dass_B£t 
 
 ^ 
 
 
 
 Presented hy 
 
> 
 
 THE 
 
 OBSTETRIC CATECHISM: 
 
 B Y 
 
 JOSEPH WARRINGTON, M. D 
 
 PHILADELPHIA: 
 J . G . A U N E R , 
 
 No. 333 Market Street. 
 1842. 
 
=& 
 
 
 Entered according to Act of Congress, in the year 1842, by Crolius & 
 Gladding, in the Clerk's Office of the District Court of the United States for 
 the Eastern District of Pennsylvania. 
 
 out 
 
 W. Ii. S3ioe*ttfr¥s r 
 7 S '06 
 
PREFACE. 
 
 TO MY OWN OBSTETRIC PUPILS, AND TO STUDENTS OF 
 MEDICINE GENERALLY. 
 
 Gentlemen, I dedicate this little work to you. 
 
 Were I in the midst of you, as I present each a copy, I 
 would address you principally in the following words : 
 
 I have designed this little book, as an aid to you in the 
 prosecution of your studies in a very important branch of 
 the science and art of medicine, or as an occasional re- 
 membrancer for you, when you are engaged in the practice 
 of your profession, remote from any experienced living 
 counsellor. 
 
 It is written for you, as a sort of vade mecum, a leading 
 string, or reviver of your knowledge in this matter, and in 
 this respect as far as it goes, I am sure it will be useful to 
 you ; but remember, it is not your text book : it is your 
 test book : it is your catechist or inquisitor, not to tell you 
 
IV PREFACE, 
 
 any thing new, but to enable you to determine what you 
 do, or what you do not already know. 
 
 Your knowledge of the great principles on which the 
 important subject of obstetrics is founded, is to be derived 
 from other sources ; from well approved standard works : 
 as those written by Velpeau, by Dewees', by Rigby, by 
 Ramsbotham, by Meigs, &c, and to understand either, or 
 all of them well, you must give faithful attention to the study 
 of the anatomy of the female pelvis, and all those organs 
 which are concerned in the process of conception, gestation, 
 parturition and lactation. These you must study by per^ 
 sonal application of your scalpel, under the direction of a 
 skilful anatomical teacher. 
 
 Then follow closely upon the demonstrations of your Ob- 
 stetric Professor through his whole course — examine his 
 various pictorial illustrations, anatomical and physiological 
 specimens, and give earnest heed to his demonstrations of 
 the mechanism of the various kinds of labor upon the 
 mannekin, — nay more than this, embrace every possible 
 opportunity to exercise yourselves, either alone with a 
 demonstrator, or in small classes, till you become familiar 
 with every variety of presentation, position, mode of cor-? 
 recting those which are deviated — the proper mode of per- 
 forming version — >the use of obstetric instruments, &c. 
 This done, my little book will be of service to you, and I 
 shall be gratified, if, when you use it as a catechism of your 
 knowledge in midwifery, you shall have been so well in- 
 structed by the method I have just pointed out, that you 
 
PREFACE. 
 
 may detect any error which may exist, either from want of 
 critical knowledge on my own part, or which may have 
 been inadvertently committed, in the haste I have made to 
 supply it to those who have demanded it of me for your 
 sakes. while, as some of you know, I have been labori- 
 ously engaged in teaching and practising the art, at a pe- 
 riod too, when many of the puerperal women in the exten- 
 sive Lying-in Charity, which it is my duty to superintend, 
 have been severely visited by diseases which have required 
 the utmost vigilance and promptitude of treatment, — me- 
 tritis and metroperitonitis. 
 
 I have not followed the systematic arrangement adopted 
 by any obstetric writer in preparing this little offering. If 
 I have been biased by any extrinsic influence, it has been 
 by that of the courses of obstetric instruction given in the 
 University of Pennsylvania, my Alma Mater. I have not, 
 however, calculated it for the meridian of that school 
 only. 
 
 The grand principles of this science and art are the 
 same every where ; and from the numerous institutions for 
 medical teaching, which have sprung up around the parent 
 stalk, throughout the different sections of our wide spread 
 country, we may hope for a powerful and honorable com- 
 petition for excellence in the mode of illustrating these prin- 
 ciples, and the extension of facilities for properly qualify- 
 ing the candidates, to enter usefully upon the exercise of 
 one of the most important functions which one human 
 being can exert towards another. 
 
Vi PREFACE. 
 
 I have written out the matter now presented to you during 
 the minutes not the hours of my leisure ; and, there- 
 fore, lay no claim to great precision in the language I have 
 used. The questions are to be taken, as though they were 
 put to you extemporaneously and familiarly, and the an- 
 swers are mostly made out as though you were unex- 
 pectedly called upon to give them, and in this I consider 
 consists some good quality in the little essay now put into 
 your hands. 
 
 I have addressed you numerous interrogatories, but I 
 have omitted many things, some too which are very im- 
 portant ; but should I discover that you profit well by what 
 I have already done, I shall aim, time permitting, to cate- 
 chise you at some future period, upon the whole subject 
 of obstetric medicine, which I consider includes not only 
 practical midwifery, but obstetrics proper, and the diseases 
 of women and young children. 
 
 Very respectfully yours, 
 
 JOSEPH WARRINGTON. 
 
 No* 229 Vine Street, Franklin Square* 
 Philadelphia, 3d mo, {March) 1, 1842* 
 
CONTENTS. 
 
 Anatomy of the female pelvis, 1 
 Anatomy of the fetus, - 15 
 Anatomy of the contents of 
 
 the female pelvis, - 23 
 
 Menstruation, - - 40 
 
 Disorders of the menstrual 
 
 function, - • 48 
 
 Leuconhcea, 69 
 
 Vaginitis, 73 
 
 Irritable uterus, - - 79 
 
 Prolapsus of the uterus, .. 81 
 Retroversion of the uterus, 83 
 Treatment of displacements, 87 
 Inflammation of the orgaus 
 
 of generation, - - 93 
 Treatment of hysteritis, 97 
 
 Ulceration of the uterus, - 99 
 Mode of using the specu- 
 lum, .... 99 
 Treatment of ulcers of the 
 
 uterus, - - 101 
 
 Phagedenic ulcers of the 
 
 uterus, - - 103 
 
 Cancer of the uterus, - 105 
 Physometra, - - 107 
 
 Hydrometra, - - - 108 
 Hydatids, - - - 109 
 Cauliflower excrescence, 110 
 Tumours within the uterus, 
 
 polypi, &c - 113 
 
 Generation, - - 1 1 5 
 
 Pregnancy, - - - 118 
 Development of the grand 
 
 uterus, - - - 119 
 Effects of gravidity, - 124 
 
 Physiological changes caus- 
 ed by pregnancy, - 126 
 Structure of the ovum, - 128 
 Placenta, cord, &c. - 133 
 
 Nutrition of the ovum, - 135 
 Superfetation, - 139 
 
 Development of the embryo 
 and fetus, - - 141 
 
 Peculiarities of the fetus, 145 
 Fetal circulation, - 145 
 
 Physiological changes after 
 
 birth, - 147 
 
 Function of placenta, - 151 
 Extra-uterine pregnancy, 152 
 Treatment of extra-uterine 
 
 pregnancy, - 157 
 
 Signs of pregnancy, - 158 
 Development of the uterus 
 
 from pregnancy, - 161 
 Physical signs of pregnancy, 163 
 Physical examination, touch- 
 ing, - - 164 
 Auscultation, - 168 
 Condition of the vagina, and 
 
 of the urine, - - 171 
 Diseases o{^ pregnancy, - 172 
 Treatment of pregnant fe- 
 males, - • 185 
 Duration of pregnancy, - 194 
 Labor, - - 195 
 Changes effected by labor, 198 
 Signs of labor, . . 200 
 Stages of labor, - 203 
 Characteristics of the stages 
 of labor, - - 205 
 -Changes produced by labor, 206 
 Duration of labor, - 208 
 Presentation and position, 209 
 Particular positions of the 
 
 cephalic extremity, - 210 
 Mechanism of labor, - 212 
 
 Mechanism of first position, 213 
 Mechanism of second and 
 
 third positions, - 215 
 
 Mechanism of posterior va- 
 rieties, - - 216 
 Convertibility of the posi- 
 tions, - - 219 
 Arrangement of the bed for 
 
 delivery, - - 220 
 
 Preparation of the patient, 221 
 
Vlli 
 
 CONTENTS. 
 
 Diagnosis of labor, - 224 
 
 Mode of making an exami- 
 nation, - 226 
 
 Rule for the use of the hands 
 in making- flexion and ro- 
 tation, - - 229 
 
 Manner of protecting the 
 
 permseum, 
 
 231 
 
 "Management of transverse 
 
 positions, - - 233 
 
 Delivery of the placenta, 234 
 Manual assistance, - 236 
 Irregular contractions of the 
 
 uterus, - - 237 
 
 Hour-glass contraction, - 239 
 Mode of acting in such 
 
 cases, - - 239 
 
 Adhesion of the placenta, - 241 
 Proper time for cutting the 
 
 cord, - - - - 241 
 Mode of receiving and dis- 
 posing of the child, - 242 
 Asthenic condition of the 
 
 child, - - - - 243 
 Asphyxia - 244 
 
 Treatment proper in these 
 
 cases, - - - -245 
 Tumors on the scalp, - 246 
 Washing and dressing the 
 
 child, &c. - - - 247 
 Putting the mother up in 
 
 bed, - - - - 249 
 After treatment, - - 251 
 After pains, - - - 251 
 Pelvic presentations, - 243 
 Varieties of pelvic presenta- 
 tion, - 254 
 Mechanism of pelvic pre- 
 sentation, - 255 
 Management of pelvic pre- 
 sentation, - - - 259 
 
 Management of feet pre- 
 sentations and version 264 
 Version by the head, - - 264 
 Version by the feet, - 265 
 Position for version, - - 266 
 Different steps of version, 267 
 Rules for the particular 
 hand, - - - - 269 
 
 Management of the arms, 271 
 Deviated breech presenta- 
 tions, - - - 273 
 Use of fillet, - - - 274 
 Use of blunt hook, - 275 
 Use of vectis, - - 276 
 Forceps, - - - - 278 
 Application of forceps, - 281 
 Necessity of cephalotomy - 289 
 Mode of performing it, - 289 
 Instruments to be used, - 291 
 Gastro-hysterotomy, - 294 
 Premature artificial delivery, 395 
 Presentation of anterior fon- 
 tanels, - - - - 296 
 Presentations of the face, 298 
 Mechanism of face presenta- 
 tions, - - - - 301 
 Management of do. - 303 
 Other deviated positions - 305 
 Shoulder presentations, - 306 
 Spontaneous version, - 308 
 Management of shoulder 
 
 cases, - - - - 309 
 Various causes of complica- 
 tion of labor, - - - 313 
 Doublets, - - - 313 
 Obliquity of the uterus, - 315 
 Retroversion of the uterus, 316 
 Ante- version, &c. - 318 
 
 Spasmodic contractions of - 
 
 the uterus, - - 320 
 
 Rupture of the uterus, 321 
 
 Puerperal convulsions, - 323 
 Treatment of do. - - 325 
 Atony, or inertia of the ute- 
 rus, .... 327 
 Inversion of the uterus, - 329 
 Use of ergot in cases of in- 
 ertia, - - - 331 
 Abortion, - 333 
 Symptoms of abortion, - 535 
 Treatment of do. - - 337 
 Uterine hemorrhage, during 
 
 pregnancy, - 337 
 
 Management of accidental 
 
 hemorrhage, - 339 
 
 Management of cases of pla- 
 centa previa, - - - 340 
 
OBSTETRIC CATECHISM. 
 
 What part of the osseous system of the female, is of 
 most importance to the practical accoucheur ? 
 That portion called the pelvis. 
 
 Where is the pelvis situated ? 
 
 At the lower extremity of the trunk, between the last 
 lumbar vertebra and the upper portion of the ossa femora. 
 
 Of how many bones is the adult pelvis constituted ? 
 Four. 
 
 What are they ? 
 
 One sacrum, one coccyx, and two ossa innominata. 
 
 Where is the sacrum situated ? 
 
 Between the last lumbar vertebra above, and the coccyx 
 below, and between the ossa innominata behind. 
 
 What is the shape of the sacrum ? 
 Triangular or pyramidal — concave anteriorly and con- 
 vex posteriorly. 
 
 1 
 
Z ANATOMY OF FEMALE PELVIS. 
 
 How many articulating surfaces does it present ? 
 
 Four. Its base above, for connection with the lumbar 
 vertebra ; its apex below, for the coccyx, and one on the 
 upper half of each side for the posterior portion of the 
 ossa innominata. 
 
 What is found on the anterior surface of the sacrum 1 
 Four or five quadrangular facettes, with the same number 
 of transverse lines, marking the point of fusion of the 
 originally distinct bones ; at the ends of these transverse 
 lines an equal number of foramina— for the passage of the 
 anterior branches of the sacral nerves. 
 
 What muscles are attached to the outer edges of the 
 sacrum, and between these holes ? 
 The pyramidal muscles. 
 
 What is attached to the sharp edges of the inferior half 
 of the sacrum ? 
 
 The sacro-ischiatic ligaments. 
 
 What is the general appearance of the posterior portion 
 of the sacrum ? 
 
 Convex, and very rough. 
 
 What do we find in the median line ? 
 Several spinous processes. 
 
 What is to be seen at the upper portion of the posterior 
 face ? 
 
 Articulating surfaces for the last lumbar vertebra. 
 
 What exists at the lower portion ? 
 
 A triangular notch, in which terminates the spinal canal. 
 
 What is to be seen on each side of the spinous processes 
 of thfc sacrum ? 
 
ANATOMY OF FEMALE PELVIS. 3 
 
 Four or more foramina for the transmission of the pos- 
 terior branches of the sacral nerves. 
 
 What is the object of the rough surfaces near the edges 
 of the posterior face of the sacrum ? 
 
 To present points for the strong attachment of sacro-iliac 
 and sacro-ischiatic ligaments. 
 
 What is the object of the broad oblique and somewhat 
 rough surface, at the upper lateral portions of this bone ? 
 For articulation with the ilia or innominata. 
 
 What is the situation of the coccyx ? 
 At the inferior termination of the sacrum, with which it 
 is articulated. 
 
 What is its shape ? 
 Triangular. 
 
 What projects upwards, or backwards, from its base ? 
 Two prolongations, resembling horns. 
 
 What is the shape of its apex ? 
 Tuberculated and rounded. 
 
 What is attached to its edges ? 
 
 The ischio-sacral, or short sacro-ischiatic ligament. 
 
 What muscles are inserted into its edges ? 
 The ischio-coccygeal muscles. 
 
 What muscle is attached to its point? 
 The external sphincter ani muscle. 
 
 Of how many bones is the coccyx originally composed ? 
 Three or four. 
 
 What kind of articulation exists between the sacrum and 
 
 ccyx ? 
 
 Gynglimoid, or hinge-like. 
 
 coccyx ? 
 
4 ANATOMY OF FEMALE PELVIS. 
 
 What is the direction of the motion of the coccyx upon 
 the sacrum ? 
 
 Antero posterior. 
 
 What is the extent of movement usually allowed to the 
 apex of the coccyx ? 
 
 From half an inch to an inch. 
 
 Does the presence of the coccyx necessarily interfere 
 with the process of labour ? 
 
 Only when it is partially or completely anchylosed. 
 
 What is the general shape of an os innominatum ? 
 
 It has a very irregular quadrangular shape, appearing as 
 if strangulated at its middle, and twisted in two opposite 
 directions. 
 
 How many surfaces has it? 
 
 Two, one external and one internal. 
 
 What is the arrangement of its internal surface ? 
 It is divided into two nearly equal portions ; the upper 
 one, extensively excavated, is called the internal iliac fossa. 
 
 What occupies this broad expanse ? 
 The internal iliac muscle. 
 
 What do we find at the posterior margin of this upper 
 portion 1 
 
 An articulating surface for junction with a portion of the 
 sacrum. 
 
 What is the general shape of the inferior portion ? 
 Triangular. 
 
 What opening exists, about the centre of this lower 
 portion ? 
 
 The obturator foramen, or subpubic opening. 
 
ANATOMY OF FEMALE PELVIS. 5 
 
 What constitutes the point of division between the upper 
 and lower portions of the ossa innominata? 
 
 The linea-ilio-peetinea, running from the crest of the 
 pubis, backwards towards the junction with the sacrum. 
 
 What is to be observed on the external or femoral surface 
 of the os innominatum ? 
 
 First, the external iliac fossa. Secondly, the acetabulum. 
 Thirdly, the subpubic, or obturator foramen, surrounded 
 by the edges of the pubis, the ischium and the ischio- 
 pubic ramus. 
 
 What occupies the external iliac fossa ? 
 The glutei muscles. 
 
 What is noticed on the upper edge of the os innomina- 
 tum ? 
 
 The crest of the ilium. 
 
 What is attached to this crest ? 
 
 Muscles in its central portion, Poupart's ligament at the 
 anterior, and the sacro-iliac ligaments at the posterior ex- 
 tremity. 
 
 What is seen on its anterior edge ? 
 
 First, the antero-superior spine of the ilium, next a 
 small semilunar notch, then the inferior anterior spine of 
 the ilium, the groove for the psoas and iliacus muscles, 
 then the ileo-pectineal eminence for the insertion of the 
 psoas parvus muscle, then a triangular smooth surface, the 
 spine of the pubis. 
 
 What is the arrangement of the posterior edge of this 
 bone ? 
 
 First, the posterior spine of the ilium ; a small irregular 
 notch ; the posterior inferior spine of the ilium ; which 
 
 1* 
 
6 ANATOMY OF FEMALE PELVIS. 
 
 articulates with the sacrum, then the great ischatic notch, 
 and lastly the posterior portion of the tuberosity of the 
 ischium. 
 
 Of how many distinct bones is the os innominatum 
 originally composed ? 
 
 Three, the ilium above, the ischium directly below, the 
 pubis in front of the last, and rather below the first. 
 
 At what points are these bones consolidated into one at 
 a later period of life ? 
 
 In the acetabulum, or cotyloid cavity, at the pectineal 
 eminence and at the middle of the ischiopubic ramus. 
 
 At about what period of life, does this consolidation take 
 place ? 
 
 The age of puberty. 
 
 What are the principal articulations or symphyses of the 
 pelvis ? 
 
 One for the two pubic bones to each other in front, and 
 one for each ilium to the sacrum behind. 
 
 What is the mode of articulation of the symphysis 
 pubes ? 
 
 The two articular surfaces are applied to each other, and 
 sustained firmly in that position, by strong ligamentous 
 fibres, before and behind. Underneath, the fibrous arrange- 
 ment is so abundant, as to give to it the character and name 
 of sub-pubic ligament. 
 
 Is the symphyses pubes of the adult female susceptible 
 of spontaneous separation, or of having one extremity 
 moved upon the other ? 
 
 There are strong reasons for believing that no perceptible 
 
ANATOMY OF FEMALE PELVIS. 7 
 
 degree of motion can be effected in a healthy condition of 
 the parts. 
 
 What is the character of the posterior or sacro-iliac 
 symphysis ? 
 
 The sacrum is placed like an inverted key-stone at the 
 top of an arch, between the two iliac bones ; strong bands 
 of ligamentous fibres extend across from the sacrum to the 
 ilium on each side, and thus a strong symphysis is effected. 
 
 Is there a bursa, or synovial sac, found in either of these 
 symphyses ? 
 
 In the symphysis of the pubes, there is to be seen an 
 approximation to a bursa ; it is however far from complete. 
 
 In each of the sacro-iliac junctions there are found some 
 small points of condensed fatty matter, but no regular 
 bursa. 
 
 Does the pelvis derive support from any other points 
 than those at which the bones are articulated ? 
 
 The whole edge of the sacrum below its junction with 
 the ilium gives attachment to a very strong ligament which 
 converges as it passes downward and forward to be inserted 
 into the tuberosity of the ischium. 
 
 What is inserted into the spinous process of the ischium ? 
 
 Some strong bands of ligamentous fibres, which extend 
 across the lower part of the ischiatic notch, and are inserted 
 into the lower part of the sacrum and the edge of the 
 coccyx. 
 
 Where is Poupart's ligament situated ? 
 
 It commences at the anterior superior spinous process 
 of the ilium, and extends to the crest of the pubis, crossing 
 to a small extent beyond the symphysis. 
 
8 ANATOMY OF FEMALE PELVIS. 
 
 Where is the obturator membrane found ? 
 
 Filling up nearly the whole of the obturator foramen, 
 admitting merely of space sufficient to allow the transmis- 
 sion of small vessels, nerves and muscles. 
 
 If we divide the pelvis into two equal parts, by a section 
 through the acetabula, what will be found in the anterior 
 portion ? 
 
 The bodies and rami of the pubes, the arch of the pubes, 
 the rami of the ischia, and the obturator foramina. 
 
 What will be found in the posterior half? 
 The sacrum and coccyx, the bodies of the ischia and 
 ilia, the sacro-sciatic notches. 
 
 What do the lateral portions of the pelvis include ? 
 The ischia and ischiatic notches with a part of the obtu- 
 rator foramina. 
 
 How is the pelvis divided above and below ? 
 Into false pelvis above, and true pelvis below. 
 
 What forms the boundary line between the two ? 
 The linea-ilio-pectinea. 
 
 What is the upper portion called ? 
 
 Pavilion ; false pelvis ; and abdominal pelvis. 
 
 What is its general description ? 
 
 It is defective directly in front, is expanded and elevated 
 at the sides, while posteriorly it is again diminished except 
 in the central portion, where it is somewhat filled up by 
 the promontory of the sacrum and the lower lumbar verte- 
 brae. 
 
 What influence do these lumbar vertebra?, and the pro- 
 montory of the sacrum exert on the position of the child ? 
 
ANATOMY OF FEMALE PELVIS. 9 
 
 They project so far into the cavity of the abdominal 
 pelvis as to divide it into two portions, and cause the child 
 to slide off to one side. 
 
 What is the distance between the superior anterior 
 spinous process of one ilium and that of the other ? 
 From nine to ten inches. 
 
 What is the distance between the middle point of one 
 crest and that of the other ? 
 From ten to eleven inches. 
 
 What is the depth of the upper or abdominal pelvis, that 
 is, from the top of the crista to the linea-ilio-pectinea ? 
 From three and one fourth, to three and a half inches. 
 
 Which is of most importance in obstetrics, the superior 
 or inferior pelvis ? 
 
 The inferior, or emphatically the pelvis. 
 
 What is its general shape ? 
 Conoidal, with its base upwards. 
 
 What are its principal openings ? 
 One above, and one below. 
 
 What are these openings called ? 
 Straits. 
 
 Why? 
 
 Because they are rather more contracted than the space 
 between them. 
 
 What is the space between the straits called ? 
 The cavity or concavity, basin, etc. 
 
 Are these straits just alluded to, not identical with the 
 cavity ? 
 
 They are the initial and terminal portions of the true 
 
10 ANATOMY OF FEMALE PELVIS. 
 
 pelvis, but should always be distinguished from the cavity- 
 its elf. 
 
 What is the shape of the superior strait ? 
 Cordiform, or somewhat elliptic, with one side of the 
 ellipse depressed. 
 
 What constitutes the superior strait ? 
 The top of the symphysis pubes, the linea-pectinea, the 
 linea-ilea, and promontory of the sacrum. 
 
 What is the circumference of the superior strait? 
 From thirteen inches, to thirteen and a half. 
 
 What number of diameters of this strait are recognized 
 in practice ? 
 Four. 
 
 What are they ? 
 
 First, antero-posterior, or sacro-pubic, measuring from 
 four, to four and a half inches. Second, oblique, from 
 points in the linea-ileo-pectinea diagonally to the sacro-iliac 
 symphysis, measuring five inches. Third, the transverse, 
 or bis-iliac, on the transverse median line, from one point 
 of the linea-ileo-pectinea to the opposite, measuring five 
 and one fourth inches. 
 
 What is the direction of the axis of the superior strait ? 
 
 It commences about the point of the coccyx : passes at 
 right angles with the plane of the strait through its centre, 
 and would make its exit through the abdominal parieties 
 about the umbilicus. 
 
 What relation does this axis hold to the pelvis, and to 
 that of the body ? 
 
 It is always uniform with regard to the pelvis, but it is 
 variable with regard to the body. 
 
ANATOMY OF FEMALE PELVIS. 11 
 
 What practical hint is derived from a knowledge of this 
 variability ? 
 
 That in difficult or tedious labors we should oblige the 
 patient to incline her body forward to make its axis corres- 
 pond with that of the superior strait. 
 
 What is the shape of the plane of the inferior strait? 
 It is oval, or slightly cordiform, if we allow the coccyx 
 to encroach upon its posterior extremity. 
 
 What are the boundaries of the inferior strait ? 
 
 The sub-pubic ligament in front, the rami of the pubes 
 and ischia on each side, and the sacro-ischiatic ligaments 
 and coccyx behind. 
 
 What is the circumference of the inferior strait? 
 Twelve inches. 
 
 From what points do we reckon the antero-posterior 
 diameter ? 
 
 From the posterior portion of the sub-pubic ligament, to 
 the point of the coccyx. 
 
 What is this distance ? 
 
 Four and a half inches ; the mobility of coccyx allows 
 half an inch more, making it five inches. 
 
 From what points do we reckon the transverse diameter ? 
 From the posterior part of the tuberosity of one ischium , 
 to that of the other. 
 
 What synonyme have we for this diameter ? 
 Bis-ischiatic diameter. 
 
 What does it measure ? 
 Four inches. 
 
12 ANATOMY OF FEMALE PELVIS. 
 
 What other diameters should be remarked in this inferior 
 strait ? 
 
 Two oblique. 
 
 Whence are they measured ? 
 
 From the junction of the ramus of the pubes, and the 
 ramus of the ischium on either side across to the centre of 
 the sacro*ischiatic ligaments on the opposite sides* 
 
 What is the space ? 
 
 Four inches ; the same as the transverse diameter. 
 
 What is the direction of the axis of the inferior strait ? 
 
 Commencing just below the promontory of the sacrum, 
 it passes downwards perpendicularly through the centre of 
 the plane of the inferior strait, at the point of intersection 
 of the antero-posterior and transverse diameters, and thus 
 out about the posterior commissure of the undilated, or 
 through the centre of the dilated vagina. 
 
 What is the difference between the transverse diameters 
 of the superior and inferior straits ? 
 
 The transverse diameter of the inferior strait is one and 
 one fourth inches shorter than that of the superior strait. 
 
 If we push back the coccyx, and thus make the antero- 
 posterior diameter of the inferior strait equal to that of the 
 oblique, or transverse of the superior strait, with what body 
 might we compare the cavity of the pelvis ? 
 
 That of a cylindroid, twisted one sixth of its circumfer- 
 ence upon its axis. 
 
 What are the supero*inferior measurements of the pelvis ? 
 
 From the top of the symphysis to the lower edge of -the 
 sub-pubic ligament, one and a half inches. From the top 
 of sacrum to the point of coccyx, five inches ; when the 
 
ANATOMY OF FEMALE PELVIS. 13 
 
 coccyx is pushed back, from five and a half to six inches. 
 From the linea-ilio-pectinea to the tuberosity, three and a 
 half inches ; from the crest of ilium to the bottom of tuber- 
 osity of the ischium, seven inches. 
 
 What is the distance from the bottom of the sub pubic 
 ligament to top of the promontory of the sacrum ? * 
 
 Four and a half inches. 
 
 What is the distance from the bottom of sub pubic liga- 
 ment to the hollow of the sacrum ? 
 Four and three fourth inches. 
 
 What is the distance from the bottom of the tuberosity 
 of one ischium to the linea-ilio-pectinea directly opposite ? 
 Six inches. 
 
 - What is the height of the arch of the pubes, from a line 
 drawn on a level with the tuberosities of the ischia? 
 Two inches. 
 
 Into what peculiar arrangement is the interior of the 
 pelvis distributed ? 
 
 On each side of the antero-posterior median line are 
 . found two lateral inclined planes. 
 
 What is the direction of the anterior inclined planes on 
 each side ? 
 
 Commencing nearly or exactly at the sacro-iliac sym- 
 physis, they occupy all the space between that point and 
 the symphysis pubes, and passing downwards and forward 
 just in front of the spines of the ischia, over the obturator 
 foramina, they terminate on the anterior edge of the rami 
 of the pubes and ischia. 
 
 What is" the arrangement of the posterior inclined planes ? 
 
 Commencing at the sacro-iliac junctions, at or below the 
 
 2 
 
14 ANATOMY OF FEMALE PELVIS. 
 
 linea-ilio-pectinea, they occupy the space between those 
 points and the middle line of the sacrum, then pass down- 
 wards and backwards behind the spines of the ischia, over 
 the sacro-sciatic foramina and sacro-ischiatic ligaments, to 
 terminate upon the posterior edges of the tuberosities of the 
 ischia, the lower edges of the sacro-ischiatic and coccygeo- 
 ischiatic ligaments, and also the point of the coccyx. 
 
 Which of these occupies the greater space in the pelvic 
 
 canal, the anterior or posterior inclined planes ? 
 
 The anterior, being both longer and wider. 
 
 t 
 What influence do these planes exert upon the mechanism 
 
 of labor 1 
 
 They direct the presenting part of the fetus. Thus if 
 the occiput happen to be brought in contact with the pelvis 
 anterior to the spine of the ischium, it must pass down upon 
 the anterior inclined plane, and emerge under the arch of 
 the pubes ; but if the occiput happen to enter the pelvis 
 behind the spine of the ischium, the posterior inclined 
 plane compels it as it passes down, to rotate into the hollow 
 of the sacrum, that it may escape at the posterior commis- 
 sure of the vulva. 
 
 Regarding the pelvis as constituted of a series of planes, 
 extending from the sacrum to the pubes, from the linea- 
 ilio-pectinea to the coccyx and sub-pubic ligament, how 
 can we represent the axis of the pelvis ? 
 
 As a curved line, resembling that of a catheter adapted 
 to the adult male. 
 
 Of what value to practical midwifery is a knowledge 
 of the inclination of the straits upon each other, and that 
 the axis of the inferior strait is inclined to the axis of the 
 body ? 
 
OF THE FETUS. 15 
 
 That in all cases of manual or instrumental labor, the 
 assistance must be rendered in the direction of the axis of 
 that part of the pelvis to which the child is presenting. 
 
 What are the general points of difference between the 
 pelvis of the female and the male adult ? 
 
 The capacity of the female pelvis is greater than that of 
 the male, its diameters being larger, though its depth is 
 less. In the male, the arch is narrow and high, while in 
 the female it is broad, low, and well formed. 
 
 OF THE FETUS. 
 
 What is the general condition of the osseous system of 
 the fetus? 
 
 The middle portions of the bodies of the bones are usually 
 pretty well developed, though somewhat flexible, while 
 the extremities are still cartilaginous and very pliant. 
 
 What advantages result from this circumstance in prac- 
 tice 1 
 
 A greater degree of flexibility of the child, both during 
 labor, and for a short time after its birth. 
 
 What is the usual length of a fetus at term ? 
 From eighteen to twenty-two inches. 
 
 What is the distance from the tip of one acromion pro- 
 cess to that of the other ? 
 Four or more inches. 
 
16 OF THE FETUS. 
 
 May this diameter be diminished without danger ? 
 It may be diminished an inch or more without hazard 
 io the child, as it passes through the pelvis. 
 
 What is the antero-posterior, or dorso-thoracic diameter 
 of the child ? 
 
 Three and a half or four inches — but it may be reduced 
 to two inches. 
 
 What are the general measurements of the breech of the 
 child when flexed ? 
 
 From trochanter to trochanter, from two and a half to 
 three ; from sacrum to anterior part of thigh when flexed 
 forward, three inches. 
 
 What is the antero-posterior diameter of the pelvis 
 alone ? 
 
 From one and a half to two inches. 
 
 What portion of the fetus is most important in an obste- 
 tric point of view. 
 The head. 
 
 How is the fetal cranium constituted ? 
 Of several different bones, so arranged as to present an 
 ovoid figure. 
 
 How are the sutures constructed ? 
 They consist of membranous interspaces between the 
 several moveable bones of the fetal head. 
 
 How is the cranium arranged as to its compressibility ? 
 
 Part of it is compressible, the bones being moveable 
 upon, or capable of being slided over each other, — and the 
 other portion is incompressible, or not admitting of such 
 alteration in the position of the bones. 
 
OF THE FETUS* 17 
 
 The head being of an ovoid form, what names are given 
 to the two extremities of it ? 
 
 Posterior and anterior, or occipital and mental. 
 
 How many surfaces do we count upon the head of the 
 fetus ? 
 
 A superior, an inferior, two lateral, a posterior and an 
 anterior surface. 
 
 What is the boundary of the superior surface ? 
 A horizontal line, bounded by the upper part of the or- 
 bits. 
 
 What is the base of the head ? 
 
 All the immoveable part of it, viz. — the sphenoid in the 
 centre, the temporal bones laterally, together with the 
 bones of the face. 
 
 What part of the fetal head resembles a hemisphere ? 
 The posterior or occipital extremity. 
 
 What is the composition of the os frontis ? 
 Although it is divided nearly or entirely by a suture dur- 
 ing early life, yet it is usually considered as one bone. 
 
 How in regard to the occipital bone ? 
 
 Originally it was in several separate pieces, but these so 
 soon become fused together, that it is usual and proper to 
 consider it as onlv one bone. 
 
 What position do the parietal bones occupy ? 
 The lateral portions of the head, above the temporal, 
 and between the frontal and occipital bones. 
 
 How many principal sutures are thejfc and what are 
 they called? 
 
 1. The Lamdoid Suture, running from the bases of 
 
 2* 
 
18 OF THE FETUS. 
 
 the occipital and parietal bones, between these bones, and 
 along the entire lateral and upper portions of the occipital 
 bone. 
 
 2. The Saggital Suture, extending forward from the 
 upper point of the occipital bone, between the two parietal 
 bones, to their anterior angles. 
 
 3. The Coronal Suture, extending along the anterior 
 edges of the parietal bones, between them and the frontal 
 bone, from their base. 
 
 4. The Frontal Suture, extending forward between 
 the two upper edges of the frontal bone, continuous with 
 the saggital suture to the root of the nose. 
 
 What is found at the upper and anterior angles of the 
 parietal bones, and at the upper and posterior angles of the 
 frontal bone ? 
 
 A quadrangular or kite-shaped membranous space, cal- 
 led the anterior fontanelle, or the bregma. 
 
 What is found at the posterior extremity of the saggital 
 suture ? 
 
 A triangular or cruciform membranous space, called the 
 posterior or occipital fontanelle. 
 
 Is this posterior or occipital fontanelle always well 
 marked on the fetal head ? 
 
 By no means — sometimes it is readily perceived, but 
 more frequently it cannot be recognized as a triangular mem- 
 branous space — it is therefore often merely linear. 
 
 Is a knowledge of these fontanelles of much importance 
 in the practice of midwifery ? 
 
 They are of great value, as they are the chief means of 
 diagnosticating the positions of the head during labor. 
 
 If no perceptible membranous space exists at the top of 
 
OF THE FETUS. 19 
 
 the occiput — how are we to recognize the presentation of 
 the occipital extremity of the head? 
 
 By the angles at the upper and posterior ends of the pa- 
 rietal bones, and the rounded margin of the occiput. 
 
 What other fontanelles may be found on the fetal head ? 
 
 Two inferior ones at the posterior inferior edges of the 
 parietal bones, and between them and the edge of the occi- 
 pital bone. 
 
 What influence may these exert in diagnosis ? 
 Without care they may lead to error. 
 
 What are the boundaries of the posterior or occipital 
 surface of the fetal cranium ? 
 
 From a point half way between the promontory of the 
 occiput to the foramen magnum of that bone, round over 
 the parietal protuberances, to a point near the anterior ex- 
 tremity of the saggital suture. 
 
 What is the situation of the posterior fontanelle in refer- 
 ence to the centre of this posterior surface ? 
 
 It is not usually in the centre, but mostly a little poste- 
 rior to it. 
 
 What is meant by the term vertex in obstetrics ? 
 It is applied to that part of the fetal head exactly in the 
 centre of the posterior surface of the occipital extremity. 
 
 / What figure does a plane of the occipital extremity pre- 
 sent ? 
 
 Nearly that of a circle. 
 
 By what particular name is it known ? 
 Occipito-bregmatic circumference. 
 
 What is the transverse diameter of this circumference 
 called, and what does it measure ? 
 
20 OF THE FETUS. 
 
 The bi-parietal diameter, and it measures from three, to 
 three and a half inches. 
 
 What is the perpendicular diameter called, and what 
 does it measure ? 
 
 Occipito-bregmatic, and it measures from three, to three 
 and a half inches. 
 
 What is the horizontal circumference of the head 1 
 That which commences at the centre of the occipital pro- 
 tuberance, and passes round on each side of the parietal 
 and frontal bones, till its ends meet in the root of the nose. 
 
 What is the long diameter of this circumference called, 
 and what does it measure ? 
 
 Occipito- frontal, and measures four inches. 
 
 What is the name of the transverse diameter, and what 
 does it measure ? 
 
 Bi-parietal, and measures from three, to three and a half 
 inches. 
 
 What is the trachelo-bregmatic circumference ? 
 
 That which commences in front of the cervical vertebrae, 
 and passes round over the temporal, and portions of the pa- 
 rietal bones, and terminates in the bregma or top of the 
 head. 
 
 What are its diameters called, and what do they measure ? 
 
 1 . Trachelo-bregmatic, measuring three and a half inches. 
 
 2. Bi-temporal, measuring two and a half inches. 
 
 For practical purposes, what should we consider the di- 
 ameter of the base of the cranium ? 
 
 The same as those of the occipito-mental and the bi-pa- 
 rietal circumferences, of which the first diameter measures 
 five inches, and the second, three and a half inches. 
 
 ': 
 
 t^J xl ^^ 
 
OF THE FETUS. 21 
 
 What diameters present within the circumference of a 
 perpendicular longitudinal section of the cranium, and what 
 do they measure ? 
 
 1. The occipito-mental, five inches. 
 
 2. The occipito-frontal, four inches. 
 
 3. The occipito-bregmatic, three and a half inches. 
 
 4. The trachelo-bregmatic, three and a half inches. 
 
 What is the situation of the neck of the child, with re- 
 gard to the cranium ? 
 
 It is situated a little posterior to a vertical line drawn 
 through the long diameter. 
 
 Which represents the longer lever, the mental or occipi- 
 tal extremity, of which the neck is a point or centre of mo- 
 tion? 
 
 The mental extremity. 
 
 What results from this when the body and head are 
 equally compressed ? 
 
 A marked degree of flexion. 
 
 What is the relative size of the face with that of the 
 head ? 
 
 Very small. 
 
 What is the facial circumference in obstetric language ? 
 From the top of the forehead to the end of the chin, 
 through the lateral portions of the malar bones. 
 
 What are the two diameters of this facial circumference, 
 and what do they measure ? 
 
 1. The fronto-mental diameter, measuring three inches. 
 
 2. Bi-malar, two and a half inches. 
 
 Where is the centre of this circumference ? 
 In the root of the nose. 
 
22 OF THE FETUS. 
 
 To what shape is the compressible portion of the fetal 
 cranium reduceable ? 
 To that of a conoid. 
 
 To what length may the occipito-mental diameter be 
 elongated ? 
 
 From five, to six or seven' inches. 
 
 To what may the bi-parietal diameter be diminished by 
 compression ? 
 
 From three and a half, to three inches. 
 
 When strong compression is effected, in what direction 
 does it usually carry the bones ? 
 
 The os frontis is carried backwards, and the parietal 
 bones also. 
 
 Although the diameters of the facial circumference are 
 smaller than those of any other measurement, what diame- 
 ters really are presented to the plane of the superior strait, 
 in face presentations of the fetus ? 
 
 The trachelo-bregmatic, measuring three and a half, and 
 the bi-parietal diameter, measuring three and a half inches. 
 
 What obstacle is added to the passage of the head in 
 such cases. 
 
 Part of the neck of the fetus, making the occipito-breg- 
 matic diameter at least an inch longer. 
 
 When the forehead presents to the centre of the superior 
 strait of the pelvis, what circumference presents to that 
 of the pelvis ? 
 
 That which passes from the posterior fontanelle round 
 upon the bi-parietal diameter to the chin. 
 
 What is the length of the long diameter of this circum- 
 ference ? 
 
CONTENTS OF THE PELVIS. 23 
 
 From chin to posterior fontanelle, measuring from four, 
 to four and a half or five inches. 
 
 When the occiput presents favourably to the centre, or 
 better still, when the vertex presents to the centre of the 
 pelvis — what circumference presents to that of the pelvis ? 
 ;' That which includes the occipito-bregmatic, and the bi- 
 parietal diameter. 
 
 What relation does this circumference hold to the pelvis 
 in every stage of its passage through the pelvis ? 
 
 Uniformly the same with the jplanes of the straits and 
 cavity of the pelvis. 
 
 When is the head considered as engaged in the superior 
 strait, in a regular occipital or vertex presentation ? 
 
 When the posterior circumference is on a level with, 
 or a little below the linea-ilio-pectinea. 
 
 In what manner is the finger to be applied to the pelvis 
 and head to determine its degree of descent. 
 
 It should be carried up to some portion of the linea-ilio- 
 pectinea, and then applied to that part of the head which 
 is in contact with, or opposite to it. 
 
 OF THE CONTENTS OF THE FEMALE 
 PELVIS. 
 
 What muscles line the upper pelvis ? 
 The iliacus internus and the psoae muscles. 
 What is the origin and insertion of the iliacus internus 
 muscle ? 
 
24 CONTENTS OF THE PELVIS. 
 
 It rises from the anterior two-thirds of the crest of the 
 ilium, in front of the psoae muscles, and filling up the iliac 
 fossa, is inserted with the psoas muscles into the small 
 trochanter of the femur. 
 
 In what respect do these muscles affect the diameters of 
 the superior strait ? 
 
 They diminish the lateral and oblique diameters from 
 one fourth to one half of an inch. 
 
 Which diameter is the longer in the recent pelvis — the 
 oblique or transverse ? 
 
 Ramsbotham says the oblique — Hodge the transverse di- 
 ameter, while Cazeaux declares that the oblique diameters 
 are not diminished in length. 
 
 What muscles and fascia line and close up the inferior 
 strait of the pelvis ? 
 
 The pelvic fascia, including the internal iliac vessels and 
 branches — the internal obutrator and part of the levatores 
 ani, transversus perinei, and ischio-coccygeal muscles. 
 
 What are the origin and insertion of the levatores am 
 muscles ? 
 
 They arise from the inner part of the pubes, the supe- 
 rior part of the obturator foramen, and the spine of the is- 
 chium. Inferiorly the middle and anterior fibres unite be- 
 neath the rectum, enveloping this intestine, and they are 
 inserted into the sphincter ani and perineum in front. 
 
 What influence may the constituents of this pelvic floor 
 exert upon the process of labor ? 
 
 They may, owing to the rigidity of the parts or spasm 
 of the muscles, retard the exit of the presenting part of the 
 child. 
 
CONTENTS OF THE PELVIS. 25 
 
 What viscera are contained in, and attached to, the 
 pelvis ? 
 
 The rectum behind, the bladder in front, the uterus and 
 its appendages in the middle and lateral portions of the 
 cavity. The vagina, and other portions of the organs of 
 generation occupy the lower portion of and are attached to 
 the pelvis. 
 
 Do we speak of the whole group of organs of genera- 
 tion in a general or special sense ? 
 
 It should be understood in a general sense only. 
 
 How are the organs of generation classified ? 
 Into those of external, and those of internal organs of 
 generation. 
 
 What are called the external organs ? 
 Mons veneris, labia externa, clitoris, nymphae, orifice of 
 vagina and perinaeum. £ 
 
 What is usually included in this list, though it does not 
 pertain to generation 1 
 The meatus urinarius. 
 
 What is the mons veneris and where is it situated ? 
 
 It is composed of a dense fibro-cellular adipose sub- 
 stance, covering the pubes and extending up to a line 
 drawn between the anterior inferior spinous processes of 
 the ilia. 
 
 By what is it covered ? 
 By thick strong hairs. 
 
 Where are the labia externa situated, and how are they 
 arranged 1 
 
 Commencing upon the front of the symphysis pubes, 
 they extend downwards and backwards to the perineum ; 
 
26 CONTENTS OF THE PELVIS. 
 
 they are thick and prominent at their upper portion, but 
 gradually diminish and become flattened as they pass 
 towards their posterior termination. 
 
 What are the anterior and posterior points of junction of 
 the labia called ? 
 
 The anterior and posterior commissures of the vulva. 
 
 What is the texture of the labia ? 
 Principally cellular and vascular. 
 
 What kind of investment has the labia ? 
 
 It is cuticular but passing into the mucous state. 
 
 What are the boundaries of the vulva ? 
 They embrace all the parts immediately surrounding the 
 genital fissure. 
 
 What is found within the upper half of the labia ma- 
 jora ? 
 
 The nymphae, or the labia minora or labia interna. 
 
 What is the situation of the labia minora or nymphae ? 
 
 They arise from nearly the same point at the anterior 
 commissure, and pass obliquely downwards and back- 
 wards about an inch, and then are lost in the general lining 
 of the labia externa. 
 
 What is the general shape of the nymphae ? 
 Triangular. 
 
 What modifications of size or shape are they incident to? 
 
 In the infant they are always comparatively large ; and 
 they may become greatly elongated and enlarged, and con- 
 sequently suffer much alteration in shape. 
 
 Is a knowledge of this enlargement of consequence to 
 the practitioner ? 
 
CONTENTS OF THE PELVIS. 27 
 
 Enlarged nymphae maybe entangled within the obstetric 
 forceps and be torn, or otherwise they may embarrass the 
 use of instruments. 
 
 What is the anatomical structure of the nymphae ? 
 It is cellular, very vascular, and has the properties of an 
 erectile tissue. $£, Q^pu^ &fi#* * t *4 &.. 4ruu 
 
 What kind of external covering has it t 
 A very delicate dermoid, or perhaps mucous membrane. 
 
 What is to be found at the superior extremity of the 
 nymphae ? 
 
 A little hemispherical body, called the glans clitoridis. 
 
 What is this glans the termination of? 
 The clitoris, which appears to be a rudimental male 
 penis. 
 
 In what respect does it differ from the male organ ? 
 It is much less than it, and has no corpus spongiosum 
 urethrae. 
 
 What overhangs the glans clitoridis ? 
 
 A fold of membrane, called the preputium clitoridis. 
 
 How low do the nymphae descend? 
 
 To the middle of the orifice of the vagina nearly. 
 
 What is the space between the nymphae called ? 
 The vestibulum. 
 
 What are the characters of the vestibulum ? 
 
 It is a smooth, triangular surface, covering the facette of 
 the symphysis pubes ; and is bounded on each side by 
 the base of the nymphae, having the clitoris as its apex, 
 and a line drawn from the lower terminal extremity of one 
 nymphae to that of the other, through a perforated caruncle. 
 
28 CONTENTS OF THE PELVIS. 
 
 What is that tubercle or caruncle called ? 
 The meatus urinarius. 
 
 What is the position of the urethra, with regard to the 
 arch and symphysis pubes ? 
 
 Mostly immediately below the one and behind the other. 
 
 What is found immediately below the meatus urinarius ? 
 The orifice of the vagina. 
 
 What are the boundaries of the orifice of the vagina ? 
 All that portion just in front of the part embraced within 
 the sphincter vaginaf muscle. 
 
 What muscle surrounds the vagina at its orifice ? 
 The sphincter vaginae. 
 
 What are its origin and insertion ? 
 
 It arises from the posterior side of the vagina near the 
 perinaeum, thence it runs up the sides of the vagina near 
 its external orifice opposite to the nymphae, and covers the 
 corpus cavernosum vaginae, and is inserted into the crus 
 and body of the clitoris. 
 
 What influence can it exert ? 
 
 It is often feeble, but sometimes so powerful as to close 
 firmly the orifice of the canal. 
 
 What is found posterior to the orifice of the vagina ? 
 The perinaeum. 
 
 How long is it when undistended ? 
 About one and a half inch. 
 
 To what extent might the term perinaeum be applied ? 
 To every portion of the distensible parts found at the 
 inferior opening of the female pelvis. 
 
CONTENTS OF THE PELVIS. 29 
 
 What is the shape of the perinaeum ? 
 As usually deseribed it is triangular. 
 
 What are its boundaries ? 
 
 As viewed by some obstretricians, as including all the 
 distensible parts of the inferior opening of the pelvis, its 
 boundaries should be those of the inferior strait of the 
 pelvis. 
 
 What is the composition of the perinaeum? 
 
 Several muscular layers, as the transversus perinaei, the 
 levatores and sphincter ani muscles, &c, then a considera- 
 ble portion of distensible cellular and dermoid tissue, &c. 
 
 Of what degree of dilatation is the perinaeum suscepti- 
 ble ? 
 
 Nearly or quite sufficient to cover the head of the child 
 when extruded beyond the inferior strait. 
 
 What is the vulvo-uterine canal ? 
 
 It is the vagina, a canal leading from the vulva to the 
 uterus. 
 
 What is its condition in the virgin female ? 
 It is small, and near its orifice is nearly closed by a du- 
 plication of lining membrane called the hymen. 
 
 What is the shape of the orifice of the hymen ? 
 
 It is variable, sometimes triangular, sometimes oval, 
 round, lunated, and even cribriform, or pierced with seve- 
 ral holes. 
 
 About how far within the vulva is the hymen in the adult 
 female ? 
 
 Half an inch. 
 
 3* 
 
30 CONTENTS OF THE PELVIS. 
 
 What becomes of the hymen after it is ruptured ? 
 
 The lacerated surfaces cicatrize, and form several little 
 eminences upon the surface of the vagina, which have 
 been called carunculae myrtiformes. 
 
 Is it a settled matter that all the mulberry-like caruncles 
 are formed in this way ? 
 
 Velpeau, at least, thinks that two or more of them exist 
 originally and independently of this cicatrization of the 
 ruptured portions of the hymen. 
 
 What is found at the inferior portion of the hymen and 
 anterior to it 1 
 
 A depression, called the fossa navicularis. 
 
 What is its inferior boundary ? 
 
 The frcenum labiorum, frenulum perinei, or the four- 
 chette. 
 
 What is the general shape of the empty bladder in the 
 female ? 
 Globular. 
 
 Does the urethra pass off in a strait or curved line from 
 the body of the bladder ? 
 
 In a line curved downwards and forwards. 
 
 How long is the female urethra ? 
 About one inch. 
 
 By what is it lined ? 
 Mucous membrane. 
 
 In what direction do the folds of the mucous membrane 
 of the urethra run ? 
 
 Longitudinal and not transverse. 
 
CONTENTS OF THE PELVIS. 31 
 
 What is there in the female urethra, analogous to the 
 prostatic portion in the male ? 
 
 A thickened condition of the vagina, anteriorly, and a 
 development of the cellular membrane on the posterior 
 part of the urethra. 
 
 What is to be found at the orifice of the urethra ? 
 A little caruncle generally, sufficiently prominent to 
 offer some resistance to the touch of the finger. 
 
 What little folds exist in the canal of the urethra ? 
 Folds of mucous follicles, which are sometimes con- 
 siderably developed. 
 
 What is the length of the vagina, or vulvo-uterine canal? 
 From four to six inches. 
 
 What is its direction in the pelvis ? 
 It is curved upwards. 
 
 What are the directions of its long diameters ? 
 
 At its external extremity the long diameter is in the di- 
 rection of the genital fissure, antero-posterior — near its 
 middle the long diameter is transverse and longer than the 
 first, while at the upper part it is still longer. 
 
 What is the length of the antero-posterior diameter of 
 the orifice of the vagina ? 
 
 From half an inch to an inch, in its undistended state. 
 
 What difficulty results from this small size of the exter- 
 nal orifice of the vagina ? 
 
 Pain and difficulty in the introduction of pessaries and 
 other instruments. 
 
 What part of the vagina has most sensibility ? 
 The external orifice, just at the point of union or transi- 
 tion of dermoid and mucous tissues. 
 
 en 
 
32 CONTENTS OF THE PELVIS. 
 
 What is the anatomical structure of the vagina ? 
 Cellulo-fibrous, with a mucous lining membrane. 
 
 Whence is the mucous secretion furnished in the vagina ? 
 From a large number of mucous follicles arranged within 
 the canal. 
 
 What is the arrangement of the lining mucous mem- 
 brane ? 
 
 Arborescent — -some of the folds are longitudinal, particu- 
 larly those anterior and posterior, while others are trans- 
 verse, and are sometimes called columns of the vagina. 
 
 What supply of blood-vessels has the vagina ? 
 Besides the arteries which carry blood to it, the canal 
 is nearly surrounded by a plexus of veins. 
 
 In what respect is the texture of the vagina different 
 from that of the nymphae ? 
 
 It is non erectile, and its upper portion probably contains 
 some muscular fibres. 
 
 What kind of organ is the uterus ? 
 
 It is a gestative, not a generative organ. 
 
 What is the particular shape of the uterus ? 
 Pyriform, or conical, somewhat flattened antero-poste- 
 riorly. 
 
 Which is the flatter surface, the anterior or the poste- 
 rior? 
 
 The anterior. 
 
 For general purposes of description, what shape may we 
 assume for the uterus ? 
 Triangular. 
 
 How many sides and angles has it ? 
 Three sides and three angles. 
 
 
 
CONTENTS OF THE PELVIS. 33 
 
 What go off from the superior angles ? 
 Two appendages called fallopian tubes. 
 
 What name is given to the part above these tubes ? 
 Fundus of the uterus. 
 
 What portion is called the body of the uterus ? 
 
 All that part between the superior angles and the cylin- 
 drical portion ; in other words, all the truly triangular por- 
 tion of the whole organ. 
 
 What portion is called the neck ? 
 All the cylindrical portion. 
 
 What covers the uterus externally ? 
 Peritonaeum. 
 
 What is meant by the terms broad ligaments of the 
 uterus ? 
 
 They are lateral expansions of peritonaeum from the 
 sides of the uterus towards the lateral and posterior por- 
 tions of the inner surfaces of the pelvis. 
 
 What is the shape of the cavity of the uterus ? 
 Triangular. 
 
 What relation do the anterior and posterior portions of 
 the walls of the uterus hold to each other ? 
 
 They are so nearly in contact, that there is very little 
 space between them. 
 
 What is found at each angle of this cavity ? 
 
 The orifice of each fallopian tube at the two upper 
 angles, and the internal mouth of the uterus at the lower 
 angle. 
 
 What kind of lining membrane has the cavity of the 
 uterus ? 
 
 It appears to be a mucous membrane. 
 
34 CONTENTS OF THE PELVIS. 
 
 How is it ascertained that the lining consists of a mucous 
 membrane ? 
 
 Both from its physiological functions and its pathologi- 
 cal derangements. 
 
 What cavity is situated below the internal orifice of the 
 uterus ? 
 
 The cavity of the neck. 
 
 What is the shape of this cavity ? 
 
 It is somewhat elliptical, or barrel shaped. 
 
 What is the arrangement of the lining or internal surface 
 of the neck ? 
 Arborescent. 
 
 What are found in the folds of the neck ? 
 A number of mucous follicles formerly called ovula 
 nabothi. 
 
 What is the character of the external mouth of the 
 uterus ? 
 
 It is somewhat elliptical, with its longer diameter trans- 
 verse ; it presents an anterior and a posterior smooth 
 rounded lip, and more or less prominent. 
 
 Which of these lips is the larger ? 
 
 The anterior is larger and broader than the posterior. 
 
 What is the usual shape of the orifice of the uterus in 
 the virgin female 1 
 
 Rounded and very small. 
 
 How may we distinguish one which has been the sub- 
 ject of one or more pregnancies or deliveries ? 
 
 By the fact that it is more elliptical and somewhat jagged 
 at the edges. 
 
CONTENTS OF THE PELVIS. 35 
 
 What technical name is sometimes given to the external 
 os uteri ? 
 
 That of os tincae, from its resemblance to the mouth of 
 a tench fish. 
 
 How is the vagina reflected from the os uteri ?j 
 Anteriorly it passes off so directly and apparently at 
 right angles, that the anterior lip appears to be on a level 
 with it. Posteriorly it passes off in a duplication from 
 the middle portion of the neck, and thus presents a cul-de- 
 sac, and at the same time gives an impression to the finger 
 that the posterior lip is longer than the anterior. 
 
 How long is the uterus ? 
 Two and a half inches. 
 
 How wide at the upper angles ? 
 One and a half inches. 
 
 What is the length of the neck ? 
 One inch. 
 
 What is the thickness of the uterus ? 
 Its body is half an inch thick. 
 
 What sensation should a healthy living uterus commu- 
 nicate to the touch ? 
 
 The os tincae should present a smooth surface with re- 
 gular surface of lips, and about the density of a dead 
 uterus hardened in alcohol. 
 
 What is the texture of the uterus ? 
 It is essentially fibrous, but susceptible of great develop- 
 ment during pregnancy. 
 
 From what circumstance do we infer the existence of 
 muscular fibres in the uterus ? 
 
36 CONTENTS OF THE PELVIS. 
 
 The phenomenon of alternate contractions during partu- 
 rition. 
 
 What has been observed by Professor Hodge, of the 
 direction in which the fibres contract during the effort to 
 expel the placenta ? 
 
 That they flatten the uterus and shorten its antero-pos- 
 rior diameter. 
 
 What is the arrangement of the muscular fibres ? 
 
 They appear to originate in a medium line, at the front, 
 back and sides of the uterus, and to run off towards the 
 fallopian tubes and round ligaments, &c. 
 
 Where are the circular fibres distributed ? 
 About the neck, and around the upper angles or cornua 
 of the uterus. 
 
 Who has best succeeded in demonstrating the arrange- 
 ment of the muscular fibres ? 
 
 The late Madame Boivin of Paris. 
 
 Where are the ovaries situated ? 
 
 In the folds of the lateral or broad ligaments, at a little 
 distance from the uterus, one on each side. 
 
 What office do these bodies perform ? 
 They are the seat of conception, they mature for fecun- 
 dation the germ of the new being. 
 
 How are they connected with the uterus ? 
 
 By a ligamentous attachment only. They project from 
 the posterior portion of the broad ligament, but are cover- 
 ed by it and are suspended only by one edge. 
 
 What is the shape of the ovaries ? 
 They are oval bodies, slightly flattened antero-poste- 
 riorly. 
 
CONTENTS OF THE PELVIS. 37 
 
 What is the usual size of the ovaries 1 
 Rather smaller than the testicle of the male. 
 
 What other investment has it beside the peritonaeum ? 
 A proper tunica albuginea. 
 
 What is the texture of this coat ? 
 Sometimes thick, sometimes thin. 
 
 What is found in the parenchyma of the ovary, after the 
 seventh, eighth, or ninth year of female life ? 
 
 Ten, twenty, or thirty little bodies, called the Graaefian 
 vesicles. 
 
 What are these vesicles ? 
 
 The capsules which contain the ovules. 
 
 What is the condition of these vesicles after the detach- 
 ment of the ovule ? 
 
 A little globule of blood at first fills the capsule, which 
 is afterwards absorbed, leaving only a little yellow body 
 called the corpus luteum. 
 
 How long are the fallopian tubes ? 
 So" <T^ From four to five inches. 
 
 What is their general shape ? 
 
 That of a trumpet, having the small end at the angles of 
 the uterus, and the larger, floating free in the cavity of the 
 pelvis. 
 
 What is the general arrangement of the cavity of the 
 fallopian tubes ? 
 
 At the termination m the uterus the duct or canal is large 
 enough to admit of a middle sized probe, it then dimi- 
 nishes towards the middle, so that at this part scarcely a 
 bristle could pass along it, after which, it continues to in- 
 crease somewhat irregularly, until it acquires a diameter of 
 two or three lines. 
 
 4 
 
38 OBSTETRIC CATECHISM. 
 
 What is the outer extremity called ? 
 The pavilion. 
 
 What is the peculiar mode of termination of the fallo- 
 pian tubes ? 
 
 They have a digitated or fimbriated extremity called, the 
 corpus Jimbriatum, or morsus diaboli. 
 
 What direction do the tubes take in the cavity of the 
 pelvis ? 
 
 They go off nearly horizontally, but are exceedingly 
 tortuous, and curve backwards, and towards the ovary, to 
 some part of which the largest of the fimbriae is sometimes 
 attached. 
 
 What is the anatomical structure of the tubes ? 
 
 Its principal tissue is fibrous, having perhaps some mus- 
 cular fibres interspersed. It is lined by mucous membrane 
 and covered by a peritonasal coat. 
 
 Into what cavity do the fallopian tubes open ? 
 
 Into the cavity of the pelvic portion of the peritonaeum. 
 
 In what part of the female system do the mucus and 
 serous tissues unite ? 
 
