enlarged vessels which are always developed, in a high degree, in the uterine walls opposite the seat of the placenta. The laceration of these vessels leads to immediate danger, from draining hæmorrhage after delivery, and to more remote danger, from inflammation being liable to spring up in the torn and wounded sinuses of this part, and extreme uterine phlebitis following as a direct consequence. But still I hold turning to be the proper mode of practice in unavoidable hæmorrhages which cannot be restrained by less active measures, and where immediate delivery is demanded, with the os uteri well dilated, or easily dilatable, and the child still alive, or presenting transversely.

Besides turning, other modes of artificial delivery of the infant are occasionally resorted to in placental presentations. If the attendant flooding is such as not to require forced delivery till after the waters are evacuated, and the head well advanced in the passages, then version would be dangerous and inapplicable, and the use of the forceps offers the safest and easiest mode of extracting the infant. Further: in original pelvic presentations extraction may be at any time effected, when required, by seizing and dragging at the feet of the child.

V. Artificial Separation of the Placenta.-The arrestment of unavoidable flooding by total detachment of the placenta should, I believe, be our line of practice when the combination of circumstances is as follows-viz., the hæmorrhage is so great as to show the necessity of interference, and is not restrainable or restrained by milder measures, (such as the evacuation of the liquor amnii;, but, at the same time, turning, or any other mode of immediate and forcible delivery of the child, is especially hazardous or impracticable, in consequence of the undilated or undeveloped state of the os uteri, the contraction of the pelvic passages, &c. Or, again, the death, prematurity, or non-viability of the infant, may not require us to adopt modes of delivery, for its sake, that are accompanied (as turning is) with much peril to the mother, provided we have a simpler and safer means, such as the detachment of the placenta, for at once commanding and restraining the hæmorrhage, and guarding the life of the parent against the dangers of its continuance. Hence, as I have elsewhere stated, I believe that the suppression of the flooding by the total detachment of the placenta will be found the proper line of practice in severe cases of unavoidable hæmorrhage, complicated with an os uteri so insufficiently dilated and undilatable as not to allow of version being performed with perfect safety to the mother: therefore, in most primiparæ ; in many cases in which placental presentations are (as very often happens) connected with premature labour and imperfect development of the cervix and os uteri: in labours supervening earlier than the seventh month; when the uterus is too contracted to allow of turning; when the pelvis or passages of the mother are organically contracted; when the child is dead; when it is premature, and not viable; and where the mother is in such an extreme state of exhaustion as to be unable, without immediate peril of life, to be submit ed to the shock and dangers of turning, or forcible delivery of the infant. This enumeration is far

from comprehending all the forms of placental presentations that are met with in practice; but it certainly includes a considerable proportion of the cases of this obstetric complication, and among them, all, or almost all, of the most dangerous and most difficult varieties of unavoidable hæmorrhage. In adopting the practice, one error, which I would strongly protest against, has been committed in some instances. Besides completely detaching and extracting the placenta, the child has subsequently been extracted by direct operative interference. If the hæmorrhage ceases, as it usually does, upon the placenta being completely separated, the expulsion of the child should be subsequently left to Nature, unless it present preternaturally, or the labour afterwards show any kind of complication, which of itself would require operative interference under any other circumstances. Both to detach the placenta and extract the child would be hazarding a double instead of a single operation.

Comparative Mortality attendant upon Turning, and upon the total Separation of the Placenta.-One circumstance which strongly led me to advocate, in unavoidable hæmorrhage, the preference of the detachment of the placenta to the operation of turning the child, was the fact of the great mortality which followed the latter operation, as contrasted with the few mothers that died when the placenta was spontaneously expelled, or accidentally extracted before the infant. In speaking of the relative maternal mortality resulting from the two modes of practice, Mr. Barnes very properly points out, that when I spoke of the mortality attendant upon the separation of the placenta before the child as amounting to one in fourteen only, (ten in 141 mothers having died,) I had included cases in which the placenta was thrown off spontaneously before the child, along with others in which it was artificially detached; and he doubts if the results would not be widely different" if the statistics comprehended the latter class of cases only, "in which the severe operation of detaching the placenta, by the introduction of the hand, had been resorted to." The best answer to this objection consists in a statement of the results hitherto obtained from the practice of artificially detaching the pla

centa.

"Seventeen cases," says Dr. West, "have been recorded in the English journals, during the past fifteen months, of detachment of the placenta before the birth of the child in cases of placenta prævia. In the case recorded by Dr. Simpson, to whom it had been communicated by Mr. Cripps, the placenta was removed by an ignorant midwife, and ten hours elapsed before the child was born, during which time, however, no hæmorrhage took place. In sixteen out of the seventeen cases, the bleeding is said to have ceased immediately on the detachment of the placenta; but Dr. Everitt mentions, that although the flooding abated on the separation of the placenta, it did not entirely cease until after the application of cold externally; and he insists on the fact as proving, in cases of this kind, the hæmorrhage comes from the uterine as well as the placental ends of the lacerated veins. The life of the mother was preserved in every case but one, (out of the seventeen,) and then the previous hæmorrhage

had been so profuse as almost to exhaust the patient, who died three hours after delivery. All the children were still-born, except in the case related by Mr. Stickings."

I do not stop to inquire whether in one and all of these seventeen cases the artificial detachment and extraction of the placenta ought to have been followed. At present I adduce them, not as affording evidence of the propriety of the practice, but as affording evidence of its safety.

