of the cavity, and strengthens the parietes of the heart at a point peculiarly requiring support." 116. Mr. Stallard has, in these observations, drawn attention to a very interesting subject, well worthy of the renewed attention of pathologists.* VI. AN ESSAY, LITERARY AND PRACTICAL, ON INVERSIO-UTERI. Part 2. By John Green Crosse. This is a continuation of the elaborate monograph we have already given some account of,† and is marked by the same laborious research which characterized its predecessor. It is, however, more interesting and original than that, and will be perused with advantage. Mr. Crosse describes several stages or degrees of inversion, viz., simple depression of a portion of the fundus, which may give rise to a severe or even fatal hæmorrhage. It soon passes, however, into the state of introversion, in which the fundus and a portion of the body of the organ is "received into the remainder of the body and cervix, the convexity of the fundus being palpable at the os tincæ." Perversion is said to exist when more or less of the inverted portion passes through the os tincæ. In total inversion the cervix, as well as the rest of the uterus, is inverted. The former part of the Essay comprised a description of the varieties of the disease and their distinctive symptoms, and the present one commences with an account of the author's opinion of the alleged Al "Infrequency of Inversion."-According to statistical evidence, this disease is of very rare occurrence. Thus, of Mauriçeau's 850 cases selected for publication, only six were examples of this. Dr. Collins met with no example in 16,654 deliveries at the Dublin Lying-in Hospital, while Dr. M'Clintock, speaking of that hospital, states that no case was met with amidst seventy-one thousand deliveries. A lying-in hospital is not, indeed, the place we ought to expect to meet with an occurrence which generally arises from mismanagement. However this may be, the disease is by no means so rare as the above statement would show, many authors, whose works are cited by Mr. Crosse, relating several cases. together he has been enabled to collect 400 cases, of which 350 occurred after parturition, 40 from polypus, and 10 from various other causes. The belief in the great rarity of the disease is calculated to favour the overlooking of its minor degrees. These have been observed by several of Mr. Crosse's medical friends since he has so particularly directed attention to the subject; but he believes that uterine hæmorrhage still frequently occurs without partial inversion being suspected as its cause. "No other case," he observes, "has, in relation to the infrequency of its occurrence, been so often brought into a court of justice as inversio uteri ;" and in truth the instances, some of which of recent occurrence he cites, in which not merely ignorant midvives, but practitioners supposed to be qualified, have mistaken, mutilated, or removed this organ, are frightfully numerous. * See Med.-Chir. Rev., No. 35, p. 174, and N. S., No. 9, p. 40. 1847] Crosse on Inversio- Uteri. 125 The perpetrators of such outrages, who have sometimes been screened by well-meaning medical men, should be placed beyond the pale of professional sympathy, as, although our law courts seem little competent to deal with such delinquents as they deserve, the exposure of their misdeeds, and the consequent loss of reputation this entails, is a debt we owe to the public; for, although we should be careful not to render patent the errors our brother-practitioners may fall into in the exercise of a fallible judgment, we should refuse to place in this category those results of ignorance so mischievous and glaring as to render the pursuit of the profession by their authors a matter dangerous to society. There is a limit beyond which our duties as members of society are paramount to all considerations of medical etiquette. Passing over the sections upon the symptoms and pathology of the disease, we come to that which treats of The Causes and Mechanism of Inversion.-Causes of a contradictory and insufficient character have been assigned as competent to the production of Inversion. Predisposing Causes may exist long prior to the occurrence of the accident, and among these may be classed whatever tends to enfeeble the system, inversion, in the majority of instances occurring in women of delicate frame and relaxed fibre, with such a loose state of the pelvic soft parts as usually yields to a quick or precipitous delivery. The erect posture is favourable to its production, many instances having occurred in which the woman was suddenly delivered before she could assume a recumbent one. Over-distension of the uterus, as by the liquor amnii, has been supposed to dispose the organ to this accident. Mr. Crosse's investigations do not corroborate this view; for, in such case, we should expect the accident to more frequently follow the birth of twins, while of the 400 cases he has collected, only four were examples of this. Moreover the accident is of far more frequent occurrence in the young primipara than in women who have already borne children. He believes that some of the worst cases have depended upon great thinness or defective density of the uterine parietes; but he regards a derangement of the normal vital action of the organ, rather than its different