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CONTRIBUTIONS TO MEDICINE AND MIDWIFERY.
2. S. 2 #43
CONTRIBUTIONS
TO
MEDICINE AND MIDWIFERY.
BY
THOMAS EDWARD BEATTY,
M.D., M.R.I.A., M.D. T.C.D. HON. CAUSA ;
PRESIDENT OF THE KING AND QUEEN'S COLLEGE OF PHYSICLANs IN IRELAND ;
HONORARY FELLOW AND FORMERLY
PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS IN IRELAND ;
HONORARY FELLOW OF THE OBSTETRICAL SOCIETY OF LONDON ;-&
CORRESPONDING MEMBER OF THE OBSTETRICAL SOCIETY OF EDINBURGH ;
PHYSICIAN TO THE CITY OF DUBLIN HOSPITAL ;
Ex-PROFESSOR OF MIDWIFERY, AND FORMERLY
PROFESSOR OF MEDICAL JURISPRUDENCE IN THE ROYAL COLLEGE
ſº OF SURGEONS IN IRELAND ;
FORMERLY PRESIDENT OF THE PATHOLOGICAL AND OF THE OBSTETRICAL
SOCIETIES OF DUBLIN ;
ETC.
DUBLIN :
FANNIN AND CO., GRAFTON STREET.
LONDON : LONGMANS, GREEN, AND Co.; SIMPKIN, MARSHA.L, AND Co.
EDINBURGH : MACLACHLAN AND STEWAR.T.
1866.

R. D. WEBB AND SON, PRINTERS, DUBLIN.
TO
WILLIAM STOKES, M.D., M.R.I.A.
REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF DUBLIN, ETC.
My dear Dr. STOKES,
If the highest, world wide, well earned professional
fame—if a mind imbued with exalted notions of the
dignity of our noble profession, and an untiring endea-
vour to elevate its tone by precept and example—if a
professional life strongly marked by the most rigid
adherence to rectitude, etiquette, and honor—if private
and social worth, revered and valued by all who have
been privileged to witness and enjoy it—if any of
these qualities in a professional brother reflect honor
on a work, the object of his patronage, I well may
feel proud when permitted to dedicate these “Contri-
butions” to you, who in your own person so eminently
combine all these and many other grounds for public
and private esteem. But when, in addition, I can look
back to a long, uninterrupted, happy, affectionate
friendship, in the course of which I have had many
vi
occasions to be thankful for unmerited benefits con-
ferred, and more than brotherly care lavishly extended
to me in sickness, I am happy to add gratitude to pride,
and with both sentiments to offer this volume for your
acceptance.
Believe me most sincerely yours,
THOMAS E. BEATTY.
18, Merrion Square, North.
September, 1866.
P. R. E. F. A. C. E.
-º-
IN submitting the following pages to the considera.
tion of my professional brethren, I deeply feel that an
apology should be made for what some may probably
consider this obtrusion of old materials for their perusal.
Many of the subjects which will be found discussed
have been long since satisfactorily arranged, and soun
principles are now entertained upon points which, whe
some of the subjoined papers were written, were objects
of doubt, hesitation, and scepticism. Whether these
“Contributions,” feeble though they be, had any influ-
ence in settling controversies or establishing lines of
practice, it is not for me to presume to infer; but it is
consolatory to perceive that modern ideas correspond
in many particulars with those expressed several years
ago, in various communications which I had the honor
to submit to the surgical and obstetrical societies of
this city. Time has rolled on, and with it the deluge of
professional writings which issue yearly, monthly, daily
from the press has naturally engulphed bygone contri-
viii
butions; whilst the laudable love of fresh knowledge,
and the desire to keep pace with the times, have so en-
grossed the attention of professional readers, that few
have the inclination, even if leisure permitted, to go
back to the periodicals of former days, and investigate
the history of theories and modes of practice.
Many of my professional brethren who have contri-
buted with far more ability than myself to the Dublin
Medical Journal and the Dublin Medical Press, have
been content to enjoy the reputation gained at the time
of their respective publications, and have modestly
allowed their productions to remain in those volumes,
where diligent cultivators of sound learning may seek
for them and profit by their perusal. It may be very
fairly asked of me : “Why not follow such a good
“example, and refrain from the exhumation of contri-
“butions whose value must have diminished in the
“lapse of time?” In answer to such an inquiry I have
only to say that it has been more than once suggested
to me by professional friends, on the soundness of
whose judgment I have every reason to rely, that a
collection of some of those papers which, treating of
practical subjects of the deepest importance, were not
unfavourably received at the time of their publication,
would now constitute a not unwelcome record of the
views then entertained, and of the part I had taken in
the endeavour to bring about that wholesome state
ix
of opinion which now so happily prevails. Encouraged
by this perhaps too favourable opinion of my past
labours, the natural vanity of parental affection was
stimulated, and I felt a desire to gather my papers
together, and place them safely under one cover. Some
of these treat of subjects with which I confess I would
wish to have my name associated; those, for instance,
on the Forceps, Ergot of Rye, Chloroform, Cancer of
the Uterus, and Abdominal Aneurism. With the for-
ceps I have an hereditary connexion ; for it will be
perceived by the reader who honors these pages with
a perusal, that I have introduced an account of the
part taken by my father, the late Doctor JoHN BEATTY,
in restoring this valuable instrument to its proper posi-
tion in this country.
It is not without considerable doubts that I now
submit this volume to the criticism of modern readers.
Many of the articles are only what they profess to be
—“Contributions”—written from time to time on
subjects then occupying much professional attention.
They were only so many fragments thrown into the
general stock, from which others might work up
more elaborate essays. In the same form and with
no greater pretension, they are now collected and
arranged, not in chronological order, but according
to the subjects of which they treat. The date of each
publication is affixed, from which some idea may be
x
formed of the state of opinions and practice at those
particular periods. To these I have added some more
elaborate articles, extracted from the Cyclopædia of
Practical Medicine, a work with which I was associ-
ated, and to which I contributed others besides those
which are now reproduced. I have also reprinted
some introductory lectures delivered at various times
and places. *
It cannot be laid to my charge that I have adopted
this method of bringing myself before my professional
brethren with a view to future reward or promotion,
for their unbounded favours have left me nothing more
to wish for or to which I could aspire. The many evi-
dences of the esteem of my brethren in both branches
of our profession, with which I have been honoured,
might well satisfy the most soaring ambition, and afford
grounds for the deepest thankfulness, which I now
desire to express; and again I repeat, that my cup of
professional honors is full even to overflowing.
I cannot deny myself the gratification of expressing
to my highly esteemed and valued friend Professor
MACNAMARA, the deep obligation under which he has
laid me by his superintendance of this volume through
the press. Notwithstanding the full demands upon his
time in the discharge of his hospital and professorial
duties, along with the attention necessary to his pri-
vate practice, he has devoted an amount of care and
xi
labour upon this volume without which it would have
been impossible for me to have completed the task. The
high reputation established by Dr. MACNAMARA in his
recent masterly work “Neligan on Medicines, by Mac-
namara” (to all intents and purposes a new work) renders
any eulogy from me superfluous. To his sound judg-
ment, untiring energy, and great skill the appearance
of the following sheets in their present form is to be
attributed, and I am happy thus publicly to offer him
my most cordial thanks for his valuable assistance.
Merrion Square, Dublin,
September, 1866,
C O N T E N T S .
CHAPTER I.
Observations on the Use of Instruments in cases of Difficult
and Protracted Labour.—By JoHN BEATTY, M.D. - * =
CHAPTER II.
Observations on a Species of Premature Labour to which
Pregnant Women are not unfrequently liable.—By AN
ExPERIENCED PHYSICIAN - gºs - - gº
Letter from Dr. JoHN BEATTY on a Species of Premature
Labour, &c. - -> {- º - {º
CHAPTER III.
Extracts from the Reports of the South Eastern Lying-in
Hospital, from April, 1834, to August, 1837 - -
CHAPTER IV.
Cases illustrative of the use of the Forceps º - *
CHAPTER W.
On the means of preventing Uterine Haemorrhage after delivery
On the influence of Ergot of Rye on the foetus in utero s
CHAPTER WI.
On Chloroform in Midwifery in conjunction with Ergot of Rye
On the use of Chloroform in Midwifery * - sº
Further remarks on the use of Chloroform in Midwifery ſº-
CHAPTER VII.
On Purulent Effusions into the Joints, &c. in Puerperal Women
Page
29
32
37
86
124
141
177
191
204
219
xiv. CONTENTS,
CHAPTER VIII.
A case of Pregnancy complicated with a Tumor occupying
nearly the entire pelvis * sº º- - -
CHAPTER IX.
On a rare and hitherto unnoticed form of death in Cancer of
the Uterus - tº a - t- - -
CHAPTER X.
Cases of Retroflexion of the Uterus successfully treated -
CHAPTER XI.
Case of Calculus in the Female Bladder tº- - -
CHAPTER XII.
On Frottement in Peritonitis tº - - -
ºr
CHAPTER XIII.
Inversion of the Urinary Bladder through the Urethra, with
large Prolapsus of the Rectum in a female child - º
CHAPTER XIV.
On Aneurism of the Abdominal Aorta {- tº- wºm
CHAPTER XV.
On Impotence
CHAPTER XVI.
On Rape º - * - - - * -
CHAPTER XVII.
On Doubtful Sex tº- - e- tº- - º
CHAPTER XVIII.
On Persons found dead gºs * - - º
CHAPTER XIX.
Operation for the Cure of Dysmenorrhoea tº- º tº e
Page
241
263
273
290
296
300
304
332
367
398
427
552
CONTENTS. XV
Page
CHAPTER XX.
Plastic Operations on the Female Genito-urinary Organs - 563
CHAPTER XXI.
An Address delivered before the Dublin Obstetrical Society at
the opening of the Seventh Session gº tºº - 581
CHAPTER XXII.
An Address delivered before the Dublin Obstetrical Society at
the opening of the Twenty-fifth Session - º - 603
CHAPTER XXIII.
Address delivered in the City of Dublin Hospital - - 619
INDEX º iºn gº º ſº tº – 641
CONTRIBUTIONS
TO
MEDICINE AND MIDWIFERY.
CHAPTER I.
I HAVE thought it due to the memory of my father,
the late Doctor John Beatty, to prefix to the present
volume of “Contributions” two of his papers, which at
the time they were published produced much sensa-
tion in the medical world. I do so now with the
greater satisfaction, inasmuch as the principles then
enunciated by him have been very generally admitted
to be correct; and the practice he proposed has been
universally adopted. When truths of great importance
have been long engrafted on men's minds, and acted
upon in the usual routine of life, the source from which
they have come is very apt to be forgotten; and those
who every day apply them with the happiest results
may be quite unconscious of their origin. I therefore
now reproduce the papers alluded to, hoping that a
perusal of them may not be uninteresting to the pre-
sent generation, upon whose practice they have ex-
ercised such a large and beneficial influence.
On the 5th of October, 1829, the late Dr. Beatty
read the following paper before the Association of the
1
2
College of Physicians, and it appeared in the volume
of Transactions published in 1830. The reason why
this paper was written has been already alluded to by
me, in the opening address delivered at the Dublin Ob-
stetrical Society, in November, 1862. On that occa-
sion I made the following observations:—
“Another source of rejoicing is the present state of
“ public opinion and practice respecting the midwifery
“forceps. When I compare the existing practice with
“what it was fifty years ago in this country, it is to
“me particularly a subject of congratulation and pride.
“At the time I allude to, for some time before it, and
“for many years after, including a period of fully forty
“years, this instrument was banished from practice
“ through the whole of this country. The feeling was
“so strong against its employment, and the leaders of
“ the outcry were so powerful, that no one dared to
“question the authority by which it was condemned.
“The perforator and crochet were the only means in
“use; craniotomy was the only operation. This indis-
“criminate adoption of the mutilating instruments was
“the wonder of strangers, and was the opprobrium of
“ the Dublin school. The submission to the authority
“alluded to was so complete, that I am almost perfectly
“correct in saying “no one dared’ to question it. But
“there was one faithful priest who had kept the sacred
“fire burning in spite of all attempts at its extinction,
“and, towards the close of a most laborious profes-
“sional life, had the courage to proclaim the merits
“of the forceps, and the success that had attended
“ their use in his hands. This was done at a time
“when even to mention the name of the instrument
“was considered a heresy, and nothing short of ex-
“communication could be expected by him who was
3
“rash enough to recommend its use. That individual
“was the late Dr. Beatty, my father; his paper was
“read at the Association of the College of Physicians,”
“ and published in the first volume of the new series
“of their Transactions. That first opened the eyes of
“Irish practitioners, who had for so long groped along
“in the darkness of error ; but it was not to be ex-
“pected that any very rapid change would take place.
“To convert an entire nation, long schooled in a par-
“ticular doctrine, is a work of time ; but the good seed
“ was sown ; 105 cases in one man's private practice
“were proclaimed to the world, and the reformation
“was begun.”
In order to corroborate what has been said respect-
ing the practice previous to 1829, I will here quote a
passage from the only Report of the Dublin Lying-in
Hospital that had been published up to that period.
Doctor Joseph Clarke was elected master of the hos-
pital in November, 1786, and held that office for the
appointed time—seven years. At that period the
Dublin Lying-in Hospital was the only place in Ireland
where lectures on midwifery were delivered, or where
practical midwifery could be learned. The weight of
authority of the person filling the important position
of head of that noble institution was consequently
greater then than it is at present, when so many pro-
fessorships and schools of midwifery exist in the land.
The high reputation and acknowledged ability of Dr.
Clarke gave additional force to his opinions; and all
who had no other source from which to derive infor-
mation naturally bowed to his decisions, and adopted
his precepts.f. In 1793 the period of Dr. Clarke's
* October 5th, 1829.
t While master of the hospital, he gave four courses of lectures every year,
1%
4
mastership terminated ; and then, as he afterwards
stated, he wrote his Medical Report of the Lying-in
Hospital. This Report was not promulgated until
twenty-three years afterwards, when, in May, 1817, it
was read before the Association of the College of
Physicians, and was printed the same year in the first
volume of the Transactions of that Society. In notic-
ing tedious labours, Dr. Clarke observes :—“It is cer-
“tain that a labour really tedious under the best
“management is not without danger both to mother
“ and child. I am, however, fully convinced that this
“danger is seldom lessened by the common expedient
“of extracting instruments.” Under this conviction,
“forceps were used in fourteen cases only in our hos-
“pital; and in some of these cases I yielded my own
“opinion to the sanguine expectations of my assistants.
“Cases of convulsions excepted, I have rarely had rea-
son to be well pleased with the effects of extracting
instruments, and not unfrequently have I had much
reason to deprecate their evil consequences. Wher-
ever labour is protracted to a dangerous length by
unusual resistances, there is nothing but mischief to
be expected from their application ; but where the
expelling powers are impaired by debilitating dis-
eases, the interposition of an artificial extracting
“ power is more rational and justifiable. Let it be re-
“ membered that in the hospital such means were em-
“ployed in one of 728 cases; and in private practice
“it is so long since I have had occasion to use or even
“to think of using them, that I am persuaded a fair
“opportunity of applying forceps with good effect will
{{
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* It appears from this that the forceps were in common use in this
country previous to Dr. Clarke's election to the mastership of the Dublin
Lying-in Hospital in 1786,
5
“not occur to a rational practitioner in one of a thou-
“sand cases.” Dr. Clarke seems to have carried this
maxim to a still greater extent, for we learn from Dr.
Collins, in a highly interesting memoir of Dr. Clarke
published after his death, that “He only used this in-
“strument [the forceps] once in the multitude of cases
“under his care in private.” That these principles and
this practice were adopted by Dr. Clarke's pupils and
followers is well known to all who recollect those times.
One of them, a most distinguished practitioner, and who
had filled the office of Master of the Lying-in Hospital,
and had for very many years enjoyed one of the largest
obstetric practices in this city, mentioned at a meeting
of the Obstetrical Society in 1842, that “he had once
“tried the forceps, and failed.” That Dr. Clarke, who
was confessedly one of the ablest and most distinguished
men who have raised the reputation of obstetric prac-
tice in the city, should have adopted this early preju-
dice against the employment of the midwifery forceps,
is only another instance of how the greatest minds may
be found yielding to prejudices equally unfounded. In
the case of the illustrious Dr. Denman, than whom a
sounder and more brilliant writer never lived, we find
an instance of prejudice against the midwifery binder ;
and the few lines in which he condemns its employ.
ment have most surely caused the loss of many lives.
I have thought it important to adduce these proofs of
the state of instrumental midwifery in this country, in
the early part of the present century, in order to explain
why it became necessary to write and publish a defence
of the forceps in the year 1829.
In order to show the foundation on which the fol-
* It is remarkable that in this report of Dr. Clarke's no mention is
made of the number of times the perforator and crochet were employed.
6
lowing paper was based, I may mention that the writer
of it was elected assistant physician to the Dublin
Lying-in Hospital in the year 1788, just two years
after Dr. Clarke had been appointed master, and that
he filled the office of assistant during a period of five
years; he and Dr. Clarke leaving the hospital at the
same time, in 1793. He very rapidly acquired a large
practice. From an accurate registry of his cases, I find
that in thirty-eight years and five months (he died in
June, 1831), his private patients numbered 5,616. In
Dr. Collins' account of the private practice of Dr.
Clarke, he states that “during the lengthened period
“ of forty-four years, he attended the unexampled
“ number of 3,878 patients.” It hence appears that in
three years and a-half less than Dr. Clarke occupied,
my father attended 1,738 patients more than he did.
This, I think, may fairly be claimed as an unexampled
number.
Observations on the Use of Instruments in Cases of Dif.
ficult and Protracted Labour. By JoHN BEATTY, M.D.
[Read 5th of October, 1829.]
IN every case of midwifery, the chief object to be
attained by the practitioner should be the preservation
of the lives of both mother and child entrusted to his
care. The great majority of cases require no extraor-
dinary assistance, and the duty of the accoucheur con-
sists principally in watching the progress of the efforts
which nature makes, and guarding against any unfa-
vourable accident, or deviation from the ordinary
course. Unfortunately, however, some few cases do
occur, in which from particular circumstances instru-
mental aid is required ; and while we may lament the
7
necessity for such interference, it is our duty diligently
to inquire into the merits of the means proposed to
assist delivery, and to select those that we find most
likely to effect the purpose already mentioned, that of
preserving our patient and her offspring.
It is of importance that every man practising mid-
wifery should avoid as much as possible the use of
instruments in delivery; for it is certain that, if he
suffers his patience to be too readily exhausted, or
yields too easily to the suggestions and alarm of the
patient or her friends, he will frequently be induced
to promote delivery too soon, very much to the injury
of the patient, and consequently to his own character.
On the other hand, he has an important duty to per-
form, in judging of the necessity and the proper time
for using instruments, and the kind suited to each par-
ticular case ; for as much or more mischief may be done
by delaying their use when absolutely required, as by
having recourse to them too soon. In fact, in this, as
in most other situations, the man who has patience to
watch, judgment to discriminate, and firmness to act,
will be the best qualified to perform the duties required
of him.
Having endeavoured, during a long and actively
employed life, to regulate my practice by such prin-
ciples, I have formed the following conclusions respect-
ing the comparative value of the different instruments
used in long-protracted or difficult labours. And I
am induced to give a faithful account of my own expe-
rience, and of such means as I have occasionally em-
ployed, because I have reason to know that my opi-
nions on the subject differ from those of some of the
most eminent and justly esteemed members of the
profession in this city,
8
I do not propose to enter into a detail of the causes
and nature of long-protracted and difficult labours.
These are so fully treated of and explained in all works
on midwifery, that it would be useless to repeat them
at present; but I may observe that the cases in which
mechanical skill is required may be comprised in two
divisions. 1st. Those where there is a disproportion
between the head of the child and the passage through
which it must come; and, 2ndly. Those in which,
although no mechanical impediment exists, the expul-
sive powers of the mother are not sufficient to accom-
plish the delivery.
Under the former will be found those caused by the
deformity of the bony parietes of the pelvis, and by
disease or rigidity of the soft parts, as well as unna-
tural size of the head of the foetus, face presentations,
and transverse position of the head ; and under the
latter, those in which delivery is delayed by general
weakness of the patient, haemorrhage, frequent faint-
ings, convulsions, great exhaustion, fever, &c.
To assist delivery under such circumstances, two
classes of instruments have been devised ; 1st. Those
by which extraction may be effected without injury to
either mother or child; 2dly. Those by which the life
of the latter must necessarily be sacrificed. I need
scarcely remind the members of an enlightened and
humane profession, that the adoption of the latter alter-
native is a step calling for the most serious consider-
ation, and one that involves an awful and heavy
responsibility. The value of human life is not to be
estimated by the age, nor is there, in the eye of the
law either human or divine, any distinction between
that of the octogenarian and the child unborn.
It matters little, therefore, what the nature of the
9
situation is in which a fellow-being committed to our
care is placed, whether it be a fever striking him in the
prime of life, or a disease requiring the performance of
a capital operation, or the perils attending his first
entrance into the world, it is our bounden duty to
employ such means as will best ensure his safety.
Let it not be imagined that by these observations I
would inculcate that the well-being of the mother is
to be overlooked in endeavouring to save the child.
Far from it; the very nature of the sentiments points
out the contrary ; but what I desire to maintain is,
that the life of the child in utero is as sacred as if it
had breathed and walked, and that its destruction can
only be conscientiously resorted to, when every other
means by which it and its parent might be saved
have been fairly tried and found inefficient.
The perforator and crotchet were the instruments
employed formerly, and, so late as 1746, Lamotte
states that “when he began practice he found several
“old surgeons, who, when they were called to attend
“women in labour, took their instruments with them,
“ and brought away the child by their means. A
“woman being in labour a day and a half or two
“ days was more than sufficient to set them at work,
“ and this was the only resource they had in all cases
“indiscriminately. So universal had this practice
“ become, that, as Dr. Chamberlain observes, it gave
“rise to the report that whenever a man came, the
“mother, or child, or both must die.”
Daventer had no knowledge of any other instru-
ment, and states in his quaint language that “when-
“ever the head of the infant falls down into the narrow
“cavity of the pelvis, and is there so that the least
“ descent is not upon the force of the pains, and all
10
“remedies have been tried in vain, the infant is to be
“ handled and drawn out as a dead one.”
F ortunately for the character of the profession, as
well as for the cause of humanity, a revolution was
effected by Chamberlain, who by the introduction
of a harmless instrument gave rise to the investigation
of the true nature of difficult labours, and by the suc-
cess attending its use in his hands, and those of his
three sons, fully proved the value of the principles on
which it was constructed, and the certainty with which
its intention might be accomplished.
The effect of Chamberlain's invention of the forceps
was, to bring about the classification of difficult labours,
and to lead practitioners to discriminate between cases
in which the life of the child must be sacrificed, and
those in which it could be saved. Since his day
every systematic writer on midwifery has borne ample
testimony to the value of the instrument, and from a
collation of the evidence it may be fairly inferred that
the employment of the perforator and crotchet should
be the practitioner's last resource. Thus Smellie says:
“If you can neither turn nor deliver with the forceps,
“ the head must be opened, and delivered with the
“crotchet.” Also he adds, “Indeed this method for-
“merly was the practice, and is still in use with those
“who do not know how to deliver by the forceps.”f
Chapman, after reflecting on the too frequent use of
the perforator and crotchet, states “ that most births
“may be accomplished without instruments by the
“assistance of the hand only, or, where instruments are
“really required, by the help of the forceps, which
“are not only perfectly safe and convenient, but ex-
* Treatise on Midwifery, 5th edition, p. 153.
f Op. cit., p. 183.
11
“tremely useful, and in some cases absolutely neces-
“sary.” And again he says: “All I shall say of this
“noble instrument (the forceps) must necessarily fall
“short of what it justly demands; those only who
“ have used it, and experienced the excellency of it, to
“ their own advantage and the security of their off.
“spring, can be truly sensible of its real worth. As I
“think myself bound to recommend it strongly to the
“gentlemen of the profession, I shall omit no opportu-
“nity of endeavouring to do it justice.”f
Sir Fielding Ould says: “If there be not a certainty
“of the child's death, the best adapted instrument is
“ the forceps, which is in general use all over Europe;”
and again he asserts that “with attention and care the
“infant will never be destroyed by this instrument.”
Mr. William Dease of this city, whose practice was
extensive, and whose discrimination and judgment were
universally admitted, says that “the forceps, prudently
“applied, is an instrument which in good hands may
“safely effect delivery in difficult labours, is what every
“practitioner must have been repeatedly convinced
{{ of. "S
Dr. Merriman says: “The assistance to be afforded
“in difficult labours will frequently be that of the for-
“ceps, for unless in cases of distorted pelvis, the head
“of the foetus will frequently have sunk low enough
“to allow the ear to be felt.”||
Dewees, after some judicious observations upon the
fallacy of arguing against the use of any thing from its
abuse, says: “Let those who are to practice midwifery
* Treatise on Midwifery, 3rd edition, p. 73.
t Op. cit., p. 86.
it Treatise of Midwifery, p. 153.
§ Observations on Midwifery, p. 40.
| On Difficult Parturition, 3rd edition, p. 42.
12
“ become well acquainted with the elementary parts of
“ their profession, and then gradually proceed to the
“more difficult operations connected with it, and the
“clamours against the use of the forceps will in a great
“measure cease.”...“It is certainly within our recollec-
“tion, when cases similar to those which are now almost
“universally relieved by the forceps were as certainly
“treated by the crotchet, the child was a certain vic-
“ tim, and the mother a probable one.”f
Denman says: “When there are signs of imminent
“danger, however averse we may be to the use of instru-
“ments, we may be induced to try the forceps, though
“ the case might not be altogether such as we might
“choose for their application, merely to take a chance
“of saving the life of a child, which must otherwise be
“ inevitably lost.”
Millot was so convinced of the value of the forceps,
and its fitness for the purpose for which it was con-
structed, that “he calls upon the French government,
“in the name of the thousands of individuals who owe
“ their lives to it, to place a bust of the author in the
“School of Medicine, with an inscription commensu-
“rate to the services he has rendered to humanity.”$
Maygrier states his conviction that “in a few years
“ the forceps will be the only instrument employed by
“ the accoucheur.”||
Madame Lachapelle, in her Pratique des Accouche-
ments, after some excellent remarks upon the use of the
perforator, concludes by saying that “it is only in
* System of Midwifery, 8th edition, p. 286.
+ Op. cit., p. 292.
f Introduction to Midwifery, 3rd edition, p. 353.
§ Supplément des Accouchements, seconde édition, p. 132.
| Nouveaux Elémens des Accouchements, seconde édition, p. 384.
13
“cases of absolute necessity that it should be made use
“of; and that in order to create such extremity, the
“forceps and turning must have been found imprac-
“ticable.”
Many other authorities might be quoted, but this
body of testimony must be sufficient to convince any
candid inquirer, that the voice of the profession is deci-
dedly opposed to the precipitate employment of the
deadly instruments. It is therefore the duty of every
practitioner to investigate the nature of the cases in
which the forceps may be applied, the time at which
they may be best used, and the manner of employing
them. I may here observe, with Denman : “We are to
“remember that the forceps are not to be applied
“ because we have the power of using them, but because
“ the necessity of the case is such as to require their
{{ use.”
Much has been written with respect to the period at
which such a necessity may be said to have arisen; but
it is with this as with most other actions of the animal
economy, no precise time can be assigned ; the urgency
of a case cannot be estimated by the number of hours
that labour may have lasted, but by the state of the
mother in each particular case.
Doctor Denman defines difficult labours to be
“ those in which, although the head of the child pre-
“sents, the delivery is not terminated in twenty-four
“hours from the commencement of real labour.” Every
practitioner must be aware that such cases are by no
means unfrequent, and that the efforts of nature in
very many of them, and even in others of much longer
duration, are sufficient eventually to expel the child.
* Pratique des Accouchements, p. 85.
14
But when labour is thus protracted, circumstances may
and do often render it desirable to expedite delivery.
These, as I have said, relate not to time, but to the
condition of the mother; some women being able to
bear a much greater length of suffering than others.
In the more simple cases, those that are unconnected
with convulsions, haemorrhage, &c. the state of exhaus-
tion of the mother and cessation of labour pains are
the best indications for the interference of art.
Doctor Osborne says that “in the state indicating the
“use of forceps, all the powers of life are exhausted, all
“capacity for further exertions is at an end, and the
“mind as much depressed as the body: they would both
“sink together under the influence of such continued
“ and unavailing struggles.”
Now, to wait for such a period as this is but to
delay the operation until the chances of success are
almost lost; in fact, there will be but little prospect of
any thing but the removal of a dead child from a
dying mother; and it is such a practice that has at
times brought this valuable instrument into disrepute
and disuse : the want of success has been charged upon
the operation, where it ought to be laid at the door of
the operator. It is with us in this as it is with the
surgeon in strangulated hernia, the operation should
be performed as soon as the necessity for it is found to
exist, every moment's delay diminishing the prospect
of a successful termination ; and it is to this principle
that so many happy results from the use of the scalpel
in that disease, in modern times, are to be attributed.
Let not the accoucheur, therefore, wait until the powers
of life are exhausted ; his duty is to prevent such an
occurrence, and this is to be done by the timely appli-
cation of the forceps. Delivery with this instrument
15
may be attempted in whatever position the head may
be, if it be sufficiently low in the pelvis, while at the
same time the os uteri is dilated, and the soft parts are
relaxed. As soon as matters are in this state, the prac-
titioner should proceed to deliver without waiting until
the mother's strength is so exhausted as to raise alarms
for her safety, and oblige him to fly to any means of ex-
traction without regard to the life of the child. Delay
under such circumstances, and running the patient to
the last extremity, in giving her and nature (as it is
called) every chance, is, in my opinion, a main cause
of the too frequent use of the perforator. “Neque
temerè, neque timidè’ is the best motto by which the
accoucheur can be guided in such circumstances.
By this timely interference the evils attending upon
difficult labours, such as contusions, inflammations,
and sloughing of the soft parts, will be obviated, as it is
generally found that these effects are proportionate to
the length of time the parts have been subject to pres-
SUII’é.
With respect to the ill effects said to follow the use
of the forceps, I am bold to say that though I have
read and heard of such, I never witnessed any, when
the instrument was used in time, or with proper discri-
mination and dexterity, and where the patient was not
already too much exhausted ; and from the success that
has attended the use of the forceps in my hands, I might
also assert that no unpleasant consequences can occur,
provided the proper time be selected.
In looking over my case-book, I find that during
forty-two years in which I have been actively employed
in the practice of midwifery, the first five years of which
were spent in the Dublin Lying-in Hospital as pupil
and assistant to Dr. Clarke, it has fallen to my lot, in
16
my private practice, to have delivered one hundred and
eleven women with forceps or lever; and, having kept
a faithful registry of my practice, I am enabled to speak
with certainty of each case, however remote as to time.
I have to lament the death of my early and highly
esteemed professional companions and friends, Doctors
Pentland and Tuke, and Mr. Creighton, who co-operated
with me in several of them, and could bear testimony
to the facts. I can, however, still appeal to several
highly respectable practitioners in this city, who have
done me the favour to consult me in different cases.
In this extensive number, which, it will be admitted, is
sufficient to put the merits of the practice to the test, it
might be expected that some proportion of fatality or
accident should be found; but the valuable part of the
statement, and what I wish to impress upon the minds
of the profession, is that in no instance of the hundred
and eleven cases mentioned above did any unpleasant
result follow ; none of the mothers died, none of them
had their perinaeum lacerated, nor any of those evils
which are set forth as the effects of the forceps; and,
still more, all the children that we had any reason to
think were alive at the commencement were born
living, and none of the whole number had any injury
or mark whatever inflicted by the instrument. From
this extensive experience of the value of the forceps, I
think I am justified in saying that the opinions of the
authors already quoted are fully supported by the facts.
With respect to the operation, no great dexterity is
required for its performance; a little management in
the introduction of the blades, and patience in the ex-
traction, are all that is required to bring it to a happy
termination. The instrument I have always used is
that which is called male and female, from the trans-
17
verse opening in the root of one blade, through which
the other is passed. Other practitioners prefer the
curved forceps. It is quite immaterial which is chosen,
provided they are used in proper time, and with good
judgment.
Having ascertained by the rules already laid down
that immediate delivery is desirable, my custom is to
empty the bladder and rectum, by the catheter or an
enema, if required. The patient being placed on her
side, as near to the edge of the bed as possible, I pro-
ceed by introducing the female blade of the forceps,
slowly and carefully, over the upper side of the head of
the child, until it reaches beyond the ear ; this being
accomplished, the chief difficulty is overcome, for the
male blade being passed through the slit in the female
blade, readily applies itself in the proper position, by
gently urging it forward under the inferior side of the
head. It is of importance to attend to this order of
proceeding, for if the female blade were introduced to
the under side, it would be difficult, from the relative
position of the patient and the bed, to pass the male
blade through it. The application of the instrument
usually brings on slight action of the uterus, although
it may have ceased for several hours. This I always
wait for, and, taking advantage of the natural effort, the
perinaeum being supported by the nurse-tender, or my
own left hand, I have seldom found any difficulty in
extracting the child alive and uninjured, provided it
were so previous to the commencement of the operation.
The operation as performed in this manner gives so
little pain, and delivery is in general so easily accom-
plished by it, that I have been several times requested
by patients, with whom I had previously employed
forceps, to use them in subsequent labours.
2
18
I have been called upon in several protracted cases
of labour, some of them of first children, and of women
advanced in life, to give sanction to delivery with the
perforator and crotchet, and have found the instru-
ments ready prepared for the operation ; when I have
recommended a trial with the forceps, and fully suc-
ceeded in bringing into the world living children, with
very little if any trouble to myself, no risk to the
mother, and no injury to the child. This is well known
by several most respectable practitioners in Dublin,
who have been witnesses to the result.
When I contrast the feelings created at such a
moment, in the operator, the patient, and her friends,
with those experienced when the body of a child (of
whose previous life the mother had no doubt), is
dragged mutilated into light, I confess that I cannot
understand why the latter should ever be adopted,
without the fullest certainty of the impracticability of
the former. What adds to the horror of the perforator
is, that it is no uncommon circumstance to have a child
born alive and cry, whose head had been opened, and
the brains partially destroyed. Doctor Burns says:
“By the rash and unwarrantable use of the crotchet,
“living children have been drawn through the pelvis
“with the skull opened, and have survived in this
“shocking state for a day or two.” Daventer, Cham-
berlain, and others give instances of women delivered
by the crotchet of dead children, “as they supposed,
“when to their great surprise the miserable infants
“filled their ears with cries.” Mr. Dease states that
“he has seen instances where the child has been miser-
“ably dragged alive into the world, with a great part
“of the brain evacuated.”f
* Principles of Midwifery, 6th edition, p. 465.
+ Observations in Midwifery, p. 40.
<3
19
Similar instances have, I understand, occurred in
this city; in one of which humanity prompted the
accoucheur to plunge the child into a vessel of water,
to put an end to its cries and its existence.
I can never forget a scene of horror to which I was a
witness in the year 1800. I was called upon to see a
very young lady, in labour of her first child, who was
under the care of one of the oldest and most eminent
practitioners in this city (since dead); her labour was
most violent, which she bore with great impatience and
noise. The head had been down on the perinaeum (he
said) several hours; I proposed to give more time, and
an opiate—not doubting the powers of nature—or to try
the forceps, which he declined, on account of its being
her first child, and the apprehension he entertained of
her being exhausted ; and finally he opened the head.
The operation, as it always does, excited extraordinary
uterine action, and before it was well concluded, or the
brain evacuated, so as to lessen the bulk of the head,
the child was propelled into the world alive and crying.
The old gentleman, whose patient she was, was a
person of very fine feelings, and the reader may imagine
his sufferings on viewing the effect of a rash and ill-
judged operation. He declared no earthly consideration
should ever induce him again to witness the application
of the perforator.
The following cases occurred to me lately, and as
they fully exemplify my principle, I will give a brief
account of them.
Mrs. M., 30 years of age, and remarkably corpulent,
took labour of her first child early on Friday, the 28th
of November, 1828, and at six p.m. the membranes
ruptured; from this I will date the commencement of
real labour. The pains continued to increase in seve-
2%
20
rity and frequency until 2 o'clock, p.m. on Monday
following, a period of sixty-eight hours from the eva-
cuation of the waters. During the whole of this interval
she had not slept, and had taken no sustenance except
a small quantity of whey ; consequently her strength
was a good deal exhausted. The bowels had been freed,
and during the last twenty-four hours the bladder was
twice evacuated by the catheter. The head of the child
was now sufficiently low in the pelvis, the os uteri was
dilated, and the external parts were relaxed. In this
state of things I proposed to deliver her by the forceps,
which at first produced alarm in her mother and
friends, and even in the nurse-tender ; and I was ear-
nestly asked if I could not do something to save both,
and not kill the child; for they understood that when
instruments were introduced in delivery, the child was
always destroyed. I assured them that my object was
to save both, and showed the instrument I meant to
employ, explaining at the same time the nature of the
operation. With this they were perfectly satisfied. I
then applied the forceps as I have already described,
and waited patiently for a pain; on its occurrence I
gave assistance, and during its continuance a living boy
was born, without scratch, or bruise, or injury to the
perinaeum.
This was a case in which there was no likelihood of
labour being over for several hours, if left entirely to
nature, and in which there was considerable danger
that both mother and child would suffer materially
before its completion ; all this was prevented by a few
moment's well-timed exertion, which produced inde-
scribable satisfaction in all persons concerned. I called
to the recollection of my patient, that the wife of a right
honourable friend of hers had been delivered by me
21
some years before of her first child, under similar cir-
cumstances, and with the same result, at an age very
little under forty years.
December 21st, 1828.-I was called to a patient
who had been upwards of twenty-four hours in very
severe labour of her first child; I found the head
pretty low in the pelvis, though not on the perinaeum.
A very respectable midwife, who had been in attendance
from the commencement, stated that it had been in the
same situation or position for twenty hours, and within
that period a tumour had formed upon it, which was
now so great that the midwife, who had frequently
witnessed the operation with the perforator, but had
never seen the forceps used, except once by myself
several years before, said, “Sir, I fear this case will not
“admit of the use of the forceps, as the head is so much
“swelled.” I replied that although I could not posi-
tively promise success, yet I would give the child the
only chance it had for life, and that if I failed in the
attempt, it would then be necessary to resort to other
means, as the patient was greatly exhausted, and the
soft parts had been long subject to very strong pres-
sure. With some difficulty I accomplished the intro-
duction of the forceps, and desiring the attendant to
protect the perinaeum, I waited for a pain ; three of
these efforts of nature were made (during which I gave
the necessary assistance) without extraction; but during
the fourth, and within fifteen minutes of the commence-
ment of the operation, a large living boy was safely born.
I requested the midwife to examine the perinaeum
carefully, for her own satisfaction and that of her friends,
and she declared it to be perfectly unhurt. This
is a case in which the head would certainly have been
opened by those who are prejudiced against the forceps,
22
as the apparent disproportion between it and the pelvis
would have led them to suppose that there was suf.
ficient reason to authorise the use of the perforator.
The occurrence of convulsions in difficult labour has
been considered as affording a sufficient ground for the
immediate delivery by opening the head; yet even in
this case many lives may be saved by a judicious use
of the forceps. I would by no means advise that much
time should be spent in endeavouring to save a child
while the mother is in imminent danger ; but I would
strongly insist upon the necessity of trying means to
prevent it, particularly as the operation by the forceps
does not occupy so much time as that by the perforator;
and should the attempt fail, it is easy to have recourse
to the latter. That such a principle admits of practical
application, the following case fully testifies.
In the year 1814, a gentleman residing eighteen miles
from Dublin called on me to request I would accom-
pany him with all expedition to see his wife, who had
been suddenly seized with labour of her first child,
attended with convulsions before he left home. We
reached his house in about five hours from the time he
left it. I found the lady lying on the parlour floor,
labouring under severe convulsions, and quite insensible,
in which state she had remained during her husband's
absence. On examination the head was found to be
low in the pelvis, and the os uteri dilated. Without
removing her I introduced the forceps, and in a few
minutes succeeded in extracting a female child alive.
The mother was now removed to bed. The convul-
sions ceased in a short time; her senses were restored,
and the recovery was as speedy as if no untoward cir-
cumstance had occurred. I may observe that the gen-
tleman had no more children, and the child then born
23
is now alive, and heiress to his large estates—a conso-
lation of which he must have been deprived had I
rashly employed a destructive instrument. If I had
experienced much difficulty in this case, I would have
thought myself justified, nay, called upon to sacrifice
the child, but certainly not until I knew it was unavoid-
able ; and I state it to show that in the worst of cases
the milder means may be resorted to with considerable
prospect of success.
With respect to the use of the perforator, Dr. Denman
justly observes: “The reason for and justification of
“opening the head must be decided from the state of
“the mother, and that state must be such as to prove
‘ her inability to expel the child, and the impossibility
“of extracting it by those means which have been con-
“trived for the purpose of delivering women, giving at
“ the same time a chance for preserving the lives of
“ children.”
In fact, the legitimate cause for using this instru-
ment is distortion of the pelvis. Dr. Osborne considers
that “a foetus at full maturity cannot pass alive, if the
“dimensions of the pelvis from pubis to sacrum be only
“two and a-half inches.” Dr. Clarke of Dublin says
that “three and a-half inches is the least diameter
“ through which he has known a full-grown foetus to
“ pass entire.” These measurements are taken with
reference to the head of the child, which being of a
variable size in different cases, the proportion it bears
to the passage must be also variable : hence arises the
danger of confining ourselves to actual instead of
relative measurement—for a pelvis that would admit
the passage of one head might be unable to transmit
another.
I do not mean to depreciate the value of actual mea-
24
surement in enabling us to form an opinion, but I
would warn the practitioner against judging from it
alone, and hastily concluding that safe delivery is im-
possible; and also against concluding that every female
with a distorted spine has a deformed pelvis. In all
such cases we should ascertain, if possible, whether the
distortion of the spine commenced in infancy, or about
the time or subsequent to puberty; if it commenced
in infancy, it will be reasonable to suspect that the
pelvis participates in the deformity, and is contracted
in its dimensions; but if it did not come on until the
growth of the body was perfect, or nearly so, we may
hope to find no deformity in the pelvis. Such distortion
of the spine frequently takes place in delicate females
after marriage, and even after having had some chil-
dren ; and then I never knew it to interfere with the
pelvic bones. In cases of contracted pelvis, it behoves
the practitioner, as Dr. Merriman observes, to be exceed-
ingly cautious ; not to suppose upon light or insufficient
grounds that the distortion is too great to allow the
child to pass, and particularly so when there is a question
about employing the perforator. The fact is, there
have been instances where, by the effect of nature alone,
living children have passed through a pelvis scarcely
measuring three inches.* Therefore our attention
should be directed more to the effect produced
upon the head by the action of the uterus, than
to the actual dimensions of the pelvis. If we
find, after several hours of hard labour, that no de-
scent of the head into the pelvis has taken place,
and that the patient's strength is beginning to fail,
we may expect that it will be necessary to diminish
*Burns on Midwifery, p. 462, and Hamilton's Practical Observations
on Midwifery, Part II, p. 129.
25
the bulk before expulsion is accomplished; but so long
as the pains have any effect, however small, in forcing
down the head, we are warranted to look for the birth
of a living child. In a case of this description the
forceps or lever will often be of the greatest assistance.
It is truly surprising to witness the degree of com-
pression that the head of a child will bear without
detriment.
Smellie relates the case of a young woman, only fif-
teen years old, whom he delivered of a living child by
the forceps, and the child's head being large had been
Squeezed to a great degree, so as to alter its form, but
in a few days it completely regained its natural
figure.*
Dr. Denman also gives an account of a child born
alive, with a depression of fully an inch in depth on
the left parietal bone, occasioned by the projection of
the os sacrum ; but the depressed part gradually rose,
and in a few months regained its original level.f. I
have myself often witnessed the birth of children
whose heads had suffered very great compression, yet
no unfavourable symptoms followed. We are not to
be deterred, therefore, from attempting delivery by the
forceps, because the disproportion may appear too
great ; but we must be convinced that it is really so,
by ascertaining the impossibility of extracting the child
entire. If we have patiently and fairly tried the for-
ceps or lever, and failed in the attempt, we will then
have recourse to the perforator with greater assurance
of its necessity, and perfect freedom of conscience. In
this case I would express myself in the emphatic lan-
guage of Dr. Burns : “I beg that, as the practitioner
• Treatise on Midwifery, 5th *ition, p. 153.
i Introduction to Midwifery, p. 183.
26
“values the life of a human being, and his own peace
“ of mind, he will not desist, and have recourse to the
“crotchet in cases at all doubtful, until it has been
“well ascertained that neither the lever nor forceps
“could be used.” By the adoption of this principle,
many labours will be brought to a happy termination
which appear to threaten the death of the child. In my
own practice it has been followed with the greatest
success, and I am happy to state that, since the year
1804, I have used the perforator and crotchet but
three times, while the majority of the hundred and
eleven forceps cases occurred in the same period.
In conclusion, I will observe that nothing short of
the most imperative necessity can warrant the use of
the destructive instruments, and no case can be con-
sidered as demanding them until every means by which
both mother and child might be saved have been put
into requisition and fairly tried. Let us ask, with De-
wees, what is to be feared from a proper application of
the forceps ? Is their mode of action such as to do
injury to either mother or child when well directed ?
Certainly not. Then there is nothing to be appre-
hended from their structure, application, and mode of
action, since they neither cut nor contuse mother or
child when well directed. They neither create un-
necessary pain nor inordinately augment that which
may be present, but are truly calculated, in the lan-
guage of Dr. Denman, to supply the insufficiency or
want of labour pains. If this be so, and it is admitted
by Dr. Denman himself, why should they be con-
demned because in common with every thing we pos-
sess they may be abused ? I repeat it, the object of the
practitioner should be to preserve both mother and off.
spring ; if, unfortunately, he should ultimately fail in
27
this endeavour, he must then decide between the two,
and sacrifice the child. To be driven to such an ex-
tremity is one of the most painful situations in the
practice of midwifery; it forces a man to perform an
operation differing in principle from every one in use
among medical men. All others are done with a view
to the ultimate benefit of the sufferer ; but this alone
tends to his immediate destruction. Such a considera-
tion, together with the heavy responsibility a man in-
curs by becoming the voluntary destroyer of a human
being, should make us pause ere we lightly reject means
by which results so lamentable and awful might be
avoided.
28
CHAPTER II.
THE other of those papers written by the late Dr. John
Beatty, that I wish to republish, is one relating to a
most important subject, which was very imperfectly
understood in this country at least, if not in all coun-
tries, at the time of the publication of his observa-
tions, viz., syphilis in the unborn offspring of parents
apparently healthy.
I am the more induced to republish this paper at the
present time, because a recent writer, whose work has
been translated by the New Sydenham Society,” appears
to have been ignorant of its existence, as no notice is
taken of it in his highly valuable and almost exhaustive
work.
The origin of the paper alluded to is curious and in-
teresting, for it shows in an unmistakable manner that
the subject was not generally understood at the time.
In June, 1821, a paper was read at the Association of
the College of Physicians, entitled “Observations on
a species of Premature Labour to which pregnant
women are not unfrequently liable,” by “An Experienced
Physician.” It was well known at the time that this
communication was from the pen of the late Dr. Joseph
Clarke, who was in every way entitled to call himself
an experienced physician, having been Master of the
* Syphilis in New-born Children. By P. Diday.
29
Dublin Lying-in Hospital, and having for many years
enjoyed a very large practice in this city. The question
proposed in that paper was answered by the late Dr.
Beatty, in a paper read at the Association in December,
1821. Both papers were published in the fourth vo-
lume of the Transactions of the Association, in 1824,
from which I now extract them.
Observations on a species of Premature Labour to which
pregnant woman are not unfrequently liable. By an
Experienced Physician.
[Read June, 1821.]
There is a species of miscarriage, or premature labour,
to which my attention in private practice has been for
many years frequently called. It is one of those cases
which I have found constantly distressing to the patient
and perplexing to the physician.
I have looked into many books, and consulted with
several eminent and experienced physicians and sur-
geons on the subject, without procuring much satisfac-
tory information. It is my wish, therefore, through the
medium of the Transactions of this Association, to excite
the attention, and, if possible, to collect the observations
of experienced practitioners in regard to it. How far it
may be practicable to accomplish this design time only
can determine ; the goodness of intention will, it is
hoped, justify the attempt.
The case to which I allude is this :—A lady, appa-
rently healthy, conceives, and carries her child in the
usual way, till, about the seventh or eighth month of
pregnancy, she by degrees ceases to perceive the
motions of her child; and in about ten days or a fort-
night after this event she falls in labour, and a foetus,
30
evidently dead for some time, is expelled. This often
happens three, four, five, or six times in succession, or
perhaps more frequently, to the same patient, and
about the same period of pregnancy. The first time
such accident happens there has generally been some
cause to weaken the patient during gestation ; but, in
the subsequent instances, it rarely happens that any
adequate cause can be assigned. Women who have
borne many healthy children have sometimes fallen into
this pernicious habit, and continued it for a length of
time, and afterwards had living children. A memorable
instance of this kind occurred in the lady of a Viceroy
in Ireland, about thirty years ago. In such cases it is
evident that miscarriage happens in consequence of the
foetus dying in utero.
The following question, therefore, is naturally sug-
gested :—What are the most likely means of prevent-
ing the death of the foetus in utero As the foetus
necessarily draws its nourishment entirely from the
mother, it is reasonable to suppose that its existence
must intimately depend on the quantity or quality of
the fluids supplied by her.
In some cases we have good reason to think that
more blood circulates in the mother's system than is
consistent with the health of the child in utero ; more
frequently, however, we have very good reason to sus-
pect the contrary; viz., that a deficiency of blood takes
place in the maternal constitution. In not a few cases
I have had reason to suspect the existence of acrimony
in the fluids of the mother : by the imprudence of
husbands, a venereal taint has been sometimes acquired
which required the use of mercury, and which perhaps
has been insufficiently employed. The wives of such
are particularly liable to the disease in question, al-
31
though no unequivocal venereal symptoms shall exist.
The most likely method, then, of preventing the death of
the foetus in utero is to consider whether, in the
mother's constitution, there be symptoms of redun-
dant, or deficient, or acrimonious blood. The symptoms
of a plethoric constitution, and the best means of re-
ducing it, are too well known to require any lengthened
detail. The symptoms of a debile constitution are
equally well known.
I have only to remark, under the second head, that
in some such cases I have had reason to think very
small bleedings, at distant intervals, of use, although
little indicated by symptoms. Was this by creating a
tendency to plethora 2 This is an effect of which vene-
section has been accused. Symptoms of acrimony in
the fluids are more equivocal and uncertain, as well as
the means of correcting it.
In the unimpregnated state, sulphureous mineral
waters, goat's whey in the proper season, tepid bathing,
strong decoctions of Sarsaparilla, and slight mercurial
courses may be tried. Where there are no decided
syphilitic symptoms on either parent, and a healthy
child in existence, and assurances of no subsequent ex-
posure to recent infection, it appears rather unreason-
able to press the use of mercury to any extent, and in-
deed it will seldom be submitted to.
Here, however, experience appears deficient; further
observations seem to be wanting ; and the experienced,
into whose hands these remarks may fall, are entreated
to forward to this Association any facts tending to
illustrate this obscure and interesting subject.
32
A Letter from Dr. Beatty on a species of Premature
Labour, &c.
[Read December, 1821.]
I have been gratified with the perusal of a paper
written by an eaſperienced physician, “on a species of
“ premature labour to which pregnant women are not
“unfrequently liable ; viz., when a lady, apparently
“healthy, conceives, and carries her child in the usual
“way till about the seventh or eighth month of preg-
“nancy, and by degrees ceases to perceive the motions
“ of the child; and in about ten days or a fortnight
“after this event she falls into labour, and a foetus,
“evidently dead for some time, is expelled,” &c.
The subject of the above communication attracted
my attention when very young in the profession, and
has continued to do so ever since. So early as the
year 1798, when I was resident assistant at the Dublin
Lying-in Hospital, I delivered a woman in Great
Britain-street of a putrid child, in the eighth month of
pregnancy, which she told me had been the case with
several children that she had had before, and that she
despaired of having living issue.
I inquired very particularly into the state of health
of both the parents, and suspecting venereal taint to
be the cause, I proposed to them the use of mercury
and separate beds, until I should be satisfied with the
quantity of mercury used. They readily complied
with the proposal, and the result was a living boy in
due time, after the mercury had been discontinued ;
and their happiness at the event may be more readily
supposed than described, as they were both at the time
pretty far advanced in life, and never had another
child.
33
Several similar cases occurred to me from that time
with similar success, which I shall pass over, as they
rest only on my own experience, and shall therefore
confine myself to a very few, in some of which I was
assisted by Mr. Colles and Mr. Todd.
In my case-book, to which I have referred, I find that
in August, 1812, I attended the wife of a staymaker,
who was delivered of a putrid child in the seventh or
eighth month, which, she said, was the third that she
had born dead. I discovered so much of venereal af.
fection as to recommend that they should put them-
selves under the care of some experienced surgeon for
the use of mercury. They applied to Mr. Colles, and
when she was pregnant in the following year, Mr. Col-
les told me that they had not continued a sufficient
time under his directions to satisfy him that they were
cured of the venereal complaint; which I found to be
the case in July, 1813, when I delivered her again of
a putrid child in the eighth month. I then declared
that I never would attend her again, until Mr. Colles
told me that he was satisfied with the result of the
mercury used. They again returned to him, and fully
attending to his directions, in October, 1814, I attended
her, when she bore a living girl at the full period of
gestation. She has had several living children since.
In October, 1816, I delivered the wife of a cavalry
officer of a putrid child in the eighth month. The
gentleman had been on the continent with his regiment
without his wife, and had contracted a slight venereal
complaint, of which his surgeon considered him well
before his wife joined him in France. I could not de-
tect any venereal symptom in the parents, but was so
satisfied with the cause of the child's death, from the
peculiar appearances on the body, that I recommended
3
34
them to consult some eminent surgeon ; and Mr. Todd
was called in, who met the regimental surgeon with me,
and advised the use of mercury, which was regularly
persevered in by both for several weeks. After this
course, pregnancy was soon the result, and in Novem-
ber, 1817, I had the gratification of attending her when
she had a living girl. She has had several living chil-
dren since.
A nurse who had contracted venereal disease by
suckling the child of a general officer, and was supposed
to be cured, had two dead putrid children in the seventh
or eighth month. I requested Mr. Todd to see her,
and take her under his care, which he did, and the poor
woman has had several healthy children since.
In April, 1818, I attended a very fine, healthy look-
ing woman of her first child, which was born in the
eighth month, dead and putrid. This, I hoped, was
from some accidental cause, particularly as she said
that she had received a fright some time before. How-
ever, in June, 1819, she again lay in in the eighth
month of a dead venereal child, and I recommended
that she should see some surgeon, as her husband now
confessed that he had been disordered before marriage.
Mr. Todd saw her, and took both under his care until
he was satisfied with the use of mercury. She lay-in
in September, 1820, of a living boy.
I never attended any person who had dead children
that I suspected of venereal complaints, who did not
readily submit to mercury, so strong and general is the
desire for posterity, except a celebrated courtezan who
lived for several years with a friend of mine, and every
year produced a putrid child. As she was very comely
in her person, of which she was supposed to be liberal
to many, and did not wish for living offspring, she
35
never would use mercury. It was remarkable of this
lady, that she frequently disordered men, but never my
friend, except in the first connexion.
In answer to the learned author's question, “What
“are the most likely means to prevent the death of the
“foetus in utero?” I would, with diffidence, and with
that respect to his opinion which I think he merits from
every man engaged in the practice of midwifery, say,
the use of mercury. It has in every instance succeeded
with me, and I think will be found to do so in the great
majority of cases. I have not met with any case which
I thought safe to commit to the use of sulphureous
mineral waters, goat's whey, tepid bathing, decoction of
Sarsaparilla, or blood-letting ; but that such cases may
have occurred to other practitioners I am not disposed
to doubt.
I have met with several cases wherein very delicate
women have borne dead children at the seventh month,
but not putrid ; and have, where I did not suspect
venereal taint, constantly succeeded in avoiding the ac-
cident by a rigid confinement, even to one floor, and by
a very strict attention to keep the bowels gently free,
from the earliest period of gestation to the end of the
eighth month ; and several, to whom I gave permission
to go out at that time, have thanked me, saying they
were never so happy as in their confinement, and would
not accept of my offered emancipation. I do not re-
member a single instance where good health, good
looks, and a continuation of bearing living children
were not the rewards of the confinement.
Every man engaged in my profession must have met
with dead and putrid children, the result of accidents,
but they are not such as the learned author points out,
and require no further notice.
3 *
36
If the above cases and observations should appear to
be worthy of a place in the Transactions of the Medi-
cal Association, as a reply to the very interesting paper
which I have perused with such pleasure, I shall feel
obliged by their insertion.
37
CHAPTER III.
Eatract from the Reports of the South Eastern Lying-in
Hospital,” from April, 1834, to August, 1837.
ONE of the most important services which can be
rendered to the science of midwifery, by an institution
such as this, will be afforded by an accurately preserved
register of the cases treated within its walls. Such a
register was carefully kept in the record of the South
Eastern Lying-in Hospital.
The following form of tables which I adopted in the
institution appears to be sufficiently comprehensive,
without being too minute.
WOMEN DELIVERED.
Naturally . & , 1164 Turning 6
Artificially , ſº ſº 18 By 3 Perforator 3
*= * Forceps 9
Total, 1182 tº-
18
PRESENTATIONS. DURATION OF LABOUR.
Head . 1104 Under 6 hours & te . 557
Face & ſº 4 or 1 in 295'5 Above 6 and under . 12 . 381
Breech . 25 or 1 in 47°28 12 . © , 24 . 155
Inferior Extre- 24 . tº . 36 . 43
mity . . 15 or 1 in 79 36 . tº . 48 . 17
Superior do. . 5 or 1 in 236°4 48 . * . 60 . 4
Placenta | 4 or 1 in 295'5 60 . tº . 75 . 2
|Funis . * 6 or 1 in 197 75 . ſº . 96 . 2
Head and hand 1 96 . * . 136 . I
Twin cases . 18 or 1 in 65.75 -º-º-º-º:
* Total, 1182
Total, 1182
* Founded and supported by the author, but long since closed. The
hospital contained twenty-five beds for intern patients; and, besides that
accommodation, women were attended by pupils from the hospital at their
own homes.
38
Total number of children born, 1,200
Males, 614, of whom alive, 558, dead, 56
Females, 586 . e . 553 . 33
Total, 1,200 1,111 89
PRESENTATION IN TWIN CASES. FATE OF CHILDREN IN TWIN CASES.
Both head in º . 10 Both alive in tº º , 13
Both feet º e I Both dead . e e ... 3
Both breech . e © l One alive, one dead e ... 2
First head, second feet . 4 * = -
First head, second breech 2 Total, 18
Total, 18
Of the 89 children still-born, there were
Footling cases . e . 10 Forceps cases 3
Breech . tº © G. . 12 Perforation © . 3
Funis . º © e • 4 Premature . & º . 12
Twins . © © 8 Putrid . º º tº ... 8
Arm and turning . 6 Natural & º º . 19
Ruptured uterus l Acephalous I
MOTHERS DIED.
Of puerperal fever & 11
Haemorrhage after delivery I
Ruptured uterus tº & 1
Abscess of ovarium . º e e ... 2
Inflammation of uterus . & tº , 1
Pneumonia I
Total, 17
The first point to which I wish to direct atten-
tion is the table indicating the duration of labour; in
referring to which, the number of women whose labour
exceeded twenty-four hours appears to be sixty-nine :
this is in the proportion of a fraction above one in
seventeen to the whole number, 1,182.
My reason for bringing this prominently forward at
present is that, since the first report of this hospital was
published in 1835, Professor Hamilton of Edinburgh
39
has favoured the profession with his “Practical Obser-
vations on various subjects relating to Midwifery,” in
which he devotes a great many pages to the manage-
ment of the different kinds and stages of labour. In
contrasting the result of his practice with the recorded
evidence of the protraction of labour in London, Paris,
and Dublin, Dr. Hamilton does me the honour to quote
my first Report of the South Eastern Hospital. His
work, excellent as it is, and coming from the pen of an
author whose great experience, high character, and
acknowledged talents entitle him to the respect and
confidence of the profession, contains some doctrines
respecting the management of labour, from which, with
the greatest deference to his opinion, I feel myself
called upon to express my dissent.
In many points relating to the management of dif.
ficult labour my experience leads me to coincide en-
tirely with the learned professor; but I regret that I
cannot equally subscribe to the opinions contained in
the following passages relating to the first stage of
labour. In speaking of that part of the process of par-
turition, Dr. Hamilton states that “when the natural
“ powers are alone trusted to, this stage is often
“greatly protracted, and he of course inferred that
“ injurious effects must be the consequence.” What
these injurious effects are supposed to be, we learn
at page 122 : Firstly, that “the powers of the uterus
“may be inadequate to expel the infant with safety
“to its life, or to the future health of the parent.”
Secondly, that “after the birth of the infant the
“uterus may contract irregularly, so as to occasion
“retention of the placenta.” Thirdly, that “ after
* Practical Observations, part I. p. 158.
40
“ the expulsion of the placenta the contractions of
“the uterus may be too feeble to prevent fatal haemor-
“rhagy.” And lastly, that “supposing the patient
“should escape all those untoward circumstances, febrile
“ or inflammatory affections of a most dangerous nature
“may ensue from the previous protraction of pain, and
“ the irregular distribution of blood.”
Acting on the belief that the first stage of labour was
thus often greatly and dangerously protracted, the pro-
fessor states:—“From the year 1800, the author
“has advised his pupils to secure the termination of
“ the first stage of labour within twelve or fourteen
“ hours from its actual commencement ;” and further,
“By the adoption of this rule, the author can con-
“fidently assert that no patient under his charge for
“ the last thirty-five years has been above twenty-four
“ hours in labour, and, excepting in cases of dispropor-
“tion, none so long.”
In the following table, extracted from the registry of
the South Eastern Lying-in Hospital, a record is given
of sixty-nine women whose labour exceeded twenty-
four hours. Separate columns are allotted to the number
of hours each woman was in labour, the sex of the child,
the fate of the child, and the fate of the mother. A
second table is added, showing the number of women
whose labour was between twenty-four and thirty-six
hours, and so on, and likewise the number of children
born alive and dead, and their sex. A short notice of
the still-born children follows, showing the cause of the
death of the child in each case.
* Practical Observations, Part I. p. 195
If





No.
Hours in Labour.
Sex of Child.
W | H | #8 9T
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Fate of Child.
Fate of Mother.
No.
I9 || 97
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39 37
99 || Of,
87 | 93
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87 39
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Sex Of Child.
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W | H | Ig | 6%
W | H | O3 || 83
CI | IWI 98 || 13
OT | IWI | 96 || 93
W | H | 99 || 93
CI | "IW 88 I9
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42
Of the nineteen children born dead, thirteen were
males.
Of the eight children born dead, under thirty-six
hours of labour, one was in a case of convulsions oc-
curring in a first labour, at the end of twenty-five
hours, when delivery was effected by the forceps; two
were cases of presentation of the breech, attended with
much difficulty in passing through the pelvis; one was
a case of placental presentation; one was in a case of
ruptured uterus ; and three were in cases of difficult
labour, in two of which the delivery was assisted by
the forceps.
Of the four born dead under forty-eight hours, three
were in cases of uncomplicated difficult labour; one
was delivered by the forceps.
Of the two born dead under sixty hours, one was a
breech case, the other a natural presentation.
The one case born dead under seventy-two hours was
a breech presentation.
The one under eighty-four hours was in a case re-
quiring delivery by the perforator.
Of the two born under ninety-six hours, in one case
the mother was four days in labour before admission—
delivery accomplished by the perforator. In the other
the labour, though constant, was not severe.
The one case in which the labour lasted 136 hours
was terminated by the perforator. The details of this
case were given in the last Report of the Hospital.
From this table, faithfully extracted from the Hos-
pital book, it appears that of the sixty-nine women
whose labour exceeded twenty-four hours, only one
died, No. 38, and hers was a case of ruptured uterus;
that fifty children were born alive, and nineteen dead,
thirteen of whom were males; and that of the nineteen
43
children still born, one was in a case of convulsions;
one in a placental presentation ; one in a case of ruptured
uterus; four were breech presentations; three were de-
livered by the perforator, and the remaining nine were
ordinary head presentations.
From this record, I think I am justified in saying
that protraction of labour beyond twenty-four hours is
not per se productive of those injurious effects de-
scribed by Dr. Hamilton, and that many women may
be allowed to go beyond that time with safety to them-
selves and their offspring. I believe there are few
practitioners in this country whose experience could
not furnish many instances of labour happily concluded
for both mother and child at the end of thirty-six or
forty-eight hours; and I make bold to say that in no
country is the mortality attending lying-in women less
than in Ireland.
The opinion, therefore, advanced by Professor
Hamilton—that the first stage of labour is often
greatly protracted when the natural powers are alone
trusted to ; and that when it is, injurious effects must
of course be the consequence—seems to me objection-
able ; because it leads to interference in many cases in
which it is manifestly unnecessary, and it is calculated
to introduce what has been so well decried by Dr.
Blundell, “a meddlesome midwifery.” The effect of
such a recommendation, on the mind of a young and
inexperienced practitioner, must be to induce him to
harass his patient by frequent examinations during the
early stage of her labour; a practice which is always
prejudicial to the patient, by producing excitement and
irritation in the vagina and OS uteri, and thus causing
what we would desire to avoid, viz., a rigid condition
of the parts. It is likewise calculated to excite an un-
44
due degree of restlessness and anxiety on the part of
the attendant, and to induce him to have recourse
to blood-letting, &c., in many cases where such pro-
ceeding is uncalled for; and, by the alarm thus produced
in his patient's mind, to suspend or materially inter-
rupt the proper course of labour. Let it not be ima-
gined that by the foregoing remarks I wish to dispense
with or undervalue blood-letting, opium, &c. in cases
demanding their employment. What I desire to com-
bat is, the doctrine that all labours shall be reduced to
the same limit, and that the period of delivery is to be
measured out by the clock, allowing a certain number
of hours to the performance of certain stages of the
labour in all cases. I object to this, because I know that
the powers of endurance are as various as the consti-
tutions of patients, and that one woman will bear with
impunity a labour under which another will sink.
Symptoms, then, and not time, are the guides to which
we should look for the regulation of our practice, and
upon that doctrine the treatment of patients in the
New Lying-in Hospital has been founded ; with what
success is now laid before the profession.
I now pass on to the consideration of those cases in
which it appeared necessary to assist the natural efforts
of the uterus by artificial means. These are twelve in
number : nine in which the forceps were employed, and
three in which it was judged imperative to use the per-
forator.
Before I detail these cases, I think it right to state
that, though I have felt it necessary to disagree with
the opinions advanced by Professor Hamilton on the
subject of ordinary labour, it gives me much pleasure
to express my entire concurrence in his views and doc-
trines respecting the management of laborious labours;
45
and it will appear, on perusing the history of the fol-
lowing cases, that the practice pursued was just that so
ably and clearly recommended by Dr. Hamilton. No-
thing can be more judicious than the following: “On
“ the whole it may be concluded, that so long as there
“are no untoward symptoms in respect to the general
“health, so long as the pains continue to advance the
“infant, and so long as the passages remain in their
“healthy natural state, the contractions of the uterus
“may be expected to complete delivery. But when-
“ever symptoms of derangement of the general health,
“ or evidences of the uterine contraction ceasing to
“advance the infant, or of there being an impediment
“to its advance in consequence of some state of the
“passages, become apparent; and, more especially,
“whenever circumstances denoting injurious pressure
“ or interrupted circulation in the important parts con-
“cerned in parturition occur, the natural efforts can no
“longer be trusted to.” And again : “The obvious
“ duty of the practitioner in every case must be
“to ascertain what the natural efforts can accom-
“plish, and when he is satisfied that the delivery
“cannot be permitted to go on without some injury
“to the mother or to the infant, he is no longer to de-
“lay assistance; keeping this principle in view, the
“ time allotted for the efforts of nature must be regu-
“lated by the symptoms of the individual case.”f
With respect to the kind of aid to be afforded, we
have the following rational and important observa-
tions:—“He considers that after the second stage
“has commenced, if regular pains continue, and the
“infant become wedged in the passage, the practi.
* Practical Observations, Part II. p. 51.
f Op. cit., Part II. p. 97.
46
“tioner is imperiously called upon, supposing the in-
“fant to be within reach of the forceps, to interfere,
“before there is a probability that the pressure may
“ destroy the infant's life, and certainly before any un-
“toward symptom threaten the mother. The forceps,
“if properly applied, can do no harm whatever to the
“mother; while, by diminishing the bulk of the infant,
“it enables the practitioner to lessen as well as shorten
“her sufferings.”
I have said that the practice at the New Lying-in
Hospital was founded on such principles as these, and
I now proceed to relate the cases as they occurred, and
the result of them.
CASE I.—A woman, aged thirty-six years, in labour
of her seventh child ; two of the former children had
been still-born after long labour. She was now forty-
eight hours in strong labour, at the end of which time
the head was firmly fixed in the pelvis, the greater part
of it having passed the brim; her pulse was 120. Her
strength failing, and the pains diminishing, I applied
the forceps, not without some difficulty, in consequence
of the tightness with which the head was grasped by
the pelvis ; and by slow degrees I succeeded in dis-
lodging it and extracting the child, still-born. This
woman had a good deal of inflammation of the vagina
and incontinence of urine for some days. I could not
discover any breach of the bladder or urethra, and she
went out of the hospital well. She has since appeared
at the dispensary, and states that she retains her urine
perfectly, unless when making any great exertion, when
Some of it escapes.
CASE II. was that of a woman, thirty years of age,
* Practical Observations, Part II. p. 106.
47
pregnant for the first time. She succeeded, after severe
labour of forty-eight hours, in passing the greater por-
tion of the head of the child through the brim of the
pelvis, but at the end of that time the abdomen became
tender; her pulse rose to 120; she vomited dark,
greenish matter, and the pains failed. Unwilling to
expose her to greater risk, I delivered her with the
forceps of a live child, measuring twenty-one inches,
and large in proportion ; and although it was her first
birth, there was not the slightest crack in the perinaeum.
She recovered without any unpleasant consequence.
CASE III.-Bridget Boland, aged twenty-five years,
first pregnancy, delivered October 10th, 1835. The
head presented in the first position, and the labour pro-
gressed steadily but slowly, so that at the end of twenty-
four hours the OS uteri was completely dilated, and a
portion of the head had passed the brim of the pelvis.
The pains continued severe and constant, and at the
end of thirty hours the greater portion of the bulk of
the head had passed into the cavity of the pelvis, but
not so low as to occupy the hollow of the sacrum, or
make any pressure on the perinaeum. From this time
there was no advance in the progress of the head, but
a tumour began to form on the scalp, which became
very large before delivery, and from its bulk was very
likely to mislead a superficial inquirer as to the ad-
vance of the presenting part. In this condition the
head remained for six hours, notwithstanding frequent
and strong pains. Seeing that the natural efforts were
apparently unavailing to accomplish delivery, the pulse
of the woman becoming frequent, and a degree of rest-
lessness (which is so often the precursor of bad symp-
toms) having come on, and finding by the stethoscope
that the child (notwithstanding the pressure it had
48
undergone for thirty-six hours) was still alive, I deter-
mined to give it a chance for life, and deliver it by the
forceps. The instrument was applied slowly and cau-
tiously, without using any force that could injure either
mother or child ; and when the blades were locked, the
junction lay within the vagina, and the handles pressed
upon the fourchette ; one blade lay towards the sym-
phisis pubis, the other towards the sacrum.* I am
thus particular in describing the position of the instru-
ment when applied, as it will convey a good idea of the
part of the pelvis the head was lodged in, and the por-
tion of the head that had passed the brim. So far I
felt certain that no injury had been inflicted on either
mother or child, and being determined to proceed non
vised arte, it now remained to try whether the amount
of force I felt justified in using would be sufficient to
extract the head. The blades lay one to the pubis, the
other to the sacrum ; consequently, in the direction of
these points, lateral motion of the instrument could
alone be produced. Grasping the handles loosely,
So as not to make too great pressure on the head, 1
swayed them backwards and forwards two or three
times during each pain, without using much extractive
force. By this means, having loosened the head in its
* The instrument employed was the short straight forceps, measuring,
total length, 103 inches; length of blade from upper part of the lock, 63
inches; length of handle, 4 inches; widest part between the blades when
closed, 3 inches; outside the blades between the same part, 3} inches.
I think the proportions of Dr. Hamilton's forceps better adapted for
general use than the instrument above described; it is longer, and not so
wide between the blades. While upon this subject, I wish to mention
that many of the forceps to be found in the cutler's shops are dangerous
to use, in consequence of the sharpnes of their edges. Care shonla be
taken that no sharp edge should exist, either on the outside or in the fenes-
trum ; the former may injure the mother, the latter may cut the scalp of
the infant in the act of extraction.
49
position, I was enabled to cause it to descend slowly at
each return of pain, by gently assisting the uterus;
taking care to apply the force in the direction of the
axis of that part to the pelvis in which the head was
placed. Finding a manifest advance, I was encouraged
to persevere, without being at any time tempted to
make use of such power as could inflict any injury,
and after twenty minutes' patient endeavouring, I was
gratified by the delivery of a living boy, without a fibre
of the perinaeum having been damaged. In this case
I would have felt myself bound to desist, if I had
experienced any considerable resistance either in the
introduction of the instrument, or in the attempt at
extraction.
The mother recovered without an unpleasant symp-
tom, and left the hospital, with her child, at the end of
ten days.
CASE IV.—Mary Brady, aged twenty-four years, first
pregnancy, delivered October 16th, 1835. The circum-
stances of this case resembled very much those of the
case just detailed, with this difference, that in the pre-
sent one labour was allowed to go on to forty-eight
hours before recourse was had to operation, whereas
the former was delivered at the end of thirty-six hours.
The reason was, that urgent symptoms did not manifest
themselves so soon in this as in the former instance.
The pulse kept moderate until within a few hours of the
time at which she was delivered, and the os uteri, which
was very slow in dilating, had not permitted the head
to pass through until nearly twenty-four hours had
elapsed. From that time a slow advance of the head
took place, but at the end of thirty-six hours not more
than one-third of it had passed the brim of the pelvis.
In four hours more about one-half had been forced
4
50
through, and from that time little progress was made,
notwithstanding strong and regular pains continued.
Still, as no unpleasant constitutional or local symptoms
were present, I contented myself with watching the case,
so as to be ready to act as soon as required. The
patient's strength now began to decline, and her pulse
rose to 110; the vagina at the same time began to lose
the moist cool feel it had hitherto preserved, and to
become hot and dry. When matters had thus begun
to change, I felt that I was no longer justified in with-
holding assistance, and finding the child alive, I deter-
mined on using the forceps, notwithstanding that I
could not feel the ear, nor was the head near the peri-
naeum. I accordingly proceeded, in the presence of
Dr. Brown and Mr. Armstrong, who happened to visit
the hospital at that time; and, I think it right to men-
tion that from the high and apparently locked position
of the head, both of these gentlemen were doubtful of
the success of the operation, neither was I sanguine
myself, and I mentioned to the pupils that it was by no
means certain that I would be able to effect delivery in
that way; nevertheless, I felt myself bound to make
the attempt, under the same prudent restrictions as in
the last case. By a little management I was enabled to
slide the blades of the instrument up to their proper
situation, and by degrees, assisting the pains when they
occurred, I succeeded in delivering the patient safely
of a living girl. Both left the hospital well on the
twelfth day.
CASE W.—Winifred Meeton, aged twenty-eight years,
seventh pregnancy, delivered October 18th, 1835. This
woman had borne six children, in the delivery of which
she had always difficult labour, and her last child was
extracted elsewhere by the perforator and crotchet. In
51
this labour, the head presented in the first position, and
great part of it was forced through the brim of the
pelvis, which was evidently diminished somewhat in its
antero-posterior diameter. A considerable opposition,
also, to the delivery in this case arose from a conver-
gence of the spinous processes of the Ossa ischia, which
encroached upon the cavity of the pelvis, and resisted
the passage of the head. Finding, at the end of twenty-
four hours' hard labour, that there was little prospect
of delivery by the natural efforts, and having the for-
mer labours as a guide, I determined not to wait too
long without attempting to rescue the child from its
perilous situation, if it were consistent with the mother's
safety. Accordingly, the forceps was cautiously intro-
duced, and as cautiously used as an extractor, and in
half an hour from the commencement of the operation
a living boy was born, who, with his mother, continued
to do well, until they left the hospital on the tenth
day.
CASE WI.-Sarah Collins, aged thirty-six years, ninth
pregnancy, delivered September 30th, 1836. In this
case the head presented in the fourth position (Nae-
gelé), and the labour was very severe from the begin-
ning. At the end of twenty hours the head was firmly
fixed in the pelvis, with the anterior fontanelle towards
the pubis, and in six hours more, finding that no ad-
vance had taken place, and that the vagina was becom-
ing tender to the touch, while the pulse was gradually
increasing in frequency, the delivery was effected by
the forceps, the child being dead. This patient made
a good recovery.
CASE WII.-This was the only instance in which I
ever knew it necessary to assist the delivery of the
head in a breech or footling case, by instrumental aid.
4%
52
Catherine Connor, aged thirty years, delivered Novem-
ber 12th, 1835. The child presented by the feet, and the
labour went on without any remarkable circumstance,
until the arms had been got down after the expulsion
of the breech, when great difficulty was found in the
passage of the head. This was not owing to any im-
proper force used in pulling at the body of the child,
for I happened to be in the ward at the time of the de-
livery, and superintended the management of the case
myself. The labour pains continued strong, and the
cord pulsated for a considerable time, during our en-
deavours to extricate the head. But in all my attempts
to accomplish this I failed; and at last, after more than
half an hour, finding that the circulation in the funis be-
came weak, I determined on using the forceps. Unfor-
tunately the instrument was not in the hospital, and I
had to send to my own house (a very short distance)
for it; this caused a trifling delay, which, however, was
fatal to the infant, for before the messenger returned
pulsation had entirely ceased. I passed the blades
along the sides of the head, having the body of the in-
fant carried forward between the thighs of the mother,
and with some difficulty I succeeded in extracting the
head. We tried all means to resuscitate the infant,
without success.
CONVULSIONS.
CASE VIII.-Mary Nolan, aged twenty years, of a
full plethoric habit, first pregnancy, admitted Decem-
ber 20th, 1836.
On admission, the os uteri was dilated to the size of
a half-crown piece, and the pains were regular and effi-
cient. Labour progressed steadily, and at the end of
four hours the dilatation of the os uteri was nearly
53
complete, soon after which the head began to advance
into the pelvis, and at the end of six hours the greater
portion of it had passed the brim, and nearly filled the
hollow of the sacrum. The pains continued to recur
with considerable violence, without making much im-
pression on the position of the head ; and the external
parts being rigid and dry, she was bled to sixteen ounces.
This had the effect of relaxing the vagina and perinaeum,
but at the expiration of twenty-four hours the head,
although lower in the pelvis, and moving at each pain,
had not yet come to press strongly on the perinaeum.
In four hours more (twenty-eight from admission),
there was no untoward symptom calling for interfer-
ence; the pulse was eighty, the pains regular, and the
head manifestly advancing, when she was suddenly
seized with a violent convulsion. Delivery by the for-
ceps was immediately had recourse to, and much diffi.
culty was experienced in the operation, owing to the
unmanageable state of the woman, and the great size
of the infant's head, which was found to measure four
inches between the parietal protuberances. The child
was dead. The delivery was accomplished at one
o'clock, A.M. of the 21st. From that time she had four
convulsions, diminishing in severity through the night;
but towards morning she sank into a comatose state,
from which she could be roused, not however to con-
sciousness, but to mania, her face being flushed, her
eyes starting, the pupils contracted ; and she resisted
with violence any attempt to administer medicine by
the mouth. She did not speak, and when allowed to
remain undisturbed, her breathing was stertorous, ac-
companied by a hissing noise in expiration.
21st. Eight o'clock, A.M.–Finding the above men-
tioned symptoms to have set in, and her pulse 140, she
54
was bled to twenty-four ounces; and in a few hours the
bleeding was repeated to thirty ounces, as the former
abstraction had produced no relief. The blood drawn
on both occasions was highly buffed and cupped : has
had no convulsion through the day.
Six o'clock, P. M. The breathing less laborious ; pulse
130; her head was shaved and cold lotion applied.
22nd. Spent a restless night ; comatose symptoms
still continue, but the violence of the mania is some-
what abated. A bolus of calomel and jalap was got
into her mouth, which she swallowed, and an enema
with spirits of turpentine having been administered in
four hours afterwards, the bowels were well freed.
Six o'clock, P. M. Symptoms as before. To be bled
to eighteen ounces, and a blister applied to the head.
23rd. Passed another restless night; the urgent
symptoms of coma rather less, but she is quite insen-
sible to questions put to her ; pulse 130. Ordered a
repetition of the bleeding to sixteen ounces, and a
blister between the shoulders.
Six o'clock, P. M. The symptoms have yielded since
last report; she can now answer yes or no; there is
not much stertor in her breathing, and her pulse has
fallen to 118, and is soft ; she passes faeces and urine
involuntarily.
24th. She had some quiet sleep during the night,
and is more collected this morning; complains of the
blister on her back ; takes her drink; pulse 100.
From this time she continued gradually to improve,
but she had no recollection of any part of her labour.
RUPTURED UTERUS.
CASE IX. —Anne Gaynor, aged twenty-seven years,
an extern patient living in Purdon-street; fifth preg-
55
nancy, March 11th, 1837. Labour commenced at seven
o'clock in the evening, the waters were soon discharged
spontaneously, and the head came down into the pelvis
in two hours. The pulse was a little excited, and the
countenance florid; the vagina rather dry, but cool.
The pains continued smart but ineffectual, communi-
cating very slight impulse to the infant's head, and re-
curring every ten minutes. The patient was very rest.
less, getting out of bed occasionally and walking about,
and when in bed she was continually changing her
position. At eleven o'clock there was a discharge of
about four or five ounces of blood from the vagina, but
there was nothing remarkable in the pain immediately
preceding the occurrence. Shortly after, however, her
pulse began to alter in character, becoming smaller and
quicker; her complexion began to fade, and the pains,
in the same gradual manner, declined in degree, but
not in frequency, for about two hours, when they ceased
entirely. About this time she began to complain of
pain in the epigastrium, where the fundus uteri pro-
jected in a remarkably prominent manner. A soft suf-
fused swelling appeared above the pubis, which conti-
nued to ascend slowly towards the umbilicus, and ex-
pand laterally, masking the uterus as it advanced, by
intervening between it and the parietes of the abdo-
men. Vomiting now set in, and intense thirst, to relieve
which she drank large quantities of cold water, but
immediately rejected each draught. The sinking of
countenance, depression of strength, restlessness, and
anxiety progressed very gradually but steadily from
this period, until the pupils in charge of the case (who
had neglected to send for assistance to the hospital
when alarming symptoms had setin), reported the con-
dition of the woman. On visiting her, she was found
56
to be moribund, the pulse imperceptible, and the ex-
tremities cold. The head of the infant being still in
the pelvis, it was delivered by the forceps, immediately
after which the woman expired.
On introducing the hand, a large laceration was
found at the neck of the uterus, immediately in the
neighbourhood of the promontory of the sacrum, which
was unusually prominent and sharp ; and, on passing
the hand through the rent, a large quantity of coagu-
lated blood was found in the abdomen among the in-
testines. Leave could not be obtained to make any
further examination of the body.
In this case it is manifest, from the symptoms, that
death was the consequence of haemorrhage into the
cavity of the peritonaeum. This mode of termination
might possibly have been avoided, if timely notice had
been given ; but the woman, if saved from death from
this cause, would still have had to encounter the usual
danger of peritonaeal inflammation. It is to be re-
marked that two symptoms mentioned in books, and
often present in cases of ruptured uterus, did not ac-
company the instance just detailed : namely, a sudden
pain and sensation as of something having given way
within the patient, and a receding of the presenting
parts. The latter was prevented by the low position
the head had reached in the pelvis before the laceration
took place. The unusual prominence and sharpness of
the promontory of the sacrum furnish an explanation
of the readiness with which rupture took place in the
case before us. For, the woman having previously
borne children, it is easy to conceive how the neck of
the uterus must have been compressed against this
sharp ridge, whereby an amount of inflammation capa-
ble of altering its texture would have been excited,
57
which would render the part thus diseased unable to
bear the distention attendant upon a subsequent
labour.
On reviewing these cases, it will appear that of the
nine cases of delivery by the forceps, six of them were
head presentations in uncomplicated labour, in four
of which the child was saved. In the footling case
the loss of the infant was, no doubt, owing to the delay
in procuring the instruments; and in the other two
cases of head presentation, complications arose (con-
vulsions and rupture of the uterus) which usually cause
the death of the foetus.
It may be objected to the practice above detailed,
that in the first four cases delivery might have been
accomplished by the natural efforts, and therefore in-
strumental aid was not necessary. True, delivery might
have been accomplished, but I would ask at what risk
would the experiment of waiting be made 7 Urgent
symptoms of local and general irritation had manifested
themselves in all before any attempt was made to assist
the uterine effort, and the head of the infant was
arrested in such a position as precluded the hope that
it could be passed through (if at all) without several
hours' severe labour, and a corresponding increase in
the dangerous symptoms; which must have arisen to
such a height before delivery as would place the
woman's life in immediate danger, and her future com-
fort in considerable jeopardy, besides in all probability
destroying the life of the child. From this state of
peril the women were rescued, and three of the children
were born alive, which, under other treatment, must
have been sacrificed. They were, I say, rescued by a
safe operation, and they recovered as well as if their
labour had been natural and easy.
58
With respect to laceration and sloughing of the
vagina, bladder, &c., stated by some authors to be
caused by the forceps, and used as an argument against
their employment, I am of opinion that in the majority
of cases, when these lamentable results occur, the blame
is unmerited ; because I have seen the worst inflam-
mation and sloughings of these parts follow in cases
where the perforator had been used, and even in some
where no instrument whatever was employed. The
truth is, the mischief is effected by the pressure of the
infant's head upon the soft parts of the mother, and
after this has been continued with sufficient intensity,
for a sufficient length of time, the inflammation caused
thereby will run its course, no matter in what way
delivery is accomplished, whether by the natural efforts
or by instruments. But it frequently happens that de-
livery is effected in these cases by instruments too late
to prevent the unhappy results alluded to, and then the
operation is charged with the consequences. If an ac-
curate account of the subsequent condition of all
women after delivery could be obtained, I much fear
that the histories of those cases in which labour had
been allowed to run too long before interference was
used would be anything but satisfactory. The lament-
able sloughings of the vagina, with subsequent closure
of the passage by the process of cicatrization ; or the
still more distressing sloughing of the bladder with its
attendant urinary fistula, are seldom mentioned in
lying-in hospital reports, because the patients are
usually removed from these institutions before such
results have become very apparent ; and thus a case
left to nature, in which delivery is effected by the
natural efforts, is set down as a favourable one, without
any notice of its consequences.
59
That injury may have been effected by unwarrant-
able roughness in the use of the forceps, or by ill-made
instruments, I admit; but that injury is even likely to re-
sult from the use of this instrument, when judiciously
employed, I entirely deny. I have seen a surgeon, in
performing the operation of lithotomy, force his forceps
through an imperfect opening into the bladder, and
then, having grasped the stone, finding that he could
not extract it by ordinary force, place his foot upon the
cross-bar of the table, and pull with all his might,
nearly falling on his back when the stone came out with
a jerk. I have known the patient to die after such a
proceeding; but am I on that account to decry the
operation, and deny its saving powers, when the instru-
ments are in the hand of a skilful and dexterous sur-
geon 7 By no means. I charge the blame where it is
due ; I decry the bungler ; but my faith remains un-
shaken in the operation, when conducted upon rational
and scientific grounds. Whence then proceed the
local injuries to which I have alluded ? Manifestly
from delay, after urgent symptoms have set in. This
opinion is not advanced for the purpose of recommend-
ing harsh or hasty interference in all cases (the table
of prolonged labour already given shews that such is
not my practice); but it is with the view of inculcating
the obligation to watch our cases closely, and to inter-
fere when necessary, and then only.
This point of necessity is the great question in dis-
pute between practitioners, and I trust there are few at
the present day willing to follow the directions of Dr.
Osborne, “to wait till the powers of nature are abso-
“lutely or altogether exhausted,” when, as it has been
said by the late Dr. Beatty, “our interference can only
“remove a dead child from a dying mother.” On the
60
contrary, I am happy to believe that the prejudice so
long existing against the timely use of the forceps is
subsiding, and that many practitioners will agree with
Dr. Hamilton, “that the great utility of this mecha-
“nical contrivance is, that it enables the practitioner
“to prevent the occurrence of those untoward symp-
“toms which Dr. Osborne has described as alone war-
“ranting the use of the instrument.”
DELIVERY BY THE PERFORATOR.
The three cases in which it was found necessary to
diminish the size of the head occurred in first labours.
All these women, as well as many of those delivered by
the forceps, had a very close resemblance in their
external configuration; one which I have generally
found to foretell a difficult labour, viz., a low, thick-
set, brawny frame, with broad shoulders and thick limbs;
short, stumpy fingers, as if the last joint of each had
been cut off; very rigid, muscular fibre ; and nates so
large as to render examination per vaginam difficult.
Such cases seldom terminate without much trouble and
anxiety.
CASE I. occurred in a woman of the above descrip-
tion, aged thirty, pregnant of her first child. The os
uteri was more than forty hours dilating, although the
pains were very severe and true, during the whole of
which time her pulse remained moderate and her belly
without tenderness. At the expiration of fifty hours
her pulse rose to 100; she became restless and unma-
nageable, insisted on getting into another bed, her belly
became tender, and her stomach rejected drink. She was
bled to sixteen ounces, with the effect of calming the de-
lirium, and of causing relaxation of the os uteri. Find-
ing that, notwithstanding very strong pains, the third
61
of the head only had passed the brim of the pelvis at
the expiration of fifty-nine hours, and that the rapidity
of the pulse and soreness of the belly were increasing,
I determined, in consultation with Dr. Montgomery, to
deliver her with the perforator, which was done accord-
ingly. In this, as in the subsequent case, I found that
my fingers passed into the evacuated skull were the most
efficient mechanical agent for the extraction of the head.
The patient suffered a good deal from inflammation of
the vagina, but she recovered perfectly.
CASE II. was that of a woman, aged thirty, pregnant
for the first time, and possessed of all the unfavourable
external characters already mentioned. She was seized
with labour pains in the evening of the 24th of Decem-
ber, having been a month previously for two or three
days in the hospital on account of false pains. She con-
tinued in labour all the 25th, and on the 26th she came
into the hospital. On her arrival the pains were severe
and frequent, and the abdomen was observed to be
remarkably prominent, with the uterine tumour very
high. There was great difficulty in making an exami-
nation, owing to the size and rigidity of the nates; but
at length the os uteri was discovered very high up, and
dilated to about the size of a six-pence. The edges of
the orifice were particularly sharp, giving the impres-
sion of an aperture punched in a very tense and thin
membrane. The membranes were entire, and the head
could be felt.
27th. The pains continued all night, depriving her
of sleep ; no alteration in the condition of the parts;
no impression on the os uteri or head during a pain.
Ten o'clock, P.M. ; no change ; bowels have been well
freed. Ordered an anodyne with thirty drops of tinc-
ture of opium.
C I
62
28th. Matters remained in precisely the same state;
pains severe ; no sleep; pulse 82; os uteri not dilating.
To be bled to sixteen ounces.
29th. Pains continue severe and regular; her cries
have been unceasing for the last two days; os uteri no
more dilated; pulse 98. Having failed to cause a ces-
sation of the pains or relaxation of the os uteri by the
opium and bleeding, and finding that no effect was to
be produced on the head by the uterine action, I con-
sidered that the fibres of the uterus must be acting
irregularly from over-distention ; which opinion was
strengthened by the great size and prominence of the ab-
domen. Itherefore punctured the membranes, and gave
exit to a large quantity of liquor amnii. Four, P.M.;
OS uteri dilated to the size of a half crown ; head more
advanced, though still very high ; anterior fontanelle
to be felt behind the pubis and the sagittal Aſture
running directly backwards. Ten, P.M. No advance ;
tumour forming on the head ; pains as before.
30th. Passed a severe night of labour ; os uterimore
dilated, its edges thick; tumour of scalp very large, but
the bulk of the head had not entered the brim of the
pelvis. She was greatly exhausted; the pains were
weaker ; the abdomen tender ; and the vagina becom-
ing dry, hot, and painful. She had now been 136
hours in severe pain, and had had no sleep for five
nights; there was no prospect of natural delivery, so,
on consultation with Dr. Montgomery, it was judged
imperative to deliver her by the perforator, which was
done accordingly, and a large child was extracted with
the face to the pubis. In this, as well as in the former
and several other cases of difficult labour that occurred,
the fluid that was discharged from the uterus, imme-
diately after the child, was thick, of a dirty yellow
63
colour, and excessively foetid, resembling the contents
of an unhealthy abscess, and in great quantity. The
waters discharged when the membranes were punc-
tured were of the usual limpid appearance, and it is
not easy to account for so remarable change in the cha-
racters of the fluid ; but it is one which I have fre-
quently remarked in difficult labours. The woman
recovered after suffering a good deal of inflammation
of the uterus and vagina, which was subdued by blood-
letting, mercury, stuping the belly, and syringing the
vagina.
CASE III.-Rose Aidy, aged twenty-seven years; first
pregnancy; delivered March 19th, 1837. This patient
was admitted on the 16th, having had pains for two days
previously. She was of low stature, and in external
configuration corresponding with the description I have
already given as one indicative of a difficult labour.
On admission the pains were slight, the os uteri dila-
ted to the size of a sixpence, with the sharp and thin
edge. The abdomen very prominent and conical;
pulse 80.
17th. Had some sleep ; the pains regular, but not
severe; pulse 80; os uteri dilated to the size of a shil-
ling, still very rigid and sharp. To be bled to sixteen
OUID.CéS.
R. Antimonii tartarati gr. ii.
Aq. font. Šviij. Sumat cochl. j. amp. Omni hora.
18th. No further dilatation of the os uteri. She
complains of Soreness of the vagina on examination.
The bowels not having been freed, two purgative ene-
mata were administered. Ten o'clock, P.M. ; pains
stronger, os uteri of the size of a half crown, the edges
thicker, but very rigid, no advance of the head. An
64
enema containing forty drops of tincture of opium was
administered, which, however, was speedily rejected.
19th. Had some sleep ; pains more frequent and
severe. The waters were discharged spontaneously
during the night. Os uteri not more dilated; complains
of soreness of the belly on pressure ; pulse 84. To be
bled to twenty-four ounces, and to take an anodyne
draught containing thirty drops of tincture of opium.
The foetal heart was heard at the right side below
the umbilicus.
Four o'clock, P. M.; has had no pains since twelve
o'clock, has slept some, and passed water; os uteri
a little more dilated, and the infant's head more
forced into the brim of the pelvis ; a tumour of the
scalp projects through the os uteri; pulse 92. Nine
o'clock, P. M.; strong and frequent pains since last
report, os uteri dilated. The tumour on the head very
large, and the right parietal bone overlaps the left con-
siderably, but there is no advance of the bulk of the
head through the brim of the pelvis. Blood trickling
from the vagina, and the discharge foetid. She has
vomited repeatedly a dark-coloured fluid during the last
few hours, and there is great tenderness of the belly;
pulse 120. Considering these symptoms, and that she
was now eighty-two hours in labour since her admis-
sion, I judged it not safe to allow her to pass another
night without being delivered, and the head being
quite beyond the reach of the forceps, I was obliged to
have recourse to the perforator. Great difficulty was
experienced in getting the head through the pelvis
after its contents had been discharged, and nearly an
hour was occupied in the delivery. In half an hour
after the operation the patient's pulse had fallen to 104,
and she was left with directions to have an anodyne
draught, if restless.
65
20th. She slept well without opium, has no pain in
the abdomen, passed water freely this morning. Pulse
80. Bowels confined : to have one ounce of castor oil.
This patient had no unpleasant symptom afterwards,
and recovered as well and as speedily as the other
women in her ward.
PUERPERAL FEVER.
The hospital was visited three times by this terrible
malady. The first attack was in the month of October,
1834; the second took place in the month of February,
1836; the third in the month of January, 1837; and
at each time erysipelas was raging as an epidemic in
the surgical hospitals, and diseases of a typhoid type
were very prevalent in the city.
At the period of the first attack the hospital was very
full, owing to the circumstance of puerperal fever having
been for some time prevalent in the Rotunda hospital.
This, coupled with a manifest disposition to the disease
which had existed throughout the whole summer and
autumn, contributed to its development at that time.
The first patient who fell a victim was attacked on
the ninth day after delivery, when she was walking
about the ward, and preparing to leave the hospital.
An attack at so late a period is rather a rare circum-
stance. The disease was most malignant in this and
the other cases that occurred at that time. It com-
menced with rigor, followed by pain in the belly of a
very severe kind; the countenance quickly became of
a muddy yellowish cast; the pulse rapid and feeble;
the belly tympanitic ; wandering of mind during the
last twelve hours; cold clammy sweat ; and death on
the third day. The second patient was attacked on
the same day, being the third day after delivery, and
5
66
died within a few hours of the former. In the third
case the progress of the disease was slower; death did
not take place until the fifth day. These were the only
fatal cases of the disease ; but several patients were
affected at the same time with fast pulse, dry hot skin,
tender belly, great thirst, suppression of lochia, and
restlessness, shewing the great disposition to the disease
which then prevailed.
The treatment pursued in the cases which terminated
unfavourably consisted of leeches to the belly and con-
stant stuping, with the occasional application of flannel
wet with turpentine; calomel and opium given in fre-
quent doses; and the free inunction of mercurial oint-
ment. When the belly became tympanitic, the turpen-
tine alone, and in combination with castor oil, was
given internally. The same treatment was adopted
in six of the cases which recovered;” and I found that
when the system became affected by the mercury
the symptoms began to subside. Finding that nine
cases had occurred in a short space of time, I came
to the resolution of not admitting any other patient
into the hospital, and I cleared the wards with as much
expedition as was consistent with the safety of the
patients. I kept the hospital closed for a fortnight,
during which time it was thoroughly cleansed and ven-
tilated, and all patients who applied were attended at
their own homes.
The co-existence of puerperal fever with erysipelas
was very remarkable at this time, and during the whole
summer. It is well known that the latter disease com-
mitted terrible ravages in hospital and private practice
during the greater part of the year; and whether the
* One of these was a woman who had been more than a month in hos-
pital, having been retained in consequence of a cutaneous eruption.
67
diseases are identical or not, the experience then
afforded gives strong ground to suppose that the same
influence is favourable to the production of both. A
case which occurred in my private practice, in the early
part of that summer, goes far to establish, in my mind, a
close connection at least between the two diseases. It
was the only case of true puerperal fever I saw during
that epidemic in private, and occurred in a lady resid-
ing a few miles from Dublin. She was attacked about
thirty-six hours after delivery, and was dead in forty-
eight hours after. The child to which she had given
birth was in four days afterwards seized with erysipelas,
beginning on the right hand and arm, and then appear-
ing on the face, body, and left leg, which rapidly be-
came gangrenous, of which disease it died in five days.
In the second attack of puerperal fever, which oc-
curred in February, 1836, the first case about to
be related is one which, under other circumstances,
might be considered as not being entitled to the
name of puerperal fever, because the organs princi-
pally affected were not those in which lesion is usually
found in this disease. But from its being the first
case that occurred at that period, from the typhoid
symptoms by which it was attended, and from the
severity of the disease in the other women who were
immediately attacked in the same ward, I have little
hesitation in ascribing it to the same influence that
produces the better marked puerperal fever, although
the local affections in this case were different from
those which are usually present.
CASE I.—Anne Early, aged twenty-two years, first
pregnancy, delivered January 30th, 1836, of a living
child, after nine hours of labour; continued well the
next day.
5*
68
February 1st. Complains of acute pain in the left
side, under the breast, and extending to the back, which
prevents her making a full inspiration, and produces a
good deal of dyspnoea. There is some tenderness over
the uterus, increased on pressure ; countenance flushed,
pulse 130, small. She was bled to sixteen ounces, cup-
ped on the side, and ordered a laxative draught.
Ten o'clock, P.M. No relief; breathing, forty in the
minute ; dyspnoea increased ; pulse 140. Examination
with the stethoscope indicated intense bronchitis in
both lungs. Repeat bleeding to sixteen ounces, and
to take a pill containing two grains of calomel, and
one third of a grain of opium every two hours.
2nd. Had profuse perspiration during the night,
which still continues; symptoms as before ; slight
cough, but no expectoration. Tenderness of the belly
continues. The calomel was increased to three grains,
and opium to half a grain every two hours.
Ten o'clock, P. M. Breathing easier, feels less oppress-
ed; countenance pale ; pulse 130. No appearance of
salivation. The pills were ordered to be continued
and a blister to be applied to both sides.
3rd. Slept none ; breathing laboured; great exhaus-
tion ; countenance sunk ; pulse 130, weak and small ;
no expectoration ; intense muco-crepitating rale all
over the chest on both sides. Belly more distended and
tender. Ordered an emetic of ipecacuanha and tarta-
rated antimony.
Four o'clock, P. M. Great distress in breathing; pec-
toral sounds less audible, chest sounds dull on percus-
sion ; pulse scarcely perceptible.
R. Ammon, carb. 3ss.
Mist. camph. 3v.j.
Sumat àj. omni horá.
69
From this time she continued to sink, and died early
on the morning of the 4th. *
Post-mortem.—A copious effusion of sero-purulent
fluid was found in both sides of the chest. The fluid
resembled closely that usually found in the peritonaeum
in cases of puerperal fever. Patches of lymph adhered
in different places to the serous membrane. The lungs
were compressed, dark-coloured, but not hepatized, and
when cut into they gave out a large quantity of frothy
sero-purulent fluid. There was a small quantity of
fluid in the pericardium. The peritonaeum exhibited
vascularity in different places, but there was no effu-
sion of lymph or fluid into its cavity, neither were
there any adhesions.
CASE II.-Jane Beatty, aged twenty-two years, se-
cond pregnancy, delivered at seven o'clock, P. M., Fe-
bruary 2nd, 1836.
This woman lay in the bed opposite to hers whose
case has just been detailed. A few hours after delivery
she had a rigor, and soon complained of severe pain in
the belly, accompanied by vomiting ; pulse 110. She
was leeched freely and fomented over the belly, and an
emollient enema was administered.
3rd. Nine o'clock, A. M. Belly tympanitic ; severe
pain ; vomiting continues; countenance muddy and
sunken ; pulse 104, weak. Gave her an ounce of spirit
of turpentine, which was soon rejected. Ordered a
turpentine fomentation to the belly, and pills of ca-
lomel and opium every second hour.
Four o'clock, P. M. All symptoms worse.
Ten o'clock, P. M. Evidently sinking ; pulse imper-
ceptible ; feet cold; vomiting continues.
4th. At seven o'clock, A.M. she died, just thirty-six
hours from the time of delivery.
70
P. M., seven hours after death.-The tympanitis of
the belly had subsided, and the uterus could be felt as
high as the umbilicus. On opening the abdomen, the
peritonaeum lining its walls and covering the viscera
was found minutely injected with red vessels in every
part, but particularly over the uterus, fallopian tubes,
and ovaries. There was a small quantity of thin, uni-
form, reddish-coloured serous fluid in the cavity, but
no lymph. An incision in the long axis of the uterus
displayed its walls of great thickness, and its inner sur-
face was of a deep chocolate colour, particularly in the
cervix and neighbouring part of the vagina. A small
quantity of serum existed in the pericardium, but there
was no trace of disease in the pleurae.
CASE III.-Margaret Mooney, aged twenty-nine years;
delivered February 2nd, 1836. In this case the infant
presented with the breech and was born alive, after a
labour of three hours.
4th. Ten o'clock, A. M. Had a shivering fit in the
night, complains of pain in the belly, increased on
pressure ; great thirst ; countenance sallow ; pulse 120.
To be bled to sixteen ounces, and leeches to the abdo.
men, with fomentation ; calomel and opium every
second hour.
Ten o'clock, P. M. Belly tympanitic; pain severe ;
countenance sunk; pulse 130. Continue the pills; two
drachms of mercurial ointment to be rubbed into the
belly.
5th. Slept well; pain and tenderness of the belly as
before; lies on her back; has not passed water for seve-
ral hours; a catheter was introduced, which gave exit
to some turbid, high-coloured urine. Continue the
pills and ointment.
71
Ten o'clock, P. M. Belly not so much swollen ; passes
faeces involuntarily ; pulse 128. Sleeps a great deal.
6th. Belly more tympanitic; pulse 140, weak; coun-
tenance greatly sunk. Continue pills, with a mixture
of carbonate of ammonia.
She continued to sink, and expiredatseven o'clock, P.M.
CASEs IV. and W.-Julia Cahill and Elizabeth Kelly.
These two patients were delivered in a ward distant
from that occupied by the last three, at one o'clock,
A. M., February 5th. They both shivered in the even-
ing of that day, and soon were attacked with pain in
the belly. Cahill, who was a strong, plethoric woman,
was bled to sixteen ounces. Kelly being weak, thin, and
pale, was not bled, except by leeches to the belly. The
disease ran a somewhat longer course than in the other
women who died. Cahill died on the 8th, and Kelly
lived to the 9th. They had both very early exhibited
the sallow, muddy, sunken countenance, a symptom
which I have always found to forebode a fatal termi-
nation. No post-mortem examination was made of
these women.
Three other patients were attacked with alarming
symptoms, which yielded to treatment similar to that
just mentioned in the other cases.
The hospital was now closed against any further ad-
missions. Patients who were sufficiently convalescent
after delivery were sent home, and the walls were tho-
roughly cleansed, painted, and whitewashed, after being
exposed to the vapours of chlorine for two days. The
admission of patients was resumed in a fortnight, and
no new case of the disease appeared for twelve months,
when in the month of January, 1837, a fresh burst of
the disorder took place.
Five women were now attacked, of whom three died ;
72
and it is to be remarked that on this occasion, also, the
first patient in whom the disease exhibited itself had
severe symptoms of thoracic disease similar to those
in case No. I.
CASE WI.—Mary Finlay, aged twenty-six, fourth
pregnancy, delivered January 7th, 1837, after a labour
of six hours.
9th. Complained of pain in the right side, with cough
and dyspnoea; tenderness over the uterus; pulse 120.
She was bled from the arm to sixteen ounces; and in
the evening, finding that the pain and difficulty of
breathing continued, and that the stethoscope indi-
cated bronchitis in the right lung, she was cupped on
the side, and ordered pills containing two grains of
calomel, one grain of ipecacuanha, and a quarter of a
grain of opium; one pill to be taken every second hour.
10th. Pain in the abdomen has increased, and ex-
tended over the cavity. Pulmonary distress not re-
lieved ; pulse 130, weak. Leeches were applied over
the uterus, followed by fomentations; the pills to be
continued.
11th. The leeches produced some remission of the
abdominal pain, but the difficulty of breathing still
continues, and both lungs now appear engaged, the
physical phenomena of bronchitis being manifest on
both sides of the chest. The pulse, from its weak cha-
racter, forbids further depletion. Blisters were applied
to the sides. No appearance of mercurial action.
Pills continued, and a drachm of mercurial ointment
put into each axilla.
12th. Was attacked with diarrhoea this morning
which still continues, and has exhausted her very much.
The colour of the skin on the face, neck, and chest is
dingy; pulse 140, feeble ; belly tympanitic. Ordered
73
tincture of opium with aromatic confection, and cam-
phor mixture. She continued to sink, and died at ten
o'clock, P. M.
On examination after death considerable effusion of
sero-purulent fluid was found in both sides of the chest,
and the lungs contained the frothy fluid characteristic
of the last stage of bronchitis. In the abdomen the
peritonaeum was very vascular, and the same kind of
fluid as in the chest was found effused. Patches of
lymph covered the intestines, and were numerous
about the pelvic viscera.
CASE WII.—Alice Kavanagh, aged thirty-three years,
delivered of her fourth child after a labour of fourteen
hours, same day as last case. This was a poor, wretched-
looking, dejected creature, confined in the same ward
with Finlay. She was attacked on the second day
after delivery with shivering, to which speedily suc-
ceeded acute pain in the uterine region. Pulse 120,
small and weak.
Her whole condition contra-indicated general blood-
letting. Leeches were applied to the abdomen, and
repeated in six hours. Fomentations were used dili-
gently, and she was ordered calomel with opium every
second hour. The disease assumed the typhoid type
from the first in this patient ; she soon put on the
leaden hue of countenance, resembling that observed in
cholera so strongly, that those who saw her were imme-
diately struck by it. The symptoms progressed in spite
of all measures used to arrest them, and she died on
the 12th, the fourth day after the seizure.
CASE VIII.—Sophia Cameron, aged twenty-one years,
delivered of her second child January 10th, 1837, after
five hours' labour.
This patient came into the hospital under peculiar
74
mental depression. She was attacked on the second
day after delivery with severe pain in the belly, which
soon occupied the entire region, and she could not bear
the slightest pressure on any part. Pulse 120. She was
bled to sixteen ounces, and leeches were applied over
the whole abdomen. She got a draught of six drachms
of castor oil, with the same quantity of spirits of tur-
pentine, which was soon rejected by vomiting. Intense
thirst harassed her, and whatever she drank was speedily
rejected. Calomel and opium, with mercurial frictions,
were freely employed, but without effect. She became
delirious on the third day of the attack; and, although
her pulse was imperceptible, her strength continued
surprisingly great ; she was able to sit up occasionally
in the bed, and her last act was to make a turn from
the right side to the left, when she instantly expired.
No examination.
The hospital was again closed, and the same means
of purification were pursued as on the former occasion.
The wards were re-opened in a fortnight, after which
we had no more of the disease. It appears remarkable
that at both periods of its invasion the disorder showed
itself first in the thoracic organs. Its occurrence in
these two cases was very different from the extension
of the disease from the abdomen to the thorax, which
is so common in the last stages of ordinary cases, when
pain in the former cavity ceases, and oppression of
breathing comes on. But, in the cases alluded to, the
first symptoms complained of were pain in the side,
and dyspnoea, and to these succeeded the usual symp-
toms of abdominal disease ; the former, however, Con-
tinuing the most prominent throughout.
We had a striking instance of the portability of the
disease during the former visitation, in the case of a
75
woman living in Camden-place, a considerable distance
from the hospital. This woman took her labour, and
sent to the hospital for assistance; she was attended by
two of the pupils who had been about the patients then
ill, and she was seized with puerperal fever on the second
day, and died on the fifth. Being the only patient in
that district who at that period was attended from the
hospital, I was anxious to know whether the disease
was existing in her neighbourhood; but on careful
inquiry we could not learn that any other woman had
been affected by it. From this it is fair to conclude
that the infection was conveyed to her by her attend-
antS.
It is not usual to believe that persons not puerperal
can be influenced by the disease under consideration ;
but three cases occurred during the former epidemic
which afford some grounds for thinking that such may
be the case. The two nurses who were engaged about
the sick were both attacked with a low form of fever,
in which great prostration of strength was a prominent
symptom, and from which they recovered very slowly.
The unusual exertions in watching which they were
called upon to use at the time might, no doubt, have
contributed to produce fever, but it seems at all events
a coincidence worthy of remark. The third case was
one which had been under treatment for a considerable
time in the hospital, in consequence of
PARALYSIS AFTER IDELIVERY.
Anne Kiernan, aged twenty-one years, delivered of
her first child November 26th, 1836, after a labour of
seven hours; infant alive. Nothing remarkable oc-
curred during labour or afterwards, until she com-
plained on the second day that she could not move
76
her right leg, and that it felt benumbed and dead. On
examining the limb, no swelling or pain could be dis-
covered at any part that could indicate the approach
of phlegmasia dolens; on the contrary, the sensibility
of the limb appeared considerably lessened.
Frictions, with warm turpentine, were ordered to
the limb, but without any effect upon the condition
of the part. At the end of a fortnight, finding that no
improvement had taken place, a course of blisters along
the line of the sciatic nerve was commenced, beginning
above, and going downwards. This plan, together
with attention to her general health, had the effect of
gradually restoring the power of the limb. In a month
she was able to walk across the ward with the assist-
ance of a stick, but even yet the leg was dragged along
with difficulty, and when carried forward, the foot hung
loose and vacillating, the toes pointing to the ground.
In another month she had regained considerable power
over the muscles, her progression was much more firm
and steady, and the sensibility of the limb was almost
entirely restored. She continued to improve until the
month of February, at which time she was walking
about nearly well, and preparing to leave the hospital,
when puerperal fever made its appearance in our wards.
I have mentioned that, on the invasion of the disease,
the hospital was closed, and cleared of all patients ;
but this woman being very poor, and more than two
months having elapsed from the time of her confine-
ment, I felt no apprehension in allowing her to remain.
On the 5th of February she was seized with alarming
symptoms. There was great general uneasiness and
depression ; the pulse beat 130 in a minute; she com-
plained of pain in the epigastric region, and there ap-
peared to be much embarrassment in the respiration.
77
The next day all the symptoms were aggravated, and
she was removed to Sir Patrick Dun's Hospital, where
she died in about a week of pericarditis. The post-
mortem examination of her body disclosed a striking
specimen of the disease having passed to its third
stage. There was a considerable quantity of sero-puru-
lent fluid in the pericardium, and flakes of lymph
covered the heart and lined the sac.
Here again, if it was not the effect of contagion, was
a striking coincidence of disease. It will be observed
that it was a serous membrane that was engaged, and
that it terminated in effusion similar to that poured
out in the peritonaeum in many cases of puerperal fever,
and that the affection came on at a time when disease,
invading other serous membranes, was prevalent in the
hospital.
It is not presumed, from a single case like this, to
found any positive opinion as to the real origin of the
disease; but, coupling it with the typhoid form of fever
with which the two nurses were affected, I cannot
divest my mind of the idea that I formed at the time,
that they were all the result of exposure to the noxious
influence of puerperal fever.
ABSCESS IN THE OVARIUM.
Two out of the seven cases of death occurred from
abscess in the ovarium bursting into the peritonaeum.
The first was in a woman aged thirty-eight years, after
delivery of her first child. She came into hospital on
the 30th December, with false pains, and did not fall in
labour until the 4th of January.” From her age and
* This woman stated that the only occasion on which she had seen her
husband, and could have become pregnant during the year, was on the
19th of March, 1834, making a period of 291 days, or forty-one weeks and
four days of utero-gestation.
78
peculiar make, to which I have already referred when
describing the instrumental cases, I expected a difficult
labour, an anticipation in which I was not deceived, as
it lasted three days. She was delivered, however, with-
out assistance, which I withheld in consequence of a per-
ceptible though slow progress of the head through the
pelvis. Next day, pulse 120 ; bad cough, which she
had before admission ; belly not tender ; bowels freed.
Following day, pulse as before ; intense bronchitis of
both lungs, inflammation of vagina, and foetid discharge.
