no change of position of the shoulder or arm, and that it was altogether unyielding, as soon as my strength was somewhat repaired, I endeavored to bring down the other foot. I found the uterus more firmly contracted than before. My strength being much enfeebled from long continued indisposition, the uterine contractions so paralysed my hand and arm that I was unable to advance it without assistance, which at my request (Dr. LEE, the gentleman who had sent for me,) afforded, by holding my elbow and pressing it forward as I directed. I found as I advanced my hand, that the body of the uterus had completely accommodated itself to the form of its contents. The leg of the child was extended at full length; the uterus contracted longitudinally around it in an hour-glass form, was divided into two sacks, the upper containing the foot with the placenta, a complete ring being formed around the ankle. The contraction could be distinctly felt externally, the fundus of the uterus reaching the epigastrium. By slowly and with difficulty insinuating finger after finger through this ring, it gradually yielded; the foot was brought down and secured as the other. In a short time the desired evolution took place, and delivery was effected. As soon as the hand passed above the stricture, the uterus contracted from its fundus, and the placenta joined together by a firm membrane, were immediately removed. Nothing unpleasant took place subsequently, and the patient continued to do well.

The presentation of the upper extremities is generally so hazardous both to mother and child, that every case of the kind affords something of interest to the profession. In this instance, the most important question which presents itself is the possibility or probability of delivery by the unaided action of the uterus; the irregular uterine contraction, the whole force of that organ being exerted laterally in opposition to its expulsive power; the irritation at the cervix tending to continue this state of things; the stricture on the leg of the child, together with the unyielding condition of the presenting part-all forbid the probability of such a result; but that delivery may take place with this presentation by uterine action alone, I can testify, whether by spontaneous evolution or whether the child was forced out in its doubled and

unnatural position, I am not able to say. DENMAN reports several cases of spontaneous delivery with this presentation, and witnessed them to have taken place by evolution or change of position, and was of opinion that practitioners should avail themselves of this knowledge to avoid the pain and danger which attends the operation of turning. Dr. DEWEES has never seen a case of this kind, but says the testimony in regard to its sometimes occurring is conclusive. He mentions several cases as reported by others, and justifies us in considering it as a resource after all rational endeavors have failed. Dr. COLLINS, in a practical treatise, (published in Bell's Medical Library,) containing deductions from the result of sixteen thousand six hundred and fifty-four births, in the Dublin lying-in-hospital, under his mastership, during a period of seven years, states that no instance of this kind occurred. Dr. CLARKE, during his attendance in the same institution, in seventeen thousand nine hundred and twenty-two cases, gives the same report, except one case which is mentioned only on the authority of a midwife in the institution. From these facts, Dr. COLLINS thinks the occurrence of spontaneous evolution is so little to be expected, that in a practical point of view it may be considered almost fanciful. While I cannot consider the idea of a hope of relief in this way fanciful, I at the same time could not (except under peculiar circumstances,) look to it with any confidence for ultimate security to the patient; but this well founded conviction with practitioners generally, urging them to give opportune assistance, has no doubt given relief in many cases which would have resulted in this way. In regard to the shoulder, by the firm contraction of the uterus, being so tightly wedged in the inferior strait as not to permit the slightest motion upwards, Dr. DEWEES says: "I will not say that this is never the case, but I must declare it seldom happens unless the proper time for acting has been lost." So far he has never met with a case in which he could not turn, where it was desirable, and then states, "that this perhaps has arisen from having been generally able to watch the proper moment for the operation." It is the testimony of every experienced and sensible accoucher, that the safety both of mother and child, requires him, in cases of this presentation,