 At the fimbriated extremity of the fallopian tubes. 
 
 What other ligaments has the uterus besides the broad 
 ligaments ? 
 
 The anterior, or round ligaments, and the posterior, or 
 utero-sacral ligaments. 
 
 What are the points of origin and insertion of the round 
 ligaments? 
 
 They arise from the superior part of the body of the 
 uterus, just below and a little in advance of the fallopian 
 tubes, and pass horizontally forwards through the abdomi- 
 nal canal, to be distributed beneath the mons veneris, 
 upon the bodies and symphysis of the pubes. 
 
CONTENTS OF THE PELVIS. 39 
 
 Where are the posterior uterine ligaments situated ? 
 
 They spring from the posterior portion of the neck near 
 its middle, and diverging, they ascend towards the middle 
 portion of the lateral edges of the sacrum, and are lost in 
 the cellular membrane which covers that bone. 
 
 With what are all the uterine and ovarian ligaments 
 invested ? 
 Peritonaeum. 
 
 In what direction do the nerves, blood-vessels, and ab- 
 sorbents reach the uterus ? 
 
 Through the folds of the peritonaeum or the lateral liga- 
 ments. 
 
 What is the condition of the internal organs of genera- 
 tion in the fetus ? 
 
 They are very small, the uterus is almost lost in the 
 broad ligaments. The same may be said of the ovaries. 
 
 At about what age do the ovaries appear to become vas- 
 cular ? 
 
 Seven years. 
 
 i 
 What physiological changes have taken place at the 
 
 period of life called puberty ? 
 
 All the internal organs have become more developed, 
 
 more vascular ; the uterus has acquired greater size and is 
 
 more soft ; the mons veneris is covered by hair ; there is 
 
 an increased flow of blood to the pelvic viscera, and to the 
 
 head ; the face becomes more or less flushed ; the voice is 
 
 altered, and the moral sensibility is more acute. 
 
 At what period of life do these changes occur ? 
 v At the fourteenth or fifteenth year in temperate climates. 
 
40 OBSTETRIC CATECHISM. 
 
 What function i* the genital organs then capable of per- 
 forming ? 
 
 That of reproduction. 
 
 What function does the uterus actually perform when 
 all these physical changes have regularly occurred 1 
 That of menstruation. 
 
 What is to be understood by the function of menstrua- 
 tion ? 
 
 That in which the uterus at regular periods secretes a 
 certain amount of sanguinolent fluid. 
 
 What are the synonymes of menstruation ? 
 
 Catamenia, menses, courses, monthlies, terms, monthly 
 terms, monthly periods, the reds, being unwell, indis- 
 posed, has her troubles, &c. 
 
 Whence is this fluid furnished ? 
 From the cavity of the uterus. 
 
 What proof have we that it is derived from this source ? 
 
 It is always accompanied by some degree of uterine irri- 
 tation : when occlusion of the orifice of the uterus exists, 
 the secretion is still eliminated by the capillaries, but re- 
 tained within the cavity of the uterus. 
 
 What are the characteristics of the menstrual fluid ? 
 
 It is a sanguinolent fluid, of a peculiar quality and odour, 
 of a color usually between that of venous and arterial blood ; 
 it is not coagulable, nor does it putrify readily. 
 
 At what periods of life does this secretion usually com- 
 mence ? 
 
 In hot countries, from nine to ten years. 
 
 In temperate climates, from fourteen to fifteen years. 
 
 In cold regions, from eighteen to twenty years. 
 
MENSTRUATION. 41 
 
 At how early a period are females of tropical climates 
 known to be capable of bearing children ? 
 At ten years old. 
 
 What influence have these hot climates upon the con- 
 tinuance of the power of reproduction ? 
 
 Females who begin this function early, also decline 
 early. 
 
 What is observed in this respect in regard to cold coun- 
 tries ? 
 
 That the capability of reproduction, though beginning 
 later is continued to a much more advanced age. 
 
 What difference is observable in the condition of females 
 residing at the top, and those at the bottom of high moun- 
 tains ? 
 
 Those on the top are more tardy, but continue much 
 longer, while those at the foot, have the function of men- 
 struation begin and end much sooner. 
 
 What difference is observed between the girls residing 
 in a country place, and those who inhabit large cities ? 
 
 That those in the country do not usually begin as soon 
 to menstruate as those who live luxuriantly in large towns. 
 
 What influence does temperament usually exert ? 
 
 Those of nervous temperament usually menstruate ear- 
 lier and more abundantly than those of phlegmatic tem- 
 perament. 
 
 How are the cases of precocious menstruation to be 
 regarded ? 
 
 As the result of some idiosyncracy. 
 
 What is the condition of the genital organs in all these 
 cases of extremely early menstruation ? 
 
 4* 
 
42 OBSTETRIC CATECHISM. 
 
 The internal organs, as the uterus and ovaries are pre- 
 cociously developed. 
 
 What may be easily mistaken by an ignorant parent for 
 precocious menstruation in her daughter? 
 
 A sanguineo-mucous or sanguineo-serous discharge from 
 the vulva. 
 
 What is the duty of the physician in this respect ? 
 To make a careful inquiry into the actual state of the 
 case before he decides it to be precocious menstruation. 
 
 What are the general symptoms accompanying a men- 
 strual effort ? 
 
 An unpleasant feeling of languor, weariness about the 
 loins, sense of fullness in the hypogastrium, a disposition 
 frequently to urinate and defecate. 
 
 Sometimes great nervous excitement, perhaps even hys- 
 teria. 
 
 The breasts swell and feel more or less tight and painful ; 
 there is headach, palpitation, and a peculiar odour of the 
 breath in some cases. 
 
 What is the usual color of this fluid at the first time 
 it is discharged ? 
 
 Pale red or pink color. 
 
 How long does the first discharge continue ? 
 Sometimes only a few hours, and rarely ever more than 
 two or three days. 
 
 At what period do these symptoms and the discharge 
 return ? 
 
 At the end of one lunar month. 
 
 When the menstrual function is fairly established, how 
 many days are usually occupied in the discharge? 
 In temperate climates from five to seven days. 
 
MENSTRUATION. 43 
 
 What influence does the health of the patient exert upon 
 the menstrual function ? 
 
 Delicate women usually menstruate more abundantly 
 than the more robust, but in some diseases it is altogether 
 interrupted. 
 
 What is the usual quantity discharged at each period ? 
 
 In temperate climates, probably from four to six ounces. 
 In the tropical climates, from ten to fifteen ounces ; while 
 in frigid zones, the quantity is very small. 
 
 What is observed in corpulent women in reference to 
 menstruation ? 
 
 That they usually have a greater discharge than those 
 who are thin. 
 
 Is the menstrual function easily disturbed ? 
 
 In those of nervous temperaments and irritable constitu- 
 tions, it is very easily disturbed by physical and moral 
 causes. x 
 
 What is the usual duration of the menstrual period of 
 female life ? 
 
 About thirty years. 
 
 At what age does this function usually subside ? 
 At from forty-five to fifty ; in Philadelphia at about 
 forty-seven years, but much earlier in hot countries. 
 
 What is the period of female life at which this function 
 subsides usually called ? 
 Change of life. 
 
 What is observed in reference to the subsidence of this 
 function at this period of life ? 
 
 It becomes very irregular, sometimes profuse for one 
 time, then passes over,a month or more, then returns pro- 
 
44 OBSTETRIC CATECHISM. 
 
 fusely, and finally subsides altogether ; when slight, it is 
 usually painful ; and when profuse, debilitating. 
 
 Into what character of discharge does menstruation often 
 pass before it ceases altogether ? 
 
 Into that of a leucorrhcea, or sero-mucous, or albuminoid 
 fluid. 
 
 What physical changes are observed to take place in the 
 female upon the arrival of this period of her life ? 
 
 Her capillary circulation becomes less active, the cellular 
 and adipose matters of the mammas are absorbed, there 
 is a general shrinking of her person, and that beautiful ro- 
 tundity of her form disappears. 
 
 What alteration does her pulse undergo ? 
 It becomes slower and feebler, and it acquires more of a 
 congestive, or apoplectic character. 
 
 In what respect is this period to be regarded as the 
 critical period of life ? 
 
 Because it is observed that generally, if there be no local 
 predisposition to disease, women usually have their health 
 improve after the cessation of menstruation: but if strongly 
 disposed to any malignant affection, this disease is liable 
 to become more rapid in its course to a fatal termination. 
 
 What precise knowledge have we respecting the cause 
 of the function of menstruation ? 
 
 None whatever, notwithstanding the numerous specula- 
 tions on this subject. 
 
 Are we to regard the local plethora and ordinary uterine 
 irritation, or activity, as a physiological, or a pathological 
 condition ? 
 
 As strictly physiological. 
 
MENSTRUATION. 45 
 
 Do any of the appendages of the uterus exert any influ- 
 ence over the menstrual function ? 
 
 The ovaries appear to be indispensable to it, as upon 
 their non existence the function does not occur, and upon 
 their removal it becomes suspended. 
 
 Admitting that we know very little of the cause of the 
 catamenia or menses, what does its regular appearance in- 
 dicate ? 
 
 A healthy condition of the genital organs, and a capability 
 for procreation or reproduction. 
 
 Are there no exceptions to the rule that women cannot 
 conceive unless they have menstruated ? 
 
 Some cases are recorded in which women have con- 
 ceived without having menstruated, but it is supposed that 
 with them, conception took place just before the menstrual 
 period would have occurred. 
 
 Which period is most favourable to conception, before or 
 after menstruation ? 
 
 Immediately after the secretion has taken place. 
 
 What opinion was formerly entertained respecting the 
 quality of the menstrual fluid ? 
 
 That it was extremely noxious both to animal and vege- 
 table substances. 
 
 What is true in reference to its quality ? 
 That it possesses no noxious qualities when in a healthy 
 condition. 
 
 What rules of conduct should be observed by the female 
 during the menstruating portion of her life ? 
 
 All those hygienic rules which are necessary to ensure 
 her a good physical and moral education. 
 
46 OBSTETRIC CATECHISM. 
 
 What conditions of her constitution should involve the 
 question of the propriety of her marriage ? 
 
 The existence of scrofula, rickets, phthisis, and such 
 transmissible diseases. 
 
 What precautions should be employed in early life to 
 prevent the occurrence of such constitutional disorders ? 
 
 Every means should be used during childhood to de- 
 velop and give tone to the various tissues of the system. 
 
 What must be regarded, in the present habits of society, 
 as injurious to the health of growing girls ? 
 
 The use of ligatures and corsets about the body, in 
 dress; the want of free gymnastic exercises for the devel- 
 opment of the skeleton, and consequently of the organs 
 within it ; too much constraint and confinement of body 
 in one position in the schools. 
 
 What is the value of pedestrian exercise in the physical 
 education of young ladies ? 
 
 All physical exercises, as gymnastics, and particularly 
 those on foot, as walking, jumping rope, and dancing in 
 the open air, contribute greatly to the establishment of the 
 health and keeping all the secretions in proper order. 
 
 What regulations should be enforced in regard to diet ? 
 
 The digestive organs should be kept in order by a 
 moderate allowance of nutritious but not stimulating diet, 
 composed principally of vegetable and farinaceous sub- 
 stances. 
 
 What attention should be paid to the condition of the 
 skin ? 
 
 It should be kept in a soft and transpirable condition by 
 cleanliness, regular bowels, and a proper amount of warm 
 clothing, particularly upon the limbs. 
 
MENSTRUATION, 47 
 
 What amount of sleep is necessary, and when should it 
 be obtained ? 
 
 Not less than eight hours, which should begin with the 
 early part of the night. 
 
 What precautions are necessary with respect to mental 
 exercises or cerebral excitement ? 
 
 To avoid both to any considerable extent, and to dis- 
 courage precocity of intellect. 
 
 What care should be taken in reference to the moral 
 feelings ? 
 
 They should be regulated, and the passions should not 
 be excited by reading, conversation, or other means. 
 
 What influence may much excitement produce at the 
 time at which the secretion ought to occur ? 
 
 Super-excitation of the system may so operate upon the 
 genital organs as to prevent the occurrence of the secre- 
 tion. 
 
 Under such circumstances what course should be pur- 
 sued ? 
 
 The patient should be subjected to restricted diet, saline 
 cathartics, and sometimes even to venesection. 
 
 How should we treat any nervous symptoms which may 
 occur in connection with the menstrual effort ? 
 
 It is not often necessary to interfere much with them : 
 mild anti-spasmodic remedies, such as spirits of nitre, 
 camphor water, assafcetida, and such articles may be ad- 
 ministered. 
 
 Suppose the capillary circulation be feeble, as indicated 
 by cold extremities, soft feeble pulse, &c, what treatment 
 ought to be adopted ? 
 
 That which would give tone and vigor to the system, 
 
48 OBSTETRIC CATECHISM. 
 
 as good diet, proper exercise, bathing, pleasant company, 
 and agreeable mental excitement ; a proper course of tonics, 
 particularly mineral preparations, may be usefully em- 
 ployed. 
 
 What is to be understood by the phrase, " retention of 
 the menses ? 
 
 That they have never appeared, however old the female 
 may have become. 
 
 What is meant by the phrase, " suppression of the 
 menses?" 
 
 That having been once established, they cease to appear 
 during some part of the menstruating period of female 
 life. 
 
 What technical term have we to signify either of these 
 states ? 
 
 Amenorrhea a. 
 
 Upon what causes may the tardy appearance of the 
 menses depend ? 
 
 Defect, or absence, or want of proper development of 
 the organs of generation, particularly of the uterus, or 
 ovaries, or both, or diseases of them. 
 
 Do defects of this kind always interfere with the health 
 of the patient so circumstanced ? 
 
 No, it sometimes happens that women so circumstanced 
 enjoy good health. 
 
 Why is a knowledge of this fact important ? 
 
 That females may not be subjected to the powerful 
 action of medicines supposed to be emmenagogues or spe- 
 cifics for producing the menses. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 49 
 
 What proofs have we of the evil consequences of at- 
 tempting to force the menstrual secretion in some of these 
 instances of tardy appearance ? 
 
 Many instances on record, in which upon dissection, 
 organs were absent or but very partially developed, and 
 one particularly seen by Dr. Hodge, in which after long 
 and ineffectual treatment by emmenagogues, cathartics, and 
 serious injury to general health? the professor in consul- 
 tation, examined the patient but could find no uterus. 
 
 Under what plan of treatment did she improve 1 
 A general invigorating plan, including proper exercise in 
 .the open air. 
 
 Under what other circumstances may emansio mensium, 
 or retention of the menses occur ? 
 
 When the health is bad, and the organs partially de- 
 veloped, and again when the health is bad and all the 
 organs apparently developed. 
 
 What is the opinion of some experienced teachers re- 
 specting the popular notion that the retention of the menses 
 is the cause of the ill health ? 
 
 That it is the contrary of what is true, that the ill health 
 is the cause of the retention in those cases in which the 
 organs are properly developed. 
 
 • Upon what may this ill health depend ? 
 Upon a bad diajthesis, as phthisis, scrofula, &c. ; impro- 
 prieties in living, neglect of the means of proper physical 
 development, errors in the physical education, causing the 
 female to remain a child until a late period of her life. 
 
 To what condition of the system is the term chlorosis 
 applied ? 
 
 To that, in which about the menstruating period of life, 
 
 5 
 
50 OBSTETRIC CATECHISM. 
 
 there is great pallor of the skin, and torpor of all the func- 
 tions of the system. 
 
 What does this state of the system indicate ? 
 An impairment of the vis vitae, a general functional de- 
 rangement. 
 
 Why is it called chlorosis ? 
 
 Because persons affected with it, are vulgarly said to 
 have green or falling sickness. 
 
 How does it generally begin to develope itself? 
 By a desire to eat outre articles ; as dirt, slate pencils, 
 recently quenched coals, &c. 
 
 What is the condition of the alimentary canal ? 
 Torpid throughout ; digestion slow, bowels constipated, 
 stools clay colored. 
 
 What is the probable cause of the pallid, or pale yellow 
 or greenish color of the skin ? 
 The extreme torpor of the liver. 
 
 How is this to be distinguished from icterus ? 
 
 By the want of the yellow deposit in the adnata of the 
 eyes. 
 
 What is the condition of the cerebral and vascular sys- 
 tems ? 
 
 The intellect is very torpid, and the pulse soft and with- 
 out force. 
 
 How is the nervous system affected ? 
 The nerves of sensation and motion, are sometimes 
 greatly disturbed, hence hysteria, and neuralgic pains. 
 
 What is at present to be said, respecting the plans often 
 adopted for the treatment of this affection ? 
 ., The practice is very often erroneous, as the neuralgic 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 51 
 
 pains in the side have been mistaken and treated for pleu- 
 risy with serious consequences. 
 
 What reasons may practitioners have had for diagnosti- 
 cating inflammatory diseases, and resorting to depletion in 
 these cases ? 
 
 Probably, that in conjunction with the pain, there is 
 sometimes palpitation and febrile excitement. 
 
 What are the consequences of the case becoming chro- 
 nic? 
 
 They are often serious. 
 
 What is the usual condition of the organs under such 
 circumstances ? 
 
 They are sometimes found diseased and altered, but 
 most frequently they are in an anemic condition. 
 
 What are the results of this disease ? 
 Some patients recover and get entirely well ; while 
 others become affected with dropsy, &c. 
 
 Does the uterus ever perform its functions during this 
 chlorotic state ? 
 
 Some patients have a slight, serous menstruation — some- 
 times it even contains red particles. 
 
 What conditions of life are most favourable to the occur- 
 rence of chlorosis ? 
 
 All densely populated places, where there is a deficiency 
 of good air and exercise, and hence especially in the large 
 manufacturing towns of Europe. 
 
 What are the true indications for treatment in cases of 
 chlorosis ? 
 
 To give strength to the system by restoring the healthy 
 condition of the digestive apparatus. 
 
52 OBSTETRIC CATECHISM. 
 
 What is to be done to the reproductive organs, at this 
 time ? 
 
 No especial attention is to be given to them, until the 
 constitution is improved. 
 
 What regard should be had to the full development of 
 all the organs in the body ? 
 
 This is most important, and every proper means should 
 be used for this purpose. 
 
 What kind of medicines should be used ? 
 Such alterative medicines as moderately increase the 
 action of the mucous membranes. 
 
 If calomel be employed, in what way ought it to be 
 administered ? 
 
 In doses of one half, to one eighth of a grain, and 
 cautiously repeated. 
 
 W T hat regard should we have for the powers of digestion 
 during this course of medicines ? 
 
 Carefully avoid impairing the function of digestion. 
 
 Is it proper to use any additional alteratives ? 
 
 The preparations of sarsaparilla are appropriate in some 
 of these cases in conjunction with the calomel, or blue 
 pill. 
 
 Why is iodine, or some of its preparations indicated ? 
 Because, in proper doses they stimulate the organs of 
 digestion. 
 
 What influence do the mucous secretions exert, if left 
 within the cavities in which they were formed ? 
 
 They irritate the system and disturb the digestive func- 
 tion. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 53 
 
 How then ought they to be disposed of? 
 They should be carried off by proper laxative, or aperi- 
 ent medicines. 
 
 What may be regarded as the best medicines for this 
 purpose ? 
 
 Rhubarb, aloes, senna, castor oil, &c. 
 
 Under what circumstances would moderately stimulating, 
 or cordial, bitter tinctures, become useful ? 
 
 When there is a sluggish, or cold state of the system. 
 
 What course should be adopted, when the alterative and 
 aperient plan have been carried into effect ? 
 
 The patient should be put upon the use of tonics ; as 
 infusions of camomile, or wild cherry bark ; or the prepara- 
 tions of iron ; as the rust, the sulphate, and the iodide of 
 iron. 
 
 Is it reasonable to expect the catamenia to appear before, 
 or after the restoration of the health ? 
 Not until after the health has improved. 
 
 From what causes may the menses be retained, when 
 the organs are well developed, and the health of the female 
 good? 
 
 By occlusion of the os tincae, absence of the vagina, 
 closure of the hymen, or vulva, or some such mechanical 
 obstacle to its escape. 
 
 What occurs in such cases ? 
 
 The secretion goes on, but the fluid is accumulated, 
 because it has no outlet. 
 
 What consequences result from this obstruction ? 
 
 In time, the abdomen swells, the condition of the patient 
 excites suspicion, and the opinion of a physician is appeal- 
 ed to. 
 
 5* 
 
54 OBSTETRIC CATECHISM. 
 
 What course should he pursue ? 
 
 First, make a careful inquiry into the history of the case, 
 then make a proper physical examination of the parts. 
 
 What may he expect to find in case the occlusion exists 
 in the hymen ? 
 
 Distension of the part, with a sense of fluctuation ; and 
 the membrane of a dark blue color. 
 
 What may he expect to find in case the atraesia exists 
 in the orifice of the uterus ? 
 
 If at the os tincae, he may find a tumor like the extremity 
 of an ellipse, projecting into the vagina, and fluctuating 
 under the touch. 
 
 If at the internal os-uteri, the neck and external os-uteri 
 may be but little changed from natural, but the body may 
 be found expanded out into a sort of globular tumor, some- 
 what compressible to the touch. 
 
 What becomes of this affection, if not relieved by an 
 operation ? 
 
 Sooner or later an opening is formed, and the fluid 
 escapes. 
 
 What is the direction of the opening ? 
 It is various ; sometimes into the rectum, and sometimes 
 into other parts. 
 
 If the hymen be entire, what kind of an opening should 
 be made into it ? 
 
 Crucial, or stellated. 
 
 Suppose the vagina to be absent, what risk would there 
 be in attempting an incision for the escape of the accumu- 
 lated fluid ? 
 
 It would be dangerous to attempt operation for the exit 
 of the retained menses. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 55 
 
 When the obstruction exists in the uterus itself, what 
 plan should be adopted ? 
 
 The orifice should be gradually dilated by a series of 
 bougies. 
 
 Is this an operation easy to be accomplished ? 
 It is not. 
 
 What is the true method of doing it ? 
 
 Pull the os tincae forward by a finger in the vagina, or 
 anus, and keep it pressed towards the pubis, to make the 
 neck of the uterus have the same axis as the inferior strait, 
 and then cautiously pass the bougie. 
 
 What condition of the nervous system, is often an ac- 
 companiment of amenorrhcea ? 
 Neuralgia, hysteria, &c. 
 
 Is it probable that the uterus ever becomes the seat of a 
 congestion and irritation ? 
 
 It probably does so, in some cases, and it then appears 
 as though the system was above the secreting point. 
 
 What consequences might arise from stimulating treat- 
 ment in such cases ? 
 
 It might bring on serious consequences, as congestion, 
 apoplexy, &c. 
 
 What then should we do ? 
 
 Diminish cerebral irritation by depletion, by cooling 
 saline laxatives, antimonials, &c. 
 
 What would be proper after this had been effected ? 
 
 Restore the secretions by warm bath, hip bath, warm 
 injections, &c. Allowing the patient, warm weak penny- 
 royal tea, &c. 
 
56 OBSTETRIC CATECHISM. 
 
 Do purgatives interfere with the performance of this 
 secreti >n ? 
 
 They do not, as has been supposed by some. 
 
 Into how many varieties is suppression of the menses 
 divided ? 
 
 Into two — acute and chronic. 
 
 How do we distinguish acute suppression ? 
 By the action of its cause during the flow. 
 
 How does the cause operate in chronic suppression ? 
 During the interval of the secretion. 
 
 Which is the severer form of suppression ? 
 That in which the cause acts and arrests the secretion 
 during its flow. 
 
 What class of females is most liable to suffer from this 
 suppression 1 
 
 Those of irritable constitutions or temperaments. 
 
 What may be regarded as predisposing causes of sup- 
 pression ? 
 
 Irritability of the system. 
 
 What are some of the actual causes of affection ? 
 
 Certain moral influences, violent passions of the mind, 
 frights from falls, sudden bad news, terror, dread, rumors of 
 wars, sudden transitions, &c. 
 
 How far may physical causes operate in this respect ? 
 
 The sudden application of cold to the external surface — 
 violent diseases, fever, inflammatory affections, irritation 
 of powerful medicines, stimulating drastic cathartics, — all 
 may act in the production of the suppression of the cata- 
 menia. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 57 
 
 How does sudden suppression affect the system ? 
 
 The effect of sudden suppression, or that of the cause 
 producing sudden suppression, is often very severe, and 
 greatly disturbs the system which is most predominant in 
 the individual, producing hysteric convulsions, &c, in the 
 nervous, apoplexy in the vascular, or sanguineous tempera- 
 ment — attacks of gout, if the patient have a gouty diathe- 
 sis, &c. In some cases severe uterine neuralgia is induced 
 by this check of the secretly action. 
 
 What are the indications for treatment ? 
 
 They must be founded on the temperament and diathe- 
 sis of the patient. The indication is always to diminish 
 the secondary irritation, and restore the action to the uterus. 
 Thus we are to clear the primae viae by vomiting and 
 purging, if obstructed, then commence with the mildest 
 anti-spasmodic medicines, as ether, assafoetida, camphor, 
 hyosciamus, if the nervous system be much disturbed. 
 
 Under what circumstances may vascular depletion be 
 required ? 
 
 When there is much plethora, or vascular excitement, 
 the lancet should be used : if there be local pain without 
 general vascular disturbance, cups or leeches should be ap- 
 plied to the part affected. 
 
 Which should be resorted to first, vascular depletion or 
 anti-spasmodics ? 
 
 In cases of vascular excitement, anti-spasmodics are of 
 little avail, unless preceded by loss of blood sufficient to 
 reduce the circulation. 
 
 When is the use of opium indicated ? 
 Only when the course just proposed has been tried, and 
 other anti-spasmodics have failed to quiet the system. 
 
58 OBSTETRIC CATECHISM. 
 
 What is the best revulsive treatment in cases of sudden 
 suppression ? 
 
 Hot pediluvia, long continued, and rendered stimulating 
 by some spices, as mustard, ginger, &c. 
 
 What is probably one of the very best emmenagogues 
 we possess for this state of things ? 
 Copious enemata of warm water. 
 
 What should be done conjointly with the use of ene- 
 mata? 
 
 Place the patient in bed and give her warm drinks, as 
 mint tea, pennyroyal tea, &c, to bring on perspiration. 
 
 Suppose, however, she be febrile ? 
 Then these stimulating drinks would be improper, till 
 she had been purged and perhaps bled. 
 
 What should we hope to gain from the application of 
 warm poultices to the vulva ? 
 
 They are useful, and preferable to the custom of sitting 
 the patient over the vapour of hot water, for the promotion 
 of secretion from the uterus. 
 
 When might leeches be applied to the genital organs ? 
 Whenever there appears to be a fullness of the uterine 
 vessels, and the secretion does not return to their relief. 
 
 Where should they be applied ? 
 
 To the pudendum, to the vagina, or to the os uteri itself. 
 
 When the system shall have been brought to its proper 
 standard by the means already proposed, and the catamenia 
 do not still appear, what additional means should be used ? 
 
 This would be the proper time for the administration of 
 emmenagogues, so called. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 59 
 
 Upon what causes does chronic amenorrhcea depend ? 
 
 Mostly upon bad condition of the general health, owing 
 perhaps to serious disease in some organs, as phthisis, he- 
 patitis, &c. 
 
 In this case, to what part of the system should our 
 remedies be addressed? 
 
 To that affected — if the pulmonary organs, to the lungs, 
 if the hepatic system, to the liver, &c. 
 
 What train of functional disturbance mostly accompanies 
 chronic amenorrhea ? 
 
 Spinal irritation, cerebral congestion, and irregularities 
 of the digestive apparatus. 
 
 What kind of secretion sometimes affords a partial sub- 
 stitute for the true menstruation ? 
 Leucorrhoea. 
 
 What is the proper treatment for chronic amenorrhcea ? 
 
 That which improves the general health, as alteratives, 
 general tonics, and those aperients which act particularly 
 on the lower bowels. 
 
 In what way do the so called emmenagogue medicines 
 usually act ? 
 
 Some act generally upon the constitution — some more 
 locally upon the lower bowels — some upon the bladder, and 
 a very few directly upon the uterus itself. 
 
 With what organs does the uterus appear to have a di- 
 rectly sympathetic connection ? 
 With the mammas. 
 
 What advantage does this knowledge afford us in the 
 treatment of amenorrhcea ? 
 
 That by stimulating the mammas, we have sometimes 
 excited the secretory action of the uterus. 
 
60 OBSTETRIC CATECHISM. 
 
 What direct applications have been made to the uterus 
 with benefit ? 
 
 Injections per vaginam, often or more drops of acetate of 
 ammonia to one ounce of milk. 
 
 What means have been thought useful in promoting the 
 menstrual secretion, by acting directly upon the nervous 
 system ? 
 
 Electricity and galvanism. 
 
 What is to be said of the effect of physical excitement 
 of the organ by matrimony ? 
 
 It may be adapted to a few particular cases, but it is of- 
 ten attended by an aggravation of the condition of the uterus, 
 sometimes inducing permanent disease in it. 
 
 What are probably the very best general remedies operat- 
 ing on the bowels we can use in amenorrhoea? 
 Rhubarb and aloes in combination. 
 
 What substances have been thought useful by acting on 
 the kidneys or bladder ? 
 
 The spirits of turpentine, the copaiba, and various other 
 balsamic preparations. The tincture of cantharides has 
 been thought useful by many. 
 
 What other articles of the materia medica are supposed 
 to have a sort of specific action upon the uterus ? 
 
 Madder, guaiacum, savin, iodine, strychnine, and black 
 hellebore. 
 
 In what doses should the savin and the black hellebore 
 be administered ? 
 
 Half a grain of the extract, or from five to ten grains of 
 the powder of savin — of the tincture of hellebore from ten 
 or twelve drops to a teaspoonfull, two or three times a day, 
 one or two weeks before the expected time. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 61 
 
 Can either of these powerful remedies be used in any or 
 every condition of the system ? 
 
 The system should be properly prepared for the action 
 of either of them, by bleeding, purging, &c, whenever 
 there is a plethoric or an inflammatory diathesis. 
 
 What plan of treatment may be continued through the 
 whole time, without regard to periods ? 
 
 The hydriodate of iron, madder, spirits of turpentine, 
 and tincture of cantharides. 
 
 What is meant by the term dysmenorrhcea ? 
 Painful menstruation. 
 
 How is the secretion in regard to amount and frequency? 
 
 It may be, and generally is, regular in regard to its re- 
 turn, but the quantity secreted is usually less, though some 
 think it is rather greater. 
 
 What opinions exist in reference to the cause ? 
 
 Some say the difficulty exists in the secretion of the 
 fluid, others that it is owing to an obstruction, or difficult 
 excretion of the fluid after it has been secreted. 
 
 What temperaments seem to be most liable to it ? 
 Nervo-sanguine temperaments. 
 
 At what age of menstrual life does it occur 1 
 Women are subject to have it occur at any portion of 
 their menstrual life. 
 
 What is the usual condition of health in the intervals ? 
 Good : — if impaired, it mostly is so from some other 
 cause. 
 
 What are the symptoms of dysmenorrhcea ? 
 A sense of coldness, nervousness, &c. Pain in the up- 
 per part of the sacral region, thence round the ilia, or 
 
62 OBSTETRIC CATECHISM. 
 
 through to the hypogastrium — sense of fullness and bearing 
 down. 
 
 Are these feelings constant or paroxysmal ? 
 
 They occur in paroxysms, like labour pains ; indeed in 
 some cases it is difficult to distinguish them from efforts at 
 abortion. 
 
 What sympathetic disorders arise from the paroxysms of 
 dysmenorrhea ? 
 
 Flatulence, constipation, vomiting, bilious nervous head- 
 ach, palpitation, throbbing, &c. ; sense of fullness and 
 actual congestion in the lower part of the abdomen. 
 
 What is the usual duration of one of these paroxysms ? 
 
 Sometimes this severe suffering continues for a day or 
 two, when the secretion appears and the patient becomes 
 easier. 
 
 What is noticed as peculiar in the discharge in some 
 cases 1 
 
 That it is membranous and thrown off in shreds, or in 
 an entire sac resembling the shape of the internal surface 
 of the uterus. 
 
 What is probably the exact character of this mass ? 
 
 Opinions appear to be various. Some think it a coagu- 
 lation of blood, and not the lymph of inflammation, as that 
 formed in cases of croup. 
 
 What is the probable cause of the pain, if the latter idea 
 be correct ? 
 
 The pain would then seem to depend upon the severe 
 contractions of the uterus to expel the coagulum, &c. 
 
 What influence does this condition of the secretory func- 
 tion of the uterus appear to have upon the general health ? 
 
 Very often the health of the patient in the interval re- 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 63 
 
 mains good, though the disease has continued to return 
 with unabated severity from one to twenty years. It is 
 however true, that the health may become impaired in 
 some cases, during the existence of dysmenorrhcea. 
 
 What is the condition of the mouth and neck of the 
 uterus in the female affected with dysmenorrhcea ? 
 
 In general the neck is tumid and the mouth a little open. 
 
 What is known respecting the capability for conception, 
 in females affected with dysmenorrhcea ? 
 
 As a general rule, females so affected do not conceive — 
 but numerous exceptions to the rule exist. 
 
 What are the general predisposing causes of this disease? 
 Temperament, particularly that of the nervo-sanguine. 
 
 What may be regarded as occasional causes of this dis- 
 ease ? 
 
 Cold, violent mental emotions, fright, &c. It has been 
 brought on by matrimony — it is sometimes the result of 
 metastasis of cutaneous or neuralgic disorders, or of gas- 
 tric affections. 
 
 What agency may displacements of the uterus exert in 
 the production of dysmenorrhcea ? 
 
 It is very liable to follow any displacement of the uterus. 
 
 What may be considered as mechanical causes of dys- 
 menorrhcea ? 
 
 Besides the various displacements of the uterus which 
 may be regarded to some extent decidedly mechanical, 
 causes are occasionally found in obstructions of the internal 
 and external os uteri, and also in the canal of the cervix 
 uteri. 
 
 What may be said of the severity of the pain in some 
 cases of dysmenorrhcea ? 
 
 That it is greater than that of labor. 
 
64 OBSTETRIC CATECHISM. 
 
 What idea is entertained respecting the inflammatory or 
 neuralgic character of this affection ? 
 
 Some think it neuralgic or spasmodic, which is often 
 true — others regard it as inflammatory. By some good 
 authority it is thought that it most probably depends upon 
 excitement of the vascular system, upon a congestion not 
 amounting to actual inflammation. In other words, an 
 exaltation of vitality — a nervous excitement with vascular 
 congestion. Some practitioners, as Dr. Dewees, thought 
 it depended upon low or depressed action. 
 
 How is the treatment of this affection to be divided ? 
 Into that which is to be applied during the paroxysm, 
 and that to be used in the interval. 
 
 What should first be resorted to in the paroxysm ? 
 
 A free bleeding to the amount of thirty or forty ounces — 
 next, cups or leeches to the sacrum — then enemata of warm 
 mucilages, and as soon as the vascular excitement has 
 been allayed, the warm hip bath should be employed. 
 
 When may narcotics be resorted to ? 
 As soon as vascular excitement is allayed, anodyne ene- 
 mata may be used with advantage. 
 
 What anodynes are best in this case ? 
 
 Dewees recommended camphor enemata, and Parrish 
 found marked benefit from directing patients to take four 
 grains of camphor, three times a day, two or three days 
 before the time of the paroxysm. The Dover's powder 
 is also useful in allaying pain and exciting the action of 
 the skin. Other narcotics, as hyosciamus, &c, are some- 
 times beneficial. 
 
 What other article has been thought useful in diminish- 
 ing the severity of the attack ? 
 The acetate of ammonia. 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 65 
 
 What should be done in the interval to prevent the re- 
 turn of the paroxysm ? 
 
 Endeavour to ascertain the cause of the dysmenorrhcea, 
 and if possible remove it. Thus if the patient have dis- 
 placement of the uterus, it must be corrected. The same 
 may be said of the digestive organs, which should be re- 
 stored if out of health, by proper exercise, alteratives, 
 tonics, and laxatives. 
 
 What may be said of cold bathing 1 
 
 It is useful in the intervals to keep down any inordinate 
 vascular excitement. 
 
 Can every patient bear the action of cold bathing ? 
 
 Not every one, and hence it must be tried cautiously. 
 To those whom it suits it is very useful. 
 
 What internal remedies have been proposed in the in- 
 terval as useful in the prevention of the returns of the par- 
 oxysms ? 
 
 Sulphuric acid, sulphate of zinc, preparations of senega, 
 volatile tincture of guaiacum, fyc. 
 
 What can be said of the efficacy of the last article, — so 
 highly recommended by Dr. Dewees ? 
 
 Experience has taught that it is not useful in all cases. 
 
 What should be the immediate object of the treatment 
 just before the expected paroxysm ? 
 
 To relax the system and prevent spasm by using the 
 warm bath — by retiring early to bed — by opening the bowels 
 by large warm mucilaginous enemata — by the use of warm 
 injections into the vagina — warm cataplasms to pudendum, 
 and by a moderate use of anodynes. 
 
 What is the proper treatment of mechanical dysmen- 
 orrhea ? 
 
 Some practitioners are in the habit of dilating the con- 
 
 6* 
 
66 OBSTETRIC CATECHISM. 
 
 stricted portion of the mouth or neck by bougies of differ- 
 ent sizes. 
 
 Can this plan be relied upon as effectual? 
 It has not succeeded in all cases, though it generally 
 mitigates the suffering. 
 
 What are we to understand by the term menorrhagia ? 
 An increased or excessive secretion of the menses. 
 
 Are we to receive this term in a positive or relative 
 sense ? 
 
 Menorrhagia is a relative term, as different persons dif- 
 fer so much in regard to the amount, and the same person 
 may be so different at different times in this respect, that 
 it is to be considered as a menorrhagia, only when it is 
 productive of bad consequences. 
 
 What is the pathology of menorrhagia ? 
 It is evidently in some cases the result of an inflamma- 
 tory action. 
 
 What period of life is most incident to it ? 
 It most commonly occurs at the latter part of menstrual 
 life. 
 
 What are some of its causes ? 
 
 Nervous excitement, vascular excitement, fevers, &c, 
 cold checking perspiration, causing internal congestions, &c. 
 
 By what is it aggravated ? 
 
 By some diseases and displacements of the uterus, as 
 anteversion, retroversion, &c. 
 
 With what is menorrhagia easy to be confounded ? 
 With hemorrhage from the uterus, caused by polypi, ul- 
 cers, cauliflower excrescences, &c. 
 
 
DISORDERS OF THE MENSTRUAL FUNCTION. 67 
 
 What are the only positive means of discrimination in 
 such cases ? 
 
 Careful physical examination. 
 
 With what other affection may menorrhagia be con- 
 founded ? 
 
 Abortion and its attendant hemorrhage and lochia. 
 
 Upon what should the treatment be founded ? 
 As accurate a knowledge as possible of the cause. 
 
 What kind of treatment is mostly indicated ? 
 
 An anti-phlogistic treatment, sometimes involving san- 
 guineous depletion — then revulsives to the lower extremi- 
 ties, by dry warm feet, blisters, setons, and stimulating lini- 
 ments, &c. 
 
 What internal remedies should be given ? 
 
 The saline laxatives, saline mixture, digitalis, &c, and 
 when the excitement is allayed, small doses of ergot should 
 be administered. 
 
 What treatment seems peculiarly proper in the intervals ? 
 
 The application of cold, moderate at first, but gradually 
 
 increasing in intensity, as the cold bath, cold douches, &c. 
 
 Upon what do the irritative forms of menorrhagia de- 
 pend ? 
 
 Upon an irritable condition of the uterus, perhaps the 
 result of over excitement of the organ. 
 
 Towards what point should our attention be particularly 
 directed in such cases ? 
 
 The condition of the uterus. 
 
 What is the result to the patient, from protracted men- 
 orrhagia, arising from any of the several causes ? 
 
 Extreme debility, anemia, dropsy, and sometimes com- 
 pletely broken health. 
 
68 OBSTETRIC CATECHISM. 
 
 Which should claim our attention most, the constitution 
 or the discharge ? 
 
 Gooch, says in this case, take care of the discharge ; 
 but Hodge, says very properly, take care of both. Re- 
 move all aggravating causes ; thus, if displacements exist, 
 rectify them, abstain from all sexual excitements, and take 
 care to improve the tone of the system, support patient 
 with animal food, &c, clothe her warmly, particularly 
 about the feet, give her a proper allowance of wine, make 
 use of rough frictions and other revulsive remedies, as dry 
 cups, rubefacients, and particularly blisters. 
 
 What internal remedies may be administered, as astrin- 
 gents, to check the discharge ? 
 
 The sugar of lead, or the sulphate of zinc ; one of the 
 best preparations, is probably rhatany. Monesia, and infu- 
 sion of red roses have been recommended, so also, have 
 small doses of ergot, say four or five grains, four or five 
 times a day. 
 
 Are females liable to any other affections during the 
 menstrual life, which seem to depend upon it ? 
 
 They are, particularly to a white secretion from the 
 uterus and vagina, sometimes from both. 
 
 What is this white secretion called ? 
 
 Fluor-albus, or leucorrhsea, or vulgarly " whites." 
 
 Upon what does this secretion appear to depend ? 
 
 The application of specific virus, as that of gonorrhoea ; 
 the presence of some irritating body, as. polypus, and 
 other tumors ; and it may arise from any of the ordinary 
 causes of inflammations. By some, indeed it is regarded 
 as a uterine catarrh. 
 
 What difficulties are there in the way of correct diagno- 
 
 sis ? 
 
LEUCORRHCEA. 69 
 
 Perhaps, principally, the ignorance of physicians, grow- 
 ing out of the reluctance on the part of patients, to make 
 their true situation properly known. 
 
 Into what divisions should we separate leucorrhcea? 
 Into uterine leucorrhcea, and vaginal leucorrhcea, a dis- 
 tinction some think important to be made. 
 
 What are the rational signs of leucorrhcea being uter- 
 ine ? 
 
 J. It often comes on as the precursor of beginning 
 menstruation. 
 
 2. It sometimes occurs immediately before the red dis- 
 charge, and again exists, after the red discharge has ceased, 
 thus leaving the patient only one or two weeks freedom 
 from any discharge. 
 
 3. Sometimes uterine leucorrhcea entirely substitutes 
 the red menstrual secretion. 
 
 What other circumstances have been noted in regard to 
 it? 
 
 It sometimes comes on about the critical period ; rarely 
 is seen after the fiftieth year of life, and is most frequently 
 preceded or accompanied by symptoms of uterine irritation ; 
 it also often follows abortion, and even some cases of 
 parturition at term. 
 
 What symptoms are usually attendant upon the irruption 
 of leucorrhcea ? 
 
 Sometimes they are acute, resembling those of menstrua- 
 tion, or even of dysmenorrhcea ; as pain in the back, fever, 
 sometimes nervous disturbance, as hysteria, <fcc, flatulency, 
 dysuria, pain down the thighs, fulness and sense of tension 
 of the labia ; after these bad feelings have existed a time, 
 the discharge usually comes on. 
 
70 OBSTETRIC CATECHISM. 
 
 What is the general character of the discharge ? 
 
 Generally it is serous, or watery, and perfectly trans- 
 parent ; sometimes it is mucous, and occasionally it is 
 albuminiform and adhesive. 
 
 Whence is this adhesive secretion thought to originate ? 
 From the glands in the neck of the uterus. 
 
 How long may the disturbances resulting in leucorrhcea 
 continue ? 
 
 From a few hours to several days. 
 
 What are the symptoms in chronic leucorrhcea ? 
 
 They are the same as, but less intense than, the acute. 
 They sometimes occur in the interval of the menses, 
 though the discharge sometimes substitutes the catamenia. 
 Chronic leucorrhcea is usually less inflammatory, but still 
 it exhausts the patient if long continued. 
 
 What is the result to the constitution, of the exhaustion 
 by such secretions ? 
 
 Increased irritability, in proportion to the reduction of 
 strength. 
 
 What is probably the correct opinion respecting many 
 cases of disease in females called spinal irritation ? 
 
 That in very many cases they originate in irritation, 
 from displacement or otherwise, in the uterus. 
 
 How does Dr. Hodge trace up the chain of morbid ner- 
 vous actions or sympathies in these cases ? 
 
 " If a patient have uterine irritation or leucorrhcea, irri- 
 tation is extended to the spine, and may finally induce 
 universal neuralgia — -as odontalgia, otalgia, <fcc, &c, dysp- 
 noea, palpitation, dyspepsia, &c. 
 
 To what point should we direct our remedies in such 
 cases ? 
 
LEUCORRIICEA. 71 
 
 To the cure of the original uterine irritation, and then 
 the other affections will subside, if they have not been too 
 long continued. 
 
 What characteristics of the discharge distinguish the 
 chronic from the acute form of leucorrhoea ? 
 
 In the chronic form the discharge is usually thinner than 
 in the acute variety. 
 
 Which variety is most obstinate and difficult to cure ? 
 That which is thick like albumen. 
 
 What relation does this leucorrhoeal secretion hold to 
 the morale of the female who is subject to it ? 
 
 Certain moral causes or impressions act upon this secre- 
 tion to aggravate it, and this again seems to re-act upon 
 the morale of the patient and render it more irritable. 
 
 How are we to explain the occurrence of leucorrhcea in 
 place of menstruation ? 
 
 In some cases the excitement in the uterus is not suffi- 
 cient to cause a red discharge ; when the excitement is not 
 very great we may have leucorrhoea ; but again, when the 
 excitement is inordinately high even monorrhagia may be 
 the consequence. 
 
 What are some of the prominent causes of leucorrhoea ? 
 
 Want of cleanliness, over stimulation of the organs by 
 prostitution, &c. 
 
 Stimulating emmenagogues, the irritation of foreign 
 bodies as pessaries, &c, particular diseases of the uterus, 
 including displacements, abortions, remains of placenta, 
 &c. &c. 
 
 Are we to regard leucorrhoea as the result of an inflam- 
 matory action ? 
 
 By some very respectable authority it is regarded as 
 
72 OBSTETRIC CATECHISM. 
 
 rarely inflammatory, but as the result of a moderate degree 
 of irritation or excitement. 
 
 How is simple leucorrhoea to be distinguished from the 
 specific affection called gonorrhoea ? 
 
 In gonorrhoea there is usually ardor urinse, and it is said 
 by some surgeons that a discharge may be actually squeez- 
 ed from the urethra in cases of gonorrhoea, while neither 
 of these symptoms attend simple leucorrhoea. 
 
 How are we to diagnosticate uterine from vaginal leucor- 
 rhoea ? 
 
 By the fact that the former is connected with menstrua- 
 tion, sometimes complicated with it, and sometimes be- 
 comes a vicarious substitute for it. 
 
 What rules of treatment are we to observe for uterine 
 leucorrhoea ? 
 
 The same that have been laid down for the management 
 of cases of emansio mensium or chlorosis. When con- 
 nected with menorrhagia, to be treated as such. 
 
 What is to be done with those cases of leucorrhoea de- 
 pendant upon displacement of uterus, the presence of 
 foreign bodies, or diseases of the uterus ? 
 
 Remove the cause by appropriate treatment, and the 
 leucorrhoea will soon subside. 
 
 What treatment is necessary for the acute form of leu- 
 corrhoea ? 
 
 Some cases require antiphlogistics, as general bleeding, 
 cups, leeches, and alteratives, and after reduction of general 
 excitement, the use of proper local remedies, as tepid and 
 cold injections of mucilage into the vagina. If much ir- 
 ritation exists in the parts, warm fomenting injections 
 should be used to favor the discharge. 
 
LEUCORRHCEAe 73 
 
 What should be done if the disease persist notwith- 
 standing the use of these remedies ? 
 
 o 
 
 Revulse, by blisters upon sacrum, and hypogastrium ; 
 and if these do not succeed, treat it as a case of uterine 
 irritation. 
 
 What is the duty of the physician in attempting the 
 management of chronic cases of leucorrhcsa ? 
 
 To discover if possible, and remove the predisposing, 
 the actual and the aggravating causes. 
 
 What may be said respecting the use of local remedies ? 
 
 That in general too much reliance is placed upon them, 
 and too little regard had to the improvement of the general 
 health by proper constitutional remedies. 
 
 What remedies have been thought to act directly upon 
 the secretory surfaces of the uterus and vagina ? 
 
 Of those to be used internally or by the stomach, the 
 balsam of copaiba, the spirits of turpentine, the tincture of 
 cantharides, and decoction of logwood. 
 
 In the menorrhagic leucorrhcea, or that complicated with 
 menorrhagia, the ergot has been prescribed. 
 
 Some of the preparations of iodine have been thought 
 useful ; externally the use of continued blisters, or of pus- 
 tulation from tartar emetic ointment ; while cold douches 
 to the back and into the vagina, have been useful, in allay- 
 ing the local irritation. 
 
 When may we hope to derive benefit from astringent 
 injections ? 
 
 When the constitutional and local excitement have been 
 subdued by the means already pointed out. 
 
 What is to be said respecting the frequency of vaginal 
 leucorrhcea ? 
 
 7 
 
74 OBSTETRIC CATECHISM. 
 
 It is more common than that from the uterus, and very 
 many females are incident to it. 
 
 What are the causes of vaginal leucorrhoea ? 
 
 The irritations from certain foreign bodies in the vagina, 
 as pessaries, &c. The use of instruments in terminating 
 labor, or abortion ; violence done to the vagina in the com- 
 mission of rape, &c. Chemical or vital irritants, as stimu- 
 lating injections, the escape of urine into the vagina, acrid 
 discharges from the uterus, the presence of tumors in the 
 uterus and vagina, &c, excessive venery, or prostitution, 
 &c, &c. 
 
 How far may leucorrhoeal discharge depend upon en- 
 feebled condition of the general health ? 
 
 It is sometimes dependant upon this condition of the 
 general health entirely. 
 
 To what extent is it dependant upon sympathetic irrita- 
 tions in other parts ? 
 
 It is known in some instances to be caused by gastric 
 irritation, by ascarides in the rectum, by diseases in the 
 anus, as hemorrhoids, fistulae, &c. 
 
 How far may habits of life, and the condition of climate 
 operate in its production ? 
 
 They may have considerable influence. The women 
 who use foot stoves, who indulge in various luxurious 
 habits, or who reside in very moist climates, are said to be 
 more prone to it than those under different circumstances. 
 
 To what state of the vagina is it owing ? 
 Generally to an inflamed state of the canal. 
 
 Is it more common in the married or unmarried female ? 
 In the married female, though even very young girls are 
 sometimes affected with it. 
 
VAGINITIS. 75 
 
 When dependant upon vaginitis, what are its symp- 
 toms ? 
 
 There is then a sense of fulness in the pelvis, some- 
 times, though rarely, pain, but more frequently a sensa- 
 tion of heat in the course of the vagina : with this there 
 is often tenesmus, and a mucous discharge from the rectum, 
 also dysuria, the urine being natural in quality, but the 
 canal of the urethra irritable from the extension of the 
 irritation from the vagina. 
 
 Into how many stages do some authors divide this affec- 
 tion ? 
 
 Into two, the acute or severe, and the chronic or mild 
 stages, or forms. 
 
 What is the usual character of the discharge in the 
 severe form ? 
 
 It is acrid, sometimes red like bloody serum. 
 
 What is it when the inflammation is milder ? 
 
 It resembles mucus or muco-puruloid matter; sometimes 
 it is of a greenish color ; when the affection has become 
 decidedly chronic, the discharge is usually of a thin yel- 
 lowish colour. 
 
 How does acute vaginitis usually terminate ? 
 
 By resolution, or it runs into a chronic or milder form. 
 
 To what extent does it go when it is very severe and 
 somewhat protracted ? 
 
 It then may involve the muscular or fibrous coat; unless 
 however, the mucous coat shall have been destroyed by 
 the inflammation, or ulceration, or by a wound, the sur- 
 faces do not become adherent to each other. In some in- 
 stances moreover, sloughing does actually take place. 
 
76 OBSTETRIC CATECHISM. 
 
 What is the diagnosis of gonorrheal inflammation of 
 the vagina ? 
 
 In this variety of vaginitis there is ardor urinae, inflam- 
 mation in the inguinal lymphatics, and in the severer 
 forms, ulcerations of the os tincae have been observed. 
 
 Is it necessary that the vaginitis shall be of a specific 
 character, to produce an irritation in the penis from the 
 act of coition ? 
 
 Leueorrhcea may be so acrid as to cause irritation in the 
 male organ when exposed to contact with it. 
 
 What is the appropriate treatment of acute leueorrhcea? 
 
 Vascular and intestinal depletion, revulsives, &c. If 
 the general vascular system be affected, venesection, saline 
 cathartics, low diet ; — locally, cups to the back, or leeches 
 to the vulva ; then promote secretion by warm hip bath, 
 warm mucilaginous injections into the rectum and vagina. 
 
 What is proper after the inflammation has been re- 
 duced ? 
 
 Astringent washes, as solutions of sulphate or acetate of 
 zinc, acetate of lead, alum, borax, nitrate of Silver. 
 
 What peculiar effect does alum produce ? 
 
 It coagulates the secretion, particularly if tke alum be 
 previously burnt. 
 
 Suppose the inflammation to have been such as to be 
 followed by adhesions of the walls of the vagina, what 
 treatment should be pursued ? 
 
 The contractions and occlusions thus formed should be 
 overcome by the use of bougies or other proper dilating 
 instruments. 
 
 What are some of the causes of chronic leueorrhcea ? 
 Chronic inflammation of the vagina, displacements of 
 the uterus, ulcerations in the vagina, or uterus, &e. 
 
CHRONIC VAGINITIS. 77 
 
 Can chronic leucorrhoea be readily distinguished from 
 chronic gonorrhoea ? 
 
 It is almost impossible to make out the difference be- 
 tween them. 
 
 What are the general indications in the treatment of the 
 chronic foim of leucorrhcea or vaginitis ? 
 
 To improve the general health by the use of fresh air, 
 wholesome diet, tonics, alteratives, as preparations of 
 iodine, &c. ; then resort to local treatment, if there be 
 ulcerations first cure them. As alterative remedies, the 
 balsam of copaiba, and tincture of cantharides, have had 
 some reputation. 
 
 Have we probably any specific for the cure of this com- 
 plaint ? 
 
 Nothing which can be relied upon as such. 
 
 What kind of topical applications are best when the 
 system has been prepared for their use ? 
 
 Astringent washes of decoctions of logwood, nutgalls, 
 oak bark, &c. 
 
 Should any rule be observed in reference to the mode of 
 application ? 
 
 They should be passed slowly, but far up, to distend 
 the whole vagina, and bring the remedy in contact with the 
 whole mucous surface. 
 
 What mineral astringents are useful ? 
 
 The sulphate, or acetate of zinc, or of lead, one drachm 
 to half pint of mucilage of gum arabic, to render it slightly 
 adhesive to the vaginal surface. The alum, as mentioned 
 in the reduced state of acute vaginitis, is particularly 
 useful. 
 
 7* 
 
78 OBSTETRIC CATECHISM. 
 
 What is the probable origin of the pure milky white 
 discharge which occurs in some cases ? 
 
 Its origin is not well denned ; it is sometimes supposed 
 to come from the glands of the neck of the uterus, but it 
 has been seen issuing from the vulva. 
 
 What is the best mode of cure of this- peculiar state 
 giving rise to this discharge ? 
 
 The application of the solid nitrate of silver, or a strong 
 solution of the article to the part affected. 
 
 Upon what affections besides those of the uterus may 
 the pain in the back, &c, depend ? 
 
 It may be caused by some disease in the kidneys, in 
 the bladder, &c, or it may be of a neuralgic, or rheumatic 
 origin, independent of any uterine affection. 
 
 In those dorsal or lumbar pains accompanying disturb- 
 ance of the uterus, is the pain constant or intermittent ? 
 
 It is sometimes intermittent, paroxysmal, and of a neu- 
 ralgic character ; it is mostly moderated by assuming the 
 recumbent position ; sometimes the pain is constant even 
 when lying down. 
 
 Are these painful sensations necessarily the result of 
 inflammation? 
 
 They do not always depend upon inflammation, but fre- 
 quently upon a state of irritation. 
 
 What are we to understand by the phrase " irritable 
 uterus?" 
 
 A morbid sensibility of this organ, without inflamma- 
 tion or change of structure ; a condition which has con- 
 tinued in some cases for several years without effecting any 
 organic lesion perceptible to the senses. 
 
IRRITABLE UTERUS. 79 
 
 What influence does this irritability of the uterus ap- 
 pear to have over the exercise of its functions ? 
 It causes them all to be painfully performed. 
 
 What is the effect of touching the uterus while it is in 
 an irritable state ? 
 
 It is extremely painful, sometimes causing the patient 
 to scream. 
 
 Can the function of reproduction be carried on in cases 
 of irritable uterus ? 
 
 Sterility mostly, though not perhaps always, accompa- 
 nies irritable uterus. 
 
 What are the principal causes of irritability of the 
 uterus ? 
 
 Disturbance of function, and displacements of the ute- 
 rus; in some cases, it is dependent upon the character of 
 the constitution, frequent labors, abortion, &c. 
 
 By what circumstances is the sensibility aggravated ? 
 By distension of bladder, or rectum ; by any severe ex- 
 ercise which causes pressure upon the uterus. 
 
 Is this affection necessarily complicated with any 
 other ? 
 
 It often exists entirely alone, but in some instances it is 
 combined with an inflammatory state of the organ. 
 
 What influence may depressed or disturbed states of 
 mind have over the production of this affection ? 
 
 They may exert so potent an influence as to require the 
 condition of the mind to be improved before any other treat- 
 ment can be effectual. 
 
 What consequences may irritable uterus produce if not 
 speedily cured ? 
 
80 OBSTETRIC CATECHISM. 
 
 Dysmenorrhcea, or menorrhagia, or a train of morbid 
 sensibility, or nervous excitability, hysteria, spinal irrita- 
 tion, &c. 
 
 What are the curative indications in irritability of the 
 uterus ? 
 
 The removal of any or all the causes which have pro- 
 duced it. Thus, if there be any displacement of the 
 uterus, it must be properly restored, and kept in its proper 
 situation by mechanical or other efficient means. If it has 
 come on after any violent effort of the uterus, as after 
 labor, or abortion, the patient must be kept quiet, and her 
 bowels moderately open ; if there be any local inflamma- 
 tory excitement, leeches may be applied to the sacrum, or 
 groins. 
 
 Is there any objection to the application of leeches di- 
 rectly to the uterus in case of irritability of that organ ? 
 
 Their application would be painful, and sometimes ag- 
 gravating. 
 
 What constitutional remedies should be employed ? 
 
 During the three weeks immediately succeeding the 
 menstrual discharge, she should use the cold bath, "either 
 local or general, with a view to obtain a reaction and 
 healthy glow of warmth, and by thus increasing the 
 strength, diminish the irritability of the nervous system. 
 
 Cold douches down the back — cold water into the va- 
 gina — large quantities of cold water into the rectum and 
 colon to distend them, and produce the two-fold effect of 
 removing the feces and giving tone to the nerves. 
 
 What rule for diet and exercise should be observed ? 
 In the more chronic or protracted form, the diet should 
 be nutritious, and solid or animal, and not entirely vegetable. 
 
PROLAPSUS UTERI. 81 
 
 The patient should be carried out into the open air when- 
 ever possible, and she should use exercise on foot whenever 
 she is able, without aggravating her symptoms. 
 
 What is to be said respecting counter-irritants ? 
 
 They, such as tartar emetic, croton oil, moxa, and per- 
 petual blisters or setons seem to be in general too irrita- 
 ting to the system, and rather aggravate than relieve. 
 
 Under what circumstances are narcotics called for ? 
 
 During severe attacks of pain, the cicuta in two 
 grain doses, three or four times a day, gradually increasing 
 the quantity if necessary ; stramonium, belladonna, hy- 
 osciamus, lactucarium, <fcc, are sometimes very useful in 
 allaying the pain, provided the use of them is continued 
 through several weeks. 
 
 What alterative tonic have we which is often useful in 
 these cases ? 
 
 Lugol's solution of iodine, or the hydriodate of potash. 
 Five, or ten, or twelve drops, three times a day, of the 
 strong solution, continued a long time, often improves the 
 appetite and the vigor of the general system. 
 
 What other parts of the pelvic viscera of the female have 
 been observed to be subject to this morbid irritability ? 
 
 The vagina, vulva, and urethra. 
 
 What treatment is proper for these cases ? 
 
 The same as for irritable uterus. 
 
 To what variety of displacements is the uterus subject? 
 
 To prolapsus in its several degrees — to retroversion par- 
 tial and complete — to anteroversion — to anteflexion — to 
 retroflexion, and to a hernial displacement. 
 
 What are we to understand by prolapsus of the uterus ? 
 
 Its precipitation along the canal of the vagina. 
 
82 OBSTETRIC CATECHISM. 
 
 How many degrees of prolapsus are there ? 
 