Calomel, ipecacuanha, and opium every two hours;
blister to the back, stupes to the belly, and syringing
with warm water to be used frequently to the vagina.
The day after, the chest was somewhat relieved ; the ste-
thoscope gives less indication of bronchitis; belly tender,
particularly in the right iliac region ; pulse 120. Pills
of calomel, Dover's powder, and James' powder, and
friction with mercurial ointment were ordered. Follow-
ing day, being the fourth after delivery, the pain in the
belly became greatly and suddenly increased; the breath-
ing hurried ; countenance livid and sunken ; pulse 140 ;
extremities cold ; vomited her drink. She died that
night. On examining the body, the lungs were found
full of the frothy fluid of the last stage of bronchitis.
In the belly patches of lymph were discovered on the
peritonaeum ; a large quantity of pus in the pelvis; the
uterus and left ovarium enlarged and highly inflamed,
and a large gangrenous abscess in the right ovarium,
which had burst, and given issue to the matter found
in the pelvis. The vagina and rectum were both ex-
tensively inflamed.
The other case occurred in a woman aged thirty
years, who was delivered of her first child on the 15th
of February, after an easy labour of eight hours. She
79
complained of pain in the uterine region extending to
the right side, on the second day after delivery ; pulse
120. She was leeched freely, purged, stuped, and
slightly mercurialized, under which treatment the
urgent symptoms subsided, but never entirely disap-
peared. The pulse continued at 100, and the skin
hot; however, she appeared to be getting better until
the 25th, just ten days from her delivery, when she was
suddenly seized with violent pain in the belly, rigor,
and vomiting ; pulse 140, weak; she sank rapidly, and
died in twenty-four hours. I suspected the cause of
death to be the same as in the last case, and an exami-
nation of the body disclosed appearances very nearly
similar. A gangrenous abscess had formed in the right
ovary, which had burst, and poured its contents into
the peritonaeum. There was intense inflammation of
all the abdominal viscera, the intestines exhibiting a
cherry-red colour, and largely covered by recent lymph.
The uterus and vagina were not diseased, as in the for-
Iſle I Ca,Se.
While upon this subject, I wish to record a very re-
markable case of recovery from an accident similar to
these just related. Margaret Grant was delivered in
the hospital on the 31st of October. She went on well
for three days, when symptoms of inflammation of the
uterus and its appendages set in, with great pain and
tenderness of the hypogastric region, and high fever.
These were in a great measure subdued by leeches and
mercury, &c., but a swelling and tenderness in the right
iliac region, accompanied by a certain amount of fever,
continued for ten days, at which time she was removed
to Sir P. Dun's Hospital, where she remained nearly a
month, and was then discharged as well. She continued
at home for three weeks (suckling her child, which was
80
not healthy), but still complained of a swelling and sore-
ness in the right iliac fossa. At the end of that time
the circumstances took place which I now proceed to
relate, in the words of my friend Dr. Houghton, who
was at that period attending the practice of the hos-
pital, and undertook the treatment of the case, and to
whose bold and judicious practice she is certainly in-
debted for her recovery.
“On Friday, the 9th of January, her father came
“running into the hospital, South Cumberland-street,
“at half-past ten o'clock, earnestly requesting that me-
“dical aid should be instantly given her, as she was
“suddenly seized with some inward pain, which left her
“in a dying state. I went with him to their dwelling
“in Grand Canal-street. She lay screaming with agony
“on her left side, with her knees drawn towards her
“belly. She threw her arms to me supplicating some
“relief, not moving, however, any part, except the
“upper extremities and thorax. Her breathing was
“entirely thoracic ; she related to me, with difficulty,
“that about half-past nine o'clock (an hour before),
“while at stool, having passed a little from her bowels,
“she was all at once seized with a pain of excruciating
“intensity at the right side of the belly, about the iliac
“region. She was placed on the bed immediately, in
“the opinion of the people present, dying; she vomited
“ and fainted. On proceeding to examine her abdomen,
“she screamed to keep off my hand from touching her;
“it was swelled up in a round form, especially at the
“lower part, where she could not bear the least touch.
“This sensibility extended up to the epigastrium, de-
“creasing, however, from below. Her pulse at this
“ time was about 80 ; her hands were cold ; and her
“face, besides expressing intense pain, was somewhat
81
“sunk. She got a strong opiate, and her feet were put
“into very hot water. I saw her again in an hour and
“a-half; she had vomited the draught: her pulse had
“risen and become stronger; and the abdominal sore-
“ness had rather increased. I then bled her ad deli-
“quium, which ensued when a pint of blood was drawn.
“She complained of a scalding pain in both the rectum
“and vagina, which was probably caused by the inflam-
“mation invading the part of the peritonaeum lying
“ between those parts. At half past one o'clock she com-
“menced taking pills, consisting of five grains of calo-
“mel and one of opium, every half hour, and a blister
“was placed over the abdomen, to be dressed with mer-
“curial ointment in ten hours. Towards evening, at
“half-past seven, she appeared in less pain : the pulse
“was about 140; same position of knees; breathing
“entirely thoracic ; had passed urine under her with
“great pain; no evacuation from the bowels.
“Saturday, 10th.--Dr. Beatty came with me. Her
“ pulse was about 130 ; pain in belly had much abated ;
“ had not slept any. Has taken fourteen grains of opium
“ and one ounceof calomel; no sign of mercurialization;
“slightly drowsy ; voice louder. Examination per va-
“ginam discovered os uteri of a natural size ; not ten-
“ der, or in any other respect different from usual.
“Ordered her to take the calomel and opium every
“second hour. The blister rose well, and was dressed
“with strong mercurial ointment.
“11th. Appears to be decidedly improved; face ex-
“pressive of less suffering; belly bears pressure with
“little pain ; pulse 126. Vomited the medicine; can
“take but little drink; tongue white. The medicine
“was ordered to be repeated, and a large injection,
“salts, tincture of jalap, &c. to be thrown up.
- 6
82
“12th. Improvement continues : pulse 108, strong
“ and regular. Injection brought away a large dejec-
“tion of black faecal matter : passes water freely; com-
“plains much of severe stitches in the right hypochon-
“drium; bears pressure over the abdomen ; vomiting
“continues; the medicine was ordered to be omitted,
“and the place where the stitches are to be stuped with
“turpentine, and afterwards rubbed with strong mer-
“curial ointment.”
“14th. There commenced yesterday afternoon a
“dribbling from the vagina of purulent matter, which
“continued through the night, and at five o'clock this
“ morning she was seized with pains resembling those
“of labour, during which gushes of matter issued from
“ the vagina, and still continue to occur at intervals,
“accompanied by pains. She is more decidedly im-
“proved to-day than she has been yet : the face is
“much better; pulse 104, full and strong; bowels
“copiously evacuated ; passes water freely; got some
“sleep in the night for the first time since the accident.
“Mouth becoming sore and fetid ; the pain and stitches
“in right hypochondrium much relieved : ordered
“three grains each of mercury with chalk and of
“ powdered rhubarb every third hour, and a draught
“at bed time, containing thirty drops of tincture of
“opium, in an ounce of peppermint water.”
“15th. Continues to improve ; pulse 100, regular ;
“ pain on pressing abdomen generally, quite gone, but
“still considerable on pressing over the uterus ; mouth
“sore ; has been since yesterday in a profuse perspira-
“tion, without any rigor. A flannel swathe was ap-
“plied round her belly, and the turpentine enema and
“anodyne draught was directed to be repeated.” .
“27th. I have not seen her for some time (being
83
“myself unwell). She has been taking the anodyne
“draught at night since, and is now decidedly ad-
“vanced to recovery. She still has some pain on
“pressing the region of the uterus, and there is a ful-
“ness with hardness, particularly on the right side.
“She is much troubled with tenesmus, accompanying
“the discharge of gelatinous matter, sometimes tinged
“with blood; her face is much improved. This day
“the discharge from the uterus, having ceased for ten
“ days, recommenced. Ordered to use an injection,
“ per vaginam, of decoction of chamomile, and to have
“an anodyne enema. From this date her amendment
“was progressive.”
“May 2nd. I called to see her to-day. She is grown
“full and strong, but the belly is somewhat swollen,
“ and some tumour still remains in the region of the
“right ovary, or, to speak less inferentially, in the right
“iliac region. She has never menstruated since, al-
“ though the milk was stopped at the time of the acci-
“dent, now nearly four months ago. She speaks of
“going out to Malta to join her husband, who is a sol-
“dier stationed there.”
From this very accurate description of the case, there
can be little doubt that a burst of some kind had taken
place into the peritonaeal cavity; and looking to the
previous history, there is strong ground to presume
that it was an abscess of the uterus or ovarium that had
given way, probably the latter. The recovery is worthy
of record, inasmuch as it shows the efficacy of bold
and scientific practice. The quantity of opium and
calomel administered was very great, and I think it is
likely that either of them alone would not have been
successful. The opium was given in accordance with
the views of Dr. William Stokes; but it appears that
84
the salivation by the mercury completed the resolution
of the inflammation, and probably the absorption of the
effused fluid. The discharge of pus from the uterus at
a subsequent period shows that more than one abscess
had existed.
HOOPING COUGH.
Hooping cough has been very prevalent during the
last six months, and several very severe cases of it were
brought to the dispensary. This is one of the disor-
ders which the children of the poor have with great
severity, in consequence of the exposure to cold in the
early stages aggravating the bronchitis with which it
always commences. I have never yet met with a case
of hooping cough that was not attended with inflam-
mation, more or less severe, of the bronchial mucous
membrane at its commencement. A disregard to this
stage, or the adoption of means calculated to increase
rather than diminish its violence, is a great reason why
the disorder is sometimes met with in so aggravated a
form ; and there is no measure so calculated to do mis-
chief as the free exposure to all weather. To this the
children of the poor are of course greatly exposed. In
some of those cases in which bronchitis had gone to a
great length before application for relief, the whole
attention was directed to this complication. Close con-
finement, depletion, calomel and ipecacuanha, and blis-
ters, formed the chief ingredients in the course of treat-
ment. After the inflammatory stage was got under,
the spasmodic was attended to ; but great caution was
observed in passing from the treatment proper to the
one to that suitable to the other. The mixture which
was introduced into practice by the late Dr. Beatty,
and the formula of which has been given in one of the
early numbers of the Dublin Medical Journal, has been
85
employed with great success in the latter stage. It is
as follows:—
R. Tinct. cinchonae. comp. 3v.
Tinct. Opii, camph.
Tinct. cantharidis a a 3ss. M.
Of this a teaspoonful is given three times a day, in an
ounce of flaxseed tea ; and to a child of three or four
years old a dessert spoonful; and up to a table spoonful
for a dose to children of ten or twelve. It is evident,
from the nature of this mixture, that its use cannot be
commenced while any inflammatory action is going on.
But if the proper time be selected for its administra-
tion, its efficacy in arresting the spasmodic cough is
often surprising. It sometimes puts an end to the dis-
ease in a week when given judiciously.
86
CHAPTER IV.
FROM what has been already stated, in the earlier part
of this volume” respecting the banishment of the mid-
wifery forceps from the practice of the profession in
this country during a period of at least forty years, it
will be understood that the attempt to restore that
instrument to its proper position, made in 1829 by
my father, could not be at once successful; but that it
must have taken some years before the complete eradica-
tion of long-rooted prejudice could be accomplished.
In fact, a generation had to die out, and the reforma-
tion had to be undertaken by their successors. Many
practitioners in this city, and throughout Ireland,
adopted the new light ; but until the publication of
the Report of my hospital (the South Eastern), no
account of the use of the forceps had been published.
This will explain why even so late as the year 1842 I
thought it expedient to write and publish the following
paper in the Dublin Medical Journal, vol. 21; for even
then there were some of the old school extant and in
large practice, and it was thought necessary to take
some step to counteract the weight of their influence.
CASES IILUSTRATIVE OF THE USE OF THE FORCEPS.
I have adopted the title prefixed to this paper, because
it is intended to contain a detail of some cases of diffi-
* Page 2 and seq.
87
cult labour, in which the use of the forceps is, in my
mind, clearly shown. By the term use, I mean its
beneficial employment where great danger threatened
both mother and child; and I wish it to stand in strong
contrast with abuse, to which this instrument, in com-
mon with every other valuable agent employed in
medicine, is exposed.
In all branches of the healing art, mechanical assist-
ance is employed only in cases where it is deemed
necessary for the relief of our patient. What well-
educated surgeon would employ pulleys to reduce a
dislocation, if he could replace the bone with his hands?
Who would pass a catheter into the bladder, if he could
as speedily and safely relieve retention of urine with-
out it 2 Who would have recourse to the scalpel in
strangulated hernia, if by the taxis, &c. he could rescue
his patient from danger ? The surgeon does not em-
ploy pulleys, catheter, and knife because he can use
them, but because he knows that they are necessary for
the well-being of the sufferer under his care. A similar
rule is applicable to all instrumental interference in the
practice of midwifery; it should always be the dernier
ressort. We do not employ artificial aid simply because
we have an opportunity of doing so, but because the
circumstances of the particular case before us demand
such assistance. “A prudent use of instruments in the
“practice of midwifery is of greatimportance; but the
“necessity alone of freeing our patient from impending
“ or present danger should induce us to resort to
“ them.” This sentence should be engraven on the
mind of every practitioner; and it will appear that in
the cases I am about to relate the practice adopted was
founded on similar principles.
* Collins' Pract. Treat., p. 9.
88
“Impending or present danger.” Two questions
here present themselves:—1st. What are the dangers
to be feared in difficult labours ? 2nd. How do we
know them to be impending or present 2 Upon an in-
timate acquaintance with the true solution of these
questions, depends the difference between the well-in-
formed, reflecting, experienced accoucheur, and the
ignorant, reckless empiric. There is no term more
abused than eaſperience, as it is frequently applied to
medical men. It is no proof of experience that one
has attended a vast number of cases of any particular
disease—of fever, for example. A physician may have
seen many persons recover, and others die of this
malady, during a long practice; and yet, for want of
observation and reflection, be totally devoid of experi-
ence; just as a traveller may pass from St. Petersburgh
to Constantinople, and, from a similar cause, be no
wiser at the end of his journey. So it is in midwifery.
He alone who studies the phenomena of natural labour
in all its phases, and observes, compares, and treasures
in his memory the ever varying course of this natural
function, under different circumstances, in different
constitutions, he alone is to be considered experienced,
and can judge of the symptoms indicative of danger
in any given case.
In studying the phenomena of labour, there are five
principal subjects for consideration :-1st. The moving
power. 2nd. The body to be moved. 3rd. The chan-
nel of exit. 4th. The materials lining that channel.
5th. The constitutional temperament of the patient.
It is well known that, in the majority of instances, such
a harmony exists between these several objects, as to
secure the safe termination of the process; but any de-
viation from the proper proportion that 1, 2 and 3 bear
89
to each other, is productive of either delay or difficulty
in the delivery. Thus, a deficiency in No. 1 (the con-
tractile power of the uterus) may, while Nos. 2 and 3
(the foetus and pelvis) are of normal dimensions, be the
sole cause of protracted labour. It is certainly erroneous
to place such a case as this under the head of difficult
labours, as has been done by Denman. There is here
no difficulty to be overcome, the delay arises from the
want of the vis a tergo. Neither the patient nor her
child are exposed to danger from the tediousness of the
labour, and this leads to an important caution against
judging of the danger of a case from the time it occu-
pies. We should always bear in mind the difference
between delay and difficulty. Delay implies deficiency
in the moving power, while difficulty suggests the idea
of an abnormal condition of Nos. 2 and 3; either an
excess in the dimensions of the foetus, or a diminution
in the capacity of the pelvis. Now, while simple delay
is seldom productive of bad results, and is usually
remediable by appropriate treatment, difficulty arising,
as I have said, from mechanical obstruction, resisting
the energetic action of the expulsive force, always in-
duces danger.
This leads us back to the first question proposed,
what are the dangers to be feared in difficult labours?
Before this question is answered, it will be necessary to
make a few observations upon the fourth and fifth sub-
jects for consideration ; viz., the materials lining the
channel of exit, and the constitutional temperament of
Our patient.
It should always be borne in mind, that in every
case of labour there are a great number, and a great
variety, of important parts intervening between the
head of the child and the bony parietes of the pelvis,
90
There is first the cervix and os uteri, together with the
vagina, which, with the mucous membrane common to
all, form the innermost layer. These are parts endowed
at this particular period with a high degree of organ-
ization ; the blood-vessels especially being of much
greater size than in the unimpregnated state. Outside
this layer there is, at the upper and back part, the cul
de Sac of the peritonaeum, dipping down between the
rectum and back of the uterus and vagina. This mem-
brane does not descend so low in the pelvis during the
latter part of gestation as it does previous to impreg-
nation; but during labour it follows the descent of the
cervix uteri, and will be found below the level of the
promontory of the sacrum. That it is so is manifest
in those cases where laceration takes place, as it so fre-
quently does at the junction of the vagina and uterus,
or at the lowest part of the posterior surface of the
latter organ ; in all of which cases the rupture extends
into the cavity of the peritonaeum. It may be a ques-
tion whether the vomiting that occurs in the advanced
stage of difficult labour, and the tenderness of the ab-
domen that accompanies it, may not be partly produced
by pressure of this fold of the serous membrane against
the promontory of the sacrum, just as similar symp-
toms arise when it is subjected to pressure in strangu-
lated omental hernia. The anterior surface of the
vagina is in close contact with the back of the urinary
bladder and the urethra, with which parts it is inti-
mately united. Along the sides of the vagina, and
loosely connected with it by cellular tissue, we have the
funnel-shaped muscular sling, constituted of the leva-
tor ani muscles; and external to these muscles are
found anteriorily the obturator internus, and poste-
riorly the pyriformis muscles. Along the back of the
91
vagina runs the rectum, and in addition to these parts
there are the internal iliac arteries and veins, with their
several branches; the uterine nerves ; and the roots of
the great sciatic nerves, with the obturator nerve before.
All these, with the several fasciae, and the cellular
tissue that surrounds them, form a soft lining to the
pelvis, along whose cavity the head is propelled in
labour. We should never lose sight of the fact, that
such a combination of living tissues is interposed be-
tween the solid unyielding walls of the pelvis and
the foetus during parturition.
The last subject for consideration, and not the least
important in a practical point of view, is the constitu-
tional temperament of the patient. To those who are
extensively occupied in the practice of midwifery, it
will not be necessary to insist upon the vast variety of
constitutions that we encounter, nor upon the influence
that this diversity exercises over the powers of endu-
rance in different patients. But it is always necessary
to impress upon the minds of students, that labour is
not a process performed by inanimate machinery, but
that it is a complex function discharged by living tis-
sues, whose properties and energies are regulated by
the peculiar temperament of individuals. Thus we see
some patients sink under a labour, which, for severity
and length of duration, is not to be compared to what
others will endure with perfect safety ; and hence we
are led to discard time alone as a measure of danger.
Some patients are prone to inflammatory action, phleg-
monous or erysipelatous, as the case may be ; others
are endowed with a nervous energy, originally deficient,
or easily exhausted ; and others again are of a sluggish
habit, that pervades every organ, and require stimu-
lants to rouse their dormant powers ; while a fourth
92
class, in whom hysteria prevails, have all their func-
tions so modified by this protean malady, as to baffle
attempts at accurate description, and require the
greatest skill for their management. These are but a
few of the modifications of temperament that might
be enumerated; but they are sufficient to show any re-
flecting mind that we are not to expect uniformity of
phenomena in labour, or similarity of effects from ap-
parently similar causes.
We are now in a predicament to answer the ques-
tion : What are the dangers to be feared in difficult
labours ? They are threefold: 1st. The death of the
mother, or the child, or both, before delivery. 2nd.
The death of the mother after delivery. 3rd. Inflam-
mation, terminating in abscess or sloughing of the soft
parts within the pelvis, and producing effects fatal to
the future comfort of the patient. The life of the
mother may be sacrificed from two causes before the
labour is terminated : either by actual exhaustion, pro-
duced by the combination of prolonged pain and exer-
tion, or by rupture of the uterus or vagina; in either
of which cases the fate of the child most commonly
corresponds with that of the parent. And when the
mother survives delivery, it is notorious that the pres-
sure to which the infant has been subjected is too fre-
quently sufficient to destroy it before it is born. The
death of the mother after delivery may follow in con-
sequence of the rupture of the uterus, or of collapse, or
of the effects of inflammation excited in the soft parts
lining the pelvis; and this, probably, after a dead child
has been delivered. Or if the effects of inflammation
are not sufficient to destroy her life, she is exposed
(having most likely given birth to a still-born infant)
to the danger of sloughing of the vagina, whereby con-
93
striction or obliteration of that canal is produced, or
the more lamentable consequence, sloughing of the
back of the bladder and urinary fistula, rendering her
for life a loathsome victim of erroneous practice. Such
are some of the dangers to which women and their
offspring are exposed in difficult labour; no light risks,
it will be admitted, and such as every practitioner is
bound, if possible, to avert. But in order to avert, he
must foresee them ; he must perceive that danger is
impending. - -
This involves the second question : How do we
know danger to be impending or present 2 We have,
in the condition of our patient, sufficient evidence of
the approach or existence of all these sources of danger,
except rupture of the uterus ; and we should always
bear in mind the possibility of the occurrence of this
accident in every case of difficult labour. The term
eahaustion explains the condition meant to be implied
by it; muscular irritability and nervous energy are ex-
pended, all capacity for further exertion is at an end ;
the powers of life seem failing, and the mind as much
depressed as the body; they would both sink together
unless relieved by artificial assistance. But before the
patient has arrived at this formidable condition, into
which the attendant should never allow her to fall,
there is a train of symptoms exhibited in the case suffi-
ciently indicative of danger. These are so well and so
concisely laid down by Dr. Merriman, that I will take
the liberty of transcribing them from his valuable
synopsis, “1. Severe shivering fits, unconnected with
“ dilatation of the os uteri, or the passage of the head
“through the os eaſternum. 2. Frequent or constant
“vomitings after the os uteri is largely dilated. 3.
“The accession of fever indicated by a quick pulse, a
94
“furred tongue, a hot dry skin, and great thirst. 4.
“Great restlessness or jactitation. 5. An anxious and
“disturbed mind. A disposition to sing in a plaintive
“ and wailing tone of voice has, in particular, been
“considered as a very frightful symptom. 6. The
“want of true uterine action, though there may be
“irregular and unproductive pains. When this hap-
“pens after many hours of labour, it is always an
“unfavourable symptom. 7. Great heat and soreness
“in the vagina and os uteri. 8. The discharges from
“the uterus and vagina being offensive both in colour
“ and smell. 9. Violent and continual pain, and sore-
“ness and tenderness of the belly, increased upon pres-
“sure. 10. Low, muttering delirium. 11. A quick and
“weak, or low, sinking pulse. 12. Clammy sweats. In
“ proportion to the number and severity of these symp-
“toms will be the danger of the patient; it becomes the
“duty of the practitioner, therefore, to combat by appro-
“priate remedies each of these symptoms as they arise;
“but if several are present at once, unless artificial aid
“be timely afforded to deliver the patient, both mother
“ and child will perish.” The second danger mentioned
above is, the death of the mother after delivery. This
may happen from collapse or exhaustion, but it is most
frequently caused either by rupture of the uterus, or
inflammation of the soft tissues, the result of the me-
chanical violence offered to them by the prolonged
pressure of the head of the child. Some or all of the
symptoms just mentioned will be observed in such
cases during labour, and they will also be found to
attend those protracted labours in which, although the
life of the mother is spared, the local mischief that
ensues bears ample testimony to the injury inflicted. In
judging of the means best calculated to rescue two
95
living beings from such dangers, it should be recollected
that it is the continuance of the pressure that does the
mischief, rather than its intensity. We know that the
soft tissues of the body are endowed with a resiliency,
a power of resistance, that enables them to bear a tem-
porary compression of great amount without injury ;
while inferior pressure continued for a length of time
will terminate in their disorganization. The malinger-
ing soldier is well aware of this fact, and acts upon it
when he wishes to produce an ulcer. He straps a piece
of coin or other hard substance tightly upon the part.
At first no effect is produced, and if the apparatus is
removed in a short time, there is no evil consequence ;
but if the same amount of pressure be continued for
some hours, such a degree of injury is inflicted as ter-
minates in the destruction of the part, and a sloughing
ulcer is the result.
Bearing this physiological fact in mind, we should
be always cautious how we permit the soft parts in the
pelvis to be subjected to continued pressure, after we
have evidence that there is an arrest to the progress of
the head through its cavity; or that delivery by the
natural efforts is either impossible, or so remote as to
be improbable; while at the same time the local and
constitutional symptoms already detailed give warning
of impending danger. We should be cautious, I say,
on this point, with reference to the mother ; and we
should never lose sight of the fact, that we have a living
infant also in our charge. Its life depends upon the
progress of the labour. Its head will bear a very con-
siderable amount of compression for a short time, but
there is a limit to such endurance.
The exact period at which pressure becomes incompa-
tible with foetal life is difficult to determine in any
96
given case ; but I think it may fairly be presumed, that
the amount of pressure capable of producing dangerous
symptoms in the mother, must, at the same time, ope-
rate prejudicially on the child, and if not removed, will
soon terminate its existence. I very much fear that
this is a point too much overlooked by practitioners
and writers on midwifery; the safety of the mother is
kept too exclusively in view, and the fate of the infant
is too often neglected. This carelessness about the life
of the child may suit the views of certain political
economists, by whom the diminution of the human race
may be an object greatly desired; but the conscientious
practitioner should remember that there are different
modes of infringing the sixth article of the Decalogue ;
he should recollect that acts of omission are as criminal
as acts of commission, and that allowing a fellow-crea-
ture to remain in a perilous situation until life is sacri-
ficed, while he had the means of rescuing him from his
danger, will as surely rise up in judgment against him
as if by his own hand he had dealt the fatal blow.
The inference to be drawn from these observations
is, that where we have evidence that the continuance of
labour is attended with danger to mother or child, or,
as is most commonly the case, to both, we are bound
to afford such assistance as will, without hurt to either,
place both in a state of safety. But let no one pretend
to judge of the necessity for artificial interference, who
has not fully and carefully studied the phenomena of
labour. It is from symptoms he is to draw his conclu-
sion, and if he is not thoroughly conversant with those
indicative of danger, his opinion must be ill-founded,
and his practice rash and empirical. And here I would
urge upon the attention of the reader the observations
made upon this point several years ago by my late
97
father. “It is of importance that every man practising
“midwifery should avoid as much as possible the use
“of instruments in delivery ; for it is certain that if he
“suffers his patience to be too readily exhausted, or
“yields too hastily to the suggestions and alarm of the
“ patient or her friends, he will frequently be induced to
“promote delivery too soon, very much to the injury
“of the patient, and consequently of his own character.
“On the other hand, he has an important duty to per-
“form in judging of the necessity and the proper time
“for using instruments, and the kind suited to each par-
“ticular case; for as much or more mischief maybe done
“ by delaying their use when absolutely required, as by
“having recourse to them too soon. In fact in this,
“as in most other situations, the man who has patience
“to watch, judgment to discriminate, and firmness to
“act, will be the best qualified to perform the duties
“required of him.”
In the observations that follow I wish it to be under-
stood that I omit the consideration of those cases in
which the capacity of the pelvis is so much diminished
by malformation, tumours, &c. as to render the pas-
sage of an entire child impossible, and that I will allude
only to the more common cases of difficult labour, in
which, after several hours of severe pain, the head has
been forced to a greater or less extent into the cavity
of the pelvis, and is then arrested. When matters have
arrived at that state, the practitioner's mind becomes
alive to the dangers that may ensue. If some favour-
able change does not take place, the signals of distress
will soon be exhibited, but with a rapidity varying in
different cases from diversity of temperament. The
pulse will become fast, the skin hot, the belly tender,
* Dublin Medical Transactions, New Series, vol. 1, Part I., p. 41.
7
98
the vagina hot, and the stomach irritable. These are
signs which we know indicate impending or present
danger—danger to the mother, and danger to the child.
Knowing this, is it not our duty to avert them? Who,
if he could, would not with a word terminate such
a labour at such a time 2 Who would not wish to pos-
sess the means of shortening the agony and danger of
his patient and her offspring 2 Leave her unassisted,
and what have we to expect P A protraction of suf.
fering, an aggravation of danger to the mother, and
death to the child. That we have a safe and efficient
means of averting these, by the careful use of well-
constructed forceps, will appear in the detail of the
following cases. And here I would observe, that all
the operations which it has fallen to my lot to perform
with the forceps are here set forth ; there are none con-
cealed. I have not selected cases favourable to my
views, and left the unfavourable ones behind in my
note-book; but all are given, and all are favourable.
I look upon this fact as most important, because it is
likely that if the lacerations, contusions, and other evil
consequences that haunt the imagination of some prac-
titioners were actually attendant on the operation, it
is likely, I say, that I would have encountered some of
them : it is not probable that such good luck would
have been constant in my hands, and that all my patients
would have escaped.
CASE I.—Age thirty-six; seventh pregnancy. All her
former labours had been very long and difficult, and in
two of them the children had been still-born. The
labour set in strongly, and the os uteri dilated slowly.
It yielded after twenty-four hours had elapsed, and the
head entered the brim of the pelvis. The pains con-
tinued strong during the ensuing twelve hours, and the
99
head was slightly advanced during that time. At the
end of this period, being thirty-six hours from the com-
mencement of labour, the pulse became a little accele-
rated, but as there was some continuing advance of the
head, the labour was allowed to proceed. In six hours
thereafter the head had passed to the extent of about
two-thirds through the brim of the pelvis, and appeared
tightly jammed in the aperture. The patient's pulse
was still faster than before, but no tenderness of the
belly was complained of. Her strength being good,
and the pains regular, it was not judged necessary to
interfere; but, at the end of forty-eight hours from the
beginning of labour, unfavourable symptoms had fully
appeared. Her pulse was now 120 ; the pains had
greatly diminished ; her strength was failing; and she
suffered considerable pain on pressing the abdomen.
Her stomach had become irritable, and rejected her
drinks. Under these circumstances the forceps were
applied. It required some care and patience to get the
blades of the instrument into their place ; but at last
this was accomplished, and by slow degrees, and well
graduated lateral motion of the instrument, the head
was dislodged from its position, and brought down to
press upon the perinaeum. The rest of the operation
was sufficiently easy. The child was extracted still-
born. This woman suffered a good deal from inflam-
mation of the vagina, which was subdued by fomen-
tations, injections, and poultices, but no sloughing took
place. She left the hospital in a fortnight quite well.
I regretted at the time, and still continue to do so, that
I had not performed the operation at the end of thirty-
six hours, instead of waiting to forty-eight, as I have
no doubt the inflammation of the vagina would have

7 %
100
been prevented thereby, and decidedly the child would
have had a much better chance of being born alive.
CASE II.-Age twenty-eight years; seventh preg-
nancy. This woman had borne six children, in the de-
livery of which she had always difficult labour, and the
last child had been extracted by another practitioner
by the perforator and crotchet. In this labour the
head presented in the first position, and it was evident
that the brim of the pelvis was somewhat diminished
in its antero-posterior diameter. A considerable oppo-
sition to delivery, also, arose in this case from a conver-
gence of the spinous processes of the ossa ischia, which
encroached upon the cavity of the pelvis, and resisted
the passage of the head. At the end of twenty-four
hours, finding from these two causes the progress of
delivery was impeded, the head having come down to
rest upon the spinous process below, while the remain-
ing portion was engaged in the brim of the pelvis;
perceiving that there was little prospect of delivery
being accomplished by the natural efforts; and hav-
ing former labours as a guide as to what was to be
expected, I determined not to wait too long without
attempting to rescue the infant from its perilous situa-
tion, if it were consistent with the mother's safety.
Accordingly the forceps was cautiously introduced, and
as cautiously used as an extractor; and in half an hour
from the commencement of the operation, I was gra-
tified by the birth of a living boy, who with his mother
continued to do well, until they left the hospital on the
tenth day.
CASE III.-Age thirty-six years; ninth pregnancy.
In this case the head presented in the fourth position
of Naegelè; and instead of changing in the course of
the labour to the first, as it usually does in this presen-
101
tation, it continued to descend with the anterior fonta-
nelle towards the pubis. At the end of twenty-four
hours (labour being severe) the head was firmly fixed
in the pelvis, and in six hours more finding that
no advance had taken place, and that the vagina was
becoming tender to the touch, while the pulse was
gradually increasing in frequency, delivery was effected
by the forceps. The child was dead. This patient re-
covered without any unpleasant symptom.
CASE IV.-Age thirty years; fourth pregnancy.
This was a footling presentation, and the labour went
on without anything remarkable until the arms had
been extracted, when great difficulty was found in
the passage of the head. The labour pains conti-
nued strong, and the cord pulsated for a considera-
ble time during the endeavours made to extricate the
head. But all attempts to accomplish this in the ordi-
nary way having been tried for nearly half an hour, and
failed, and finding the pulsation in the funis becoming
weak, I determined upon using the forceps. Unfortu-
nately some delay, which proved fatal to the infant,
took place in procuring the instrument; for, before its
arrival, the cord had ceased to pulsate. I passed the
blades along the sides of the face and head, having the
body of the infant carried forward between the thighs
of the mother, and with some difficulty I succeeded in
extracting the head. The mother did well.
All these cases occurred in women who had pre-
viously borne children; but I now come to a class of
patients in which the employment of the instrument is
by some deemed inadmissible and improper. I allude
to women in labour of first children, and it will be
seen by the sequel whether the dread of the instru-
ment in such cases is well founded or not.
102
CASE W.—Age twenty-five years; first pregnancy.
The head presented in the first position, and the labour
progressed steadily and slowly, so that at the end of
twenty-four hours the os uteri was completely dilated,
and a portion of the child's head had entered the brim
of the pelvis. The pains continued severe and constant,
and at the end of thirty hours the greatest portion of
the bulk of the head had passed into the cavity of the
pelvis, but not so low as to fill the hollow of the sacrum
or make any pressure on the perinaeum.
From this time there was no advance in the progress
of the head, but a very large tumour formed on the
scalp. In this condition the head remained for six
hours, notwithstanding frequent and strong pains. The
woman was now thirty-six hours in strong labour. It
was plain that the natural efforts were unequal to over-
come the difficulty. The pulse had risen to 110, and
great restlessness had commenced. By the stethoscope
the child was found to be alive; but how long it would
remain so under such severe pressure was very doubt-
ful. I therefore determined to give it a chance for life.
The forceps were applied slowly and cautiously; and
when introduced the blades lay one behind the pubis, the
other along the sacrum. This shows the position of the
head, that it had not turned from the oblique position.
By grasping the hands loosely, and swaying them back
and forward two or three times during each pain, with-
out as yet using much extracting force, I loosened the
head in its position, and then gradually caused it to
descend, and in twenty minutes a living boy was deli-
vered without a single fibre of the perinaeum having
been damaged, a careful assistant having duly sup-.
ported that part. The mother and child left the hos-
pital on the tenth day.
103
CASE VI.-Age twenty-four years; first pregnancy.
This case was very similar to the one just described;
with this difference, however, that in the present one
labour was allowed to proceed for forty-eight hours be-
fore the operation was performed, whereas the former
was delivered at the end of thirty-six hours. The rea-
son was, that urgent symptoms of danger did not mani-
fest themselves so soon as in the former instance. The
pulse kept moderate until within a few hours of the time
at which she was delivered, and the os uteri, which was
very slow in dilating, had not permitted the head to pass
through until nearly twenty-four hours had elapsed.
From that time a slow advance of the head took place,
but at the end of thirty-six hours not more than one-
half of it had been forced through the brim, and from
that time little progress was made, notwithstanding
strong and regular pains continued. Still, as no un-
pleasant constitutional or local symptoms were pre-
sent, I contented myself with watching the case. In a
few hours the patient's strength began to decline, and
her pulse rose to 110; the vagina at the same time
began to lose the cool, moist feel it had hitherto pre-
served, and to become hot and dry. When matters had
assumed this form, I felt that I was no longer justified in
withholding assistance, and finding the child to be still
alive, I determined on using the forceps. By steady
and cautious management I was able to apply the in-
strument, and I succeeded in delivering a living girl.
They both left the hospital well on the twelfth day.
CASE VII.—Age twenty ; first pregnancy. In this
case the necessity for the employment of the forceps
arose from the patient having been seized with convul-
sions in the latter end of the second stage of labour.
The pains were strong and effective, the os uteri dilated
104
in four hours, and in six hours most of the head had
passed through the brim of the pelvis. At the expira-
tion of sixteen hours the head had made no further
advance; the perinaeum was very rigid, and the vagina
dry. The patient being of a plethoric habit, she was
bled to sixteen ounces, with decided benefit, for soon
afterwards the vagina and perinaeum became cool and
relaxed. At the end of twenty-four hours the head
had come down so far as to touch the perinaeum, but
did not as yet press upon it. In four hours more,
when at each pain the head was forcibly distending the
perinaeum, the patient was seized with convulsions.
Delivery by the forceps was instantly had recourse to ;
and much difficulty was experienced in the operation,
owing to the restless state of the woman and the great
size of the infant's head, which was found to measure
four inches between the parietal protuberances. The
child, as is most usual in convulsions, was born dead.
The mother recovered, and left the hospital well.
The remaining cases occurred in my private prac-
tice.
CASE VIII.—Age twenty-two years; first pregnancy.
This lady was sixteen hours in labour before I was sent
for. She was attended by an intelligent midwife. I
was called to her in consequence of retention of urine,
none having been passed for fourteen hours. I found
the head on the perinaeum, which it distended at each
pain ; the external parts were relaxed. The pains
very weak, and few in number ; pulse 75. I passed
the catheter, and drew off one pint and a-half of water;
gave a drachm of ergot in divided doses, and left the
patient in the hands of her attendant, expecting that
delivery would soon take place. I was surprised to get
a message nine hours afterwards, requiring my attend-
105
ance again. I found her just in the same state as that
in which I had left her, with the exception of a more
accelerated pulse, more exhaustion, and an irritable
stomach. I at once delivered her with the forceps of a
very large still-born boy. The mother soon recovered.
CASE IX. —Age thirty-two; first pregnancy. Labour
commenced about four o'clock in the evening, and the
pains continued during the night and following day
without interruption. In the course of the second
night the pains became violent, and Dr. Guinness of
Clontarf was sent for to see her, she having been pre-
viously under the care of a midwife of much experi-
ence. He saw the patient at four o'clock, A. M. He
found the os uteri not dilated, and the pains most vio-
lent and distressing. At his desire I was sent for, and
saw her at half-past eleven o'clock, A. M. I found the
os uteri then dilated to the size of a half-crown piece,
not very thick, but exceedingly rigid. The waters had
been discharged spontaneously in the course of the
morning. The pains were violent and frequent ; in
fact, there seemed to be no intermission, and no impres-
sion seemed to be made on the os uteri. There was
greatirritability and impatience; flushed countenance;
hot skin; pulse 80. We agreed that it would be advis-
able to take some blood from her arm. This was ac-
cordingly done to the extent of eighteen ounces, with
decided relief. The character of the pain was imme-
diately altered. It became more regular and natural,
and there was an intermission or suspension from time
to time between the pains.
An emollient enema was now administered. At one
o'clock, P.M., the os uteri was felt soft and yielding ; the
head of the child still above the brim of the pelvis. At
106
three o'clock the os uteri was completely dilated, and
about one-half of the head had passed through the brim
in the second position. The pains were violent and
frequent. At four o'clock no advance of the head had
taken place; but a very large tumour had formed upon
it. The bones felt remarkably firm ; the external parts
were well relaxed ; pulse 110; restlessness and im-
patience to a great degree, so much so that it was diffi-
cult to keep the patient in bed. The child was ascer-
tained to be alive. Seeing that the patient was now
forty-eight hours in labour, during the whole of which
time it had been most violent ; that there was little
prospect of the labour being concluded by the natural
efforts, or at most that such an event was very remote;
and that from the present condition of the patient it
was probable, indeed almost certain, that most dan-
gerous symptoms must arise before it could take place;
seeing that the child was now alive, but that from the
manner in which its head was embraced by the pelvis,
and the length of time that must be spent in fruitless
efforts to dislodge it by the unassisted efforts of the ute-
rus, its death before delivery was in the highest degree
probable ; seeing all these circumstances, we agreed
that an attempt should be made to deliver our patient
by the forceps. The blades were introduced; slow,
swaying traction was employed during a pain, and in
ten minutes the head was so dislodged as to come down
to and press upon the perinaeum. I now withdrew the
instrument, and allowed the uterus to accomplish the
remainder of the delivery; this was happily effected in
a few minutes, and a living boy was born, without the
least injury to mother or child.
Ifancy that there is no one who will object to this case,
107
as illustrative of the use of the forceps. What would
any one predict of the case at four o'clock P What were
the dangers ? What was the result 2
CASE X.—Aged thirty-four ; first pregnancy. At
eleven o'clock, A.M., while sitting in her drawing-room,
the membranes ruptured without any pain, and the
waters commenced to escape. I saw her at two o'clock,
P. M. No pain had then occurred. The os uteri was
very high in the pelvis, and dilated just sufficiently to
enable the finger to pass through. The head could be
reached with difficulty, and the scalp was found
wrinkled and doughy. She remained all that night
and the following day without pain, until two o'clock,
P. M., when slight pains set in. These became more
severe at seven o'clock in the evening, when I was sent
for. I found the os uteri dilated to the size of a half.
crown piece, and soft. Labour progressed naturally
until ten o'clock, P.M., at which time the OS was fully
dilated, and the head was engaged at the brim of the
pelvis in the second position, about one-third of it
having passed through. Free vomiting accompanied
this stage of the labour. When matters were in this
state, the pains began to diminish in strength, and
although they did not entirely cease, they became weak
and inefficient. Two hours passed over in this way
without any advance of the head. I had satisfied
myself that the pelvis was sufficiently large to allow
the head to pass, and at twelve o'clock I gave her
a scruple of ergot, and repeated the dose in ten mi-
nutes. This quickly restored the energy of the uterus,
and the head began to move downwards, until it
came to press upon the perinaeum, which point it
reached at two o'clock, A. M. A very large tumour was
formed on the scalp, which partially protruded through
108
the external parts at each pain; the perinaeum was
rigid and unyielding, and after a few efforts at expul-
sion the pains again subsided, and became short and
feeble. From this time no advance was made. At
each pain the perinaeum became distended for a mo-
ment, and then the pressure subsided. The stomach
again became irritable, and rejected the drinks taken
by the patient. She became very restless; the pulse
rose in frequency, but diminished in size and strength;
the abdomen became painful, and she complained of a
burning sensation within. At eight o'clock, A. M. the
pains had nearly ceased ; the pulse 120, and thready :
the vomiting was distressing, accompanied by hiccup;
the pain in the abdomen increased, and delirium com-
menced. Under these circumstances I determined on
delivering her by the forceps. The instrument was
easily applied, and with a few efforts directed in the
axis of the orifice of the vagina, the head was brought
through. No uterine action was excited by the opera-
tion. The perinaeum, although rather rigid, was well
guarded by an intelligent nurse, and not a single fibre
was lacerated. The uterus still remained inactive, and
I was obliged to extract the shoulders of the infant;
the rest easily followed. The child was dead; the
limbs were spasmodically contracted, the fingers bent,
and the surface was in many places livid. The placenta
was found in the vagina, from which it was easily re-
moved. The uterus contracted well, and no haemor-
rhage followed. The patient recovered well.
CASE XI.-Age twenty ; first pregnancy. I was
called to this lady at ten o'clock, A. M.; her attendant,
Mr. Rumley, not being in town. I learned that she had
been in strong labour for two hours. The OS uteri was
found nearly dilated, and the head descending in the
109
first position. The pains were very strong and fre-
quent. I waited until twelve o'clock, when Mr. Rumley
arrived, and I gave the patient into his charge and re-
tired. At ten o'clock, P. M., I was sent for by Mr.
Rumley, and I found the patient undelivered. I learned
that the pains had continued very strong during the
day, that the head had come down to a certain point
in the pelvis soon after I had left, and that it was there
arrested. On examining closely, it was found that at
each pain the head came down to the spinous processes
of the ischia, beyond which it could not pass, owing to
a convergence of these processes. Her pulse was 110,
her skin very hot, and she had much thirst. After
waiting an hour, and seeing that there was no advance
of the head, we considered that the deformity was not
sufficient to forbid a cautious trial of the forceps, and
accordingly the instrument was applied, the blades
lying in the oblique diameter of the pelvis, to avoid
the projecting spines of the ischia. Cautious attempts
at extraction were now made ; by degrees the difficulty
was overcome, and a living girl was delivered. The
patient recovered without any unpleasant symptom.
CASE XII.-Age thirty-seven ; first pregnancy. This
patient was under the care of Dr. M'Cormack, who has
furnished me with the following notes of her case :—
“Her labour pains came on at first very slightly, on
“Friday, April 2nd, about twelve o'clock. She was,
“however, able to be up and about during the day.
“The pains did not increase until Saturday morning,
“on which day I saw her. On examination I found
“the os uteri dilated to about the size of a shilling, the
“head presenting in the first position, and the pains
“frequent, though not severe. On Sunday, when I
“again saw her, I found the os uteri fully dilated, and
110
“retracted. The membranes had broken ; the pains
“were very frequent and violent, but the head ap-
“peared to be making no progress. On Sunday even-
“ing the pains had almost ceased. The os externum
“was hot and rigid ; the bowels had not been freed.
“I ordered an aperient draught, and after its operation
“an opiate ; hoping that after its effects uterine action
“might set in. However, the only effect it produced
“was relaxation of the os externum. On Monday
“morning, finding that no uterine action had recurred,
“I administered ergot of rye, first in half-drachm doses
“in infusion, repeated twice; and later in the day by
“giving three doses in powder, of twenty grains each.
“No uterine action was produced by either dose. I
“ then thought it advisable to send for Dr. Beatty.”
I found this patient in a very exhausted state, her
pulse 120 ; the belly tender to the touch ; the head
fixed in the pelvis, but not touching the perinaeum ;
the vagina and the os externum rather dry and rigid ;
and altogether forming a case by no means favourable
for success with the forceps. However, I determined
on giving a fair trial of the instrument, and having in-
troduced the blades, I proceeded to extract, first mov-
ing the handles laterally, in order to loosen the head in
its position. In about half an hour the delivery was
accomplished, and, although the perinaeum proved to
be very unyielding, no injury of any kind was inflicted.
The child was dead. The mother recovered perfectly.
CASE XIII.-Age twenty-five; first pregnancy. This
lady was low in stature, corpulent, and of firm, rigid
fibre. She had enjoyed uninterrupted health during
her pregnancy. Labour began at five o'clock, A. M. by
rupture of the membranes. Pains set in about an hour
afterwards, and continued regular through the day.
111
The head presented in the fourth position ; the os uteri
dilated slowly, and at seven o'clock, P. M. it had disap-
peared, fourteen hours having been occupied in this
stage of labour. The head descended gradually until
eight o'clock, P. M., at which time the prominent point
of it had reached the perinaeum; but although the pains
were very severe, no change in its position was effected
from that time. The anterior fontenelle remained to-
wards the right foramen ovale, and did not at any time
turn towards the back of the pelvis, as it so frequently
does when it descends in the fourth position. An
enema was now administered, which acted freely on the
bowels, but made no impression on the situation of the
head. The pains continuing violent, the pulse got fast
and soon rose to 130, the face becoming greatly flushed,
and the skin hot. From midnight until two o'clock,
A. M. this state continued, when I took blood from her
arm to the amount of eighteen ounces. The blood
became speedily cupped and buffed. No change was
produced by the bleeding. At four o'clock, A. M. find-
ing that no advance of the head had occurred since eight
o'clock on the previous evening, notwithstanding severe
labour pains, and finding that the pulse had now risen
to 140, with great thirst and exhaustion, I determined
on delivering the patient. I obtained the assistance of
Dr. Montgomery, who agreed with me that it would be
dangerous to allow the patient to remain longer unde-
livered, and that the forceps might be employed. I
accordingly introduced the instrument, and with a
good deal of difficulty the position of the head was
rectified by turning the anterior fontenelle towards
the hollow of the sacrum. When this was accom-
plished, extracting force was applied, and in about half
an hour from the commencement of the operation the
112
head was brought down so as to distend the perinaeum.
Having got it so far, and finding the uterus acting
vigorously, I withdrew the instrument, and the head
was soon expelled. The countenance of the infant was
very livid, the eyes were much suffused, and it lay as if
it were comatose. The umbilical cord was cut across
and allowed to bleed, and this, joined to the usual
means of stimulation, soon succeeded in reviving the
child; no laceration of any kind took place, although
the head of the child measured fifteen inches and one-
eighth in circumference.
CASE XIV.-Age thirty ; first pregnancy. I was
called to see this case by Surgeon Neville, who had the
charge of the patient from the commencement of her
labour, it having lasted then thirty-six hours. I
learned from him that the pains were at first short, but
very distressing; that the membranes had ruptured
spontaneously about twenty-fours after labour had
commenced, giving exit to a very small quantity of
liquor amnii, at which time the os uteri was dilated
to the size of a crown piece. Shortly after this occurred
the pains became weaker, and then ceased ; the patient
began to complain of exhaustion and restlessness; the
pulse, which had been 86 previously, now sank to 58
in the minute, and a cold perspiration covered her sur-
face. From this state she was roused by the adminis-
tration of small doses of wine and water, and the pains
returned with increased vigour. The os uteri now
dilated freely, and the head passed through it about
twenty-eight hours from the beginning of labour. The
progress of the head continued for two hours more, at
which time it had almost reached the perinaeum. The
pains now again diminished in strength and frequency,
recurring only at long intervals, and being short and
113
ineffectual. In this condition the patient remained for
four hours, at the end of which, finding that no pro-
gress was making in the advance of the head, I was
sent for. I saw the patient just thirty-six hours from
the beginning of her labour. The pains had now
ceased, she was tossing about in the bed, complaining
of excessive weakness; the pulse was 100, and very
feeble ; the stomach rejected her drinks, and the dis-
charge from the vagina was of a very foetid nature.
Under these circumstances I was of opinion that speedy
delivery was called for, and having drawn off a large
quantity of water from the bladder, I proceeded to the
operation with the forceps. After the blades were ap-
plied, a good deal of difficulty was experienced in first
dislodging the head from the position in which it was
placed; but after this was accomplished, the rest of the
delivery was performed with considerable ease, and a
living boy was extracted. The mother recovered with-
out a single bad symptom.
CASE XV.-Aged eighteen; first pregnancy. This
lady, of a weak, delicate constitution, came over from
England for her confinement. She had suffered a good
deal from headache during her pregnancy; but when I
first saw her a few days before, she was pale, free from
pain in her head, and with a languid pulse. Labour
set in at two o'clock, P. M., and continued with severity
until ten o'clock, P. M., at which time the os uteri
was fully dilated. The head was passed with some
difficulty into the cavity of the pelvis, and the pains
became most urgent and severe. The patient soon
began to complain of great pain in her head, and her
pulse became more frequent; and not long after she
thought she saw strangers standing at her bedside.
This was quickly succeeded by loss of vision; where-
8
114
upon I at once opened a vein in her arm, and abstracted
eighteen ounces of blood. The operation was hardly
concluded when she was seized with convulsions. This
took place about midnight. The bandage was removed
from the arm, and twenty ounces of blood were allowed
to flow. Her hair was cut off, and cold applied to her
head. I despatched a messenger to my house for the for-
ceps, and Dr. Peebles was requested to give his assist-
ance. The patient lay in a comatose state after the
last bleeding, in which she continued until the ar-
rival of Dr. Peebles. We agreed that delivery with
the forceps should be performed, and the operation was
accomplished in the usual manner. The child was
dead. After the operation the patient continued in a
very weak state for several hours; no convulsions re-
curred, and she finally recovered without any bad
symptom.
In these fifteen cases the operation was performed
with complete success, so far as the mother was con-
cerned; not a fibre of the perinaeum was torn in any
of them, although eleven were first deliveries. In one
case only local inflammation followed the operation,
and in that case (the first) I have already said that I
delayed to interfere longer than I ought, and the result
to the mother and child is evidence that procrastina-
tion was fatal to the latter, and caused the local, but
temporary, inconvenience to the former. Of the fif.
teen children, seven were born alive, and eight dead;
but of these, six were born under circumstances that
would have caused a similar result independently of the
operation. Thus, in three of the cases (VIII., X., and
XII.), ergot of rye had been administered some hours
previous to delivery. Now, it is well known that when
a certain time elapses between the administration of
115
this drug and delivery, the child is most commonly still-
born. It is difficult to state exactly what length of
time is required to cause the death of the infant in
such cases; but I have reason to believe, from some ob-
servations I have made, that in two hours after a full
dose is given the child's life will be in danger. In
the cases above alluded to, a greater length of time
than that intervened between the taking of the medi-
cine and the delivery of the patient. The death of
these children, therefore, cannot be ascribed to the ope-
ration. Two cases (VII. and XV.) were attended with
convulsions, an accident that notoriously destroys the
life of the foetus before birth. And the case (IV.) in
which the footling presentation occurred must also be
struck off the list, inasmuch as the funis had ceased to
pulsate before the operation was commenced. We thus
have the cases, in which it is fair to estimate the value
of the operation with regard to the infant, reduced to
nine. In seven of these, living children were born;
and of the two that were dead, I have reason to think
that the result was owing in one of them (I.) to the
delay of a few hours after urgent symptoms had be-
come manifest.
It is not consistent with the nature of this communi-
cation to enter upon any minute description of the
operation with the forceps; but I cannot conclude
without making a few observations upon the form of
instrument most suitable, in my mind, to those cases
in which the head is arrested in the pelvis, before it
has come down to touch the perinaeum. In such a
position, a longer instrument than that in common use
will be found of great advantage; and a blade con-
structed as in the accompanying sketch will be more
easily introduced, and when both blades ". passed
116
along the head, the handles will be more readily locked
together than when the usual form is given to the in-
strument. The entire length, including the handle, is
twelve and a half inches; of the blade to the lock,
eight inches; of the fenestrum, five and a quarter
inches; the greatest breadth of blade, one inch and three-
eighths; the widest part of the fenestrum, one inch ;
the distance between the blades when joined, three
inches at widest part ; distance between the extreme
points, one inch and one-eighth; weight of whole, ten and
a quarter ounces. The sides of the blades enclosing
the fenestra are nearly round, slightly flattened upon
the inner and outer surfaces, but having no sharp edge
either on the outer border or the margin of the fenes-
tra. The advantages which such an instrument pos-
sesses over others are, first, that from its narrowness
the blades are more easily introduced ; secondly, that
when both blades are applied the handles can be locked
with greater facility, and from the length of the blades
the lock will not be within the vagina; and thirdly,
that, from the rounded form, there is no danger of hurt-
ing the mother in their introduction, or of cutting the
scalp of the child's head with the inner edge of the
fenestra in its extraction. This is a point upon which
too much stress cannot be laid in ordering or choosing
an instrument, for most of those which are found at
the cutlers are finished with such sharp edges, that
both mother and child are in danger of being injured
by their use. With such an instrument as I have
described, and with an accurate knowledge of the
anatomy of the pelvis, and of the mechanism of par-
turition, it will be difficult (if reasonable caution be
used) to inflict any violence upon either of the objects
of our care. But a clear view of the relation that the
2.
ſ º

117
brim, the cavity, and the outlet of the pelvis bear to
each other, and of the line described by the axis of the
entire cavity, must be entertained by the operator to
insure a successful termination.
The accompanying diagram should be painted on the
mind's eye when this operation is undertaken. On re-
ferring to it, the parts just alluded to will be found
delineated, and it will be seen that the axis of the
cavity is a curved line, extending from the centre of
the plane of the brim to the centre of the plane of the
outlet. Force applied for the extraction of a head
must be used in the direction of the axis, at the par-
ticular part in which the head may be placed; and the
direction of the force must be altered as the head de-
scends, so as to correspond with the ever-varying direc-
tion of the axis of the cavity. If this rule be not ſol-
lowed, injury and failure are very likely to occur. The
position of the handles of the instrument, when it is
properly applied on the head, will point out the direc-
tion in which the extracting force is to be employed.
Thus, when the head is high up in the pelvis, it will be
found that after the blades have been passed up, and
the lock joined, the handle will be directed backwards,
and will press against the fourchette. Under such cir-
cumstances, any attempt to pull in the direction of the
outlet will be fruitless and mischievous ; but if we fol-
low the natural curve of the cavity, and draw first
backwards, then downwards, and lastly forwards, ac-
cording as the head is moved through the cavity, we
will find our efforts crowned with success; and unless
the operator be devoid of common sense and discretion,
and use brutal violence, he will scarcely do any injury
to his patient. If the head be lower in the pelvis than
in the case we have just supposed, it will be found
118
that the handles of the forceps will look propor-
tionably downwards, or even forwards, as the head
is placed nearer to the vulva; and this direction must
be followed in beginning the operation. In this case, a
shorter instrument than the one described, but con-
structed in the same manner, will be more convenient.
From having at times seen awkward attempts made
to introduce the blades, I am induced to add a few re-
marks upon the method of using the instrument. The
point should never be urged forward in the direction
of the long axis of the blade. Such a proceeding is
calculated to inflict injury on the mother, if the blade
is sharp on the outer edge, as it is in most forceps
foundin cutlers' shops. On the contrary, the operation
should be commenced by laying the concave surface of
the blade flat upon the lowest part of the child's head,
and when so placed the handle will project between
the thighs of the patient; then bringing the handle
slowly down, and by a series of lateral sweeping move-
ments, during which the point is at the same time
slowly passed over the side of the head, describing on
it a curved line, the blade is coaxed as it were into its
proper place. No force should be ever used; if any re-
sistance is encountered, it is an indication that some
error has been committed. Better to stop, and even to
withdraw the blade, and begin afresh, than use violence
to urge it forward. When one blade is thus placed, the
handle will be found to lie close to the fourchette ; it
should be given to an assistant to hold steady, and
then the same proceeding should be adopted to insure
the safe introduction of the other. If both blades are
properly placed, the handles will lock readily. If they
do not, it is evidence that one or other blade is
misplaced ; that blade must be withdrawn and re-

119
applied, and on no account should force be used to
make the blades lock. To make all this more plain, I
append a wood-cut, which speaks for itself. Having
got the head fairly embraced by the instrument, the
extracting force should be applied in the direction in
which the handles point. If the head be high up in the
pelvis, they will be found pressed hard against the four-
chette, and pointing backwards. In that direction, then,
the handles must be drawn in the first instance, and as
the head is moved the handles come more directly
downwards; in which case the direction of the force is
to be changed, still following the rule that it must be
used in the direction of the handles. By degrees, as
the head comes to rest upon and distend the perinaeum,
the handles will point forwards, and finally they will
be found between the thighs of the patient, in which
position the last part of the delivery is accomplished.
This quality of pointing out by necessity the axis of that
part of the pelvis in which the head is lodged, and thus
enabling us without fail to use our extracting force in
the most suitable direction, gives a great superiority in
my mind to the straight blades over those with the
lateral curve which are so much used. The latter, from
their curved form, give an erroneous idea of the posi-
tion of the head, and may cause the expenditure of
much unavailing force in a wrong direction.
As I have already said, it is not my intention to give
a detailed description of the operation with the forceps,
but I thought it well to offer these few remarks upon
what appear to me important points connected with it.
In conclusion, I would say, let no one undertake it
without good instruments, great patience, and an ac-
curate knowledge of the position of the head, and of
the anatomy of the parts through which it has to pass.
120
If he bring these to the task, he will have reason to
rejoice at saving lives from imminent peril.
As an illustration of what can be done with the for-
ceps above described, I will quote one case from my
note book.
September 16th, 1859.-A'lady, tall, thin, and deli-
cate, eight months and a half pregnant for the third
time, living three miles from Dublin, had taken a house
in town by my desire for her confinement, and was in
the act of getting into her carriage to come to town
when she was seized with a convulsion. This was at
about twelve o'clock in the day. I was sent for, and
reached her as soon as possible. Her former labours
had been natural. I learned that for a week previous
to the present attack she had been complaining of
head-ache. I found her, after a second fit, quite col-
lected, and free from pain in the head. I examined,
and found no sign of labour. The convulsions returned
every hour, increasing in severity, but with intervals of
complete consciousness. At nine o'clock, P.M. there was
some slight labour pain, but still no dilatation of the
os uteri. At eleven o'clock the os was open to the size
of a shilling, and the convulsions still kept recurring
every hour. At twelve o'clock another bad fit, when
I found the os uteri about as large as a two-shilling
piece, and soft. I tried dilatation with my fingers, and
succeeded in enlarging the opening to such an extent
that if it had been desirable to turn the child, one would
have been able to force the hand into the uterus.
The head of the child lay well down on the cervix
uteri. A moment's reflection convinced me that if I
could get my hand into the uterus I could as well in-
troduce the blades of my forceps, and accordingly, hav-
ing ruptured the membranes, I proceeded to pass the
121
instrument—first one blade, then the other—along the
sides of the head, and I readily closed the handles.
Then by slow traction I drew the head through the os
uteri and into the pelvis, and delivered a live boy, who
is now seven years old, strong and healthy. I think an
instrument capable of accomplishing a feat such as
this does not require any further commendation. One
great object in the selection of an instrument for the
delivery of a living child, should be to choose one that is
least likely to inflict injury upon either the mother orher
offspring. This desideratum is, I think, fully attained
in the forceps which I have just described. The rounded
form of all parts of the blades, both of the outer edge
and the inner border of the fenestra, gives such secu-
rity against injury that even in the hands of a bungler
little danger may be apprehended. The blades, owing
to their narrowness and elongated form, slip into their
places with so much ease, that but little dexterity is
required in their application ; and although appa-
rently slight, they are abundantly strong to bear any
amount of force justifiable in delivery by the forceps.
Having spoken of the danger of delaying to use the
forceps after the circumstances of the case point out
the necessity for interference, I quote the following
as recorded in my case-book, as it shows very forcibly
how the life of a child may be sacrificed by timidity.
On the 3rd of August, 1856, I was requested by a
professional friend, who was confined to bed by illness,
to attend for him a lady who had just commenced her
first labour. I found the patient short in stature, with
rigid fibres, and thirty-two years of age. The os uteri
was dilated to the size of a shilling ; the pelvis was
small, and the external parts firm and unyielding. The
labour progressed slowly notwithstanding very strong
pains. At the end of fourteen hours the OS uteri was
122
fully dilated, and the head had passed into the brim of
the pelvis, through which about half of the head had
been forced, but the remainder was held fast. I saw
from the little effect that very strong pains had that it
would be necessary to aid their efforts before delivery
could be accomplished ; and if the patient had been my
own and not another's, I would have taken measures in
accordance with this view ; but as the gentleman for
whom I had undertaken charge of the case was not as
fully convinced of the value of the forceps as I was, I
did not wish to interfere without communicating with
him. I went to him and reported the exact condition
in which matters stood. He urged delay; and Ireturned
to the patient, promising to send word from time to time
how the labour went on. At the sixteenth hour
there was no advance, the pulse had risen to 110, and
the pains were severe. A note to my friend brought
back an answer requesting further delay. Eighteen
hours elapsed, and a large tumor had formed on the
child's head, which gave a deceptive appearance of
advance, but none had in reality occurred. Another
report was sent, and a qualified consent to the operation
was returned. Another hour was allowed to pass, when,
finding there was no likelihood of the natural efforts
being of any avail, I determined to deliver the patient
with the forceps. I found great difficulty in applying
the instrument, the head was most firmly embraced by
the narrow brim, and the soft parts were swollen by the
pressure they had undergone. By great patience and
gentle manoeuvring I got the blades in proper position,
and then a considerable amount of steady traction was
requisite to dislodge the impacted head. At last, after
considerable delay, the delivery was completed, just
twenty hours after the commencement of labour. A
very large boy was born dead. I have no doubt a dif.
123
ferent result would have been the consequence of earlier
delivery, and the mother would have been spared a
considerable amount of inflammation of the vagina
which she had to suffer.
The same patient put herself under my care three
years afterwards, when about to be confined of her second
child, and I find the following entry in my case-book.
June 26th, 1859.-This is the lady who was delivered
by me with forceps on August 3rd, 1856. On that
occasion, owing to her not beingmy own patient, I waited
to communicate with the gentleman who had been
engaged to attend her, and at last used the instrument,
but the child was dead. On this occasion the same
narrowness of the pelvis gave the same obstruction, and,
having seen the danger of delaying too long, I used the
forceps at the end of eight hours, and delivered a large
living girl. The patient never had a bad symptom ;
she was out of bed on the sixth, and in her drawing-
room on the tenth day.
I think it right to mention that while I thus strongly
advocate the timely use of the forceps in cases requir-
ing their employment, I have not used them in a rash
or indiscriminate manner. This will appear when I
state that since the foregoing paper was written in
1842, I have had recourse to the instrument in my
private practice only thirty-five times.” Many of these
forceps cases were first labours; and in twenty-eight
cases the children were delivered alive, the other seven
were dead. I am happy to say, in addition, that I have
only used the perforator twice in the same twenty-four
years,
* It is more than probable that the very free use I have made of the
ergot of rye has tended to diminish the number of cases in which otherwise
the forceps might have been demanded.
124
CHAPTER W.
In the January number of the Dublin Medical Jour-
mal for the year 1834, I published a paper “On the
means of preventing Uterine Haemorrhage after De-
livery,” concluding with some observations on the use
of a medicine then but little known in this country,
the Secale cornutum. This was followed by two other
papers on the same drug—one published in the May
number of the same journal for 1844, entitled, “On
the influence of Ergot of Rye on the Foetus in Utero.”
The third appeared in May, 1846, under the title,
“Further Observations on the use of Ergot of Rye.”
These papers are now reprinted in the order in which
they were published.
ON THE MEANS OF PREVENTING UTERINE HAEMORREIAGE
AETER DELIVERY.
Uterine haemorrhage, after delivery of the child, is
One of the most formidable accidents that can befall a
parturient woman. The immense quantity of blood
that is sometimes thus lost in a single gush, is well cal-
culated to strike terror into the boldest heart unaccus-
tomed to witness this phenomenon. The loss sustained
in the bloodiest operations of surgery shrinks into in-
significance when compared with the deluge thus
poured out; and it is certainly wonderful that life
is not even more frequently extinguished when this
125
accident occurs. It would appear as if the consti-
tution of the woman was better able to bear the sud-
den abstraction of a large quantity of the vital fluid
at this particular time than at any other, probably
in consequence of the habit so long maintained in
the system, of devoting a large portion of it to the
purposes of the foetus now expelled. The great num-
ber and size of the uterine vessels in the advanced
stage of gestation give lodgment to a corresponding
quantity of blood, which, so far as the actual wants of
the maternal system are concerned, must be considered
as so much superadded to the mass of that fluid usually
circulating in the body. We do not find that other
parts of the system suffer materially in nutrition dur-
ing the existence of pregnancy; nay, a general plethora
is not an unfrequent concomitant of this state; while
we observe what may be esteemed (in comparison with
their former dimensions) a new series of capacious
vessels filled with blood destined for the support of a
distinct being. The entire of the blood circulating in
the uterine vessels at any given moment may there-
fore be considered as an extra quantity, useless to the
mother; and it is perhaps not going too far to suppose
that if the arteries and veins of the uterus were sud-
denly obstructed at their entrance and exit, and the
mass of blood contained in them thus cut off from the
general circulation, the mother would not suffer any
material inconvenience.
However this may be, it must have struck every prac-
titioner in midwifery that puerperal women bear ute-
rine hamorrhage better than any other class of patients
do an equal loss from any other source. But there is
a limit beyond which this form of haemorrhage cannot
be borne; differing certainly in different women—some
126
appearing to sink under a loss which will scarcely affect
the pulse of others. What the amount of this quantity
is in each individual we cannot previously determine,
neither can we always foretell when the haemorrhage
is likely to occur; as some women, after having borne
many children safely, will be attacked and carried off
by this form of haemorrhage; while others may have
it once or twice, and afterwards pass through several
succeeding labours without it. It therefore becomes
the duty of every practitioner to be particularly watch-
ful of this dangerous accident, and to treat every pa-
tient as if she were liable to its invasion. The means
used may be unnecessary for many, but can be injuri-
ous to none, and if one patient out of a thousand
be saved by their employment, it is a sufficient reason
for their adoption.
Uterine haemorrhage after delivery can arise from
one cause alone, that is, from a patulous state of some
or all of the great uterine sinuses, resulting from a
want of due contraction in the uterine parietes. The
only remedy for this is a proper contraction of the
fibres through which these vessels pass obliquely.
Uterine contraction is, therefore, the only protection
against uterine haemorrhage ; and, unless in the case of
morbid adhesion of the placenta, when this mass can-
not be expelled by the natural means, it will be always
effectual. With respect to the hour-glass contraction,
caused by irregular or partial action of the fibres of
the uterus, I am inclined to think that it arises in many
cases from too much haste in delivery, by which the
uterus is emptied before it is disposed to expel its con-
tents; or from neglecting to secure a complete and
permanent contraction of this organ after it has dis-
charged itself.
127
Now, when we consider the means employed to pro.
duce contraction of and arrest haemorrhage from the
uterus, we find that direct stimulus by external force,
applied to this organ by grasping, friction, and firm
pressure over the pubis, is decidedly the best; and any
man who, in such a dilemma, places his chief reliance
on these means, will have little reason to regret his
confidence in them. I speak now of cases unattended
with morbid adhesion of the placenta. I know that
this was the course pursued by my father, the late Dr.
Beatty, and that during a very extensive midwifery
practice for forty years, he never lost a patient from
uterine haemorrhage. Let it not be supposed that I
wish to discard other assistance, such as the application
of cold, &c.; I only desire to place the former in the
first rank.
Early impressions are very lasting, and therefore I
have a vivid recollection of one of the first cases of
serious uterine haemorrhage I ever had to treat. I was
called in the middle of the night to a patient who had
been attended by a very young man, a student in mid-
wifery. The labour had been natural and easy; but after
the birth of the child, and before the expulsion of the
placenta, a deluge of blood escaped; and when I arrived
there was not only a sea of it under the patient, but
also a stream along the floor which had issued from the
foot of the bed. I found the attendant as pale as a
corpse, and almost frightened to death, with a bucket
full of water beside him, and numerous cloths soaked
in water, which he diligently applied to the exter-
nal parts; notwithstanding which, the bleeding still
continued. The woman was blanched, the pulse fail-
ing at the wrist, she was tossing her arms about, and
crying out for more air. On passing my hand over the
128
abdomen, and feeling the uterus large and flaccid, I
immediately exerted all my force in grasping and
firmly pressing this organ downward into the pelvis,
and very soon found it contracting forcibly under my
fingers. At this moment a rush of coagulated blood
took place, which nearly extinguished the little remain-
ing spark of life in the attendant, but was a source of
great consolation to me, as I regarded it as a token of
having succeeded in my endeavours. In this I was
not deceived; the uterus had fairly contracted, and the
hamorrhage was at once arrested. I kept up the pres-
sure on the uterus with my left hand, and passed the
forefinger of my right into the vagina, to ascertain the
state of the placenta, which I now found lying loose in
that passage, from whence, after having put on a
tight binder, it was easily removed. The woman reco-
vered, but she had lost so much blood that some days
elapsed before she could be pronounced out of danger.
This case made a strong impression on my mind,
and convinced me of the great efficacy of external
force in producing contraction of the uterus. I am
well aware that many authors direct, in cases such as
this, when the placenta is retained, that the hand
should be at once introduced for the purpose of ex-
tracting that body. But I am quite sure that the pro-
ceeding I adopted was the best for the patient, inas-
much as by it she lost much less blood than must have
attended that operation—a circumstance of no small
moment to an individual who had already suffered so
severe a loss. If I had found the natural contraction
of the uterus insufficient to expel the placenta, I would
then of course have proceeded to extraction.
Now, as I have already said, we cannot tell when
haemorrhage may take place after delivery ; and no one
129
will deny that it is much better to prevent its occur-
rence, if possible, than to have to contend with it after
it has commenced. The best way, then, to effect this
purpose is to look for the natural protection; that is,
to insure a full and complete contraction of the uterus.
This is attained by making the organ itself perform the
whole process of expelling the child, even to the feet;
and never, by any injudicious haste, assisting the de-
livery by pulling the child. A practice pretty gene-
rally employed in this city, and lately taken notice of
by Dr. Maunsell, is of great utility in this part of the
process; that is, after the expulsion of the shoulders, to
place the left hand on the abdomen of the woman, and
to follow the uterus by firm pressure until the whole
child is expelled. After this has taken place, if the
child be alive and cry, the right hand, which had been
employed in supporting its head and body, may now
be disengaged, and the child laid in the bed, until more
important matters are attended to. The chief of these
is the proper application of an appropriate binder, pre-
viously passed loosely round the body of the woman.
This I consider a very important part of the treatment,
for it at once insures an equal and firm pressure on the
uterus, and prevents its subsequent relaxation, while it
leaves the practitioner at liberty to attend to the child.
I sometimes use a binder made according to a pattern
which I have constructed, and have found of the great-
est use and convenience. It is made of jean or twilled
calico, doubled, and broad enough to reach from the
eighth or ninth rib to the trochanters, with two long
triangular pieces (termed, in millinery, gores) let in to
enlarge the diameter below, and to fit the hips just as
female stays are made. It is furnished with a row of
buckles arranged along one end; and at the other with
9
130
a corresponding number of straps made of the same
material as the binder. The straps are about seven inches
long, and are sewed not to the edge but about seven
inches from it, so that when they are passed through
the buckles, the floating portion passes under the op-
posite end, and protects the skin from pressure. A very
thin piece of whalebone, one-third of an inch broad, is
inserted, so that when the binder is applied, it runs
straight down the middle of the abdomen from the
thorax to the pelvis. A bandage such as this fits easily
without any unequal pressure when drawn tight, never
shifts its place when well made and properly applied,
and effectually accomplishes the object for which it is
intended. I have employed it with several ladies who
had been in the habit of using the common kind, and
they invariably expressed the greatest comfort from its
llS62.
It has been said above that the binder should be
passed round the patient before the birth of the child,
and this, whether the ordinary one or that just de-
scribed be employed. Such a proceeding will be found
possessed of many advantages. We have it ready to
tighten at the very time when pressure is most wanted
and most useful ; and we are saved the necessity of
moving the patient to put it on at a time when perfect
quietness is so much required; as it is well known that
in women disposed to uterine haemorrhage any motion,
however slight, may cause it to take place. The binder
may be slipped under the patient at any time during
the labour, but I prefer delaying it until the head of
the child has entered the pelvis; for its application is
taken by the woman as an earnest of a speedy delivery
from her sufferings, and if the labour be not terminated
in a reasonable time after it is put on, she is apt to be-
131
come disappointed and dispirited. If the membranes
have ruptured early, and the waters are draining away,
the bandage is easily kept from moisture by doubling
up the part that passes under the left hip of the patient,
and keeping folded napkins under her, which can be
changed as often as is required. If the membranes con-
tinue entire until a late period of the labour, we can
by similar means preserve the binder dry, whether we
allow the waters to break spontaneously, or we rupture
them intentionally. In either case it is well, when first
put on, to double up the part upon which the patient
would lie; and this is easily restored to its proper place
when it becomes necessary to tighten the bandage.
As soon as the child is expelled, and when the uterus
is felt, by the hand still kept on the abdomen, to be
well contracted, the binder may be tightened. If it is
of the pattern just described, it is best to begin with
the middle straps, and proceed regularly downwards,
after which the upper may be secured. The neces-
sary attentions may now be paid to the child, and the
cord divided in the usual manner. By following this
line of practice I generally find, after separating the
child, that the placenta is thrown down into the
vagina, and thus all uneasiness with respect to it is
removed. When the placenta is thus detached, and
lying loose in the vagina, I see no use in allowing it
to remain there any length of time; there is no risk of
hamorrhage by its removal, for that is guarded against
by causing and maintaining a proper contraction of the
uterus; and to delay its extraction is only to prolong
the anxiety of the patient and her friends. It may,
therefore, be withdrawn as soon as suits the practi-
tioner's convenience. If, on the other hand, the pla-
centa should be retained within the uterus (a circum-
- - 9%
132
stance which, except in the case of morbid adhesion,
I never met with in patients treated as above), it must
be treated according to the established rules, which it
is unnecessary to mention here.
The course of proceeding just detailed is admirably
calculated to prevent the hour-glass contraction of the
uterus, by causing it to contract uniformly, and from
its fundus; and it is also our best protection against
that insidious and too frequently fatal accident, re-
laxation of the uterus after delivery, accompanied by
internal haemorrhage—a circumstance which usually
does not occur until the practitioner has left the house,
sometimes not for several hours after. A remarkable
instance of this was lately mentioned to the writer by
Dr. Montgomery, in which it took place twenty-four
hours after delivery. This form of haemorrhage is sup-
posed by Dr. Ramsbotham to have been the cause of
the death of the Princess Charlotte. One passage from
the highly valuable work of the author just named will
be sufficient to explain the views I entertain, and the
benefit to be derived from permanent pressure on the
uterus. Speaking of the relaxation of the uterus after
delivery, and its subsequent enlargement, he says:—
“But it sometimes happens that after the uterus has
“expelled its contents, after it seems to the hand to
“ have acquired a considerable share of contraction
“ and of diminution in size, it suddenly relaxes and be-
“comes larger and more flabby, it increases in bulk
“ and extension in every direction. At the time this
“increase of size is going on, or shortly after, the pa-
“tient complains of faintness; her countenance loses
“its colour and its usual appearance; her pulse be-
“comes quicker and smaller, and she has other symp-
“toms of depression. On examining the napkins and
133
“linen, a very trifling discharge of blood is found to
“have taken place externally, which leads to the belief
“ that the patient is not then losing much blood, and
“ therefore little alarm is excited from the obvious
“loss; but if this security be indulged without farther
“ and more minute inquiry, if the case be not under-
“stood, the patient will soon be placed in a situation of
“danger from which she will with difficulty be extri-
“cated. If at this time the hand be applied upon the
“abdomen, and such a degree of grasping pressure be
“made on the uterine tumour as shall produce some
“contraction, or if uterine action spontaneously come
“on, a quantity of coagulated and fluid blood is im-
“mediately expelled, which leads the patient to sus-
“pect that she is then flooding, and she generally
“expresses such suspicions with much anxiety for
“her safety. After such an evacuation of blood, the
“uterine tumour lessens in bulk, and becomes firmer
“under the hand. As long as the pressure of the hand
“is continued, or in case the frequent repetition of
“natural contraction ensues, the uterus maintains a
“diminished bulk; but upon the pressure of the hand
“being removed, or if repeated, returns of the after
“ pains do not take place, the same occurrences are re-
“newed, the uterine tumour assumes less firmness, and
“again increases in size; the sensation of faintness also
“returns. Upon external pressure being again made, a
“similar evacuation is the consequence. These occur-
“rences may be repeated, till either the uterus attains
“a more perfect and permanent state of contraction,
“whereby its subsequent distention and the further
“efflux of blood from its vessels are prevented, or till
“ the woman sinks from loss of blood.” Now, with
* Ramsbothain's Observations on Midwifery, Part I. p. 187.
134
such convincing evidence of the utility of continued
pressure, it appears strange that so experienced and
able a writer should overlook the obvious remedy of
permanent pressure by means of an appropriate ban-
dage; but so it is, and throughout his otherwise most
excellent work no mention whatever is made of such
a resource. I am inclined to think that if the binder
had been in more common use, the work would not
have contained so long a list of cases of uterine haemor-
rhage after delivery, and probably the country would
not have to lament the premature death of an amiable
Princess. It is much to be feared that the high au-
thority of Denman has misled many practitioners, par-
ticularly in the sister country, as to the true value of
the binder, and has induced them to relinquish it alto-
gether in the practice of midwifery. Indeed, I have
reason to know that in several parts of England it is
very rarely used. “Some years ago,” says Denman,”
“it was a general custom to bind the abdomen very
“ tight immediately after delivery, with the view of
“aiding the contraction of the integuments, and of
“preserving the shape of the patient. In some coun-
“ tries, India in particular, this was practised to a de-
“gree that one cannot think of without shuddering, at
“the mischief which must of necessity have been very
“often occasioned. In this country the practice has
“ been very much discontinued as useless and perni-
“cious, and it is now wholly or nearly laid aside, ex-
“cept in particular cases which have already been spe-
“cified, till five or six days after delivery, when a broad
“band, daily but very gradually drawn a little tighter,
“may be applied not only without injury but with
“some advantage.” From this it is evident that he did
* Introduction to the Practice of Midwifery, p. 426, 6th edition.
135
not appreciate the power of this agent to produce and
maintain uterine contraction, the only important object
to be attained by its use; the subsequent shape of the
patient, although a matter of some moment, being so
very light when compared with her present safety, that
it is scarcely to be taken into the account. What the
pernicious effects of it are to which he alludes, but
which he does not mention, I cannot understand; at
least, I have never known any to follow its use. Many
modern authors recommend pressure and the use of
the binder after haemorrhage has actually commenced.
A late distinguished writer,” in speaking of uterine
haemorrhage after the expulsion of the placenta, thus
expresses himself:—“By far the most important reme-
“dies, and those on which I place the chief reliance in
“these formidable attacks, are constant and powerful
“pressure on the fundus uteri, and the application of
“cold to the external parts. These means are always
“within reach, however sudden and impetuous the
“rush of blood from the uterine vessels may be, and if
“ promptly had recourse to, they will, in a large majo-
“rity of cases, prove completely successful in saving
“life. The abdomen should be strongly compressed
“with the binder, and folded napkins placed under it;
“and, in addition, the hands of an assistant should be
“applied over the fundus uteri, firmly to squeeze and
“press this organ.”
This is very excellent advice, and should of course
be followed in all such cases of emergency. But the
object of the present observations is to recommend
a precautionary rather than a remedial line of conduct.
To prevent is always better than to cure, provided the
means employed be safe ; and I am sure there is no
* Dr. R. Lee on some of the Most Important Diseases of Women, p.214.
136
man who has had to encounter uterine haemorrhage
who would not most anxiously desire to avoid so alarm-
ing and dangerous an occurrence. It is very true, as
has been already stated, that with a great majority of
patients such precautions as have been mentioned are
unnecessary; but who can tell when they may not be
absolutely required? The safe course, therefore, is to
treat all parturient women as if they were about to be
attacked with haemorrhage; they are in fact all in dan-
ger of it, and when the means proposed are safe, simple,
and easily executed, I do not hesitate to recommend
their adoption to every one anxious to conduct a labour
to his own satisfaction, and the safety of his patient.
SECALE CORNUTUM.
There is probably no medicine upon the virtues of
which more contradictory testimony has been given
than the secale cornutum; some authors attributing to
it very energetic powers in causing contraction of the
uterus, while others totally deny that it is possessed of
any. In such a divided state of professional opinion, I
think it is incumbent on every one who has had an
opportunity of witnessing its effects, to record his expe-
rience, in order that it may be added to the general
stock. Accordingly I proceed to relate a case which
occurred to me in the month of June, 1833, in which
it seemed prudent to administer this medicine.
Mrs. K., aged thirty-five, pregnant of her fourth child,
took her labour early in the morning of the 21st. The
pains were very slight, and did not increase in severity
during the whole of that day, although the membranes
had ruptured early, and the waters continued draining
away. She slept, with occasional interruptions, during
the night, and the pains continued of the same slow,
137
weak character during the following day. Some in-
crease in their severity, however, occurred about 2,
P.M., and at 5, P. M. I was summoned for the first time.
On my arrival, I found that the pains, which had been
pretty strong for about two hours, had now entirely
subsided, and she was walking about her chamber. On
examination I detected the head of the child present-
ing with the vertex, and almost touching the peri-
naeum, the os uteri dilated, and the external parts re-
laxed, moist, and cool. I retired to an adjoining room
to wait for the return of pains, expecting that a short
time would terminate the labour. Hour after hour
passed by, however, without any recurrence of uterine
action, during which time the bowels were freely acted
on by castor oil, which she had taken previous to my
arrival. At length, at half-past ten o'clock, just six
hours from the cessation of the pains, and about thirty-
six hours from the commencement of labour, finding
the uterus still sluggish, I determined to try the ergot.
For this purpose I infused thirty grains of the powder
in four ounces of boiling water for five minutes. The
fluid was then strained through muslin, and the powder
caught on the filter was divided into three parts. One
of these I mixed with half the infusion, and gave it to
my patient. She had not swallowed it five minutes
when the pains returned with considerable force, and
continued to increase in severity and duration, so that
at last there was no intermission, it appearing as if there
was one continued effort made by the uterus to expel
its contents, and in less than twenty minutes the labour
was terminated by the birth of a living boy, followed
by the immediate expulsion of the placenta. There
can be no doubt that this delivery was effected by the
ergot of rye, The case was one particularly suited to
138
its exhibition; there was no mechanical impediment
to the exit of the child; the parts were all dilated and
relaxed, and all that was required was the vis a tergo,
which was most satisfactorily obtained by one dose of
the medicine. Had I failed in this case with the ergot,
and if the uterus had remained much longer inactive,
I would not have hesitated to employ the forceps.
It may be asked, how comes it that a medicine capa-
ble of producing such prompt and decided effects with
some practitioners should fail in the hands of others?”
I think the reason must lie in one of these causes:
either the medicine was not carefully chosen, or the
dose was too small, or the cases were unfit for its ope-
ration. There is good reason to believe that many of
the failures are owing to want of care in the selection
of the medicine, particularly since the experiments of
MM. Boettcher and Kluge, which show that the efficacy
of the medicine is greatly influenced by the time of
year at which it is gathered. It appears from the ob-
servations of these gentlemen (noticed in No. VIII. of
the Dublin Medical Journal), that the ergot collected
from the rye before harvest is very energetic, while
that taken from the grain after it is cut is quite inert.
If, therefore, the latter have been used, it will fail to
produce the desired effect, and throw discredit upon the
genuine article. Another circumstance to be attended
to is that by keeping it loses its virtues, in consequence
of becoming mildewed, so that it should never be em-
ployed after it is a year gathered; and during that
time it should be kept in well-corked bottles. It is
likely that, in some of the instances of failure, the dose
* A practitioner in extensive practice in Dublin lately observed to the
writer, that “he was tired trying the ergot of rye, for he had never found
“it of the least use.”
139
has been too small, from men being afraid to give too
large a one; but if proper cases be selected for its ex-
hibition, doses of thirty grains may be given ; or it
may be administered in the manner which I have al-
ready described in the case of Mrs. K. at page 137. M.
Kluge recommends doses of ten grains, repeated every
ten minutes; but I think it would be better to give such
a dose as I have mentioned, which will probably not re-
quire repetition more than once, and, if the case be
suitable, can scarcely cause any mischief. This medi-
cine is certainly inadmissible where there is any me-
chanical impediment to the exit of the child, from de-
ficiency in the pelvis, or other cause. It should never
be used to enable a uterus to overcome a difficulty, as
in such case there must be danger of rupturing that
organ; its legitimate use is to stimulate a torpid uterus,
when there is no serious obstacle to the escape of its con-
tents. On these grounds it is useful in cases such as
the one described, where inactivity of the uterus is the
only impediment to delivery; or when internal haemor-
rhage has taken place from relaxation of the uterus
after delivery; or when dangerous hæmorrhage attends
the expulsion of hydatids. In cases of both the latter
description I have known it to act beneficially. I lately
attended, for my friend Dr. Montgomery, a lady in
her accouchement, who after a previous delivery was
very near dying from relaxation of the uterus, which
he at once controlled by the ergot of rye.* I mention
this particularly, in consequence of the denial of its
efficacy in that condition of the organ lately made by
Dr. Lee, who says: “In a few cases the ergot of rye
“has been administered both before and after the ex-
* Since writing the above, a similar case occurred to Dr. Montgomery,
in which this medicine was administered with a like happy result.
140
“pulsion of the placenta, but invariably without any
“sensible benefit; and many other cases have been
“related to me where it appears to have been equally
“ inefficient in exciting the uterine contractions.”
Some years ago I saw a case with the late Mr. Gre-
gory, in which the woman was dying from hamor-
rhage attendant on the expulsion of hydatids, which
had been mistaken for pregnancy. Some of the mass
had been expelled, but the great bulk remained be-
hind, and she was flooding to a frightful extent. He
administered the ergot in a large dose, which was
quickly followed by forcible contraction of the uterus,
and the expulsion of some basins full of hydatids,
which put an end to the haemorrhage. I think this
woman's life was saved by the medicine, for no manual
operation could have effected their extraction without
a great and dangerous increase of haemorrhage at the
time. In all these cases, forcible contraction of the
uterus was the only thing to be desired; there was no
apprehension for the safety of this organ, because there
was no resistance to the expulsion of its contents, and
I think such cases are peculiarly those in which the
ergot is indicated. After the child is born, and when
haemorrhage takes place from relaxation of the uterus,
it may be administered to any woman as an adjunct to
the means proposed in the earlier part of this chapter.
If we find these endeavours to arrest the haemorrhage
fail, then the ergot may be administered; but from
what has been already said on uterine haemorrhage
after delivery, I think such cases ought to be very rare.
* On some of the Most Important Diseases of Women, p. 215.
141
On the influence of Ergot of Rye on the Foetus
in Utero.
[Read before the Dublin Obstetrical Society, March, 1844.]
It is not my intention on the present occasion to oc-
cupy the time of the Society by any very lengthened
observations on the use of the ergot of rye ; but I wish
to lay before the members an account of some effects
of this drug, which I have observed during an exten-
sive employment of it, and of which I have not been
able to find any notice in the authors who have treated
of the medicine. Since the revival of the use of the
secale cornutum by Dr. Stearns of New York, up to
the present time, a variety of conflicting opinions have
been entertained respecting its value as an obstetrical
agent. Some authors of the highest repute have de-
clared its utter inutility and incompetence to excite
uterine action, no matter how eligible the circum-
stances, or how carefully the dose has been apportioned.
Another class, of equally high character, is found to
attribute the most rapid and energetic effects to its
employment ; so much so as to lead to its denounce-
ment, as too violent an agent for obstetrical purposes,
appearing to be injurious to the child at all times; its
impression being destructively transmitted from the
mother to the infant; in some instances even involving
both in the same sacrifice. A third and numerous
class of high authorities is recorded as maintaining an
opinion equally at variance with the truth as the two
preceding ; viz., that the ergot may be always given
with advantage, the safety of the mother or of the
child never being endangered. It would be tedious
and misplaced to quote, on the present occasion, the
142
authorities above alluded to; and, moreover, it is unne-
cessary to do so, inasmuch as they will be found in
Mr. Wright's elaborate and valuable prize essay on
Ergot of Rye, in the fifty-third volume of the Edin-
burgh Medical and Surgical Journal.
On reviewing these discordant statements among
authors of acknowledged celebrity, it becomes an object,
not only of theoretical but of practical interest, to en-
deavour to search out the causes which have been
instrumental in producing this discrepancy of opinion.
When we find such names as Chaussier, La Cha-
pelle, Desormeaux, Gardien, and Capuron in the list of
those who maintain the inertness of the Secale cornu-
tum, had we not practical experience to the contrary,
we would be inclined to bow to such high autho-
rities, and agree with the latter, that “it is a drug which
“it is requisite speedily to expunge from the list of
“ the Materia Medica.” But when, in numerous in-
stances, we have witnessed the efficacy of the medicine,
and find its character substantiated by the united expe-
rience of so many who have successfully employed it, we
are disposed to look for some reason for its failure in
the hands of the practitioners above-mentioned. Two
causes of such failure may be suggested : first, the
administration of the drug in inadequate doses; second,
the inferior quality of that which was employed. It is
not improbable that the French authors whose names
have been just mentioned, were disposed to use the
ergot with great caution, owing to the circumstance of
the drug being at that time considered in France and
Switzerland as a highly noxious substance, and capable
of producing fatal effects on those to whom it was ad-
ministered. This may have led them to employ it in
quantities too small to produce the desired effect upon
143
the uterine fibres. But it is more likely that the second
cause just alluded to may have led to the failure, for it
is owing to investigations conducted more recently that
we have become aware of the perishable nature of the
medicine, and the readiness with which its peculiar vir-
tues are destroyed. Ignorance of this fact may have
led to the administration of the ergot in an inert con-
dition, owing to its having been deteriorated by keep-
ing. There is scarcely any medicine which spoils more
quickly, and requires more care in its preservation,
than the one under consideration; and even in the
present day, with all the knowledge of its properties
which we possess, I have reason to know that it is at
times employed in a state in which it is utterly devoid
of its peculiar properties, and completely inert as an
obstetrical agent.
Some time ago I was in attendance on a lady at a
short distance from this city, in whose case I wished
to administer the ergot. Having recently used the dose
which I habitually carry about with me, I sent a
messenger to a respectable apothecary living in the
adjoining suburb, to whom I wrote a note, requesting
that if he had any good and fresh ergot he would send
me some, or if not, that he would send on the messenger
to my own house for it. In a short time the man returned
with a paper from the apothecary, on opening which I
found a black, damp mass, more like wet turf-mould
than any thing else. If I had used this, in ignorance
of its being spoiled, of course disappointment would
have been the consequence, and my faith in the power
of the drug would have been shaken.
The second objection, viz. that the ergot is at all
times destructive to the life of the child, has probably
arisen from the employment of the medicine at im-
144
proper times. Thus recourse has been frequently had
to its aid in cases of difficult labour arising from
mechanical opposition to the exit of the child. In
such a case the destruction of the infant is almost sure
to follow, for the delay which necessarily occurs be-
tween the administration of the dose and the expul-
sion of the head is almost certain to produce fatal
results.
I have already incidentally stated” that I consider
a delay of two hours after the ergot has been taken as
dangerous to the life of the child. I will afterwards
revert to this subject; at present I will only observe,
that persons who employed the drug under circum-
stances like these must have been thereby led to form
the opinion that it was invariably hazardous to the
life of the infant.
The third class of authors above alluded to have
formed far too sweeping an opinion of the merits of this
medicine, when they state that it may be always given
with advantage, the safety of the mother or of the
child never being endangered. This is a kind of
praise most likely to do mischief, and damage the
reputation of a valuable remedy, by inducing others to
employ it under circumstances in which it is quite
inadmissible.
From a very extensive use of the ergot, I am quite
prepared to maintain that none of the three opinions
is correct, but that the truth lies between them. The
medicine when fresh, and carefully preserved, is in
fact one of great energy, and influences not only the
mother but also the infant. It requires to be used
with great discretion, for while it will in one case
effect the delivery of a living child, it will in another
* Page 115.
145
destroy the life of the child before birth; or operate so
injuriously upon it as to cause its death shortly after
it is born ; or produce a peculiar effect on its nervous
system, which I have observed and will presently
describe, but which I do not find noticed in any work
I have perused.
The difference of effect upon the infant depends
upon the length of time which intervenes between the
administration of the dose to the mother and the
conclusion of the labour. If this take place quickly,
no mischief is done to the child; if it be alive when
the medicine is taken, it will be born so ; but if a delay
of even two hours should occur, the probability is that
the child will be still-born. It is, I believe, generally
imagined (and until lately I entertained the opinion
myself) that the death of the child is owing to the
kind of action excited in the uterus by the ergot, differ-
ing from the natural labour-pain in this, that after the
contraction of the uterus has been excited, no com-
plete relaxation of its fibres takes place ; there is an
occasional increase in the strength of the effort, but it
never relaxes so long as the influence of the ergot con-
tinues. It is, as it were, one continued pain, at times
greater, but never entirely ceasing. The effect of this
continued contraction of the fibres of the uterus, upon
the great blood-vessels which traverse its walls to reach
the surface of the placenta, must be to intercept the
circulation to a certain degree. Now, although this
cause no doubt contributes in some cases to produce
unfavourable effects upon the child, I am disposed to
think that it is not the only cause of fatal mischief,
but that in some there is a noxious influence exerted
on the nervous system of the infant, which produces
results varying in intensity, from the development
T
10
146
of certain spasmodic affections of its muscular system
after birth, to the destruction of the infant. A few
cases from my note-book will serve to illustrate the
position I have here taken up. I will first, however,
mention some in which the medicine was given with
advantage to the mother and safety to the child.
CASE I.—Mrs. C., fifth pregnancy. Her former
labours had been natural and easy, occupying on the
first occasion fifteen hours; on the second, nine hours;
on the third, six hours; and on the fourth, five hours.
On this occasion the pains were from the beginning
weak, and slow in returning, and after the head had
come down to rest on the perinaeum they became more
faint, and appeared insufficient to expel it. The soft
parts were well relaxed, and a little more energy in the
uterine action was all that seemed requisite to insure
a speedy delivery. Nineteen hours had elapsed since
the labour commenced, and finding the pains dimin-
ishing rather than increasing in strength, I gave my
patient thirty grains of the ergot, and in ten minutes
after she had swallowed the dose a strong pain came
on, which completed the delivery of a living child.
CASE II.-Mrs. T., of a pale, delicate habit, and lax
fibre, was thirteen hours in labour of her first child. The
head was easily passed through the brim and into the
cavity of the pelvis, although the pains had not been
strong during any part of the process. When the
head distended the perinaeum, the pains subsided in
strength and frequency, and although no mechanical
obstacle to delivery existed in the soft parts, the
labour was arrested by a deficiency of energy in the
expelling power. The ergot was given in the same
dose as in the former case, and a living child was born
in fifteen minutes after its administration.
147
CASE III.-Mrs. A. This lady was confined two years
previously of her first child, at which time her labour
was only ten hours in duration, but she had profuse
haemorrhage after the birth of the child. On the pre-
sent occasion labour began at six o'clock, P.M., by the
discharge of the liquor amnii, soon followed by pains.
I saw her at eight, P.M., when the pains were trifling,
but recurring with regularity every quarter of an hour.
They increased until ten o'clock, at which time the os
uteri was nearly dilated and soft. Some haemorrhage
now appeared, which continued (although at no time
profuse) through the remainder of labour. At eleven
o'clock about one-third of the head had passed
through the brim of the pelvis, but the strength of the
pains diminished so as to have no effect in its advance-
ment. The patient now complained of a constant pain
in the back, not only without any remission, but with an
occasional increase in severity. She soon began to ex-
perience great exhaustion and sinking, complained of
want of air, and cried out to have the doors and windows
of the room opened. The pulse continued natural and
steady. Some cordials were administered, which had
the effect of restoring her. In this state she remained
until one o'clock, A.M., when finding no return of true
uterine action, the os uteri and external parts being
perfectly relaxed, I gave thirty grains of ergot; this
was followed in the space of a quarter of an hour by
one good pain. I now repeated the dose, which quick-
ly produced energetic action of the uterus. Three
pains expelled the child, alive, just twenty minutes
after the first dose had been given. The placenta was
found lying in the vagina, from whence it was readily
removed, without the loss of an ounce of blood. The
cord in this case was only fourteen inches long.
10%
148
CASE IV.-This lady, Mrs. K., was pregnant of her
fourth child; all her previous labours had been natural
and easy. On this occasion the pains were unusually
few and feeble, and she was thirty-four hours in slow
labour before I was called to see her. The membranes
had ruptured early, and the liquor amnii continued to
drain away. I found her walking about her chamber
without any pain. On making an examination, I dis-
covered the os uteri dilated, and the head nearly resting
on the perinaeum. The pains were now suspended for
five hours, at the end of which time I gave her the usual
dose of secale cornutum. In five minutes after she had
taken the medicine the pains returned, at first feebly,
but gradually increasing in strength. The child was
expelled alive in half an hour.
CASE W.—Mrs. M. This lady was very near dying
from uterine haemorrhage after her first confinement,
which took place in the country. This caused her to
come to town, and to place herself under my care on the
present occasion. Labour pains set in at four o'clock,
A. M., and continued with regularity until seven o'clock,
when they diminished a good deal in strength. A
slight draining of blood now appeared, which having
rather increased at eight o'clock, made me uneasy about
the delivery of the patient, who was of a very thin and
feeble frame, and weak constitution. I prepared the
ergot in the usual way, by infusing sixty grains of
the powder in four ounces of boiling water, and add-
ing some sugar. Of this I now gave her half, which
soon restored the uterine contractions, and in half an
hour the head was born. I then gave the remaining
portion of the medicine before the shoulders were ex-
pelled. The uterus contracted firmly, extruding the
child alive, and leaving the placenta in the vagina, from
149
whence it was removed without any further loss of
blood. #
CASE WI.—Mrs. A. ; fifth pregnancy. Her former
labours had been easy and natural, and sometimes very
rapid. This was the case at her last confinement, on
which occasion the child was born before I could reach
her house. At the present time the labour was very
slow and protracted. The soft parts were well relaxed,
and the head was quite moveable in the pelvis. The
only obstacle to delivery seemed to be an inert and
sluggish uterus. To rouse the dormant powers of this
organ the ergot was given in two doses, at an interval
of twenty minutes between them. Labour pains were
excited in a short time after the last portion had been
swallowed, and a living girl was born in one hour from
the administration of the first dose.
In these cases we find that the duration of labour
after the administration of the medicine varied from a
quarter of an hour to two hours, and that in every in-
stance the child was born without any unpleasant effects.
I will now record a few cases in which a longer period
than two hours elapsed after the dose was given, and in
which the peculiar effects upon the child to which I wish
to direct attention were observed. These effects are cer-
tain spasmodic conditions of the muscles of the whole
body, alternating with relaxation or palsy, and accom-
panied by evidences of derangement of the functions of
the cerebro-spinal system. It will be perceived that
there is in these cases a difference in the intensity of the
affection, in some appearing slighter than in others, but
the kind of affection will be recognised in all. In an
interesting paper by Dr. Catlett” he notices the ten-
dency of ergot to produce hydrocephalus in the early
150
stage of infantile life, and having detailed five cases in
which the death of the infant from this disease took
place at different intervals after delivery, he says:—“It
“will be seen that of the above there are none connected
“with a first delivery, or any in which the child was
“subjected to any lengthened or forcible impaction.
“Is there any warrant from this fact to infer that the
“ergot had here exerted any specific influence upon
“the foetal constitution, as alluded to by Dr. F. H.
“Ramsbotham, independent of the extra-mechanical
“pressure induced by its action ? It becomes indeed
“a very interesting question, if it be admitted that
“ergot has an agency in the cerebral disturbance thus
“set up in the infant economy, to determine in what
“manner it is effected : whether, as above hinted, it
“be a purely mechanical effect, or occurring through
“the medium of direct absorption into the foetal
“system.”
It appears to me that the cases I am about to relate
will go a great way towards the solution of this ques.
tion, by the evidence they afford of a directly poisonous
effect produced on the infant before delivery.
CASE VII.-Mrs. N. was eighteen hours in labour
of her first child. The pains were weak and ineffec-
tive, and at the end of sixteen hours they seemed to
diminish in strength and frequency. The os uteri was
was well dilated, and the child's head nearly rested on
the perinaeum, which was pliable and cool. A dose of
ergot was given, and was followed by a second in
twenty minutes, the first not having produced any
uterine action. From this period the pains became
more active, but at no time were they violent, and at
the expiration of two hours from the administration of
the medicine the child was expelled, to all appearance
151
dead. The surface of the whole body, as well as the
face, was of a deep blue colour, resembling the appear-
ance presented by a child in whom the foramen ovale
is open. All the muscles were in a state of rigid con-
traction ; so much so that the limbs remained straight,
and could be with difficulty bent. The fingers were
straight, with the exception of the last phalanges; these
were bent, and crooked downwards, being firmly fixed
in that position. No effort was made at inspiration.
The cord was now divided, and blood was allowed to
flow from the cut extremity, which it did slowly. A
warm bath was provided, pulmonary insufflation was
employed, and at the end of fully half an hour my
exertions to restore animation were successful. The
child breathed, but the rigidity of the muscles con-
tinued for a long time after it showed signs of life, and
when the tonic spasm relaxed, it was only for a short
period, and was quickly succeeded by general convul-
sions. This condition of alternate convulsion and re-
laxation continued without intermission for three days.
During this time leeches were applied to the temples,
and the head was extensively blistered. The spine was
also blistered from the occiput to the middle of the
back, and the usual antispasmodic medicines were
given by the mouth and rectum. By degrees the in-
tensity of the convulsion appeared to subside, and the
interval of relaxation became longer, the strabismus,
which had been very great, now disappeared, and the
child finally recovered.
CASE VIII.—Mrs. P. This was a case of placenta
presentation, to which I was called by Mr. Murphy of
Rathgar. The haemorrhage had ceased when I saw the
lady, but I found her very much exhausted, complain-
ing of noise in her ears, with a small, thready pulse at
152
120. On examination I found the os uteri dilated to
the size of a half-crown piece, with an edge of the
placenta encroaching on its area towards the left side.
There was no pain at this time, although there had
been some in the course of the morning. The exami-
nation reproduced hamorrhage; I immediately plugged
the vagina, and gave her thirty grains of ergot, which
were repeated in a quarter of an hour. Pains soon
came on, weak at first, but regular ; they increased so
much in an hour after the medicine had been given,
that I removed the plug, and found, as I expected, the
OS uteri more dilated, and the membranes tense, and
protruding at each pain. I now ruptured the mem-
branes, and from that moment all haemorrhage ceased.
A warm cordial draught of wine and water was admin-
istered to the patient. The pains increased in power,
and at the expiration of two hours and a half from the
time the ergot was given, a girl, apparently still-born,
was delivered. This child presented precisely the same
appearances as those described in the last case, but it
required a perseverance in our efforts of two hours'
duration before it could be considered safe to relinquish
our attention to it. At length it was quite restored,
the spasmodic state of the muscles relaxed, and no
convulsions followed.
CASE IX.—Mrs. N. This was the third time I was
called to attend this lady. Her two former labours had
been natural ; on this occasion, after labour had been
well established for four hours, the pains ceased entire-
ly, and did not return until after waiting eight hours,
during which time stimulating injections and frictions
to the belly, &c. were employed. Finding there was
no sign of the return of uterine action, I gave sixty
grains of the ergot in divided doses. The uterus was soon
153
thrown into action, and in three hours the child was
born, blue, stiff, and insensible. After great ex-
ertions respiration was established, but the child had
severe convulsions, which lasted for forty-eight hours
after its birth. These subsided, but left the child in a
state resembling paralysis, with occasionally a convul-
sive motion of the muscles of the face and limbs, and
fixed strabismus. No treatment seemed to have any
effect upon this condition. Twenty days after its birth
the following report was taken : “This child has re-
mained in a state of insensibility up to the present
time; the strabismus has lately disappeared, but it
seldom opens its eyes. The limbs are apparently
powerless. It makes no effort to suck, but it swallows
breast-milk with difficulty when put into its mouth ;
this difficulty is increasing. The bowels act naturally.”
In this state the child lingered on until the twenty-fifth
day, when it died.
CASE X.—Mrs. M. This lady was in labour of her
third child. Her previous labours had been very slow.
I saw her on the present occasion after she had been
ten hours ill. The waters had been discharged, the
os uteri was quite dilated, but the head had not entered
the pelvis. No pain having occurred for an hour after
my arrival, I gave her the ergot as usual. Its opera-
tion was very tardy, it did however excite the uterus
to act, and in two hours and a half after its adminis-
tration the child was born, livid, rigid, and dead. No
resuscitation could be effected.
CASE XI.—Mrs. K. This lady's labour began at
midnight by rupture of the membranes, without pain.
It was her eighth pregnancy. On my arrival I found
the os uteri dilated to the size of a shilling, and the
head presenting. Matters remained in this state for
154
nine hours, when a sudden and copious hamorrhage
took place, and flowed with great rapidity. I imme-
diately gave the ergot, and plugged the vagina. Pains
did not come on for nearly an hour, and then were
weak, but continuous. The child was born in three
hours after the medicine was given. It was dead, livid,
and rigid ; the hands were firmly clenched. No suc-
cess attended our efforts at resuscitation.
CASE XII.-Some time ago I was called, in consul-
tation with Sir Philip Crampton, to see a child then
three years old, and labouring under a very remark-
able spasmodic disease. When the child was carried
into the room by its mother, it appeared as if every
muscular fibre in its body was in a state of paralysis.
The limbs all hung loose and powerless; the head fell
about by its own gravity, unsupported by the muscles
of the neck. The countenance was idiotic. While we
looked at the child, this state of utter flaccidity was
slowly changed into one of spasm of every muscle of
the body. The limbs were contracted into the most
grotesque forms, the back was forcibly bent back-
wards, the head was extended, and flexed, and rotated,
and these motions were performed slowly and in suc-
cession. After this paroxysm of muscular action, the
whole child relapsed into its former state of flaccidity
and helplessness, and this scene was repeated several
times while it remained in the room. We were told
that this condition had continued since its birth. I
was so much struck by the resemblance this condition
bore to that in which I had seen the children above
described, that I inquired from the lady what was the
nature of her labour when this child was born, and I
learned that it had been long and tedious, and that she
had got ergot of rye to quicken the pains. The child
155
was still-born, great difficulty was experienced in re-
suscitating it, and it had never been free from the
alternate spasm and palsy since its birth.
In the cases just recorded, the condition of the in-
fants was very unlike that of still-born children deli-
vered under ordinary circumstances, and when no ergot
had been administered to the mother. The distin-
guishing characteristics are, the general lividity of the
Surface; the universal rigidity of the muscular system,
producing the stiffened limbs and clenched hands in those
łnfants in whom life was eatinguished; and the remark-
able kind of alternating spasm and palsy which super-
vened in those that were resuscitated. The nearest
approach to this state in new-born children, and that
which most resembles it is, the condition in which child-
ren are born dead, with symptoms of congestion of the
cerebral vessels; in whom, it is true, we find the coun-
tenance suffused and livid, but the peculiar affection of
the muscular and nervous system is wanting. Children
presenting this appearance of congestion are usually
born after difficult labour ; but in the instances above
detailed this was not the case—some of them were
tedious, but none of them difficult.
That the foetus in utero is capable of being influenced
by the circulating fluids of the mother is proved by
the well-known fact of the communication of syphilis,
small-pox, &c. to the unborn child; and that sub-
stances taken into the stomach of the mother can affect
the infant is shown by the experiments of Majendie,”
who found in the foetus of animals the odour of cam-
phor, and the colour of madder, with which he had fed
the mothers. It is still further established by the case
* Velpeau de l'art des accouchements, p. 196.
156
reported by M. D’Outrepont,” of a foetus poisoned by
opium taken by the mother.
Admitting this point to be established, it remains to
be seen whether the effects described above, and im-
puted to the direct agency of the ergot of rye, bear
any resemblance to the effects produced by the intro-
duction of this drug into the circulation. Upon this
point we have very satisfactory information in the
elaborate essay of Mr. Wright, already alluded to.
Before proceeding to recount the results of his experi-
ments, he takes notice of some of the epidemics of
spasmodic ergotism, caused by eating bread made of
rye containing a large portion of ergot, which visited
different parts of the continent during the last century.
This disease almost devastated Freybourg, and overran
many of the cantons of Lusatia, Saxony, and Sweden.
According to Widelius, the patients were attacked with
spasms and convulsions, accompanied with violent
pains, which were said to equal those of luxation, and
to be similar in their type. In some instances the
patients became lethargic, and when recovering from
such state gave respectively signs of stupidity, intoxi-
cation, and extreme lassitude, after which the fit
subsided for a time. But there generally remained
vertigo, tinnitus aurium, nebulae oculorum, rigidity of
the members, and excessive feebleness.
In 1722 Silesia, in 1723 the environs of Berlin, and
in 1736 Wirtemburg in Bohemia sustained the disas-
trous effects of ergotism. The disease commenced
with a disagreeable sensation of tingling or itching in
the feet, a violent cardialgia then came on, and the
disease ascended to the hands and the head. The
* Revue Medicale, t. iv. p. 121.
157
pains in a short time subsided, the head became heavy,
and vertigo prevailed, the eyes appearing to have a
thick mist before them. The fingers and hands were so
spasmodically contracted that no force could straighten
them, and the pain was described as equalling that of
luxation. Some of the patients became totally blind,
and others had double vision. The memory also failed,
the conversation was wild and unintelligible, and the
movements staggering and awkward. Some became
maniacal, some melancholic, and others comatose. The
disease was usually accompanied with opisthotonos.
Of five hundred patients, three hundred infants pe-
rished, considering as such all under five years of age.
Burghard gives an account of a convulsive epidemic
which raged in the canton of Silesia. The patients
were the subjects of excessive spasms, which convulsed
the extremities, and the head, eyes, and lips in particu-
lar, attended with an aberration of reason which no
medicine could restore. Those who died showed, pre-
viously to dissolution, a sort of paralysis, which degen-
erated into apoplexy. Such as were fortunate enough
to recover laboured for some time under excessive
debility, particularly of the joints, stiffness and even
immobility of the limbs, enfeebled intellect, &c.
This short abstract shows the convulsive character
of the disease induced by the use of ergot as a matter
of food, and points out the brain and spinal marrow as
the organs principally under its influence.
Let us now inquire into the effects of this drug when
introduced directly into the circulation; and here I
may remark that the foetus in utero, with respect to the
introduction of noxious matters into its system, is cir-
cumstanced similarly to animals on whom we experi-
mentalize by injecting fluids into their veins; for if the
158
poisonous material does reach the foetus, it can only do
so by the route of the umbilical vein.
Eageriment 1.—Mr. Wright injected a strong infusion
of ergot into the jugular vein of a dog, which cried and
struggled violently on receiving it, the urine flowing
in a full stream, the pupil dilating immediately, the
pulsations of the heart being too rapid to be counted.
In four minutes its action was much diminished in
force and frequency, and general muscular flaccidity
prevailed, with slight quivering in the whole frame.
In another minute the heart beat with singular rapidity
and force, during which complete opisthotonos came
on. After the lapse of another minute and a half the
dog cried in a plaintive tone, the heart beat slowly and
laboriously, the breathing was remarkably slow and
profound, and under these circumstances the animal
died in exactly nine minutes from the period of injec-
tion.
Eageriment 2–Another dog was treated in a similar
way, but when only half the quantity was injected exces-
sive spasmodic action ensued, with dilation of the pupil
and discharge of faeces. In three quarters of a minute
the convulsions had ceased, and there were only to be
observed the most perfect helplessness and flaccidity of
the limbs, with a quick and feeble pulse. This state
continued through the further space of half a minute,
when very slight tremor of the muscles of the hind
and fore legs succeeded, accompanied with a drawing
down of the lower jaw and perfect emprosthotonos.
The motion of the heart was now very slow and inter-
mittent. The emprosthotonos, with an occasional
convulsive sigh, continued until four minutes and a
half from the commencement, when all signs of life
were gone.
159
Several other experiments were made by Mr.
Wright, with different quantities of the infusion, and
all produced results differing in intensity, but similar
in kind.
The question now arises, does the blood of the
mother become impregnated with the noxious proper-
ties of the ergot ? This point also has been settled by
Mr. Wright, who has proved that the oil of ergot
(upon which the peculiar action of the drug seems to
depend) is present in the blood of animals who have
taken the medicine by the mouth. He detected the
oil in the blood of a dog to whom he had given
the powdered ergot; and he gives an account of the
method pursued, which it is not necessary to mention
here; but he has established the fact by his investiga-
tions, and we are thus enabled to comprehend how the
influence of the drug can be extended from the
mother to the unborn child.