to watch with the utmost diligence, for the earliest possible moment that he can succeed in turning. If from delay the extremity is forced too low in the pelvis, and the uterus become too firmly contracted on the body of the child to admit the possibility of such relief, we must endeavor to avail ourselves of the relaxing effects of blood-letting, opiates, &c.; and where the object cannot be accomplished by these means, and the child's life is destroyed by pressure, (which always ultimately occurs in such cases) instruments are speedily resorted to for the safety of the mother. It is not probable then that many cases of spontaneous evolution can occur, and no doubt this speedy and proper assistance presents the true reason why Dr. DEWEES never saw an instance of this kind, particularly as he testifies that he never met with a case in which he could not turn when desirable. This will also apply to Drs. COLLINS and CLARKE, who in no instance waited for relief in this way. These gentlemen were not liable to the delay which country practitioners often experience. In the neighborhood in which I reside, the poorer classes, and the negroes, of which there are large numbers on almost every plantation, seldom seek the aid of a physician until a perfectly ignorant old woman who generally has the management of such cases, becomes alarmed and asks for advice. The majority of these women, totally unacquainted with any difficulty that may arise, and judging of danger only by the length of time the victim of their ignorance has been in torture, will probably wait in all cases twenty-four hours or more, the efforts of nature; and if a physician is then sought, his distant residence or his absence when sent for, may sometimes extend it to a still longer period. Considering these circumstances here or elsewhere, it is not difficult to understand why the experience of one so situated should not accord with those whose location, &c. brings them in proper time to the bed-side of the patient; and we may readily credit the fact that he may occasionally, or at least in one instance, meet with a case where turning could not be deemed practicable by any prudent man. The following is a case in point, which confirms the experience of DENMAN and others, that in this presentation, nature will sometimes, unaided, effect a delivery, and makes it

conclusive that we are justified under some circumstances in considering the propriety of delay even in this most perilous condition, but I am satisfied we should never indulge such a hope except where the pelvis is very large and well expanded, or the child very small. On the 29th of April, 1838, I was called to Mrs. W. the wife of an overseer on one of the plantations in my neighborhood, who had been in labor during the preceding evening and night, under the management of an ignorant woman. On examination, I found the child's shoulder forced low and firmly impacted in the pelvis; the hand and arm protruding, much swollen and livid; pain almost constant; the uterus firmly contracted on its contents, so that the presenting part did not yield in the least to pressure; indeed, it was perfectly immovable. The mother's pulse was feeble and very much hurried, but the uterine action continued most violent. I at once judged the only hope of relief to consist in lessening the body of the child by perforation. An experienced medical friend being near, I sought his assistance. He agreed with me exactly in regard to the deplorable condition of our patient, and expressed a doubt whether she could survive long enough for us to procure obstetrical instruments, which were not at hand. While we were expressing our views and sympathies, the midwife came from the adjoining room, and announced the safety of our patient. The child was delivered without aid, but whether evolution took place or whether the child was forced out doubled up on itself, I cannot say, as I was not in the room at the moment it was effected. The child was at the full period, large, and somewhat swollen. The capacity of the pelvis was very great. The woman was of a healthy, vigorous constitution, and convalesced speedily. She had given birth to several children previously, and has also to one since, without the slightest difficulty.

CASE OF CLOSURE OF THE OS UTERI,

WHICH REQUIRED AN OPERATION. BY T. R. PUGH, SALEM, FAUQUIER CO. VA.*

To the Editor of the Maryland Medical and Surgical Journal. SIR-Having recently met with a case of closure of the os uteri which required an operation, and which seems to be somewhat uncommon in this country, I would like to see it published in your valuable Journal.

The following is a correct account of the case: Mrs. sent for me about the 10th of June; when I saw her, she appeared to be suffering from an attack of dysmenorrhoe; but upon enquiry into the history of her complaint, she informed me that she had not menstruated for two years, neither had there been a discharge of any kind from the uterus since she had her last child, about two years ago. The usual remedies for dysmenorrhoe were tried without effect. An examination per vaginam was made, which confirmed my former impression; but fearing I might be mistaken, I requested Drs. PEYTON and WITHERS to see her. The former gentleman saw her and made repeated examinations, and was decidedly of my opinion. As there seemed to be considerable enlargement about the abdomen, and her symptoms became alarming, we agreed to puncture the uterus, as affording the only hope of recovery.

I performed the operation on the 22d June, in the presence of and assisted by Dr. PEYTON, in the following manner, viz: I introduced a common middle sized scalpel wrapped with fine calico upon the index finger of the right hand to the point or indentation left by the closure of the os tincæ; then seizing the handle of the instrument beyond the os externum, I gently forced it through the coats of the organ; the instant it penetrated the organ, a gush of fluid took place, which was followed by relief, after discharging about two pints. I introduced a tube, which remained in about

This communication also came to hand too late for our last number. We hope to hear from the doctor frequently.

VOL. II.-No. 1.

EDS.

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