days; a general sense of debility, weariness, pain in her bones, loss of appetite. To these symptoms were added when I saw her; severe pain in her head; dry tongue, furred in the centre, with the edges, and small islets here and there, dry, smooth, and perfectly clear; a quick pulse, 120, small and irritable; flushed cheeks, and a hot dry surface; abdominal tenderness, and diarrhœa; urine dark coloured, depositing a thickperience, is situated in the winding of a miserable lane, dusky-coloured sediment. These symptoms gradually increased in intensity, but they were all present when I first saw my patient. In three days, however, the headache had gone on to delirium, and on the 31st may notes record-violent delirium; great depression marked by loaded tongue; teeth and gums covered with sordes; picking of the bed-clothes; cold extremities; quick irritable pulse; in fact, a tendency to death by asthenia. But there were no spots or vibices, or discharge of blood from the bowels either in this or any of the other cases. Up to this period my treatment had been, cold to the head, and sponging the surface with vinegar and water; the daily exhibition of an enema of a cupful of starch, containing half an ounce of the syrup of poppy, (which will generally control the diarrhoea ;) mustard poultices daily to the ankles; and the exhi bition of ten grains of the Pulv. Soda Comp. of Guy's Hospital every six hours, with a draught containing ten grains of carbonate of soda, and three of carbonate of ammonia, in an ounce of water, every three hours. On the 31st, however, it was quite clear that the patient was in great danger, and would die, unless I could keep her alive; I therefore discontinued the cold and the medicine, and having procured a bottle of wine, I directed the nurse to give my patient a wine-glassful every three hours, or oftener, according to circumstances: my directions being," the more delirium, the more wine." These directions were well followed up, and the best part of the bottle was gone next morning. The patient was still very ill, but we had established a footing, and our enemy was half vanquished. There was more warmth in the extremities; the pulse was firmer and fuller, though still ranging from 120 to 130; and there was a little moisture on the skin. I kept up this advantage. On September 5th my patient had taken three bottles of wine, and was safe. I need not describe the process of amendment,—the gradual abatement of delirium, replaced by sleep, the increased action from the skin, the lowering of the pulse, and the gradual cleaning of the tongue,— these are familiar features, and pleasing ones, too, in the diary and the retrospect of all practical men. By a reference to the diagram it will be seen, that there is a remote cluster of cottages, to which,—by way, I presume, of special honour,-the name of "city" has been given. The city, as I know, from many years' ex in an isolated corner of the parish. It consists of five tenements, duly marked and numbered in the diagram. From time immemorial it has been celebrated for its open undisguised dirt. Deep ditches filled with stagnant water, open privies, pigsties abutting upon the road, and half obstructing the view of five miserably-built cottages, are the salient objects in this dreary and melancholy picture. And yet it is not with these, viz., pigsties, ditches, and filth, that I am now about to find fault, or accuse of any participation in what I am going to relate. It was here,-to the cottage marked No. 2,-that Susan Pegg, the nurse of Mrs. Garrad, was brought, and she went through the disease with nearly the same symptoms and intensity as No. 1. The treatment was the same, with one exception,—i.e., I began the wine earlier, on the fourth, instead of the seventh day. She recovered, and her convalescence was more rapid than in the former case. As usual, in the country, there was a great outcry about "the fever," and no one would go near poor Mrs. Pegg, the mother of eight children, except the wife of John Threadgill, who lives in the cottage marked No. 3. The cases of fever that followed Susan Pegg, in this locality, with the result, were as Children of No. 2. All recovered. Child of No. 2. Recovered. Nurse of No. 2. Recovered. Children of No. 2. Recovered. CASE 10.-Ann Threadgill, the daughter of No. 7, a girl aged 18, left her place at Stowmarket, to nurse her mother. She was attacked with premonitory residing at Stowmarket, four miles from his father's symptoms on the 19th, and on the 20th was delirious. residence. After his mother (No. 2,) fell down with She had, in addition to the other symptoms, inflam- the fever, he visited her several times, but previmation of the tonsils, which caused great difficulty in ously to the 21st of November he had not been getting either medicine or wine into the stomach. at home for a fortnight. He was attacked with She died on the 5th of December, on the 15th day of fever in Stowmarket on the 21st, and sent home the attack. I injected broth and wine into the rectum, to Finborough, on the 22nd, by the medical officer and believe she was kept alive several days by this of the parish of Stowmarket. He had the disease This was the only fatal case. severely, but recovered under the use of large quantities of wine. I did not hear of any case arising means. November 21st. CASE 12.-John Steggall, living in the cottage marked 4, was attacked with the premonitory symptoms of fever on the 27th of November. He had not worked nor spoken with any of the parties or their relatives who had hitherto had fever. Mrs. Pegg (No.2,) however, had one day called at the door of the house of the farm upon which he worked, for milk; she remained outside the door, and he (John Steggall,) had not seen her. He had, however, precisely the same kind of fever in its worst form, but recovered under the same treatment as I have detailed in the first case. This man's home is remote from the "city," but in going and returning from his work he passed night and morning, within half a mile of it. None of this man's family or his neighbours, residing in eight or ten cottages joining his own, had fever. November 29th. CASE 13.-William Davy, a married man, aged 40, was attacked on the 29th of November. He had worked one day with John Threadgill, the father of No. 10, and husband of No. 3. His residence is marked 5. He had the disease mildly, and none of his family or neighbours caught it. I have now to relate one of the most singular features in the history I am detailing. By referring to the diagram and again returning to the "city," it will be found that this locality consists of three houses divided into the residences of five families. Pegg and Threadgill's history has been related. Locke and his wife (two elderly people living next door to Threadgill,) migrated as soon as the fever broke out to some friends in a distant parish, and escaped. The third house it will be perceived is separated from Pegg's by a garden. This house was inhabited by |