It might appear strange at first sight, and difficult
to understand, how a medicine taken in the usual
medicinal doses, and with apparent impunity, by the
mother, should nevertheless act injuriously on the foetus
in utero. But the difficulty is in a great degree
removed, when we consider, first, that the system of
the mother is very generally acted on by the ergot,
though not to any injurious extent; and secondly, that
infants are so susceptible of the action of narco-
tics. That the maternal system is more or less in-
fluenced by the ordinary dose of the ergot is shown
by the remarkable depression in the pulse, which so
constantly follows the administration of this drug; the
rate of the pulse often falling twenty beats in the
minute, and in some instances dangerous comatose
symptoms having ensued. This, coupled with the fact
160
above alluded to, that infants are peculiarly liable to
be dangerously affected by very minute doses of nar-
cotic medicines, enables us to comprehend how the
foetus may be injured by a poisonous matter circulating
with the blood of the mother.
It is plain that the longer the time that elapses after
the medicine has been taken into the stomach of the
mother, the more certainly will its noxious principles
be absorbed and mixed with her blood; the more cer-
tainly also will these principles be transmitted to the
foetus by the constantly arriving current of blood
through the umbilical vein ; and the more likely will
the foetus be to suffer from their effects.
From these observations I think we are justified in
coming to the conclusion, that the administration of
ergot of rye to a woman in labour is attended with
danger to the child, whenever a time sufficient for the
absorption and transmission of its noxious properties
elapses before the child is born ; and from the cases
above stated I am inclined to place two hours as the
limit of safety, and to consider a prolongation of labour
beyond that period as perilous to the infant.
It would appear that the degree of effect produced
differs with the time that elapses between the exhibi-
tion of the dose and the birth of the child. In some
we find spasm and lividity, with a capability of being
perfectly restored to life ; in others resuscitation was
followed by convulsions terminating in idiotcy, with
alternate spasm and palsy ; in others the convulsions
were followed by death at a remote period; and in
others the life of the child was completely extinguished
before birth.
Two practical deductions may be drawn from these
observations,—first, that the ergot should never be
161
given in any case where there is a likelihood of the la-
bour lasting more than two hours after its administra-
tion, except where it may be employed to secure the
life of the mother, as in the cases of placenta presen-
tation and of accidental haemorrhage above quoted
(Cases VIII. and XI.); and secondly, that if we find
delivery delayed to two hours, resort should be had to
artificial means to save the life of the child.
Further Observations on the Use of Ergot of Rye.
[From the Dublin Quarterly Journal of Medical Science, May, 1864.]
In a former paper I dwelt at some length upon the
injurious effects sometimes produced on the foetus in
utero by the administration of the ergot of rye to the
mother during labour. I propose on the present occa-
sion to call attention to results beneficial to the partu-
rient female which follow the judicious administration
of the drug. We are all aware of the formidable
character of haemorrhage after delivery. There is no
accident that more completely and suddenly threatens
the extinction of life, and there is none more calcu-
lated to alarm, and even to unnerve, the most experi-
enced practitioner. There is another consequence of
delivery, which, although not equally dangerous, is
nevertheless productive of the greatest suffering, and
is at times uncontrollable by the means ordinarily
employed to procure relief; I allude to the occurrence
of after-pains. Every practitioner has to encounter
these very formidable and distressing consequences of
labour, and although the means of combating them
are well laid down in treatises on midwifery, and well
11
162
understood by the profession, it appears to me that we
can go a step in advance, and adopt measures to prevent
their occurrence in certain cases in which we have
reason to expect them.
That certain women are more prone than others to
uterine haemorrhage after delivery is a truth of which
every practitioner is well aware, and that a patient
who has once suffered severely from this accident is
very likely to encounter a similar danger on every
subsequent occasion, will be equally admitted as true.
There are two very opposite conditions of the system
which favour the occurrence of this formidable accident.
The first is the full plethoric habit, where the heart is
in strong and rapid action, and all the vessels are
gorged with blood, as is indicated by the flushed skin,
headache, thirst, and bounding pulse. The second is
the weak, delicate, lax-fibred state, characterized by
pale countenance, spare limbs, slow and weak labour-
pains, and feeble, though it may be rapid, pulse. Of
these the first is that which bears the attack with the
greatest impunity, and least danger to life. In that con-
dition there seems to be a superabundance of blood in
the system, the loss of which, within certain limits, is
more advantageous than otherwise, and from the tonici-
ty that pervades the uterine in common with the other
muscular fibres of the body, the flow of blood is more
easily arrested when it exceeds bounds compatible
with safety to life. In the second condition, on the
contrary, every drop of blood which is poured out in-
dicates its loss by a corresponding depression of the
system; such patients, with their languid frames, their
nervous and often hysterical disposition, at once shew
the ill effects of haemorrhage; they become rapidly
weak and gasping, the pulse soon fades under the
163
finger, and the loss of half the amount of blood easily
and safely spared by the former class of patients will
place the life of one of the latter in the greatest jeo-
pardy. In addition to this, there is not the same na-
tural means of arresting the haemorrhage which exists
in the first described class; the uterus is languid and
slow to act, and when artificially excited to contrac-
tion, seems unable to continue the effort for any
sufficient length of time; relaxation soon takes place,
the vital stream again rushes forth, and again the
struggle has to commence between the medical attend-
ant and death.
In addition to the ordinary well-known means of
treating uterine haemorrhage after delivery, I have
been in the habit for some years of placing great
reliance on the use of ergot of rye in full doses; and
although, from the precautions I am in the habit of
employing to secure contraction of the uterus, cases of
haemorrhage have been rare in my practice, yet some
have occurred in which I have derived most essential
aid from this drug. The mode of administration may
be the same as that described in my remarks at page
137; or sixty grains of the powder may be infused in
four ounces of boiling water, a little sugar added, and
half of the infusion, with the suspended powder, may be
given for a dose, and repeated if necessary. And here
I would observe that, to act beneficially, the drug
must be employed early. It will not do to wait until
the system has been exhausted, and the vital powers
reduced to the lowest ebb ; for then the action of
the ergot may be more prejudicial than advantageous,
owing to the power it possesses of depressing the
action of the heart. It will not take the place of
opium in restoring the balance of the circulation, and
C 2.
164
renovating the nervous system, in the last stage of that
frightful accident; but, when given in proper time,
before the loss of blood has been excessive, it will
prevent the necessity of giving opium, by checking the
flow of the vital fluid, and thus husbanding the
strength of the patient. I do not intend to give a
detailed account of all the cases in which I have em-
ployed the ergot to arrest haemorrhage after it has
commenced ; I will only state generally, that in my
experience it has never failed to effect this object; and
I have the pleasure of being able to say that I never
lost a patient from this accident whom I had under my
care from the commencement of the labour. I have
seen patients die of haemorrhage, no doubt; but these
were cases where I was called in at the termination,
just in time to witness the last struggle. Before I quit
this part of my subject, I wish to advert to what
appears to me to be a not very uncommon error, viz.,
that opium is a remedy for uterine haemorrhage after
delivery. This is an error which is calculated to do
immense mischief, by inducing practitioners to give
opium at a time when its operation is most detrimental
to the patient. That opium is invaluable in the latter
stages of these cases no one is more ready to admit
than myself. It soothes the horrible jactitation, reno-
vates the failing nervous energy, and acts as a restora-
tive to the exhausted system ; and when, by its
salutary operation, sleep is procured, all danger is
generally at an end. This beneficial action has, I am
sure, led to its administration at an improper time.
Because it is good in one stage, it has been supposed to
be applicable to another; and while it is only really
valuable as a means of correcting the ruinous effects of
loss of blood, it has been erroneously imagined that it
165
is capable of arresting the flow in the earlier stage.
This, I repeat, is a grievous error, and if generally
acted upon, is likely to lead many an unwary practi-
tioner into trouble. What we want in the early 'stage
of uterine haemorrhage is uterine contraction ; but no
one will maintain that opium is capable of attaining
this object. On the contrary, we know very well that
opium suspends the action of the uterine fibres, and
for this purpose we give it in cases of turning, where
we wish to diminish the resistance to the introduction
of the hand offered by the uterus. In like manner we
give opium to relieve severe after-pains, which are
produced by violent spasmodic contractions of the
uterus, and we find they are suspended by that
medicine. Does it not appear strange, then, that the
same medicine should be given at a time when we
should anxiously look for the most prompt and ener-
getic uterine action, and employ every means in our
power to solicit this desirable condition ?
That opium is capable of inducing hamorrhage
when given soon after delivery I once learned to my
cost. In November, 1839, a lady, whom I had often
attended before, was confined. She was subject to
after-pains of the most intense kind, far exceeding any
pains she ever had before the birth of her children ;
and on more than one occasion I was sent for in two
hours after I had left her, and found her suffering the
greatest agony, which I had very great difficulty in
allaying. On the occasion above referred to, I wished,
if possible, to anticipate the severity of the attack;
and accordingly I had a dose containing thirty drops of
tincture of opium ready, and gave it to her as soon as
the infant was born. The result was inertia of the
uterus, and although she had never had haemorrhage -
166
before, flooding soon came on. The removal of the
placenta, by passing the hand into the uterus, did not
control it ; and, in spite of the most active employ-
ment of the ordinary means, the loss went on. So
profuse was the deluge of blood, that I am convinced
if I had not had my dose of ergot in my pocket, the
delay necessary to procure it would have placed my
patient in the greatest danger. However, by its timely
administration, the paralysed condition of the uterus
was overcome, the fibres contracted, and the rush of
blood was arrested. This was one of the most alarm-
ing cases of haemorrhage I ever met with, and I have
not the least doubt it was caused by the opium.
Let opium then, be given with a view to its proper
object, and let it not be expected to do the very
opposite to that for which we so often employ it. Given
prematurely, it must do mischief: given at the proper
moment, it will rescue patients from the grave. The
ergot of rye should be our sheet-anchor at first, when
we want to arrest the hamorrhage, and opium after-
wards when we wish to restore the exhausted vital
powers.
The principal object, however, of the present com-
munication, is not to treat of the means for arresting
haemorrhage after its commencement, but to recommend
a practice calculated to prevent its occurrence in certain
cases, where, from previous experience, we have reason
to know it is likely to occur. There are some females,
as I have already mentioned, who are more prone than
others to this affection, and in whom every labour is
followed by severe and dangerous flooding; and I
conceive it to be a matter of the greatest importance
to be able to avert so serious a calamity, when we have
timely notice of the predisposition of our patient.
167
With a view to attain this object, I have been in the
habit, for some years, of anticipating the danger by the
administration of the secale cornutum immediately
upon the birth of the child, and before haemorrhage
takes place, with a success that will be best estimated
after a perusal of the following cases.
CASE I.—Mrs. M. This lady had been attended by
my father at the birth of several children, and was
always disposed to haemorrhage after delivery. On
more than one occasion the discharge was very abun-
dant, and at the last accouchement she was reduced to
a state of very great danger. I was engaged to attend
her for the first time in the year 1835, and being
aware of her disposition to haemorrhage, as well from
her own statement as from the record of her case in
my father's books, I was determined to anticipate the
accident, and prevent its occurrence, by securing a full
and permanent contraction of the uterus. Accordingly
I prepared an infusion of ergot, sixty grains in four
ounces of water, leaving the powder in suspension, and
as soon as the head of the infant had cleared the peri-
náeum I gave her half the quantity. Due attention
was paid to following the uterus down into the pelvis
with the hand, and a proper binder was carefully ad-
justed. In a quarter of an hour after the birth of the
child, the remaining portion of ergot was administered,
and the placenta was expelled in a few minutes after-
wards, accompanied by much less than the quantity of
blood lost by most women after delivery.
I attended this lady again in the year 1838, when
she had a premature confinement at the end of the
eighth month. She had travelled sixty miles to town
in one day, and on the following day the waters of the
ovum were discharged without pain, which did not
168
come on till forty-eight hours afterwards. The labour
was weak and slow, and, as I had reason to fear her
old enemy, haemorrhage, I gave her the ergot as before,
and with an equally favourable result.
CASE II.—Mrs. B. In June, 1835, this lady was de-
livered of her third child when I attended her for the
first time. She had previously been under the care of
two physicians of eminence, one of whom attended her
in her first, the other in her second confinement. On
both occasions she suffered, after the birth of the child,
from profuse and dangerous hamorrhage, which, par-
ticularly on the second occasion, was arrested with
considerable difficulty. I prepared the usual dose of
ergot, and administered it in divided doses, half just
as the head was about to clear the external orifice, and
the other half immediately after the complete expulsion
of the child. The result was most satisfactory; the
placenta was thrown off without any difficulty, and
very little blood accompanied its separation. This
lady has been attended by me at the birth of four
other children, and, by adopting the same measures,
always with the same success. 4
CASE III.—Mrs. M. This lady was very near dying
of uterine haemorrhage after her first confinement,
which took place in the country. In the year 1838
she was again pregnant, and came to town to place
herself under my care. She was a pale, thin, nervous,
delicate person, and she looked to her approaching
accouchement with great alarm. Labour set in early
in the morning, and continued rather steady for three
hours, when the pains subsided, and a slight draining
of blood took place. She continued in that state for
two hours, the membranes having previously ruptured,
when, finding the os uteri well relaxed, and the head
169
low, I gave the usual dose of the ergot of rye; this
soon restored the pains, and the head was born in half
an hour. I then gave a similar dose, the delivery was
accomplished, the uterus contracted firmly, the pla-
centa was found in the vagina, and no further haemor-
rhage occurred.
This lady has been confined under my care on three
subsequent occasions, and by the adoption of the same
treatment her labours have been safely terminated.
CASE IV.—Mrs. O., of a pale complexion and lax
fibre, was confined in 1839, after a weak, slow labour,
and in an hour and a half after delivery she had a very
profuse haemorrhage, which I found much difficulty in
arresting. She also suffered most severely from after-
pains, which continued with great intensity for two
days. In 1841, she was again delivered after a long,
weak labour. I gave the ergot just as the head of the
infant had escaped from the vagina. The placenta was
found at the orifice, and was easily removed without
any loss of blood, and no after-pains followed this
delivery. This proceeding has been twice adopted
with the same lady since that time, and in both in-
stances I have had the satisfaction of witnessing
similar happy results.
CASE W.—March, 1845, I was engaged to attend a
lady, Mrs. H., pregnant of her eighth child, and whose
approaching confinement was contemplated with the
deepest anxiety by her friends as well as by herself,
owing to the great danger that attended all her former
deliveries, from the occurrence of uterine haemorrhage.
She was delivered on the 9th of March, after a weak
labour of twelve hours duration.
As soon as the head of the infant came to press upon
the perinaeum, I administered the first dose of the
170
medicine, for I knew by the relaxed condition of the
external parts that there would be no delay, and there-
fore no danger to the child, as soon as the uterus could
be induced to act more vigorously. The pains were
markedly increased in strength and frequency, and in
twenty minutes after the dose had been taken the child
was born ; the ergot was now repeated ; there was one
small gush of blood and no more. The placenta was
found in the vagina, from whence it was easily removed
in ten minutes after the birth of the child, and her
recovery was rapid.
Both the patient and her sister, who had been with
her in all her former confinements, were astonished at
the termination of this labour. Her sister, who, from
sad experience, was quite conversant with open win-
dows and doors, vinegar cloths, deluging with cold
water, fanning, brandy, and all the other usual re-
sources, assured me she could scarcely bring herself to
believe that all was safely over, so unlike was this to
any confinement her sister had ever had before.
CASE WI. occurred in the month of September,
1845. It resembled the former case in many respects,
but was more formidable, owing to the complication of
cardiac disease. I was called, without any previous
warning, in the middle of the night to attend this
lady, Mrs. L., who had already given birth to several
children. On my arrival at her house, I was informed
by the nursetender that she was in the habit of having
frightful haemorrhage after her confinements, and that,
unfortunately, the gentleman who had always attend-
ed her was engaged, and could not come to her. She
said, moreover, that the lady was subject to fainting
fits during her labour. With this by no means
pleasant intelligence, I ascended to the bedchamber,
171
where I found a small, delicate-looking female, nervous,
and a good deal agitated, of course, at seeing a
stranger instead of her usual attendant, in whom she
justly had so much confidence. She was in weak and
slow labour, and on examination I found the os uteri
dilated to the size of a crown-piece, and very yielding ;
the external parts were well relaxed. She was breath-
ing hurriedly, with occasional gasping, her pulse 130,
and the heart beating in a very tumultuous manner.
While Iwaited to observe the course of her labour, she
began to fall off into one of her usual sinking states,
from which she was roused by camphor, ammonia,
and wine. I now made up my mind to finish the
labour as speedily as possible ; and accordingly I
ruptured the membranes, and, having prepared the
ergot of rye in the usual manner, I administered
one half at once. This had the effect of increasing the
uterine action very obviously in a quarter of an hour.
The os uteri soon dilated completely, the head came
well down into the pelvis, and there were no more signs
of fainting. At the end of half an hour I gave the
remainder of the medicine, with the effect of augment-
ing the labour pains, and was gratified to find the
rapidity of the pulse greatly diminished as the labour
progressed, until at last it did not exceed one hundred
in the minute. The child was born alive in forty minutes
after the first dose had been given. The placenta was
found in the vagina after the cord was tied and cut,
and my patient did not lose two ounces of blood after
its removal. I remained with her two hours after
her delivery, and left her at the end of that time per-
fectly well. Her old friend took up the attendance on
the following day, and I received a note from her
husband, stating that he had never known her to have
so favourable a delivery before.
172
CASE VII.—In January, 1846, I was called upon to
attend Mrs. W., a lady who had previously borne nine
children. She told me that on every occasion she had
suffered most severely from flooding ; and that, for
twelve hours after each delivery, she was accustomed to
be deluged with cold water, to have doors and windows
open, and to get brandy in large quantities, sometimes
to the amount of a quart, before she was considered
out of danger; the result being that she was never
able to leave her bed for some weeks after her confine-
ment. On this occasion her labour was slow and weak
for four hours, when a slight drainage of blood came
on. I found the os uteri soft and yielding, and gave
the usual dose of ergot, which soon quickened the
pains. The child was born in half an hour afterwards,
when the dose of ergot was repeated. The placenta
came away in a short time, without the loss of a tea-
cupful of blood. She was out of bed in a week, and in
her drawing-room on the fourteenth day after her
delivery.
The cases I have adduced are, I think, sufficient to
shew the value of the practice I would wish to recom-
mend. They are, in my mind, convincing proofs of
the efficacy of the secale cornutum as a means of pre-
venting one of the most formidable evils we encounter
in obstetric practice. Indeed my confidence in its
power is so great, that I now fearlessly undertake the
management of cases which, without such aid, we must
all dread to encounter. -
It appears to me that the ergot prevents uterine
haemorrhage after delivery in two ways; first, by in-
ducing a complete and permanent contraction of the
uterine fibres, thus causing constriction of the blood-
vessels; and secondly, by diminishing the force and
173
frequency of the action of the heart, and thus render-
ing the effusion of blood less impetuous, and more
easily restrained. In all cases where this medicine is
given in a full dose, it has the effect of moderating the
action of the heart, and, in the sixth case I have
mentioned, its salutary influence over that organ was
most marked and beneficial.
I have found the timely administration of the ergot
most useful in preventing, or in greatly moderating,
those frightful after-pains with which some women are
so grievously afflicted. I have seen a patient writhe in
agony far greater than any she had suffered during
labour, for many hours after delivery, and I have
given opium in such cases to an extent beyond what
would be borne under other circumstances, with im-
punity, and with but little avail. Seeing the severe
and intractable nature of such cases, I was induced to
try the effects of the secale, hoping that by the rapid
and permanent contractions of the uterus produced
through its influence, the painful spasms of the organ
might be averted. I was encouraged to expect this
effect from what occurred in the fourth case just
related, and in several instances I have used the
medicine for this purpose, and with happy results.
The mode of administration and the dose are the same
as those employed to restrain haemorrhage. It ap-
pears to me that the ergot proves beneficial in these
cases, by causing perfect contraction of the fibres of
the uterus, and keeping them in this condition; and
also by preventing the formation of clots of blood in
the interior of the organ, by the presence of which the
spasmodic action is excited and kept up. It is un-
necessary to give the details of any of the cases in
which I have given the drug for the purpose of pre-
174
venting the occurrence of after-pains, but I think it
right to state that some cases have presented them-
selves, in which its beneficial action was not so decisive
as in the greater number of instances it has been.
Before I conclude, I wish to record my testimony in
favour of the secale cornutum as a means of arresting
severe and protracted menorrhagia, unconnected with
organic disease of the uterus. For this purpose I em-
ploy it in doses of five grains three times a day, and
by its use I have frequently succeeded in cases which
resisted other plans of treatment. Great care should
be taken to assertain the absence of organic disease in
these cases, and examination should be made not
only with the finger but with the speculum, for ulcer-
ation of the os uteri; polypus also may exist, which
will elude detection by the former mode, but will at
once be made manifest by the latter. It is quite plain
that if the discharge of blood be caused by organic
disease, the flow will not be stopped by the internal
administration of ergot of rye, and therefore, if it be
given in such a case, the value of the remedy will be
unfairly depreciated. But if, after due examination,
organic disease cannot be detected, I think the medi-
cine may be relied on as a very efficient agent. I
have often observed in patients who have taken the
medicine in five-grain doses for two or three days, that
they complain of a peculiar cramp-like pain in the hips
and thighs, which becomes more severe if the medicine
be continued. This I consider a very good indication,
as in all the cases where it has occurred the disease
has been speedily removed.
Since the foregoing papers were written, various pre-
175
parations have been proposed, and some of them have
been adopted and introduced into the Pharmacopoeias
of the United Kingdom ; the object being to afford a
ready means of administering the secale cornutum in
well defined doses of uniform strength. In the British
Pharmacopoeia three such are to be found, viz.:-the
fluid extract, the infusion, and the tincture. These are
all good, the fluid extract the best ; and if there was
always time to write a prescription, and send to the
chemist (perhaps in the middle of the night), and wait
for its return, they would no doubt answer their pur-
pose. But the midwifery practitioner does not know
the moment he may want the valuable assistance of
this powerful drug. He may be miles away from any
pharmaceutist, and his patient's life may depend upon
the immediate administration of this hamostatic. On
this account I see no reason to alter the opinion I
have long entertained, and myself acted upon, viz.: that
every man engaged in midwifery practice should carry
in his pocket-case sixty grains of carefully prepared pow-
dered ergot of rye. It is a very delicate medicine, and
requires great care in its management and keeping. My
practice is to have four hundred and eighty grains of
freshly powdered ergot divided into sixty-grain doses,
and each dose wrapped in metallic paper, the metallic
surface being kept inside next the powder, and the whole
covered with common paper. One of these packets is a
very small and light addition to the weight and bulk of
a common pocket-case, which I presume every practi-
tioner carries about with him, and with it he is prepared
for every emergency that may require the use of the
drug. An infusion is readily made by pouring four or
five ounces of boiling water on the powder, which,
with the addition of a lump of white sugar, and a table-
176
spoonful of sherry wine, makes a very palateable mix-
ture. This may be given in two or three doses as
required. I have not for many years gone out night
or day without my dose of ergot in my pocket, and I
advise all other practitioners to adopt the same rule.
The convenience of this, compared with the alternative
of putting a bottle of one of the fluid preparations in
the pocket every time one goes out, is too evident to
require further comment.
177
CHAPTER WI.
ON CHLOROFORM IN MIDWIFERY IN CONJUNCTION WITH
ERGOT OF RYE.
[From the Dublin Quarterly Journal of Medical Science, vol. 10, p. 1,
August 1st, 1850.]
THE observations contained in the following pages
were communicated to the Dublin Obstetrical Society
on two different occasions, the last being the monthly
meeting held in April, 1850. From the cases detailed,
it will appear that I have been an early labourer
in the field of investigation respecting the merits of
chloroform as an anaesthetic agent in parturition ; but
I have purposely abstained from publishing the results
of my experience in this most interesting and impor-
tant field of research, until I had tested the accuracy of
my conclusions by repeated investigations. In a matter
like the present, where a variety of conflicting opinions
are entertained, and where the usual, and even more
than the usual amount of scepticism, which attends
the introduction of every improvement in medicine, is
found to prevail, it is the imperative duty of all who
have had opportunities of ascertaining the value of the
newly proposed means, to weigh well and consider in
all its bearings the plan, or remedy, before the stamp
of approval be placed upon it.
Actuated by such feelings, I have for a long time
carefully investigated the value of chloroform as an
12
178
anaesthetic agent in labour, and I have fully satisfied
myself that it is possessed of the powers ascribed to it
by the distinguished professor, Dr. Simpson, who first
employed and recommended it for this purpose; and,
moreover, that its employment, when properly conducted,
is not attended with any injurious effects upon either
mother or child. I have never seen any unpleasant
result from it, and I believe that, out of the many thou-
sand cases in which this agent has been employed in
parturition, not a single case of death has occurred from
its use. The immunity from danger in this class of
cases may be ascribed to two causes, viz.:-First, the
position of the patient, and second, the condition of her
stomach with respect to repletion. The horizontal
posture is that in which the peculiar effects of chloro-
form are most easily produced, and in which conse-
quently the least quantity is required to produce
anaesthesia. That is the position in which it is always
administered to the parturient woman ; while in many
surgical operations, and particularly in tooth-drawing,
the patient is placed in the upright position, when a
larger quantity of the drug must be used, and in such
cases it is that fatal results have most frequently
occurred. With respect to the second cause, viz. the
repletion of the stomach, it has been proved most
satisfactorily, that if chloroform be administered when
the stomach is full, dangerous effects are more readily
produced, and fatal consequences are more likely to
ensue. Now in cases of parturition it seldom happens
that the use of chloroform is commenced until some
hours have elapsed after the commencement of labour,
and during all that time the patient is little disposed
to take any food ; so that when the time arrives at
which it may be deemed prudent to administer chloro-
179
form, the stomach is empty, and thus another cause
of immunity from danger is secured to the parturient
woman. These circumstances have, no doubt, contri-
buted to preserve the class of cases under consideration
from injurious effects, and ought to encourage the
timid and wavering to lay aside prejudice, and be
guided by sound principles and experience. Let it
not be forgotten, however, that the grand desideratum
in the use of chloroform is its purity. Without this,
there is no security against unpleasant consequences.
The pure agent is harmless when properly admin-
istered ; but the impure, with similar precautions in
the mode of using it, is sure to cause cough, spasm of
the chest, excitement, and delirium, before the anaes-
thetic effects are produced, and headache, with conges-
tion of the brain, afterwards. Various means have been
proposed for testing chloroform, but they were all
difficult in their application, and unlikely to be em-
ployed by persons in active and extensive practice.
To Dr. W. Gregory we are indebted for the descrip-
tion of a method whereby any one, however engaged
in practice or unused to chemical investigations, can
for himself test every drop of chloroform he employs by
a simple process. His paper was read before the Royal
Society of Edinburgh in March, 1850, and was sub-
sequently printed in the Monthly Journal of that city.”
It is of great value, and should be carefully studied
by all who are interested in the success of anaes-
thetic treatment. He ascribes the injurious effects of
the chloroform in ordinary use to the presence of cer.
tain volatile oily impurities, which must be removed
before it can be safely employed. These oils contain
* Monthly Journal of Medical Science, p. 414, May, 1850.
12%
180
chlorine, have a disagreeable smell, and, when inspired
or smelt, cause distressing headache and sickness. It is
therefore highly probable that when these symptoms
occur, as they do with some individuals, from the use
of chloroform of more than the average goodness of
quality, they depend on the presence of a trace of these
poisonous oils. The test which Dr. Gregory recom-
mends for these impurities is agitation of the chloro.
form with sulphuric acid, which should be quite
colourless, pure, and of the full density of 1840 at
least. This, when agitated with the impure chloroform,
becomes yellow or brown, from its action on the oils,
which it chars and destroys. Any change of colour is
easily seen by the contact with the colourless chloro-
form which floats above. Pure chloroform gives no
colour to the acid. As this is a subject upon which
too much stress cannot be laid, I will transcribe Dr.
Gregory's instructions for the purification of the adul-
terated drug : -
“The chloroform having been tested as above, and
“found more or less impure, is to be agitated with oil
“ of vitriol [half its volume will be sufficient], and
“allowed to remain in contact with the acid, of course
“in a clean, dry, stoppered bottle, and with occasional
“agitation, till the acid no longer becomes darker in
“colour. As long as the action is incomplete, there
“will be seen after rest at the line of contact a darker
“ring. When this no longer appears, the chloroform
“may be drawn off, and for greater security once more
“acted on by a quarter of its volume of the acid,
“which should now remain colourless. It is now to
“ be once more drawn off, and in a dry, stoppered
“bottle, mixed with a little powdered peroxide of man-
“ganese, with which it is gently agitated, and left in
181
“contact until the odour of sulphurous acid is entirely
“ destroyed, and the chloroform has acquired a mild,
“agreeable, fruity smell. It has then only to be
“ poured off into a proper phial. It will now leave no
“disagreeable smell when evaporated on the hand.
“Mr. Kemp has observed, in repeating this process
“for me, the very curious fact, that as soon as the
“action is complete, and the oily impurities are de-
“stroyed, but not sooner, the chloroform, tested with
“ the acid in a tube, exhibits a strongly convex surface
“downwards, where it rests on the pure acid, or, what
“is the same thing, the acid becomes concave at its
“upper surface. The smallest trace of impurity, not
“sufficient to affect the density of the chloroform, we
“ have found to render the line of junction horizontal.”
We have thus in our power a very simple means
of testing and purifying chloroform before employing
it ; and if strict attention be paid to this most impor-
tant point, I have little doubt much of the prejudice
which still prevails against it will be removed.
I do not propose to enter into a detailed description
of the method of using this agent ; this has been done
already by Dr. Simpson of Edinburgh, and by Dr.
Murphy of London, to the first of whom we are in-
debted for the introduction of this valuable addition to
obstetric medicine, and to the latter for his able and
impartial investigation of the subject. The practical
and candid communication of Dr. Denham, published
in the Dublin Quarterly Journal of Medical Science,
contributed in no small degree to place the value of this
remedy in its true light.
I may just state generally, that in ordinary cases
I commence the administration when the OS uteri is
nearly dilated ; then I pour about one hundred and
182
twenty minims at first on the folded handkerchief, which
is held at a distance of five or six inches from the patient's
face as she lies on her side, and is slowly approached
nearer and nearer until the edges of the handkerchief
overlap the upper part of the cheek. In ordinary labour
I never produce insensibility, but as soon as the breath-
ing becomes at all loud, I remove the handkerchief, and
suffer the effects to subside, and then recommence the
process. By this means the patient is never deprived
of consciousness, but is relieved from the agony of
her labour pains, and also from that distressing and
persistent ache in the back, in the interval between the
pains, of which some women complain so loudly. They
are conscious of the uterine effort being made, and use
the ordinary straining to assist it, but they suffer little
or no inconvenience.
To be able to accomplish this with safety to the
mother and her infant, to hear a woman declare
immediately after her delivery that her labour was
“heaven,”—is no small triumph of art, and will be a
lasting memorial of the genius and perseverance of Dr.
Simpson. The stage of excitement which has been
observed in some cases wherein chloroform was em-
ployed is, I have no doubt, attributable to the use of an
impure specimen, and is not to be expected when the
pure drug is employed in the manner just described.
As a proof of the happy effect produced upon patients
treated after this fashion, I may state that those who
have once used the inhalation have called loudly and
early for it in subsequent labours.
That injurious and fatal results have followed the
use of chloroform in surgical practice I do not mean to
deny, though no fatal case has ever occurred in mid-
wifery, principally for the reasons already stated; but
183
in the majority of the unfortunate cases some satis-
factory reason will be discovered to account for what
occurred. The upright position, a full stomach, an
over dose, or an impure medicine,—these, or some of
them, will be found to have been present in such cases,
and will be quite sufficient to satisfy a fair and candid
inquirer that the blame should be laid on the in-
cautious employer rather than on the agent employed.
There is now no excuse if we fall into the mistakes
which others have made, and which have been dis-
covered and pointed out by the investigations of patient
inquirers. Who now fears to prescribe opium, arsenic,
or prussic acid to remove disease? yet who will deny the
deadly nature of these substances when incautiously
used? All are aware of the powers of these poisons,
but have learned by their own experience and that of
others how to prepare them, and apportion the dose so
as to keep without the limits of danger, and yet to se-
cure the effects they wish to produce. And so it must
be with chloroform: it is far too valuable and too power-
ful a substance to escape the strict scrutiny of science ;
as our acquaintance with it is short, we cannot be sup-
posed as yet to be familiar with all its properties; and
it is no reason that a hasty judgment of condemnation
should be passed upon it, if it has been awkwardly and
rashly employed by some in the infancy of the inven-
tion. I do not dwell for one moment upon the propo-
sition that it is the duty of the obstetric physician to
conduct his patient through her labour, with as much
speed and as little suffering as are compatible with the
safety of herself and her offspring. To argue upon a
proposition so self-evident would be but waste of time
and words. That we are possessed of an agent whereby
this great object can be accomplished is proved by the
184
many thousand cases in which chloroform has been
employed.
The use and value of this drug in natural and opera-
tive cases has been fully set forth in the essays already
mentioned, and I do not wish to occupy time and space
by quoting from my case-book instances of this descrip-
tion; suffice it to say, that I have employed it freely
and with the greatest satisfaction to myself and my
patients for more than two years. My principal object
in this communication is to show how chloroform can
be advantageously used, in a class of cases which seem
almost to forbid its employment; I allude to tedious
labours produced by sluggishness of the uterus. If the
first effect of a good dose of chloroform be the arrest of
uterine action for a short time, a fact admitted by Dr.
Murphy, and borne out by my own experience, it fol-
lows as a matter of course, that if the pains be slow
and weak, they will be the more surely and effectually
interfered with. Now, it has happened to me to have
patients under my care who were determined to inhale
chloroform during labour, and who were most clamor-
ous to get it at a time when the uterus was indisposed
to act with vigour and celerity. To give the vapour
so long as matters thus stood would have only in-
creased the evils and protracted the labour; but by
combining the use of ergot of rye with chloroform the
difficulty was quite removed. In order to illustrate this
practice, I will set forth some of the cases in which
I have derived the greatest advantage from such a pro-
ceeding. º
CASE I.—Mrs. W. was attended by me for the first
time in September, 1848, having had several children
previously. During the last month of her pregnancy
she was in a very distressing state of mental depression,
185
and continually spoke with apprehension of danger and
of death in her approaching confinement. She ex-
pressed a strong desire to be treated with chloroform, and
was quite pleased when I promised to let her have it.
Labour came on at the proper time, commencing with
slight pains, which continued, with little increase in
strength or frequency, from an early hour in the
morning until night. She was in a state of great
alarm and solicitude throughout the day, and remained
thus until 10 o'clock, P.M., when, finding no improve-
ment in the character of the labour, I gave her sixty
grains of ergot of rye in two doses, at an interval of a
quarter of an hour. This soon established full uterine
action, and in twenty minutes she was in strong labour.
She now became very much excited and unruly, dash-
ing herself about in the bed, and could not be pre-
vailed on to remain quiet. To obtain the promised
chloroform was her only object, and she clamoured
loudly for its administration. Finding that labour
was now fully established, and that the os uteri was
nearly dilated, I commenced the use of chloroform
from a pocket-handkerchief, on which I had poured
sixty minims of the fluid. This was at 11 o'clock, P.M.,
and almost immediately a complete calm ensued; she
became tranquil and composed, and never afterwards
betrayed the least want of temper. Her consciousness
never deserted her. She continued to speak rationally
all through, and expressed the greatest delight from
the inhalation.
She was safely delivered of a living boy at half-past
12 o'clock, A.M. When asked what she thought of the
medicine, she said it was heaven, and that she was
conscious of every pain, and could make the effort to
bear down, but felt no suffering. This lady had been
186
subject to intense nervous headaches after all her pre-
vious confinements, on which occasions the pain and
intolerance of light were so great that she was obliged
to have every ray of light excluded from her chamber,
and the most perfect stillness observed in the house.
The attacks usually lasted from twenty-four to thirty-
six hours, when they gradually subsided. On the pre-
sent occasion, however, nothing of the kind occurred.
When I called to pay my visit the following day, I
found the shutters open, and the chamber full of light.
My patient lay perfectly free from all pain, happy and
thankful, saying she could scarcely believe it was all
over, so unlike was it to what she used to suffer. Her
recovery was the most rapid she ever made.
This case affords some points for remark; first, we
observe the beneficial effects of ergot of rye in inducing
uterine action in a case rendered tedious by inertness
of that organ, and thus bringing the patient into a
condition favourable for the use of chloroform. It was
quite manifest at the time I gave the ergot that the
uterus was not disposed to efficient contraction, and
that many hours would in all probability elapse before
healthy action would commence. By the influence of
this drug a long night of fruitless labour was avoided,
and the patient was speedily relieved from suffering.
Secondly, a remarkable feature in this case is the im-
munity from headache subsequently to delivery. This
I think must be attributed to the soothing effect of the
chloroform on the nervous system, acting as a sedative,
and calming the excitement which formerly used to be
so distressing.
CASE II.—Mrs. F., pregnant for the first time. This
lady was most anxious to use chloroform in her ap-
proaching labour, and I promised it to her if nothing
187
occurred to cause me to refrain from its employment.
When the pains commenced they were very slow and
weak, and continued so for twenty hours, at the ex-
piration of which time the os uteri was dilated to the
size of a half-crown piece. The pelvis was roomy and
the soft parts relaxed. She was most importunate to
begin the inhalation ; but, the pains not being suffi-
ciently strong to warrant its administration, I gave the
ergot of rye, which quickened uterine action, and in
twenty minutes labour was well established. I then
commenced the use of chloroform, under the influence
of which she was kept for two hours, when she was
delivered of a living boy.
Insensibility was never induced in this lady; she
was conscious during the whole time, and frequently
held the handkerchief herself during the pains, soliciting
more chloroform, and expressing the greatest relief and
comfort from its use. One ounce of chloroform was
consumed in this case.
CASE III.-Mrs. C. In this case of first pregnancy
labour began by rupture of the membranes without
pain. In six hours there was some faint uterine action,
which continued to go on slowly for a long time. At
length, at the end of eighteen hours, finding the os
uteri soft and nearly dilated, I administered the usual
dose of ergot of rye. This soon gave strength and
effect to the pains, and I then began the use of the
chloroform. It was continued for one hour and twenty
minutes, when delivery of a living girl was accome
plished, after a labour of twenty-one hours' duration.
During the whole period of the inhalation this patient
was not insensible, but enjoyed the happiness of being
conscious of the uterine action, without feeling its
paln.
188
CASE IV.-Mrs. P., second pregnancy. On the oc-
currence of labour, the pains assumed a well-marked,
steady character, and continued so for four hours, at
which time the os uteri was nearly dilated, and the
vagina cool and moist. Having expressed a desire to
use inhalation, she was now permitted to commence,
and in a short time the labour pains were suspended.
This was followed by sleep, which was most sound for
one hour. On awaking from this condition the pains
did not recommence, so I determined upon giving her a
dose of ergot of rye. She got sixty grains in the usual
way, which soon produced a marked change in the
pains; they became more frequent and increased in
strength, and when well established the chloroform was
resumed. There was now no interruption to the pains;
the labour progressed most satisfactorily, and at the
end of an hour from the recommencement of the
inhalation the delivery was happily accomplished.
In this case the influence of the chloroform in sus-
pending uterine action was most clearly shown ; but
when the contractions were induced by the artificial
assistance of the ergot, it seemed to have no power to
arrest them. This is a point of great value, for it
shows the importance of combining these two valuable
and powerful agents. In cases such as I have related,
by causing the action of the ergot to precede that of
the chloroform, we secure the patient against a suspen-
sion of her labour.
• CASE W.-Mrs. A., sixth pregnancy. A severe
attack of uterine haemorrhage had attended this lady's
previous confinement, two years before her present
labour. Being anxious to prevent a similar event, I
gave her a dose of ergot when she was about seven
hours in labour, and the os uteri and soft parts fully
189
dilated. In twenty minutes the pains were very severe,
and the vapour of chloroform was now inhaled with
avidity. From the first time of the inhalation the
pains were materially relieved, and soon disappeared,
leaving the patient free from suffering, but not insen-
sible. At times she appeared to slumber for a moment,
and then awoke again, saying she had had a pleasant
dream. She said she was conscious of the efforts which
would have been pains, but she felt none; the child was
born in twenty minutes from the first inhalation, and
the duration of the labour was eight hours. The quan-
tity of chloroform used was four drachms.
CASE WI.-Mrs. P., second pregnancy. In this case
there was considerable delay in the first stage of labour,
owing to the head of the child presenting with the face
to the pubis, and there being a very weak and ineffi-
cient amount of uterine action. After three hours had
elapsed, and no evidence of increasing power being
manifested, I administered sixty grains of ergot in the
usual manner. By its aid the uterus was stimulated
to contraction, and the pains were rendered strong and
efficacious. As soon as the labour was well established,
she was permitted to commence the inhalation of chlo-
roform. The labour progressed rapidly from this time,
the head came down well through the pubis, and in
half an hour from the first use of the vapour the child
was safely delivered. This lady remained conscious
during the entire time of her labour. The inhalation
seemed to exercise a very marked influence upon the
condition of the soft parts, causing them to be relaxed
rapidly and freely. The duration of labour in this
case was five hours; the quantity of chloroform con-
sumed was three drachms, and the time of its influence
was only half an h -
iiOtił'.
190
These cases will serve as a specimen of those that are
met with in practice, where weak and slow power in
the uterus produces a tedious labour, and where the
patient, ill disposed to bear the pain attendant on even
such a feeble uterine effort, is clamorous for the inhala-
tion, so long looked for as the great source of relief
from suffering. To proceed at once to the exhibition
of chloroform in such cases would certainly protract
the labour to a great extent, and might also produce
very unpleasant consequences. It has been said that
uterine haemorrhage has occurred more frequently in
women who have inhaled chloroform, than is usual
with those treated in the ordinary way. It must strike
any one conversant with such matters, that the uterus
most likely to be relaxed after delivery is that in
which the pains have been most infrequent and feeble.
If chloroform alone be given in such a case, it would
be very likely to increase the tendency to relaxation
after delivery ; but when its use is preceded by that
of the ergot of rye, such danger is completely guarded
against.
It will be seen in the above cases that in none of
them were uterine pains suspended after the dose of
ergot had been taken ; the labour went on vigorously,
notwithstanding the use of the anaesthetic agent, and
in all of them delivery was accomplished with the
most perfect safety to mother and child.
Having thus, I trust, shown how chloroform may be
employed in cases that at first appear to be quite unfit
for it, let me again impress upon those who may em-
ploy these medicines the absolute necessity of making
sure that they are pure and fit for use. I have repeat-
edly expressed the opinion that when ergot fails to
produce its proper effect, it is owing to the use of an
191
impure, spoiled, and therefore inert specimen. The
ergot is a very delicate medicine, and is readily in-
jured by either age or damp. It should never be kept
more than twelve months, and ought to be preserved
in a perfectly dry situation. If good at first, and thus
treated, it will not disappoint when brought into ope-
ration. The purity of chloroform is of the greatest
importance, and this should be carefully looked to by
the practitioner himself. He has in page 180 an easy
method set before him, whereby he can test and purify
the drug ; and I feel confident that, if attention be
paid to these important points, the approval of the
profession will be given to the use of anaesthetics in
midwifery, and a large amount of human suffering be
thereby removed.
This contribution was followed by the following
paper, which I read before the Surgical Society of
Ireland on the 25th of March, 1852.
It may be in the recollection of some of the members
present, that a paper written by me was published
just two years ago in the Dublin Quarterly Journal,
the object of which communication was to testify to the
value and safety of the use of chloroform in the practice
of midwifery, and to point out how this new and
powerful agent might be employed in conjunction
with the ergot of rye, another medicine of immense
importance in obstetric practice. Since that time I
have continued to use chloroform very extensively,
and with the happiest results. I have given it to every
patient who desired to have it, unless I saw some good
reason to refuse. I have not pressed it upon any, and
192
rejoice, at the end of two years' additional experi-
ence, to be able to state that in all cases its use has
been productive of the greatest relief and happiness,
and that in no case has anything unpleasant occurred
to either mother or child during its administration, or
subsequent to delivery. Several patients, after being
confined under its influence, have in subsequent preg-
nancies come back from great distances, some from
remote parts of England, to Dublin, in order to be
treated in a similar manner; and there are many whom
no consideration would tempt to undergo a labour
without it. It will be easily imagined that my con-
fidence in the power of the agent has increased with
my experience, and I now feel distressed when obliged
to witness the sufferings of a patient, prolonged perhaps
in a first case for hours, when I have the power to
alleviate her agony, and (without for a moment inter-
fering with her consciousness) to render her labour a
“pleasure,” “happiness,” or “heaven,”—phrases which
have been frequently made use of to me by patients to
whom chloroform has been administered.
The application of chloroform in midwifery is very
different from its employment in surgical practice. In
the latter we have a person not suffering any pain, upon
whom a painful operation is about to be performed,
and in whom it is desired to induce such an amount of
insensibility as will render him unconscious of the pro-
ceedings of the operator. The sopor in such a case is
much deeper than any that is necessary in obstetric
practice. The time during which anaesthesia is re-
quired is usually much shorter, and the more intense
effect of the chloroform is therefore more safely pro-
duced, than if it were to be continued during the length
of time sometimes necessary in labour. In midwifery,
193
on the contrary, the use of chloroform is not begun
until the patient is already, and has been probably for
some hours, in a state of suffering. The object in such
a case is to relieve existing pain ; and it is a fact no
less remarkable than true, that a smaller amount of the
narcotic vapour is required to effect this, than to
render a non-sufferer insensible to a painful operation,
whilst a larger amount is subsequently borne with im-
punity. For this reason it is that when a pure drug is
employed, a very few inhalations from the apparatus
which I now use suffice to produce a decided effect upon
the sufferings of the patient; and a degree of relief so
marked as to be spoken of with the greatest satisfaction
and gratitude, is obtained long before any approach to
insensibility is perceived.” But this is not enough for
the occasion; the effect has to be kept up sometimes for
many hours, and if a sopor as deep as that induced
for surgical purposes were necessary, no doubt the pro-
ceeding would not be unattended with danger; but
fortunately in midwifery practice no such amount of
* Since the time this paper was read before the Surgical Society, I had
seen in the Dublin Medical Press of the 24th of March, 1852, a quotation
from a communication in the American Journal of Medical Sciences, by
Professor Byford of Evansville Medical College, United States, which
bears upon this point.—“I am led to believe that, in estimating the bene-
“ficial or injurious influences likely to be exerted by this powerful medi-
“cine, our attention has not been sufficiently directed to the condition of
“the nervous system, particularly in regard to the presence or absence of
“pain, or other preternatural excitement. I apprehend that we will find
“the same laws governing our physical system to obtain with respect to
“its use as we are compelled to take into account when we call to our aid
“any of the powerful narcotics; one of which laws is the preservation, in
“a great measure, of the general system, by the nervous system being pre-
“occupied by exalted or morbid excitement. This principle may account
“for the fact, borne out, I think, by statistics upon the subject, that the
“untoward and melancholy effects of chloroform seldom if ever occur in
“cases where the system is labouring under great pain, as for instance,
“iabour, toothache, &c.”
*
13
194
narcotic influence is required. The slow and gradual
administration of small quantities of the vapour, re-
newed from time to time as required, will be sufficient
to keep the patient for hours together in a tranquil
happy state, in full possession of her consciousness,
talking to her friends about her, knowing well when a
pain is coming on, applying the inhaler to her lips,
and asking to have a fresh supply of chloroform when
its effects are diminished in consequence of its con-
sumption.
The course of a labour treated with chloroform is
usually as follows. Take, for instance, a first case, in
which labour has been going on for eight, ten, or
twelve hours, with that increasing amount of suffering
which all females experience until the os uteri is nearly
dilated. At this time we know that the pains usually
become most severe ; and the patients lose their self-
control, becoming uneasy, impatient, and loudly com-
plaining of the sufferings which they undergo. If,
under these circumstances, we now commence the judi-
cious use of chloroform, the first effect, after a few inha-
lations, will be calmness. Instead of tossing about in
the bed, the patient becomes perfectly quiet, she ex-
periences relief, and the friends who are standing
around begin to be astonished at the almost instanta-
neous effect which has been produced. They had be-
come anxious at the amount of suffering she seemed to
be undergoing, and are now surprised at the calmness
which has been brought about through the assistance
of chloroform. I would say that in eight cases out of
ten the patients express the most exalted kind of satis-
faction at the relief thus obtained. They sometimes
say, “Oh I this is so delightful, so pleasant ſ” In fact, a
feeling of inexpressible happiness is produced in most
195
patients by inhaling the chloroform, for perhaps two
or three minutes, in the way I will presently mention.
I have seen a woman who had been tossing about in
her bed, perfectly uncontrollable, (because to a cer.
tain extent delirious, as such patients often are) lie
calmly and quietly down, without any stage of ex-
citement, and remain so for the space of four or five
hours, without for one instant losing her consciousness
or self-control, or making loud exclamations, or remov-
ing herself from the position in which she had been
directed to remain.
The next effect which is produced by the judicious
administration of chloroform is the total disappearance
of that horrible aching in the back, of which patients
complain in the intervals of the pains, and which
makes them call on the nurse in attendance not to
relax the pressure on the back which it is usual on
such occasions to make. This intolerable ache is never
felt after the administration of chloroform has begun ;
so long as it is kept up, the distress is done away with.
After some time the patient will call out loudly for
more chloroform, feeling the benefit which she has
drived from its previous administration. We accord-
ingly let her have a little more, and by degrees, as
she becomes conscious of the approach of the pains, she
takes the medicine again, and in this way passes hours
without suffering. Some patients will sleep in the
intervals of the pains. We know how valuable such
natural rest is during labour; and I have observed that
the administration of chloroform does not in the least
degree interfere with it; on the contrary, it rather
helps to produce natural sleep, when not pressed to the
extent of sopor or insensibility. As the time of deli-
very approaches, the amount of chloroform should be
13*
196
rather increased, because the patients suffer more at
this time than at any previous stage of their labour;
and it will require a larger quantity for the purpose of
alleviating pain, though not enough to produce the full
effect which is produced in surgical practice. In fact, I
can testify most distinctly that in no case will it be
necessary to produce sopor or stertorous breathing in
the course of the labour; and it is worthy of remark
that the patients, when the labour is over, will tell
you that they knew they had the pains, but did
not feel them. In this way I have known patients to
be delivered of their child without their own know-
ledge. In one instance, the lady had the chloroform
for the second time. The first time she had it for two,
and on a recent occasion for four hours. On the latter
occasion she was conversing with me during the whole
period of her labour, and was perfectly conscious all
the time. Nevertheless, her child was born, and she
was not conscious of the fact, nor of the particular
moment when it took place. Another case which
occurred more recently was even more striking. It
was that of a lady who had her first labour, which
was a very long, painful, and difficult one, about a
year previously, without chloroform. Upon the second
occasion, which happened during the last month, she
begged to have the chloroform, and she had it accord-
ingly for four hours. As many patients do, she held
the apparatus herself during the greater part of the
time in her hands, and it was so difficult to get her to
inhale the chloroform properly, that I was obliged to
make her hold her nose with her own fingers, in order
to make her breathe through her mouth, which of
course she could not have done if she had been in a
state of insensibility. While thus employed, the child
197
was born, the umbilical cord was tied, and the nurse
was sitting at the fire with the infant in her arms,
without the mother being in the slightest degree con-
scious of what had taken place ; and in about five
minutes afterwards, this lady turned round in bed, and
said to me, “Do you think it will be soon over ?” I
replied, “Don’t you know that the child is born ?” and
I will never forget the expression of her countenance
when she said, “Now, don't deceive me, but tell me
truly, shall I soon be well ?” In short, it was not until
the child was placed in the bed with her, that she could
be made to believe that her delivery had been accom-
plished, and she then declared most solemnly that she
had not the slightest idea till that moment of what had
taken place. -
When effects of this kind are experienced, I need
not say that those with whom chloroform has been
once used would not on any account undergo a labour
without it ; and, as I before stated, many ladies have
come from distant parts of England and other places
to obtain the benefit they expected from its adminis-
tration. No ill effects have ever happened, so far as I
am aware, to either mother or child.
If the chloroform be pure (and that is a most
important point), one of the effects said to be produced
by it is completely avoided, and that is, the stage of
excitement. I never now see in my own practice any
instance where excitement is caused by it. There is
no excitement, no bewilderment, and the effect at once
is that of calm ; but if the chloroform be not pure, you
may be sure that the tumbling, tossing, and delirium
which have been ascribed to its employment will be
produced.
The longest time which I have had occasion to use
198
it in labour was five hours, and the shortest a quarter
of an hour; yet even to secure a quarter of an hour
of relief from pain towards the close of a labour is a
great matter. The delight which a patient experiences
at escaping from the severe sufferings which attend
the last stage of labour, and of having her child brought
into the world without undergoing them, can be well
imagined.
As I have heretofore remarked, the manner of using
the chloroform in midwifery practice is different from
that when we employ it to produce anaesthesia for sur-
gical purposes. In the latter case we give it as rapidly
as the case will permit, so as to produce an immediate
effect on the constitution. The reverse, however, is true
in midwifery practice; for there it should be given very
gradually, and increased in proportion as the sufferings
of the patient increase ; and therefore I think the
apparatus should not be the same in midwifery as in
surgical practice. I have already stated,” that in my
earlier employment of chloroform for the benefit of par-
turient women, I used a handkerchief as the medium
for its application, and my impression then was that
this was the best way in which it could be administered.
Since then, however, I received a letter from Dr.
Murphy of the London University, commenting on this
practice, and suggesting that an instrument which
he was in the habit of using, and which he sent me,
would answer the purpose much better than a hand-
kerchief. He said that when a handkerchief was
used the chloroform was necessarily diffused through
the room, that you could not regulate the amount
which the patient inhaled as well as you could with
the apparatus he sent, and that the waste of the
* Page 185.
199
chloroform is much greater. He therefore begged me
to make a trial of the instrument. I did so, and since
that time I have constantly used it, and have had no
reason to regret its employment. It was made by
Mr. Coxeter, instrument-maker to the London Univer-
sity. For surgical purposes nothing could be better
than Dr. Fleming's apparatus; and those who have
read his concise and explicit publication, must be fami-
liar with his mode of administering chloroform in sur-
gical practice. But I would not like to allow so large an
amount of vapour to be inhaled by a midwifery patient
as that which escapes in his apparatus, because it is
not necessary to give so much, and, not being necessary,
I think it would be improper to administer it.
The apparatus alluded to is evidently a modification
of the instrument formerly used by Dr. Simpson for
the administration of ether, and called by him the
“ether flask;” a representation of which is given in the
Transactions of the Obstetric Society of Edinburgh,
session 1846–47, and from which it differs principally in
being furnished with two valves on the upper surface ;
one opening inwards to admit of atmospheric air into
the mouth along with the vapour of chloroform, the
other opening outwards to admit of free expiration. It
consists of a small round chamber, about two inches in
diameter and one inch deep, in which a piece of sponge
is placed, and to which a conical mouthpiece is attached,
just large enough to cover the patient's mouth. The
aperture by which the mouthpiece and chamber com-
municate is about three-fourths of an inch in diameter,
and is stopped by a cork when the instrument is not in
use; the opening by which the sponge is introduced into
the chamber is on the upper surface, is about an inch
and a half in diameter, and is closed by a well-fitting
200
cover, in which is the valve for the admission of atmo-
spheric air. The manner of using it is simple enough.
After pouring a teaspoonful of chloroform on the sponge,
previously moistened with water and well-squeezed,
the mouth-piece is loosely applied to the mouth of the
patient, and she is directed to make a few inspirations.
By the nose being left uncovered, and by means of the
valve in the cover, a large portion of air is admitted
along with the vapour of chloroform, and thus it gains
access to the lungs in a diluted state—a circumstance
which I consider essential to the safe and satisfactory
use of chloroform in midwifery practice.
If there be any difficulty in getting the patient to
inhale properly, it is only necessary to lay hold of the
nose, and tell her to suck the chloroform out of the
tube, and she will very soon learn the proper way of
doing so. By means of an apparatus of this kind we
can keep a patient for any length of time calm, tranquil,
happy, and free from pain, no matter how protracted
the labour may be, and without for one moment ren-
dering her insensible.
The dose can be properly graduated with the instru-
ment; we can put as much as we like into it, and can
be certain that no more will be inhaled by the patient ;
whereas on the handkerchief she may inhale a great
deal more than we may wish her to get. In this way
one drachm will go as far as an ounce on a hand-
kerchief. I was formerly in the habit of using an
ounce of chloroform on a handkerchief in the space of
one hour; I now seldom use more than a drachm in
the same time. The patient may hold the instrument
herself, and this in itself is a security against an over-
dose; for if she become insensible, she is no longer
201
capable of holding it to her mouth, and cannot there-
fore inhale too much of the chloroform.
I have extracted particulars of thirty-three cases in
which I have used chloroform, in addition to those alrea-
dy recorded, and shall give a brief abstract of them.
Two of the patients had the chloroform for five hours,
both first cases; two for four hours, one being a first
case ; three for three hours, two being first cases; four
for two hours, three being first cases; four for an hour,
and a half, two being first cases; six for one hour, two
being first cases; twelve for periods under half an
hour. Total, thirty-three cases. Of these cases, one
was of thirty hours' duration, three of twenty-four
hours, three of twenty hours, one of fifteen hours,
eight of ten hours, fifteen of five hours, and six under
five hours.
I have already advocated the use of ergot of rye
in conjunction with chloroform in certain cases, and
will now mention the particulars of a very recent case,
which is perhaps as good an example of the value of
the combination of these medicines as could possibly
be presented Within the last week I attended a
lady whom I had delivered on some former occasions,
and who had several children before she became my
patient. As occasionally occurs with others, it happen-
ed with this lady that the great majority of her labours
were of a preternatural character. She had had shoul-
der presentations four times, a couple of breech-pre-
sentations, and several premature children of four and
five months. Upon the present occasion her labour
commenced early in the morning, about three o'clock,
and the pains were exceedingly weak for twelve hours
afterwards, at which time I was sent for, and on my
arrival I found an arm presenting at the os uteri, which
202
was then dilated to the size of a half-crown piece, and
very soft, with the membranes still unbroken ; but the
uterine pains were very weak and unfrequent. She had
already experienced the torture of turning so often as
to dread a repetition of the process; and she had
made up her mind that if it was a cross-birth she
would have chloroform administered, as she could not
venture to submit to turning again unless under its
influence ; several of her friends who had used chloro-
form having told her of the advantages to be derived
from its employment. At the labour which preceded
the one of which I am now speaking, she was near dying
from haemorrhage; indeed I do not think I ever saw any
patient so near death who survived as she was on that
occasion, owing to complete inertness of the uterus, and
its inability to contract. Here, then, was a case of arm-
presentation, an inert uterus, a woman calling for chlo-
roform, and turning absolutely necessary. What was
to be done 2 I was confident that if I turned the child
under the existing circumstances, and emptied the
uterus, which was so little disposed to contract, I should
run a risk of producing a haemorrhage as terrific as that
which followed her previous labour. I therefore com-
menced by giving her a dose of the ergot of rye, and I
watched its effects. As soon as the pains became in
the least degree quickened, I commenced the use of
chloroform. She inhaled for two minutes, and then I
passed in my hand, ruptured the membranes, and got
the child turned. The whole operation did not last ten
minutes; scarcely a drop of blood was lost, and when
it was over, she told me that she would not care again
about having a child which would require to be turned,
provided she suffered no more than she did on that
occasion.
203
Again let me impress upon my readers the import.
ance of only using chloroform which is genuine and
pure ; for I consider it, when properly prepared and
judiciously used, as one of the greatest blessings which
has ever been introduced into the practice of midwifery.
I would urge upon persons engaged in midwifery
practice not to allow themselves to be foolishly
deterred by the nonsense of those who talk of after-
consequences, and who say that patients who have had
chloroform are likely to suffer from disease of the
lungs and brain after its administration. This is all
absurd. Shortly after you remove the apparatus the
effect of the agent is gone, and the patient is perfectly
free from its effects : but there is, I fear, one rea-
son which has interfered with its introduction into
practice—namely, that it involves a good deal of
trouble; for the man who uses chloroform must stay
by the patient's bedside and watch its effects upon her.
This, I am afraid, is one cause why gentlemen are not
so anxious to use chloroform as they ought to be ; but
it is a very bad one, and any man who takes charge of
a woman in labour should recollect that it is his duty
to get her through it as quickly and with as little suf-
fering as he possibly can, consistently with her safety.
I am quite sure that any man who experiences, as I
have done, the gratitude which women express with
whom it has been employed, will never lose an opportu-
nity of using an agent which he has found so exceed-
ingly useful.
Chloroform requires to be studied in order to learn
its safe and proper use ; but its discovery will immor-
talize the name of Simpson, which will be handed down
as that of a benefactor to medical science on the same
a l- -
page as that of Jenner.
204
After the appearance of the preceding paper, the
use of chloroform in midwifery gradually gained
ground in this country, and some practitioners who
had been prudently cautious about its administration
became converts to its merits. Still, however, many
remained sceptical, and, in the early part of 1854, a
writer in London published a most virulent abuse
of it, and of all who employed it in the practice of
midwifery. On the 20th of April, 1854, the paper
which follows was read before the Dublin Obstetrical
Society, and republished in the May number of the
Dublin Medical Journal, vol. 17, new series.
FURTHER REMARKS ON THE USE OF CHLOROFORM IN
MIDWIFERY.
It may be in the recollection of some of the members
of the Obstetrical Society, that in the last paper on the
use of chloroform in midwifery, published by me, I
stated my belief that there was no case of ordinary
labour in which it would be found necessary to produce
complete sopor; but that the mode and extent of ad-
ministration set forth therein would be quite sufficient
in all cases to procure the relief sought for by the use
of the drug. A very short time elapsed after the pub-
lication of that essay, when I met with the following
case, which served to show me that the opinion therein
advanced was not strictly tenable, but that circum-
stances may and do arise—rarely, I believe—in which,
instead of giving small and often repeated doses of chlo-
roform (so as to secure freedom from pain without de-
privation of consciousness) it will be necessary to make
a full and free use of the drug, in order to overcome
the highly exalted state of the nervous system, and to
procure repose.
205
*~
October 2nd, 1852. Mrs. , aged 23 years, a
thin, spare, delicate, highly nervous and excitable per-
son, was taken in labour of her first child at 11 o'clock,
P.M. The pains increased for four hours, when the
os uteri was nearly dilated, and the head of the child
was well advanced through the cavity of the pelvis. She
was very anxious to have the chloroform, and accord-
ingly the inhaler was used in the manner previously de-
scribed by me. She continued the use of the drug for
six hours without intermission, and without any signal
benefit or relief, seeming to suffer more pain than the
great majority of patients, and being less influenced
by the inhalation than I had ever before witnessed.
She dashed herself about with uncontrollable violence,
and, notwithstanding she had inhaled in six hours
fully four ounces of chloroform, which were given
through the inhaler, she resisted its anaesthetic influ-
ence. At this juncture I saw that my usual mode of
administration would not do, and that something more
decisive must be resorted to. The pains were violent;
the head had just come to press on the perinaeum;
the prospect of delivery in a short time was but faint;
I therefore determined to get her at once completely
under the full action of chloroform. With this view,
I placed a piece of sponge in the bottom of a tumbler,
and, having moistened it with the drug, I applied the
mouth of the glass over the mouth and nose. Her
violence was soon subdued, and she fell into sleep, in
which condition I kept her for four hours, during
which the pains continued with equal violence as
before. At the end of that time, finding the head had
not made advance through the pelvis, I had recourse
to the forceps, and delivered a very large living boy.
I was struck with the rapidity with which this lady
206
recovered consciousness after the chloroform was with-
drawn from her. In a quarter of an hour after the
child was born, she was the only person in the house
who could remember the name of the woman who had
been engaged to nurse the child, and where she lived.
This showed that her sensorium was not materially or
permanently effected by the enormous amount (six
ounces) of chloroform which was consumed during the
ten hours of her labour.
I have since met with two or three patients whose
tolerance of chloroform was nearly equal to that just
described, but none to come up to it.
The following case exhibits in a striking manner the
value of chloroform in puerperal convulsions, one of the
most perilous conditions attendant on parturition :-
September 29th, 1852.—Whilst still in the house of
a patient who had been just delivered of her first child,
after using chloroform for eight hours, I was summoned
to a lady residing ten miles from Dublin, whom I had
attended at the birth of three children while she had
lived in town, but on this occasion, having made up
her mind to remain in the country, she had placed
herself under the care of a gentleman in her neighbour-
hood. I reached the house at four o'clock, P.M., and
as I entered her room she was seized with a most
violent convulsion. Immediately I opened a vein in
the arm, and took upwards of twenty ounces of blood.
The convulsion subsided, but she did not recover con-
sciousness. I was struck by the extraordinary extent
to which her limbs and face were swollen, and I now
learned from the gentleman in attendance that she had
suffered during the last two months from a gradually
increasing swelling of the feet and legs, which finally
reached the thighs, upper extremities, and face. She
207
#
had taken labour early in the morning, and was de-
livered about twelve o'clock of a very deformed child,
which did not live. Very soon after the expulsion of
the child she complained of pain and swimming in her
head, and became confused in her ideas and speech. It
was on the occurrence of these symptoms that I was sent
for. No convulsion had taken place before the one I
witnessed, but the threatening symptoms had never
subsided from the commencement. As she did not
recover after the bleeding, I expected she would not be
long without another attack of convulsion. In this I
was not disappointed, for in about a quarter of an hour
she was again seized, and again I drew a similar
quantity of blood from the arm. The hair was cut off,
cold was applied to the head, still there was no sign
of any return to consciousness on the subsidence of the
fit. Tartar emetic in large doses was with difficulty
got into the stomach. In less than half an hour
another violent fit supervened. Her state was now one
of great danger. Bleeding could not be carried any
farther. The pulse was small, fast, and feeble. Chlo-
roform appeared to hold out the only hope for her. I
at once commenced its use, with the most decided effect
upon the convulsion. It subsided more rapidly than
either of the others had done, she slept more naturally
after it was over, and seemed rather less stupid when
the sleep ended. Nothing like consciousness, however,
appeared. I sat by the bedside and watched the advent
of another fit, which being perceived I applied the
chloroform and cut it short. This occurred several
times, with intervals gradually prolonged between the
attacks. At the end of two or three hours she opened
her eyes and looked about her, though still quite
unconscious and unable to answer questions. From
208
the state of stupor she gradually passed to a condition
of mania, like that which I had before seen in patients
recovering from severe convulsions. She sat up in bed
endeavoured to get out of it, and knew nobody around
her. In this state the chloroform was of the highest
benefit, for by its use she was speedily calmed down,
and being kept under its influence she soon fell asleeep.
Whenever she awoke and showed signs of similar vio-
lence, the same remedy was at hand to tranquillize her ;
and in this manner she was kept under its influence
for twelve hours, at the end of which time she was
able to recognise the friends about her, and she slowly
but completely recovered.
I am not aware that this powerful agent has been
used by any one in cases of uterine haemorrhage; and,
from the imperfect knowledge hitherto attained of its
truly wonderful properties, it is not surprising that
its application to such cases should have been looked
upon as inadmissible by even its warmest supporters.
In the case which I am about to relate I was, (so to
speak) compelled to resort to chloroform for assistance,
and I am happy to say I did not call in vain. The suc-
cess was so striking, and the result so gratifying, that
I did not hesitate to employ it in another and a similar
case, which occurred since I commenced to put these
observations together for publication.
February 14, 1853.—I was brought five miles from
Dublin to attend a lady who, while she resided in the
city, had been under my care in three former confine-
ments. On my arrival I found the head just passing
through the vulva, the labour having been short and
easy. The child was soon expelled, and before the
placenta came away a very profuse haemorrhage took
place. Sixty grains of ergot of rye were now adminis-
209
tered, pressure was of course attended to, and the pla-
centa being found in the vagina was removed. The
haemorrhage continued with great rapidity, notwith-
standing very good contraction of the uterus. Vinegar
and water, freely applied, seemed unavailing. The
ground was covered with snow at the time. I ordered a
bucketfull to be brought up to the room, and making
up balls I passed them into the vagina, and heaped the
hips and abdomen with the snow. By these means the
haemorrhage was at last arrested, but the patient, a
very small, slender woman, was reduced to a very low
ebb indeed. The pulse was nearly imperceptible, the
breathing distressed and gasping, and the formidable
complaint of noises in the ears was urgently made.
Fifty drops of laudanum in brandy were given, and in
a quarter of an hour, the symptoms growing worse,
seventy drops more with large quantities of brandy were
administered. Great exhaustion, great nervous excite-
ment, great desire for sleep, harassed the patient. Re-
pose was indispensable to her safety ; Opium did not
procure it ; time was of consequence. It occurred to
me that if I could tranquillize the nervous system for
even a short time, the opium she had taken would
come into play, and continue the narcotic influence so
essential to her life. I fortunately had chloroform
with me, and as she lay tossing from side to side and
calling for air, I applied the chloroform to her nose.
She soon became more calm; by degrees the jactitation
ceased ; she assumed a more composed attitude ; and,
to my great delight, sleep, quiet and natural, soon
came over her. Hot jars were applied to her feet and
legs, and finding the sleep so natural, I held the instru-
ment with the chloroform at a distance from her mouth,
so as to keep up the action in a faint degree. It was
T A
Jil it
21()
most interesting, and, as may be well imagined, very
exciting, to watch the state of the pulse during this
time. I was too far off to get any assistance. I had
tried an experiment with a powerful agent, but my firm
belief was that the new medicine would save her life.
With the finger on the pulse while she slept, I waited
for the returning wave, sometimes imagining the pulse
was greater, again finding it feeble as before. But it
did increase in strength, and before she had slept half
an hour there was a manifest improvement in the
beat. The feet were kept warm, and the sleep was kept
up for two hours, at the end of which time she awoke
most miraculously refreshed. In fact, I never saw any
patient so thoroughly recovered at the end of twenty-
four hours as this lady was at the end of two hours.
She rapidly returned to perfect health.
Encouraged by the marked benefit derived from the
administration of chloroform in this hitherto forbidden
kind of case, I was led to employ it under similar cir-
cumstances on the 8th of the present month (March).
A lady was delivered of her third child after an
easy natural labour, and as soon as the placenta came
away, a rush of haemorrhage followed, which continued
with great violence for an hour. Ergot and the usual
means succeeded in arresting the flow of blood, but she
was left in a very exhausted condition. Absence of
pulse, prostration, sighing, jactitation, &c. were pro-
minent. Laudanum in doses of fifty drops, repeated in
ten minutes, and brandy freely given, failed to procure
rest. Indeed the opium seemed rather to prevent
sleep. I now placed a piece of sponge in the bottom
of a conical shaped wine-glass, and having moistened
it with chloroform, I held the glass over the mouth and
nose of the patient. The medicine did not fail to pro-
211
duce its usual soothing effect. The nervous excite-
ment soon passed away, the eyelids closed by degrees,
and healthy natural sleep was induced. This was
maintained for two hours, during which the warmth of
the body returned, the pulse reappeared at the wrist
and slowly regained strength, and at the end of the time
when she awoke she said she felt perfectly well and
happy. She described the first effects of the chloroform
as being most delightful, and declared that the peace
of mind and soothing of the whole nervous system
which were produced by it resembled a foretaste of
heaven.
My attention was arrested on reading, in the Dublin
Medical Press of January 11, 1854, the report of the
meeting of the Royal Medico-Chirurgical Society, held
on the 13th December, 1853, when Dr. R. Lee read a
paper purporting to contain an account of certain cases
of parturition in which chloroform was inhaled with
pernicious effects. The report in the Medical Press
corresponds with that given in the Lancet of December
24, 1853; and as no attempt has been made to contra-
dict the truth of these reports, I am justified in suppos-
ing them to be correct. When a man is arraigned for
libel in a court of justice, it is usual to read the article
for which he is accused, and with your permission I
will imitate that example and read the document in
question :-
“In these seventeen cases the author traced a series
“of injurious consequences to the employment of
“chloroform during labour. Thus, in Case I. and II.,
“the contractions of the uterus were arrested by the
“chloroform, and delivery was completed by crani-
“otomy. In Cases III., IV., W., X., XIV., XV., and
14*
212
“XVI., insanity and great disturbance of the brain
“followed its use. The necessity for delivery by the
“forceps was attributed to its employment in Cases
“WI., VIII, XI., XII., and XIII. Dangerous or fatal
“ peritonitis or phlebitis ensued after the exhibition of
“chloroform in Cases VII., VIII., XI., and XIII. Epi-
“lepsy occurred in Case XIV.; and dangerous fits of
“syncope arose from its use in Case XVII. The re-
“ ports of friends had confided many more analogous
“cases, and public rumour swelled the list still further,
“but he was desirous of confining attention to those
“which came directly under his own observation. He
“ thought that a contemplation of the subtle action of
“this poison on the nervous system would have in-
“duced caution in its application to practice, but, on
“the contrary, the greatest levity had characterised its
“employment. Very soon after the discovery of its
“ physiological effects, the author was astonished and
“confounded by the announcement of its application to
“midwifery; and it was not difficult for him to foresee
“that rashness in its application and use would lead
“to most deplorable results, and he regretted to find
“that in this he had not been mistaken. It was not
“wonderful that women doomed to bring forth their
“offspring in pain and sorrow should seek to escape
“from the troubles of our race by means of this trea-
“cherous gift of science; neither could we feel surprise
“that the instances of women who were saved from the
“grievous pains of child-bearing, without bad conse-
“quences, should have for a time reduced to silence
“those unwelcome monitors who pointed to the possible
“evils of this new agent; but it did seem strange
“to the author that, amidst so wide-spread an experi-
“ence as now existed of the noxious and dangerous
213
“effects of chloroform, it should be necessary for him
“to assemble the proofs of the havoc it had made.
“The two most serious effects produced by chloroform
“on women in labour were, a languid and deficient
“contraction of the uterus, and a greater susceptibility
“to the risks that arise from inflammation and fever.
“With regard to the first, the direct testimony of his
“own senses convinced him that the action of chloro-
“form did very manifestly slacken the uterine contrac-
“tions, and in some cases had put a stop to them
“altogether. Of the second class of effects, the risks of
“the puerperal condition were much complicated; for
“to inflammation and fever must be added severe
“cerebral and nervous disorders. He had no doubt
“that the use of this noxious agent ought to be ex-
“pelled from the practice of midwifery. In conclusion,
“the author observed that though his opinions had
“been confirmed by conversation with the most discreet
“and experienced practitioners, yet he entertained
“grave doubts of the result of the present appeal to
“the good sense of the profession, when he considered
“the arts used to propagate a faith in this practice. It
“ had become almost an extra-professional question.
“There was a systematic concealment of truth by phy-
“sicians; appeals were made to the natural timidity of
“woman ; and the most fallacious promises of perfect
“safety were boldly held out. Conceited or ignorant
“women of fashion made a pastime of this as of other
“quackeries, and the cause of science and humanity
“was placed in the hands of the most presumptuous
“ and frivolous part of the community, while young
“ and inexperienced mothers were decoyed to their
“destruction. If he had helped to rescue the medical
“ profession from the dominion of a great and dangerous
214
“error, and had placed some restraint on an ignomini-
“ous and disgraceful practice, the author would rest
“satisfied that this essay had not been written in
“vain.” -
As I have been amongst the earliest advocates in
this country of the use of chloroform in parturition,
and am, by daily experience, more and more thoroughly
convinced of its immense advantages, I cannot suffer so
gross an attack upon the characters of those who employ
this agent to pass without making some observations on
the subject, at this the first meeting of the Obstetrical
Society which has taken place since I read the report
of the meeting of the Royal Medico-Chirurgical Society,
at which the paper was read.
Two points are to be attended to in commenting
upon this most extraordinary document:-1st. The
cases by which the prejudice of the author is supposed
to be bolstered up; and next, the offensive language in
which sentiments and opinions equally offensive are
expressed. Unfortunately, the cases have not been
published, and, therefore, we are at a loss to know
what value to place upon them ; but, judging from the
headings under which they are grouped in the pub-
lished report, I think the reputation of chloroform in
midwifery has little to apprehend from this attempt to
extinguish it.
Thus we are told that in Cases I. and II. the contrac-
tions of the uterus were arrested by chloroform, and
delivery was completed by craniotomy. Now we do
not require any details to enable us to perceive the
folly of adducing such cases as pernicious consequences
of chloroform. Every one who has written on the use
of chloroform in parturition has stated, that when
given in large quantity, so as to cause insensibility,
215
the effect, at first, is to arrest the action of the uterus.
Every one who has had real experience in the use of the
drug is well aware of this, and cares little about it ;
for he knows that in a very short time the action will
return and go on as well as before. But he also
knows that if the agent be judiciously and cautiously
employed in the manner I have advocated, so as to
diminish sensibility to pain without destroying con-
sciousness, no such arrest of uterine contraction takes
place, but, on the contrary, the fibres seem to act with
increased vigour. But if, in these cases cited by Dr.
Lee, the medicine had been used rashly and too freely
at first, and a temporary suspension of uterine action
had occurred, why they should eventuate in cranio-
tomy does not appear. We all know that uterine con-
tractions are often suspended naturally for hours in
the middle of a labour, when no chloroform had been
used ; but that alone would never lead one to resort to
craniotomy; there must be something else in the case,
besides mere want of action in the uterus, to warrant
such a proceeding ; and so it must have been in these
cases cited by Dr. Lee. Very likely the uterine action
was interfered with by a precipitate employment of
the drug ; but it is also likely that the cases were such
as would have required craniotomy equally, if chlo-
roform had never been used ; for I cannot for a mo-
ment imagine, that a physician of Dr. Lee's experience
would resort to such an operation on the simple
grounds of a temporary arrest of uterine action. In
the absence of details of these cases, we may safely put
them down as post hoc, ergo propter hoc cases, and class
them among the absurd exaggerations (to use no more
severe term), with which partisans so often attempt to
mislead their hearers. If the cases ever occurred, they
216
were bad cases requiring craniotomy, in which chlo-
roform was used, perhaps rashly and unskilfully; and
because the drug had been employed, the necessity for
the extreme proceeding was attributed to it, when it
might as well have been imputed to the cup of tea the
patient had taken a week before.
We have, next, seven cases in which insanity and
great disturbance of the brain are stated to have fol-
lowed the use of the drug.
In the absence of all clue to the nature of these cases,
I can only observe that when they are published, the
profession will have an opportunity of judging of their
value ; but, in the mean time, from a large experience
in the use and effects of chloroform, I think it right to
mention that I have never met with a single instance
of such results, and therefore must be excused for
receiving with very great doubt any such assertion.
The necessity for delivery by the forceps was attribu-
ted to its employment in five cases. Why or wherefore
does not yet appear ; and I expect it will require some
ingenuity to connect the effect with the supposed cause.
Dangerous or fatal peritonitis or phlebitis occurred
in four cases after the exhibition of chloroform ; and
why should they not occur in these cases as well as in
the thousands of cases in which they occur where no
chloroform has been used ? No one has ever said that
patients who have used chloroform are to be exempt
from the ordinary consequences of parturition ; and
unless it can be shown that a greater number of Wo-
men are attacked by the diseases just mentioned, after
the use of chloroform, than without it, it is absurd to
adduce such instances as proofs of the “pernicious ef-
fects” of chloroform. One case of epilepsy and one
case of dangerous fits of syncope make up the seven-
217
teen witnesses upon whose testimony this “treacherous
gift of science,” this “ noxious agent, ought to be ex-
pelled from the practice of midwifery.” An indiscreet
and rash advocate frequently damages his cause by
furnishing arguments for his own discomfiture. The
animus of Dr. R. Lee can be easily discovered from
the sentiments expressed in the paper under consi-
deration. It is quite plain that he exerted all his
ingenuity, and adduced all the cases he could, to da-
mage the reputation not only of chloroform, but of all
who advocate its use ; and yet, by this very effort, he
furnishes them on the very best authority, that of a
reckless and bitter opponent, with the grand fact, that
he can adduce no instance in which a fatal result can
be traced to the use of chloroform in midwifery.
Where, in these seventeen cases, do we find those
“most deplorable results,” those “noxious and danger-
ous effects,” that “havoc" attributed to this “treacher-
ous gift of science”? Where but in the brain of a par-
tisan who is wilfully blind to the wonderful and still
undeveloped powers of a new agent, with which it is
evident he is still unacquainted, and seems determined
to remain so. Leaving such exaggerated epithets to
find their value with all rational observers, I cannot
conclude without indignantly repelling the language
applied to myself and others who have used and re-
commended the use of chloroform :—“There is a sys-
tematic concealment of truth by physicians;” and
again, “an ignominious and disgraceful practice.”
Now, freedom of discussion—freedom in the fullest
sense of the word in which it can be used in polite
society—I advocate and admire ; without such freedom
we cannot arrive at satisfactory conclusions in many
points of practice. But the unwarrantable license of
218
such expressions as I have just quoted must be con-
demned by all, as subversive of that decorum which
should attend controversy between medical gentlemen,
and must be characterized as an audacious libel by
those implicated in the accusation.
219
CHAPTER VII.
BEFORE introducing the following contribution to the
notice of readers of the present day, it is necessary to
make some remarks upon the pathology of the affection
of which it treats. Twenty-seven years ago the sthenic
type of disease was still prevalent in this country.
The change to the typhoid character which has since
manifested itself had only begun to be perceptible, and
that asthenic form, so well described by Dr. Stokes
in his admirable address to the British Medical Associa-
tion in 1865, had not as yet been fully recognised.
Acute pneumonia and pleuritis, and peritonitis were
encountered every day, demanding phlebotomy for
their cure, and disappearing under its employment.
The synocha of Cullen, with its well marked crisis, was
familiar to all practitioners. Inflammation was recog-
nised as the chief element in most diseases, and the
antiphlogistic treatment was found suitable in many
instances in which it would now be avoided. The
humoral pathology which had reigned in a former age
had then been discarded, and all diseases were looked
upon as consisting in organic changes in the Solids.
Many affections, which now receive the name of
pyaemia, were then classed under inflammation of the
veins, or phlebitis, and post-mortem examinations con-
firmed the truth of the doctrine. The researches of
220
Mr. Arnott" and Dr. Robert Lee demonstrated the
rapidity with which inflammation excited in a vein
spreads along its course, causing thickening and obli-
teration of its canal, and the formation of deposits of
pus in its track. But the mere extension of inflamma-
tion by continuity failed to explain phenomena that
frequently occurred in these cases; such as the collec-
tions of purulent matter found in parts of the body far
removed from the inflamed vein, sometimes in the
brain, sometimes in the eye, lungs, liver, &c. To afford
a satisfactory explanation of these cases, it became
necessary to revert to the theory of vitiated fluids
introduced into and carried with the blood to distant
localities, and there giving rise to purulent formations.
This contamination may be either pure pus, unheal-
thy pus, or vitiated secretions taken up by the veins
and thus poisoning the blood, a condition to which the
term pyamia, or pus-contaminated blood has been
applied. Blood thus poisoned, it is now known, pro-
duces a train of effects and symptoms of the most
dangerous and deadly character; sometimes rapidly
exhausting the vital powers, producing purulent de-
posits in various parts of the body, and ending in
collapse and death ; at others, taking a longer time to
destroy its victim, although the character of the morbid
effects is of the same type. In considering the different
sources of infection in cases of pyamia, and the nature
of the secondary pus formations, Dr. Toddi makes the
following observations:—“But perhaps the puerperal
“state is above all others that most favorable to the
“ production of pyaemia, or an allied disease. After
“the womb has expelled its contents, there remain on
* Medico-Chirurgical Transactions, vol. xv.
t Clinical Lectures, page 213, second edition.
221
“its surface many open mouths of large veins only
“plugged by coagula, and most favorably situated for
“ the absorption of any morbid matter which may be
“ present, pus, decomposing discharges, or putrescent
“remains of the ovum. Or the mouths of the veins
“ themselves may become the seat of inflammation and
“the formation of pus, which under certain circum-
“stances may find a ready entrance into the circula-
“tion.”
The paper which follows treats of cases which would
now be known and designated as cases of pyamia; but
at the time they occurred, that formidable condition
and its pathology were scarcely recognised. Patholo-
gists were on the track, and subsequent investigations
and experiments brought to light the truths respecting
the fatal results of the introduction of various noxious
matters into the blood with which we are now familiar.
These observations will explain why the phenomena
described in the following pages are ascribed to phlebi-
tis alone; and why the treatment of the cases was
different from what would now be adopted. Generous
support and stimulants have now taken the place of
leeches and mercury; and our endeavour is to uphold
the system, and enable the patient to live until the
virulence of the poison is subdued. The subject was
at the time the paper was written but imperfectly
understood, and as a small addition to the general stock
the following contribution was offered.
On Purulent Effusions into the Joints, &c. in
Puerperal Women.
Read before the Surgical Society of Ireland, January 25th, 1839, and
published, Nov. 1st, 1839, in the Dublin Medical Journal, vol. xvi.
IT having fallen to my lot to witness some examples
222
of this rare form of disease in puerperal women, I am
induced to make the following communication, more
particularly as although the affection has been treated
of in detached papers by different authors, yet it
appears not to have received the attention which its
importance demands, as I cannot find it noticed in
any of our most approved systematic works on mid-
wifery. I am further induced to call attention to
this formidable consequence of parturition, because of
the obscurity in which it is sometimes veiled ; an
obscurity which leads me to imagine that the disease
may not be in reality so rare as it would appear to be,
and that by a close attention to its nature a greater
number of instances might be discovered.
The affection to which I allude is purulent effusions
in several and remote parts of the body, principally
about the joints, and often communicating with their
cavities. The symptoms which accompany the early
stage usually commence within a few days after deli-
very, and consist of severe pain, tumefaction, and
sometimes redness of one or more of the large joints,
together with intense fever, loss of appetite, and great
thirst, and occasionally, but not always, pain and
tenderness in the lower part of the abdomen. The
absence of the last symptom leaves the case with a
strong resemblance to acute rheumatism, for which I
have known it to be mistaken ; and this has led me to
suppose that some cases described as the latter, and
terminating fatally, in puerperal women, were instances
of this disease ; and it thus accounts for the horror of
rheumatism in lying-in patients which I have sometimes
heard expressed. -
Now there is no reason why rheumatism should be
223
more fatal in a woman recently delivered than under
other circumstances; but the disease under consider-
ation is peculiarly formidable, and this, taken in con-
junction with the resemblance between them at the
commencement, serves to strengthen the above opinion.
There is another reason why this disease may have
escaped observation, even in cases in which it has
proved fatal, and that is the very great obscurity of
the local signs of purulent effusion which frequently
prevails; an obscurity often greater at the termination
than in the earlier stages of the affection. This arises
from the matter not being confined in any regular
cavity, or circumscribed by any defined cyst, but being
on the contrary effused into the cellular tissue, and
extending widely under the integuments, and through
the substance of the muscles. I have seen a case in
which large collections of matter existed about the
knee and shoulder joints, and communicated with their
cavities, accompanied by extensive destruction of the
cartilages covering the heads of the bones, in which all
tumefaction and redness had subsided several days
before death ; and the parts presented so little altera-
tion from the usual external appearances, that a person
who had not witnessed the course of the disease, would
see nothing to induce him to make any particular ex-
amination.
From these circumstances it appears to me, that the
addition of a few more cases to those already recorded
may not be an unacceptable nor unprofitable contri-
bution.
The first instance of this affection which came under
my notice was in the case of Mrs. B., a young lady
aged twenty years, whom I saw, in conjunction with
224
Dr. Shekleton, after her first accouchement, in Decem-
ber, 1831; and during the progress of the disease we
were assisted by Dr. Graves and Mr. M. Collis.
This lady was seized immediately after delivery with
severe uterine haemorrhage, for which she was treated
by Dr. Shekleton in the usual manner, and with suc-
cess. Among the other remedies employed on that
occasion, the free application of cold water to the
abdomen and nates was had recourse to. The haemor-
rhage being arrested, all matters appeared to be going
on favourably for some days, when febrile symptoms,
preceded by rigor, made their appearance, accompanied
by severe pains in different parts of the body, particu-
larly low down in the back, and in the neighbourhood
of the large joints.
The sufferings of this patient were most intense from
the first invasion of the pains to her death, which did
not take place until the expiration of six weeks. The
slightest attempt at motion produced such intense
agony that she lay permanently on her back; and
although severe pain was complained of in that region,
it was utterly impossible to make any examination
into its condition. The hips, knees, and shoulders
appeared to be the joints most affected; and although
some redness and tumefaction were present in these
situations, there was little that could lead to the sup-
position that purulent matter was deposited, except
towards the close of the case, when a large, doughy,
uncircumscribed swelling was observed on the inner
and upper part of the left thigh, into which an open-
ing was made, and from which a quantity of healthy
pus was discharged. The pulse from the period of the
rigor was seldom below 120, often more frequent, and
it soon became small and feeble. The thirst was consi.
225
derable; and the skin was dry, red, and glazed. The
countenance was flushed in the commencement, and
soon became sunken, contracted, and muddy ; and the
face, together with the rest of the body, was frequently
bathed with perspiration. Whilst lying immoveable
in this state of suffering, it was found, about the third
week of her confinement, that the under sheet of the
bed was soiled by matter, which was at first supposed
to proceed from a bed-sore. It was then determined
that an examination should be made; and accordingly
two strong persons undertook to raise her in the hori-
zontal position from the bed. This being done, the back
was examined, while she was suspended in the arms
of the assistants, and it was found that a portion of
the integuments, of the size of a crown-piece, had given
way over the upper part of the sacrum, from which
opening purulent matter dropped freely. The edges
of this opening were unattached to the parts beneath ;
and on making pressure in the neighbourhood, a large
quantity of pus was expelled ; but there was no hard-
ness of the surrounding parts, indicative of a limitation
of the purulent deposit. No abatement of the constitu-
tional symptoms followed the opening just described ;
but, on the contrary, the condition of the patient be-
came daily more and more distressing. The irritative
fever increased ; the pain on motion continued exces-
sive ; and the daily repetition of elevating her from
the bed, in order to apply fresh dressing to the back,
was a scene of agony to the sufferer, and to those in
attendance upon her. In this state she lingered until
death put a period to her sufferings. We were only
permitted to make a superficial examination of the
body, and found an extensive detachment of the skin
of the back in the situation mentioned. The hand
*
15
226
could be passed in all directions under it, and there was
no defined limit to the separation. I regret we could
not make any more particular inquiry, as I have no
doubt that we would have found purulent deposits in
most if not in all the parts in which pain had been
complained of.
The second case was that of a woman named M*Evoy,
aged twenty-eight years, who was delivered in the
Lying-in Hospital, Cumberland-street, after a short and
favourable labour, on the 28th of December, 1836. In
the course of the subsequent night she was seized with
a severe rigor, which lasted for a considerable time, and
on the following day she was found affected with severe
pain in the large joints, particularly the knees, shoul-
ders, and elbows. The pains were so excruciating as
to cause her to scream with agony even when at rest,
and to deprive her totally of the power of voluntary
motion. Her abdomen was not at this time unusually
tender, nor did she experience any tenderness in the
uterine region for some days after the accession of
these symptoms. The pulse was 120, and hard, and
the countenance indicated intense suffering. The thigh
on the left side began to swell, but not to any great
degree, nor did it present any redness of the surface.
Venesection was employed on the first attack of the
disease; and the use of calomel and opium was adopted
without delay, in the hope of bringing the system
under its influence. The calomel, however, soon pro-
duced diarrhoea, and passed away by the bowels. At
this time the hospital was visited by puerperal fever,
and as I determined to close the wards for the purpose
of purification, this patient was removed to the City of
Dublin Hospital on the 2nd of January, 1837, and
227
placed under the care of Dr. M'Adam, with whom I
continued to see her until her death.
On her admission into the latter hospital she was
perfectly helpless, and it was with great difficulty she
was carried to her bed. Her countenance at this time
was highly flushed, and expressive of great agony ; her
respiration was hurried ; her face suffused with perspi-
ration ; the pulse full, quick, and bounding; the tongue
dry and red. Voluntary motion was impossible, and
even passive motion could not be effected without
great torture. The joints most complained of were
the left knee and elbow, and the right shoulder. The
affected joints were red and swollen ; the redness was
very bright over the right shoulder. Diffuse patches
of redness were also visible on the left forearm, the
back of the left hand, the middle finger, and the calf
of the right leg. She complained of considerable pain
in the left thigh, as well as in the uterine region of
the abdomen. The diarrhoea still remained, and her
thirst was insatiable.
January 1st.—Spent a sleepless night; the pains
still severe and unremitting; abdomen very tender,
and rather tumid. Pulse not so full as yesterday ;
tongue red, dry, and glazed. Leeches were applied to
the abdomen, and two grains of calomel and half a
grain of opium were ordered every second hour.
4th.--Total absence of sleep ; complains more of
pain in the left thigh, which is perfectly powerless.
The pain in the right knee and elbow not so severe,
and she has some command over these joints. Pulse
smaller, 130; tongue red and dry ; some appearance
of sordes on the teeth; bowels now rather confined.
On examination the left thigh was found considerably
1.5%
228
swollen, perfectly pale, tense, hot, and extremely tender,
in short labouring under phlegmasia dolens. The ten-
derness is greatest in the groin, and towards the outer
part. Leeches were applied to the groin ; calomel and
opium to be continued.
5th.-Yesterday evening the diarrhoea returned, ac-
companied with severe tormina. Her pulse became
very intermittent; the respiration hurried and diffi-
cult, with severe pain in the praecordial region. The
calomel was now omitted, and mercurial inunction,
together with mercury with chalk, and Dover's pow-
der, were ordered. A blister was applied over the
region of the heart, which had the effect of relieving
the pain and the difficulty of breathing.
6th.-Pulse still intermitting; pain and tension of
left thigh increased. Abdomen very tender and tym-
panitic ; countenance occasionally highly flushed ;
tongue dry and glazed. Leeches were again applied to
the abdomen : she was ordered camphor mixture,
with carbonate of ammonia ; beef tea ad libitum. The
mercurial frictions were continued.
8th.-Pulse though strong still intermits. The tym-
panitis has subsided, but considerable tenderness of
the abdomen remains. Left thigh as before ; great
pain in the left knee and elbow; right knee and elbow
much better. Numerous aphthas were discovered on
the inside of the lips and fauces. Leeches again applied
to the abdomen, followed by fomentations.
9th.-The intermission in the pulse has now ceased,
but she is harassed with frequent attacks of violent
diarrhoea, which were checked by the administration of
pills containing a grain of opium each, and by anodyne
enemata. The pain and tension of the thigh have de-
creased, and she can move it slightly ; the abdomen
229
also is less tender. Ordered a repetition of the leeches
and mixture.
10th.—The patient appears on the whole better; her
tongue is now moist, but the aphtha still remain. The
leeches to be again applied, and the mixture to be re-
peated.
11th.-Diarrhoea still urgent, unless when controlled
by opium. The local affections are considerably im-
proved; a small abscess on the back of the middle
finger of the left hand was opened. A red patch was
this day detected on the back part of the left thigh.
Her pulse is smaller, 130; the tongue again dry, red,
and glazed. The countenance is more anxious and
collapsed; the respiration is hurried. The stimuli
were increased, and she was ordered to have opiates
as before, and mulled wine.*
From this date the constitutional symptoms increased
in severity, the diarrhoea continued, she became more
and more weak, and finally died exhausted on the
23rd ; just twenty-six days from the time of delivery.
On examining the body, our attention was first
directed to the abdomen and uterus; and here no
morbid appearance of any serious import was disco-
vered. The peritonaeum was free from disease, and but
a trifling quantity of serous fluid existed in its cavity.
The uterus was to all external appearance healthy, and
no result of inflammation could be detected on its
surface; but on cutting into it the veins were found
thickened, and at some distance from the organ were
filled with dark coagula. The hypogastric and iliac
veins were also inflamed, thickened, and lined with the
* In the treatment adopted in this case may be perceived a glimmer of
that light since shed by the labours of Graves, Todd, Stokes, &c. on the
proper mode of treating such affections.
230
same material. Some days previous to death all ap-
pearance of tumefaction and redness had so complete-
ly subsided from the joints affected by pain, that we
did not expect to meet much morbid affection in these
situations. To our surprise, therefore, on making an
incision through the integuments on the outside of
the left knee, a large quantity of healthy pus flowed
out. This was effused under the integuments and in
the cellular tissue of the neighbouring parts, and ex-
tended into the cavity of the joint, the cartilage cover-
ing the heads of the bones being in many parts very
much eroded. A similar exploration was made of the
right shoulder and elbow; and in both situations large
deposits of purulent matter were found; that about
the elbow communicated with the joint, in which there
was extensive destruction of the cartilages. That in
the neighbourhood of the shoulder was extensively
diffused amongst the muscles, but did not open into
the articulation.
The third case to which I will allude was a highly
interesting one, the particulars of which were stated
at the Pathological Society by Professor Harrison;” and
the recently removed parts, together with a drawing,
were exhibited by him on that occasion.
Anne Grumley, aged 30, was delivered of her second
child in the Lying-in Hospital, Rutland square, on the
9th of March, 1839, after an easy and favourable la-
bour. Five days after delivery she was attacked with
fever, and symptoms of inflammation of the uterus,
from which she was relieved by appropriate treatment,
and was discharged from the hospital on the 24th of
March. A few days afterwards, finding herself quite
well, she returned to her situation as cook in a gentle-
man's family; but she soon perceived an erysipelatous
* Dublin Medical Journal, vol. xv. p. 510.
231
swelling of the right ankle, to which she applied hot
turpentine, which considerably aggravated the symp-
toms; and she was removed to Sir Patrick Dun's
Hospital on the 2nd of April.
On admission, the right ankle and dorsum of the
foot were swollen, hot, painful, and of a bright red
colour; the leg was also swollen, but colourless. These
symptoms were accompanied by low fever.
7th.—The limb generally was swollen and hot ; she
was attacked with diarrhoea last night.
11th.—The swelling has been gradually increasing,
and engages the whole limb up to the groin. It is co-
lourless, shining, soft, but not pitting on pressure, nor
attended with pain on pressure except in the groin, and
along the inside of the thigh. Motion of the limb
gives great pain. The patient is very weak, and lies
constantly on the back. Delirium at night; abdomen
tympanitic; diarrhoea continues; first sound of the
heart almost inaudible.
13th.-Pulse 130, very weak and indistinct. Deli-
rium at night. Tenderness in groin less ; glands in
groin slightly enlarged. Complains of acute pain in
the back, and inside of the right knee on the slightest
motion, but not much on pressure ; no pain on flexion
of the ankle joint. She is very irritable and restless,
constantly moaning.
15th.—Pulse 130, exceedingly weak. Pain gone,
except on moving the leg; swelling shining, hot, not
tense, pitting on deep pressure; countenance sunk;
restless. Slept last night without an anodyne.
16th.-Pulse 135, a shade stronger. Had a quiet
night; three dejections since yesterday; was very much
excited in the evening. A blue spot has appeared on
the sacrum ; limb same as yesterday.
17th.—Pulse 132, very feeble and indistinct; skin
232
very hot; subsultus tendinum ; tongue dry and brown ;
countenance very much sunken, has the appearance of
a corpse; she lies motionless on the back. A gangren-
ous spot on the right heel; raved a little during the
night; only one motion since yesterday; refuses nou-
rishment.
18th.—Looks a little better. Pulse 140, very weak.
Delirium this morning; spot on the back enlarging; gan-
grenous spots on both heels; shining appearance of the
skin of leg gone; feeling of fluctuation in the right knee.
19th.-Swelling of limb subsiding rapidly. She died
this evening at six o'clock, just six weeks from the time
of delivery.
On examination after death, all the venous branches
of the foot, leg, and thigh, with the iliac vein as high
as the inferior cava, were found filled with grumous
blood, mixed with a substance like purulent matter; the
lining membrane of the veins was rough, and had lost
its natural polish ; the spermatic veins were thickened
as they approached the vena cava; and the uterine
veins were remarkably indurated. The internal iliac,
uterine, and spermatic veins of the right side were
similarly affected. There was deposition of pus in the
ankle joint, and also in the knee joint ; the cartilage
of the patella was abraded ; there was also a slight
purulent deposit in the body of the gastrocnemius mus-
cle ; this abscess communicated with one of the veins;
the lymphatic vessels were healthy; the integuments
and subcutaneous cellular tissue were hard, and filled
with serum.
Having been so fortunate as to see this case, I was
struck with the resemblance the veins, when separated
from the body, bore to the plates illustrating Dr. Lee's
paper on Inflammation of the Weins of the Uterus, &c.
233
in the Medico-Chirurgical Transactions, vol. xv. part 1,
to which plates I would refer the reader who wishes to
have a more accurate idea of the condition of the veins
in Professor Harrison's case.
This case is peculiarly important, as it shows the
connexion between the inflamed vein and a purulent
deposit more clearly than any other with which I am
acquainted.
Mr. Palmer informs me that in June, 1837, a young
woman was admitted into Mercer's Hospital, labouring
under phlegmasia dolens, with which she was attacked
in about ten days after delivery. She died in eight
weeks after admission ; and purulent matter was dis-
covered in all the large joints of the extremities, in
several of which the cartilages were extensively eroded.
There are few tissues in which purulent deposits
have not been found as well as in the joints. They
form in the brain, in the eye, in the cavities of the
thorax and abdomen, in the muscular tissue of the
heart, in the parenchyma of the lungs, liver, and spleen,
in the substance of the uterus, in the ovaria, and in
the external cellular membrane. It is the opinion of
Andral and other pathologists, that these purulent
deposits are the result of absorption of pus; and that
the pus, after it is absorbed from the suppurating cavity,
is separated from the blood on the surface or in the
interior of the various organs.
In the second case just mentioned it is difficult to
accept this explanation, for no matter was found in the
uterus, from whence it has been supposed to have been
carried in other cases. There was hence no source from
which the purulent matter could be derived; and we
are forced to conclude that its appearance in the distant
and separate places in which it was discovered was the
234
result of a peculiar kind of inflammation. What this
kind is has been demonstrated by Mr. Arnott in his
valuable paper on the secondary effects of inflammation
of the veins.” It is impossible to compare the great
number of cases of phlebitis quoted by Mr. Arnott, and
arising from a variety of causes, accidents, operations,
&c. with those just related, and not be struck with the
strong resemblance existing between them. In some
of Mr. Arnott's cases, injury of a vein, as "by ligature,
was the exciting cause of the subsequent fatal malady.
And in others, succeeding to amputation, the venous
inflammation was distinctly traced to the surface of the
stump. In like manner, the source of fatal cases follow-
ing parturition has been found in the uterine, hypo-
gastric, and spermatic veins, and thence extending to
the vena cava, by Mr. Wilson,f M. Louis, Dr. Davis,"
M. Velpeau, Dr. A. Lee,"| M. Cruveilhier; and in the
case by Mr. Harrison, not only were the uterine and
neighbouring veins found inflamed, but the inflamma-
tion had extended to the iliac veins, and thence upwards
to the cava, and downwards to the small branches of
the leg, in the calf of which one of the purulent deposits
was found actually communicating with the cavity of
a small vein.
It has been most satisfactorily shown by Dr. R. Lee,
in his researches respecting the pathology of “Phleg-
masia Dolens,” that this affection owes its origin to
inflammation of the uterine veins, thence extending to
the iliac and femoral veins. Now it is worthy of remark
* Medico-Chirurgical Transactions, vol. xv.
t Transactions of a Society for the Improvement of Medical and Chirur-
gical Knowledge, vol. iii.
f Archives Générales, Mars, 1826.
§ Medico-Chirurgical Transactions, vol. xii.
|Archives Générales, Octobre, 1824.
T Important Diseases of Women.
235
that, in the four cases I have alluded to, as well as in
many similar on record,” this peculiar affection was
present, and formed a prominent feature in the course
of the disease. Seeing, then, that these purulent deposits
in the joints and elsewhere are frequently produced in
cases not puerperal, by direct injury of a vein, and the
inflammation consequent thereon ; and observing, also,
that when these effusions of pus take place in the
puerperal state, they are so constantly accompanied by
an affection known to be produced by venous inflamma-
tion, it is, I think, fair to infer that the formidable
disease under consideration is to be attributed to the
same cause. This view of the subject would lead to
the conclusion that there is an affinity between the two
affections; and I am strongly disposed to think that
they are essentially similar, differing only in degree of
intensity. The cause of the inflammation in both
cases is to be found in the sudden and great changes
effected in the condition of the uterus by delivery. In
fact, after the accomplishment of the process, this organ
may be regarded as an injured part. The violent and
often long-continued efforts made by its muscular fibres
to expel the foetus, whereby, after the discharge of the
liquor amnii, the inner surface of the cavity is brought
into apposition with the body of the child, and strongly
compressed against it ; the sudden separation of the
placenta, which had been so long in close connexion
* Two cases related by M. Velpeau, in his paper on phlegmasia alba
dolens, bear strongly on this point. In one of these, death took place on
the sixtieth day after labour; in the other, on the twenty-sixth, under
great constitutional disturbance and exhaustion. In both, purulent matter
was contained in the hypogastric and femoral veins. In the first case, the
interpubic cartilage was softened, and pus was found in this situation ; the
same appearance was found in the left Sacro-iliac symphysis; the hip
joint also contained purulent matter. In the second instance, the sacro-
iliac and pubic symphyses were in a state similar to that just mentioned.
236
with a large portion of the uterine surface; the sudden
exposure of the large orifices of the uterine blood-vessels,
which had been hitherto sealed by the presence of this
body; the probable admission of atmospheric air into
the cavity, in consequence of the imperfect contraction
or subsequent relaxation of the uterus ; all these act-
ing on an organ so highly organized as the uterus is at
the full period of gestation, must be regarded as so
much violence done to it; and when to this we add
the presence of the hand in its cavity, so often required
in turning, and in the extraction of a retained placenta,
and, further, the free application of cold to assist in
restraining haemorrhage, it becomes more a matter of
wonder that this organ so frequently escapes, than that
it should be occasionally excited to inflammation.
The immunity of some patients from serious conse-
quences after the most protracted and difficult labours,
and the apparent readiness with which others fall vic-
tims, in whom delivery has been easily accomplished,
lead us to look for some remote or predisposing cause
to account for such results. This, I think, on inquiry,
will be found divisible into two kinds; the first exist-
ing in the patient herself, the second in external influ-
ences. With respect to the first, it would appear that
there is in some persons a peculiar aptitude or dis-
position to run into inflammation from trifling causes.
If we look into the history of phlebitis in general, we
will find that this is manifest, no matter what the im-
mediate cause may be. How many persons, for instance,
suffer the operation of venesection with impunity, yet
now and then rapid death from phlebitis is the con-
sequence. This result cannot be attributed to the
simple operation from which so many suffer no ill
effects, but clearly to some peculiar habit in the patient.
237
In like manner, after amputations, numberless cases go
on to perfect recovery, while in some rare instances
venous inflammation sets in, extends rapidly to remote
situations, and destroys the patient. Again, in that
formidable disease which sometimes follows wounds
received in dissecting (a disease which, if not identical
with, has at least a great resemblance to phlebitis), how
rarely do we see it occur in comparison with the number
of wounds received every session ; and how often do we
find one individual suffer repeated attacks, while his
fellows escape free. This can be accounted for only on
the supposition that there has been some peculiar sus-
ceptibility in the few unfortunate sufferers; and I
believe it will be found, on inquiry, that in the majority
of these cases the individuals were in a bad state of
health at the time, produced by over-exertion of mind
or body, or perhaps both. I have been informed by
Dr. Houston, that the late lamented Mr. Shekleton was
broken down in health by over fatigue in dissecting a
celebrated horse of Sir Colquhoun Grant's, when he
received the fatal wound which deprived the profession
of one of its brightest ornaments. And in the case of
my esteemed friend and former pupil, Dr. Mayne, of
the Richmond School, who has just recovered from a
severe attack of this disease, he was on this, as on a
former occasion in which he suffered, in bad condition
from over work in the discharge of his duties, in which
he is so distinguished for energy and zeal. The second
kind of predisposing cause consists in exposure to
noxious external influences. In the second case related
above, it will be observed that the patient was seized
with phlebitis while puerperal fever was present in the
hospital. On the occasion when this paper was read
before the Surgical Society, Mr. Cusack said “he had
238
“observed the disease just described in females after
“ parturition, and thought that it varied according to
“ the epidemic constitution of the period, and other
“similar influences. He thought that when inflamma-
“tion of the periosteum, or of the synovial membrane,
“took place after childbirth, it proved healthy or un-
“healthy according to the state of the constitution,
“season of the year, epidemic tendency, &c. indepen-
“dently of parturition.”
In like manner, Dr. Murphy said “that he had also
“seen cases of the kind described by Dr. Beatty, and
“ had noticed that they preceded the invasion of puer-
“peral fever, indicating as it were the occurrence of a
“change in the atmospheric constitution, preparatory
“ to the approach of that disease.”
With the nature of this malignant influence we are
entirely unacquainted, but we are too familiar with its
effects in the occasional prevalence of erysipelas and
puerperal fever conjointly; and to its presence may, I
think, be ascribed the occurrence of some of the cases
of phlebitis that present themselves.
The disease under consideration is one of a very fatal
character. All the cases of it that have come within
my own knowledge have terminated in the death of the
patient. A similar result took place in the instances
mentioned by Mr. Arnott, by Dr. Marshall Hall, by
Mr. Higginbotham, and by Dr. Lee ; and it is stated
by Mr. Arnott, that “on inquiring of Dr. Merriman
“concerning a disease of the joints in puerperal women,
“that gentleman informed me that he had seen such
“cases, but that he did not know of one that had ter-
“minated favourably.” Mr. Cusack, however, informed
me that he had seen some cases recover with anchylosis
of the affected joints. The symptoms so soon assume a
239
typhoid character, that general bloodletting is inadmis-
sible, except in the very commencement; and although
local depletion by leeches gives a temporary relief, it
does not appear to check the progress of the disease.
Mercury, which so powerfully controls inflammation in
general, seems to have little influence in this disorder ;
and I have remarked a peculiar resistance to its specific
operation in patients afflicted with phlebitis. It is al-
most impossible to produce salivation, no matter in
what way the mineral is employed, and if given by the
mouth, it is very frequently productive of distressing
diarrhoea. In fact, until we arrive at the knowledge of a
more successful way of combating phlebitis in general, I
fear that midwifery practitioners will have to bear the
same testimony to the fatal nature of these cases. I
would be strongly disposed to try the effects of turpen-
tine or the balsams, in any case that may unfortunately
occur in future, from the known effects of these medi-
cines in deep seated inflammations of the eye which do
not yield to mercury. The observations of Mr. H.
Carmichael have shown that turpentine is capable of
arresting iritis in cases where mercury has failed ; and
Mr. Rynd has informed me that he has lately employed
the balsam of copaiva with great success in similar
instances.
In reflecting on the fatal nature of this form of
puerperal phlebitis, the question naturally occurs, why
it is that, although arising, as has been stated above,
from the same cause, and being of the same nature,
phlegmasia dolens should be nevertheless a compara-
tively tractable and innocent affection ? The answer
is that, although of the same origin and kind, the two
affections differ in degree of intensity. This is conso-
nant with what we know of phlebitis commencing in
240
other situations, and from different causes. In some
the disease is limited to the veins in the neighbourhood
of which it originates, and the patients recover; in
others the venous inflammation is more extensive, it
attacks distant parts, and after a struggle of some
weeks destroys its victim ; in others, again, the case is
more rapid, and runs its fatal course in as many days.
We have the testimony of Mr. Freer, quoted by Mr.
Hodgson, that dangerous symptoms came on suddenly
four hours after ligature of the saphena, and soon ter-
minated the life of the patient.
In like manner, we find different degrees of phlebitis
arising from inflammation of the veins of the uterus
after parturition. 1st, the milder form, producing the
phlegmasia dolens; 2nd, the more severe, producing,
in addition to this affection, purulent effusions into the
joints and elsewhere, and running a course of from four
to eight weeks: and to these I would be inclined to
add a third degree, parallel to the case mentioned by
Freer, a degree in which death takes place in a very
few days. Mr. Travers* draws a distinction between
the cases where the inflammation of a vein terminates
in the formation of pus, and where it terminates in the
deposition of adhesive matter, or lymph. He observes
there is a marked difference in the symptoms accompa-
nying these states; the first is a protracted irritation
producing hectic, and ending in exhaustion ; the second
is a typhoid fever, which speedily produces delirium,and
terminates within a few days. Under this last head I
would include some of those awfully rapid cases of
puerperal fever, which terminate fatally in twenty-four
or forty-eight hours after delivery, and in which but
trifling post mortem appearances are to be found.
* Cooper and Travers' Surgical Essays, vol. i.
241
CHAPTER VIII.
IT is well known to accoucheurs that tumors of various
kinds are occasionally met with in pregnant women,
which occupy the pelvis so completely as to offer an
effectual barrier to the passage of the foetus through
the vagina. Dr. Greenhalgh has lately published a
most interesting and valuable paper on the subject of
“Tumors complicating Pregnancy.” In this memoir
he relates fifteen cases, of which four were tumors of
the uterus, one of them (Case VII.) bearing a strong
resemblance to that which I am now about to relate.
In July, 1840, I published the following paper in the
seventeenth volume of the Dublin Medical Journal.
A Case of Pregnancy complicated with a Tumor
occupying nearly the entire Pelvis.
On the 18th of January, 1840, I was requested to visit
Mrs. , a lady thirty-two years of age, of tall, erect
figure, well formed, healthy, and for the first time
pregnant. She was then in the eighth month of gesta-
tion, having menstruated last on the 17th of the pre-
vious May. She stated that up to the time of her preg-
nancy she had enjoyed good health, but that soon
after that occurrence she began to suffer from distress-
ing symptoms in the pelvic viscera. The bladder
became very irritable, with frequent desire to pass
# St. Bartholomew's Hospital Reports, vol. i., 1865.
16
242
water, and often attended with much difficulty in dis-
charging its contents. The expulsion of the contents
of the bowels was also impeded, and an unusual degree
of constipation was the result. These symptoms in-
creased until the third month, when they had arrived
at such a pitch as to compel her to apply to a physician
for assistance. After quickening, which occurred at
the end of the fourth month, all these local annoyances
vanished, and she continued in good health till the time
of my visit. She mentioned that there was a tumor in
the upper part of the abdomen, which had been first ob-
served in the right inguinal region, and which had risen
gradually with the progress of pregnancy. I expressed
a desire to examine this tumor, and waited on her the
following morning for that purpose. I then found the
uterus as distended as is usual in the eighth month of
pregnancy; and a hard, round tumor, having a flat
broad base, about the size of an orange, projecting from
the right side of its fundus. An irregular protube-
rance, not so large as the former, was found to exist at
the opposite side of the uterus, and the whole fundus
had an irregular knobbed feel. In addition to these ex-
crescences, which were manifestly growths from the
uterus, a small tumor, about the size of a tennis-ball,
which was moveable, and at times, as the patient stated,
escaped altogether from the touch, was perceived high
up in the right side under the ribs. This tumor had
been observed by her before the occurrence of preg-
nancy, and had never occupied a lower position. Feel-
ing pretty certain that the tumors attached to the
uterus were of the common fibrous kind, and knowing
that these are often not confined to one part of that
organ, I was led to suspect that the symptoms com-
plained of in the early months of gestation might have
243
been produced by the existence of similar growths from
the lower part. To satisfy myself on this point, I pro-
posed, and with much difficulty obtained permission, to
make a vaginal examination, when to my very great
consternation I found the entire pelvis blocked up by
an enormous dense mass. About an inch from the
orifice of the vagina the finger came in contact with a
globular body, projecting the vagina forwards, and
compressing that canal so much towards the symphysis
pubis, that the point of the finger could barely pass
upwards between them, but not so high as to enable
me to ascertain what lay above the brim. The higher
the finger passed, the wider the tumor expanded,
and it appeared to be continuous with a substance
curving forwards over the brim of the pelvis, which
could only be barely touched with the extremity of the
finger; but nothing like the os uteri could be distin-
guished. The vagina, as it lay in front of this mass,
seemed free from any adhesion to it, and was quite
healthy throughout. Having examined the anterior
relations of the tumor, I proceeded to discover its
situation posteriorly, and passing my finger into the
rectum, it very soon encountered the back of this morbid
growth, pressing upon the anterior wall of the rectum,
and flattening that intestine against the hollow of the
sacrum. The rectum, as well as the vagina, seemed to
have no adhesion to the tumor, and its walls were
healthy so far as the finger could reach. It was thus
manifest that the tumor lay between the vagina and the
rectum, and from the absence of any connexion between
it and either of these canals, I inferred that it was
placed within the cul-de-sac of peritoneum which passes
down between them, and that it had pushed that mem-
brane before it until it almost rested on the perinaeum.