 Three. First — descent, where the position is slightly 
 altered, without however any marked deviation of the axis 
 of the uterus, but with the neck often bent a little forward. 
 Second — precipitation or prolapsus, where the organ has 
 descended low into the vagina, and has changed the direc- 
 tion of its axis, from a correspondence with that of the su- 
 perior strait to that of cavity, or even inferior strait, with 
 its anterior surface upwards. Third — procidentia, or com- 
 plete prolapsus, where the organ with part or all of its 
 appendages, ttial escaped the vulva, with its axis corres- 
 ponding more or less to the axis of the whole body. 
 
 What is the most common cause of prolapsus ? 
 
 Increased size and weight of the organ, particularly 
 when accompanied by relaxation or elongation of the liga- 
 ments, and especially of the utero-sacral ligaments. 
 
 During what period of pregnancy is the uterus most 
 likely to become prolapsed? 
 
 Between the first and the fourth months, while the organ 
 is heavy and yet not large enough to be supported by the 
 bony structure of the pelvis ; again, shortly after parturi- 
 tion, while the organ is still large and heavy, and the liga- 
 ments very much relaxed or elongated. 
 
 What ligaments are most important to the support of 
 the uterus in situ ? 
 
 The utero-sacral, or posterior ligaments of the uterus. 
 
 What part does the vagina perform in the support of 
 the uterus ? 
 
 Probably none at all ; though in this respect obstetric 
 anatomists differ in opinion 
 
RETROVERSION OF THE UTERUS. 83 
 
 What influence should the knowledge of the risk of ac- 
 cidents have upon our management of puerperal females ? 
 
 They, that is, any others than perhaps savages and very 
 laborious women, should be kept in the horizontal posi- 
 tion several days after parturition, until the uterus may 
 have approached to its usual size, and the ligaments have 
 regained their usual tonicity and degree of contraction. 
 
 What are the exciting causes of prolapsus, in single or 
 unimpregnated women ? 
 
 Great muscular exertion, which sometimes induces it in 
 strong girls, sudden and severe falls, constriction of the up- 
 per portion of the body, and consequent pressure upon 
 the intestines, and through them upon the pelvic viscera, 
 as produced by tight lacing, severe straining to relieve 
 constipated bowels, <fec. 
 
 With what other displacement of the uterus may pro- 
 lapsus be confounded ? 
 
 With partial or even complete retroversion. 
 
 What is meant by retroversion ? 
 
 A tilting of the fundus and body of the uterus back- 
 wards, while the neck and body are carried forwards, and 
 sometimes upwards. 
 
 How many varieties of this do we recognize ? 
 Two — the partial and the complete retroversion. 
 
 What other peculiar condition of the uterus is there, in 
 which the body may be carried more or less backward ? 
 
 Retro-rlection, in which the uterus is bent backwards 
 upon itself, in such manner that the mouth and a por- 
 tion of the neck may have their usual direction, while the 
 fundus, body, and part of the neck are so bent backwards 
 as to form an angle with the inferior portion. 
 
 ) 
 
84 OBSTETRIC CATECHISM. 
 
 Are either of these displacements capable of being posi- 
 tively diagnosticated by the rational or sympathetic signs ? 
 
 No ; there are numerous other affections liable to occur 
 in the female pelvis, which give signs strongly resembling 
 displacements. \Thus, congestions of the uterus, irritable 
 uterus, irritable urethra, irritable vagina, irritable rectum, 
 polypus, and other tumors in the uterus or vagina, as- 
 carides in the rectum, or accumulation of hardened feces in 
 that intestine, have all produced sympathetic symptoms 
 similar to those of prolapsus or other displacements. 
 
 What are the symptoms usually attendant upon displace- 
 ment ? 
 
 Many of the symptoms of local inflammation— weight in 
 the pelvis while in the erect position— bearing down — dis- 
 position to strain, as if to evacuate the bladder or bowels — 
 sensation as though something must fall away — pain in the 
 sacro-lumbar region, thence all round to the hypogastrium — 
 pain in the bones of the pubes, probably from the stretch- 
 ing of the round ligaments : this is relieved at once by ly- 
 ing down — pains sometimes intermittent, like those of 
 labor — a more or less fixed pain in the side, sometimes in 
 one side, sometimes in the other, sometimes in the one 
 inguinal region or the other, and often with a sense of 
 dragging from the umbilicus. 
 
 What effect has certain states of the bowels on the feel- 
 ings of patients who have displacements of the uterus ? 
 
 If the bowels are moved regularly and without effort, 
 and the patient is not in a highly irritable condition, she 
 may feel comparatively well ; but if the bowels be consti- 
 pated, the weight of the feces aggravates the feelings of the 
 patient : and if she have a diarrhoea, the frequent actions 
 
DISPLACEMENTS OF THE UTERUS. 85 
 
 t)f the bowels greatly increases her distress, by still more 
 dragging down the uterus. 
 
 Which most sympathises in this local disturbance of the 
 uterus, the vascular or nervous system ? 
 
 The vascular system is usually little affected, but the 
 nervous sympathies often become very extensive ; thus, 
 the spinal marrow, the brain itself, take on the character of 
 spinal or cephalic irritation, and in time neuralgia of almost 
 every organ may occur in succession or simultaneously. 
 
 What appears to be proof that this irritation has depend- 
 ed upon displacement of the uterus? 
 
 The fact that in some cases instantly, and in most others 
 sooner or later, all these distressing affections have ceased 
 after the restoration of the uterus to its proper place. 
 
 As there are many other affections already alluded to, 
 which cause symptoms resembling displacements of the 
 uterus, is it proper that the physician should at once deter- 
 mine, by physical examination, what the true diagnosis is ? 
 
 This should be regarded as a fundamental rule in the 
 duty of treating diseases, but as in this case the feelings of 
 both patient and physician should be spared, if possible, it 
 has been advised first to treat all these acute symptoms by 
 rest in bed, with the head and shoulders low, light diet, 
 laxative medicine, warm fomentations, warm injections, 
 and if apparently necessary, leeches to the groins, and the 
 internal use of such mild narcotics, as will under ordinary 
 circumstances of irritation, quiet the system. 
 
 Suppose the train of symptoms denoting engorgement, 
 irritability, or displacement of the uterus, should occur in 
 a patient directly after parturition, what treatment should 
 be adopted ? 
 
 Keep the patient constantly in bed, or on a sofa, in a 
 
86 OBSTETRIC CATECHISM. 
 
 horizontal position, for six, eight, ten, or twelve weeks, 
 till such distressing symptoms are removed. 
 
 Will it be proper to practice this irksome restraint upon 
 a female during this whole period, without having ascer- 
 tained the real condition of the pelvic viscera, by physical 
 examination ? 
 
 In married females this examination may be resorted to 
 with less reluctance, and may be made early, but in young 
 and unmarried females it has been thought proper to try 
 the curative effects of rest, diet, and the means mentioned ; 
 but should these fail to remove all the symptoms, such an 
 examination ought undoubtedly to be made. 
 
 As patients are apt to have their general health suffer 
 from long confinement, cannot some means be devised by 
 which she may use some exercise ? 
 
 If there be no engorgement or acute irritation, her sys- 
 tem must be invigorated, and she must be permitted to ex- 
 ercise moderately. 
 
 When the acute symptoms have been relieved by rest 
 or otherwise, what is mostly necessary to complete cure, 
 or afford permanent relief to the displacement, while the 
 patient is recruiting her general health by exercise ? 
 
 Such mechanical support as will retain the uterus in its 
 proper situation until the general health becomes restored, 
 and the ligaments of the uterus acquire their natural to- 
 nicity. 
 
 What is the general history of these artificial means of 
 support for the uterus ? 
 
 From the earliest records of medicine, instruments called 
 pessaries, have been in use. Sometimes it has been pro- 
 posed to substitute them by external bandages and com- 
 
TREATMENT OF DISPLACEMENTS. 87 
 
 presses. The latter have however proved less generally 
 effectual, and consequently the pessary of variable forms 
 and materials have been found necessary. 
 
 What is the modus operandi of most of the bandages 
 now in use ? 
 
 They compress the inferior part of the abdomen, and 
 may be properly called abdominal supporters ; but at the 
 same time, they either force down the small intestines into 
 the cavity of the pelvis upon the uterus, or by the firm 
 pad placed in front of the abdomen, and directly above 
 the pubes, they form such a plane as to cause the abdomi- 
 nal viscera to descend into, or towards the pelvis, when 
 pressed upon from above, by the diaphragm and other 
 respiratory muscles. 
 
 What is the effect of the perineal pad and straps ? 
 
 They contribute in conjunction with the circular band, 
 to subject the uterus to more or less pressure, in conse- 
 sequence of its pressing up the perinaeum to the orifice of 
 the uterus. 
 
 What is probably the cause of the objections to the use 
 of pessaries for the relief of prolapsus and other displace- 
 ments of the uterus ? 
 
 The fact that they are often made of improper materials, 
 unsuitable forms, and that most physicians misapprehend 
 the manner of application, and their mode of operation for 
 the support of the displaced organs. 
 
 What is the first thing essential to the successful use of 
 the pessary ? 
 
 That the uterus be replaced in its natural situation, for 
 without this the pessary will fail to answer the purpose 
 intended. 
 
88 OBSTETRIC CATECHISM. 
 
 What ar*> the materials of which the pessary should be 
 composed ? 
 
 Glass, or silver well gilt, or pure gold. 
 
 What is the shape of the pessary ? 
 
 It is very variable, according to the fancy of the prac- 
 titioner, but particularly so according to the shape of th© 
 vagina, and the condition of the displacement. 
 
 What forms are mostly entitled to preference ? 
 
 1. The common flat circular form. 
 
 2. The ring-shaped, with very thick edges. 
 
 3. The oval-ring, curved upwards at one or both ex- 
 tremities. 
 
 What is the objection to the globular pessary ? 
 
 1. It is introduced through the osteum vaginae with 
 difficulty. 
 
 2. It does not always sustain the uterus in its natural 
 situation. 
 
 3. It is often extremely difficult to remove it when it 
 has been introduced. 
 
 What position should the round flat pessary occupy in 
 the vagina ? 
 
 It should be parallel with the rectum, that is, its convex 
 surface should be applied to the rectum, with its upper 
 edge in the cul de sac of the vagina, and its lower edge 
 upon the perinaeum. 
 
 Is the uterus then supported in the direction of the 
 thickness, or the diameter of the pessary ? 
 
 It cannot be effectually supported in any other than the 
 direction of the diameter of the pessary. 
 
 In what way does the pessary appear to act in the sup- 
 port of the uterus ? 
 
 As a lever, of which the convex surface rests upon the 
 
TREATMENT OF DISPLACEMENTS. 89 
 
 Tectum as a fulcrum, and the muscles of the perinaeum act 
 at the lower edge, while the uterus is supported upon the 
 upper edge. 
 
 Which form of pessary has been regarded as best for the 
 support of a retroverted uterus ? 
 
 The oblong or elliptical ring pessary, which must be 
 long enough to have one of its extremities go up behind 
 the neck and under the body of the uterus, while the other 
 end is supported by the perinaeum, or by the pubes. 
 
 What class of pessaries are supposed to be best for fe- 
 males who have had many children, or those affected with 
 irritable uterus, or those who have ulcerations upon the 
 os uteri ? 
 
 The ring pessaries with edges sufficiently thick to ele- 
 vate the uterus from contact with the floor of the vagina. 
 
 What consequences may result from having the pessary 
 too small ? 
 
 Both pessary and uterus may become prolapsed or re- 
 troverted. 
 
 What is to be said of the stem pessary, or the pessary 
 en bilboqaet of the French ? 
 
 It is usually too irritating to be useful. 
 
 What is the proper method of introducing a pessary ? 
 
 Frequently it is sufficient that the patient lie upon her 
 left side, with her hips to the edge of the bed. It is usually 
 more convenient for the practitioner that she lie upon her 
 back, and in some difficult cases it is necessary that she 
 have her hips brought to the foot of the bed, and her feet 
 on chairs each side of the seat of the practitioner. The 
 vulva is then to be well lubricated, and the posterior com- 
 missure so put upon the stretch by the index finger of one 
 
 8* 
 
90 OBSTETRIC CATECHISM. 
 
 hand, as to dilate the orifice of the vagina. The pessary 
 also, well lubricated, is now to be introduced edgewise in 
 the direction of the long diameter of the vagina, by making 
 it press firmly upon the finger, which rests upon the pos- 
 terior commissure, and taking care not to allow the upper 
 edge to contuse either of the nymphse, press firmly but 
 gradually onward, until it has entered the orifice of the 
 vagina — then observing that it turns over with its concave 
 surface upwards — continue pressing upon its anterior edge 
 till it is made to rest in the fossa in the perinaeum, behind 
 the posterior commissure of the vulva, having its upper 
 edge completely imbedded in the cul de sac of the vagina. 
 
 At what part of this operation does the patient expe- 
 rience pain ? 
 
 While the instrument is passing through the orifice of 
 the vagina. It is usually instantly relieved, as soon as the 
 pessary has fairly passed beyond this point. 
 
 Would it not be best to replace the uterus with the 
 finger, before attempting the introduction of the pessary ? 
 
 It would always be best, and in those cases in which the 
 finger is too short for carrying up the fundus in cases of 
 retroversion, it is best to elongate it by carrying up upon 
 it a flexible metallic bougie, with which the organ may be 
 replaced. 
 
 What advantage can be gained by passing a finger into 
 the rectum in these cases ? 
 
 The replacement may thus often be facilitated, but opera- 
 tions through the rectum are often very painful to the 
 patient. 
 
 What instructions should be given to the patient, if she 
 should feel that the lower edge of the pessary presses 
 anteriorly ? 
 
TREATMENT OF DISPLACEMENTS. 91 
 
 To insert the finger into the vagina, and press the in- 
 strument backwards and rather downwards. 
 
 What sensation does the patient usually experience after 
 the pessary is properly placed ? 
 
 Sometimes, immediate relief; this however is not always 
 the case for a few days. In some cases moreover it cannot 
 be borne. 
 
 How long is it usually requisite for a patient to continue 
 the use of the pessary ? 
 
 Three, six, nine, twelve, or more months. 
 
 How long may she usually wear a glass, or a gilt pes- 
 sary without removing it ? 
 
 In general six months ; at the end of which time it is 
 usually necessary that she have it removed to be re-gilded, 
 or to substitute one of different size, whether it be of glass 
 or other material. 
 
 How are such pessaries to be kept clean in the vagina ? 
 By the use of injections. 
 
 Is the removal of pessaries easily accomplished ? 
 
 Not in all cases; sometimes they canbe extracted only 
 by the aid of a suitable hook, or a vectis properly con- 
 structed, or they may even require the use of proper for- 
 ceps. 
 
 What can be said of the elytroid pessary of Cloquet ? 
 That it is not found to answer the desired purpose. 
 
 What are some of the evil consequences which may 
 result from pessaries ? 
 
 Irritation, inflammation, ulcerations of the vagina and 
 orifice and neck of the uterus ; when injudiciously em- 
 
92 OBSTETRIC CATECHISM. 
 
 ployed, or unsuitably constructed, the neck of the uterus 
 has become strangulated in the perforation of the flat pes- 
 sary, &c. 
 
 What should be done if the pessary be found doing any 
 injury ? 
 
 It should be removed and its use entirely abandoned, or 
 it should be substituted by one adapted to the case. 
 
 What surgical means have been devised for the radical 
 -cure of prolapsus uteri? 
 
 The removal of a portion of the mucous membrane of 
 the posterior or anterior part of the vagina, then bringing 
 the edges together so that by their adhesion the vagina 
 may be diminished in size. 
 
 What is meant by the term anteversion of the uterus ? 
 That condition of the uterus in which its body and 
 fundus are thrown forward against the bladder. 
 
 Is this of frequent occurrence ? 
 
 It is believed to be rare, and especially in the unmarried 
 female. 
 
 What symptoms does it produce ? 
 
 Several of those attendant upon prolapsus and retrover- 
 sion, but especially does the patient complain of sense of 
 pressure against the bladder ; sometimes this feeling is so 
 strong as to have given rise to the idea that calculus ex- 
 isted in the bladder. 
 
 What attempts are to be made to remove the cause of 
 such distressing symptoms ? 
 
 The indications are to restore the displaced fundus to 
 its proper situation, and retain it if possible by a well ad- 
 justed pessary. 
 
INFLAMMATION OF THE ORGANS OF GENERATION. 93 
 
 Is it an affection easily to be managed ? 
 
 In general it is not ; it is probable that it often depends 
 upon some mechanical cause, as the pressure of impacted 
 feces in the sigmoid flexure of the colon, the presence of 
 ovarian or other tumors, &c. 
 
 How are we to study or regard inflammatory affections 
 of the organs of generation in the female ? 
 
 In relation to the tissue which is affected. Thus, in 
 inflammation of the mons veneris the effects of the disease 
 are modified by the density of the structure ; hence when 
 it suppurates, the pus being bound down, burrows more or 
 less as though under a fascia. 
 
 In what respect does inflammation of the vulva differ 
 from that of the mons veneris ? 
 
 This structure being much less firm, great tumefaction 
 from sanguine congestion and edema are apt to follow. 
 Suppuration also takes place more readily. 
 
 With what is common inflammation of the vulva often 
 complicated ? 
 
 With an aphthous eruption, as seen in the mouths of 
 young children. 
 
 What class of females are subject to inflammation of the 
 uterus ? 
 
 It is liable to occur in single as well as married women, 
 and in the pregnant and non-pregnant condition. 
 
 What is it called when it attacks the substance of the 
 uterus ? 
 
 Hysteritis, or metritis. 
 
 To what grades of inflammation is this organ liable ? 
 As most others, to acute and chronic inflammation. 
 
94 OBSTETRIC CATECHISM. 
 
 What are some of the causes of metritis or hysteritis ? 
 
 Blows., falls, sympathetic irritation in other organs, vio- 
 lence to the uterus during parturition, &c. 
 
 The causes which produce dysmenorrhoea, also some- 
 times give rise to metritis. 
 
 The uterus may also become inflamed from the appli- 
 cation of syphilitic virus applied directly to it, or it may 
 liave been indirectly communicated along the vagina. 
 
 To what other specific inflammation is the uterus liable ? 
 To gout or rheumatism. 
 
 What symptoms accompany metritis ? 
 
 Chill, fever, pain in back, but particularly in the hypo- 
 ; gastrium. The bladder is irritated and little urine can be 
 retained, great pain is experienced in any attempt at mo- 
 tion ; when the attack is severe the patient is obliged to 
 lay down upon the back, have the legs drawn up to take 
 off all pressure from the affected part. In the milder 
 forms there is less pain, and little or no sympathetic sign 
 of the local affection. 
 
 What condition of the parts is found on physical exami- 
 nation ? 
 
 Vagina and uterus hot, the uterus thickened, hard, con- 
 gested, heavy, and painful to the touch. 
 
 What are the varieties of termination of metritis ? 
 Resolution, abscess, chronic inflammation, induration, 
 and ramollissement or softening-. 
 
 What is the general character of induration of the 
 uterus ? 
 
 1st. The whole uterus, with its neck is large. 
 
 2d. The organ may frequently be felt above the pubes, 
 regular in shape, and little if at all, sensitive to the touch. 
 
IIYSTERITIS, ETC. 95 
 
 3d. Balanced upon the point of the finger it feels heavy, 
 and by this weight in the vagina it causes the sensation of 
 prolapsus. 
 
 Does this induration pass speedily into any other form 
 of disease ? 
 
 It often remains stationary for a long time, even during 
 the balance of life without injury to the patient. 
 
 Is it always free from morbid sensibility, when in this 
 indurated state ? 
 
 It is not ; on the contrary, it sometimes remains irritable 
 for days, weeks, and even years, and this irritation, as has 
 been said already, is sometimes kept up by the displace- 
 ment of the organ, whether it be prolapsed, or retro verted. 
 
 Are the functions of menstruation and reproduction ne- 
 cessarily interfered with by the occurrence of induration of 
 the uterus ? 
 
 Patients may continue to menstruate, but if they become 
 pregnant, .they will be likely to abort. 
 
 Is ramollisement or softening of the substance of the 
 uterus usually extended to the entire organ ? 
 
 It is perhaps altogether a rare mode of termination of 
 inflammation, but when it does so occur, it is more fre- 
 quently confined to a part, than extended to the whole 
 organ. 
 
 What parts of the uterus may be the seat of abscess ? 
 
 Sometimes it occurs in the substance, and points towards 
 the cavity of the abdomen or pelvis, sometimes it opens 
 upon the inner surface of the uterus. 
 
 When the abscess points towards the external surface of 
 the uterus, what process is usually commenced ? 
 
 The serous membrane, viz : the peritonaeum, usually 
 
96 OBSTETRIC CATECHISM. 
 
 suffers from local inflammation which results in adhesion? 
 and thus a cyst is formed which contains the effused pus 
 until ulceration is effected into the rectum, and the matter 
 passed off per anum ; or the coats of the bladder are per- 
 forated and the pus escapes with the urine, or an opening 
 is made between the vagina and bladder, or between the 
 uterus, vagina, and rectum ; or lastly, and least frequently, 
 a perforation is made through the cyst into the cavity of 
 the abdomen, and fatal peritonitis is induced. 
 
 What is the prognosis of abscess in the uterus ? 
 
 Mostly, unless the abscess open into the cavity of the 
 peritonaeum, life may be preserved, though the patient's 
 health may remain a long time impaired. 
 
 What treatment is appropriate to acute metritis ? 
 
 One strictly antiphlogistic, as venesection, saline ca- 
 thartics, antimonials, local bloodletting, low diet, perfect 
 rest, and some active revulsives, as fomentations, blisters, 
 
 &c. &c. 
 
 What is to be said respecting the use of cold or astrin- 
 gents ? 
 
 That though useful in some cases and some stages of 
 the disease, they are entirely inadmissible in rheumatic or 
 gouty constitutions. 
 
 If the inflammation terminate in induration, how is it to 
 be treated ? 
 
 Attempts are to be made to dicuss it bjr the use of reme- 
 dies believed to act powerfully as discutients, as small and 
 repeated doses of mercury, in the form of calomel, blue 
 pill, or corrosive sublimate. By many the cicuta has 
 been thought to act in this way, and latterly the Lugol's 
 solution of iodine, in doses of from eight to ten drops, 
 
 
TREATMENT OF HYSTERITIS, ETC. 97 
 
 three times a day, has had some reputation for this pur- 
 pose. 
 
 Is it necessary to confine the patient to her bed for the 
 discussion of the induration ? 
 
 Freedom from excitement should be secured to her, but 
 often she may be permitted to move about while under 
 treatment, provided the heavy organ be supported upon a 
 pessary. 
 
 What train of symptoms would indicate the termination 
 in suppuration ? 
 
 A continuance of the pain, with constitutional irritation, 
 together with a sense of throbbing in the part. 
 
 What treatment should be adopted under such circum- 
 stances ? 
 
 A continuance of the anti-phlogistic treatment, until the 
 abscess opens spontaneously, or points in such direction 
 that it can be opened artificially. 
 
 What particular portion of the uterus is most liable to 
 inflammation ? 
 
 That part which dips into the vagina, or the neck and 
 mouth of the uterus. 
 
 What are some of the numerous causes of inflammation 
 of this part of the uterus ? 
 
 1. Extension of inflammation from the mucous mem- 
 brane of the vagina — hence it is often connected with va- 
 ginitis. 
 
 2. It is sometimes caused by the posterior lip dropping 
 down into, and becoming strangulated in the orifice of a 
 flat pessary ; mechanical shocks, as violence in coition, &c. 
 
 9 
 
98 OBSTETRIC CATECHISM. 
 
 What symptoms usually accompany inflammation of 
 the neck of the uterus ? 
 
 They are similar to those of mild metritis, as pain in the 
 back, heat and weight in the pelvis, &c. 
 
 What evidence can we have that the inflammation is 
 confined to the neck, and does not involve the body ? 
 
 The neck is found tumid, and the body not so, when 
 examined by the touch. 
 
 What are some of the terminations of inflammation of 
 the neck of the uterus? 
 
 In resolution, in induration, in scirrhous, in ulceration 
 both simple and malignant. 
 
 How are we to distinguish simple from syphilitic ulcera- 
 tion of this part ? 
 
 Simple ulceration is said to have smooth regularly de- 
 fined edges, while those of the specific character have 
 irregular margins. 
 
 What varieties of simple ulcerations may affect the neck? 
 
 1. Simple ulceration of the mucous membrane, resem- 
 bling an abrasion of the mucous surface. . 
 
 2. One in which there are deposites of small patches of 
 lymph, as aphthae, &c. 
 
 How is the corroding ulcer to be distinguished from 
 either of these varieties ? 
 
 By the fact that it digs out the internal surface of the 
 mouth and neck of the uterus. 
 
 Can simple ulcerations always be recognized by the 
 touch ? 
 
 They cannot ; it is rarely safe to rely upon the touch 
 for a knowledge of their character. 
 
ULCERS OF UTERUS SPECULUM. "9 
 
 How then are they to be recognized? 
 
 By means of a speculum or well adjusted tube, passed 
 so adroitly into the vagina, as to enable the eye of the prac- 
 titioner to see the part affected, and thus derive more ac- 
 curate knowledge respecting it. 
 
 What varieties of speculum are there, and of what ma- 
 terials are they composed ? 
 
 They are made of glass or of some of the metals. Some 
 are complete tubes, either cylindrical, or somewhat coni- 
 cal — consisting of a single piece — such are composed of 
 glass, pewter, or the mixed metals. Others are so divided 
 that they operate with handles upon a hinge, and resemble 
 a tube cleft longitudinally, with a pivot so adjusted that the 
 two extremities of the blades can be more or less widely 
 separated. Others are so constructed as to consist of three 
 equal blades, so adapted as to move upon each other, and 
 thus to be passed into the vagina while folded up, and af- 
 terwards expanded, to bring the orifice of the uterus into 
 view. 
 
 Which variety of those now in use is probably best 
 adapted to most purposes for which the instrument is re- 
 quired ? 
 
 The quadri valve instrument, which is so constructed 
 that it enters the vagina in a small compass, yet it is ca- 
 pable of great expansion when necessary, by compressing 
 the two handles- 
 How is the speculum to be introduced? 
 When no great precision in the examination is requisite, 
 the patient may be placed on her left side, close to the 
 edge of the bed — or what is to be preferred, she may be 
 placed on her back, with her feet resting at the end of the 
 bed, and the breech brought down to her heels. If, how- 
 
 L6FC. 
 
100 OBSTETRIC CATECHISM. 
 
 ever, any careful investigation of the condition of the os 
 tincae is necessary, it becomes almost indispensable that 
 the hips should be brought upon the edge of the bed, ele- 
 vated by a pillow or some suitable padding;, while the feet 
 are extended upon chairs or suitable supports outside of 
 the bed. The patient's limbs should be properly covered 
 with drawers, and over all should be placed a sheet or 
 blanket, having in the central seam an orifice ripped suffi- 
 ciently large to receive the instrument as far as to the 
 handles. The examinator is then to be seated or stationed 
 between the knees of the patient, while the instrument, 
 well lubricated, is to be passed by one hand through the 
 orifice, as far as to the handles or base. The vulva is also 
 to be w r ell lubricated by the other hand, one or two fin- 
 gers of which are to be passed into the orifice of the va- 
 gina, to press back the perinaeum. As soon as the posterior 
 commissure of the vulva is put sufficiently upon the stretch, 
 the point of the instrument should be carried down upon 
 the back of these fingers, which should thus form a plane, 
 along which the embout, or rounded wooden extremity of 
 the speculum, can be guided over the posterior surface of 
 the vagina. This done, the fingers are to be withdrawn, 
 and that hand called to aid the other in cautiously passing 
 the speculum onwards in the axis of the vagina to the cul- 
 de-sac behind the uterus. The handles may then be care- 
 fully pressed towards each other, when the embout, be- 
 coming disengaged, is forced out by the spring contrived 
 for the purpose, and thus leaves the upper portion of the 
 vagina accessible to the eye of the examinator. 
 
 What kind of light is best adapted to the purpose of such 
 examinations ? 
 
 A bright moveable light, such as a free burning lamp or 
 candle. 
 
TREATMENT OF ULCERS OF THE UTERUS. 101 
 
 What obstructions may present to the ready discovery 
 of the state of the parts ? 
 
 A greater or less quantity of tenacious mucus, or even 
 coagulated blood, may be attached to the surface of the os 
 tincae. This must be wiped off by a mop made of fine 
 sponge or charpie, or washed away by a detergent injec- 
 tion. 
 
 What is the proper treatment of ulcers of the os tincae? 
 
 Depletory, while any marked inflammatory action ex- 
 ists — then astringents, and for the mucous ulcerations the 
 nitrate of silver, either in substance or in proper solution, 
 and applied by means of a camel's hair pencil. 
 
 Is it essential that the patient should be kept at rest 
 during the treatment ? 
 
 If possible, the patient should be kept at rest, and pres- 
 sure should as much as possible be taken from the uterus. 
 Where, however, quietness is impracticable, the patient 
 should have the ulcerated surface of the uterus isolated 
 from the mucous membrane of the vagina, by the use of a 
 properly adjusted pessary. The dressings or w r ashings 
 can then be applied with better effect. 
 
 Are dressings to the os tincae of easy application ? 
 
 They can rarely be properly applied unless through the 
 speculum, previously introduced, to bring the affected part 
 into view. 
 
 Is it important that an accurate distinction be made be- 
 tween pure inflammation of a part, and irritation and dis- 
 orders of function merely ? 
 
 It is highly important, as the therapeutic indications are 
 
 essentially different in many of these cases. 
 
 9* 
 
102 OBSTETRIC CATECHISM. 
 
 What is meant by the term phagedenic or corrosive 
 ulcer of the mouth or neck of the womb ? 
 
 That variety of ulcers which is constantly extending by 
 the progress of ulcerative absorption. 
 
 Is it proper to regard this as always malignant and in- 
 curable ? 
 
 It is mostly sufficiently malignant in its character to 
 produce serious', and generally fatal inroads upon the con- 
 stitution, but it is sometimes amenable to appropriate reme- 
 dies. 
 
 In what class of females does it usually occur ? 
 
 In those of a lymphatic temperament, and who have pas- 
 sed the menstruating period of life in most, but not in all 
 cases. 
 
 Is its existence generally recognized early after its com- 
 mencement ? 
 
 As it is usually not attended with very severe pain, the 
 patient ascribes the discharge which attends it to too fre- 
 quent a menstruation, or if she be passed this period of life, 
 she thinks menstruation has returned. 
 
 What sensations are usually experienced by those who 
 have this disease ? 
 
 Principally, a sense of weight, bearing down, as occurs 
 in prolapsus or partial retroversion. 
 
 What condition of the uterus, <fcc, is to be recognized 
 by the finger in the touch. 
 
 The circumference of the neck is found enlarged, and 
 the orifice very considerably so — it seems to to be infundi- 
 bulated or dug out — sometimes the finger will pass readily 
 to the internal os uteri. 
 
I 
 
 PHAGEDENIC ULCERS, ETC., OF UTERUS. 103 
 
 Is the body of the uterus moveable or fixed in these 
 cases ? 
 
 It is usually quite free and moveable — sometimes it is a 
 little engorged. The neck only or the internal surface 
 being implicated. 
 
 Can an accurate diagnosis be obtained by the touch 
 alone ? 
 
 No, the sense of sight through the medium of the spec- 
 ulum becomes necessary to recognise the alterations which 
 have taken place. 
 
 What influence does this affection exert upon the con- 
 stitution of the patient ? 
 
 Although it is usually attended with very little pain, yet 
 sooner or later the patient becomes reduced to a state of 
 great feebleness and prostration. The absorption of the 
 vitiated secretion produces hectic fever, great emaciation, 
 followed by edema, &c. 
 
 What parts become subsequently involved in the erosive 
 process which is going on ? 
 
 The bladder, or rectum, or both, become opened.so that 
 the urine escapes by the vagina ; or in the event of the 
 rectum being ulcerated, the feces pass by the same route. 
 
 What precautionary measures are to be adopted to pre- 
 vent an aggravation or rapid extension of the disease ? 
 
 The constant use of detergent injections into the vao-ina, 
 and perhaps into the uterus itself, with a view to remove 
 as effectually as possible all the matter as fast as secreted. 
 
 What local medicines may be used ? 
 
 Those of an astringent character have generally been 
 thought proper, after a due ablution of the surfaces with 
 bland mucilages, or simple warm water; thus the sulphate 
 
104 OBSTETRIC CATECHISM. 
 
 or acetate of zinc, in the proportion of one, two, or three 
 grains to the ounce of water, may be thrown up by a 
 syringe, or carried upon charpie, through the speculum by 
 some suitable instrument. 
 
 The solution, or solid nitrate of silver, has also been 
 used in such cases. 
 
 Is it proper to rely upon local treament alone ? 
 It will be highly important to attend to all the hygienic 
 measures which improve the general health. 
 
 In regard to the use of injections into the cavity of the 
 uterus, how, and by what means should they be intro- 
 duced ? 
 
 In the present ignorant condition of nurses, the practi- 
 tioner should always apply them, and that if possible two 
 or three times a day. The mucilage of flaxseed, slippery 
 elm, pith of sassafras, starch or barley, should be carefully 
 strained, and then conveyed through a gum elastic catheter, 
 the eyelet end of which should be first carefully introduced 
 upon the point of the finger into the cavity of the uterus, 
 and so retained by the hand of the patient or a proper as- 
 sistant, that it be not driven forcibly against the walls of the 
 uterus when adapting the pipe of the syringe to it : or a 
 silver tube curved into the proper shape may be substituted, 
 and to this the syringe when charged may be so fitted as 
 to pass up the whole contents into the cavity of the uterus. 
 
 This operation with whatever kind of instrument, should 
 be conducted with great care, as not only the instrument 
 improperly introduced may do much injury, but there is 
 some danger of forcing the fluids along the fallopian tubes 
 into the cavity of the peritonaeum, and thus causing fatal 
 peritonitis. 
 
CANCER OF THE UTERUS. 105 
 
 Is cancer of the uterus a very common disease ? 
 
 In this country it is believed really to be one of very 
 rare occurrence, though there are many affections of the 
 uterus which are ascribed to cancer, and yet are not car- 
 cinomatous. 
 
 What portion of the uterus is most liable to be attacked 
 with cancer? 
 The neck. 
 
 What is the usual mode of attack of cancer ? 
 
 First, the parts become the seat of irregular indura- 
 tion of a scirrhous character, being more nodulated, harder 
 and more dense and painful than simple induration ; one 
 lip is mostly sensibly larger than the other. 
 
 What is usually observed in regard to the vagina in these 
 cases ? 
 
 That it is more or less shortened, and sometimes adhe- 
 rentto adjacent parts. The same may be said of the uterus, 
 which is usually found immoveable, being bound down to 
 the bladder, or rectum, or both. 
 
 What is subsequently observed in respect to the march 
 of the disease ? 
 
 Sooner or later, corrosive ulceration with hemorrhage 
 from the surface which is sometimes studded by a fungus 
 growth takes place. 
 
 The patient also experiences deep seated lancinating pain, 
 (which is generally, though not uniformly pathognomo- 
 nic of cancer,) and after a time the nervous system suffers 
 severely, while sooner or later the aspect of the patient 
 changes : she loses the solidity of muscular and cellular 
 tissue, she may previously have possessed, and substitutes 
 for it, a straw colored surface, with more or less edema of 
 the whole cellular membrane. 
 
106 OBSTETRIC CATECHISM. 
 
 What should be the treatment of cancer of the uterus ? 
 
 At the very incipient stage, it should be antiphlogistic ; 
 after it has made some progress, we can do no more than 
 palliate by keeping the system constantly under the influ- 
 ence of cicuta, hyosciamus, &c, though sooner or later, 
 we are generally compelled to use opium in some form or 
 preparation, in gradually increasing doses, to keep up a de- 
 gree of narcotism. 
 
 By these means the action of the disease is sometimes 
 arrested in its early stage, and its development retarded for 
 a greater or less length of time. 
 
 When ulceration occurs, the same care should be taken 
 to wash away the vitiated secretions. 
 
 What is to be said respecting the propriety of amputat- 
 ing the neck of the uterus ? 
 
 Although this operation has been frequently practised in 
 Europe, in cases of real or supposed cancer, the recorded 
 results are not sufficiently favorable in cases of true carci- 
 noma as to gain our approbation for the practice. 
 
 The diagnosis of the disease while strictly confined to 
 the inferior portion of the neck, is not sufficiently clear to 
 justify an indiscriminate resort to it ; and further, when it 
 has become clearly developed, the parts above the reach of 
 the knife are so often invaded by the same disease, that 
 little or no benefit could arise from the cutting away of a 
 part only of the disease. 
 
 What do you mean by the term physometra ? 
 Tympanitis uteri, or a distension of the uterus by a 
 quantity of air supposed to be secreted within its cavity ? 
 
 Does the mucous membrane of the vagina probably ever 
 secrete air also ? 
 
 It is believed that it sometimes does, as some females 
 
 
 
PHYSOMETRA. 107 
 
 have these discharges of air per vaginam only when in the 
 unimpregnated state, and others when pregnant. 
 
 Is it ever attended with any serious consequences ? 
 
 Not when it passes off readily, which it does do some- 
 times with considerable noise ; but when it is confined 
 within the cavity of the uterus, the patient suffers more or 
 less from distension. 
 
 Upon what condition of the system, does it depend ? 
 
 Some suppose it dependent upon alow degree of inflam- 
 mation of the mucous membrane ; others ascribe it to some 
 peculiar condition of the nervous system, which presides 
 over the secretory processes. 
 
 How is the distension of the uterus from this cause, to 
 be distinguished from pregnancy ? 
 
 By percussion, auscultation and bailotlement : 
 
 1. Percussion produces a resonance which cannot be 
 perceived in pregnancy. 
 
 2. Auscultation in this case, cannot detect the sound of 
 the fetal heart, &c. 
 
 3. Ballottement, cannot recognise the existence of a 
 body moveable in a fluid, within the cavity of the uterus. 
 
 What treatment is to be used in these cases ? 
 
 There is no specific remedy known for this affection * if 
 the air do not pass off under contraction of the uterus, or 
 by the shock of the abdominal muscles, by coughing, or 
 otherwise, it may be necessary to dilate, or perforate the 
 os uteri, and allow the air to pass through a catheter, or 
 canula ; after which, it has been proposed to apply to the 
 inner surface of the uterus, solution of nitrate of silver, 
 or some preparation of chlorine, &c, with the view to alter 
 the condition of the surface which gives rise to this secre- 
 
108 OBSTETRIC CATECHISM. 
 
 tion, — particular regard should be had to the healthy con- 
 dition of the general system. 
 ... 
 What do you mean, by the term hydrometra 1 
 
 Dropsy of the uterus, from an accumulation of serous, 
 albuminous, or muco-purulent fluid, within its cavity. 
 
 Is this condition easily diagnosticated ? 
 
 It is not, being easily confounded with pregnancy,— 
 having a similarity of sympathetic signs, though the stomach 
 is said usually to sympathize less than in pregnancy. 
 
 What physical examination is best adapted to clear the 
 diagnosis ? 
 
 Ballottement, by which the uterus is found to contain a 
 fluid, but having nothing moveable suspended within it* 
 
 Auscultation moreover, detects no sounds of the fetal 
 heart. 
 
 What treatment is proper for hydrops uteri, or hydro- 
 metra ? 
 
 A general diuretic treatment, might be somewhat useful, 
 but, it is mostly necessary to perforate the uterus, by a stilet 
 or catheter in its orifice, or pass a trochar and canula, into 
 some part of the neck which can be reached by the va- 
 gina. 
 
 Should we regard dropsy of the uterus, as a dangerous 
 complaint ? 
 
 It should be so considered, but chiefly from the morbid 
 action going on in the inner surface of the uterus, and its 
 liability to ulceration through its walls into the cavity of 
 the abdomen. 
 
 What is supposed to be the origin of hydatid formations, 
 which sometimes distend the uterus ? 
 
 Atone time, they were supposed to spring from mucous 
 
HYDATIDS. 109 
 
 surfaces, and hence, originate in the lining membrane of 
 the uterus. At present the prevailing opinion is that they 
 depend upon the serous membranes for their nutrition, 
 and it has been observed, that they are rarely or ever found, 
 except in some way or other, connected with pregnancy. 
 In such cases, they are usually first developed upon the 
 surface of the ovum. 
 
 What influence do they exert over the developement of 
 the ovum itself ? 
 
 When numerous, they interfere with the nutrition of the 
 ovum, which then blights, so that upon extrusion there is 
 little appearance of the original ovum. 
 
 % . 
 
 What are the symptoms of hyatids in the uterus ? 
 
 They considerably resemble those of ordinary preg- 
 nancy, and hence, cannot be satisfactorily diagnosticated, 
 until they begin to be extruded* 
 
 Women affected with hydatid formations in the uterus, 
 are rather more liable to have occasional or constant bloody 
 serous discharges, from the uterus, for a greater or less 
 length of time, before expulsion takes place. 
 
 In the early months, the diagnosis is very obscure, but 
 when the uterus is greatly distended, physical exploration 
 and ballottement, prove the non-existence of a fetus in 
 utero. 
 
 What opinions have been entertained, respecting the 
 dependence of hydrometra upon hydatids ? 
 
 Dr. Denman, regarded dropsy of the uterus, as a very 
 large hydatid ? 
 
 Suppose the existence of hydatids be suspected, or even 
 satisfactorily made out, what plan of treatment ought to be 
 
 adopted ? 
 
 10 
 

 110 OBSTETRIC CATECHISM. 
 
 As a general rule it will be proper to palliate any dis- 
 turbances which may occur, and then war, until symptoms 
 of labour come on, when if the extrusion of the mass or 
 masses be tardy, administer ergot sufficient to excite the 
 expulsive action of the uterus. 
 
 What other morbid formations are liable to take place 
 in or about the uterus ? 
 
 Cauliflower excrescence, fibrous tumors, polypi, moles, 
 and osteo-sarcomatous tumors. 
 
 What is the nature of a cauliflower excrescence ? 
 
 It appears to be composed of a tissue of vessels bound 
 together by slight attachments of cellulai membrane, and 
 covered by a smooth but very fragile envelope of the same 
 character ; to the touch it feels like a fungus or cauliflower, 
 whence the English name. 
 
 By some of the French, it is called vivace. When ex- 
 posed to the eye, it displays a bright arterial color. 
 
 What is its general texture ? 
 
 Very slight, it is ruptured by slight pressure, the touch 
 of a finger, or the point of a syringe, or even the contrac- 
 tions of the vagina, or pressure of the perinaeum upon it, 
 hence it readily pours out a great deal of serum and very 
 often some blood, and thus drains the patient. 
 
 In some instances, its texture is more firm. 
 
 What proofs have we, that it consists almost entirely of 
 vessels of the most delicate texture ? 
 
 Immediately after death it is found completely collapsed, 
 with scarcely a vestige of its character while living, and 
 when strangulated by a ligature, the same thing is observed. 
 When the ligature comes away, there is usually only a half 
 putrid membranous mass detached by it. 
 
CAULIFLOWER EXCRESCENCE. Ill 
 
 What is its usual point of origin ? 
 
 The neck or orifice, though sometimes the cavity of the 
 body of the uterus. 
 
 What period of life is most incident to it ? 
 Though of rare occurrence, it may attack at any period 
 of married or single life. 
 
 What influence does it exert upon the health of the 
 patient? 
 
 The constant drainage to which she becomes subject, 
 sooner or later renders her anemic, gives her a pallid, or 
 straw colored appearance : it is also usually accompanied 
 by more or less edema, and other evidences of debility. 
 
 With what other diseases may this cauliflower excres- 
 cence be confounded ? 
 
 With polypus, and the fungus which sometimes springs 
 from a cancerous base in the uterus. 
 
 What is the prognosis of cauliflower excrescence ? 
 It is generally unfavourable. 
 
 What treatment has been proposed and adopted for it ? 
 
 Astringents of various kinds ; and in using these to avoid 
 the rupture of the surface of the tumor it is proposed to 
 have the patient's hips elevated, and then pour the fluid 
 into the vagina from a suitable vessel. 
 
 Has any surgical treatment ever been resorted to, for its 
 removal ? 
 
 The ligature has been applied to its base for that purpose, 
 and its removal has thus been accomplished. The os 
 uteri has also been ablated. 
 
 What should be applied to the base of the tumor after 
 removal, to prevent its return ? 
 
112 OBSTETRIC CATECHISM. 
 
 The nitrate of silver, or what Churchill has regarded 
 better, the butter of antimony, through the speculum. 
 
 To what part of the uterus, may the more solid tumors 
 be attached ? 
 
 Some spring from the outer surface, under the peritonaea! 
 coat, others on the inner surface, and others again have 
 their origin in the substance proper of the organ. 
 
 What is the character of these morbid growths ? 
 
 Sometimes they appear to be purely fibrous, sometimes 
 encysted, that is, having a fluid, mucous, serous, puruloid, 
 or tubercular matter in the centre, or in several foci, 
 surrounded by a fibrous envelope. Sometimes again they 
 appear to be entirely fleshy, and at some others they are 
 calcareous or osteo-sarcomatous. 
 
 What name is given to the pediculated tumors which 
 spring from the uterus ? 
 Uterine polypi. 
 
 What is their general character ? 
 
 They are mostly fibrous, smooth to the touch, and very 
 vascular, and covered by a serous membrane. 
 
 Some are more of a mucous character, and others again 
 are hard and glandular in structure ; those partaking of this 
 particular formation, are thought most frequently to spring 
 from the glandulse nabothi, about the neck of the uterus. 
 
 What portions of the uterus do they generally spring 
 from ? 
 
 From the mucous membrane of the cavity, of the body, 
 of the neck, and from the orifice of the uterus. 
 
 What symptoms usually accompany uterine polypi? 
 TheyJ are very various — mostly, they are those of a 
 nervous character, none of which are pathognomonic. 
 
TUMORS WITHIN THE UTERUS. 113 
 
 There is mostly leucorrhcea, sometimes dysmenorrhea, 
 menorrhagia, and almost always a sensation of prolapsus. 
 
 Is the presence of tumors within the uterus, always 
 easily diagnosticated ? 
 
 It is sometimes very difficult to do so. It has however 
 been observed, that in many of these cases the uterus seems 
 to be elongated to such a degree as to admit of the introduc- 
 tion of the female catheter nearly its entire length into its 
 cavity. 
 
 What sensations does the patient usually experience, 
 when the tumor becomes so long as to rise above the 
 superior strait of the pelvis ? 
 
 The mechanical inconveniences which usually attend 
 pregnancy, arrived at the same degree of developement — 
 the general health may be good. 
 
 By what means is it to be distinguished from pregnancy ? 
 By auscultation and ballottement. 
 
 Is it easy to discriminate between the existence of 
 tumors in the uterus, and those in the ovaria, or either of 
 these from extra-uterine fetation ? 
 
 The diagnosis would be in general, difficult. 
 
 What consequences may result from inflammatory action 
 in tumors, otherwise quiescent, and producing little irrita- 
 tion ? 
 
 When such tumors become the seat of inflammation, 
 more or less rapid changes in their structure may take 
 place, and serious results may follow. 
 
 What treatment should in general be employed ? 
 
 Those which are palliative, or simply discutient, as the 
 iodine, cicuta, tartar emetic by inunction, &c. Attempts 
 at removal by the knife would in general be improper. 
 
 10* 
 
114 OBSTETRIC CATECHISM. 
 
 By what means may the distressing sense of pressure 
 upon the rectum, and neck of the bladder be relieved ? 
 Occasionally by the use of suitable pessaries. 
 
 What class of uterine tumors call for and admit of re- 
 moval by surgical means ? 
 
 Those which are pediculated, as polypus, and as cauli- 
 flower excrescences. 
 
 Which is the better and the safer mode of removal, by 
 the knife or scissors, or by the ligature ? 
 In a large majority of cases by the ligature. 
 
 With what other affections of the uterus, have polypus 
 tumors been confounded ? 
 
 With pregnancy, with prolapsus, with retroversion, and 
 more readily than with either, chronic inversion of the 
 uterus. 
 
 How is it to be distinguished from pregnancy ? 
 
 It can be confounded with pregnancy only when the 
 tumor is formed and retained within the cavity of the 
 uterus, but then the constancy or frequency of the discharge, 
 together with the patulous orifice of the uterus, should 
 clear the diagnosis, or at least determine that true pregnancy 
 does not exist. 
 
 How can we discriminate between polypus and prolap- 
 sus, or retroversion of the uterus ? 
 
 1st. By the character of the tumor when it is a prolapsus, 
 the shortening of the vagina, and the recognition of the 
 descent of the body, upon examination through the rectum ; 
 and also, the situation of the os tinea?. 
 
 2nd. From retroversion, because in this sort of dis- 
 placement, the orifice of the uterus, is thrown strongly 
 
GENERATION. 115 
 
 forward, and no pedicle ean be recognised, by the finger 
 in the vagina or rectum. < 
 
 From what peculiar condition of the uterus is it very 
 difficult to distinguish it ? 
 
 Chronic inversion of the uterus. The distinction must 
 be based partly upon the history of the affection, and the 
 result of a careful physical examination. 
 
 What is generation ? 
 
 It is the function of reproducing the species after the 
 form originally impressed upon it. It is therefore the 
 function peculiar to animated or living beings. 
 
 What is the simplest form of generation ? 
 
 Fissiparous generation, which does not require sexual 
 organs — it is in other words, generation by spontaneous 
 division. 
 
 What is the next higher grade or kind of generation ? 
 
 That which is called germniparous, consisting in the for- 
 mation of buds or germs on some parts of the body, either 
 internally or externally. 
 
 What are the germs in the female of the higher order of 
 animals ? 
 
 The ovules, situated within the ovarian vesicles. 
 
 At what period of life do these germs in the human fe- 
 male exist? 
 
 Between that of puberty and the " change of life." 
 
 Where is the male germ found in vegetable life ? 
 In the pollen of plants. 
 
 What is the male germ in animals ? 
 
 It exists in the fluid secreted by the testicles. 
 
116 OBSTETRIC CATECHISM. 
 
 What is necessary to constitute conception or fecunda- 
 tion ? 
 
 The contact of the male and female germs. 
 
 What may be said of the theories of generation ? 
 
 That they are numerous and some of them vague, and 
 it is true that the whole subject is shrouded in an impene- 
 trable mystery. 
 
 What are the two principal theories in reference to con- 
 ception ? 
 
 1. That of epigenisis, which is probably the oldest, and 
 which supposes that it depends upon the conjunction of 
 the male and female germs in the uterus, and that each 
 contributes its portion to the formation of the new being. 
 
 2. That of evolution, in which it is assumed that the 
 mother furnishes the entire molecule, and that the stimulus 
 of the male sperm only excites it into vital activity. 
 
 When is the embryo formed ? 
 
 At the time or soon after a fecundating copulation. 
 
 What is the condition of this fecundated ovule at the 
 time of conception ? 
 
 It is an amorphous mass, like a drop of mucus or al- 
 bumen. 
 
 Which appears to be the most rational theory of gene- 
 ration ? 
 
 1. That of the ovular, in which it is believed that the 
 elements of the new being reside in the ovule, secreted by 
 the ovary. 
 
 2. That of evolution, in which the sperm of the male 
 operates merely by its stimulus upon the female germ or 
 ovule within the ovarium. 
 
GENERATION. 117 
 
 Is the semen masculinum, in its totality, necessary to 
 produce a fecundation of the female germ ? 
 
 Yes. 
 
 What were the experiments of Spallanzani, of Prevost, 
 and Dumas, in reference to this ? 
 
 They found that it was necessary that the fluid they 
 used for artificial fecundation, should contain the peculiar 
 animalcules or molecules found in the semen masculinum. 
 Spalanzani has maintained that the animalcules are not 
 essential to fecundation. 
 
 Is there any analogy in the modes of fecundation in 
 vegetables and animals ? 
 
 The presence of the pollen is necessary to the develope- 
 ment of the germ. 
 
 How does fecundation take place in the fish? 
 By the deposite of the male sperm upon the spawn of 
 the females. 
 
 What is the mode of fecundation in the frog and other 
 of the batracian animals ? 
 
 The male sperm is thrown upon the female eggs, as 
 they pass from her body. 
 
 Is a true copulation necessary in the mammiferous ani- 
 mals ? 
 Yes. 
 
 Is it necessary that the male germ be deposited within 
 the female body ? 
 It is. 
 
 Is it most probable that the ovary is the point at which 
 the two germs meet? 
 
 That idea is generally embraced by physiologists of the 
 present day, 
 
118 OBSTETRIC CATECHISM. 
 
 What changes take place in the ovary after a fecundating 
 copulation ? 
 
 One of the vesicles enlarges rapidly, soon rises above 
 the surface of the organ, absorption of its peritonei cov- 
 ering takes place, and it is soon embraced by the fallopian 
 tube, and carried toward the cavity of the uterus. 
 
 What is the appearance of an ovarium after the ovule 
 has been removed ? 
 
 First, there is an effusion of blood into the cavity, whence 
 the ovule was taken — then a yellow cicatrix called the cor- 
 pus luteum, or yellow body. 
 
 What is to be understood by the term oviparous gene- 
 ration ? 
 
 That in which the ovum or egg, when once fecundated, 
 may be immediately laid by the female, and its maturity 
 take place out of the body. 
 
 What do we mean by viviparous generation ? 
 
 That in which the fecundated ovum may be detached 
 from the ovary soon after copulation, but is brought to 
 maturity in a special reservoir, called a womb or uterus. 
 
 Is there a true gestation in oviparous animals ? - 
 It cannot be regarded as a true gestation, because the 
 egg is gradually advancing towards the external opening 
 of the oviduct during its process of development. 
 
 How many kinds of pregnancy are there ? 
 
 Two — uterine or normal, and extra uterine or abnormal 
 pregnancy. 
 
 What is the character of, or what constitutes a uterine or 
 normal pregnancy ? 
 
 The fact that the ovule when fecundated, is removed 
 from the ovary, carried along the fallopian tube and de- 
 posited in the cavity of the uterus. 
 
PREGNANCY. 119 
 
 What would you consider to be preternatural, abnormal, 
 or extra uterine pregnancy ? 
 
 The circumstance of the development of the fecundated 
 ovule in the ovarium, the fallopian tube, in the cavity of the 
 peritonaeum. 
 
 Into how many varieties is true uterine pregnancy di- 
 vided ? 
 
 Simple pregnancy with one ovum. 
 
 Double, triple, &c. pregnancy, when there are two, 
 three, or more fetuses. 
 
 Complicated pregnancy, when there exists a polypus, 
 great quantity of water, or any diseased state of the pro- 
 duct of conception, or of the womb itself. 
 
 What varieties does extra uterine, irregular or abnormal 
 pregnancy present ? 
 
 Four varieties, determined by the seat occupied by the 
 fecundated germ. 1st, Ovarian ; 2d, Abdominal ; 3d^ 
 Tubal ; 4th, Mixed or interstitial pregnancy. 
 
 What changes take place in the system, after a fecundat- 
 ing copulation 1 
 
 The tubes which were erect during the copulation, con- 
 tinue so ; the uterus participates in the general turgescence, 
 and is prepared to undergo a new development. 
 
 What is the usual size of the neck of the uterus in the 
 unimpregnated adult female ? 
 One inch long, half inch thick. 
 
 What size does it acquire during the first two months of 
 pregnancy ? 
 
 It is somewhat thicker, and nearly two inches long. 
 
 How long does this development of the neck continue 
 to take place \ 
 
 Until the fourth month. 
 
120 OBSTETRIC CATECHISM. 
 
 When does it begin to shorten again ? 
 During the fifth month. 
 
 How much shorter is it at the end of the fifth month ? 
 One third. 
 
 i How much at the end of the sixth month ? 
 One half. 
 
 How much less at the end of the seventh month ? 
 Two thirds. 
 
 What is the state of the neck at the end of the eighth 
 month ? 
 
 Nearly all expanded. 
 
 Is this a rule without exceptions ? 
 
 No, it is true in general, but cannot always be relied on 
 as a positive sign of the advancement of pregnancy. 
 
 What is the condition of the os uteri during the various 
 periods of pregnancy ? 
 
 It is apparently patulous, but is really plugged by mu- 
 cous or albumenoid matter during the earlier months, and 
 mostly during the greater part of pregnancy. 
 
 What change takes place in the form of the uterus ? 
 It becomes more regularly pyriform* 
 
 What portions then become most rapidly developed ? 
 The anterior and posterior surfaces. 
 
 Which of these two surfaces developes the most ra- 
 pidly ? 
 
 The posterior. 
 
 How much of the uterus is behind a line drawn in the 
 length of the ovary through the fallopian tubes at the end 
 of the fourth month ? 
 
 Two thirds. 
 
DEVELOPMENT OF THE GRAVID UTERUS. 121 
 
 At what period of pregnancy does the body of the ute- 
 rus become completely spherical ? 
 At the end of the fifth month. 
 
 Has the neck begun to shorten at this time ? 
 
 Yes. 
 
 What is the original position of the uterus in its non- 
 gravid state ? 
 
 It is situated in the axis of the superior strait, with its 
 fundus just above the brim of the pelvis. 
 
 Does it descend a little during the first and second 
 months ? 
 
 Yes — but chiefly because of its development. 
 
 Does it continue to bear the same relation with the axis 
 of the pelvis as it is precipitated ? 
 It does. 
 
 Does this precipitation ever extend as far as to the 
 vulva ? 
 
 Yes, in some rare cases. 
 
 Does its orifice then point forwards ? 
 It points forwards in the direction of the axis of the 
 vagina. 
 
 Where is the fundus usually found at the third month of 
 pregnancy ? 
 
 A little above the margin of the superior strait. 
 
 What is the situation of the uterus at the end of the 
 fourth month ? 
 
 A large portion of it is out of the cavity of the pelvis. 
 
 How high is the top of the fundus at the end of the 
 fifth month 1 
 
 U 
 
122 OBSTETRIC CATECHISM. 
 
 Generally half way between the pubes and umbilicus of 
 the mother. 
 
 How high at the end of the sixth month ? 
 On a level with the umbilicus. 
 
 How high at the end of seven months ? 
 
 Two or three finger's breadth above the umbilicus. 
 
 How high at the end of the eighth month ? 
 It has reached the epigastric region. 
 
 Where is the fundus at the end of the ninth month ? 
 
 Usually rather lower than at the end of the eighth, in 
 consequence of the rapid anterior development of the 
 organ. 
 
 What relation does the gravid uterus hold with the in- 
 testines ? 
 
 It carries the intestines upwards and backwards, being 
 itself in contact with the parieties of the abdomen. 
 
 Is a knowledge of this arrangement important in gastro- 
 hysterotomy ? 
 Yes. 
 
 What are the dimensions of the uterus at the full period 
 of utero-gestation? 
 
 Twelve inches from fundus to orifice, eight and a half 
 inches transversely, and nine antero-posteriorly. 
 
 Is the axis of the uterus liable to be modified by the 
 pressure of the abdominal muscles ? 
 It is so, particularly in first pregnancies. 
 
 Does the tension of these muscles in a first pregnancy 
 usually retain the axis of the uterus more nearly parallel 
 with the axis of the body ? 
 
 Yes. 
 
DEVELOPMENT OF THE GRAVID UTERUS. 123 
 
 What other circumstances or causes, modify the direc- 
 tion of the axis of the uterus during gestation ? 
 
 The uterine ligaments, abdominal viscera, and spinal 
 column. 
 
 Is the orifice of the uterus always directed to the por- 
 tion of the pelvis opposite to that towards which'the fundus 
 presents ? 
 
 It is mostly nearly so, though sometimes it is rather 
 posterior to this right line. 
 
 Is the orifice of the uterus sometimes thrown so far 
 back into the hollow, or above the promontory of the 
 sacrum, in cases of anterior obliquity as to be out of reach 
 of the finger ? 
 
 When there is anterior obliquity it is always so. 
 
 Are the walls of the gravid uterus thicker than when in 
 the unimpregnated state ? 
 Very slightly thicker. 
 
 What changes does the uterine parenchyma pass through 
 in this development ? 
 
 It becomes softer, the muscular fibres are developed, 
 the nerves, blood-vessels, and lymphatics all increase in 
 size. 
 
 By how many times are the blood-vessels enlarged ? 
 
 Arteries four times, and the veins even more than this. 
 
 What is meant by what are called venous sinuses ? 
 Enlargements and duplications of the veins merely, 
 Their orifices are patulous upon the internal surfaces. 
 
 Is the sensibitity or irritability of the uterus increased 
 with gestation ? 
 
 It is so, and this is important to be borne in mind in 
 the management of pregnant women. 
 
124 OBSTETRIC CATECHISM. 
 
 Does the embryo enlarge the uterus by the irritation of 
 its presence ? 
 
