With the utmost respect for your private and public character, and my best wishes for your welfare, believe me `to be your devoted and humble servant.

AMOS HAMLIN.

HON. SAMUEL L. MITCHILL.

CASE of RUPTURED UTERUS: communicated by Dr. CHATARD, of Baltimore, to Dr. MILLER.

HE case which I now communicate to you, would have been one of the most interesting, and would, perhaps, have contained details very seldom met with in the annals of medicine, if prejudice, which in every nation and every age has too often retarded the progress of our art, had not op. posed to me its ridiculous obstacles. Nevertheless, I will candidly make known to you what I have observed and effected. I think if the self-love of a physician is agreeably flattered when he affords to his fellow practitioners occasions to applaud his success; this same self-love should not be mortified, when he acquaints them with cases of his ill success, which may expose him to criticism, but must necessarily render them more watchful in those difficult cases, in which all human skill and dexterity are often unequal to the obstacles to be overcome.

The negro woman who is the subject of this case, was so much below the common size, that she would have been taken for a child, instead of an adult. However, she must have been advanced in age; for, about twelve years ago, she bore a dead child, which undoubtedly had not arrived at full time, and of which she was delivered alone, without any assistance whatever. When I was called to visit her this last time, she was attended by a midwife of this city, a woman of much experience acquired by a practice of forty years. I was informed by her, that she had been with the patient about fifteen hours; that the membranes had been broken before her arrival; that the head of the child was in the position in which she had first found it; that the belly of the woman was harder, more elevated and more painful than she had ever observed it in any other parturient woman; that its anterior part however, from the pubes to the navel, was remarkably soft, though painful; that each of the labia puden

di was swelled to the size of the fist; that her pains were ineffectual though frequent; and finally, that from the commencement, her pulse had been very weak. A stay of two

hours, and an examination of her condition, too exactly confirmed the account of the midwife. The head of the child was well situated at the brim of the pelvis, but was evidently stopped there by a disproportion between it and the ante ro-posterior diameter, although every thing else was right. I endeavoured, as the midwife had already done, to push back the head in order to discover the degree of force by which it was wedged in between the pubes and sacrum. My efforts having been as unsuccessful as hers, I resolved to try the forceps: they were applied with all possible tenderness. and attention. Again unsuccessful, I agreed with the midwife to leave the case to nature till day light. This delay, far from lessening my uneasiness, only doubled my fears. However, things went on thus till noon, when thinking that I perceived some favourable change in the progress of the head, which I attributed to emollient fomentations and injections, I again applied the forceps: but failing again, an idea occurred to me of employing one of its blades as a lever, and pushing the head towards the right iliac fossa, by fixing it on the occiput turned to the left. This manœuvre perfectly succeeded. But upon examining the womb again, how great was my astonishment at finding a foot instead of the head! I confess that not yet suspecting a rupture of the uterus, I at first thought that there were two children, and that the lower extremity of one was placed near the head of the other. Having laid hold of this foot, I attempted the delivery in this manner; but the other extremity opposing the passage of the body, I brought it down, taking care to secure the first by means of a loop. Every thing succeeded, until the head came down to the place where it had before been stopped; and although its position appeared to be very favourable, I could not bring it through. Not doubting the death of the child, for its umbilical cord seemed to be without circulation and almost putrefied, I ventured to pull a little more at the body, before applying the forceps, as I intended, and as Baudelocque recommends in such cases. But by a degree of force infinitely less than what I have frequently employed in common cases, the head was separated from the body. Much distressed at this sad accident, I introduced my hand into the womb to extract the head by putting my fore-finger into the mouth, when most unfortunately the low

er jaw came away with as much facility, as the head from the body. I then suspected that the child must have been dead a considerable time from its parts having so little cohesion; and it recurred to my memory, that when questioning the patient, I had been informed by her, that four days before, she had been seized with a violent bilious vomiting, during which her belly had acquired its then present form; that it had ever since continued to be painful; and lastly, that she had not experienced the same sensations from the child, as before. However, not suspecting a rup-→ ture of the uterus, I sent for a crotchet, that I might be able to extract the head by diminishing its bulk as much as necessary. But when I put my hand up into the vagina, I found that the intestines had fallen down into it and displaced the head. The womb, if I may be allowed the expression, had disappeared, and my hand passed from the vagina into the cavity of the belly, with no other resistance than what was occasioned by the different viscera contained in it. The head was found near the liver. I then sent for Doctor Davidge to consult with him on the case. We agreed in the opinion that the patient had but a few hours to live; and that the Cæsarean operation would but hasten her death, which happened soon after. Her master Mr. W. very obligingly gave us permission to open the body, but her husband, and perhaps her relations, opposed our design, and thus prevented me from affording you more interesting details.