* * *
-s fº Sº
10 “
244
The surface of the tumor, as felt in the vagina and rec-
tum, was uniformly smooth, of great hardness, and no
where gave the least indication of containing fluid. At
first it appeared quite immoveable, but it was afterwards
ascertained to yield a little to steady pressure upwards,
exerted from the rectum and vagina at the same time.
On examining the inguinal regions, no trace of tumor
could be detected on either side, and it was thus made
plain that if the mass extended into the abdomen, it
must lie behind the uterus. Nothing certain on this
point could be determined ; but from the abdomen not
being more than usually prominent, and from the total
absence of tumor in the groins, I was inclined to think
that the morbid growth did not reach higher than the
back of the cervix uteri, and that it was in fact a
growth of a kind similar to those attached to the
fundus. The motions of the foetus were distinctly felt
through the abdominal parietes. The foetal heart was
audible high up on the left side, near the umbilicus;
and the placental souffle was so strong in the right
groin, that it was as distinctly perceptible by the hand
as by the ear. On laying the hand flat over the region
in which the sound was heard, a remarkably distinct
thrilling sensation was communicated, which conveyed
to the mind just the same ideas that are produced by
the audible phenomena.
I immediately informed the lady's husband of the
critical position in which I found her, and I requested
a consultation on the case. Dr. Johnson was selected
to meet me, as he had seen her during the first months
of her pregnancy. We met on the 21st, and Dr.
Johnson then stated that when he had before seen our
patient, the existence of pregnancy was doubtful. He
had made a vaginal examination, had found the pelvis
245
occupied as at present, and had requested to be informed
when quickening took place, in order that some plan of
proceeding should be determined upon ; but the dis-
tressing symptoms under which the lady had laboured
having disappeared at that time, she neglected to com-
municate with Dr. Johnson, and took no further steps
about her situation until the present time.
Dr. Johnson was as unsuccessful as myself in his
attempts to reach the os uteri ; he thought he could
distinguish something like it by forcing his finger
between the tumor and the pubis, as high as the im-
patience of the patient would permit ; but the parts
were so indistinct that it was impossible to determine
whether the object was not a fold of mucous membrane.
Dr. Johnson agreed in the opinion I had formed
of the case, and of the great probability that delivery
could only be accomplished by the Caesarean section ;
and recognizing its great importance and most pro-
bable termination, he suggested that a fuller consulta-
tion should be held. Dr. Collins was accordingly asso-
ciated with us; he saw the lady on the 24th, and on
that occasion suggested the probability that the foetus
was placed with the breech downwards, in consequence
of the height at which the foetal heart was audible.
It was now agreed that preparations should be made
for the Caesarean operation, and Mr. Cusack having
been chosen as the operator, it was judged right that
he should see the patient and examine her previous to
the occurrence of labour.
Mr. Cusack visited the lady with me on the 28th, and
on the 30th we had a full consultation, consisting of
Drs. Johnson and Collins, Mr. Cusack and myself. It
was now agreed that we should wait for the occurrence
of labour, and after the uterus had been allowed to act
246
for a few hours, if no favourable change was effected,
that the operation should be performed before the
patient's strength was exhausted. The uniform and
great density of the tumor precluded any hope of
reducing its size by puncture; and at the same time led
us to expect little yielding of it to compression when
labour would set in. Any attempt at extirpation,
besides the impossibility of performing it completely,
was looked upon as equally if not more dangerous than
the Caesarean section.
From this date I continued to watch my patient with
painful anxiety. Nothing of importance occurred until
February 18th, when I found her labouring under a
distressing cough, which produced false pains. She
complained of headache, flushing of the face, giddiness,
and indistinct vision, together with loss of sleep ; her
pulse was fast, and her skin hot. Under these circum-
stances I did not delay to abstract eighteen ounces of
blood from her arm ; and on visiting her the following
day, I found the depletion had been followed by very
decided relief, and that she had enjoyed good sleep
during the night.
21st.—Labour commenced shortly after midnight by
a smart gush of haemorrhage, which continued for nearly
an hour, and was succeeded by pains. I was sent for
at half-past one o'clock, A.M., and on my arrival I found
that the haemorrhage had ceased ; but from what I saw
it was manifest that it had been very abundant. On
making a vaginal examination, I was surprised and
gratified to find that the tumor seemed to be higher
up in the pelvis than it had been formerly ; that it
did not approach so near to the perinaeum ; and that
the finger could pass more freely between its anterior
surface and the symphysis pubis. I could now reach the
247
expanded cervix uteri with the point of my finger,
and could trace distinctly the continuity between it and
the tumor; but the os uteri was no where to be found.
I now, according to pre-arrangement, summoned Dr.
Collins, who arrived at half-past two o'clock, A.M. The
pains continued through the night, but were feeble and
inefficient. We remained with our patient, and at nine
o'clock, A.M. Dr. Johnson joined our consultation. The
tumor had now receded so far that there was room
for two fingers to lie laterally between it and the pubis;
but still the os uteri could not be distinguished, although
a greater portion of the cervix had come within reach,
forming a round and elastic tumor above the brim of
the pubis. The pains being still weak, a purgative
enema was administered, by which the bowels were
freed, but no decided improvement in the character of
the pains was effected. Four o'clock, P.M. Drs. Johnson
and Collins visited again; no material change had taken
place, and the pains had nearly subsided. We met
again at ten o'clock, P.M.; there was no return of uterine
action, and we agreed to throw an opiate enema into
the rectum, in the hope of refreshing and recruiting our
patient's strength by sleep.
22nd. We met by appointment at seven o'clock, A.M.
and found that our medicine had produced the desired
effect, the lady having enjoyed several hours of tran-
quil sleep. There was no return of pain, but about
six o'clock another gush of blood occurred from the
vagina, which continued to flow for about an hour. A
very decided change had now taken place in the condi-
tion of the parts; the expanded cervix uteri was now
retracted, and corrugated into a fleshy ridge, occupying
the angle at the upper part of the great tumor, where
it had appeared to be continuous with the substance of
248
the uterus. This was in fact the posterior lip of the os
uteri, now dilated; and anterior to it the transparent
membranes could be felt, forming a smooth, tense, and
elastic tumor, about the size of a large nut. The uterus
recommenced to act at nine o'clock, A.M., and at twelve
o'clock the pains were of a more decided character than
they had yet been. The elastic tumor formed by the
membranes was more distinct, and protruded into the
vagina. The great tumor had receded so much as to
leave the lower part of the pelvis free, and thus enabled
me to pass my hand into the vagina, a thing quite im-
possible before. The pains continued to increase in
strength, and getting my knuckles applied to the
tumor, I made steady pressure upwards in the direction
of the axis of the brim of the pelvis, and was gratified
to find that, as I pressed, the tumor was sensibly ele-
vated, and the membranes advanced more and more
into the vagina: great care was taken not to rupture
the membranes during this operation. The spontane-
ous discharge of the waters took place at half-past two
o'clock, P.M. and on making an examination, I dis-
covered the breech of a male child presenting with the
back to the pubis of the mother. This was an additional
cause of rejoicing, and the anticipations of difficulty and
danger which clouded the commencement of the labour
were now in a great degree dispelled.
It had been arranged at our last consultation, that if
the breech were found presenting when the membranes
broke, I should pass up my hand, and try to get down
the feet. This I endeavoured to do, but although I got
my left hand fairly into the uterus, so as to reach the
knees of the foetus, I found I could not bring down the
feet without using more force than I thought commen-
surate to the advantage likely to accrue from the
249
proceeding. The difficulty arose from the limited space
left free at the brim of the pelvis—about the anterior
half—being the entire portion not occupied by the base
of the great tumor; and in addition to this, on passing
my hand into the uterus, I found that the tumor pro-
jected into its cavity, so as to encroach upon its
dimensions, and diminish the space through which the
legs must sweep in coming down. Finding this, I
relinquished the attempt, and left the uterus to effect
what it could in propelling the infant. The labour
was not strong, and the pains, though frequent, were
not very efficient. At eight o'clock, P.M. Dr. Collins
came to me; at that time both hips of the foetus could
be felt, and the scrotum had become very much swollen
from the continued pressure. The pains had gradually
diminished in strength and frequency during the last
two hours, and the patient's pulse had risen to 100.
Under these circumstances we determined on assisting
the delivery, and I passed the forefinger round the left
groin of the infant; no force that I could employ made
the least alteration in the position of the presenting
part, and after Dr. Collins had tried in a similar manner
with like success, I passed the blunt hook round the
groin, and by steady traction exerted for about half an
hour, I got down the breech and feet. There was some
delay in getting out the head; so much so, that I thought
we should be obliged to resort to craniotomy. This,
however, would not have been of any consequence, as
the funis had ceased to pulsate before the breech was
extracted.
The head was finally got past the tumor unmutilated,
and the delivery was safely accomplished at nine o'clock,
P.M. being thirty-nine hours from the commencement of
labour, including the intermission of the pains on the
25()
evening and night of the 21st. No ha-morrhage
followed the removal of the placenta, which took place
in half an hour after the birth of the child, and in two
minutes afterwards the patient was in a sound sleep,
in which I left her at eleven o'clock.
23rd. Ten o’clock, A.M.–Passed a restless night,
with unpleasant dreams, and frequent starting from
sleep; makes no complaint except of general Soreness.
The uterus is nearly as high as the umbilicus, and the
tumors on the fundus are very prominent ; a large
projection from the uterus occupies the right inguinal
region. Some tenderness of the abdomen; pulse 104;
skin cool; no thirst ; has not passed water; lochia
natural. Warm fomentations were ordered to the
abdomen, and the following medicine :-
R. Pil. Hydrargyri,
Pulv. Ipecac, comp, a fi gr. j. M.
Ft. pil, tertià quâque horá Sumenda.
Nine o'clock, P. M.–Some disturbed sleep through
the day; passed water freely three times; a slight
rigor at eight o'clock; abdomen very tympanitic ; no
pain, but very tender on pressure ; passed a large
quantity of flatus; pulse 110.
R. Aq. Cinnam. Åj.
Pulv. Rhei gr. x.
Magnes. gr. viij.
Tinct. Rhei 3ij.
Mannae 3ij.
M. ft. haust, statim Sumendus, et repr, primo mane.
24th. Nine, A. M.–Took both draughts; bowels not
freed; suffered much through the night from flatus;
great tympanitis; belly very tender ; pulse 120; no
thirst. Ordered an emollient enema, with two drachms
of spirits of turpentine ; and to continue the pills.
251
Twelve o'clock.-Bowels well freed; great relief.
Nine o'clock, P.M.–As before.
25th. Nine, A. M.–Had severe pain in the early
part of the night; got two drachms of castor oil at two,
A. M. which operated at four o'clock, with great discharge
of flatus, followed by quiet sleep. Belly still tender;
external parts very much swollen ; suffers much from
piles. To go on with the pills and to have a poultice
to the perinaeum.
Nine P.M.–Has slept two hours; less tympanitis;
belly tender ; pulse 120.
26th. Nine, A. M.—Had some sleep ; belly not so ten-
der; bears pressure better; pulse 1.12; tongue clean.
Ordered some chicken broth, and a draught contain-
ing two drachms each of castor oil and of turpentine.
Nine, P. M.–Passed two large evacuations, with a
great quantity of flatus. Took a cup full of chicken-
broth ; feels easy.
27th.-Breasts now for the first time painful and
hard; lochia abundant; pulse 112. Belly less tender,
and free from swelling ; piles very painful. Chicken
broth again.
From this date she improved gradually until March
1st, when Dr. Collins withdrew from the attendance.
March 5th.-Slept well, pulse 90; says she is quite
well, and free from any uneasiness; is very hungry
for her dinner, and asked leave to have her bed made
this evening. The uterus has diminished in size, but
is very irregular on its surface, and the right groin is
still filled by the hard tumor already described.
This lady's recovery was very complete, and she was
able to ride out in a carriage in the fifth week after
delivery.
252
what had been anticipated, one of the most interesting
cases that has ever fallen under my observation. When
we consider the manner in which the pelvis was
blocked up by a tumor nearly as large as the head of
an infant at birth, leaving not room for a finger to pass
between it and the pubis; and when the dense and
unyielding nature of the mass is recollected, it seems
almost incredible that a foetus at the full period should
have been born whole and unmutilated, without any
operation for the removal of the obstructing body. A
reflection upon the nature of the tumor, its situation,
and attachments, and also upon the manner in which
the uterus contracts upon its contents in labour, will
help to explain the extraordinary spontaneous elevation
which was effected. I have already stated that, at
the time I made the first vaginal examination, I was
impressed with the belief that the tumor was of the
nature of the common fibrous or fleshy tumor of the
uterus. In arriving at this conclusion, I was much in-
fluenced by the presence of the tumors attached to the
fundus uteri, about the nature of which there could be
very little doubt, as well as by the feel of the great
tumor itself. The great density, as well as the absence
of elasticity, showed that it contained no fluid, and
hence that it could not be one of those enlarged ovaries
which, becoming distended with fluid or semifluid mat-
ter, sometimes fall down into the pelvis below the os
uteri, and impede delivery.” Its situation between the
vagina and rectum precluded the idea of its being
similar to those steatomatous growths which have been
found attached to the parietes of the pelvis, a very
remarkable instance of which is recorded by Dr. Drew
* Merriman's Difficult Parturition, plate 1.
253
of Fermoy,” in which, by a judicious and bold opera-
tion, that physician removed the obstruction and saved
the patient. This opinion respecting the nature of the
tumor was afterwards confirmed during labour, by
tracing its connexion with the cervix uteri in the first
instance, and by finding at a subsequent period, when
I passed my hand into the uterus, that the tumor pro-
jected into its cavity, and in fact implicated both sur-
faces of the cervix. The situation of the tumor was
proved to be the cul-de-sac of the peritonaeum, by its
position between the rectum and the vagina, and the
subsequent elevation of it out of the pelvis. The only
attachment it had was ascertained, during labour, to be
to the back of the neck of the uterus. In addition to
these points, it is necessary to bear in mind that the
axis of the uterus deviated considerably from the usual
line previous to the accession of labour ; the Os, instead
of occupying the middle or posterior part of the brim
of the pelvis, being directed so much forwards as to
be placed above the symphysis pubis. It is manifest
that, under these circumstances, before the contents of
the uterus could be expelled, the obliquity of the organ
should be rectified ; and accordingly we find the first
efforts of labour directed to this point, which was in a
great measure accomplished by the gradual retraction
of the posterior portion of the neck of the uterus, and
the shortening of the long diameter of the whole organ
by the contraction of its longitudinal fibres. This
could not be effected without at the same time drawing
the tumor to which it was attached along with it, and
thus elevating it out of its position in the pelvis. In
this manner, by the natural efforts of the uterus, aided
by subsequent pressure with the hand, this formidable
* Edinburgh Medical Surgical Journal, vol. i.
254
obstacle to delivery was removed so far as to enable
the organ to expel its contents.
That the uterus is capable of diminishing its long
diameter will be admitted by all who have studied the
arrangement of its fibres in the gravid state, and
watched the phenomena of labour; and I might con-
tent myself with reasoning upon this, in support of the
explanation now offered of what took place in the in-
stance just detailed ; but as a case in illustration often
does more than argument in support of a position, I
will take the liberty of adducing a very remarkable
proof, which I find recorded in the Medical Museum,”
of the power possessed by the uterus of elevating its
lower portion. The case is related by Thomas Antrobus,
surgeon in Liverpool.
“Sarah Parr, aged 33, and the mother of three
“children, in May, 1759, as she was wheeling clay to
“make bricks, was of a sudden seized with prolapsus
“uteri, and continued in that condition, without asking
“any advice, till the 4th of September, 1760, at which
“ time she made application to the Liverpool Infir-
“mary, and was admitted a patient under my care.
“Upon examination, I found the os tinca and neck
“of the womb protruded out of the vagina to a very
“large size, much inflamed, some small ulcerations
“about the os uteri, and a discharge of matter issuing
“from them; at the same time she informed me she was
“quick with child. I much doubted what she said ;
“and thought from the appearance I then saw she was
“imposing on me, and that it was morally impossible
“what she then related could be true. I introduced
“my finger through the diseased and prolapsed mouth
“ and neck of the womb, which were both sufficiently
* Vol. i. p. 226, London, 1763.
255
“dilated to admit it, but could not perceive the least
“appearance of conception by the touch ; nor was it
“possible I could, as the parts were so tumified, and she
“at that time could not be pregnant much above four
“ months, reckoning from the first time I saw her to
“the time of her delivery. To abate the pain and in-
“flammation, I ordered her to be blooded ; a lenitive
“electuary to keep her bowels easily open ; the part
“to be fomented with an emollient formentation, and
“to be anointed with the white liniment. By this
“method she became easier, the part softer, and less in-
“flamed. I attempted then to replace the prolapsion,
“but found it impossible unless I used more violence
“ than I thought was consistent with safety.
“As the woman came twice in the week to the in-
“firmary, I had frequent opportunities of examining
“her condition, and at last was sufficiently convinced
“that she was with child, which gave me reason to
“imagine I was mistaken in the parts fallen down, and
“that it could not be a prolapsion of the uterus, but
“of the vagina ; for I could not apprehend how it was
“possible a woman could conceive when the os uteri
“was protruded out of the external orifice. But when
“she was in labour, and the prolapsion receded, the
“internal orifice, which before did appear externally
“out of the labia, had the same scirrhous appearance
“to the touch internally as it had to outward percep-
“tion, and through this orifice the child was delivered,
“when the prolapsion came down again out of the
“body, with the child's head enclosed in it; which
“proves to demonstration it was a prolapsion of the
“cervix and os uteri, and not of the vagina.
“As this tumid body became so large near the end
“of gestation, the poor woman and her mother ear-
256
“nestly entreated me to attend her in labour, which I
“readily promised, as the case was very extraordinary.
“When she had gone her full time, she gradually fell
“into labour about six in the morning, on the 31st of
“January, 1761. At ten I was desired to see her; ac-
“cordingly I visited her, and when I approached the
“bed, she informed me all that great swelling, as she
“called it, went up of a sudden into her body again in
“the first pain, though it had never returned before
“since it first came down. I asked her if she was
“certain it returned when the pain was on her, or in
“the remission. She answered me, when the pain was
“strong upon her, as she lay on her side, and that it
“gave her great pain as it went up.
“How the sudden disappearance of this part, which
“had so long been elapsed from its natural position,
“and which at any other time before labour could not
“be returned by art, but upon the first attack of her
“ pains did recede, I must confess seems difficult to
“account for. Whatever was the cause, when I came
“to examine by the touch, I found the whole prolapsion
“returned, the os uteri to point in its natural situation,
“but grown exceedingly scirrhous, as I have observed
“before, by being so long exposed to the cold air, and
“from the great degree of inflammation which had
“attended it.”
Thus far is all it is necessary to quote of this very
extraordinary case,” in order to support the view I have
* For the satisfaction of those who may not have an opportunity of
consulting the old record in which Mr. Antrobus' case is preserved, I ex-
tract the remainder of his account of it :—
“As the pains were true and strong, as the head presented, as there
“was no flooding, nor any symptom which threatened immediate danger
“ of life, I left the work to be done by the force of the natural pains for
“many hours, but at last found them not sufficient to dilate the vastly
257
taken of the means by which the removal of the ob-
structing tumor was accomplished in the case I have.
detailed. I think there can be little doubt that the
same cause effected the elevation in both cases, and that
was the contraction of the longitudinal fibres of the
uterus on the accession of labour.
The distress which my patient suffered in the pelvic
viscera during the earlier months of pregnancy is at-
tributable to the gradually increasing size of the uterus,
which, added to the bulk of the tumor already occu-
pying the cavity, must have made considerable pressure
on the bladder and rectum ; and the subsequent relief
of these symptoms was owing to the elevation of the
uterus at the time of quickening, when, ceasing to oc-
cupy the pelvis, it became lodged in the abdomen, and
thus diminished the pressure to which the pelvic viscera
had been exposed. -
The manner in which the child presented was most
fortunate, and contributed greatly to the facility with
which the delivery was accomplished; for had the head
appeared first at the brim of the pelvis, I much doubt
“rigid os uteri. The waters were well collected before the head of the
“child; though the ostincae in twelve hours was not dilated much above
“ the circumference of a crown, yet the pains were true and strong all the
“ time. Afterwards I endeavoured gently to dilate in every pain, and
“ by my assistance I found the os uteri to yield a little ; at last the mem-
“branes broke, the waters ran off, the uterus contracted more forcibly
“upon the body of the child, and propelled the head through the exter-
“nal orifice, enveloped in the parts which had before prolapsed. Not-
“withstanding the head of the child was advanced out of the body, I
“found the greatest difficulty in extricating it out of the vastly restricted
“OS uteri; but at length, by oiling well the parts, and by pressing back
“ the prolapsion with both my hands towards the os pubis, the head be-
“came more elongated, and was soon born ; the remainder of the body
“ and the placenta followed easily, I then replaced the prolapsion into its
“natural situation with my hand, and left the poor woman to rest, who
“has been remarkably well ever since, and is now out of all danger.”
| 7
258
if it could have passed without the use of the per-
forator.
This case may be considered important in many
respects, but in none more than in tending to increase
our dependence upon the resources and efforts of nature
under circumstances apparently hopeless; and afford-
ing a caution not to proceed hastily to the performance
of operations, before we have the most ample evidence
that the natural powers are unequal to the task, or
that the continuance of their exertion is dangerous to
the mother.
I cannot conclude without expressing my warmest
thanks to Drs. Johnson and Collins, for the very kind
and able assistance they afforded me in the management
of this interesting case.
The case just narrated was like one that occurred in
this city five years previously, in the practice of the late
Dr. Montgomery, and published by him in the sixth
volume of the Dublin Medical Journal, 1835. In his
case, which was a more intractable one, the Caesarean
operation was performed, and the patient died in twenty-
one hours after the operation. This gave him an oppor-
tunity of ascertaining the nature of the obstruction by
a post-mortem examination, and his account of the
appearances is as follows:—
“Permission having been obtained to open the body,
“the examination was made at twelve o'clock next day
“by Mr. Porter, Mr. Collis, and myself, with the assist-
“ance of Mr. William Day. There was no tendency to
“reunion of the wound in the integuments, and the same
“may be said of the incision into the uterus. On turn-
“ing aside the abdominal coverings, the tumor came
“prominently into view, rising up out of the pelvis, and
“occupying the right half of the abdomen as high as the
259
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ribs of that side. The uterus lay to the left, but was
lifted completely out of the pelvis, so that even the os
uteri was altogether above the brim, and pointed
towards the abdominal ring of the left side. The
bladder, also, had undergone a similar change of place,
and the cavity of the pelvis was so entirely occupied
by the tumor, that the point of the finger could not
pass into it from above. The upper half of the tumor
was quite unattached to any of the surrounding parts
except the uterus, and Mr. Porter, by drawing this part
of it forwards over the symphysis pubis, raised the
whole mass out of the cavity of the pelvis, to the peri-
toneal lining of which the tumor was attached by
several membranous bands, apparently the result of
inflammation. The vagina was cut across and the parts
removed ; the morbid growth was now at once recog-
nised to be a fibrous tumor growing from the substance
of the uterus, and covered with the peritoneum, which
naturally forms the investing membrane of the latter
organ. It had sprung from the posterior surface and
right side of the uterus; the part of it which formed
the medium of attachment measured between nine
and ten inches in circumference, and occupied nearly
one-half of the whole length of the organ, comprising
the upper part of the cervix, and the greater part of its
body. In form the tumor was kidney-shaped, with its
concave edge towards the uterus; its length was be-
tween eleven and twelve inches, and its average width
five and a half. The portion of it which was embedded
in the pelvic cavity was of greater dimensions than
any other part, measuring transversely five and a half
inches, from before backwards five, and in depth four
and a half inches, and its circumference in that situation
- º : I le 4-1- ;4 •y £" +l, ~l-, + c,
a teen inches; while above the cavity of the pelvis
17%
260
{
{
its thickness did not amount to four inches, and its
“circumference did not exceed fourteen. From this
“circumstance, joined with the fact already ascertained,
that the tumor had grown from the posterior part of
“ the cervix and body of the uterus, as well as from
“ the history of the growth of such tumors generally,
“it appears perfectly plain that the first growth of the
“ tumor must have been in the cul-de-sac between the
“rectum and vagina, where it formed several super-
“ficial adhesions with the surrounding pelvic perito-
“neum, which of course fixed and detained it in that
“situation, where it continued to grow until it had
“completely filled all the space there afforded ; when
“ its further increase was accommodated by its rising
“ into the abdominal cavity, carrying with it the uterus,
“ of which it was a part, and also the bladder.” The
“ parts as removed weighed nearly ten pounds, so that
“ the tumor must be about eight pounds in weight;
“ its external surface was very vascular, containing
“vessels as large as a goose-quill passing into it from
“ the uterus; its consistence was remarkably dense and
“solid to the touch, and when cut into, its structure
“was found to be strictly fibro-cartilaginous, the corps
“fibreuse of the French pathologists, or that species of
“ tumor to which Dr. Baillie has applied the name of
“fleshy tubercle. The knife did not encounter any
“bony spiculae, which are so frequently met with in
“such structures ; there were two or three small cells
“in the centre of that part of the tumor which lay op-
{
{
* In a very valuable and instructive paper by Dr. Ingleby, inserted in
the Dublin Journal of Medical Science, there are (vol. vi., p. 341, et seq.)
some very apposite remarks on the subject of these fibrous tumors as
connected with pregnancy and labour, and a highly interesting case is
detailed in illustration ; some of the particulars of which strikingly resem-
ble those under our present consideration, -
261
“ posite to the promontory of the sacrum. It seems
“remarkable that, with a tumor of such dimensions
“occupying the cavity of the pelvis, the bladder and
“rectum could have performed their functions even
“so well as they did : but in fact the bladder was
“raised altogether out of the pelvis, and so escaped
“much compression ; and the part of the pelvis in
“which the rectum is lodged was less occupied or
“pressed on by the tumor than any other part of the
“ pelvic cavity, which, I should observe, was rather
“above the ordinary capacity; for the tumor being
“principally confined to the right side, to which it was
“attached, its greatest measurement of five and a half
“inches coincided with that oblique diameter of the
“ pelvis, and its lesser measurement of five inches with
“ the opposite one ; so that the rectum lying at the
“extremity of the latter was less interfered with than
“it could be under any other arrangement. It is very
“remarkable, and sometimes appears quite inexplica-
“ble, how tumors of a solid structure, embedded in the
“ pelvic cavity, can acquire such a size in such a situa-
“tion, and yet interfere so little as they sometimes do
“with the action of the bladder and rectum. I had
“once a patient affected with fibrous tumor springing
“from the back of the uterus, which acquired such a
“size that it pressed up the diaphragm above, while it
“weighed thirty-two pounds, and yet the unfortunate
“subject of the disease experienced little or no difficulty
“in the discharge of either urine or faeces.”
From the great size of the tumor in this case of Dr.
Montgomery's it is quite plain that nothing but the
Caesarean operation was suitable, as there was no possibi-
lity of moving the tumor out of the pelvis; while in the
case which fell into my hands the absence of any bulk of
262
tumor above enabled me to push it up during labour,
and get it so far out of the way as to leave sufficient
room to extract the foetus.
We may draw a useful conclusion from the case I
have detailed, with respect to the danger of deciding too
quickly upon the impossibility of delivery being accom-
plished through the natural passages, and the necessity
for performing Caesarean section. The pelvis was so
completely filled up by a dense tumor, apparently
immoveable, that no one could have foreseen what did
occur when labour set in. All who saw the case with
me agreed in the belief that nothing but the Caesarean
section could deliver the patient. This opinion was
strengthened by our knowledge of Dr. Montgomery's
case, which occurred five years before, and with which
we were all familiar. But, contrary to our expectations,
we found that nature did interfere so much with the
obstacle, that effectual assistance could be given to her
efforts, and the abdominal section was dispensed with.
263
CHAPTER IX.
IN cases of cancer of the uterus the ordinary causes of
death are irritative fever, haemorrhage, exhaustion,
peritonitis from the ulceration extending to the peri-
toneum, or enteritis. One or more of these effects of
the disease are usually found to exist, and contribute
to terminate the life of the patient. Previous to this
release from her sufferings, it is not uncommon to find
the vagina turned into a cloaca through which faeces
and urine escape involuntarily. This fearful aggrava-
tion of misery is caused by the ulcerative process
opening communications between the vagina and the
rectum and bladder, through which the contents of
these viscera are discharged. It is quite true that in
the majority of cases the immediate cause of the ex-
tinction of life is often a combination of those just
mentioned. But there is another form of death of
which three instances have occurred in my practice,
and to which I called the attention of the profession in
the year 1854, in a communication made to the Patho-
logical Society of Dublin, and published in the Dublin
Medical Journal of that year. The cause of death to
which I allude depends upon the manner in which can-
cerous disease spreads from the uterus to the urinary
bladder, and the rate at which ulceration succeeds to
the deposit of carcinoma in the tissues of the latter
organ. In the great majority of cases the induration
of the coats of the bladder gives rise, first, to great
264
irritability of that viscus, and frequent desire to pass
water; and, finally, ulceration having taken place, in-
continence of urine is the result. But in some instances
the contamination takes place more slowly, and over a
broader surface, and the openings of the ureters into
the bladder become blocked up by the cancerous
deposit, which extends even a short way into those
canals. While this process is going forward, the urine
discharged from the bladder gradually diminishes in
quantity, and at last is totally suppressed. The cathe-
ter may be passed through the urethra, but the bladder
will be found empty. The kidneys, however, have not
ceased to perform their function ; the urine is still
secreted, and finding no exit into the bladder, it accu-
mulates in the ureters, distending these canals and the
pelvis of the kidneys to an enormous extent. The well
known consequences of such an obstruction now begin
to develop themselves. Symptoms of uraemic poison-
ing appear, coma supervenes, and the patient dies.
This is the most merciful manner in which the life of
the unfortunate victim of this incurable disease can be
brought to a close ; and when it so happens, it is a sub-
ject for much thankfulness. But too often ulceration
proceeds at a rate too rapid to permit of this easy and
unconscious descent into the grave; one or both of the
blocked-up ureters are opened by the spreading ulcera-
tion, a sudden rush of urine takes place through the
vagina, the coma gradually clears away, and the patient
wakens up, to undergo the longer and more distressing
career of decay and death that are now before her.
The first case in which I had an opportunity of
witnessing the form of death just described was that of
a woman under my care in the City of Dublin Hospital,
in the year 1835. She was going through the usual
265
course of cancer of the uterus, when, after the disease
had made considerable progress, it was observed that
the urinary secretion became sensibly diminished, and
at last disappeared altogether. The exploration of the
bladder with the catheter showed that viscus to be
empty. Drowsiness was afterwards succeeded by coma,
and with the occasional occurrence of convulsions the
case after some days terminated in death. A post-
mortem examination revealed the cause of the pheno-
nema. The preparation is in the Museum of the Royal
College of Surgeons, where it is marked F.C. 665, and
in the catalogue it is thus recorded by the then distin-
guished curator, the late Dr. Houston.
“CANCER OF THE UTERUS.
“The body and fundus are unaffected, but the os
“tincae and cervix have been almost completely de-
“stroyed by ulceration, a few ragged shreds only mark-
“ing their former situation. The greater part of the
“vagina is involved in the disease, and its inner surface
“forms one extensive ulcer, hard to the feel, and
“remarkably fungous. The bladder is very much
“contracted, and communicates with the vagina by
“several small openings, which give the posterior wall
“of that organ a cribriform appearance. The mucous
“membrane is thickened and partially ulcerated. The
“rectum is healthy; the ovaries are sound. The
“ ureters are much compressed inferiorly, and dilated
“from the point of obstruction as far as the pelvis of
“each kidney.” -
The next case of this kind which fell under my
observation was that of a lady in the year 1846. She
* Catalogue of Museum of the Royal College of Surgeons in Ireland,
rea cro R ſ \ſº
* * * * * ~ *
---, 1
v Úi, }}. t’c’s
266
was over sixty years of age, and had suffered many
months from slowly developed cancer of the uterus.
She had not suffered in any remarkable way until seven
or eight weeks before her death, when her bladder
became more than usually irritable, and she was
troubled with frequent micturition. At first the
quantity of water passed was of the natural amount,
but by degrees it diminished until two weeks previous
to the fatal termination, when the secretion appeared
to be suspended. No urine was subsequently voided,
and none was found in the bladder when sought for by
the catheter. A strong urinous smell was now per-
ceptible from her body and her breath ; she became
heavy and drowsy, and by degrees sank into a state
of deep snoring coma, in which she expired. I was
not permitted to examine the body, but have no doubt
the case was one of these in which the ureters are
blocked up by the disease.
The third case of ureters obstructed by cancerous
deposit which I had an opportunity of witnessing
terminated in a manner differing from the two already
recited. I will quote it as it appears recorded in the
transactions of the Pathological Society of Dublin, before
which body I exhibited the specimen on the 25th
of February, 1854.
“CANCER OF THE UTERUS.
“Dr. Beatty detailed the following case, and ex-
“hibited the recent specimen : A woman greatly
“emaciated was admitted into the City of Dublin
“Hospital under Mr. Tufnell, suffering from hamor-
“rhage from the uterus, and was transferred to my
“care. The hamorrhage had recurred on several
“occasions, with severe lancinating pains in the loins
267
“ and down the backs of the thighs. On examination
“ it was found that the uterus was in a cancerous
“condition, the os hard and rugged ; and, on being
“exposed with a speculum, well marked cancerous
“ ulceration was observed. At this time hamorrhage
“ was the prominent symptom, and the repeated returns
“ of it were averted by the introduction into the vagina
“of bags of fine muslin, filled with matico leaves
“ moistened with infusion of ergot of rye. The disease
“ ran its usual course, the patient becoming gradually
“weaker, but for the last few months of her life she
“ had no haemorrhage of importance. Three weeks ago
“ the urine, which had gradually diminished in quantity,
“ became totally suppressed till the day before yes-
“terday, when she died. Though not expecting to find
“urine in her bladder, I had introduced a catheter and
“drew off a few drops of dark bloody fluid, but no
“urine. About ten days before her death she was
“attacked with severe pain in the left side of her chest,
“with great dyspnoea, and a very fast fluttering pulse.
“The pain was only slightly relieved by treatment, and
“she sank under well marked pericarditis. On ex-
“amining the body, we found an explanation of the
“unusual way in which she died. Her death arose
“not from any of the ordinary causes, but from one
“which I have observed in two other cases. There is
“a preparation in the Museum of the Royal College of
“Surgeons, taken from a woman who died under my
“care, very similar to that which I now exhibit; and I
“lately attended a lady who died from a similar cause.
“I find no mention of this cause of death in cancer of
“ the uterus in any of the authorities, and therefore I
“think it of importance to dwell on it. On opening
“ the abdomen, we found the disease had commenced in
268
“the cervix uteri; the body of the organ was not larger
“than usual, but excessively hard, and closely adherent
“to the bladder in front. An incision into the latter
“viscus disclosed the cancerous degeneration which
“ had extended to it from the uterus occupying the
“whole of its lower portion, including the openings of
“ the ureters, which were completely blocked up, so
“ that the renal secretion could not enter it. The
“ureters are enormously distended with urine, which
“is also accumulated in the pelvis of each kidney.
“Both of these organs are highly congested, and much
“larger than natural. In this case I may remark we
“find the unusual occurrence of three ureters, two from
“one of the kidneys. In consequence of this obstruc-
“tion the urine was thrown back upon the system, in
“which case the patients usually die comatose, unless
“ the ulcerative process should again open the closed
“ ureter, and give exit to the urine. In the case before
“us, however, neither of these occurred, but effusion
“took place into the pericardium, which contained
“nearly a quart of fluid, dark-coloured, thin, and serous.
“Both surfaces of the pericardium were covered with
“recently deposited lymph.” &
It might at first appear difficult to account for the
phenomena in the case just described, and to connect
the effects with the cause in a satisfactory manner; but
a careful consideration of the pathological changes
which of necessity took place will help to dissipate any
obscurity that may surround the question. The kidneys
were found very much enlarged and congested. This
was of course the consequence of the total obstruction
to the escape of the urine, whereby turgescence of all
* The parts are preserved in the Museum of the Royal College Of
Surgeons, Dublin.
269
the vessels and inflammation of the tissues were produced.
These organs in fact were brought into the very condi-
tion in which they are found in cases of acute renal
dropsy, arising from exposure to cold and suspension
of transudation by the skin; the immediate exciting
cause being different in the two cases, but the effects
on the kidneys being the same. Now, in whatever way
this diseased condition of the kidneys may be brought
about, we are quite justified in expecting the same
results in each case ; and as we know that not only
general anasarca, but effusions into one or more of the
serous cavities, is a common consequence of the idio-
pathic congestion, there is not much difficulty in
perceiving how such may arise in what, for want of a
better phrase, I will for the moment call the traumatic
congestion. In confirmation of the view just advanced,
I will quote a passage from the clinical lectures of the
late Dr. Todd.* Speaking of acute renal dropsy, in
which the kidneys are congested, inflamed, and enlarged
as in the case just recited, he observes :—“The second
“class of complications connected with this form of
“dropsy are, first, inflammations of serous membranes.
“The pericardium and the pleura are these which are
“most subject to those inflammations, but sometimes
“ the peritoneum is affected. Pericarditis, indeed, is a
“frequent concomitant of albuminous urine in all forms
“ of diseased kidney, as was some years ago well proved
“by the late Dr. Taylor from a large induction of cases.
“These acute inflammations are, however, more com-
“mon in the acute dropsies than in those which are
“ associated with the various states of chronic disease
“of the kidneys. Effusions are also apt to take place
* Edited by Dr. Beale, second edition, 1861, page 467.
270
“into the serous cavities, with or without previous
“inflammation. The peritoneum, although the least
“liable to inflammation, is the most subject to these
“effusions.”
Dr. Todd then gives the details of a case of acute
renal dropsy, which is an interesting example of the
simultaneous supervention of pleurisy and peritonitis
with pericarditis. I will give a short abstract from this
case, retaining only the portions that bear upon the
subject in hand :—
“The patient was a fine-looking young man, aged
“twenty-three years, of regular habits, and who had
“never suffered from privations. He was admitted
“into King's College Hospital, October 12th, 1840.
“After exposure to cold three weeks before his ad-
“mission, universal anasarca came on, beginning at
“ the face and eyelids, and spreading quickly to the
“scrotum, limbs, and trunk, accompanied with much
“ pain in the back, and a marked diminution in the
“quantity of the urine, which never exceeded a pint
“ and a half in twenty-four hours, and often fell much
“below that amount.
“On the 12th of November the dropsy remained
“much the same ; there was extended dulness over the
“region of the heart, giving rise to the fear that some
“ pericardial effusion had taken place.
“At midnight on the 16th he was seized with severe
“rigors, and vomiting of bilious matter, accompanied
“with severe pain in the left side opposite the seventh
“ and eighth ribs. The breathing also became quick
“ and difficult; a very tympanitic condition of the abdo-
“men came on, but there was no pain, on pressure of
“ that region. Pulse 130.
“On the 18th the abdomen was swollen and tender
271
“all over ; the breathing was hurried; the abdominal
“pain was much increased by deep inspiration. The
“quantity of urine decreased considerably. On the
“ 19th the abdomen had become much more painful;
“urine very scanty; much thirst. Hiccup came on,
“ and caused much distress. On the 22nd the patient
“sank rapidly, but retained his consciousness to the
“ last.
“On opening the body, the peritoneum was found
“everywhere covered with flakes of recent lymph ; it
“was very abundant on the peritoneal surface of the
“bowels, and on the concave surface of the diaphragm.
“Recent lymph was also effused upon the pleura, but
“in less quantity than on the peritoneum, and serum
“was found in considerable quantity in both pleural
“sacs. There were some patches of recent lymph on
“ the cardiac layer of the pericardium. The brain and
“its membranes were healthy. The kidneys were
“about one-fourth larger than natural, and, on section,
“ presented the white cortical and red tubular portions
“of the scarlet-fever kidney. Urea was found in the
“blood taken from the heart, and in the serum effused
“into the pleurae.”
In this highly interesting case we have a striking
example of the secondary effects produced by a con-
gested and inflamed state of the kidneys accompanied
by almost total suppression of urine. Inflammation
and effusion into no less than three serous cavities were
the result; and I think, comparing the state of the kid-
neys in Dr. Todd's case with that in which these organs
were found in the case I have detailed, where great
congestion and inflammation existed caused by the
mechanical suppression of urine, there cannot be much
difficulty in admitting that the pericarditis and large
272
effusion of fluid into the pericardium in the latter case,
were the result of a morbid condition similar to that
which gave rise to the inflammations and effusions in
the former. -
A very beautiful and accurately coloured drawing
by Mr. Conolly, of the recent parts of the natural size,
is preserved in the collection of drawings in the City
of Dublin Hospital, from which I have had a reduced
copy made for the present contribution. The enlarged
and congested kidneys and the distended ureters are
well shewn.
I have searched all the authorities within my reach,
and find no recognition of this form of death in cancer
of the uterus, with the exception of a passing notice of
my last case in Dr. Churchill's last edition of his valu-
able work on the Diseases of Women. I can hardly
imagine that the three cases I have mentioned are
without parallel in the experience of others,” but the
silence of writers on uterine diseases shews that similar
examples must be rare, and adds to the importance of
the present record.
* Since the above was written, Mr. Macnamara informs me that he,
also, had witnessed a similar termination in a case of cancer uteri under
his care. I had seen the case in consultation with him some three or four
weeks previous to the patient’s death. Her sufferings at that period
were of a most agonizing character—constant racking pain almost render-
ing life intolerable—and they could only be relieved by the inhalation of
chloroform, of which drug Mr. Macnamara informs me that she consumed
enormous quantities; twelve fluid ounces, towards the close or her life,
being her daily consumption. Three days before her death the discharge
of urine disappeared, shortly after which her sufferings gradually miti-
gated until they were merged in coma, in which state death supervened.
CANCER OF THE UTER Us Ex-ENDING to THE BLALLER
AND BLOCKING UP THE URETERs.
-
---
---

273
CHAPTER X.
Cases of Retroflea-ion of the Uterus successfully
treated.
[Communicated to the Obstetrical Society, April, 1847.]
DR. ASHWELL’s valuable treatise “On the Diseases pecu-
liar to Women” contains the following passage” :—
“There is no doubt in the profession about the exist-
“ence of procidentia, inversion, and retroversion of
“the uterus; but there are many practitioners who
“question whether the uterus is ever anteverted, ante-
“flexed, or retroflexed. It is true that these states
“sometimes require nice diagnosis; that they are
“exceedingly uncommon ; that in slight and even more
“marked degree they may exist undetected; that they
“are rarely productive of serious symptoms; and that
“ perhaps in few instances can they be said to have
“caused death. But still they exist; it is therefore
“important that they should be fully described.”
The opinion expressed in the above passage has led
me to communicate the following cases of retroflexion,
an accident which is rare in occurrence, and produces a
train of very distressing symptoms, many of them at-
tendants upon other and various diseases of the pelvic
viscera, but which, taken together, form a group suffi-
ciently characteristic of this displacement of the uterus.
The first notice of this affection is to be found in
* Page 587.
18
274
Dr. Denman's Introduction to Midwifery.” “Another
“complaint similar to that of which we have been
“speaking, and which has been called a retroflexion of
“ the uterus, has occurred in practice. By this term
“is implied such an alteration in the position in the
“parts of the uterus, that the fundus is turned down-
“wards and backwards between the rectum and vagina,
“whilst the OS uteri remains in its natural situation :
“an alteration which can only be produced by the
“ curvature or bending of the uterus in the middle, and
“in one particular state ; that is, before it is properly
“contracted when a woman has been delivered. A
“suppression of urine existing at the time of delivery,
“ and continuing unrelieved afterwards, was the cause
“of the retroflexion of the uterus in the single case of
“the kind of which I have been informed by Dr.
“Thomas Cooper, and the symptoms were like those
“which were occasioned by the retroversion. When
“ the urine was drawn off by the catheter, which was
“introduced without difficulty, the fundus of the uterus
“was easily replaced by raising it above the projection of
“ the sacrum, in the manner advised in the retroversion,
“ and it occasioned no further trouble.” This is the
whole of Dr. Denman's observations upon this subject.
He had never met with the displacement himself, but
had its description from another practitioner, to whom
it presented itself in a very recent form, and in which
instance, for that reason, the malposition was easily
rectified.
The part of the uterus at which this deflection takes
place is that at which the neck and body of the organ
join, and the angle at which the body is bent upon the
neck varies, being sometimes very acute, and at others
* Page 78, sixth edition.
275
more obtuse. The displacement is most commonly the
result of pregnancy. It could scarcely, if at all, occur
during gestation, owing to the fulness and tension of
the uterus during that state ; but in all the instances
which have come within my knowledge, or which I find
recorded, the occurrence of the accident was subsequent
to delivery. Velpeau” saw fifteen cases in which it
occurred in the unimpregnated uterus, but after par-
turition. Dr. Davist is of opinion that this incurva-
tion may have occurred congenitally, as the effect of
an originally imperfect development, or as a result of
disease either of the uterus itself or of the organs in
immediate contiguity to it; but he gives no cases of
either kind. This displacement is very different from
retroversion, in which the os and cervix uteri are
thrown upwards; whereas in retroflexion these parts
maintain their natural position, while the fundus is
thrown downwards. The only case of death with which
I am acquainted is one recorded by Velpeauí in which
the patient died at the end of fifteen years, of insur-
mountable constipation.
The time at which this displacement takes place is
most probably immediately after delivery, when the
uterus is still large, but soft and pliable; it is, however,
most likely to be overlooked at the time of its occur-
rence, because the very urgent symptoms do not mani-
fest themselves until the woman rises from her bed,
and resumes her usual occupations in the upright
posture ; then it is that gravity causes the pressure to
be felt by the surrounding viscera, and the symptoms
declare the nature of the malady. But it unfortunately
* De l'Art des Accouchements, Bruxelles, p. 522.
+ Obstetric Medicine, p. 589.
f Loc. cit. *
18
276
happens that often these sensations are endured for a
long time without complaint, in the hope that they
will subside as the woman regains her strength. The
organ by this delay becomes fixed in its unnatural
position ; a certain amount of chronic inflammation
alters its tissue and moulds it into its new shape, ren-
dering fruitless all attempts at restoration by mechani-
cal means alone ; and thus a case becomes most obsti-
nate, which if discovered in time might have been easily
remedied. The case related by Dr. Denman, already
quoted, describes the symptoms and appropriate treat-
ment of retroflexion in its recent state ; the cases that
follow shew the displacement in its more common or
chronic form. We should form a more favourable
prognosis in recent cases, on account of the greater
ease with which they can be rectified. The means to
be adopted are those which we employ to restore a retro-
verted uterus; and after the organ has been placed in
its proper position, great care should be taken to keep
the patient lying as much as possible on her face until
the uterus has shrunk to its original size.
Dr. Davis is of opinion that cases of chronic deflec-
tions are to be considered as totally incurable by any
efforts of art exclusively, without the aid of nature as
exerted during the changes and developments which
are the special attributes of pregnancy. A similar
opinion is entertained by many practitioners, and such
will be most likely the case with all who confine their
efforts at cure to mechanical means alone. The altered
condition of the tissue and texture, as well as of the
shape, must be attended to ; and the chronic inflamma-
tion, which is the effect of the alteration in shape and
the cause of alteration in tissue, must be combated by
appropriate treatment before we can expect success in
277
our attempts to restore the organ to its natural shape.
Upon this theory the treatment of the following cases
was founded :
CASE I.—A. M., aged thirty years, has had six chil-
dren; complains of severe dragging pain in the loins,
groins, and back, aggravated by walking or making any
violent effort. She has considerable pain and difficulty
in defaecation, and during the attempt she has the
sensation of something blocking up the passage, and
preventing the exit of the contents of the bowels. She
has a good deal of irritability of the bladder, which
causes her to rise frequently at night in order to relieve
that organ. She states the menstrual function to be
pretty regular as to time, but variable in quantity, and
always accompanied with much pain; and she labours
under rather profuse leucorrhoea during the intervals.
On making a vaginal examination I found the os uteri
occupying nearly its usual position, perhaps a little
more inclined towards the pubes than natural ; it was
enlarged, and tender to the touch. On carrying the
finger along the back of the cervix, it soon encountered
a prominent tumor, pressing the posterior wall of the
vagina downwards and forwards, and evidently con-
nected with the upper part of the cervix uteri, with
which it made an acute angle into which the finger
could sink. On exploring the rectum, this round and
hard tumor was found pressing into its cavity from
before, and blocking up the area of the bowel. An
examination of the os uteri, through the speculum
vaginae, disclosed that part of the organ swollen and
congested, and superficially ulcerated. The patient
dated her present state of suffering from a bad confine-
ment of twins, which took place four years previously,
and since which she has never felt well. . As she was a
278
confidential servant in the nursery of a lady who had
four young children, she was consequently a great
part of the day on her feet, and had to carry one of
the children in her arms whilst out for their daily air-
ing. This greatly increased her suffering, and at last
her mistress applied to me about her, when I took her
into the City of Dublin Hospital. I confined her closely
to bed, and endeavoured to reduce the chronic inflam-
mation with which the uterus was evidently affected.
This was accomplished by means of leeching the os
uteri, the warm hip-bath, mercury, and the injection
of plain warm water into the vagina. Under this
treatment the pain and uneasiness subsided. The
ulceration was then attended to, and by the applica-
tion of a strong solution of nitrate of silver it was
gradually healed. No attempt had been made to restore
the uterus to its original condition previous to the
removal of the swelling and inflammation of the organ;
for I was of opinion that any force exercised in order
to reduce the displacement, while such an unhealthy
state continued, would only tend to produce further
inflammation, while it would most likely fail in ac-
complishing what was intended. I was pleased to find
that the displacement of the fundus became less and
less apparent, as the size and painful condition of the
uterus were lessened ; and at last, at the expiration of
three months from the date of her admission, the organ
could be pushed fairly into the upright position without
inducing much pain. It still, however, had a ten-
dency to fall back whenever the patient stood or walked.
for any length of time. This was remedied by the use
of a sponge pessary with which she was furnished, and
she finally returned to her master's house, where she
resumed her former occupation.
279
CASE II.—Mrs. T., a small, thin, delicate-looking
lady, whom I had attended in her two confinements, the
last of which took place in September, 1842, consulted
me in November, 1844, on account of very distressing
symptoms under which she had now laboured for
many months. She complained of inability to walk,
owing to the weight and dragging sensation experienced
in the pelvis and loins. She also stated that there was
a constant tenesmus, but, at the same time, a great
difficulty in passing the contents of the bowels; and
that, when the effort was made, it was constantly ac-
companied by a most violent pain in the epigastric
region, which she compared to a tearing of the bowels
from their proper place. She suffered from menorrhagia
and leucorrhoea to a considerable degree, and was
greatly worn down and emaciated.
A vaginal examination disclosed the cause of all her
suffering. The uterus was found to be retroflexed, the
fundus dipping down between the vagina and rectum,
while the cervix maintained its usual position. Con-
gestion and ulceration of the os uteri were present in
this as in the former case. This lady was not aware
of any sudden invasion of her present malady, but
stated that the symptoms had come on gradually,
having commenced a few months after her last con-
finement. At that time she had had profuse ute-
rine haemorrhage, which required the most energetic
measures for its restraint-amongst others, strong and
continued pressure upon the uterus; and, in reflecting
upon her case, the question has arisen in my mind,
whether such pressure, in a very thin woman, with a
very shallow pelvis, might not have contributed to the
production of the present displacement. However that
may be, more than two years elapsed between that con-
finement and my being called again to see her.
280 3:
The horizontal position was strictly enjoined, with
directions to lie as much on the face as possible; and,
as great benefit had resulted in the former case from
the local abstraction of blood, I applied a few leeches
to the os uteri in this likewise. This was productive
of a most serious result, for the leeches had scarcely
dropped off, when the most violent flooding I ever saw,
even in parturition, came on, and which I found it
impossible to restrain without plugging the vagina
very firmly and closely. The plug was removed the
following day, and no further bleeding took place. The
blood must have come from the cavity of the uterus,
for the leech-bites could not have furnished the quan-
tity which rushed from the vagina.
The ulcer on the os uteri was healed by the ap-
plication of nitrate of silver and the injection of
Saturnine wash, and various attempts were made to
restore the uterus to its proper position. It, however,
seemed to be permanently fixed in its unnatural
position, not owing to the resistance of any part of the
pelvis, or to the existence of adhesions, for the whole
organ could be freely moved up and down in its cavity,
but by the parts having become accustomed to their
new condition, and having grown in that position.
Sponge, and globular wood pessaries were tried, with
various results. At one time I made an effort to pass
the uterine sound into the cavity of the uterus, in the
hope of being able to elevate the fundus by that means,
but the acuteness of the angle formed between the
body and cervix formed an insuperable barrier to that
manoeuvre. A ring pessary of boxwood was found to
give the greatest relief and support ; and, after a
confinement of two months to bed, she was able to go
about with comparative ease, The bowels continued
281
very costive, as they had been all along, and she made
use of the enema syringe daily with good effect. I had
a confident hope that a permanent cure of the displace-
ment would be effected if she became pregnant again,
provided that abortion did not occur, a circumstance
very likely to happen from the unnatural condition of
the uterus.
I was well pleased to learn, in the beginning of the
year 1846, that my patient imagined herself with child,
and in a short time it became manifest that she was so.
Every precaution was adopted to guard against, mis-
carriage, and happily with good effect, for the preg-
nancy went on without any unfavourable occurrence,
and the lady's health and local symptoms improved as
it progressed. She was finally delivered of a healthy
child on the 6th of October, 1846.
Having been warned of her disposition to uterine
haemorrhage by what had occurred in her former
confinement, and after the application of leeches, I took
the precaution of giving her the ergot of rye, in the
manner and at the time already described by me at page
175 of these contributions, and she escaped without
any loss on this occasion. She had been previously
informed of my intention to keep her a long time in
bed after her recovery, and she submitted with readi-
ness to an imprisonment of two months. At the end
of that time she was allowed to lie on a sofa, with
liberty to sit up to her meals, and at last to walk
quietly about her chamber. I examined the condition
of the uterus at this period, and was gratified by find-
ing it in its natural position. She was now allowed
free liberty through the house ; she is still nursing her
infant, is free from all her former delicacy and uneasi-
ness, and has grown fat.
282
CASE III.-I was consulted for the first time by this
lady, aged forty-three years, the mother of several
children. She stated that she had several miscarriages
of late, between the third and fourth months of preg-
nancy, and was now apprehensive of a similar occur-
rence, as she was very near her usual time of abortion.
She said she had suffered for a long period from great
debility and weight about the pelvis, and that there
was a remarkable protrusion into the vagina whenever
she went to stool, giving her the idea that a large lump
of faeces was arrested in the rectum, and was forced
forwards by the effort to relieve the bowel. This
prevailed to such an extent that she was compelled to
apply her fingers to the part, and press the tumor
backwards and upwards, when, as she imagined, the
faeces took their proper direction, and a sufficient stool
was passed. She had leucorrhoea to a considerable
extent, occasionally tinged with blood, but no urinary
distress.
I suspected the nature of the case, and an examina-
tion verified the diagnosis of retroflexion of the uterus,
with ulceration of the os uteri. The organ was en-
larged, perfectly moveable in the pelvis, but no reason-
able amount of force could restore it to its natural
position. Symptoms of abortion, as she anticipated,
soon set in, and a foetus of three months was expelled.
The uterus now diminished in size, but still held its
contorted position, and the same distress in defaecation
continued.
Attention was now paid to the ulceration of the os
uteri, which healed rapidly under the caustic treatment,
and she was instructed in the manner of using the
Sponge pessary, which was made by enveloping a piece
of sponge of a suitable size in a loosely-fitting covering
283
ofoiled silk. A pessary thus prepared can be introduced
by a patient with great ease, and removed by a piece of
tape attached to the sponge. She was by this means
enabled to resume her former position as mistress of
her house, which she had been compelled to relinquish
for a long time before ; but she was unwilling to
submit to the prolonged confinement to the horizontal
position, and the application of leeches to the OS uteri,
which I informed her would be necessary in order to
effect a complete cure.
This case, for the reason just stated, did not termi-
nate as favourably as the other two ; but it is interest-
ing as furnishing an instance of pregnancy occurring
during displacement, and abortion being the con-
sequence. If the habit of abortion had not been
established previous to my seeing the patient, there
would have been a greater probability of gestation
proceeding to the full period, when the displacement of
the uterus would have been rectified.
In conclusion, I would observe that it is not unlikely
these cases are more common than is generally ima-
gined; that the diagnosis from the symptoms and from
an examination by the vagina and rectum is not diffi-
cult; and that much benefit can be obtained by atten-
tion to the pathological condition of the uterus.
At the meeting of the Obstetrical Society, February,
1862, I made the following communication :-
During the session of this society held in the year
1847, I had the honour of reading a paper on retro-
flexion of the uterus, which paper was afterwards
284
published in the August number of the Dublin Quar-
terly Journal for that year. In that communication I
spoke of retroflexion as an accident of “rare occurrence,”
and one that had been characterized by Dr. Ashwell
(whose treatise had been published the year before) as
“exceedingly uncommon ;” and after giving the details
of some cases which had come under my observation, I
concluded in the following words:–“In conclusion, I
“would observe that it is not unlikely these cases are
“more common than is imagined; and that the dia-
“gnosis from the symptoms, and from an examination
“ by the vagina and rectum, is not difficult.” Subse-
quent experience has shown that this opinion was cor-
rect, and retroflexion or retroversion of the uterus is
now known to be very far from uncommon. In the
paper alluded to, I drew a distinction between retro-
version and retroflexion; and I am still disposed to con-
sider the distinction as important, more particularly
in reference to treatment,
Dr. Simpson discards the distinction ; and while he
admits the two forms of displacement, he includes both
under the term retroversion. \
That the uterus is capable of being retroflexed, that
is, of being bent back upon itself, the fundus doubling
down into the cul-de-sac of the peritoneum, while the
cervix maintains its natural position, is a fact now well
known to all investigators of uterine disease ; and that
the uterus is capable of being retroverted—that is, the
whole organ being upset, and the fundus falling down
behind while the cervix is turned up before—without
any flexion taking place in the organ, must be equally
admitted. 1
It appears to me that the difference between these two
conditions is so well marked as to warrant us in treat-
285
ing them as two distinct affections; and accordingly
the observations I am now about to make shall be con-
fined to the true retroflexion. This condition is often
met in conjunction with chronic inflammation and
enlargement of the uterus ; and sometimes it is accom-
panied by ulceration of the os and cervix uteri. It is
sometimes, however, discovered unconnected with any
organic disease, and appearing to be a simple alteration
in the form of the organ. Examples of the latter are
more rare than those of the former; and when they do
occur are productive of much less suffering to the
patient, and are more easily remedied. Most com-
monly there is a certain amount of enlargement, the
result of inflammation, which keeps the organ in a
state of painful sensibility; and when this is accom-
panied by ulceration of the cervix, it gives rise to the
distressing sensations complained of when the patient
stands or walks; and more particularly during the act
of defecation, when the contents of the bowels are forced
past the tender fundus displaced and bulging into the
canal of the rectum. Whether this inflammation of
the uterus be the cause of the displacement, by enlarg-
ing the fundus, and thus giving it additional weight and
tendency to topple over, or whether it is the result of
the unnatural and strained position in which the organ
is placed by the retroflexion, I will not now stop to
discuss. It is enough for my present purpose to state
that the inflammation is at times, and not rarely, found
to exist; and when it does exist, it should have much
influence in modifying the treatment. We are indebted
to Dr. Simpson for the invention of several ingenious
mechanical contrivances for rectifying these various
displacements of the womb ; and when a case is in a
fitting state for their use, some of them, as I will show,
286
are of very great value. But all cases are not so when
first presented to us; and I conceive it is a want of
discrimination between suitable and unsuitable cases
which has led, from time to time, to unpleasant results
and condemnation of the instruments. The treatment
that will produce very satisfactory effects in one state
of the organ will be very injurious in another. To
attempt to force an inflamed uterus into its natural
shape and position, and to keep it in that restored
condition by artificial support, must only increase the
existing inflammation, and if persevered in, will surely
place the life of the patient in great danger. On the
other hand, when there is no inflammation of the
uterus, or if, when there is, proper means have been
adopted to remove it, there is no doubt that the use of
mechanical support may be had recourse to with great
advantage.
In those cases of retroflexion in which the distortion
has existed for a long time, when the fundus is enlarged,
and painful when pressed with the finger either in the
vagina or the rectum, and still more, when this condi-
tion is accompanied, as it often is, with ulceration of
the os and cervix, our exertions must be directed, in the
first instance, to remove these morbid conditions by
rest, leeches, warm hip-baths, light diet, vaginal injec-
tions, direct applications to the ulcers, and all the usual
means known to be of service in such cases. When by
such means the bulk and tenderness of the uterus are
diminished, then the case will be benefited by having
recourse to mechanical aid. The uterine sound will
enable us to replace the uterus in its natural position ;
but, as is well known, when it is withdrawn, the organ
quickly resumes its abnormal displacement. The con-
trivances proposed by Dr. Simpson for the purpose of
287
keeping the uterus in its proper position may be divided
into movable and immovable. His first suggestion was
of the former kind, the oval ball with the stem attached
to it. The stem being passed into the cavity of the
uterus kept it straight as long as it remained ; but it
was found that the instrument slipped out of the canal,
and became of no use in a short time. To remedy this,
Dr. Simpson made use of a more fixed or immovable
form of instrument, whereby the uterus is kept firmly
fixed in one position, by means of a framework of wire
turning up over and grasping the anterior portion of
the pelvis. In Dr. Simpson's hands this instrument
has answered its purpose, but in those of others its use
has sometimes produced very great suffering, obliging
the attendant to remove it from his patient. It appears
to me that these failures have arisen from the too great
and unnatural fixity given to the uterus by the instru-
ment. I say unnatural, because in the healthy state
the uterus is by no means fixed in its position, but
moves about according as the bladder and rectum are
filled and emptied, and also according as the position
of the woman is horizontal or perpendicular. A rigidly
fixed position is, therefore, not what the uterus is
accustomed to or demands, and is not in my mind
either necessary for, or conducive to, the rectifying of
retroflexion of that organ.
The bent condition in which we find the womb in
retroflexion is what we want to remedy; and this I
have found can be accomplished without the compli-
cated and formidable-looking apparatus just alluded to,
and in a way much less likely to produce inflammation.
As I have said in the commencement of this paper, I
confine my observations to the true retroflexion of the
uterus. Now the method I have found successful is
288
the following. If inflammation or ulceration be dis-
covered, no mechanical appliance is used until they are
removed ; and when the uterus is brought into a con-
dition to bear interference, it is then restored to its
proper position by the uterine sound, if it has not
become rectified by the treatment used for the reduction
of the inflammation—a happy termination which is
sometimes obtained. When replacement by the sound
has been effected, the uterus must be kept in its proper
shape for four or six weeks, by Dr. Simpson's first
described stem-pessary with the oval ball at its bottom ;
but as that will not keep its place without an additional
support, a flat box-wood pessary of the ordinary kind
is introduced. This prevents the falling out of the
uterine stem, and at the same time permits the metallic
ball to move about over its smooth surface, thus obvi-
ating the danger of keeping the uterus permanently
fixed. A stem introduced into the uterus, and kept in
it in this way, produces no irritation. After a few
weeks the vicious bend in the tissues of the organ will
be overcome, and the retroflexion be found rectified.
But something more remains to be done. It is neces-
sary for some time to prevent any relapse ; and for
this purpose, after the stem and box-wood pessary are
removed, a simple ring of gutta percha is introduced
into the vagina. This ring is made by bending a rod
of gutta percha, a quarter of an inch in diameter, into
a circle of the same diameter as that of the flat box-
wood pessary just removed. When this ring is intro-
duced into the vagina, and the woman stands up, it
assumes the same position as a flat pessary under
the same circumstances, namely, a very oblique one.
If the finger be passed into the vagina of a woman in
the erect position, whilst she is wearing a flat pessary,
289
the instrument will not be found lying horizontally,
but very much sloped, its anterior margin being felt
down near the orifice, while the posterior rises high up
in the vagina, behind the cervix uteri. The ring, when
introduced, assumes the same position ; and the great
advantage it has over the flat pessary is that, while the
posterior part of its periphery rises up behind the cervix
uteri, and offers resistance to the fundus if disposed to
fall back, the cervix is permitted to pass through the
wide ring, and descend to its proper position in the
vagina. The uterus, previously straightened by the
uterine stem, is thus kept in its natural form by this
very simple means. Six or eight weeks will be suffi-
ciently long to wear this ring, at the end of which time
it may be removed.
I have treated many cases of retroflexion in this
manner, and with very great success. I have never
found the uterine stem to produce pain or require
removal, when used as I have mentioned, although the
patients have walked and moved about freely; and the
ring gives so little annoyance, that those wearing it are
not conscious of its presence,
19
290
CHAPTER XI.
ON the 10th of January, 1863, I read before the
Dublin Obstetrical Society the following notes of a
case, in which a large calculus was expelled from the
female bladder through the urethra.
Eliza Simcock, aged forty, unmarried, by occupation
a milliner, was always healthy until about a year ago,
when she first complained of irritability of the bladder,
and scalding in the passage of urine. At the end of a
year she came up to Dublin from Waterford, where she
resided ; and, before seeking medical advice, she was
persuaded by some of her friends, with whom she was
staying, to take a dose of turpentine, which greatly in-
creased the scalding, and produced haemorrhage from
the bladder. She was now seen by Mr. Haffield, who
shortly afterwards asked me to take her into the City
of Dublin Hospital. She was admitted on the 28th of
September, 1861.
She was at that time a most miserable object, being
attenuated to the last degree, her pulse fast and feeble,
and her sufferings constant. Night and day she had
the bed-pan under her in the bed, which was rendered
necessary by an incessant incontinence of urine mixed
with blood and pus, of a very abominable fetor; and
every drop that passed caused intense agony. The vulva
was highly inflamed, and pus flowed freely from the
vagina. A quantity of sabulous matter, deposited from
291
the urine, covered the orifice of the urethra and the labia,
extending into the vagina. A warm hip-bath and a
draught with thirty drops of laudanum were ordered.
These gave some slight relief, but no sleep.
Sept. 29th.-Still suffering too much to permit of
any exploration of the bladder. Camphor, hyoscyamus,
and potash ordered ; and the hip-bath to be continued,
with the anodyne at night.
Oct. 5th-Some alleviation of her sufferings having
been obtained, I passed a catheter into the urethra, but
not into the bladder, for it was obstructed at the neck of
the bladder by a solid body which occupied the canal.
Being satisfied that there was a calculus in this situation,
I came the next day, October 6th, determined to attempt
its removal, when I found that, in the course of the
night, after great pain and straining, and a dragging,
tearing sensation in the urethra, she was suddenly
relieved by something passing away, followed by a
large discharge of urine, pus, and blood. The body
which had been expelled was one inch and a half long,
one inch broad, and weighed two drachms. It was
rather soft and pultaceous on the surface, and was laid
aside for further examination.
The bladder was now well washed out with warm
water, injected through a gum-elastic catheter, and ten
drops of dilute nitric acid in an ounce of water were
ordered every six hours. The warm bath and anodyne
draught to be given at night.
Oct. 7th.-The patient passed a tolerable night, and
had the first sleep she had enjoyed for many weeks.
The irritability of the bladder is much diminished, but
the incontinence of urine still remains. The bladder
was again injected with half a pint of warm water, which
19%
292
was retained without much pain, and then withdrawn.
The bath and anodyne to be repeated at night.
From this date she continued to improve steadily.
The power of retaining the urine was gradually restored.
The bladder was washed out every day, and the quantity
of water thrown in was daily increased, and borne well.
She was finally discharged, without any incontinence
of urine, on the 20th of October.
On examining the calculus which had been expelled,
it was found that the soft pultaceous matter that formed
the outer coating was easily peeled off, leaving a calculus
of the very peculiar form delineated in the accompany-
ing wood-cut. It looked like a common pebble, from
the surface of which stood out all round a vast number of
stony processes, forming an incrustation like stalac-
tites. My first impression was that this was a foreign
body which had been introduced into the bladder
through the urethra, and had formed the nucleus around
which these curiously shaped deposits had been formed;
but it was not so. My friend Dr. John Barker kindly
examined the specimen for me, and I give his analysis
as he furnished it to me:–“The body of the calculus
“is composed chiefly of oxalate of lime with some lithic
“acid. The stalactites on the calculus are nearly pure
“oxalate of lime. The envelope and crusts are formed
“of earthy phosphates; in the former is a quantity of
“animal matter.”
A glance at the fearfully jagged surface of this cal-

293
culus is sufficient to explain the torture the woman
must have suffered during its sojourn in her bladder;
and in the soft coating in which it was encased we have
a striking example of the means by which nature often
endeavours to alleviate or remedy disease. If it had
not been that this putty-like material was thrown round
the calculus, and thus a smooth surface given to what
had been so rugged, it is impossible it could ever have
escaped through the urethra by the natural efforts.
We now know of six modes by which calculi can be
removed from the female bladder. Of these, two are
natural efforts, and four artificial. Of the two natural,
that of which the present case is an instance is the most
common, when the stone is of small size ; and instances
are by no means rare in which this occurs. But it is
not often we meet with cases like the present, and that
which was described at our last meeting by Dr. Byrne, in
which stones of such large dimensions escape through the
urethra. The rapidity with which the urethra resumed
its healthy condition, and the perfect control regained
over the sphincter, is very important in a practical
point of view, for it shows the great extent to which
forcible dilatation of the urethra may be carried with
impunity.
The second natural effort by which stones escape from
the bladder is by ulceration through the coats of that
viscus into the cavity of the vagina. Sir Benjamin
Brodie gives a notice of such cases in his work on
urinary diseases. I lately saw a case with Dr. Banon,
in which a very large stone made its way out in this
manner; but as he intends to bring forward the case
at a future meeting of the society, I will not further
allude to it at present. The four artificial methods are,
dilatation, incision of the urethra, incision into the
294
bladder, and lithotrity. I have already alluded to the
extent to which the urethra may be safely dilated; by
safely, I mean without leaving incontinence of urine
behind it. Whenever the stone is of moderate size, this
method should be adopted. The prepared sponge tents
—such as are described by Dr. Simpson, and used for
the dilatation of the cervix uteri—will be found very
useful when employed for ten or twelve hours before
the operation. Incision of the urethra, either along its
upper or lower surface, has had many supporters. It
is imagined that the texture of the canal is less injured
by, and yields more readily to, the force used in extrac-
tion, and that the wound in the tissues will heal more
quickly than the tone of the canal can be recovered
when dilatation has been carried to any great extent, and
that thus a security against an incontinence of urine is
provided. In cases where the stone is very large, and
the operation through the urethra is preferred, this
mode of proceeding may be used with advantage. The
third artificial method is that of cutting directly into
the bladder, through the anterior wall of the vagina.
From the ease and certainty with which large openings
into the bladder are cured every day, I think no one
need be afraid to perform the operation in question,
when a stone is of too large dimensions to pass by the
urethra. The operation is readily performed ; and by
the wire sutures the wound will be at once healed, and
no chance of incontinence of urine—which sometimes
follows operations through the urethra—will occur. It
is obvious that this operation is more applicable in
cases of women who have borne children than in vir-
gins. In the latter, the narrowness of the vagina and
the presence of the hymen must render the operation
more difficult than when the vagina is wide and dila-
295
table, and a good view can be got of the parts to be
incised. Of the fourth method, or lithotrity, I would
observe that, although at first one would be inclined to
think it the best and safest mode of proceeding, it has
been found to offer great difficulties, the chief of which
arises from the ease with which the urine escapes from
the bladder along the sides of the instrument; and
when this occurs, there is always danger of injuring
the inner coat of the bladder by the blades of the
lithotrite.* If this can be avoided, and the bladder can
be kept tolerably full of water, the operation is one
which offers great advantages.
* Since the above passage was written modern ingenuity has devised im-
provements in this instrument which have reduced the risk to a minimum.
For full information on this subject I must refer the reader to Mr. Thomp-
son's masterly treatise on Lithotomy and Lithotrity.
296
CHAPTER XII.
To physicians of the present day, who are so well
skilled in the minutiae of physical diagnosis of disease,
and have so many valuable works at hand to instruct
and guide them, it may seem superfluous to reprint the
short notice which follows, as it contains nothing with
which all well-informed practitioners are not now
familiar. But the author begs to remind the reader
that this communication was made more than thirty
years ago, when physical diagnosis was still little ad-
vanced from its infancy in this country, and before any
of the great works which are now standard and classi-
cal had issued from the press, Frottement had been
observed in pericarditis, but there was no evidence
that any one had previously detected that phenomenon
in inflammation of the peritoneum.
The cases here detailed, and the observations made
on them, were at the time of their publication new, and
constituted a not unimportant “contribution.” The
subject of frottement in peritonitis was afterwards taken
up and dwelt upon by Dr. Bright. This explanation
will shew why it has been thought right to reproduce
what might otherwise have appeared a trifling com-
munication. The notice appeared in the September
number of the Dublin Medical Journal for the year
1834, vol. VI.
297
Frottement observed in Peritonitis.
As any thing that can contribute to our means of
discovering the diseases of the heart must be looked on
as in the highest degree interesting to the practical
physician, it has occurred to me that a notice of some
cases which have come under my observation, although
not of disease of the heart, may serve to corroborate
the views so ably set forward and maintained by Dr.
W. Stokes, in his paper on the diagnosis of pericarditis,
in the fourth volume of the Dublin Medical Journal.
It is there stated, that the opinion broached by Collin,
in 1824, and which had gained no credence for nearly
ten years, is founded in fact, and that we have a physical
sign of inflammation of the serous lining of the pericar-
dium, viz. a “frottement,” or sensation of rubbing
together of two uneven surfaces, distinguishable by the
application of the hand, and by auscultation. The cases
furnished by Dr. Stokes in illustration of this point are
most interesting and instructive, and, accompanied as
they are by his judicious observations, must be consi-
dered as opening a new field in the departments of
practical medicine and pathology. With a view to
show that similar effects are produced in the peritoneum,
when that membrane is the subject of inflammation, I
have been induced to make the present communication.
In January, 1832, a woman aged thirty years was
admitted into my ward for the diseases of females in
the City of Dublin Hospital, labouring under dropsy of
the left ovarium. The tumor filled the abdomen from
the pubis to the ensiform cartilage, and was remarkably
hard and unyielding. A few days after admission she
was attacked with severe pain in the belly and febrile
symptoms, which continued for a week, and required
298
the abstraction of blood, and other antiphlogistic treat-
ment, before she was relieved; during which time a
remarkable sensation was communicated to the hand
when applied over the umbilicus and its neighbourhood.
The sensation was that of a grating or rubbing together
of two uneven and rather dry surfaces, and was ren-
dered most evident by ordering the patient to take a
full inspiration, thereby causing the abdominal parietes
to move more freely over the surface of the tumor. By
the application of the stethoscope a loud and distinct
“frottement” was audible, extending over a space of
about five inches in diameter, with the umbilicus for a
centre. In a few days the pain and inflammatory
symptoms subsided under the treatment employed, and
with them the sensation just described, and the audible
phenomena altogether disappeared.
In the December following I had an opportunity of
observing similar effects, in the case of a young lady
who was under my care for excessive enlargement of
the spleen. The tumor occupied the left half of the
abdomen, dipping down into the pelvis on that side,
and its anterior edge passed the median line of the
body, particularly at the lower part, where it extended
considerably into the right side. She was seized with
inflammation of the tumor, and during its continuance
phenomena precisely similar to those described in the
last case were perceived; there was the same creaking
sensation when either the hand or the stethoscope was
applied to the surface, and this entirely subsided when
the inflammation and pain were arrested.
It would appear that this method of diagnosis of
disease of a serous membrane is applicable only in those
situations where one, at least, of the opposed surfaces
is adherent to a solid resisting body. I am not aware
299
that such phenomena as have been mentioned can be
perceived in inflammation of the peritoneum under
ordinary circumstances, where the soft pliable walls of
the abdomen are in contact with the mass of intestines;
but when a large solid tumor comes to occupy the
cavity, as in the instances above mentioned, the case
resembles that of the pericardium with the heart within
it, and similar physical signs of disease of the serous
surfaces become apparent.
It has appeared to me that these cases may be em-
ployed as confirming the truth and accuracy of the
diagnosis of pericarditis, and with that view I wish to
record this brief notice of them.
30()
CHAPTER XIII.
THAT the following case is of great rarity appears
from the fact that in the most recent works” it is the
only instance quoted, with the exception of one similar
related by Mr. Crosse of Norwich, and alluded to
by Dr. Graily Hewitt. The affection has received
from authors different names, introversion of the
bladder, eversion of the bladder, and, as I have called
it, inversion of the bladder. It consists in a turning
inside out of the urinary bladder through the urethra
in the female ; just as the uterus is turned inside out
through the os uteri in that formidable accident, in-
version of the uterus after parturition.
It would at first seem impossible that such an occur-
rence could ever take place, when the smallness of the
orifice of the urethral opening into the bladder is con-
sidered ; and it is not surprizing that Mr. Crosse should
have been at first doubtful of the nature of the case
which he met with. The instance of this rare affection
which came under my observation was exhibited by
me to the Pathological Society of Dublin on the 22nd
of February, 1862. I quote the account from the pro-
ceedings of that Society published in the Dublin Quar-
terly Journal of Medical Science of that year.
* Dr. M'Clintock, Dr. Graily Hewitt, &c.
301
Inversion of the Urinary Bladder through the Urethra,
with large Prolapsus of the Rectum, in a female child.
On the 20th of January last a female child, aged one
year and eleven months, was sent to me from the country
to the City of Dublin Hospital, with a statement that
there was something wrong with the genital and urinary
organs. She was a fine, strong, handsome child. The
appearance of the parts was most extraordinary. Just
between the labia there was a scarlet tumor about the
size of a chestnut ; and it at once struck me that it
was the inner surface of the bladder, similar to what
has been seen in cases of vesico-vaginal fistula, or of
malformation where the anterior wall of the abdomen
is open above the pubes, and the inner coat of the blad-
der protrudes. - -
Upon touching it with my finger, the child cried
violently. It could be forced back, and even replaced
by pressure; and the urethra was sufficiently large to
admit of the easy passage of my forefinger into the
replaced bladder, showing the case to be one of com-
plete inversion of the bladder through the urethra.
The mother told me that the inversion of the bladder
did not take place until the child had a fit of crying
when it was twelve months old. There was also a
large prolapsus of the rectum, which occurred when
she was nine months old, in consequence of an attack
of diarrhoea. The child remained in hospital up to
Monday last, and continued quite well. I kept her in
for the purpose of devising some means to remedy the
defect. On Sunday morning, however, she was attacked
with severe croup, which terminated in her death on
Monday evening. I was thus enabled to obtain the
specimen now before the society, showing the bladder
302
turned inside out through the urethra. It had now
lost some of the scarlet colour, and something of its
size. In the prolapsus of the rectum there was nothing
remarkable; but, combined with the other defect, it
gave the parts a very curious appearance. The uterus
was in situ, and the ovaries were very large for a child
of her age. I had never seen another instance of such
inversion. The child died of croup, and the specimen
showed a very perfect, well-formed false membrane,
lining the trachea, and forming a tube within it. The
gentleman who made the post-mortem examination told
me that the deposit of false membrane did not extend
lower down than the bifurcation of the trachea.”
It has been stated that this affection is peculiar to
children ; but it is not so, for in some of the older
authors instances are adduced where it has been ob-
served in women advanced in life. In an article of
great power and research, written by Mr. Phillips of
London, on the “Abnormal Anatomy of the Bladder,”
and published in Dr. Todd's Cyclopaedia of Anatomy,
1836, the following passage occurs:—
“Among the acquired changes of conformation of
“ the urinary bladder there is one which may be
“ termed introversion. In this affection, which is rare,
“the superior portion of the organ is so depressed as
“to be brought near to its neck, to project into the
“urethra, and in woman to make its appearance at the
“external orifice of that canal. Choparti relates from
“Percy the following observation —The patient was
“an abbess aged fifty-two, in whom the fundus of the
* The preparation is in the author's possession.
t Traité des maladies des voies urinaires, tom. i. p. 399.
303
“bladder was impacted in the neck, having also passed
“ along the urethra, and forming at its external orifice
“a tumor of the volume of the egg of a pigeon, red,
“fleshy, unequally tumefied, which when pressed upon
“with the finger returned into the canal, and reap-
“peared without any violent exertion. An analogous
“case occurred to Foubert.* The patient died ; the
“body was examined after death, and it was found
“ that the posterior and superior region of the bladder
“was depressed into the form of a cone, whose apex
“ had penetrated the neck of the bladder, a portion of
“ileum about six inches long being lodged in this de-
“pression.”
In neither of these cases does the inversion appear
to have been so complete as in the case which came
under my notice.
* Memoires de l'Academie de Chirurgie, tom. ii. p. 36.
304
CHAPTER XIV.
ALTHOUGH the diagnosis of aneurism of the abdominal
aorta is now so familiar to all well-informed practitioners
that few cases of that disease remain long undiscovered,
yet it was not so until after the first quarter of the
present century had elapsed. Dr. Stokes begins the
chapter on abdominal aneurism, in his masterly work
“On Diseases of the Heart and Aorta,” in the following
words:–“Our knowledge of the diagnosis of this
“affection may safely be said to date from the year
“1830, when Dr. Beatty of this city published his
“accurate observations on a single case of the disease.
“Although Morgagni had shown that the lesion had
“ been often mistaken or overlooked, while Laennec
“had indicated the physical signs of aneurism, yet it
“was not until after Dr. Beatty's record of a case of
“aneurism of the abdominal aorta that physicians were
“enabled to diagnose that disease, or even led to suspect
“it in cases which before had been differently inter-
“preted. We must not lose sight of the fact that, in
“the years 1827, 1828, and 1829, as is shown by Dr.
“Beatty, an individual labouring under this disease,
“with marked and violent symptoms, was carefully and
“repeatedly examined by the most eminent physicians
“in Dublin, London, and Paris, and yet without a
“suspicion being formed of the real nature of the case.
“And when we find such names as those of Graves,
305
“Cheyne, Brodie, Colles, Townsend, Wilson Philip,
“and Andral among those in attendance on the patient,
“we can come to no other conclusion than that, up to
“ the period in question, the diagnosis of the disease, at
“least from its symptoms, had never been established.”
After the foregoing testimony from such an authority, I
feel that little apology is needed for now republishing
the paper alluded to. I do so, with the addition of the
written opinions of some of the great men through
whose hands the patient passed during his years of
intense agony. This may now fairly be done, as they
have all passed away from this life, and I am the
sole survivor of all who were consulted on the case.
A case of Aneurism of the Abdominal Aorta, with the
Dissection and Observations.
IT has been well said by Martinet,” that “ diagnosis is
“ the most important part of pathology, for it not only
“enables the physician to ascertain the nature of dis-
“eases, but also the treatment best adapted for their
“relief.” It embraces the solution of that great ques-
tion which is presented to every man who investigates
disease, and which it is his first duty to endeavour to
solve: “What is the organ affected, and what is the
“nature of its derangement 2" A strict inquiry into
the symptoms, and an examination of the functions of
the different organs will, for the most part, lead to a
detection of any derangement in their performance,
and hence to the organ affected. But there are excep-
tions to this rule, among which may be ranked aneu-
risms in the thorax and abdomen.
To discover the existence of this disease in the
* Manuel de Pathologie,
20
306 *
incipient stage, or even after it may have attained to a
considerable and fatal extent, has ever been admitted to
be a matter of great difficulty, and to this effect we have
the testimony of many celebrated writers on the subject.
Morgagni” relates some cases in which the disease was
mistaken, even by himself and others, in which, on
examination after death, so little had the previous
symptoms indicated the true nature of the disease, that
it was totally overlooked, and the tumors were called
by different names. Hodgsoni remarks, “Aneurisms
“in the thorax or abdomen frequently prove fatal,
“ before a knowledge of their existence is confirmed by
“ that evidence which the appearance of the tumor
“externally generally affords.” Richerandí says, “It
“is only when the disease becomes accessible to the
“senses of the sight and touch, that internal aneurisms
“afford signs that can be relied on. Up to that mo-
“ment any that exist are but equivocal. Frequently,
“in opening dead bodies, dilatations are discovered of
“ the existence of which there had been nothing during
“life to cause a suspicion, and frequently such tumors
“burst before they have attained a size sufficient to
“ destroy the parietes of the cavity in which they
“exist.”
Other authorities might be quoted, if necessary, to
prove what is now universally admitted. This diffi-
culty in the diagnosis occurs chiefly when the disease is
situated in the descending aorta. If it spring from
the arch of this artery, there are some circumstances
which point it out more clearly, such as deranged cir-
* Epist. xl. sec. 27.
t Diseases of the Arteries and Weins, p. 88.
i. Dict, des Sciences Medicales, art. Aneurisme.
| Hodgson, p. 93. Burn's Diseases of the Heart.
307
culation and pulsation at the wrist, cough, sense of
suffocation, difficulty of swallowing, and often a distinct
pulsation perceived by the patient ; but when it is at a
greater distance from the heart, the interruption to the
circulation is not so manifest. In many it does not occur;
and even if present, it is not discoverable at the part
usually examined, the wrist; while the other symptoms
caused by its pressure on the organs and its vicinity
are at the same time very equivocal, being indicative of
many diseases in these organs, as well as of aneurism
of a neighbouring artery. While this difficulty in the
discovery of so fatal a disease exists, it is the duty of
every man to whom an opportunity occurs of witness-
ing it, to communicate the observations he may have
made; in the hope that by an accumulation of facts in-
ferences may be drawn tending to elucidate this obscure
but important subject, and to assist future observers in
its diagnosis. Under this impression I have drawn up
the following case, from very full notes taken during
the progress of the disease, leaving, as unimportant,
the details of the treatment, as it will appear that the
true nature of the malady was not suspected during
life; but I will endeavour to draw as accurate a picture
as the varying and contradictory symptoms of the case
will admit of. This case is valuable, inasmuch as the
patient was under my inspection from the earliest stage
of the disease; and having, from peculiar circumstances,
watched its progress with great anxiety, no symptom
or change escaped my observation.
J. M. Esq., aged thirty-three years, of robust frame
and regular and temperate habits of life, was seized in
August, 1827, with dull pain in the loins, which, from
his being subject to rheumatic affections, and having
then recently been exposed to chill, terminating in a
20%
308
heavy cold, was thought to be lumbago. I saw him
about a fortnight after the commencement of the attack,
and he then complained of a fixed dull pain in the
back, not situated in the external muscles, but occupy-
ing a deeper situation, as he described it, as if it were
between the bowels and the spine. The smallest sudden
change of position produced acute pain, shooting from
the loins towards the spine ; and although, in the first
stage of the illness, he was comparatively at ease when
standing or walking, yet soon the making a false step,
or any irregular movement, even stooping to tie his
shoe, produced suffering so severe that he could no
longer leave the house. This ailment, which was at first
confined to the loins, soon extended gradually round the
belly. The bowels were kept open, yet the belly swelled
much, even to tympany; but there was no increase of
pain on pressure, nor any tumor perceptible then, nor
afterwards, when the distention was reduced. He was
very flatulent, and whenever he lay for any time the pain
increased, whilst he was commonly relieved on standing
up, by discharge of wind upwards. Pulse natural; appe-
tite good, but pain usually supervened on eating; urine
natural, although he had a slight suppression for a few
days, which was removed by sweet spirit of nitre.
At this time Dr. Cheyne saw him frequently with me.
Antimonials, mercurials, narcotics, purgatives, cupping,
and blistering to the loins, &c., were all tried without
producing any decided effect. After some slight im-
provement he went in September to Cheltenham ; there
he saw Dr. Boisragon. In the course of three weeks there
was an almost total remission of pain, and an amendment
in strength and spirits. In another week, however, pain
returned, with uneasiness in the bowels at night, which
constantly compelled him to rise and walk about, when
309
change of position and discharge of wind upwards gene-
rally gave relief. Under Dr. Boisragon's directions he
used the Cheltenham waters for about six weeks, with
occasional doses of blue pill and rhubarb. He used the
warm bath, and friction with the flesh-brush, and en-
tirely changed his manner of living, eating animal food
three or four times a day, and drinking wine, or brandy
and water. In November he returned to Dublin free from
pain, and improved in appearance ; but within a week
the pain returned in both sides with increased violence.
It was now no longer a shock caused by change of posi-
tion, but a most severe spasmodic twisting and pulling
of the whole tract of the intestines, but more particu-
larly in the region of the colon at both sides. This
would last to a degree of torture, for some hours at a
time, and then subside ; some feeling of it constantly re-
curred with violence now and then after meals, so great
as to compel him to leave the table. He was now likewise
distressed by a dull pain, apparently distinct from the
spasm of the sides through the whole abdomen, as if
there was a weight that pulled it internally from every
part. This uneasiness was always worse in bed, and
continued to increase the longer he lay ; even when he
went to bed freed from it, he was awakened in two or
three hours, and compelled to rise. His sleep was thus
broken ; he rarely enjoyed it for above two hours at a
time, and sometimes did not close his eyes; frequently
he dressed himself and walked about, or sat and read
for hours, which relieved the pain, and enabled him to
rest in bed for an hour or two before its return. It
appeared to him as if the pain came on as the matter
descended in the bowels, and it was always relieved by
evacuation : this led him to have recourse to injections,
which he used freely. He also thought that heat was
310
concerned in the production of pain, for although he
could not remain in bed, it always relieved him to lie
down on a sofa or chairs in the day-time; and when at
a subsequent period he tried the hot bath, this pain of
bowels invariably came on, and equally so whether he
lay or sat upright in it. -
Dr. Graves saw him in November : a course of
turpentine injections and blistering appeared to re-
lieve all the symptoms at this time, but after about
a month they recurred with severity, and seemed in-
sensible to the same treatment. New remedies were
resorted to with temporary intermissions of the pain :
all seemed at first to give relief, and then to lose
their effect. At this period he lived pretty much as
formerly, eating meat, but not any vegetables, and
drinking wine. He continued during the winter much
in the same state, with occasional violent attacks of
pain and spasm, and often with an intermission of days
between them. He tried the effect of opiate injections,
which always produced immediate ease; but the consti-
pation of the bowels which followed their use, and the
distress thereby produced, were so great that he was
obliged to discontinue them. He was not, however, at
any time incapacitated from attending to business in
court. At one period during the term the effect of
speaking in an important cause was very striking; he
had been suffering greatly during the whole day, and
could with difficulty remain in court; but all pain fled
when he arose to address the bench, and he continued
perfectly well while speaking, and during the following
evening. From the end of April, 1828, the distressing
pain of the bowels became worse, and from the harass-
ing effects of it, and the total loss of rest, his strength
greatly declined, and his appetite for the first time
311
became bad; his pulse however continued good. It
was at this period that he resumed the use of warm
baths, and experienced the unpleasant increase of pain
from them which I have already mentioned. In June
he began to use bark and cold baths; the former was
soon discontinued, as he thought his stomach un-
pleasantly affected by it. The baths did not cause any
redness or glow of skin, but gave a feeling of increased
strength, and materially affected the pain in the sides;
when this was sharpest, the plunge into the bath at once
relieved it, sometimes for hours, though often but for
half an hour or less.
Mr. Colles saw him often during this month. He
now commenced horse exercise and riding in a gig.
In the early part of July the pain, which had been
latterly most felt in the left side, changed for a
time to the right iliac region, and, on One occasion,
after exposure to cold, rigors came on towards even-
ing with great severity, and lasted for about six hours.
He now went on circuit, and continued away during
the last three weeks of July and the first week of
August, travelling in a gig for the sake of air and
exercise. He always found the heat of court oppres-
sive, as it produced weakness and return of pain. One
day in particular, of great heat and labour, was fol-
lowed by two days of severe pain and spasm in the
sides, and great consequent derangement of the bowels;
for I should mention that the spasm, when it became
severe, appeared to prevent the passage through the
intestines, and impeded the operation of medicine; which
derangement in its turn appeared to produce and in-
crease the pain. Throughout the whole of the illness
there was incessant occasion for keeping the bowels
well freed; the least accumulation, for above five or
312
six hours, bringing on the pain, or perhaps the spasm
in the sides. In about a fortnight after setting out on
circuit he was seized at night, without any cause that he
could trace, with frequent violent spasm in the left side,
attended with symptoms differing from those in former
attacks. It was now a continued dull pain in the left
loin and hip, and down the thigh of that side, with fre-
quent violent spasms shooting forward in a straight direc-
tion to the belly; these spasms occurred on change of
posture, or any movement however slight; they felt to
him more muscular than former pains, and proceeding
from a point nearer to the surface. When they seized
him he could feel the bowels in front, directly opposite,
hard, and as it were in a state of twisting and contor-
tion. This state continued without intermission two
days, and then gradually ceased. While the pain
continued he felt very chilly, and found it neces-
sary to have a fire, although the days were fine.
After an interval of eight days he had another attack
precisely similar, but more severe ; each time the
bowels were much constipated, yielding slowly and
with difficulty to medicine. Notwithstanding these
exhausting attacks, he found himself at the end of cir-
cuit stronger and more at ease than when he left home;
his appetite was improved, and his bowels were more
easily freed.
The pain in the right side now entirely subsided,
and the general uneasiness in the bowels diminished ;
but he was affected at night by cramps in the feet
and legs, and a convulsive twitching of the legs fre-
quently came on with any return of the pain in the side
or of uneasiness in the bowels, particularly when in
bed or lying down. He found the bowels at this
period more obedient to medicine, and freed with a
313
less quantity than usual, for latterly the natural action
seemed quite gone, a great deal of medicine being re-
quired to produce evacuation. Bleeding from piles, to
which he was habitually subject, and which at times had
been very considerable, now ceased. He remained in
Dublin from the 7th till the latter end of August, and
during that period continued to suffer much in the
same manner; the colicky pains recurring from time to
time with great violence, and his sleep being constantly
broken. It appeared to me at this time, and I men-
tioned the circumstance to himself and some of his
friends, that in its nature and situation the pain in the
bowels very much resembled that produced in the lead
colic ; and in looking over the work on Diseases of
the Abdomen, by M. Andral, I found a description of
a disease resembling the colica pictonum, but not caused
by lead, which he states to be rare, and not of long
continuance. It is but fair to state that no definite
opinion of the disease had been formed by us at this
period ; the symptoms were so variable, and the indica-
tions of organic disease so obscure, that notwithstand-
ing the able and valuable medical and surgical assistance
which we had called to our aid, no satisfactory diagnosis
could be given. In the end of August, finding that no
amendment took place, I urged him to go to London,
and if possible to proceed to Paris, where I was most
anxious he should be seen by M. Andral. After wait-
ing some days for the subsidence of an attack of pain,
he set out, and reached London without difficulty. He
remained at Woolwich for a fortnight, and there he
had the benefit of the advice of Mr. Fitzpatrick. Upon
a suspicion of the existence of stricture in the rectum,
he proposed to have Mr. Brodie's opinion on the case ;
his examination placed the healthy condition of the
314
gut beyond a doubt. I may observe that I had pre-
viously been led to investigate this organ on a similar
suspicion, with the same result. Our patient improved
at Woolwich, and determined on going to Paris,
which he reached about the middle of September.
He was encouraged to take this step by the presence
in that city of Dr. Graves, who had seen him in
Dublin, and was acquainted with M. Andral; they,
together with Dr. Townsend, who was there likewise,
had two or three meetings on the case, in each of which
the most minute examination of the abdomen and of
the history of the symptoms was made by M. Andral,
who, after mature deliberation, gave his opinion that
the symptoms complained of were the result “d'une
neurose intestinale.” He said he found nothing that
indicated organic disease, and that there was a great
analogy between the sufferings of Mr. M. and those
complained of by persons under the influence of lead.
During his stay in Paris, which continued about three
weeks, until early in October, he improved in every
respect; the pains almost entirely subsided, his appetite,
spirits, and flesh returned, he ate and drank without
restraint, and his nights were passed in sound, refresh-
ing sleep ; his letters at that time were most cheering,
and everything promised a perfect recovery. He con-
tinued well through the journey back to England,
almost up to the very moment of landing at Dover,
when suddenly, while walking the deck of the packet
with Dr. Townsend, who accompanied him, a most
violent pain shot through the back and bowels, the
effect of which was instantaneously to throw the whole
of the belly into a state of spasm and torture, and in
this state he continued for several hours. By the use
of opiates he so far recovered as to be able to come
315
down to dinner, and the paroxysm subsided; this was
the first he had had for a month or more. He reached
London the following day, and on the 7th of October
he saw Dr. Wilson Philip, under whose care he remained
three weeks. Doctor Philip pronounced that the com-
plaint arose from indigestion, and that the pain and
spasms of the intestines were produced by the disengage-
ment of gas, from the ill-digested matter retained in
them. He prescribed with a view to correct this state,
and the patient appeared to improve daily.
Mr. M. left London on the 25th of October, and
reached Dublin in a few days. On his arrival I saw
him, and found him much improved in appearance, and
he described all his symptoms as greatly alleviated.
Soon after his return to Ireland the law term began,
and he resumed his labours with confidence and spirit.
In a few days, however, the hopes of recovery were
blighted by a fresh attack of pain and spasm, and now
for the first time he complained of the pain extending
to the chest ; this became so severe the first night of
its appearance, that he put a blister over the lower part
of the sternum, to which place the pain was then con-
fined; the following day it moved to the right side,
and occupied exactly the region of the liver. When
desired to point out the seat of suffering, he traced the
boundaries of the liver with accuracy, and complained
at the same time of severe pain in the right scapula.
Dr. Townsend visited him constantly during this period,
in conjunction with Dr. Graves and myself. He was
now confined entirely to his room, but could not lie
down in bed; he either sat propped up with pillows or
in a high sloping-backed chair; any attempt at the
horizontal posture brought on increase of suffering.
Notwithstanding the severity of this attack, the pulse
316 *:
continued steady at 80, but blood drawn from his arm
exhibited the inflammatory crust. In a week he was
able to leave his room, and the pain in the right side
gradually subsided. He had resumed the amusement
of singing on his return to Ireland, in which art he was
an admired proficient, and his evenings were now
usually enlivened by this recreation: I mention this to
shew how little the respiratory function was interrupted.
In the course of a fortnight he was so far recovered as
to be able to use exercise on horseback, which he con-
tinued until early in December. He now experienced
a fresh accession of pain, for although comparatively
well in the interval, he had frequent returns of it since
the last severe fit. It did not now occupy the region of
the liver as before, but extended across the chest, and
round the sides to the back, following the attachments
of the diaphragm. The pain was of a darting, spas-
modic character, but the respiration remained natural.
His sufferings became very severe at this time; every
part of the abdomen was in a state of torture and spasm,
particularly the left iliac region ; the pain seemed
to shoot through the bone at this place; and the muscles
of the back, extending up to the scapula, commenced
to feel uneasiness. A cup of strong coffee frequently
procured relief at this period. He was now obliged to
have recourse to narcotics pretty freely; neither bella-
donna, stramonium, nor hyoscyamus afforded any
alleviation ; the preparations of opium alone being of
|UIS62.
On the 3rd of January, 1829, he commenced to take
the carbonate of iron, for although it had been tried in
an early stage of the disease without benefit, we wished
to exhibit it again ; this and the use of the tepid
shower bath were persevered in for some days, but not
317
finding any advantage from them, they were laid aside.
On the 10th the sulphate of quinine in large doses was
ordered; this appeared to produce great benefit, the
pains were mitigated, and the nights improved so much
as to enable him to omit an opiate, which for some
time he had been obliged to take on going to bed. On
the 13th he felt so well in all respects, and so free from
pain, that he ordered his gig and rode out in it for two
hours; the day was cold, but he returned in a glow of
warmth, and passed the evening in great comfort; he
sang one of the most difficult songs this evening with
perfect strength of voice; his night was good, and the
following day he took a similar airing with the same
results. On the 15th he awoke with pain in the left
side, corresponding in situation and extent with the
former pain in the right side; this rapidly increased in
severity, and before the evening amounted to intense
suffering. His pulse now for the first time varied from a
state indicative of perfect health ; it arose to 100, and
never fell again. He was bled largely from the arm
and cupped on the side without any relief. The follow-
ing day the pain still continued in the side, and ex-
tended up the back and down into the left ileum ;
severe spasms of the muscles of the back and belly,
with pain darting from the pit of the stomach to the
spine, now set in ; these continued with great violence,
subject to occasional intermissions, and yielding to a
certain extent to opiates. On the 17th it was thought
advisable to salivate him with mercury, and the large
doses of opium were suspended; but no language could
describe the agony he suffered during that day. The
spasms of the back and side came on with such violence
as frequently to force him to cry out, and, leaping from
the chair in which he sat, to throw himself flat on his
318
face on the bed, in which posture he obtained a partial
and temporary relief; his screams at this time, although
he was naturally a strong-minded man, were heard
from top to bottom of his house. Opiates were again
had recourse to in large doses, with relief, and from
that time the quantity taken was enormous; his flesh
now rapidly declined, and his strength diminished. He
was unable to leave his bed after the 18th, but he was
obliged to preserve the sitting posture, from the great
increase of pain in the back and side whenever he at-
tempted to lie down.
Dr. Cheyne now saw him, and continued in at-
tendance with Dr. Graves and myself until his death.
The pain continued with much severity until the last
few days of this month, when he had a temporary
remission. On the 1st of February, having passed
a good night with sleep, he became uneasy at about
seven in the morning, and on taking a drink he was
suddenly seized with violent pain in the left groin,
and the crest of the left ileum, extending to the back
and over the whole abdomen ; the muscles of which,
together with those of the back, were thrown into a
state of violent spasm. The abdomen at this time was
tense and firm, like the feel of a tetanic belly; profuse
perspiration of the upper extremities and head now
generally accompanied the attacks of pain. This state
continued until he took ninety drops of black drop in
the course of two hours, when he obtained complete
relief; the belly became gradually soft, and he had an
evacuation of the bowels. This state of ease continued
until the following evening, when the pain returned in
the left side, high up under the ribs, and across the
chest, with spasm of the muscles of the back ; fifty
drops of black drop procured relief. Thus the case went
319
on, the pain seizing sometimes one place, and sometimes
another, and yielding to the opiate, which was obliged
to be increased in its dose, so that on the 12th of
February he took 135 drops of black-drop. Ema-
ciation now proceeded rapidly, and his strength failed
considerably; the skin, to the size of a dollar over the
left nates, sloughed in consequence of the pressure upon
it during the time he was obliged to sit upright; for-
tunately the necessity for preserving this posture had
ceased, and he was now able to lie on his side. About
this time he first complained of difficulty in swallowing,
the morsel appearing to be stopped before it reached
the stomach ; this was attended with pain, and when
fluids were swallowed a gurgling noise was heard in the
chest. The respiration was also affected by swallowing,
and considerable panting followed every draught, so as
to render it necessary for him to pause for some time
between each mouthful. A sharp, burning pain was
now felt in the upper part of the left thigh, proceeding
from the body and terminating abruptly about midway
above the knee ; this was not constant, but, like the
others, came on in fits. On the 13th the pain left its
former position in the left side, and attacked the right
in the region of the liver. On the 14th it returned to
the left side, extending across the chest, with difficulty of
breathing and speaking. The pulse, since he was con-
fined to bed, ranged from 110 to 120, and his daily
dose of black-drop at this time was from 150 to 200
drops. Notwithstanding this amount of opiate, he was
never drowsy or apparently narcotised, but at times a
state of great excitement was produced, during which
he talked much, and often wandered : the largest quan-
tity he took was on the 18th, when it amounted to 285
drops; on that day the pain and spasms were most
320
severe.” The liver could now be distinctly felt en-
larged, and it increased daily in size. The prostration
of strength and emaciation became so great that he
was unable to sit up to evacuate the bowels; whilst
great and distressing flatulency prevailed. Of this,
together with the stools, which were now always fluid,
I contrived to relieve him by introducing the oesopha-
gus tube of the stomach-pump into the rectum, and
drawing off the contents by the syringe. This operation
sometimes occupied a good deal of time, as I was obliged
to wait for the action of the colon to pass on the con-
tents; the rumbling of the wind gave notice of its
approach, and in this way I got off great quantities of
both flatus and faeces, so that for the last ten days of
his life he was not called upon to make any exertion.
In this way he went on, daily becoming more ghastly,
and the wandering increasing; although at times, when
anything of importance presented, he was perfectly
collected, and seemed as if he had the power of recall-
ing his faculties on an emergency. Of this he gave
some striking instances a very few days before death.
On the 24th the pulse fell in the evening to 108, and
on the 25th to 100 ; this day his countenance was par-
ticularly ghastly, and his debility extreme. On the 26th
his pulse was 104; he awoke more collected, and seemed
better than for some days; at one o'clock he turned on
his side to have his back rubbed with eau de cologne,
and on speaking to him shortly after, he seemed to pant
more than usual; he then called me and said he felt
greatly exhausted; instantly he was seized with slight
convulsion, and lost all consciousness; he turned on his
* The effect of opium in producing retention of urine was strongly
marked in this case. I was frequently obliged to empty the bladder by
the catheter after he commenced the large doses.
321
back, a rush of faeces and urine took place into the bed,
and for the space of an hour he continued to live,
moaning and turning his head from side to side ; the
pulse kept firm at first, then began to fail, and about
three o'clock he died.
The body was examined on the following day in the
presence of Dr. Cheyne, Dr. Graves, Dr. Townsend, Dr.
Wm. Beatty, Dr. Greene, Mr. Harris, and myself. On
exposure, the emaciation appeared extreme. Before
proceeding to the dissection, we wished to let some of
the gentlemen present, who had not attended him, feel
the enlarged liver, but we were much surprised to find
that no tumor could be perceived : this, though at the
time inexplicable, was afterwards satisfactorily ac-
counted for. The thorax was now opened and the right
lung was found healthy, but in the left cavity of the
pleura a large effusion of blood, partly coagulated, pre-
sented. The lung was compressed, and the inferior
border appeared slightly carnified, leaving the rest of
the organ healthy. The incision being carried into the
abdomen disclosed the viscera contained in it, the
external appearance of which was natural; the longi-
tudinal fibres of the large intestine were strongly deve-
loped; the stomach adhered to the diaphragm by a small
band of membrane; and the liver, which during life had
appeared so much enlarged, was found very little in-
creased in size, and in structure quite healthy, but the
outer convex surface was marked by deep indentations,
corresponding to the ribs, as if it had been subject to
strong pressure against them. When the intestines and
liver were removed, a large firm tumor was discovered
about the size of the head of a child a year old, lying
upon the three last dorsal vertebrae, its transverse
diameter being a little longer than the perpendicular,
21
322
and extending with a curved outline to the kidney on
both sides, having the aorta passing down before it, in
a sort of groove on the anterior surface. The artery
was cut across at the bifurcation, and slit up above the
tumor, by which a round, well defined hole, as large as
a shilling, was exposed on its posterior surface, a little
above the origin of the coeliac artery, communicating
with the tumor, which thus proved to be an aneurism
of the aorta. On examination it was found that it was
covered by the crura of the diaphragm, which were
expanded and stretched tightly over its surface, forming
an outer coat for it, on which many filaments of nerves
were observed to run. In removing the tumor, an ir-
regular opening was discovered at the upper and left
part, through which the blood found in the thorax had
escaped. The aneurismal sac was deficient at the back
part, and its place was supplied by the three last dorsal
vertebrae on which it lay. The bodies of these were
deeply eroded, but the intervertebral cartilages remained
sound and entire, forming prominent white rings be-
tween the destroyed vertebrae. At the left side of the
eleventh dorsal vertebra an opening large enough to
admit the end of a finger was found, leading into the
spinal canal. The heart was small; there was concentric
hypertrophy of the right ventricle, the walls of which
were thicker than those of the left. The stomach and
intestines were slit open through their whole extent,
and, with the exception of partial softening of the mu-
cous membrane, were quite healthy. The course of the
symptoms in this case, although strange, and at the time
inexplicable, can be accounted for by the position and
growth of the tumor, and its influence upon the parts
with which it was connected. In the commencement,
when it was yet small, it produced the dull fixed pain
323
which was mistaken for rheumatism; and this may be
considered the first stage of the disease. As it advanced
in size, it gave rise to the train of symptoms in which
this case differs from any that I have found recorded; I
allude to the severe suffering of pain and spasm in the
tract of the alimentary canal. This, so far as I know, did
not occur in other cases, but in this it was so great that
for several months it formed the whole subject of com-
plaint, and the attention was directed entirely to these
organs. This can be satisfactorily explained by a refer-
ence to the situation of the tumor : it was placed in
the neighbourhood of the solar plexus, and the pressure
exerted by it upon this great nervous centre at once
produced irritation in the whole of the organs supplied
by filaments from it, and caused the “neurose intesti-
nale” of Andral. The obscurity in the diagnosis was
caused in a great measure by this class of symptoms;
but from what I have observed on the situation of the
disease, it will appear they were accidental, and there-
fore are not to be expected in similar cases, unless the
tumor occupies the same position : this may be said to
constitute the 'second stage. The third and last stage
commenced when the tumor, having by its pressure
destroyed the vertebrae, opened a communication with
the spinal canal; it is marked by the occurrence of the
pain and spasms of the external muscles, and parts
supplied by the spinal nerves indicative of irritation of
the medulla spinalis.
It might be expected that the pulsation of so large a
tumor would have been perceptible, and thus the nature
of the disease have been developed.* But it is evident
* Sir Astley Cooper, speaking of Abdominal Aneurism, says, “When
“an aneurism is seated above the coeliac artery, its pulsation may be dis-
“ tinctly felt at the scrobiculus cordis.”—Lectures, edited by Tyrrell, vol. ii.
21%
324
it was not so in this case, or else some of the many
physicians who examined him must have discovered it.
Andral, amongst others, made a most minute examina-
tion of the abdomen ; his expression on the occasion
was, “il faut vous bien palper, monsieur,” yet he detected
no pulsation. In fact, the situation of the tumor
entirely precluded the possibility of ascertaining its
existence by the touch: firmly bound down to the spine
by the crura of the diaphragm, and protected on the
sides by the ribs, it lay secure from observation. A few
days before death I perceived a pulsation in the epigas-
trium, which, on examining more closely, I found to be
that of the artery, but I could discern nothing of tumor
or diffused pulsation, and as it is usual to be able to
feel the beating of the aorta in thin persons, I took no
more notice of it. I regret much that we were not led
to employ auscultation to the spine, as I think it very
probable the disease would have been thus discovered ;
but as there was not the most remote suspicion of the
existence of such a disease, the examination was not
made. The chest was examined on two occasions before
death, by two most experienced and successful stetho-
scopists, Doctors Graves and Townsend, and no lesion
was discovered. Auscultation affords a ready means
for the diagnosis of aneurisms in the limbs, in those
cases in which there is no perceptible pulsation. The
“bruit de Soufflet,” heard on applying the stethoscope,
is very striking, and points out the nature of the disease;
and it is fair to suppose that this indication would have
been afforded had the instrument been used along the
Spine.
The intermissions seem to be the most inexplicable
part of the case; they formed part of the grounds upon
which Andral and others founded the opinion that the
325
disease was in the nerves; but although so remarkable
a circumstance, the case is not singular in this respect,
for Scarpa relates one in which there was a complete
suspension of suffering, at a period of four months from
the commencement of the disease.
Scarpa's case resembles the one I have detailed in
many particulars, and like it the aneurism was not dis-
covered until after death. It commenced with constant
pain in the loins, extending to the abdomen; more severe
at night than during the day, and at times attended
with violent spasms in those parts. During the first
four months no remedies were employed but rhubarb
and diuretics, and nettles were applied to the loins. At
the end of this period there was an intermission, and
during seventeen days he was completely relieved from
all suffering. The pain, however, recurred, and he now
put himself under the care of a physician who consi-
dered the disease rheumatism, and gave him sudorifics,
and blistered the loins, under which plan the disease
increased. He then consulted another physician, who
suspected calculi in the kidney, and treated him with
volatile liniments, soap pills, and emollient drinks, but
without any relief. He had at that time a fixed but
extended pain in the left lumbar region, and an almost
continual restlessness. His pulse was natural; there
was no fever nor vomiting. The inferior extremities
were sometimes cold, whilst the superior and the head
were often covered with perspiration, particularly when
the pain was violent, which happened most frequently
after dinner, or during the night. The pains then
extended to the left inferior ribs, and to the left groin
and thigh, and sometimes to the testicle of that side.
It was observed that these pains were most severe in
rainy or stormy weather. Opium in large doses alone
326
gave relief; at times assafoetida was combined with it.
He found himself better when seated on the bed, and
bent forwards. No pulsation was ever felt by the
patient or others. He died suddenly about nine months
after the commencement of the disease. On examina-
tion, an aneurism of the aorta was discovered lying on
the lower dorsal vertebrae; it had burst, and the blood
was effused behind the peritoneum in such quantity as
to raise this membrane the whole way from the dia-
phragm to the left crural arch. The aorta ran down in
front of the tumor, undilated; on slitting it open, the
communication between them came in view ; it was
about an inch in diameter, with hard and callous edges.
The aneurismal sac was deficient at the back part, and
its place was supplied by the dorsal vertebrae on which
it lay. These were very much eroded and destroyed,
but the intervertebral cartilages remained entire. Here
was a case very similar to that of Mr. M. in its symp-
toms, progress, termination, and the position of the
tumor, yet differing from it in not being attended with
the colicky pains in the bowels. Still more striking is
the similarity in point of size and position. In the
case of aneurism mentioned by Morgagni,” in an old
man, the tumor was of a large crescentic form under
the diaphragm, the horns pointing downwards, the
posterior parietes of the sac were deficient, and the
last two dorsal vertebrae were eroded, leaving the in-
tervertebral substance sound: yet this patient had no
pain, nor sense of weight, nor difficulty of breathing.
