of last Summer*. I was desired to attend on the occasion. On my arrival the pains were so slight that I deemed an examination unnessary. During the night the pains continued, but in the most trifling degree, yet they were sufficient to rupture the membrane, and shortly afterwards the pains entirely ceased. Being some miles from home I slept at the house where my patient was confined, and on Monday morning I made my first examination. I found the head presenting in a natural position and very low in the pelvis; I encouraged my patient with the hopes of a speedy delivery on the return of the pains; these I waited for in vain till Tuesday afternoon: I was now prevailed upon by the request of herself and friends, as well as the weak state in which she was, to deliver the child by the forceps. This was the first case in which I ever used that instrument, and I succeeded in delivering the child in a few minutes with but little pain, considering this was her first pregnancy.

The child was a little under a full grown foetus, and from her very great size before delivery I immediately judged there were twins; this was really the case. No hæmorrhage succeeded; the placenta was retained by the undelivered child. I continued to encourage my patient with flattering expectations and a little wine, without informing her of the nature of her situation. I waited two hours, no pains returned, nor was there any hæmorrhage, but a great degree of languor. I now introduced my hand into the uterus, ruptured the membranes of the second child, and delivered it by the feet: flooding to an alarming extent instantly succeeded. With as much promptitude as possible I brought away two placentæ, being obliged for this purpose to introduce my hand a second time into the uterus. The gush of blood was now such as I had never before witnessed; the woman exhibited every symptom of mor tal syncope, not a trace of pulsation remaining. I was prepared with cloths wetted with brandy and vinegar, and having thrown off the bed cloaths excepting the sheet, I instantly covered the loins, pubes, and abdomen with them, changing them frequently for others. The flooding soon abated, but this arose from the sunk state of the patient, who had, in a few moments, lost not less than 6 or 7 pounds of blood. For some minutes scarcely a vestige of life was apparent; every attendant had left me excepting one; with her assistance I carefully administered cordials, and my pleasure was great at finding a gradual return of life. The flooding continued in

*Having lately changed my residence, I am obliged to narrate the case from recollection, my notes being left behind,

a trifling

a trifling degree for a short time, and then altogether ceased. Good nursing and attention gradually restored the woman.

Was this case to occur to me again I would deliver the first child ،، per artem," for the great distension of the uterus con

'nected with the weak state of the woman rendered the return of labour pains improbable; but after the delivery of the first child, the uterus being relieved, and no very bad symptom intervening, I might safely, I think, have waited, and allowed nature a reasonable time to have resumed her efforts. I am, Gentlemen,

Your most obedient servant,

ER.

AN ESSEX PRACTITIONER.

April 14, 1811.

To the Editors of the Medical and Physical Journal.

e In cases of wounds attended with denuded pericranium, do not hastily act upon the principle that an exfoliation must sooner or later follow, for this may not eventually be the case one time in ten." Sir William Blizard's M. S. Lectures on Surgery.

GENTLEMEN,

NOTWITHSTANDING the great advances made in sur

gical practice towards that perfection which it is the honourable aim of the practitioners of the present day to exert every effort to approach, still there exist too many discouraging obstacles to its perfect attainment, without reviving those which increasing knowledge and the result of attentive experuments have happily removed. No. 144 of your Journal contains at p. 146 the following remark, under the title "Theoretical Suggestions for the improvement of Practical Surgery.

99

In the operation of trepanning the skull, when the scalp is sufficiently removed it is essential to remove just so much of the pericranium and no more, as the head of the trephine will include, because the cranium when denuaed of its pericranium will, like other bones denude of their periosteum, grow carious." The former part of this quotation, doubtless, conțains most useful advice, but I conceive not a new suggestion ; no dexterity can justify a wanton use of the knife, nor should an occasional happy effort of nature in a sound system cause an implicit reliance that such efforts will prove successful under every variety of constitutions, or alway be adequate to the counteraction of ill directed modes of cure.

To

To a young mind the necessary distinctions which terms are intended to convey are not always present, and first impressions are ever of high importance. The term carious excites instant alarm, and the difference between that state of bone and diseased bone are too often overlooked. That tedious exfoliation, in defiance of the most skilful surgery, will follow de nudation of pericranium and periosteum, under some circumstances, is irrefutably true, but it is no less true that apprehension of such an event being unavoidable, has led to practices which have produced the dreaded evil; e. g. when exposed bone has assumed an appearance indicative of that des truction having taken place, which sometimes precedes exfoliation, how common has it been to adopt very active measures upon the principle that such an event must necessarily succeed, when an exactly opposite mode of reasoning and of practice would have been nine times out of ten (as observed by Sir William Blizard) successful.

Let not then the young and inexperienced practitioner be needlessly alarmed, when with laudable zeal and anxious thirst after knowledge he reads the above statement, and hastily adopt sentiments which may influence his practice, to his own discredit and the injury of his patient. "Exfolia tion,' ," said the sagacious Pott, "from a cranium laid bare by external violence, and to which no other injury has been done than merely stripping it of its covering, is a circumstance which would not so often happen, if it was not taken for granted that it must be, and the bone treated according to such expectation."