 It probably does, not however so much by mechanical 
 distension, as by exciting the vital process of development, 
 a result of irritation caused by fecundation ; as the ovum 
 enlarges it keeps up irritation within the uterus. 
 
 If the ovum be accidentally ruptured and discharged, is 
 not the development of the uterus arrested ? 
 It is probably in all cases. 
 
 How is the vagina affected during the process of uterine 
 development ? 
 
 It becomes rather shorter during at least two months ; 
 and from the fourth month it becomes longer and larger. 
 
 How is the peritonaeum, which is spread over the uterus 
 and its appendages, enlarged during gestation ? 
 By development, and not mere stretching. 
 
 Do the fallopian tubes and ovaries remain vascular after 
 conception ? 
 
 They do for some time. 
 
 How are they situated in reference to the uterus at the 
 end of pregnancy ? 
 
 They hang along side of this organ in the folds of the 
 peritonaeum. 
 
 Do the round ligaments assume a muscular character ? 
 
 They do — Velpeau says he has seen them contract 
 during labor, and they often draw the uterus forward 
 during pregnancy. 
 
 What effect has advanced pregnancy upon the urinary 
 bladder ? 
 
 It is mostly carried upwards and forwards as the uterus 
 enlarges. 
 
EFFECTS OF GRAVIDITY. 125 
 
 What effect has this upon the situation of the urethra ? 
 It then becomes nearly perpendicular. 
 
 Where may you expect to find the meatus in this case ? 
 Drawn a little back from its usual situation. 
 
 How would you introduce the female catheter under 
 these circumstances ? 
 
 By depressing the handle and carrying the point under 
 the sub-pubic ligament. 
 
 Is the straight catheter always sufficient to pass into 
 the cavity of the bladder? 
 
 It is sometimes better to use the curved or male catheter, 
 in consequence of the direction which the cavity is forced 
 to take by the pressure of the uterus. 
 
 What effect does the pressure of the gravid uterus 
 sometimes exert on the functions of the pelvic viscera ? 
 
 It often causes obstructions to the natural functions of 
 the bowels as well as bladder. 
 
 Is the rectum sometimes more free after the fourth 
 month ? 
 
 Yes — but very frequently it is beyond the influence of 
 the abdominal muscles, and hence is often the seat of great 
 fecal accumulations. 
 
 In what manner are the respiratory organs affected 
 during the latter months of pregnancy ? 
 
 During the eighth and part of the ninth month, the 
 fundus of the uterus presses the diaphragm, liver, &c. 
 upwards, and thus shortens the vertical diameter of the 
 chest and expands its base. 
 
 What effect is sometimes produced by the distension of 
 the skin of the abdomen ? 
 
 11* 
 
126 OBSTETRIC CATECHISM. 
 
 Sometimes its texture is modified, leaving resemblances 
 to cicatrices. 
 
 Is the liability to crural hernia diminished as pregnancy 
 advances ? 
 
 Yes, because the intestines are carried up above the ab- 
 dominal rings, and their place is occupied by the uterus. 
 
 Is the woman more subject to umbilical hernia ? 
 Yes. 
 
 At what period of pregnancy does the navel pout out ? 
 About the fifth and sixth months. 
 
 Why does it flatten again after this ? 
 
 Because the fundus of the uterus rises above it. 
 
 Why are women during pregnancy particularly disposed 
 to varicose veins, and to edema or anasarca ? 
 
 Because of pressure upon the vena cava and absorbents. 
 
 Does this varicose state of the limbs sometimes continue 
 after delivery ? 
 
 Yes — and is then increased at every subsequent preg- 
 nancy. 
 
 While all these changes are going on externally, what 
 is taking place in the cavity of the uterus ? 
 
 Its lining membrane becomes more developed, more 
 villous and vascular. 
 
 Is this modification in the cavity of the uterus supposed 
 to be the result of a peculiar irritation ? 
 
 Yes — the irritation or stimulus of fecundation. 
 
 What is secreted by the lining of the uterus ? 
 A layer of coagulable lymph, gelatinous in character, 
 which speedily becomes organized, vascular, and reddish. 
 
PHYSIOLOGICAL CHANGES BY PREGNANCY, 127 
 
 What is this membrane called ? 
 Decidua or caduca. 
 
 How long does it remain next the uterus ? 
 During pregnancy. 
 
 When and how is it disengaged ? 
 
 At the time of parturition, when it is thrown off by 
 uterine contractions at the same time with the placenta. 
 
 How low down the cavity of the uterus does this lining 
 extend ? 
 
 To the internal os uteri. 
 
 What is the character of its external surface ? 
 Villous or shaggy. 
 
 What does Velpeau call this membrane ? 
 Jlnhistous, and considers it unorganized. 
 
 What are the proofs of its organization ? 
 Its vascularity ; it was injected by Ruysch, Burns, &c. 
 The decidua of a cat has been injected by Drs. Goddard 
 and Betton. 
 
 Is its growth or development another proof of its organi- 
 zation ? 
 
 Yes — it is also subject to diseases, and it becomes very 
 thin towards the last, like serous or cellular tissue. 
 
 Is it pervious ? 
 
 It has no perforations in it ; it lines the whole cavity of 
 the body of the uterus, and covers the orifices of the tubes 
 and the internal os uteri. 
 
 What is the use of this decidua ? 
 
 It forms the medium of contact between the uterus and 
 the ovum. 
 
128 OBSTETRIC CATECHISM. 
 
 After how many days from conception does it line the 
 cavity ? 
 
 Probably four, five, or six. 
 
 What is the arrangement of the ovule in reference to its 
 investments ? 
 
 It has two membranes ; the chorion externally, and the 
 amnion internally, surrounding it. * 
 
 Are these membranes endowed with vitality ? 
 They are. 
 
 What does the inner membrane contain ? 
 A fluid in which is suspended a corpuscule, or cicatri- 
 cula. 
 
 What is the probable size of the ovum at the time of 
 its entrance into the uterus from the fallopian tube ? 
 It is supposed to be about the size of a hemp seed. 
 
 What length of time does it probably require for the 
 ovule to pass along the tube from the ovary to the uterus ? 
 A week, or a little more. 
 
 As the ovum cannot fall into the cavity of the uterus, in 
 what manner is it accommodated upon its arrival at the end 
 of the fallopian tube ? 
 
 As it becomes developed it adheres to, and causes a 
 growth of that part of the membrana decidua, which is in 
 contact with that angle of the uterus. 
 
 Does this action give rise to the apparent formation of 
 two membranes. 
 It has that effect. 
 
 What names have been given to these ? 
 
 That with which the ovum is in contact, is called the 
 decidua reflexa, or decidua ovi ; and that which is next the 
 uterus, the decidua vera, or decidua uteri. 
 
PHYSIOLOGICAL CHANGES BY PREGNANCY. 129 
 
 Does this arrangement correspond with that of the pleura 
 pulmonalis, and the pleura costalis ? 
 
 It does, for like the lungs, the ovule is thus really exte- 
 rior to the sack of decidua, though apparently enclosed 
 by it. 
 
 Are the two layers of the decidua, viz : decidua reflexa, 
 and decidua vera at once in close contact with each other? 
 
 No, one is closely attached to the ovum, while the other 
 is loose around it. 
 
 Is there any fluid interposed between the two layers ? 
 The interspace is filled with fluid. 
 
 At about what period of pregnancy do these two layers 
 come in contact ? 
 
 About the fourth month. 
 
 Does any portion of the shaggy surface of the chorion 
 come in contact with the uterus ? 
 
 No ; for the two layers of the caduca or decidua are in- 
 terposed. 
 
 How, then, does the ovum derive its support from the 
 uterus ? 
 
 The decidua receives the blood from the uterus, and 
 transmits it to the ovum through the shaggy surface or the 
 radicles of the chorion. 
 
 What are the anatomical characters of the chorion ? 
 
 It is a serous or white membrane, and does not carry 
 red blood ; its internal surface is smooth, but externally, 
 it is villous or shaggy ; its little flocculi being like so many 
 radicles. 
 
 Are these radicles vessels ? 
 
 Some physiologists consider that they are vascular, and 
 
130 OBSTETRIC CATECHISM. 
 
 others regard them as areolar spongioles, and not permea- 
 ble conduits. 
 
 Does the chorion increase in thickness and strength as 
 it becomes developed ? 
 
 It is believed that it does at the same time that the de- 
 cidua becomes thinner. 
 
 Does the chorion form the basis of the placenta ? 
 This point is not well settled, though in the opinion of 
 * Hodge, Dewees, and some others, it does. 
 
 What are the characteristics of the amnion ? 
 
 It is a delicate small sac situated within the chorion. 
 
 Is it different in any respect from the chorion? 
 
 Yes ; it is smooth, transparent, though it is slightly ad- 
 hered in places to the chorion by means of mucous fila- 
 ments or lamellae, which cover its outer surface. 
 
 What fluid does it enclose ? 
 The liquor amnii. 
 
 Is the amnion originally in contact with the chorion 
 throughout? 
 
 No ; originally it is smaller than the chorion. 
 
 What is interposed between the two membranes ? 
 
 A kind of vitriform substance, enclosed in a delicate re- 
 ticulated sac. 
 
 At about what period of gestation does the amnion come 
 in contact with chorion ? 
 
 After the second month ; though agreeably to Velpeau 
 there is much difference in different individuals, in this 
 respect. 
 
 Is the amnion a stronger membrane than the chorion ? 
 It is usually much stronger. 
 
LIQUOR AMNIl. 131 
 
 What is the character of the liquor amnii ? 
 It is peculiar ; unctuous, and rather more consistent than 
 pure water ; has also rather greater specific gravity. 
 
 What circumstances may modify its color and odour? 
 The excretions from the fetus. 
 
 What is the relative quantity of the fluid during the 
 whole period of gestation ? 
 
 At first it forms but a thin stratum, but it increases rapidly 
 till the second month. At three months it weighs more 
 than the fetus. After this period the quantity of the fluid 
 relatively diminishes. 
 
 What is the quantity usually present at birth of the 
 fetus ? 
 
 A pint : sometimes quarts, and in a few rare cases even 
 gallons. 
 
 Does this increased quantity appear to exert any influ- 
 ence on the health of the child ? 
 
 It usually produces no manifest effect. 
 
 What appear to be the uses of this fluid ? 
 
 Although its intrinsic use is not known, it is evidently 
 adapted to allow space and facilities for motion, develop- 
 ment, &c, of the fetus. 
 
 May the presence and increase of the liquor amnii be 
 regarded as a concentric stimulus to the development of 
 the uterus? 
 
 This opinion is entertained by some highly respectable 
 authority. 
 
 Is the liquor amnii subject to any changes in colour and 
 quality ? 
 
 It is modified in this respect by various causes ; as dis- 
 eases, &c. 
 
132 OBSTETRIC CATECHISM. 
 
 What does Velpeau suppose to be located between the 
 amnion and chorion, until they are approximated by the 
 development of the amnion ? 
 
 The reticulated tissue, containing a sort of vitreous hu- 
 mor. He calls it the reticulated body, which after the 
 chorion and amnion come together, corresponds to the al- 
 lantoid of inferior animals. 
 
 What is the vesicula alba ? 
 
 A small tube in connexion with, if not surrounding the 
 umbilical cord, extending from some part of the small in- 
 testines. Velpeau says it comes from the ileum ; Oker, 
 Rigby and Ludlow consider the appendicula vermiformis as 
 the remains of it. 
 
 Is it situated between the chorion and amnion ? 
 Some teachers think it is outside of the chorion. Vel- 
 peau says it is between the chorion and amnion. 
 
 How is it composed ? 
 
 It consists of two, perhaps of three membranous layers. 
 
 What appears to be its use ? 
 
 To supply the embryo with nutriment during the early 
 periods of its development, and until the placental circu- 
 lation is established. 
 
 At what time does it totally disappear ? 
 
 By the end of the third or fourth month of gestation. 
 
 Are there any blood-vessels distributed through it? 
 Yes ; both arterial and venous. 
 
 What are these called ? 
 
 Vitello-mesenteric, or omphalo-mesenteric vessels. 
 
 By what means is the embryo connected with the mem- 
 branes ? 
 
 By the umbilical cord. 
 
PLACENTA, CORD, ETC. 133 
 
 What is the composition of this cord ? 
 
 It consists of two arteries and one vein, of a layer of 
 amnion, and perhaps also chorion, with some albuminous 
 or gelatinous matter interposed. 
 
 Whence do these vessels originate, and in what do they 
 terminate ? 
 
 The arteries are continuations of the primitive iliacs, 
 while the vein, goes to pass under the edge of the liver and 
 enter the cava. 
 
 They terminate in a great number of branches at the 
 circumference of the ovum, upon a portion of the chorion. 
 
 What is this congeries of vascular radicles called ? 
 Placenta. 
 
 What is the usual size of the placenta at the full period 
 of utero gestation ? 
 
 Its diameter is from six to eight inches ; its circumfer- 
 ence, from eighteen to twenty-four inches ; and its thick- 
 ness from a few lines at the circumference to an inch or 
 two in its centre. 
 
 What is the character of its inner or fetal surface ? 
 It is smooth, lined with the amnion. 
 
 What arrangement exists on its external or uterine sur- 
 face ? 
 
 It is arranged in convolutions or sulci, which are dis- 
 tributed between masses, sometimes called placentules. 
 
 Is there any membrane thrown across the uterine surface 
 of the placenta ? 
 
 The decidua is believed by many physiologists to extend 
 over its whole surface. 
 
 12 
 
134 OBSTETRIC CATECHISM. 
 
 Can the amnion be removed from the inner surface of 
 the placenta ? 
 
 It can be readily peeled off from the inner surface. 
 
 Is the chorion more firmly attached to it ? 
 .. It is almost inseparably so. 
 
 What is the mode of communication between the em- 
 bryo and uterus during- the first weeks of its uterine 
 existence ? 
 
 Through the membranes entirely. The decidua receives 
 blood from the uterus, transmits the elements of nutrition, 
 through the fetal membranes to the embryo. 
 
 What is Professor Hodge's theory of the mode of forma- 
 tion of the placenta ? 
 
 " The shaggy surface of the chorion enlarges at the point 
 at which the ovule happens to come in contact with it, and 
 at that point the placenta is formed, chiefly out of the 
 shaggy surface of the chorion, and also of the decidua, 
 which may be regarded as the uterine portion of the pla- 
 centa." 
 
 What is the composition of the placenta ? 
 Its tissue is peculiar ; it is somewhat cellular, but is made 
 up chiefly of ramifications of the cord. 
 
 Is this susceptible of proof by injection ? 
 
 The tissue of the placenta may be distended by injecting 
 the arteries, and when these vessels are filled, the fluid 
 passes out by the vein. 
 
 Is it proper to consider the placenta as composed of two 
 parts, the fetal, and the uterine portions ? 
 
 It will admit of that mode of demonstration, particularly 
 during the early part of pregnancy. 
 
NUTRITION OF THE OVUM. 135 
 
 What are these two portions ? 
 
 One, the fetal, is composed of the chorion, and the other, 
 the uterine, is derived from the decidua. 
 
 Can these portions be readily separated from each other? 
 That process can be effected by maceration, as late as 
 the second month of pregnancy. 
 
 Do any large blood vessels pass from the uterus into the 
 placenta ? 
 
 No ; the communication between the uterus and the 
 decidua, is by capillary veins and arteries only. 
 
 What are the proofs of this ? 
 
 The decidua may be injected from the uterus during the 
 early periods of pregnancy. 
 
 How many kinds of circulation are carried on in the 
 placenta ? 
 
 Two ; one through the very minute utero-placental 
 vessels for the purpose of sustaining the vitality and 
 nutrition of the placenta ; the minute vessels extending 
 from the substance of the uterus into the placenta : and the 
 other, a large circulation, through the vessels of which the 
 placenta is chiefly composed ; the blood coming from and 
 returning to the fetus, in a manner analagous to that in 
 which a small supply of blood is sent to th£ substance of 
 the lungs for their nutrition, while the whole mass which 
 is to be sent over the body, is passed through the great 
 vessels of the lungs, during extra uterine life. 
 
 What becomes of the blood of the fetus, after it has been 
 carried out through the umbilical arteries ? 
 
 It returns to the fetus through the umbilical vein. 
 
 Do the uterine veins increase in size as they approach 
 the placenta ? 
 
 They usually increase very greatly. 
 
136 OBSTETRIC CATECHISM. 
 
 Do they open directly into the placenta ? 
 
 No ; they open upon the decidua by patulous orifices — 
 this membrane therefore acts like a valve over them, to 
 prevent the blood from escaping into the cavity of the 
 gravid uterus. 
 
 What is the proof of this arrangement ? 
 
 The fact that if the placenta be separated before the 
 uterus contracts, more or less venous hemorrhage occurs 
 as a consequence. 
 
 What were Lee's observations in reference to this 
 vascular arrangement ? 
 
 " If air be forcibly thrown into either the spermatic 
 arteries or veins, the whole inner membrane of the uterus 
 is raised by it ; but none of the air passes across the de- 
 ciduous membrane into the placenta, nor does it escape from 
 the semilunar openings in the inner membrane of the uterus, 
 until the attachment of the deciduous membrane to the ute- 
 rus is destroyed. There are no openings in the deciduous 
 membrane corresponding with the valvular apertures in 
 the internal membrane of the uterus." 
 
 Upon which individual, mother or child, does the pla- 
 centa depend for its organic vitality ? 
 Upon the mother. 
 
 What proofs have we of this ? 
 
 First, the fact that if the placenta be separated from the 
 uterus, it becomes atrophied. Secondly, the placenta 
 may become diseased ; it may become inflamed, and sub- 
 sequently adherent to the uterus. Thirdly, the placenta 
 may sometimes be kept alive after the death of the fetus. 
 
 To what changes is it mostly subjected under such cir- 
 cumstances ? 
 
 It generally becomes carneous and somewhat shrivelled, 
 
PHYSIOLOGICAL CHANGES BY PREGNANCY, 137 
 
 in consequence of the failure of the fetal circulation through 
 it. 
 
 What are Professor Hodge's views respecting moles ? 
 He thinks they are probably nothing more than diseases 
 or alterations of the placenta. 
 
 Is the placenta very easily separated from the internal 
 surface of the uterus when it is in a healthy state ? 
 »& It is — by passing up the fingers between the uterus and 
 placenta, it may be very easily separated. Slight jars, 
 shocks, and any thing which excites uterine contraction, 
 may be a means of causing a separation of the placenta, 
 and giving rise to uterine hemorrhage. 
 
 What is the usual length of the umbilical cord ? 
 
 About the length of the child at term, say eighteen or 
 twenty inches, though it is sometimes much longer or 
 much shorter than this. 
 
 What inconveniences are liable to result from the cord 
 being much longer than this ? 
 
 It is then apt to become tied into knots by the various 
 movements of the fetus. It is also liable to become pro- 
 lapsed during labor, when of greater length than that men- 
 tioned. 
 
 What are some of the consequences of too short a cord ? 
 
 Delivery may be retarded, or the placenta may be pul- 
 led down, and hemorrhage follow, or the uterus may be 
 inverted. 
 
 What is the length of the cord at the end of the third or 
 fourth week ? 
 
 Half an inch. Velpean, however, says he has mostly 
 found the cord about the length of the embryo or fetus, 
 
 12* 
 
138 OBSTETRIC CATECHISM, 
 
 throughout every period of gestation at which he has been 
 able to dissect it. During the very early period it appears 
 like a gelatinous bag. 
 
 Have the vessels of the umbilical cord any valves ? 
 No ; an injection passed into the arteries will return by 
 the veins, and vice versa. 
 
 Is the cord composed of these three vessels only ? 
 No ; it has also a greater or less amount of gelatinous 
 matter in it. 
 
 When you take hold of the umbilical cord, how many 
 tissues are between your fingers ? 
 Amnion, chorion, and the two arteries and one vein. 
 
 Is the chorion very intimately attached to the cord ? 
 Yes, it appears almost inseparable from the reticuled tis- 
 sue which contains the vessels and the gelatine. 
 
 Is the cord capable of bearing much force applied to it ? 
 No ; it sometimes is broken by the weight of the child 
 at birth. 
 
 What is the arrangement of the membranes in cases of 
 twins ? 
 
 &, Each embryo has its own membranes and its own pla- 
 centa. 
 
 In cases of twin ova, when an ovule is conveyed into 
 the uterus by each fallopian tube, how many membranes 
 are interposed between each fetus ? 
 
 Six — Amnion, chorion, decidua, decidua, chorion and 
 amnion. 
 
 What number in case the two ovules pass down one fal- 
 lopian tube ? 
 
 Then there are probably but four, viz. — amnion, chorion, 
 chorion and amnion. 
 
SUPER-FETATION. 139 
 
 What opinions are entertained by most physiologists re- 
 specting superfetation, admitting the theory of generation, 
 now generally believed in, to be correct ? 
 
 That it would be impossible for impregnation to take 
 place, after the uterus becomes occupied by a decidua, and 
 perhaps also an ovum. 
 
 How are the facts, however, of women giving birth to 
 two or more children at once, of different sizes, and ap- 
 parently of different ages, to be accounted for ? 
 
 Upon the idea that originally it was a twin pregnancy, 
 but that some cause had suspended the development of 
 one of the fetuses. 
 
 What is the probable explanation when the fetuses are 
 born at different periods, and well developed ? 
 
 That there has been a double uterus, one of which con- 
 tained the ovum first fecundated, and the other the second. 
 
 What in case of the delivery at the same time of two 
 children, one white and the other black ? 
 
 That the woman had been the subject of two fecundat- 
 i ing copulations in quick succession by men, one white, 
 and the other black. 
 
 May not superfetation take place in cases of pre-existing 
 extra-uterine pregnancy ? 
 
 It may, indeed, at any time when the uterine cavity is 
 not filled with any substance, and so long as the tubes are 
 open. 
 
 To what part of the uterus is the placenta mostly at- 
 tached ? 
 
 According to the experience of some, mostly to one 
 of the sides of the uterus. 
 
140 OBSTFTRTC CATFCIIISM. 
 
 What seems to determine its location? 
 
 According to some physiologists, it is formed of the villi 
 of the chorion at that point of the membrane to which the 
 cord happens to attach itself, and this is probably most 
 frequently near one fallopian tube or the other. 
 
 Are there any nerves in the placenta 1 
 
 None have yet been satisfactorily discovered. 
 
 Is this mass supplied with lymphatics ? 
 It is believed by many that they exist in this body in 
 considerable amount. 
 
 How long does the new being retain the name of 
 embryo ? 
 
 During the first, second, and third months of gestation: 
 for up to this period its formation is incomplete. 
 
 What name has it during the balance of its intra-uterine 
 existence ? 
 
 It is called fetus. 
 
 What is the earliest period at which an embryo can be 
 seen within its investments ? 
 
 About the tenth day, and then only by the aid of a 
 magnifying glass. 
 
 What does it appear to be at this time ? 
 A mere amorphous vesicle. 
 
 Does it quickly undergo considerable changes ? 
 It soon enlarges, and presents two bodies or vesicles at- 
 tached to each other. 
 
 Of what are these two bodies the elements ? 
 The head and body of the future fetus. 
 
 Which of these two bodies or vesicles is the head ? 
 The larger of the two. 
 
EMBRYO. 141 
 
 Is it important to be acquainted with the different de- 
 grees of development of the fetus ? 
 It is. 
 
 What does the embryo resemble in the next or second 
 degree of its development? 
 
 A kidney-bean, or a grub-worm or maggot curved upon 
 itself. 
 
 What probably is first developed in the embryo ? 
 Some think the spine and the heart. 
 
 What is the mode of addition of the different parts of 
 the embryo, to constitute the fetus ? 
 
 Professor Hodge and some others think it is by super- 
 addition, pullutation or generation, and not by evolution, 
 or unfolding. We are ourselves, however, inclined to be- 
 lieve in the latter mode of development. 
 
 From what part of the curved embryo is this generation 
 carried on? 
 
 From the convex, and never the concave surface. 
 
 What is the general order of succession in this process 
 of pullutation or generation of parts ; admitting this idea to 
 be correct ? 
 
 First the features appear, though rather indistinctly; 
 then the roots of the upper extremities, then the coccyx, 
 and then the lower extremities. 
 
 Which portion of the limbs appears first ? the arm and 
 thigh, or the fore-arm and leg, &c. ? 
 
 According to those who believe in pullutation, the arm 
 and thigh, and not the fore-arm and leg, with the hand 
 and foot, as Velpeau has it. 
 
 Does the embryo change its name at the end of three 
 months ? 
 
 Yes ; it is then called fetus, 
 
142 OBSTETRIC CATECHISM. 
 
 What is the extent of its development at this time ? 
 
 The teguments are distinct, though very soft and rose- 
 coloured ; the head is still proportionately very large, the 
 nose prominent, though both the mouth and eye-lids re- 
 main closed : the osseous system begins to be observable, 
 through the gelatinoid coverings, and the digits qf the ex- 
 tremities are quite distinct, and even exhibit a surface for 
 the future nail. 
 
 What is the length of the head and body of the fetus at 
 this time ? 
 
 From vertex to coccyx, it measures about three inches* 
 
 At about what period of gestation, does the muscular 
 system become sufficiently developed, to exert the^ power 
 of motion ? 
 
 From the middle to the end of the fourth month. 
 
 What is to be understood by the expression, the viabili- 
 ty of the fetus ? 
 
 That the fetus, which has hitherto enjoyed only a sort 
 of vegetable life in utero, is now sufficiently developed to 
 admit of living independently of the uterus, or in other 
 words, to enjoy extra-uterine and animal life. 
 
 At what period of fetal existence does this viability 
 occur? 
 
 At about the end of the sixth month. 
 
 Are fetuses very likely to live when born at the end of 
 the seventh month ? 
 
 It is the experience of some, that they rarely live. 
 
 Are children, born at the end of the eighth month less 
 likely to live, than those born at the ninth month ? 
 
 Professor Hodge thinks not, though that opinion was 
 entertained by Professor James. 
 
FETUS. 143 
 
 What is the condition of the eye of a fetus at seven 
 months ? 
 
 It has been supposed that from the fourth to the seventh 
 month, the eye was closed by what was called the mem- 
 brana pupillaris. That at this time the membrane bursts, 
 and that vision becomes possible to the child born at this 
 time. 
 
 What is Velpeau's view of this condition of the eye ? 
 
 He appears to think that the iris is not developed until 
 the seventh month, that it originates at first as a simple 
 ring, which grows concentrically so as at last to leave the 
 opening commonly called the pupil of the eye. 
 
 In what manner is the fetus usually situated in the cavity 
 of the uterus, at the full period of gestation ? 
 
 Its general form is that of an ellipse, its limbs crossed 
 and flexed in front of the abdomen. 
 
 What is the long diameter of this ellipse ? 
 From vertex to coccyx. 
 
 What is its measurement ? 
 About twelve inches. 
 
 What is the average weight of a fetus at term ? 
 From seven to eight pounds ; perhaps seven pounds for 
 the male, and six for the female child. 
 
 What was about the greatest weight noted by Madame 
 Lachapelle, in four thousand cases ? 
 
 Less than twelve pounds. 
 
 In Philadelphia, Dr. Hodge weighed one thirteen and 
 a quarter pounds ; and Dr. Condie one, sixteen pounds 
 twelve hours after birth. 
 
144 OBSTETRIC CATECHISM. 
 
 In twin cases, are each of the children as large as in 
 single pregnancy ? 
 
 No, each fetus is usually smaller, but the sum of the 
 twins is greater than in a single pregnancy. 
 
 What is the average height of the fetus at term ? 
 From eighteen to twenty-two inches. 
 
 Is there any difference at different periods as to the point 
 of insertion of the umbilical cord ? 
 
 In the early part of fetal existence the cord is inserted 
 near the pelvis, but this point becomes more remote as the 
 body becomes developed. 
 
 Where is the umbilical cord situated at term ? 
 About half way between the pubes and ensiform carti- 
 lage. 
 
 What is the condition of the cerebrum, during the latter 
 part at least of fetal life ? 
 
 The brain is soft and less consistent at birth than after- 
 wards. 
 
 Does the brain appear to be of any physiological im- 
 porance to the fetus ? 
 
 No : some children have been born without any brain, 
 and yet had all the other organs developed. 
 
 Do the viscera of the fetus bear the same relation of size 
 to each other as those of the adult ? 
 
 No— the liver is much larger — the lungs smaller and 
 dense, they are very slightly if at all porous or crepitous. 
 
 Is there any structure in the fetus which is peculiar to 
 it, and useless to extra uterine life ? 
 Yes — the thymus gland. 
 
 Where is it situated ? 
 
 In the anterior portion of the superior mediastinum. 
 
PECULIARITIES OF THE IETUS. 145 
 
 How many lobes lias it ? 
 Two, but no excretory duct. 
 
 Does it remain developed long after birth ? 
 No — it diminishes rapidly after the extra uterine func- 
 tions become established. 
 
 What is the object of the gland ? 
 Its uses are not known. 
 
 Is there any peculiarity in the fetal heart ? 
 
 It is like a single heart, both auricles receiving blood 
 from the vejns, and both ventricles simultaneously propel- 
 ing it into the arteries. 
 
 Is the septum between the ventricles complete at term ? 
 Yes — but it is imperfect between the auricles. 
 
 What is the name of the orifice between the two auri- 
 cles ? 
 
 Foramen ovale, or foramen of Botal. 
 
 Is there any valve-like formation connected with it ? 
 Yes, there is an arrangement of this kind situated on the 
 left side of the foramen ovale. 
 
 How does the blood from the placenta get into the fetal 
 heart ? 
 
 It enters the umbilicus of the fetus through the umbili- 
 cal vein, which passes up under the edge of the liver, 
 where it empties into the left branch of the sinus venae 
 portarum, giving off several branches to the liver. Some 
 portion of the blood then passes along what is called the 
 ductus venosus, into the left hepatic vein, which runs into the 
 ascending vena cava. The blood then mixed with that in 
 the cava, is carried up the cava until it reaches the eusta- 
 chian valve, which directs a large portion of it through the 
 
 13 
 
146 OBSTETRIC CATECHISM. 
 
 foramen ovale into the left auricle, at the same time that the 
 right auricle receives the blood which comes down from 
 the descending cava. 
 
 How is the blood disposed of, after it has been thus car- 
 ried into the heart ? 
 
 The two ventricles, supplied with blood at the same in- 
 stant from each auricle, now contract and force blood along 
 the pulmonary artery and aorta. 
 
 Is the pulmonary artery well developed during fetal life? 
 
 It is adapted only to carry blood sufficient to nourish 
 the lungs, and it is not large enough to carry all the blood 
 of the general circulation. 
 
 What route is presented as a substitute for the pulmonary 
 circulation ? 
 
 A short duct is given off from the pulmonary artery to 
 the aorta a little below its arch. 
 
 What is this vessel called ? 
 The ductus arteriosus. 
 
 How then is the fetal blood carried back to the placenta ? 
 
 That which is forced out of the right ventricle is carried 
 through the ductus arteriosus. That from the left ven- 
 tricle passes the usual route of the arch of the aorta. At 
 the point of insertion of the ductus arteriosus, the blood 
 from the two ventricles continues to pass through the aorta 
 as low as to the iliac arteries, which give off branches ; 
 which under the name of internal iliacs, turn upwards, one 
 on each side of the bladder and pass out at the umbilicus 
 and proceed to the placenta, under the name of the umbili- 
 cal arteries. At the same time, a sufficient quantity is 
 carried along the primitive iliacs to nourish the lower ex- 
 tremities. 
 
CIRCULATION IN THE FETUS. 147 
 
 Is the circulation of the fetus carried on within, or with- 
 out the cavity of the peritonaeum ? 
 
 Outside of it at all points. This large membranous sac 
 covers the inner and lateral portions only of the circulatory 
 apparatus. 
 
 What changes take place in this circulation, after the 
 birth of the child ? 
 
 The air rushes into the lungs, upon the effort to respire ; 
 the column of blood, which before passed along the ductus 
 arteriosus from the right ventricle, now passes along the 
 pulmonary artery, into the lungs ; thence it returns through 
 the pulmonary vein, into the left auricle. The effect of 
 this is to render the ductus arteriosus useless, and it con- 
 sequently becomes filled with a coagulum. The current 
 of blood coursing from the lungs through the left auricle, 
 closes down the valvular formation on the left side of the 
 foramen of Botal or the foramen ovale, and thus cuts off the 
 direct connection, which heretofore had existed between 
 the right and left auricles. From this moment, the action 
 of the heart becomes double ; that is, the right auricle and 
 right ventricle, act as it were independently of the left 
 auricle, and left ventricle. The lungs now performing the 
 function of aeration, or decarbonization of the blood, the 
 placental circulation becomes no longer necessary, and the 
 ductus venosus is obliterated. 
 
 What becomes of the vessels which were peculiar to the 
 fetus ? 
 
 Upon the establishment of the extra-uterine circulation, 
 they become first obliterated by coagula, and then either 
 remain in the character of ligaments, or are entirely ab- 
 sorbed. 
 
 What are the physiological characters of the fetus ? 
 
148 OBSTETRIC CATECHISM. 
 
 While yet an embryo, it grows, is nourished, and it has 
 fluids to sustain it. It is endowed with vitality from the 
 period of its detachment from the ovary, 
 
 Does it form its own blood ? 
 It does. 
 
 What is the color of the fluid which it first circulates ? 
 White. 
 
 How small an amount of red blood can be seen about 
 the heart, while the embryo is in a transparent or translu- 
 cent state ? 
 
 A mere drop or two, about the region of the heart. 
 
 Is the blood of the fetus exactly like that of the mother ? 
 
 No, it is peculiar ; its color is between that of maternal 
 arterial and venous blood ; is said to resemble the menstrual 
 fluid. 
 
 Is its consistence as firm as that of adult blood ? 
 
 No ; its coagulum is softer, its red globules are smaller. 
 
 Does it contain so large a portion of phosphoric salts ? 
 It does not. 
 
 If the fetus then forms and circulates its own blood, 
 does it not require a relatively greater force to propel it 
 through the placenta and umbilical vessels ? 
 
 Yes, and hence the simultaneous action of the two 
 ventricles to carry the blood with double force. 
 
 Does the blood of the mother circulate at all through 
 the fetal vessels ? 
 
 No ; it is probable that the decidua receives blood from 
 the uterus, but returns it again to that organ without trans- 
 mitting it to the other portions of the placenta, at least not 
 more than to supply it with nutriment. 
 
PHYSIOLOGY OF THE FETUS. 149 
 
 Would the circulation of the mother, be too strong for 
 that of the embryo or fetus ? 
 
 Yes, it is highly probable that it would destroy it by the 
 momentum with which the blood would be impelled into 
 it if there were a direct communication between the mother 
 and fetus. 
 
 What proofs have we, that the maternal blood is not 
 circulated in the fetus ? 
 
 1. Injections cannot pass from the vessels of the mother 
 into those of the fetus : nor if the vessels of the fetus be 
 injected, can the matter of injection be conveyed through 
 the placenta into the vessels of the uterus, at least not 
 without previous lesion of structure. 
 
 2. If after the birth of the child, the umbilical cord be 
 cut, there is no continuous hemorrhage from it, — only a 
 part of the blood it had contained, is squeezed out by con- 
 traction of the uterus. 
 
 3. The fetus cannot be poisoned through the mother. 
 The child may die from rupture of the cord, without the 
 mother being affected. 
 
 4. The entire ovum has been thrown off by the uterus, 
 and when deposited in warm water, has been known to 
 live many minutes, perhaps an hour ; its circulation going 
 on without any effusion of blood. 
 
 What effect does hemorrhage from the mother, have 
 upon the fetus ? 
 
 None, whatever, directly ; the woman may suddenly 
 
 die from very profuse hemorrhage, and yet the child will 
 
 survive some time ; — if, however, she be exhausted by 
 
 constant discharge, the fetus will suffer much thus, and 
 
 fail to become well developed, even though the mother 
 
 may survive. 
 
 13* 
 
150 OBSTETRIC CATECHISM. 
 
 Is the circulation of the fetus more rapid than that of the 
 mother ? 
 
 It is ; the motions of the heart have been determined by 
 the stethoscope to be nearly or quite twice as frequent as 
 those of the mother's heart. 
 
 What part of the fetus receives pure placental blood ? 
 The left side of the liver only, because every other 
 portion has the blood from the fetal veins mixed with it. 
 
 What is the proportion in which the different organs re- 
 ceive the placental blood ? 
 
 This has not yet been satisfactorily ascertained ; it m ay 
 be proposed as a matter of interesting calculation. 
 
 Why are the upper parts of the fetus better developed 
 than the lower extremeties ? 
 
 Because more blood is carried through the carotids and 
 sub-clavians, than through the lower branches of the aorta. 
 
 Is more pure blood carried into the left than into the 
 right ventricle ? 
 
 In consequence of the arrangement of the eustachian 
 valve, blood which is brought from the placenta, mingled, it 
 is true, with a part of the blood in the portal circulation, is 
 thrown into the left auricle through the foramen of Botal. 
 From this ventricle it is thrown into the arterial branches 
 of the aorta, which go to supply the head and upper ex- 
 tremities, while the blood in the right ventricle is thrown 
 out into the root of the pulmonary artery, and thence 
 through he ductus arteriosus into the aorta, below the 
 branches which supply the upper portions of the body. 
 The right ventricle receives from the aorta the blood of the 
 vena cava descendens. 
 
FUNCTIONS OF THE PLACENTA. 151 
 
 What is the apparent object of the placenta? 
 To afford the changes necessary in the blood for the 
 nutriment and development of the fetus. 
 
 What changes are probably effected in the placenta ? 
 Those similar to that effected in the lungs by respiration, 
 in other words, hematosis. 
 
 Is it probable that oxygen is eliminated in the placenta 
 and transmitted to the blood through its tissue ? 
 
 A supply of oxygen is necessary to hematosis. It is 
 indispensible to all animals, to the chick in ovo, &c. 
 
 Is there any difference of color in the blood circulating 
 in the arteries 1 
 
 It is redder in the arteries than veins, although the dif- 
 ference is not so great as in the adult. 
 
 How does pressure upon the cord cause the death of the 
 fetus ? 
 
 By interrupting the process of hematosis, and not by 
 suspending the circulation merely, because this may go on 
 in the fetus independently of a cord or placenta, or when 
 these are compressed. 
 
 Is it probable that the fluids in which the fetus is sus- 
 pended affords it any nutriment ? 
 
 This is an unsettled question, Professor Hodge and 
 some others think not. They suppose that the placenta is 
 in some manner the medium of nutriment. 
 
 Has the fetus any of the functions of animal life 1 
 Its faculties are dormant ; although the different organs 
 of this kind of life are developed in succession — as ears, 
 eyes, nose, &c, yet it is doubtful whether they are brought 
 into exercise during intra-uterine life. 
 
152 OBSTETRIC CATECHISM. 
 
 Is it probable that the fetus has sensation while in 
 utero ? 
 
 Of the touch or tact only ; and it most likely does not 
 suffer from ordinary compression during parturition, as it 
 is then probably comatose. 
 
 Does it probably suffer under severe obstetric operations 
 upon it ? 
 
 It is probable that it does suffer from such causes. 
 
 Is there any probability that the child may cry in utero ? 
 Not the least, unless possibly when the mouth of the 
 child can come in contact with the atmospheric air. 
 
 OF EXTRA-UTERINE PREGNANCY. 
 
 What is the second class of pregnancies usually adopted 
 by obstetric writers ? 
 
 Irregular, abnormal, or extra-uterine pregnancy. 
 
 Of how many varieties does it consist ? 
 
 1st, Of Ovarian pregnancy. 
 
 2d, Of ventral or abdominal pregnancy. 
 
 3d> Of tubal pregnancy. 
 
 4th, Of interstitial pregnancy. 
 
 What is meant by the term ovarian pregnancy ? 
 That in which the embryo becomes developed in the 
 ovary. 
 
 What by ventral or abdominal pregnancy ? 
 That in which the ovule or embryo becomes deposited 
 in the cavity of the abdomen and developed there. 
 
VARIETIES OF EXTRA-UTERINE PREGNANCY. 153 
 
 What by tubal pregnancy ? 
 
 That in which the embryo becomes developed in the 
 tube. 
 
 What are we to understand by interstitial pregnancy ? 
 
 That in which the ovule has in some way or other be- 
 come situated between the layers of muscular fibres in 
 the uterus, and there acquires a degree of development. 
 
 Have we any precise knowledge of the causes of these 
 different varieties of extra-uterine pregnancy ? 
 
 We have no precise knowledge of the causes — our 
 ideas are merely speculative on this subject. It has been 
 ascertained by experiment that if the fallopian tube be ob- 
 structed by ligature, or by excision of a portion of it, be- 
 fore the ovule has passed through its canal, it becomes 
 unable to arrive at the uterus, and it may be somewhat 
 developed in the ovary or tube as a consequence, &c. 
 
 Does the development of the fetus go on in the body, 
 or at the surface of an ovary ? 
 
 At the surface, and rarely, if ever, in the body. 
 
 What then are the investments of the embryo 1 
 Amnion, chorion, and peritonaeum. 
 
 Upon what does abdominal pregnancy probably depend ? 
 Upon irregular action of the tubes. The morsus dia- 
 boli not embracing or retaining the ovum. 
 
 What is the process by which the ovum forms a nidus 
 in which to be developed 1 
 
 Its presence in the cavity of the peritonaeum, probably 
 excites inflammation and an effusion of coagulable lymph, 
 which surrounds the ovum, as the decidua would in the 
 cavity of the uterus. 
 
154 OBSTETRIC CATECHISM. 
 
 Upon what does tubal pregnancy possibly depend ? 
 Upon a stricture of the tube, preventing the passage of 
 the ovum into the cavity of the uterus. 
 
 What in this case are the investments of the embryo ? 
 Amnion, chorion, and parieties of the tube. 
 
 Can interstitial pregnancies be satisfactorily accounted 
 for? 
 
 Not at all, unless under the supposition that when the 
 ovum reaches the parieties of the uterus in the tubes, it is 
 arrested at that point and ulcerates its way into the sub- 
 stance of the walls of the organ. 
 
 For what length of time may the ovum continue to de- 
 velop, in these cases of extra-uterine pregnancy ? 
 For one or two months. 
 
 What usually becomes of it after that time ? 
 
 It usually dies, becomes encysted in its own membranes, 
 then gradually converted into a sebaceous matter, and looks 
 as though it had been kept in spirits. 
 
 Is it subject to decomposition while thus encysted? 
 It rarely becomes decomposed unless the cavity of the 
 cyst is exposed to atmospheric air. 
 
 Are the placenta and cord mostly found appended to the 
 embryo in these cases ? 
 
 In all cases where there is any degree of general devel- 
 opment. 
 
 What substitutes the decidua ? 
 Coagulable lymph. 
 
 What is the condition of the cavity of the uterus in 
 these cases ? 
 
 It is always furnished with a decidua. 
 
PECULIARITIES OF EXTRA-UTERINE PREGNANCY. 155 
 
 Does this decidua remain in the uterus as long as the 
 embryo remains in the pelvis or abdomen ? 
 
 Not usually, — it is sometimes thrown off in a few 
 months. 
 
 Do any inconveniences result to the mother in those 
 cases in which the fetus lives and continues to be de- 
 veloped ? 
 
 Serious consequences usually ensue ; irritation, inflam- 
 mation, suppuration, ulceration, and sloughing are all 
 liable to take place ; sometimes to an extent to cause the 
 death of the mother. 
 
 What kind of accident may accompany the rupture of 
 the cyst, and cause the immediate death of the mother ? 
 Profuse hemorrhage. 
 
 If death do not happen from this cause what may pro- 
 duce it more tardily ? 
 Peritonael inflammation. 
 
 Do any instances occur, in which the fetus becomes 
 considerably developed, without causing fatal irritation ? 
 
 There are instances on record when the woman has car- 
 ried such a fetus many years. 
 
 What then usually happens about the end of the ninth 
 month ? 
 
 A parturient effort takes place, and sometimes the de- 
 cidua and some coagula are thrown off; uterine action 
 then subsides. 
 
 Does the patient ever recover after such parturient 
 efforts ? 
 
 Some women live many years after such an event. 
 
156 OBSTETRIC CATECHISM. 
 
 Is it possible for them to have a true pregnancy while 
 they are carrying the product of uterine conception ? 
 
 Some cases of this kind are on record, and there is no 
 reason why pregnancy should not recur after the decidua 
 has been discharged from the cavity of the uterus. 
 
 What is the more common result ? 
 
 Irritation, followed by inflammation and abscess, open- 
 ing externally, as at the umbilicus, groin, perinaeum, or 
 into the intestines. 
 
 What are the symptoms of extra uterine pregnancy ? 
 They are very irregular, and differ somewhat from 
 those of normal or uterine pregnancy. 
 
 What takes place in regard to the catamenia ? 
 
 It mostly returns at the usual period of quickening, and 
 then continues regular, especially if the decidua have been 
 thrown off. 
 
 What is the condition of the mammae X 
 They mostly become flattened. 
 
 Is there any difference in the time at which the fetus is 
 felt? 
 
 If it acquires any muscular development, it is felt earlier 
 than in natural pregnancy. 
 
 Is the ovary liable to take on an effort to abnormal gene- 
 ration ? 
 
 Yes — it has been known to contain hair, teeth, fyc, 
 which were probably the result of abnormal generation. 
 
 What other instances are known which lend support to 
 j the doctrine of emboitment or encasement of germs ? 
 
 The fact recorded (in Coxe's Med. Museum, vol. ii. No. 
 
 
TREATMENT OF EXTRA UTERINE PREGNANCY. 157 
 
 2. — Sept. and Oct. 1805,) in which a fetus was found 
 within the abdomen of a boy, fourteen years old ; and 
 the case recently related by Velpeau, where the rudiments 
 of a fetus were engrafted on the testicle of a male, &c. 
 
 What are the indications for treatment in cases of extra- 
 uterine pregnancies ? 
 
 Generally palliative, to relieve or remove irritation as 
 much as possible. 
 
 What is to be done when the cyst is ruptured ? 
 Support the patient's strength by tonics, cordials, &c. 
 
 Suppose an abscess should form and point externally ? 
 Apply fomentations, poultices, &c. 
 
 Would it be advisable to open an abscess, if it could be 
 reached by an incision ? 
 
 By good authority, it is thought that it would be best, 
 (provided the peritonaeum would not be opened,) to make 
 a free incision, to evacuate the contents of the abscess, and 
 thus remove the irritation. 
 
 Would it be proper to favor the removal of the contents 
 of the abscess by injecting it with cleansing washes ? 
 
 This would probably greatly facilitate the restoration of 
 the patient's health. 
 
 Is the placenta mostly adherent to some part of the ab- 
 scess ? 
 
 It is usually attached strongly to some portion of the 
 wall of the sac. 
 
 How is it to be separated ? 
 
 By washing the debris away as fast as it sloughs. 
 
 14 
 
158 OBSTETRIC CATECHISM. 
 
 Would gastrotomy be advisable in the early stage of ab- 
 dominal pregnancy ? 
 
 The opinion is entertained by some that it would be 
 safer for the mother that it be done, and thus save her from 
 the subsequent irritation. 
 
 OF THE SIGNS OF PREGNANCY. 
 
 Into how many classes may the signs of pregnancy be- 
 divided ? 
 
 Two — rational, or sympathetic, or physiological ; and 
 positive, physical (or mechanical) signs. 
 
 What is usually regarded as the first rational sign ? 
 Suppression of the menses. 
 
 Can this sign be relied upon ? 
 Not positively. 
 
 What other causes may suppress or suspend the men- 
 strual function ? 
 
 Exposure to cold, uterine congestions, or structural dis- 
 eases of the organ. 
 
 Are the menses always suppressed by pregnancy ? 
 Not always during the first months. 
 
 Are there any cases in which women menstruate only 
 during pregnancy ? 
 
 Such cases are very rare, but have been mentioned by 
 Dewees, Daventer, and Baudelocque. 
 
SIGNS OF PREGNANCY. 159 
 
 When do the mammary glands become sympathetically 
 affected ? 
 
 One or two months after conception, these glands en- 
 large, become the seat of slight pains or pricking sensa- 
 tions. 
 
 When do they begin to secrete milk ? 
 Usually toward the latter end of pregnancy. 
 
 Is milk never found in the mammae, unless the female 
 be pregnant or nursing ? 
 
 Milk is sometimes secreted by old women, and occa- 
 sionally by very young girls. 
 
 Do the breasts never become tumid or painful, except 
 during, or as a consequence of, pregnancy ? 
 
 They are liable to become tumid and painful from other 
 causes — as cold, uterine irritation, &c. 
 
 What changes do the nipples or papillae undergo, du- 
 ring pregnancy ? 
 
 They become enlarged, developed, more tumid, darker 
 coloured. 
 
 Do any changes occur in the areola ? 
 
 It becomes larger and darker coloured — in brunettes it 
 becomes almost black. The mucous follicles, about the 
 nipple, become more prominent, and the veins more blue. 
 
 May not these changes occur from other causes than 
 pregnancy ? 
 
 They may arise from mechanical irritation, as frequent 
 handling, &c. — also, from sympathetic irritation in the 
 uterus, &c. 
 
 What changes take place in the uterus during the early 
 weeks or months of pregnancy ? 
 
 It enlarges, becomes developed, at first in all directions. 
 
160 OBSTETRIC CATECHISM. 
 
 At what time does the development of the uterus begin 
 to form a tumor in the abdomen ? 
 In the third and fourth months. 
 
 Do young married females mostly become considerably 
 developed about the pelvic region, before they are impreg- 
 nated ? 
 
 Yes, not only their hips, but their breasts also, are apt 
 to become t nlarged. 
 
 Is there any difference in the direction of the abdominal 
 tnmor in different women, or in the same woman at differ- 
 ent pregnancies ? 
 
 Yes — in women whose abdominal muscles are relaxed, 
 the uterine tumor is more prominent. 
 
 Is the tumor of which we have been speaking, a posi- 
 tive evidence of pregnancy ? 
 
 It is not a positive evidence, because some women be- 
 come very fat, internally, after marriage. 
 
 Have women any power to conceal the abdominal de- 
 velopment, when they wish to appear not pregnant ? 
 
 They can frequently succeed in doing so, by their man- 
 ner of carriage and dress. 
 
 What is the order of development of the abdominal tu- 
 mor, in cases of pregnancy ? 
 
 There is no great enlargement till the third month ; at 
 this time there is a fulness in the hypogastrium — at four 
 months the tumor is larger — at five months the uterus is 
 above the pubes, &c. 
 
 Is there any alteration in the size of the abdomen during 
 the first two months ? 
 
 No — there should be no distinct tumor found in the ab- 
 domen during the first and second months. 
 
DEVELOPMENT OF THE UTERUS FROM PREGNANCY. 161 
 
 Is there any tumefaction in the hypogastric region, du- 
 ring the third month ? 
 Yes — there is usually. 
 
 Upon what does it depend ? 
 
 Partly upon the development of the abdominal parie- 
 ties, and partly upon the circumstance, that the intestines 
 are carried up by the fundus of the uterus. 
 
 What is the general condition of the upper and lateral 
 portions of the abdomen, at the third month ? 
 
 It is flat above, and rather puffy in the iliac fossae. 
 
 Has this usualty been regarded as a valuable diagnostic 
 sign of pregnancy ? 
 
 By many, it has been so considered. The French have 
 the adage — "En ventre plat, enfant il y a." 
 
 Where is the top of the uterus situated, in the fourth 
 month ? 
 
 It is immediately above the superior strait, and the tu- 
 mor can then be just felt. 
 
 Where is the top of the tumor in the fifth month ? 
 Half way up to the umbilicus. 
 
 Where at the sixth month ? 
 At the umbilicus. 
 
 Where at the seventh month ? 
 
 Three fingers' breadth above the umbilicus. 
 
 Where at the eighth month ? 
 At the epigastric region. 
 
 Where at the ninth month ? 
 
 It does not rise higher during this month, but usually 
 expands more into the lateral portions of the abdomen and 
 
 14* 
 
162 OBSTETRIC CATECHISM. 
 
 pelvis. Towards the end of gestation, it seems even to 
 descend a little. 
 
 Is the protrusion of the navel always a diagnostic sign 
 of pregnancy ? 
 
 No — though usually perhaps always present at certain 
 stages of true pregnancy ; yet it may occur from other 
 causes than pregnancy, as the existence of large tumors, 
 &c. 
 
 May enlargements of the abdomen from obesity cause 
 an equal degree of protrusion ? 
 
 We believe that in fat women, who are not pregnant, 
 the umbilicus is always sunken. 
 
 Is the gait of a female altered by pregnancy ? 
 
 It is more vacillating ; the feet are placed further apart. 
 
 How is the existence of pregnancy to be verified, ad- 
 mitting all the sympathetic signs to be fallacious ? 
 By physical examination. 
 
 In what does this examination consist ? 
 In examination by the hand of the external surface of 
 the abdomen, <fcc. 
 
 What is the proper position for this object? 
 
 On the back, in a state of flexion, then examine with a 
 hand of the temperature of her body, request her not to 
 strain, nor hold her breath. 
 
 What is to be gained by this ? 
 
 A knowledge of the size and kind of tumor which 
 occupies the cavity, and sometimes also of its contents. 
 
 How can you appreciate the existence of any thing 
 within the cavity of the tumor, by such an external ex- 
 amination ? 
 
PHYSICAL SIGNS OF PREGNANCY. 163 
 
 By applying the bare cold hand upon the surface of the 
 abdomen, a shock is transmitted to the contents of the 
 uterus, which if endowed with vitality will sometimes 
 move with a force which can be felt. 
 
 What position is most suitable for this purpose ? 
 The patient should be on her back ; have her shoulders 
 raised, her limbs and abdomen flexed. 
 
 May she contract the abdominal muscles ? 
 No ; she should keep every thing as flaccid as possible, 
 she should breathe easy, and make no straining effort. 
 
 Should the hand of the examiner, be removed immediate- 
 ly after it has been applied to the abdomen ? 
 
 No ; it should be kept some moments in contact with 
 the surface, that it may appreciate any movements which 
 may take place. 
 
 Is this external examination sufficient to enable the 
 accoucheur always to diagnosticate pregnancy? 
 
 No ; it is liable to fail, from a variety of circumstances. 
 
 What other resource is there ? 
 Examination per vaginam. 
 
 What is this process called in professional language ? 
 The touch. 
 
 What is the relative importance of this operation to the 
 accoucheur in pregnancy and diseases of the uterus ? 
 
 By some high Authority it is regarded as important to 
 the accoucheur, as the lever to the mechanic, and the 
 compass to the mariner. 
 
 What conduct should the accoucheur observe when about 
 to make this kind of examination ? 
 
 That which has regard to the sense of delicacy, on the 
 part of the female. 
 
164 OBSTETRIC CATECHISM. 
 
 To whom should he make the proposition for an ex- 
 amination ? 
 
 To a third person, as a nurse, the husband, or to some 
 matronly female. 
 
 How should he dispose of himself, while such a propo- 
 sition is communicated to the patient ? 
 
 He should retire into another room until the decision is 
 made. 
 
 What arrangements should be made in order to conduct 
 the examination most satisfactorily ? 
 
 The room should be darkened, and the patient dressed 
 lightly, and placed in the suitable position. 
 
 Should the physician insist upon having a third person 
 present ? 
 
 He should always do so if it be at all practicable. 
 
 How should the patient be placed ? 
 The horizontal position will sometimes answer, though 
 many advantages are gained by the erect position. 
 
 If she be placed in the horizontal position, upon what 
 part of her body should she recline ? 
 
 When the simple touch to determine the condition of 
 the neck and mouth of the uterus, is to be resorted to only, 
 she may recline upon her left side : — but if both external 
 and internal examination is to be made, she should be 
 placed upon her back, with her hips to the edge of the 
 bed, and her lower extremities flexed. 
 
 What accommodations should the nurse furnish for the 
 physician ? 
 
 Several napkins, some unctuous matter, a chair by the 
 bed, a basin of warm water, soap, &c. 
 
ARRANGEMENTS FOR PHYSICAL EXAMINATION. 165 
 
 How should the accoucheur sit ? 
 
 At the side of the bed, with his right hand towards the 
 hips of the patient, if she be on her left side, but if on her 
 back, he should sit with his face towards her, that he may 
 reach his left hand to her abdomen. 
 
 What is the rule for carrying the hand under the cover- 
 ings ? 
 
 The clothes should be properly raised at their lower 
 edges, by the left hand, and then the right hand with the 
 index finger lubricated, passed cautiously up under the 
 clothes without uncovering the patient. 
 
 Suppose your patient to be standing, how should she 
 be arranged? 
 
 She should be allowed to rest her hips against something 
 firm, and then recline forward as if to lean upon the ex- 
 aminer. 
 
 How should the examiner be situated ? 
 Either upon a low seat, or resting upon one knee, in 
 front of the patient. 
 
 To what portion of the genital fissure should the finger 
 be carried ? 
 
 Always to the posterior commissure, avoiding contact 
 with the mons veneris if possible. When the finger has 
 thus gained access to the vagina, it should be turned to 
 present its radial edge to the arch of the pubes. 
 
 Can the touch afford us any good idea of early preg- 
 nancy ? 
 
 Yes ; it may even then appreciate the changes which 
 have occurred in the uterus. 
 
 What is the earliest period however at which any posi- 
 tive information can be acquired ? 
 After the fourth month. 
 
166 OBSTETRIC CATECHISM. 
 
 What can be recognised in the uterus after this time ? 
 The existence of a body suspended in a fluid. 
 
 What name has been given to the process by which 
 this knowledge is obtained ? 
 
 Ballottement, or uterine palpitation, or percussion. 
 
 How is this performed ? 
 
 By the application of the index finger of one hand to 
 the mouth or neck of the uterus, while the other hand is 
 applied upon the abdomen over the fundus of the uterus. 
 The finger in the vagina, is then suddenly to push up the 
 part of the uterus with which it is in contact; while the 
 palm of the other hand is prepared to receive any impres- 
 sion which such a shock may make ; the percussing finger 
 is to be kept applied to the os or cervix uteri, that it may 
 determine whether any body floating within the cavity, 
 descends upon it. In this way very frequently it is pos- 
 sible to determine the existence of a body within the uterus 
 and even to a certain extent the degree of its development. 
 
 Does the woman usually experience a fluctuation or 
 fluttering about the end of the fourth month ? 
 She does. 
 
 What is this sensation called ? 
 Quickening. 
 
 Is it proper to regard this as the period at which the 
 child becomes quickened into life ? 
 
 ^|The child is endowed with life at all its stages of uterine 
 existence. 
 
 Should it not be viewed as an evidence that the degree 
 of the development of the fetus is such, that it can exert 
 muscular movement at this time ? 
 
 This would be the proper view to take of it. 
 
OF APPARENT MOTIONS OF THE FETUS. 167 
 
 Is this period always fixed at four or four and a half 
 months ? 
 
 No ; some women feel the fetus earlier, and some later 
 than this. 
 
 Upon what does this difference of time probably depend ? 
 Either upon difference in degrees of development, or 
 upon the different degrees of sensibility in mothers. 
 
 When does quickening really take place ? 
 .At the time of conception. 
 
 What other movement takes place during pregnancy 
 which is apt to excite the attention of the woman ? 
 The slipping up of the uterus out of the pelvis. 
 
 When does this happen ? 
 
 Almost invariably between the fourth and fifth month. 
 
 Does the occurrence of this sensation of " quickening," 
 and the other signs enumerated, remove all doubts as to 
 the existence of pregnancy ? 
 
 No — some women have all these signs, and are not 
 pregnant ; even some who think they not only feel, but 
 see the movements of the child through the abdominal pa- 
 rieties. 
 
 May a woman be pregnant, when none of these symp- 
 toms occur ? 
 
 Yes — when if they have occurred at all, they have been 
 very slight, and no motion whatever has been noticed. 
 
 What other means of diagnosis has the obstetrician, be- 
 sides that of the external and internal touch ? 
 Auscultation. 
 
 What are we to appreciate by auscultation ? 
 The existence or non-existence of the vital actions of 
 the fetus. 
 
168 OBSTETRIC CATECHISM. 
 
 How many modes are there of performing it ? 
 v Mediately through the stethoscope, or immediately by 
 the application of the ear to the surface of the abdomen. 
 
 Does delicacy require that mediate auscultation be used 
 in cases of supposed pregnancy ? 
 
 It is certainly most proper when it will answer. If im- 
 mediate auscultation is resorted to, the under dress of the 
 patient should be allowed to cover her person. 
 
 What does auscultation afford, which ballottement does 
 not? 
 
 Ballottement determines the existence or non-existence 
 of a body within the uterus, but does not indicate its vi- 
 tality — auscultation contributes much to determine the lat- 
 ter, by mostly recognizing the sounds peculiar to the fetus, 
 <fec, when it is alive in utero. 
 