Ifind also, in the Medical Gazette for April 25th, 1829,
a case by Mr. Mayo, of aneurism of the aorta between the
crura of the diaphragm, stretching across the spine, and
reaching to the top of the kidneys; yet in this case,
* Epist, xl. sec. 26.
327
although the patient had been for six years subject to
violent attacks of pain in the back and loins, with numb-
ness of the limbs, and for three weeks before his death
suffered excruciating pains in his back and left inguinal
region, compared to boiling lead poured down the
thigh, there is no mention of pain in the bowels. The
apparent increase of size in the liver in the case of
Mr. M. was evidently caused by the great bulk of the
aneurismal tumor pressing it downwards, and forcing
its inferior margin below the ribs; and the difficulty in
discerning it after death, before the body was opened,
was the result of the bursting of the sac, by which its
size was diminished, and the liver was suffered to re-
sume its original position. The deep indentations with
which the liver was marked gave evidence of the
pressure to which it had been subjected, and may
account for the attack of pain in the right side which
so much resembled hepatitis.
APPENDIX.
IN a diary kept by the patient I found the following
entries:–
“August 31st, 1828.-Isaw Mr. Fitzpatrick at Wool-
wich.”
[Mr. F. was a distinguished surgeon of the Royal
Artillery, and a friend of the patient.]
“After minutely enquiring into my case, he gives a
“pretty decided opinion that my disorder is a species
“of tympanitis, and lends me Dictionnaire des Sciences
“Medicales, in which this malady is fully treated, vol.
“56, art. ‘Tympanite.’
328
“September 2nd.—Mr. Fitzpatrick paid me a long
“visit. Recommends consultation with Dr. Maton as
“the calmest, most considering of the London faculty;
“one of sound judgment and knowledge, and likely to
“give every attention to the case. Warren more bril-
“liant, and often making a distinguished hit when
“others have failed, but liable to take up a notion
“hastily and pursue it. Philip a complete man of
“system, having greatly studied disease of the liver, and
“ready to refer every illness to its derangement; a man
“of talent, and often useful in such diseases, but not
“ desirable for me.
“September 3rd.—Examined me in bed, and says he
“never felt intestines more sound or free from disease
“throughout ; there is, however, a slight enlargement
“of liver beyond what is natural, close upon the colon,
“but no disease. Upon the whole he thinks there is
“nothing serious the matter; that the seat of disease is
“in the rectum ; it may be a varicose vein, or some
“warty excrescence connected with piles, perhaps
“brought on by chill and cold in 1827. Recommends
“an accurate examination by an eminent surgeon. We
“choose Brodie, and then to have a consultation of all.”
That this advice was adopted appears from the
following letter written by Mr. Fitzpatrick:—
“Woolwich, Sept. 6th, 1828.
“My dear Sir,
“I send enclosed Mr. Brodie's letter, which is satis-
“factory as far as it goes, for on the accuracy of his
“tact you may depend; but his letter still leaves your
“case undecided upon, whilst the absence of those whom
“I was desirous of consulting imposes on me the obliga-
“tion of giving you what I wished to avoid, an unsup-
“ ported opinion on your disease. Some of your
329
“symptoms are what medical men call nephritic, but
“they are too limited, too obscure to afford decisive
“evidence of the existence of that complaint. Brodie's
“examination has placed the healthy condition of the
“rectum beyond a doubt; hence your sufferings appear
“to me to depend on an abraded, perhaps ulcerated
“condition of the colon at its sigmoid flexure, or at
“ the part termed ‘caput coli,' or possibly of both,
“accompanied with a thickening at those points, pro-
“ducing a constriction of the intestine, and consequently
“opposing difficulties to the passage of the faeces, parti-
“cularly if in a solid or indurated form, and thus pro-
“ducing those violent spasms from which you so
“severely suffer—spasms which may often be produced
“ by a distention of the intestines by flatus, independent
“of the operation of faecal influence.”
After giving instructions as to treatment, Mr. Fitz-
patrick concludes thus:—
“I approve of your projected trip to Paris. The man
“whom you mention is possessed of a high character,
“ and you will there also find many others of a deser-
“vedly high repute; and now that you are on the
“wing, I would not have you return to Ireland without
“ the written opinions of every man of celebrity in this
“country and in Paris. I mention a written opinion,
“as the man who will give you that will necessarily
“bestow some consideration on your case, and will feel
“himself called upon to suit his practice to his theory.”
Soon after this, Mr. M. went to Paris, and consulted
Andral, whose written opinion I now transcribe —
“Je pense que les symptomes eprouvés par M. M.
“sont le resultat d'une neurose intestinale. Je ne
“trouve chez lui rien qui démontre d'une lesion de
330
* texture ; les fonctions seules paraissent modifiées.
* Je trouve le plus grand analogies entre les accidens
* que éprouve M. M. et ceux dont se plaignent les per-
* sonnes qui ont manïé le plomb. Je conseille, 1°. L'ap-
* plication souvent repetée de quelques sangsues au
* fondement, faite de maniere qu'il en resulte chaque
* fois une fluxion sans ecoulement sanguin abondant.
* 2°. L'emploi des bains gelatineux, auxquels on fera
* succêder l'emploi des bains sulfuro-gelatineux, et en-
* fin l'emploi des bains sulfureaux purs. Si ces bains
* ne sont pas suivis de l'effet qu'on peut en attendre,
* il faut essayer les bains de vapeurs. 3°. De frictions
* faites sur le peripherée cutanée avec une brosse rude
" chaque soir ; les bains chaque matin. 4°. Les prepa-
* rations opiacèe et des purgatifs lors du retour des
* accès. Ces medicamens qui font la base du traite-
* ment qu'on employe a l'Hopital de la Charité de
* Paris contre la colique de plomb me semble convenir
" dans le cas actuel. 5°. L'usage habituel du petit lait
" pour tisane. 6°. Une nourriture doux, et une exer-
" cice journalier, soit a pied, soit a cheval.
* ANDRAL."
Paris, 22, 7bre, 1828.
Mr. M. subsequently returned to London, and there
saw Dr. Wilson Philip. In his diary I find the follow-
Ing :-
* October 7th, 1828.—Dr. Wilson Philip pronounces
· * confidently that my complaint arises from indigestion ;
" that the first attack was lumbago, which operating on
" a previously weakened state of the digestive organs,
* particularly the duodenum, checked the action of the
" bowels, thereby causing the ill-digested matter to
" remain in them, disengaging gas, and by means of it
331
“producing spasms and the other symptoms of pain
“from which I have suffered. He says that the object
“must be to restore by medicines a healthy action of
“the digestive organs; that the present secretion of
“bile is bad, and the liver sluggish.
“October 14th.—Says that he now can give an
“opinion of my complaint with still greater confidence
“ than before, and of my entire recovery at no great
“ distance of time.”
“After this history of that remarkable case, we can,”
says Dr. Stokes, “come to no other conclusion than that
“up to the period of its publication in 1830, the
“ diagnosis of the disease, at least from its symptoms,
“ had never been established.”
332
CHAPTER XV.
WHEN the Cyclopædia of Practical Medicine was origi-
nated by Dr. Forbes, Dr. Tweedie, and Dr. Connolly in
1832, I occupied the Professorship of Medical Jurispru-
dence in the Royal College of Surgeons in Ireland; and
I was requested by those gentlemen to contribute
several articles on state medicine to that work. Among
these I find some which I think may not unfitly be
included in the present volume, inasmuch as they treat
of highly important practical subjects which are conti-
nually brought under the cognisance of practitioners
in medicine and midwifery. They are now reprinted
in their original form, with the addition of a few remarks
which time and changes in the law have rendered
necessary.
Impotence.
IMPOTENCE or the incapacity of sexual intercourse, and
sterility or the inability of procreation without loss of
the power of copulation, are subjects which require to
be considered, first as physiological questions, involving
the consideration of all the causes temporary as well
as permanent from which these defects may arise; and
secondly, as medico-legal subjects, forming disqualifi-
cations for the matrimonial state, or affording pleas in
exculpation of alleged rape or affiliation.
Impotence may exist either in the male or female ;
333
it is, however, most commonly found in the male, as
from the nature and conformation of the genital organs
in the female physical impediments to coition more
rarely occur, and she is generally enabled to admit the
venereal congress at least in a passive manner. Ste-
rility, on the other hand, is nearly confined to the
female, for if the male be capable of accomplishing the
act of coition, including of course the ejaculatio seminis,
no farther question as to his virility can arise.
The causes of impotence may be divided into three
classes: 1. Organic ; 2. functional; 3. moral.
In the human species, as in all the warm-blooded
vertebrated animals, the procreation of the species is
effected by a congress of the two sexes, and a variety
of organs are provided, upon the integrity of which
the due performance of this function mainly depends.
The male is destined to furnish a peculiar fecundating
secretion, which is to be deposited in the body of the
female, and for this purpose he is furnished with glands
which prepare this fluid, and also with a conduit by
which it is conveyed to its proper destination ; while
the female, being the recipient, offers a cavity into
which this secretion is received, and is, moreover, fur-
nished with an organ where the embryo is originally
produced by the specific action of the fluid from the male.
Without attempting to enter into an explanation of
the process of generation, which has been rightly
designated as “one of those mysteries which the present
“state of our knowledge does not enable us to explain
“ or even to comprehend,” it may be admitted as the
result of observation and experiment, that a failure in
any part of this complicated apparatus is attended by
impotence or sterility.
* Bostock's Physiology, vol. 1, p. 72.
334
I. Impotence in the male.—In order to effect pro-
creation he must possess all the organs of generation
in a state capable of performing their respective func-
tions, and this leads us to the first class of causes of
impotence.
1. Organic.—Organic impotence may proceed from
different sources; there may be, (a) deficiency of some
of the organs of generation ; (b) malformation of these
organs; (c) diseases of some of them, or of the parts in
their immediate neighbourhood, sufficient to impede
the procreative function.
(a) Deficiency of the penis, whether natural or acci-
dental, is an absolute cause of impotence. A congenital
deficiency of this organ is very rare, but it has been
observed. “J'ai traité et guéri,” says Foderé, “d'une
“incontinence d’urine un jeune soldat plein de courage
“et de vigeur, qui, avec des testicules bien conformés,
“n'avait à la place de la verge q'un bouton, comme un
“mamelon, parlequelse terminait l’urêtre. Il m'assura
“ avoir été toujours ainsi, et que ce bouton se renflait
“quelquefois en la presence des jeunes personnes du
“sexe, et qu'il en sortait par le frottement une humeur
“blanche.”* Accidental deficiency of the penis is
more common. This may arise from amputation or
destruction by disease. In a subject lately procured
for the purpose of dissection in the College of Surgeons,
Dublin, the writer witnessed an instance of complete
deficiency of the penis from operation. In this subject,
which was a very old man, the amputation had been
performed so long before death that the cicatrix was
nearly obliterated, and many who saw the case supposed
it to have been one of congenital deficiency.
* Médecine Légale, tom. 1, p. 364.
335.
It is difficult to determine the extent to which the
penis may be mutilated without destruction of the
power of procreation. The glans has been frequently
lost without being attended by impotence, and both
corpora cavernosa have been destroyed, but the urethra
being preserved, the individual retained his virility.*
Frank also states an instance of a gun-shot wound of
the penis which carried away so much of the organ
that it remained curved after cicatrization, nevertheless
it served the purpose of procreation.f From these and
numerous similar instances, as well as from the effects
produced on the generative function by that malforma-
tion, to be presently considered, termed hypospadias, it
would appear that in order to insure impotence there
must be complete deprivation of the penis, as a rem-
nant capable of entering the vagina is sufficient for
impregnation.
That the testicle is the only essential organ concerned
in the secretion of semen is now generally admitted, an
opinion supported by comparative anatomy, as well as
by the daily proofs we have in the castration of animals.
A different opinion formerly prevailed, chiefly on the
authority of Aristotle, who was led to deny the neces-
sity for the existence of testicles from having seen a
bull capable of impregnating a female after castration.
But he was led into error by not being aware that if
copulation were performed immediately after castration,
the quantity of semen retained in the vesiculae semi-
males would confer fertility on the coitus. The complete
absence of the testicles then, whether natural or ac-
cidental, must render the individual unfruitful.
Congenital deficiency of the testicle is a very rare
* Paris and Fonblanque, Med. Jur., vol. 1, p. 2, 205.
f Delect. Opusc. Medic, tom. 4, p. 313.
336
occurrence, if ever it takes place. Foderé doubts that
it does, and the case adduced by Cabrolio of a soldier
addicted to sexual pleasures in whose body no testicles
were found, although the vesiculae seminales were dis-
tended with semen, has been supposed by Portal to
have been one of those instances in which the testicles
are retained in the abdomen during the whole of life,
and that they thus escaped observation. It is not to
be inferred that an individual is impotent or sterile in
whom no testicles are found in the scrotum. We know
that in some instances these organs do not descend
from the abdomen for some time after birth, and in-
stances are not wanting in which this delay is prolonged
through the whole period of existence. In order to
distinguish if the absence of the testicle be real or not,
it is necessary to enquire on the one hand into the
previous history of the individual, and on the other
into his present condition and general habit. The first
may indicate the previous existence of these organs in
the scrotum, and their removal by operation or accident,
in which case the external marks of mutilation, such as
cicatrices, will be apparent. We do not think, generally
speaking, that an absolute congenital deficiency of tes.
ticles can take place without producing in the constitu-
tion the general phenomena by which the character of
the male is obliterated, and that of the female simulated.
In these cases of apparent absence of testicles, therefore,
iſ the usual general signs of virility are observed, if
masculine activity and vigour, combined with a well-
developed muscular system, a strong deep voice, with
the usual covering of hair on the chin, breast, and
pubis, and at the same time no cicatrix indicating cas-
tration, are present, we must be cautious in condemn-
ing the individual. However, it is necessary to be
337
circumspect in inductions from the general habit.
Marc knew a man in Paris whose features, thin beard,
smallness of hands and feet, and voice altogether femi-
nine, indicated a defect in genital organization, yet in
whom none such existed ; the testicles occupied their
proper situation, and the man had many children.”
Foderé considered the retention of the testicles in the
abdomen as a source of increased vigour and fecun-
dating power. “Ces organes paraissant tirer du bain
“chaud ou il se trouvent plongés plus d'aptitude à la
“sécrétion, que lorsqu’ils sont descendus au dehors
“dans leurs enveloppes ordinaires.”f This is at variance
with the opinion of Hunter, whose views on the subject
seem more correct, as he considers the delay in the de-
scent of the testicles to arise from imperfection in their
development. However, this imperfection does not go
the length of rendering the organ useless, and therefore,
when the other signs of virility are present, we are not
justified in taking the absence of the testicles from their
usual situation as an absolute proof of impotence.
“Nous avons vu en France, dit Voltaire, trois frères de
“la plus grand naissance, dont l'un possédoit trois
“testicules, l'autre n'en avoit q'un seul, et le troisième
“n'en avoit point d'apparens; ce dernier étoit le plus
“vigoureux des trois.”f -
Complete extirpation of the testicles, although it
deprives the individual of the power of procreation, is
yet not accompanied by total extinction of venereal
desire, and it has been observed that eunuchs of this
description retain the power of copulation in an imper-
fect manner. This is so well known in the East, that
* Dict, des Sciences Méd. art. Impuissance.
t Méd. Lég, tom. 1, p. 370.
f Mahon, Méd. Lég., tom. 1.
22
338
the eunuchs who have charge of the seraglios are
deprived of the penis as well as of the testicles. This
power in the castrato is alluded to by Juvenal,” and it
is said that the unfortunate victims of avarice and bad
taste in modern Italy are by no means deficient in
capability of erection and penetration. However, this
imperfect power of copulation does not remove such
persons from the class of impotent, as the most impor-
tant part of the function, the emissio seminis, is wanting.
Monorchides, or persons with but one testicle, are not
deprived of the power of procreation. This was at one
time doubted, and in the year 1665 the parliament of
Paris decided that such an imperfection rendered the ma-
trimonial contract invalid. But numerous instances in
man, as well as in the inferior animals, have completely
disproved that opinion. It must be admitted, however,
that if the remaining testicle be small, attenuated, and
withered, and if a sufficient length of time has been
passed in unfruitful matrimony, such a development
must afford a strong probability of sterility.
(b) Malformation.—Impotence may be absolute when
the genital organs exist, but are malformed or patho-
logically altered. -
The penis varies from the natural formation in
different ways that have been accounted causes of
impotence. Mere diminutiveness of this organ, where
the subject is otherwise vigorous, cannot be included
under this head; and it would appear that the genital
organs, although originally of diminutive size, are
capable of considerable development even after the age
of puberty. Of this the case related by Dr. Wilson is
a good example. “I was,” says he, “some years ago
* Sixth Satire.
339
“consulted by a gentleman on the point of marriage
“respecting the propriety of his entering that state, as
“his penis and testicles very little exceeded in size
“those of a youth of eight years of age. He was then
“six and twenty, but never had felt the desire for
“sexual intercourse until he became acquainted with
“his intended wife; since that period he had experi-
“enced repeated erections, attended with nocturnal
“emissions; he married, became the father of a family,
“and these parts, which at six and twenty years of age
“were so much smaller than usual, at twenty-eight had
“increased nearly to the usual size of those of an adult
“man.” But excessive size, more particularly excess
in length, may be considered as a relative cause of im-
potence, from the contusion and laceration inflicted on
the female at each attempt at intercourse. Such cases
as these are very rare. P. Zacchias cites an instance
in which the female was always thrown into syncope
from this cause.
The orifice of the urethra is occasionally formed in
an irregular manner, and this constitutes the most com-
mon malformation of the penis. It sometimes opens in
the perinaeum, sometimes on the dorsum of the penis,
constituting the malformation termed epispadias ; but
most frequently in the under surface of the penis; this
defect is called hypospadias. This malformation was
considered by Mahon, P. Zacchias, Faselius, and Haller
as an absolute cause of sterility, but certainly without
sufficient foundation ; for there are numerous instances
recorded in which impregnation has been effected by
individuals in whom the urethra opened in an unusual
manner, provided the orifice was in that portion of the
* Lectures on the genital organs.
22%
340
penis that entered the vagina. Kopp relates the case
of a peasant at Hanau, in whom the urethra opened on
the under surface of the penis at the distance of eleven
lines and a half from the extremity of the glans, not-
withstanding which he was the father of five children.”
Simeons of Offenbach gives eight cases of hypospadias.
The first and second were married and had children ;
the first six, and the second four. The third and fourth
were brothers; the fifth and sixth were sons of the
first ; the seventh was remarkable as having had an
action for a divorce against him, and the eighth was an
infant.f Foderé quotes four cases of hypospadias, in
all of which the power of impregnating was preserved;f
and Belloc states that he knew at Agen a man who
had the orifice of the urethra at the base of the frenum
of the glans, and who left four children perfectly
resembling himself, two of whom had the same mal-
formation.S. From the cases on record in which im-
pregnation has taken place without the possibility of
intromisssion, it is clear that the emissio seminis in any
portion of the vagina is sufficient for this purpose, and
that it is not necessary that this fluid should be carried
to the uterus, or to any great distance within the vagina.
We shall have occasion to revert to these cases in speak-
ing of female impotence, but at present we mention
them as affording an explanation of the subject before
us. It may, therefore, be assumed that malposition of
the orifice of the urethra does not necessarily constitute
a cause of impotence, unless the opening be situated in
a part that cannot enter the vagina. Even in the
* Annales de Méd. Politique, tom. 3.
f Dict, des Sciences Méd. tom. 24.
f Méd. Lég. tom. 1. p. 367.
§ Cours de Méd. Légale, p. 129.
341
latter case impregnation may be effected by artificial
means. The experiments of Spallanzani,” who suc-
ceeded in his attempts to impregnate animals by inject-
ing semen into the uterus, led Mr. Hunter to adopt the
same course in the case of a man by whom he was con-
sulted in consequence of malformation of the urethra.f
The orifice of the canal was in the perinaeum, through
which the semen escaped during coition ; and Mr.
Hunter directed him to collect this fluid in a syringe
and instantly to inject it into the vagina. The experi-
ment succeeded, impregnation took place, and the
female was delivered of a child in nine months.
A contracted state of the prepuce, by which the
emission of the seminal fluid is impeded, may be a cause
of impotence, but this is easily removed by operation.
A more serious case is that in which the prepuce ad-
heres to the glans, and the orifice of the urethra itself
is contracted. The writer has at present under his
care a boy, eleven years of age, in whom a malforma-
tion of this kind exists. The reflected portion of the
prepuce adheres universally to the glans, and is firmly
attached to the orifice of the urethra, which opening is
so contracted as scarcely to permit the passage of an
eye-probe. The urine is, of course, voided in drops.
If this case be permitted to go on to puberty without
relief, there is strong reason to imagine that impotence
would be the result.
Malformation of the excretory ducts of the testicle
may also prove a source of impotence. Mr. Hunteri
represents a case in which the epididymis, instead of
passing to a vas deferens, terminated in a cul-de-sac. A
* CEuvres de Spallanzani, tom. 3, p. 58.
+ Trans. Royal Soc. 1799.
f Animal Economy, p. 47, plate 5.
342
similar conformation sometimes occurs in the vesiculae
seminales, where, instead of entering the urethra, they
terminate, after being joined by the vasa deferentia, in
shut sacs. It is evident that when such a disposition
of parts exists on both sides, the semen, although
secreted, cannot be ejaculated, and therefore the indi-
vidual is rendered absolutely impotent.
(c) Diseases.—The diseases of the genital organs
which cause impotence may be divided into those
affecting the penis, and those affecting the testicles. Of
the former may be enumerated excess or defect of
muscular or nervous energy, inducing priapism, or
paralysis. Priapism gives rise to a temporary impo-
tence when the erection is so vigorous as to close the
urethra in such a manner that the semen cannot pass
into it. Defect of energy in the vessels, nerves, or
muscles of the genital organs, sometimes prevents the
influx of blood to the corpora cavernosa in a quantity
sufficient to cause erection, which produces a state of
atony approaching to paralysis, constituting the ana-
phrodisia paralytica of Dr. Cullen. This is a disease
not unfrequently met with. Instances of it are given
by Chaptal, Gessner, Weicard, quoted by Foderé,” and
also by Mahon,f in which it was removed by local
stimulants.
Strictures in the urethra, when the canal is greatly
diminished, may oppose such a barrier to the exit of
the semen as to render the individual impotent; but it
is extremely difficult to ascertain to what extent a
stricture may exist without producing this effect. We
know that many persons in whom strictures in this
canal are found do not lose the procreative power, and
* Méd. Lég, tom. 1, p. 382. + Ib. p. 58.
343
therefore, unless in extreme cases, where the finest
bougies are with difficulty passed, we should be cautious
in assuming this as a cause of impotence. The open-
ing of the conjoined ducts of the vesiculae seminales
and vasa deferentia may be closed by scirrhous en-
largement of the neck of the bladder, by enlargement
of the prostate gland, a scirrhous state of the veru-
montanum, or by disease of the duct itself. Foderé
alludes to the cases of two individuals mentioned in a
French Journal,” who having full powers of copulation
could never expel semen. On examination after death
the seminal ducts of one were found filled with matter
of stony hardness; and in the other the extremity of
these ducts was callous and blocked up. All these
causes produce inability for procreation by obstructing
the passage of the semen, although this fluid be duly
secreted.
But the cause of impotence may lie in the secreting
organ itself, the texture of which is so altered by disease
as to interrupt the performance of its natural function.
Thus scirrhus, cancer, scrofula, when they effect the
entire substance of the testicle, produce such an obliter-
ation of its intimate structure that the seminal fluid is
no longer formed. The form of disease described by
Andral must be considered as belonging to this class :
“Un état d'induration grise ou blanche du parenchyme
“avec disparition des conduits séminiferes; le testicule
“représente alors une masse homogene, dure, ou l'on
“ne trouve plus aucune trace de son organization
“primitive.”f But in order to constitute complete
impotence it is necessary that both testicles should be
implicated, and that the disease pervade the entire
* Journal de Médecine de Paris, Ann. 1680.
+ Amat. Pathol, tom. 2, part xi. p. 669.
344
organ ; for a small portion of the gland remaining un-
injured may be still capable of secreting semen in a
quantity sufficient for impregnation. “In the first
“method adopted in the East for making eunuchs, we
“are informed that the masculine efficiency was de-
“stroyed by bruising the testes, (a method of castration
“still pursued in some places with regard to animals,)
“ and destroying their functionary powers along with
“ their organization. Instances of generating, however,
“seem to have occurred among eunuchs made in
“this manner, and are explained on the supposition
“ that part of the testes remaining uninjured was still
“capable of preparing the necessary secretion, and fur-
“nishing it to a certain extent.”
Local injury may be followed by atrophy of the
testicle, and it is well known that a state of complete
inaction, such as is observed in those who have main-
tained a strict monastic life, is often attended by a
similar result. Elephantiasis is said to cause a wasting
of the genitals and a loss of all sexual appetite; but this
is denied by other authorities. A species of idiopathic
atrophy of the testicles is described by Baron Larrey,
which affected many of the French troops on their
return from Egypt. In these cases the organs became
soft to the touch, and gradually diminished in size
without any pain. Foderé mentions that he observed
in some young deserters condemned to work at the
canal of Arles, that the testicles melted away just as if
they had never existed.;
Diseases of the neighbouring parts may also prove a
source of impotence, by affording obstacles to the
venereal congress. These are extraordinary obesity,
* Dr. J. G. Smith, Forensic Medicine, p. 450.
t Méd. Lég. vol. 1, p. 369.
345
and very large scrotal hernia and hydrocele. Obesity,
when extreme, must be considered a disease; of this,
Martin, king of Aragon, furnishes a striking example.
“He is stated by historians to have been so corpulent
“that neither mechanical contrivances nor medical
“treatment could render him any assistance towards
“the accomplishment of venereal congress.”* Large
scrotal hernia and hydrocele, by distention of the in-
teguments, cause recession of the penis, and render
coition impracticable. Besides, these tumors are con-
sidered by Foderé to impede the secretion of semen,
either by causing too great tension of the spermatic
vessels, or by so compressing them that their diameter
is obliterated. This effect, however, must be of rare
OCCULI'I'ên Ce.
2. Functional.—One of the most remarkable changes
which take place in the transition from youth to man-
hood is the development of the sexual organs, and the
new train of sensations by which it is accompanied.
Puberty is the season of life when the generative func-
tion is called into active operation, and unless impaired
by excesses or disease, it usually continues in vigour
until the sixty-fifth year. “The genital organs,” says
M. Virey, “offer two states during life, in the young
“ and old, which are the frozen zones of existence ; the
“intermediate state is the torrid zone of life. The
“infant has nothing to give, the old has lost all.” f
This doctrine, however, must not be received without
limitation ; for instances of precocity, as well as of pro-
tracted generating power, are not wanting. Dr. Ryan'ſ
cites some examples of children precociously developed,
* Paris and Fonplanque, Medical Jurisprudence, vol. 1, p. 369.
t Ryan's Medical Jurisprudence, p. 124.
I Loc. cit.
346
even before the fourth year; and he alludes to a case
of a boy described by M. Wirey, who at seven years of
age was as fully developed as an adult, and who made
the most furious attacks on his female acquaintances,
and absolutely deprived one of them of that which she
could never regain. Instances of vigorous senectitude
are also occasionally met with. Of these the case of
the celebrated Thomas Parr is, perhaps, the most strik-
ing. He married at the age of one hundred and twenty,
and was compelled to do penance for an amour in his
hundred and fiftieth year. But looking on these as
exceptions to the general rule, it may be said that ex-
treme youth or old age are incompatible with the
exercise of the generative function.
There are, moreover, certain states of the body in
which, although the genital organs be perfect, impo-
tence may nevertheless exist, in consequence of inca-
pability of erection. This may arise from constitutional
frigidity, or what may be termed the apathetic tem-
perament. The offspring of infirm aged persons, of
parents too young, or of those worn down by debauch-
ery, often present examples of this condition. The
appearance of persons of this temperament is thus
described by a French writer :* “The hair is white,
“fair, and thin, no beard, countenance pale, flesh soft
“ and without hair, voice clear, sharp, and piercing, the
“eyes sorrowful and dull, the form round, shoulders
“strait, perspiration acid, testicles small, withered,
“pendulous, and soft ; the spermatic cords small, the
“scrotum flaccid, the gland of the testicles insensible,
“no capillary growth on the pubis, a moral apathy,
“ pusillanimity, and fear on the least occasion.” Impo-
tence arising from this cause is usually incurable.
* Dict, des Sciences Méd. art. Impwissance,
347
A more common source of impotence is a particular
weakness of the generative organs arising from too
early coition, from abuse of venereal pleasures, or from
indulgence in the pernicious crime of masturbation.
In persons whose organs are debilitated by these causes
erection does not take place, although the mind be
highly excited by lascivious ideas. The erector muscles
have lost power from over use, and are to a certain
extent paralysed ; and if semen escapes, it is clear,
serous, without consistence, and consequently deprived
of prolific virtue.
Among the causes of general debility capable of
producing impotence have been reckoned defect of
nourishment, bad quality of food, and unwholesome
regimen. But we would observe that these influences
must be exerted to the very extreme before they can
produce the effect described, for in Dublin, where
misery, poverty, and starvation exist to a degree per-
haps unparalleled on the face of the globe, procrea-
tion proceeds with extraordinary rapidity; and it has
fallen to the writer's lot, through his connexion with
the Coombe Lying-in Hospital, to witness the birth of
numberless infants whose unfortunate parents had not
for years partaken of a wholesome meal.
The habitual abuse of spirituous liquors, long watch-
ing, excessive evacuations of blood, bile, saliva, or
faeces, as they tend materially to depress the powers of
the constitution, may prove temporary causes of im-
potence. To this class Marc” adds the sedative action
of opium, hyoscyamus, and tobacco. The influence of
the narcotic gases, in consequence of the sedative effects
they produce on the sensitive system, sometimes give
rise to a temporary impotence. Of this the following
* Dict, des Sciences Méd. art. Impwissance.
348
case given by Foderé is a good example. “J'ai traité
“un homme àgé d'environ quarante ans, qui, ayant
“échappé à un étát apoplectioue occasioné par la
“vapour du charbon, reste tellement impuissant pen-
“dant six mois, qu'il étoit absolument insensible à
“toutes les caresses que sa femme, qu'il aimoit jusqu’
“à la jalousie, mettait en usage pour l'exciter. Il
“reprit complètement ensuite son étát naturel.” Cer-
tain substances, as the nymphaea or water-lily, nitre,
camphor, colchicum, and indeed most of the diuretics,
have been supposed to exert directly sedative effects
on the generative organs. That this specific action
can cause impotence is probably too much to assert,
although some writers have done so ; but from the
beneficial effects we have obtained from the use of
nitre and camphor in cases of over-excitement of the
generative apparatus, attended with nocturnal emis-
sions, it would appear that these substances are pos-
sessed of properties which tend to moderate the venereal
appetite. We have heard of a patient rebelling against
the continuance of the use of colchicum, in consequence
of its impairing his virility. Dr. Paris mentions a
peculiar species of impotence arising from debility
which deserves notice. “It depends,” says he, “upon
“a want of consent between the immediate and secon-
“dary organs of generation ; thus the penis acts with-
“out the testicles, and becomes erected when there is
“ no semen to be evacuated ; while the testicles secrete
“too quickly, and an evacuation takes place without
“any erection of the penis.”f
We have aleady alluded to the effects of strict chastity
on the testicles. In this state of decay impotence is
* Méd. Lég. tom. i. p. 382.
t Med. Jur. vol. i. p. 208.
349
the final result. There are some diseases which stimu-
late the generative organs, such as gout, rheumatism,
hemorrhoids, calculus in the bladder or kidneys: in
the latter disease the constant irritation propagated to
the glans penis frequently urges the sufferer to coition
even during the most severe pain. But there are others
which extinguish venereal desire during their continu-
ance. These are nervous and malignant fevers, which
engage the sensorium from their commencement, and
are accompanied with general weakness and prostration
of excitability; and disease of the brain and spinal
cord, occasioned either by internal or external causes.
Hennen” mentions a case of a soldier who was rendered
impotent by a blow on the occiput. With reference to
the effect of disease on the generative function, Foderé
mentions a circumstance worth being remembered,
which is, that it is possible that certain diseases may
produce such an alteration in the constitution, that an
impotent man may find himself cured of his impotency
on their cessation. He adduces the instance of Aven-
yoes, who stated he had been without offspring during
the whole of his youth, but became a father on recover-
ing from a severe fever. Zacchias states a similar
instance. An artizan lived twenty-four years with his
wife without having children, when he was attacked by
an acute disease from which he recovered ; the fruit of
his convalescence was the birth of a son, after which he
had many children. It is well known that persons
recovering from acute diseases are often extremely
salacious. Dr. Dunlopf gives an instance of this on the
authority of a friend who visited the hospitals in New
York, and who stated that patients recovering after the
* Military Surgery.
t Beck's Med. Jur. by Dunlop.
350
yellow fever exhibited most furious sexual passion, to
the great inconvenience of the nurses and their assist-
antS. - -
3. Moral.—We have already treated of those causes
which produce permanent impotence, and of those
disturbances of the constitution which during their
continuance suspend the generative function : we have
now to observe upon those causes which in a sound con-
stitution, with perfect genital organs, are capable of
suspending their action, but the cessation of which
leaves them free to fulfil their office. These are strong
mental emotions, such as too ardent desire, fear of not
being loved or of being incapable, shame, timidity,
surprise, jealousy, hatred, disgust, in short any thing
by which the mind is forcibly arrested. A temporary
impotence from this class of causes is by no means a
rare occurrence. Of all the causes just mentioned, the
fear of incompetence is most frequently productive of
impotence. It was a knowledge of this fact which led
Hunter to adopt the remarkable mode of treatment
which proved so successful in a case of impotence. He
prevailed on the person to promise on his honour to
pass six nights in bed with a young woman without
attempting sexual intercourse, and before the allotted
time had expired the patient's only fear was lest the
force of desire should induce him to break his promise.
Similar instances have occurred to most medical men,
and have been cured by the same means. The facility
with which the most vigorous man is rendered impotent
by this cause led to the supposition that supernatural
agents were concerned in effecting it, and the natural
credulity of mankind soon confirmed the idea. This
belief in the powers of enchantment, or, as the French
term it, “nouer l'aiguillette,” has prevailed in most
351
ages and countries. We have accounts of it in the
East, in Egypt, among the Greeks and Romans; and
even some of the early fathers of the church, St. Jerome
and St. Augustin, are said to have been imbued with it.
Like other forms of enchantment, persons were found
who made it their business to practice it, and even
princes were subject to their dominion. Nero and
Amasis were, at the suggestion of their concubines,
rendered impotent by incantation. In this process
there was always something to arrest the imagination ;
some drug was administered, some obscure and unintel-
ligible words were pronounced, or written on paper with
blood, and tied about the victim's neck; a lock of his
hair was tied, with certain mysterious ceremonies, or
some other equally absurd practice pursued, no matter
what, so that the proper impression was made upon
the mind, and as long as this continued, it had the
power of preventing erection by the very fear of
failure. The progress of knowledge has done for this
species of witchcraft what it has for others, and it
is now confined to the lowest and most ignorant
people.
II. Impotence and sterility in the female.—It is neces-
sary to distinguish between these two conditions in the
female, as it is quite possible for a woman to be impotent
and not sterile, and sterile but not impotent; in other
words, there may exist a malformation of the genital
Organs of such a nature as to prevent intercourse, on
the removal of which she becomes fruitful; and, on the
other hand, she may be perfectly competent to copula-
tion, yet never conceive. The latter is by much the
most common, and is believed to occur more frequently
in the female than impotence does in the male. Strictly
speaking, impotence can only be said to exist in the
352
female when the vagina is incapable of admitting the
penis. By this incapacity, however, sterility is not
always insured, as it will appear from cases to be pre-
sently alluded to, that impregnation has taken place
when intromission was impossible. But laying aside
these instances as exceptions, it may be stated generally
that an impervious vagina is attended with impotence.
Such a condition of the ſemale organs may be the
result of various causes existing either in the hard or
soft parts. It is rare to find the impediment originating
in the former, but Foderé alludes to a malformation of
the pelvis, such as considerable depression of the pubis,
or exostosis, as capable of opposing the act of generation:
we cannot, however, believe that deformity of the pelvis
caused by approximation of the pubis and sacrum can
offer such a barrier as he supposes; and we are strength-
ened in our disbelief by the many instances recorded,
in which impregnation took place notwithstanding the
highest degree of deformity. But an exostosis, when
it attains a great magnitude, may very well prove an
obstacle to coition. The cause of impotence is more
frequently found in the soft parts, and this may be
absence or occlusion of the vagina. Cases in which the
vagina was altogether wanting are not numerous, but
there are some recorded, and of these one of the most
remarkable is detailed in the Causes Célèbres.* We
will not give the case at length, but the leading facts
were the following. A young woman in Paris was
married in her twenty-fifth year to a young man named
La Hure. Six years were passed without consumma-
tion of the marriage; and then the woman was ex-
amined by a midwife, who declared all the external
* Tom. vii, and x., Vingtième Cause.
353
organs of generation wanting, and their place occupied
by a solid body pierced by a small hole. The woman
admitted that she had never menstruated; nevertheless
she had always enjoyed good health. A surgeon,
named Dejours, who saw the case at this time, supposing
it one of simple occlusion of the vagina, proposed to
divide the barrier, in hopes of reaching and laying open
the cavity. He accordingly carried a scalpel to the
depth of two fingers' breadth, but instead of reaching a
vagina, he was still opposed by solid resisting parts.
Finding this, he judged that he had nothing to hope
for in going further, and that he should run great risk
of wounding the bladder or rectum. He therefore en-
deavoured to keep open the wound he had made by
the introduction of tents, and this opening remained
during life. Matters continued quiet for eight years
more, when the husband, disgusted with his wife, de-,
manded a divorce. The woman died at Lyons ten years
afterwards, and on examination it was found that the
place of the vagina and uterus was occupied by a hard
compact substance, in which no cavity could be traced.
Not long ago a case somewhat similar was exhibited to
the Society of the Faculty in Paris, in which no uterus
or vagina existed, and the perinaeum was pierced by a
small hole, which was the termination of the urethra.
A more common case is that in which the calibre of
the vagina is so diminished as to resist the intromission
of the penis. Several instances of this malformation
are to be found in writers on legal medicine and mid-
wifery, one of which we may mention, as it affords a
striking example of the manner in which nature accom-
modates parts to the offices they are called on to perform.
A young girl, married at the age of sixteen, had the
vagina so narrow that a goose-quill could scarcely
23
354
enter it. A young and vigorous husband had failed in
all his attempts, and some of the faculty who were
consulted declared copulation impracticable. Never-
theless, after eleven years this woman became pregnant
without any increase in the dimensions of the vagina.
Her friends of course despaired of the possibility of
delivery ; but about the fifth month of pregnancy the
vagina began to dilate, and at the full time it had ac-
quired a size sufficient to admit the passage of the
infant.* In the celebrated Joan of Arc, the Maid of
Orleans, according to the account of two physicians who
were ordered to examine her, the vagina was found so
contracted that coition must have been impracticable.
Malformation of this kind is frequently removable by
appropriate treatment. In a case which occurred to
Benevoli, he employed emollient fomentations and tents,
and by gradually increasing the size of the latter, suc-
ceeded in removing the imperfection.
In those cases in which the uterus is divided longitu-
dinally into two chambers, it sometimes happens that
the septum is prolonged into the vagina, even to the
vulva.f. In this condition of parts, if the intervening
membrane be firm and rigid, it may oppose a barrier to
coition. The vagina may also be too short, and termi-
nate abruptly in a cul de Sac ; this disposition of parts
may be congenital, but it may also be the result of
difficult labour. When congenital, it is usually attended
by absence of the uterus.
The inflammation which sometimes follows difficult
labours (particularly if instruments have been incau-
tiously used) has been known to cause adhesion of the
sides of the vagina, and so cut off all communication
* Mém. de l'Acad, des Sciences de Paris. 1712.
+ Andral.
355
with the uterus. The writer is acquainted with a very
remarkable instance of this accident at present” in the
Coombe Lying-in Hospital, Dublin. The sufferer is a
young healthy woman, in whom there is a fistulous
opening between the bladder and the vagina, and just
beyond the opening the sides of the vagina adhere firmly.
She applied at the hospital in hopes of obtaining some
relief from her miserable state, which she said was the
consequence of a tedious labour, during which instru-
ments of some sort were employed. It is remarkable
in this case, that although the outlet for the menstrual
discharge is closed, there is no indication that it is
poured out by the uterus, for none of the signs of con-
fined menses are present. We are therefore inclined to
suppose that the cavity of the uterus itself has been
obliterated by the inflammation, and consequently that
an operation would not be attended with success.
The vagina is frequently found closed at its orifice;
this may be caused in different ways. It is sometimes
produced by neglected inflammation and excoriation
of the labia in children, and even in adults; and this
has extended in some cases to a complete closure of the
canal, so that no passage has remained but a small one
at the superior anterior part for the discharge of urine.
Dr. Ryani states that he has seen four cases of cohesion
of the labia externa at the age of puberty, so complete
that only a small probe could be introduced at the
superior commissure. Dr. Merriman once met with an
instance where the entire opening of the labia was so
perfectly closed, in an infant of two years old, that there
was not the smallest aperture through which the urine
* This was in the year 1833.
+ On Difficult Parturition, 3d edit., p. 129.
23%
356
could escape.* We find in the works of Ambrose Paré,
Ruysch, Fabricius Hildanus, Benevoli, and others, ex-
amples of complete obstruction of the vagina, either at
its orifice or at a greater or less depth, by a membrane
of such strength as to resist intromission. Dr. Merri-
mani relates the case of a young woman whom he was
called to attend in her first accouchement, and on pro-
ceeding to make an examination he found it impossible
to introduce his finger into the vagina, that passage
being closed by a membranous expansion about one-
tenth of an inch in thickness. This membrane occupied
the entire opening of the vagina, with the exception
of a small aperture through which a pea could hardly
have passed. It was finally ruptured by the child's
head, and delivery was safely accomplished. The same
author gives another case related by Dr. Tucker, in
which the obstruction was even more complete. “The
“labia pudendi were observed to have the usual situa-
“tion and appearance; but being expanded, they were
“discovered to be connected to each other by a strong
“opaque membrane, nearly a finger's breadth, not dis-
“tinguishable from their external skin in texture and
“appearance, which was stretched from the surface of
“ the perineum (of whose outward skin it seemed like-
“wise a continuation or production) over the longitu-
“dinal sulcus between the labia, and over the clitoris,
“quite to the pubis. About the middle of this mem-
“brane there was a circular aperture, with a strong
“ring, just large enough to admit a female catheter
“one-eighth of an inch in diameter.” In this case the
membrane was so strong that it resisted the forcible
impulse of the child's head during several pains, and
* Manual of Med. Jurisprudence, p. 221.
+ Loc. cit. p. 216.
357
was at last divided artificially from the aperture to the
frenum labiorum. These and many similar instances
on record are the cases to which we referred in speaking
of hypospadias, as confirmatory of the doctrine laid
down there, viz., that an emissio seminis at the orifice
of the vagina is sufficient for impregnation, and they
afford instances of what may be considered paradoxical,
that is, of women being impotent, yet conceiving. The
following case from Foderé is so striking that we cannot
omit to mention it. A young man had married a young
woman, with whom, although he had frequently made
the attempt, he could never consummate the marriage,
“à son gré.” At the end of three months he demanded
a divorce, although she declared herself pregnant. She
was now examined by many skilful surgeons, who found
a hard callous membrane placed at the mouth of the
vagina; this they divided, and the operation succeeded
so well that the husband relinquished his claim for
divorce. The woman was delivered, in six months after
the operation, of a male infant at the full term, and of
great vigour. From these cases it is plain that this
hypertrophied state of the hymen, although it affords
a barrier to copulation, is yet capable of removal by
operation, and therefore it cannot be considered as a
permanent cause of impotence.
Narrowness of the mouth of the vagina is sometimes
accompanied by a communication between that canal
and the bladder or rectum. Foderé states two cases of
this description, in both of which sterility prevailed.
Procidentia of the uterus might be supposed to create
impotence, were it not that some very remarkable
instances of the contrary are recorded. In the fourth
volume of the London Medical and Surgical Journal
358
is a description of two cases of this disease, in both of
which impregnation took place, although the natural
orifice had been fixed without the vulva for years.
We now come to speak of sterility, or of those cases
in which, the vagina being pervious, impregnation does
not occur. This may depend upon imperfect develop-
ment or total absence of the uterus, obliteration of its
openings, diseases of this organ, obstruction or disease
of the fallopian tubes, and absence or disease of the
ovaria. That form of imperfection in the uterus in
which one-half of the organ is wanting, and which case
is attended with but one ovarium and one fallopian
tube, does not entail sterility. Chaussier relates a case
of this kind in which several children were born at the
full time.* But there is a variety sometimes found
which must render the woman barren ; in which the
uterus is so small that it is with difficulty found in the
pelvis, and the fallopian tubes appear to terminate in
the extremity of the vagina. We have already said
that unnatural shortness of the vagina is frequently
connected with absence of the uterus. Columbus dis-
sected a woman who had always complained of great
pain in coitu, in whom he found the vagina very short,
and no uterus at its termination. A similar case oc-
curred to Dupuytren :f the vagina was only one inch
in length, the ovaria and fallopian tubes were well
developed, but no uterus existed. Foderé states that
this malformation may be discovered during life by the
smallness of the breasts, &c.; but in the case mentioned
by Dupuytren the breasts were well formed, the external
genitals developed, and the whole appearance was femi-
nine. It is plain that sterility must attend this defect.
* Andral.
t Répertoire d'Anat. Pathol. t. v. p. 99.
359
The different orifices of the uterus may be obliterated,
and thus impregnation will be prevented. The open-
ing of the fallopian tubes has been found closed; and
this may be owing to a simple continuation of the
lining membrane of the uterus over it, or to the
existence of a particular membrane blocking up the
mouth of these tubes, or to an obliteration of the tube
itself, which sometimes extends to the distance of some
lines from the uterus. When both tubes are thus
circumstanced, no utero-gestation can go forward, for
obvious reasons. But the mouth of the uterus itself is
occasionally obstructed either by an adventitious mem-
brane stretched across, or by an agglutination of its
sides; and when this is the case, sterility is the result.
Besides the closing of the uterine extremity of the
fallopian tubes, these canals are sometimes impervious
throughout their whole extent; sometimes the ob-
struction is situated about the middle, and at others
the fimbriated extremities alone are blocked up ; and
this latter is frequently caused by an intimate adhesion
between them and the ovaria.”
The ovaria are sometimes wanting. This deficiency
may exist at but one side, a specimen of which is pre-
served in Dr. Hunter's museum ; and Dr. Baillie takes
notice of others in which these organs were deficient on
both sides. Dr. Denman says he was shewn two pre-
parations by Dr. R. Hooper, in which the fallopian tubes
terminated bluntly, and without any aperture, fimbriae,
or ovaria.f
Besides these impediments to impregnation, there
are certain diseases of the female genital organs, which,
when they exist, are found to cause sterility. Polypus
* Morgagni. Bailly. Richerand. Andral.
f Denman's Midwifery, sixth edition, p. 42,
360
in utero is very generally considered to belong to this
class; but although the opinion is generally correct, it
is not universally true, for it has happened that concep-
tion took place notwithstanding the presence of a very
large tumor in the uterus. Of this the late Dr. Beatty”
has described a very remarkable instance, which oc-
curred in Dublin in the year 1820. The patient was a
lady twenty-five years old, who, in consequence of the
indisposition of her husband, had left his bed in May,
1819, to which she did not return until August, 1820.
In the previous May she first perceived what she termed
a “lump in her womb,” attended with external swelling
and soreness on pressure at the lower part of the abdo-
men. This swelling was not permanent, but was ob-
served to disappear during the menstrual period.
Finding an increase in her unpleasant symptoms, she
applied to Dr. Beatty in September, and on the 28th of
that month he made an examination per vaginam.
The os uteri was found dilated to the size of a dollar,
and in its opening was a large dense substance with a
regular smooth surface. On the 10th of November,
while out in her carriage, she had a moderate discharge
of blood from the vagina, and upon examination the
parts were found as they were a month before. At two
o'clock the following morning she miscarried, the em-
bryo was entire, the membranes not being ruptured ;
the contained foetus was about three months old—a
period corresponding with the time at which connubial
intercourse had been resumed, and at which she had
last menstruated; and just three months after she first
experienced uterine uneasiness. The tumor was ex-
pelled in six days afterwards by pains resembling labour,
* Trans, of the Association of Coll. of Phys. in Ireland, vol. iv.
361
the uterus was inverted by its descent, but on separa-
tion of the slight attachment between it and the tumor
it was easily reduced. The weight of the tumor was
found to be nearly four pounds. This lady was deli-
vered of a healthy boy on the 10th of February, 1822.
This was an instance of pregnancy occurring during the
existence of a tumor of considerable magnitude in the
uterus; but we believe it to be an exception to what
usually takes place.
Diseases of the ovaria in which the natural structure
of these organs is obliterated, and both of them en-
gaged, are obstacles to impregnation. Leucorrhoea,
when profuse, is also very often attended with barren-
ness; but this is by no means a constant effect, as we
have known instances in which this disease existed to
a great extent without preventing impregnation.
A question has arisen whether menstruation is neces-
sary in order that a woman shall be prolific ; and it is
often said that women who do not menstruate cannot
conceive.* This is generally true when applied to those
who have never menstruated, but is not so in cases that
have had even a single monthly discharge. Foderéf
states that in the first edition of his work he had
maintained that females who do not menstruate are
sterile; but he was afterwards obliged to change his
opinion, from having observed some patients under his
own care enjoying good health without this evacuation,
and bearing many children. One of them was a woman
thirty-five years old, the mother of five children, the
last of which she was suckling. She was in good robust
health, and had never menstruated but once at the age
of seventeen years. It would appear that a single oc-
* Paris and Fonblanque, Med. Jur. vol. 1, p. 214,
t Méd. Légale, vol. 1, p. 397, ed. 2me.
362
currence of this periodical evacuation is a sufficient
indication of generative power; and although irregu-
larity in subsequent years is frequently attended by
sterility, it is not to be taken as an absolute cause of it.
There is a form of dysmenorrhoea described by Dr.
Denman* and Dr. Dewees’f of Philadelphia, which both
these authors state to be productive of barrenness.
The striking peculiarity in this disease is the formation
of an adventitious membrane in the uterus, which is
expelled after severe and protracted suffering at each
menstrual period. This membrane is sometimes thrown
off in pieces, and at others entire, at which time it
bears the strongest resemblance to the decidua, so much
so that, when it occurs in unmarried females, it may
and sometimes does give rise to most painful suspicions.
There is a preparation in the Museum of the College of
Surgeons, Dublin, of an entire membrane of this kind,
which might deceive the most experienced eye. Mor-
gagni relates a very remarkable instance in which
pregnancy occurred during the existence of the habit
just described ; but it is probable that in that case there
was a suspension of the disease for a time when the
capability of conceiving might exist.
It is well known that instances have happened in
which persons who have lived for years in unfruitful
matrimony, being divorced, have formed new alliances,
and have both had children. This is a fact which in
the present state of our knowledge we are not able satis-
factorily to explain, and we will not delay the reader by
offering any speculative opinion upon it.
Treatment.—The treatment of impotence and sterility
must be influenced by the causes from which they
* Denman's Midwifery, 6th edit. p. 90.
+ Dewees' Midwifery, p. 154.
363
spring, some of which are incurable, while others may
be removed by appropriate remedies. Those cases
which depend upon congenital deficiency of the penis,
testicles, vagina, uterus, fallopian tubes, or ovaria,
belong to the former ; but we have seen that some of
those arising from malformation and disease of these
parts are susceptible of cure. Such are phymosis,
adhesion of the prepuce to the glans with diminution
of the orifice of the urethra, priapism, partial paralysis,
strictures in the urethra, diseases of the neighbouring
parts, contracted vagina, occlusion of the mouth of this
canal by adhesion of the labia, or by a dense hymen,
prolapsus and procidentia uteri, polypus in utero, leu-
corrhoea, dysmenorrhoea; all these are more or less
capable of removal either by operation or general treat-
ment. The cases of impotence which depend upon
functional or moral causes are much more numerous
than those just mentioned, and frequently become the
subjects of medical treatment. If old age be the cause,
there is little to be done; medicines are useless, and
temporary stimulants are often worse. There have
been instances of old debauchees, who, wishing to make
a last attempt, have taken some of the nostrums, such
as the Venetian pastilles, Italian lozenges, &c. and have
perished without success in the very effort. Cases
arising from debility of the generative organs, from too
early coition or the abuse of venereal pleasures, are not.
unfrequently met with, and indeed furnish the great mass
of dupes to quackery. In the treatment of such cases
there are many points which must be strictly attended
to. We must be careful to remove from the imagina-
tion or regimen all that may excite the generative
apparatus, while we endeavour to strengthen the sys-
tem by mild nourishing diet and gentle tonics. We
364
must combat on the one hand muscular weakness, and
on the other nervous susceptibility, and so restore the
equilibrium between the two systems. The local appli-
cation of cold water has a great effect in allaying the
excitable state of the generative organs, and should be
had recourse to at least twice a day. If the impotence
be owing to moral or physical irritation, the constitu-
tion must be lowered by spare diet, cooling acidulated
drinks, exercise in the open air, and removal from all
objects which excite venereal desires. This plan of
treatment we think preferable to the employment of
narcotics, which sometimes produce unpleasant effects,
and are always hurtful to the digestive organs. In
those cases which are purely the effect of atony of the
generative organs, and do not arise from their over-
excitement, a different line of conduct must be pursued.
The diet should be full and generous, with a liberal
allowance of spices and wine ; and the exclusion of all
objects of a nature to excite the senses need not here
be recommended. Frictions to the loins, and the
cold bath, will be found useful; sometimes it will be
necessary to substitute the warm bath when the cold
does not produce the healthy reaction we desire. If
these means fail, we may then have recourse to stimu-
lating applications to the loins, thighs, and pubis, and
electricity may be used with advantage. In the year
1776, Dr. Graham opened an establishment in London,
in which were a number of electrical beds, destined to
awaken the dormant generative powers in cases such
as we have described.
Modern systematic writers have discarded that class
of medicines formerly grouped together under the name
of aphrodisiacs, from their supposed power of exciting
365
a desire for venery : it consisted of stomachics, aro-
matics, oderiferous gums, balsams, resins, essential and
volatile oils, perfumes, particularly musk, phosphorus,
opium and aromatics combined, and cantharides. These,
with the exception perhaps of cantharides, seem to act
only as general stimulants, and do not possess any
specific powers over the organs of generation. Can-
tharides, as is well known, when administered in large
doses, are sometimes capable of inducing a violent state
of irritation of the urinary and genital organs, indicated
by strangury, bloody urine, priapism, &c.; but this
condition can never be induced without other violent
constitutional symptoms being also brought on, to the
great hazard of life;” and we are much inclined to
doubt that a person labouring under these effects is dis-
posed to venereal enjoyments. However, cantharides
have been for a long time employed as an aphrodisiac,
and for this purpose they entered into the composition
of many secret remedies, such as the Venetian pastilles,
Italian lozenges, love-potion of Italy and Turkey, &c.
to the use of which we believe many have fallen victims.
The “remède de magnanimité” of Koemfer, so called
after its inventor, is composed of opium, musk, and
ambergris, and is extensively employed in the East,
where it is taken daily by the great for the purpose of
exciting venereal desires.
From what has been said in commenting upon the
different causes of impotence, it is unnecessary to pro-
long this article by any further notice of their medico-
legal application; we will therefore conclude by de-
ducing, in the words of Dr. Ryan, from the preceding
statements, the following general principles:–
* Christison on Poisons, p. 456.
366
“1. To declare either sex impotent, it is necessary
“that certain physical causes be permanent malforma-
“tions, or accidental lesions, and be evident to our
“senses, which art cannot remedy, and which prevent
“ the faculty of exercising a fecundating coition.
“2. These causes, when rigorously examined, are
“few in number.
“3. The moral causes of impotence ought not to be
“taken into consideration, as they would serve as an
“excuse for an individual accused of impotence.”
* Ryan's Medical Journal, p. 133.
367
CHAPTER XVI.
Rape.
THE high value set upon female purity, and the heavy
penalty incurred by its loss, in the banishment of the
delinquent from society, have led most civilized coun-
tries to inflict the severest punishments on the indi-
vidual guilty of a forcible violation of the weaker sex.
When we consider, on the one hand, the condition of
a virtuous female thus plunged into an abyss of misery,
a release from which by death has been voluntarily
sought by many; and, on the other, contemplate the
number of profligate persons who are found in all
countries and societies, whose chief occupation seems
to be the corruption and debasement of the female sex;
we cannot fail to rejoice that the strong arm of the law
should interpose its protecting shield, and visit with its
severest judgments one of the grossest crimes which a
man can perpetrate. By the law of England, rape is
defined to be the carnal knowledge of a woman by force
and against her will, and until the passing of the act
4 & 5 Vic. c. 56, s. 3, by which transportatton for life
has been substituted, death was its penalty. All classes
of females are equally protected. Even the common
prostitute is included, because she may at the very time
have determined on a reformation of her former habits.
In Scotland, before the passing of the act just quoted,
the ravisher was exempted from the pains of death only
368
in case of the woman's subsequent consent, or her decla-
ration that she yielded of her own free will; and even
then he was to suffer an arbitrary punishment either by
imprisonment, confiscation of property, or a pecuniary
fine.” In the State of New York death was formerly the
punishment for committing a rape on a married woman
or a maid ; and it was also ordained at the same time,
that if a woman had been ravished, and afterwards
consented to her ravisher, her husband, father, or next
of kin might sue by appeal against such offender.
These laws, however, have been repealed, the punish-
ment altered, and appeals of felony abolished. The
acts now in force prescribe the punishment of imprison-
ment for life in the state-prison of the offender and of his
accomplices, if he have any, for ravishing by force any
woman-child of the age of ten years and upwards, or
any other woman. An assault, with an intent to com-
mit a rape, may be punished by fine and imprisonment,
or both.
In the case of adults, it is necessary, in order to con-
stitute a rape, that the act shall have been committed
against the will of the female ; but in the case of
children, in whom the power of judging between right
and wrong is not supposed to exist, the matter of con-
sent is of no moment, and the deed is equally criminal
whether it be obtained or not. “A female infant under
“ten years of age is in law deemed incapable of con-
“senting to any act, much less to her dishonour; the
“carnal knowledge of such infant, whether she yield
“ or not, is therefore virtually a rape; but whether, if
“ the child be above ten years of age, it be also a felo-
“ny has been questioned. Sir Matthew Hale was of
“opinion that such profligate actions, either with or
* Edin. Encyclop. vol. xi. p. 823.
369
“without consent, amount to rape and felony, as well
“since as before the statute of Queen Elizabeth ; but
“in his Summary, the learned judge appears to have
“altered his opinion ; and the present practice is that,
“if the child be under ten years of age, it is felony by
“ the statute; but if she be above ten and under twelve,
“ then it is no rape if she consented, but only a misde-
“meanour;” and this practice has now been made law
by the 24 & 25 Vic. c. 100, s. 51. The French code
extends the period to fifteen years, and punishes the
crime committed on a child of that age by hard labour
for a limited time.f “In New York the carnal know-
“ledge of a woman-child under ten years of age is
“punished by imprisonment in the state-prison for life.
“In Massachusetts and Illinois death is the punishment.
“In Virgina, New Hampshire, Connecticut, and New
“Jersey imprisonment either for life or a long term
“ of years is directed. All these specify the period
“of ten years. The law in Vermont varies from this.
“It directs that whenever any individual over the age
“ of fifteen shall abuse any female under eleven with
“ or without her will, he will suffer fine and imprison-
“ment.”
By the ancient law of England the woman was
required to make her accusation immediately after the
commission of the outrage. At a subsequent period
she was allowed forty days as the utmost limit; but by
the law as it at present stands there is no time of limit-
ation fixed. However, although there is no limit fixed
by law, public opinion demands an early discovery ;
and an accuser who has postponed her complaint for
* Paris and Fonblanque, Med. Jur. vol i. p. 419.
+ Capuron, p. 1.
£ Beck, p. 60.
24
370
any unreasonable length of time is listened to with
great caution by a jury. In fact, this is a crime so
easily charged, so hard to be proved, and so much
harder to be rebutted, that it is of the utmost import-
ance that no time shall be allowed for concocting a
malicious tale, particularly if medical testimony is to
be adduced, as a few hours are often sufficient to efface
appearances that might have been evident on an early
examination. Indeed, in all cases the greatest caution
is necessary in judging of the guilt of an accused party.
There is generally no witness to confirm the direct
testimony of the accuser as to the fact ; the whole case
turns upon the woman's assertion, and unless there is
strong collateral evidence, such as a speedy disclosure
to her friends and the authorities, and an early medical
examination, we are of opinion that it should require
the clearest and most unshaken testimony on the cross
examination to gain credence with a jury. It is better
-that ten guilty should escape than that one innocent
man should suffer; and however we abhor the crime,
and would wish the heaviest punishment to overtake
the guilty, we cannot help offering this caution to
medical men and jurors, knowing as we do the depravity
of the human heart, and the lengths to which it will
sometimes go to accomplish the ends of malice or
revenge. It is not impossible, nay, it has sometimes
happened, that a woman who has freely consented to
surrender her virtue will afterwards turn round on her
paramour, and denounce him as her ravisher. This
becomes a case of the greatest intricacy, from the fact
of the principal feature (that of the venereal congress
having taken place) being true. It now passes out of
the hands of the medical jurist, and becomes a question
with the jury whether they believe the deposition of
371
the woman as to consent or not. This, it must be
confessed, is a most difficult question to solve, and it
requires all the ingenuity of the bar to sift to the bottom
all external circumstances which may contribute to
prove the negative. Cases of a mixed kind are also
sometimes met with ; as when a woman will at first
resist the advances of a suitor, and even continue her
resistance for a time, but afterwards, from the excite-
ment of passion or some other cause, yields to his desire.
This is a case, if possible, more puzzling than the former,
because marks of violence on the limbs of the female,
from her previous struggling, may be evident, which
would naturally lead to the supposition that the act
had been accomplished by force. We confess that we
should be inclined to deal harshly with a man under
such circumstances, from the difficulty of understanding
what constitutes consent. The act is committed in
secret ; there are no witnesses; the woman is bruised
on the limbs and body, and her person is violated : it
is not likely that a formal question of “Will you con-
sent 7" has been put, followed by an answer of yea or
nay; and yet, after the employment of so much force,
the man defends himself by saying the woman consented,
which she denies. The jury alone can determine which
is to be credited ; but, as we have already said, appear-
ances are strongly in favor of the woman, and a strug-
gle of such violence and duration, followed by coition,
amounts, in our opinion, if not to a legal, at least to a
moral rape. Having spoken thus generally of some of
the difficulties attending the investigation of accusa-
tions of rape, we proceed to consider some of the points
upon which medical testimony is more particularly
required.
Of the physical signs of violation.—These are the
24%
372
absence of the signs of virginity, marks of violence,
tumefaction, or laceration of the pudenda, with effusion
of blood, and bruises on other parts of the body, parti-
cularly on the breasts, arms, and thighs. It must be
evident that the most important of these, that is, the
want of the attributes of the virgin state, together with
the injuries inflicted on the genital organs, as evidenced
by inflammation and tumefaction, cannot apply to all
women, but only to virgins; for in married women,
or those previously in the habit of sexual intercourse,
the negative signs are of course of no value, and the
positive are not likely to occur. And this narrows our
present observations to the signs of rape committed on
virgins.
The investigation of this subject must be preceded
by an exposition of the signs of virginity. This is a
question which has occupied the attention of anatomists
and physiologists from an early period; but it does
not appear that any very accurate conclusions have
been agreed upon.
The existence of the hymen is the sign upon which
the greatest stress has been laid by some authors, while,
strange to say, its presence has been esteemed by others,
among whom we find Ambrose Paré, Columbus, Dionis,
and Buffon, as an unnatural formation. However, at
the present day, it is generally considered as an attribute
of the human virgin. The hymen is a membranous or
membrano-Carneous structure, which is situated at the
entrance of the vagina, and serves to form a boundary
between that passage and the external genitals. It is
formed by duplicatures of the lining membrane of the
vagina, and is usually of a crescentic form, leaving an
opening into the vagina at its upper part. This opening
serves as an outlet for the menses, and in the average
37 3
of adult subjects is large enough to admit the index
finger sufficiently high up into the vagina, to effect an
examination of the os uteri, withoutinjury to the hymen.
Dr. Davis states that in breech presentations he has
sometimes introduced his finger into the vagina of the
infant without injuring this membrane. The shape of
this membrane, however, is various and uncertain. In
some cases it is more or less circular, presenting through
its centre a round aperture of three or four lines in
diameter. At other times only a part or exclusive
portion of the orificial extremity of the vagina, some-
times the superior, at other times the inferior portion
of it, is seen to be veiled over with this structure. In
some rare cases the hymen is an imperforate circular
membrane attached to the edge of the orifice of the
vagina in every part, so as to close the canal completely.
We have already alluded to some of these cases in the
preceding chapter. Another form of the hymen is,
when there are two crescental portions attached to the
more carneous structure of the external orifice laterally.
The structural tissue of the hymen seems in some mea-
sure to vary in different instances. “In most foetal
“subjects it seems to be distinctly membranous, whilst
“in some others it partakes also of a carneous character.
“Hence, probably, the very different descriptions given
“ of it by different authors. By Soranus it is accord-
“ingly described as being membranous; by Avicenna
“as venous and ligamentous; by Riolanus as carneous;
“by Berengarius as retiform, consisting of vascular and
“delicate ligamentous tissue , by Columbus as a thick
“substance ; and by Spigelius as partly carneous and
“ partly nervous.” In order to see this membrane in
* Princip. and Pract. of Obstet. Med. by Dr. Davis, p. 100.
374
the living subject, it is necessary to separate the labia
and even the thighs to a considerable distance from
each other; for the opening into the vagina is quite
closed up by the external parts in the ordinary positions
of the body. The hymen is usually torn up by sexual
intercourse, and its rupture is attended by an effusion
of blood; an appearance upon which so much reliance
was placed by the Jews as a test of virginity, that the
nuptial sheets were constantly exhibited to the relations
on both sides, and preserved by the friends of the
woman as evidences of her chastity. In case this token
of virginity was not found on them, she was to be
stoned to death at her father's door. After the rupture
of the hymen, its remains shrivel towards their base
into several small excrescences at the orifice of the
vagina. These are thick, red, and obtuse at their
extremities, and from their fancied resemblance to a
myrtle-berry, have been called carunculae myrtiformes.
They generally disappear after frequent connexions or
deliveries. The carunculae which are found at the
opening of the vagina are not, however, always remains
of the hymen. Dr. Conquest” remarks that the carun-
culae may be found when the hymen is entire. Dr.
Davist observes that the greater part of the circle at
the basis of the hymen when that structure remains,
and at the same locality when it has suffered rupture,
may occasionally be seen studded with caruncles of
different origin; such extra caruncles in some cases
being few and small, but in others large and numerous.
He alludes to one case, which was that of a young lady
of unquestionably good character, who, in consequence
of some irregularities imputed to a gay husband, to
* Outlines of Midwifery, p. 17.
f Loc. cit. p. 101.
375
whom she had been recently married, became the sub-
ject of a professional examination : there presented at
the orifice of the vagina on either side, and in imme-
diate contiguity to the carunculous remains of the
hymen, two large multifoliated masses of structure, dis-
posed in parallel layers in such a manner as scarcely to
fail to suggest the idea of a pair of epaulettes. These
are the forms under which the hymen is usually found;
but it should be borne in mind by the medical jurist
that it is liable to certain malformations, with which he
should be acquainted. It is commonly a thin membrane,
easily ruptured by any large body introduced into the
vagina. But it sometimes occurs that it is possessed of
so much firmness as to resist the intromission of the
penis. This unusual degree of thickness and strength
may belong to a hymen composed of one uniform
membrane ; or to that conformation of it termed cri-
briform, from its being pierced by a number of holes.
In this latter condition the membrane is commonly
exceedingly strong, and capable of resisting the ordi-
nary means of rupture. It is a state, however, that
does not prevent impregnation, some cases of which
are related by Dr. Davis; and as they relate to an im-
portant medico-legal point, we refer to them, in addition
to those already mentioned in the last chapter.
One of these cases of cribriform hymen we transcribe
in consequence of its great interest: “It was usually
“narrated in his peculiarly terse style by the late Dr.
“Haighton, in his lectures on midwifery in Guy's Hos-
“pital. The subject of it had been the lady of one of
“ the physicians to that or to the neighbouring hospital
“of St. Thomas. It was become matter of post-mortem
“ history even in the time of Dr. Haighton. The hymen
“was perforated by many small apertures; but it never-
376
“theless was so strong that it had resisted all the efforts
“of the husband to effect its rupture. That gentleman,
“however, concealed his chagrin ; nor did he take any
“means to accomplish artificially what he had failed to
“effect by the ordinary means. Under these circum-
“stances the lady drooped and became unhappy; but
“she also, at no distant period, became the subject
“ of faintings and sickness, and eventually of great ab-
“ dominal enlargement, and anasarca of her lower ex-
“tremities. During the urgency of these symptoms
“she was advised to go to Bath for the benefit of the
“waters and of the other good things to be obtained at
“that celebrated city. No remedy was found, how-
“ever, even there for the lady's dropsy, and the symp-
“toms became more and more urgent every day. Find-
“ing no relief at Bath, and giving up all hope of re-
“covery any where, she determined, after a residence
“ of some weeks at that place, to return to London, in
“ order that her remains might be more conveniently
“ deposited in the monumental vault of her family.
“Whilst on this journey, which she was performing in
“a post-chaise, she was seized with a severe abdominal
“ pain, which she naturally enough ascribed to a spasm
“of the intestines. This colic, which was moderate and
“bearable at the commencement, became so extremely
“violent in its progress, that she was obliged to stop
“suddenly at an inn on the road, where in less than an
“hour she was radically cured of her dropsy by becom-
“ing the mother of a well-grown living child. The
“hymen was thus ruptured without the assistance of
{{ art. 33%
We have alluded to these cases to shew that it is pos-
* Op. cit. p. 104.
377
sible for all the moral guilt of a rape to be incurred
without the conditions necessary to satisfy what formerly
was the law upon the point, namely, the intromission
into the vagina of the penis, &c. Nowadays, how-
ever, proof of penetration only is required. See 24 &
25 Vic. c. 100, s. 63. According to this statute, forcible
vulval penetration would seem to be as much a rape
as if the hymen had been ruptured, and perfect intro-
mission of the male organ into the vagina had been
effected.
Besides these sources of difficulty presented to the
medical jurist in malformation of the hymen, there are
some cases, and probably not a few, in which this mem-
brane has never existed at all; or having been at first
formed of great tenuity, has been ruptured and destroyed
in early life. Accidental circumstances may also serve to
obliterate it, such as disease, improper practices, or acri-
monious discharges; and instances are not wanting
where it has been destroyed by the pressure of the con-
fined menstrual fluid. From the cases alluded to above,
it appears that impregnation may take place without
rupture of this membrane, but in these instances perfo-
ration is not supposed to have occurred. It is, however,
stated by Zacchias that intromission may be effected
when a disproportion exists between the organs, when
the hymen does not exceed the ordinary size, but is
thick and hard, and when connexion has taken place
during the presence of menstruation, or fluor albus,
without damage to this membrane. Gavard* found it
perfect in a female thirteen years of age, who was labour-
ing under the venereal disease, Ruyschi has said that
* Foderé, Méd. Lég. t. iv. p. 340.
f Observ. Anat, Chirurg. xxii.
378
if coitus take place during or immediately after the men-
strual excretion, this membrane is often not ruptured.
From these several circumstances of variety in the ori-
ginal formation and appearance of the hymen, its power
of resisting the natural means of rupture in some cases,
and its yielding in others to the slightest force, we are
inclined to think that the accuracy necessary in forming
a medico-legal opinion cannot be attained by looking
to this sign alone. We must, however, agree with Dr.
Beck” that formerly it would be difficult to support an
accusation of rape where the hymen was found entire,
although its presence cannot be considered as an unequi-
vocal proof of virginity ; for, as we have stated, it has
been asserted on good authority that it is not always rup-
tured in coitu. An instance is related by Dr. Smith,i
in which an accusation of rape fell to the ground in
consequence of the presence of this membrane. This
occurred in the case of a man named Stewart, who was
tried at the Old Baily in 1704 for ravishing two female
children. The evidence being at variance as to the fact
of penetration, the children were sent out of court, and
the eldest was found to have the signs of virginity.
The state of the vagina is the next point worthy of
consideration. In young subjects it is extremely
small; but as the female advances towards puberty it
becomes increased in its dimensions. In a healthy
adult virgin the parietes of the vagina are remark-
ably firm and substantial, and from the only function
it has to perform, that of giving exit to the menstrual
excretion, it is rigid and narrow. The internal sur-
face is lined with a mucous membrane, which is re-
markable for the peculiarity of being much wrinkled
* Elm. of Med. Jur. by Darwall, p. 52.
t Prin. of For. Med. p. 410.
379
or folded together into shallow, irregularly transverse
rugae, the peculiar use of which is to qualify the passage
for being indefinitely developed during parturition.
These folds are removed by frequent sexual intercourse,
and nearly obliterated in women who have borne one
or two children. The dilatation of the vagina, and the
smoothness of its internal surface, are not however to
be taken as unequivocal proofs of want of chastity, for
these appearances may arise from other causes. There
are disorders of which the tendency is to render it so,
as fluor albus, chlorosis, or menorrhagia ; and certain
malpractices will also occasion the same dilatation as
sexual intercourse; and, on the other hand, coitus may
have taken place, and the vagina afterwards re-assume
its contracted condition.
Generally speaking, in virgins the external labia are
thick, firm, elastic, and internally of a bright red
colour, with their edges so opposed as to occlude the
entrance into the vagina ; while in married women, or
those accustomed to coition, they are soft, pale, and
have an interval of greater or less extent between
them. But these signs will be found to vary according
to the age, temperament, and state of health of the
individual. Thus, in persons of a sanguine tempera-
ment, although in the habit of venereal enjoyment, the
colour, firmness, and thickness of these parts will be
preserved ; and virgins of advanced age and weak leu-
cophlegmatic habit of body, or those afflicted with
leucorrhoea or menorrhagia, may present appearances
which, if the above signs were supposed to be valid,
would lead to a conclusion of an opposite character.
The same observations will apply to the state of the
frenum labiorum, or posterior commissure of the pu-
denda. Some authors have esteemed the integrity and
380
rigidity of this part as a proof of virginity, but no
positive conclusion can be drawn from it, for it fre-
quently remains untouched even after parturition.
From the observations just made, we feel ourselves
compelled to acknowledge that there are no anatomical
signs by which we can attest the presence of virginity.
Taken singly, they are fallacious; and even viewed in
connexion, they can only favour the conclusion as to
the chastity of the female; but the converse is not
established by the absence of these signs, as they may
be all absent from causes already enumerated, although
their absence may serve to corroborate the opposite
opinion in suspected cases.
Signs of defloration.—In this inquiry it is necessary
to take into account the age, strength, and state of
mind of both persons concerned. The sexual organs
of both should be examined, and this as speedily as
possible after the alleged assault, for if the woman
have reached the period of puberty, no satisfactory in-
formation can be obtained by a professional examina-
tion unless made immediately after the commission of
the act. In children, from the great disproportion of
the parts, the violence is greater, and the effects con-
sequently remain for a longer time; but in a subject
of full organic development, the appearances conse-
quent to connexion are very fleeting. If the examina-
tion be made early, and particularly if the female have
been a virgin, besides the state of mental excitement in
which she may be found, there may be physical signs
consisting in local marks of violence. The parts are
found lacerated, tumefied, and bloody or inflamed, and
painful to the touch ; the hymen most commonly rup-
tured ; and sometimes the presence of semen can be
detected. Besides these marks upon the genitals, there
381
are usually bruises or ecchymoses on other parts of the
body, particularly on the arms, thighs, nates, and
breasts. In children the local appearances are more
evident, from the greater injury the parts have re-
ceived ; and the inflammation is sometimes so great as
to incapacitate them from walking. But in married
women, even a very speedy examination will fail to
afford much assistance, from the previously dilated
condition of the parts. It should be borne in mind
that the female genitals are liable to diseases which
may imitate the appearances just pointed out. Of this
fact a case related by Dr. Percival” is a striking ex-
ample. A girl, four years of age, and in good health,
was suddenly seized with inflammation of the pudenda,
and symptoms of defloration, with pain in making
water. She had slept two or three nights in the same
bed with a boy fourteen years old, and had complained
of being very much hurt by him during the night.
The symptoms increased in violence, and the child
died on the ninth day. An inquest was held on the
body, and Mr. Ward, under whose care the patient
had been in the Manchester Infirmary, deposed that
death was caused by external injury. A verdict of
murder was returned against the boy, and he was
accordingly taken into custody. A very short time
afterwards, however, several similar cases occurred in
the same neighbourhood, in which there was no ground
for supposing that violence had been offered. For-
tunately for the boy his trial had not come on, and
Mr. Ward now informed the authorities of the mistake
he had committed, and the prisoner was discharged.
This kind of disease appears to be to a certain extent
epidemic, and is very fatal. Thus, out of twelve cases
* Medical Ethics, p. 103 and 231.
382
mentioned by Mr. Kinder Wood,” only two recovered.
It is usually preceded by febrile symptoms for two or
three days, and when the genitals are examined, they
are found inflamed and swollen. The colour is dark,
and ulceration with gangrene quickly follows. The
fever assumes a typhoid character, and death shortly
takes place.
The presence of the venereal disease in the female,
when its invasion corresponds with the period at which
the outrage is stated to have occurred, that is, in from
three to eight days afterwards, is a very strong corro-
borative proof of defloration, if the aggressor is found
on examination to be afflicted with the same disease.
This is not uncommonly the case in young children, in
consequence of a very prevalent notion entertained by
the lower orders, that connexion with a virgin is a cer-
tain cure for the disorder. Appearances resembling
gonorrhoea, however, should be looked at with a very
scrupulous eye, as it is now perfectly well known that
children, particularly those of strumous delicate con-
stitution, are liable to purulent discharges from the
vagina, which very much resemble the consequences
of impure connexion. These discharges take place
during dentition, or from the presence of worms in the
intestinal canal, and are also sometimes observed in the
male sex from the same causes.
We are indebted to Sir Astley Cooper; for the fol.
lowing energetic observations on this peculiar affection.
“There is a circumstance on which I am exceedingly
“anxious to dwell—L allude to a discharge from young
“females, and I hope that there is not one here this
“evening but will be strongly impressed with the im-
* Med. Chir. Trans. v. vii. p. 84.
# Lectures on Surgery.
383
“ portance of the subject. Children from one year old,
“and even under, up to puberty, are frequently the
“subjects of a purulent discharge from the pudendum,
“chiefly originating beneath the preputium clitoridis;
“the nymphae, orifice of the vagina, and the meatus
“urinarius are in an inflamed state, and pour out a
“discharge. The bed-linen and rest of the clothes are
“marked by it. It now and then happens to a nervous
“woman to be alarmed at such an appearance, and she
“suspects her child of having acted in an improper
“manner; and perhaps not quite clear herself, she is
“more ready to suspect others, and says, Dear me, (if
“she confesses,) it is something like what I have had
“myself. She goes to a medical man, who may unfor-
“tunately not be aware of the complaint I am speaking
“of, and he says, “Your child has got the clap.' I can
“assure you a multitude of persons have been hanged
“for such a mistake. I will tell you exactly what
“takes place in such cases. The mother goes home and
“says to the child, ‘Who is it that has been playing with
“‘you? who has taken you on his knee lately P’ The
“child innocently replies, “No one, mother; nobody
“‘has, I declare to you.” The mother then says, ‘Oh,
“‘don't tell me such stories; I will flog you if you do.’
“And thus the child is driven to confess what never
“happened, in order to save herself from being chas-
“tised. At last she says, “Such a one has taken me on
“‘his lap.” The person is questioned, and firmly denies
“it ; but the child, owing to the mother's threats, per-
“sists in what she has said. The man is brought into
“a court of justice; a surgeon who is ignorant of the
“nature of the discharge I am now speaking about
“gives his evidence; and the man suffers for that
“which he never committed. The mother is persuaded,
384
“if there be a slight ulceration on the parts, that vio-
“lence has been used, and a rape committed.
“If I were to tell you how often I have met with
“such cases, I should say that I have met with thirty
“in the course of my life. The last case I saw was in
“the city ; a gentleman came to me, and asked me to
“see a child with him who had a gonorrhoea on her.
“I went, and found that she had a free discharge from
“ the preputium clitoridis. I said that there was
“nothing so common as this. There was considerable
“inflammation, and it had even proceeded to ulceration,
“which I told him would soon give way to the use of
“ the liquor calcis with calomel. “Do you tell me so 2°
“he replied ; “why, suspicion has fallen on one of the
“‘servants; but he will not confess. If he had ap-
“‘peared at the Old Bailey, I should have given my
“‘ evidence against him ; for I was not aware of what
“‘you have just told me.’ I told him that if the man
“ had been hanged by his evidence, he would have
“deserved to be hanged too. I am anxious that this
“complaint should be known by every one present,
“ and that the remarks which I have made should be
“circulated throughout the kingdom. When a child
“has this discharge, there is a heat of the parts, slight
“inflammation ; and this sometimes increases, and
“goes on to ulceration. This disease sometimes occurs
“in children at the time of cutting their teeth.”
In the year 1831 a man was arrested in the city of
Dublin on a charge of rape committed on a child; the
only evidence of which was the presence of a purulent
discharge from the pudendum. Popular opinion, as is
usual in such cases, ran high against him ; and it was
only through the positive opinion of an intelligent
surgeon that the case was explained, and the man
385
liberated. A case of a somewhat similar nature lately
came under the observation of the writer. A lady and
gentleman came to his house one evening in a state of
great alarm and excitement, accompanied by their child,
a girl of four years old, whom they stated to be afflicted
with a terrible disorder, communicated to her by some
person in their employment. They had previously
shewn the child to an apothecary, who confirmed their
worst apprehensions, and at once declared that the girl
had got a clap. On examination the parts were found
in a state resembling that just described, with a free
purulent discharge ; and it was with no small degree
of pleasure the writer was able to console the parents
by assuring them that their child was labouring under
no uncommon affection, and that a few days would set
all to rights. It has rarely fallen to his lot to witness
a more sudden transition from grief to joy than this
announcement effected.
Dr. Ryan.* mentions the case of a delicate girl, aged
eleven years, who had a purulent discharge from the
external genitals, and accused a young man of eigh-
teen, whose genitals were developed in an extraordi-
nary degree, of having violated her person. Two
apothecaries swore the girl had been violated, a rape
committed, and gonorrhoea communicated. Dr. Gordon
Smith, Mr. Whitmore, and Dr. Ryan were of a different
opinion. The case was grievously mismanaged for
the prisoner; the only evidence produced in his favor
was Dr. Smith's, which was contrasted with that of the
two medical witnesses for the prosecution, who had
refused to examine the person of the prisoner, although
assured that he had no discharge from the urethra, and
had not had any for six months previously. The man
* Med. Jur. p. 185.
25
386
was found guilty at the Middlesex sessions, and sen-
tenced to six months' imprisonment, and lectured by
the chairman on his good fortune that he was not
hanged. The mother of the child confessed to Dr.
Smith that she had had the discharge since she was five
years old.
From these and other similar instances, we cannot
too strongly urge the necessity of an early examination
of both parties. By following this course, it has hap-
pened that the man has been acquitted where marks of
disease were discovered in the female, because no signs
of gonorrhoea have been detected about himself. A
case related by Sir Matthew Hale” furnishes an instance
where an innocent man might have been saved from a
malicious prosecution, to the hazard of his life, by this
precaution. Foderéf mentions two cases from Zacchias,
where the falsehood of an accusation was determined by
a comparative inspection of both parties. Besides the
presence or not of disease, there are other points to be
determined by examination. Thus it may happen that
the man is impotent; the penis may have been lost by
sloughing, accident, design, or cancer ; the female
organs may be so constructed as to prevent the possi-
bility of penetration ; in all of which cases an inspection
of both parties can alone give grounds for conclusive
opinions. It has been remarked by a writer in a cele-
brated periodical work, with reference to the purulent
discharge of which we have just spoken, that “we must
“take care not to run into the opposite error of ascrib-
“ing inflammation, ulceration, and discharge in cases
“where violence has been alleged, to this disease with-
“out sufficient grounds; for it is extremely probable
* Paris and Fonblanque, Med. Jur. vol. i. p. 418.
+ Méd, Lég. vol. iv. p. 363,
387
“that diseases which occur so rarely should happen to
“appear in a child to whom violence was offered, un-
“less that violence had some effect in producing it.”
On this point we think it right to observe that the
laceration, tumefaction, and inflammation consequent
on the violation of a child are very different from the
disease under consideration, and could scarcely be con-
founded with it. Its great resemblance is to true
gonorrhoea; and that point can be settled by a personal
examination of the man accused. Dr. Deweest states
that when this disease arises in very young subjects, it
almost always proceeds from a neglect of cleanly atten-
tion to these parts, either by withholding a frequent
use of lukewarm water, or permitting the child to remain
too long wet. Children, however, of a more advanced
age have also discharges of a purulent character, that
seem to arise from a morbid action of the mucous
membrane of the vagina. This frequently shews itself
about the fifth year, and may continue, if neglected, to
almost any period. It should be recollected that vio-
lence has been sometimes inflicted on the external
genitals for the purpose of sustaining an accusation
against an innocent person. A remarkable case of this
sort is related by Foderé.j. A female at Martigues, in
1808, accused eight or ten of the principal persons of
the place of having violated her grand-daughter, aged
about nine years and a half, at an inn. She laid her
complaint before the juge de paix, and stated that she
would withdraw it provided the accused would accommo-
date the matter with her. She had procured a daughter
of the inn-keeper, aged sixteen years and an idiot, as a
* Edin. Med. Surg. Journ., vol. xiii. p. 491.
f Treatment of Children, pp. 236, 435.
f Méd. Lég. tom. ii. p. 456.
25%
388
witness. As the charge was obstinately persisted in,
Foderé, with two officers of health, was ordered to ex-
amine the child in presence of the judge ; and suspicion
was immediately excited from the delay used in admit-
ting the visitors. On examining the parts, he found
the hymen untouched, and the vagina extremely narrow.
Around the pudenda, however, a red circle about the
size of a crown was observed, which appeared to have
been induced recently ; and this was indeed the fact ;
for at the end of half an hour the circle had decreased
in size, and the redness disappeared. Had this been
the effect of great violence, it is natural to suppose that
it would have increased in intensity of colour. A report
was prepared, stating the above facts; and the conse-
quence was that the accuser was put in prison, and
finally ordered out of the city.”
The chief point in an accusation of rape, necessary to
be proved, is the act of coition; but as considerable
difference of opinion has existed as to what legally con-
stitutes this act, it is necessary to make some observa-
tions upon it. Some authorities have maintained that
simple penetration was sufficient, while others have
judged that without emission the crime is not complete.
In the case of Russen, the schoolmaster who was tried
for a rape committed on a girl under ten years of age,
it was proved by two surgeons on behalf of the prisoner,
and corroborated by four others who had examined the
girl, that the hymen (which they considered an indubi-
table mark of virginity) was whole and unbroken, and
that the passage was so narrow that a finger could not
be introduced. But Mr. Justice Ashhurst, who tried
the case, left it to the jury whether any penetration
* Consult Sir William Wilde on this subject:-‘‘Medico-legal Obser-
vations,” 1853, passim.
389
were proved; for if there were any, however small, the
rape was complete in law. The jury found him guilty,
and he received judgment of death. But before the
time of execution, the matter being much discussed, the
learned judge reported the case to the other judges for
their opinion, whether his directions were proper; and
upon a conference it was unanimously decreed that the
directions of the judge were perfectly right. They held
that, in such cases, the least degree of penetration was
sufficient, though it may not be attended with the
deprivation of the signs of virginity. It was, therefore,
properly left to the jury by the judge ; and accordingly
the prisoner was executed. This occurred in the year
1777. On the other hand, Lord Coke, Sir Matthew
Hale, and Hawkins held that there must be both pene-
tratio and emissio seminis, and this appears to have been
the decision of Skynner, C. B. Gould, Willis, Ashhurst,
Nares, Eyre, and Hotham, against Lord Loughborough,
Buller, and Heath ; Lord Mansfield, though present,
having given no opinion of his own. The argument is
stated to have turned on the words carnal knowledge,
to which the majority contended that emissio seminis
was absolutely necessary.* This state of the law ren-
dered cases of rape extremely difficult to prove ; for in
virgins it is not all likely they would be conscious of
any such circumstance having taken place, particularly
when we consider the state of fright, pain, and weakness
into which they are necessarily thrown; and even in
married women it does not appear that they are always
conscious of emission—indeed, we should be inclined to
suppose the reverse. Judge Buller stated, in giving
judgment on a case in 1787, that he recollected a case
where a man had been indicted for a rape, and the
* Paris and Fonblanque, Med. Jour. vol. i. p. 433.
390
woman had sworn that she did not perceive anything
come from him ; but she had had many children, and
was never in her life sensible of emission from a man.
Again, in the case of children, it is manifestly im-
possible that evidence of emission can be obtained ;
and, as has been well remarked by Dr. Paris, if it be
true that certain eunuchs have the power of erection
(as under circumstances mentioned in the preceding
chapter they undoubtedly have), and consequently
of penetration, they may morally ravish without incur-
ring the punishment of rape; for it is certain that
they can have no emissio seminis. Or a man may
have perpetrated all the more atrocious parts of his
crime, and yet, being interrupted in the least volun-
tary constituent of it, escape the well-merited ven-
geance of the law ; while it is evident, on the other
hand, that the innocent victim has suffered in body,
mind, and reputation as much as if the crime had been
legally completed.* It has been stated in defence of
this practice of requiring proof of emission, that it is
quite necessary to make the proof of the crime difficult
in order to avoid false accusations, for it often happens
that the only chance an innocent man has is the cross-
examination of the prosecutrix ; if, therefore, it be
necessary to prove all the circumstances, including
emission, it follows that there is a greater likelihood of
the witness tripping in her evidence.
The question with respect to requiring proof of semi-
nal emission in cases of rape was settled by an act
(9 Geo. IV. chap. 31, passed June, 1828,) which cites
“ that upon trials for the crimes of buggery and
“of rape, and of carnally abusing girls under the re-
“spective ages hereinbefore mentioned, offenders fre-
* Paris and Fonblanque. vol. i. p. 433.
391
“quently escape by reason of the difficulty of the proof
“which has been required of the completion of these
“ different crimes; for remedy thereof be it enacted,
“that it shall not be necessary in any of these cases to
“ prove the actual emission of seed in order to consti-
“tute a carnal knowledge, but that the carnal know-
“ledge shall be deemed complete upon proof of pene-
“tration only.” By the same act the crime of rape, or
of the abuse and carnal knowledge of a girl under ten
years of age, was punishable by death. Abuse and
carnal knowledge of a girl between ten and twelve
years of age was considered a misdemeanour only, pun-
ishable by imprisonment, with or without hard labour.
In Philadelphia, where the law was the same as with
us, it has become common of late years to indict for an
attempt to commit a rape rather than for the crime
itself, and chiefly from the difficulty of proof. Emission,
however, is not considered essential in Pennsylvania
(according to Judge Cooper); and properly, he adds,
for it is not the essence of the crime, and it may happen
without being perceived in cases of violence. In Illi-
nois it is expressly enacted that so much of the law
regulating the evidence in case of rape as makes emis-
sion necessary is hereby repealed.*
This crime may be committed on a female at any
period of life after she has passed mere infancy. We
have already mentioned the law as applied to children.
In this case the charge of violation requires the most
accurate inquiry, because the material evidence in other
cases, that of the sufferer herself, is wanting, from her
being incapable as a witness in consequence of her
youth. “If the rape be charged to have been committed
“on an infant under twelve years of age, she may still
* Beck, p. 67.
392
“be a competent witness, if she hath sense and under-
“standing to know the nature and obligation of an
“ oath, or even to be sensible of the wickedness of tell-
“ing a deliberate lie ; nay, though she had not, it is
“ thought by Sir M. Hale, that she ought to be heard
“without oath, to give the court information ; and
“others have held that what the child told her mother
“ or other relations may be given in evidence, since
“the nature of the case admits frequently of no other
“ proof. But it is now settled by a solemn determina-
“tion of the twelve judges, that no hearsay evidence
“can be given of the declarations of a child who hath
“not capacity to be sworn ; nor can such child be ex-
“amined in court without oath ; and there can be no
“ determinate age at which the oath of a child ought
“either to be admitted or rejected; but their admissi-
“bility depends upon the sense and reason they enter-
“tain of the danger and impiety of falsehood, which is
“to be collected from their answers to questions pro-
“ pounded to them by the court.” Females, before
they reach the time of life at which menstruation com-
mences, are generally ignorant of the consequences
likely to result ; and this, coupled with want of
physical power, may often tend to facilitate the com-
mission of rape. But at the age of puberty it has been
doubted whether a woman of ordinary strength may
not successfully resist the attempts of a single man.
Farr, in speaking of this subject, expresses himself
in the following terms:–“But the consummation of a
“rape, by which is meant a complete, full, and entire
“coition, which is made without any consent or per-
“mission of the woman, seems to be impossible, unless
“some very extraordinary circumstances occur. For
* Paris and Fonblanque, vol. i. p. 421.
393
“a woman always possesses sufficient power by draw-
“ing back her limbs, and by the force of her hands to
“prevent the insertion of the penis, whilst she can
“keep her resolution entire.” Dr. Beck quotes the
following answer given by the medical faculty of Leipsic
to the question, whether a single man could ravish a
woman. “Si circumstantias quae in actu coèundi con-
“currunt consideramus, non credibile, nec possibile
“videtur, quod unus masculus nubilem virginem (ex-
“cipe impubem, teneram, delicatam, aut simul ebriam
“puellam) absºlue ipsius consensu, permissione atque
“voluntate vitiare, aut violento modo stuprare possit ;
“dum feminae cuilibet facilius est si velit, penis immis-
“sionem recusare, vel multis aliis modis impedire, quâm
“viro eidem invitae planè intrudere.”f It is necessary,
therefore, to be extremely cautious in admitting the
truth of accusations, unless the bodily power of the
man far exceeds that of the complainant. At the same
time, however, we should not entirely agree with the
positive opinions just quoted, for we think it possible
that by long continued violence, intimidation, or other
circumstances the man may ultimately prevail.
The question naturally arises here, can a female be
violated without her knowledge? In which case the
crime would be equally great, for it would be still
without her consent. There are different ways in
which we may suppose this to be effected, as during
sleep, or stupefaction caused by inebriation or narcotics,
or during a fit. As to the possibility of rape being
committed on a virgin during natural sleep, we are
very much inclined to doubt it, notwithstanding the
decision of the faculty of Leipsic, “Dormientem in sella
* Beck, p. 41.
f Valentini Pandectae, vol. i. p. 61.
394
“virginem insciam deflorari posse.” When we con-
sider the violence inflicted, and the pain that attends a
first intercourse, we think it scarcely possible that any
natural sleep could be so sound as to preserve the
woman unconscious of what was going forward. The
case is not exactly the same with married women, in
whom from previous sexual intercourse the parts are
more dilated. In such cases we must admit the possi-
bility, but not at all the probability, for even in them
natural sleep, however heavy, would be most likely
broken by the attempt at violation. That a female,
whether virgin or not, may be ravished during the
insensibility attending intoxication, the administration
of narcotics, or disease, will be readily granted. As the
sufferer can give no direct testimony as to the fact, the
only corroboration to be obtained is from a personal
examination ; but as we have already mentioned, this
can be of use alone in the case of her being a virgin.
There is reason to think that narcotics have been not
unfrequently administered for the purpose of facilitating
the commission of rape, which circumstance is justly
considered a great aggravation of the offence, and,
when proved, is sure to draw down the heaviest punish-
ment on the perpetrator. A case occurred in Dublin,
in April, 1831, in which a gentleman was tried for a
rape, and convicted, chiefly in consequence of an im-
pression made on the minds of the jury, that some
soporific had been administered by him to the young
lady, by means of which he was enabled to effect his
purpose.f. By the abuse of chloroform or other anae-
sthetics also it is evident that coition can be obtained
without the consent of the female; but all such charges
* Valentius, Novellae Méd. Lég. cas. I.
+ Dublin Morning Post, April 20, 1831.
395
require careful examination, as frequently they have
been made, without a shadow of foundation. In some
such cases the charge has even been made “bonā fide”
though falsely, a statement that can well be understood
by all those who have had any extended practical expe-
rience in the employment of anaesthetics. There is
another mode in which this crime may be commit-
ted, wherein, although the woman is not unconscious,
she makes no resistance, neither does she consent :
that is, when a man obtains admission to the bed-
room of a married woman, and imposes himself on
her as her husband. This constitutes a case of rape,
and subjects the offender to the legal penalty. The
same holds good in the case of forcible abduction, where
a woman is compelled to marry and is afterward vio-
lated by force.
The fact of sexual intercourse being proved or admit-
ted, it now remains to be ascertained whether the
woman consented or not. If she be dead, which some-
times happens from the violence employed, the most
material part of the evidence, her own testimony, is of
course wanting, unless she have lived long enough to
give information before her death. In the well-known
case of Abraham Thornton, who was tried some years
ago in England, for the murder of Mary Ashford (a
case remarkable for being the last in which a wager of
battle was offered, such right having been immediately
afterwards abolished by the statute 59 Geo. III. c. 46;)
the prisoner admitted having had carnal knowledge of
her, but stated that it was with her own consent; and
although the general tenor of the evidence was in op-
position to this assertion, the death of the unfortunate
woman rendered it impossible to ascertain the truth. It
was formerly imagined that the occurrence of pregnancy
396
after violation was evidence of the consent of the woman.
This opinion was maintained by Dr. Bartley* and Dr.
Farri on the supposition that women under the in-
fluence of the depressing passions, such as fear, terror,
&c. could not conceive. It is said by Mr. Dalton, that
if a woman at the time of the supposed rape do con-
ceive with child by the ravisher, this is no rape, for
(he says) a woman cannot conceive unless she doth
consent. Such an opinion was founded on the idea
that a certain amount of enjoyment on the part of the
female is necessary towards conception. But it has
been clearly ascertained that this is not the case, and
the process of impregnation may go forward, totally
without the will, consent, or enjoyment of the female.
“That so absurd a notion as that conception evidenced
“consent should in modern times have obtained
“amongst any whose education and intellect were
“superior to those of an old nurse, is indeed sur-
“prising: at this day, however, facts and theory con-
“cur to prove that the assentation of nature in this
“respect is no ways connected with violation of mind.”f
Such is the opinion of all medical jurists of modern
times; and it is supported by the many facts on record,
of impregnation having taken place in consequence of
connection had with females during insensibility from
disease or the influence of narcotics.
It was ruled, in the case of the king against Fleming
and Windham,S A.D. 1779, that if the party be dead,
the deposition of the girl, taken before the committing
magistrate and signed by him, may after her death be
* P. 43.
+ P. 43. -
f Burn's Justice, tit. Rape.
§ Leach's C. L. p. 996, and Paris and Fonblanque, vol. i. p. 439.
397
read in evidence at the trial of the prisoner, although
it was not signed by her, and she was under twelve
years of age ; provided she was sworn and appeared
competent to take an oath ; and all the facts necessary
to complete the crime may be collected from the testi-
mony so given in evidence. But, as is the practice in
other criminal cases, it is not necessary that the female
should be sworn, if her testimony is given while she
is dying, she being conscious of her state at the time ;
for it is considered that the awful situation in which
she is placed is as sure a guarantee of truth as any
form of oath could be. At the same time it is quite
necessary to have proof of the soundness of her under-
standing at the time, for without this the solemnity of
the occasion and the anticipation of death may not
have a sufficient impression on her mind.
398
CHAPTER XVII.
Doubtful Sea.
AMONG the freaks of nature there is none which has
given rise to more erroneous ideas or more barbarous
practices than those varieties in the formation of the
organs of generation, which have given origin to the
term hermaphrodite. This word, derived from ‘Eppins,
Mercury, and Appoèvrn, Venus, conveys the notion of
an individual partaking of both sexes, and capable of
both begetting and conceiving. The ancients believed
in the possibility of such a combination in the human
body; and enactments existed both in Greece and
Rome, ordering the destruction of infants born with
confusion of the sexual organs. At Athens all the
unfortunate beings considered to be hermaphrodites
were thrown into the sea, and at Rome into the Tiber.
In modern times it is admitted that no such phenomenon
ever existed in the human species as a perfect herma-
phrodite; although there are numerous instances of
preternatural structure which gives the appearance of
a double sex. In the lower orders of organised bodies
hermaphrodism is common ; thus in vegetables it is so
prevalent as to have led some to suppose it to be an
attribute of the order; and the more nearly the other
classes of beings approach the vegetable, the more
common is this combination of sex among them. Of
this, zoophytes, mollusca, acephali, and gasteropodes are
399
examples. In these animals two kinds of hermaphrodism
exist: in some it is absolute, that is, the animal is capa-
ble of impregnating itself, as in some of the bivalves, as
oysters and mussels; but in others, as the univalves,
this power is not possessed, but a union of two indivi-
duals is necessary, both, however, becoming impreg-
nated at the same time.
We look in vain for any such admixture in the
higher order of animals, though some extraordinary
approaches towards it are recorded. According to Sir
E. Home” and J. Hunter, f such combination is most
frequently met with in neat cattle, the individuals so
circumstanced being known by the name of free-martins.
In these, however, the testes and ovaria are always too
imperfect to perform their functions. Instances are
not wanting in the human species, in which, either from
malformation of the genital organs in one or other of
the sexes, or from a real attempt at mixture of the two
in the same individual, considerable difficulty arises in
deciding on the proper sex. This is the point to which
the present chapter is more particularly directed, and it
should be recollected that it is one of material import-
ance; for upon the opinion pronounced by medical
examiners may depend the employment in life of an
individual, the right of inheritance to property, and the
judicial decisions concerning impotence and sterility.
Sir E. Homeſ considers that all the monstrous pro-
ductions hitherto noticed and described as hermaphro-
dites may be reduced to one of the four following
classes:–1. malformations of the male ; 2. malforma-
tions of the female ; 3. males with such a deficiency in
* Phil. Trans. 1799.
t Anim. Econ.
1. Loc. cit.
400
their organs that they have not the character and
general properties of the male, and may be called
neuters; 4. where there exists a real mixture of the
organs of both sexes, although not sufficiently complete
to constitute the double organ.
1. Malformation of the urinary and generative organs
of the male.—Cases of this class usually depend upon
imperfection of the scrotum and urethra; there is no
deficiency of the natural parts, nor addition of foreign
parts, but the confusion of sex arises from the scrotum
being split along the middle line, each half containing
a testicle, and resembling one of the labia majora of
the female. The deep slit between these parallel folds
of skin very much resembles the vulva, and the simi-
larity is heightened by the circumstance of the urethra
being usually split likewise in these cases, and opening
in the perinaeum, which, having a red and tender ap-
pearance, is easily mistaken for the vagina. In conse-
quence of the urethra terminating at the perinaeum, the
penis is imperforate; and thus, if it be of small size, it
may be supposed to be the clitoris. It is this malfor-
mation of the male organs which more than any other
has given origin to mistakes respecting the mixture of
the sexes. The case of the negro described by Chesel-
den” was of this kind. In him the scrotum was divided
into two separate bags, with a deep slit between them,
representing the labia majora and commencement of
the vagina. Over these hung down the penis; the im-
perfection of the scrotum extended to the canal of the
urethra,_a circumstance appropriately compared to
the fissure of the hare-lip being continued through the
bony palate. The penis was united by its under surface,
* Anatomy of the Human Body, p. 314.
401
through its whole length, to the folds of skin contain-
ing the testicles, resembling an enlarged clitoris, to
which resemblance the absence of the urethra contri-
buted. The urethra opened with a large aperture in
the perinaeum, between the divisions of the scrotum,
and from its size was mistaken for a vagina. Cheselden
describes another case similar to the preceding, which
he met with in the person of a European.
Persons afflicted with such malformations as we have
described have not only been taken for females, but
have been married as such. Adélaide Preville was
married, lived the last ten years of her life in Paris,
and died in the Hôtel Dieu of that city. Giraud dis-
covered by examination of the body after death that it
was of the masculine sex, and except a false vagina,
which consisted in a cul-de-sac placed between the rec-
tum and bladder, this individual presented no resem-
blance to a female.* There is a very remarkable case
related by Marc,f in which an individual, after having
passed for a female for many years, was at length dis-
covered to belong to the male sex, and was restored by
public ordinance to his proper station. On the 19th of
January, 1792, the curé of the parish of Ber certified
the birth of a girl, and gave her the name of Marie
Marguerite. This child arrived at the age of fourteen
without having particularly attracted the attention of
the parents. It shared the bed of a younger sister, and
grew up among other young persons with whom it was
associated by education, exercise, and childish amuse-
ments. At this time Marie complained of pain in the
right groin, where a tumor soon manifested itself. The
* Recueil périod. de la Soc. de Méd. Paris.
t Dict, des Sciences Méd. t. xxi. p. 91; et Jour. de Méd. Chirurg, et
Pharm. Paris, Feb. 1806.
26
402
village surgeon took it for a hernia, and applied a truss.
This instrument gave too much pain to be borne, and
was soon laid aside. The tumor descended, and the
pains ceased. Some months afterwards the left groin
was affected in a similar manner, and on the supposition
of the tumor in it being also a hernia, a double truss
was put on, which was as speedily thrown off as the
former. At sixteen years of age an offer of marriage
was made, but refused by the parents as an unsuitable
match for their daughter. Three years afterwards
another proposal was made and broken off, after having
been accepted. Nevertheless, as Marie advanced in age,
all the graces of her person began to disappear; her
clothes did not fit as well as before ; her air and carriage
had something extraordinary; from day to day her
tastes changed, and became more masculine ; indoor
occupations seemed to interest her less, and she pre-
ferred field-work to her former duties. These masculine
dispositions, and the report of the surgeon that Marie
had been hurt in such a manner as to prevent her ever
marrying, did not prevent a third lover from aspiring
to her hand. This match was much desired by the
friends on both sides, but the parents of Marie knowing
that she was not formed as other women, and recollect-
ing that she had never menstruated, did not wish to
deceive the son of an old friend, and determined on
having a medical examination of their daughter.
Worbe was requested to perform this office. The sur-
prise of all was great indeed when he declared Marie
to be a man. She (or he) shed tears at the announce-
ment, and was for some months before she could be
reconciled to the idea of not being a woman. At last
he took the resolution of petitioning the authorities to
alter the registry, and declare him of the male sex. A
403
commission was accordingly appointed, consisting of
three medical men, to inquire into the circumstances of
the case, who reported that on examination they found
the scrotum divided through its whole extent, each
division containing a rounded body, which they recog-
nised as true testicles. Between these parts a fleshy
prolongation was observed, having a cleft at its ex-
tremity, but imperforate, covered by a process of skin
which was in reality the prepuce. The penis was but
little developed ; and beneath it, at about an inch and
a half from the margin of the anus, an opening was
discovered, caused by the abrupt termination of the
urethra in the perinaeum. As to the rest of the body
they found nothing remarkable, except a considerable
development of the breasts, resulting, as they imagined,
from the form of clothing usually worn. They there-
fore gave it as their opinion that Marie belonged to the
male sex; and the authorities declared it to be so, and
ordered that the registry of birth and baptism should
be altered. Dr. Worbe states that in 1816 this indi-
vidual was twenty-three years of age, hair and eyebrows
auburn, a light beard appearing on the upper lip and
chin, the sound of the voice masculine, height four feet
eleven inches French measure, skin very white, consti-
tution robust, and the limbs round but muscular. The
form of the pelvis did not differ from that of a male,
the knees were not inclined inwards, and the hands and
feet were large and strong. A year had not elapsed
from the time of his metamorphosis when he was con-
sidered as one of the best farmers in the canton. On
being questioned with respect to what he felt when
sleeping with females, whether he had not desires
different from those of others, and if curiosity had not
prompted him to discover what opportunity permitted
- 26*
404
him so easily to observe, he answered, blushing, “quel-
“quefois, mais je n'osais pas.”
Dr. Schweikard* has published the history of an
individual who up to the age of manhood was thought
to belong to the female sex. He had been baptized as
a girl, and regarded as such, until to the astonishment
of all he demanded permission to marry a girl then
pregnant by him. He submitted to an examination,
when it was found that the penis was situated lower
than ordinary, was not quite two inches long, and a little
less bulky than usual. The imperforate glans offered
a slight curve towards the lower part ; the inferior
surface of the corpora cavernosa was deprived of urethra,
but presented a channel or groove along its middle line.
Behind and under the corpora cavernosa, between their
root and the anterior superior part of the scrotum, a
prominent oval opening was remarked ; this was the
orifice of the urethra through which the urine flowed,
and in consequence of its vicinity to the penis the
stream was conducted along the under surface of that
organ so as to appear to issue from its orifice. The
scrotum, situated below this opening, contained the
right testicle only, that of the left being probably
retained in the abdomen. In all other respects the
physical constitution of this individual was perfectly
masculine. According to his account, the desire for
women and the secretion of semen were observed at
puberty. He had frequently performed coition, and
had, besides a child born before marriage, two other
children well formed, born in wedlock. This case was
evidently only an instance of hypospadias, of which
malformation we have already spoken in the last
chapter ; and it is a further confirmation of the
* Hufeland's Journal, t. xvii. no. 18.
405
opinion there advanced, that persons labouring under
it are not to be considered incompetent to procreation.
It is most probable that the semen during the act of
coition was conducted along the penis, as the urine is
stated to have been, at least so far as to enter the vagina.
A case very similar to that just mentioned is detailed
by Dr. Wageler.”
The malformation of which we have now spoken is
that which most frequently causes mistakes in the male,
but by a careful examination of the individual the
obscurity must be easily removed. There are other
degrees of imperfection which are sometimes observed,
but can never lead to much confusion. One of these
consists in a close application of the penis to the anterior
surface of the scrotum, by a continuation of the skin of
the latter over the former. In such a case the penis is
bound down in its unnatural situation, and the urine
passes downwards ; the erection of the organ cannot
take place; it may become turgid, but never erect, and
intromission is of course impossible. A case of this
description occurred to Mr. Brand,i in the person of a
child seven years of age, who had been baptized and
brought up as a girl; he found a malformation of the
male sexual organs consisting of the presence of such
an unnatural integument. By a slight incision he
liberated the restricted part, and proved to the parents
that they had mistaken a boy for a girl.
Another form of lusus which has given rise to mis-
take of sex is that in which the urinary bladder, or
rather the rudiment of it, opens directly above the
pubis, through a deficiency of the abdominal muscles
* Annales de Méd. Politique de Kopp, v. 129.
+ Vide Brewster's Edinburgh Encyclop. art. Hermaphrodites, and Beck's
Medical Journal, by Darwell, p. 45.
406
and integuments at that part. In these cases the blad-
der can scarcely be said to exist; all that appears of it
is a red fungous mass protruding through the integu-
ments, consisting of the mucous lining of the viscus,
with the ureters opening on it, together with the vesiculae
seminales and vasa deferentia. The penis is always
very short, scarcely exceeding two inches, and, from
deficiency of the urethra, imperforate. The testicles
are generally well formed, but are sometimes retained
in the abdomen. Persons with this malformation are
observed to vary in their sexual appetites; some being
totally deficient in sexual desire, others exhibiting it
in a trifling degree, while others have it strong. It
may readily be supposed that persons constructed in
this manner are impotent; but it sometimes happens
that the vasa deferentia open in a small tubercle at the
root of the penis, in which case it is possible that im-
pregnation may be effected by the individual. It is
only by such a disposition of parts we can explain the
pregnancy of a young girl in Linlithgow, Scotland,
stated to have resulted from her sleeping with a young
person who, from a malformation such as we have
described, was supposed to be a female.* It is plain
that if the seminal ducts opened externally above the
pubis, such an event could not have taken place.
2. Malformations of the female generative organs.—
There are two sorts of malformation in women which
may lead to error in judging of the sex. The first con-
sists in excessive dimensions of the clitoris. Although
hypertrophy of this organ occurs most frequently in
warm countries, it has also been observed in cold. Sir
E. Home doubts that it ever takes place in these lati-
tudes, and is also of opinion that even in those situations
* Wide Pitscottie's History of Scotland, p. 104.
407
where it is most frequently observed, the enlargement
never proceeds to such a length as to lead to any serious
doubt. There are, however, some instances on record
in which the increase in size was such as to cause the
clitoris to resemble and be mistaken for the male organ.
Columbus notices an instance in which it was the size
of a finger. Haller observes one case in which he states
that it was seven inches in length ; and it has been
said to reach the extent of twelve inches.” However,
notwithstanding any excessive dimensions of the clitoris,
an attentive observer will readily discover the differ-
ence between the genital organs of a female with such
a development, and those of a male. Thus, for instance,
in a celebrated hermaphrodite exhibited in Paris and
London in 1777, named Marie Auge, the clitoris was
found to resemble perfectly the male organ, but it was
unprovided with a urethra, and imperforate ; it was
situated above the other parts of generation, which pre-
sented no peculiarity, except an unusual contraction
of the vagina. Schneider met with an instance in a
child of two years old still more likely to mislead; he
examined it after death, and found neither labia majora
nor minora, nor the usual cleft between them ; the
clitoris was an inch and a half long, resembling a penis,
with a well formed glans and prepuce, but it was imper-
forate, a small spot occupying the situation at which
the male urethra terminates. Some lines below this
organ there was an opening by which the urine was
transmitted; but this passage seemed also destined to
perform the functions of a vagina, for it led directly to
the uterus, and was of a length proportionate to the age
of the subject; the vaginal rugae were distinct, and at
the upper part of the orifice a small opening was ob-
* Dict, des Sciences Méd. art. Clitoris.
408
served which led to the bladder, and was in fact the
orifice of the true urethra. In Sir E. Home's* paper
on hermaphrodites he gives an account of a Mandingo
negress whose clitoris was two inches long, and of the
thickness of an ordinary thumb; at first view the ex-
tremity seemed formed like a glans, but on more mi-
nute examination it was found imperforate and not so
round as a true glans, but more pointed; the clitoris
was capable of erection, during which state its size in-
creased to three inches. The other parts of generation
were well formed, the urethra was situated just beneath
the clitoris, which obstructed the flow of urine so much
as to compel her to raise it when about to evacuate
the bladder. Her person was very masculine, the
mammae were little developed, the voice was rough,
and the countenance resembled that of a man. Beclardi
has given a very detailed account of a female who was
exhibited in Paris in 1814, as an hermaphrodite, from
which we extract the following. Marie Madeline Lefort
was the name of the individual; she was then sixteen
years of age, and in the general form of her body re-
sembled a male ; the voice was masculine, a beard
appeared on the upper lip and chin, the breasts were
developed, and the limbs were slightly hairy. The
external genitals presented a rounded mons veneris
covered with hair, but the symphisis pubis was elon-
gated as in the male; beneath it protruded a conoid-
shaped body, twenty-seven centimetres in length when
flaccid, but more when erect; this was surmounted by
an imperforate glans, covered the three-fourths of its
extent by a prepuce. Inferiorly this enlarged clitoris
was furnished with a canal, which, however, did not
* Phil. Trans. 1799.
