as the size of the os would permit the careful introduction of the forceps, with the patient upon the side, back, or the knees, I would not hesitate to apply them within the cervix.

Where the waters break very early in primiparæ, there is no provision on the part of nature for expanding the cervix. This mishap explains the relative duration of labor in presentations of the breech, in which the membranes are usually fractured by the first pains. I can discover no valid objection to a forcible and uniform dilatation of the unyielding os; in head presentations, by means of the forceps introduced within the cervix. There certainly is less danger of causing a rupture of the womb by their careful employment in such cases than from incisions into its substance. And where the indications to deliver are imperative, as where we have reason to believe that the convulsions will not cease until the uterus is emptied of its contents, or that the contingencies which beset the lives of parent and child are multiplied by the delay, we should proceed at once to their application.

The only case of arrest of labor by preternatural rigidity of the os in which we would not apply the forceps within it, whenever practicable, is in placenta prævia. In this unfortunate presentation, the peculiar development and vascularity of the cervix, and of the inferior segment of the womb, increase the liability to its rupture, and contra-indicate the employment of the forceps, until the os is fully dilated or dilatable.

March 24, 1868, Seven P.M.-My friend Dr. E. Kneipcke of Chicago, was called to visit Mrs.-aged 28, in labor with her first child. She had already been in labor for three days and three nights. Four physicians and as many midwives had been in attendance. The last of those who preceded Dr. K. had given the patient one and a half grains of morphine, by actual weight, in order to put a period to her pains and convulsions! The waters escaped with the first pains.

For twelve hours the convulsions had continued as frequently

as once in five minutes.

the size of a half-dollar.

The os was rigid, hard, and of about

So much of the uterus as the basin

could contain was prolapsed into the pelvic cavity.

I saw this patient, at Dr. K.'s request, at half past nine. She was in a semi-conscious state between the pains and convulsions, which were synchronous; the os was of the size stated, its margin thick, well-defined all around, and cartilaginous to the touch, resting upon the perinæum. The soft parts were hot, dry, and very much swollen. In reality the os felt like an ivory ring of an inch and a half in diameter, and half an inch in thickness, placed directly around the presenting vertex. These symptoms were verified both by the doctor's private pupil and my own, as well as by ourselves.

We applied the extract of belladonna to the os most thoroughly and then determined to attempt the use of the forceps. The rigid ring about the vertex did not appear to relax or yield in the least. By my direction the patient's hips were brought to the edge of the bed, and she was placed in position, as in ordinary forceps cases. Chloroform was then administered by Dr. K. to the extent of complete anæsthesia. Having warmed a Naegel's forceps, and anointed the back or external surface of both blades with the extract of belladonna, I proceeded by careful and coutinued manipulation to introduce the right-hand blade. This part of the instrument brought the os uteri into the shape of a button-hole, and filled it completely. It was only by persevering effort, stretching the orifice with the blade on the one side and the finger on the other, that it was made possible to insinuate the second blade at all.

The instrument was finally adjusted in the direction of the occipito-mental diameter of the child's head, and the delivery accomplished. The utmost precaution being taken, the soft parts sustained no injury, and the woman recovered without any untoward symptoms, having survived the prolonged suffering and § IV. - 6*

the convulsions, not to speak of the morphine, six doctors, two medical students, and four midwives.

I would not be understood to recommend the employment of the forceps in all cases of extreme rigidity of the os uteri, indiscriminately. The established rule that they are contra-indicated when the os is neither dilated nor dilatable, is doubtless the more safe and proper one. But there are exceptions to this as to other general rules. Where, in consequence of the rigidity of the os uteri, either the severity of the eclamptic fit, or undue pressure of the uterus upon the body and funis of the child, are likely to produce fatal results; where the uterus has been prematurely emptied of the waters, and the woman threatens to die, from the exhaustion of a tedious labor, before her delivery is accomplished; where there is no especial reason, because of previous disorganization of the uterine cervix, or of placenta prævia, to fear an easy rupture of the womb; when other and more simple. means of facilitating the dilatation or expansion of the unyielding cervix have proved ineffectual, and sufficient time has elapsed to test the powers of nature and of patience, we certainly regard the careful use of the forceps as an available and advisable expedient.

Whether the novel method of applying the extract of belladonna in the latter case to the internal surface of the cervix will facilitate its absorption, and the consequent relaxation of the unyielding fibres, only repeated experiment can determine.

VII.

RUPTURE OF THE THORACIC AORTA IN AN

INFANT.

BY H. H. HOFMANN, M.D., PITTSBURG.

MRS. L. A., aged twenty-five, primipara, felt labor pains on the morning of the 21st April, the pains becoming severer until evening, when I was called. Upon examining and finding the membranes protruding, I ruptured them. The pains continuing very severe, but labor making no progress, I gave chloroform to lessen the severe expulsive pains. Having made no further progress at midnight, I brought her fully under the influence of the anaesthetic, applied the forceps, and in a short time delivered her of a healthy female child, weighing about ten pounds. April 22.-Saw mother and child, both doing well; child had taken the breast. April 23.-Early in the morning I received a message that the child was vomiting blood. Upon my arrival, I found the child weak and pale; had had a passage from the bowels consisting of dark blood. I could not make out a clear diagnosis, but suspected the rupture of a blood-vessel. Prog nosis very doubtful. Child continued vomiting blood, also passing some from the bowels, until 1, P.M., when it died.

Assisted by Drs. Cowley, McClelland, and Seip, I made an autopsy eight hours after death. Body not emaciated, skin of a waxy, pale color; rigor mortis very slight. All the organs in the chest in a healthy condition. Lungs well inflated, proved by the hydrostatic test. Stomach and intestines filled with dark blood; the oesophagus in its middle third had a sug

gilated appearance. Aorta showed a rupture from about the seventh to the ninth intercostal arteries. Cellular tissue, behind and to the left of the aorta, infiltrated with serous blood. The rupture could not be traced directly from the aorta into the œsophagus; the aorta otherwise apparently in a healthy condition.

I could find no cause for this rupture. Child had not been crying much. Could the chloroform have been the cause of it? And, if so, why does it not act thus more frequently? And, again, why at so late a period?