 Is it an important improvement in the means of ob- 
 stetric diagnosis ? 
 
 It should be considered as a very important improve- 
 ment in obstetric diagnosis. 
 
 How many sounds are to be discriminated by this aus- 
 cultation ? 
 
 Two — one depending upon the motions of the fetal 
 heart, and the other said to depend upon the circulation of 
 blood in the placenta. 
 
 What is the difference in these sounds ? 
 
 The first has a quick double beat or sound, amounting 
 from one hundred and forty to one hundred and fifty in the 
 minute ; the other is synchronous with the actions of the 
 maternal heart. 
 
 What is the character of the first kind of sound ? 
 
 It has been aptly compared to the ticking of a watch 
 under a pillow. 
 
AUSCULTATION. 169 
 
 What is the character of the other sound that is heard ? 
 It is like the cooing of a dove, or like the passage of a 
 fluid through a great many cells. 
 
 What is it called ? 
 
 Placental soufflet, or placental sound. 
 
 Is it proper to rely upon the absence of the sounds, as 
 an evidence of death of the fetus ? 
 
 Not if other symptoms of its vitality present strongly. 
 
 Upon what does it probably depend ? 
 
 Not upon the circulation of blood in the placenta, but 
 upon the circulation of blood through the uterine vessels, 
 about or over that part at which the placenta is seated. 
 
 May this sound be confounded with any other ? 
 Yes, with the pulsations in the iliac arteries, &c. 
 
 Is any caution to be used, that the patient's clothing may 
 not confuse the sound ? 
 
 The friction of the patient's dress may confuse it, unless 
 care is taken to keep it smooth upon the abdomen. 
 
 What may obscure these sounds while the child is ac- 
 tually alive ? 
 
 The existence of the placenta at the posterior part of the 
 uterus ; or there may be a very fat omentum interposed. 
 
 Is it proper to decide that pregnancy does not exist, if 
 this soufflet cannot be heard ? 
 
 No — the situation of the placenta may be such, that al- 
 though its circulation may be active, it cannot be heard. 
 
 What is the earliest period of pregnancy at which aus- 
 cultation becomes of any value ? 
 
 Kennedy is reported to have heard it at the twelfth 
 
 15 
 
170 OBSTETRIC CATECHISM. 
 
 week, but it is scarcely to be relied upon, until at the end 
 of the fourth, or during the fifth month. 
 
 What is the condition of the mother most favourable for 
 auscultation, as regards corpulency ? 
 
 The thinner she is, the more readily cari the sounds be 
 heard, if the position of the child is favorable. 
 
 What situation of the fetus is most favorable for emit- 
 ting the sounds of its heart 1 
 
 That in which its back is applied to the anterior parie- 
 ties of the uterus. 
 
 At what part of the uterine tumor is the fetal sound 
 most frequently heard ? 
 
 Generally at the lower and lateral portion of the uterus. 
 
 What would modify the position at which these sounds 
 are most distinctly heard ? 
 
 A change in the position of the child. 
 
 Suppose the breech presented to the as uteri* where 
 should the fetal sound be most readily heard ? 
 
 Higher up toward the fundus of the uterus. 
 
 Is auscultation of any value in the diagnosis of compound 
 pregnancies ? 
 
 In twin pregnancies, there would be two points whence 
 the sound should emanate, one above and another below. 
 
 Would the placental souffle!, as it is called, be much al- 
 tered by a twin pregnancy ? 
 
 Not necessarily, especially, if the placentas were at- 
 tached to each other, or the fetuses had one common pla- 
 centa. 
 
 What other signs have recently been spoken of as evi- 
 dences of pregnancy ? 
 
 A blue appearance of the living membrance of the va- 
 
CONDITION OF VAGINA, URINE, ETC. 171 
 
 gina, dependant probably merely upon venous congestion 
 of the part. 
 
 Is this to be regarded as a certain sign ? 
 
 Its evidence should be received with great caution. 
 
 How should we regard the report of the chemical 
 changes of the urine, as an evidence of pregnancy ? 
 
 By no means as positive, inasmuch as there is yet much 
 conflicting testimony on this subject. 
 
 Do the sympathetic or secondary disturbances of the 
 system during pregnancy, sometimes amount to disease ? 
 
 Yes, and are entitled to be called the diseases of preg- 
 nancy. 
 
 Into how many classes may these diseases be divided ? 
 Into local and general. 
 
 In what way are the local diseases induced ? 
 By pressure and sympathy. 
 
 What are some of the consequences induced by enlarge- 
 ment of the uterus ? 
 
 Pressure on the neck of the bladder, prevents a free dis- 
 charge of urine, and often causes a distension. 
 
 What consequences may result from this distension ? 
 
 Retroversion of the uterus, inflammation of the bladder, 
 &c. 
 
 Does the bladder suffer more or less during the later, 
 than in the earlier, stages of pregnancy ? 
 
 Generally it suffers less in the later stages, because it is 
 then flattened out over the surface of the uterus. 
 
 Can it therefore retain much urine ? 
 No — but a small quantity in general, though it some- 
 times becomes enormously distended. 
 
172 OBSTETRIC CATECHISM. 
 
 What influence would a greatly distended bladder exert 
 over auscultation ? 
 
 It would probably render it very obscure. 
 
 What effect does pressure of the uterus exert upon the 
 rectum ? 
 
 It causes a frequent disposition to defecate, bringing on 
 diarrhoea in some cases. 
 
 Is the irritation of the rectum to the same degree at all 
 periods of pregnancy ? 
 
 It is less as the uterus ascends, till toward the latter 
 stage. 
 
 Is the rectum liable to be greatly distended by hardened 
 feces during the latter periods of pregnancy ? 
 
 Yes — inconsequence of pressure upon it high up 1 the 
 bowel becomes torpid or partially paralysed. 
 
 Is the distension ever so great as to require manual or 
 mechanical aid to relieve it ? 
 
 The contents of the rectum sometimes become so hard 
 and large, that they can not be evacuated by any other 
 means. 
 
 Does this distension necessarily completely suspend the 
 function of defecation ? 
 
 It does, at least partially, though sometimes the bowels 
 appear to the patient to be regular, when in fact only a 
 little mucous and feces pass, while the great mass is re- 
 tained. 
 
 Does the irritation caused by the pressure of the uterus, 
 or by the presence of the scybalse, ever give rise to dys- 
 entery ? 
 
 Yes. 
 
DISEASES OF PREGNANCY. 173 
 
 What are some of the consequences of pressure of the 
 developed uterus ? 
 
 Pain in the right side, similating liver complaint. 
 
 Upon what depends the pain frequently felt in one or 
 both of the iliac regions, as the uterus becomes enlarged ? 
 Probably upon the stretching of the round ligaments. 
 
 Which of the round ligaments is the shorter ? 
 The right one. 
 
 Towards which side of the abdomen does the uterus 
 usually incline, as it becomes developed. 
 Towards the right side. 
 
 How is this inclination accounted for ? 
 
 First, by the shortness of the right round ligament, and 
 secondly, by the presence of the rectum on the left side of 
 the spine usually. 
 
 Does the pressure of the fundus of the uterus upwards, 
 produce any inconvenience to the stomach ? 
 It frequently causes dyspeptic symptoms. 
 
 What are some of the effects of pressure upon the bow- 
 els ? 
 
 Displacements through several natural openings in some 
 instances — hence hernia in certain periods of pregnancy. 
 
 How are we to account for ventral hernia in pregnancy ? 
 
 Pressure of the uterus, causes separation of the fibres 
 of the abdominal muscles, and the escape of the bowel 
 between them. 
 
 What kind of displacement of the bladder is apt to re- 
 sult from pressure of the uterus upon it ? 
 * Hernia into the vagina, or less frequently into the crural 
 
 ring. 
 
 15* 
 
174 OBSTETRIC CATECHISM. 
 
 What are some of the effects of pressure of the uterus 
 upon the great blood vessels ? 
 
 Congestions of the inferior vessels, hemorrhoids, vari- 
 cose veins, &c. 
 
 How is the edema, to which some women are subject, 
 to be accounted for? 
 
 By pressure of the uterus upon the veins and lymphatics. 
 
 Is this pressure apt to affect the labia ? 
 
 It sometimes causes great distension and swelling. 
 
 Does pressure of the uterus exert any unfavorable in- 
 fluence on the nerves of the lower part of the body? 
 
 Pressure on the crural and obturator nerves, often caus- 
 es cramps, spasms, and neuralgic pains. 
 
 What are the local sympathetic diseases of pregnancy ? 
 Irritation of the uterus and adjacent parts. 
 
 Is the excitement into which the uterus is thrown, usual- 
 ly to be regarded as a healthy action ? 
 
 In the natural state of society it is so ; but in civilized 
 life, this irritation often induces disease. 
 
 Does the vagina ever become sympathetically affected ? 
 It becomes the seat of a sensation of fullness, heat, and 
 often a leucorrhoeal discharge. 
 
 Does leucorrhcea ever thus become a symptom of preg- 
 nancy ? 
 
 In some doubtful cases this state of the vagina may aid 
 in forming a diagnosis. 
 
 Do the glands of the vagina ever secrete very profusely 
 during pregnancy ? 
 
 Sometimes the discharge is very copious, and is occa- 
 sionally thrown out very suddenly. 
 
DISEASES OF PREGNANCY. 175 
 
 From what other parts at this time may a copious and 
 sudden discharge take place ? 
 
 Probably from between the uterus and decidua, between 
 the decidua and chorion, or between the chorion and am- 
 nion. 
 
 What abnormal formation upon the ovum may give rise 
 to this discharge ? 
 Hydatids. 
 
 What peculiarly distressing sympathetic irritation is 
 sometimes brought on in the vagina or vulva by preg- 
 nancy ? 
 
 An inflammatory affection, resembling aphthae, called 
 pruritis vulvae. 
 
 What effect has the pressure of the uterus anteriorly 
 upon the skin ? 
 
 It sometimes greatly distends it and renders it painful. 
 
 Do the abdominal muscles participate much in the con- 
 sequences of this pressure ? 
 
 They are often put upon the stretch, and are occasion- 
 ally thrown into spasm and pain. 
 
 In what pregnancy are these symptoms the most dis- 
 tressing ? 
 ' /Usually, though not always, in the first. 
 
 What sympathetic effect has pregnancy upon the 
 stomach ? 
 
 It mostly becomes disturbed, the patient being distressed 
 with nausea and vomiting. 
 
 Is the stomach always afflicted thus by pregnancy ? 
 Not invariably. 
 
176 OBSTETRIC CATECHTSM. 
 
 AVhat kind of sensation is it which women experience 
 at the stomach, or epigastric region ? 
 
 A sense of sinking ; sometimes of fullness, nausea, 
 sometimes resulting in vomiting. 
 
 What circumstance aggravates this nausea of the ' 
 stomach ? 
 
 Motion ; it usually comes on the moment of rising from 
 bed. 
 
 What is this disturbance usually called ? 
 Morning sickness. 
 
 Is it confined to the morning alone ? 
 It sometimes lasts the whole day. 
 
 Does it always commence in the morning ? 
 It sometimes comes on in the evening, the patient being 
 quite free from it at other times of day. 
 
 Is this morning sickness a popular sign of pregnancy ? 
 It is by some persons regarded as an invariable or infal- 
 lible sign. 
 
 Does this irritable state of the stomach become very sus- 
 ceptible to the impressions of odors ? 
 
 Both the smell and taste seem to be affected -by this 
 irritability of the stomach. 
 
 Is the stomach affected by moral causes ? 
 It is rendered worse by depressing, and better by ex- 
 citing moral causes. 
 
 Does any serious consequence ever result from this 
 irritation of the stomach ? 
 
 Sometimes it results in confirmed dyspepsia. 
 
 What then happens ? 
 
 Flatulence, cardialgia, pyrosis, gastrodynia, and saliva- 
 tion. 
 
DISEASES OF PREGNANCY. 177 
 
 In what way is the appetite depraved ? 
 The patient is apt to have fastidious tastes, longings ; 
 desires for outre articles, as slate pencils, charcoal, <fcc. 
 
 Is it necessary that this desire should be indulged ? 
 No — we should not encourage such morbid propen- 
 sities. 
 
 What is the popular notion respecting this ? 
 That these longings, if not gratified, will result in some 
 defect or deformity of the child. 
 
 Is it necessary always to withhold the object desired ? 
 The patient may be indulged in every reasonable desire 
 without impropriety. 
 
 Do these inconveniences always occur 1 
 No — some women are better during pregnancy than any 
 other time. 
 
 How long do the annoyances alluded to generally exist ? 
 Some patients suffer only a month, some three or four. 
 
 When are they usually most severe ? 
 During the second and third months. 
 
 When does the distress usually begin ? 
 
 Immediately after the suspension of the menstruation. 
 
 Is gastritis ever a consequence of this sympathetic irri- 
 tation 1 
 
 Yes. 
 
 What is the pathological condition of the stomach in 
 pregnant women ? 
 
 Usually it is not inflamed, but mostly in a state of ir- 
 ritation, or rather according to some of sedation. 
 
178 OBSTETRIC CATECHISM. 
 
 Is there any indisposition produced by another cause, 
 similar to the sickness of pregnancy ? 
 
 Sea sickness, in which also there is irritation, or seda- 
 tion of the nerves of the stomach. 
 
 From what may we infer that the stomach is not in- 
 flamed ? 
 
 It is relieved by taking food, and especially by stimuli, 
 /cordials, &c. 
 
 Is it mostly accompanied by any sympathetic reaction '! 
 There is usually no sympathetic fever. 
 
 Is ordinary sickness of the stomach in pregnancy usually 
 productive of unpleasant consequences? 
 
 Mostly without any bad consequences, however long 
 the sickness may continue. 
 
 What affords temporary relief? 
 
 Lying down, fresh air, moral excitement, &c. 
 
 Does the liver become implicated in the consequences of 
 pregnancy ? 
 
 It often becomes the seat of pain, and is also function- 
 ally deranged. 
 
 What evidence have we of hepatic derangement? 
 The urine is high colored, bowels are torpid, skin sallow, 
 and sometimes the patient becomes jaundiced. 
 
 Is there any other peculiarity about the skin in some 
 cases of pregnancy ? 
 
 It becomes covered by brown or yellow spots called 
 maculae. 
 
 Where do these spots usually appear ? 
 Upon the face and neck. 
 
DISEASES OF PREGNANCY. 179 
 
 Do they present any bad omen ? 
 
 No, they are of little consequence, and usually go off 
 after delivery. 
 
 Upon what visceral derangement do they seem to de- 
 pend ? 
 
 Upon the hepatic affection. 
 
 What part of the glandular system is apt to sympathise 
 with the gravid uterus ? 
 
 The salivary glands sometimes become greatly excited. 
 
 Do the gums become inflamed ? 
 Not necessarily. 
 
 What is the character of the salivary discharge ? 
 Thick and ropy, sometimes very abundant. 
 
 How are the mammary glands affected ? 
 
 They almost always become enlarged, slightly painful, 
 and they occasionally secrete milk very early in preg- 
 nancy. 
 
 What name is given to a tumefaction, which sometimes 
 extends much beyond the ordinary excitement ? 
 Mastodynia. 
 
 Suppose the mammae after having been distended, should 
 become shrunken and flattened, what indication would it 
 present ? 
 
 That the development of the ovum had become sus- 
 pended. 
 
 What other sympathies are involved in pregnancy ? 
 
 Those of a general nature are, first, excitements of the 
 cerebrospinal axis ; and secondly, those of the Vascular 
 system. 
 
180 OBSTETRIC CATECHISM* 
 
 How are the brain and the mental faculties affected ? 
 The brain becomes more impressible, and the mind more 
 susceptible in most cases. 
 
 Does pregnancy ever cause much depression of the 
 faculties ? 
 
 The patient sometimes becomes despondent, and thinks 
 every thing is wrong. 
 
 Does the opposite state of things ever occur ? 
 In some cases the sense of smell and taste become more 
 acute, and the mind much more active and effective. 
 
 Is the vascular system necessarly excited at the same 
 time ? 
 
 The vascular system is not necessarily excited in such 
 cases. 
 
 Is the excitement of the cerebrum ever attended by 
 mania ! 
 
 In some cases, though it rarely comes on till after de- 
 livery. 
 
 What are some of the consequences of this excitement 
 of the brain and spinal marrow ? 
 Hysteric convulsions. 
 
 Does a moderate degree of this stimulation of the ner- 
 vous system ever produce a favorable result ? 
 
 In some cases the patient is able to use her muscles 
 more freely than when unimpregnated. 
 
 What disturbances are produced in the lungs, or thorax 
 by this nervous excitement ? 
 
 Dyspnoea ; sometimes palpitation and spasmodic cough. 
 
 What effect has this nervous stimulation upon the uterus 
 itself? 
 
DISEASES OF PREGNANCY. 18 1 
 
 \ It increases its sensibility, and renders it often extremely 
 sensitive to the touch. 
 
 What influence has it upon the muscular fibres of the 
 uterus ? 
 
 It often causes irregular contractions, somewhat re- 
 sembling labor. 
 
 What effect has this excitation upon the general sensi- 
 bilities of the patient ? 
 
 She sometimes has nervous chills, a kind of universal 
 tremor. 
 
 When are these sensations experienced ? 
 Sometimes at the very commencement of pregnancy. 
 
 Are they liable to produce much muscular movement ? 
 In some cases they amount to regular hysteria. 
 
 Do some patients experience a condition opposite to 
 this ? 
 
 They become faint even during sleep. 
 
 Does this condition of the uterus, ever excite any dis- 
 turbance of the cephalic nerves ? 
 
 Some females suffer much from otalgia, odontalgia, 
 cephalalgia, &c. 
 
 Is toothach very common in pregnancy ? 
 
 With some females it is, and some ladies lose a tooth at 
 every pregnancy, in consequence of the recurrence of 
 odontalgia. 
 
 It has been said that some females become better, more 
 able to make exertion, &c, during pregnancy; are any 
 patients in an opposite condition ? 
 
 Some women become very feeble, and unable to walk, 
 during the greater part of pregnancy, until after delivery. 
 
 16 
 
182 OBSTETRIC CATECHISM. 
 
 We have spoken now of the nervous excitability as a 
 consequence of pregnancy, — what are occasionally its 
 effects upon the vascular system ? 
 
 Most young women become more developed; their 
 vessels enlarge, and carry more blood ; the whole body, 
 pelvis, &c, become increased in size. 
 
 Is this a natural and salutary consequence of pregnancy ? 
 It should be so regarded. 
 
 How is this change brought about? 
 
 By a plethoric condition of the blood vessels. 
 
 Under what circumstances does this plethora become an 
 evil? 
 
 In civilized life, females who live luxuriantly, and do 
 not use much physical exertion become subject to local 
 congestions. 
 
 What then, is the best remedy for the natural plethora 
 of pregnancy ? 
 
 Free exercise and temperate living. 
 
 What sympathetic disturbance, is a usual preventive of 
 plethora ? 
 Nausea and vomiting, as in the morning sickness. 
 
 After what period of pregnancy, does it usually exist 
 most conspicuously ? 
 
 The fourth month, and later when the stomach usually 
 has become more tranquil. 
 
 What kind of pulse is presented in this plethora ? 
 It is not frequent ; rather slow and full, indicating con- 
 gestion. 
 
 What is the condition of the veins ? 
 They are usually very full. 
 
DISEASES OF PREGNANCY. 183 
 
 What are some of the consequences of this plethora ? 
 Sense of general fullness — headach, particularly on 
 lying down. 
 
 How is the respiration affected ? 
 
 It is oppressed, and there is usually a difficulty in taking 
 a deep inspiration. 
 
 What is the condition of the heart, in this general ple- 
 thora ? 
 
 It labors irregularly and with difficulty ; there is palpita- 
 tion combined with oppression. 
 
 What is the consequence of the congestion of the portal 
 system ? 
 
 Distress in the epigastric region, and aggravation of the 
 dyspeptic symptoms where they co-exist. 
 
 What effect has plethora upon the viscera at the lower 
 part of the abdomen ? 
 
 Sensation of weight and distress, especially at the usual 
 menstrual period. 
 
 What evil consequences may arise from plethora in the 
 uterus ? 
 
 Hemorrhage from the cervix, or from the inner surface 
 of the uterus, from detachment of the placenta. 
 
 Is it of importance to attend to these symptoms ? 
 They sometimes become exceedingly dangerous. 
 
 Does this plethora ever cause effusions of blood, in any 
 other part than the uterus ? 
 
 Haemoptisis, haemetamesis, sanguineous apoplexy, of 
 brain or lungs, and melanosis, may result from it. 
 
 What other evil may happen from extreme turgescence 
 of the blood vessels in the brain ? 
 i \ Convulsions. 
 
184 OBSTETRIC CATECHISM. 
 
 What other species of effusion may result from this 
 plethoric condition of the vascular system ? 
 
 Serous effusions upon the brain, into the thorax, the 
 abdomen and the general cellular tissue, &c. 
 
 What effect have these effusions upon the excited con- 
 dition of the nervous system ? 
 They aggravate it. 
 
 How are the bowels sometimes affected by it ? 
 They sometimes pour off the water or serum of the 
 blood in large amounts. 
 
 What is the general condition of the l^lood, in a preg- 
 nant female ? 
 
 It is usually altered ; has more coagulable lymph or 
 buff upon it when drawn. 
 
 Is this the result of inflammatory action, during preg- 
 nancy ? 
 
 \ It is not necessarily dependent upon inflammatory 
 action. 
 
 Is this plethoric condition never attended by fever ? 
 In some cases, it is combined with fever and inflamma- 
 tory action. 
 
 How should we regard a little febrile condition of the 
 patient if she have no plethora ? 
 
 It is not to be looked upon as a serious affair ; it gener- 
 ally goes off after delivery. 
 
 What is it apparently the result of? 
 Nervous excitability ; it is not apt to be followed by 
 debility. 
 
 What are the symptoms of this nervous fever? 
 Dry skin, small pulse, &c. 
 
DISEASES OF. PREGNANCY. 185 
 
 What means are best calculated to relieve this irritability 
 of pregnancy ? 
 
 Cold bath, sponging with cold water. 
 
 What might we regard as suitable temporary remedies ? 
 Anodynes ; particularly those of an anti-spasmodic cha- 
 racter, as assafoetida, ether, &c. 
 
 Why not use the narcotic anodynes, as camphor, and 
 opium, &c? 
 
 When the system becomes habituated to the use of them, 
 the irritability is usually increased. 
 
 Is it safe to deplete very much, during pregnancy ? 
 Too much depletion induces debility, and consequently 
 increases irritation. 
 
 Should the treatment of pregnant women generally, be 
 mild or active ? 
 
 The treatment should be mild, in most cases. 
 
 Should it be preventive or hygienic, rather than cor- 
 rective or medical ? 
 
 It should be rather prophylactic and hygienic — the 
 professional counsellor should give proper attention to 
 suitable exercise of body and mind, rather than medicine 
 in most cases. 
 
 What general rules should be laid down, in reference to 
 the diet ? 
 
 It should be light, easy of digestion ; chiefly vegetable. 
 
 Suppose the patient is dyspeptic, and subject to flatu- 
 lence ? 
 
 Allow her some light animal food, and mild condiments. 
 
 What rule should be observed, in regard to her drinks 1 
 They should W simple, and in moderate quantities. 
 
 16* 
 
186 OBSTETRIC CATECHISM, 
 
 What ill consequences may arise from drinking large 
 quantities, even of water ? 
 
 In the opinion of some, it is apt to increase plethora. 
 
 What popular prejudice exists in regard to the amount 
 of diet, required by pregnant women ? 
 
 That they require more food while pregnant, and that it 
 should be richer and better than usual. 
 
 How far should this idea be favored ? 
 It is in general, fair to suppose that a woman in this 
 situation would require more. 
 
 After the period of morning sickness has passed, what 
 should she do to remove plethora ? 
 
 She should use as much exercise as may be consistent 
 with her physical ability. 
 
 What are some of the good effects of exercise ? 
 
 When taken regularly and in moderation it excites secre- 
 tion, and prevents dyspepsia, increases strength and re- 
 moves irritability. 
 
 Suppose the patient be too feeble to walk, what kind of 
 exercise can she substitute for it ? 
 Riding, sailing, &c. 
 
 What are some of the disadvantages of too much exer- 
 cise ? 
 
 Pain, fatigue, spasms, abortion and premature labor. 
 
 Suppose your patient was already very plethoric, would 
 you oblige her to use exertion to wear it off? 
 
 This plethora should first be reduced by proper direct 
 means before she be recommended to use exertion. 
 
 What treatment of a general nature, is proper to allay 
 the great irritability of some pregnant women ? 
 General bathing, using merely the cold bath. 
 
MANAGEMENT OF DISEASES PREGNANCY. 187 
 
 Suppose the cold bath is followed by a sense of chilli- 
 ness, what should be substituted ? 
 It should be tepid, or warm. 
 
 What peculiar advantages does the warm bath offer, at 
 the later stages of pregnancy ? 
 
 It is very useful to promote the relaxation of the system. 
 
 What consequences might occur if the bath were too 
 hot? 
 
 Labor might be brought on, especially if the woman be 
 plethoric. 
 
 What are some of the more distinct means of reducing 
 plethora ? 
 
 Venesection, is the most efficient. 
 
 How do pregnant women usually bear bleeding? 
 Very well — most of them think they require it, and to 
 many of them it is almost indispensible. 
 
 Is it better to bleed freely and rarely, if you bleed at all, 
 than to bleed a little, and often ? 
 
 Bleed freely, and empty the turgid vessels. 
 
 What may happen from frequent and small bleedings ? 
 A febrile and irritable condition of the patient's system. 
 
 After a free bleeding, whereby a plethoric state is re- 
 moved, what are the best measures for preventing its 
 return ? 
 
 Free exercise, bathing, &c. 
 
 How would you treat a local inflammation, as pleuritis, 
 hepatitis, &c, during pregnancy ? 
 
 By free bleeding, and after the reduction of the inflam- 
 mation, an early use of opiates. 
 
188 OBSTETRIC CATECHISM. 
 
 Why resort to opiates ? 
 
 To prevent the strong liability to premature uterine 
 contractions. 
 
 What unfavorable influence may irritation of the bowels 
 exert upon the uterus ? 
 
 It is very likely to bring on contractions, and false 
 pains. 
 
 What treatment is proper in the febrile state of the 
 system accompanied by nervous chills, and debility 1 
 
 Here omit venesection, but administer instead, spirits of 
 nitre, antimonials, &c. 
 
 What should be done during the apyrexia ? 
 Mild tonics should be given. 
 
 What advice should be given the patient, when she ex- 
 periences difficulty in urinating in consequence of the 
 pressure of the uterus ? 
 
 To bear forward, or to place herself on her knees, and 
 if necessary, press the uterus upward, when it rests upon 
 the pubes. 
 
 Suppose this means will not afford her the necessary 
 relief, what should be done ? 
 
 Introduce the catheter, and allow the urine to escape 
 through it. 
 
 What precautions are to be taken, in the introduction of 
 the instrument under such circumstances ? 
 
 Bear in mind, that as the bladder is compressed by the 
 uterine tumor, it is usually carried so high up as to put the 
 urethra upon the stretch, and fix it parallel with the pos- 
 terior surface of the symphysis pubes, and that the bladder 
 itself is pressed forward over the symphysis. Conse- 
 quently, the point of the catheter, is to be carried along 
 
MANAGEMENT OF DISEASES OF PREGNANCY. 189 
 
 parallel with the symphysis until it gets above it; the 
 handle is then to be depressed, in order to carry the point 
 of the instrument into the cavity of the bladder. 
 
 What evil consequences may result from the long reten- 
 tion of the urine ? 
 
 Paralysis of the bladder, or its rupture and the death of 
 the patient. 
 
 What useful mechanical measure may be resorted to, to 
 obviate or remove the pressure of the uterus upon the 
 bladder ? 
 
 A broad bandage applied in front of the lower part of the 
 abdomen and carried round to the back, or even across 
 the shoulders. 
 
 When the uterus presses upon the rectum, and causes a 
 tenesmus, how should it be relieved ? 
 By pressing the uterus upward. 
 
 What means should be used to remove the impacted 
 feces from the rectum ? 
 
 If oleaginous injections do not succeed, the mass must 
 be removed by a finger or a spoon-handle, or some similar 
 instrument. 
 
 How is the pain which is often felt in the abdominal 
 muscles, the skin, &c, to be relieved ? 
 
 By rubbing them with oleaginous and anodyne mix- 
 tures. 
 
 Supposing much of the abdominal pain to depend upon 
 the existence of flatus in the intestines, what should be 
 done to relieve it ? 
 
 Remove the flatus by some carminative or gently stimu- 
 lating laxative, or antispasmodic. 
 

 190 OBSTETRIC CATECHISM. 
 
 If the intestines become inflamed, how may they be 
 treated ? 
 
 By cups, leeches, &c, to the sides of the abdomen ; 
 and the other modes of treatment considered proper in or- 
 dinary cases. 
 
 What other cause may give rise to pain in some portion 
 of the abdomen ? 
 
 Either of the varieties of hernia, if they become stran- 
 gulated, or the bowel inflamed. 
 
 What is the proper mode of treating hernia ? 
 
 Reduce it and keep it supported by a proper truss or 
 bandage, which presses upon the opening only — properly 
 adjusted adhesive straps, often answer this purpose very 
 well. 
 
 What is the most usual kind of vesical hernia ? 
 Into the vagina, although it has been known to take 
 place into the abdominal or the crural ring. 
 
 How is it to be relieved ? 
 
 By supporting the superincumbent uterus by a proper 
 bandage. 
 
 What caution should pregnant women observe .in re- 
 gard to dress ? 
 
 It should be such as to make no pressure on the abdo- 
 men ; they should abandon the use of corsets, or have 
 them so constructed as not to compress the body. 
 
 How should the hemorrhoids of pregnant women be 
 treated ? 
 
 By laxatives, leeches, cold poultices, &c. 
 
 What is the proper treatment for varices ? 
 Bleeding and proper bandaging. 
 
MANAGEMENT OF DISEASES OF PREGNANCY. 191 
 
 What other exciting cause besides pressure is liable to 
 produce anasarca, varices, &c, in pregnant women? 
 General plethora. 
 
 What serious evil may be apprehended from great dis- 
 tension of the lower extremities by anasarca ? 
 Gangrene and sloughing. 
 
 What surgical treatment does it sometimes require ? 
 Evacuation by puncturing. 
 
 How is the sympathetic vaginitis of pregnant women 
 to be treated ? 
 
 When the patient is plethoric, by free general bleeding, 
 then followed, if necessary, by leeching and cold astrin- 
 gent washes, and alterative injections of nitrate of silver, 
 of alum, <fec. 
 
 What means should be resorted to for the relief of pru- 
 ritis vulvae ? 
 
 General bleeding if plethoric, and then mucilaginous in- 
 jections, well charged with borax, and occasionally with 
 laudanum, or better still, the aqueous solutions of opium. 
 
 Under what circumstances would the sulphate of zinc 
 or nitrate of silver be useful ? 
 After the removal of plethora. 
 
 How strong a solution of the nitrate of silver should be 
 used ? 
 
 Two, three, or four grains to the ounce of water. 
 
 How should we treat irritation of the bladder ? 
 By the use of bland diuretics. 
 
 What treatment is most proper for the diarrhoea of preg- 
 nant women ? 
 
 As it is mostly the result of, or accompanied by, inflam- 
 matory action, it should be treated fey depletion, mild laxa- 
 tives, regulated diet, &c. 
 
192 OBSTETRIC CATECHISM. 
 
 When might astringents be used ? 
 After the inflammation has been cured. 
 
 Should the remedies applied to the stomach for morn- 
 ing sickness, be curative or palliative only ? 
 
 Palliative only — thus let the patient eat before she rises ; 
 let her take her cup of coffee and a piece of bread in bed, 
 or instantly after rising. Her food should be solid most- 
 ly ; she should not indulge much in liquids. 
 
 What should she do if she becomes again sick after eat- 
 ing ? 
 
 Lie down at once, or go directly out and walk in the 
 open air. 
 
 What temporary medicines may she. take to relieve the 
 vomiting, when it is urgent ? 
 
 Lime water and milk, and other antacids. Hot drinks, 
 as catnip tea, infusions of cloves, nutmegs, mace, &c. 
 
 Suppose more active measures be necessary, what other 
 articles may be administered ? 
 
 Spirits of turpentine in small doses, and wine in mode- 
 rate quantities : the aromatic sulphuric acid may be ad- 
 ministered, and in some urgent cases, sinapisms' may be 
 applied over the region of the stomach. 
 
 What notice should we take of her longings, if her sick- 
 ness be urgent I 
 
 They should be gratified to avoid irritability, unless she 
 desires improper and outre articles. 
 
 What organ should we regard as the primary seat of ir- 
 ritation of the stomach ? 
 
 The uterus ; and hence none other than mild palliative 
 measures can be useful. 
 
MANAGEMENT OF DISEASES OF PREGNANCY. 193 
 
 If the liver become torpid and jaundice occur, how must 
 it be treated ? 
 
 By mild alteratives, gentle mercurial course, and especi- 
 ally the proper use of alkalies. 
 
 Suppose the secretions from any organ become very 
 abundant during pregnancy, how should they be man- 
 aged ? 
 
 Great care should be taken not to arrest them suddenly. 
 
 Suppose the patient suffered from mastodynia ? 
 
 Care should be taken not to remove it at once by the 
 application of cold, for fear of causing a metastasis. It 
 should be moderated by warm application, leeches, &c, 
 if necessary. 
 
 What kind of plaster is very useful, and usually suffi- 
 cient to relieve it. 
 
 The Diachylon or soap plaster. 
 
 What other means often succeed ? 
 Frictions with anodyne liniments. 
 
 Is it important to distinguish neuralgia of a part from in- 
 flammation ? 
 
 It is : and the treatment should be conducted accord- 
 ingly. 
 
 What kind of anodynes are best, if the pain be purely 
 nervous ? 
 
 Camphor, hyosciamus, ether, assafetida, &c, but not 
 opium. 
 
 How should we treat the pains in the chest in pregnant 
 
 women ? 
 
 With cups, leeches, &c, if inflammation exist — but if 
 it be merely neuralgic, palliate with assafetida, camphor, 
 &c., carefully withholding opium, if possible. 
 
 17 
 
194 OBSTETRIC CATECHISM. 
 
 Suppose there is pain in the abdomen, with indications 
 for bleeding, what subsequent treatment should be used ? 
 
 In such case, give opiates by the stomach, or in ene- 
 mata, to prevent the contractions of the uterus. 
 
 How should we treat a severe cephalalgia or otalgia ? 
 By leeches, laxatives, <fcc, upon general principles, and 
 after excitement is allayed, give anodynes. 
 
 Suppose the woman have severe tooth ache, what ob- 
 jection would there be to the extraction of the tooth ? 
 f> Any sudden and powerful shock, as that of extraction of 
 teeth, might bring on contractions of the uterus, and re- 
 suit in premature delivery. It is therefore better, as soon 
 as it is admissible, to give anodynes. 
 
 What is meant by the term labor in obstetric language 1 
 It signifies an effort on the part of the uterus, and the 
 mother to expel its contents. 
 
 Is it to be regarded as a mere mechanical action, or a 
 vital function ? 
 
 It is a function, partly dependant upon mechanical, 
 though principally on vital action. 
 
 What is the time at which labor takes place after con- 
 ception ? 
 
 It is apparently irregular, in consequence of the diffi- 
 culty of knowing the precise time of conception. 
 
 What is the ordinary period of calculation ? 
 
 Ten days from the last menstrual period, making nine 
 calendar months and ten days, or ten lunar months — two 
 hundred and eighty days, from the last day on which the 
 menses appeared. 
 
DURATION OF PREGNANCY. 1*95 
 
 What is the most probable length of time ? 
 Nine calendar months. 
 
 Do some women go longer than this ? 
 
 Some have gone ten calendar months, three hundred 
 and eleven days, as was proved in the Gardner Peerage 
 case, in England. 
 
 What was the length of pregnancy in a case under the 
 notice of Dr. Dewees ? 
 
 Two hundred and ninety three days. 
 
 What difference is usually noticed in the condition of 
 the child, when the pregnancy has been protracted ? 
 It is usually better developed, and is more vigorous. 
 
 How many kinds of cause of labor are there ? 
 | Two — natural, (or spontaneous,) and accidental. 
 
 What is the actual cause of labor ? 
 
 At present it is unknown to physiologists. 
 
 What are accidental causes ? 
 
 All such as indirectly excite the uterine fibres to con- 
 traction, whether at full time or prematurely. 
 
 What influence may excitement or injury of any of the 
 viscera have upon the production of labor ? 
 
 It is mostly liable to excite the contractions of the 
 uterus, and thus bring on labor. 
 
 What influence has the mind or morale of the patient 
 on labor ? 
 
 Certain moral impressions excite labor, while others 
 suspend or prevent it. 
 
196 OBSTETRIC CATECHISM. 
 
 What effect are violent inflammations of any of the 
 viscera, or any febrile condition of the general system, 
 liable to have upon labor? 
 
 They always increase the liability to uterine contrac- 
 tions. 
 
 Does the fetus perform any active part during labor ; 
 that is, does it contribute in any way by its own efforts to 
 effect its delivery ? 
 
 None whatever; it is in this respect entirely passive. 
 
 What is the main agent in the process of labor 1 
 The uterus. 
 
 What may be regarded as important accessory aids ? 
 The abdominal muscles, the diaphragm, and indeed all 
 the voluntary powers of the mother. 
 
 What evidences have we that the uterus is the principal, 
 and may be the sole agent in the expulsion of the ovum ? 
 
 Labor has sometimes taken place during sleep, and the 
 ovum has been expelled immediately after the apparent 
 death of the patient ; it also has happened while she was 
 comatose and could use no effort. 
 
 What evidences are offered to the sense of touch, that 
 the uterus contracts ? 
 
 If you place the hand on the abdomen when the wo- 
 man complains of pain, you can feel the uterus grow hard 
 and firm. 
 
 If you apply the finger to the uterus per vaginam, you 
 will feel it tightening itself up when the patient complains 
 of pain. 
 
 Does the state of the mind exert any influence upon the 
 contractions of the uterus in labor ? 
 
 Although uterine contraction is not subject to the voli- 
 
FUNCTION OF LABOR. 197 
 
 tion of the patient, yet moral causes do exert great influ- 
 ence over it. Sometimes increasing the violence of the 
 contractions, but more frequently suspending them, or 
 rendering them much more feeble. 
 
 What effect has great anxiety upon labor ? 
 It almost always retards it, while on the other hand, 
 confidence and hope increase and facilitate it. 
 
 To what part of the system may the excitement of the 
 uterine system be translated ? 
 To the brain and spinal marrow. 
 
 What are the usual consequences of such a translation ? 
 Puerperal convulsions. 
 
 To how many kinds of contraction is the uterus sub- 
 ject? 
 
 Two : tonic, and alternate, or spasmodic. 
 
 What is to be understood by the term tonic contrac- 
 tion ? 
 
 A regular and permanent contraction of all the muscular 
 fibres of the uterus. 
 
 What synonyme has tonic contraction ? 
 Tonic rigidity. 
 
 What is meant by spasmodic contractions of the uterus ? 
 Those contractions which take place suddenly, continue 
 a few minutes and then subside. 
 
 & 
 
 What terms are synonymous ? 
 
 Alternate contractions, painful contractions, labor pains, 
 
 Is not tonic contraction of the uterus painful ? 
 Not usually. 
 
 17* 
 
198 OBSTETRIC CATECHISM. 
 
 What are its effects ? 
 
 It squeezes the blood from the vessels, and diminishes 
 the size of the uterine tumor. 
 
 Where is probably the seat of the pain during the spas- 
 modic contraction ? 
 
 About the neck of the uterus. The pain however is 
 not always proportioned to the degree of the contraction* 
 
 What is the usual order of frequency of the spasmodic 
 or alternate contractions of the uterus in labor ? 
 
 At first, about once in half an hour, then gradually 
 more frequently. 
 
 What is the effect of these alternate contractions upon 
 the uterus ? 
 
 They dilate the orifice, and gradually force out some 
 portion of the ovum. 
 
 What effect has the dilatation of the os uteri upon the 
 long diameter of the uterus ? 
 It shortens its long diameter. 
 
 What effect has the dilatation of the os uteri upon the 
 membranes which were situated over the cervix and os 
 uteri ? 
 
 They necessarily become separated from their connexion 
 with that part ? 
 
 What happens to the membranes, as the os uteri be- 
 comes considerably expanded ? 
 
 They mostly pass out into the vagina, and present 
 what is usually called, the " Bag of Waters." 
 
 What influence does the presence of this " bag of 
 waters" usually exert upon the vagina ? 
 
 It distends it, and often excites a copious secretion of 
 mucus. 
 
CHANGES EFFECTED BY LABOR. 199 
 
 What becomes of this " bag of waters" under the con- 
 tinued and repeated contractions of the uterus ? 
 
 It ruptures or bursts, and suddenly discharges its con- 
 tents. 
 
 Are you to expect always to find a " bag of waters" 
 in the vagina after the woman has been in labor some 
 time ? 
 
 Not always ; for it sometimes happens that the mem- 
 branes rupture before the os uteri is dilated to any extent, 
 but even when this does not happen, the presenting part 
 of the fetus may be applied so closely to the membranes 
 at the os uteri, that there is little or no fluid interposed : — 
 again, the size of the ovum may be so great, or the mem- 
 branes so full, that it is impossible for a segment of the 
 contents of the uterus to pass beyond the level of its 
 orifice until rupture takes place. 
 
 What does the uterus embrace, as soon as the waters 
 are forced off? 
 The fetus. 
 
 W'hen are the accessory powers of the mother brought 
 to bear upon the fetus ? 
 
 Mostly, soon after the expulsion of the waters. 
 
 In what way do these act ? 
 
 First, the woman fixes the diaphragm by a deep in- 
 spiration, and then suspending the respiratory effort 
 she contracts the abdominal muscles so as to bear down- 
 ward ; then she fixes her lower extremities, which are 
 generally flexed, by putting her feet against some solid 
 body ; afterwards she seizes hold of some immoveable 
 body, if she can reach it, and thus brings into action all 
 her voluntary powers, for forcible and violent expulsive 
 effort. 
 
200 OBSTETRIC CATECHISM* 
 
 Are these accessory powers very important in some 
 eases of labor ? 
 
 Although some women are delivered by the contrac- 
 tions of the uterus solely, yet in the greatest number of 
 cases, these accessory powers become indispensable for 
 the completion of parturition. 
 
 How is the uterus sustained in situ during the powerful 
 effort of the accessory powers ? 
 
 The lower part of it is fixed in and rests upon the mar- 
 gin of the pelvis. 
 
 Can a woman excite the tonic, or bring on the spasmodic 
 contractions of her uterus, by the voluntary exertion of 
 the accessory powers ? 
 
 By the effort of the abdominal muscles she can fre- 
 quently stimulate the uterus into action. 
 
 Are the accessory powers ever necessary to aid in the 
 dilatation of the os uteri? 
 
 No : on the contrary, the patient should be prohibited 
 from using them by bearing dow^during the dilating pro- 
 cess. 
 
 What observation would go to give an idea that the ac- 
 cessory powers were not always completely under the 
 influence of the will of the patient ? 
 
 That of the fact, that when the child is pressing against 
 the os uteri, or some of the soft parts of the vagina, it 
 seems to be impossible for the mother to avoid bearing 
 down. 
 
 What are some of the precursory signs of labor, or 
 rather what are the evidences that the woman has nearly 
 completed the full term of utero-gestation ? 
 
 A subsidence of the abdominal tumor, so that pressure 
 
SIGNS OF LABOR. 201 
 
 is taken off from the epigastrium, and the woman feels 
 more buoyant, free, and comfortable : the brain, heart, 
 lungs, and all the superior viscera performing their func- 
 tions more readily. 
 
 What sensation is then usually experienced about the 
 pelvis ? 
 
 One of pressure, uneasiness, constant desire to urinate, 
 or defecate every ten or fifteen minutes. 
 
 What alteration is observed about the vulva or vagina ? 
 
 A more or less copious secretion of transparent, or 
 mucous albumen-like fluid usually takes place ; the tissues 
 are also usually much softened and relaxed. 
 
 By what kind of process does this occur ? 
 By a vital or physiological process. 
 
 What is the consequence if this secretion do not take 
 place? 
 
 The external parts remain hard and rigid. 
 
 Into how many stages is labor usually divided ? 
 Three. 
 
 What is the first stage ? 
 
 That in which the os uteri is undergoing the process of 
 dilatation sufficiently to permit the child to escape through 
 it. 
 
 i 
 
 What constitutes the second state ? 
 The expulsion of the child from the uterus through the 
 soft parts of the mother. 
 
 What does the third stage include ? 
 The complete expulsion of the appendages of the fetus, 
 viz : the placenta and membranes. 
 
202 OBSTETRIC CATECHISM. 
 
 What is the usual situation of the fetus in utero, at the 
 commencement of labor, or the full period of gestation ? 
 
 It is flexed upon itself; its back being usually applied to 
 the anterior portion of the uterus, its occiput towards the 
 anterior half of the maternal pelvis, and the vertex applied 
 to the orifice of the uterus. 
 
 Where are the first pains of labor usually felt ? 
 In the back, or hypogastric region. 
 
 Are they uniform in this respect in the same women at 
 different times ? 
 
 No : sometimes they begin in the back, and sometimes 
 in the lower part of the abdomen. 
 
 When may they be considered as most regular ? 
 When they are felt first in the back, and extend round 
 to the pubic region. 
 
 What inconvenience does the woman usually experience 
 beside the pain in the early stage of labor ? 
 
 A sense of weight and of constant inclination to evac- 
 uate the bladder and bowels. 
 
 When does the woman begin to express her desire to 
 seize hold of some support, that she may exercise her ac- 
 cessary powers ? 
 
 Usually at the end of the first stage of labor. 
 
 What is the usual state of the mind during the first 
 stage of labor ? 
 
 Irritable, petulant, desponding.^ 
 
 What is her physical condition ? 
 
 She is often chilly, flatulent, sick at stomach, sometimes 
 vomiting small quantities of food recently taken, but mostly 
 little else than air. 
 
SIGNS OF LABOR. 203 
 
 What is the popular opinion respecting the prognosis 
 afforded by sick stomach ? 
 
 That sick labors are early labors, and this idea is usually 
 correct, for nausea relieves rigidity. 
 
 What is the condition of the pulse in the first stage ? 
 It is usually small and feeble in the first stage. 
 
 What may be inferred from the fact that there is a secre- 
 tion of mucus tinged with blood from the vagina ? 
 That the woman is actually in labor. 
 
 What is this secretion called by nurses and other wo- 
 men ? 
 A show. 
 
 Whence does it arise ? 
 
 Probably from the vessels which are ruptured by the 
 separation of the membranes from the mouth and neck of 
 the uterus. 
 
 May a woman have a great deal of pain about the back 
 and abdomen, and yet not be in labor ? 
 
 She may have spurious, inefficient, though sometimes 
 very severe pain. 
 
 How are these to be distinguished ? 
 By the touch. 
 
 What sensation do they communicate to the finger of 
 the accoucheur, when introduced against the os uteri ? 
 
 Is it found that the uterus does not contract at all, 
 or if at all, not in a manner to open the os uteri. 
 
 Is the dilatation of the os uteri regular and uniform, or 
 does it progress more rapidly at one time than another ? 
 
 It usually dilates very slowly at first, but afterwards 
 more rapidly. 
 
204 OBSTETRIC CATECHISM. 
 
 What is the usual shape of the os uteri during labor ? 
 At first it is round, but as it dilates, it assumes the shape 
 of the part of the fetus which is about to engage in it. 
 
 What prognosis can be founded upon the condition pre- 
 sented by the os uteri to the touch ? 
 
 It is very uncertain ; as a general rule, when the os 
 uteri is soft and fleshy, though somewhat thick, the dilata- 
 tion will proceed rapidly. 
 
 What may be expected, when you find the os uteri firm 
 and thin ? 
 
 Generally, that the labor will be slow in its first stage. 
 
 Can these conditions be relied on with any confidence ? 
 No : practitioners of long experience are often disap- 
 pointed in them. 
 
 What is the best mode of testing the degree of dilation 
 at each pain I 
 
 The application of the finger in contact with the os uteri 
 during several successive contractions. 
 
 What portion of the whole duration of labor, is usually 
 occupied by the first stage ? 
 About ten-twelfths. 
 
 What for the second expulsion stage ? 
 About one-ninth. 
 
 What for the third stage, or complete expulsion of the 
 placenta, &c? 
 
 One twenty-fourth. 
 
 Does the first stage involve mother or child in danger ? 
 Not necessarily, unless the membranes rupture prema- 
 turely ; then the child may sujffer. 
 
CHARACTERISTICS OF THE STAGES OF LABOR. 205 
 
 May either mother or child, incur any risk during the 
 second stage ? 
 
 The mother rarely incurs any hazard, but the child may 
 be said to be in imminent danger, in many cases. 
 
 What accident may happen to it ? 
 
 It may become apoplectic from the forcible pressure of 
 the uterus upon it, while its head is retained in the pelvis, 
 or if expelled too rapidly, it may be in a state of asphyxia. 
 
 Is the mother subjected to any danger, during the third 
 stage ? 
 
 Her danger at this time is often imminent; hemorrhage, 
 inversion of the uterus, &c, are liable to occur. 
 
 What sort of pains usually characterize the first, or 
 dilating stage of labor ? 
 
 They are usually described, as cutting, grinding, or 
 tearing pains. 
 
 In what respect do those of the second stage differ ? 
 They are forcing, bearing down, expulsive. 
 
 What position does the woman usually assume, during 
 the first stage ? 
 
 She will sit, stand, or walk about ; sitting or kneeling 
 down only when she has a pain. 
 
 What attitude does she usually assume, when in the 
 second stage ? 
 
 She mostly prefers to lie down, flex her body and lower 
 extremities, but extend her arms to embrace something, 
 with which to support the bearing down effort she is about 
 to make. 
 
 What is her physical condition during the second stage ? 
 Her pulse becomes excited both by the effort, and the 
 
 18 
 
206 OBSTETRIC CATECHISM. 
 
 occasional suspension of respiration. She is mostly be- 
 dewed with perspiration, and when a pain comes on, her 
 face becomes florid, sometimes almost livid. 
 
 Is the increase of the pulse necessarily owing to febrile 
 excitement ? 
 
 No ; it is the result of exercise, and should be distin- 
 guished from the pulse of inflammation. 
 
 What are some of the consequences of this effort? 
 
 Mostly an increased secretion of serum, from the skin, 
 and mucus from the cavities ; occasionally also, ecchy- 
 mosis of the conjunctiva, epistaxis, and even apoplexy, or 
 cerebral congestion. 
 
 What consequences often result if the secretions do not 
 increase under this effort ? 
 
 The patient is almost sure to become febrile. 
 
 What is the condition of the mind, during the second 
 stage ? 
 
 It is more calm and confident, the patient now often 
 solicits the return of pains, and she rarely now imagines 
 that she will die before labor is accomplished. 
 
 What disturbance is she liable to experience in her lower 
 extremities, in this stage ? 
 Severe cramps, and pain. 
 
 Why do these take place now ? 
 
 In consequence of the pressure exerted by the child's 
 head, upon the sacral nerves. 
 
 What condition of the brain may supervene in this 
 £tage of labor ? 
 
 Delirium, or mania may ensue- 
 
CHANGES PRODUCED BY LABOR. 207 
 
 What urgent sensation takes place when the presenting 
 part of the child is brought in contact with the perinaeum ? 
 An impulse to evacuate the bowels. 
 
 Should the patient be allowed to rise to comply with 
 such a desire ? 
 
 It would be unsafe, as well as unavailing for her to rise 
 for that purpose at this stage of the labor. 
 
 To what extent does the perinaeum usually stretch over 
 the presenting part of the child ? 
 
 Generally sufficient to cover the part presenting. 
 
 What takes place in reference to both the moral and 
 physical condition of the patient, immediately after the 
 extrusion of the child ? 
 
 The uterine pains now usually at once subside ; the 
 woman, in an ecstacy of gratitude expresses herself 
 relieved ; her moral sensibilities are sometimes wrought 
 up to their highest degree. 
 
 What usually occurs soon after this ? 
 The uterus again contracts for the purpose of expelling 
 the placenta. 
 
 How many steps, or stages are there for the expulsion 
 of the appendages of the fetus ? 
 
 Three ; one in which the separation of the placenta is 
 effected, and the other in which it is thrown into the 
 vagina, and the third, in which it with the membranes is 
 expelled from the vagina. 
 
 By what power is the placenta usually expelled from 
 the yagina ? 
 
 By the voluntary powers of the mother alone, unless 
 aided by the hand of an assistant. 
 
208 OBSTETRIC CATECHISM. 
 
 What amount of hemorrhage usually attends the expul- 
 sion of the placenta, under most favorable circumstances ? 
 Perhaps half a pint, rather more or less. 
 
 Suppose hemorrhage should become profuse, in what 
 length of time might it destroy the life of the mother ? 
 
 It is asserted by very respectable authority, that it would 
 require only five or six minutes. 
 
 Whence does this blood escape ? 
 
 From the patulous orifices of the large veins, opposite 
 to the point at which the placenta was attached. 
 
 What are the sources of danger, during the third stage 
 of labor ? 
 
 Simple exhaustion from the severe efforts made during 
 the second stage, but particularly from hemorrhage. 
 
 What would you call a tedious labor ? 
 
 One which occupies twenty-four or more hours. 
 
 What are some of the causes of tedious labor ? 
 
 Rigidity of the soft parts, small size of the pelvis, or 
 deviations of the presenting part of the child ; want also 
 of regular action of the uterus. 
 
 What is the usual and proper direction of the uterine 
 forces ? 
 
 Such as to propel the contents downward and a little 
 backward, in the direction of the axis of the superior strait 
 of the pelvis. 
 
 How is the direction of the uterus modified by the effort 
 of contraction ? 
 
 It is carried more and more into a line with the axis of 
 the superior strait. 
 
PRESENTATION AND POSITION OF THE FETUS. 209 
 
 What is to be understood by the term floor, or bottom 
 of the pelvis ? 
 
 The lower end of the sacrum, the whole of the coccyx, 
 and the perinaeum. 
 
 When the presenting part of the child is carried down 
 to this part, what direction has it next to take ? 
 
 It must be propelled forwards along the curvature of 
 the coccyx and perinaeum. 
 
 What do obstetricians mean by the word presenta- 
 tion ? 
 
 That some portion of the contents of the ovum becomes 
 situated at the orifice of the uterus, at or near the centre of 
 the pelvis. 
 
 What is meant by position of the fetus in mid- 
 wifery ? 
 
 That some part of the presentation is directed towards 
 some particular, or specified part of the maternal pelvis. 
 
 How are labors usually classified ? 
 
 Into rapid, slow, easy, difficult or laborious, assisted or 
 unassisted, manual and instrumental, simple and complex, 
 eutocia and dystocia. 
 
 What conditions are necessary for the performance of 
 natural labor ? 
 
 That the uterus should contract regularly, the child 
 present favorably, and that the pelvis be sufficiently large, 
 and the soft parts of the mother be sufficiently relaxed. 
 
 Is it necessary that the vertical extremity of the fetal 
 ellipse present to the pelvis, that the labor may be natural ? 
 
 This is the most favorable position ; but the labor may 
 be natural if the pelvic extremity present. 
 
 18* 
 
210 OBSTETRIC CATECHISM. 
 
 How are natural labors classified ? 
 
 First, into those in which the vertical extremity of the 
 fetal ellipse presents favorably ; and secondly, into those 
 in which the pelvic extremity presents to the pelvis of the 
 mother. 
 
 Why does the cephalic extremity present most fre- 
 quently ? 
 
 Probably, 1. Because the head is heavier than any 
 other equal bulk of the body, and therefore descends in the 
 liquor amnii. 2. Because in the formation of the peculiar 
 figure of an ellipse the cephalic extremity is better adapted 
 to the small extremity of the ovoid cavity of the uterus. 
 
 How many grand varieties of occipital positions are 
 there ? 
 
 Two. First, in which the occiput presents to some 
 part of the anterior half of the circle of the superior strait. 
 Second, in which the occiput presents to some part of the 
 posterior half of the superior strait. 
 
 Why is it preferable that the occiput present to the an- 
 terior semicircle of the pelvis, in cases of cephalic pre- 
 sentations ? 
 
 Because the head can then most readily descend along 
 the planes of the pelvis, and by easy movement upon the 
 neck, pass out under the arch of the pubes. 
 
 How many positions of the head are generally recog- 
 nized ? 
 
 Six — of which three are anterior, and three are posterior. 
 
 What is the first position of the occiput ? 
 That in which the occiput presents to that portion of 
 . the linea-ilio-pectinea, which is within the left acetabulum, 
 and at the same time the sinciput or bregma, presents to 
 the right sacro-iliac symphysis. 
 
PARTICULAR POSITIONS OF CEPHALIC EXTREMITY. 211 
 
 What diameters of the child's head correspond* to the 
 different parts of the pelvis, in the first position. 
 
 The occipito-bregmatic diameter of the head, corresponds 
 to that oblique diameter of the pelvis, which extends from 
 the left acetabulum to the right sacro-iliac symphysis — the 
 bi-parietal diameter of the head corresponds to the other 
 oblique diameter of the pelvis. The occipito-mental di- 
 ameter of the head, corresponds to the axis of the superior 
 strait, and upper part of the cavity of the pelvis. 
 
 What in the second ? 
 
 The occiput is towards the right acetabulum ; the sinci- 
 put toward the left sacro-iliac symphysis ; the oeeipito- 
 I bregmatic diameter, therefore, corresponds to this oblique 
 diameter of the pelvis, while the bi-parietal, also, corres- 
 ponds to the other oblique diameter. The occipito-mental 
 diameter corresponds to the axis of the pelvis. 
 
 What in the third ? 
 
 The occiput is directed to the symphysis pubes, and 
 the sinciput to the sacrum. The occipito-bregmatic di- 
 ameter of the head, therefore, corresponds to the antero- 
 posterior or sacro-pubal diameter of the pelvis ; the bi- 
 parietal diameters of the head to the transverse diameters 
 of the superior strait of the pelvis ; the occipito-mental 
 diameter corresponds to the axis of the pelvis. 
 
 What in the fourth ? 
 
 The occiput is directed to the right sacro-iliac junction ; 
 the sinciput or the bregmatic, to the left acetabulum. 
 Hence the occipito-bregmatic diameter corresponds to this 
 diameter, and the bi-parietal diameter of the head to the 
 other oblique diameter of the pelvis. The occipito-mental 
 diameter corresponds to the axis of the pelvis, 
 
212 OBSTETRIC CATECHISM. 
 
 What in the fifth ? 
 
 The occiput is directed to the left sacro-iliac symphysis ; 
 the sinciput or bregma to the right acetabulum. Hence 
 the occipito-bregmatic diameter corresponds to this oblique 
 diameter of the pelvis, while the bi-parietal does to the 
 other oblique diameter. The occipito-mental diameter of 
 the head corresponds to the axis of the superior strait. 
 
 What in the sixth ? 
 
 The occiput is directed to the sacrum, and the sinciput 
 or bregma to the symphysis pubes. The occipito-breg- 
 matic diameter corresponds to the sacro-pubal or antero- 
 posterior diameter of the superior strait of the pelvis ; the 
 bi-parietal diameter corresponds to the transverse diameter 
 of the pelvis, and the occipito-mental diameter corresponds 
 nearly or entirely with the axis of the superior strait. 
 The contractions of the uterus continuing, the shoulders 
 come down, and in the first position &f the right shoulder 
 is carried along the right anterior inclined plane to the 
 symphysis pubes. The occiput in the first position 
 is carried down the left anterior inclined plane, toward the 
 symphysis pubes, and the forehead upon the right poste- 
 rior inclined plane, toward the middle of the sacrum. 
 
 This is the second effect of the contractions of the uterus. 
 
 What is this change of the position of the head techni- 
 cally called ? 
 Rotation. 
 
 How does the child's head pass through the inferior 
 strait ? 
 
 The occipito-mental diameter corresponds to the axis of 
 the inferior strait ; the occipito-bregmatic to the antero- 
 posterior, or coccy-pubal diameter ; the transverse diameter 
 
MECHANISM OF FIRST POSITION. 213 
 
 of the head to the transverse or bis-ischiatic diameter of 
 the mother. 
 
 When does extension take place ? 
 When the head of the child begins to enter and pass 
 through the inferior strait. 
 
 When does expansion of the perinaeum begin to take 
 place ? 
 
 As soon as the head fairly engages in the inferior strait. 
 
 What is this expansion called ? 
 The perinaeal tumor. 
 