+ Jour. de Med. Chir, et Phar. Mars, 1815.
409
run the whole length, but was pierced in the middle
line with five small holes, capable of admitting a small
probe. Beneath and behind the clitoris there was a
sulcus, bordered on each side by a narrow and short
labium, which on being handled gave no sensation of
containing any body like a testicle. This sulcus or
fissure was very superficial, being blocked up by a
dense membrane, but which gave, when pressed by the
finger near the anus, the idea that it was spread over a
cavity. At the anterior superior part, near the clitoris,
this membrane was pierced by a round opening, which
readily admitted a moderate-sized catheter. The ex-
ternal abdominal rings were very small, and gave no
indication of containing testicles. The urine was passed
partly through the opening in the membrane described,
and partly through the small cribriform openings in
the canal extending along the under surface of the
clitoris. This was taken from her own account, as she
found it impossible to void urine in the presence of
the examiners. The bladder could not be reached
by a catheter introduced through the large opening,
but the instrument could be easily passed upwards and
backwards, and in this manner it glided along the
posterior surface of the membrane closing the vagina,
which being felt between the point of the instrument
and the finger, seemed about twice as thick as the skin.
She had menstruated regularly from the age of eight
years, and on one occasion, when Beclard examined her
during menstruation, he observed the fluid to pass
through the opening already described, and the catheter
then introduced was withdrawn full of menstrual blood.
She considered herself a woman, and preferred the
society of men, and was persuaded that a trifling opera-
tion would render her fit for matrimony. This indi-
410
vidual belonged decidedly to the female sex; she had
many and the most essential of the female organs of
generation, the vagina and uterus, the latter organ
moreover performing its natural function with regular-
ity; and those characters of the male which she ex-
hibited were only of a secondary class, such as the
proportions of the limbs and body, shoulders, and pelvis,
the size of the larynx, tone of voice, development of
hair, and the prolongation of the urethra beyond the
symphisis pubis; this, however, was not complete, for
the canal did not extend to the extremity of the mimic
penis.
The second kind of malformation of the female
generative organs likely to mislead as to the sex of the
individual, is a protrusion of the internal parts. The
uterus when prolapsed has at times assumed so close a
resemblance to the penis, that it has actually been mis-
taken for it by medical men of the highest character.
The following case came under the observation of Sir
E. Home, who has given the particulars in his paper
on hermaphrodites. “A Frenchwoman had a prolap-
“sus uteri at an early age, which increased as she
“grew up. The cervix uteri was uncommonly narrow,
“ and at the time he saw her (when she was about twenty-
“five years old) projected several inches beyond the
“external opening of the vagina ; the surface of the
“internal parts from constant exposure had lost its
“natural appearance, and resembled the external skin
“of the penis; the orifice of the ostincae was mistaken
“for the orifice of the urethra. This woman was
“shewn as a curiosity in London, and in the course of
“a few weeks made four hundred pounds. I was in-
“duced by curiosity to visit her, and on the first in-
“spection discovered the deception, which, although
411
“very complete to a common observer, must have been
“readily detected by any person intimately acquainted
“with anatomy. To render herself still more an object
“of curiosity, she pretended to have the powers of a
“ male : as soon as the deception was found out, she
“ was obliged to go away.” There is in the Philoso-
phical Transactions the history of an hermaphrodite
which seems to be exactly similar to this, as is fully
proved by the menses flowing regularly through the
orifice of the supposed penis. The French physicians
were, however, so perfectly convinced of her manhood,
that they made her change her dress and learn a trade.
To this she readily submitted, and the account says she
could perform very well the functions of a man, but
not those of the other sex.
3. Males with such a deficiency in their organs that
they have not the character and general properties of the
male, and may be called neuters.—This form of herma-
phrodism usually takes place in individuals originally
intended for the male sex, and is nothing more than
the effect produced by atrophy, or absence of the testi-
cles, a circumstance to which is frequently joined a
defective development of the penis. The genital organs
do not appear to grow with the rest of the body, but
continue in the same state as at birth. In many the
characters of both sexes seem mixed; in others there
is a slight predominance of one or the other, discover-
able chiefly by moral circumstances, such as the kind
of life, habits, and pursuits of the individual. An in-
stance of this kind of deformity occurred to Hufeland
at Koningsberg. An individual named Marie Dorothée
Duriée, aged twenty-three years, was examined by him
and Mursinna, who both declared the sex to be female,
412
while Stark and Martens were of opinion that the same
person belonged to the male sex.
A marine soldier, aged twenty-three years, in the
year 1779 was admitted a patient into the Royal Naval
Hospital at Plymouth, under the care of Sir E. Home.
He had been there only a few days when a suspicion
arose of his being a woman, which induced Sir E. Home
to examine into the circumstances. He proved to have
no beard, his breasts were fully as large as those of a
woman at that age ; he was inclined to be corpulent ;
his skin uncommonly soft for a man ; his hands fat
and short ; his thighs and legs very much like those of
a woman ; the quantity of fat upon the os pubis re-
sembled the mons veneris; the penis was unusually
small as well as short, and not liable to erections; the
testicles were not larger in size than we commonly find
them in the foetal state; and he had never felt any
passion for women. In this case the testicles had been
imperfectly formed, and the constitution was deprived
of the influence which it naturally receives from them.
The two following cases shew a still greater degree of
imperfection in the male organs; they are mentioned
by Sir E. Home.
A woman near Modbury in Devonshire, the wife of
a day-labourer, had three children; the first was con-
sidered to be an hermaphrodite ; the second was a
perfectly formed girl; and the third an hermaphrodite
similar to the first. In the year 1779 the eldest was
thirteen years of age, and of a most uncommon bulk,
which seemed to be almost wholly composed of fat ;
he was four feet high ; his breasts as large as those of
a fat woman; mons veneris loaded with fat; no penis;
a prepuce one-sixth of an inch long, and under it the
meatus urinarius, but no vagina. There was an imper-
413
fect scrotum with a smooth surface, without a rapha
in the middle, but in its place an indented line ; it con-
tained two testicles of the size they are met with in the
foetus. The younger one was six years old, uncom-
monly fat and large for his age ; the external parts of
generation differed in nothing from those just described
except in the prepuce being an inch long. Both were
nearly idiots. The immense accumulation of fat, and
the uncommon size of these children, accords with the
disposition to become fat so commonly met with in the
free-martin and in eunuchs. -
4. Where there easists a real micture of the organs of
both seaſes, although not sufficiently complete to constitute
the double organ.—Cases of this description, which most
nearly approach the absolute hermaphrodite, are less
common than these we have mentioned. A remarkable
instance is mentioned in Dr. Baillie's Morbid Anatomy.*
The person was twenty-four years of age, and bore the
name and dress of a woman, had the breasts of a female
and no beard, and yet had a very masculine appear-
ance. The clitoris and meatus urinarius had the na-
tural appearance, but there were no nymphae, and the
labia pudendi were unusually pendulous, resembling a
split scrotum, and contained a testicle each. The vagina
was found to terminate in a cul-de-sac, two inches from
the external surface of the labia. She had no partiality
for either sex, and had never menstruated.
The Memoirs of the Academy of Dijon contain the
following case communicated by M. Maret.j Hubert
J. Pierre died at the hospital in 1767, aged seventeen
years. Particular circumstances had led to a suspicion
of his sex, and these induced an examination after death.
* Third edit. p. 410.
t Mahon, t. i. p. 100; and Beck, by Darwell, p. 43.
414
His general appearance was more delicate than that of
the male, and there was no down on his chin or upper
lip. The breasts were of the middle size, and had each
a large areola. The bust resembled a female, but the
lower part of the body had not that enlargement about
the hips which is usually observed at his age. On ex-
amining the sexual organs, a body four inches in length
and of proportionate thickness, resembling the penis,
was found at the symphisis pubis. It was furnished
with a prepuce to cover the glans, and at its extremity,
where the urethra usually opens, was an indentation.
On raising this penis, it was observed to cover a large
fissure, the sides of which resembled the labia of a
female. At the left side of this opening there was a
small round body like a testicle, but none on the right.
However, if the abdomen was pressed, a similar body
descended through the ring. When the labia were
pushed aside, spongy bodies resembling the nymphae
were seen, and between these and at their upper part
the urethra opened as in a female, while below these
was a very narrow aperture covered with a semilunar
membrane. A small excrescence, placed laterally, and
having the appearance of a caruncula myrtiformis,
completed the similarity of this fissure to the orifice of .
the vagina. On further examination the penis was
found to be imperforate; the testicle of the left side
had its spermatic vessels and vas deferens which led to
the vesiculae seminales. By making an incision into the
semilunar membrane, a canal one inch in length and
half an inch in diameter was seen, situated between the
rectum and bladder. Its identity with a vagina was,
however, destroyed by finding at its lower part the
verumontanum and the seminal orifices, from which by
pressure a fluid, resembling semen in all its properties,
415
flowed. The most remarkable discovery was, however,
yet to be made. The supposed vagina, together with
the bladder and testicles, was removed. An incision
was made down to the body noticed on the right side.
It was contained in a sac, filled with a limpid and red-
coloured liquor. From its upper part on the right side
a Fallopian tube passed off, which was prepared to em-
brace an ovarium placed near it. It seemed thus proved
that the body in question was a uterus, though a very
small and imperfect one, and on blowing into it air
passed through the tube.
In 1807, an individual was exhibited at Lisbon, unit-
ing the organs of both sexes in one of the highest degrees
of perfection that has probably been ever seen. This
person was twenty-eight years of age, and possessed
the male organs,—a penis (or what represented one),
capable of erection, covered by a prepuce, and pierced
for a third of its length by a canal, and testicles. The
air and appearance were masculine, the colour dark,
and a light beard covered the chin. The female organs
were the labia, vulva, and vagina, well formed, but very
small; the larynx and voice were feminine, and so were
all the dispositions; she menstruated regularly, and was
twice pregnant, but was prematurely delivered each
time, once at three, the other at five months.” This, if
the account respecting the testicles be correct, is one of
the nearest approaches to a true hermaphrodite with
which until recently we were acquainted in the human
subject.
In the Memoirs of the Royal Academy of Sciences of
Parisi there is a very accurate description by M. Petit
of a similar mixture of organs. The person had wholly
* Dict, des Sciences Méd., art. Hermaphrodite.
+ An. 1720.
416
the character of a man, but was of a delicate constitution;
he was a soldier, and died of his wounds. The appear-
ance of the penis is passed over; but the scrotum not
containing testicles drew M. Petit's attention, and in the
dissection he found testicles in the situation of the ovaria,
attached to two processes continued from an imperfect
vagina, but having vasa deferentia, which passed in the
usual manner to the vesiculae seminales; the vagina
communicated with the urethra between the neck of the
bladder and the prostate gland.
But the most important instance of this kind of malfor-
mation is recorded by Dr. Banon in the Dublin Medical
Journal for 1852.* It is the most perfect specimen on
record of the fusion of sex in the human subject, and
is most valuable from the accurate and lucid description
of the parts discovered by him in the course of his
minute and careful dissection. The highly interesting
preparation is preserved in the Museum of the Royal
College of Surgeons, Dublin.
From Dr. Banon's able and elaborate account of
this case I extract the following description :-
“Amongst the male convicts detained in the Rich-
“mond Government Prison there was one named
“Andrew R., aged twenty-six years, convicted of sheep-
“stealing at the Ballyconnell Sessions on the 11th of
“April, 1848, and sentenced to seven years' transpor-
“tation. Some time after his conviction he was removed
“ to the Mountjoy Prison, where he remained from the
“16th of December, 1850, to the 14th of April, 1851,
“when he was again sent to the Richmond Prison, his
“health having broken down under the severer dis-
“cipline of the former. He now for the first time
“came under my care, and was admitted to hospital
* Dub. Med. Jour., vol. xiv. p. 71.
417
“on the 15th of April, 1851, with symptoms of phthisis,
“which disease proved fatal to him on the 2nd of
“October following. Although it had been for some
“ time known to those about him that he possessed
“ certain peculiarities of the organs of generation, I
“was only made acquainted with the circumstance two
“ days before his death, when unfortunately it was too
“late, from his sinking state, to procure from himself
“such an account of his tastes, disposition, and habits
“ as would have added much interest to the facts I am
“enabled to state, and which I had much difficulty in
“obtaining, owing to the great unwillingness of the
“friends to give information about him.
“It appeared that after birth there was considerable
“doubt in determining the sex to which the infant
“belonged, but it was at length declared, by a wise
“woman in the neighbourhood, to be a female, and
“accordingly was baptized by the name of “Anne.’ In
“a year subsequently, however, the organ representing
“ the penis had so increased in size that a different
“conclusion was arrived at, and the name changed to
“‘Andrew.” After this period he was always looked
“upon and treated as a male, and as he grew up he
“excelled in several of the manly exercises. It does
“not appear, however, that he ever exhibited strong
“sexual desires, but as far as his predilections went,
“ they were, according to his own account, for females,
“in whose company, he stated, a certain degree of ex-
“citement occasionally took place, during which the
“penis would become erect. How far this statement
“can be relied upon it is difficult to say, as he had a
“strong objection to have his imperfections known or
“alluded to in the slightest manner, even by his own
“immediate relatives. His voice was deep-toned, and
27
418
“decidedly that of the male. His mother, however, is
“of opinion that he had not much sexual inclinations
“of any kind, but that he was a male, principally from
“ the fact of his having never menstruated. The ap-
“pearance of this individual during life did not strike
“me as possessing the female character, though I had
“for several months before his death daily opportunities
“of observing him. It is true he was then broken
“ down and emaciated, and the features altered from
“long-continued mental and bodily suffering. Shortly
“before his death, however, when aware of the herma-
“phroditic appearances, I thought I could detect a
“feminine expression in the features of the upper part
“of the face. The depth of the lower jaw, and the
“appearance of the teeth, partook more of the male, as
“did also that of the hair, larynx, arms, hands, thorax,
“lower limbs, and feet. There were but slight traces
“of beard, or of hair over the body; the pubis was
“covered with scarcely the usual quantity. The hip-
“bones were prominent, and the pelvis fan-shaped and
“otherwise decidedly female, but all the plumpness
“natural to that sex, if it ever existed, had now totally
“disappeared, as had also the mammae, of which glands
“ the rudiments alone remained.
“The external generative organs presented the fol-
“lowing peculiarities:—The penis, or organ represent-
“ing it, was not under the usual size of that organ in
“the adult, and was supplied with glans, corona glandis,
“ and prepuce, of the normal formation in the male.
“It was, however, imperforate : a rudimentary opening
“alone existing in the site of the orifice of the urethra,
“admitting a bristle to be passed for about a line. I
“may here mention that on dissection after death the
“ body of the penis was found to be composed of cor-
419
“pora cavernosa, separated by the septum pectiniforme,
“and attached above by the triangular ligament to
“the pubis. The crurae were well seen, converging
“from the rami of the pubis and ischium to the body
“of the penis, which derived its supply of blood from
“ the usual sources. The further dissection of the
“organ brought into view a substance much resem-
“bling the corpus spongiosum urethrae, which could be
“traced forwards towards the glans, and backwards to
“ the perinaeum, where it became bifurcated, enclosing
“ the orifice of the urethra, behind which its divisions
“ again became united, and here terminated in a vas-
“cular spot not far removed from the situation of the
“bulb in the male. On further dissection, the trans-
“versus perinei muscle and artery were observed, but
“no trace of the prostate or of Cowper's glands could
“ be found.
“The female organs were represented, in the first
“ place, by rather well-developed labia, each termi-
“nating somewhat abruptly behind, the fourchette not
“being present. Within the labia were seen the
“ nymphae, having much the same relations to the under
“surface of the penis as they have to the clitoris in the
“female. Next was seen the orifice of the urethra,
“ before alluded to, as enclosed between the bifurcations
“of the substance resembling the corpus spongiosum,
“ presenting the appearance of a longitudinal slit, and
“ leading directly, as in the female, to the urinary
“bladder. Behind this orifice was placed another
“opening of a more circular form, and leading to a
“canal in the direction of the female uterus, and sepa-
“rated in front from the urethra, and behind from the
“rectum by distinct septa. A very perfect crescentic
“fold occupied the site of the hymen, and encroached
27%
420
“so considerably on this vaginal opening as to prevent
“ the introduction of a larger instrument than a No. 8
“catheter. The female character, generally, may have
“been somewhat modified by the extreme emaciation
“present ; and from the same cause, perhaps, it was
“ that I could find no trace of the mons veneris.
“On opening the cavity of the abdomen, my attention
“was first directed to an examination of a glandular
“body which had been observed and felt externally to
“occupy the internal abdominal ring on the right side,
“ and which, consequently, from its shape and size, as
“well as situation, might be supposed to be a non-
“ descended testis. It, however, proved to be nothing
“more than an enlarged lymphatic gland, lying imme-
“diately behind but not connected with the spermatic
“cord as it passed out of the ring. The cord on this
“side was much larger than on the left, where it re-
“sembled the round ligament in the female. On the
“right side it could be distinctly felt externally,
“ descending from the ring towards the pubis. On
“dissection in this part of its course, it was found not
“to contain either the was deferens or spermatic vessels;
“ and at its termination it was connected with a small
“sac, containing fluid, near the pubis. From the
“internal abdominal ring the right spermatic cord
“ proceeded backwards and inwards towards the fossa
“ or cul-de-sac between the bladder and rectum, in
“which region a very remarkable condition of parts
“presented itself. On drawing forwards the bladder,
“it was evident that some firm, resisting body inter-
“vened between it and the rectum, which, on closer
“observation, proved to be a well-formed but small
“uterus, bearing the exact relations to the bladder,
“rectum, and peritoneum which it does in the normally-
421
“formed female. It was now found that a No. 8
“catheter could be passed from the vaginal opening
“before described into the cavity of the uterus. The
“broad ligaments were seen connected with the round
“ligament on the left side, and, to a lesser extent, with
“the spermatic cord on the right. My reason for so
“ designating the latter will become apparent when I
“come to explain its connexion with the male reproduc-
“tive organ not yet described. The Fallopian tube,
“which was single, passed from the left cornu of the
“uterus backwards and inwards between the rectum
“ and the body of the uterus, to the right of which it ter-
“minated in a large and well-formed corpus fimbriatum.
“In this course the Fallopian tube was tortuous and
“twisted on itself, and contained between its convolu-
“tions an oblong substance, which, on examination,
“had the character of muscular fibre. During its
“whole course this tube was completely permeable,
“ and opened freely at the corpus fimbriatum and into
“ the cavity of the uterus. On lifting up the corpus
“fimbriatum, it was found to rest on an ovary lying
“near the right side of the body of the uterus, and
“firmly bound down in this situation by the perito-
“neum. No trace could be seen of a second Fallopian
“tube or ovary, on a very careful dissection. w
About an inch and a half external to the ovary,
“however, I found a body, pendulous in the true pelvis,
“in front of the right sacro-iliac synchondrosis, and
“immediately behind the iliac artery as it descends
“into the pelvis, which, after minute examination, I
“ ascertained to be a testis. Applied to its anterior
“ and inferior surface was seen the epididymis, rather
“longer and in a more unravelled state than usual, but
“still divisible into a globus major, a body, and a
422
“globus minor. The vas deferens was plainly seen
“emerging from it, taking a very remarkable course.
“It first passed forwards and outwards in the direction
“of the internal abdominal ring, towards which it
“reached about half way, then turned back, forming
“a loop, the convexity of which looked towards the
“ring. It next took a course inwards, and somewhat
“backwards, in the direction of the uterus, to which it
“was finally connected by the broad ligament of the
“right side.
“In the first part of its course the was deferens was
“ of good size, but as it approached the uterus became
“exceedingly fine and delicate. It could, however, be
“traced into the substance of this organ, which it
“ perforated a short distance below its right cornu in
“an oblique direction towards the cervix, which was
“ proved by mercury having been pressed through this
“tube into its cavity. The remarkable course taken
“by the was deferens in this instance, and its final
“destination, are well worthy of remark, and will be
“again alluded to when considering the possibility of
“the occurrence of self-impregnation under this pecu-
“liar arrangement of organs. It is evident that there
“was a strong tendency in this duct, in the first in-
“stance, to pursue its usual course to the abdominal
“ring, towards which it may be presumed it was drawn
“by the contractions of the gubernaculum. A case is
“mentioned in which the vas deferens was drawn down
“into the scrotum by the same means, the testis still
“remaining in the abdomen.
“Connected with the vas deferens I looked anxiously
“for the vesiculae seminales, but in no situation could
“I find the least appearance of either of them. Neither
“could a second testis be found.
423
“The testis in this instance presented in a remark-
“ably perfect manner the anatomical characters of that
“gland in the well-formed male. The tunica albuginea
“was first carefully dissected off, and then came into
“view the delicate tunica vasculosa and the tubular ar-
“rangement proper to the testis. As further proofs of
“ its identity, I may mention its connexion with the
“ epididymis, which was itself easily recognisable from
“its partially unravelled state, and also the source
“from which it derived its supply of blood. The sper-
“matic artery was traced from its origin to this gland;
“ and the plexus pampiniforme, formed by the com-
“mencement of the spermatic vein, was seen closely
“connected with it; the left spermatic artery passed
“towards the left cornu of the uterus, where it divided
“into three principal branches, one supplying the left
“side of the uterus, and communicating with thc
“vaginal arteries; the second, conveyed by the Fallopian
“tube to the corpus fimbriatum and ovary, which it
“supplied ; the third passed in the direction of the
“round ligament, towards the left abdominal ring.
“The left spermatic veins were small, and there was
“no appearance of the plexus pampiniforme. It has
“been suggested that the corpus Wolfiani occasionally
“does not become absorbed completely, and that the
“remains of it might possibly be mistaken for a testis,
“ particularly as it then consists of a collection of con-
“voluted diverticula, not unlike the tubular structure
“of the testis ; but here the characters are too well
“marked to admit of such a doubt. Neither could the
“vas deferens be mistaken for the remains of its duct,
“known as the ‘duct of Gaertner, an error into which
“it is said Hunter fell in his description of what he
“considered the vesicula and was deferens of one of his
“free-martins.”
424
With respect to the formation of such monsters as we
have spoken of Sir E. Home was of opinion that the
only mode in which it can be explained is by supposing
the ovum, previous to impregnation, to have no distinc-
tion of sex, but to be so formed as to be equally fitted
to become a male or a female foetus ; and that it is the
process of impregnation which marks the distinction,
and conduces to produce either testicles or ovaria out
of the same materials. The following circumstances
are in favour of this opinion. The testicles and ovaria
are formed originally in the same situation, although
the testicles, even before the foetus has advanced to the
eighth month, are to change their situation to a part at
a considerable distance. The clitoris in foetuses under
four months is so large as to be often mistaken for a
penis, and serves to explain an erroneous opinion at one
time maintained in France, that the greater number of
miscarriages between three and four months have been
remarked to be males ; which mistake arose from the
above circumstance. The clitoris originally appears,
therefore, equally fitted to be a clitoris or a penis, as it
may be influenced by the ovarium or testicle. In con-
sidering this subject, it is curious to observe the number
of secondary parts which appear so contrived that they
may be equally adapted to the organs of the male or
female. In those quadrupeds whose females have
mammae inguinales thé males have also teats in the
same situation ; so that the same bag which contains
the testicles of the male is adapted to the mammae of
the female. In the human species, which has the
mammae pectorales, the scrotum of the male serves the
purpose of forming the labia pudendi of the female, and
the prepuce makes the nymphae. The male has pectoral
nipples as well as the female ; and in many infants
425
milk, or a fluid analogous to it, is secreted, which proves
the existence of a glandular structure under the nipple.
This view of the subject throws some light on those
cases where the testicles are substituted for the ovaria ;
since, whenever the impregnation fails in stamping the
ovum with a perfect impression of either sex, the part
formed will neither be an ovarium nor a testicle, some-
times bearing a greater resemblance to one, sometimes
to the other; and may, according to circumstances,
either remain in the natural situation of the ovaria, or
pass into the situation proper to the testicle, whether
it be the scrotum of the male or the labia pudendi of the
female.
Means of ascertaining the true Sea of a supposed
hermaphrodite.—We say supposed, because, as has been
already stated, we do not acknowledge the existence of
a true hermaphrodite in the human species. Some
cases no doubt have occurred in which it was very
difficult to assign the proper sex; but even the most
perfect of these complications of the genital organs did
not give the individual in whom they existed the power
of double copulation. Thus in the case of Hubert
Pierre it is not easy to decide to which sex he really
belonged. Again, we must admit that great difficulty
existed in coming to a conclusion when we find such
men as Hufeland, Mursina, Stack, Martens, and Metyger
disagreeing. From these and other cases which might
be quoted, we must agree that cases do occur in which
the greatest difficulty must be felt, and the greatest
caution should be used in forming an opinion. These
cases of great difficulty all belong to the last class of
malformations: in the other classes the solution is not
so difficult. In proceeding to make an examination for
the purpose of ascertaining the sex of an individual,
426
the greatest care should be taken not to mistake
appearances, and these should be all accurately noted
down. The different openings that present themselves
should all be explored with appropriate instruments
(taking care not to inflict any wound or cause pain), in
order that their direction may be ascertained. An
accurate inspection of the whole body should be made,
to elicit any predominance of the constitutional cha-
racters of either sex which may exist. These examina-
tions should not be made hurriedly, but should continue
for a length of time, and be frequently repeated, before
a positive opinion is given ; for the tastes, habits, and
propensities of the individual must be taken into
account, as well as the physical conformation in doubt-
ful cases. It is of importance to be informed whether
a discharge of blood has ever escaped from any of the
openings, and if repeated, whether it has been periodi-
cal ; as that circumstance alone will be sufficient to
decide us in coming to a conclusion. In the case of
young children it is best to wait until the parts become
more fully developed, as it has happened that instances
of confusion of sex when young have at the age of
puberty taken a decided leaning to one or the other
sex. Above all, it is necessary to be most cautious in
believing all that is stated by the individual or the
friends, as, from interested motives, they may misrepre-
sent facts in such a way as to lead us into error.
427
C H A P T E R X W III.
Persons Found Dead.
UNDER this head we propose to treat of those causes by
which life is suddenly or quickly extinguished in per-
sons previously in the apparent enjoyment of good
health. Cases of this kind are peculiarly the objects of
legal investigation by the coroner; and as all medical
men are liable to be called on to assist him with their
professional information and opinion, it is of the utmost
importance that clear notions of the true nature of the
phenomena which present themselves should be enter-
tained. The object of such inquiry being to ascertain
whether death was natural or owing to some accidental
cause, the whole subject of sudden death may be con-
veniently arranged under two heads,-namely, 1. sud-
den death from natural causes; 2. Sudden death from
violent causes; comprehending under the latter every
variety, whether the result of accident or of criminal
intention.
Our first duty on the discovery of a supposed dead
body is to ascertain whether any spark of life still
remain, by rekindling which animation may be restored;
and this leads us, before entering on the causes and
phenomena of sudden death, to consider the states of
body which may resemble death, and to point out the
means of discrimination between those cases in which
428
life is really extinct, and those in which the exercise of
the vital power is only suspended. Nothing is more
certain than death ; nothing is at times more uncertain
than its reality: and numerous instances are recorded
of persons at the verge of the grave, or actually pre-
maturely buried, before it was discovered that life still
remained; and even of some who were resuscitated by
the knife of the anatomist. Pliny, who devotes an
entire chapter to this subject, entitled “De his qui elati
revixerunt,” amongst other instances gives that of the
Roman consul Avicula, who, being supposed dead, was
conveyed to his funeral pile, where he was reanimated
by the flames, and loudly called for succour; but be-
fore he could be saved, he was enveloped by the fire
and suffocated. Bruhier,” a French physician, who
wrote on the uncertainty of the signs of death in 1742,
relates an instance of a young woman upon whose sup-
posed corpse an anatomical examination was about to
be made, when the first stroke of the scalpel revealed
the truth. She recovered, and lived many years after-
wards. The case related by Phillipe Peu is somewhat
similar. He proceeded to perform the Caesarean section
upon a woman who had to all appearance died unde-
livered, when the first incision betrayed the awful
fallacy under which he acted. A remarkable instance
of resuscitation after apparent death occurred in France,
in the neighbourhood of Douai, in the year 1745, and
is related by Rigaudeaux, f to whom the case was con-
* “Dissertation sur l’incertitude des signes de la mort, et l'abus des
“interremens et embaumens précipites.” Bruhier mentions 180 cases in
which persons still living were treated as dead; of these, 52 were buried
alive, 4 were opened before death, 53 revived spontaneously after being
placed in their coffins, and 72 were supposed to have died when they really
had not.
t Journal des Sgavans, 1749.
429
fided. He was summoned in the morning to attend a
woman in labour, at a distance of about a league. On
his arrival, he was informed that she had died in a
convulsive fit two hours previously. The body was
already prepared for interment, and on examination he
could discover no indications of life. The os uteri was
sufficiently dilated to enable him to turn the child, and
deliver by the feet. The child appeared dead also ;
but by persevering in the means of resuscitation for
three hours, they excited some signs of vitality, which
encouraged them to proceed; and their endeavours
were ultimately crowned with complete success. Rigau-
deaux again carefully examined the mother, and was
confirmed in his belief of her death ; but he found that,
although she had been in that state for seven hours,
her limbs retained their flexibility. Stimulants were
applied in vain; and he took his leave, recommending
that the interment should be deferred until the flexibility
was lost. At five P.M. a messenger came to inform him
that she had revived at half past three. The mother
and child were both alive three years after. There is
scarcely a dissecting room that has not some traditional
story handed down of subjects restored to life after
being deposited within its walls. Many of these are
mere inventions to catch the ever-greedy ear of curi-
Osity; but some of them are, we fear, too well founded
to admit of much doubt. To this class belongs the
circumstance related by Louis, the celebrated French
writer on medical jurisprudence. A patient who was
supposed to have died in the Hôpital Salpêtrière was
removed to his dissecting room. Next morning Louis
was informed that moans had been heard in the theatre;
and on proceeding thither he found, to his horror, that
the supposed corpse had revived during the night, and
430
had actually died in the struggles to disengage herself
from the winding-sheet in which she was enveloped.
This was evident from the distorted attitude in which
the body was found. In a debate on the subject of
premature interments which took place in the French
senate, in the present year (1866), Cardinal Donnet,
the Archbishop of Bordeaux, in a speech which made a
great sensation, adduced many instances within his own
knowledge of people certified dead by authority who
turned out to be alive. He remembered a case when
he was a young priest of an old man who lived twelve
hours after the legal warrant for his burial was issued.
In another case at Bordeaux a young girl was certified
to be dead. He (M. Donnet) providentially came to the
house just as she was about to be screwed down. He
conceived doubts about her dissolution, spoke to her in
a loud voice, and had the inexpressible happiness of
hearing her answer. That woman, who belonged to
one of the most respectable families at Bordeaux, was
still alive, a wife and a mother. He would mention
another case, yet more striking. In 1826, a young
priest, preaching on a hot day in a crowded church,
suddenly fell down unconscious. He was taken home
and laid out for dead. A medical certificate of his
death was given, and preparations were made for his
funeral. The bishop of the cathedral in which he had
been preaching came to the foot of his bed, and said
the De Profundis. The measure of his coffin was taken,
and he, alive all the time, heard the orders given for
his burial, and was not able to protest against them.
At length the voice of a friend of his boyhood pro-
duced a magical effect upon him, and he awoke. “That
“priest,” said Cardinal Donnet, “is now, at the distance
“of forty years, alive ; he is here among you, a mem-
431
“ber of this senate, and he now supplicates the go-
“vernment to frame better regulations so as to prevent
“terrible and irreparable misfortunes.” Allowing for
much of fiction with which such a subject must ever
be mixed, there is still sufficient evidence to warrant a
diligent examination of the means of discriminating
between real and apparent death. Indeed, the horror
with which we contemplate a mistake of the living for
the dead should excite us in the pursuit of knowledge
by which an event so repugnant to our feelings may be
avoided.
Life consists (at least as far as we can perceive) in
the presence of a preserving principle proper to all
organized beings, and peculiar to each species, which
opposes itself continually to the influence of the physical
and chemical agents that surround us. We daily witness
the effects of these agents in altering the forms and
nature of inorganic substances, while our frames
resist them in every latitude. This power, in conjunc-
tion with sensation and motion, constitutes the state of
life; a state which subsists so long as this power remains.
But we do not see this power; it only renders itself
sensible by the motions given to the heart, lungs, and
other organs; and it is by the existence of these motions
that we generally judge of the existence of life. This
isolated abstract principle cannot subsist, as far as we
know, without the instruments by which it makes itself
visible; it is for this reason that these are to be par-
ticularly considered on the present occasion, without
in the least, however, diverting us from the consideration
of a great first cause. If life depends upon the presence
of a force or power continually opposed to the action
of physical and chemical laws, real death will be the
loss of this force, and the abandonment of organized
432
bodies to these agents; while apparent death will be
only the suspension of the exercise of life caused by
some derangement of the functions which serve as the
instruments of vital action. This suspension may last
for a considerable time, if we may judge by the cases
collected by credible authors, to some of which we
have alluded, and by the numerous instances of drowned
persons restored to life after long submersion. From
this definition of life and death it would follow that
putrefaction is the only evidence of real death ; but in
many instances it would be attended with much in-
convenience, and often with danger, to wait for this
confirmation of the extinction of life. In malignant
diseases, and during times of severe general sickness,
the keeping of bodies disinterred until putrefaction
announced the reality of death would be a measure
fraught with considerable risk to the lives of the
survivors. It then becomes desirable that we should
be acquainted with those signs by which we may judge
that life is extinguished by the interruption of its
functions.
As respiration is a function most essential to life, and
at the same time the most apparent, the cessation of it
may be considered as an indication of death. But as
in certain diseases and states of great exhaustion it
becomes very slow and feeble, so as to the casual ob-
server to appear quite extinct, various methods have
been adopted for ascertaining its existence. Thus,
placing down or other light substance near the mouth
or nose, laying a vessel of water on the chest as an
index of motion in that cavity, holding a mirror before
the mouth in order to condense the watery vapour of
the breath, have all been proposed and employed; but
they are all liable to fallacy. Down, or whatever sub-
433
stance is employed, may be moved by some agitation
of the surrounding air; and the surface of a mirror
may be apparently covered by the condensed vapour
of the breath, when it is only the fluid of some exhala-
tion from the surface of the body. We therefore agree
fully with the judicious observations of Dr. Paris” on
this subject. “We feel no hesitation in asserting that
“it is physiologically impossible for a human being to
“remain more than a few minutes in such a state of
“ asphyxia, as not to betray some sign by which a medi-
“cal observer can at once recognise the existence of
“vitality; for if the respiration be only suspended for
“a short interval, we may conclude that life has fled
“for ever. Of all the acts of animal life this is by far
“ the most essential and indispensable. Breath and life
“are very properly considered in the Scriptures as
“convertible terms; and the same synonym, as far as
“we know, prevails in every language. However slow
“ and feeble respiration may become by disease, yet it
“must always be perceptible, provided the naked breast
“ and belly be exposed; for when the intercostal mus-
“cles act, the ribs are elevated and the sternum is
“pushed forward : when the diaphragm acts, the abdo-
“men swells. Now this can never escape the attentive
“eye ; and by looking at the chest and belly we shall
“form a safer conclusion than by the popular methods
“which have been usually adopted.”
The absence of the circulation of the blood has been
looked on as a certain indication of death ; but this is
a test not much to be depended on, for it is well known
that persons may live even for hours in whom no trace
of the action of the heart and arteries can be perceived.
In applying this test, it is necessary to remember that
* Paris and Fonblanque, Medical Journal, vol. ii. p. 10.
28
434
it often occurs that the pulse at the wrist cannot be
felt if the limb be extended or everted ; but if it be
bent, and the hand turned inwards, it becomes percep-
tible. We should therefore perform this movement,
by which the artery is relaxed, and the passage of the
blood is facilitated when only feebly propelled. Some-
times, also, the artery can be felt between the thumb
and first metacarpal bone when it is not to be found at
the wrist. It is well to seek for the artery at the bend
of the arm, as the pulse can often be felt there after it
has left the wrist. In these examinations it is necessary
to press very lightly, lest we should obliterate the pul-
sation altogether ; and care should be taken to guard
against mistaking the beating of the arteries in one's
own fingers for that of the artery under examination.
The trial should be made at every part where large
arteries pass; and sometimes the proceeding of laying
the body on the left side, and placing the hand under
the region of the heart, may be adopted. The stetho-
scope may be used with great advantage in these cases,
as any motion of the heart will be sure to become
sensible through the aid of this instrument.
The temperature of the body has also been proposed
as a guide; but this is very fallacious, as it is well known
that the cooling of a body after death is influenced by
many circumstances, such as age, habit of body, and
the disease of which the person died. With respect to
age, it has been observed that the bodies of young per-
sons retain their heat longer than those of old. In
fact, in old age, the winter of life as it has been termed,
death is scarcely any thing more than to become cold;
and in these cases the temperature of the body is
rapidly reduced to that of the surrounding medium.
Hence we derive a caution in judging of priority of
435
death among a number of bodies overwhelmed by the
same accident; for the body of a young person found
warm and that of an old one found cold would not
indicate that the former had survived the latter.
The habit of body has also been observed to exert an
influence over the rate of cooling after death, and it is
found, casteris paribus, that fat bodies lose their heat
slower than lean, but putrefy sooner. The disease
which has destroyed life is a powerful controlling agent
in the loss of temperature after death. Thus it has
been long known that in apoplexy the body retains its
heat for a considerable time. This has been particularly
noticed by Portal. Again, in that disease or accident
frequently witnessed in tropical climates, the “coup de
soleil,” we are informed by Badenoch that the bodies
of the sufferers remain warm much longer than in
other forms of death. In most kinds of asphyxia except
that by drowning, but especially in asphyxia by noxious
gases, the dissipation of the animal heat is greatly de-
layed. In cases of the latter description Orfila found
the heat preserved for twelve hours after death ; and
we are informed by Samoelowitz, that during the great
plague at Moscow, the bodies of those who were speedy
victims to that disease preserved their temperature
much longer than the bodies of those who die by or-
dinary diseases. Besides these cases in which the
animal heat is preserved to an unusual length of time
after death, there are others in which it is rapidly lost
during life, and even when there is no danger of death,
as in some forms of hysteria and in syncope. It is also
an effect of submersion in water, and is usually observed
in the bodies of those restored to life after drowning.
Flexibility of the limbs succeeding their rigidity is one
of the most characteristic signs of death ; we say, suc-
28%
436
ceeding their rigidity, because so long as the limbs are
flexible, if the flexibility has not succeeded stiffness, we
may presume that there are some remains of life. We
are indebted to Nysten and Louis for some valuable
observations on the occurrence and duration of the
cadaveric stiffness. The rigidity of the muscles com-
mences in the trunk and neck; it then spreads to the
thoracic extremities, and finally reaches the legs and
feet, and in subsiding it follows the same course. Its
duration is in proportion to the lateness of its occur-
rence, it being found to continue longer in those cases
in which it commences latest. Its energy and duration
are always in a direct ratio with the degree of develop-
ment and energy of the muscular system at the moment
of death ; thus it is extremely strong in the bodies of
athletic individuals, in those who die of tetanus, or who
are asphyxiated by noxious gases whose deleterious
action does not affect the contractility of the muscles.
In all animals, the moment when stiffness commences
is that in which the vital heat appears to be nearly ex-
tinct. Professor Louis, from observations made upon
more than five hundred subjects after death, found that
at the moment of the absolute cessation of the vital
movements, the articulations began to become stiff even
before the loss of animal heat. Foderé has verified the
justness of this observation several times in hospitals,
and concludes that the flexibility of the limbs is one of
the principal signs by which we may judge that a per-
son is not dead, although there is no other sign of life.
During the whole time this contraction of the muscles
continues, they resist the action of chemical forces, and
it is only when suppleness is restored that putrefaction
commences. Nysten regards this stiffness as a measure
of the resistance opposed by organic to chemical forces.
437
Life on the point of extinction seems to take refuge in
the muscles, and there causes the spasms we speak of
and during their continuance is able to resist the opera-
tion of chemical forces. -
The occurrence of the cadaveric stiffness is sub-
ordinate to the same causes which influence the loss of
temperature. We have seen that old age favours the
dissipation of animal heat, and in like manner it is
observed that the muscular rigidity comes on soonest
in the bodies of old persons. The habit of body in
which the temperature is longest preserved is that in
which stiffness of the limbs is slowest in its invasion ;
thus the bodies of full and fat persons remain longer
flexible than those of meagre and lean. And again,
those diseases which are followed by a long continuance
of warmth are also remarkable for leaving a corpse in
an equal degree flexible ; while those in which the
body is rapidly cooled, as haemorrhage for example,
favour the approach of the muscular spasm ; and after
death from these, the body becomes soonest and some.
times suddenly stiff. From this concurrence between
the spontaneous cooling of the dead body and the super-
vention of the cadaveric stiffness, it might be pre-
sumed that accidental cooling would be followed by a
similar effect; and this is precisely what takes place ;
for bodies left exposed in cold situations, as on a field
of battle, are found to become rapidly stiff.
The rigidity of the body is a criterion of great value,
as it points out the general contraction of the muscular
fibre which occurs shortly after dissolution ; but in
regarding it as a test of death, it is necessary to guard
against mistaking the stiffness which arises from other
causes for the cadaveric stiffness. In persons frozen
but not yet dead, or, in other words, susceptible of
438
reanimation, the rigidity of the body is very great; but
on close examination it is found not to be confined to
the muscular system, but to pervade all parts of the
body. The breasts, belly, and skin are all equally hard
with the muscles, to which alone the stiffness is confined
in that from death. This, coupled with the crackling
noise caused by forcible flexure of a joint, will be
sufficient mark of discrimination between the two.
Moreover, it can scarcely be a source of error, because
it is an effect of the accident to which the person has
been exposed, and if it do not yield to the gradual appli-
cation of heat, the appropriate remedy, it will be an
indication that the subject is really dead.
The stiffness that occurs in certain forms of syncope
and convulsive diseases can never be confounded with
cadaveric rigidity, if proper attention be paid to the
facts connected with it ; for in the former case it takes
place immediately after the invasion of the disease, and
always precedes apparent death, while the body still
preserves a considerable degree of warmth; whereas the
cadaveric stiffness is not observed until some time
after death, and when the heat of the body is scarcely
sensible. In all stiffness of this kind there is much
difficulty in moving a limb ; so far it resembles that
from death ; but after having bent the limb, on ceasing
to apply the force it immediately flies back to its
former position ; while the dead limb, on the contrary,
remains in the position in which it is placed. If death
really takes place in any of these convulsive diseases,
the muscular contraction ceases with the extinction of
the nervous influence to which it was owing, and the
true cadaveric stiffness succeeds at the proper time,
and runs its usual course. But, above all, the termina-
tion of the cadaveric rigidity in flexibility serves to
439
distinguish it from every other, and is a certain indica-
tion of dissolution.
That peculiar cast of countenance termed from its
first describer the Hippocratic, has been regarded by
some as another sign upon which reliance may be
placed in judging of the reality of death. It is thus
described by Hippocrates: “The forehead wrinkled and
“dry; the eye sunken; the nose pointed, and bordered
“with a violet or black circle ; the temples sunken,
“hollow, and retired ; the ears sticking up ; the lips
“hanging down; the cheeks sunken ; the chin wrinkled
“ and hard ; the colour of the skin leaden or violet,
“the hairs of the nose and eye-lashes sprinkled with a
“yellowish white dust.” Such is the alteration in the
human physiognomy which usually takes place after
death. But it is also produced by the near approach
of death ; often by the sight of imminent danger; and
is also commonly observed in criminals at execution,
whatever may be the degree of tranquillity assumed.
Moreover, those who perish by sudden death, or of
short disease in which dissolution is not expected, pre-
serve their usual physiognomy; while, on the other
hand, the countenance may be pale, ghastly, and con-
tracted in nervous and hysterical affections without
extinction of life. Finally, there are some individuals
whose integuments during life have a leaden and ca-
daverous aspect, and whose countenance during natural
sleep puts on an appearance little removed from the
Hippocratic. From these causes we think that little
reliance can be placed on the countenance as a test of
death.
The changes that take place in the eye after dissolu-
tion are remarkable, and have been regarded by some
authors as satisfactory indications of death. These are,
440
the cornea becoming opaque, and covered with a thin
slimy membrane, which breaks in pieces when touched,
and is easily removed by wiping; and general flaccidity
of the eye-ball, which may be perceived by placing the
finger on the upper eye-lid and moving it gently over
the surface of the eye; when the point of the finger
will sink on coming over the cornea, and a distinct ring
will be felt, marking the attachment of this membrane
to the sclerotic coat. Certainly these signs are valid in
many forms of death, but they do not exist in all, and
therefore are not infallible. The reason why they are
sometimes present and at others wanting, is evident
when we consider the causes upon which these changes
depend. The cornea owes its brightness mainly to the
tension of the eye-ball, produced by a full secretion of
the humours. This is proved by evacuating a portion
of the humours of a recent eye, when the cornea will
become flaccid and opaque ; or by taking an eye some
time dead, and with the cornea already opaque, and
compressing the humours towards the anterior part,
when the cornea will reassume its brightness. We find
the appearance of the living eye influenced by the
same cause, and hence we see the dim cornea in very
aged and meagre persons produced by a deficiency in
the ocular in common with every other secretion. We
do not speak of the arcus senilis, but of the general
opacity of the cornea observed in such individuals.
Hence we can understand why in death after long ill-
ness, when the powers of reparation have been for a
length of time impaired, the eye should exhibit its want
of fulness by a flaccid and dim cornea. On the other
hand, we are led to expect, when death takes place Sud-
denly in a healthy person, that the eye will preserve its
441
lustre for a much longer period ; and this experience
confirms, for it has been observed that after death by
apoplexy, asphyxia, prussic acid, &c. the eyes preserve
their integrity for a considerable time, owing to their
being at the time of death in a state of tension by the
due secretion of the vitreous and aqueous humours.
Moreover, it has been observed that in severe diseases
of long continuance, and even in some affections of the
mind, the eyes have become dim and shrunken although
death may not happen, and thus another source of
fallacy arises.
Different physical tests have been proposed for doubt-
ful cases, such as incisions, burns, blisters, cupping,
flagellation, &c.; but of these it may be said that there
are so many instances of disease affecting the nervous
system, in which their application causes no sensation
in the sufferer, that they will be still less likely to pro-
duce any effect on the sensorium in a body nearly
deprived of life. The influence possessed by galvanism
in the production of muscular contraction in the living
body has led to its adoption as a test of death ; and
with certain limitation it is one of considerable value ;
for although the muscles retain their contractility for
some time after absolute death, yet if the death be real,
they soon lose it, and becomes insensible to this stimu-
lus. On the other hand, if the least spark of life remain,
the contractility will be also present, and on the appli-
cation of the galvanic fluid it will be evidenced by
contraction. Galvanism thus becomes a test not of life,
but of the reality of death, for if the muscular fibre
does not obey it, there can be no doubt that vitality is
extinguished. It should be recollected, however, that
different parts of the muscular system retain their
442
contractility, and consequently their obedience to the
galvanic stimulus, for different periods after death.*
Nysten found, in the body of a guillotined criminal
which was given to him immediately after execution,
that the contractility of the left ventricle was extin-
guished in forty-nine minutes after decapitation ; that
of the stomach, intestines, and urinary bladder conti-
nued for fifty-six minutes; while that of the right
ventricle and diaphragm remained for two hours. He
found the locomotive muscles lose their contractility
in proportion to their free exposure to the atmosphere,
and those that were not at all exposed continued exci-
table during four hours; but the auricles of the heart,
although in contact with the air during the whole
time, did not cease to contract, when stimulated, for
four hours and forty minutes. From many similar
opportunities of observation possessed by Nysten, he
concludes that the muscles cease to be influenced by
galvanism after death in the following order: 1. left
ventricle ; 2. intestines and stomach ; 3. urinary blad-
der ; 4. right ventricle—this retains its contractility
under galvanism for one hour ; 5. Oesophagus, for half
an hour longer ; 6. iris; 7. muscles of animal life; 8.
auricles.
We have now alluded to the chief criteria of real
death ; and we may conclude this part of our subject
by stating that those most entitled to consideration are
flexibility subsequent to rigidity of the joints, loss of
contractility of the muscles under galvanism, and in-
cipient putrefaction. These are not liable to any
important fallacies: the rest are, for the reasons al-
ready mentioned, more or less equivocal.
It now remains, before we proceed to consider the
* Dict, des Sciences Méd. art. Mort.
443
causes of sudden death, to make a few observations on
the changes which the human body undergoes after
dissolution ; and we prefer doing so in this place,
because the subject naturally follows that which we
have just discussed, and also because a knowledge of the
attendant phenomena and their causes is often of the
highest importance to the medical jurist, in enabling
him to determine the length of time a body submitted
to his inspection may have been dead ; or the period
at which dissection may be attempted with a prospect of
useful results. It is sometimes of the utmost moment
to the surviving relatives of an individual found dead
that it shall be determined at what time death took
place; of this, a case mentioned by Dr. Male” serves as
a good illustration. At the Lent assizes held at
Warwick in the year 1805, a cause was tried in which
a gentleman who was insolvent left his own house
with the intention (as it was presumed from his
preceding conduct and conversation) of destroying
himself. Five weeks and four days after that period
his body was found floating down a river. A com-
mission of bankruptcy having been taken out against
the deceased a few days after he had left his home, it
became a question of great importance to the interests
of his family to ascertain whether he was living at that
period ; for if it could be proved that he was not, his
property would remain untouched by the legal pro-
ceedings. From the changes which the body had
undergone, it was presumed that he had drowned him-
self the day he left home ; and to corroborate this
presumption, the evidence of Sir George Gibbes of
Bath was required, as he had lately been engaged in ex-
periments on the changes produced in animal substances
* Elements of Juridical Medicine, p. 101.
444
by immersion in water. He stated on the trial that it
required five or six weeks to effect changes similar to
those observed in the body of this individual; and upon
this evidence the jury were of opinion that the deceased
was not alive at the time the commission was taken out,
and the bankruptcy was accordingly superseded.
A few weeks back the writer of this article, in passing
along the canal on the south side of Dublin, on a
Saturday, observed a crowd collected on the bank. On
approaching, he discovered the object of their attention
to be the body of a man recently withdrawn from the
water. None of the bystanders knew anything of the
individual, or of the time at which he had been
drowned ; but, from the fresh appearance of the body,
the general belief was that he had fallen in the preced-
ing evening. From certain appearances (which will be
more fully treated of hereafter) the writer was induced
to doubt the truth of this supposition, and to assert that
the man had lain in the water for at least five days.
An accidental circumstance served to corroborate this
opinion. Seeing the individual well dressed, and not
observing any hat, the writer inquired whether one had
been found with him, to which he received a negative
answer ; when a boy, who lived in the neighbourhood,
came forward and mentioned that a hat and handker-
chief were found in the water at that place on the
previous Tuesday morning, just five days from the time
of finding the body. These articles were afterwards
proved to have belonged to the deceased. This was a
case in which, from the appearances presented by the
body, very positive testimony could have been given as
to the length of time that had elapsed since death ; and
in case any question similar to that in the preceding
445
instance were pending, such testimony must have been
of the highest importance.
The changes that take place in the body after death
may be divided into those which occur before, and those
which follow the invasion of putrefaction.
To the first stage belong diminution of temperature,
contraction of the muscles constituting cadaveric
stiffness, and lividity of certain portions of the surface.
We have already taken notice of the causes by which
the loss of heat and muscular rigidity are influenced,
and therefore it is unnecessary to allude to these phe-
nomena at present. The extensive lividities usually
observed on the back parts of the body shortly after
death are entirely owing to gravitation ; the blood, still
fluid, and no longer kept in its proper course by an
impelling power, obeys the physical law by which it is
inclined to seek the most depending situations, and this
takes place in the interior as well as on the exterior of
the body; of which we have examples in the gorged
state of the posterior portion of the lungs, and in the
vascular turgescence exhibited by the gastro-intestinal
mucous membrane in the lowest part of depending
convolutions.” That all these appearances are the result
of gravitation is proved by the fact that we can produce
them in other situations by altering the position of the
body; thus, if it be turned on the face, instead of re-
maining as it usually does on the back, the skin of the
face, breast, belly, and anterior parts of the limbs will
be found livid, while the back will retain its natural
colour, and the congestions in the anterior of the body
will all be found in the anterior part of the organs.
Nay, the lividity, having formed on the back, can be
* Trousseau, Dissertation inaugurale. Paris, 1825.
446
made to disappear, if the body be turned before it be-
comes cold, and the blood coagulates. Of this the
writer has convinced himself by experiment. As it has
happened that these lividities have been mistaken for
the effects of violence, and suspicions of murder have
arisen therefrom, it is necessary, in judging of such
appearances, to take into consideration the great extent
of surface occupied by them, the attitude in which the
body may have lain during the first few hours after
death, and the absence of any effusion or infiltration of
blood into the cellular tissue. We shall have to recur to
this subject when we come to treat of the effects of
blows on the dead body, and their resemblance to the
consequences of injuries inflicted during life.
The second stage is marked by the occurrence of
putrefaction. This is a process peculiar to organized
substances, and it seems to follow as a consequence of
the manner in which their ultimate elements are com-
bined during life. These elements are few in number
—oxygen, hydrogen, carbon, and nitrogen constitute
the great bulk of organized substances. Other ele-
ments, as phosphorus, sulphur, iron, lime, potassa, and
silica are occasionally present, but in quantities so small
as not to invalidate the statement just made. But we
find these elements combined in various proportions,
and thus constituting the different proximate principles
of which our bodies are made up, such as fibrin, albu-
men, gelatine, urea, stearine, elaine, cholesterine, &c.
which in composition differ from each other chiefly
in the proportion of their component elements. Now
these combinations are not such as the ultimate elements
have the greatest disposition to form ; in other words,
their natural affinities lead them to different combina.
tions and to the production of more permanent com-
447
pounds, namely, water, carbonic acid, ammonia, &c.
This disposition is controlled by vitality, and as long as
it continues, the operation of chemical laws seems sus-
pended; but as soon as life is extinguished, the elements
abandon their former combinations, and enter into new
ones, and this constitutes putrefaction. The presence
of nitrogen expedites this process, and hence vegetable
substances, which with few exceptions are deficient in
this element, undergo the change more tardily and im-
perfectly; and some animal substances, as fats, oils,
cholesterine, in which nitrogen is absent, are little dis-
posed to the putrefactive fermentation.
The human body, in common with other animal
substances, suffers this dissipation of its principles after
death ; but as the phenomena attending this change
are not constant as to time, order, and results, it is ne-
cessary to inquire into those causes which influence its
COUITS6.
The conditions necessary to the speedy putrefaction
of a dead body are exposure to air, moisture, and a
moderate degree of heat. The presence of air, however,
does not appear to be essential, although its exclusion
retards the process. Putrefaction in vacuo was denied
by Gay-Lussac, but some experiments by Guntz of
Leipsic have proved the possibility of its occurrence.
He took some pieces of human flesh, and having freed
them from any air that might be lodged among the
fibres by plunging them into mercury, he passed them
into jars inverted over and filled with the same fluid.
The flesh rose to the top of the jar, and the apparatus
was kept in a moderate temperature. Putrefaction
went on, but at a slower rate than if the air had been
admitted. In a few days the flesh became soft and
pulpy, and of a grey colour. Gas was generated, which
448
was found to be carbonic acid gas, and some highly
fetid fluid covered the surface of the mercury: the
flesh had lost one-third of its weight. He also ascer-
tained that blood alone will putrefy in vacuo. For
this purpose he placed the forefinger of his left hand
under an inverted jar filled with mercury, and then
made an incision into the integuments. The blood
rose to the top, and in five days it was found to be
undergoing putrefaction. An accident by which the
apparatus was upset prevented an analysis of the pro-
duct. These experiments show that though the presence
of air expedites the process, it is not essential.
A moderate temperature is a most important condi-
tion. If the heat be too high, it prevents the occurrence
of putrefaction by rapidly dissipating moisture; and if
too low, the process is equally arrested, and, it would
appear, from the same cause,_for the fluids being con-
verted into solids by congelation, are as efficiently
deprived of the power of assisting putrefaction, so long
as they continue in that state, as if they were altogether
removed. The practice of packing salmon in ice for
the purpose of preserving it fresh during long voyages
is a familiar illustration of this point. But the most
extraordinary instance on record is the preservation of
the mammoth discovered some years ago in Siberia
enclosed in a block of ice, on breaking into which the
animal was found entire and fresh. This being a speci-
men of an extinct species of animal, it is of course im-
possible to calculate the number of centuries it must
have been enveloped in its icy tomb. Below 50° Fah-
renheit the process is slowly performed, and at 32° it
is altogether suspended. The temperature most favour-
able to its perfection is from 60° to 80° or 90°. This
is the range of the thermometer during our summer,
449
and hence at this time putrefaction most readily goes
forward.
Moisture is an indispensable condition. This is
shewn by the readiness with which substances other-
wise disposed to putrefy are preserved by drying, as
smoked meats, fish, &c.; and still more strikingly by
the preservation of animals buried in sand. Caravans
in crossing deserts have been overwhelmed by the shift-
ing sands, and the bodies of men and camels have lain
for centuries until exposed by a similar cause, when they
were found dry and shrunken, but with outany sign of
having undergone putrefaction. Instances of this kind
have occurred in Egypt, Arabia, and Persia. Chardin”
mentions the preservation of certain bodies in the sands
of Khorassan (Persia), where they had been buried two
thousand years.
It is supposed that the preserving power possessed by
some burying places, as the vaults of the Cordeliers at
Toulouse, and those of St. Michan's, Dublin, is owing to
the dry and absorbent nature of the surrounding soil.
In these situations bodies rarely putrefy, but they
undergo a process of natural mummification. The pro-
ducts of putrefaction, when conducted under favourable
circumstances, are water, ammonia, carbonic acid, car-
buretted hydrogen, phosphuretted hydrogen, nitrogen,
and hydrogen gases, and there remains a friable matter
of a deep-brown colour containing the salts of the body
and some carbon.
From these cursory observations it must appear that
the transformation of a dead body will be influenced by
the medium in which it is placed. The media existing
naturally, and to which all others may be referred, are
* Traité des Exhumations Juridiques, par MM. Orfila et Leseur, vol. i.
p. 382.
29
450
the earth, air, and water. But as these do not exist in
a purely separate state, being found mixed together,
as air impregnated with water, water with air, and earth
with both, the term group may be given to these com-
binations. Thus we have earthy group, watery group,
and aerial group, by which are meant the combinations
usually existing between these media. A group is
called cold when the temperature is below 32°; cool be-
tween 32° and 60° ; warm between 60° and 100°; and
hot when it is above 100°.
The metallic oxides and salts which enter into the
composition of the earth exercise but a small influence
in the transformation of a dead body. The action of
this medium depends upon the greater or less exactness
with which it excludes the access of air and water. Thus
sandy soils, which quickly absorb water, and argillaceous
soils which collect water round a dead body, differ mate-
rially in their effects; in the former decomposition goes
on slowly, and is sometimes, as we have seen, altogether
prevented; in the latter putrefaction readily takes place,
and sometimes the transformation into adipocire is
effected. Fresh ground or gardens which are rich in
mould, and the soil of churchyards, appear to act as a
sort of ferment which assists putrefaction; for it is found
that flesh enters sooner into the putrefactive process
when surrounded by substances already undergoing
that change.
We have alluded to the formation of adipocire, and it
is necessary, before we leave this part of our subject, to
make a few observations on this curious phenomenon.
Adipocire, so termed from its resemblance to fat and
wax, is a peculiar substance of a soft ductile nature and
whitish colour, produced by dead animal substances
undergoing decomposition under particular circum-
451
stances. We are indebted to Fourcroy for the first
scientific account of this peculiar transformation. His
attention was directed to it on the occasion of the cele-
brated exhumations practised at the ancient burying-
place des Innocens at Paris, in the years 1785, '86, ’87,
when from fifteen to twenty thousand bodies were re-
moved for the purpose of eradicating this cemetery.
This spot differed from common burying-grounds, where
each individual body is surrounded by a portion of the
soil. It was the burying-ground of a large district,
wherein successive generations of the inhabitants had
been deposited for upwards of three centuries. The
remains of the human bodies immersed in this mass of
putrescence were found in three different states, accord-
ing to the time they had been buried, the place they
occupied, and their relative situations with regard to
each other. The most ancient were simply portions of
bones irregularly dispersed in the soil, which had been
frequently disturbed. A second state, in certain bodies
which had always been insulated, exhibited the skin,
the muscles, tendons, and aponeuroses dry, brittle, hard,
more or less grey, and similar to what are called mum-
mies in certain caverns. The third and most singular
state of these soft parts was observed in the bodies which
filled the common graves or repositories. These were
cavities thirty feet in depth and twenty on each side,
appropriated to contain the remains of the poor.
Each cavity contained between one thousand and
one thousand five hundred, packed side by side in
rows, without any intervening earth ; so that it
was, when filled, an entire mass of human bodies,
separated only by two planks of about half an inch
thick. The first of these receptacles which was opened
in the presence of Fourcroy had been closed for fifteen
29*
452
years, the coffins were in good preservation, but a little
settled, and the wood had a yellow tinge. When the
covers of several were taken off, the bodies were observed
at the bottom, leaving a considerable distance between
their surface and the cover, and flattened as if they had
suffered a strong compression. The linen which had
covered them was slightly adherent to the bodies, and,
with the form of the different regions, exhibited, on re-
moving the linen, nothing but irregular masses of a soft .
ductile matter of a grey-white colour. These masses
environed the bones on all sides, which had no solidity,
but broke by any sudden pressure. The appearance of
this matter, its obvious composition, and its softness re-
sembled common white cheese ; and the resemblance
was more striking from the prints which the threads of
the linen had made upon its surface. The grave-diggers
asserted that they never found this matter in bodies
interred alone; but that the accumulated bodies of the
common graves only were subject to this change.
Fourcroy remarked that the conversion appeared in
different stages of advancement, so that in various bodies
the fibrous texture and colour, more or less red, were
discernible within the fatty matter; that the masses
covering the bones were entirely of the same nature,
offering indistinctly in all the regions a grey substance,
for the most part soft and ductile, sometimes dry, always
easily separated in porous fragments, penetrated with
cavities, and no longer exhibiting any traces of mem-
branes, muscles, tendons, vessels, or nerves. By exa-
mining this substance in the different regions of the
body, it was found that the skin is particularly disposed
to this remarkable alteration. It was afterwards per-
ceived that the ligaments and tendons no longer existed,
or at least had lost their tenacity, so that the bones were
453
entirely unsupported, and left to the action of their own
weight. In all the bodies so changed the abdominal
cavity had disappeared. The integuments and muscles
of this region being converted into the white matter,
like the other soft parts, had subsided upon the vertebral
column, and were so flattened as to leave no place for
the viscera; and accordingly there was scarcely ever
any trace of them observed in the almost obliterated
cavity. The thorax was also flattened, and its viscera
were no longer discernible. Sometimes an irregularly.
rounded mass was found, which appeared to have arisen
from the fat and fibrous substance of the heart. The
features of the face were converted into adipocire, and
no longer distinguishable, and some of the same matter
occupied the cavities of the mouth and orbits. The
cranium constantly contained the brain, changed into
a similar substance. From various observations it was
found that this fatty matter was capable of enduring in
these burying places for thirty or forty years, and was at
length corroded, and carried off by the aqueous putrid
humidity which there abounds.
Adipocire, according to M. Chevreul, consists of mar-
garic acid, oleic acid, a little bitter substance, of an
orange coloured principle which tinges the acid, of a
trace of odorous principle, of ammonia, very small quan-
tities of lime and potass, and some salts. The alkalies
we have mentioned partly saturate the margaric and
oleic acids. The latter exists in a very small proportion
relatively to the margaric, which abounds in this sub-
stance. It is easy to perceive from this analysis that
adipocire is a soap with double acid and ammoniacal
base. Sometimes, however, the acids are found com-
bined with lime. This has been observed when bodies
undergo the change in water containing carbonate or
454
sulphate of lime ; and also in earth permitting the
infiltration of water which has dissolved these salts in
its progress through it. In both cases the ammoniacal
soap is first formed, and is then decomposed by the
calcareous solution ; margarate and oleate of lime, and
carbonate or sulphate of ammonia being the result. To
prove that such is the case, the following experiments
were made by Orfila and Leseur.
On the 4th of December, 1828, they interred a sto-
mach, a portion of skin with the subjacent cellular
tissue, two testicles, and an omentum, all belonging to
the human subject. Each of them was enveloped in
linen, and placed in a small deal box, which was buried
at a depth of two feet and a half. They were disinter-
red on the 30th of July, 1829, seven months and twenty-
seven days after having been deposited in the ground.
In place of the stomach they found about half a drachm
of adipocire not in the least ammoniacal, but composed
of margaric and oleic acids and lime. The skin pre-
sented here and there the appearance of adipocire, and
furnished on analysis a calcareous soap ; the testicles
were similarly transformed. The omentum had pre-
served its aspect and structure in several places, whilst
in others it was changed into a yellowish fatty mass,
having the odour of Roquefort cheese, and composed of
lime and the acids mentioned above. These distin-
guished experimenters were pretty certain that the
presence of the calcareous soap at the expense of the
ammoniacal, in these substances, was owing to the rain-
water in filtering through the ground having dissolved
some of the calcareous salts, which having thus got
access to the interior of the wooden box decomposed
the ammoniacal soap, and changed it into calcareous :
still they thought it necessary to prove by direct
455
experiment that it really was so. Accordingly they
prepared an ammoniacal soap with pure stearic acid
and caustic ammonia, and plunged it into a solution of
sulphate of lime. At the end of three weeks, on examin-
ing the soap, it was found entirely changed into stea-
rate of lime, and sulphate of ammonia was formed.
They also made another experiment: two human sto-
machs were buried, one in a leaden box enclosed in a
wooden one, the other in wood alone : seven months
afterwards they were taken up. The stomach contained
in the wooden box was transformed into a soap partly
ammoniacal but chiefly calcareous, whilst that inclosed
in the lead offered no trace of saponification, and was
but little altered.
“It is manifest,” say they, “that, in this last experi-
“ment, the progress of the putrefactive process had
“ been greatly retarded in consequence of the double
“envelope, and particularly of the leaden case ; and
“every thing leads to the conclusion that, if the appa-
“ratus had remained underground as long as was
“requisite for converting the stomach into soap, this
“soap would have been of the ammoniacal, and not of
“ the calcareous kind.” -
Adipocire is only formed when fat and some azotised
substance are found together. The fatty matter fur-
nishes the margaric and oleic acids, and the other the
ammonia. This is proved by the following circum-
stances. Entire dead bodies, or entire parts of a dead
body, such as a head, one of the limbs, or the thorax,
parts in which are found skin, fat, muscles, &c. are
changed into adipocire in stagnant or gently moving
water; but isolated muscle furnishes but a small portion
of this substance, and that only when it is rich in fat.
* Traité des Exhumations Juridiques, tom. i. p. 366.
456
Fat washed, freed from blood, and separated from parts
which contain azote, is not transformed into adipocire,
neither does the fibrine of the blood, when perfectly
washed and free from fat, undergo the change. Orfila
found that portions of skin previously deprived of the
subjacent cellular tissue were not saponified after eight
months of inhumation ; while similar portions of the
skin of the same individual, to which the cellular sub-
stance was left adhering, and buried during the same
time, were converted into adipocire. It appears that
a sojourn of about three years in the ground is neces-
sary for the complete transformation of a body, and that
the change goes forward more quickly in water; and it
is only when a number of bodies are buried in the same
grave that the process is perfect, those at the bottom
being the first to undergo it. A thick stratum of earth
over the grave is necessary, in order to confine the
gases given out in the first stages of putrefaction.
The chief object of the medical jurist to whom a dead
body is submitted for inspection is to ascertain the
cause of dissolution. In order to assist in this investiga-
tion, we will follow the arrangement already proposed.
I. DEATH FROM NATURAL CAUSES.—Death is the inevi-
table condition to which all bodies that possess life must,
sooner or later, be reduced. This termination of their
existence forms a grand distinction between organized
and unorganized matter. The gradual termination of
life, or natural death strictly so called, is very different
in its phenomena from the more common or accidental
death. In natural death man expires, as it were, in
detail; the external functions and those of the animal
life being almost annihilated, whilst those of organic
life still remain in vigour. The active powers gradually
desert each organ ; digestion languishes; secretion,
457
absorption, and capillary circulation are arrested; the
general circulation is then suspended in the large vessels,
and, lastly, the contractions of the heart cease. In acci-
dental death the general circulation and respiration
are first arrested, while the other functions are succes-
sively and slowly extinguished. So that it has been
said that, in the former, life is first extinguished in the
parts, and then ceases in the heart, the influence of death
being exerted, as it were, from the circumference to the
centre; while, in the latter, it ceases first in the heart,
and then in all the parts, death proceeding from the
centre to the circumference. The termination of life
termed natural death is a very rare occurrence in the
human species in a civilized state ; animals often reach
it ; but the cessation of existence from mere old age
has become with us a rare phenomenon. Haller esti-
mates the average probability of human life, and de-
duces the conclusion that only one individual in fifteen
thousand reaches the hundredth year. Accidental death,
in contradistinction to natural death, becomes therefore
an object particularly worthy of attention. This may
take place in two ways—either as the slow and gradual
termination of a lingering disease ; or as the sudden
result of some great disturbance of the animal economy,
and then called sudden death, as in apoplexy, hemor-
rhage, concussion, asphyxia, &c.
We now come to consider the natural causes of sud-
den death, and our observations upon them must be
necessarily brief, as it would not be possible to enter
into detail upon them in this essay. However, we
may notice some of the most frequent and most
remarkable. These are apoplexy ; rupture of an aneu-
rism or of a large vessel into one of the cavities; bursting
of purulent cysts, or other collections of fluid, or of
458
bloodvessels into the air-passages; ossification of the
valves of the heart; rupture of this organ; asphyxia
idiopathica.
Apoplexy may occur at any age, but in the great
majority of cases the age is above fifty years; certainly
it may be said to be a disease rather of the decline of
life. It is a disease which in some instances may be
mistaken in its early symptoms, and may terminate
fatally in situations which preclude any observation of
the event. Those most predisposed are of a full ple-
thoric system, with large head and short neck. Diseases
of the bloodvessels of the brain, such as ossification of
the arteries, aneurism, and obstruction of the sinuses,
lead to rupture of their coats; and it is well known
that hypertrophy of the heart sometimes produces
apoplexy. In ordinary cases an examination of the
brain sufficiently develops the complaint. Blood is
usually found in some part of this organ, rarely on the
surface, more commonly in or about the corpora striata
or optic thalami, or effused into the ventricles. In old
apoplectics, who have had many shocks, cysts enclosing
clots of blood are found, and the brain surrounding
them is often observed in different stages of inflamma-
tion or ramollissement. It should be borne in mind
that persons seized with apoplexy may fall from a
height, and thus bear marks of external injury which
might mislead a superficial enquirer as to the cause of
death. In cases of rupture of internal aneurisms, or
purulent cysts, or of ossification of the valves of the
heart, an examination of the body will exhibit the true
nature of the disease. The last of the natural cases of
sudden death which we have mentioned is that pecu-
liar disease termed by Mr. Chevallier “asphyxia idio-
pathica.” A case of this rare and remarkable affection
459
came under the observation of the writer a few years
ago. The subject of it was a healthy woman, forty
years of age, in the ninth month of pregnancy. She
complained suddenly one evening of weakness and sick-
ness of stomach, and on making an effort to vomit, she
fell back and expired without any struggle. The writer
examined the body the following day, and enquired
diligently after every cause of death in each of the
cavities; but he never saw more healthy organs, and,
taken altogether, certainly never a sounder body. But
the state in which the heart was found led to a discovery
of the nature of the case. The parietes of this organ
were entire, but quite flaccid, and all its cavities were
empty; while its proper veins were much distended
with blood. This so exactly resembled the appearances
described by Mr. Chevallier, and the manner of death
corresponded so fully with that of the cases he mentions,
that it was thought justifiable to refer the cause of
death to the disease just alluded to. Mr. Chevallier
accounts for death in these cases by supposing a sudden
loss of power in the vessels, chiefly in the minute ones,
to return the blood to the heart; in consequence of
which this organ, after having contracted so as to empty
itself, and then relaxing, continues in that state for
want of its accustomed stimulus, and so dies. We men-
tion this in order to show that such cases are sometimes
to be met with, and that it is necessary to be prepared
to detect them. For further information we must refer
to the paper alluded to.
II. DEATH FROM v1OLENT CAUSEs.-The wide extent
of this division, and the great importance of the topics
included in it, render it of the deepest interest to the
medical jurist. The violent causes of sudden death
may be reduced to seven heads, viz. asphyria, poisoning,
460
wounds, burning, cold, starvation, and lightning. As-
phyxia may be defined to be the suspension of the func-
tion of respiration, and consequently of the circulatory
and cerebral functions. The interruption may affect pri-
marily either the mechanical or chemical phenomena
of expiration. The mechanical are the motions of the
parietes of the chest, producing inspiration and expira-
tion ; the chemical are the disappearance of oxygen
from the air taken into the lungs, the disengagement of
carbonic acid gas, and the conversion of the venous
into arterial blood. Asphyxia may commence by the
cessation of either of these classes of phenomena; but
in whichever it first begins, it speedily involves the
other, and both are soon equally suspended. A violent
compression of the thorax, such as is produced by the
falling of heavy beams of timber, portions of buildings,
roofs of mines, &c.; a double wound, giving entrance to
the air into both cavities of the chest ; rupture of the
diaphragm, by which the abdominal viscera gain admis-
sion to the chest; the effusion of large quantities of fluid
into the pleura—all these put an end to the mechanical
phenomena of respiration by interrupting the motions
of the thorax. In other cases these motions cease, but
from a different cause ; we allude to paralysis of the
muscles that move the parietes, which happens when
the spinal marrow is cut across, or is pressed on, above
the origins of the phrenic nerve, or above the third
cervical vertebra, or when the whole nervous energy is
destroyed, as by lightning. Most commonly, however,
it is the second class, or the chemical phenomena of
respiration, that cease first ; and the motions of the
chest are only interrupted because the black blood,
which is then driven into all the organs, and especially
into the muscles and brain, does not carry along with
461
it the power of excitation necessary to carry on the
functions of these parts. This interruption of the
chemical phenomena may be produced in various ways:
thus sometimes there is total interception of the pas-
Sage of air into the lungs, as when an animal is placed
in vacuo, or is smothered, drowned, or strangled ; at
other times an aeriform fluid does enter these organs,
but is not possessed of the principle necessary to act on
the blood contained in them, such as azote and hydro-
gen gases. It may be that the gas inhaled is endowed
with deleterious properties; either that it irritates the
lungs, as the sulphurous acid, muriatic acid, and
ammoniacal gases; or that it acts upon the whole
animal economy as a poison, such as the carbonic acid,
nitrous acid, carburetted hydrogen, and hydro-sulphu-
retted gases. Thus we find that, by the total intercep-
tion of all air, or by the inhalation of noxious gases,
the chemical phenomena of respiration may be arrested.
It is to this we shall direct our attention at present, as
the cases in which the mechanical phenomena are first
affected are more rare, and will be afterwards considered
in treating of death from wounds or bruises, and
from lightning.
The causes which produce death by asphyxia are
drowning, hanging and strangulation, smothering, and
the inhalation of noxious gases, or of air deprived
of oxygen. e
We shall first proceed to consider the medico-legal
questions that may arise in the case of a body found
in water. These may be arranged under the following
heads:—1. whether the body was immersed before or
after death ; 2. whether the individual has fallen in by
accident, has drowned himself, or has been thrown in
by others.
462
1. The inference that the person was living at the
time of immersion is drawn from an attentive examina-
tion of the external state of the body, and from a careful
anatomical investigation. The body of a drowned per-
son usually presents the following appearances. It is
commonly very cold, apparently even colder than the
actual temperature ; the limbs are more or less stiff,
according to the time that has elapsed since death ; the
visage is swollen, often dark-coloured, but sometimes
pale ; the eyes are half open, and the pupils dilated ;
the mouth is filled with froth ; the tongue is advanced
beyond the teeth ; and the chest and belly are elevated,
the latter being often much distended. This state of
the body is common to those who perish in cold clear
water, as the sea, rivers, &c.; but the body is sometimes
drawn out warm, although death is so complete that
animation cannot be restored, the countenance violet-
coloured, and the veins of the neck turgid. This hap-
pens in drowning in warm fluids or in alcoholic liquids,
or in marshes where deleterious gases are disengaged,
or when the person has fallen into the water in a state
of intoxication. The ends of the fingers are often found
rubbed or scraped, and dirt or sand, of a nature similar
to that of the bottom of the water, is perceived under
the nails. Coupled with these is the negative sign
furnished by the absence of any lesion that could have
caused death previous to submersion. The internal
appearances disclosed on opening a drowned body are
generally the following. The epiglottis is found ele-
vated, and a quantity of froth fills the trachea and
bronchi; the lungs are dilated and gorged with blood;
black and fluid blood is found in the right cavities of
the heart in a much greater quantity than in the left ;
the diaphragm is depressed, and water of a nature
463
similar to that in which death took place is discovered
in the stomach. In the head there is turgescence of
the blood-vessels, more or less intense as the death has
been more or less speedy, and in proportion to the
amount of struggling made by the individual. Orfila,”
in a memoir read at the Academy of Medicine, has
reviewed all the signs given by authors for determining
Whether immersion took place before or after death ;
and the conclusion he draws is that there is no certain
sign of submersion during life but the presence of water,
similar to that in which it is found, in the stomach and
air-passages; provided that, with reference to the sto-
mach, the water has not been swallowed before sub-
mersion, and has not been injected after death ; and
with respect to the lungs, that the water shall have
penetrated to the last bronchial ramifications, and has
not been injected before death; and that the body shall
not have remained long in a vertical position in the
water, so that the water might have entered after death.
It would appear from this that we possess two certain
signs of submersion during life; but the restrictions
imposed on them are such that, taken apart from others,
they are almost useless in the great majority of cases.
In speaking of water in the air-passages, Orfila must
have meant the froth formed by this fluid with the air;
for it is very seldom found in substance in this situa-
tion. Devergief states that in a great number of cases
he could find but very slight traces of water in the
trachea ; and in two only did he observe it in any
quantity. Indeed, from the observations of Cullen, f
* Archives Gén. de Méd. Août, 1827.
+ Annales d'Hygiène et de Méd. Lég. t. ii. p. 432.
J. Letter to Lord Cathcart.
464
Goodwyn,” and Meyer, f it is plain that but a very small
quantity of water enters the air-passages in drowning;
and this is speedily converted into froth by the motion
given to it in the attempt at respiration. On the
subject of this froth Devergie makes some interesting
observations, the substance of which is as follows. It
is commonly white, consisting of numerous and very
small bubbles, constituting a lather rather than a froth
properly so called. It never adheres to the trachea by
mucus, but is in immediate contact with that tube.
All the bubbles that form it have a watery envelope,
easily broken, and often in opening the trachea the
greater part disappear like soap-bubbles. The froth of
drowned persons, then, has but little analogy with the
expectoration of pneumonia or catarrh ; and it is suffi-
cient to have attentively observed it to avoid confound-
ing them. Its formation necessarily brings with it the
idea of vitality, for it cannot take place without motion,
an impulse communicated to a fluid and a gas in mutual
contact. In order to appreciate its mode of formation,
and the value that it may possess as a sign of submersion
during life, it appears necessary to enquire how it is
produced in other cases than asphyxia by submersion.
In bronchitis, for example, the individual is induced
to expectorate, because the extreme bronchial ramifica-
tions are filled with mucus, and the air can no longer
reach them, and come into contact with the blood to
effect the necessary changes. The invalid expels a
frothy matter, because the mucus secreted under the
influence of bronchial irritation is beaten and mixed up
with the air by the alternate and quick efforts of inspi-
ration and expiration which constitute coughing. The
* Connexion of Life with Respiration.
t Medical Repository, vol. iii. new series.
465
formation of the froth takes place more easily as the
irritation is nearer to the last bronchial ramifications,
where the tubes, being of a smaller diameter, are more
easily obstructed. It is, on the contrary, produced with
great difficulty in the trachea, on account of the great
dimension of this canal. In drowned persons similar
phenomena take place after they have expelled a part
of the air contained in their lungs. They are soon
solicited by the desire to respire; a small quantity of
water enters the trachea, and causes a most distressing
stimulus, of which we have a proof in the great suffering
experienced by persons into whose larynx a drop of
fluid has accidentally fallen while swallowing; a brisk
and sudden expulsion of the water is effected, but it is
rarely complete : the portion which remains dissolves a
little mucus, and becomes viscid, whilst, at the same
time, new inspiratory efforts draw in a new quantity of
water; from that time the air, agitated with this fluid
rendered more viscid, constitutes the froth. This is
formed with more difficulty in the trachea than in the
last ramifications of the bronchi; and consequently we
esteem its existence in the superior part of the trachea
as a more certain sign of the life of the individual at
the moment of submersion, than when it is met in the
extreme branches. This phenomenon does not leave
very durable traces of its existence, for it is sensibly
diminished, and even often disappears under the influ-
ence of putrefaction. The portion of the air-passages
where it is preserved during the longest period is at
the bifurcation of the trachea. In winter it may be
discovered in most cases after eight or ten days, but
later it completely disappears. It is true that if we
except the water contained in the stomach, the other
signs of submersion have not a more extended duration.
30
466
It should be understood that the water thus taken into
the lungs is not, as it was formerly supposed, the true
cause of death, an opinion to which Baron Larrey
seems to incline in his Mémoires. The experiments of
Goodwyn have shewn that a much larger quantity of
water than that which is found in the lungs of drowned
animals may be introduced into the air-passages with-
out causing death. Thus he passed into the lungs of
a cat, through an opening in the trachea, two ounces of
water, a large quantity when compared with the size of
the animal. It had, immediately, difficulty of breathing
and a feeble pulse; but these symptoms soon abated,
and it lived several hours afterwards without much
apparent inconvenience: after this he strangled it, and
found two ounces and a half of fluid in the air-tubes
and cells.
The presence of water, then, in the lungs of drowned
persons in the form of froth is to be considered as an
accidental and not an essential circumstance, although
it is one of very constant occurrence. If this fluid be
found in large quantity and in substance, that is, not
beaten into froth, the inference would be that it had
passed in after death. With respect to the presence
of water in the stomach, it has been proved by many
authors to be a constant occurrence. And when it is
discovered in this organ, and is identical with that in
which the body is found, it furnishes a strong indication
of submersion during life, being a necessary consequence
of the act of deglutition ; for it has been proved by
Fine, Orfila, and Marc that it is never found in bodies
plunged into water after death, and cannot be made to
enter the stomach without the assistance of a tube
passed into the oesophagus.
From the above-mentioned circumstances the follow-
467
ing conclusions are drawn by Devergie: 1, that almost
all the signs, taken singly, do not prove that the indi-
vidual was living at the moment of immersion ; 2, that
the one which furnishes the strongest presumption is
the existence of froth placed in immediate contact with
the lining membrane of a sound trachea ; 3, that this
sign acquires a greater value as its situation is nearer
to the mouth ; 4, that water in the air-passages is a
sign of little value, for if it can penetrate the trachea
after death, and extend even to the last bronchial
ramifications, as Orfila has shewn, it becomes almost
useless; 5, that water in the stomach is one of the most
constant signs, but its value is greatly diminished by
the difficulty of proving its identity with the fluid in
which the body has been immersed; 6, that if each sign
taken singly gives no certainty, the assemblage of all
in the same individual may enable a positive conclusion
to be drawn.
The proofs that death occurred before immersion are
drawn from the absence of all those signs just enume-
rated ; thus the thorax and abdomen will be found flat,
—no excoriation of the ends of the fingers, no dirt or
sand under the nails, no turgescence of the cerebral
vessels, and no froth in the air-passages. The lungs
will be collapsed, and the diaphragm will not have
passed the natural line. The stomach will be found
not to contain any of the fluid in which the body is
found, and, in addition to these negative proofs, marks
of violence may be discovered on the body quite suffi-
cient to account for death. These marks are divided
by Foderé" into three classes: 1st, those which are
totally independent of any connexion with the circum-
stance of drowning. Of this nature are the usual signs
* Méd. Lég. tom. iii. p. 112.
30%
468
of poisoning; a regularly formed ecchymosis round the
neck, indicative of strangulation ; or wounds inflicted
by fire-arms or cutting instruments. All these lesions
have an essentially distinct character which cannot be
mistaken, and hence the evident importance of examin-
ing carefully the external appearance of all bodies
found in water. It was by pursuing such an investiga-
tion that Deveaux discovered, in the body of a woman
found in water, a penetrating wound under the left
breast, made by a very small instrument which had
reached her heart. 2dly. Marks of violence which may
have resulted from accidents attending submersion, or
may be caused by previous homicide, such as unequal
irregular wounds which do not penetrate far into the
body, contusions, fractures, and luxations. In all such
cases we should ascertain, if possible, the height from
which the individual may have fallen, and the resistance
he may have encountered in the fall, The rapidity of
the current, and the roughness of the banks of a river,
may also cause extensive wounds. Dr. Fine remarks
that the rapidity of the Rhone, and the numerous mills
erected on its side, often produce most shocking wounds
in the bodies which are driven against the stakes in the
stream, or are drawn into the machinery. 3dly. There
may be lesions received after death. These are to be
distinguished from those inflicted during life, by the
lividity and flaccidity of their edges, the absence of
tumefaction and redness and want of haemorrhage, or, if
the latter be present, by the fluidity of the blood.
2. It being ascertained that the subject was immersed
while living, it is often of importance to be able to say
whether the drowning was the result of accident, of
suicide, or of homicide. The solution of these questions
is to be obtained by an examination of what may be
469
termed the external circumstances of the case. The
locality of the water may be such as to account for the
deceased having accidentally fallen into it, or its situa-
tion may at once preclude the possibility of such an
event. Indications of struggling on the brink, such as
tearing of the ground, and many footsteps, together
with ecchymoses on the person of the deceased, may
lead to the supposition of homicide. Thus, in the case
of Mr. Taylor, who was murdered at Hornsey in De-
cember, 1818, marks of footsteps deep in the ground
were discovered near the New River; and on taking out
the body, the hands were found clenched, and contained
grass which he had torn from the bank.”
However conclusive the existence of ligatures on the
hands and feet of the deceased may appear as to the
Question of the forcible interference of others, it should
be recollected that suicides have sometimes adopted
such precautions in order to insure their death. There
are some instances on record in which the individuals
seem to have pursued this course.i. In June, 1816, the
body of a guaging instrument-maker, who had been
missing for some days previously from his home, was
discovered floating down the Thames. On being taken
out, the wrists were found tied together and made fast to
his knees, which were in like manner secured to each
other. He had been in a state of mental derangement
for two years. The cord with which he had tied himself
was recognised as one which had hung from the ceiling
over his bed, and by which he used to raise himself up,
as he had been confined to bed for some weeks. He was
a good swimmer, and it was presumed he had taken
this precaution to prevent himself from employing that
* Paris and Fonblanque, Med. Jur. v. iii. p. 41.
t Op. cit.
470
power. The verdict returned was, “Found drowned.”
The other instance was that of a man aged twenty-eight,
who with a wife and child was reduced to great distress.
On a certain day he took an affectionate leave of his
family, declaring he would not return until he had
procured some employment by which he should be able
to buy bread for them. The following day his body
was taken out of the New River, with his hand and legs
tied. A card with his address was found in his pocket,
and also three-pence; when he left home he had five-
pence, and it was supposed he had purchased the cord
with the deficient sum ; the verdict brought in was
“Insanity.” Another case of a similar nature has been
lately published. It was that of a gentleman who was
found in the Seine at Paris, having his feet, wrists, and
neck tied with a cord. After detailing the appearances
on the body, the reporter concludes with the following
note: “Mr. X— had bound his neck, limbs, and
“hands by means of a rope with slip-knots, in order to
“put it out of his power to aid himself when in the water,
“ and thereby to render certain the execution of his
“suicide.”* We mention these cases to shew how
cautious a medical man should be in forming an opinion
in similar instances, and how necessary it is to weigh
well every circumstance before he expresses that opinion
before a legal tribunal.
It is often, as has been already mentioned, of the high-
est importance to the survivors, that an approximation
to the time which has elapsed since death should be
arrived at. For assistance in such an investigation the
medical jurist will turn in vain to the systematic works
on legal medicine, it being only within the last few
years that any accurate information on the subject was
* Ann. de Hygième et de Méd. Lég. t. ix. p. 207.
471
possessed by the profession. We are indebted to M.
Devergie for the first essay on this interesting subject,
one concerning which the most vague notions were
entertained previously to the publication, in the year
1829, of the memoir alluded to. The observations of M.
Devergie are entitled to much consideration, from the
unrivalled opportunity afforded for their formation.
He was authorized to carry on his investigations at the
establishment in Paris called “La Morgue,” a building
on the banks of the Seine, to which are carried all
bodies found dead in the city and its environs, and
where they are exposed during three days for the pur-
pose of recognition by their friends. The number thus
exhibited exceeds 300 annually, and includes all man-
ner of violent deaths. In case of the sudden disappear-
ance of an individual his friends repair to the Morgue,
and leave with the porter an accurate description of his
person, his clothes, and the period at which he was last
seen; and when a body is brought in, it is carefully ex-
amined, and if it corresponds with any of the descrip-
tions that have been left, notice to that effect is sent to
the persons interested, who come and claim it. The
number of bodies recognised is large; in the first six
months of the year 1829, out of 148 bodies 116 were
claimed. Of this number 62 were drowned, of whom
45 were recognised. Being thus furnished with posi-
tive information as to the time of immersion and that
of finding the body, Devergie was enabled to prosecute
his enquiries with great accuracy. He found that in
general no change takes place on the exterior before
the fourth or fifth day, and that the cadaveric rigidity
frequently continues two, three, or even four days after
immersion. This is probably owing to the coldness of
the medium in which the body is placed. About the
472
fourth or fifth day the skin on the palms of the hands
begins to whiten, and this change of colour takes place
particularly on the ball of the thumb, and the fleshy
eminence on the inner side of the palm over the me-
tacarpal bone of the little finger, together with the la-
teral surfaces of the fingers. The back of the hand does
not partake of this colouring, and the rest of the body
presents nothing particular. On the sixth or eighth day
the skin at the back of the hand begins to whiten, at
the same time that the sole of the foot has acquired a
similar tinge ; the skin of the face is softened, and of a
more faded white than the rest of the body. On the
fifteenth day the face is slightly swollen and red; a
greenish spot begins to form on the skin over the mid-
dle of the sternum ; the hands and feet, with the excep-
tion of the dorsum of the latter, are quite white, and
the skin of the palm of the hand is wrinkled. The sub-
cutaneous cellular tissue of the thorax is reddish, and
the cortical substance of the brain takes on a green
colour in the upper part of that organ. At one month
the face is reddish brown, the eyelids and lips are green
and swollen, the neck is slightly green, and a spot of
about six inches in diameter, brown in colour and with
a green areola, occupies the superior and middle part
of the sternum. The scrotum and penis are enormously
distended by gas, the latter being sometimes in a state
of erection from that cause. The skin of the hands and
feet is quite white and very much wrinkled, presenting
the appearance of having been long enveloped in a poul.
tice. The hair and nails are still very adherent. The
lungs are emphysematous, and fill the cavity of the
chest, overlapping the heart, a condition different from
that which these organs present at a more advanced
period. At a month and a half, besides the appearances
473
first mentioned, the neck and thorax are found very
green, and the cuticle begins to detach itself round the
base of the hand where it joins the wrist. At two
months the body is covered with slime, which pene-
trates through the clothes. The face is enormously
swelled and of a brown colour, the lips are tumefied
and separated so as to expose the teth. The skin on the
middle of the abdomen, as well as that of the arms,
forearms, thighs, and legs, is still in a natural state.
This is a most remarkable fact, and establishes a striking
difference between the progress of putrefaction in water,
and when the body is exposed to the atmosphere, in
the latter case the abdomen being the first part to
manifest any change. At this period the skin has be-
come detached from the hands and feet, and, having the
nails attached to it, forms as it were a glove. The skin
and nails of the feet are longer in separating than those
of the hand. The hair begins to fall off, and is easily
removed by pulling. The veins are almost completely
empty of blood, and commonly distended with gas.
The inner surface of the arteries is red, and that of the
trachea between the cartilages presents the same colour.
If at the moment of death the right cavities of the heart
were gorged with blood, the internal surface of the ven-
tricle is of a jet black colour; and in contrary cases an
analogous appearance is presented on the opposite side.
Devergie considers this a most important diagnostic
mark of death by asphyxia. At two months and a half
the green colour of the skin extends to the arms, fore-
arms, and legs; the nails are completely detached from
the hands and feet; some adipocire is formed on the
cheeks, chin, breasts, arm-pits, and anterior part of the
thighs; the abdomen is greatly swollen by putrefaction
within : the muscles at this period preserve their natural
474
colour, and do not appear altered in texture. At three
months and a half there is observed destruction of the
scalp, eye-lids, and nose, to such an extent as to make it
difficult to tell the age of the individual. The skin of
the breast is generally of a greenish brown ; the centre
of the abdomen is of an opaline colour, and scattered
with small ulcerations caused by the water. Larger
corrosions are found in different parts of the body.
The hands and feet are completely naked of skin. The
lungs no longer fill the thorax, but leave between them
and the pleura costalis a space filled with reddish serum.
At four months and a-half occurs complete destruction
of the face and scalp, leaving the skull bare ; the re-
mains of face, the neck, and anterior part of the thighs
is entirely converted into adipocire ; and small emi-
nences, indicating the commencement of calcareous
incrustation, are observed on the prominent parts.
The brain present traces of adipocire in its anterior
part. Devergie has not classified the changes that take
place at more advanced periods. The paper from which
we have extracted the foregoing account has been
severely criticised by Orfila,” who endeavours to over-
turn the facts and doctrine contained in it. But we
think he has been satisfactorily and triumphantly re-
plied to by Devergie, f who adduces, as the best proof
of the validity of his conclusions, four cases in which
the periods of immersion, varying from fifteen days to
one, two, and eight months, were ascertained by the
help of his table.
As the physiological phenomena observed in persons
dead from hanging and strangulation are nearly the
same, we shall consider them together in the present
* Traité des Exhumations Juridiques, t. ii. p. 83.
t Annales d'Hygène Pub. et de Méd. Lég. t. v. p. 429.
475
section, pointing out the differences between them as
we proceed.
Notwithstanding the authorities of Boerhaave, Mor-
gagni, and Portal, who imagined that apoplexy was the
immediate cause of death in hanging, it is now generally
admitted that the event is owing to suffocation. This
opinion is confirmed by the experiments of Gregory and
Brodie, from which it appears that if an artificial open-
ing be made into the trachea of an animal, below the
ligature by which it is suspended, it will continue to
live. But we must admit that other injuries are some-
times inflicted, of themselves sufficient to account for
death, such as compression of the nerves of the neck, and
fracture or dislocation of the spine. With respect to
the former, Dr. Paris remarks, “Although the pres-
“sure of a ligature on the nerves of the neck cannot be
“considered as the immediate cause of death in hang-
“ing, yet Mr. Brodie has very justly observed that if
“ the animal recover of the direct consequence of the
“strangulation, he may probably suffer from the effects
“of the ligature upon the nerves afterwards. Mr.
“Brodie passed a ligature under the trachea of a guinea-
“pig, and tied it tight on the back of the neck with a
“knot; the animal was uneasy, but nevertheless
“breathed and moved about. At the end of fifteen
“minutes the ligature was removed ; on the following
“morning, however, it was found dead. On dissection
“no preternatural appearances were discovered in the
“brain, but the lungs were dark and turgid with blood,
“ and presented an appearance similar to that which is
“observed after the division of the nerves of the eighth
“pair. “I do not,' observed Mr. Brodie [manuscript
“notes], “positively conclude from this experiment
“that the animal died from an injury to the eighth
476
“ pair, but I think that such a conclusion is highly
“probable ; and it becomes an object of inquiry
“whether a patient, having recovered from hanging,
“may not in some instances die afterwards from the
“injury of the par vagum.” Fracture or dislocation of
the spine, when they do take place, must of course con-
tribute to the speedy death of the individual; but these
accidents are very rare, even when the fall is great
as in public executions.f. In numerous instances which
have come under the observation of the writer this
cause of death was never observed. As in the case of
drowning, two questions present themselves for solution
by the medical witness: 1. whether the individual was
suspended before or after death ; 2. whether it was an
act of suicide or of murder. An individual found sus-
pended may have been killed in different ways; first,
he may be hung up after having been murdered ; and
again, he may have committed suicide by hanging, after
having previously tried to destroy himself by other
methods in which he has failed, as by fire-arms, cutting
the throat, &c. In the first case we might be led to
mistake murder for suicide, and, in the second, suicide
* Paris and Fonblanque, Med. Jur. v. ii. p. 44.
f The Rev. Dr. Haughton in some highly scientific investigations which
he has made upon this subject has arrived at the following conclusions.
“It has been ascertained by me that the shock of a ton dropped through
“one foot is just sufficient to fracture the anterior articulating surfaces of
“ the second vertebra at their contact with the atlas; and that this frac-
“ture allows the shock to fall upon the medulla oblongata so as to produce
“ instantaneous death. As the result of some consideration bestowed upon
“this subject, I would recommend the adoption of the following rule:–
“ Divide the weight of the patient in pounds into 2240, and the quotient
“will give the length of the long drop in feet.
“For example, a criminal weighing 160 pounds should be allowed 14
“feet drop. If local circumstances will not allow of the long drop being
“employed, the requisite shock should be produced by strapping a shot to
“ the feet, so as to secure the shock of 2240 foot-pounds to the medulla.”
477
for assassination. It is necessary, then, to be aware of
the signs by means of which death by strangulation in
general may be distinguished, in whatsoever manner it
may happen. These are lividity and distortion of the
countenance, protrusion of the eyes, which are fre-
quently suffused with blood, projection and wounding
of the tongue by the teeth. The latter depends upon
the position of the rope : if it be below the circoid
cartilage, the tongue is pushed out ; but if it presses
above the thyroid cartilage, it is carried along with the
os hyoides backwards. In addition; we have the mark
of the cord around the neck forming a livid depressed
circle, the fingers usually bent, the nails blue, and the
hands nearly closed, with swelling of the chest, shoulders,
arms, and hands, and sometimes ecchymoses in these
situations; also semi-erection of the penis, and emissio
seminis. Cases of death by hanging occasionally present
themselves in which the countenance is pale ; this arises
from the suddenness of death in some individuals, and
particularly if the spine be dislocated. On dissection,
the body presents nearly the same appearances as those
described as caused by drowning, with the exception
of water in the air-passages. A bloody mucus issues
from the mouth and nose; but this is very different
from the froth of drowned persons. The principal
vessels of the head and neck are filled with blood, and
sometimes ruptured. With respect to the bruised mark
of the rope round the neck, it is stated by M. Klein” to
be an uncertain sign, an opinion founded on fifteen
cases of suicide by hanging, in all of which it was
wanting. Remerf of Breslau has more lately investi-
gated this subject on an extended scale, and out of one
* Journal de Méd. Prat. de Hufeland (1815).
t Annales de Hygiène Pub. et de Méd. Lég. tom. iv. p. 166.
478
hundred cases collected by him eighty-nine presented
the Sugillation on the neck in an evident manner. In
one case, instead of ecchymosis, the skin was found of a
yellowish brown colour like parchment; in two others,
the skin was excoriated ; in another, putrefaction pre-
vented any certain examination ; and in nine cases it
is expressly mentioned that ecchymosis was wanting.
It follows from this that, out of one hundred hanged
persons, nearly one-tenth were found without a bruised
mark. But if this proportion be sufficiently great to
induce medical jurists to withhold unlimited confidence
in this sign, it is at the same time too small to destroy
the validity of the general rule that such impressions
are found in hanged persons. In all the cases which
have come under the observation of the writer, the mark
of the rope was most distinct. These were all executed
criminals, in whom, from the nature of the ligature
and the height of the fall, such impressions might be
expected ; but even in the most unfavourable circum-
stances the ecchymosis has been strongly marked.
Remer” mentions that it has taken place notoriously
in those found strangled in a position in which either
the feet or the knees had not left the ground. In all
the instances observed by us, the ecchymosis did not
occupy the part of the skin with which the rope was in
contact, but formed two lines on either side of it, one
above, the other below ; while the intervening portion,
the part actually compressed by the cord, resembled
dark-coloured parchment.
It is quite necessary that the medical jurist should
not be content with the discovery of a blue ring on the
neck, but that he should cut into it in order to examine
the extent of the extravasations, and the injury done
* Loc. cit.
479
to the parts in its neighbourhood. The height of the
fall must cause a difference in the injuries inflicted on
the parts composing the neck. When the individual
falls from a considerable height, as in public executions,
the lesions produced are very extensive. Dr. Houston
has published an account of some dissections of crimi-
nals in whom the similarity of injury is most remark-
able.” “Both the individuals were strong plethoric
“ men, executed for murder. Their death was evident-
“ly caused by strangulation. The cervical vertebrae
“were unbroken, and the spinal marrow and brain
“presented no trace of injury. In both, the sterno-
“mastoid muscle on the right side (the opposite to that
“on which the knot of the rope was applied) was
“ecchymosed, contused, and broken ; that of the left
“side was only slightly bruised. The os hyoides and
“ thyroid cartilage were completely severed from each
“other. The omo-hyoid, sterno-hyoid, and thyro-hyoid
“muscles were so bruised and lacerated, that only
“some stretched shreds of them remained to hold the
“ parts together. The thyro-hyoid membrane was also
“ torn across, and the epiglottis, pulled from its root at
“the back of the thyroid cartilage, had passed up with
“the os hyoides and tongue into the back part of the
“mouth. The skin alone remained unbroken, and
“interposed between the rope and the cavity of the
“ pharynx. This was the only region of the neck which
“gave evidence of much injury; the great vessels and
“ nerves all escaped unhurt. In two other criminals,
“which more lately I have had an opportunity of exa-
“mining, precisely the same effects had been produced
“ by the rope on the soft parts of the neck, and without
“any injury to the brain or spinal marrow.” The
* Dublin Hospital Reports, vol. v. p. 317.
480
preparations from which the above statement is taken
are preserved in the museum of the Royal College of
Surgeons, Dublin. The semi-erect condition of the penis
and the emission of semen are signs which, although
frequently met with, are not constantly found in hanged
persons. Thus Klein, in the memoir alluded to, states
he did not perceive them in any of the instances ex-
amined by him, and Remer found them only in the
proportion of three to four. In some of the cases ex-
amined by the writer they were wanting, but in the
majority there were evident traces of excitement of the
organs of generation. The practice adopted by worn-
out libertines, of causing themselves to be half hanged
in order to arouse their dormant generative power, is
a proof that some effect is produced on these organs by
suspension. But as erection is not constantly found in
hanged persons, we cannot accord to this phenomenon
much value as an indication of death by strangulation,
unless when accompanied with other characteristic
signs. It adds, then, to the certainty of this kind of
death, but it is no proof when it exists alone, for it has
been found in other forms of violent death ; and its
absence is no proof of the contrary. A remarkable
proof of the occurrence of this phenomenon in hanging
is given by M. Guyon,” surgeon-major at Martinique,
who attended the execution of fourteen persons, with a
view of ascertaining the truth respecting the disputed
subject of emission. Being situated near them at the
place of execution, he observed the penis of all become
erect at the moment of strangulation, and immediately
after five of them made water abundantly. An hour
after execution he found in nine of them the penis in a
* Anderson's Quarterly Journal of the Medical Sciences, vol. ii. p.
151.
481
state of semi-erection, and its canal filled with a kind
of matter with which the shirt was too profusely im-
pregnated to allow it to be supposed that it came from
any other organ than the prostate.
The second question is, whether it was an act of suicide
or of murder. It is admitted by most medico-legal
writers that this is a difficult and unlikely method of
committing murder, unless the assailants be numerous
and powerful. Dr. Smith remarks, “It is perhaps not
“going too far to say that a man cannot be hung alive
“by others, unless his hands be previously tied, and
“ probably his legs also.” Accordingly, when a body
is discovered hanging, the first impression is usually
that the individual has hung himself. But this opinion
should not be confirmed until an accurate investigation
has been made into all the external circumstances con-
nected with the occurrence. It should first be ascer-
tained that death has been caused by strangulation; for
it has happened that crafty murderers have destroyed
their victim in some other manner, and then suspended
the body in order to create the suspicion of suicide.
But supposing strangulation to be recognized, particular
attention should be paid to the part of the neck which
bears the impression of the ligature, and the kind of
mark left by it. Thus, if we find the track of the cord
low down, and that it passes horizontally round the
neck, while another and fainter impression exists at the
upper part, taking an oblique course, it should excite
suspicion that manual strangulation had been resorted
to in the first instance, and that the body had been
hung up after death. An examination of the dress and
person of the deceased will sometimes aid the inquiries
of justice, by pointing out the signs of resistance and
struggling, or of robbery. It is necessary, however, to
31
482
judge of any marks of external violence with great
caution, for although they may generally be esteemed
proofs of homicide, they may have been purely acci-
dental, or have been inflicted by the individual previous
to voluntary suspension. De Haen records the case of
a person who, while hanging, inflicted several wounds
on his face; and Ballard” mentions a case of suicide
in which the individual first cut his throat partially.
The following interesting case is related by Dr. Male.f
“An apprentice-boy in my neighbourhood, working
“alone in an attic, tied one end of a rope loosely round
“his neck whilst his master was from home, probably
“without any intention of destroying himself, and
“twisted the other round the projecting part of the
“top of a door, the planks of which were irregular and
“somewhat divided ; a small stool on which he stood
“slipped from under him, when he fell forwards, stri-
“king his temple against the corner of a box which cut
“ him to the bone. He lay along the floor, his head and
“shoulders elevated only a few inches above it; the
“cord not being tied had run nearly its whole length,
“ and then caught between the planks of the door, in
“which state he died. The wound was magnified by
“ popular rumour into many, and vengeance was de-
“ nounced against the innocent master, who was accused
“of having first killed and afterwards suspended the
“boy. On examining the body, the mark of the cord
“ was found to extend from ear to ear; the vessels of
“the brain were turgid, the thyroid cartilage broken,
“the mails blue, and the hands firmly closed. From
“this and other important circumstantial evidence the
“coroner's jury were convinced that the charge was
* P. 409.
t Juridical Medicine, p. 243.
483
“unfounded.” It should be recollected that a person
may be hanged accidentally, and therefore the usual
verdicts of insanity, or felo de se, are not to be given
without due caution in those cases where proofs of
homicide do not exist. A remarkable instance of this
kind is related by Dr. Gordon Smith,” which occurred
in April, 1821, in Northamptonshire. A girl, aged
thirteen, was swinging in a brewhouse, and near the
rope used by her for that purpose was another for the
purpose of drawing up slaughtered sheep. In the
course of the exercise her head got through a noose of
this second cord, which pulled her out of the swing, and
kept her suspended at a great height until she died.
We have said above that it is difficult, without an over-
whelming force, to hang an individual against his will;
but, on the other hand, it is surprising with what facility
death may be accomplished by this means, in situations
which at first view would seem to preclude its possibility.
The late Prince of Condé, who committed suicide on
the 27th August, 1830, was found hanging to a window-
shutter, with his feet touching the ground and his knees
bent. The attitude in which the body was found raised
some suspicion of foul play, and a most accurate inves-
tigation of all the circumstances connected with the
event was instituted, from which it appeared to have
been a case of voluntary suicide. An interesting
memoirſ on the subject was published in January,
1831, in which are related several instances, accom-
panied by illustrative plates, of self-destruction by
hanging, where the bodies were found in the most
extraordinary situations and attitudes. In one, a man
was found in a granary hanging by a cotton handker-
* Principles of Forensic Medicine, p. 236.
+ Annales de Hyg. Pub. et de Méd. Lég. tom. v. p. 156.
31%
484
chief made fast to a rope which stretched across ; the
knees were bent, so that the legs formed a right angle
backwards; the feet were supported on a heap of grain,
over which the knees hung at a distance of a few inches.
In another, a prisoner was found hanging to the bars
of a window so low that he was nearly sitting on the
ground ; he had previously tied his hands together.
In a third, the body was found in a vertical position,
with the heels resting on a window-stool. In a fourth,
an Englishman, a prisoner in Paris, hung himselfin his
cell, which was an apartment with an arched roof, and
at the lower part of it was a grated window, the
highest part of which was not near the height of a
man ; nevertheless he hung himself to this grating, and
was found almost sitting down, with his legs stretched
out before and his hips within a foot and a half of the
ground. In a fifth, the attitude of the body was similar
to the first ; the man had suspended himself to a large
iron pin driven into the wall to support the bed-curtains,
and his feet, bent at a right angle, rested on the bed,
while his knees approached it within a few inches. In
a sixth, the point of suspension was so low that the
person (a female) was obliged to stretch out her legs,
one before, resting on the heel, the other behind, resting
on the toes, in order to accomplish her purpose. In a
seventh, a female was found stretched at the foot of her
bed, the legs, thighs, and left hip lying on the floor;
the upper part of the body was raised, and suspended
by a cord fixed round the neck, and fastened to the
hospital-bed. There are other cases recorded in the
memoir alluded to, of persons found hung in equally
extraordinary situations, but we think it unnecessary
to particularize them. A few years ago a man aged
seventy-five destroyed himself at Castle Carey, by
485
fixing a cord round his neck while sitting on his bed-
side, leaning forward till his purpose was accomplished.
His wife, who had for years been bed-ridden, and there-
fore not likely to have been fast asleep, was in the room
during the transaction, and knew nothing of what was
going on.” In order to show the power of the will and
firmness of resolution in certain suicides, we quote the
following remarkable case from Remer.f “Une femme
“alla, avec l’intention de se pendre, de la chambre ou
“ses enfans se trouvaient, dans celle oil ils couchaient.
“Sa fille ainée, agée d'environ huit ans, la suivit bien-
“tôt, et la trouva pendue ; la fille exerga tant de trac-
“tions sur sa mére pour la détacher, qu’elle y parvient
“en rompant le lien. Alors la mère, qui avait toujours
“la corde au cou, repoussa son enfant dans la premiére
“chambre, la reprimanda, et lui ordonna, ainsi qu'à ses
“fréres et ses sours, de rester où ils etaient, revient sur
“ses pas, et se pendit une seconde fois. Les enfans
“allaient chercher du sécours, mais il n'était plus
“temps.” From these cases we learn how quickly con-
sciousness must be destroyed in this form of death ; for
were it not so, some exertion would be made by the
individuals to save themselves after the experiment
had been tried to a certain extent.
Strangulation, properly so called, differs from hang-
ing in the individual not being suspended ; but whether
death be caused by suspension, or a ligature drawn
tight, or by the hand alone, or any other pressure on
the trachea, the physiological phenomena are the same.
Strangling is a more common method of committing
murder than hanging, arising from the greater facility
with which it is accomplished. A remarkable instance
* Beck's Med. Jur. by Darwall, p. 283.
+ Loc. cit. *
486
of this is that of Dr. Clench, who was strangled in a
hackney-coach in London, in 1692, by two men who
called him out in the night under pretence of taking
him to visit a patient. After driving about the city
for more than an hour the two murderers left the coach,
and the coachman found Dr. Clench sitting in the
bottom with his head against the cushion. He was
quite dead, and had a handkerchief, in which was a
piece of coal placed just over the windpipe, bound
about his neck. The coachman had not the slightest
knowledge of the transaction, having heard no noise
while driving the carriage.
The appearances presented by strangled persons,
when a ligature has been employed, do not differ much
from those already detailed as characteristic of death
by hanging. The position of the rope-mark constitutes
the chief point of distinction ; if it be not at the upper
part of the neck, there can be no doubt the person was
not hanged, dislocation of the neck is not to be expected,
but the cartilages of the larynx and trachea frequently
suffer. The track of the ligature in strangling is
horizontal, and usually rather low down on the neck.
A question has arisen as to the possibility of strangling
being resorted to for the purpose of suicide. Upon this
subject Foderé remarks:–“ Je dirai relativement au
“second chef de la question, qu’en général les impres-
“sions circulaires laissées par la simple strangulation
“forment seules une présomption d'homicide, parcequ'il
“ n'est guère possible de se donner la mort par ce
“moyen, les mains cessant de faire force au moment
“ou la compression commence à s'exercer.” Notwith-
standing this opinion, he relates a case communicated
to him by Desgranges of Lyons, on which the Society
* Méd, Lég, tom. iii. p. 174.
487
of Medicine were consulted, and replied that voluntary
strangulation was possible. The case was that of an
individual found strangled in a hayloft by a handker-
chief which had been tightened by a stick. Another
case of a similar description is given by the same au-
thor. One of a more recent date is recorded by Dr.
Dunlop,” on the authority of a navy-surgeon, a friend
of his. A Malay, who on board of a man-of-war in the
East Indies had made repeated attempts to commit
suicide, at last succeeded by the means alluded to. He
tied a handkerchief round his neck, and with a small
stick twisted it several times, and then secured it
behind his ear to prevent it from untwisting. Jealousy
was the cause assigned for the act. The well-known
case of General Pichegru, who was found strangled in
prison in Paris during the consulate of Bonaparte,
gave rise to various suspicions; and the rarity of this
form of suicide, together with a general disbelief in its
possibility, served to strengthen the common fame of
that day, that he had been thus privately murdered in
order to avoid the risk of a public trial. Certainly the
condition in which the body was found seemed to point
to such a conclusion. It was lying in bed on the left
side, in an easy attitude, the knees being bent, and the
arms lying down by the side, with a black silk hand-
kerchief twisted tightly round the neck by means of a
stick passed under it. The cheek was torn by the ends
of the stick in its rotations. In allusion to this case
Remerf observes: “Je n'ai d'ailleurs ici aucune inten-
“tion de me constituer le défenseur d'un homme qui a
“ trop versé de Sang pour ne pouvoir pas prendre fa-
“cilement sur lui un meurtre de plus. Bien mieux
* Beck's Med. Jur. by Darwall, p. 290.
f Ann. de Hyg. et de Méd. Lég. tom. iv. p. 186.
488
“j'accorde que ce genre de mort n'est que très rarement
“le résultat d'un suicide, mais je doute que sur cette
“seule considération, et sans autres preuves plus fortes,
“on puisse absolument affirmer qu'il y a eu meurtre.”
Indeed, when we consider the number of cases that
occur of suspension, some of which we have mentioned,
where the position in which the body is found estab-
lishes with what promptitude the loss of sense must
have taken place, or how strong the desire of self-de-
struction must have been when the resolution was once
taken, we think it is going too far to deny the possibility
of death by voluntary strangulation, however cautious
we may be in receiving testimony on the subject.
Persons destroyed by manual strangulation exhibit,
instead of the circular ecchymosis on the neck, irregular
patches corresponding to the fingers of the assailant.