mechanical properties, as the usual predisposing cause-a partial inertia or a want of contraction inducing the depression or first stage of the displacement. Relaxation of the round ligaments has been classed among the predisposing causes, and they are at all events passive and incapable of affording resistance. The previous occurrence of the disease seems to have taken place in very few cases. Hæmorrhage, generally dependent as it is upon partial inertia of the uterus, may act as a predisposing cause by increasing that inertia ; but, if the blood has accumulated in the cavity, its sudden escape may be attended with inversion. The attachment of the placenta to some part of the fundus uteri seems to be almost an essential condition for the production of the disease, and may be regarded as forming a connecting link between the predisposing and determining causes. But neither this or any other of the predisposing causes have much effect, unless several of them be conjoined. The immediate or determining causes of inversion may be classed under three heads. "1, Such as are situated in the uterine tissue itself; 2, such as act upon the outer surface of the organ, pressing or driving it down; and 3, such as act upon its internal surface, drawing or pulling it down." Though not competent to commence the displacement causing depression, the uninverted portion of the uterus will act upon the portion already incipiently inverted from any cause, as upon an extraneous mass, and complete the inversion. The expulsive abdominal nisus of the patient may much aid in the production of depression, and afterwards assists in every stage until complete perversion; and it is indeed sometimes the most active power in the production of the worst cases of rapid inversion. In many recorded cases we find the inversion to have been latent or unsuspected for hours, or a day or two, until some expiratory effort has increased it to perversion and prolapse. In the third class of causes, violent traction through the cord, has often induced the accident; but in an enfeebled constitution, and when the predisposing causes are numerous or considerable, the slightest traction by a careful practitioner may suffice to induce the first degree of the affection. The weight and even the bulk of the placenta, by distending the lower part of the uterus and exciting its expulsive action, may thus contribute to the completion of the inversion. A short funis, or one that is coiled around the body of the child, may render depression unavoidable when the placenta is attached to the fundus. The too rapid removal of the body of the fœtus from the uterus, after the birth of the head, will, upon the principle of a tendency to a vacuum (?), draw down the relaxed fundus." Morbid adhesion of the placenta, by the encouragement it affords to traction at the cord, may also cause inversion. Not only must the predisposing and efficient causes unite for the production of this displacement, but there is usually a plurality of each contributing to this. Mr. Crosse has an excellent chapter upon the Diagnosis of the Disease, and treats it more minutely than any other writer we are acquainted with. We have only room for one or two of his general remarks. "In no instance has the importance of a correct diagnosis been more strikingly illustrated than in uterine inversion, which has been mistaken more often, in proportion to its frequency, than any other malady of its class, and, perhaps, of any class. These mistakes have usually been attended with the most fatal effects, for many are the examples, attested by the best authorities, where it is observed that, had the nature of the case been timely known, it would have been rightly treated, and life easily saved. "In commencing this section by considering recent inversion, I find reason to remark that errors in its diagnosis have frequently been but hasty and inconsiderate impressions, which a moment's reflection would remove; or they have arisen from the want of previous experience, and the absence of all suspicion, owing to the real or supposed rarity of the displacement. The short and dogmatical rules of some of our most esteemed writers, would indicate the diagnosis to be very easy; the authentic records of our art seem to show the contrary, even as regards recent inversion post partum, which in its earlier stages has been mistaken for the head of another fœtus, another placenta, a mole, an excrescence, a polypus, a tumour, and a clot of blood; and, in its more advanced stages, for not only some of these, but for still more unaccountable diseases and displacements. It is very difficult to explain the source of all these erroneous impressions, which not only midwives, but even well-educated and practised surgeons have acknowledged, until we consider that the emergency is great and sudden,—some opinion or other must be rapidly formed, 1847] Crosse on Inversio- Uteri. 127 and those ideas with which the mind is more familiar first present themselves. The pressing urgency of the circumstances is even greater than the surgeon estimates them to be, for uterine inversion, at the close of the delivery, is a case that leaves little time for consideration, none for preparation, ere a decision must be arrived at, or the risk be incurred of the patient's expiring of her undetected, or misunderstood, and consequently maltreated, disorder." P. 317. Prognosis.