 To what degree does the perinaeum become expanded ? 
 Sometimes till it is large enough to cover the whole 
 cranium. 
 
 When may extension of the child's head be considered 
 as perfect ? 
 
 Just as the face is clearing the perinaeum. 
 
 When does the perinaeum offer the greatest resistance 
 to the escape of the child ? 
 
 At the time in which the parietal protuberances are 
 about to escape. 
 
 What takes place in regard to the position of the head, 
 after it clears the perinaeum ? 
 
 Restitution, in which the face of the child takes the 
 oblique position at right angles with the direction of the 
 shoulders. 
 
 What change of positions do the shoulders undergo. 
 They rotate on the inclined planes. The right shoulder 
 to get under the sacrum, and the other the symphysis. 
 
214 OBSTETRIC CATECHISM. 
 
 What direction does the head assume as the shoulders 
 become engaged under the symphysis, and in front of the 
 sacrum ? 
 
 The occiput presents to the left tuberosity of the ischium, 
 and the chin towards the right. 
 
 Do the shoulders engage in the same inclined planes in 
 which the head did ? 
 
 No ; always in the opposite ones. 
 
 What change takes place in the axis of the body of the 
 child as the shoulders escape ? 
 
 The body curves upon its axis laterally to accommodate 
 itself to the curvature of the axis of the pelvis. 
 
 What part of the child offers the greatest resistance to 
 the delivery in cephalic presentations ? 
 The head. 
 
 What other portion offers the next degree of difficulty ? 
 The shoulders. 
 
 Which shoulder is delivered first ? 
 
 In cases of early labor the pubal shoulder first, but in 
 cases of great rigidity of the perinaeum, the pubal shoul- 
 der is frequently thrown back under or behind the sym- 
 physis, and the sacral shoulder thrown out first. 
 
 Do the same diameters of child's head present to the 
 same planes of the pelvis, in the second as in the first po- 
 sition of cephalic presentations ? 
 
 The measurements are the same in both cases. 
 
 What circumstance offers the only interference to as 
 ready a delivery in the second as in the first position ? 
 
 The presence of the rectum, sometimes impacted with 
 feces. 
 
MECHANISM OF SECOND AND THIRD POSITIONS. 215 
 
 Which way does the occiput present after restitution 
 has taken place in the second position ? 
 To the right side. 
 
 Does rotation occur quite as readily in the second as in 
 the first position ? 
 
 When the rectum is distended with feces, rotation does 
 not take place so readily. 
 
 What difficulties does the third position present which 
 are not experienced in the first and second positions ? 
 
 The fact that it has the occipito-bregmatic diameter, pre- 
 senting to the short or antero-posterior diameters of the 
 pelvis of the superior strait. 
 
 Does rotation of the head take place in the third posi- 
 tion ? 
 
 It does not. 
 
 Do the shoulders rotate. 
 They mostly do. 
 
 Does restitution of the child's head take place in the 
 third position ? 
 
 No: or at least only to a less extent than in either of 
 the others. 
 
 Why is the first position more frequent than the second 
 or others ? 
 
 It is not easily accounted for, though some think it is 
 dependent upon the position of the cecum. 
 
 Is the second position any more unfavorable than the 
 first? 
 
 Yes : owing to the slightly greater degree of difficulty 
 of rotation of the head, in consequence of the situation of 
 the rectum on the left side of the sacrum. 
 
**6 OBSTETRIC CATECHISM. 
 
 Why are third positions uncommon ? 
 
 Because of the difficulty of retaining two convex sur- 
 faces, the sinciput and the promontory of the sacrum in 
 contact with each other. 
 
 What peculiar difficulty is liable to present in cases of 
 third position ? 
 
 The pressure of the anterior fontanelle against the pro- 
 montory oi the sacrum. 
 
 How do the shoulders rotate in cases of third position ? 
 Either right or left comes under neck of pubes. 
 
 Why is the fourth position more frequent than the 
 fifth ? " 
 
 Probably for the same reason which renders the first 
 more frequent than the second position. 
 
 What is the mechanism of the labor in the fourth posi- 
 tion ? 
 
 First, flexion takes place, though perhaps to a less 
 degree than in the anterior varieties ;— then the occiput 
 rotates along the right posterior inclined plane ; flexion is 
 now increased, and the forehead is thrown behind the arch 
 of the pubis. No extension can take place until the occi- 
 put has passed over the whole length of the sacrum, and 
 the forehead has passed out under the arch of the pubes. 
 
 What other parts than the head and neck are involved 
 in flexion, as the child enters the cavity of the pelvis ? 
 The thorax and shoulders. 
 
 What conditions are necessary in this case for favorable 
 delivery ? 
 
 That the parts of the mother be very much relaxed, or 
 the child small. 
 
MECHANISM OF POSTERIOR VARIETIES. 217 
 
 What accident is liable to happen to the mother, as the 
 head passes from the inferior strait ? 
 Rupture of the perinaeum. 
 
 Is the bladder more likely to suffer in these than in oc- 
 cipitoanterior positions ? 
 
 Towards the latter stages of labor it is liable to grea^ 
 distension from the forcible pressure of the anterior part 
 of the head. 
 
 What change takes place in regard to the head after it 
 has cleared the perinaeum ? 
 Revolution backwards. 
 
 Which way does the face of the child turn when it has 
 cleared the inferior strait ? 
 
 Towards the left thigh of the mother. 
 
 Under what circumstances may the forehead, and not 
 the anterior fontanelle come out under the arch of the 
 pubes ? 
 
 When the child is small, or the perinaeum much re- 
 laxed, or the coccyx very moveable. 
 
 In what direction do the contractions of the uterus carry 
 the child in the early period of the second stage of labor ? 
 Directly down into the hollow of the sacrum. 
 
 What inconvenience arises in reference to the body of 
 the child ? 
 
 In the posterior varieties the child's spine bends under 
 the contractions of the uterus, and therefore, the expul- 
 sive powers are less efficient than in the anterior position. 
 
 What is the mechanism of the fifth position ? 
 The bi-parietal and occipito-bregmatic diameters, cor- 
 responding to the oblique diameters of the superior strait, 
 
 19 
 
218 OBSTETRIC CATECHISM. 
 
 the contractions of the uterus force the occiput down along 
 the left posterior inclined plane, and the bregma along the 
 right anterior plane. 
 
 Which way does the face turn, after it has escaped the 
 vulva ? 
 
 To the inside of the right thigh. 
 
 Does the forehead present any difficulty in its passage 
 under the arch ? 
 
 It is believed by some that it escapes less readily than 
 the occiput. 
 
 Which is the most rare position of all the occipital pre- 
 sentations ? 
 The sixth. 
 
 Why does it occur rarely ? 
 
 Because of the extreme difficulty of having two rounded 
 surfaces, like the occiput and promontory of the sacrum 
 kept in contact with each other. 
 
 What is the mechanism of labor in the sixth position ? 
 
 The head is driven directly down the central line of the 
 sacrum without any rotation. The shoulders are rotated 
 as in the third position, except that they are reversed. 
 
 What are the two main points to be studied, in reference 
 to the mechanism of all the positions ? 
 
 The characteristics of the first and the fourth positions, 
 as containing the elements of the mechanism in all the 
 other cases. 
 
 Why are the two transverse positions of the head at the 
 superior strait easily convertible into the first or second, 
 fourth or fifth ? 
 
 Owing to the rotation of the head upon the inclined 
 planes. 
 
CONVERTIBILITY OF THE POSITIONS. 219 
 
 Why may the fifth position become converted into the 
 first, and the fourth into the second ? 
 
 Owing to the greater length of the anterior inclined 
 planes. 
 
 Is labor to be steadily regarded a natural function ? 
 In almost all cases it is to be so regarded. 
 
 Why then should the judicious practitioner be present 
 at all labors ? 
 
 That he may encourage his patient, and prevent mis- 
 chief from improper interference on the part of others. 
 
 Is correct diagnosis in cases of labor difficult and im- 
 portant ? 
 
 It is highly important, and often difficult. 
 
 What influence is the practitioner to exert in natural 
 labors ? 
 
 A negative influence, rather to prevent mischief than by 
 being himself very active. 
 
 What general or particular treatment should the ac- 
 coucheur direct during the latter parts of pregnancy ? 
 
 That the patient should use a proper amount of exercise, 
 live principally upon vegetable diet, simple drinks, keep 
 her bowels free, and observe that her bladder is freely 
 and entirely evacuated. 
 
 How would you keep her bowels open ? 
 
 By a laxative diet, or if necessary, by the use of olive 
 oil, or what sometimes is better, by the use of emollient 
 enemata, &c. 
 
 What should you impress upon her mind in reference 
 to her bladder? 
 
 To observe that it is evacuated completely, and to notice 
 whether the quantity passed is actually as great as usual. 
 
220 OBSTETRIC CATECHISM. 
 
 What amount of exercise should she adopt ? 
 It should be free and regular, throughout her whole 
 pregnancy, so long as it can be continued without pain. 
 
 What remark should you make to the patient in refer- 
 ence to her apprehensions of debility during labor ? 
 
 That her apprehensions are ill founded, that she is really 
 stronger that she thinks she is, and that she will be able to 
 exert herself more and more as the labor advances. 
 
 By what means should you promote relaxation ? 
 
 First, adopt the rule already laid down of vegetable 
 diet and open bowels, then if she continue to have a 
 rigid fibre, relax it by antiphlogistic treatment, as bleeding, 
 nauseants, &c. 
 
 What kind of room should the patient select for her 
 nursery during her parturient and puerperal states ? 
 
 It should be spacious and well ventilated, so circum- 
 stanced that it can be darkened when necessary. 
 
 What arrangement should be made in reference to the 
 bed? 
 
 It should be so situated as to be accessible if possible at 
 each side and the foot, but at the right side and foot at 
 least. It should have posts sufficiently high to enable her 
 to place her feet against either one as may be desired, and 
 if curtained, these should be kept drawn that the bed may 
 be well ventilated. 
 
 What objection to her being delivered on one bed, and 
 after labor transferred to another ? 
 
 There is often much hazard in making the transfer, as 
 hemorrhage, &c. might be thus brought on* 
 
 How should you have the bed prepared for delivery ? 
 First, have the bed, if of feathers, properly flattened 
 
ARRANGEMENT OF THE BED FOR DELIVERY. 221 
 
 down, then place upon the middle portion of it .upon which 
 the hips will rest after delivery, a folded sheet, blanket, 
 or any soft material to protect the bed below from the 
 lochia, which may escape beyond its immediate recipients. 
 Then place on the lower sheet or blanket, fold the lower 
 end of this in several short folds so near the middle of the 
 bed, that when the patient is placed in her proper situation 
 after delivery, this fold will be below her hips. Place 
 upon the lower portion of the bed, first an oil-cloth, or 
 some other impervious material, and over this, several 
 folds of clothing, as blankets, sheets, or something of 
 this kind, so arranged as to cover principally, or entirely, 
 the portion of the bed thus left bare by the folding up of 
 the lower sheet. Bring the lower edge of these folds a 
 little over the foot or edge of the bed, at which the ac- 
 coucheur is to sit. Then place the pillows diagonally across 
 the bed, that they will be comfortably under the patient's 
 head when she is sufficiently flexed. The usual bed 
 covers may be placed within reach to allow the patient to 
 use them as she may wish, when she is placed on the bed. 
 To that bed post against which her feet are to be fixed 
 when she is placed on the bed, attach a towel or strong 
 band, in such manner that her hand may embrace the 
 loop of it when she is properly flexed. 
 
 What principle object should the physician have in 
 view in giving directions for the preparations of the bed ? 
 
 That the patient may lie upon her left side so curved 
 forward as to throw the axis of the body into nearly the 
 same line with that of the uterus. 
 
 How should the patient be prepared to be placed on the 
 bed? 
 
 Her body clothing should be so adjusted that she need 
 
 19* 
 
222 OBSTETRIC CATECHISM. 
 
 not have ft at all soiled. For this reason her skirts should 
 be laid aside ; her linen so folded up around her waist that 
 it will be beyond the risk of discharges, a bandage suita- 
 ble for encircling her abdomen after delivery, should be 
 placed around her waist, and so pinned as to retain her 
 linen as folded up ; and next a sheet or blanket should be 
 folded in double in the direction of its length, the centre 
 of this fold should be placed in front of the abdomen, and 
 carried round on each side to the middle of the back, or 
 better still, one portion should be carried round the left 
 side over the back, to meet the other portion on the right 
 side, where it should be carefully pinned with a large pin. 
 The night or bed gown, which should be a short one, can 
 then be allowed to drop down from the shoulders to the 
 waist. The patient should have stockings on, without 
 any garters to retard the circulation ; her feet should mostly 
 also be protected by slippers. She should then, if the 
 stage of her labor require, be placed upon her left side, 
 with her hips within a foot of the lower end of the bed, 
 her body flexed forward, her lower extremities drawn up, 
 that her feet may be placed against the right foot post of 
 the bed ; the lower side of the sheet is then to be drawn 
 out smoothly under her, while the upper portion is to be 
 carried out also smoothly behind her ; it will thus protect 
 her completely from any exposure of her person ; next 
 over this may be drawn a suitable amount of bed clothes. 
 
 What provision should be made in reference to the man- 
 agement of the child at its birth ? 
 
 There should be provided a proper ligature for the 
 umbilical cord, — a pair of sharp edged, but blunt ended 
 scissors, should be at hand ; also suitable clothing, in 
 which to envelope it when born. 
 
 There should also be the means at command of raising 
 
PREPARATION OF BED, ETC. 223 
 
 the temperature if necessary— there should be at command 
 an abundant supply of warm water, and also some suitable 
 stimulants, as spirits, aq : ammonias, or something of the 
 kind, to excite respiration if necessary. 
 
 What accommodation should be furnished the accou- 
 cheur ? 
 
 A chair to sit upon, some unctuous matter with which 
 to lubricate his hand, and the soft parts of the mother ; 
 several napkins — a short apron or napkin across his lap ; 
 and the nurse should also fold napkins on his arms. 
 
 Should the physician endeavor to promote relaxation of 
 the os uteri and the perinseum ? 
 
 It is proper to do the one, during the first, and the other 
 during the second stage of labor. 
 
 How is this best effected ? 
 
 By passing up large warm enemata into the rectum, or 
 by bleeding from the arm, or by the use of nauseants in 
 the first instance, and by the repeated use of warm moist 
 cloths, in the second instance. 
 
 Should the practitioner attend to the condition of the 
 stomach, bowels and bladder ? 
 
 He should inquire into the state of all these organs, and 
 attend to regulate them. 
 
 What course of conduct should the accoucheur exercise 
 while in attendance upon the parturient female ? 
 
 It should be such as would preserve her feelings free, 
 and inspire her with proper confidence in him — he should 
 remain calm under all circumstances, carefully avoid, by 
 any action or even change of countenance, exciting her 
 apprehensions of an unfavorable termination of her case ; 
 he should offer candidly all reasonable prospects of a 
 
224 OBSTETRIC CATECHISM. 
 
 happy and safe delivery, though he should cautiously avoid 
 any promise as to this or the time of its occurrence. He 
 should suppress all unnecessary talking, or allusions to any 
 other cases which may have been known, or reported to 
 be fatal or hazardous ; he should advise his patient against 
 straining, or forcibly bearing down during the first stage, 
 but strongly urge the necessity of it, during the second 
 stage. He should carefully ascertain the state of the blad- 
 der and bowels, and direct accordingly ; he should recom- 
 mend his patient to remain up considerably, during the first 
 stage, but to lie down, during the remaining period of 
 labor. He should not remain constantly with her during 
 the first stage, but not be absent from her subsequently 
 until the whole process is completed. 
 
 What consequences may happen from the patient bear- 
 ing down too early ? 
 
 Too early rupture of the membranes. 
 
 What risk does the child incur if the membranes become 
 ruptured before the first stage is completed, particularly if 
 the woman bears down very forcibly ? 
 
 It may be fatally compressed. 
 
 Is it always easy to determine whether the patient is in 
 labor or not ? 
 
 To the young practitioner it is often very difficult ; even 
 experienced accoucheurs cannot always decide positively. 
 
 What are the usual means of discriminating true from 
 false pains by the history of the case ? 
 
 By the character of the pains: true labor pains are mostly 
 alternate, showing a distinct interval of ease between them, 
 while in colic, or neuralgic pains, they are more irregular, 
 and in the pains attendant upon inflammation, they are 
 more constant and accompanied by more febrile action. 
 
DIAGNOSIS OF LABOR. 225 
 
 What condition of the os uteri, should be found in 
 regular labor ? 
 
 It should usually be found somewhat dilated ; and when 
 a finger is applied to it during a pain depending upon 
 uterine contraction, it will be found to be tightened up by 
 being drawn as it were, over the lower segment of the 
 ovum. 
 
 Suppose you had reason to conclude that the patient 
 was afflicted with false pains, how should you attempt to 
 relieve them ? 
 
 By attempting to remove the supposed causes ; if they 
 I depended upon constipation, by cathartics, or enemata ; 
 I if upon inflammatory action, by bleeding, &c; if upon 
 neuralgia or spasms, by proper anodynes, or counter irri- 
 tants, &c. 
 
 Can you always positively assure a woman that she is 
 in labor, if you find her os uteri dilated to the size of a 
 ten cent piece ? 
 
 Though this circumstance, accompanied by pains of a 
 more or less regular character, may be considered as suf- 
 ficient data for diagnosticating the actual existence of labor, 
 yet it has happened to some practitioners to observe this 
 state of things in women who have subsequently gone from 
 one to four weeks after this, before they were delivered ? 
 
 When should she be put to bed for the completion of 
 labor ? 
 
 When you believe the os uteri is nearly or entirely 
 dilated. 
 
 Why should you have her flexed forward ? 
 That the axis of her uterus may be thrown into a line 
 with the axis of the superior strait. 
 
226 OBSTETRIC CATECHISM. 
 
 What accommodation should be supplied to the accou- 
 cheur, when he is about to make an examination, or is 
 preparing to assist the patient by receiving her child, &c? 
 
 The nurse should adjust a napkin around each fore arm, 
 place a sheet, or folded cloth upon his lap, put within his 
 reach several napkins, diapers or cloths, and a cup of lard 
 or pure oil. She should do this quietly, and he should 
 take his seat with as little parade as possible. 
 
 Thus seated and otherwise accommodated, what should 
 he proceed to do ? 
 
 To make a proper examination, to determine the exact 
 state of the case if possible. 
 
 How should he make this examination ? 
 
 He should be seated with his right side to the bed; with 
 the left hand, he should separate cautiously the upper from 
 the lower fold of the sheet, which had been placed around 
 the patient before she was placed on the bed ; when a 
 pain occurs, he should lubricate the index finger of the right 
 hand, and keeping this finger flexed towards the hollow 
 of the hand, at the same time that the thumb is strongly 
 extended, (thus guarding the finger, from the risk of having 
 the ointment on it rubbed off on the clothes, and subse- 
 quently perhaps, smeared upon his coat sleeve,) he passes 
 his right hand between the folds of the sheet, the lower 
 edges of which had been slightly separated by the left 
 hand. The left hand is then to be carried, exterior to all 
 the covers, to the region of the right trochanter ; at the 
 same time, the right hand glided along, between the folds 
 of the sheet in the manner directed ; is to be passed a little 
 posterior to the spot upon which the left hand slightly 
 rests, viz : upon the right trochanter ; in a this way the 
 knuckle of the examining finger may with considerable 
 
MODE OF MAKING AN EXAMINATION. 227 
 
 certainty be brought to the sulcus between nates, or to the 
 raphe of the perinaeum, and then glided forwards, until it 
 slips into the genital fissure over the posterior commissure, 
 without bringing it in contact with the sensitive apparatus 
 at the anterior commissure ; when once the finger has 
 gained this aperture, it may be extended along the vagina, 
 with its radial edge towards the arch of the pubes, and 
 thus cautiously applied to the orifice of the uterus, &c. 
 
 What is the importance of making this examination at 
 the time of a pain ? 
 
 First, that he may determine whether she is really in 
 labor or not, and next to ascertain the degree of dilatation 
 of the os uteri, and if possible the presentation of the 
 child. 
 
 Is it easy for you always to determine the presentation 
 of the child, previous to the rupture of the membranes ? 
 It is mostly easy to do so, unless it be a presentation 
 I of the side, or back of the child. 
 
 Is the position easy to be recognised through the mem- 
 branes ? 
 
 In general it is not, until after they are ruptured, and 
 the presenting part fairly engaged in the pelvis. 
 
 Does labor usually proceed more rapidly after the rupture 
 of membranes, if the os uteri be properly dilated ? 
 It does. 
 
 How should you rupture the membranes ? 
 
 By pressing the point of t^e finger into the fold of the 
 membranes, if the bag of water be large ; if not promi- 
 nent, the nail of the finger should be directed towards the 
 oresenting part of the child, and then by a little vibratory 
 
228 OBSTETRIC CATECHISM. 
 
 motion it gradually wears them away. This must be 
 done with great caution. 
 
 Should you use any precautions for your protection from 
 the sudden escape of the liquor amnii, when you open the 
 membranes ? 
 
 The wrist should be enveloped in a napkin, and one 
 should also be applied to the perinaeum and vulva, so that 
 at the instant you burst the membranes, you may withdraw 
 the finger, and apply the napkin to absorb the discharge. 
 
 Should you change the saturated napkins privately ? 
 
 They should be either handed quietly to the nurse, or 
 laid secretly at the bottom of the bed-post without calling 
 aloud to any one about them. 
 
 Should you after this time keep any thing applied to the 
 breech of the patient to absorb the discharges ? 
 
 This should be done by applying successively folds of 
 a sheet, or better still, by changing napkins as fast as they 
 become saturated. By this plan, the patient is rendered 
 more comfortable. 
 
 If you rupture the membranes, at what period of a pain 
 should you do it ? 
 
 At the commencement of a pain. 
 
 Should the accoucheur interfere with the process of 
 labor, during the second stage ? 
 
 He should let it alone, if he have ascertained that the 
 position is correct. 
 
 Under what circumstances may you facilitate the pro- 
 gress of the head through tr\e pelvis ? 
 
 Provided flexion is not complete, you may apply the 
 finger against the side of the forehead, (not on the fonte- 
 nelle,) and pushing it up, facilitate the flexion. 
 
MANNER OF AIDING FLEXION AND ROTATION. 229 
 
 Which finger should be used ? 
 
 The index of the left hand, for the first and fifth posi- 
 tions, and that of the right hand for the second and fourth 
 positions. 
 
 When should the patient be encouraged to bear down ? 
 As soon as the os uteri is dilated, and the first stage 
 complete. 
 
 If she do not know how, what instructions should you 
 give her ? 
 
 To take in a full breath, and bear down the whole time 
 of a pain ; — to bend herself forward, &c. 
 
 Should she be careful to relax herself, as soon as the 
 pain is off? 
 
 This should be insisted upon in most cases. 
 
 What kind of drink should she have to revive her during 
 the second stage ? 
 
 Give her a drink of lemonade or toast water, and fan 
 her, &c. 
 
 How should you assist rotation, if the fetus require it ? 
 
 If in the first position, by passing the index finger of the 
 right hand over the parietal protuberance, and press from 
 behind forward : or what may be better, introduce the index 
 finger of the left hand, to the left temple of the child, and 
 press it from below backwards. 
 
 If in the second position, the left finger is to used in the 
 right parietal, or the right for the left temporal bone. 
 
 If in the fourth position, with a view to facilitate rotation 
 
 into the hollow of the sacrum, the left index finger is to be 
 
 applied to the left parietal bone, or the right to the right 
 
 temporal bone. 
 
 If in the fifth position, to rotate to the sacrum, the right 
 
 20 
 
230 OBSTETRIC CATECHISM. 
 
 index to the right parietal bone, or the left index to the 
 left temporal bone. 
 
 Suppose you are not certain of your diagnosis at this 
 stage of the labor ? 
 
 Do nothing until you are certain of the diagnosis, and 
 indications. 
 
 What is the proportionate force of the uterine contrac- 
 tions, during the labor ? 
 
 Inversely as the size of the organ. 
 
 When is the force of the contractions of the uterus at its 
 acme ? 
 
 When the presenting part is about to pass through the 
 genital fissure. 
 
 Is there any danger of rupture of the perinaeum in most 
 cases of labor ? 
 
 It has been known to rupture during the progress of 
 natural labor. 
 
 How must the perinaeum be supported ? 
 
 It is best done by the accoucheur, applying the palm of 
 his hand over the perinaeum, and keeping his wrist directed 
 towards the child's head. 
 
 What should be interposed between the hand and peri- 
 naeum? 
 
 A napkin which will receive the feces if any escape. 
 
 In what direction may the perinaeum be ruptured or 
 lacerated ? 
 
 From the fourchette backwards ; through the centre ; or 
 at the anus. 
 
 Is it ever necessary to resist the descent of the child, 
 when the perinaeum is in danger ? 
 It is, if the perinaeum is not relaxed, 
 
PROTECTION OF THE PERINEUM. 231 
 
 When is the greatest danger of laceration 1 
 At the moment that the parietal protuberances are passing 
 through the vulva. 
 
 When the head escapes, what attention should be given 
 in reference to the cord ? 
 
 To ascertain whether it is around the child's neck, and 
 if so, to loosen it by drawing upon the placental extremity 
 of it. 
 
 Should the head of the child be supported after its ex- 
 trusion ? 
 
 It should repose in an expanded hand of the accoucheur. 
 
 What attention should be given to the shoulders, if they 
 no not readily rotate ? 
 
 Assist the rotation by pressing the proper one under the 
 arch and the other into the hollow of the sacrum. 
 
 Under what circumstances may the accoucheur draw 
 a little upon the head ? 
 
 When the perinseum offers a strong resistance to the 
 exit of the shoulders. 
 
 In what direction should he draw upon the head ? 
 
 If a shoulder be thrown up behind the symphysis pubes, 
 the traction should be towards the sacrum, sufficient to 
 disengage the pubal shoulder ; but if this be already free, 
 the traction may be made in the direction of the axis of the 
 vagina. 
 
 Having cleared the shoulders from the grasp of the peri- 
 naeum, should you hasten the delivery of the rest of the 
 child ? 
 
 No ; its delivery should be rather retarded, in order to 
 allow the uterus to contract well upon it and the placenta. 
 
232 OBSTETRIC CATECHISM. 
 
 What should you do as soon as the bod)'' is extruded ? 
 Carry the child round and place it in such a position as 
 to be free from the discharges of the mother. 
 
 What attention does the mother require, as soon as the 
 
 child is born ? 
 
 Ascertain that the uterus is contracted. 
 
 /■ 
 
 How? 
 
 Place your hand on the abdomen, under a part or all of 
 the clothing, and then feel where the uterus is. 
 
 What is the difference in the mechanism of the second 
 position ? 
 
 The assistance which it requires, is to be given in a 
 direction opposite to that of the first, and with the left 
 hand. 
 
 Should you attempt to convert a third, into a first or 
 second position of the vertex ? 
 Yes ; whenever possible. 
 
 Suppose flexion does not take place, how could you 
 assist it? 
 
 By passing the finger of the right hand, up under the 
 arch of the pubes and applying it over the occiput and 
 drawing it down, or by passing up two fingers of the left 
 hand, one on each side of the frontal bones, and pressing 
 them backwards and upwards. 
 
 When you find some difficulty in converting the third 
 into the first or second, how should you proceed ? 
 
 Pass in the hand, and carry up the whole head during 
 absence of pain and then convert it. 
 
 In reference to the first or second position, howjfar back 
 
TRANSVERSE POSITIONS, ETC. 233 
 
 may the occiput be, to justify our considering it still a first 
 or second position ? 
 
 Very far back when still high in the pelvis. 
 
 Are transverse positions rare ? 
 
 They so rarely occur, as not to have a place in most 
 systems of midwifery. 
 
 Does the occiput or the vertex enter the superior strait 
 readily in the posterior varieties ? 
 
 It usually enters the superior strait, perhaps more readily 
 than when it is anterior. 
 
 What is the usual difficulty in the case in the course of 
 the labor ? 
 
 That of getting the flexion to take place, to a sufficient 
 degree. 
 
 How should you assist the flexion ? 
 
 By pressing against the forehead, or by passing a finger 
 into the rectum, and drawing the occiput forward if it 
 cannot be reached through the vagina. 
 
 Why is the perinaeum in greater danger in this than in 
 other cases ? 
 
 The occiput is applied to it with more force. 
 
 What do some scientific and experienced accoucheurs, 
 think a good rule in all cases of occipito-posterior position, 
 if diagnosticated early ? 
 
 Always to direct the occiput toward the anterior part of 
 the pelvis. 
 
 How would you convert a fourth into a second position ? 
 
 By pressing against the pubal side of the face with a 
 finger of the right hand, or upon the sacral side of the 
 occiput with the fingers of the left hand. 
 
 20* 
 
234 OBSTETRIC CATECHISM. 
 
 How would you convert a fifth into a first position ? 
 
 By pressing against the face, temple, or cheek ; or 
 against the sacral side of the occiput with the finger of the 
 left hand in the first, and of the right hand, in the second 
 instance. 
 
 What strong objection might be suggested against this 
 practice of artificial conversions ? 
 
 That the oblique position of the child originally, may 
 make it necessary that the neck be twisted more than one 
 third of a circle. 
 
 What is the result of experience on the subject ? 
 That no injury does arise from the practice. 
 
 What conversions should you make of the sixth position? 
 Into a fourth or fifth position : this conversion is some- 
 times spontaneous. 
 
 Where may you expect to find the fundus uteri after the 
 extrusion of the child ? 
 
 Most frequently in the umbilical or hypogastric region, 
 though occasionally it is met with in the left iliac fossa. 
 
 Suppose you find the uterus firm, should you feel 
 uneasy, however large it may be? 
 
 If it be very firm and somewhere below the umbilicus, 
 we perhaps should not feel uneasy, but if larger than that, 
 we should suspect twins. 
 
 Should the woman be expected to deliver herself of the 
 placenta ? 
 
 In the majority of instances the uterus spontaneously 
 expels it into the vagina. 
 
 How many pains does it usually require ? 
 Two, three, or four. 
 
DELIVERY OF THE PLACENTA. 235 
 
 Is it ever necessary to stimulate the uterus to contract, 
 to expel the placenta ? 
 
 It is sometimes necessary to do so by friction. 
 
 Should you ever pull at the cord, unless you are very 
 sure the uterus is well contracted ? 
 Never more than to draw the cord into a right line. 
 
 What danger attends the practice of strong traction upon 
 the cord. 
 
 Hemorrhage, inversion of the uterus, &c. 
 
 Under what circumstances may you assist by acting on 
 the placenta ? 
 
 When the uterus has remained some time torpid and will 
 not contract. The patient must be otherwise in good con- 
 dition, her pulse and respiration regular. 
 
 In what direction should you act upon the cord, or the 
 placenta ? 
 
 Always in the axis of the part of the pelvis in which the 
 placenta is situated. < 
 
 How is this to be done ? 
 
 By passing up a finger and allowing it to act as a 
 pulley. 
 
 In what direction when the placenta is in the vagina ? 
 
 In the axis of the vagina. In the axis of the inferior 
 strait, at first, and afterward along the plane of the peri- 
 naeum. 
 
 Should you ever hook your finger into the placenta, 
 when it comes within reach? 
 
 It may be proper to do so in case the mother does not 
 expel it. The accoucheur should always carry it back- 
 ward toward the sacrum and the perinaeum. 
 
236 OBSTETRIC CATECHISM. 
 
 When you get the placenta partially through the vulva 
 how should you act upon it to secure the delivery of the 
 membranes ? 
 
 Retard its expulsion from the vulva ; then rotate the 
 placenta upon its axis to twist the membranes into the 
 form of a cord. 
 
 What should you do in cases of inertia of the uterus ? 
 Stimulate the uterus to contraction. 
 
 By what means ? 
 
 By external frictions over the uterus, and by pinching it 
 up, as it were, through the parieties of the abdomen. 
 
 What kind of internal stimulants may be resorted to ? 
 
 Ergot may be administered, but as its effects are here 
 uncertain and slow, it would be best to pass a hand into 
 the uterus. 
 
 Should the placenta be squeezed ? 
 If the placenta be properly squeezed by the hand so 
 introduced, the uterus might be stimulated to action. 
 
 Does the presence of the coagula behind the placenta, 
 seem to retard its delivery ? 
 
 This has been regarded as one of the causes of delay in 
 its expulsion. 
 
 Does the contraction of the os uteri ever prevent the de- 
 livery of the placenta ? 
 
 This is probably a rather frequent cause of retention of 
 the placenta. 
 
 What varieties of contraction are there of the os uteri ? 
 That of the internal and that of the external os uteri. 
 How do you ascertain this ? 
 
 By the sense of touch upon introducing a finger within 
 the orifice. 
 
IRREGULAR CONTRACTIONS OF THE UTERUS, 237 
 
 Suppose the fundus and body are well contracted, how 
 long should you wait before you act to assist the delivery? 
 
 No time need be lost in making a reasonable attempt at 
 overcoming the contraction, and expediting the expulsion 
 of the placenta. 
 
 What hazards are known to result from the practice of 
 leaving the patient until spontaneous expulsion takes place ? 
 Irritation, inflammation, low fever, &c. 
 
 Should you ever leave your patient so long as the pla- 
 centa remains undelivered ? 
 
 She should not be left more than a few minutes at a 
 time, because, although in some cases no accident has 
 happened from a long continued retention, it is proper you 
 should guard against danger by proper attempts to remove 
 it. 
 
 What practice is best for relaxing the mouth of the 
 uterus, and for inducing the contraction of the fundus and 
 body? 
 
 Friction over the body of the uterus — the application of 
 cold— by sponges of cold water — by a stream of cold 
 water from a height, &c. 
 
 What should you do if external frictions and the use of 
 cold do not succeed ? 
 
 Pass in the whole hand and seize the placenta with the 
 fingers and bring it down ; provided, however, the inser- 
 tion of a single finger has not been sufficient to effect this 
 purpose. 
 
 What instrument may be used when the hand can not 
 be passed ? 
 
 Dewees' hook — or as he has called it, his wire crotchet. 
 
238 OBSTETRIC CATECHISM. 
 
 What objections to the use of this hook? 
 
 It would seem to be a dangerous instrument, as when 
 passed beyond the ringer, it may be hooked into the sub- 
 stance of the uterus. 
 
 What advantages do the uvula forceps of Dr. Bond offer ? 
 
 They may be safer than the hook of Dewees, but still 
 they are not always capable of being made to pass up on 
 each side of the placenta. 
 
 What advantages do Dr. Hodge's placental forceps 
 offer. 
 
 They can be introduced as one blade, and then one or 
 both of them made to revolve around the placental mass, 
 after which they act as common forceps. 
 
 What is the consequence of very violent contraction of 
 the body, as well as of the neck of the uterus ? 
 
 Prostration of the patient's strength, great exhaustion, 
 faintness, &c. 
 
 What should we rely upon most confidently, for the 
 relaxation of such spasm 1 
 Free doses of opium. 
 
 May contraction ever take place at the internal os uteri ? 
 It may, and perhaps most frequently does in cases of 
 retention of the placenta. 
 
 How should we overcome this constriction ? 
 
 By the gradual insertion of the fingers, and perhaps the 
 whole hand cautiously. In some cases bleeding and other 
 relaxing measures are necessary. 
 
 What other part of the uterus may become spasmodi- 
 cally contracted ? 
 
 Any other parts of the body of the uterus. 
 
ADHESION OF THE PLACENTA. 239 
 
 What is this peculiar contraction called, in which the 
 fibres of the middle portions of the body contract, while 
 the other portions remain somewhat relaxed ? 
 
 Hourglass contraction. 
 
 Is there danger of hemorrhage in this case ? 
 Hemorrhage may take place both above and below the 
 constricted part. This complication is probably rare. 
 
 Does this kind of accident require prompt attention ? 
 It should be attended to promptly, because it usually is 
 a case accompanied with much suffering. 
 
 What have you to do to overcome it ? 
 
 Induce the fundus by frictions to contract on the abdo- 
 men, and then introduce your other hand into the uterus, 
 and pass it up conically through the point of stricture. 
 
 Should you try to pull the placenta away instantly ? 
 
 Efforts should be made to extract it cautiously, and al- 
 low the contractions to take place regularly, as the mass 
 is removed. 
 
 How should you secure the regular contractions of the 
 uterus, while the hand is still in it ? 
 
 By proper frictions upon the abdominal parieties, over 
 the fundus of the uterus. 
 
 How should you effect the relaxation of the stricture, 
 if the means just proposed do not succeed ? 
 
 Put the patient into a warm bath, give her opiates, or 
 bleed her. 
 
 Is preternatural adhesion of the placenta very common ? 
 It is not by any means very common. 
 
 Is the diagnosis of such adhesion easy ? 
 It is not always easily made out. 
 
240 OBSTETRIC CATECHISM. 
 
 How should you act in a case of real or supposed ad- 
 hesion of the placenta ? 
 
 Pass up the hand in a conical form, and when you 
 reach the part, expand it. 
 
 Which portion of your fingers should you place in con- 
 tact with the uterus, in order to detach the placenta ? 
 
 The pulpy portion when you can, but this would be 
 difficult when the placenta is at the fundus. 
 
 Suppose the adhesions are very firm, should you at- 
 tempt to strip off the whole placenta from the surface of 
 the uterus ? 
 
 It should always be done when practicable, without in- 
 juring the substance of the uterus. 
 
 What consequences are to be expected from retention of 
 parts, or the whole of the placenta ? 
 
 Irritation, pain, inflammation of the uterus, and putre- 
 faction of the placenta, with the risk of the consequences 
 of absorption of pus. 
 
 How should you treat the case if putrefaction should 
 occur 1 
 
 Detergent washes, carried up into the cavity of the 
 uterus by a suitable syringe. 
 
 What kind of syringe should you use ? 
 
 One of the ordinary kind, which can be attached or in- 
 troduced into the end of a gum elastic catheter, which 
 should be carefully introduced into the cavity of the uterus, 
 and the fluid then passed from the syringe through it — or 
 a syringe having a long curved pipe, with a bulbous ex- 
 tremity, may be used for the same purpose. 
 
TREATMENT OF ADHERENT PLACENTA. 241 
 
 What kind of fluid should be injected into the cavity of 
 the uterus ? 
 
 That which is bland, mucilaginous, and detergent, as 
 flaxseed tea, solution of castile soap, &c. 
 
 Is the cord sometimes so tender as to be very easily 
 broken ? 
 It is in some cases. 
 
 What practice should you resort to for the purpose of 
 removing the placenta in the case of rupture of the cord ? 
 
 The fingers or the hand should be carefully introduced 
 within the vagina, and if necessary, within the cavity of 
 the uterus, and then cautiously embrace as much of the 
 mass as practicable, at the same time allowing the uterus to 
 expel it if possible ; if not, draw it gradually in the direc- 
 tion of the axis of the part through which it is to pass. 
 
 What is meant by the phrase of the lying-in chamber, 
 " clearing the woman ?" 
 
 The complete removal of the placenta with its mem- 
 branes, and of all the coagula and other discharges which 
 are to be found in the vagina and about the breech of the 
 woman, as well as the application of a soft dry napkin to 
 the vulva. 
 
 Is it proper to cut the cord immediately after tha child 
 is extruded? 
 
 It is better to wait until respiration, and the capillary 
 circulation are established. 
 
 Under what circumstances should we feel at liberty to 
 cut the cord ? 
 
 If the child cry, or respires freely, and a red or arterial 
 
 color may be seen on the face and other parts of the skin, 
 
 the division of the cord may be made with propriety. 
 
 21 
 
242 OBSTETRIC CATECHISM. 
 
 What is the object of applying a ligature upon the cord ? 
 To arrest the circulation in the cord, and prevent hemor- 
 rhage from its vessels when they are divided. 
 
 How many ligatures should you place upon the cord ? 
 
 One ligature only is necessary in the great majority of 
 cases ; some practitioners think it proper to apply two liga- 
 tures for the purpose of cleanliness, and to avoid the pos- 
 sible risk of hemorrhage in case of two placentas inoscu- 
 lating with each other. 
 
 At what distance from the abdomen should the ligature 
 be applied? 
 
 About two inches. 
 
 What precaution should you take in relation to the pos- 
 sibility of the occurrence of umbilical hernia ? 
 
 See that this does not exist, or if it does, apply the 
 ligature sufficiently far beyond it. 
 
 In what manner should you take up the child to give 
 it to the nurse ? 
 
 The best plan is to have a napkin so folded and applied 
 near the breech of the mother, that with one hand one of 
 its extremities can be placed under and support the head 
 as soon as it is extruded ; as the body passes out, these 
 folds are gradually expanded until the whole child is ex- 
 tended upon it. Then as soon as the cord is divided 
 the child is enveloped in this napkin, and thus easily lifted 
 to the receptacle helcl by the nurse, for as the child is 
 usually covered by a very slippery or pasty matter, it is 
 often difficult or disagreeable to handle it properly. If, 
 therefore, the napkin be not used, it will be found perhaps 
 most convenient to pass the palm of one hand behind the 
 thorax and nape of the neck, while the other is passed 
 
MODE OF RECEIVING AND DISPOSING OF THE CHILD. 243 
 
 under the thighs, and the legs embraced with the index 
 finger between them. It has been suggested as an im- 
 provement upon this method, to pass the palm of the hand 
 under the thorax, having its radial edge towards the chin 
 of the child, and thus raise it up from the bed to the re- 
 ceiver held by the nurse. The child is thus easily held by 
 the hand, and is thus for a moment kept in a position 
 nearly as much flexed as when in utero. 
 
 How should the nurse receive and dispose of the child ? 
 
 She should be provided with a large piece of flannel or 
 soft warm cloth, which she should present at the left side 
 of the accoucheur : she should then envelop the child and 
 retain it in her lap, or place it in some safe situation, till 
 she is prepared to wash and dress it. 
 
 What do you mean by an asthenic condition of the child 
 at birth ? 
 
 That it is feeble, the features are shrivelled and narrow, 
 resembling old persons. The child is blue, does not respire 
 freely ; its circulation is very feeble ; it groans, does not 
 cry, nor seem to make any effort to breathe, or if it 
 breathes, it does so very feebly. 
 
 How should you manage such a condition ? 
 
 Endeavour to stimulate its respiratory muscles by warm 
 bath, cold douches alternately ; by dry heat, slight friction 
 with the end of the fingers ; do not fatigue it, but wash it 
 with warm alcoholic fluids, then apply warm cloths ; assist 
 its respiration by blowing into its lungs, <fcc. ; give it barley 
 water, gum water, sugar and water, &c. ; do not let it be 
 fatigued with nursing ; take care not to weary it by dress- 
 ing ; wrap it in a warm flannel or in cotton wadding, to 
 accumulate animal heat as much as possible. 
 
244 OBSTETRIC CATECHISM. 
 
 What do you mean by asphyxia ? 
 A state of apparent death, in which the child is per- 
 fectly motionless, and either pale, or livid. 
 
 How many kinds of asphyxia do you recognise ? 
 Two ; simple, and congestive asphyxia. 
 
 What are the common causes of this state ? 
 Pressure in the passage through the pelvis. Pressure on 
 the cord or the placenta, by arresting the circulation, &c. 
 
 Is the brain of much importance during intra-uterine 
 life ? 
 
 It does not appear to be. The child is like a plant, ap- 
 pearing to have a mere vegetable existence while in utero. 
 
 What causes operate after to produce asphyxia ? 
 
 Compression upon the cord around the child's neck : 
 knots in the cord which may arrest its circulation. The 
 retention of the membranes over the child's head. The 
 floodings of the large quantities of the liquor amnii or 
 blood over the child. Suffocation under the bed clothes, 
 or by the membranes around the head. The respiratory 
 organs clogged with mucus, &c. 
 
 What evidences have we of the state of simple as- 
 phyxia ? i 
 
 Pallor, absence of blue blood on the surface, absence of 
 respiration. The breast, &c. may have a bluish appear- 
 ance, but other parts are pallid. 
 
 What evidences have we of the congestive state of as- 
 phyxia ? 
 
 The face is swollen and turgid with blood. There is 
 absence of respiration and circulation ; the whole surface 
 is more or less blue, and the extremities of the body cold. 
 
ASTHENIA AND ASPHYXIA. 245 
 
 Are these two distinct affections, or are they probably 
 degrees of the same condition ? 
 
 It is probable that they are but degrees of the same 
 state. 
 
 How should you treat asphyxia ? 
 
 Remove all mechanical impediments to the respiration 
 or circulation ; place the child free from the cloths, &c, 
 clear all mucus from about its glottis ; assist its respira- 
 tion, if it be able to swallow, give it a little fluid to wash 
 away the mucus. Keep the child connected with the 
 placenta as long as any circulation exists. Keep the body 
 warm, put it into a basin of warm water ; bring this to the 
 bed and lift the child into it, before the placenta is re- 
 moved ; then dry it at once by warm cloths ; when it comes 
 out, use free friction in this case, about the respiratory 
 muscles with towel or hand ; use brandy, alcohol, harts- 
 horne, liniments, and also stimulating injections : then 
 dash on some cold spirits, or cold water, then in a moment 
 wipe it off, and plunge it into the warm bath again, &c. 
 Imitate the process of respiration, by pressing the thorax 
 and abdomen, alternately with the head : some times 
 breathe into the lungs, pressing the larynx slightly against 
 the spine to prevent the air from passing through the eso- 
 phagus into the stomach, if you cannot soon succeed thus, 
 use the tracheal pipe or quill to convey the air into the 
 lungs. 
 
 How must this tube be used ? 
 
 Pass it along the side of the mouth and throat, over the 
 glottis, and then force in a small quantity of your own 
 breath. 
 
 What can be said of the value of galvanism or electri- 
 city in these cases ? 
 
 21* 
 
246 OBSTETRIC CATECHISM. 
 
 They have not generally succeeded, and the apparatus 
 is rarely at hand. 
 
 Are you speedily to abandon this treatment if your first 
 efforts do not succeed ? 
 
 By no means ; the efforts must be persisted in for half 
 an hour, an hour, or even more before relinquishing any 
 attempts to resuscitate it ; and after you have succeeded 9 
 oblige the nurse to keep up some frictions over the skin 
 for some time. 
 
 How would you treat the congestive form of the affec- 
 tion ? 
 
 The same as before, adding some care to diminish the 
 amount of blood in the veins of the child. Therefore, do 
 not tie the cord ; for if the symptoms be urgent cut the 
 vein at least, some say the whole cord, and thus let the 
 blood escape. 
 
 How much blood may you thus take away ? 
 From half an ounce to an ounce. 
 
 Are children ever born with tumors on the scalp ? 
 It not unfrequently happens that tumors of greater or 
 less size are found on the scalp. 
 
 Of what character are they ? 
 
 Generally bloody, and are of the character of ecchymo- 
 sis. 
 
 How are they formed ? 
 
 Most likely by the excessive pressure made upon the 
 body of the child within the uterus or pelvis, the blood is 
 squeezed out into that portion of the scalp which is not so 
 compressed. 
 
WASHING AND DRESSING THE CHILD. 247 
 
 May these tumors be supposed to be fractures of the 
 cranium ? 
 
 They may, and sometimes they strongly assimilate frac- 
 tures with depression of a portion of the bone. 
 
 Are fractures of the cranium often met with ? 
 They are not. 
 
 What should you do for the relief of the tumor? 
 Apply cold leadwater, &c. with a view to discuss it. 
 
 Should you use frictions ? 
 
 No : because by so doing you may excite inflammation 
 in the tumor. 
 
 Suppose it is inclined to suppurate, how should you 
 do? 
 
 Poultice it, and promote the formation of pus. 
 
 Should you open it freely ? 
 
 It should be freely opened, unless as happens in some 
 cases, absorption goes on very rapidly. If opened, it is 
 to be dressed as a simple suppurating wound. 
 
 Should the practitioner pay attention to the mode of 
 washing the child ? 
 
 He should carefully superintend this process. 
 
 How should the nurse get rid of the sebacious matter 
 which mostly covers it ? 
 
 By the free application of unctuous matter, the best of 
 which is animal oil. 
 
 What kind of soap should be used ? 
 
 It should be mild, bland, and not strongly alkaline. 
 
 Should the nurse use brandy, &c, on all occasions ? 
 
 It is by no means necessary on all occasions. It need 
 not be used unless the child is in a very feeble or asthenic 
 state. 
 
248 OBSTETRIC CATECHISM. 
 
 How should you dress the cord ? 
 
 Take a piece of linen about six inches square, cut it in 
 a central hole, through this draw the umbilical cord, then 
 fold this linen up in such manner as to envelope the cord 
 completely, keeping its cut extremely directed toward the 
 child's chin. A more simple method, and one which we 
 prefer to this, is, to take a piece of linen about four inches 
 wide and six long, and cut into the middle of its extremi- 
 ties, a slit about an inch long. Holding the cord at right 
 angles with the body, this slit is to be drawn from 
 above downward, to fit closely to the root of the cord. 
 This is then to be turned up toward the chin, one of the 
 lateral portions of the linen is to be turned over in front 
 of it, and then the other in the same manner. Next 
 raise the upper end of the cord, and fold these three lay- 
 ers of linen under it, until there will thus be seven thick- 
 nesses of the linen interposed between the cord and the 
 teguments of the abdomen. The balance of the linen folds, 
 if any, may be brought down in front of the cord. It 
 will in this manner be sufficiently isolated from the body of 
 the child, and the dressing can be easily renewed if neces- 
 sary. Over this, as in the other case, a roller of flannel, 
 just wide enough to reach from the axillae to the hips, is 
 to be fastened. 
 
 What is the object in thus enveloping the cord ? 
 
 To prevent the contact of it, as a putrefying mass, with 
 the surface of the abdomen, and thus cause great irritation 
 of the skin. 
 
 How long does this cord usually remain attached to the 
 umbilicus of the child ? 
 
 Three, to five or seven days, and in some few instances 
 even much longer than this. 
 
PUTTING THE MOTHER UP IN BED. 249 
 
 What is the principal object of the belly band or roller ? 
 Merely to support the cord in its proper situation, and 
 retain the dressings upon it. 
 
 Should you allow the nurse to pin the roller tight ? 
 It should never be pinned so tight as to interfere with 
 muscular motion, whether respiratory or otherwise. 
 
 How in other respects may the child be dressed ? 
 
 According to the desire of the mother or friends, pro- 
 vided the clothing be such as to keep the child sufficiently 
 warm, and allow it sufficient freedom of motion. 
 
 What should you allow the child to have after it is 
 dressed ? 
 
 The milk from the breast at once if possible, but if not, 
 it may be supplied with a few teaspoonsful of warm sugar 
 and water, till circumstances favor its application to the 
 breast of the mother. 
 
 What cautions should be observed in reference to the 
 placing of the woman in her proper situation in bed after 
 delivery ? 
 
 Every attention should first be paid to " clearing" the 
 woman — a soft napkin should be applied to her vulva — 
 the bandage should be put properly over the hypogastric 
 and pubic regions — she should then be carefully slided up 
 in bed, in the completely horizontal position, without be- 
 ing allowed to raise herself up. 
 
 Would you have her placed up in bed instantly after her 
 delivery ? 
 
 She should be allowed to remain quiet until her respira- 
 tion and circulation become tranquillized. 
 
 What dangers may arise from close compression of the 
 vulva by the napkin ? 
 
 It may arrest the discharge of the blood from the vagina, 
 
250 OBSTETRIC CATECHISM. 
 
 plug it up by a coagulum, and thus obscure hemorrhage in 
 some cases. The cloth should therefore be applied but 
 loosely to the vulva. > 
 
 When should there be a bandage or binder placed on 
 the abdomen of the woman ? 
 
 There should be a suitable bandage for the purpose of 
 supporting the abdomen after its sudden evacuation by de- 
 livery. 
 
 How wide should this be ? 
 
 Sufficient to reach from the trochanters upwards, to at 
 least the false ribs. 
 
 What dangers is the woman subject to, unless the ban- 
 dage is applied ? 
 
 Faintness, sense of exhaustion, inertia of the uterus, 
 hemorrhage, &c. 
 
 Would it be well to apply a compress under the ban- 
 dage? 
 
 It is proper to do so, with a view to compress the intes- 
 tines down upon the fundus of the uterus. 
 
 Should you pin on the bandage yourself? 
 It would be best for you to do so, with a view to have it 
 properly done. 
 
 Where should you begin to pin it ? 
 At the upper part of it. 
 
 What kind of bandage or binder should be used ? 
 
 A common towel is very suitable, but some are to be 
 found intended to fit to the back, and then over the ab- 
 domen. 
 
TREATMENT OF THE PATIENT. AFTER PAINS. 251 
 
 Should you keep the patient in the horizontal position 
 for several days ? 
 
 This should be done to avoid the risk of hemorrhage or 
 of prolapsus, &c. 
 
 What kind of diet may she be allowed ? 
 Very light — as gruel, panada, barley water, toast water, 
 crackers, &c. 
 
 What kind of drinks should she have, and at what tem- 
 perature should they be administered? 
 
 Cool, simple drinks. If feverish, water with swee 
 spirits of nitre. 
 
 What regulations should you enjoin about company? 
 
 None should be admitted for a day or two, until the pa- 
 tient is well rested, and even then the visitors should not 
 be allowed to disturb her tranquillity. 
 
 Is the woman subject to pains subsequent to delivery ? 
 
 Most women recently delivered, except those with their 
 first children, have attacks of spasmodic uterine pain, a 
 short time after delivery. 
 
 What is their character ? 
 
 They are spasmodic, alternate, and neuralgic. 
 
 What is the usual cause ? 
 
 Some think they are owing to the presence of coagula in 
 the uterus. 
 
 Do they ever depend upon the particular condition of 
 other organs ? 
 
 They sometimes no doubt depend upon certain condi- 
 tions of the stomach, bowels, and even bladder. 
 
 Should you always enquire into the cause before pre- 
 scribing for them ? 
 
 This should be done with much care, as the indication 
 of treatment diners greatly. 
 
252 OBSTETRIC CATECHISM. 
 
 How should you treat them, when they depend upon 
 the condition of the nervous system ? 
 
 They should be allayed by anodynes, the best of which 
 are camphor, morphia, &c. 
 
 Should you ever direct warm injections for the relief of 
 after pain ? 
 
 Whenever they appear to depend upon the existence of 
 any irritation in the bowels, as flatulence, faeces, &c. 
 
 Are there any cases in which vascular depletion becomes 
 useful ? 
 
 Whenever there is a plethoric or feverish condition of 
 the system. 
 
 Is it ever necessary to evacuate the bladder by the 
 catheter ? 
 
 It is necessary to ascertain the condition of the bladder, 
 and if full, relieve it by the catheter. 
 
 Are there any cases of misplaced after pains ? 
 When pains attack the region of the coccyx, the knee, or 
 other joints, they may be so considered. 
 
 How would you treat this variety ? 
 By the free use of anodynes. 
 
 Are after pains ever dependant upon want of tonic con- 
 traction of the uterus ? 
 
 They probably mostly depend upon inefficient contrac- 
 tion of the uterus ; and are, therefore, to be obviated by 
 procuring the complete contraction of the organ. They 
 are often prevented, or if they occur, may be often relieved 
 by free, long continued friction over the uterus soon after 
 delivery. 
 
PELVIC PRESENTATIONS. 253 
 
 Are pelvic presentations to be regarded as dangerous for 
 the child ? 
 
 They are to be so regarded, because of the liability of 
 the head to be arrested in the pelvis of the mother, alter 
 the body is extruded. 
 
 Why are they unfavorable for the mother ? 
 
 Because of the usual delay in the first and second stages 
 of the labor, and the consequently greater amount of physi- 
 cal exertion which is necessary for her to complete it* 
 
 Why are they more dangerous for the child ? 
 
 Because during the second stage, the child is far more 
 liable to be fatally compressed, both as regards the cord, 
 and the delay of respiration while the head is within, and 
 the body without the uterus; 
 
 How are you to diagnosticate breech presentations ? 
 
 The os uteri and bag of waters are not quite so large as 
 iri the cephalic presentations ; the finger can usually detect 
 a sulcus between the limbs ; sometimes, also, the genital 
 organs can be felt, but a still more conclusive evidence 
 presents, when in passing up the finger, you can feel the 
 crista of an ilium and the fold in the groin. 
 
 Does the presence or the absence of the meconium af- 
 ford any value in the diagnosis ? 
 
 Usually it does not, because it is not always present iri 
 pelvic presentations ; whereas it is sometimes found de- 
 posited within the inferior portion of the ovum in some 
 cases of cephalic presentation. 
 
 How are pelvic presentations divided ? 
 
 Into regular and irregular presentations— or into breech, 
 
 feet, and knee presentations. 
 
 22 
 
254 OBSTETRIC CATECHISM. 
 
 Which of these are regarded as irregular and unfavour- 
 able ? 
 
 Those of the feet and the knees. 
 
 What is the first change which the uterus effects upon 
 the form of the child in cases of breech presentations ? 
 Still greater flexion into the form of an ellipse. 
 
 What are the different varieties or positions of the pelvic 
 presentations ? 
 
 For all practical purposes four are sufficient, but some 
 teachers make six, taking the sacrum for the occiput, and 
 the posterior part of the thighs for the anterior fontanelle. 
 
 What then is the first position of the breech presentations? 
 The sacrum to the left acetabulum, and the posterior part 
 of the thighs to the right sacro-iliac symphysis. 
 
 What the second ? 
 
 The sacrum to the right acetabulum, and the posterior 
 part of the thighs to the left sacro-iliac symphysis. 
 
 What the third ? 
 
 Thfi sacrum to the symphysis, and the posterior part of 
 the thighs to the sacrum of the mother. 
 
 What the fourth ? 
 
 The sacrum to the right sacro-iliac symphysis, and the 
 posterior part of the thighs to the left acetabulum. 
 
 What the fifth ? 
 
 The sacrum to the left sacro-iliac symphysis, and the 
 posterior part of the thighs to the right acetabulum. 
 
 What the sixth? 
 
 The sacrum to the sacrum, and the posterior part of the 
 thighs to the pubes of the mother. 
 
MECHANISM OF PELVIC PRESENTATIONS. 255 
 
 What is the mechanism of labor in the first position of 
 breech presentation ? 
 
 How does rotation take place in this case ? 
 
 The left hip is carried along the right anterior inclined 
 plane, and the right along the left posterior to the median 
 line of the sacrum and coccyx. 
 
 Which hip comes under the symphysis pubes in the 
 first position ? 
 The left hip. 
 
 Do the shoulders rotate in the uterus at the same time 
 that the hips rotate in the pelvis ? 
 
 They are believed to remain fixed in the uterus. 
 
 Is the diagnosis of pelvic presentations easy ? 
 
 Generally so ; the bag of water is usually smaller, and 
 the presenting part is softer than the head ; moreover there 
 is a sulcus between the limbs. The crest of the ilium, and 
 the fold in the groin, aid greatly in making out breech 
 presentations. 
 
 In what direction does flexion take place after the hips 
 are delivered ? 
 
 Laterally, to accommodate the body to the axis of the 
 pelvis. 
 
 Does restitution of the hips take place ? 
 In many cases this does occur. 
 
 How are the shoulders delivered ? 
 
 One of them passes on the anterior inclined plane, to 
 appear under the arch of the pubes, while the other passes 
 along the posterior inclined plane, to appear in front of 
 the coccyx. 
 
 What effect has the rotation of the shoulders upon 
 the neck of the child ? 
 
 It twists the neck of the child one sixth of a circle. 
 
256 OBSTETRIC CATECtfJSM. 
 
 Does restitution of the shoulders take place after they 
 are delivered? 
 
 It does, unless some resistance be applied to the body. 
 
 Is it important that the head should present in a par- 
 ticular direction, for its safe delivery. 
 
 It is highly important that the head present its occipito- 
 mental diameter, to the axis of the pelvis. 
 
 What hazard may result if the practitioner draw forcibly 
 on the body of the child, as soon as it is delivered ? 
 
 The direction of the head may be so altered, that the 
 occipito-mental diameter, instead of corresponding with the 
 axis of the pelvis, becomes thrown across, to correspond 
 with one of its diameters, and thus its delivery would be 
 impracticable, 
 
 In what direction would the unaided efforts of the uterus 
 and abdominal muscles, force down the head after the 
 body is expelled ? 
 
 Generally with its occipitofrontal or occipito-mental di- 
 ameter to the plane of the inferior strait. 
 
 In what direction should the body of the child be car- 
 ried, to favor the ready engagement of the head in the in- 
 ferior strait ? 
 
 In all the anterior varieties of pelvic presentation, the 
 body should be properly wrapped in a napkin, and carried 
 up towards the front of the abdomen of the mother. In 
 the posterior varieties, the body is in the same manner to 
 be depressed towards the sacrum of the mother. 
 
 Is there any difference in the mechanism of the second 
 position of the breech ? 
 