We must not expect, however, to find the internal
mark of suffocation so distinct as in cases of hanging,
because the closing of the air-tube not being so com-
plete, the functions of respiration and circulation go on
in some measure for a longer time. Traces of violence
on the chest and limbs are also frequently observed, in
consequence of the struggling and force employed in
the act.
Death by smothering is nearly allied to the former.
It consists in cutting off the supply of air to the lungs,
by forcibly closing the mouth and nostrils. This form
of death is more usually accidental than intentional,
because, unless in the case of very young or old feeble
persons, it is a difficult method of committing murder.
Children have been smothered in bed accidentally, by
the nurse or a pillow overlaying them in such a manner
as to close the mouth and nostrils. Persons in a state
of intoxication may be smothered accidentally by fall-
489
ing with the face in mud, shallow water, or the like, and
being unable to extricate themselves they perish by
suffocation. But drunken persons are also easily de-
troyed by intentional smothering, of which the woman
Campbell, murdered by the notorious Burke and Hare
in Edinburgh in 1828, furnishes a melancholy example.
This was the last of three charges of murder laid in the
same indictment, as having been committed within six
months in the same way and for the same purpose, of
supplying subjects for the anatomists' dissecting-room ;
and there is now no reason to doubt that, in conjunc-
tion with their two accomplices who turned king's
evidence, they had carried on the dreadful trade of
human butchery to a far greater extent. The direct
evidence of the manner of death, as derived from the
testimony of the accomplices, was that Burke and Hare
were fighting together, when the deceased, in attempt-
ing to part them, was struck down by Hare to a sitting
posture on the floor; that Burke, as soon as he had
overpowered his companion and thrust him on the bed,
threw himself on the deceased, kept her down by the
weight of his body, and, covering her mouth and nose
with one hand while he applied the other under her
chin, held her thus for ten or fifteen minutes till she
was dead. The most remarkable appearances pre-
sented by the body, when examined two days after
death, were the following:—joints flaccid ; features
composed, red, and rather more turgid than natural ;
lips affected with dark livor; conjunctivae of the eyes,
even in the horizontal position of the body, much in-
jected with blood; a little fluid blood on the left cheek,
proceeding apparently from the nostrils; tongue not
protruded or torn by the teeth ; the scarf skin under
the chin much ruffled, and the surface of the true skin
490
dry and brown when denuded, but without blood or
surrounding ecchymosis; integuments everywhere very
free of lividity except on the face; no effusion of blood
or laceration of the parts around the windpipe ; no in-
jury of the cartilages; the os hyoides and the thyroid
cartilage farther apart than usual, in consequence of
stretching of their interposed ligament: on the inside of
the windpipe some tough mucus, not frothy, with a few
points of blood between it and the membrane, which
last was healthy; organs within the chest perſectly
natural; the lungs remarkably so, and unusually free
of infiltration ; blood in the heart and great vessels,
and indeed throughout the whole body, very fluid and
black, and accumulated in the right cavities of the
heart and great veins. There were some appearances
of violence on the limbs and in the spinal canal, unne-
cessary to notice, as they were the effects of injuries
after death caused by forcibly doubling up the body to
enclose it in a box. Upon this case Dr. Christison*
(from whose admirable and detailed account we have
extracted the foregoing) very justly observes: “A con-
“viction has gained ground among the public, and has
“ been encouraged by the sentiments currently ex-
“pressed in society by some medical men, that the
“signs of suffocation generally, and as they existed in
“ the body of the woman Campbell in particular, are
“so obvious and characteristic that they would of
“ themselves, and independently of a knowledge of
“collateral circumstances, at once attract the attention
“of a professional person conversant with anatomy,
“and excite a very strong and well-grounded suspicion
“of the cause of death. This idea, if erroneous, must
“ have a pernicious tendency in various ways. A
* Edinburgh Med, and Surg. Journal, vol. xxxi. p. 243.
491
“sufficient reason for my taking notice of it is, that it
“may throw medical inspectors off their guard, by
“leading them to expect strongly-marked appearances
“in every case of death by suffocation. That such ap-
“pearances are very far from being always present
“should be distinctly understood by every medical
“man.
“In the body of the woman Campbell no person of
“skill, whose attention was pointedly excited by being
“told that from general circumstances murder was
“probable, but the manner of death unknown, could
“ have failed to remark signs that would raise a sus-
“picion of suffocation. But if his attention had not
“ been roused ; if, for example, he had examined it in
“the anatomical theatre of an hospital, without know-
“ing that suspicions from general circumstances were
“entertained regarding it, he might have inspected it
“even minutely, and yet neglected the appearance in
“question. Nay, a person of skill and experience
“would have been more likely to do so than another,
“ because every one who is conversant with pathological
“anatomy must be familiar with such or similar ap-
“pearances as arising from various natural diseases.”
Persons found dead with Wounds.-On the trial of
Count Koningsmark for the murder of Mr. Thynne, Mr.
Hobbs, a surgeon, being pressed by counsel to dis-
criminate between the relative mortality of certain
wounds found on the body of the deceased, replied, “I
“believe there never was a wound but it might prove
“mortal.” This is an opinion in which every one who
has had opportunities of witnessing a variety of injuries
must coincide, from the extraordinary and unexpected
results which sometimes follow. Thus, individuals have
been known to recover from wounds which, from their
492
extent and the importance of the organs implicated, left
no room for hope ; while others have perished after the
infliction of violence so slight, and producing such trivial
local effects, as to have almost escaped observation.
Such consequences, however, must be considered as ex-
ceptions to the usual course observed in similar instances;
and, taking wounds in general, we must admit that they
allow of classification in reference to their mortality.
Any such classification can never be made complete or
definite, from the exceptions just alluded to, as well as
from the impossibility of proving the absolute similarity
of two wounds, however they may resemble each other,
when one individual dies and the other recovers, and
also from the endless varieties of constitution in differ-
ent individuals. It is, therefore, upon their usual or
more common effects that such a division can be adopted
for our present purpose.
The term wound, in medico-legal phraseology, is
much more comprehensive than the same word in sur-
gery. In the latter it means a solution of continuity;
but in the former it also comprises injuries of every
kind caused by mechanical violence, such as bruises,
contusions, fractures, luxations, &c. in which sense it is
to be understood in the observations that follow.
The chief points to be decided by the medical ex-
aminer, in the case of a body found dead with wounds,
are, 1st, Were they inflicted during life 2 2dly, Were
they the cause of death 7 and if so, were they the result
of suicide or homicide 2 In order to settle these points,
it will be necessary to consider the classification of
wounds just alluded to. They have been divided, for
the purpose of medico-legal inquiry, into four classes,
1st, those absolutely mortal; 2d, dangerous; 3d, not
mortal; 4th, accidentally mortal. This division of
493
wounds is founded, as already stated, upon the usual
terminations of such injuries, because it is well known
that death sometimes follows those of the slightest de-
Scription ; and that others of the gravest kind termi-
nate in recovery. Metyger* mentions an instance of
death from ha-morrhage brought on by the slightest
scratch of the thumb-nail. Dr. Parist states he has
seen a case in which the extraction of a tooth was fol-
lowed by death in forty-eight hours; and a similar case
is recorded by Mr. Blagden.j An instance occurred
lately to the writer of this article, in which a fatal hae-
morrhage followed a superficial incision made into the
upper gum of an infant to liberate one of the incisor
teeth. On inquiry, it appeared that another child of
the same family had died of haemorrhage from some
equally slight cause. Leech-bites have been known to
produce death in children ; and in the case of Brain,S
tried for the murder of Watts, it was proved that the
deceased died instantly from a blow on the calf of his
leg. On the other hand, we are not without instances
of equally surprising recoveries from injuries of the
severest kind. We have seen persons survive extensive
fractures of the skull, in whom portions of the brain
have protruded. Dr. Male mentions the case of a
mendicant in Paris, from whose skull a portion of the
bone was detached large enough to be used by him to
receive alms. The celebrated case of Mr. Tipple,
whose thorax was transfixed by the shaft of a gig, is a
striking illustration of the present subject. Dr. Dun-
* Page 327; and Beck, by Darwall, p. 324.
+ Paris and Fonblanque, Med. Jur., v. ii. p. 116.
f Med. Chir. Trans. vol. viii. p. 224.
§ Cro. Eliz. 778. Paris and Fonblanque, v. ii. p. 122.
| Related by Mr. W. Maiden. London, 1812.
494
lop” records a case of a duel in the West Indies, in
which one gentleman hit another in the eye, the ball
of which was completely obliterated ; and the leaden
bullet, passing in through the orbit, came out in front
of the external ear; notwithstanding which destruction
of the eye as well as injury of the brain, the officer re-
covered with the same facility as if he had only under-
gone the infliction of a flesh-wound.
On account of these variations from the usual course,
the consideration of injuries from wounds in a medico-
legal point of view is, on the Continent, and was for-
merly in these countries, a matter of much more
intricacy than it is at present. A person inflicting a
wound on another was held amenable for the conse-
quences during a year and a day—a most inconvenient
principle of responsibility, and one particularly calcu-
lated to create confusion, by either involving the
innocent, or suffering the guilty to escape. Chaussier
relates a case illustrative of this point. Two men who
had had some previous misunderstanding encountered
each other on a public walk, when, after some alterca-
tion, one of them struck the other with a light cane
and retreated; the other, enraged, pursued him, but
had not advanced many steps when he fell dead. On
examination of the body, it was found that he had an
aneurism of the aorta, which had burst from the excite-
ment under which he laboured at the moment. For-
tunately for the administration of justice in this king-
dom, that act of the legislature called the Ellenborough
Act, relieves the medical witness of the present day
from those serious embarrassments under which our
predecessors must have laboured ; as, by it, wounding
with an intent to kill is deemed equally criminal
whether death be the result or not. This, considering
* Beck's Med. Jur. p. 332.
495
man as an accountable being, is the true and just view
to take of the crime.* Still, however, the testimony of
the medical witness will always be important, as by the
nature of the injury, its seat, and direction, the evil
intent is often to be inferred.
Of mortal wounds, those which may cause instant
death are wounds of the brain, of the heart and large
vessels connected with it, of the spinal marrow, of the
neck, and blows on the stomach : these, when severe,
are all for the most part followed by immediate death;
and occasionally, even when apparently trivial, have a
similar termination. Wounds of the brain must gene-
rally be considered as less fatal than those of the
heart, in consequence of the recoveries which are some-
times observed to take place after them, and even
wounds of the heart are not necessarily immediately
fatal. The Duc de Berri lived eight hours after being
stabbed through the left ventricle, and other similar
cases are on record. Next in order as mortal wounds
may be mentioned those which interfere with the
function of respiration, such as extensive wounds of
the diaphragm, and injuries which lay open both sides
of the thorax in a considerable degree, and thus impede
the dilatation of the lungs. Among dangerous wounds
must be ranked those of the pharynx and Oesophagus,
stomach and chylopoietic viscera, the danger of which
will of course be in proportion to the extent of the
injury; also wounds of the urinary bladder, and of
large bloodvessels in the head, thorax, and abdomen ;
severe contusions over any of these cavities; wounds
of the extremities implicating the great bloodvessels, or
causing compound fractures, or in tendinous situations
from the danger of tetanus supervening. In the class
* Unfortunately this very just act has been repealed.
496
of slight wounds are included those injuries by which
the skin and muscles are bruised or divided, and when
no tendon, aponeurosis, large nerve, or bloodvessel is
touched, and the system has not received any severe
shock; to this class belong simple fractures and luxa-
tions. The last class, or wounds accidentally mortal,
are influenced by different causes, which render this
division an arbitrary one, and will be considered when
we come to treat of those circumstances which alter
the medico-legal character of wounds.
In the preceding part of this chapter allusion has
been made to the spontaneous lividities which occur on
the surface of dead bodies; the nature and causes of
which, and the means of distinguishing them from the
effects of contusions inflicted before death, are there
pointed out. But there is another source of error con-
nected with the examination of the surface, upon which
it is necessary to dwell a little before we proceed to
consider wounds of particular parts; that is, the possi-
bility of appearances being caused by violence offered
to the body after death, which will resemble those that
result from injuries received during life.
That such a resemblance does occur is certain, if the
blow be inflicted within a certain time after dissolution,
and the power of discriminating between the two is of
the utmost moment to the medical jurist. We are in-
debted to Dr. Christison for the most accurate informa-
tion we possess on this subject.” His attention was
forcibly drawn to it on the occasion of the trial of Burke
and Hare at Edinburgh for the murder of the woman
Campbell, for the purpose of selling her body. Before
the confession of the accomplice, the whole weight of
the case rested on the medical evidence ; and one of
* Edin. Med. and Surg. Journ. v. xxxi. p. 236.
497
the questions to be answered was, whether certain
bruised marks and subcutaneous extravasations of blood,
found on different parts of the body, were indications
of injuries received before death. Being unable to find
in authors on medical jurisprudence any information
precisely applicable to the case, except what rested on
physiological speculation, Dr. Christison proceeded to
subject the question to the test of experiment. For
this purpose a large dog being strangled, and the hair
on various parts of the head, trunk, and legs being
shaved, heavy blows were inflicted on these spots with
a hammer, at intervals of from five minutes to two
hours after death ; but at the end of twenty-four hours
no trace of injury appeared in the seat of any of the
blows. The next experiment was made on the body of a
female an hour and three-quarters after death. Several
heavy blows were inflicted with a stick across both
shins, on the fore-part of the thighs, on the breast, and
on the side of the neck. In less than ten minutes deep
bluish-black discolorations followed the blows on the
breast and neck. Twenty-five hours after death the
blows were shewn on the thighs by faint stripes con-
sisting of bluish-black points. On the breast and neck
the stripes were as deep in tint as any contusions inflict-
ed during life, but without swelling, the colour corre-
sponding with the prominent part of the stick. A severe
blow had been struck over the crest of the ileum twenty-
three hours after death, which caused ruffling of the
cuticle at the time, but no further appearance of in-
jury. The third experiment was on the body of a
man. It was struck with a stick on the left side of the
back three hours and a quarter after death. More
blows were struck on the right side seventeen hours
after death. An examination was made forty-seven
32
498
hours after death, when the blows first struck were
marked by two long narrow stripes of dark lividity,
with an intervening colourless stripe corresponding
with the prominent part of the stick. The redness was
confined in this, as in the former case, to the mere sur-
face of the true skin, the rest being natural. The marks
of the later blows consisted of dryness and brownness of
the surface, without effusion. The fourth was on the
body of a young man, four hours after dissolution. It
was struck with a stick, and on subsequent examination
it was found that wherever the cuticle had been commi-
nuted, the mark was dry and brown, but there was no
other discoloration of the skin. The subject of the fifth
experiment was a stout young man, on whose back
several heavy blows were struck with a mallet two
hours after death. The body was inspected five hours
afterwards, and presented deep lividities in the seat of
the blows, but the substance of the skin was nowhere
infiltred or discoloured. The general conclusions to be
drawn from the preceding facts are thus stated by Dr.
Christison.
“In respect to eaternal contusions, the experiments
“show that for some hours after death blows will
“cause appearances which, in point of colour, do not
“differ from the effects of blows inflicted recently before
“death ; that the discoloration generally arises, like
“lividity, from an effusion of the thinnest possible
“layer of the fluid part of the blood on the outer sur-
“face of the true skin, but sometimes also from an
“effusion of thin blood into a perceptible stratum of
“the true skin itself; and that dark fluid blood may
“ be even effused in the subcutaneous cellular tissue
“in the seat of the discolorations, so as to blacken
“ or redden the membranous partitions of the adipose
499
“ cells; but that this last effusion is never extensive.
“It can hardly be doubted that the appearances now
“ described will exactly imitate slight contusions in-
“flicted during life; but I conceive that the blows in
“ the latter case must be trivial.
“When a blow inflicted during life is more severe,
“it may have the following effects, few or none of
“which, so far as we know, can originate in violence
“after death. 1. There may be swelling from the
“amount of the extravasation ; this is certainly never
“caused in the dead body. 2. When the violence has
“ been applied a few days before death, there will be a
“yellow margin round the black mark, which is another
“appearance that cannot be formed except during life.
“3. There may be clots of blood in the subjacent cel-
“lular tissue, either with or without swelling : these
“appearances I have never seen accompanying con-
“tusions caused in the dead body; but it may be
“doubted whether clots might not be formed if the
“injury was inflicted very soon after death, and had
“ the effect of lacerating a considerable vessel in the
“neighbourhood of loose cellular tissue. 4. In the in-
“stances in which the blood does not coagulate at all
“after death, contusions caused during life may be re-
“cognised by the extent of the effusion into the cellu-
“lar tissue. In a part not liable to be infiltred by its
“depending position, and not in the vicinity of a large
“vein, a deep effusion of fluid blood, which fills and
“ distends the cells of the cellular tissue, can hardly be
“ produced on the dead body. 5. Perhaps one of the
“most characteristic signs of a contusion inflicted
“during life is incorporation of blood with the whole
“thickness of the true skin, rendering it black instead
“ of white, and increasing its firmness and resistance.
32%
500
“This sign may not be always present, for, as every
“one knows, a blow may cause extensive extravasation
“below the skin, without affecting the skin itself. But
“when present, I am disposed to consider it character-
“istic, because I have never been able to produce it in
“the dead body, and it is not easy to conceive how
“such a change can be wrought in so dense a texture
“as the skin, without the force and agency of living
“vessels.
“It is impossible to fix absolutely the limit of the
“interval beyond which contusions cannot be imitated
“ by violence applied to the dead body. It appears to
“vary with the state of the blood, and the time which
“elapses before the body cools and the joints stiffen.
“Sometimes the appearance of contusions can hardly
“be produced two hours after death (Eageriment 5th);
“sometimes they may be slightly caused three hours
“ and a quarter after it (Eageriment 3rd); but I should
“be inclined to think this period very near the ex-
“ treme limit. Wherever the warmth of the body and
“laxity of the muscles were not considerable at the
“ time the injury was inflicted, we may be sure the
“appearance of contusions cannot be considerable (Ea:-
“ periment 2nd). It is probably, therefore, only on the
“ trunk that even in the most favourable state of the
“body, namely, when the blood remains altogether
“fluid, any material mark of contusion can be produced
“so late as two hours after death.”
With respect to wounds of the head, it is well known
that all kinds of violence are more dangerous in some
constitutions than others. In good constitutions wounds
may not be dangerous, which, in old, bilious, or scro-
fulous habits, are often attended by death, chiefly in
consequence of the erysipelatous inflammation which
501
succeeds them. Fracture of the bones of the cranium
may take place without any correspondent injury of
the integuments, and the symptoms in such cases are
extremely equivocal and deceitful. A mere simple
fracture, when no more is implied than solution of con-
tinuity confined to the bony substance, without displace-
ment or injury to the neighbouring parts, is not
necessarily an event of great importance. In so simple
an occurrence we can hardly suppose bad consequences
to arise. Simple cases like these, however, are very
rare, and these injuries are almost always complicated
with some affection more or less severe of the internal
parts. Although fractures may be considered more
dangerous when accompanied with depression, yet we
cannot ascertain the precise degree of injury sustained
by the contents of the cranium from the external
wound, nor does it follow that the more extensive it is,
the more certain is the danger. In fact our knowledge
of the economy of the brain is very limited, and though
injuries of it are generally of a most serious character,
yet we find surprising recoveries take place. The effu-
sion of a small quantity of blood or pus upon its surface
may, and often does, cause the most alarming symptoms,
and terminate in death ; while, on the other hand, large
portions of the brain itself have been removed, and
foreign bodies, as a musket-ball, and portions of the
skull, have been lodged in it, and recovery has taken
place. It is hence exceedingly difficult to define the
exact amount of injury to the head necessary to cause
death ; nevertheless, in case of a body found dead with
fracture of the skull, and where no other sufficient
cause of death can be ascertained, we are justified in
attributing the event to the injury. We come to this
conclusion from our knowledge of another effect of
502
violence offered to the head, and which must always
accompany the former in a greater or less degree,_
namely, concussion or commotion of the brain. By
concussion of the brain is meant a violent and sudden
shake of the organ, without any apparent wound or
mark of injury being left. It may be caused by violence
offered directly to the head, or transmitted to it by falls
on the feet or nates. A remarkable instance of the
former is given in the transactions of the Royal
Academy of Paris. A stout young criminal was con-
demned to be broken on the wheel, and wishing to
escape the execution, ran head foremost against the
wall of his dungeon, and instantly fell dead. On open-
ing the head, not the slightest appearance of injury was
discoverable in either skull, brain, or spinal marrow,
except a very minute separation in the squamous suture
of one side.
Certain injuries done to the face belong to this divi-
sion of wounds. When these are confined to the face
alone, the most serious consequence may be no more
than deformity; but mortal wounds have been inflicted
through the face on the contents of the cranium. The
most common of these is where a sharp-pointed instru-
ment is struck into the eye, and pierces the orbital plate
of the frontal bone. The celebrated comedian Charles
Macklin was tried in the year 1753 for the murder of
a brother-player, whom he struck accidentally in the
eye with a cane, in some altercation that took place in
the green-room.* Thomas Hallam, the sufferer, died
the next day, and it was found that the point of the
cane had passed through the orbital plate, and wounded
the brain. A case occurred some years ago in Dublin
of a similar nature. A gentleman received a thrust of
* State Trials.
503
a watchman's pike in the eye, in some drunken broil in
the street; the immediate effects were so trifling, and
the external wound so slight, that he took no notice of
it until he was attacked with inflammation of the brain,
which killed him in a few days. Mr. Colles, under
whose care he was, opened the head, and found a small
round hole in the orbital plate of the frontal bone, in
the neighbourhood of which there was a large collection
of pus. The part is preserved in the museum of the
College of Surgeons of Dublin. In like manner, blows
upon the nose have not only crushed that organ, but
also driven the ethmoid bone up into the brain ; and
sharp-pointed instruments have sometimes penetrated
the brain through this organ, and proved fatal. Such
instances as these show how necessary it is to investi-
gate with the greatest accuracy all cases of sudden
death ; for without the greatest care and attention
cases of this description must elude discovery. We
make this remark in order to induce medical exami-
ners to bestow more pains on the highly important
trust they undertake, for it must be confessed that in
investigations of this sort we fall far short of the dili-
gence of our Continental brethren.
As connected with wounds of the head, we may ob-
serve that children, either before or after birth, may
be, and have been, destroyed by fine sharp-pointed in-
struments passed through one of the fontanelles. A
Parisian midwife was executed some years ago, on its
being discovered that she was in the habit of procuring
still-born children for those who desired it, by piercing
the brain of the infant before its birth with a fine wire.
A wound of this description leaves very little mark,
and would of course escape superficial observation.
The neck comprises many important parts, a wound
504
of which is necessarily followed by death. Wounds of
the integuments and muscles of the neck may be con-
sidered simple wounds, although they are sometimes
difficult to heal in consequence of the mobility of the
parts; but wounds of the carotid arteries, jugular veins,
and spinal marrow are for the most part immediately
fatal. Lacerated wounds of the carotid artery, however,
may not be quickly followed by death, an instance of
which came within our knowledge some years ago. The
artery was torn by the horn of a cow, and the bleeding
from the wound, although considerable, was not suffi-
cient to destroy the patient, who survived long enough
to have the artery tied, and subsequently recovered. It
has been said that a complete division of the trachea is
mortal; but the danger attending a wound of this sort
arises from the injury usually inflicted upon the great
vessels and nerves in its neighbourhood at the same
time, more than from the wound of the air-tube itself;
for we know that mere division of this part is not neces-
sarily fatal, although it may be very difficult to heal,
from the great mobility of the part, and the constant
passage of the air through it. Wounds of the pharynx
and oesophagus are much to be dreaded, as well on
account of the other important parts which must be
wounded along with them, as from the circumstance
that through this channel the nourishment of the body
is conveyed, and that the act of deglutition is directly
opposed to a speedy adhesion of the parts. The fol-
lowing case gives a good picture of the dangers and
difficulties attending wounds of these parts.” A few
years ago a prisoner in Edinburgh jail cut his throat
transversely, dividing the larynx quite across at the
upper end of the cricoid cartilage, and the separated
* Edin. Med Surg. Jour. v. xvi. p. 353.
505
extremities receded from each other to the distance of
three inches ; the great vessels and nerves escaped
injury from the cut being so high. The professional
gentlemen who saw him were satisfied that the oesopha-
gus was also cut entirely across. Several attempts
must have been made, as another opening was after-
Wards discovered in the windpipe. In this state a junc-
tion of the parts was found to be impracticable, and the
ligatures that had been applied with a view of making
the best possible approach were separated by his inces-
Sant exertions in passing water through the mouth, and
out at the wound, in which way he used several buckets
full in the course of one day. He was supported in the
first instance by nutritious enemata, and afterwards by
means of a tube conveyed through the wound into the
Oesophagus and stomach. After much trouble to the
practitioners, and considerable risk to the patient, the
functions of breathing and ingestion were carried on
through a tube in each passage introduced by the
wound, the tracheal tube being removed when it was
necessary to apply the other. The man was afterwards
tried, acquitted, and liberated from jail, and continued
to live under the disadvantages mentioned. Besides
the parts just alluded to, the neck gives passage to the
par vagum and the great sympathetic nerve, injuries
of which, even partial or at but one side, must be con-
sidered of the most dangerous kinds, as from them
principally the cardiac and pulmonary plexuses are
formed. Injuries to the spinal marrow, either by frac-
ture or dislocation of the vertebrae, or by a wound
penetrating between two of the vertebrae, are absolutely
fatal. Fracture or dislocation are generally the result
of accident, as a fall, or what coachmen are liable to—
striking the head against a low arch-way in driving
506
under it. They also sometimes, though rarely, occur
in hanging. But they may happen in consequence of
disease; a striking example of which came under the
observation of the writer some years ago. A boy, who
was under treatment in the Richmond Hospital (Dublin)
for some disease of the leg was one morning, during
the visit sitting up in his bed talking to those around
him, when his head suddenly fell forward on his breast,
and he dropped dead. On examination, it was found
that the root of the odontoid process of the second
vertebra, and the tranverse ligament which binds it in
its situation, were ulcerated, and in the motion of the
head it had broken off, and compressing the spinal cord
had produced instantaneous death.
A consideration of the important organs contained in
the thorax will lead us to estimate the danger arising
from wounds which penetrate sufficiently deep to reach
them. Wounds of the lungs we know are not necessa-
rily fatal, though for the most part they are exceedingly
dangerous from the size and number of the bloodvessels
by which they are traversed. These organs are some-
times seriously injured, although no external wound be
present. This arises from the fractured portion of a
broken rib being driven into their substance, of which
injury hamorrhage, emphysema, and inflammation are
the consequences most to be dreaded. Nevertheless,
although injuries of these organs are of a very serious
nature, and not unfrequently terminate fatally, we find
occasionally that they support most extensive injury.
This is familiar to many military and naval surgeons
who during the late war had opportunity of observing
the powers of nature in repairing extensive injuries of
these organs; and we before alluded to the case of a
gentleman who recovered after having both sides of his
507
thorax transfixed by the shaft of a gig. It is quite
true that penetrating wounds of the heart are, generally
speaking, mortal, but there are so many cases on record
of individuals who survived, some of them for days,
others entirely, after wounds of this organ, that we
cannot agree with those authors who maintain that
such injuries are necessarily and instantly mortal. At
the battle of Corunna a soldier received a shot in the
chest, and fell insensible. He was found by a comrade
with signs of life, who carried him off the field, and he
was immediately embarked with the troops and brought
to Plymouth, where he died fourteen days after the
receipt of the wound. Mr. Fuge, who records the case,”
states that, on examining the body, two quarts of blood
were found in the left side of the thorax, the lung of
that side being compressed towards the spine. A
transverse opening an inch long was observed in the
right ventricle of the heart, near the origin of the
pulmonary artery, and the ball was lying in the peri-
cardium. To the same paper is appended an account of
a suicide who lived forty-four hours after discharging
a pistol into his breast, and in whom the right ventricle
was found wounded, and the ball in the pericardium.
Dupuytren, in his “Leçons Orales,” expresses his opi-
nion that wounds of the heart are oftener cured than is
generally imagined. He founds his belief on the
instances of animals killed in the chase, in whom balls
and the cicatrices of former wounds have been found,
and also on similar instances in the human subject.
Many individuals have presented all the symptoms of
wound of the heart, and yet recovered; and he alludes
particularly to the case of a soldier, in whom, six years
after the healing of a wound of the chest, a musket ball
* Edin. Med. Surg. Jour. v. xiv. p. 129.
508
was found in the right ventricle of the heart, near its
apex. From these circumstances we think we are jus.
tified in stating that wounds of all parts of the heart,
provided they are narrow, are not necessarily immedi-
ately fatal. Acupuncture of this organ has been
practised at Warsaw with impunity. If, however, the
wound be considerable, some lines for example, death
is usually instantaneous, from the great deluge of blood
that is poured into the pericardium and chest. Under
a wound of less dimensions the individual may survive
for some days. Thus, in one of the cases mentioned by
Dupuytren, a man thirty-four years of age received two
stabs of a knife, one in the belly, the other in the chest,
of six and seven lines in length. He lived for eight
days, and then died with symptoms of diseased brain,
having been affected with tetanic convulsions for two
days before his death. The stomach was found perfo-
rated, and there were four ounces of blood in the left
side of the chest, which had come from one of the in-
tercostal arteries opened by the wounding instrument.
In the pericardium was observed a perforation three
lines and a half long, and a wound of the same extent
in the middle of the left ventricle. In another indi-
vidual, who died mad after attempting suicide by
amputating the penis, several small wounds of the heart
were found, which must have been inflicted several days
before with a small round instrument found in his
possession. Another man, aged forty years, lived
seventy-two hours with three wounds penetrating the
left ventricle, inflicted by himself with a sharpened file.
In the thesis of M. Sanson numerous instances are
mentioned of persons surviving wounds of both ventri-
cles, some of them for twenty days. The Duc de Berri,
whose case has already been alluded to, lived for
509
eight hours, although stabbed through and through
the left ventricle with a long round instrument used by
saddlers in piercing leather. All these instances go to
prove that wounds of this organ are not necessarily
instantaneously fatal,—a very important fact in legal
medicine, for it sanctions the possibility of an individual
removing to a considerable distance after the receipt of
a mortal wound, and being found dead some hours or
days after. As an illustration of this fact, involving a
question of life or death, we may adduce the following
case mentioned by Dr. Dunlop,” as having been tried
in Glasgow in the year 1819.
The keeper of a house of bad fame in Greenock was
indicted for the murder of a sailor by shooting him
through the chest. It appeared from the evidence of
the medical witnesses, that the auricles and part of the
aorta "next the heart were shattered to atoms by the
slugs and brass nails with which the piece was charged,
and in their opinion he must have dropped down dead
the moment he received the shot; therefore, as the body
was found in the street, and the door of the house was
eighteen feet up an entry, it followed that the prisoner
must have run after him into the street, and there shot
him. For the prisoner, it was urged and proved that
he had shot him through the door of his own house,
which he was attempting to enter by force. And
besides direct testimony to this effect from those within
the house, and from a lad who was along with the de-
ceased at the time, it came out in evidence that there
was a stream of blood from the house to the place where
the body was found, which could not have run from
the body towards the house, as the threshold of the
* Beck, by Darwall, p. 335.
510
door was on a higher level than the pavement of the
street. On this evidence the prisoner was acquitted.
In judging of wounds of this organ, the size and shape
of the instrument and the depth and direction of the
wound are to be considered. The extent of the
wound, as we have already stated, makes a great differ-
ence in the chance of recovery. But there is one cir-
cumstance which is not very easily explained, that is,
how so large a wound as a musket-ball must make
permits life to be carried on for an instant. It is gene-
rally admitted that wounds of the aorta and vena cava
are mortal; but this must be taken with limitation, for
very small punctured wounds may certainly be inflict-
ed without involving the life of the individual. What
the extent of a wound necessary to cause death is, we
cannot precisely say ; but we can conceive the possi-
bility of these vessels being pierced with an acupunc-
ture needle with impunity.
The thoracic duct, from the important function it
performs, can scarcely be wounded without inducing
fatal consequences. This arises as well from the extra-
vasation of its contents into the thorax, as from the
interruption to the supply of nutriment to the body.
Wounds of the diaphragm have been generally divided
into those of its tendinous and of its muscular portions;
but the distinction is useless, for it is not ascertained
that injuries of one portion are less serious than those
of the other ; and it is certain that both are highly
dangerous. There is a source of danger connected with
wounds of this muscle, which it is well to bear in mind,
and that is the possibility of some of the abdominal
viscera being pushed through the opening, and there
being strangulated. Dr. Gordon Smith.” relates a case
* Principles of Forensic Medicine, p. 279.
511
of this sort. A sharp-pointed weapon had passed
through the diaphragm, notwithstanding which the
patient made a rapid and perfect recovery to all appear-
ance. At the end of about three months, he died from
strangulated hernia of the stomach, which had passed
through the wound of the diaphragm into the thorax.
Wounds of the abdomen, however slight, provided
they penetrate its cavity, must be considered dangerous,
from the great tendency of its lining membrane to take
on inflammatory action, and the rapidity with which
inflammation runs over its surface when once estab-
lished. And the serious character of such wounds must
not be underestimated, notwithstanding the many and
brilliant recoveries which have followed the extensive
wound necessarily inflicted on this membrane in the
operation of ovariotomy. Penetrating wounds may
also strike one or more of the viscera contained in the
abdomen, in which case the danger arises both from
the lesion of the organ itself, involving derangement of
structure and function, and from the effusion of its
contents into the abdominal cavity. And a wound
of the abdomen, even though it do not penetrate its
cavity, may prove fatal in consequence of opening an
artery, such as the epigastric—the patient succumbing
from hamorrhage—a case of which kind has been
placed on record by Mr. Colles. &
Wounds of the stomach are to be deemed highly
dangerous, although there has been great diversity of
opinion concerning their mortality. Dr. Beck takes
notice of the declared opinions of some of the German
colleges upon this point. A wound of the stomach
was declared only accidentally mortal by the faculty of
Giessen, and absolutely mortal by the college at Frank-
fort; while, in another case, a wound was considered
512
mortal by the faculty at Leipsic, and not so by that of
Helmstadt and Wirtemburg. The fact is that very
extraordinary escapes have followed wounds of this
viscus. The writer recollects the case of a pauper in
the House of Industry in Dublin, about the year 1814,
who had received a wound of the stomach some years
previously, from which he recovered, with a fistulous
opening in the side, of considerable size, communicating
with the stomach. He kept this plugged with a tent
of lint or tow, and, to gratify visitors, he would, for the
reward of a few pence, take a large drink of milk or
other fluid, and, withdrawing the plug, suffer it to flow
out through the external opening. Another remark-
able case was that of Alexis St. Martin, which assisted,
in the hands of Dr. Beaumont, in throwing such light
on the physiology of digestion. These and similar
instances tend to show that wounds of the stomach
inflicted from without, although highly dangerous, are
not absolutely mortal. But we can scarcely say the
same of rupture of the stomach caused by a blow or
contusion on the part, inasmuch as the contents have
then no chance of an external outlet, and must be
poured into the peritoneal cavity. While upon this
subject, we may remark that rupture of the stomach
may take place without external violence, and it then
commonly causes death after a train of symptoms that
closely resemble the effects of the irritant poisons. This
accident usually occurs from the efforts to discharge,
by vomiting, the contents of an over-filled stomach.
When the organ is in this condition, it is carried for-
ward, and makes an abrupt turn on the lower end of
the Oesophagus, which acts as a valve, and opposes the
exit of the contained matters. A striking case of this
513
kind is related by Dr. Lallemand.* A woman, con-
valescent from a long attack of dyspepsia, being desirous
to make amends for her long privations as to diet, ate
one day to satiety. Ere long she was seized with a
sense of weight in the stomach, nausea, and fruitless
efforts to vomit. Then she all at once uttered a piercing
shriek, and exclaimed that she felt her stomach tearing
open ; afterwards she ceased to make efforts to vomit,
soon became insensible, and in the course of the night
expired. In the fore part of the stomach there was
a laceration five inches long, and a great deal of half-
digested food had escaped into the cavity of the abdo-
men. Professor Barzelottif notices a case in which the
rupture was caused not by the accumulation of food,
but by the accumulation of gases arising from depraved
digestion, similar to what arises in cows which have
eaten largely of clover. In these cases the train of
symptoms would lead one to suspect the administration
of an irritant poison, but sometimes death is instantane-
ous. Dr. Christisonſ mentions the case of a coal-heaver
in London, who, while attempting to raise a heavy
weight, suddenly cried out, clapped his hands over his
stomach, drew two deep sighs, and died on the spot.
On dissection, a lacerated hole was found in the stomach,
big enough to admit the thumb, and the stomach did
not contain any food. These cases show the great
danger arising from simple rupture of the stomach, but
the danger is still more increased when the laceration
is effected by external violence; for then, besides the
injury done to the organ itself, the solar plexus and
semilunar ganglion are implicated in its effects. These
* Inaug. Dis. Paris, 1818. Christison on Poisons, first edition, p. 88.
+ Medicina legale, ii. p. 22.
j: Loc. cit.
33
514
parts are so essential to life, that injuries to them are
sometimes followed by the most rapid and perfect
death, the entire vital power appearing to be at once
extinguished.
Persons suffering laceration of the intestines from
blows or contusions are likewise exposed to the greatest
danger; but perforated wounds do not appear of the
same mortal character; and when proper treatment is
pursued, very surprising recoveries have taken place.
Wounds of the small intestines are said to be more
dangerous than those of the larger, in consequence of
the more important functions they perform, and of
their being supplied with a greater number of nerves;
but we cannot perceive the value of this distinction, as
the principal dangers—extravasation and inflamma-
tion—are not influenced by either of these circum-
StanceS.
Individuals may be killed by wounds of the liver;
although small superficial wounds, if the sufferer escape
inflammation, may not be attended by serious conse-
quences; but more extensive and deeper injuries may
cause a fatal haemorrhage, by opening some of the
numerous and large bloodvessels by which that viscus
is traversed. Laceration of the liver by falls is not an
uncommon occurrence ; and when it happens, it most
commonly causes the death of the patient. Besides
the injury to the liver itself, its great reservoir, the gall-
bladder, is exposed to perforation and rupture ; and
this is an accident of the most fatal character, from the
effusion of bile into the peritoneum. This secretion
and the urine are the most irritating of all the fluids of
the body, and never fail to cause death when suffered
to escape into the belly. Wounds of the urinary blad-
515
der, therefore, except at the part uncovered by perito-
neum, are of the most fatal kind.
Before we leave this part of our subject, we wish to
make some remarks upon a form of accident which has
been long known and described, but about which very
vague and unphilosophical notions have been enter-
tained ; we allude to what have been termed wind-con-
tusions. It is not rare to find upon a field of battle dead
bodies preserving their form and the integrity of their
surface, and not presenting externally any lesion by
which death can be accounted for ; but if the body be
opened, some of the viscera of the thorax or abdomen are
found bruised and ruptured, with an extravasation of
black fluid blood or of the contents of the stomach and
intestines. When the nature and extent of these internal
lesions are considered, it is evident that death must
have been instantaneous, and the vital powers so quickly
and completely destroyed, that there has not been time
sufficient to allow of the infiltration of blood into the
cutaneous tissue, so as to produce ecchymosis. As this
kind of injury has been observed particularly after
battles, it was imagined that death was caused by the
wind of cannon-balls, that is, by the compression of the
air caused by the passage of the shot in the vicinity of
the individual. But when we consider the fluidity and
elasticity of the atmosphere, and the little resistance it
makes to the passage of bodies through it, we must per-
ceive that this explanation is untenable ; for the un-
confined air never can be compressed to such a point
as to become a mass capable of contusing or even giv-
ing a severe shock to our bodies. It is now generally
believed that these lesions are caused by the contact of
the cannon-shot itself when towards the close of its
33%
516
trajet. For the first moment of projection, when the
force is greatest, it pierces, tears, and carries off all that
occurs in the line of its direction ; but when it ap-
proaches the end of its course, and its velocity is con-
siderably diminished, it loses the power of producing
these effects; and as the skin is supple and extensible,
and the parietes of the thorax and abdomen are flexible
and elastic, and protected by clothing, they yield to
the impetus without tearing, and resume their original
form as soon as the compressing force ceases to act.
But the parts which lie deeper than the parietes, and
whose tissue is less flexible, and is supported by bone,
experience necessarily the full force of the compression,
and are thus contused, bruised, or in some instances re-
duced to a complete pulp. Any doubt of the validity
of this explanation is removed by a reference to reports
of cases of injuries not dependent on fire-arms, in which
the same laceration and contusion of the viscera of the
abdomen and thorax have been found without any ap-
pearance of external injury. Chaussier relates the case
of a strong man, thirty years of age, who, while driving
a cart heavily laden with stones, attempted to get on
the back of one of the horses, and falling in the endea-
vour, the wheel passed slowly over his left shoulder,
crossing the clavicle near the sternum, and continuing
its course obliquely over the entire left side of the
thorax. The body was found the following morning
on the road, lying on the back with the track of the
wheel marked on the clothes by a broad streak of mud.
Nevertheless, on stripping the body, there was no ap-
pearance on its exterior that could lead to a knowledge
of the cause of death. However, after removing the
integuments and muscles of the thorax, it was found
that the clavicle was torn from the sternum, and all
517
the ribs of the left side were fractured, but there was
no ecchymosis under the skin or round the fractures.
The first rib was broken in one place near the sternum,
but all the rest in two places, about three inches
apart, which corresponded with the breadth of the
wheel. These fractures were not complete, but were
limited to the inner surface. On opening the thorax,
the pericardium was found distended with coagulated
blood, and a large rent was discovered in the left
auricle of the heart. From this it is evident that pres-
sure by the passage of a heavy body may cause bruis-
ing or rupture of the internal parts, without leaving
any appearance of its action on the exterior ; and in
like manner those great contusions and sudden deaths,
without external mark of violence, observed after ac-
tions, are to be ascribed to the size and weight of can-
non-shot striking the body with diminished velocity.
We do not think it necessary to dwell upon wounds
of the extremities, as the danger of speedy death in
these cases depends upon the escape of blood from some
of the great blood-vessels implicated in the injury, a
complication which is easily detected by dissection.
But there is a form of injury connected with this part
of our subject on which it is necessary to make a few
observations. We allude to wounds of the external
parts of generation in the female, which may prove
fatal by excessive haemorrhage; the peculiar structure
of the parts, consisting of erectile tissue which is very
vascular, giving rise to a continued, steady, though not
very rapid flow of blood. In illustration of this point
we may refer to two cases related by Mr. Watson. The
first is that of a woman who resided near Edinburgh,
whose husband was tried and convicted of having
murdered her in the year 1826. “The body,” says Mr.
518
Watson, “of this unfortunate person was inspected by
“Mr. Newbigging and myself. We were informed of
“her having died suddenly. She seemed to be about
“fifty years of age, of stout form, of very low rank,
“having lived in a small, dirty, ill-furnished house,
“having only some shavings and straw upon the floor,
“covered with a rug, for a bed. The clothes in contact
“with the private parts were stained with blood. No
“appearance of injury could be perceived on any part of
“ the body externally ; but upon separating the labia
“ pudendi a wound about an inch and a quarter in
“ length was observed upon the inner side of the right
“ nympha. This wound was evidently recent, its sur-
“face being covered with coagulated blood. Externally
“it consisted of a remarkably clean, straight incision
“ parallel with the nympha. Internally the finger
“could be introduced in four different directions to the
“ depth of about two and a quarter inches in each ;
“ upwards and backwards towards the division of the
“iliac artery; backwards towards the tuberosity of the
“ischium ; laterally towards the hip-joint; and up-
“wards towards the mons veneris. In each direction
“ the wound was of nearly the same diameter, which
“readily admitted the finger, and had distinctly an
“obtuse termination. By injecting warm water into
“the large vessels, we found that none of them had
“ been wounded, and the penetrating instrument seemed
“to have been forced only through the cellular tissue.
“The weapon had passed up to the peritoneum at the
“right side of the pelvis, under which there was a con-
“siderable effusion of blood, but had not penetrated it.
“Another very small, but also very clean external in-
“cision was observed at the side of that above described.
“The cavities of the cranium, thorax, and abdomen
519
“were each examined, and their contents found to be
“quite healthy and natural. The haemorrhage, there-
“fore, which had taken place from the wound was the
“only cause which we could assign for her death, and
“this we knew from the nature and structure (erectile
“spongy tissue) of the parts cut, must have been pro-
“fuse.” It was proved on the trial that the wound
was inflicted by a razor. -
The second case is very similar to that first described.
It occurred in the person of a woman who lived in
Edinburgh, and whose sudden death was occasioned by
a wound received on the morning of the 1st of January,
1831. This case was examined by Mr. Mitchelhill and
Mr. Watson. They found the body dressed in the or-
dinary day-clothes, which they removed carefully, and
observed no wound or tear on them, but the lower
parts were drenched with blood. They then discovered
that the haemorrhage had proceeded from a wound of
the left labium pudendi, consisting of a very clean
incision about three quarters of an inch in length,
parallel with the margin of the labium. When the
finger was introduced into this wound, it entered a
bloody cavity sufficiently large to contain a small hen's
egg, and from this cavity the finger could be passed up-
wards towards the symphysis pubis, downwards towards
the perinaeum, and backwards by the side of the vagina
and rectum. Its greatest depth at any of these places
was between two and three inches. When the internal
part of the wound was laid open, the divided orifices of
several pretty large arteries and veins were seen, and
particularly the divided extremities of the large artery
going to the clitoris. By the evidence adduced at the
trial of two young men, brothers, for the murder of
this woman, it was obvious she had received a wound
520
at the first floor of a common stair, almost immediately
after which she was precipitated headlong to the bottom
of the stair. In reference to these cases Mr. Watson
remarks, “In both, this part of the body seems to have
“been selected by the murderers to effect their design
“secretly; for in both, particularly in the first, the
“wound was concealed to a superficial observer; and
“ they may have had an idea, from the frequency of
“flooding in females, that their death might have been
“supposed to have happened either from this cause or
“by accidentally injuring themselves by sitting down
“ upon some sharp body. For it is a curious fact that
“in both cases the probable murderers were the first
“to go for medical aid to the deceased.”
Circumstances affecting the medico-legal character of
wounds.—So far we have considered wounds according
to the consequences that usually attend them : but the
medical jurist should ever bear in mind the fact that
injuries, naturally belonging to the class of slight
wounds, may acquire the character of severe, dangerous,
or mortal, from the co-operation of circumstances more
or less extraneous, and therefore relieving the inflictor
more or less from responsibility. We have already al-
luded to the memorable aphorism of Mr. Hobbs, that
there was never a wound but it might prove mortal.
Let us now inquire into those circumstances that are
thus capable of altering the medico-legal character of
wounds: these are age, sex, constitutional peculiarities,
previous injury or disease, subsequent injury or disease,
malum regimen.
Of age it may be said that adult age is on the whole
the most favourable to recovery from injuries; of this
we have a very striking example in the case of burns,
the effects of which are much more severely felt by
521
young subjects, and the mortality attending them is
greater in this class than in persons who have reached
adult age. Fractures may perhaps form an exception
to this, as it is observed that this species of injury is less
fatal in children.
Sea is a circumstance of aggravation in the case of
blows on the breast of a female. This organ being in
early life endowed with peculiar sensibility, and in
later years being prone to take on cancerous action
when excited by injury, is naturally a very vulnerable
part, and a comparatively trifling blow in this situation
may be followed by the severest effects. In like man-
ner an injury on the abdomen of a pregnant woman
must be regarded as a more dangerous accident than
the same force applied under different circumstances.
Constitutional peculiarities do not form a good excul-
patory plea unless the wound be slight. They are of
two kinds, constitutional infirmities and malformation.
Slight wounds may be rendered dangerous, and even
mortal, from an extreme irritability of the nervous sys-
tem. We see this in the different effects produced on
different patients by surgical operations, some bearing
with fortitude what others unaccountably sink under.
The scrofulous diathesis and venereal taint influence the
result of wounds, and diseases of the bones and joints
have succeeded in such constitutions to injuries which
would have been of little consequence in sound ones.
The hamorrhagic diathesis is one calculated to increase
in a remarkable manner the danger of slight wounds,
some striking examples of which have been already
mentioned. Original or accidental malformation may
likewise contribute to the fatal effects of a slight injury.
Thus, transposition of the viscera may bring an organ
within reach of a wound that might have been other-
522
wise harmless. A very remarkable instance of such
malformation is preserved in the museum of the Dublin
College of Surgeons. The subject was a woman ad-
vanced in life, who died in one of the hospitals of the
House of Industry, and who had never given any indi-
cation during life of her peculiar formation. On exam-
ination of the body after death, all the viscera of the
thorax and abdomen were found transposed. The
heart was at the right side, the liver at the left, the
stomach and spleen at the right, the coecum in the left
iliac fossa, the sigmoid flexure of the colon in the
right, and all the bloodvessels were transposed to
correspond. But besides such a general transposition,
there may also be a partial malposition. Thus, an
artery usually deeply seated may take a superficial
course, and prove a source of danger in case of a slight
wound inflicted in that situation. A case in which
death occurred in consequence of malposition of an
artery happened in the hands of one of the most expe-
rienced surgeons in Dublin some years ago. A fish-
bone stuck in the throat of an individual, who applied
to the gentleman alluded to for relief. A probang
was passed down the oesophagus, when suddenly an
immense gush of blood took place from the mouth of the
patient, and he dropped dead in his hands. On ex-
amining the body to ascertain the cause of this unex-
pected fatality, it was found that the arteria innominata,
instead of following its usual course in front of the
trachea, had dipped down between it and the oesophagus,
just at the spot where the fish-bone had lodged, the
point of which had been forced by the probang through
the oesophagus into the artery, and thus caused the
death of the patient. Besides these congenital malfor-
mations, there may be accidental displacement of a
523
viscus, as in hernia, by which a blow in certain situa-
tions will be made more dangerous.
Previous injury or disease is a plea sometimes set up
in extenuation of guilt; but it is a feeble one, and in
fact untenable if the injury is of a usually dangerous
character, or has manifestly accelerated the death of
the individual. It may, however, be used with ad-
vantage if the injury was slight; but the degree of
weight that should be allowed to it in law is sometimes
very difficult of decision. The chief questions on the
subject are, 1st, Was the new injury adequate to cause
serious mischief in ordinary cases? 2nd, Whether did
the injury or the previous disease or accident occasion
death? 3rd, Did the alleged previous harm really ex-
ist, or was it the consequence of the injury? Chaussier
relates the case of a boy who was killed by a very
gentle stroke of a switch upon the head, which in ordi-
nary cases would have caused no mischief, but proved
fatal in this in consequence of previous absorption of
the skull at the particular part struck. An interesting
illustration of the second question has already been
quoted from the same author, in which death was pro-
duced by the bursting of an internal aneurism. Cases
that come under our third head are very common ; we
will content ourselves by quoting one by Dr. Klapp of
Philadelphia.” An individual in that city, who was in
habits of intemperance, engaged in a brawl, received
an injury, and died thirty-eight hours after the affray.
He walked and spoke after receiving the injury, and
even drank part of a pint of spirits, but was shortly
seized with insensibility, dilated pupils, and oppressed
breathing, and died without any return of sense. The
* American Medical Recorder, v. i. p. 156, and Beck, by Darwal, p.
352.
524
bone and the brain beneath the injured part were ex-
amined and found natural. The mucous membrane of
the cardia and the upper part of the stomach were
greatly inflamed ; the other parts were not diseased.
Before the court, Drs. Hartshorn and Klapp gave it as
their opinion that the injury to the head had not been
the cause of death, and that there was no appearance
of a blow on or near the region of the stomach. A
verdict of acquittal was the result. But supposing the
injury to be of such a kind as would alone prove fatal,
then the second question arises, Whether did the injury
or the previous disease cause death? There are circum-
stances which may render this a nice question to
answer : thus, for instance, the disease and the injury
may cause the same symptoms and appearances as in
apoplexy and extravasation of blood from a blow. In
cases of this kind confusion and difficulty are sure to
occur, when the investigation is made according to the
Continental system ; but in these countries the animus
with which the injury was inflicted being the chief ob-
ject sought after, the medical witness is saved from the
nice distinctions laid down in foreign authors.
Subsequent injury or disease may also alter the
medico-legal character of injuries. It may happen that
a disease totally unconnected with the effects of an
injury may invade a person who has received a wound,
and carry him off. This is a case which sometimes
creates great difficulty. Thus, a typhous fever may
attack an individual labouring under a wound of the
head, or spontaneous pleurisy may occur after injury
to the chest ; in both of which cases it is evident that
great obscurity must exist. We recollect the case of
a boy who was admitted into the Richmond Hospital,
Dublin, labouring under a wound of the head with a
525
small depressed fracture of the right parietal bone.
He went on well for some days, when headache came
on, flushed countenance, fast and hard pulse, dry and
burning skin, and thirst with sickness of stomach. It
was at once supposed that inflammation of the brain
had set in, and preparations were making for trephin-
ing him, when attention was accidentally turned to
his right arm, from which he had been bled on the day
of his admission, and in it, in the neighbourhood of the
puncture, and spreading up the arm under the fascia,
a large collection of matter was discovered, on the
liberation of which all the bad symptoms gradually
disappeared, and the boy recovered well without any
operation. This was a case in which a subsequent dis-
ease put on the appearance of the worst consequences
of the injury, and was at first mistaken for them.
Zacchias relates an instance illustrative of the diffi-
culty that may occur in these cases. During a period
in which the plague raged at Rome, a man received a
wound on the head which denuded the bone, but left
no fracture. The wound appeared favourable for the
first three days; but at the termination of that period
a fever came on, accompanied with bilious vomiting
and violent inflammation of the wounded part. On
the fourth day the wound was gangrenous, petechiae
and buboes occurred, and he died on the sixth. It ap-
peared afterwards that he had been visited during the
first two days of his illness by a friend, who had died
of the plague on the fourth day after communicating
the disease to the wounded person. Tetanus is a conse-
quence of wounds which must occur to every one as
likely to alter their medico-legal character. A case
occurred a few years ago in England, in which the
supervention of this disease upon a slight injury had a
526
great influence upon the fate of a prisoner. A gentle-
man fired a gun loaded with small shot at a boy whom
he found trespassing on his ground. He wounded him
slightly in the leg, and the boy appeared going on well
until he was attacked with tetanus, of which disease he
died. The gentleman was tried, found guilty of murder,
and executed. This case forms a good example of what
has just been stated respecting the English practice in
such cases; for if the wound had been inflicted with a
stick, or whip, or other implement, it is almost certain
that a verdict of murder would not have been returned
against the prisoner; but a gun having been used, made
it appear that the intent was to do some grievous
bodily harm, and the heaviest penalty of the law was
accordingly inflicted.
Malum regimen, or improper treatment, often consti-
tutes a very strong exculpatory plea, as by it the
character of wounds may be materially altered for the
worse. Accidental or inevitable want of skilful attend-
ance is not a valid plea ; but if the omission was inten-
tional or avoidable, it takes off the responsibility of the
inflictor in a great degree. If a patient should refuse
to submit to proper treatment, or should persevere in
the use of forbidden articles of food, or should expose
himself to cold or a vitiated atmosphere, it is plain that
he must contribute to place himself in a more unfavour.
able position, the result of which can only be charged
on himself. On the part of the medical attendant
misgovernment may arise either from negligence or bad
treatment, by either of which the danger of a wounded
person may be greatly aggravated. “In general,” says
Dr. Beck, “when a dissection proves that no wound
“mortal in its nature has been received, and when none
“of the circumstances already enumerated can be urged
527
“as causing its fatality, the death of the patient should
“be attributed to the surgical attendant rather than to
“the author of the wound, provided it can be proved
“that he neglected the sick person, or maltreated him
“by leaving foreign bodies in the wound which might
“have been taken away; by not suppressing haemor-
“rhage; by not evacuating collections of pus when
“necessary; by employing tents unnecessarily; by ne-
“glecting or hurrying operations; or by not causing
“the proper regimen to be observed.”
In cases where bodies are found dead from wounds
or bruises, a very important question arises which the
medical jurist is frequently called upon to solve, that
is, are the wounds the result of suicide, of accident, or
of murder? In the greater number of cases in which
our assistance is required, the circumstances of the
case are so well known, or can be so proved by wit-
nesses, that there can be no doubt of the cause of in-
jury or of the true author of it. But there are cases
in which, to fulfil the objects of justice, it is necessary
to determine whether the wounds inflicted on an indi-
vidual were by himself or others. The solution of this
question is always delicate, often embarrassing, and
very difficult. The circumstances to be attended to in
this inquiry are, first, the seat of the wounds; second-
ly, their direction; thirdly, the probable weapon used.
There are few wounds that one person can inflict upon
another which may not be accomplished by an indivi-
dual on himself. Some, however, form an exception
on account of their extreme difficulty. For instance,
it would be hard to believe that a wound with a sharp-
pointed instrument in the spinal marrow was self-
inflicted ; and in death from fire-arms wounds from
* Med. Jur. by Darwall, p. 327.
528
behind can scarcely be supposed to have been volun-
tarily effected. Incised wounds are seldom inflicted
for the purpose of suicide except on the throat, but
instances have occurred where individuals have resort-
ed to wounds of the extremities and amputation of the
penis for this purpose. A case occurred recently with-
in our own knowledge, where the suicide, having
failed, as often happens, to destroy himself by cutting
his throat, deliberately bared his left arm, and cut it
across to the bone, dividing the brachial artery, from
which he bled to death. The circumstance of fire-arms
being discharged in the mouth of an individual is suffi.
cient to warrant the belief that it was not done by the
hand of another. Thus, attention to the seat of the
wound will often determine whether it is the result of
accident, suicide, or homicide, and will throw light up-
on the evidence of witnesses as to the circumstances
under which the injury was inflicted. The direction
of the wound will likewise often determine the intent,
and the question of suicide or homicide. When the
wound does not pass through the body, there will be
little difficulty in ascertaining the direction in which it
came and in which it passes. In a case of supposed
suicide by means of a knife or pistol, the course of the
wound should be examined, whether it be upwards or
downwards, and the length of the arm should be com-
pared with the situation and direction of the injury.
It should be ascertained whether the right or left hand
has been used ; and as the former is that most com-
monly employed, the direction should correspond with
it; but if the direction corresponds with the left, it
should then be inquired whether the deceased were
left-handed. When a wound is alleged to have been
inflicted by accident, we may inquire into the probabi-
529
lity of the statement by comparing the stature of the
body with that of the inflictor, and the relative position
of the two at the moment the wound was received. In
fact a stab given by an individual of small stature to
one of greater size is naturally directed from below
upwards, and the contrary if it is the larger of the two
who has inflicted it. An example of this occurred
some years ago at Marseilles,” in two men of different
height, who fought a duel with swords on a public
walk. The weapon of each of the combatants reached
the heart of the other at the same moment, and they
fell dead together. Their bodies being examined, it
was found that the wound given by the small man was
directed from below upwards, and that by the larger
from above downwards. The situation and mode in
which a wound is inflicted will often point out the in-
tention of the perpetrator. Foderéf relates a case
illustrative of this point. A miller was assassinated at
his own door by a butcher, who pretended that he had
no intention of killing him, but had only threatened
him with his knife in consequence of some maltreat-
ment which he had received ; that the miller renewed
the attack, and in attempting to pursue him, made a
false step and had fallen on the weapon. A single
external wound, which led downwards to two wounds
of the left ventricle of the heart, separated from each
other by an interval of two lines, shewed that the ac-
cused had employed the same method to destroy his
victim as that used by butchers in that country to kill
cattle ; that is, after having driven the knife into the
heart, they withdraw it some distance, and replunge it,
so as to make a second internal wound. Thus the
* Méd. Lég. t. iii. p. 195.
f Ibid. p. 196.
34
530
direction of the wound compared with the respective
statures of the two adversaries, (the butcher being much
smaller than the miller,) proved that the blow had
been inflicted obliquely from above downwards, that is,
whilst the miller was sitting at his door, and not by a
fall after getting on his feet, in which case the wound
must have taken an opposite direction.
In case of wounds from fire-arms perforating the
body, different opinions have been formed as to whether
this circumstance should determine the distance at
which the shot was fired; and at first we might be led
to suppose that if a pistol bullet passed through, the
instrument from which it was discharged must have
been very near. But this is found to depend so much
upon the strength of the charge, the direction of the
ball, and the resistance offered by the parts of the body,
that we cannot venture to draw any conclusion from it.
It is, however, of importance to be able to discriminate
between the entrance and exit wound, as a means of
ascertaining the direction of the shot. That made on
entering is smaller than the other, and has its edges
inverted and depressed ; while the latter is much
larger, with ragged, everted, and uneven edges,—a
circumstance depending upon the direction in which
the force is applied to the skin, as well as upon the
diminished velocity of the ball. This appearance may
also be observed in the clothing, and is even more con-
stant there than in the person of the sufferer, and
should in all cases be looked for, as being capable of
removing all doubts upon this point which might
otherwise exist. When any of the flat bones are per-
forated by balls, the same difference in the size and
appearance of the two openings is to be observed. A
trial in which the defence rested upon the difference
531
between the wounds took place a few years ago in Kent,
and is recorded by Dr. Gordon Smith.” An officer in
the preventive service was indicted for the murder of
a man who was shot in the night, under circumstances
of a suspicious nature as to his pursuit at the time.
There was no doubt that he was in company with a
party of smugglers, and came by his death accidentally.
He was retreating before the prisoner, who tripped, and
in the fall his gun went off. It seems that, on the other
hand, several shots were fired on the part of the smug-
glers in their retreat, and that the deceased was killed
by one of them. This appeared from the testimony of
a navy surgeon of considerable experience, who ex-
amined the body. He found the wound in the upper
part of the groin much smaller than that in the lower
part of the buttock, which was twice or three times the
size of the former, and was ragged and uneven. Frag-
ments of the bone were likewise felt at the hinder
opening, but none in the cavity of the pelvis. From
these appearances he gave his opinion that the ball had
entered in front, and had consequently come from his
own party.
The probable weapon with which a wound was in-
flicted will often assist in disclosing the true nature of
the accident. The singularity of shape which some
wounds present, and the comparison that may be made
between them and that of different instruments, has
sometimes served to illuminate obscure cases. Such is
the case related by Desgranges, and quoted by Foderé,
of an individual who, having got drunk in a pot-house,
left it to return home at eleven o'clock at night, the
ground being covered with snow. He was found dead
the following morning, beside a ditch near his own
* Principles of Forensic Medicine, p. 290.
34%
*D
532
house. Desgranges examined the body, which at first
offered no trace of wound, bruise, or violence ; but on
turning the head from left to right, an oblique wound
was discovered scarcely three-quarters of an inch in
extent, under the base of the lower jaw, and about the
height of the larynx. The little finger introduced into
this wound shewed it to be wider and more extensive
within than appeared from the external incision. The
clothes of the deceased were stained with blood, and
there was a large quantity poured out on the snow. It
appeared that this wound had been inflicted with an
auger, which the deceased had carried out of the pot-
house under his arm, with the point foremost, and upon
which he, being drunk and hardy able to walk, had
fallen. This instrument was found lying beside him
covered with dry blood, having been extricated by the
deceased from the wound, but not before it had wounded
the left carotid artery.
While upon this point, we think it well to insert the
declaration of Sir Everard Home relative to the re-
markable case of the death of Sellis, a servant of the
Duke of Cumberland, and the simultaneous injury
received by His Royal Highness. Sir Everard's decla-
ration seems to indicate that Sellis had committed
suicide after attempting the life of the duke. “I
“visited the duke,” he says, “upon his being wounded,
“ and found my way from the great hall to his apart-
“ment by the traces of blood which were left on the
“passages and staircase. I found him on the bed, still
“bleeding, his shirt deluged with blood, and the drapery
“above the pillow sprinkled with blood from a wounded
“artery, which puts on an appearance that cannot be
“mistaken by those who have seen it. This could not
“ have happened had not the head been lying on the
533
“pillow when it was wounded. The night-riband,
“which was wadded, the cap, scalp, and skull were
“obliquely divided, so that the pulsations of the arteries
“of the brain could be distinguished.”...“While dress-
“ing these wounds, a report came that Sellis was dead.
“I went to his apartment, found the body lying on its
“side on the bed, without the coat and neckcloth, the
“throat cut so effectually that he could not have sur-
“vived a minute or two. The length and direction of
“the wound was such as left no doubt of its being given
“by his own hand; any struggle would have made it
“irregular. He had not even changed his position ;
“his hands lay as they do in a person who has fainted.
“They had no marks of violence upon them. His coat
“hung upon a chair out of the reach of blood from the
“bed ; the sleeve from the wrist to the shoulder was
“sprinkled with blood, quite dry, evidently from a
“wounded artery, and from such kind of sprinkling
“ the assassin of the duke could not escape.”
Some light may be thrown upon cases of death from
fire-arms by attention to collateral circumstances. Thus,
in some instances the crime has been brought home to
an individual by means of the wadding employed. A
case of this kind occurred in France in 1818, and a
similar one more recently in England; in both of which
the wadding was examined, and discovered to have
been torn from paper found in the possession of the
murderer. If the ball be discovered, a comparison of
it with the gun or pistol from which it is supposed to
have been fired may assist in the enquiry. Thus, in a
case of alleged suicide in which the pistol was found
beside the body, on comparing the ball with the barrel
* Edin. Ann. Regist, vol. vi. part ii. p. 19 ; and Beck, by Darwell,
p. 308.
534
of it, it was found too large to have entered it, and so
the question of suicide was set at rest, and attention
was directed to detect the murderer. If a flint pistol
have been employed for the purpose of suicide, it has
been imagined that the discoloration of the fingers
from the combustion of the priming would confirm the
case as one of suicide; but this mark, besides being
capable of imitation by a crafty assassin, is becoming
every day of less value, in consequence of the general
application of detonating locks to all kinds of fire-arms.
Persons found burned.—In cases where bodies are
found dead with traces of extensive burning upon
them, the medical jurist to whom the investigation
may be committed has some delicate and interesting
questions to solve. This difficulty has been of late
years increased by the admission of the possibility of
spontaneous human combustion, and he is now expected
to state—first, whether burning was the cause of death
or not, or, in other words, whether the body was burned
before or after death ; second, whether the burning
was spontaneous or ordinary combustion. It is much to
be feared that a want of information respecting the
peculiarities of these different cases has led, even in
times not very remote, to the condemnation of innocent
persons. “On a vu, dans le courant du dixhuitième
“siècle, condamné à périr sur l'échafaud un malheureux
“ habitant de Rheims, accusé d'avoir assassiné sa femme,
“et de l’avoir ensuite brulée, afin de se dérober au
“supplice qui l’attendait; et M. Vigné a jetté des
“fleures sur la mémoire de l’infortuné Millet, dont la
“femme sujette à l’ivrognerie fut trouvée le 20 Février,
“ 1725, presque entièrement consumée dans sa cuisine,
“à un pied et demie du foyer.” Two cases related by
* Foderé Méd. Lég. tom. iii. p. 204.
535
Dr. Christison,” on the authority of the late Dr. Duncan,
appear to us of a similar nature. In each the prisoner
was accused of having murdered his wife, and burnt
the body afterwards to conceal the murder. “The
“first was the case of a man, Gilchrist, who was con-
“demned and executed at Glasgow. The prisoner and
“his wife lived on tolerably good terms, but used to
“take fits of rambling, and get drunk for days together.
“At last, on One of these occasions, after their return
“home in the evening, the people who lived in the
“floor above them heard a noise like that of two per-
“sons struggling, and soon afterwards a rattling or
“gurgling and moaning, as of one choking or bleeding
“to death. They so strongly suspected that all was
“not right, that they called down to Gilchrist through
“ the floor that they were afraid he was killing his wife.
“In no long time they were further alarmed by the
“smell of fire and the filling of the house with smoke ;
“upon which they went down to Gilchrist's apartment
“ and demanded admission. After some delay he ad-
“mitted them, and in doing so appeared to have come
“out of an inner room, where he said he was asleep in
“bed. On letting them in, he stumbled over the body
“of his wife, who lay in the outer apartment quite dead,
“kneeling before a chair and very much burnt. In
“these circumstances the prisoner was accused of hav-
“ing murdered her, and then burnt the body to con-
“ceal the manner of death; while, on the contrary, he
“alleged he had gone to bed tired, and knew nothing
“ of what had befallen her till he was awakened by his
“neighbours, and that he presumed her clothes had
“caught fire while she was intoxicated and burnt her
“to death. The medical gentleman who had been ap-
* Edin. Med. and Surg. Journal, vol. xxxv., p. 316.
536
“ pointed to examine the body, merely reported that
“ they found the body so much burnt that they could
“learn nothing from it as to the cause of death. The
“general evidence was all against the prisoner. He
“was accordingly condemned, although the precise
“manner of his wife's death was not proved even pre-
“sumptively, and the sentence was put in execution ;
“but to the very last he vehemently and solemnly de-
“nied that he was guilty.” The second case occurred
to Dr. Duncan within the same year, at Leith. “The
“general evidence was of the same nature as in the
“case of Gilchrist, but even stronger against the pri-
“soner. He lived on bad terms with his wife. On
“ the evening of her death she returned home at a late
“ hour with a lighted candle, after getting some whis.
“key at a neighbour's. At this time the prisoner was
“ in bed ; but some time afterwards there was heard
“a considerable noise like that of struggling, and of
‘ chairs pushed up and down the room ; and after this
“ the man was heard in an adjoining bedroom, endea-
“vouring to quiet his child who was crying. Pre-
“sently the neighbours were alarmed by a strong
“smell of fire proceeding from the prisoner's apart-
“ments. At last a man forced his way in by breaking
“ the window. On entering he found the room full of
“ smoke, and observed something burning red in a
“corner, over which he instantly threw a pitcher of
“water, and which proved to be the body of the wo.
“man burning on the hearth.” Dr. Duncan was pre-
sent at the examination of the body under the she-
riff's warrant, and reports as follows. “We found
“some parts of the body, especially the belly, burnt to
“a cinder. We then examined the parts on which
“ the fire had acted more moderately, namely, the face
{
537
“ and extremities, and here there was every mark of
“vital reaction ; some spots were merely red and in-
“flamed ; others scorched to a hard transparent crust,
“but surrounded with distinct redness, and a great
“many blisters filled with lymph perfectly different
“from those produced on the dead body, which are
“not filled with a fluid, but with air or vapour. In
“short, we found appearances exactly similar to those
“of fire on a living body, and therefore we reported
“as our unanimous opinion that the deceased was
“burnt to death.” As there was no proof of the pri-
soner's having set fire to her, he was not found guilty,
but the jury returned the intermediate verdict of not
proven. {
It is remarkable that although the possibility of
spontaneous human combustion was not mooted at the
time of these occurrences, yet the acute mind of Dr.
Duncan led him to perceive something extraordinary
in the phenomena which presented themselves; and he
particularly comments upon the violent and destruc-
tive action of the fire, compared with the small quan-
tity of combustible matter consumed. In neither case
was there any trace of burning in the house or furni-
ture, and in the last the woman was found on the
hearth with part of her clothes unburnt, and a chair
from which she had fallen quite entire. She was dead
when the neighbours entered, and in the dark the
body was discovered by a red light issuing from it.
Upon reviewing these cases, particularly the last, we
cannot avoid acknowledging that Dr. Christison had
some grounds for believing that the body was in that
singular state in which it is apt to undergo spontaneous
combustion ; it being difficult to explain otherwise the
great extent of injury inflicted. It is not our inten-
538
tion at present to enter into a discussion of the theory
of spontaneous human combustion, but we wish to
direct the attention of practitioners to that interesting
phenomenon, in order that they may be prepared to
detect it should it occur ; and we have mentioned the
instances just quoted as examples in which a know-
ledge of this possible peculiarly morbid condition of
body might have saved the lives of innocent persons.
But since Dr. Christison gave expression to that opi-
nion, it is right to add that Baron Liebig has, in a
most able memoir, questioned the possibility of the
occurrence of such a phenomenon as spontaneous hu-
man combustion.* -
Was the body burnt before or after death 3 —This
question can only be solved by a reference to the phe-
nomena which are known to occur on the application of
a burning heat to a living and a dead body, and by
observing those indications of vital reaction which are
peculiar to the former, and remain visible after life is
extinct. We are indebted to Dr. Christisoni for some
interesting experiments and observations made for the
purpose of arriving at a more certain knowledge of these
phenomena; particularly with a view of ascertaining
whether the effects of a burn on a living body can be
imitated immediately after death by the application of
heat. It appears that the most immediate effect of the
application of heat to a living body is a blush of redness
to a considerable extent around the burnt part, remov-
able by gentle pressure, disappearing in no long time,
and not permanent after death. Next to this in order
(according to the author quoted), and occurring most
generally at the very same time, is a narrow line of
* Letters on Chemistry, 3rd edition, p. 280, et seq.
t Edin. Med. and Surg. Journ. vol. xxxv. p. 321.
539
deep redness, separated from the burnt part by a stripe
of dead whiteness, bounded towards the white stripe by
an abrupt line of demarcation, passing at its outer edge
by insensible degrees into the diffuse blush already de-
scribed, but not capable of being removed like it by
moderate pressure. In every instance in which Dr.
Christison watched the effects of the actual cautery, as
well as in those cases observed for him by others, this
deep crimson line appeared in a very few seconds, some-
times in five, generally within fifteen, and once only
so late as thirty seconds. Dr. Christison never failed
to observe this appearance on the bodies of persons
burnt a few hours before death, forming a line on the
entire skin near the burn, from a quarter to half an
inch in breadth, and about half an inch from the burn.
Blistering is the next appearance in point of order, but
it is not a very constant consequence of a burn if life
be extinguished a few minutes afterwards. When the
heat is applied by means of a scalding fluid, blisters
usually appear in a very few minutes. Yet sometimes,
in very extensive burns of this kind, especially in
young children, there is no vesication at all in many
hours. “It follows, then, that the only effects of burns
“which appear immediately after the injury and remain
“in the dead body are, first, a narrow line of redness
“near the burn, not removable by pressure ; and, se-
“condly, blisters filled with serum; that the former is
“an invariable effect, but that the latter is not always
“observable when death follows the burn in a few
“ minutes.”
In order to try whether these appearances could be
imitated by the application of burning substances after
death, Dr. Christison made the following experiments:
1. In a stout young man who had poisoned himself
540
with laudanum, a very hot poker and a stream of boil-
ing water were applied to the skin of the chest and in.
side of the arm one hour after death.
2. A stout young woman died in ten or twelve days
of a low typhoid fever, and at her death was but little
attenuated. Ten minutes after death, boiling water
was poured in a continuous stream on the breast and
outside of one of the legs.
3. A very powerful athletic young man poisoned
himself with laudanum. Four hours before death a
tin vessel filled with boiling water was closely applied
on several parts of the anus, and a hot smoothing iron
was held to the outside of the hip-joint. Half an hour
after death a red-hot poker was applied to three places
on the inside of the arm. The body was examined in
thirty-eight hours. “Some of the spots burnt during
“life presented a uniform blister filled with serum; on
“two there was no blister, but the cuticle was gone,
“ and the true skin dried into a reddish translucent
“ membrane, at the edge of which there were drops of
“serum, and also particles of the same fluid dried by
“evaporation. Round all these spots there was more
“ or less scarlet redness, particularly round the two
“ spots last mentioned. A bright red border, half an
“an inch wide, surrounded the whole burns; and the
“redness was not in the slightest degree diminished
“by firm pressure. The spots burnt after death were
“some of them charred on the surface, and not ele-
“vated ; two presented vesications, but the blisters
“were filled with air, the cuticle over them dry and
“cracked, and the surface of the true skin beneath was
“also quite dry. On the white parts of the skin there
“was no adjacent redness.” Similar appearances were
presented in the two former experiments to those now
541
mentioned as the effects produced after death. Three
other experiments were made on amputated limbs im-
mediately after operation, with results of a similar
nature. From these experiments it appears that the
application of heat to the body, even a few minutes
only after death, cannot produce any of the signs of
vital reaction formerly described ; and that a line of
redness near the burn, not removable by pressure, and
likewise the formation of blisters filled with serum, are
certain signs of a burn inflicted during life.
Was the burning spontaneous or ordinary combus-
tion ? It is remarkable that in by far the greatest
number of cases which have been brought forward to
support the theory of spontaneous human combustion,
the victims were females. Sixteen out of seventeen
cases related by Kopp, and all those, amounting to
eight, given by Lair, were of this sex. In like manner
the four cases mentioned by Dr. Apjohn as having
occurred in Ireland were all old women, and in all the
use of spirituous liquors had been carried to a great
extent. This kind of combustion is stated to penetrate
the body with extraordinary rapidity, and the flame
which accompanies it to be of a blue colour, lambent,
and with difficulty extinguished by water: but although
it acts so rapidly and extensively on the body, it is
said that objects in the neighbourhood, unless those
in actual contact with it, are not attacked. The trunk
of the body is the part that, it is alleged, suffers most,
being generally almost entirely consumed, while the
head and extremities are less injured. A peculiarly
greasy fuliginous deposit on all the articles in the
chamber has been also described as a characteristic of
this accident. The rapidity and depth of these com-
bustions, together with the small quantity of other
542
surrounding combustibles consumed, are said to con-
trast strongly with the slowness observed when bodies
are burned on a funeral pile or at the stake, and should
lead us to understand that similar effects cannot be the
work of criminal intention; for when burning is resorted
to in order to conceal crime, its operations are infinitely
more slow, more imperfect, and extend more to sur-
rounding objects than in those cases which the sup-
porters of this theory believe to be examples of spon-
taneous human combustion.
Persons found dead from cold.—Death from this
cause is by no means rare in countries where the winter
is usually very severe, as we learn from travellers
in Siberia, Lapland, Switzerland, &c.; and even in
other countries, when the winter is unusually severe,
cases occur which equally illustrate the destructive
effects of cold. If such accidents happen at a distance
from inhabited places, in snow and frost, they are gen-
erally too strongly marked by circumstances to be mis-
taken. But they may occur in populous places, and
even in large cities, and are then more liable to mis-
construction and suspicion. “The degree of cold neces-
“sary for the production of its fatal effects varies in a
“very remarkable degree with the strength and circum-
“stances of the individual to whom it is applied, as well
“ as with the rapidity of the cooling process. In some
“instances we find man enduring an extreme degree of
“cold with but little inconvenience, whilst in others we
“see him perishing in a temperature at which water re-
“tains its fluidity.“* There is a very striking descrip-
tion of the effects of cold in the account of the first
voyage of Captain Cook. When the Endeavour was
off Terra del Fuego, Sir Joseph, then Mr. Banks, Dr.
* Paris and Fonblanque, Med. Jur. vol. vii. p. 59, vol. VII.
543
Solander, and some others of the company wished to
make a botanical excursion to a mountain that appeared
but a short distance from the shore. They set out,
twelve in number, including domestics. An intense
cold soon seized them, which they were encouraged to
resist by Dr. Solander, who had crossed the mountains
separating Sweden from Norway, and knew the fatal
effects of yielding to its influence. He assured them
that whoever sat down would sleep, and that whoever
slept would never awaken. Nevertheless, he was him-
self the first to yield to the desire for sleep, against
which he had warned the rest. He begged to be al-
lowed to lie down ; he stretched himself, and slept some
time upon the ground covered with snow, and it was
with great difficulty that his friend Banks could rouse
him to go a quarter of a mile to a fire which he had
lighted. A black servant of Mr. Banks lay down also,
replying to the threats of death held out that he only
desired to be allowed to sleep and die. Dr. Solander,
when aroused at the end of five minutes, had almost
lost the use of his limbs, and his feet were so shrunken
that his shoes fell off. It was not possible to waken
the negro, and he perished with another negro who had
been left for a moment with him to assist him. All the
persons in the expedition felt the effects of the cold
more or less, but the whites were all saved, even Mr.
Buchan, a painter, who had a fit of epilepsy, to which
he was subject. -
In this example, as well as from more recent obser-
vations in the polar seas, it appears that a great degree
of cold, particularly when joined with fatigue, produces
in the body a stupor and numbness almost insup-
portable, and that the ardent desire for sleep arising
from this stupor is such that it cannot be conquered
544
by fear of the consequences. We also perceive that
men least accustomed to cold are those who most readily
sink under its influence, as we find the negroes dying
while the whites were saved ; and also that strength of
mind and body tended much to enable the sufferer to
resist, since Sir Joseph Banks, a man endowed with great
moral and physical energy, was the one who suffered
least of the whole party. The same cause will enable
animals to sustain cold with impunity. For instance,
among hybernating animals, as the dormouse and mar-
mot, it has been observed, in experiments made to as-
certain the cause of their sleep, that the most vigorous
are the most susceptible of invigoration by heat; and
that they are least readily thrown into a state of slum-
ber by artificial cold during summer. Foderé who was a
Swiss, says that whilst inhabiting his native mountains
all the cases of death of this nature whose histories he
could discover were those of sickly persons, children, old
men, or females. From Mr. Brodie's experiments, to
ascertain the source of animal heat, it is plain that the
temperature of animals is in some way or other depen-
dent upon the integrity of the functions of the nervous
system : and hence the power of an animal to resist
cold will be determined by his power of generating
heat. Now it is found that any cause by which the
powers of the nervous system are impaired favours the
action of cold upon the body; and for this reason an
individual labouring under the effects of a narcotic
may be killed by a degree of cold that otherwise would
have been quite supportable. It is for this reason, also,
that intoxicated persons perish in severe cold more
readily than those whose nervous system is not so im-
paired. Dr. Paris” notices two instances that occurred
* Loc, cit.
545
in London a few winters back, of drunken persons being
taken to the watch-house, and there not being any charge
against them, they were dismissed by the constable of
the night, and perished in the streets. A military friend
of his communicated to him an instance where, out of
a great number of troops who were exposed to intense
cold, the only one who perished was under the influence
of intoxication. This was also exemplified on a large
scale in the disastrous retreat of the French troops from
Russia, for we learn from Labaume's account that in-
toxication seemed to insure death.
Mr. Brodie is inclined to think that cold probably de-
stroys the principle of vitality equally in every part,
and does not exclusively disturb the functions of any
particular organ. This opinion is supported by the ex-
periments of Dr. Chassat.
In the case of persons found apparently dead from
cold, if the accident be recent, attempts ought to be
made to restore life. The application of heat should
be very gradual ; and artificial respiration may be
tried with a prospect of utility. Internal stimulants
should be cautiously administered after signs of re-
turning animation are apparent.
Persons found dead from hunger.—Food being ne-
cessary to the maintenance of life, it is plain that its
deprivation cannot be endured for any length of time
without causing death, and those cases of long fasting,
or of refraining altogether from food for years, have all
turned out to be impositions. It has, however, been
ascertained that the want of nourishment is borne
differently by different persons, a difference depending
on age, health, constitution, sex, &c. Thus, a great
number of persons doomed by some calamity at sea or
elsewhere to perish by this dreadful death, do not all
35
546
die at the same time, but some, according to their con-
stitution, have the sad privilege of surviving their
companions in misfortune. Young persons bear hunger
worse than old, and sooner sink under its influence,—
a fact no less correctly than beautifully illustrated by
Dante in his description of the sufferings of Count
Ugolino and his children, four in number, all enclosed
in a dungeon together, and condemned to death by
starvation. The father is represented as surviving
until the eighth day, having witnessed the death of his
sons in the order of their age, beginning with the
youngest. We see that in general, of the two sexes,
women bear the privation of food more easily than
men; thus, in all accounts of long voluntary abstinence,
three-fourths or more of the individuals are of the
female sex. Women usually do not consume much,
and all being equal as to age and health, they require
much less nourishment than men. The power of re-
sisting hunger varies also with the total privation or
otherwise of water. Redi” made many experiments to
discover how long animals could live without food.
Of many fowls that he kept without eating or drinking,
none passed the ninth day. He gave to one as much
water as it chose, of which it drank freely and often
during sixteen days, and it did not die until the twen-
tieth. Dogs in like manner lived much longer when
allowed water. But it would appear from a number
of instances, that the moisture of the atmosphere of the
place in which an individual may be confined may
compensate in some degree for the want of drink.
Foderé relates an instance where three women in Pied-
mont were overwhelmed by snow, and shut up in a
narrow stable without any provision for thirty-eight
* Osservazioni intorno agli animi wiventi, No. 3, 4.
547
days, and at the end of that time were rescued alive ;
and he thinks it probable that they owed their preser-
vation to the moisture of the place of their confinement;
the absorbents on the skin being thus able to derive a
certain portion of fluid for the use of the system.
Chaussier reports the case of some workmen who re-
mained fourteen days without eating or drinking, shut
up in a deep damp quarry by the sudden falling in of
the roof. They were withdrawn at the end of that
time, with a small feeble pulse, scarcely any heat, and
just a spark of life remaining, which was with difficulty
kindled. The absorption of moisture had sustained
them, as it did the women before mentioned. A very
striking instance of the power of water to prolong life
occurred in the case of Luc Antoine Viterbi, who
starved himself to death in prison in Corsica.” From
the fifth to the sixth day, to hunger insensibly succeeded
the much more grievous suffering of thirst, which
became so acute that on the sixth, without deviat-
ing from his resolution, he began to moisten his mouth
occasionally, and to gargle with a few drops of water
to relieve the burning pain in his throat; but he let
nothing pass the organs of deglutition, being desirous
not to assuage the most insupportable cravings, but to
mitigate a pain which might have shaken his resolution.
Until the tenth the thirst became more and more in-
tolerable, when, overcome by excess of pain, he seized
the jug of water and drank immoderately. On the
thirteenth, the unhappy man thinking himself at the
point of death, again seized the jug and drank twice.
On awaking on the morning of the fourteenth, and
finding his powers restored, he fell into a rage with his
keepers, protesting that they had deceived him, and
* Paris and Fonblanque, Med. Jur. v. ii. p. 69.
35*
548
then began beating his head against the wall of his
prison, and would inevitably have killed himself had he
not been prevented. During the nineteenth, the pangs
of hunger appeared more grievous than ever; so in-
sufferable indeed were they, that for the first time
Viterbi let a few tears escape him, but his invincible
mind instantly spurned this human tribute. On the
twentieth, he declared to the gaoler and physician that
he would not again moisten his mouth, and feeling the
approach of death he stretched himself, asking, as on a
former occasion, whether he was well out, and added,
“I am prepared to leave this world.” Death did not
this time betray his hopes. On the twenty-first, Viterbi
was no more. In this interesting case, which we have
here abridged, we perceive the effect of a small portion
of fluid in producing vigour in a body worn out by
abstinence. There can be no doubt that Viterbi would
have died much earlier if he had not made use of the
water. In the examination of bodies dead from hunger,
the following characters are usually observed. There
is general emaciation of the body, together with an
acrid fetid odour. The eyes are open and red, the
tongue and throat dry, and the intestinal canal is empty.
The gall-bladder is usually filled with bile, which ex-
udes and tinges the neighbouring viscera. The lungs
are shrivelled, and all the other organs healthy. It is
thought by Foderé that some conjecture may be drawn
as to whether the person has been totally deprived of
water or not ; for, according to the experiments of
Dumas, the dogs which he killed by thirst had the viscera
inflamed, and the blood thick and coagulated—pheno-
mena which did not present themselves in the bodies of
those dead from hunger alone.
Persons found dead from lightning.—Death from this
549
cause is sufficiently common to warrant a consideration
of it in this place. Its phenomena may be studied by
observing those of common electricity, as it has been
sufficiently proved that they are identical. The human
body is affected by both alike, and death, whether occa-
sioned by the discharge of an electrical battery or that
of a thunder-cloud, exhibits effects precisely analogous.
Two theories respecting the manner of death by light-
ning are extant, the first that of Mr. Hunter, the second
of Mr. Brodie. Mr. Hunter supposed that when death
is thus occasioned, there is an instantaneous and total
destruction of the vital principle in every part of the
body, and that the muscles are therefore relaxed and
incapable of contraction ; that the limbs do not stiffen
as after other forms of death, nor does the blood coa-
gulate, and that putrefaction is rapidly set up. On the
other hand, Mr. Brodie concludes from his experiments,
given from his manuscript notes by Dr. Paris,” that an
instantaneous extinction of vitality does not take place,
but on the contrary the functions of the brain are those
on which the electric shock exercises its primary in-
fluence. In one of his experiments an electric battery
of six jars having been charged with electricity, the
shock was made to pass through a guinea-pig, in the
longitudinal direction from the head to the tail. The
animal immediately fell on one side insensible, as if
stunned ; a convulsive action of the muscles of the ex-
tremities was observed, but did not long continue, and
the function of respiration was not interrupted. In a
few minutes sensibility was restored and the animal re-
covered. In another experiment a shock from nine
jars was passed in the same manner through another
guinea-pig. The animal immediately fell on one side,
* Med. Jur, vol. ii. p. 64.
550
exhibited a convulsive action of the voluntary muscles
of the limbs, but uttered no cries, and although atten-
tively watched, no signs of respiration could be dis-
covered after the shock had passed through. In three
minutes Mr. Brodie opened the chest, and found the
heart acting with regularity and vigour about eighty
times in the minute, and circulating dark-coloured
blood. The peristaltic motions of the intestines were
visible, and the muscles obeyed the galvanic stimulus.
In this experiment it is plain that neither the irrita-
bility of the muscular system at large nor that of the
heart was destroyed by the shock, but death took place
as from a severe injury of the head and destruction of
the functions of the brain. In this case Mr. Brodie
remarks that if the lungs had been artificially inflated
the action of the heart might have been maintained,
and the animal probably restored to life.
When a discharge of lightning strikes a human
body, it may affect the surface and produce vesications,
which most commonly, according to Mayer, pass in the
direction of the spine ; or it may penetrate a parti-
cular part of the body and act locally. The clothes are
not unfrequently torn, and buttons, coin, or other me-
tallic substances melted, but occasionally cases are met
with where the clothes are uninjured. Death has some-
times occurred when the thunder-cloud has appeared
to be at a considerable distance. This is accounted for
by supposing it to be a discharge of electricity from the
earth to the cloud, which had become negatively elec-
tric, constituting what is termed the returning stroke.
All discharges of electricity occur in consequence of the
approach of two bodies in opposite states of electrical
excitement. When a substance excited positively is
brought near another in its natural state and insulated,
551
the electric equilibrium of the latter is instantly distur-
bed, the parts nearest to the former become negative,
and the distant ones positive. If the body is not insu-
lated, its electricity passes into the earth, and the whole
becomes negatively electric. If, on the contrary, the
exciting body be negative, it causes the contiguous
parts of a body in its vicinity to become positive.
Hence it is established as a law, that an electrified body
tends to produce in a contiguous substance an electric
state opposite to its own. The electricity developed in
this way is said to be induced, or excited by induction.
The construction of the Leyden phial is upon this prin-
ciple ; when the inside of the jar is rendered positive
by contact with the prime conductor, the outside, if in
communication with the earth, parts with electricity
and becomes negative ; both surfaces are therefore
electrified, but in opposite states; and if a communi-
cation be established between them by a good conduc-
tor, the excess of electricity instantly passes along it,
and both sides of the jar return to their natural condi-
tion. Now when a negatively electric cloud approaches
the earth, all objects in its vicinity are positively exci-
ted ; and when it comes within striking distance,—that
is, so near that the tendency of the electricity to pass
from the positive to the negative body overcomes the
resistance of the intervening portion of air, the equili-
brium is restored with a report and a flash of light,
exactly as in the discharge of the Leyden phial. If a
person is found in an open place or under a tree shortly
after a thunder-storm, with the ordinary appearances
mentioned above, we may attribute his death to light-
ning, and particularly so, if the metallic substances
about him are found melted and his clothes torn or
burnt, while dissection exhibits no other cause of death.
5
5
2
CHAPTER XIX.
THE operation of dividing the os and cervix uteri pro-
posed by Sir James Simpson for the relief of persons
suffering from dysmenorrhoea had not received the
approval of or been adopted by practitioners in Ireland
before I read the following paper at a meeting of the
Surgical Society on the 1st of December, 1855. I had
then recently paid a visit to Edinburgh, and, through
the kindness of Sir James, I had witnessed the per-
formance of the operation several times. On my return
to Dublin it was not long before I encountered the
cases which are detailed in the communication alluded
to, and on them the operation was performed. Other
practitioners have since that time adopted this mode
of treatment, but even yet it has not been as fully
appreciated as I think its merits demand.
Operation for the Cure of Dysmemorrhoea.
It has been for some time well known to the mem-
bers of the medical profession generally, but particu-
larly to those who devote themselves to the study and
treatment of female diseases, that there is a certain de-
rangement of the function of menstruation which pro-
duces an amount of distress seldom exceeded by any to
which human beings are liable. The particular de-
rangement to which I wish to direct attention this even-
ing is dysmenorrhoea, or painful menstruation—an affec-
553
tion which, so far as pain is concerned, is not exceeded by
almost any disease with which I am acquainted. This
disease is distressing in more senses than one. The pain
the patient suffers at the time when nature makes her ac-
customed monthly effort is severe to an intense degree.
I have seen her fall on the ground and writhe in convul-
sions from the excessive severity of the pain. She goes
through this for a time ; she recovers from it, but she
recovers only to look forward to another attack at a
time when she knows it will surely recur; so that she
not only suffers the agony during the attack, but under-
goes a month's mental anxiety in the anticipation of
the same agony over again ; nay more, she has to go
through this suffering for the greater part of her life ;
for, as too often happens, it lasts until that period of
life when this function ceases, or marriage puts an end
to it. The influence of marriage is various. If preg-
nancy occurs after marriage, it almost always cures this
affection, but not always; and if pregnancy does not
follow marriage, the dysmenorrhoea continues, and is
often aggravated so as to be a most distressing accom-
paniment of the woman's life.
The question, then, naturally arises—Why is this
difference found between married women labouring
under this disease ? The explanation is this : we find
dysmenorrhoea existing under different conditions of
the uterus. In some instances we find it where there is
such an extraordinary amount of constriction of the Os
uteri, as not only to produce this disease, but in itself
to constitute a source of sterility. Impregnation seems
in such cases to be impossible, and that being the case,
the woman goes on suffering during the whole of her
menstrual life. In other cases we find dysmenorrhoea
where such constriction does not exist, and these are
554
cases where, I believe, pregnancy occurs after marriage,
and the dysmenorrhoea is cured as the result.
To cure this disease a variety of remedies have been
proposed by writers of all times, and a variety of treat-
ment has been recommended, arising from the different
views of the nature of the disease taken by those writers.
Some suppose it to arise from a peculiar inflammation
of the uterus, which so deranges the natural function as
to produce such extraordinary pain when the menstrual
period has commenced. Others consider it to be of a
neuralgic character, and with that view have recom-
mended medicines calculated to relieve such affections.
The late Dr. Mackintosh of Edinburgh was the first to
direct attention to the mechanical cause of this disease.
He observed the constriction of the os uteri, and he
argued that if he could overcome that constriction, and
thereby give a free discharge from the uterus at the
monthly period, the dysmenorrhoea would be cured.
Accordingly he proposed that mechanical means should
be used in order to dilate the os uteri, with a view to
relieve the constriction. He introduced a series of
bougies, beginning with those of small size and gradu-
ally advancing to those of larger calibre ; and he de-
scribes the result of his treatment as quite satisfactory.
Other practitioners, however, have not found this
treatment as successful as Dr. Mackintosh. I have
often tried it myself, I know that it has been tried by
others, and I am not satisfied that it is at all entitled
to the praise which Dr. Mackintosh has bestowed upon
it. The common bougies we are in the habit of using
were employed, but it was found that they could only
be temporarily applied, and that after remaining a
certain time in the uterus they had to be withdrawn,
and the uterus left free for some hours at least before
555
another application could be made. Under these
circumstances, Dr. Simpson was led to the opinion
that, if we could pass in a bougie which would remain
permanently in the uterus, so as to keep the os per-
manently dilated until a larger one could be put in
its place, the desired result would be accomplished.
Accordingly, he constructed this instrument which I
hold in my hand (a short stem with a bulb at the end),
the object of which was to pass within the cervix uteri,
to remain there, and after a time to be withdrawn, one
of a larger size being introduced in its place, and so
on. Now, there is no doubt that we can dilate the
os uteri by such means to a considerable extent. We
can dilate it also by means of the sponge tent to such a
degree as to permit the finger to pass freely within the
Os, even up to the fundus; but here is the objection to
such a mode of procedure. So soon as you desist from
the dilating process, the os contracts itself again, and
becomes almost as tight an os uteri as if you never
interfered with it. Seeing this result follow the me-
chanical dilatation of the os, Dr. Simpson was led to
advise an operation by which a permanent dilatation
could be effected, and accordingly he some years ago
proposed that incisions should be made in the cervix
uteri. He has performed this operation for some years
in Edinburgh with great success, but I am not aware
that it has been performed in this country; and as I
had an opportunity of operating lately myself on four
individuals, three of them in one week, I thought it
might not be uninteresting to the Society to lay an
account of these cases before them.
The operation which Dr. Simpson performs consists
in the introduction of an instrument within the cervix
uteri, armed with a concealed cutting blade, which can
556
be propelled to any distance, regulated by a screw
in the handle below. Dr. Simpson operates in this
manner: he passes the instrument within the cervix
uteri; he then expands the blade to a certain extent,
and by that means divides the tissues which exist at
the inner extremity of the cervix uteri. The instru-
ment is then turned, and a similar cut is made on the
opposite side, after which the blade is allowed to project
more, and is withdrawn through the os, cutting the
whole tissue of the cervix as it comes out. It is then
turned, and a like incision is made in the opposite side
of the cervix. Dr. Simpson performs this operation
without the aid of a speculum—in fact, in the dark,
and with no other guide except a forefinger introduced
into the vagina. The remarkable dexterity which he
has acquired enables him to perform this operation
with great ease, and it seemed to me that it gave him
very little trouble to do it; but it occurred to me that
when you cut into the cervix uteri in the dark, you
cannot tell but the blade may go farther than you
intend, and perhaps wound the vagina in coming out.
I think the operation can be performed more safely
through the speculum, for then you are able to see
very well what you are doing. The speculum in my
hand is the latest improved kind which has been made
in Edinburgh. It is an improvement on the old three-
valve speculum, the handles being now made so as to
fold up, the length of the instrument being shortened
by nearly an inch, the screw being done away with
altogether, and its place and purpose supplied by a
common spud on the side of the outer blade, upon
which the inner blade locks. With this instrument
you obtain an excellent view of the uterus, and when
not in use it is easily carried in your pocket. Having
557
introduced this speculum, you can easily get the
cutting instrument into the uterus, and having done
so, you can incise as much as you think necessary with
perfect safety, cutting through the tissue of the cervix
uteri on both sides. -
Persons have asked, What is the object of making a
simple incised wound, which will heal by the first
intention ? Now, the fact is, the two sides of the
wound, when the operation is done rightly, divaricate,
and as it were refuse to unite. If you pass your finger
up, you will find that the two lips of the wound gape
widely. It has been recommended to touch the wound
with caustic to prevent union, but it will hardly be
found necessary to do so. The bleeding in these cases
is not so great as some persons would suppose, if the
operation be conducted in a cautious manner. The
danger of bleeding is from the internal portion of the
cervix—the part in connexion with the immediate body
of the uterus, where it is surrounded by a plexus of
veins—but the incision there should be of very slight
extent. A plug of lint may be introduced after the
operation.
CASE I.—Mrs. A., aged forty-two, of a large full
habit, had been married seventeen years, and had
never been pregnant. She had suffered from dys-
menorrhoea in a very severe form all her menstrual
life. The menstrual periods were regularly every
four weeks; the quantity was always scanty, and the
pain most severe.
This lady had been under medical treatment for
many years, and some years ago had been subjected to
the process of dilatation of the cervix uteri, by means
of bougies and tents, which gave her very great pain,
and left her as much afflicted as ever. I found the os
p
558
uteri very small and round, permitting a bougie (No.
8) to pass with difficulty.
October 20th, 1855 : I performed the operation of
dividing the os and cervix uteri in the following
manner: The patient being placed on her left side,
with the hips well over the edge of the bed and towards
the window, I passed a large three-bladed speculum,
and displayed the cervix of the uterus. Having passed
a bougie through it, to ascertain the direction of its
canal, and finding it to be in the axis of the speculum,
I passed the point of Simpson's hysterotome through
its whole length ; and then, having regulated the screw
so as to allow the cutting blade to project slightly, I
caused that part to leave its concealment by approxi-
mating the handles. By this proceeding, the opening
of the cervix into the body of the uterus was incised
on one side, and the constriction at that part was
relieved. The blade being allowed to withdraw within
its sheath, the instrument was turned, and a similar
incision was made on the opposite side. Care was
taken not to carry the cutting-blade too deeply into
the tissues of the uterus in this stage of the operation.
The screw was now turned so as to allow of a greater
divarication of the blade, and the whole instrument was
withdrawn, keeping the sharp edge pressed against one
side of the cervix as it came out, and deepening the
cut as it approached the os, taking care that at that
part the whole substance of the organ should be
divided. This done, the instrument was turned and
again passed into the uterus, when a similar proceeding
produced an incision of the other side resembling the
former one. Little bleeding supervened. A plug of
lint was passed through the speculum down to the os,
and the speculum was withdrawn.
559
21st : She had suffered no pain, and had slept well.
I removed the plug, and found the wound gaping and
not inclined to close. She dressed herself and went
down stairs in the evening.
22nd : Went out in a carriage without feeling any
discomfort.
23rd and 25th : On both these days I touched the
angles of the wound with caustic to prevent any inclina-
tion to closing.
27th : She left town this day.
November 30th : I heard from this lady to-day.
She has had no return of the menstrual function since
the operation.
CASE II.-Mrs. B., aged twenty, a year and a half
married, and no pregnancy. She had suffered from
dysmenorrhoea for many years, and had become worse
lately. I found the os uteri in this lady so small that
No. 7 bougie would not pass. I introduced a very
small sponge-tent, made after the manner recommended
by Dr. Simpson, and allowed it to remain for twenty-
four hours, and then withdrew it and introduced one a
little larger. These had the effect of dilating the cervix
uteri, so that the end of the cutting instrument could
be easily introduced.
October 19th, 1855 : I operated this day as in the
former case, and introduced a plug of lint. There was
little bleeding at the time, but having got up in the
course of the day, and gone into an adjoining room,
she was alarmed by finding a good deal of blood escap-
ing, and sent for me. I found her in bed, the bleeding
had ceased, and I only increased the size of the plug,
and left her. Next day, found she had slept well. I
removed the plug, and found the wound gaping.
On the 23rd and 25th I touched the angles of the
560
wound with caustic, and on the 26th she left town. I
have not heard anything of this lady since. A sister
of this patient was with her during my attendance,
and told me she had been operated on by Dr. Simpson
some years before for the same complaint, and with
complete success.
CASE III.-Mrs. C., aged twenty-two. This lady,
who had been three years married, had suffered se-
verely from dysmenorrhoea ever since the function had
commenced, and had never been pregnant. The os
uteri was very small, scarcely admitting a No. 8 bougie.
I operated on the 19th of October, and took my leave
on the 25th, having applied caustic twice to the wound.
November 12th : This lady came to my house, bring-
ing a friend with her for advice. She said she had
done so in consequence of the great relief she had re-
ceived from my treatment, as she had menstruated the
week before with perfect ease, and without any pain
whatever.
CASE IV.—Mrs. D., aged twenty, married two years.
This lady described her sufferings at the menstrual
periods as being most intense, and said she had been
so afflicted since the time when her monthly illness
first appeared. She had never been pregnant, and
the pain had become more severe lately. I found the
os uteri small, as in the preceding cases. As she was
near the menstrual period, I postponed the operation
till it was over, and on the 9th of November I divided
the os and cervix uteri. The same course was pursued
as in the other cases, and at my last visit, which was
on the 15th, I found the wound open and admitting the
point of the forefinger to sink into it. There has not
been time to judge of the effects of the operation in
this case as yet.
561
Since the preceding paper was written I have con-
tinued to perform the same operation in similar cases,
and with very constant success. Every year patients
have presented themselves with whom I have thought
it necessary to adopt this proceeding, and I have never
hesitated to have recourse to it. Out of thirty cases
in which I have operated I have never but once found
any unpleasant result. The case to which I allude was
that of a lady, the wife of an officer. She was thirty-
five years of age, and had no children, though fifteen
years married. She had suffered severely from painful
menstruation since puberty, but was otherwise healthy.
The operation was performed in the usual manner, and
all went on well until the fifth day, when I touched the
surfaces with solid nitrate of silver. On the evening of
that day she had very profuse haemorrhage, for which
I plugged the vagina ; and on the next morning, on re-
moving the plug and introducing the speculum, I found
the entire of the cut surfaces in a state of dark, angry-
looking, unhealthy ulceration, from which blood flowed
freely. I threw in a pint of strong alum wash with
a vagina syringe, then brushed the ulcerated parts
with a dilute lotion of perchloride of iron, and again
plugged the vagina. I ordered five grains of gallic acid,
one grain of sulphate of quinine, and five drops of di-
lute sulphuric acid in a draught to be taken every third
hour. The haemorrhage, though checked for a while,
returned with great violence from time to time during
four days. Each day I renewed the plug, dressing
the sore, and at last the ulcer assumed a more healthy
aspect, the bleeding ceased, the healing process went
forward, and the patient recovered.
In some of the cases pregnancy occurred soon after
the operation. In one of those which was treated in
36
562
the early part of the present year, this has taken place,
and the lady is now in the seventh month. Hers was
one of the worst cases of dysmenorrhoea I ever met
with. She was two years married, the os uteri would
scarcely admit a probe to pass, and the agony she suf.
fered at the menstrual period was frightful to witness.
In performing the operation I still continue to use
the large three-bladed speculum, and Sir James Simp-
son's hysterotome, taking care that the outer portion
of the cervix and the os externum shall be completely
split open. If this be done, there is little chance of
the wound reuniting. As a measure of precaution I
lay a small roll of lint transversely between the cut
surfaces, and then pass up through the speculum a
ball of French wadding about the size of an orange,
pressing it with a rod firmly against the uterus, while
the speculum is withdrawn, leaving the ball in the
upper part of the vagina. This is also withdrawn on
the following day, and fresh lint and wadding are intro-
duced. I repeat the dressing three or four days in
succession, and then do nothing but syringe out the
vagina with a weak alum wash for a few days more.
Having found the one-bladed hysterotome of Sir
James Simpson most effective and satisfactory, I have
not abandoned it for the modification suggested by
Dr. Greenhalgh, in which two blades are made to cut
opposite sides at the same time; neither have I adopted
the scissors with which Dr. Marion Sims and Dr.
Barnes recommend the operation to be performed. I
do not deny the merits of these modern instruments,
and am quite sure that in the hands of their able
inventors the operation is most satisfactorily performed
by them ; I only desire to state that in my experi-
ence I have found no reason to find fault with or to
discard an old, long-tried, and useful servant.
563
CHAPTER XX.
Plastic Operations on the Female Genito-Urinary
Organs.
[Read before the Surgical Society, March 9, 1861.]
THE subject of plastic operations with metallic sutures
has occupied so much attention during the last few
years, that I am induced to hope the following cases
may not be uninteresting. There is no doubt that the
revival of the use of metallic sutures by Marion Sims
was a very great boon to surgery; and although we
may not be disposed to go the whole length with him
when he states,” “I declare it as my honest and heart-
“felt conviction, that the use of silver as a suture is
“ the great surgical achievement of the nineteenth cen-
“tury,” we must acknowledge that to him and Dr.
Bozeman we are indebted for vast improvements in
the treatment of cases which were formerly considered
hopeless.
Although, as Dr. Simpson has shown, these very
eminent operators have been forestalled by Mr. Gosset,
who, in The Lancet of November 29th, 1834, describes
a case of vesico-vaginal fistula cured by him by
means of “gilt-wire suture,” and the steps of whose
operation bear a very striking resemblance to that of
the American surgeons, still we must award the merit
of working out and perfecting the process to the latter;
* Anniversary Discourse, New York, 1858.
36*
564
just as the credit of the discovery of the Atomic
theory in chemistry is awarded to Dalton, because he
laboured hard, and with great skill and patience worked
out that theory, which did not originate with him, but
was notoriously first promulgated by Higgins, then
Professor of Chemistry in the Royal Dublin Society.
In noticing the operations for vesico-vaginal fistula, we
should not forget that to Mr. M. Collis of this city
we are indebted for the first impetus given to them
in this country.
His paper on the subject, read before the Obstetrical
Society in May, 1856, and published in the Dublin
Quarterly Journal, details an operation differing from
those that preceded it, in the proposal to split the edge
of the fistula all round, instead of cutting off a portion
of it, and then bringing the split edges together by
means of quill-sutures. Mr. Collis kindly submitted to
my inspection the first operation performed by him in
this manner, and I found the orifice quite closed. I
am inclined to think that his proposal to split the edge,
instead of paring away tissue, might and ought to be
adopted in cases where the opening is very large, and
saving of substance is of importance. In most cases
the tissue is sufficiently thick to afford of this being
easily done; and when it is, there is less strain on the
ligatures, of whatever material composed.
It will be seen that, in the following cases, some of
the operations differed from those proposed by either
Dr. Sims or Mr. Bozeman, and partook more of the mo-
difications suggested and practised by Dr. Simpson, to
whose lecture, illustrated by woodcuts representing the
different instruments employed, we are all so much in-
debted for accurate and useful directions. In one of
them the operation contrived by Dr. Battey of Georgia,
565
U. S., was for the first and I believe the only time per-
formed in this country.
CASE I.—M. R. was sent up to me by Dr. Mackesy
from Waterford, in the hope that some relief might be
obtained from her present lamentable condition. She
is a nice interesting person, twenty-six years of age,
and two years married. She was confined on the 18th
of January, 1859, of her first child. The labour was
very severe, lasted twenty-four hours, and was termi-
nated by the assistance of the forceps. During the
operation the perinaeum gave way, and the rent ex-
tended through the sphincter ani. She was confined to
bed for three weeks, and recovered slowly. It is now
five weeks since her delivery, and she complains that
she cannot retain the contents of the bowels when at
all liquid. If they are solid, she can pass them volun-
tarily, but otherwise they escape without her knowledge.
Flatus is, in like manner, unconsciously passed. She
is still nursing her infant. She entered the private
ward of the City of Dublin Hospital under my care.
To ascertain the extent of the ulceration, I placed her
on her back on a high table, with the legs bent, and
the feet resting on the table in the lithotomy position.
I then introduced Mr. Sims' duck-billed speculum into
the vagina ; and having it well held up towards the
pubes, I got a full view of the back of the vagina and
the torn perinaeum. I now found that, in addition to
the perinaeum and anus, the rectum was split up for
about an inch and a half. The edges of the rent were
quite healed ; and the corners of the lower part, near
the verge of the anus, were rounded off just like the
corners of a hare-lip. From the nature and extent of
this injury it was plain that two operations must be
performed ; the first with a view to close the rent in
566
the rectum and sphincter ani, and the second, at a
future time, to restore the perinaeum. As it was of
great importance to have the bowels in a quiescent state
during the progress of the cure after the operation, I
had them well emptied by medicine, and the rectum
well washed out by injections, for three days previous-
ly ; and the day before the operation a quarter of a
grain of opium was given every fourth hour, to secure
torpidity of the intestinal canal. Having made these
preparations, I proceeded to operate on the 18th of
March, 1859, in presence of Mr. Tufnell, Dr. Churchill,
and Mr. Croly, house-surgeon to the hospital. The
patient was placed on her back as already described,
on a high table near the window, with a good light
shining into the vagina, now well displayed by the
speculum already mentioned, which was held up by
Mr. Croly. The first step in the operation was to pare
the edges of the rent in the rectum. This was effected
by sticking a hook into the lowest point of the torn
sphincter at one side, and with a knife cutting off the
edge from the bifurcation above down to the point,
just as in the operation for hare-lip. This was repeated
on the opposite side, leaving a A-shaped cut into the
recto-vaginal septum an inch and a half long. The
edges were now brought together by means of iron-
wire sutures passed in the following manner. A
good-sized curved needle, holding in its eye a piece of
iron-wire about six inches long, was firmly grasped at
a right angle, near to the eye, by a strong porte-
aiguille, which was kept tightly closed on the needle
by a slide run up on the blades. The point of the
needle was then struck into the lining membrane of
the vagina, close to the upper angle of the wound on
its left side, at a distance of a quarter of an inch from
567
the cut edge, and driven through the tissue between the
rectum and vagina until the point appeared through
the cut edge. The needle was urged across the gaping
wound until it was made to enter the opposite cut edge,
at a point corresponding to that from which it emerged
in the other; and being forced through the submucous
tissue as before, the point was brought out at a quarter
of an inch from the edge. When sufficient of the
needle was passed through, it was caught by a strong
forceps, and the slide on the porte-aiguille being re-
tracted, the needle was cast loose on the side where it
had first entered, and was pulled out on the right side
of the cut, carrying the iron-wire with it. This was
now cut off with a pair of scissors near the eye of the
needle, and so the first ligature was passed. In a simi-
lar way four other iron ligatures were made to tra.
verse the gap in the septum, the last being through the
edge of the anus. A thin leaden plate, an inch and a
half long and half an inch broad, with five holes pierced
down the centre, was now prepared ; and through the
holes the ends of the wires were passed, beginning at
the upper end, and so on to the last. The shield was
then pressed down to the wound, while the ends of the
ligatures were held on stretch in the left hand. This
had the effect of drawing the cut edges into close ap-
position ; and to secure them in that position, perfo-
rated shot were slid down over the ends of each pair
of wires; and the shot, seized in a strong pair of for-
ceps, was firmly forced down on the shield; and while
the wires were drawn tight, the shot was strongly
compressed, so as to hold the wires securely fixed.
This having been done for the five sutures, the ends of
the wire were cut off near to the shot, and the ends of
the cut wires were bent down on the shield. The
568
operation being thus accomplished, the patient was put
into bed, and a quarter of a grain of opium was given
every third hour. Directions were given to have the
bladder emptied by the catheter three or four times in
twenty-four hours, so as to prevent the possibility of
the urine coming in contact with the wound. This
was strictly attended to by Mr. Croly, who watched
the case with the most laudable care. No unfavour-
able symptom occurred until the 24th, the sixth day
after the operation, when a pretty smart hamorrhage
from the vagina took place, which lasted only a quarter
of an hour, and was stopped by injecting cold water
into the passage. On the 26th, the eighth day, the
ligatures were removed in the following manner.
The patient was placed in the same position as on the
day of the operation ; and the same speculum having
been introduced into the vagina, the shield and lead
buttons of shot were exposed. With a long pair of
sharp-pointed scissors the wires were successively cut
across close to the shield, beginning at the outer one ;
and all the shot being thus removed, the shield came
away, leaving a perfectly healed cicatrix, with a surface
and edges as smooth as if it had been pressed with a
hot iron. An injection of warm water was now thrown
into the rectum to soften the faeces, and the bowels
were slowly relieved without any laceration of the
newly-united parts. This constituted the first part of
the operation. It was most successful in its results.
The patient regained complete control over the bowels,
and nothing escaped without her consent. She re-
mained in hospital for ten days afterwards, when I
advised her removal for a short time to the country,
previous to any further operative proceeding. She re-
turned on the 27th of April, and on examination I
569
found the parts perfectly sound and solid; and so
much contraction had taken place, that the gap in the
perinaeum did not appear nearly so large as formerly,
and it was quite manifest that a smaller amount of
closure would be necessary than was expected. On
the 2nd of May I proceeded to finish the operation.
