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MRS. A. B. was confined at her home in the south of Scotland on June 5th, 1876. The child born was her second. She was attended by her physician, who lived in the neighbourhood, and to him I owe most of the details now to be given of he; case. The labour was easy, natural, and lasted four hours. The placenta was removed without difficulty about fifteen minutes after the birth of the child. The membranes were twisted to ensure their complete withdrawal, and then a dose of ergot was administered. At 9 A.M., all was completed and well. In the evening of the 6th, Mrs. A. B. had a feeling of cold in the back and severe lumbar pain. On the morning of the 7th, her pulse was 120, and at night it was 140, at which rate it continued till after my visit on the 8th. The temperature rose correspondingly, but no note of its height is preserved. In response to a telegraphic message, I saw the patient on the afternoon of the 8th, eighty hours, or nearly three days and a half, after her confinement. I found her with every appearance of having an attack of pymemia or puerperal fever post parturn. The abdomen was slightly tympanitic, the uterus somewhat tender. The circumstances of the case, both intrinsic and extrinsic, rendered the crisis extremely alarming and important. The lochial discharge was natural) and reported as having no fetor. Nevertheless, I made a vaginal examination, pushing the finger into the cervix uteri, and hooking away shreds of clot, which were unexpectedly found to be distinctly putrid. A second attempt brought away a small bit of membrane, putrid. Being at a great distance from proper instruments to complete what I regarded as the desirable treatment-namely, the removal by forceps of any other pieces of membrane or decidua-and time being very valuable, I had chloroform administered, with a view to the introduction of my hand into the vagina and of my fingers into the uterus, to effect the exploration and removal of what might be found that should be taken away. Doing this, I gradually penetrated farther and farther into the uterus without finding anything. At last my whole hand was inside the organ, which felt not unlike an uterus only recently evacuated. In the fundus of the uterus, it was now my extreme good fortune to find adherent an irregular lacerated patch of chorionic membrane, about four inches long and an inch broad. It was found to be fetid. After this, I left the patient. Both pulse and temperature fell in a marked manner after this operation. The alarming appearance and symptoms disappeared. The pulse remained high for several days; but the extreme anxiety of the physician and friends was subdued for good. The fetor of the discharge was recognised by the nurse after my visit, but only at first, or for less than a day. While, as is well known, there is often insuperable difficulty in classifying cases of so-called puerperal fever under the heads pyzemia, septicaemia, ichoraemia, there can in this instance be no hesitation in designating the disease as simple septicoemia. Such cases are familiar to the gynaecologist. A decomposing uterine fibroid, a decomposing blood-clot in a hzematocele, produce shiverings, sweatings, vomiting, delirium, high pulse, high temperature: a most alarming combination of symptoms, which, on the removal of their cause, is dissipated with extraordinary rapidity, in a few hours, as if by a charm. Such was the fortunate course of events in the case just narrated ; but, had the putrefying membrane continued much longer in a puerperal uterus, a fatal result was probable. It is well known that membranes, and even the placenta, may be left in utero and not give rise to alarming symptoms, even though putrefaction ensues, which is not always the case. That there is risk, however, in leaving even shreds of membrane, was known to Delamotte,-t and to White,+ who, writing in the last century on the expulsion * Read in the Section of Obstetric Medicine at the Annual Meeting of the British Medical Association in Manchester, August I877. t Traitd comhlet des Accouchemens, Nouv. ed., 1729, p. 6og. I The Management of Pregnant anzd Lying-in Women, 2nd edition. London, I7777 p. 112. of the placenta, says: " It is to be handled gently, and with great care gradually brought away, lest any parts of the caduca, chorion, or amnios should be left behind; for this would occasion a very putrid discharge, together with pain and a fever." The danger, thus too unconditionally asserted by White, more cautiously by Delamotte, is, on the other hand, and inijuriously, ignored by many, and among others by John .Ramsbotham,* who says that, " when the placenta is withdrawn, a portion of its attached membranes will occasionally, under the greatest care and attention, be separated, and be left in the uterus or vagina, without any future detriment to the patient". In the case which I have narrated, the greatest care and attention did not secure the complete withdrawal of the membranes. The position of the persistently remaining shred renders it unlikely that any forceps would have reached it and removed it entirely; nor is it probable that it would have come away in the discharges early enough to allow of the preservation of life, already most seriously threatened. It is under these circumstances that I propose the new operation of investigating the interior of the uterus by the carefully carbolised hand of the accoucheur, with a view to finding and removing decomposing substance. In such a state of matters, I have hitherto used the practice of Baudelocque;t namely, antiseptic intra-uterine injections. I employ a double catheter, and I have repeatedly had reason to be satisfied with the results. But, in the cases where I have used this treatment successfully, there has not been washed out by the injections any shred of hidden membrane; and I very much doubt whether injections, in the case which I have narrated, would have produoed this supreme result; for, besides the difficulty of directing the current so as to envelope and remove the adherent membrane, there is the absence of any knowledge where the hidden membrane is-absence, perhaps, even of suspicion of its presence. There is, of course, as yet, no properly formed professional opinion as to the length of time after delivery during wlhich it is possible to introduce the whole hand into the uterus in a natural case ; and it is the whole hand that has to be introduced with a view to doing completely the operation I propose. The nearest approach to conditions similar to those of my case is found in instances of retention of the placenta. Active interference in this morbid condition implies introduction of fingers, and often of the whole liand; and the difficulty feared is contraction of the internal os uteri or higher up. Hegar, a recent author: on the subject, writes as follows. " Osiander gives the advice to wvait an hour.... Kilian allows two hours to pass. Jorg, Seiler, Schmidtmann, give similar directions. Hohl says from a quarter to a whole hour....Boivin allows a space of an hour. Paul Dubois limits the in. terval to an hour, or at most an hour and a half.... Chailly and Cazeaux follow his example. Maygrier, as well as his collaborator and trans. lator T. von Siebold, express similar views. AMaygrier allows two hours of expectation. Burns will not leave the lying-in room until the placenta is extracted; and, if this is not effected within an hour, then he may go away. Clarke, Merriman, Ramsbotham, R. Lee, and the American Meigs, entertain similar views." In another place, Hegar, expressing his own views as to the length of waiting under special circumstances, says that removal of the placenta may be effected even two days after delivery without special difficulty or force ; and that, if the whole hand be not introduced for this purpose, at least a few fingers may be pressed into the uterine cavity. The latest author on this subject, M. Bailly,§ decribing cases of retained placenta, concludes his article by laying down " that the uterus remains, in general, permeable for the hand of the aecoucheur (iTuing more than an hour after delivery ; that exceptionally, and in virtue of a natural inexplicable disposition, uterine retraction may, long before the end of the first hour, render the introduction of the accoucheur's hand into the womb very difficult, and greatly impede or obstruct deliverance that, if the woman has taken ergot of rye a short time before the end of her labour, she ought to be delivered in less than a quarter of an hour after the birth of the child, to avoid the eFffcts of the contraction of the cervico-uterine orifice and of the retentioio of the placenta in the uterus". There can be no doubt that these opinions of liegaand B;illy require reconsideration, as the historical details wlhich I shall presently give will show. But these historical details, wuhile they compel modification of the views generally held, and contribute valuable data, do not leave the subject in a satisfactory state, it being evident that 'iuch

Remarks on the Investigation of the Interior of the Uterus by the Carbolised Hand at Long Intervals after Delivery