 There is no essential difference except that the rotation 
 takes place in an order reversed from that in the first posi- 
 
MECHANISM OF PELVIC PRESENTATIONS. 257 
 
 lion ; that is, the right hip and shoulder rotate on the left 
 anterior, and the left hip and shoulder on the right poste- 
 rior inclined planes, and the occiput on the right anterior 
 inclined plane. 
 
 What is the usual mechanism of the labor in the third 
 position of the breech ? 
 
 Although the breech may engage with the sacrum to the 
 pubis at the superior strait, the hips and shoulders are 
 mostly twisted upon the inclined planes, and thus come 
 down obliquely, and finally present one to the coccyx, 
 and the other to the pubes at the inferior strait. 
 
 Is the head in any greater danger of being arrested at 
 the superior strait in the third, than in either the first or 
 second positions ? 
 
 The occipito frontal diameter may become wedged in 
 the antero-posterior diameter of the superior strait, and 
 thus require manual or instrumental assistance to disen- 
 gage it. 
 
 What is the mechanism of the fourth position of the 
 breech ? 
 
 Here the sacrum is to the right sacro-iliac symphysis, 
 the right hip toward the right acetabulum, and the left one 
 toward the left sacro-iliac symphysis ; as the child de- 
 scends, the left hip is carried down the left posterior in- 
 clined plane, and the right hip down the right anterior in- 
 clined plane to the arch of the pubes ; the shoulders follow 
 the same route, the occiput is driven down along the right 
 posterior inclined plane to the middle line of the sacrum 
 and coccyx, to eseape at the posterior commissure of the 
 vulva. 
 
 22* 
 
258 OBSTETRIC CATECHISM. 
 
 What is the principal difficulty in this case, and that of 
 the fifth and sixth positions ? 
 
 The liability of the head to become arrested at the supe- 
 rior strait in consequence of the chin being carried back 
 by the forced curvature of the thorax. 
 
 Is there any essential difference in the cases of presenta- 
 tion of the feet and breech ? 
 
 There is nothing essential in the mechanism of the labor, 
 except that as the first stage is shorter, the second is 
 usually more protracted. 
 
 Is the child subjected to any greater risk of its life in 
 this than in breech presentations ? 
 
 It is so, in consequence of the degree of compression 
 of the body, thorax, and neck, which are compressed by 
 the soft parts of the mother. 
 
 Why are the shoulders likely to be delivered with 
 greater difficulty in this than in breech cases 1 
 
 Because as the feet or knees make their exit through 
 the os uteri before it is much dilated, and then meet with 
 little resistance to their descent in the pelvis, the os uteri 
 is liable to embrace the arms and shoulders, and thus pre- 
 vent their ready descent. 
 
 How are knee presentations calculated ? 
 
 The anterior part of the legs compare with the occiput 
 or the nape of the neck, and the anterior part of the 
 thighs with the anterior fontanelle in cephalic presenta- 
 tions. 
 
 What is the best direction to be given to the patient 
 during the first stage of labor in reference to her bearing 
 down? 
 
 As it is desirable to prolong the first stage of labor in all 
 
MANAGEMENT OF THE EARLY STAGE. 259 
 
 the pelvic presentations especially, she should be urged 
 not to bear or force down. 
 
 Suppose you find her strongly disposed to do so, what 
 precautions should you take not to allow the membranes 
 to be ruptured too early ? 
 
 Oblige her to lie down ; if she have intestinal or vesical 
 irritation, calm them by anodyne enemata ; if she cough, 
 tranquillize it by some suitable anodyne. 
 
 When you diagnosticate any of the pelvic presentations, 
 should you make any effort to deliver the child while it is 
 yet in the uterus ? 
 
 Never, unless some accident should complicate the 
 labor, as convulsions, hemorrhage, &c, and then, not 
 unless the os uteri be sufficiently dilated. 
 
 When the hip descends should you be careful to ascer- 
 tain whether it rotates ? 
 
 Although rotation of the hip is of less importance than 
 that of the occiput, yet it is proper that you should secure 
 the rotation of the hip as it passes through the pelvis. 
 
 Should you use any traction effort on the child at this 
 time ? 
 
 None whatever ; it would be generally safer for you to 
 retard the descent of the child, that the os uteri may be- 
 come freely dilated. 
 
 Should you support the perinaeum at this period ? 
 
 You should ; not so much however to prevent its being 
 lacerated as by this means to delay the descent of the 
 child. 
 
 Should you do any thing more than to support the child, 
 and the perinaeum at this time ? 
 
 Nothing more than this ; no traction should be made on 
 any part of the child, unless it be to assist rotation. 
 
260 OBSTETRIC CATECHISM. 
 
 When the body is delivered as far as the umbilicus* 
 what attention should you give to the cord ? 
 
 Draw out a fold of it to prevent it from being put too 
 forcibly upon a stretch. 
 
 Suppose you find it compressed, how should you 
 manage it ? 
 
 Endeavour to raise up the part which compresses it, 
 then carry the cord to a part of the pelvis in which there 
 will be more space. 
 
 Which arm or shoulder is usually delivered first ? 
 That which passes over the sacrum ; though this rule is 
 not invariable. 
 
 What is the best mode of supporting the body of the 
 child when it has been delivered, and while the head is 
 still in the pelvis ? 
 
 Covered by a napkin, and resting longitudinally upon 
 your arm. 
 
 When the head is about to emerge, can you aid it to 
 any advantage by the use of the finger ? 
 
 Aid, always important, and sometimes indispensable, 
 can, and ought to be afforded at this time. 
 
 Is it proper to pull the body forcibly in a horizontal 
 line with the view to expedite the delivery of the head ? 
 
 Never ; the body must be carefully carried in such a 
 direction as to favour the occipito-mental diameter of the 
 head to retain the direction of the axis of that part of the 
 pelvis in which it is situated. 
 
 How should this be done ? 
 
 In the anterior varieties, carry the body of the child 
 over the abdomen of the mother; in the posterior varieties, 
 depress the body of the child, or carry it round towards 
 her back. 
 
DELIVERY OF THE HEAD, ETC. 261 
 
 Should you be much disturbed by the occurrence of the 
 third position of the breech ? 
 
 Inasmuch as we can have considerable command over 
 the rotation of the child's shoulders by proper manipula- 
 tions upon the breech, we should apprehend little incon* 
 venience from this position, 
 
 Should you interfere with it before the breech has de- 
 scended into the cavity of the mother's pelvis ? 
 
 No ; it is quite unnecessary to interfere at all until the 
 breech has fairly entered the cavity of the pelvis. 
 
 What assistance should you then offer ? 
 Assist or compel rotation on to one of the anterior 
 planes to convert it into the first position, 
 
 Is it probable that the direction of the head is modified 
 by the rotation of the shoulders as it descends into the 
 strait? 
 
 This idea is entertained by some who do not concede 
 that in rotations of the head in cephalic presentations the 
 shoulders are not modified by such rotation. 
 
 What is the mechanism of breech presentations in the 
 posterior positions ? 
 
 The contractions of the uterus, impel the right hip, (if 
 we take the fourth position as the type of these posterior 
 varieties,) along the right anterior inclined plane towards 
 the arch of the pubes, while the left hip is driven along 
 the left posterior inclined plane to the middle line of the 
 sacrum to become the sacral hip and usually to be deliver- 
 ed first. The body is then carried down in a state of 
 lateral flexion, until the right shoulder is carried down on 
 the right anterior, and the left on the left posterior inclined 
 plane, to be delivered at the vulva. There is then a dispo- 
 
262 OBSTETRIC CATECHISM. 
 
 sition for restitution to the oblique position which the 
 head occupies ; that is, with the spine towards the poste- 
 rior part of the right thigh, and the umbilicus towards the 
 anterior portion of the left thigh ; but the occurrence, or 
 non occurrence of this will depend upon the manner in 
 which the body is supported on the hand of the accouch- 
 eur, or on the bed of the mother. As the fetus is now 
 chiefly or entirely beyond the reach of uterine action, the 
 voluntary powers of the mother mainly drive down the 
 head of the child with its occiput on the right posterior in- 
 clined plane to pass on the perinamm, while the chin, 
 mouth, nose, eyes, forehead, and bregma successively 
 escape under the arch of the pubes. 
 
 Is it safe for you to attempt rotation in a direction op- 
 posite to that which it would spontaneously take, and thus 
 convert it into an anterior position ? 
 
 Some practical accoucheurs think it safe and easy after 
 the shoulders are delivered. 
 
 At what part of the pelvis can this forced rotation be 
 effected ? 
 
 While in the cavity, and not in either of the straits of 
 the pelvis. 
 
 What should you do with a sixth position of the pelvis ? 
 
 Endeavour first to convert it into a fourth or fifth, and 
 when the shoulders are delivered, "by the aid of the fingers 
 convert it into a first or second position. 
 
 Why can we do this with greater safety than in cases 
 of original cephalic presentations ? 
 
 Because we are in these cases able to modify the direc- 
 tion of the body to that in which we force the head. 
 
MANAGEMENT OF FEET PRESENTATIONS. 263 
 
 What is an important rule, in reference to feet cases ? 
 Not to facilitate the descent of the feet until the first 
 stage is completed. 
 
 Suppose the heels of the child are situated in contact 
 with the breech, should you pull down the feet ? 
 
 No ; you should retard the delivery in the first stage, 
 keeping up the feet, to allow the breech, &c, to descend 
 and dilate all the soft parts. 
 
 Of what principles of the healing art, is the practitioner 
 of midwifery to avail himself, in the management of diffi- 
 cult labors ? 
 
 Both medical and surgical principles, viz : those which 
 are strictly medical, by which he is to overcome difficul- 
 ties by the use of agents generally administered internally ; 
 and those which are strictly surgical, manual, or instru- 
 mental ; in which the obstacle is overcome, or aid rendered 
 by the hand alone, or by the hand and appropriate instru- 
 ments. 
 
 What circumstances may complicate labor, and render 
 medical or surgical aid, or both, necessary ? 
 
 Rigidity of the os uteri, or of the external organs, or of 
 both : hemorrhage from some part of the body, particularly 
 from the uterus ; convulsive movements of the nervous 
 and muscular systems ; inertia of the uterus, <fcc; mal-posi- 
 tions of the fetus ; deformities of the pelvis ; the existence 
 of tumors within it, &c. 
 
 What has the accoucheur to do in these cases ? 
 
 To temporize and use medical means in the cases of 
 rigidity, but he must use the hands or instruments, or both, 
 in the other varieties of complication. 
 
264 OBSTETRIC CATECHISM. 
 
 What is the character of the medical means to be used ? 
 Such as overcome rigidity when it exists* and such as 
 stimulate the uterus when necessary. 
 
 What are operations by the hand called ? 
 Manoeuvres or manipulations. 
 
 How are the instruments used in obstetricy classified ? 
 
 1. Those which do not injure mother or child : 2. Those 
 which destroy the child, for the benefit of the mother : 3. 
 Those which subject the life of the mother to risk with a 
 view to save the child alive. 
 
 What complications of labor require the use of the 
 hand ? 
 
 Those in which there are slight deviations of position ; 
 and those in which hemorrhage, or convulsions occur. 
 
 What function does the hand usually perform ? 
 The correction of the presentation ; or position, ver- 
 sion, &c. 
 
 What do you mean by version by the head ? 
 That movement by which the head is restored from a 
 deviated to a proper position. 
 
 What is meant by version by the vertex ? 
 
 That movement by which a deviation of a vertex presen- 
 tation is corrected, or reconverted to a true and favorable 
 vertex presentation. 
 
 This term applies especially to the correction of deviated 
 positions of the head simply, while version by the head, 
 usually means the bringing of the head to the axis of the 
 pelvis when some other part of the child has been pre- 
 senting. 
 
 What do you understand by the phrase version by the 
 feet ? 
 
MANIPULATION-VERSION. 265 
 
 That operation by which the hand is introduced into the 
 uterus, and the feet seized and brought down by it. 
 
 Which variety of version is most common in this 
 country ? 
 
 Version by the feet. 
 
 Which is to be preferred, when either version by the 
 head, or by the feet, is accomplishable ? 
 
 That by the head by far, as the subsequent delivery is 
 more natural and safe. 
 
 What inconveniences does the mother usually suffer 
 from an effort by the accoucheur to make version ? 
 
 Pain, risk of hemorrhage and the rupture of the uterus, 
 or other injury to it. 
 
 To what risks is the child subject, by version by the 
 feet? 
 
 It may suffer from being too severely twisted upon its 
 spine ; and also, all the inconvenience of original feet or 
 breech presentations. 
 
 Is version by the head or feet, to be resorted to with a 
 great deal of care ? 
 
 It must so, and with calculation of the capability of the 
 mother to bear it. 
 
 Should you obtain a consultation on the propriety of it, 
 if possible ? 
 
 You should, whenever it is practicable without hazardous 
 delay. 
 
 What condition of the os uteri must exist before it will 
 
 be admissible to perform version ? 
 
 That of dilation, or facility of dilation. 
 
 23 
 
266 OBSTETRIC CATECHISM. 
 
 What are you to do until this state of the os uteri is 
 obtained ? 
 
 Temporize by using proper medical treatment if any be 
 indicated. 
 
 Is it admissible to make version, after the head has 
 passed the os uteri ? 
 
 Never — you should operate as soon as possible after the 
 first stage is completed. 
 
 What dangers attend any attempt at this operation under 
 such circumstances, that is, when the head has been driven 
 out of the uterus ? 
 
 The uterus may be ruptured, and the soft parts within 
 the pelvis may be injured ; the child's head may also be 
 wounded. 
 
 At what moment can you proceed to this operation with 
 the best effect ? 
 
 Directly that the first stage of labor is complete, or the 
 os uteri sufficiently dilated to admit the passage of the 
 hand and arm. 
 
 What position should the patient be placed in for the 
 purpose of making version ? 
 
 On her back, with her hips over the edge of the bed, and 
 her feet properly supported. 
 
 Why would you have her brought to the edge of the 
 bed? ' 
 
 To allow room for the ready movements of the accou- 
 cheur in introducing his hand and part of his arm. 
 
 How should the patient's feet be disposed of? 
 
 They should be placed out on chairs or any convenient 
 staging which may enable her to keep them on a level 
 with her hips. 
 
ARRANGEMENTS FOR VERSION. 267 
 
 What position is the accoucheur to assume for the pur- 
 pose of passing the hand ? 
 
 One in front of the patient and which js more easy to 
 himself. 
 
 What attention should be given to the dress of his 
 person, to prepare for this purpose ? 
 
 He should lay off his tight coat, roll up his shirt-sleeves, 
 then put on a night-gown, or some other loose cover, with 
 as little display as possible. 
 
 How are the parts of the patient to be prepared ? 
 They should be well lubricated with some mucilage or 
 animal oil. 
 
 What calculation has the operator to make previously to 
 passing the hand ? 
 
 That by which he determines what is the position of the 
 different parts of the child, what alteration he has to make, 
 and which hand he must use to effect this object. 
 
 What is the rule in reference to the hand which must 
 be used ? 
 
 That which corresponds to the side to which the occiput 
 presents, provided the object is to make version by the 
 vertex. 
 
 What are the different steps of the operation? 
 
 First, the lubrication of the hand and soft parts ; next, 
 the dilatation of the genital fissure and vagina ; then the 
 passage of the hand into the os uteri ; next the seizing of 
 the head ; and lastly, its version. 
 
 How are you to dilate the vulva ? 
 
 By the gradual introduction of the hand in a conical 
 shape, and the point of the thumb bedded between the 
 fingers. 
 
268 OBSTETRIC CATECHISM. 
 
 What position should the hand be in ? 
 In a state of semipronation. 
 
 What is this movement technically called ? 
 Introduction. 
 
 In what condition of the patient are you to make this 
 introduction ? 
 During a pain, 
 
 In what position are you to carry the hand when intro- 
 duced? 
 
 In that of supination. 
 
 What general direction are the thumb and fingers to 
 assume ? 
 
 Thumb to the pubes, fingers to the sacrum. 
 
 In what condition of the patient are you to make the 
 rest of the manoeuvre ? 
 In the absence of a pain. 
 
 How do you seize the head ? 
 
 First, place your hand against the part within the supe- 
 rior strait, push it up in the axis of the superior strait, and 
 slide your hand under it or a little to the side of it — then 
 embrace ^he head, and carry the chin over to the iliac fossa, 
 opposite that in which the occiput is situated ; then let it 
 descend. 
 
 How should the other hand be employed at this time ? 
 It should be applied over the fundus of the uterus, to 
 support it properly. 
 
 What are the objections to this version by the head ? 
 The difficulty of seizing the head. 
 
 Should you attempt this version in all cases ? 
 It will be safe to resort to it, only when the head is 
 readily within the reach of the hand. 
 
RULE FOR THE USE OF THE PARTICULAR HAND. 269 
 
 When the head is well situated, but some accident has 
 happened to the mother, should you resort to the version 
 by the feet ? 
 
 Remembering the dangers of version, better use the for- 
 ceps if practicable. 
 
 What is the rule for the use of the particular hand in 
 version by the feet ? 
 
 Use that hand, the palm of which would correspond to 
 the abdomen of the child, and which in withdrawing it, 
 having hold of the feet, will keep the body in a state of 
 flexion during the whole version. 
 
 How are you to proceed to make the version by the feet ? 
 
 First, introduce the hand properly during a pain ; next, 
 press up the head, and pass the palm of the hand along 
 the front and one side of the child, over the whole body to 
 the breech, then cause it to descend upon the thighs and 
 legs, and next embrace the feet, retain these in the hol- 
 low of the hand until they are brought down into one iliac 
 fossa, or into the cavity of the pelvis— then slip the index 
 finger between them, retaining the heels in the palm of 
 the hand, until they are completely beyond the vulva. 
 
 Can you always seize both feet in this case ? 
 Though a skilful operator can mostly do so, it is not 
 always practicable. 
 
 How must you act if you have but one foot ? 
 
 Draw it carefully downward, in the direction of the axis 
 of the pelvis, at the same time adducting it towards the 
 other as much as possible. 
 
 How can you secure the foot drawn out, while you 
 search for the other ? 
 
 Pass a noose of a soft band or fillet upon it, and let the 
 loose extremities of the fillet remain out of the vulva. 
 
 23* 
 
270 OBSTETRIC CATECHISM. 
 
 Is it always necessary to reach the second foot? 
 It is not always necessary to search for this, if it is not 
 easily found. 
 
 What rule should be observed in reference to bringing 
 the back part of the feet to the anterior part of the pelvis ? 
 
 Always to do this, because of the much greater facility 
 of subsequent delivery of the head. 
 
 How is this to be effected ? 
 
 By acting upon the pubal leg more than on the other. 
 
 Into what position of the feet do you change a first 
 cephalic position ? 
 
 To the second, and not to the fourth position of the 
 feet. 
 
 How are you to do this ? 
 
 By acting most on the pubal [eg. 
 
 Into which position should you bring the feet, when 
 you use your right hand for version ? 
 First position. 
 
 In which position does the left hand bring down the 
 feet? 
 
 Into the second position of the feet. 
 
 What should you do when you have delivered the body 
 as far as the umbilicus. 
 
 Draw out a fold of the cord of sufficient length, to pre- 
 vent it from being ruptured. 
 
 Is it necessary for you to continue to aid the delivery of 
 the child, after you have made version or mutation ? 
 
 It is usually necessary, at least to such an extent as en- 
 ables you to assist the proper rotation of the hips, shoul- 
 ders and head. 
 
MANAGEMENT OF THE ARM?. 271 
 
 If you find the arms do not descend with the body of 
 the child, can you do any thing to encourage their descent? 
 
 Suspend the tractive effort, resist for a few moments, 
 the descent of the body, and let the uterus force down the 
 arms if possible. 
 
 Suppose however this does not occur, how are you to 
 act to get down the arms ? 
 
 Carry the body to the side, so as to admit of the intro- 
 duction of the fingers up to the elbow, and bring down 
 first the sacral, and next the pubal arm, in the proper di- 
 rection for flexion at the elbow. 
 
 Which way are you to direct the movements of the 
 arm ? 
 
 Always over the anterior portions of the child's head, 
 thorax, and abdomen. 
 
 Suppose the arms are locked behind the occiput of the 
 child, how would you disengage them ? 
 
 Press up the head during the absence of a pain, and 
 with the points of your fingers, carry the elbow over the 
 side of the head and face, and then over the thorax. If 
 you cannot succeed with your fingers, use the blunt hook, 
 as a lever for this purpose. 
 
 Suppose the shoulders delivered, and the head do not 
 advance readily, what attentions are necessary, to assist 
 its delivery ? 
 
 Instead of making traction effort at once, rather press 
 up the shoulders to the vulva, and carrying the body back- 
 wards, you pass up a finger upon the occiput and press 
 it forward ; or what would be still better, act upon the 
 chin or the malar bones by the fingers, to bring them more 
 forcibly forward. 
 
272 OBSTETRIC CATECHISM* 
 
 Would you depend much pressure upon the chin ? 
 Usually little can be gained by this plan, as the lower 
 jaw yields very readily to slight pressure downwards. 
 
 What points of the face are more to be depended upon 1 
 The malar bones, if they can be reached, as they are 
 not yielding as the lower jaw. 
 
 Suppose you fail in this, what other manual resource 
 have you ? 
 
 Apply the fingers of the other hand upon the occiput^ 
 and act upon it simultaneously. 
 
 Suppose when the head is fairly engaged in the inferior 
 strait, and it becomes arrested, what instrumental means 
 becomes necessary for its relief? 
 
 The forceps. 
 
 Is it well for you to be provided with forceps in cases 
 of pelvic presentations ? 
 
 It would be proper for you to have them at com* 
 mand in all cases of pelvic presentations, whether original 
 or rendered such by version, that the delivery of the 
 head may be effected as rapidly and as safely as possible. 
 
 Are there any cases of original foot presentations, in 
 which it is necessary to bring down the feet ? 
 
 Yes, cases of inertia, &c. , 
 
 Suppose it becomes necessary to bring down the feet 
 in original breech presentations, how would you proceed 
 to do it ? 
 
 The soft parts being sufficiently dilated, introduce the 
 proper hand, push up the breech if necessary, then pass it 
 along the thighs to the knees, descend upon the legs and 
 seize the feet. 
 
DEVIATED BREECH PRESENTATIONS. 273 
 
 Which hand should you use ? 
 
 That, the palm of which looks to the abdomen, or the 
 back part of the thighs of the child. 
 
 Do you bring down the feet in the same position at 
 which the breech was situated ? 
 
 This would always be right, as forced rotation can in 
 such cases, if necessary, be effected by acting upon the 
 legs, when they are brought down. 
 
 Are breech presentations liable to any deviations of po- 
 sition ? 
 
 They are ; hence we may have presentations of the sa- 
 crum, or either one of the ilia, &c. 
 
 Do deviations of the breech usually become rectified 
 spontaneously? 
 Usually they do. 
 
 Suppose however there should be great delay in the 
 descent of the breech, should any attempts be made to 
 rectify them ? 
 
 It would be proper to facilitate the delivery, by rectifying 
 the position. 
 
 What is the rule, in reference to the use of the hand in 
 these deviated positions of the breech ? 
 
 Pass up that hand the palm of which will look towards 
 the abdomen of the child. 
 
 Can you ever bring down the feet to any advantage ? 
 
 The advantages of this manipulation would rarely be 
 commensurate with the risk of attempting it, unless the 
 breech is high up and the child easily moveable in the 
 uterus. 
 
 Suppose the labor be far advanced, and the arrest takes 
 
274 OBSTETRIC CATECHISM. 
 
 place in the cavity of the pelvis, or inferior strait, what 
 then would you do ? 
 
 Attempt to bring down the breech by passing up the 
 hand and fixing a thumb in one groin and a finger in the 
 other. 
 
 Suppose there was not space sufficient for the passage 
 of the hand and breech together, what instrumental means 
 have you ? 
 
 The fillet, which if it can be applied, would be well 
 adapted for this purpose. 
 
 What is the fillet ? 
 
 A thin strong silk ribbon, or a thin linen tape of such 
 width as to admit its being passed along a fold in the 
 ham or groin. 
 
 How is this to be effected, while this fold is still within 
 the pelvis ? 
 
 This instrument properly lubricated, is to have one of 
 its extremities doubled up in numerous plaits or folds, 
 which are to be carried upon the point of the index finger 
 of the proper hand and applied to the fold in the groin or 
 ham ; the fillet is then to be passed on the point of the 
 finger till it is found on the opposite side of the limb ; the 
 plaits are then to be drawn out at the vulva, and thus the . 
 fold of the groin or ham, will be secured in it. With this 
 tape or ribbon, a very considerable degree of force can be 
 exerted and very efficient aid often rendered. 
 
 What resources have you for the application of the fillet, 
 if the fold of the ham or groin, is beyond the reach of the 
 finger ? 
 
 A slightly curved silver canula, containing a watch- 
 spring stillet, with an eyelet mounted upon it ; this eyelet 
 
USE OF THE BLUNT HOOK. 275 
 
 having a small loop of strong thread in it is to be carried 
 up to the fold in the ham or groin, upon the end of the 
 canula, it is then thrust forward along the fold to appear 
 at the opposite side of the limb, the end of the fillet is to 
 . be passed through this loop, the steel-spring stillet is then 
 to be retracted, and the fillet thus drawn over the groin or 
 ham, and its extremity brought within reach of the hand 
 of the accoucheur, who is thus enabled to act with it. 
 
 What other instrument have we for the delivery of the 
 hips ? 
 
 The blunt hook. 
 
 Where are you to fix it ? 
 
 In the fold of the groin or ham. 
 
 How is it to be prepared for use ? 
 Properly warmed and lubricated. 
 
 Is it proper to apprise the patient or her friends, of the 
 necessity of its use ? 
 
 With few if any exceptions, the necessity for all such 
 instruments should be explicitly stated, and consent ob- 
 tained. 
 
 Does the introduction and use of this instrument give 
 pain to the mother ? 
 
 None, if properly introduced. 
 
 Into which groin or ham, is it to be passed ? 
 
 Into the sacral groin or ham if possible, though it is 
 usually most convenient and even better to fix it in the 
 pubal limb, while in the upper part of the pelvis. 
 
 How are you to guide the instrument to its point of 
 application ? 
 
 Along the point of one or more fingers, to the body or 
 
276 OBSTETRIC CATECHISM. 
 
 thigh of the child, and when passed sufficiently far onward 
 the end of the hook should be made to slide around on one 
 of these parts to the fold into which it is to be fixed. 
 
 Can you use the blunt hook to any advantage in cases 
 in which it is difficult to bring down the arms of the child 
 with the fingers ? 
 
 Its use is sometimes indispensable, when the finger of 
 the accoucheur fail. 
 
 In what particular case, can the blunt hook be resorted 
 to, for the delivery of the head, in breech presentations ? 
 
 When it is impossible to produce flexion by the hand or 
 vectis. 
 
 How are you to use it, and where are you to fix it ? 
 First try it in the mouth carefully, next it may be fixed 
 upon the lower edge of the orbit. 
 
 How are you to correct certain deviations of presentation 
 of the head ? 
 
 By the hand if possible, but if not, by the vectis. 
 
 What is a vectis or lever ? 
 
 It is a metallic instrument several inches in length* 
 having one or both of its extremities curved to the shape 
 of the child's head. 
 
 Does its curvature increase its power ? 
 Its power is increased nearly in proportion to the degree 
 of its curvature, in certain cases. 
 
 Does this increased curvature, increase the difficulty of 
 its introduction ? 
 It does so. 
 
 What functions is it intended to perform in the hand of 
 the accoucheur ? 
 
 That of a lever, or tractor, sometimes both. 
 
VECTIS AND MODE OF USE. 277 
 
 If used as a lever, what must be the fulcrum ? 
 Some part of one hand of the accoucheur. 
 
 If used as a tractor, what force must co-operate with it ? 
 The finger or hand of the accoucheur. 
 
 Should you value it very highly as a tractor ? 
 Not when we can substitute the forceps. 
 
 What can you effect with the instrument as a lever ? 
 Flexion, and rotation. 
 
 Suppose you had occasion to increase flexion in a first 
 position of the cephalic extremity, how would you intro- 
 duce it and operate with it ? 
 
 Take it in the left hand, lubricate the vulva, the instru- 
 ment, and the right hand : then pass this in to the head of 
 the child, slide the point of the vectis along the concavities 
 of the right hand between the child's head and the os uteri ; 
 then sweep it around from the side of the head over the 
 left parietal protuberance to the occiput, taking care to keep 
 any part of the instrument from contusing the mother ; 
 when so adjusted, slip one or more fingers of the right 
 hand against the forehead, or sides of the bregma, and 
 press them upwards towards the cavity of the abdomen, 
 while the thumb of the same hand acts as the fulcrum to 
 the lever, the left hand is employed in acting through the 
 instrument to bring down the occiput. 
 
 Suppose you wanted to assist rotation in a second posi- 
 tion of the vertex, how should you pass it and operate with 
 it? 
 
 Hold the instrument in the right hand, pass in the left 
 as a guide, then introduce the vectis along the right sacro- 
 iliac symphysis under the side of the head, and then be- 
 tween it and the right ischium until you reach the parietal 
 
 24 
 
278 OBSTETRIC CATECHISM. 
 
 bone ; this done, take the handle in the left hand, pass in 
 one or two fingers of the right hand against the left frontal 
 bone, throw the thumb over the shaft of the vectis to form 
 a proper fulcrum, and then act simultaneously with the 
 instrument and the fingers to carry the occiput toward the 
 arch of the pubes and the face towards the sacrum. 
 
 Is the lever to be regarded as a dangerous instrument ? 
 Not when skilfully used in cases indicating the employ- 
 ment of it. 
 
 In what particular condition of the head is it especially 
 useful ? 
 
 In transverse positions of the cephalic extremity. 
 
 What obstetric instrument have we of much greater 
 value than the vectis or lever ? 
 Forceps. 
 
 What do these forceps represent ? 
 A pair of artificial hands. 
 
 What is the composition of the forceps ? 
 
 Two blades so arranged as to embrace the child's head, 
 and so constructed that they can be introduced separately, 
 and then locked or united to each other. 
 
 What mode of junction or locking, is the best ? 
 Perhaps the German is most preferred. 
 
 What is this particular mode of locking ? 
 
 There is a conical screw pivot near the centre of one 
 blade, and a conical notch in the other, into which the 
 pivot is to be received. Their junction is kept secure by 
 the screw carrying down the cone of the pivot into the 
 conical notch. 
 
FORCEPS. 279 
 
 How do you distinguish the forceps by the length ? 
 Into English or short, French or long forceps. 
 
 What forceps are thought to be best, French or English 1 
 Upon the whole, the French forceps properly modified, 
 are to be preferred. 
 
 What is the use of the fenestra in the blades ? 
 
 To enable some portions of the scalp and cranium, as 
 the parietal protuberances to pass through them, and thus 
 enable them to occupy apparently less space in the cavity 
 of the pelvis, and at the same time to secure a more firm 
 grasp of the head. 
 
 To what part of the pelvis, is the use of the short forceps 
 restricted ? 
 
 Inferior strait, unless perhaps we except those contrived 
 by Professor D. D. Davis. 
 
 From what parts can you deliver the head with the long 
 forceps ? 
 
 From every part of the pelvis, as a general rule. 
 
 What rule have you for the application of force in the 
 use of forceps ? 
 
 Sufficient to overcome the resistance. 
 
 To what part of the child are the forceps to be applied ? 
 Always to the head. 
 
 To what part of the head are they to be applied ? 
 To the sides, in all cases except one. 
 
 What is that one ? 
 
 In transverse positions, in which rotation cannot be 
 effected. 
 
 To which diameter of the head, are the forceps to be 
 applied parallel ? 
 The occipito mental diameter. 
 
280 OBSTETRIC CATECHISM. 
 
 Should you give the mother any pain in the introduction 
 of the forceps ? 
 
 None other than to excite the contraction of the uterus. 
 
 Is the child's head liable to receive some slight injury 
 by the use of the forceps ? 
 
 This is in some cases unavoidable, when the pelvis is 
 small or deformed, or the head badly situated, or the for- 
 ceps not well constructed. 
 
 In what particular cases are the forceps indicated ? 
 
 When there is too much resistance to be overcome by 
 the natural powers, or when the powers of the mother 
 become enfeebled by hemorrhage, or the contractions 
 irregular by convulsions, &c. 
 
 What condition of the os uteri must exist, before the 
 forceps can be applied ? 
 
 That of dilatation ; the first stage of labor should be com- 
 plete if possible. 
 
 Which practice is preferable for young practitioners ; 
 version by the feet, or forceps, in cases in which the head 
 is still at the superior strait ? 
 
 Version by the feet. 
 
 Suppose the head has passed out of the os uteri, must 
 you then use the forceps ; instead of resorting to version ? 
 
 Version would then be out of the question, and the 
 whole consideration would be upon the use of the forceps. 
 
 Is it important you should diagnosticate very carefully 
 before you attempt the application of the forceps ? 
 
 There would be hazard in using the forceps without 
 correct diagnosis. 
 
 How would you have your patient placed for delivery 
 by the forceps ? 
 
APPLICATION OF THE FORCEPS. 281 
 
 She should be placed as for the operation of version by 
 the feet* 
 
 What preparation of the patient would you have made 
 before you operate with respect to the bladder and bowels 1 
 They should be carefully evacuated* 
 
 How do you designate the blades t 
 
 Male and female, or left hand and right hand blades* 
 
 Which is male, and which female ? 
 
 The male blade has the pivot, the female the notch. 
 
 What relations must the forceps hold to the pelvis as 
 they withdraw the child's head, through the lower strait ? 
 Their concave edges must always look to the pubes* 
 
 What are the different steps in the introduction of these 
 instruments ? 
 
 In the first place the consent of the patient or her friends 
 should be obtained for the purpose, after a due explanation 
 of the necessity and object of their use. The patient then 
 being properly placed, the instruments are to be brought 
 to a suitable temperature by placing them for a few mo- 
 ments in warm water ; the male blade or left hand blade, 
 is to have its fenestrated extremity properly lubricated, 
 the vulva is also to be lubricated as well as the right hand. 
 The accoucheur taking his station between the limbs of 
 the patient, holds the male or left hand blade in his left 
 hand, a little beyond the middle towards the fenestrated 
 extremity, in the same manner that he would hold a 
 writing pen. The dorsum of the fingers of the right 
 hand is to be applied to the left labium and side of the 
 vagina, and the orifice of the uterus if within reach. The 
 handle of the blade being carried almost perpendicular to 
 the horizontal line on which the patient is placed, is now 
 
 24* 
 
282 OBSTETRIC CATECHISM. 
 
 to have its point slided cautiously along the palm of the 
 hand and the fingers, gradually approaching a parallel 
 with the patient's body, until the blade has been placed 
 by the side of the child's head in the direction of its 
 occipito-mental diameter. The handle of this blade is 
 then to be supported by an assistant, while the other blade 
 is to be taken in the right hand, and its fenestrated ex- 
 tremity lubricated as the other ; the left hand is now to be 
 properly prepared, and the dorsum of its fingers applied 
 against the right labium, side of the vagina and mouth of 
 the uterus if within reach. The handle of this blade is 
 then to be carried in a nearly perpendicular direction to- 
 wards the left groin of the patient, that its lower point may 
 be slided along the palm of the left hand in the direction 
 of the axis of the vagina, of the inferior strait of the 
 cavity of the pelvis, and if necessary, the superior strait ; 
 as this movement is effected the handle is of course cor- 
 respondingly depressed, till it comes in contact with, and 
 crosses obliquely, the blade first introduced, and then 
 the points of junction brought accurately together ; they 
 are then to be locked. 
 
 What is the general rule in reference to the concave and 
 convex edges of the blades ? 
 
 The concave edges are to look towards the pubes, and 
 the convex edges towards the hollow of the sacrum. 
 
 Should you always keep the point of the instrument 
 against the head of the child ? 
 
 This should always cautiously be done to prevent em- 
 bracing any of the soft parts of the mother between the 
 instrument and the child's head. 
 
 What dangers may result from want of care in this 
 matter ? ' 
 
MODE OF USING THE FORCEPS. 283 
 
 The inclusion of some portion of the mouth of the ute- 
 rus, or even the penetration of the abdomen, with the in- 
 strument. 
 
 Is there any danger of entangling any of the soft parts 
 in the fenestra of the blades ? 
 There is. 
 
 How are you to prevent this ? 
 
 By carrying up the hand as a guard. 
 
 How are the blades to approach each other at the 
 lock? 
 
 In nearly parallel lines ? 
 
 Should the blades always lock readily ? 
 Unless they do, it is certain that the head is not accu- 
 rately embraced. 
 
 How are you to judge whether you have the forceps 
 properly applied to the child's head ? 
 
 By their locking readily, while the blades are applied 
 in the direction of the occipito-mental diameter of the 
 child's head, as indicated by the position of the occipital 
 fontanelle or by the chin. 
 
 Is there any danger of passing up the forceps out side 
 of the os uteri ? 
 
 There is great danger of this accident without much 
 care in some cases. 
 
 What test have you that this has occurred ? 
 The complaint of the patient that you hurt her, 
 
 When you have the blades locked, should you make a 
 little compression and traction effort ? 
 
 This should be done in order to bring the instruments 
 to their proper bearing, and to ascertain that no part of 
 the mother is included. 
 
284 OBSTETRIC CATECHISM. 
 
 Should you apply a fillet upon the forceps in all cases ? 
 In none except where it is important to keep up long 
 continued and firm pressure. 
 
 Under what circumstances is the fillet necessary? 
 When there is some defect of size of pelvis, or too 
 great magnitude of the child's head. 
 
 What is the modus operandi of the forceps ? 
 Both as levers and tractors. 
 
 Should the forceps be regarded as a double lever ? 
 They should. 
 
 Where is the common fulcrum ? 
 The pivot. 
 
 What is the usual centre of motion of these levers 
 during the effort of delivery ? 
 
 The trachelo bregmatic diameter of the child's head. 
 
 Should you be particularly careful to support the peri- 
 n&um in delivery by the foreeps ? 
 
 This should be regarded as an important object of atten- 
 tion. 
 
 Is it proper for you to remove the forceps as soon as 
 the head escapes through the inferior strait ? 
 This a good general rule. 
 
 In what direction are you to move the handles of the 
 blades ? 
 
 From side to side of the head, and always from handle 
 to handle. 
 
 Suppose the whole head is situated obliquely and in the 
 cavity of the pelvis, how are you to apply the male blade ? 
 
 Elevate the handle, pass in the blade, sweep it under 
 the top of the head, then depress the handle rapidly to 
 
APPLICATION OF THE FORCEPS. 285 
 
 bring it to the side of the head, and the pivot will look 
 towards one of the groins of the mother. 
 
 How should you pass in the female blade ? 
 
 Pass it firmly into the cavity of the pelvis under the 
 top of the child's head, then by insinuating the fingers 
 under the convex edge of the blade, depress the handle 
 of the blades to sweep it over the parietal protuberance, 
 and allow the blade to lock with the pivot to the left groin 
 of the mother, in case of first or left occipito-anterior po- 
 sition. 
 
 Suppose the shoulders become arrested, how would you 
 assist their delivery ? 
 
 Continue to act with the forceps upon the head ; or lay 
 them aside and apply one hand behind, and the other in 
 front of the neck, make proper traction in this way ; or 
 pass up the blunt hook into one axilla, and thus make 
 proper traction till first one and then the other shoulder is 
 disengaged. 
 
 Suppose the head becomes arrested at the superior strait, 
 how should you proceed with the view to assist the de- 
 livery ? 
 
 Ascertain if possible, if there be any deviation ; then 
 correct it ; and if there be none, or if you cannot correct 
 it, consider what further action would be proper. 
 
 Would you turn, or apply the forceps ? 
 Turning would be safer, unless the practitioner have 
 much experience in the use of forceps. 
 
 Can you apply them easily and safely at the superior 
 strait ? 
 
 They are neither easily or safely applied at the superior 
 strait, and should not be applied at that point under any 
 
286 OBSTETRIC CATECHISM. 
 
 circumstances, unless the practitioner possess great manual 
 dexterity. 
 
 What use should you make of the hand in the applica- 
 tion of the blades, admitting you attempt to use them in 
 this case ? 
 
 Pass it into the cavity of the pelvis till it comes in contact 
 with the head sufficiently completely to protect the mother 
 from injury. 
 
 Are there any greater difficulties in applying the for- 
 ceps in the second position of the vertex than in the 
 first? 
 
 When the occiput is towards the right acetabulum, the 
 left side of the child's head to which the male blade is to 
 be applied, is so closely directed to the anterior part of the 
 pelvis, that when the first or male blade is properly intro- 
 duced, it occupies so much of the anterior commissure of 
 the vulva as to leave insufficient space for the proper in- 
 troduction of the female blade. 
 
 How is this difficulty to be obviated ? 
 
 First pass in the male blade to its proper situation : 
 having then determined what this is by the actual introduc- 
 tion, retract the blade by reversing the motion by which it 
 was passed, till it is opposite the left ischium ; then having 
 it carefully supported by an assistant, introduce the female 
 blade to its proper situation along the right sacro-iliac 
 junction. This blade is still in front of male blade ; the 
 male blade is now to be passed up to its original situation 
 under the ramus of the left pubis : when if all is right, it 
 will lock readily. 
 
 What relation does the child's head hold to the forceps 
 in the posterior positions of the occiput ? 
 
 The top of the head corresponds to the concave edges 
 of the blades. 
 
APPLICATION OF THE FORCEPS. 287 
 
 k 
 
 What rule "have we for the direction of the handles in 
 the posterior varieties ? 
 
 As the occipital extremity of the occipito mental diame- 
 ter is directed strongly backwards in these cases, it is 
 necessary to depress the handles on the perinaeum to obtain 
 the proper position of the head within the blades. 
 
 Suppose the head present with the occiput to one is- 
 chium, should you correct the deviation by the vectis before 
 you apply the forceps ? 
 
 Yes, if at all practicable. 
 
 Is it a rule in obstetrics not to apply the forceps with 
 one blade under the arch of the pubes, and one over the 
 perinaeum or coccyx ? 
 
 It should never be done. 
 
 Should we always attempt to correct the deviation by 
 the yectis, or a blade of the forceps used as a single lever, 
 before both blades are used for tractors in this kind of pre- 
 sentation ? 
 
 A persevering but judicious effort should be made for 
 this purpose, in order if possible, to prevent the necessity 
 of applying them over the occiput and face. 
 
 What other presentations of the fetus may require the 
 application of the forceps for the delivery of the head? 
 
 Presentations of the pelvic extremity, in which after 
 the delivery of the body the head is retained. 
 
 How are you to dispose of the body of the child in 
 such cases ? 
 
 In case the occiput is anterior the body is to be carefully 
 lifted up over the abdomen of the mother ; while in pos- 
 terior positions of the occiput, the body is to be carried 
 toward the sacrum of the mother. 
 
288 OBSTETRIC CATECHISM. 
 
 Suppose the chin has departed from the chest, can you 
 introduce and apply the forceps with benefit ? 
 
 It would be ineffectual in delivering the child, and sub- 
 ject the woman to much risk of injury. 
 
 Can you hope to deliver the head from the superior 
 straits after the body has been delivered ? 
 Not safely. 
 
 What accident is liable to occur in cases of pelvic .pre- 
 sentation with the body delivered but the head retained, if 
 you use great traction effort ? 
 
 Separating the body from the head. 
 
 Suppose you meet with a case in which the head is 
 retained after the body has been pulled off, what should 
 you do ? 
 
 First try to get the head in a proper position then apply 
 the forceps. 
 
 But suppose you cannot get it into the proper relation 
 with the pelvis for the safe application of the forceps, what 
 means are you to employ 1 
 
 Hooks, vectis, &c, so applied to the head as to get it 
 in such position that the forceps can be applied, or that 
 you can introduce such instruments as to enable you to 
 diminish its capacity, and afterwards extract it. 
 
 What diseases result in distortions of the pelvis t 
 Rachitis, or mollitis osseum. 
 
 Why do the distortions usually take place in the direc- 
 tion of the sacro-pubal diameter ? 
 
 From the fact that the pressure is made in that direction 
 by the superincumbent weight of the spine or body. 
 
NECESSITY FOR CEPHALOTOMY. 289 
 
 What is the smallest size of diameter through which a 
 living child can be delivered ? 
 Three inches. 
 
 If less than this, is it proper for the accoucheur to wait 
 for the effects of the natural powers ? 
 
 It is not, because all her efforts would be ineffectual. 
 
 What resource has the attendant in such case ? 
 The perforator, crotchet, and gastro-hysterotomy. 
 
 What is afforded by the perforation of the cranium, and 
 the breaking up of the pulpy mass ? 
 
 An opportunity for the vault of the cranium to collapse^ 
 and pass down more readily. 
 
 What are the diameters of the base of the skull after 
 the vault has been removed ? 
 
 The face measures one and a half inches ; two inches 
 with the lower jaw. The transverse diameter is two and 
 a half inches. 
 
 What is the operation of diminishing the size of the 
 child's head called ? 
 
 Craniotomy, cephalotomy, and embryotomy. 
 
 What instruments are used for this purpose ? 
 
 A lance shaped instrument called a perforator, which is 
 well adapted to certain purposes ; though one of a more 
 extensively useful character is Smellie's scissors, or some 
 modifications which have been made upon it. 
 
 How is the uterus to be supported for the operation ? 
 It must be supported by one or both hands of the assis- 
 tant. 
 
 25 
 
290 OBSTETRIC CATECHISM. 
 
 Suppose the head, &c. be properly supported by the 
 hands of an assistant over the abdomen, how is the opera- 
 tor to proceed to the introduction of the instrument 1 
 
 The point of the perforator or scissors, is to be well 
 guarded in one hand which is to be introduced to the pro- 
 per part of the head. 
 
 How is he to operate with it ? 
 
 Fix it, if possible, in a suture or fontanelle, push it up 
 to the shoulders of the blades if you use the scissors ; 
 then open the handles and cut from within outwards, then 
 turn the edges in another direction, and cut again till 
 you have made a considerable opening. 
 
 When you have perforated to the cranium sufficiently, 
 how are you to break up the membranes and the pulpy 
 mass of the brain ? 
 
 Pass the scissors, or some other convenient instrument 
 and rotate it freely within the cranium, at the same time 
 scoop out the mass thus broken up by it. 
 
 If the head do not readily collapse what means of assist- 
 ance have you ? 
 
 The forceps, which may be applied to the head, and 
 compress it. To retain it in this collapsed state it is well 
 to pass a fillet lightly around the handles. 
 
 Could you ever use the vectis to advantage in cases in 
 which the head has been perforated ? 
 
 It may sometimes be used with benefit to change the 
 direction of the head, or to assist in traction. 
 
 What other and common means have you to act as a 
 tractor ? 
 
 An instrument called the crotchet, or sharp hook. 
 
INSTRUMENTS FOR OMPHALOTOMY. 291 
 
 How is this instrument to be applied ? 
 
 It is to be passed through the artificial opening in the 
 head, and fixed upon some firm point within the cra- 
 nium. It is however a dangerous instrument, and never 
 to be used when it can be avoided. 
 
 How are you to guard it when introduced ? 
 By the finger applied against some other part of the 
 head to prevent any accident from its slipping. 
 
 Are crotchets ever guarded by a blade opposed to them ? 
 They are ; and it is unsafe to use one without a proper 
 guard of this kind. 
 
 What other instruments have you for opening and di- 
 minishing the child's head ? 
 
 The intra-pelvic trephine for boring into the cranial 
 bones of the child, invented by a German. The brise- 
 tete of A. C. Baudelocque, the craniotomist of Dr. Davis, 
 the cranial bone forceps of Drs. Meigs and Davis. 
 
 Should you ever use ergot in cases of considerable de- 
 formity of the pelvis ? 
 
 Never, inasmuch as there would be great danger of rup- 
 turing the uterus. 
 
 Should you perform version by the feet in such cases ? 
 It should not be attempted. 
 
 What would be the objection to this practice? 
 
 We should increase the difficulty, if there was not room 
 for the child to pass, by removing the head from the reach 
 of instruments intended to draw upon it or diminish its 
 size. 
 
 If the blades of the forceps could be introduced, do you 
 think it prudent to try the use of them ? 
 
 Yes. 
 
292 OBSTETRIC CATECHISM. 
 
 Suppose you failed, what other resource would you 
 have ? 
 
 The diminution of the child's head by the perforator, if 
 the child be dead, or if the condition of the mother would 
 justify it, the cesarean section, in case the child were still 
 alive, and could probably be saved. 
 
 Suppose the size of the forceps was so small that you 
 cannot deliver with the forceps, what should you do ? 
 
 Diminish the size of the child's head, and then apply 
 the forceps or crotchet ? 
 
 Suppose you had applied the forceps, and found you 
 could not deliver with them, how should you do ? 
 
 Open the head while the forceps are still on, then com- 
 press the bones with these instruments, and renew the 
 attempts to deliver. 
 
 Having opened the vault of the cranium, how are you 
 to apply the crotchet ? 
 
 Pass it in through the perforation upon some fixed 
 point within the cranium, as the petrous portion of the 
 temporal bone, or into the edge of the foramen magnum 
 of the occipital bone, and then draw cautiously with it. 
 
 Suppose there is not room for the bones to pass down 
 even after the brain is evacuated, what then is to be done ? 
 
 Pick, or tear, or cut away the different portions of the 
 vault of the cranium. 
 
 In the use of instruments for this purpose, should you 
 have regard to the scalp ? 
 
 Yes ; it is important not to cut it away with the bones, 
 but preserve it as a guard to the soft parts of the mother. 
 
 What instrument would you use for cutting up the bones 
 of the cranium ? 
 
 The osteotomist of Professor Davis of London. 
 
DIMINISHING THE CHILD. 293 
 
 Suppose the space is too small for you to operate with 
 the osteotomist, what could you substitute for it ? 
 The forceps of Dr. Meigs. 
 
 When this difficult operation has been decided upon, 
 is it necessary for you to complete it at once ? 
 
 Generally you may take your time at it, work at it till 
 you are weary, then give your patient an anodyne, rest 
 yourself, then resume the task. 
 
 Through what sized aperture can you bring down the 
 base of the cranium ? 
 
 One that is from one and a quarter to one and a half 
 inches antero-posteriorly, and from two and a half to three 
 inches transversely. 
 
 Is the operation of cephalotomy dangerous to the mother? 
 Not in common cases, if performed in time and with 
 proper care. 
 
 Is her situation hazarded by the necessity of breaking up 
 the vault of the cranium ? 
 It is. 
 
 Suppose the body will not pass through the deformed 
 canal ? 
 
 It must then be mutilated. 
 
 Should you make up your mind in the early part of la- 
 bor, in what manner you will complete the delivery ? 
 
 It is proper that you make a careful examination for 
 that purpose. 
 
 Suppose the pelvis be rather smaller than the standard 
 size, what should be done when labor takes place ? 
 
 Clear the bowels and the bladder, promote relaxation of 
 the soft parts — make a careful examination of the internal 
 
 25* 
 
294 OBSTETRIC CATECHISM. 
 
 capacity of the pelvis,— and if it be regular and not very 
 small, apply the forceps as soon as the head is within their 
 easy grasp. 
 
 When the pelvis is very much contracted, which is to 
 be preferred, the crotchet or the cesarean section ? 
 
 If the child be alive, and the mother in good condition, 
 it would be right to recommend the cesarean section, 
 
 What are the objections to the cesarean section ? 
 
 First, it involves the life of the mother in great jeopardy, 
 particularly if resorted to when she is in a state of excite- 
 ment or exhaustion from ineffectual labor. Second, it 
 does not always preserve the life of the child, though the 
 risk of this constitutes the least objection. 
 
 What mode have we to diminish the size of the child's 
 head in utero, besides that of the perforation ? 
 
 The crushing forceps, or brise-tete of A. C. Baudelocque, 
 
 Would you be disposed to use this instrument 1 
 It is so large and cumbrous an instrument, that we 
 think it could not be used without great hazard to the pa- 
 tient, though it is said to have been successfully employed 
 in some cases in Paris. 
 
 What plan does obstetric medicine propose, to prevent 
 the occasion for the use of instruments in cases of deformed 
 pelvis ? 
 
 The induction of artificial premature delivery. 
 
 What is the proper stage of pregnancy for this purpose? 
 The eighth month or a little earlier. 
 
 What is the proper mode of doing this ? 
 
 Stimulate the uterus to contraction, by titillating the in- 
 ternal surface of the os uteri — or if this do not succeed, by 
 puncturing the membranes. 
 
PREMATURE ARTIFICIAL DELIVERY, 295 
 
 What size of the pelvis demands this practice ? 
 When the diameter is less than three inches, say two 
 and three quarter inches antero-posteriorly. 
 
 Suppose the diameters be less than this, what must you 
 have resource to ? 
 
 To gastro-hysterotomy, i. e. the cesarean section; or to 
 the use of the crotchet. 
 
 Should you ever attempt either of these operations 
 while alone ? 
 
 Never, if possible to have a consultation. 
 
 Should you ever give ergot in any cases of mechanical 
 obstruction in labor ? 
 
 There is probably no case of this kind in which the use 
 of ergot would be proper. 
 
 What should you do ? 
 
 First correct the deviation if possible, or if none exist, 
 apply the forceps, if the capacity of the pelvis be sufficient. 
 
 What instrument becomes very valuable in cases of 
 retarded labor, in posterior varieties of cephalic presenta- 
 tion ? 
 
 The lever. 
 
 If you cannot rotate the head in case of the sixth posi- 
 tion, what instrument should you apply ? 
 
 The forceps, which in such case must be carried high 
 up in the pelvis. 
 
 Suppose you have no instrument at command, what can 
 you substitute ? 
 
 A fillet, carried up over the back part of the head, by a 
 piece of whale bone, or some flexible substance. 
 
298 OBSTETRIC CATECHISM. 
 
 Do cases of presentation of the anterior fontanelle, to the 
 centre of the pelvis, ever occur in practice ? 
 They are sometimes met with. 
 
 How does this occur ? 
 
 In consequence of the head being carried down in a state 
 of extension instead of flexion. 
 
 What diameters present to the pelvis in this case ? 
 The occipitofrontal, and bi-parietal diameters. 
 
 What diameter corresponds with the axis of the superior 
 strait ? 
 
 The trachelo-bregmatic diameter. 
 
 Does this deviation ever become spontaneously corrected 
 as it descends ? 
 
 It is believed that it might be hazardous to rely upon 
 spontaneous correction of this deviation, though this may 
 possibly occur. 
 
 Suppose however the occiput becomes arrested at the 
 linea-ilio pectinea, what is the consequence ? 
 
 The head becomes locked in the superior strait, cavity, 
 or inferior strait of pelvis. 
 
 Would such a state of things render labor impracticable? 
 It would, unless the pelvis be very large, or the head 
 very small. 
 
 What practice should you adopt to prevent the occur- 
 rence of this difficulty, if you see the patient early ? 
 
 Pass up your finger, and arrest the descent of the fore- 
 head until the occiput comes down. 
 
 Suppose you cannot succeed with your finger, what 
 should you do ? 
 
 Fix the lever upon the occiput, and pressing up the 
 forehead with the finger, bring down the occiput. 
 
PRESENTATIONS OF ANTERIOR FONTANELLES, FACE, ETC. 297 
 
 Should you do this in the absence of a pain ? 
 This is the only time in which you could expect to suc- 
 ceed. 
 
 If the head descend into the cavity, how should you 
 manage it ? 
 
 Pass in your lever under the sacral side of the occiput, 
 and effect flexion and rotation at the same time. 
 
 Suppose the head has descended into the inferior strait, 
 how should you do ? 
 
 It is desirable still to make restitution if possible, and 
 bring the occipito-mental diameter into relation with the 
 axis of the pelvis, and with this view it has been proposed 
 to pass one or two fingers into the anus, and press against 
 the head through the recto-vaginal wall, into its proper 
 relation with the pelvis, and then bring it down. 
 
 Do the obliquities of the uterus probably ever contribute 
 to cause this deviation ? 
 It is believed that they do. 
 
 Is the head in these deviations more likely to be arrested 
 in the third, than in other anterior varieties 1 
 
 This opinion is entertained by some accoucheurs. 
 
 What practice should be resorted to, to correct the 
 deviation in this case ? 
 
 Push up the head, rotate it partially, push up the fore- 
 head and allow the occiput to descend. 
 
 Would it be at all admissible to apply the forceps in this 
 kind of deviation ? 
 
 The use of them might succeed, but the practice is 
 barely justifiable. 
 
 What are face presentations ? 
 Deviations of vertex presentations. 
 
298 OBSTETRIC CATECHISM. 
 
 What diameters present to the planes of the pelvic straits 
 under such circumstances ? 
 
 Fronto-mental, and bi-temporal diameters. 
 
 What part presents to the centre of the pelvis ? 
 The root of the nose. 
 
 What then, are the difficulties of this case ? 
 
 The occipital bregmatic diameter is added to the antero- 
 posterior diameter of the thorax, as the head descends into 
 the pelvis. 
 
 Does this occur in all cases of face presentation ? 
 
 It does so when the sinciput is anterior in consequence 
 of the occiput being thrown backwards upon the spine of 
 the child. 
 
 Is the labor impracticable in that case ? 
 
 It is always so, if the child has its usual proportions. 
 
 Suppose the chin presents to the anterior parts of the 
 pelvis, is the labor equally impracticable ? 
 
 This labor is practicable, and the child may be readily 
 born alive. 
 
 What is the reason of this, since in all other cases 
 dorsum of the child to the spine of the mother is regarded 
 less favorable than when the dorsum is anterior ? 
 
 In this case it is true, there are many inconveniences ; 
 but as the chin descends nearly in the axis of the pelvis, 
 the sinciput is accommodated in the hollow of the sacrum, 
 the trachelo-bregmatic diameter nearly corresponds to the 
 occipito bregmatic diameter in cases of original occipital 
 presentation; as the head descends, the chin appears under 
 the arch, while the front part of the neck is forced strongly 
 against the posterior part of the pubes, and this part of the 
 throat becomes as it were, the centre of motion as the head 
 
PRESENTATIONS OF THE FACE, ETC. 299 
 
 is driven forward ; to have first the chin, next the face, 
 then the forehead, and lastly the sinciput, pass successively 
 over the perinseum. In consequence of the small depth 
 of the pelvis at the symphysis, the back part of the head 
 and the top of the thorax, are less forcibly engaged in the 
 superior strait, at the same time in this case, as must 
 happen in the case of those positions in which the bregma 
 comes under the arch of the pubes. 
 
 What are positions of the anterior fontanelle ? 
 Deviations of occipital positions. 
 
 How many positions of these are acknowledged ? 
 Six — the same as occipital positions. 
 
 Is it possible for you to modify or alter this position at 
 the superior strait, while the ovum is entire or recently 
 ruptured ? 
 
 If the os uteri be sufficiently dilated, to enable you to 
 carry up one or two fingers sufficiently far, you may push 
 up the forehead and let the occiput descend. 
 
 Do these deviated positions engage less readily in the 
 superior strait, than those in which the vertex presents ? 
 
 There are two causes of delay in the descent of the head 
 in deviations of this kind ; first, because this position of 
 the head offers a larger surface to the os uteri, and there- 
 fore can not pass through it so readily ; secondly, the oc- 
 cipitofrontal diameter cannot readily descend in the supe- 
 rior strait, while the thickness of the walls of the neck of 
 the uterus is added to it. 
 
 When is this deviation mostly recognized ? 
 When the head has come down into the cavity or in- 
 ferior strait of the pelvis. 
 
 What indications have we to fulfil when the head has 
 descended into the inferior strait in this deviated position ? 
 The movements of flexion and rotation 
 
300 OBSTETRIC CATECHISM. 
 
 How are you to make the rotation in this case ? 
 
 By acting on the side of the forehead with the fingers 
 of one hand, or on the parietal bone with the fingers of 
 the other. 
 
 Can you use the lever to any advantage 1 
 Yes, if properly applied, you may effect both flexion 
 and rotation with it and the fingers. 
 
 Is this a proper case for the forceps ? 
 No, not while the deviation continues. 
 
 When the deviation takes place to a still greater extent, 
 what kind of presentation have we ? 
 Presentations of the face. 
 
 '■ ; What diameters present to the pelvis in face presenta- 
 tions ? 
 
 The fronto-mental and bi-malar, apparently — though 
 really, the trachelo-bregmatic and bi-parietal diameters, 
 when the chin presents or rotates anteriorly. 
 
 Are face presentations to be regarded as rendering de- 
 livery impracticable ? 
 
 Not generally, particularly when the chin rotates under 
 the arch of the pubes. 
 
 Can the face enter the superior strait when the chin 
 presents to the sacrum of the mother ? 
 
 It can enter the superior strait without much, if any 
 difficulty. 
 
 Can delivery take place spontaneously in these cases 
 of face presentations ? 
 