-No disease of its class is more fatal than this, unless effective aid be promptly rendered. The mortality from it has been variously estimated; but Mr. Crosse, from the most extended investigation yet brought to bear upon the subject, is in a condition to affirm that "above one-third of all the cases, under whatever circumstances, or in whatever degree they occur, prove fatal very soon, or within one month after the displacement is produced." Of 109 fatal cases, collected from various sources, in 72 death took place in a few hours, generally within an hour and a half, and often nearly immediately. Eight cases proved fatal in from one to seven days, and six in from one to four weeks. "It deserves to be forcibly noted that, although 86 cases were thus brought to a close within a month, this period being passed, only one of the remaining 23 proved fatal before arriving at the chronic stage," the remaining 22 terminated at different dates extending to three or four years, and in a rare case or two, to 5 or even 20 years. The less the degree of inversion when we are called to the case, and the slower it has advanced, the smaller the amount of danger. The organ may perhaps be so relaxed as to admit of ready reduction, though entirely inverted; but this may arise from the patient being already in articulo. A rapid spontaneous inversion may be more dangerous than one inverted by traction of the cord, as the patient in the latter case may possess a strong constitution, enabling the disease to go on to its chronic stage. In the stage of depression the consequent hæmorrhage, if the displacement be not rectified, may alone kill the patient, but when the organ is extruded, we have the influence of" shock" superadded to this. Mr. Crosse believes that total inversion can only be rectified by almost immediate attempts, but the patient has a better chance of recovery by this remaining unattempted than from its accomplishment through violent means. We regret that our limited space has prevented our furnishing a more complete account of Mr. Crosse's interesting Essay, and hope that he will not long delay the publication of the concluding portion, embracing the treatment of this formidable accident and its consequences. The same reason likewise precludes our noticing a paper by Mr. Barker, describing the Removal of a Large Secondary Prostatic Calculus by Perineal Incision; the Retrospective Address of Dr. Ranking; and a short Essay by Dr. Paxton upon "Pathological Memorials," in which he ably advocates the desirableness of making pathological drawing part of medical studies. Upon the whole the volume is an excellent one, and well illustrated by numerous lithographs. I. THE CONSTRUCTION AND GOVERNMENT OF LUNATIC ASYLUMS AND HOSPITALS FOR THE INSANE. By John Conolly, M.D. 12mo. pp. 183. Churchill, 1847. II. JOURNAL OF INSANITY, Vol. III. Utica, U. S. 1846. III. THIRD ANNUAL REPORT OF THE MANAGERS OF THE STATE LUNATIC ASYLUM. By Amariah Brigham, MD. Albany, U.S. 1846. THE RE IV. TWENTY-SECOND REPORT OF THE OFFICERS OF ALTHOUGH We have recently* treated somewhat at large upon the subject of Insanity, yet so important is the topic, that we are glad to avail ourselves of every additional opportunity of adverting to it, whether to chronicle progress or to indicate the obstacles to this. All that we have seen or read since they were written but confirms the correctness of the opinion we advanced in the articles referred to, that the government of Lunatic Asylums in this country is founded upon an essentially faulty basis, and that, until this error is remedied, the management of the Insane will not continue to be such as is most conducive to their interests. At present this is a matter of the merest chance, dependent upon the amount of intelligence, good sense and forbearance possessed by so miscellaneous a class of persons, as far as mental attributes and special information are concerned, as the visiting justices and governors of these establishments. From Dr. Conolly's work we incidentally learn the mischievous powers possessed and employed by them at Hanwell, and certain it is that it required an amazing union of humanity, patience, discretion, and firmness upon the part of this philanthropist to carry his great experiment to a successful issue. Few men are equally endowed, and thus we see, as a natural effect of the interference and irritating annoyances, they are subject to a constant change of the resident medical officers in our various asylums. So peculiar is the condition of the lunatic, that we do not hesi tate to repeat our opinion, that his real well-being, whether rich or poor, can only be provided for effectually by his becoming an object of direct state-interference or management: but, supposing that the prejudices against any such centralizing procedure would prevent its adoption, we may at least imitate the Americans, who have the good sense to leave the entire management of their asylums, at least of all that relates to the patients, exclusively in the hands of a well-selected and well-paid resident medical superintendent. Until an officer of this kind is allowed absolute control over it, no establishment can be considered in a satisfactory condition. * Vide, Med. Chir. Rev. N.S., Vol. IV. pp. 56 and 394. |