REFLECTIONS.

Was the womb ruptured at the time of vomiting which happened four days before I was called in? Or at the moment in which I succeeded in unfixing the head? And if it had been ruptured during the space of four days, how could the woman survive the accident, and the position of the child remain the same? I answer these three questions in the following manner. Firstly. It is more than probable that the womb was ruptured at the epoch of vomiting; because, when the child's head was disengaged, the woman did not say that she felt any pain, which is contrary to what happens at the instant in which the womb gives way; besides there was no discharge either of blood or water immediately afterwards. Secondly. Lamotte and Hildanus say positively that they have seen women survive a rupture of the uterus four days; and according to Doctor Crantz who has writ

ten well on this subject, observers mention many such cases. Indeed, if death is not the necessary consequence of division of the uterus, as is proved by the frequent success of the Cæsarean operation, and more fully by the suppuration and gangrene of this viscus, likewise by its partial laceration and almost total extirpation; why should the patient die before any spasm of other viscera occasioned by the immediate pressure of the different parts of the child, existed, or before the accident was complicated with effusions of blood into the abdominal cavity, or intestinal hernia strangulated through the rupture?

If I conjecture rightly, the womb was ruptured at its anterior and inferior part, near its orifice, in a longitudinal direction and pretty extensively; for, as I have said above, although the belly was very tense and painful, there was nevertheless a considerable degree of softness felt at its anterior part from the pubes to the navel: and I presume, that it was to the presence of the floating intestines which had slid into this part, that we should attribute this sensation or rather symptom, which I have never seen described, and which, added to those mentioned by Doctor Crantz as announcing a proximate rupture of the uterus, may, perhaps, with some degree of reason be regarded as a pathognomonic symptom of this rupture. The midwife abovementioned informed me that she had observed this symptom joined with an elevated and hard belly but twice, during her long practice. Both the women in whom she observed it, died: and their children were extracted by crotchets, by two physicians of this city. One of those physicians, who has been dead some years, seemed to have recognised a rupture of the uterus, but contented himself by saying it was decayed. The other, who is at once very skillful and candid, extracted the child by the crotchet, but did not appear to have suspected a rupture; nor should I have discovered it, if I had at first succeeded with the forceps. It is to be regretted that this symptom, (undoubtedly aided by others which but too clearly indicated a tendency to rupture) had not led those practitioners, as well as myself, to perform the Cæsarean operation. We might possibly have saved our wretched patients; and in each case, without adding much to their sufferings, we might have positively satisfied ourselves as to the solidity of this symptom which in other cases might have been of the greatest utility, and have added to the perfection of the

Thirdly. To solve the difficulty relative to the situation of the child, which must have been the same during the four days succeeding the rupture; I will answer, that the child's head being strongly wedged down between the pubes and sacrum, must, notwithstanding the rupture of the womb, have remained in the same position, until it was disengaged; and then, the fundus uteri continuing to contract, must necessarily have turned the child in such a manner as to substitute a foot in place of the head.

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The power of contracting which the womb still possesses after its rupture, when the child has not been expelled, is admitted by Baudelocque, whose authority in affairs of midwifery is as good as any man's and I will take this opportunity to declare, that for justness and minuteness of description as well as sound reasoning, I know no book more unceptionable than Baudelocque's work on the art of midwifery.

May you, my dear friend, experience as much pleasure in reading this small memoir as I do in communicating it to you, and renewing to you the assurance of my affectionate sentiments.

A Topographical Description of the County of SARatoga, (N. Y.) with an account of the origin und treatment of some of its endemic diseases: communicated by Dr. JOHN STEARNS, of Waterford, to the Medical Society of the State of New-York; and presented to the Editors by Dr. RoMAYNE, President of said Society.

HE county of Saratoga is bounded on the south by the Mohawk river, which divides it from the county of Albany; on the east and north by the counties of Washington and Rensselaer, from which it is separated by the Hudson river; on the west by the county of Montgomery. It is about forty five miles long, and thirty wide, containing 32,000 inhabitants. The land which extends along the Hudson is level, consisting chiefly of clay, excepting that part of it which lies in Stillwater, which is generally composed of slate. As it extends towards the interior, it is found to consist of sand, loam, and clay, alternating with each other, and is generally fertile. The north western part is mountainous, and some part of it unsusceptible of complete cultivation. Near the