"Exfoliation is full as often the effect of art as the inten tion of nature, and produced by a method of dressing, calculated to accomplish such end under a supposition of it being necessary."

A few years ago, a youth of 14 bathed in a canal on a chilly day when much heated; a few hours after he complained of universal pain, had a smart rigor followed by sickness. Continuing thus indisposed for several days I was desired to visit him; he now complained of severe pain near the middle of the left tibia, that all his "other pains had gone there." On examination there was considerable inflammation with some swelling discovered; he was labouring under severe pyrexia with constipation, indicating general and local antiphlogistic treat ment, which was immediately instituted and persevered in till it was manifest an abscess in the leg was unavoidable. On this event taking place I was prevented making the neces sary opening in due time; the tumour was large and remained in a state fit for the knife several days before it was suffered to be used; upon discharging upwards of a pint of matter, I found

found the periosteum denuded to a much greater extent than I could have supposed possible in the time; the subject was become feeble, emaciated, had considerable night sweats with a thin discharge from the wound, gradual thickening and deformity of the limb; a free use of the cinchona and a more generous diet removed these instances of debility, and the sore, in a few weeks, contracted round the denuded bone, which comprehended an extent of near two inches of a very unpleasing aspect. However, as healthy granulation advanced in every direction with great general improvement of the system, I felt encouraged to aim at approximation of the sides of the sore by every possible means position and dressing could suggest. The progress of cure was slow but highly satisfactory; a very small portion of bone ultimately exfoliated, not larger than the size of a little finger nail, when a solid union of parts was effected in a limb which had borne every disheartening appearance that osseous inflammation and great thickening could bestow.

A respectable glazier of this city, middle aged, and long afflicted with dreadful arthritic attacks, was returning from a neighbouring village one tempestuous night, and had the misfortune to be thrown from his horse on a hillock of gravel; pitching upon his head, from which his hat had been previously blown, he received an extensive contusion and detachment of the right side of the scalp. Stunned by the blow he remained on the ground some time, and had barely recovered the possession of his faculties on being brought home an hour afterwards. Upon being called to his assistance I found the integuments so comminuted, swoln, and loaded with gravel, that no idea of replacing the scalp could be entertained. I directed the whole head to be well fomented, and a large emollient cataplasm applied, renewing it every six or eight hours; in a few days free digestion commenced with extensive fœtid discharge; cinchona, wine, and nutritive diet corrected and moderated this state; very considerable sloughing was followed by as healthy granulations as could be expected; the middle of the right parietal bone was bare to the extent of an inch, of nearly a circular shape, it had a faded brown appearance. I was anxious concerning the result, but determined upon a diligent application of adhesive plaister to facilitate the union of the soft parts over it; in the course of a month this was effected, so that the spot now formed a firm shining cicatrix of the size and shape of a small almond. I am, Gentlemen,

Your obedient Servant,

Chester, March 21, 1811.

GEORGE NESSE HILL.

To the Editors of the Medical and Physical Journal:

GENTLEMEN,

YOUR Correspondent, Mr. Barlow, at p. 390 of your

last Number, doubts the fact of the inoculated Small-pox proving infectious, except under particular circumstances, and then rarely; he is aware that this sentiment will meet with an adverse opinion from the advocates of vaccination, yet he is actuated to hazard it—from motives of utility!

By mentioning the advocates of vaccination in particular, does your correspondent mean to insinuate, that they only will differ in opinion with him on the subject? I thought this matter had been decided long before either vaccinists or anti-vaccinists were known. By merely turning to your 14th volume, page 311, your Correspondent may be made acquainted with several fatal cases of small-pox communicated by casual infection from those who had been inoculated; among which is the never-to-be-forgotten fact, recorded by Dr. Willan, in the year 1796, (before vaccination was in use) of the inoculation of a child, whose parents kept a shop in a small court. From this child seventeen persons caught the small-pox in the natural way, and eight of them died. Thus in order to save the life of one person, seventeen were put in danger of their lives, and eight, or nearly one half, were actually sacrificed.

These cases are comparatively of modern date; perhaps your Correspondent will be better satisfied with some of an earlier period. Let us go back to the year 1721, and we shall find records to substantiate the assertion that "infection may be traced from inoculation even when the inoculated disease has not assumed the confluent character."

Dr. William Douglas "a physician of the best credit and practice," at Boston in New England, writing to Dr. Alexander Stuart, under date of December 20, 1721,* says, "at first they gave out that it was a method not infecting, procur ing only a small quantity of eruptions, but never death, nor any bad consequence, and was an infallible security against ever after having the small-pox

"We soon found it infecting; many have died of the infection received from the inoculated, whose deaths in a great

* Published by Dr. Wagstaffe as an Appendix to his "Letter to Dr. Freind, shewing the danger and uncertainty of inoculating the Small Pox." 2d Edit. 1722.

measure