This was done by paring about three-quarters of an
inch of the edges of the torn perinaeum from the anus
forwards, and then uniting the cut edges by means of
three iron-wire sutures, without a button. The ends of
the wires were simply twisted together, and cut off
about a quarter of an inch from the wound. The same
precaution with respect to the urine was observed as
in the former operation. It was drawn off with the
catheter every six hours, and the bowels were kept
quiet by opium. On the eighth day the sutures were
removed, by clipping one side of the noose with a fine-
pointed scissors, and drawing the wire through. The
wound was found to be perfectly healed, and the
patient left the hospital on the 6th of June, a much
happier woman than she had entered it.
CASE II.—On the 28th of May, 1859, I was requested
by Mr. Banon to see Mrs. H., who had come up to town
from Limerick for advice, in consequence of inconti-
nence of urine since her confinement. This had taken
place on the 3rd of the month. Her labour was of her
first child, twenty-four hours in duration, and very
severe. No instruments were used in the delivery.
She suffered a great deal of soreness afterwards; and
on the sixth day the urine began to come from the
vagina, and had continued to do so ever since. On ex-
amination we found a large opening into the bladder
from the vagina, of a size sufficient to permit a walnut
to pass through ; the edges of the opening were thick
570
and fleshy, and in some places granular ; the whole
mucous membrane of the vagina was inflamed and raw.
I expressed an opinion that it was a very favourable
case for operation, and at Mr. Banon's desire I under-
took the case. On the 31st of the month I proceeded
to operate, in presence of Mr. Banon, Dr. Churchill,
and Mr. M. Collis. The patient was placed leaning
over the edge of a low bed, with her chest supported
by pillows, and the buttocks turned towards a window,
through which a good light came. The duck-billed
speculum of Sims was introduced into the vagina; and
being well held up, the aperture in the vagina was
brought fully into view. The edges were well pared
all round. Considerable bleeding took place from the
very vascular tissues; this was arrested by tincture of
matico, and then five stitches were put in by means of
the tubular needle, made by Mr. Young, the eminent
cutler in Edinburgh. This needle was first described
by Dr. Simpson, and it is figured in his lecture on
vesico-vaginal fistula, in the Medical Times and Gazette
for January, 1859. It is a most perfect instrument,
does its work in superior style, and is easily managed.
In the operation for vesico-vaginal fistula, the wound
being made to close in a transverse direction, the
stitches are introduced from before backwards, as the
patient lies before us, and the tubular needle enables
us to do that with the greatest ease. The wire, cut to
the length required, is introduced into the tube, and
pushed forward until the end of the wire appears at
the point of the needle. It is then withdrawn until
the end just disappears within the tube; and having
dipped the needle in oil, the point is driven into the
membrane lining the vagina, half an inch from the cut
surface; and being passed between the bladder and
571
vagina, taking care not to penetrate the former, it is
carried out through the raw edge, and then being
pushed on, it is made to pierce the far side of the fresh-
ly-pared border of the aperture ; and being passed as
before between the vagina and bladder, it is made to
emerge through the wall of the vagina, at half an inch
on the other side of the opening. When the point of
the needle is seen well above the soft parts, the wire is
steadily pushed forwards in the tube, and emerges from
the point of the needle. The extremity of the wire is
then seized with a long forceps, and pulled well down-
wards, while the needle is withdrawn over the wire,
which it leaves thus safely lodged in its proper position.
In this case five stitches were found to be necessary.
They were fastened over a leaden shield or button,
differing from Bozeman's in this particular, that while
his button has but one row of holes down the middle,
through which the wires are brought (two through
each hole), the button I used had two rows of holes
parallel to each other, or rather five pairs of holes in-
stead of five single holes, as originally described by Dr.
Simpson in the lecture already referred to. The object
of this was to get rid of the perforated shot as a means
of closing the stitches, and to close the wound by twist-
ing the wires after they were brought through the
double holes. The twister originally designed by Dr.
Coghill, consisting of an iron rod five inches long, with
two very short tubes a quarter of an inch long at-
tached on either side of its extremity, through which
the wires were passed, served to secure the stitches.
The wires, being passed through the tubes, or rather
holes, in the bulb at the extremity of the rod, were held
firmly in the left hand; and the instrument, pushed
down to the leaden button, was twisted three or four
572
times, making a close and regular cord of the wires.
It was gradually withdrawn as the twisting motion was
given, and finally withdrawn over the wires; these
were cut off within a quarter of an inch of the plate,
and the other pairs of wires were treated in the same
way until the whole were secured. The cut ends were
then folded down over the plate ; a short gum-elastic
catheter, with an Indian-rubber bag attached to it, was
secured in the urethra ; the bag had a stop-cock at its
other free side, to allow of its being emptied. The pa-
tient was placed in bed, lying on her face; a grain of
opium was given, and she was ordered a quarter of a
grain to be taken every third hour. A good nurse was
put in charge, and Mr. Banon and myself visited her
every morning and evening. On our visit the second
morning we were startled by hearing that the catheter
had slipped out in the night, and that she had passed
water by the urethra; no urine came through the
vagina. The instrument was now firmly secured, and
was removed every day and washed. No untoward
occurrence took place afterwards. On the eighth day
I removed the stitches, by placing her in the same posi-
tion as during the operation, and displaying the appara-
tus by means of the same speculum. The stitches were
removed by cutting one side of the loop with a sharp-
pointed scissors, and drawing out the wire by a forceps.
On the removal of the plate we were gratified to find
the whole wound perfectly healed, the cicatrix present-
ing a uniform smooth surface, as if it had been pressed
with a hot smoothing-iron. The catheter was kept in
for two days more, the opium was stopped, and the
bowels were freed. After this she was allowed to get
up ; the urine came naturally by the urethra, and in a
few days more she returned home. I have lately heard
573
that this patient has since been safely delivered of a
living child, and that she suffered no inconvenience of
any kind during or subsequent to her labour.
CASE III.-Mary Nolan, aged twenty-three years,
after her first labour, which was very long and difficult,
suffered great soreness of the vagina for some days, and
then found a sudden burst of urine through that pas-
sage, which has continued to come in that way ever
since. Her thighs and buttocks are excoriated. On
examination in the position already described, a very
frightful destruction of parts was discovered ; in fact,
the whole front of the vagina was gone, and one looked
through the chasm into the cavity of the bladder. The
gap extended from the vesical end of the urethra up to
the cervix uteri, and to an equal distance transversely.
It was nearly square, and measured two inches in every
direction. The patient suffered severely from inversion
of the bladder, which constantly took place when she
stood up or walked; hence she was obliged to preserve
the recumbent posture. Notwithstanding the unpro-
mising nature of this case, I was unwilling to allow the
sufferer to lose the chance of some relief, and I deter-
mined to make an effort to close this formidable breach.
It happened that Dr. Battey of Georgia, U. S., was in
Dublin just at this time. He had designed and ex-
hibited to me a modification of the operation of Sims
and Bozeman, particularly calculated for this case, and
I requested him to visit the patient with me in the
hospital. We agreed to try his operation, which I per-
formed a few days after, along with my colleagues in
the hospital and some other friends, in presence of Mr.
Pirrie, the eminent professor of Aberdeen, and author
of the great work on surgery, who was on a professional
visit to this city at that time. The earlier steps of
574
the operation were the same as those described ; the
paring of the edges of the opening, and the passing of
the wires were the same. The great extent of the
aperture made it necessary to place nine sutures in situ.
All this was done, and now came the difficulty of clos-
ing such an enormous gap ; and at this stage Dr.
Battey's contrivance came to my aid. A bar of thin
lead two inches long and one-eighth of an inch wide,
perforated with nine holes to correspond with the nine
sutures, was prepared. Instead of the second row of
holes, as used in the plate in the last operation, nine
notches were made in the edge of the plate, correspond-
ing with the nine holes. Through each of the holes
was now passed one of the distal ends of the wires, and
perforated shot was run down upon each of the wires
and closed on it by compression with a strong forceps.
When all the nine wires were thus secured, the proxi-
mal ends which hung out through the anterior edge of
the opening were grasped in the left hand and pulled
strongly downwards, thus drawing the leaden bar into
close contact with the distal side of the opening. The
traction was continued and increased, and by degrees
the upper edge was made to approximate the lower.
This occupied a considerable time, and was much as-
sisted by placing the end of a thin flat piece of wood,
like a flat ruler, under the proximal wires, and pressing
the end firmly upwards against the part perforated by
the wires, while the leaden bar and the parts against
which it was lodged were drawn down. By this means
the raw edges were finally made to touch. The next
point was to secure them in that position. This was
done by turning up each wire in succession, and lodg-
ing it in the notch in the edge of the bar above de-
scribed; and when safely lodged there, the edge of the
575
bar was strongly compressed behind it by the point of
a strong forceps, thus fixing the wire securely in its
place, the distal end already secured by the perforated
shot, and the proximal end now firmly fastened in the
corresponding notch. In this way the nine sutures were
fastened. The ends of the wires were now, for further
security, twisted by the twister. Some idea of the
great difficulty of this operation may be formed from
the fact that three hours and a half were occupied in
its performance. The catheter was introduced and
secured as usual, and opium was given as already de-
scribed. My expectation of success, small at first, was
diminished on the fourth day, when urine was found
trickling from the vagina. At the end of eight days
the apparatus was removed ; the wound was found
apparently closed on the right side for a short way;
but the strain had been too great on the left, and the
wires had cut through the soft parts, leaving a large
part united. I confess I was not disappointed at the
failure in this operation. It was almost impossible to
hope for a closure in such an enormous gap at the first
trial. The patient remained for some time in hospital,
and then went home to the country. She promised to
return ; and I intend on some future occasion to try
another operation.
Prolapse of the uterus, when complete, is well known
to cause very great inconvenience to the sufferer, and a
variety of means have been proposed for its permanent
relief. Excision of portions of the mucous membrane,
and destruction of parts of the prolapsed surface by the
application of strong nitric acid, &c. have been had re-
course to. The latter has been attended with great
success in many cases in which I have employed it, but
the cure is spread over a very long time, owing to the
576
number of applications that are necessary, and patients
get tired of waiting through the long process and the
numerous operations. The pessary is only a palliative,
and requires looking after and arranging from time to
time. The most effectual and speedy remedy for this
displacement is that proposed by Mr. Baker Brown,
consisting in a permanent closure of the vulva. Two
cases were thus treated by me in the City of Dublin
Hospital with complete success.
CASE IV.-Mary Kelly, aged sixty-five years, was
admitted on account of a very large prolapse of the
uterus, with which she had been afflicted for many
years. She was the mother of several children, and
the prolapse commenced after the birth of the last child,
twenty years ago. It had lately increased very much.
It was permanently down, not returning when she as-
sumed the horizontal position. The surface was dry
aud covered with cuticle, except near the lower part,
where some spots of ulceration existed, owing to the
trickling of urine over it, and the friction to which it
was subjected in walking. As she was a widow, past
child-bearing, I considered this a suitable case for the
operation of closing the vulva. The woman was kept
in bed for some days, and the prolapsed parts were re-
turned within the vagina, for the purpose of accus-
toming them to their natural but now unusual posi-
tion. The operation was performed in the following
manner. The woman was placed on a high table in the
lithotomy position, and securely held there close to
a window, through which light fell freely on the vulva.
I made an incision in the mucous membrane of the
labia majora, near the line where it joins the common
integument. This incision commenced on the right
577
side, nearly on a line with the orifice of the urethra,
was carried all down that side to the fourchette, and up
the opposite side to a point corresponding with that
from which the incision started. A similar incision,
parallel to the last, was made all round at one-fourth of
an inch within the vagina. When this was completed,
the strip of mucous membrane between the two inci-
sions was carefully dissected off, leaving a raw surface
one-fourth of an inch broad, all round the vulva.
Double iron-wires were now passed from side to side by
means of needles driven through the common integu-
ment, one-fourth of an inch from the cut edge, then
through the middle of the raw surface, then across the
vulva and through the opposite raw surface, and so out
through the integument at a distance from the cut
edge similar to that where it had entered. Four of
these double wires were thus passed through, and the
wound was closed by laying a piece of bougie of proper
length along the right side, first between the wires as
they emerged from the skin, and making four loops
round it by twisting the ends of the four pairs of wires
together, and a similar piece of bougie was laid along
the left side between the wires; and the edges of the
wound being strongly drawn together by pulling the
wires, they were twisted together on that side also. A
firm quilled suture was thus effected. In order to make
the junction of the edges of the integument as complete
as possible, three fine iron-wire stitches were made
through the skin in the intervals between the deeper
sutures. Opium was ordered as in the former cases;
and in order to prevent the contact of urine with the
cut edges, the catheter was passed every six hours. On
the eighth day I removed the sutures, and was gratified
37
578
to find the vulva closed by a firm cicatrix, leaving a
small aperture at the upper part corresponding to the
orifice of the urethra.
CASE W.—R. Byrne, aged sixty, was admitted into the
City of Dublin Hospital, with a very large prolapse
of the uterus, which had been down for many years.
After preparing her for treatment as had been done
in the former case, the operation as just described
was performed. The same after-treatment was pur-
sued; and, at the end of eight days a similar happy
result was obtained.
This is an operation that, I think, is only applicable
to old women. I am aware that Mr. Baker Brown
proposes to treat younger and married women by an
operation similar to that just described, but of less
extent—closing, in fact, only the posterior portion
of the vulva. I am afraid such a partial closure would
not prevent the escape of enclosed prolapsed viscera ;
but that, bit by bit, and by degrees, the bulk above
would insinuate itself into the aperture, and finally
escape from the pelvis as before.
CASE WI.—In October, 1860, I was requested by Mr.
Banon to visit a patient under his care in Jervis-street
Hospital. I found her labouring under the distress
caused by vesico-vaginal fistula; and thinking it a very
favourable case for operation, I placed myself and my
instruments at his disposal whenever he thought fit
to operate. This he did on the 15th of the month,
and he has lately favoured me with the following letter
respecting the case :—
Mountjoy-square, February 21st, 1861.
“My dear Doctor, I send you the particulars of the
“case of Catherine Ormond, on whom I operated on
579
“ the 15th of October, 1860, for vesico-vaginal fistula,
“assisted by you ; and request you will have the kind-
“ness to read them, when bringing the subject forward
“at the Surgical Society. I take this opportunity of
“telling you that I had a few days ago a letter from
“Dr. Riordan, of Bruff, informing me that our former
“ patient, Mrs. Hayes,” on whom you so successfully
“operated on the 31st of May, 1859, has recently been
“safely delivered of a full-grown child, without any
“injury whatever to the cicatrix of the fistula.
“I am very truly yours,
“A. BANON.
“Catherine Ormond, aged nineteen, was sent up to
“me by Dr. Seward of Caherconlish, and admitted to
“Jervis-street Hospital on the 29th of September, 1860.
“She states that three months previously she was
“delivered of her first child, after a very severe and
“ tedious labour, lasting three days; but she made
“apparently a good recovery, and found nothing wrong
“in passing water for nearly four weeks subsequently,
“when she lost all power of retaining it; and it conti-
“nued to trickle through the vagina ever since, keeping
“her in a constant state of irritation and misery. On
“examination, an oval fissure nearly an inch in length,
“extending obliquely from left to right, was seen
“occupying the vesico-vaginal septum at its lower part,
“and having a portion of the mucous membrane of the
“bladder protruding through it. On the 15th of
“October, the bowels having been previously emptied
“by a purgative enema, I proceeded to operate, assisted
“by Dr. Beatty, and in presence of my colleagues in
“the hospital. First paring the edges, which I suc-
* This was the patient of case No. II.
37%
580
“ceeded in doing by removing a complete ring of the
“circumference of the fistula without a break, five
“iron-wire sutures were introduced, and secured, in the
“manner described by Dr. Beatty, on the leaden plate.
“The patient was kept lying on her face for ten days.
“A No. 10 male catheter, fixed in the bladder by tapes,
“ and daily changed, conveyed the urine by drops into
“a vessel suitably placed, so that no accumulation of
“this fluid could take place in the bladder. Occasional
“doses of opium were given, and the bowels fortunately
“did not act during the whole period. The vagina
“was daily syringed with tepid water. On the eighth
“day, the sutures and plate were removed, when the
“fistula presented a smooth appearance, and looked
“quite healed. On the tenth day the catheter was
“removed, and the woman was allowed to get up.
“From this time she experienced no inconvenience
“whatever; and left the hospital shortly afterwards,
“quite well, the fistula presenting an appearance of
“firm union. She was recommended separation from
“her husband for some months. She has recently
“Written to me, expressing her gratitude for her cure.”
581
CHAPTER XXI.
An Address delivered to the Dublin Obstetrical Society
at the opening of the seventh session.
[November 29th, 1844.]
IT augurs badly for any performance when it is intro-
duced with an apology; and an audience is very apt
to listen with indifference, if not with impatience, to
an address, when the author commences by throwing
himself on their mercy, and claiming their indulgence
for the many imperfections with which he knows it is
chargeable.
The present is, I regret to say, one of those un-
fortunate occasions; unfortunate for you, who have
come expecting (and, from your experience of former
addresses from this chair, justly expecting), to hear
matter calculated to inform, elevate, and gratify the
mind; and unfortunate for myself, anxious as I am
to fulfil your expectations, yet knowing that they must
suffer disappointment at my hands. The fault, how-
ever, is not wholly mine ; the shortness of the time
which has elapsed since the committee did me the
honour to request I would deliver the opening Address
to the Society, must be my excuse ; and at the same
time it must be remembered, that to me the most
hurried and important month in the whole year is the
present month of November, in which I have had to
prepare for and commence two courses of lectures.
582
For these reasons I have had not many leisure hours
to devote to the preparation of the task which your
kindness has imposed upon me.
Honoured as I have been, by being appointed a
vice-president of this society, I felt bound, however,
to undertake at all risks the duty required of me; and
I was the more induced to do so by the consideration
that if I refused, on the plea of short notice, time must
be consumed in obtaining another to fill my place, who
would then be in a worse position than myself, and
would have better grounds of complaint that he had
not sufficient notice for preparation. I have accord-
ingly thrown together a few hurried observations, and
will trust to the kind indulgence so often experienced
at your hands while I proceed to lay them before
you. -
Under any circumstances it must now be a difficult
task to compose a suitable address at the opening of
the Dublin Obstetrical Society. From the nature of
the Society, the field over which the author can travel
in search of novel or interesting matter is necessarily
limited, and the number of able and skilful gleaners
who have already gone over the ground have left but
a few stray grains to be picked up by those who have
to follow in their wake. Many of my hearers have
been annually delighted with the able and scientific
addresses delivered by my predecessors from this chair;
and most of us have a lively recollection of that
learned, eloquent, and chaste composition with which
we were favoured, at the opening of the last session, by
Professor Montgomery.
To address a Society not limited, as ours is, to one
branch of medicine, would not be so difficult a task.
He who undertakes to open a general medical society,
583
with all its wide-spreading branches before him, can
be at no loss to find plenty of fruit ready to be
gathered, and suitable to form a cornucopia of in-
struction and entertainment. But when, instead of
many branches, he has but one presented to his view,
as is the case in our Society, and finds, moreover, that
the many refined epicures who have preceded him
have picked the choicest and richest fruit, he despairs
of collecting sufficient of the refuse to form a present-
able feast.
But fortunately, gentlemen, our Society does not
now stand in need of any forcible or eloquent argu-
ments to explain its objects or stimulate you to its
support. It has been in active operation for a period
of six years, and in all my experience of associations
for scientific purposes, I have known none that came so
rapidly into steady and useful work, none that have
been so well and uninterruptedly carried on, and none
that have been more distinguished for the value and
importance of the communications made to it, as well
as for the harmony and good temper with which all its
proceedings have been marked. There have been and
still are persons who doubt the utility of societies
formed for scientific purposes, and maintain that the
united efforts of men of letters have produced little in
academies. The names and works of great philoso-
phers who have laboured in private, sometimes almost
in secret, until their researches and theories have
reached maturity, and come forth in all their strength
upon an astonished world, have been paraded as proofs
that there is no necessity for such combinations in
order to produce great results; and it has been said
that no man likes to bestow his great labours on a
small community, for whose members he himself pro-
584
bably does not feel the most flattering partiality. Wol-
taire confesses that the great luminaries of the literary
republic were formed without the aid of academies;
and the opponents to such societies may urge, and with
La Bruyère on their side, that no academy generates a
single man of genius. No Milton, no Hume, no Adam
Smith will spring out of an academical community,
however they may partake of one common labour.
But such arguments prove nothing in the case. The
world acknowledges the pre-eminence of these illus-
trious men, and every one admits that under any cir-
cumstances such transcendant genius must have burst
forth to illuminate mankind. The real question is, are
such societies useful to science in general, and to the
individual members of which they are composed ?
That they are so, I think we have prima facie evidence
in the fact of their universal adoption in every civilized
country on the face of the globe; and the evidence is
strengthened when we inquire into the origin of some
of those whose fame is most widely spread, and most
firmly established.
If we look to the French Academy, and the Royal
Society of London, we find that these great and influ-
ential institutions were not created by the ministers or
the sovereigns of the countries in which they flourish ;
neither were they endowed with charters, or patronised
by the great in their infancy; but we discover that
they originated with those best qualified to judge of the
advantages of such associations, and best fitted to profit
by them. An academy or association can only succeed
by the efforts of the individuals themselves. It will
not be by the favour of the many, but by the energy
of the few. It is not even in the power of royalty to
create at a word what can only be formed by the co-
585
operation of the workmen themselves, and of the great
taskmaster Time. It was from a private meeting that
the great French Academy derived its origin. Several
literary friends at Paris, finding the extent of the city
occasioned much loss of time in their visits, agreed to
meet on a fixed day every week, and chose Conrart's
residence as central. All being literary men, those
who were authors submitted their new works to this
friendly society, who, without jealousy or malice, com-
municated their strictures; the works were improved,
the authors were delighted, and the critics were honest.
Such was the happy life of the members of this
private society during three or four years. Pelisson, the
earliest historian of the French Academy, has delight-
fully described it. “It was such,” he says, “that now,
“when they speak of these first days of the Academy,
“they call it the golden age, during which, with all the
“innocence and freedom of that fortunate period, with-
“out pomp and noise, and without any other laws than
“ those of friendship, they enjoyed together all which a
“society of minds and a rational life can yield of
“whatever softens and charms.” In this simple de-
scription of that happy association we have the best
answer to the objections sometimes expressed against
literary or scientific societies. The greatest men of the
age found it their interest, and made it their pleasure,
to hold periodical meetings to discuss the objects of
their mutual pursuits. It is curious to trace the pro-
gress of this private and unobtrusive society, and to
see how distinctions and honours were actually forced
upon them, Sorely against the wishes of its members.
They were happy, and they resolved to be silent; nor
was this bond and compact of friendship violated till
one of them, Malleville, secretary of Marshal Bassom-
586
pierre, being anxious that his friend Faret, who had
just printed his L'Honnéte Homme, should profit by
all their opinions, procured his admission to one of
their conferences. Faret presented them with his
book, heard a great deal concerning the nature of his
work, was charmed by their literary communications,
and returned home ready to burst with the secret.
Faret happened to be one of those light-hearted men
who are communicative in the degree in which they
are grateful, and he whispered the secret to Des Marets
and to Boisrobert. The first, as soon as he had heard
of such a literary senate, used every effort to appear
before them, and read the first volume of his Ariadne.
Boisrobert, a man of distinction and a common friend
to them all, could not be refused admission. He ad-
mired the frankness of their mutual criticisms. The
Society, besides, was a novelty ; and his daily busi-
ness was to furnish an amusing story to his patron
Richelieu. The Cardinal-minister was very literary,
and apt to be so hipped in his hours of retirement, that
his physician declared that “all his drugs were of no
“avail unless his patient mixed with them a drachm
“ of Boisrobert.” In one of those fortunate moments
when the Cardinal was “in the vein,” Boisrobert
painted with the warmest hues this region of literary
felicity, this happy little society formed of critics and
authors. The minister, who was ever considering
things in that particular aspect which might tend to
his own glory, instantly asked Boisrobert whether this
private meeting would not like to be constituted a
public body, and established by royal letters patent;
at the same time offering them his protection. The
minister's flatterer was overjoyed, and executed the
important mission, but not one of the members shared
587
in his rapture ; while some regretted an honour that
would only disturb the sweetness and familiarity of their
intercourse. Malleville, whose master was a prisoner
in the Bastille, and Serisay, the intendant of the Duc de
Rochefoucault who was in disgrace at court, loudly
protested, in the style of an opposition party, against
the protection of the minister ; but Chapelain, who
was known to have no party interests, argued so
clearly, that he left them to infer that Richelieu's offer
was a command; that the Cardinal was a minister who
willed not things by halves, and was one of those
very great men who avenge any contempt shewn to
themselves, even on such little men as they were. In
a word, they bowed their necks to the golden collar.
Such was the origin of that society whose fame has
since extended to every civilized region of the globe.
It was in the lodgings of Dr. Wilkins, in Wadham
College, Oxford, that a small philosophical club met
together, which proved to be, as Aubrey expresses it,
the incunabula of the Royal Society of London. When
the members repaired to London, they renewed their
meetings, first at a tavern, then at a private house, and
finally in Gresham College. The Society afterwards
derived its title from a sort of accident. The warm
loyalty of Evelyn in the first hopeful days of the Res-
toration, in his dedicatory epistle of Naude's Treatise
on Libraries, called that philosophical meeting “The
Royal Society.” These learned men immediately voted
their thanks to Evelyn for the happy designation,
which was so grateful to Charles the Second, who
was himself a virtuoso, that the charter was soon
granted. The king, declaring himself their founder,
“sent them a mace of silver gilt, of the same fashion and
“bigness as those carried before His Majesty, to be borne
588
“before the President on meeting days.” If we examine
into the history of all other literary and scientific
societies, we will find them originating in a somewhat
similar manner. But why do I allude to these circum-
stances, and occupy your time in listening to the details
of other societies 2 It is with the object of shewing
the spontaneous origin and growth of such institutions,
the want of which became insensibly manifest to the
learned, who supplied that want by their own private
and friendly associations. Is it likely that Bacon,
Milton, Cowley, and other great men would have sug-
gested such a method for the interchange and com-
munication of thought, if they had not anticipated that
signal benefit would result from it?
There are many advantages to be derived from the
labours of societies which limit their operations to parti-
cular subjects. Of this we have a striking proof in the
Geological Society of London, which has done more to
rescue geology from the vague and unfounded hypo-
theses of which it was composed, and to establish a
rational and purely inductive method of investigating
and generalizing facts, than ever was accomplished
before, or, most probably, would have been effected for
years to come without its aid. I do not think I arro-
gate too much for this Society, when I claim for it the
merit of having fostered, if not created, a spirit of care-
ful investigation and free communication on subjects
connected with the practice of midwifery, and thus
contributed to elevate and disseminate the fame which
Dublin has long enjoyed in this branch of medicine. I
can appeal to the communications made to this Society,
and since published by their authors, as the best evi-
dence of what I have advanced ; many of which will
not suffer by comparison with the best essays emana-
589
ting from other societies. Now I do not mean to assert
that all these papers would not have reached the pro-
fessional public without the inducement or help of this
Society, but I think it extremely probable that many
of them would never have seen the light, were it not
for the inducement held out to authors by our meet-
ings, and for the spirit of research to which they cannot
fail to give origin. A number of minds thus directed
upon one particular branch of medicine must necessa-
rily advance the science, either by making new dis-
coveries, or, what is often as valuable in a practical
point of view, by removing long established errors, or
upsetting baseless and pernicious theories. The admis-
sion of discussion upon the subjects brought before us
tends in an especial manner to promote the great Ob-
ject at which we should aim, the discovery of truth.
The advantage of having the opinions of our brethren
at once declared may be the means of correcting
mistakes into which we are all liable to fall; and from
hints dropped in the course of debate an author is often
enabled to alter or mend his communication, before he
submits it in print to the stern judgment of the public.
To the junior members of the Society I conceive the
debate which follows a paper is of very great import-
ance; it affords them an opportunity of becoming
acquainted with the mode of thinking on important
subjects which has grown up in the minds of their
seniors, and may afford a standard whereby they may
measure the amount of their own knowledge on a
variety of subjects. These remarks are, I think, pecu-
liarly applicable to this Society, where the discussion
is conducted on those principles that should ever actu-
ate a society of gentlemen engaged in the same pursuit;
where truth, not victory, is the common object; and
590
where, with all the candour and freedom with which
opinions may be stated, I have always observed that
decorum of manner and expression which softens down
objections, and accommodates, if it cannot reconcile,
conflicting opinions. Constituted as the human mind
is, there are but few if any points upon which we can
find uniformity of opinion, and in a subject so varying
as medicine we never can expect to find a perfect
uniformity. We therefore make all due allowance for
this diversity of thought, and in our discussions we take
advantage of, and treasure up what we hear, rather than
take offence at what may not exactly coincide with our
own opinions. I have had experience of many societies
during my life, and I never knew one in which the sub-
jects were debated with more temper and good feeling
than those which actuate the members of this Society;
and I trust the day is far distant when I could with
truth maintain the reverse.
Another advantage arising out of this and similar
societies is that they afford an opportunity for the for-
mation of personal acquaintanceship, and often of last-
ing friendship, between persons engaged in the same
branch of the profession. This I consider a most useful
and important result, flowing from our periodical as-
sembly in these walls. Nothing has a greater tendency
to mitigate the natural feeling of professional rivalry
than the friendly intercourse which takes place on
these occasions: nothing contributes more to the estab-
lishment of that infallible sign of a healthy state of
professional morals—friendship between rivals. You
may rest assured that when you see the contrary there
is something wrong, some want of upright and honour-
able feeling, some deviation from the straight path of
honour and honesty. It is our happiness in this city
591
to enjoy, I believe, a greater amount of professional
harmony than is to be found in any other capital. This
has often been remarked to me by strangers, and I have
no doubt one great reason of it is that there are so
many opportunities for the members to come together
and learn to value each other's friendship.”
If in this Society our meetings were confined to
those only who have already embarked in the practice
of midwifery, the observations I am about to make
might be considered unnecessary and misplaced; but it
has been wisely judged right to admit as visitors the
students who are in after years to supply our places,
when we have played our parts and retired from the
scene. I trust I may be excused in addressing a few
words to them on the nature of the profession which
they are about to adopt, and the qualities which I be-
lieve to be essential for success. This is not the time
or place to enter on any defence or eulogium of mid-
wifery; your presence here this evening testifies your
conviction of its importance as a science. Neither does
it come within my province, on the present occasion,
to offer any suggestions with reference to the best
method of pursuing its study. These are topics better
suited to the lecture-room, and I have not failed to
insist upon them in the discharge of my duty elsewhere.
I may, however, remind you that whatever may be
the amount of scientific and practical knowledge which
you may by diligence acquire, a great deal more is ne-
* A most flattering testimony to the truth of this description was borne
seven years after this address was delivered, when the late Sir Benjamin
Brodie honoured this city with his presence in 1851. That truly great
man was pleased to say that in no capital which he had visited had he
ever witnessed such a high tone of professional ethics and so much brother-
ly kindness and good feeling as he had observed among the medical men of
I)ublin.
592
cessary to form the character of a successful and ac-
complished accoucheur. It should be always borne in
mind that the special objects of our care are the
most interesting of the works of the great Creator—
woman, sensitive and delicate woman, in her hour of
peril, under the primeval curse, and her tender, helpless
offspring, in whom her hopes and affections are con-
centrated. It is impossible to conceive any situation
in which a greater demand is made upon the sympathy
and anxious care of all around, but especially on him
to whose hands are confided the issue of the painful
struggle. He should never lose sight of the deep re-
sponsibility he has undertaken, nor forget for a mo-
ment that the lives of two individuals are depending
upon the skilful discharge of his duty. He should
remember that although the majority of cases of par-
turition terminate favourably, without any demand for
the exercise of extraordinary means, yet at times cir-
cumstances arise which call for the most prompt and de-
cisive treatment, without which the life of one or both
of his charges must be sacrificed; for in no branch of
medicine is the death or safety of a patient so completely
in the hands of the attendant, as in some of the emer-
gencies of midwifery.
Without going more into detail on this point, let me
call your attention to what is further required from the
practitioner in this branch of medicine. Passing by
the intricate diseases of infants and children, which fall
especially within his province, let us pause for a mo-
ment on that wide and difficult class of derangements
of the female health commencing at puberty. This is
a season which properly calls forth the anxious solici-
tude of every mother, and it too often happens that
neglect or mismanagement at this period lays the
593
foundation of long enduring or permanent infirmity.
Here it is that a judicious exercise of professional skill
is required, and an acute, yet delicate tact is essential
to discriminate between the diseases that may exist,
and to administer the remedies appropriate to each ;
for in no class of diseases is more mischief caused by
following a routine practice than in that to which I
have just alluded.
In a more advanced stage of female life the practi.
tioner of our art has to encounter a most formidable
class of diseases, the organic affections of the womb.
These are frequently rendered formidable by conceal-
ment in their early stages, arising out of the natural
delicacy of the female character, and the repugnance
women feel to disclose their sufferings. But in this case
much may depend upon the previous reputation and
conduct of the medical attendant. If, by his skill and
kindness on former occasions, he has gained the respect
and confidence of his patient or her friends, she will
confer with him at a much earlier period than she
would under other circumstances, and thus a disease
may be discovered and checked in its commencement,
which, if allowed to proceed, would assume a most
dangerous form. Several years ago, an instance highly
illustrative of this point occurred to me. A lady whom
I was in the habit of attending had gone to reside in
England, and while there became affected with a com-
plaint for which she wished to have my advice, and she
returned to Dublin to consult me. That complaint
was speedily removed, and just previous to her pro-
posed departure she said: “As I am here, I may as
“well ask you about a little matter that may be of no
“consequence, and indeed has given me so little trouble
“that I would not think of mentioning it to any one
38
594
“else. I have for a week or two felt a small lump in my
“breast, and I wish you would look at it.” I did so,
and discovered a most malignant cancerous tumour
not larger than a hazel-nut. I at once suggested that
a consultation should be held the next day with Dr.
Johnson and the late Mr. Colles, who fully agreed
with me, and the following day we amputated the
breast. A section of the tumour confirmed the truth
of our opinion, and the lady is alive and well at the
present moment.” This providential escape was owing
to the other and totally distinct malady which led her
to come over to me, for she certainly would not have
thought it necessary to consult a stranger until the
time for operation might have passed by. I adduce
this as an instance of the value of that personal confi-
dence so essential in the treatment of female diseases.
There is still another highly important, and often
most difficult subject, upon which the accoucheur is
required to be well-informed, as questions of the highest
moment arising out of it are frequently proposed to
him, and upon his decision consequences of the most
grave nature may depend. I allude to the subject of
pregnancy, one requiring a combination of learning,
experience, and tact, in a higher degree than almost
any other subject in medicine.
Such are some of the duties required from the prac-
titioner in midwifery; let me call your attention to the
qualifications essential to their due fulfilment. Ana-
tomy and physiology, the grand foundations on which
all medical knowledge is based, must be thoroughly un-
derstood ; and the principles and practice of medicine
* This lady lived for twenty years after the operation, when she got
cancer in the other breast, which was then amputated. She recovered, and
finally died two years afterwards of apoplexy.
595
and surgery, in their most comprehensive forms, must
be familiarly and deeply engraven on the mind. With-
out such a foundation it is impossible to build up the
superstructure of scientific and practical midwifery;
and so strongly do I feel upon this point, that if I had
the power to regulate the course of study to be pursued
by students in midwifery, I would make it imperative
that a degree in medicine or surgery, or, what is better,
in both, should be obtained, before the study of mid-
wifery as a distinct branch was commenced. In many
points of view such an arrangement would be beneficial,
but particularly in this, that the mind would be better
fitted to comprehend and appreciate the phenomena
and treatment of the different departments of this par-
ticular branch. Midwifery and its natural adjuncts,
the diseases of females and children, involve in fact
some of the most intricate points in anatomy and
physiology, as well as some of the most difficult ques-
tions in pathology, medicine, and surgery; and he who
by diligent application has become acquainted with
these sciences will be in the best position to master the
difficulties which beset the path of the student in mid-
wifery.
A liberal and comprehensive medical education is
therefore the first essential qualification for midwifery
practice, and, without it, it is impossible for any man to
rise to eminence. In small localities and in the country
the practitioner is compelled to engraft midwifery on
general practice; but in large cities, where circum-
stances permit the separation, it is found to be most
advantageous to pursue midwifery as a distinct branch.
This devotion to one particular department has given
rise to the vulgar notion, that the education of the
medical practitioner (or lady's doctor, as he is popularly
38%
596
called) is different from that of other physicians and
surgeons—an idea originating in ignorance of the fact
that midwifery is only one branch of the great medical
tree, and that he who would reach it must climb up by
embracing and firmly grasping the stem, and toiling
over its several knots and asperities. There is no differ-
ent route—no short cut—the way must be travelled
step by step, and stage by stage. Having gone through
the preliminary education, and having, as I think he
should, obtained his degree, the graduate is now able to
devote his whole time and energy to the study of mid-
wifery; and I know from the testimony of individuals,
that six months’ study under such circumstances is
more valuable than double that time at a previous
period. .
Let us now suppose his term of study complete, his
time to have been diligently spent, and his hand and
head trained in the science and practice of midwifery :
is there any other qualification necessary to enable the
student to become a practitioner, and to secure a share
of public confidence 2 There are many. In the first
place, he must have a good moral character—morality
founded on, or growing out of religious principles, be.
fore all other ; but if, unhappily, such a regulator should
not abide with him, then morality conformable to the
strictest rules of society. In all branches of the medi-
cal profession a failure in this particular is most detri-
mental; but in that to which we belong, a pure and
unspotted character is the ingredient most essential to
success. It matters not what amount of ability and
learning may be brought to the task, if they be not
accompanied by strict moral rectitude, the door of
public favour will be closed against them. Another
very important ingredient is a good temper, or a steady
597
control over a bad one. The young graduate about to
embark in professional life should be aware that the
private practice of midwifery, and the public practice
of the same in hospital, are two very different things.
In the latter the patient is under the rules and control
of the institution, and from her position in society she
is accustomed to obey her superiors, so that little trou-
ble is necessary in her management. But when he
comes to deal with his equals and superiors in rank,
he will at times encounter characters requiring the
greatest skill and steadiness of temper to control and
direct them ; and he will find it necessary to exercise
this quality as much in reference to the assisting friends
as to the patient herself. To avoid giving or taking
offence, at the same time that he insists on his orders
being complied with, or refuses what he knows would
be prejudicial, should be his aim ; and by adopting
suaviter in modo, fortiter in re, for his motto, he will
often succeed where a different line of conduct would
involve him in difficulty. In addition to the quality
just spoken of the obstetric practitioner requires a very
considerable share of moral courage. To any one who
has attended a long and difficult first labour in a young
creature, the idol of her husband and family, it is un-
necessary to recal the anxious looks, the importunate
questions, the expression of surprise, amounting to dis-
appointment and even displeasure, at the delay, and
the ill-suppressed fears he has had to encounter during
the protracted and weary hours preceding its joyful
termination. But to those about to undertake this
duty I would strongly urge the necessity of coming
furnished with a large store of moral courage, by means
of which they will be enabled to pursue steadily the
course pointed out by reason and learning, unmoved
598
by the importunities of anxious friends, or the exhi-
bition of impatience with which they may be assailed.
A perfect confidence in himself, an honest announce-
ment in the beginning of the probability of consider-
able delay, a cheerful manner without levity, and a firm
determination to do what he considers right, will in-
spire his patient and her friends with reliance upon
his skill, and will enable the attendant to perform his
arduous duty with comparative ease and satisfaction.
There is another quality of the greatest importance
to persons practising our branch of the profession—
that is, secrecy. All physicians are called on for the
exercise of this virtue, but upon us the call is most im-
perative. I do not now allude to the divulging of cir-
cumstances concerning the character or conduct of
individuals, which in the exercise of our profession
may become known to us, and which of course every
man of honour feels bound to preserve within his
bosom ; but I mean to caution you against a habit of
speaking of your patients in other houses, and commu-
nicating any circumstances, however trifling, respecting
them. This pernicious habit of gossiping is certain
to produce bad results; your words and expressions,
however innocent, are liable to misconstruction, and
are likely to be sent abroad with the usual proverbial
additions, to find their way at last to the ears of the
object of them, so distorted as to appear like malicious
calumnies. In the long weary hours you will have to
spend in the houses of your patients, you will be much
exposed to fall into this temptation, which I strongly
advise you to resist. To conclude my catalogue of
qualifications, let me add physical strength and a sound
constitution. Ours is, of all branches of the medical
profession, in every sense of the word the most labori-
599
ous. Broken rest, exposure to the weather by night
as well as by day, irregularity of meal times, fatigue of
body and mental exhaustion, these are the tests which
try the vital powers; and unless the living spring be
endowed with a liberal share of elasticity, it will yield
to the superimposed weight, being unequal to its sup-
port. To preserve body and mind in a condition to re-
sist such injurious influences, the greatest attention is
often necessary. There are some adamantine constitu-
tions that can bear these trials with impunity; but, as a
general rule, I would observe that it is only by a steady
adherence to temperate habits, you can expect to pre-
serve the vigour of body and coolness of judgment
which are indispensable to a practitioner in midwifery.
Having in this hurried and very imperfect manner
detailed a few of the important requisites with which I
consider you should be furnished, in order to obtain a
respectable footing in professional life, allow me to ad-
vise you to pause on the threshold, and consider each
for himself whether he is fitted for the situation in which
he is about to be placed. It is lamentable to witness
the waste of talents and of time which we so often see
thrown away in the study of professions for which
there is no aptitude or natural bias : many a bright
genius is lost by being forced into a position unsuitable
to its nature. We are all interested in the metaphysi-
cal discussion whether there exists an inherent quality
in the human intellect which imparts to the individual
an aptitude for one pursuit more than another. The
idea of what Lord Shaftesbury calls not innate but
connatural qualities of the mind was entirely rejected
during the latter part of the last century; but of
late there appears a tendency to return to the notion,
which is consecrated by antiquity. One great fault is,
600
that our children pass through the same public educa-
tion, while they are receiving little or none for their
individual dispositions, should they have sufficient
strength of character to indicate any. The great secret
of education is to develop the faculties of the indivi-
dual, for it may happen that his real talent may lie
hidden and buried under his education. A profession
is usually adventitious, made by chance views, or by
family arrangements. The difficulty of discerning the
aptitude of a youth for any particular destination in
life is, even for the most skilful parent, always hazard-
ous, and many will be inclined, in despair of anything
better, to throw dice with fortune. Should a choice be
submitted to the youth himself, he will often mistake
slight and transient tastes for permanent dispositions.
A decided character, however, we may often observe,
is repugnant to a particular pursuit, delighting in
another ; we might find talents languid and vacillating
in one profession, vigorous and settled in another; thus
an indifferent lawyer might become an admirable archi-
tect. At present all our intellectual bullion is sent to
an university to be melted down, and to come out, as
if from a mould, a bright physician, a bright lawyer,
a bright divine ; or, in other words, to adapt them-
selves for a profession preconcerted by their parents.
By this means we may secure a titular profession for
our son, but the true genius of the avocation, in the
bent of the mind, is too often absent. Instead of find-
ing fit offices for fit men, we are perpetually discovering
on the stage of life actors out of character. A popular
writer has happily described this error: “A laughing
“ philosopher, the Democritus of our day, once com-
“ pared human life to a table pierced with a number of
“holes, each of which has a pin made exactly to fit it,
601
“but which pins, being stuck in hastily, and without
“selection, chance leads inevitably to the most awkward
“mistakes. For how often do we see the round man
“stuck into the three-cornered hole P” That much
may be done by art and education, in overcoming
natural obstacles to professional success, no one can
deny ; but that there are strong tendencies or predis-
positions in individuals to particular pursuits, which
it is well to lay hold of and to cultivate, is a pro-
position in which I think most persons will agree. A
story recorded of Cecco d’Ascoli and of Dante, on the
subject of natural and acquired genius, may illustrate
the present topic. Cecco maintained that nature was
more potent than art, while Dante asserted the con-
trary. To prove his principle, the great Italian bard
referred to his cat, which, by repeated practice, he had
taught to hold a candle in its paw, while he supped or
read. Cecco desired to witness the experiment, and
came not unprepared for his purpose. When Dante's
cat was performing its part, Cecco lifted up the lid of
a pot which he had filled with mice. The creature of art
instantly shewed the weakness of a talent merely ac-
quired, and, dropping the candle, flew on the mice with
all its instinctive propensity. Dante was himself dis.
concerted, and it was adjudged that the advocate for
the occult principle of native faculties had gained his
CallS62.
Of all professions there is not one that more imperi-
ously demands a certain amount of predisposition than
that of medicine; and of all its branches the one on
which we are now engaged requires the strongest bias,
combined with an ample endowment of the qualities
which I have recently sketched, for its cultivation and
practice. I have dwelt thus long upon this topic,
602
*>
in order to strengthen the caution with which I set
out, and to induce those now about to embark in the
practice of midwifery, to weigh well and consider their
own characters and fitness for its pursuit.
603
CHAPTER XXII.
An Address delivered before the Dublin Obstetrical
Society, at the opening of the twenty-fifth session.
[November 29th, 1862.]
WE are assembled here to-night for the purpose of
opening the twenty-fifth session of the Dublin Obstetri-
cal Society; and I seize this, the first opportunity that
presents, to offer my best thanks to the council of the
society, in the first instance, for having selected and
put my name forward, and to the members at large,
who have done me the very distinguished honour of
electing me president for the ensuing year.
The members of the society are aware that, at the
close of the last session, an important change in its
constitution was effected, and that a system which was
considered to be too much of the oligarchical was
changed for one of a more democratic character.
Under the late constitution, the presidents, of whom
there were four, and the vice-presidents, of whom there
were fourteen, and the committee, of whom there were
nine, were all self-elected, and were permanent—thus
depriving the members at large of any voice in the
selection of those who were to be the managers and
directors of the proceedings of the society. It was
thought by those who had the best interests of the
society at heart, and who were best acquainted with
604
the feelings of its members, and most alive to the great
fact now so patent throughout the world, that commu.
nities will not be satisfied without a voice in the selec-
tion of their rulers; it was thought, I say very properly,
that the time was come when the choice of the officers
should be placed in the hands of the members, and that
they should be called upon, annually, to exercise that
very important privilege and duty. Accordingly, a
new code of by-laws was drawn up by the committee,
and submitted to the consideration of the society, and
after several meetings, at which they were fully dis-
cussed, the code, now printed and distributed to the
members, was adopted. We commence to-night under
a new regime, and I have no doubt that very great
benefits will result from the combined energies of all
the members, who will henceforward feel that they have
each, individually, an interest in upholding and for-
warding the objects of this society, not only in reading
and listening to papers at its meetings, but in the elec-
tion of the officers who are to constitute its staff.
In future the council of the society will consist of one
president, two vice-presidents, one treasurer, one secre-
tary, and a committee of five, who will have no perma-
nent tenure of their offices, but will be chosen annually
by ballot, at the first meeting of the session. To have
been selected by my brethren to fill the chair of presi-
dent, at the first election under the new system, is, I
assure you, to me a source of the highest gratification
and well-founded pride. Pride not unfrequently has
its origin in very unworthy emotions, and whenever
this is the case, it is likely to subject the individual
in whom it is engendered to the contempt of his fellow
men. But when, in the course of a professional life,
after many years spent in very active public and private
occupation, after filling professorships and president-
605
ships in other places, one finds the good opinion of his
brethren undiminished, and their voices raised to place
him in the highest position among them, he would be
unworthy of the honour conferred on him if he did not
feel gratified by such an exhibition of approval. The
Dublin Obstetrical Society has now been in existence
twenty-four years. It is the oldest institution of the
kind in this empire. Dublin has the merit of having
originated two most important and useful societies
connected with the medical profession, and set an
example that has been followed by London and Edin-
burgh. This society is one, and the Pathological
Society the other. In both these branches of scientific
pursuit Dublin took the lead, and the great advantages
arising from such institutions having become manifest,
our brethren in the metropolis of England and Scotland
have wisely founded similar, and, I am happy to per-
ceive, very flourishing societies. In speaking of the
origin of this society, it should never be forgotten that
we are indebted to the wisdom, energy, and foresight of
a highly distinguished ornament of our profession for
its suggestion and establishment. Dr. Evory Kennedy,
then Master of the Lying-in Hospital, looking beyond
the walls of the magnificent institution over which he
was appointed to preside, soon perceived that, in the
great advances then being made in all branches of
science and human knowledge, there was a want of a
centre, of a place of union, where, by a combination of
the intellect and energies of the many individuals
engaged in the same pursuit, an impetus would be given
to the acquirement and diffusion of information con-
nected with our particular study. He instituted and
watched over this society in its infancy, and its impor.
tance and value are best attested by the published
606
reports of the able communications furnished at its
meetings, and the way in which its example has been
followed in other cities. Dr. Evory Kennedy's name
must therefore be ever associated with, and grate-
fully remembered by the Dublin Obstetrical Society.
In November, 1844, now just eighteen years ago, I
had the honour to deliver an address to this society, at
the opening of its seventh session. When I look back
through the years that have passed between that period
and the present, I find much to excite feelings of an
opposite character. Time, inexorable time, has plied
his busy and fatal scythe among us, and has cut down
a larger number of great and distinguished men than
usually fall so close together. Crampton, Cusack,
Marsh, Graves, Harrison, Williams, Rynd, Porter—
all these have been at times assistants at our meetings,
and all of them have died since I last had the honour
of addressing this society. Some of them were my
seniors, some of them my fellow students, some of them
my colleagues, all of them my friends. Whenever
their honoured names are mentioned, deep regret and
sorrow must arise in the breasts of all who had the
happiness and privilege of knowing and living with
such promoters of the fame of Irish medicine and sur-
gery. There is one name I have omitted from the
list which I know must have suggested itself to every
member of the society; but I have reserved it for
special mention. You all expected the honoured name
of Montgomery to appear upon my list of extinguish-
ed lights. He was more particularly associated with
us than the others were, and in the particular branch
of medicine with which this society is concerned his
loss is more seriously felt. The world at large, who
only knew him as the brilliant and eloquent lecturer,
607
the successful practitioner, and the thoughtful, accom-
plished writer, have good reason to respect the memory
of one who was a distinguished ornament to our pro-
fession, and to be proud of him who has left a monu-
ment erected by himself during his lifetime, more
lasting than bronze—his great work on the Signs of
Pregnancy. -
The members of this society, in which he held the
office of one of its presidents, may recall with affection-
ate regard his eloquent and classical address delivered
in the year 1843, and his many valuable contributions
at our meetings. But it is only those, in whose ranks
I am happy to number myself, who knew him in early
life, when the struggle for fame and position was before
him, who can duly estimate his industry, his never-
tiring assiduity, and the years of labour he bestowed
on the making of his celebrated museum—for with his
own hands he made it: many an hour I have spent
with him in his workshop. The highest rewards in
professional life naturally flowed in upon him, and he
fell, one of the galaxy of great men whose names I
have already mentioned.
But, gentlemen of the Obstetrical Society, if we have
much to regret, we have on the other hand much to
rejoice over and be proud of. During these last years
great advances have been made in our particular branch
of the profession ; and I think it is not going too far
to assert that, notwithstanding the brilliant improve-
ments in surgery, and the solid and wise modifications
in medicine, the changes in our art have preserved
more lives, and relieved more human suffering and
misery. The pains of the human female in giving
birth to her offspring are proverbial, and are, in many
cases, the greatest that nature can endure. Formerly
608
we stood by, watching the agony, looking with deep
anxiety for its termination, but powerless to alleviate
or diminish, its intensity. Thousands of years have
rolled away since the primeval curse, and countless
millions of women have gone through the great trial of
child-birth, without any means being devised to miti-
gate their woe, until, within a few years, it was dis-
covered in America that the inhalation of ether was
capable of removing the consciousness of pain during
labour. The use of this agent having been attended
with some inconveniences, it occurred to the acute and
philosophic mind of Professor Simpson, that there was
probably some other of the class of ethers that would
equally act as an anaesthetic, without producing these
unpleasant effects.
He accordingly instituted a long course of experi-
ments with a variety of vapourizing fluids, and con-
cluded by discovering that chloroform was the one
most to be relied upon to produce anaesthesia with
safety. This agent was at once approved of by the
profession, and came into general use to assuage pain
in all surgical operations, as well as in midwifery. It
is a remarkable fact that, although serious and fatal
accidents have arisen during its employment in surgery,
there is no instance (so far as I know) recorded of its
injurious or deadly consequence when administered
during labour. Any one who has witnessed the suffer-
ings of a young creature during the many, many hours
of a first confinement, who has heard the frantic, half
maniacal shriek, and seen the fearful contortions of a
frame agonized beyond the power of man to compre-
hend, will rejoice that he has in chloroform a means
of alleviating such misery, which will soothe the excited,
frenzied mind, calm the bodily suffering, and produce
gº?
609
such a happy feeling in the previously distracted
patient, that she often gives vent to the exclamation,
“Oh I this is heaven.” Any one who has attempted to
perform the operation of turning in a tightly contracted
uterus, with a patient utterly unable to control her
plunging or her screams of agony, and then, having got
the woman under the influence of chloroform, comes
again to try what can be done, will be able to appreci-
ate the enormous value of this agent, by the facility
with which he is able to go through all the steps of the
operation. His hand passes easily, the child is turned
without opposition, and the patient is delivered without
pain. To have in our hands such an agent, which
was unknown to our predecessors, and by which such
marvels are worked, is, I repeat, a good ground for
our rejoicing in the present state of our knowledge and
power.
Another source of rejoicing is the present state of
public opinion and practice respecting the midwifery
forceps. When I compare the existing practice with
what it was fifty years ago in this country, it is to me
particularly a subject of congratulation and pride. At
the time I allude to, for some time before it, and for
many years after, including a period of fully forty
years, this instrument was banished from practice
through the whole of this country. The feeling was so
strong against its employment, and the leaders of the
outcry were so powerful, that no one dared to question
the authority by which it was condemned. The per-
forator and crochet were the only means in use, crani-
otomy was the only operation. This indiscriminate
adoption of the mutilating instruments was the won-
der of strangers, and the opprobrium of the Dublin
school. Submission to the authority alluded to was
39
610
so complete, that I am almost perfectly correct in
saying “no one dared” to question it. But there was
one faithful priest who had kept the sacred fire burning
in spite of all attempts at its extinction, and, towards
the close of a most laborious professional life, had the
courage to proclaim the merits of the forceps, and the
success that had attended their use in his hands. This
was done at a time when even to mention the name of
the instrument was considered a heresy, and nothing
short of excommunication could be expected by him
who was rash enough to recommend its use. That
individual was my father, the late Dr. Beatty; his
paper was read at the association of the College of
Physicians,” and published in the first volume of the
new series of their Transactions. That first opened
the eyes of Irish practitioners, who had for so long
groped along in the darkness of error; but it was not
to be expected that any very rapid change would take
place. To convert an entire nation, long schooled in a
particular doctrine, is a work of time; but the good
seed was sown ; 105 cases in one man's private practice
were proclaimed to the world, and the reformation was
begun. The author of that paper died in 1831; and,
in 1842, I read before this society a paper entitled,
“Cases illustrative of the use of the Forceps.” There
are some of the existing members who were present
upon that occasion, and they will, I doubt not, recollect
the feelings with which my observations were received
by the then seniors of the society. One fact will suffice
to show the prevalent notions respecting the forceps at
that day. The chair of the society was occupied on
that evening by one of the most esteemed and respected
* October 5th, 1829.
611
members of the profession—a gentleman who had been
Master of the Lying-in Hospital, who for forty years had
enjoyed one of the largest practices in this city, and on
that occasion he stated that he had once tried the for-
ceps, and failed. It was expected that the discussion
On my paper would have been of an animated character,
but the hour being late the debate was postponed to
the next meeting. I came to it, prepared to have
my views canvassed and my doctrine controverted, but
there was no one to enter the lists; the opponents did
not appear ; judgment was suffered to go by default.
From that time a steady progress in the correct
appreciation of the value of this instrument took place :
additional testimony was borne by succeeding writers,
amongst whom Dr. Churchill was the earliest and most
powerful. The instrument assumed its legitimate posi-
tion in the practice of all well-educated members of the
profession, and we have lately had the gratification of
hearing in this society, and afterwards of seeing in the
Dublin Medical Quarterly Journal, a most valuable
paper by a late assistant of the Lying-in Hospital, Dr.
Sinclair, “On the timely use of the Forceps.” The
rate at which the current now runs in favour of this
instfument may be judged of, by referring to two
papers published in the first volume of the Transactions
of the Obstetrical Society of London for the year 1860.
I allude to that by Mr. Harper, “On the more frequent
“use of the Forceps as a means of lessening both
“Maternal and Foetal Mortality,” and also that by Dr.
Tyler Smith, “On the abolition of Craniotomy from
“Obstetric Practice in all cases when the Foetus is
“living and viable.” In the third volume of the
Transactions of that Society there is a most valuable
paper by Dr. Graily Hewitt, entitled, “On Unusual
39%
612
“Elongation of the Foetal Head, as a cause of difficulty
“in the application of the ordinary Obstetric Forceps,
“with description of a modified form of Instrument
“to be used in such cases.”
The restoration of the forceps to its proper position
has only been effected during the last twenty years, and
its progress was slow until within the last ten years.
It is a subject of much rejoicing to me to have lived to
see such a revolution begun, and brought to so happy a
conclusion ; and I congratulate the profession in this
country on the power they now possess, and I particu-
larly congratulate all unborn infants of the present
day on the fact that the innocuous forceps, and not the
deadly perforator, will be used to assist their entrance
into this world, if necessary.
A form of disease in the human female, formerly
utterly hopeless, has in these latter days been brought
within the reach of art, and a large number of success-
ful operations attest the vast importance and value of
the inventions. I allude to the wide and too frequent-
ly exhibited class of diseases of the ovary. Some forms
of disease of this organ do not necessarily or rapidly
terminate the life of the sufferer. Others again (the
dropsies) soon give rise to such symptoms as to require
the operation of tapping, which is after all but a pallia-
tive, and often is itself the immediate cause of death.
In those cases where tapping is resorted to, the opera-
tion has to be repeated sooner or later, and the average
duration of life does not extend beyond two or three
years. Some cases will be found recorded in which
life has been prolonged for many years, and numerous
tappings have been had recourse to, but these are only
the exceptions. The radical cure of ovarian disease
was the great desideratum, and I think we have arrived
613
at a period in the history of medicine when we can
announce that such has been found. It is not pre-
tended that any proceeding has been discovered, by
means of which every sufferer from ovarian disease can
be relieved from her malady; but from the accounts we
now have before us, and the statistics deducible from
them, we are justified in stating that the average of
recoveries after the two kinds of operation that are
now received and practised, is fully as great as that
after most of the great surgical operations undertaken
in cases which, without such interference, must termi-
nate in death. That is the true test whereby to try
the value of any operative proceeding. I have alluded
to two operations now in general use—one of them
suited to only one form of ovarian disease, the other to
all. In the first, or what is termed unilocular ovarian
dropsy, the disease consisting in an accumulation of
fluid in one of the cells of the ovary, it has been found
that if, after tapping and emptying the sac, a stimulat-
ing fluid be injected into it, inflammation of the sac is
set up, and the sac is sometimes obliterated, thus pre-
venting any future accumulation of fluid in that
quarter, and curing the disease. This operation has
been very successful, and the number of cases daily re-
corded fully justifies its adoption in all suitable cases.
I have employed it myself with the most complete
success, and I think it may be tried in all suitable cases
previous to the adoption of the other and more serious
operation—the complete extirpation of the ovary.
This is one of the greatest achievements of the present
day. Its proposal was at first received with amazement
and horror, and the first cases recorded were looked up-
on as the acme of rashness. From the original small
incision of Jefferson, only an inch and a half or two
614
inches in length, the advance was rapid and startling,
when M*Dowall of Kentucky, United States, Lizars of
Edinburgh, and Clay of Manchester laid open the
abdomen by an incision eighteen or twenty inches
long, from the ensiform cartilage to the pubes, exposed
the ovarian tumour, separated its pedicle and adhe-
sions, secured its vessels, and removed the whole mass
entire. In recording his first case, operated on in June,
1842, Mr. Clay made the following remarks:–“In
“many cases, as I shall afterwards prove, the mode
“ pursued by Mr. Jefferson (the small incision) is not
“only impracticable but really absurd. I find con-
“nected with the Jefferson mode eight cases, of which
“five were fatal; with that of Mr. Lizars, four by him-
“self, three by Dr. M'Dowall of Kentucky, one by
“Dr. Smith of Connecticut, one by M. L'Aumonier in
“France, and one by myself, making ten, of which only
“one was fatal, and that with great propriety might
“ have been attributed to other causes.” This was a
most encouraging beginning. I will not weary you by
giving a history of the operation from that to the
present time, but I will just mention the results as
published by some of those who have had most expe-
rience in this operation. Dr. Tyler Smith has lately
recorded eight cases, in which all were successful but
one. Mr. Spencer Wells has operated fifty times; of
these, thirty-three recovered, and seventeen died. Mr.
Baker Brown gives the report of sixteen cases, in which
there were only two deaths; and Dr. Clay gives a
retrospect of his operations from 1842 to the present
time. The whole number of cases operated on by him
was one hundred and four, of which seventy-two reco-
vered, and thirty-two died. Dr. Clay thinks we cannot
reasonably hope to extend our success beyond seventy
615
per cent.” When we compare these returns with the
average recoveries after the great operations in surgery,
we see good grounds to rejoice over methods now
within our reach, whereby a most formidable and
hitherto incurable disease may be fairly encountered.
There are conditions of life, states of existence, in
which, although life itself is not threatened, nor any
great bodily suffering endured, death would be almost
preferable. To linger out a number of wretched years,
loathsome to herself, and intolerable to her nearest
relations and friends, shunned by all her acquaint-
ances, and unable to mix in the every-day occupations
of the world, has been the fate of many a wretched
woman. In the great majority of these lamentable
cases the condition of the woman has arisen from mis-
management during labour, and hence the greatest
number of them are found amongst the poor, who, in
remote districts, have been obliged to depend on the
more than doubtful care of the country midwife. Dif.
ficulty arises; delay takes place; time, valuable time, is
lost in all sorts of foolish devices to expedite delivery.
Dangerous pressure is going on all the while, destructive
inflammation is established, and the mischief is done,
no matter how the delivery is afterwards accomplished,
whether by the unaided and persevering efforts of
nature, or by the assistance of a medical man, called in
* I have enquired of these gentlemen their present statistics, and have
been kindly favoured with the following:—
TOTAL NUMBER OF CASES TO JULY, 1866.
Cases. Recoveries. Deaths.
Mr. Spencer Wells, tº ſº 177 ... 122 or 68.93 per cent. .. 55 or 31:07 per cent.
Mr. Baker Brown, e e 100 . . 67 Or 67." 23 ... 33 or 33° 3?
Mr. Clay e e 140 ... 100 or 71°43 º ... 40 or 28°57 99
These results are highly satisfactory and encouraging. They shew the
accuracy of the prediction made many years ago by Mr. Clay, when he
said we cannot hope to extend our success beyond seventy per cent.
616
too late to prevent destruction of important parts by
the mortification that must ensue, and which effects are
too often charged upon him when the sad condition of
the patient becomes manifest. Sloughing of the blad-
der takes place; an aperture, varying in size from that
of a pin-hole to one of two inches square, in all direct-
tions is established ; and all control over the organ is
for ever lost. These are cases in which the “timely
“use of the forceps,” as Dr. Sinclair so well terms it,
would have prevented all the evil results. The un-
happy victims of such a fatality have been until a very
recent period condemned to a hopeless future. Vari-
ous attempts of different kinds were made, from time
to time, to relieve this terrible state, but none were of
any avail. Failure after failure damped the energy
and sickened the heart of every one who sought a
remedy. The glory of triumphing over this hitherto
unconquerable malady was reserved for our own time.
Our American brethren took the lead in this great dis-
covery. Dr. Marion Sims of New York, followed by
Dr. Bozeman, contrived and practised successfully an
operation with sutures of silver wire, by means of
which these apertures were closed and the patients re-
stored to comfort. An eminent Irish surgeon almost
simultaneously succeeded in accomplishing the same
feat by a somewhat different method. Mr. Maurice
Collis invented a mode of proceeding, by which he had
perfectly succeeded in curing several of these cases be-
fore the American operation was well known among
us. All this occurred within a few years, and now
the operations for the cure of these fistulae, as they
are improperly termed, are performed with confi-
dence and success in all parts of the empire. Cases,
instead of being avoided and discharged from hospitals,
617
are sought after, and encouraged to enter the wards,
and, after operation, are sent home to their families,
Sound in body, happy in mind, and fit and able to
take part in all former duties and pursuits. Having
been myself a successful operator in such cases, I can
bear testimony to the gratification produced in the
mind by the satisfactory results that ensue. There is
no operation that requires so much time and patience.
I have spent from one to three hours in its performance.
There is no opportunity of showing great dexterity, as
in rapid amputations, or in lithotomy. Bystanders get
weary and depart, assistants are often worn out and
wish it was over, but the operator cannot hurry; every
step must be taken with caution, and no matter what
length of time it takes, he must take for his motto
“patience.” But in success he has his reward ; to feel
that he has rescued a fellow being from the loathsome
misery of such an affliction is worth going through any
amount of labour and fatigue. This great triumph of
art is another cause of rejoicing ; and we of the pre-
sent day have good reason to be thankful that we have
lived in the time when it has been contrived.
I have endeavoured to glance rapidly at some of the
improvements which have been added to our store
during a comparatively short period, and I think I
am safe in saying that in no other branch of medicine
have so many and so great additions been effected in
the same time. Before I conclude, I would take the
liberty of suggesting to the members of this society,
that an increased responsibility is now thrown upon
them, and that we must take care that the reputation
so long enjoyed by the profession in this city shall
not suffer through any inertness of ours. We should
look across the Channel, and see what our brethren in
618
the great metropolis have accomplished in the three
years of their existence. The three volumes which I
hold in my hand testify to the great energy with which
the London Obstetrical Society has been worked. We
should recollect that our mature years are expected to
hold place with, if not to excel, our younger fellow-
labourers. I have no hesitation in saying that I
think the papers in these three volumes of transactions
reflect the highest credit on that society. I have every
hope that the ensuing session of this society will be
one of peculiar value, and nothing that I can do to for-
ward its interests shall be wanting. We have a high
vocation, and much is demanded from us ; but above
all things, while working with earnestness, exulting
in our ingenuity, and taking pride in our instruments
and handy-work, let us never forget that we ourselves
are but instruments in the hands of the Great Physi-
cian, the Great Mechanician, without whose help and
blessing all human efforts are unprofitable and vain.
619
CHAPTER XXIII.
Address delivered in the City of Dublin Hospital.
"[November 6th, 1865.]
THE commencement of another medico-chirurgical ses-
'sion brings us together again within these walls. Many
of the familiar faces of the second and third year's
students I am happy to see before me ; and I hail with
satisfaction and greeting many additions to the ranks
in the persons of those who now for the first time de-
vote themselves to our noble science. We are all come
here to discharge our respective duties, after the in-
terval of repose afforded by the summer recess. An
alternation of work and rest is as necessary in the
pursuit of medical and surgical knowledge as it is in all
other sublunary matters. There is and can be no con-
tinuous persistent course of action. If we look abroad
upon all that surrounds us, we will see that all the
phenomena of the physical and moral world are made
up of alternations; and if it were not so, the whole
fabric of created things would fall into disorder and
decay. Spring, summer, autumn, winter succeed each
other from year to year, and by their alternations
produce those influences on the surface of the globe to
which we are indebted for corn, wine, oil, and other
fruits of the earth. By man's toil and labour these
gifts of a beneficent Providence are cultivated; but
that labour is not continuous. Day and night alter-
620
nate so as to insure a period of repose, in which both
mind and body are refreshed, and enabled to renew
their daily toil with vigour. The whole organic world
participates in this periodical enjoyment of rest; vege-
tables as well as animals have their sleep at night, and
enjoy the alternations of darkness and sunshine. There
is nothing continuous in the physical world, and there
can be nothing in the mental. A mind constantly oc-
cupied in one pursuit, without any period of rest, must
break down under the unnatural effort. Some, from
peculiar strength and energy, may endure fatigue
longer than others, but even these suffer premature
decay, and in the end are exhausted long before their
more prudent fellow-labourers.
In accordance with this universal law, there is a
period of repose in the medical schools. That period
is now at an end for this year, and we reassemble to
renew our labours in the hospital, in the lecture-the-
atres, and in the dissecting-rooms. I hope the young
friends I see before me have not failed to occupy
the vacation months in a wholesome and profitable
manner. Rest from the sterner duties and deeper
studies that are requisite in the acquirement of our
profession does not mean a state of idleness. The well-
trained mind will shrink from a waste of time—that
precious time allotted to it for employment in good or
evil. The mind of every sane person must be employed
on something; and if it be not engaged on what
is good, it will be on what is evil. The body is re-
created by wholesome exercises, not by slothful habits.
Riding, walking, cricket, football, and other manly
sports invigorate the frame of youth, and build up
robust constitutions. In like manner, the mind is re-
created not by idleness, but by occupation in some of
621
the lighter but still important classes of literature;
and there can be no doubt that the student who has
occupied the leisure hours of his vacation in reading
history, or good books of travels, or biographies of
great men, or, let me add, the wonderful combination
of history and fiction to be found in the works of the
immortal author of Waverley—there is no doubt, I say,
that he who has been thus occupied, comes back to the
labours of the medical session with his mind not only
supplied with so much useful knowledge, but strength-
ened, and sharpened, and better able to grapple with
the difficulties of the numerous branches of science that
he must master. -
Numerous indeed they are, exceeding in multiplicity
those required for the attainment of any other profes-
sion. Divinity, law, and physic used to be accounted
the three professions; but there are other occupations
in which large masses of mankind are engaged, and
which, from their vast importance and usefulness, may
well be styled professions—engineering, arms, agricul-
ture, commerce. Now, of all these there is not one
that requires an acquaintance with such a wide range
of sciences as that demanded by medicine and surgery.
The student of divinity, occupied in the highest and
holiest pursuit that can engage the mind of man, has
his one great object before him ; enough, indeed, to
absorb all his time and energy; but it is single. Law,
proverbially dry and uninteresting, has no variety to
offer to its students. Statutes and precedents, and com-
mentaries thereon, constitute the materials for its study.
The profession of engineering, which in modern times
has risen to such vast proportions, and from which
have sprung those gigantic results that almost cast into
the shade the old seven wonders of the world, requires
622
from its votaries a knowledge of mathematics, physics,
geology, chemistry, the art of drawing, and surveying.
What shall we say of arms ? To enable a man to take
an active and efficient part in the protection of the in-
tegrity and honour of his country, or in the avenging
of her wrongs, he must know well history, geography,
mathematics, projectiles, and languages, in addition to
the more immediate requisites of drill and manoeuvre-
ing. In the peaceful pursuits of agriculture and com-
merce the higher branches of abstruse science are not
so requisite. A knowledge of geology, of soils, of
meteorology, and of chemistry will assist the farmer in
selecting proper crops for different localities, and ma-
naging the succession of crops to suit different soils. To
enable the merchant to use successfully that instrument
of England's greatness and wealth, commerce, he must
know the history and present condition of mankind
all over the globe, including their political and social
state, and their relations to each other as states or
peoples, their wants and their productions. Let it not
be imagined for a moment that I wish to insinuate that
these and these alone constitute the acquirements of
the multitudes engaged in the different professions at
which I have thus hastily glanced. Far from it. Nu-
merous instances will at once occur to the minds of all
who hear me, of men in different professions, highly
accomplished, and distinguished in sciences and pur-
suits outside their own more immediate calling. When
we can point with pride and veneration, in our own
day, to a Romney Robinson and a Brougham, we de
not want instances to show how brilliant genius can
overstep the bounds of knowledge required for divinity
or law.
I will here ask leave to digress for a moment, while
623
I relate an anecdote connected with Lord Brougham,
highly illustrative of this position, and which, I believe,
has never been recorded.
At the time of the formation of the Society for the
Diffusion of Useful Knowledge, Lord (then Mr.) Broug-
ham was its president. The object of the society was
to publish a series of volumes, written by the most
eminent men of the time, on all branches of science and
human knowledge. The first volume contained a pre-
face written by Mr. Brougham, and as the future vo-
lumes were to treat of all sciences, he took occasion to
allude to and make observations upon each.
Dr. Dyonisius Lardner was the editor of the work;
and shortly after the first volume, containing the pre-
face, appeared, I met Dr. Lardner at dinner at the
house of the late Dr. Graves. He then told us the fol-
lowing anecdote. The manuscript of the preface had
been sent to him by Mr. Brougham, and, in reading it
over, it appeared to him that in the observations re-
lating to astronomy Mr. Brougham had made some
mistake. Dr. Lardner wrote to Mr. Brougham stating
the opinion he had formed, and awaited his reply. Mr.
Brougham was then in the zenith of his practice at
the bar, and a leader on the north-eastern circuit of
England, where Sir James Scarlet, afterwards Lord
Abinger, was his cotemporary, and often his opponent.
Dr. Lardner's letter reached him when on circuit in
York, where he was engaged in every case, and over-
whelmed with business. From the midst of that tur-
moil he answered Dr. Lardner. He entered into the
controversy, still maintaining that his views were cor-
rect, and wound up by saying, “I write in haste in
“York, where I am on circuit, and I cannot find here
“a copy of Laplace's Mecanique Celeste; but if you
624
“look to"—mentioning a part of the work—“you will
“find that his views coincide with what I have put for-
“ward. I think his theorem is that which I now write
“out from memory.” Dr. Lardner assured us that this
quotation from Laplace covered a sheet of foolscap
paper with the usual algebraic symbols in which such
questions are worked out, and that, on comparing it
with the original, there was not a letter wrong, and,
moreover, that it convinced him that Brougham was
perfectly right in the point on which the difference of
opinion had arisen.
But to return. You will perceive that the subjects
necessary in the acquirement of other professions are
few when composed with the formidable array put
forth in the curriculum of the several licensing bodies.
Take, for instance, the Royal College of Surgeons in
Ireland, to which school this hospital is more particu-
larly attached—all the medical officers being actually,
or having been, connected with it as professors or
teachers. In the list of subjects upon which the stu-
dent is expected to be prepared to answer we find
Human and Comparative Amatomy, Physiology, Sur-
gery, Practice of Medicine, Chemistry, Materia Medica,
Midwifery, Botany, and Medical Jurisprudence. This
is a much longer list of distinct sciences than is re-
quired for any other profession; and I mention it not
to deter but to encourage you in the walk which you
have chosen. These are subjects that have occupied
the most illustrious investigators of nature ; and we
find them worked out and put before us in attractive
forms by zealous and able annotators. To analyze
man, to become familiar with his organization in health,
and admire the wonderful adaptation of means to ends
in the accomplishment of nature's objects; to trace the
6.25
effects of disease on his system ; to be able to detect
the erring organ ; to know the appropriate treatment,
and carry it out with success, is, next to the culture of
his immortal soul, the noblest, the most godlike, and
most self-rewarding occupation which can engage the
mind of a being made in God's own image. It is by a
careful study of the various subjects above enumerated
that you are to attain to the enviable position of a good
physician or surgeon. Do not imagine that this can be
accomplished in the few years devoted to your attend-
ance in the schools. To master such a multiplicity of
subjects in so short a time is simply impossible. There
is a gate at the end of your course, through which you
must pass before you are admitted on the wide field of
practice; to enable you to pass that gate you must show
a reasonable amount of knowledge; but no more is re-
quired. You get your diploma, and then, cast on your
own resources, you find how little you do know. The
fact is, you must continue a student all your life. The
greatest ornaments of our profession have always been
ready to admit that they were but learners, and had
still much to learn ; and if you trace the lives of those
eminent men, you will find that to the end they were
busy in acquiring knowledge. When Sir Benjamin
Brodie visited this city in the year 1851, he did not
come merely to see sights, but wherever he could ac-
quire fresh information he paused and studied. In his
masterly work on “Diseases of the Joints,” no mention
is made of a form of disease not unfrequent in this
country, and first described by Irish surgeons. Our
museums present many specimens of this affection, and
Sir Benjamin paid repeated visits to these collections,
and spent a long time in the examination of all the
varieties submitted to his inspection. It is well known
40
626
that Sir Astley Cooper spent some hours every day, to
the close of his life, in dissecting; and his last beau-
tiful and important work was the result of laborious
dissection, and of preparations made by his own hand
shortly before his death. One of the most eminent
men that ever ornamented the profession, the late Dr.
Graves, a giant in intellect and knowledge, was always
ready to acknowledge himself a learner. It was he of
whom the celebrated Trousseau thus spoke : “As Clini-
“cal Professor of Medicine in Paris, I have incessantly
“read and re-read the work of Graves. I have become
“inspired with it in my teachings ; I have endeavour-
“ed to imitate it in the book I have myself published
“on the Clinique of the Hotel-Dieu ; and even now,
“although I know almost by heart all the Dublin pro-
“fessor has written, I cannot refrain from perusing a
“book which never leaves my study.” And again he
says: “There is not a day that I do not in my practice
“employ some of the modés of treatment which Graves
“excels in describing with the minuteness of the true
“practitioner; and not a day that I do not, from the
“bottom of my heart, thank the Dublin physician for
“the information he has given me.” That man, thus
justly estimated by such an authority, was in the habit
of thus addressing the class at the Meath Hospital,
when he was about to make a post-mortem examination
of any case of interest : “Come now, gentlemen, let
“us go together, and learn something from this case.”
He did not say, “Come, and I will teach you;” but he
put himself on a par with the pupils, and went to learn
along with them. With such examples as these, you
will perceive that your term of pupilage is not to end
on the day you obtain your degree or diploma; it is,
in fact, only then you will see the magnitude of the
627
work before you, and, having your minds stimulated
by the fresh draughts of knowledge imbibed day by
day, you will find yourselves ranked amongst those
who, by persevering industry, have entitled themselves
to the appellation of benefactors of the human race.
The chief reason for this never-ending struggle after
knowledge and truth consists in the nature of the sub-
ject with which we have to deal; and in this we con-
trast strongly with the students of the exact sciences.
They deal with inanimate, we with animate matter.
The astronomer, the engineer, the mathematician, etc.
have to investigate questions relating to various mat-
ters, all regulated by fixed laws, and which, when once
discovered, serve as immutable bases on which future
calculations can be made with unerring certainty. We
have to do with a most complex machine, every wheel,
lever, pulley, and spring of which is undergoing a per-
petual decay and restoration, and which is only main-
tained in its integrity by the principle of life.
“The definition of life,” says Bichat, “is usually
“sought for in abstract considerations; it will be
“found, if I mistake not, in the following general
“expression : life consists in the sum of the functions
“ by which death is resisted. In living bodies, such in
“fact is the mode of existence that whatever surrounds
“ them tends to their destruction. They are influenced
“incessantly by inorganic bodies; they exercise them-
“selves, the one upon the other, as constant in action :
“under such circumstances they could not long sub-
“sist, were they not possessed in themselves of a per-
“manent principle of reaction. This principle is that
“ of life: unknown in its nature, it can only be
“appreciated by its phenomena. An habitual alterna-
“tion of action and reaction between exterior bodies
40%
628
“ and the living body—an alternation of which the pro-
“ portions vary according to the age of the latter—is
“ the most general of these phenomena. There is a
“superabundance of life in the child. In the child,
“ the reaction of the system is superior to the action
“which is made upon it from without. In the adult,
“ the action and reaction are on a balance ; the turges-
“cence of life is gone. In the old man, the action of
“ the inward principle is lessened, the action from
“without remaining unaltered ; it is then that life
“languishes, and insensibly advances towards its na-
“tural term, which ensues when all proportion ceases.
“The measure, then, of life in general is the differ-
“ence which exists between the effort of exterior
“ power and that of interior resistance. The excess of
“ the former is an indication of its weakness; the
“predominance of the latter an index of its force.”
Taking this definition of life by Bichat as a foundation,
we may, in order to show the unstable nature of the
material upon the physician and surgeon have to work,
add on the endless diversity of constitutions in per-
sons of the same age, and the various degrees of
perfection in which the different functions are per-
formed ; and lastly, the long list of diseases to which
the human body is subject, and the variations that
occur from time to time in the very nature and cha-
racter of these diseases. The unstable condition of
the materials with which we have to deal is, then, the
reason why medicine is not and never can be an exact
science. It is a science of observation. The greatest
minds have been employed upon it from the days of
Esculapius, Hippocrates, and Galen, and vast stores
of facts have been piled up by the laborious and accu-
rate observers of ancient and modern times. We of
629
the present day enjoy the advantage of their works,
and use them as finger-posts to point to what is correct,
or as beacons to warn us of the errors into which they
have fallen. And thus, though many of us are pig-
mies compared to many of our predecessors, we are in
a better position than they were ; we enjoy the fruit of
their labours, and may be compared to the dwarf on
the giant's shoulders, who sees farther than the giant
himself. This want of exactness in medicine is a chief
reason why we sometimes find men of highly educated
minds prone to run after and adopt the vilest quackery.
They have been accustomed to deal with and exercise
their minds upon the exact sciences. They are accus-
tomed to look for and to find accuracy as the result
of their investigations; and they expect that the pro-
fessor of medicine shall predict every change in the
course of a disease, and its final termination, with the
accuracy with which an astronomer foretells an eclipse
of the sun ; and that he shall adopt means to carry
them over their difficulties, with the same certainty as
an engineer lays a lattice bridge to carry a railway-train
over a ravine. Now, the true physician or surgeon
promises nothing positively. He says: I know what
I have to deal with ; I have spent my life in the inves-
tigation of man in health and in disease; I have
assisted my powers of observation by studying the
works of the masters that have gone before, or are my
contemporaries; I have derived the benefit of their ex-
perience, and compared it with my own; and, as far as
the accumulated knowledge of years, sifted and puri-
fied by passing through the filter of modern experi-
ence, can make me competent, I am willing to do my
best to relieve you. Any one who goes beyond that in
promising to cure disease is nothing but a charlatan.
630
Even surgery, accurate and improved as it is, dare not
promise a cure with certainty, for we all know that the
smallest scratch may terminate in the destruction of
life. I once saw a boy killed by a slight abrasion of the
skin of his cheek, caused by an accidental stroke of
the end of a whip. He was rapidly seized with lock-
jaw, and as rapidly carried off. We do not profess
unerring success; and hence the class of persons to
whom ‘I have alluded, unable to comprehend the
reasons for such caution, fly in disgust, and throw
themselves into the arms and into the power of some
of the numerous impostors, whose chief bait to catch
the learned, as well as the unlearned, consists in the
falsehood and effrontery with which they promise a
certain cure. But, although the true disciple of medi-
cine abstains from the dishonest boasting of the unblush-
ing quack, he knows that the resources of his art are
almost boundless, and that when used with skill and
ability, they are most frequently successful.
It is usual for those who undertake the duty of ad-
dressing the class at the opening of the medical session,
to make some observations on the manner in which
information can be best acquired, and time can be best
employed. This subject has been so amply and so ably
handled by some of my colleagues, in recent addresses
from this place (which addresses have been printed for
the benefit of the students), that I feel it would be
almost superfluous for me to attempt to add anything
to what they have said. To any of my hearers who
are so fortunate as to possess copies of these, I would
say, read them again ; and to those who have not, I re-
commend that they should apply to the distinguished
authors, and obtain copies, or borrow from those of
their fellow-students who have them. I cannot, how-
631
ever, deny myself the pleasure of reproducing on the
present occasion some passages from two of those
valuable and eloquent lectures. Dr. Benson, Professor
of Medicine in the Royal College of Surgeons, who
opened the course of clinical instruction in the year
1859, thus speaks: “The grand object you have in
“view is to know how to treat disease in all its forms.
“Disease, as the name implies, is usually attended with
“ pain or inconvenience. It proceeds from some abnor-
“mal condition of the body or of its functions. We
“ must, therefore, make ourselves familiar with the
“ body as a machine—and a wonderful machine it is—
“with its two hundred and fifty bones, to protect and
“support the soft parts; with its four hundred and
“sixty muscles, by which every motion of the body is
“ performed—walking, talking, eating, drinking, breath-
“ing, laughing, crying, etc., etc. Then, as these parts
“wear, how they are repaired by myriads of vessels
“carrying off the worn-out particles, and supplying
“fresh ; how the heart pumps the material through
“ten thousand canals, at the rate of one hundred
“ thousand strokes a day for seventy years; how these
“materials are prepared in the digestive organs, then
“sent to the heart, then forwarded to the lungs to be
“purified ; how combustion is for ever going on in
“ the lungs, to keep up animal heat; how a nervous
“system supplies every part, carrying sensations to the
“brain, and carrying the commands of the will from
“ the brain, the mind's presence-chamber ; how all this
“is set to work by that mysterious thing called Life ;
“how there are telescopes, and microscopes, and mills,
“ and chemical laboratories, and galvanic batteries, a
“forcing pump, a furnace, all the mechanical powers,
“ and so on, in the system : all this is taught by ana-
632
“tomy and physiology. And how absurd it would be
“ to think of repairing such a complex machine with-
“out a good knowledge of its structure and powers
“Then morbid anatomy shows the alterations produced
“in this machine by disease. Physiology teaches us
“the healthy functions; pathology, the unhealthy.
“Chemistry teaches us the composition of the fluids
“ and the solids, and, again, it gives us the composition
“ of our remedies. Materia medica and botany furnish
“us with these remedies. All these must be attended
“to by reading and lectures, that you may study the
“practical part, that is, medicine and surgery, and its
“subdivisions, midwifery, dentistry, etc., with effect.
“But of all the modes by which you can acquire a really
“sound acquaintance with the practical part of your
“ profession, none can at all compare with clinical
“observation and instruction. This means, literally,
“bedside-instruction. It is that which we derive from
“seeing, and feeling, and considering disease as it actu-
“ally exists before us; studying it not in books, nor
“in lectures, but in nature. What you want to know
“is how to prevent, or palliate, or cure. Here, in
“nature's own book, you study the history, the causes,
“ the varieties, and the symptoms of disease. The
“ diagnosis, or distinction of one malady from another,
“never could be learned except at the bedside. The
“ prognosis, or anticipation of results, would be vague
“—the application of remedies would be dangerous.
“It is at the bedside you must learn the lesson which
“I wish you always to bear in mind—namely, that you
“are never to prescribe for a disease, but for the
“ patient who is labouring under the disease; that is,
“you are to consider not only what may be good for a
“given disease, but what will suit the patient in every
633
“ particular, and with a due regard to all the organs of
“the body, as well as the one affected. “What will
“suit his constitution,’ is a popular phrase which
“expresses to a certain extent what I mean, but not
“the entire. For example, tartar emetic will cure
“inflammation of the lungs. You try it on two pa-
“tients: they are in adjoining beds, of the same age
“ and sex, with the same amount of inflammation. It
“does cure one, but it may kill the other. Why?
“Because, though good for the disease, it was unsuited
“ to the patient. You ought to have prescribed for
“ the man who was labouring under inflammation,
“instead of which you prescribed for the inflammation
“under which the man laboured.”
So far Dr. Benson. I think you will admit that no
apology is needed for the length of the extract.
Let me now cull a few words from the introductory
lecture of Dr. Croly, delivered from this place in the
year 1863:
“You are all, doubtless, desirous to fit yourselves for
“usefulness and respectability—to obtain a position in
“Society, as well as to earn an honourable independ-
“ence; to acquire which you must labour and toil.
“No person can do this for you ; it must be your own
“doing. Your motto should be, ‘Work, work;' and
“you will find it almost astonishing what difficulties
“you can overcome by constant diligence. Those
“islands which so beautifully adorn the Pacific Ocean
“are known to have been reared from the bed of the
“sea by the little coral insect, which deposited one
“grain at a time till the whole of those vast piles were
“reared up. Just so it must be with your exertions.
“It is not, however, by hard work for a few days, and
“ then idleness for as many more, that good can be
634
“ done. As a rule, rapid strides and then much rest
“will not succeed : remember the fable of the hare and
“the tortoise. No, my friends; it is the regular,
“steady, constant, daily, earnest work that will tell.
“These are no times for idolence or inactivity. This
“is what is emphatically called the age of progress;
“you should remember the advances which education,
“the sciences, and arts are making in all classes of
“society, in accordance with the spirit of the age. In
“ the march of improvement, do not be content with
“bringing up the rear. Be up and stirring. Your
“exertions should keep pace with the swift advances of
“universal intelligence ; otherwise, be assured you
“will find yourselves outstripped in the race. Let
“your motto be, ‘Eacelsior / eacelsior ſ”
Thus spoke the junior member of our staff two years
ago. I gladly avail myself of these two quotations, as
they express in a condensed form, and in language
more expressive and lucid than I could hope to employ,
the best advice suited to all ranks of medical students.
I would just wish to add, and to caution you, that
whatever character you establish for yourselves now
among your fellow-students will adhere to you through
life, and in future years may influence your position
materially. There may be, and I know there are,
bright exceptions in which a decided change of conduct
has redeemed an early evil reputation ; but they are
very rare. I have witnessed the rise and progress of
many medical students, including my own fellow-pupils
as well as those of succeeding generations, and I speak
in the presence of those who are equally well able to
testify to the fact, and I think they will agree with me
in asserting that, as a rule, we find that the character
635
of the man can be predicted from the conduct of the
boy; that when all of a class grow up together, and
embark in the struggle for professional position, the man
who has been well conducted in the school will be
remembered by his fellows as such ; that he who, by
dissipation and idleness and vice of various kinds, has
made himself remarkable, will never be forgotten ; and
that, when opportunity offers, the good or evil report
of a former class-fellow may often exercise an all-
powerful influence.
I said in a former part of this address that ours is a
godlike profession ; and I did not make use of that
expression hastily or unadvisedly. The occupations in
which we are engaged are those in which our Divine
Master seemed to take the greatest pleasure, and in
which He most often took occasion to exhibit His
omnipotent power. Clothed in human form, He de-
lighted to relieve the sufferings of miserable mortals;
and the great majority of his recorded acts on earth
consisted in healing the sick or restoring the dead to
life. Multitudes followed Him and flocked about Him,
and He healed them all, whether Jews or gentiles.
When questioned in the words, “Art thou he that
should come, or do we look for another ?” what de-
monstration of His divine origin was he pleased to
afford P Did He tear up mountains by their roots, and
cast them into the sea 7 or command the sun to stand
still? or shake the foundations of the earth with light-
nings and thunderings from heaven 2 No! His reply
was ; “Go and show John again those things which
“you do hear and see : the blind receive their sight,
“ and the lame walk; the lepers are cleansed, and the
“deaf hear; the dead are raised up, and the poor have
636
“ the gospel preached unto them.” He did all this by
the word of his mouth : He spake the word, and all
things obeyed him. We do not presume to work
miracles, as He did ; but surely it cannot be considered
irreverent to style that profession godlike whose mem-
bers are enabled, by the light of reason vouchsafed to
them, and by the accumulated experience of ages, to
walk humbly in His steps, and go about doing good
and healing all manner of disease among the people.
Hospitals are the stages on which these acts of mercy
are most prominently exhibited ; in them the poor,
who were more particularly the objects of divine
solicitude, find shelter, and care, and health, and re-
storation to life and energy; in them the votaries of
medical science have the fullest scope for the exercise
of those talents and acquirements with which they have
been entrusted.
I am proud to say that in this hospital it has been
the endeavour of the medical staff to uphold the repu-
tation of the science, and to fulfil their mission. I
can say emphatically that within these walls the blind
have received their sight, the lame have been made to
walk, the deaf have been made to hear, the lepers have
been cleansed, and the dead have been raised up.
Time will not permit me to enter more particularly
into detail respecting the many cases of dangerous
disease that have been treated and cured, or the many
important and daring operations which have been
performed ; but I cannot refrain from a passing notice
of one of the greatest achievements in surgery which
took place in this theatre. I allude to the splendid
operation performed by Professor Hargrave, which
many of my audiences were fortunate enough to witness.
637
The ligature of the common iliac artery (the largest
blood-vessel in the body next to the great aorta, from
which it springs), was performed many years ago, for
the first time in this country, by one of the ablest and
most dexterous surgeons of the age, the late Sir Philip
Crampton. The case was unsuccessful. The second
case fell to the lot of my highly esteemed and respected
colleague. With all the coolness arising from a per-
fect knowledge of the difficulties of the operation
before him—with all the dexterity of the long-tried,
experienced operator—in short, with all the qualities
that might be expected in the author of Hargrave's
Operative Surgery, he went through the long and
tedious dissection, never hesitating, and never hurry-
ing, until success rewarded his skill, and for the second
time in this country a ligature was tied upon the
common iliac artery in a living subject. Some circum-
stances, unconnected with the operation, caused the
death of his patient a few months afterwards, but as far
as the operation itself was concerned, it was perfect.
To be able to accomplish this or similar feats, or to
be a successful practitioner in medicine, is one of the
proudest positions to which man can attain. Let me
quote what the philosophic and eloquent Graves said
upon the subject : “I would not depreciate the utility
“of other literary pursuits, and do not wish to under-
“value the studies or the objects of other professions.
“The natural historian is justly proud of a science
“which constantly employs him in observing the works
“ of his Creator ; the chemist boasts, with reason, that
“his favourite study teaches him to lift up the veil
“which concealed some of the most precious and singu-
“lar among nature's secrets; the astronomer examines
638
“ the position and motions of distant worlds, weighs
“the satellites of Jupiter, and follows the comet to the
“remotest verge of its eccentric orb; nay, he even ven-
“tures to predict its return after thousands of years,
“and feels no doubt that a late posterity will be called
“on to record the occurrence of the event which he
“has prophesied. This is a glorious triumph of man's
“reason, and well may the votaries of astronomy and
“ physical science refer with pride to such victories over
“space and time; but is there not more of the Deity
“in a single particle of living matter than in the whole
“inanimate mass of a planet or a sun ? Is not life the
“clearest, the most direct revelation of Himself which
“ the Creator has deigned to make 2 When all was
“without form and void, the Spirit of God moved, it
“is true, on the surface of the chaotic mass, but it did
“not enter into its pores until life was to be produced;
“ then God breathed forth, and man rose vivified by
“ the divine expiration. This life—this direct ema-
“nation from the Deity—forms, then, the subject mat-
“ter of your studies; to observe its laws is the
“privilege of the physiologist; to maintain it, to resist
“the encroachment of disease, or to defer the approach
“of death, is the hallowed end of medical science.
“This is assuredly one of the noblest functions of
“reason, and for nothing should man be more humbly
“grateful to his Maker, than for having conferred on
“him the power of relieving human suffering.”
To you, gentlemen, who are embarked in the study of
the profession a knowledge of which confers the power
of relieving the sufferings of your fellow mortals, I
would recommend these noble sentiments. Let them
sink deep into your hearts, and while pursuing the
639
laborious path which leads to future eminence, recol-
lect that the object and aim of your present studies is to
place you in the ranks of that highly favoured army
whose mission and privilege it is to combat disease
and death.
THE END.
64 |
I N D E X ,
Abdomen, wounds of
Abdominal aorta, aneurism of
Abscess in ovarium tº º º & gº tº tº º ſº
Address to Dublin Obstetrical Society, 1844...
to Dublin Obstetrical Society, 1862
delivered in City of Dublin Hospital
Adipocire tº tº e º º gº tº e tº º º
composition of ...
mode of formation of tº gº tº
Andral, opinion of, in case of Mr. M. tº ſº º
Antrobus, Thomas, account of case of Sarah Parr
Aorta, aneurism of tº g tº & 9
Aphrodisiacs
Apoplexy, death from tº it tº
Arnott, Mr. on venous inflammation
Artery, common iliac, ligature of ...
Ashwell, Dr. on changes of position in uterus
Asphyxia idiopathica
Asphyxia
Avicula, case of ...
Baillie, Dr. case of hermaphroditism
Banon, Dr. case of hermaphroditism
on vesico-vaginal fistula
Barker, Dr. John, analysis of calculus removed from
Barzelotti, case of rupture of stomach tº gº tº
Battey, Dr. operation for vesico-vaginal fistula
Beatty, Dr. John, observations on use of instruments in difficult labours...
Page
511
305
77
581
603
619
450
453
454
329
254
305
364
458
234, 284
female bladder
on proper period for using forceps ...
on alleged ill effects following use of forceps ...
637
273
458
460
428
413
416
578
292
513
574
14
15
41
642
Page
Beatty, Dr. John, directions for using forceps & s 'º tº e a te e ºl 16
cases illustrating use of forceps a s e & & ºt tº e Hº 19
on compression of child’s head during delivery ... * - ſº 25
letter on a species of premature labour ... e º ſº tº ſº º 32
mixture for hooping-cough ... g & is e tº º tº tº º 85
on use of instruments in labour gº tº gº tº º & $ tº e 97
account of a case in which pregnancy was complicated with
tumor in uterus ... tº ſº tº * * * tº g tº tº º ºs 366
Beatty, Dr. T. E., extracts from Address to Dublin Obstetrical Society ... 2
report of the South-eastern Lying-in Hospital ... º e tº 37
on the effects of protracted labour & º e tº º º gº tº gº 43
cases of protracted labour ... tº ºr e & ſº tº tº gº e 46
on mode of using forceps * * * g is tº & e is tº º ſº 48
on measurement of forceps ... tº gº º tº gº º tº & ſº 48
on laceration of vagina and bladder by forceps ... tº gº tº 58
cases of delivery by the perforator tº º ſº is tº ºr tº º º 60
on puerperal fever ... us é º e g = gº tº º tº tº gº 65
observations on use of forceps # tº s & º tº g tº 86
cases illustrating use of forceps in pluripara tº $ tº tº tº gº 98
cases illustrating use of forceps in primipara ... tº gº tº 102
description of forceps e G & tº º ſe # tº q tº G & 115
on the means of preventing uterine haemorrhage after delivery 124
explanation of tolerance of haemorrhage in parturient women 125
on Secale cornatum ... * s ſº tº tº $ tº 136
on the influence of secale on the foetus in utero ... tº sº s 141
on chloroform in midwifery in conjunction with ergot of rye 177
further remarks on the use of chloroform in midwifery ... 204
on purulent effusions into joints in puerperal women & © $ 221
on case of pregnancy complicated with tumor occupying
nearly entire pelvis e tº e tº º g tº gº o & Cº º 241
on uraemic poisoning in cancer uteri ... tº $ tº tº gº tº 263
on retroflexion of the uterus ... * * * * tº tº tº tº gº 273
on calculus in female bladder... & tº wº * * * tº ſº tº 290
on frottement in peritonitis ... gº tº gº • * * tº E tº 297
on inversion of bladder through urethra with prolapsus of
rectum in female child tº tº gº tº gº e * * * tº g tº 301
on abdominal aneurism * * * tº e tº tº tº e e tº º 305
on impotence tº º te tº tº e $ tº e * † :-} tº g tº 332
on rape ... tº & gº s ſº tº * * * & ſº º tº º is 367
on doubtful sex tº gº º tº e ºt * * * $ tº e e g tº 398
on abdominal aneurism • . . . . . . tº ſº a & e º 323
on persons found dead tº gº º tº tº & & O $º tº a 427
on the cure of dysmenorrhoea ... tº º e tº gº º $ $ tº 552
on plastic operations on the female genito-urinary organs... 563
Address to Dublin Obstetrical Society, 1844 ... * tº º 581
Address to Dublin Obstetrical Society, 1862 ... tº tº º 603
Address delivered in City of Dublin Hospital, 1865 tº E & 619
Benson, Dr. on disease ... a tº e & © tº gº a º & © tº gº tº it. 631
643
Page
Bichat, definition of life by 627
Binder, description of ... § tº º 129
Bladder, inversion of, with prolapsus recti 301
Brodie, Sir B. on the effects of cold on life ... 545
on death from lightning 549
on professional ethics 591
Brougham, Lord, anecdote of * tº e tº gº tº 623
Brown, Dr. Baker, operations for prolapsus uteri 575
Bruhier, case of supposed death 428
Bruises cº e & & © tº ‘... 496
Burned, persons found ... tº ºn tº tº s e 534
before or after death & º & 538
Burns on rash use of perforator and crochet 18
Burghard on ergotism 157
Byford, Professor, on chloroform 193
C.
Cadaveric rigidity & e 437
Calculus in female bladder 290
analysis of tº tº tº 9 @ º tº a º 292
Cancer of uterus attended with uraemic poisoning ſº tº º ſº 263
Catlett, Dr. on tendency of Secale cornutum to produce hydrocephalus in
infants tº tº dº tº tº ſº 149
Chamberlain on perforator and crotchet 9
invention of forceps 10
on rash use of crotchet 18
Chapman on forceps tº 10
Chassat, Dr. on effect of cold 545
Chevreul on adipocire 453
Chloroform in midwifery ... 177
purification of 180
tests for gº tº gº º gº tº s 2 * * * tº ſº tº * * is 179
administration of tº tº gº gº tº tº s tº º g º ºs 181, 198
combined with ergot of rye e se 184
Dr. R. Lee on tº 9 tº 211
Chopart on introversion of bladder ... 302
Christison on suffocation ... tº ſº tº tº e e s tº gº tº $ tº 490
on the discrimination between wounds inflicted before and after
death tº º º 496
case of rupture of stomach 513
on spontaneous combustion * - ſº tº gº tº 535
on the effects of burns on living and dead bodies 538
Circulation as evidence of life * † tº tº º º 434
Clarke, Joseph, appointed master of Lying-in Hospital 3
tº tº tº tº a 4
report of Lying-in Hospital
644
Clarke, Joseph, on size of pelvis permitting passage of full-grown foetus ...
Clench, Dr. case of
Coition, legal definition of tº º º
Cold, death from & e º s & º
treatment of apparent death from
Collins', Mr. memoir of Dr. Clarke... to tº º
Collis, Dr. M. operation for vesico-vaginal fistula
Combustion, spontaneous ... • & ©
Conception after rape ... e e º
Consent in rape ... © tº º tº o tº º º º
Convulsions, puerperal, case of ... *
Cooper, Sir Astley, on a disease resembling gonorrhoea.
Cornea, appearance of, as evidence of life
Croly, Dr. on the study of medicine
Crotchet, horrors of g
Daventer on perforator and crotchet
on rash use of crotchet
Davis, TXr. on retroflexion of the uterus
- on treatment of
Dead, persons found
Dease on the forceps tº º º tº tº tº gº tº e
on rash use of perforator and crotchet
Death, signs of ... tº dº º
cooling of body afte tº e ºs
rigidity after e - e. & G → ...
physical tests of
changes after
from natural causes
from violent causes
from asphyxia tº 9 &
from drowning ... © º º
period which has elapsed since
from hanging tº e º
from strangulation
from smothering
from wounds
from cold
from hunger
from lightning
Deficiency of penis
Defloration, signs of
Denman on the forceps tº e
on use of forceps tº e e
definition of difficult labours e
reason for justifying use of perforator
Page
23
486
388
542
545
º º 5
564
537, 541
. 396
395
52
382
440
633
18
18
275
276
427
11
18
432
435
437
441
443
456
459
460
461
471
474
485
488
491
542
545
548
334
380
12
13
13
23
645
Denman on compression of child's head during delivery
Devergie on period which has elapsed since death occurred
Dewees on the forceps ... © e ºs tº a
Diagram for use of forceps © & &
Diaphragm, wounds of ... & © e tº g tº
Donnet, Cardinal, on persons supposed to be dead
Doubtful sex ... e - a & G is
Drowning, death from ... & © º º tº e tº º º
Dunlop, Dr. case of wound of heart
Dupuytren on wounds of heart
Dysmenorrhoea, operation for cure of
E.
Ecchymosis
Electricity e -
Ellenborough Act
Ergotism tº ſº tº &
Experienced Physician, letter of an - a e tº gº tº
Extracts from reports of South Eastern Lying-in Hospital
F.
Face, wounds of
Fever, puerperal © º º tº º ſº - - -
Fitzpatrick, Mr., opinion on the case of Mr. M.
Foderè on suicidal strangulation & © e
Forceps, on mode of using
description of ... - - - • e e © e >
proportions of
cases illustrative of use of
Fourcroy on adipocire
Frottement in peritonitis
Galvanism as test of death
Gonorrhoea simulated in young females
Gosset on metallic sutures
Graves, Dr., mode of teaching of
on the study of medicine
Gregory, Dr. W., on tests for chloroform
H.
Page
471
11
117
510
430
398
461
509
507
552
496
550
494
156
37
502
65
327
... 486
... 48, 118
... 48, 115
48
86
451
297
441
381
563
626
637
179
Haemorrhage, uterine, means of preventing, after delivery
124, 127
646
Haemorrhage, uterine, cause of & 1 & * † ºn
Hamilton, Professor, on the management of difficult labours
on the management of laborious labours ...
Hanging, death from tº $ & º º
pathological appearance o
whether suicidal or not
case of accidental tº º tº gº tº tº gº tº
Haughton, Rev. Dr., on fracture of spine in hanging ...
Hargrave, Dr., operation for ligature of common iliac artery ...
Head, wounds of
Heart, wounds of tº e ſº
Hermaphrodite ... * * * * * * ſº tº e e i tº
means of ascertaining true sex of supposed
Hermaphroditism, Sir E. Home's explanation of
case of, by Sir E. Home
Hippocrates on real death * g is
Hobbs, Mr. on the mortality of wounds
Hodgson on aneurism tº º e
Hooping cough ... tº e s tº gº tº
Dr. J. Beatty's mixture for
Houghton, Dr., case of abscess in ovarium ...
Houston, dissection of criminals hanged
Hungar, persons found dead from ...
Hunter, John, on death from lightning
Hymen tº dº tº º º
Hysterotome, Simpson's ... tº gº tº tº tº gº
I.
Impotence
causes of
treatment of
Intestines, wounds of
Inversion of bladder
J.
Joints, purulent effusion into
L.
Page
126
39
45
474
475, 479
481
483
476
637
500
507
398
425
424
410
439
491
306
84
85
80
479
545
549
372
562
332
333
362
514
301
221
Labour, Denman's definition of difficult
phenomena of *
parts concerned in
temperaments of patient in
13
88
89
91
647
Labour, danger in difficult
symptoms indicative of danger in
Lachapelle on the forceps ... © º ºs
Lallemand, case of rupture of stomach
Lamotte on perforator and crotchet
Lee, Dr. R. on chloroform e tº gº tº ſº º & G & ê tº gº
on means of checking uterine haemorrhage in parturient women
on the value of secale in checking haemorrhage in parturient women ...
on phlegmasia dolens * e g
Lefort, Marie Madeleine, case of -...
Liebig, Baron, on spontaneous combustion
Leseur and Orfila's experiments on adipocire ...
Lightning, persons found dead from
Liver, wounds of * E
Life, what constitutes
Lungs, wounds of
M.
Macnamara, Mr. on uraemic poisoning in cancer uteri
Male, Dr., case of suicidal hanging tº gº º * @ e
Malformation of urinary and generative organs of male
of urinary and generative organs in female
Marguerite, Marie, case of * * * & º E tº a tº * - e.
Maunsell's, Dr., mode of preventing haemorrhage after delivery ...
Maygrier on the forceps ...
Merriman on distortion of pelvis tº º e # 3 &
on symptoms indicative of danger in labour
Millot on the forceps tº in it
Martinet on diagnosis ... • g º & © tº & ſº tº Q & e * c º
Montgomery, Professor, account of post-mortem examination of a case of
Caesarean section
Neck, wounds of
Neuters
Opium in uterine haemorrhage
Organs of generation, malformation of
wounds of tº gº tº * - $
Orfila and Leseur's experiments on adipocire
Osborne on state indicating use of forceps
Page
92
93
12
513
211
I 35
139
234
408
538
454
548
514
43i
500
272
482
400
406
401
129
12
24
93
12
305
258
503
411
164
400
517
454
14
648
Osborne on size of pelvis permitting passage of foetus ...
Ould on the forceps
Ovariotomy, statistics of ...
Ovarium, abscess of
Paralysis after delivery ... 4 - - tº e - º e e
Paris on signs of life
erforator, horrors of
cases of delivery by - -
Pichegru, General, case of º, º º º
Premature labour, letter of experienced physician on ...
letter of Dr. John Beatty on
Protracted labour, Professor Hamilton on
Dr. T. E. Beatty on
Peritonitis, frottement in ... tº e >
Persons found dead - © tº e - ©
Persons found dead with wounds ...
burned ...
dead from cold
hunger * * .
lightning ... tº e -
Pessary, form of, for retroflexion of the uteru
Peu, Philippe, case of supposed death
Phenomena of labour tº e -
Phlebitis
Phlegmasia dolens º tº º º & Q &
Philip, Wilson, Mr., opinion of, in case of Mr. M.
Philips, Mr., on introversion of urinary bladder
Pierre, Hubert J., case of tº º - tº º º e tº e
Plastic operations on the female genito-urinary organs
Pregnancy, complicated with pelvic tumor
Puerperal fever ... © - - * * *
cases of
portability of
Purulent effusions into joints
Putrefaction after death ...
Rape ... © º º
legal definition of
signs of
what constitutes ... e - e.
without knowledge of female ...
Regimen malum
Page
23
11
615
77
75
433
18
60
487
29
32
39
43
297
427
491
534
542.
545
548
288
428
88
234
234
330
302
413
563
241
65
67
74
221
446
367
367
371
390
393
526.
649
Page
Register of South-eastern Lying-in Hospital ... • * * - - - • a sº 37
Remède de magnanimité ... º e - tº g tº - e. e - - - - • a º 365
Remer, case of suicide * & ſº & © tº & © tº * * * º, º e tº tº g 485
on case of General Pichegru & g tº * * * tº º º gº º ºs 487
Report of South-eastern Lying-in Hospital ... tº tº tº ... . . ... . . 37
Retroflexion of uterus ... - - - as ºr tº tº e - - - tº sº tº 273
Richerand on internal aneurisms ... e is e * - tº tº e - * * * 306
Rigaudeaux, case of supposed death . ... tº e s e - 4 is a s 428
Rigidity, cadaveric & sº tº tº Q tº tº & tº © tº º tº a tº tº º & 437
Royal Society of London, foundation of ... tº º is * & ºt ... 587
Ruptured uterus, case of ... * - - & © e tº - e. e e - tº º is 54
S.
Scarpa, case of abdominal aneurism tº dº tº * c > • 2 - e e s 325
Secale cornutum ... e tº e • * * ... • * * © tº a • * * 136
observations of MM. Boettcher and Kluge on ... tº º º 138
mode of administration of ... tº º º ... 137, 175
influence of, on foetus in utero * c º tº a tº ... 141
cases in which used to ſe g • & e e - 146, 167
value in menorrhagia • * * tº e e - - - p s is 174
mode of keeping of & 2 & • * = - - - sº tº e 175
Sellis, case of ... º tº e e tº e tº dº is tº º º tº º º & ſº º 532
Sims, Marion, on metallic sutures ... * † de tº tº º tº gº tº 563
Simpson, Professor, operation for cure of dysmenorrhoea tº e - ge tº gº 555
instrument for treatment of uterine displacement ... 286
South-eastern Lying-in Hospital, report of ... tº tº tº º ºg - © tº dº 37
register of ... tº ſº tº e tº gº tº ſº tº © tº º 37
table of number of cases in which labor exceeded twenty-four hours 41
Smellie on forceps © º e tº º & s is tº * c & tº & Cº. 10
on compression of child's head during delivery tº e - e e ºs 25
Smith, Dr. on accidental hanging ... © tº e º, º ºs tº º º Q tº e 483
Smothering, death from ... tº º & 9 tº gº © 2 º' & © tº tº tº º 488
Spontaneous combustion .. © º - tº º e • s e . * * * 537, 541
St. Martin, Alexis, case of • e - tº dº º e s sº º 512
Stokes, Dr. on aneurism of the aorta e º e • * * tº - © tº ºn tº 304
Stomach, wounds of tº tº e • tº º e e g • * * tº ºn tº e º 'º 511
Strangulation, death from • 2 º' tº tº gº ºn tº e © tº ſº ge tº º 485
appearances in tº e - tº tº ſº ... " ... tº º º 486
Supposed death, cases of ... • - e. & e e • * * © tº e tº tº 428
T.
Table of cases in which labor lasted more than twenty-four hours in South-
Eastern Lying-in Hospital e 41
Temperature as evidence of life ... ". & © e tº a tº tº sº e 434
650
Thompson, Mr. on lithotomy and lithotrity ... e - e. tº a º ete &
Thoracic duct, wounds of
Thorax, wounds of e G
Todd, Dr., on renal dropsy
Tumor complicating pregnancy
Tſ.
Uraemic poisoning following cancer of uterus ...
Uterus, ruptured, case of º tº e s ſº tº
cancer of, attended with uraemic poisoning
retroflexion of
prolapsed, operation for
V.
Vagina of virgin e º º tº e tº e
Velpeau on retroflexion of uterus ...
Violation without knowledge of female
"Viterbi, case of tº º º
W.
Page
295
510
506
269
241
263
54
263
273
576
378
275
393
547
Watson on wounds of external organs of generation in female ...
Wilde, Sir William, medico-legal observations
Wind contusions & © tº - - - tº e - - - -
Wood, Kinder, on gangrenous disease of the female genitals
Wounds, death from - tº e - -
definition of
classification of ... tº ºr a
whether before or after death e º 'º tº g tº
whether the result of suicide, of accident, or of murder
mortal
dangerous
of the head
of the face
of the neck
of the thorax
of the lungs
of the heart
of thoracic duct
of diaphragm
of the abdomen
of the stomach ...
of the intestines .
517
388
515
382
492
492
492
496
527
495
495
500
502
503
506
506
507
510
510
511_
511
514
651
Wounds of the liver
of organs of generation
circumstances affecting
Wright, Dr. on ergotism ... © tº ſº
experiments with Secal
Page
514
517
520
156
158
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Man.—Digestion.—Food.—The Teeth.-Absorption.—Action of Medicines.
—Blood.—Circulation.—Respiration.—Animal Heat.—Asphyxia.—Secretion.
Liver.—Kidney.—Urine in Health and Disease.-Calculi.-Nervous Force.
—The Brain.—Spinal Cord and Sympathetic System.—Motion.—Organs of
Locomotion.—The Larynx.-Speech.-Cranial Nerves.—Touch.--Taste.—
Smell.—Sight.—Hearing.—Reproduction.—The Male Generative Organs.—
Female Generative Organs.—Development of the Embryo.—Morbid states of
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LECTURE 1. Introduction. 2 and 3. Air. 4. Water. 5. Influences of Soil
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Labouring Classes. 13. Sewerage. 14. The Burial of the Dead. 15. Town
Improvement. 16. Occupations Injurious to Health. 17. The Prevention
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1866. 19. The Cattle Plague in England and Ireland. 20. Disinfection.
21. Vital Statistics of Ireland. 22. The Poor of Ireland—Medical Charities.
23. Sanitary Organization. 24. Sanitary Laws—Proposals for Codification.
*-
APPENDIx: Sanitary Act, 1866–Nuisance Act, 1866—Disease Prevention
Act, 1855—Sewage Utilization Act, 1865—Public Health Act, 1848.

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