In proof of the maternal mortality under the old and recognised forms of practice being greatly higher than under the proposed plan of the extraction of the placenta before the child, Mr. Barnes refers, apparently with some hesitation, to the statistics collected by Dr. Churchill and myself, as showing that one in every three mothers was usually lost in placental presentations. Among 174 cases of unavoidable hæmorrhage collected by Dr. Churchill, forty-eight mothers died. I have now before me a carefully collected list of 654 cases of placental presentations reported by Mauriceau, Portal, Giffard, Smellie, Rigby, Clarke, and Collins, Schweighauser, Lachapelle, Drs. John and Francis Ramsbotham, Lee, Lever, and Wilson. Among these 654 cases, 180 mothers died, or one in three-sixteenths. In corroboration of the correctness of the statistical view which Dr. Churchill and I have taken of the extent of maternal mortality in unavoidable hæmorrhage, I would further beg to refer Mr. Barnes to the observations of Dr. Robert Lee. In his Midwifery Lectures, (pp. 370, 371,) published in 1844, Dr. Lee states a number of statisti cal facts regarding uterine hæmorrhage from placental presentations, and, amongst other matters, he mentions the result to the mothers in a considerable number of cases. I shall throw all his evidence on this last point into a tabular form.

Maternal Mortality in Seventy-two Cases of Placental Presentations noted by Dr. Lee.

Hence, according to Dr. Lee's collection of statistics, the maternal mortality in unavoidable hæmorrhage, amounting to twenty-five in seventy-two cases, is rather more than one in three. And this evidence of Dr. Lee will probably be regarded as the stronger, seeing that it is totally unprejudiced in its character; for in 1845, Dr. Lee called into doubt the accuracy of all collections of statistical data made by others, and which led to the idea, that the general maternal mor. tality in unavoidable hæmorrhage was so great, as to approach one in three. At that time he was, I believe, unaware of the general result of his own previously published collection of statistical data relative to the point in question.-Lancet.

THE

MEDICAL EXAMINER,'

AND

RECORD OF MEDICAL SCIENCE.

NEW SERIES.-No. XXXIII.-SEPTEMBER, 1847.

ORIGINAL COMMUNICATIONS.

Otorrhea. By JAMES BRYAN, M. D., Lecturer on Surgery, formerly Professor of Surgery and Medical Jurisprudence in the "Academy of Medicine," Castleton, Vermont, &c., &c.

The subject of otorrhoea, or a discharge, sometimes purulent, from one or both ears, is one of considerable importance, both to the patient and to the medical practitioner. The disease is very common, particularly in infancy and childhood. From being at first a discharge from the lining membrane of the meatus auditorius externus, affording relief to some other local irritation, and acting on the principle of counter-irritation, it becomes chronic, and is itself a disease.

In teething, ophthalmia, and other inflammations, nature very commonly establishes this discharge, which undoubtedly relieves these diseases.

From this fact, which is matter of common observation, both among the profession and the people, together with the aphorism which says, "Suppression of discharges from the ears, induces diseases of the brain," it is an every day affair to see otorrhoeas entirely disregarded, and no means whatever taken to heal them.

So general is this, that individuals reach the period of puberty with this affectiou in one or both ears. The evil consequences of such continued disease, with a regular purulent discharge for years, (in one case lately under my care of thirty-two years) may

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be easily conceived. The lining membrane of the meatus becomes thickened; the membrana tympani is destroyed; the bones of the ear are loosened and discharged, the inflammation, as I have seen in more cases than one, attacks the mastoid cells, and forms fistulæ opening externally.

In some cases the progress of destruction is more summary, and the disease, passing through the delicate organs of hearing, attacks the membranes and even the substance of the brain, producing then, and not till then, "convulsions" and death.

The latter termination, though by no means so frequent as might be imagined from the proximity of the disease to the cerebral organs, is yet sufficiently common to make the subject a matter of grave consideration. At the same time it must be borne in mind, that this introcession is liable to take place at any time during the existence of a chronic otorrhea; and particularly is it the case on exposure to a cold and damp atmosphere, or to any of the causes of colds or inflammations.

The evils, then, of the prolongation of this disease, may be arranged as follows:

First. It is inconvenient, the fluids not unfrequently being very offensive.

Secondly. A permanently diseased condition of the meatus auditorius is produced-or, the bones being attacked, we may have ulceration or suppuration established in the cellular structure of the mastoid process, which may continue for a long time. Thirdly. The destruction or ulceration, or what is very common, the thickening of the membrana tympani; the latter result being, not unfrequently, induced in a few days from an otorrhea. It is well known, in fact,that a very large proportion of individuals, who are supposed to possess good hearing, have partial deafness in one ear at least, and sometimes in both, from this cause.

The ulcerative process takes place rapidly in the delicate diaphanous membrane of the tympanum; and although it has been shown by some good writers that the perforations induced by ulceration, may, by proper treatment, be healed; yet where there is no treatment, and the ulcerations heal up in the ordinary course of the disease, it is fair to infer, that the perforations remain for life. I recollect when a boy, in company with others, boys and men, a common amusement among them was to blow smoke from the segars they were using, through their ears. And a considerable per centage of these individuals in a country village could perform this feat. The destruction of the membrane itself, however, I suspect, is the most usual termination of the disease. After this it not unfrequently gets well itself, and the discharges

cease.

Fourthly. The ossicula auris are loosened and discharged, and