 It cannot unless the child be very small. 
 
 What obstacle offers to the delivery in these cases ? 
 When the chin is turned towards the sacrum, it may be 
 
MECHANISM OF FACE PRESENTATIONS. 301 
 
 said that we have the occipito-bregmatic diameter of the 
 head, and the dorso-sternal diameter of the upper part of the 
 thorax, attempting to pass down into the space of the sacro- 
 pubal diameter of the pelvis. Under such circumstances, 
 it is impossible for the oceipito-mental diameter of the 
 head to come into correspondence with the axis of the 
 pelvis ; the convexity of the sinciput is constantly applied 
 to that of the inner side of the symphysis pubes, while the 
 concavity of the mental tracheal and thoracic surface — - 
 so to speak, is opposed to the concavity of the pos- 
 terior portion of the sacrum. Hence the capacity of the 
 pelvis is insufficient for the transmission of the head and 
 shoulders of the fetus in this direction, by the uterine and 
 voluntary powers of the mother alone. 
 
 How many varieties or positions of face presentations 
 are recognized by systematic writers ? 
 
 Usually the same number as in occipital presentations. 
 
 What are the most common varieties of face presenta- 
 tions ? 
 
 Presentations of the face are nearly always resolved 
 into right mento-iliac and left mento-iliac, by the time the 
 face gets into the cavity of the pelvis. 
 
 Can the labor in these cases be terminated spontaneously, 
 or with slight assistance ? 
 
 They can, provided the chin comes under the arch of 
 the pubes. 
 
 What is the mechanism of labor in these cases ? 
 
 First, the extension becomes as great as possible — the 
 face is then carried down, the chin rotates upon the an- 
 terior plane, until it gets under the arch of the pubes : 
 flexion then takes place until the head clears the perinaeum ; 
 
 2§ 
 
302 OBSTETRIC CATECHISM. 
 
 the labor then terminates as in an occipito-posterior posi- 
 tion. 
 
 Does flexion take place at any time during labor with 
 face presentation ? 
 
 Not at all, until the chin comes under the arch of the 
 pubes. 
 
 Should you in all cases endeavor to assist the rotation 
 of the chin under the arch ? 
 Always, if possible. 
 
 What should you do if you find the child descending 
 face foremost at the superior strait ? 
 
 By the old rule, we should make version by the feet, 
 but under the counsel of more scientific instruction, we 
 should perform version by the head, and bring down the 
 vertex. 
 
 Suppose a manipulation of this kind to be admissible, 
 that is, the head still high up and easily moveable above 
 the superior strait, in what direction should you attempt to 
 bring down the occiput ? 
 
 Always at first into that opposite to that in which the 
 chin was situated, after which you must effect rotation if 
 necessary, as already stated. 
 
 Suppose the second stage of labor be complete, and the 
 face have descended into the cavity of the pelvis, how 
 should you act ? 
 
 Endeavor to rotate the chin towards the arch of the 
 pubes. 
 
 Can much be done by the use of your fingers, if you 
 well understand the mechanism of labor ? 
 
 Much may be done by these means at various degrees 
 of the progress of labor, if its mechanism be well under- 
 
MANAGEMENT OF FACE PRESENTATIONS. 303 
 
 stood, and the accoucheur use his fingers dexterously and 
 cautiously. 
 
 Suppose you find the top of the head coming under the 
 arch of the pubes, and you cannot rotate it, what instru- 
 ments may you apply ? 
 
 The forceps, with the hope of effecting delivery ulti- 
 mately. 
 
 Does the introduction of these instruments require any 
 particular care in these cases ? 
 
 Great care is necessary, as you are obliged to depress 
 the handles, and at the same time apply the ends of the 
 blades high above the pubes, and more or less against the 
 shoulders of the child. 
 
 Ought you to attempt the use of the forceps, if you 
 know the child is not alive ? 
 
 They ought not to be applied under such circumstances, 
 until the head has been prepared for them by other means. 
 
 What instruments are indicated in cases the forceps 
 cannot deliver ? 
 
 Perforator and crotchet, &c, or after the perforator and 
 the collapse of the cranium, the forceps ; though it should 
 be remembered, that the compression by the forceps, in- 
 creases the diameter of the child's head, in the direction of 
 the sacro-pubal diameter of the pelvis. 
 
 Would you ever be justified in attempting to make flex- 
 ion within the cavity of the pelvis ? 
 
 It has been proposed as proper to attempt it, though we 
 are not ourselves of the opinion that it would be difficult 
 to effect it. 
 
304 OBSTETRIC CATECHISM. 
 
 Ill what direction should you attempt to do it, if you de- 
 termine upon trying it ? 
 
 In the oblique diameter of the cavity of the pelvis. 
 
 Why do face presentations require more laborious 
 effort for their delivery than other presentations ? 
 
 Because the cephalic extremity of the fetus is removed 
 from the line of direction in which the uterine and acces- 
 sory powers act. 
 
 What deviations may we convert with advantage into 
 face presentations ? 
 
 Those in which the forehead presents, and cannot be 
 rectified by restoration to an occipital presentation. 
 
 What objections to this practice when the occiput is 
 anterior ? 
 
 They would then be converted into a case of imprac- 
 ticable labor with face presentation, unless rotation could 
 be effected by dexterous manipulation. 
 
 Should you ever allow a forehead presentation to con- 
 tinue as such when you discover it to exist ? 
 
 Never, if possible to correct it by reduction to an occi- 
 pital presentation, or an antero-mental presentation. 
 
 What should be your rule of action in these cases ? 
 
 To convert the fronto-anterior position into the chin 
 presentation, and to attempt to bring down the occiput, 
 when they are sincipito-anterior. 
 
 How should you operate with the forceps in cases of 
 mento-anterior positions of face presentations ? 
 
 Apply the blades as in cases of occipito-anterior posi- 
 tions, and as the chin clears the anterior commissure, draw 
 a little forward with the front part of the thorax against 
 the under part of the arch, then carry the handles rapidly 
 
DEVIATED PRESENTATIONS. 305 
 
 over towards the abdomen of the mother, with a view to 
 move the trachelo-bregmatic and the trachelo-occipital di- 
 ameters like radii, between the arch of the pubes, the sa- 
 crum, coccyx, and the perinaeum. 
 
 Are you liable to meet with positions of the side of the 
 child's head? 
 
 They may occur when there is great obliquity of the 
 uterus, or the top of the head should be arrested in a cer- 
 tain direction at one side of the superior strait. 
 
 How are you to recognize them ? 
 
 By the presence of an ear and a portion of the corona], 
 or of the lambdoid suture, a mastoid, or a zygomatic pro- 
 cess, <fcc. 
 
 How are you to correct this kind of deviation ? 
 
 If possible, push up the head of the child, and by the 
 hand bring down the head into its proper relations with the 
 pelvis. 
 
 When the nape of the neck presents to the centre of 
 the pelvis, what is the indication ? 
 
 To correct the deviation according to the general rules 
 already proposed. 
 
 May it happen in practice that various parts of the body, 
 as the hip, the back, one side, &c, may present to the 
 centre of the pelvis ? 
 
 However rare, they are stated to have occurred. 
 
 How do these generally result in practice ? 
 Mostly in the presentation of a shoulder, or hip, or of 
 the breech or feet, &c. 
 
 26* 
 
306 OBSTETRIC CATECHISM. 
 
 Is any change effected in the position of the child during 
 the early stage of labor ? 
 
 Great changes are sometimes effected in deviated posi- 
 tions, even before the os uteri is well dilated, or the child 
 driven down into the lower pelvis. 
 
 How are we to account for such changes ? 
 
 First, in the peculiar form of the abdominal and super 
 pelvic cavity ; and secondly, in the flexibility of the child, 
 its form is adapted to the shape of the uterus, in such 
 manner as to make its long diameter correspond to that 
 of the long diameter of the uterus. 
 
 But some persons have compared the fetus in utero, 
 to a cork inside of a bottle, which can pass through the 
 neck only in a certain direction. Is this comparison cor- 
 rect 1 
 
 Not exactly so, as the child is more pliable, yet it must 
 finally escape only in the direction of its long diameter. 
 
 When deviations of presentations of the body occur, is 
 it proper for you to wait until spontaneous version takes 
 place ? 
 
 It would not be best : we should always endeavor, if 
 under favorable circumstances, to introduce the hand, and 
 deliver by the feet. 
 
 What do we mean by shoulder presentations ? 
 
 They are presentations of the upper parts of the sides of 
 the body, which were probably originally deviations from 
 cephalic presentations. 
 
 What number of presentations of the shoulders are there ? 
 Two of the right and left shoulders, each. 
 
 What points of the pelvis and child, do we take in our 
 diagnosis ? 
 
 The pubis of the pelvis, and the dorsum of the child. 
 
SHOULDER PRESENTATIONS, 307 
 
 How do you diagnosticate the shoulder presentations ? 
 
 By the presence of a tumor, on one side of which is a 
 smooth elastic surface, the side of the neck ; on another a 
 slender bone, the clavicle ; on the opposite side a broad 
 plate of bone, the scapula ; between these a number of small 
 ridges, the ribs, and mostly, more important, a small cylin- 
 drical body, an arm, lying parallel to a larger one. 
 
 What is the value of the hand in the diagnosis of shoulder 
 presentations ? 
 
 It may assist considerably in making up the diagnosis. 
 By some practitioners it has been advised to bring down 
 the arm to determine the position. We are persuaded 
 however, that this practice is rarely if ever necessary. 
 
 Should we be very precise in our calculation of the 
 exact relative position of the back and the pelvis ? 
 
 As it probably rarely happens, that the dorsum of the 
 child is applied to the pubes with as much accuracy as 
 the occiput is to the left acetabulum, &c, we have to take 
 as a general statement, the nearest approximation to it, in 
 our practice. 
 
 What are the positions of the shoulders ? 
 Dorso-pubic, and dorso-sacral, of the right and of the left 
 shoulders. 
 
 Can spontaneous delivery ever take place in cases of 
 shoulder presentations ? 
 
 Never while they continue as shoulder presentations, 
 provided the child be at or near the term of its development. 
 In some very rare instances, the uterine and voluntary con- 
 tractions have effected such mutation in the position of the 
 
308 OBSTETRIC CATECHISM. 
 
 child as to expel it with one of the extremities, usually the 
 pelvic, presenting. 
 
 What is this mutation called ? 
 
 Spontaneous evolution, or spontaneous version. 
 
 What is to be understood by spontaneous version ? 
 
 That movement by which the body of the child, originally 
 unfavorably situated, becomes changed in such a manner 
 as to present one of the extremities, (especially the pelvic) 
 of the ellipse, that it can enter and pass through the pelvis, 
 aided by the powers of the mother alone. 
 
 How do you explain the law by which this change is 
 effected ? 
 
 As already mentioned, it depends probably upon the 
 flexibility of the fetus, and upon the direction of the uterine 
 forces aided by the contractions of the abdominal muscles. 
 
 What is the probable proportion of cases of spontaneous 
 version, in shoulder presentations ? 
 
 It has been rated at one case of spontaneous version, to 
 one thousand cases of shoulder presentations. 
 
 Should you ever wait for spontaneous version, in any 
 cases of shoulder presentations, or of those of the lower or 
 upper part of the body ? 
 
 It would not be proper to wait, if it be possible to act 
 judiciously for correcting the deviation. 
 
 Suppose you find the lower part of the body present ; 
 what is the rule of practice ? 
 
 To pass in the hand, and bring down the breech or 
 feet. 
 
RULE FOR THE USE OF THE HAND. 309 
 
 Suppose some portion of the upper part of the body- 
 present, what should you do ? 
 
 Pass in the hand, and make version by the feet. 
 
 What should be the condition of the soft parts, before 
 you proceed to an attempt at version ? 
 
 They should be relaxed or dilated, to an extent sufficient 
 to avoid contusion or laceration. 
 
 When you have diagnosticated such a deviation, should 
 you endeavor to preserve the membranes till all the parts 
 are dilated ? 
 
 This is proper in all cases of real, or supposed deviation, 
 until the parts are well dilated. 
 
 What is the rule for the use of the particular hand, and 
 its mode of introduction ? 
 
 1. That rule which applies to version by the knees or 
 feet, in all cases, viz : that hand, the palm of which, looks 
 towards the abdomen of the child. 
 
 2. When it is ascertained that the dorsum of the child is 
 towards the pubes of the mother, that hand is to be intro- 
 duced, which can be readily flexed into the iliac fossa in 
 which the breech is situated ; this will be the right hand 
 to the right iliac fossa, and the left hand for the breech in 
 the left iliac fossa. 
 
 In either of these cases, the hand is to be carried up 
 supine beyond the child or between it and the sacrum along 
 one of its sides to the breech, then along the thighs to the 
 hands or feet, which of course are to be brought down, by 
 the left hand in the second, and by the right hand, in the 
 first position of the feet or knees. 
 
 Will the same rule apply to the cases of dorso-sacral 
 positions ? 
 
310 OBSTETRIC CATECHISM. 
 
 No : here the reverse obtains, that is, in the dorso-sacral 
 position of the right shoulder, in which the breech is in 
 the left iliac fossa, the right hand must be passed up in 
 front of the child and in a prone condition, while in the 
 dorso-sacral position of the left side in which the breech 
 is in the right iliac fossa; the left hand must be passed up 
 in a prone condition between the child and the anterior 
 part of the uterus. 
 
 In passing the hand for the purpose of reaching the 
 hams or feet for version, is it proper to persist in carrying 
 it up when there is a uterine contraction ? 
 
 All attempts at acting with the hand in the uterus, must 
 be suspended as soon as the contraction takes place, and 
 moreover, the hand must be expanded upon the part of the 
 child with which it is in contact at that time, lest the 
 knuckles should cause rupture of the uterus to take place. 
 
 Is it sometimes necessary to rotate the body of the child 
 on its own axis, in some of the shoulder presentations for 
 the purpose of getting down the feet ? 
 
 This is unavoidable, particularly in dorso-sacral positions 
 of either side. 
 
 Suppose the body has been under pressure of the uterus, 
 and the shoulder is wedged down in the pelvis, must you 
 act at once, or endeavor to allay the contractions of the 
 uterus ? 
 
 It is a fundamental rule, never, if possible to avoid it, to 
 act in attempting at least the first steps of version, unless 
 when the uterus is in a state of relaxation. 
 
 If therefore the tonic contraction of the uterus upon the 
 child, be such that it is immoveable in the uterus, efforts 
 must be made by bleeding, warm bath, nauseants or opiates, 
 to overcome the constriction which this powerful organ ex- 
 erts upon its contents 
 
INSTRUMENTAL DELIv'y. IN SHOULDER PRESENTATIONS. 311 
 
 Suppose the child be dead, or you have reason to believe 
 that the mother will die if not speedily delivered, what 
 would you do ? 
 
 Deliver by the crotchet or other appropriate instrument. 
 
 How would you proceed to do this ? 
 
 Eviscerate the thorax by perforating it, and removing its 
 contents ; then remove portion after portion of the child, as 
 it comes within reach. 
 
 Should you always favor the process of version by the 
 feet, even after eviscerating the child, rather than to 
 force the head down first ? 
 
 This is preferred by good authority. 
 
 Suppose a hand should descend with the head, what 
 practice should you resort to ? 
 
 Support it at the superior strait while the head de- 
 scends. 
 
 Should you ever make traction effort upon the arm in 
 case of its descending first under any circumstances ? 
 
 Never ; such a practice would always complicate the 
 difficulty of subsequent delivery. 
 
 Does the descent of the umbilical cord ever complicate 
 labor ? 
 
 It does very materially, unless the labor is very rapid 
 and speedily terminates. 
 
 How does it do this ? 
 
 By the risk of pressure upon the cord, and arresting the 
 circulation through it, and speedily destroying the child by 
 suspending the process of hematosis. 
 
 Can a very short cord complicate the labor very se- 
 riously ? 
 
312 OBSTETRIC CATECHISM. 
 
 It may slightly retard delivery in some cases, but the 
 chief inconvenience it produces is from the sudden dragging 
 out of the placenta, and sometimes also the uterus with it, 
 and causing inversion of that organ. 
 
 What is the indication in prolapsus of the umbilical 
 cord ? 
 
 To carry it up above the superior strait, and let the head 
 descend first. 
 
 How are you to retain it there ? 
 
 Some attach it to loops at the end of flexible catheters, 
 but the better plan is that of carrying it up in a pocket, on 
 a piece of whale bone above the superior strait, and retain 
 it till the head fairly engages, then withdraw the whale 
 bone and leave the cord, and the pocket to be delivered 
 after the child. 
 
 Should you expect to gain any benefit by bringing down 
 the feet, in such cases ? 
 
 We think this rarely, if ever advisable, as the cord 
 would still be in danger. If reduction of the cord be im- 
 practicable, we would employ the forceps if the head 
 were within reach. 
 
 Do preternatural enlargements of the child or of its 
 head, ever complicate the labor ? 
 
 Enlargements of this kind may not only complicate the 
 labor, but render it impracticable without the aid of proper 
 instruments. 
 
 What practice is indicated under such circumstances? 
 
 Tap the child's head, evacuate the water, or open the 
 head and evacuate the brain ; complete the delivery by the 
 forceps or the blunt hook, if either be necessary. 
 
COMPLICATIONS OF LABOR TWINS. 313 
 
 Does the base of the cranium ever offer any special ob- 
 stacle to delivery ? 
 
 Rarely, if ever, provided it be brought down in the 
 proper direction. 
 
 In what direction is the base of the cranium to be brought 
 down, after the vault has been removed? 
 
 Always, if possible, with its facial extremity foremost. 
 
 Do you consider labor with twins, as more hazardous 
 to the mother than single pregnancies? 
 Not often so. 
 
 Are evidences of twins in utero very conspicuous, 
 usually ? 
 
 There are few, if any rational signs to be depended 
 upon as evidences of compound or twin pregnancy. 
 
 What is the most certain means of diagnosis of twin 
 pregnancies ? 
 Auscultation. 
 
 What must you hear to convince you of the existence 
 of twins ? 
 
 The sound of two hearts, each at different parts of the 
 uterus. 
 
 What are the principal causes which render twin cases 
 of labor more tedious? 
 
 The great distension of the uterus, and the unfavorable 
 direction in which the contractions fall upon either of the 
 fetuses. 
 
 Is the second stage rapid ? 
 
 It is usually so, when once one fetus is fairly engaged, 
 
 because it is usually really smaller than when it is simple 
 
 pregnancy. 
 
 27 
 
314 OBSTETRIC CATECHISM. 
 
 Is there any more clanger in the third stage of labor in 
 compound, than in simple pregnancies ? 
 
 In consequence of the great distension of the uterus 
 during the latter periods of pregnancy in such cases, it is 
 more liable to acquire an atonic state, and hence the 
 greater risk of hemorrhage, &c. 
 
 Are labors in twin cases, liable to become complicated 
 by the descent of any portion of the other child when one 
 has originally presented ? 
 
 This accident has been known to occur, and it is easy 
 to suppose that this complication is often liable to happen. 
 
 Suppose the head of one child, and the feet of the other 
 should engage in the pelvis at the same time, how should 
 you manage the case ? 
 
 If possible, push up the feet, and let the head descend ; 
 but if not, apply the forceps with a view to deliver the 
 head by the side of the feet ; if this expedient should fail, 
 it has been advised to resort to craniotomy, and embryulcia. 
 
 What other complications may take place ? 
 
 A great variety ; one of the most difficult and interest- 
 ing, perhaps, is that in which as one descends, with the 
 pelvic extremity first, its chin becomes locked under the 
 chin of the other which was presenting the cephalic ex- 
 tremity, and which had gotten down, perhaps into the 
 cavity of the pelvis. 
 
 How should you proceed with a view to save the life 
 of one child ? 
 
 Eviscerate the child which has descended, detruncate it, 
 leave the head in the cavity of the uterus, push it up 
 above the superior strait ; then deliver the second child, 
 and afterwards remove the head of the first. 
 
COMPLICATIONS OF LABOR. 315 
 
 Do any complications of labor occur from obliquities of 
 the uterus ? 
 
 It is believed that many cases of complication or devia- 
 tion, depend upon obliquities of the uterus, by which its 
 axis is thrown out of a line with that of the pelvis. 
 
 In what direction do these obliquities usually occur? 
 Laterally and anteriorly. 
 
 Do obliquities of the uterus usually correct themselves ? 
 
 They mostly do by the aid of the contractions of the 
 abdominal muscles; not always however, until after they 
 have caused serious deviation in the direction of the pre- 
 sentation. 
 
 How should you correct those deviations which inter- 
 fere with ready delivery ? 
 
 Generally by placing the patient on the part of her 
 body opposite to that, to which the uterus is inclined. 
 
 Are you justifiable in making any attempt at correction 
 within the pelvis ? 
 
 This may sometimes be done advantageously by acting 
 on the orifice of the uterus steadily, but moderately in the 
 absence of a pain, and retaining it in the acquired position 
 during the next pain, &c. 
 
 Are there any cases in which the os uteri cannot be 
 reached by the finger at the commencement of labor ? 
 
 Cases of this kind have been met with, and the igno- 
 rant accoucheur has been persuaded that there was no os 
 uteri at all, and from the apparent necessity of the case, 
 h^s proceeded to make one with his bistoury. 
 
 How is this occurrence to be explained ? 
 
 Either by the very considerable anterior obliquity of the 
 
316 OBSTETRIC CATECHISM. 
 
 uterus, or by the very great development of the anterior 
 portions of the neck of the uterus, or both of these to- 
 gether. 
 
 By what plan of practice is it to be corrected ? 
 
 By passing a bandage around the abdomen of the pa- 
 tient, and thus compressing the fundus and body of the 
 uterus backward ; then wait until the first stage of labor is 
 nearly completed, by which time you can reach the ante- 
 rior lip, which you can draw gently forward. 
 
 How are you to account for the occurrence of cases in 
 which the head of the child, instead of engaging in the 
 centre of the pelvis, becomes arrested upon the top of the 
 pubes ? 
 
 They most probably depend upon great relaxation of 
 the muscles at the lower part of the abdomen. 
 
 How are you to manage cases of this kind ? 
 
 Make pressure upon the hypogastric, or rather upon the 
 pubic region. If the case offered any unusual difficulty, 
 we would propose the application of a firm bandage 
 around the pelvis, and then urge the patient to take several 
 successive pains in a sitting or standing position strong- 
 ly inclined forwards. 
 
 Is labor ever complicated with retroversion of the ute- 
 rus ? 
 
 Rarely, at or near term ; some cases however, have 
 been reported by Merriman. 
 
 What do you mean by retroversion of the uterus ? 
 
 That in which the fundus of the uterus is thrown down 
 into the hollow of the sacrum, while the os tineas is car- 
 ried up behind the pubes. 
 
RETROVERSION OF THE PREGNANT UTERUS. 317 
 
 During what period of gestation may this condition of 
 the uterus take place ? 
 
 During the first three months only. 
 
 At what time are you to expect that labor will take 
 place in this case ? 
 
 Generally before the sixth month. 
 
 What are the inconveniences and dangers arising from 
 this accident ? 
 
 Retention of urine and feces from pressure ; more or 
 less paralysis also of the lower extremities ; inflammation 
 
 and sloughing, &c. 
 
 What are the usual causes of retroversion ? 
 
 Violent straining, as in jumping, falling, <fcc. Efforts 
 at defecation while constipated ; too great a distension of 
 the bladder; the superincumbent pressure of impacted 
 feces in the colon, &c. 
 
 What are the sysmptoms of retroversion of the uterus ? 
 
 Constant bearing down sensation, great difficulty, or 
 utter impracticability of evacuating the bowels or bladder, 
 &c. 
 
 What is the most prominent symptom, and also the 
 most dangerous one ? 
 
 Retention of urine, and distension to the immediate 
 danger of rupture of the bladder is the earliest urgent 
 symptom, though when in some cases the urine can be 
 evacuated artificially, and the bowels accommodate them- 
 selves to the aid of art, the condition of developing 
 uterus and ovum becomes the subject of great concern. 
 
 As many of these rational signs are fallacious, how are 
 we to determine the existence of the retroversion of the 
 uterus ? 
 
 27* 
 
318 OBSTETRIC CATECHISM. 
 
 By the introduction of the finger into the vagina, and 
 discovering that the os tincae is closely forced up behind 
 the pubes, while the body is thrown backwards into the 
 hollow of the sacrum, and the vagina thereby very much 
 shortened. 
 
 What are the indications for treatment ? 
 
 Reduction or restoration, if possible ; but if the uterus 
 be so far developed as not to admit of being replaced, we 
 must palliate by artifically evacuating the bladder and 
 bowels ; if the enlargement of the uterus produce serious 
 inconvenience, it will be necessary to induce abortion, by 
 rupturing the membranes, if possible, by a stilet passed 
 into the os tincae ; but if not, by a puncture through the 
 substance of the uterus, either directly through the vagina, 
 or through the recto- vaginal septum. 
 
 What other displacements of the uterus may complicate 
 pregnancy ? 
 
 Anteversion of the uterus, and hernia of the uterus. 
 
 What consequences to pregnancy may happen from 
 either of these conditions ? 
 
 Little inconvenience can happen to pregnancy from 
 anteversion of the uterus, as it is usually rectified in 
 proportion as it becomes developed ; but with regard to 
 hernia of the organ, this sort of displacement would entail 
 serious consequences upon gravidity. 
 
 Are there any physiological conditions of the patient 
 which may interfere with the function of parturition ? 
 
 There are many depending upon conditions of the ner- 
 vous, vascular, and muscular systems. 
 
 What is the most common of these physiological con- 
 ditions ? 
 
VARIOUS COMPLICATIONS. 319 
 
 Rigidity of the os uteri, perinaeum, and from original 
 tonicity, depending perhaps upon plethora, and again in 
 some instances the rigidity may be caused by an alteration 
 of structure, as adhesions, cicatrices, &c. 
 
 What process most readily overcomes the rigidity ? 
 Increased secretion, promoted by bleeding, warm bath- 
 ing, fomentations, &c. 
 
 Does rigidity ever depend upon irrritation, the cause of 
 which is direct or remote ? 
 It may, and no doubt does. 
 
 Mav the hand of the accoucheur ever be the cause of 
 this rigidity ? 
 
 By too frequent, or too roughly touching the orifice of 
 the uterus, it may become irritated, rigid, and even in- 
 flamed. 
 
 May too early a rupture of the membranes give rise to 
 rigidity ? 
 
 It is probable that in some cases the too early drainage 
 of the waters, and the pressure of the presenting part upon 
 the os uteri, may cause irritation and consequent rigidity. 
 
 By what means can the accoucheur properly expedite 
 the delivery under such circumstances ? 
 
 By such medical treatment as may diminish the vital 
 tone. 
 
 If the stomach be loaded with impurities, gentle emetics, 
 washing out the stomach, &c. Much may be done, by 
 acting on the bowels by the warm enemata, purgatives, 
 with castor oil, &c. 
 
 Bleeding is very useful, particularly if the patient is 
 febrile. After bleeding nauseating diaphoretics, &c. 
 
 Warm injections, warm fomentationsto the vulva, favor 
 
320 OBSTETRIC CATECHISM. 
 
 relaxation. Advantage will be derived from keeping the 
 patient's mind calm and confident. Use antispasmodics, 
 as assafoetida, camphor, &c. ' even laudanum may be 
 beneficially employed in some cases. 
 
 As local adjuvants, the ointments of belladonna, stra- 
 monium, &c, may be applied to the os oteri ; anodyne 
 enemata, from sixty to one hundred drops of laudanum, 
 may be given at once, after the bleeding, or purging, &c. 
 
 Is it often necessary to divide the bands or cicatrices, to 
 overcome the constriction ? 
 
 It is rarely necessary, in the cicatrices or adhesion of 
 the vagina or perinaeum, and scarcely ever in cases of 
 rigidity of the os uteri, if proper medical or constitutional 
 means are resorted to. 
 
 What danger would be involved in the division of the 
 os uteri, under such circumstances ? 
 
 Extension of the incision to a degree equal to a lacera- 
 tion of the uterus. 
 
 M a}^ labor be complicated or retarded, by irregular con- 
 tractions of the uterus ? 
 
 It may to a greater or less degree. 
 
 How are these irregular contractions diagnosticated ? 
 By the woman feeling the pain in one particular spot, 
 and by the want of expulsive effect. 
 
 Where may these spasmodic contractions occur ? 
 In various points, as the body, fundus, and orifice of the 
 uterus. 
 
 Why do we rarely have spasmodic contractions in the 
 os uteri, in cases of regular presentation of the vertex ? 
 Owing to the fact, that the orifice does not embrace the 
 
RUPTURE OF THE UTERUS. 321 
 
 neck of the child, in consequence of the manner in which 
 its chin is applied to the thorax. 3 
 
 May the internal os uteri, become spasmodically con- 
 tracted ? 
 
 It is believed by some accoucheurs, that it may. 
 
 What effect has this upon the advancement or retardation 
 of the child ? 
 
 The child descends to the superior strait, during an ex- 
 pulsory effort, and recedes at once, when the voluntary 
 powers become suspended. 
 
 What is the proper practice in this case ? 
 
 Venesection, anodyne injections, &c, to suspend the 
 actions of the uterus. 
 
 Avoid turning and forcible delivery merely because the 
 delivery is delayed on this account. 
 
 To what particular accident is the uterus liable, during 
 the parturient effort ? 
 
 Lesion of its structure, either partially or entirely, that 
 is, there may be a separation of some portion of its tissue, or 
 the rupture may extend through its entire substance in- 
 volving the peritonaeum. 
 
 What are the symptoms of rupture of the uterus ? 
 
 A sudden suspension of the alternate contractions, great 
 prostration of strength, hurried or gasping respiration, 
 rapid pulse, &c. 
 
 What are the consequences of this accident ? 
 
 They are dependant upon the extent of the accident; the 
 patient may recover from a partial rupture, but when it 
 is complete, the result is almost always fatal. 
 
 What are the indications for treatment in this case ? 
 
322 OBSTETRIC CATECHISM. 
 
 If the rupture take place in the first stage of the labor, 
 gastrotomy should be resorted to immediately, with a hope 
 to save the child, but if in the second stage, version by the 
 feet, or delivery by the forceps, should be promptly re- 
 sorted to. 
 
 Suppose the child has escaped into the cavity of the 
 abdomen, what should you do ? 
 
 Placing one hand externally over the situation of the 
 child, you should pass the other into the pelvis, and 
 through the rent in the uterus endeavor to find the feet, 
 and bring them down. 
 
 What if the rupture should occur in the vagina, is your 
 chance of delivery greater ? 
 
 It is, inasmuch as in such case the opening is not shut 
 up by contraction. 
 
 Would you think you might resort promptly to the 
 operation of gastrotomy, if you could not deliver the child 
 through the natural passages ? 
 
 That would be the only proper course. 
 
 Does this rupture ever arise from rigidity of the uterus 
 or perinaeum ? 
 
 It is believed that it does, particularly when the portion 
 ruptured has been subject to ramollissement. 
 
 Under what circumstances would you use the forceps, or 
 crotchet, &c? 
 
 In case the head was still in the cavity of the pelvis 
 though the body had passed into the cavity of the abdomen. 
 
 Are convulsions during parturition ever dependant upon 
 rigidity ? 
 
 There is much reason to believe they are sometimes 
 
PUERPERAL CONVULSIONS. 323 
 
 dependant upon this cause, as in the unavailing effort at 
 delivery, the brain becomes the seat of such degree of con- 
 gestion, as determines irregular or spasmodic contractions 
 of the muscular system. 
 
 Why do you call them puerperal convulsions ? 
 Merely because the woman affected, is in a pregnant, or 
 puerperal state. 
 
 Do you consider them different from convulsions which 
 may occur in unimpregnated women? 
 
 They do not differ essentially from those which may 
 attack unimpregnated women, or even nervous men. 
 
 How many varieties of these convulsions, do you gene- 
 rally recognize ? 
 
 Two ; hysterical and apoplectic. 
 
 Which is the most frequent variety ? 
 The apoplectic. 
 
 Which is the least dangerous ? 
 The hysterical variety. 
 
 Upon what does the latter form most frequently depend? 
 Irritability of the nervous system. 
 
 What are the general symptoms of this form of the 
 affection ? 
 
 They are similar to the higher grades of hysterical con- 
 vulsions in unimpregnated women. 
 
 What effect have these convulsions upon the labor ? 
 
 They usually suspend it, inasmuch as there appears to 
 be a sort of metastasis of muscular contraction of the uterus 
 to that of the body generally. 
 
 What are the symptoms of the apoplectic variety of con- 
 vulsions ? 
 
324 OBSTETRIC CATECHISM. 
 
 Those of congestion; mostly pain in the head, sometimes 
 intense in some one spot; there is loss of vision, perversion 
 of the hearing, &c, pulse full, slow and apoplectic. 
 
 Muscles of face much affected ; sibilating noise, frothing 
 at the mouth ; convulsion of the anterior muscles of the 
 face and body ; the patient sometimes falls into a comatose 
 state, and remains so, until another convulsion comes on, 
 though sometimes she promptly recovers. 
 
 What is the cause of these convulsions during labor? 
 They are supposed to depend upon the violence of the 
 uterine and general expulsive effort. 
 
 What are the usual post mortem appearances in cases of 
 these convulsions ? 
 
 Congestion of numerous vessels in the brain and its 
 coverings, with serous, or sanguineous effusion. 
 
 Are there some cases in which death occurs, without 
 any effusion, or apparent lesions of the brain ? 
 
 There are ; and this fact is calculated to lead to the 
 conclusion, that the convulsions may depend upon some 
 other cause than determination of blood to the cerebrum. 
 
 What effect have these convulsions upon gestation ? 
 
 Women who have these convulsive movements during 
 pregnancy are liable to have the fetus die in utero, or to 
 abort it before it is completely developed. 
 
 What effect has gestation upon the convulsions ? 
 
 Though pregnancy is not always directly a cause of 
 these morbid movements, yet the woman, in some in- 
 stances, is subject to a repetition of them, until the child 
 is delivered either at term or prematurely. 
 
 Are the pains usually suspended upon the occurrence of 
 abortion ? 
 
TREATMENT OF CONVULSIONS. 325 
 
 When convulsions occur during labor, the regular con- 
 tractions of the uterus become suspended — a mere flutter- 
 ing kind of movement is observed. 
 
 What are you to do in reference to the condition of the 
 uterus ? 
 
 Let it alone in most cases, especially during the first 
 stage of labor. Attend to the convulsion alone and allow 
 the uterus to take care of itself. This it will usually do, 
 if the tranquillity of the nervous and general muscular 
 system can be restored. If the labor have advanced 
 to the second stage, you may sometimes deliver with the 
 the forceps, if the head be low in the pelvis. 
 
 How should you treat the apoplectic Variety of these 
 convulsions ? 
 
 Bleed, twenty, thirty, forty or fifty ounces, until you 
 empty the blood vessels and relieve the plethora ; then re- 
 sort to the usual treatment for apoplexy-— cold to the head 
 — mercurial cathartics, &c. — active enemata — cups and 
 leeches may sometimes be employed after one free bleed- 
 ing. When vascular depletion has been carried sufficient- 
 ly far, sinapisms, blisters, &c, may be used as revulsives 
 or counter-irritants. When the congestion is thus re- 
 lieved, opium or camphor may be given in combination 
 with calomel and ipecacuanha, and after the system shall 
 have been properly reduced, and the disease controlled, 
 mild tonics, as valerian, <fcc, may be administered. 
 
 Should you interfere with the process of gestation, sup- 
 posing it be not complete ? 
 
 We think not, at least not until after all the usual means 
 of treatment have been fully employed. Should the con- 
 vulsions persist under such circumstances, we might con- 
 sider the propriety of premature delivery. 
 
 28 
 
326 OBSTETRIC CATECHISM. 
 
 Are some patients incident to continued effects of con- 
 vulsions, or rather to a state approaching that which results 
 in convulsions ? 
 
 Yes ; there often remains a disposition for congestion of 
 the large blood vessels. 
 
 What is the treatment proper for such a state ? 
 Revulsion by moderate bleeding, and the use of sina- 
 pisms, &e. 
 
 What do understand by inertia of the uterus ? 
 
 A want of sufficient action, either tonic or expulsive. 
 
 What are its general causes ? 
 
 During the first stage of labor, it may depend upon ple- 
 thora in the uterus. Sometimes it depends upon a trans- 
 ference of the irritation from the uterus to the brain, heart, 
 lungs, &c. — sometimes upon some diseases of the uterus, 
 or general debility from phthisis, uterine hemorrhage, &c. 
 
 May not inertia occur while the uterus possesses a suf- 
 ficient amount of power? 
 
 It may, and then it merely requires to be stimulated 
 into action. 
 
 What is the usual process by which occult hemorrhage 
 occurs ? 
 
 The blood which escapes from the patulous orifices of 
 the vessels on the inner surface of the uterus, becomes 
 coagulated at the os tincae, which it plugs up — the hemor- 
 hage, thus prevented from escaping externally, goes on, 
 and the tonic contraction of the uterus being absent, it 
 distends the uterus, until the quantity thus abstracted from 
 the system becomes so great that the patient dies at once, 
 or falls into a state of syncope, from which she can be re- 
 vived only by the most prompt measures. 
 
ATONY OR INERTIA OF THE UTERUS. 327 
 
 What influence has the presence of coagula in the va- 
 gina in this case ? 
 
 It appears to paralyse the uterus, and thus prevent it 
 from closing up its venous orifices, by tonic contraction. 
 
 What is another marked consequence of atony of the 
 uterus occurring during the second and third stages of 
 labor ? 
 
 Inversion of the uterus. 
 
 What are the degrees of inversion of the uterus ? 
 
 Three are generally recognized in this country, viz.— 
 first, simple depression — second, portion of the fundus 
 passed the orifice — third, complete inversion, in which 
 the whole organ is turned inside out. 
 
 What are the usual causes of this accident ? 
 
 First, great weight of the placenta. Second, too early 
 and too forcible traction efforts of the mother. Third, the 
 continued and forcible bearing down of the mother after 
 extrusion of the child, &c. Fourth, Dewees and some 
 others, think it may depend upon irregular contractions of 
 the fundus, &c. 
 
 What practice are you to adopt in cases of inversion ? 
 We must be governed by the existence of the degree of 
 the inversion. 
 
 What if the inversion is incomplete ? 
 
 Endeavor by firm, equable and steady compression of 
 the inverted part between the two hands, so to diminish 
 its size, that it can be passed up within its orifice, and 
 then carried up upon the back of the hand, till restored to 
 its proper relations. If, however, this reduction is im- 
 practicable, we are advised to draw the inverted fundus 
 carefully down, to complete the inversion of the organ. 
 
328 OBSTETRIC CATECHISM. 
 
 What are you to do, if the inversion be found complete ? 
 
 First, make careful compression upon it, with a view 
 to diminish its size sufficiently to pass it up within its 
 orifice ; but if this be not practicable, desist, and leave the 
 case to the gradual physiological changes which may be 
 effected in it, to adapt it to its new situation. 
 
 What degree of inversion causes the most serious con- 
 sequences, the complete or incomplete ? 
 The incomplete. 
 
 Why is this so ? 
 
 Because in this case a portion of the neck is constricted, 
 and the circulation is impeded through it, and hence venous 
 hemorrhage is kept up, inflammation and sloughing may 
 also occur from this cause, while in cases of complete in- 
 version, all constriction is obviated, and although more or 
 less hemorrhage occurs frequently or, constantly, yet there 
 are no consequences of strangulation in the part. 
 
 What is the diagnosis of this inversion ? 
 
 The moment of its occurrence, the patient complains of 
 a sudden sinking about the pelvic region, shrieks out, be- 
 comes faint, &c. Upon applying a hand at the vagina, 
 a mass of greater or less size, depending upon the degree 
 of the inversion, will be perceived without or within the 
 vulva, or perhaps even within the os uteri itself, if it be 
 merely in the first degree, (though in this there is usually 
 less sense of exhaustion.) If it be external to the os uteri, 
 the mass presents a rather dense structure, with a soft, 
 spongy, more or less rugose surface, not necessarily sensi- 
 tive to the touch. 
 
 How can you distinguish this internal surface from a 
 polypus tumor ? 
 
 This may be very difficult in some cases, but generally 
 
CASES FOR THE USE OF ERGOT. 329 
 
 perhaps the surface of the uterus is more rugose than that 
 of polypus. 
 
 May the practitioner not mistake this for a coagulum, 
 a placenta, or a presentation of another fetus ? 
 
 This would require care in his physical examination, but 
 then with these the patient does not suffer in the same 
 manner. 
 
 How are you to manage a case of inertia of the uterus ? 
 
 During the first stage of labor, but little interference is 
 necessary : we should endeavor to ascertain the causes of 
 the inertia — if plethora, bleed — if constipation, purge — if 
 from irregular distribution of the nervous influence, give 
 those medicines calculated to act upon and regulate the 
 nervous system. 
 
 How would you stimulate the uterine fibres moderately ? 
 By friction, by cathartics, by warm teas, &c. 
 
 How in the second stage ? 
 
 If the uterus be distended, rupture the membranes, pro- 
 vided the os uteri be sufficiently dilated ; then act slightly 
 upon the os tineas with the ringer, by slight traction in 
 different directions. If this did not succeed we would ad- 
 minister the ergot. 
 
 Would you consider ergot as a dangerous remedy ? 
 Highly so, if not very judiciously resorted to ; but very 
 important and useful in proper cases. 
 
 Why has it probably been productive of such fatal ef- 
 fects in practice ? 
 
 Because it has been resorted to in cases when the ad- 
 vancement of the child was opposed by vital resistances, 
 as before the os uteri or the perinaeum were sufficiently 
 relaxed to admit of ready egress of the fetus, forcibly 
 
 28* 
 
330 OBSTETRIC CATECHISM. 
 
 compressed by the ergotic contraction of the uterus. 
 Furthermore, it has been productive of immense evil when 
 administered in cases of mal-position of the child, or 
 when there has been deformity or deficiency of amplitude 
 in the pelvis. 
 
 Under what circumstances can you administer it with 
 propriety ? 
 
 Dilatation or relaxation of all the soft parts, favorable 
 positions, or presentations ; absence of any mechanical 
 resistance at the superior strait of the pelvis. 
 
 It is rarely proper to administer it in cases of first preg- 
 nancy, because of the tenacity of the vital resistances in 
 these cases. 
 
 What are the usual effects of the ergot upon the uterine 
 fibre ? 
 
 It stimulates it to tonic contraction, by which nearly 
 every portion of it acts in the direction to diminish its ca- 
 pacity, and the whole organ, therefore, acts with great and 
 persistent force upon the body within its cavity. 
 
 Does the ergot sometimes fail in producing such effect ? 
 It does so sometimes, owing either to the idiosyncracy 
 of the patient, or to the bad quality of the article. 
 
 What is the first object of the practitioner in cases of 
 hemorrhage from the uterus in the third stage of labor ? 
 
 To excite the tonic contractions of the organ, and thus 
 cause it to close up the open venous orifices. 
 
 How should you effect this ? 
 
 By friction ; by kneeding as it were the uterus ; by the 
 application of a cold hand, cloth, or sponge, or plate of 
 snow, or ice upon the pubic region : by powerful com- 
 pression; by the passage of a hand into the cavity of the 
 
USE OF ERGOT IN INERTIA. 331 
 
 uterus ; by introducing within it a sponge saturated with 
 vinegar, or by passing up a peeled juicy lemon; allowing 
 these acid vehicles to remain until expelled by the con- 
 traction of the uterus, &c. 
 
 Would you give ergot in any of these cases? 
 
 It might be given if at hand, particularly if in the form 
 of tincture, though it is the experience of some practi- 
 tioners that it rarely acts in cases of great prostration from 
 hemorrhage. 
 
 Knowing your patient subject to atony and hemorrhage 
 in the last stage of labor, would you give the ergot in an- 
 ticipation ? 
 
 We would give it just as the child was about to be ex- 
 truded. 
 
 Would you at once remove the placenta from the vagi- 
 na, or leave it in until the hemorrhage is arrested? 
 
 Pass your hand beyond the placenta, remove the coagula 
 you may meet with, and as the uterus contracts allow it to 
 come away. 
 
 What general rule should you observe in reference to 
 the mode of preventing this accident ? 
 
 See that the different stages of labor go on regularly. 
 
 Should you remain by your patient until she reacts 
 after her labor ? 
 
 You should never leave her till you have witnessed this 
 state. 
 
 Suppose your patient arrives at the term of gestation, 
 and she becomes greatly prostrated by phthisis, pulmonary 
 hemorrhage, &c, would you think proper to bring on 
 labor and expedite her delivery ? 
 
 If we can arrest the cause of the exhaustion, we ought to 
 
332 OBSTETRIC CATECHISM. 
 
 wait till term ; but if she be constantly sinking, it is 
 thought better to deliver promptly, but cautiously, while 
 the patient is yet capable of furnishing the means of he- 
 matosis to the child. 
 
 Suppose your patient be affected by syncope during 
 labor or pregnancy, should you generally be alarmed ? 
 
 Not generally ; we are rather to regard it as depending 
 upon a want of regular distribution of the nervous influ- 
 ence. 
 
 What is to be understood by the term abortion in ob- 
 stetric language ? 
 
 It signifies the separation of an ovum from the mother's 
 organs previous to the completion of its development. 
 
 To within what period of gestation do we limit the term 
 abortion ? 
 
 Till the end of the sixth month. 
 
 What do you call the expulsion of an ovum at any time 
 between the end of the sixth, and the end of the ninth 
 month of gestation ? 
 
 Premature delivery. 
 
 How many varieties or modes of abortion are there ? 
 Two : one in which the ovum is detached merely, and 
 the other, in which it is not only detached, but expelled. 
 
 Upon what conditions may abortion depend ? 
 1st. Those peculiar to the mother. 
 2d. Those peculiar to the child. 
 
 What are the various causes of abortion ? 
 Some depend upon the state of the system generally, 
 some upon the state of the uterus itself. 
 
ABORTION. 333 
 
 What condition of the general system of the mother 
 favors abortion ? 
 
 Any extremes of health, as plethora, asthenia, great 
 irritability of the nervous system, &c. Syphilis, and 
 other severe constitutional irritation, accidental diarrhcea s 
 active catharsis caused by drastic purgatives, &c. 
 
 What condition of the uterus is favorable to, or predis- 
 poses to this accident ? 
 
 Plethora ; the menstrual nisus ; irritability of its fibre, 
 &,c. 
 
 Does the female necessarily abort when subjected to the 
 influence of these predisposing causes ? 
 
 No : it usually requires the aid of an exciting cause to 
 effect the abortion. 
 
 What may be regarded as exciting causes ? 
 
 Mechanical irritants, great muscular effort, nauseating, 
 or peculiar odors ; the smell of a segar, the odor of flow- 
 ers, &c, under some circumstances produce this effect. 
 
 Is the production of abortion always within the power 
 of the mother ? 
 
 Not alwavs ; some women are unable to produce it, 
 however they wickedly attempt it, by jumping, standing, 
 taking active medicines, &c. 
 
 What is the most certain mode of effecting abortion ? 
 By rupturing the membranes, and allowing the fluids to 
 escape. 
 
 How are you to explain the action of the causes of 
 abortion ? 
 
 They must produce first organic irritation in the blood 
 vessels of the uterus, and this must extend to the muscular 
 tissue of the organ. 
 
334 OBSTETRIC CATECHISM. 
 
 What distinction are you to make between irritation of 
 the blood vessels, and that of the muscular fibres of the 
 uterus ? 
 
 It has been explained thus, according to the theory of 
 Bichat : irritation of the blood vessels involves merely the 
 organic life ; irritation of the uterine fibre involves the 
 animal life — hence when irritation of the blood vessels 
 occurs, there is not necessarily any contraction, but when 
 irritation of the uterine or muscular fibre occurs, there will 
 be contractions, and perhaps also expulsion. This how- 
 ever is to be understood as a speculation. 
 
 Will contraction of the uterine fibres arrest hemorrhage 
 so long as the ovum is retained ? 
 
 No : if the ovum be detached, it is usually a cause of 
 hemorrhagic irritation. 
 
 Suppose however you have a partial detachment of the 
 ovum, can the hemorrhage be arrested before the ovum be 
 expelled ? 
 
 It may in consequence of the coagulation of blood in 
 the orifices of the vessels, provided the surface of the de- 
 tachment be not too large. 
 
 What are the symptoms of abortion ? 
 
 Sense of weight, and pain in the pubic and sacral re- 
 gions, more or less muco-sanguineous secretion escaping 
 from the vulva, &c. 
 
 Can you diagnosticate between abortion and dysme- 
 norrhea, during the first three months of supposed preg- 
 nancy ? 
 
 Not with any confidence, even in some cases after the 
 mass within the uterus has been extruded. 
 
 What are usually regarded as the diagnostic signs of 
 abortion ■? 
 
SYMPTOMS OF ABORTION. 335 
 
 Regular, intermitting pain in the back ; hemorrhage to 
 some extent ; more or less watery discharge ; strong bear- 
 ing down, expulsive pains : most or all of these except 
 the watery discharge are met with in dysmenorrhcea. 
 
 Does abortion always become complete when once be- 
 gun ? 
 
 Not always ; the ovum may sometimes be preserved in 
 a state of vitality for some length of time, though its de- 
 velopement may not increase. 
 
 What consequences result from abortion ? 
 
 They are very various ; some women recover well and 
 enjoy even better health after one abortion, but others suffer 
 ill health, during a part or all the remainder of their lives, 
 especially when they have been caused by mechanical 
 violence. 
 
 How do you prevent abortion ? 
 
 Diminish the morbid irritability, by removing the cause. 
 If plethoric, bleed, &c. If too much reduced give nutri- 
 cious food, tonics, &c. 
 
 What are habitual abortions ? 
 
 A recurrence of a single abortion, in patients of pecu- 
 liarly irritable uterine fibre. 
 
 How are you to arrest a tendency to abortion ? 
 
 By a general antiphlogistic and revulsive plan of treat- 
 ment, which diminishes the force of the blood upon the 
 inner surface of the uterus, &c. 
 
 Blistersto the back, &c, are often useful in such cases. 
 
 Amongst the internal remedies are the sugar of lead, 
 digitalis, &c, to diminish the force of the circulation. 
 
 What valuable mechanical means have we at hand, for 
 the arrest of the hemorrhage ? 
 
336 OBSTETRIC CATECHISM. 
 
 The tampon, for the purpose of arresting the flow of the 
 blood through the vagina. 
 
 What is the best article for the tampon, or plug 1 
 Strips of bandage, or better still, a piece of sponge, cut 
 
 into an oblong shape, and so introduced as to allow of its 
 
 expansion within the vagina. 
 
 How far may the use of the tampon involve the safety 
 of the ovum ? 
 
 It has been supposed dangerous to it, but this can rarely 
 if ever happen, provided it be properly introduced, and 
 judiciously managed* 
 
 What precautions are first to be had recourse to ? 
 Reduce first of all, the force of the general circulation, 
 by vascular depletion, then allay the pain by opiates. 
 
 May the ovum be detached from the surface of the 
 uterus ? 
 
 It may become detached, after the symptoms have con- 
 tinued a short time. 
 
 How are you to act, when you discover this fact ? 
 Encourage its complete expulsion. 
 
 Suppose you find the ovum lodged in the orifice of the 
 uterus, what should you do ? 
 
 Remove it, or facilitate its detachment. 
 
 Should you give large doses of opium in this particular 
 state of things ? 
 
 If any, merely sufficient to allay the nervous irritation, 
 not enough to paralyse the uterine contractions. 
 
 Should you always make an examination per vaginam, 
 in case of supposed detachment ? 
 Yes, always, carefully. 
 
UTERINE HEMORRHAGE TREATMENT. 337 
 
 How should you proceed to effect the complete removal 
 of the ovum in such cases ? 
 
 By the finger, by Dewees' hook, or better still, by 
 Hodge's abortion forceps. 
 
 Does the hemorrhage usually cease speedily, after the 
 removal of the ovum 1 
 
 It speedily in most cases becomes reduced to a mere 
 lochial discharge, which usually subsides in a very few 
 days. 
 
 Upon what does uterine hemorrhage depend, during or 
 immediately after labor, or for some time before labor 
 begins ? 
 
 Upon detachment of some portion of the placenta. 
 
 Where is the placenta usually attached ? 
 About the fundus, or one of the sides of the uterus, near 
 one of the fallopian tubes. 
 
 What are the consequences of the detachment of the 
 placenta, to both mother and child ? 
 
 Both are endangered by it ; the mother suffers from the 
 direct loss of blood, and the fetus from imperfect hemato- 
 sis. Should any lesion of the placenta occur, the fetus 
 suffers from direct loss of blood, while the mother may 
 escape accident. 
 
 Is the detached portion of the placenta ever re-united ? 
 It is probably never re-united in such way as that the 
 function can be carried on in the part once detached. 
 
 What becomes interposed between the placenta and the 
 internal surface of the uterus ? 
 
 A coagulum of blood, which may become organized and 
 adherent both to the uterus and placenta. 
 
 29 
 
338 OBSTETRIC CATECHISM. 
 
 How are hemorrhages from the uterus during pregnancy- 
 classified ? 
 
 Into avoidable or accidental, and unavoidable. 
 
 What is meant by accidental or avoidable hemorrhage ? 
 
 That which occurs at any period of pregnancy, from an 
 accidental detachment of the placenta, when it is situated 
 at a portion of the uterus, the development of which is 
 proportionate to that of the placenta itself, as about the 
 body or fundus of the organ. 
 
 What do you mean by unavoidable hemorrhage ? 
 
 It is that which inevitably occurs from the detachment 
 of some portion of, or the entire placenta from the uterus, in 
 consequence of its being situated at a part which is devel- 
 oped more rapidly than the placenta itself. 
 
 Is the hemorrhage necessarily constant in this case ? 
 It may be arrested temporarily by the process of coagu- 
 lation, but it is subject to constant recurrence. 
 
 What are the means of diagnosis in these cases ? 
 Examination per vaginum, by which you can feel the 
 fibrous structure of the placenta over the os uteri. 
 
 How much of the hand should be introduced into the 
 vagina for this purpose ? 
 
 In order fully to appreciate the existence of placenta 
 praevia, it is mostly necessary to pass in the entire hand. 
 
 How are you to proceed to arrest the hemorrhage in 
 this case ? 
 
 It has been proposed to place the patient in a recumbent 
 posture with her hips elevated, her circulation as much re- 
 duced as may be consistent with her health, and then resort 
 to such medical means as favor coagulation of the blood. 
 
MANAGEMENT OF HEMORRHAGE. 339 
 
 Are you ever to resort to version for the purpose of ef- 
 fecting delivery before term ? 
 
 This has been proposed, and directions given to force 
 upon the os uteri for this purpose, but we regard it as 
 highly improper, We think a better method would be (if 
 any be called for,) to perforate the placenta, allow the 
 liquor amnii to escape, and the uterus to contract upon the 
 fetus, &c, as in cases of premature artificial delivery, 
 when the pelvis is known to be too small for delivery at 
 term. 
 
 What means have you of arresting the hemorrhage me- 
 chanically ? 
 
 The tampon, which may be cautiously applied, and 
 continued until complete dilatation occurs, and the uterus 
 expels it, the coagula, the placenta and the fetus from its 
 cavity. 
 
 Should you keep down the force of the circulation, favor 
 the coagulation of blood, by absolute use, by the use of 
 tampon, &c, even though you have to continue this plan 
 for five months ? 
 
 We think this would be the appropriate plan of treat- 
 ment. 
 
 Suppose you find hemorrhage coming on at the full 
 period of gestation, should you palliate during the first 
 stage of labour ? 
 
 Yes ; never introduce the hand till the os uteri is dilated 
 or dilatable. 
 
 How are you to proceed, as soon as the second stage 
 of labour commences ? 
 
 Facilitate as fast as possible the delivery of the child, 
 and as soon as it is born, place the hand on the fundus of 
 the uterus, and ensure its complete contraction. 
 
340 OBSTETRIC CATECHISM. 
 
 Suppose the pains are slow, and the head is above the 
 superior strait ? 
 
 Turn and deliver, or give ergot, and as soon as the head 
 is within reach, apply the forceps. Treat the third stage 
 according to established usage. 
 
 In cases of placenta praevia, as soon as the os uteri is 
 dilated, what are you to do ? 
 
 Pass your fingers, and then whole hand, between the 
 placenta and surface of the uterus, seize the feet, and de- 
 liver footling. 
 
 What other practice has been proposed by some of the 
 German physicians in such cases? 
 
 To let the child alone, fill the vagina with a tampon, 
 made of strips of bandage, portions of which can be re- 
 moved, as the head or presenting part is protruded through 
 the uterus ; and when it is fairly within reach, use forceps, 
 blunt hook, or authorized means for expediting the deli- 
 very. 
 
 THE END = 
 
OBSTETRIC MEDICINE. 
 
 The subscriber having fitted up for an obstetric 
 study, the spacious room over the medical and mis- 
 cellaneous book store of Crolius & Gladding, No. 
 341 Market street, north side, first house west of 
 Ninth street, is prepared to receive a larger number 
 of pupils than his late lecture room would accommo- 
 date. 
 
 The situation he now occupies is in the vicinity 
 of the University and Medical Colleges of this city. 
 The room is well lighted during the day. In the 
 evening it is lighted with gas. It is accessible by an 
 ample stairway, with an entrance from both Market 
 and Ninth streets. It is so arranged as to be com- 
 pletely isolated from the other rooms in the house, 
 by a vestibule which makes the study free from in- 
 trusion. 
 
 It contains a Library of Obstetric Medicine, con- 
 sisting of several copies each, of the works recom- 
 mended by the Obstetric Professors in the several 
 schools, as text-books ; also, at least one copy of a 
 number of valuable works on this department of 
 medicine. 
 
 The collection at present consists of 
 
 Dewees' Compendium of Midwifery, several copies. 
 Meigs' Philadelphia practice of Mid- 
 wifery - one do. 
 Meigs' Velpeau's Midwifery, - do. do. 
 James' Burns' Midwifery, - - do. do. 
 
 30 
 
342 
 
 Gooch's Midwifery,. 
 
 Denman's Midwifery, 2 vols., 
 
 Francis' Denman's Midwifery, 
 
 Collins' Midwifery, - 
 
 Smellie's Midwifery, 3 vols., with 
 
 plates, - 
 Heath's Baudelocque's Midwifery, 
 
 3 vols., 
 Osborn's Midwifery, 
 Blundell's Principles of Obstetricy, - 
 Hamilton's Midwifery, 
 Doane's Maygrier's Midwifery, 
 Hamilton's Practical Observations in 
 
 Midwifery, ... 
 
 Bard's Compend of Midwifery, 
 Rigby's Midwifery, 
 Ramsbotham's Obstetric Medicine 
 
 and Surgery, ... 
 Dionis' Midwifery, translated from 
 
 the French, 1719, - 
 Daventer's Midwifery, translated 
 
 from the Latin, 1728, 
 Memorial des Accouchemens, Par 
 
 Mad. Boivin, with 143 plates, 
 Pratique des Accouchemens, Par 
 
 Mad. Lachapelle, 3 vols., - 
 Traite Complete de I'art des Ac- 
 couchemens, par Velpeau, with 
 
 plates, 2 vols., - 
 Cours Complet d'Accouchemens, par 
 
 Jules Hatin, with plates, - 
 Lemonnier Sur l'Accouchement Ma- 
 nuel, quarto, with plates, 1 vol., - 
 Essai de Levret, Sur l'abus des regies 
 
 generates, et contre les prejug&s qui 
 
 s'opposent aux progres de I'art des 
 
 Accouchemens, - - do. do. 
 
 one 
 do. 
 do. 
 do. 
 
 copy 
 do. 
 do. 
 do. 
 
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 do. 
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343 
 
 Observations sur les pertes de sang 
 des femmes en Couche, Par M. 
 Leroux, - - - - one copy. 
 
 Dewees on Females, - one or more copies. 
 
 Gooch on Women, - - - one do. 
 
 Sir C. M. Clarke on Females, 2 vols., do. do. 
 
 Davis' Obstetric Medicine, quarto 
 
 vol., 1294 pages, - - - do. do. 
 
 Clarke's Essay's on the Management 
 of Pregnancy and Labour, and the 
 Inflammatory and Febrile Diseases 
 of Lying-in Women, - - do. do. 
 
 Montgomery on the Signs and Symp- 
 toms of Pregnancy, - - do. do. 
 
 Blundell on some of the most import- 
 ant diseases peculiar to Women, do. do. 
 
 Churchill on the Diseases of Women, do. do. 
 
 Parkman's Velpeau, on Diseases of 
 
 the Female Breast, - - do. do. 
 
 Bedford's Baudelocque on Puerperal 
 
 Peritonitis, - - do. do. 
 
 Ferguson on Diseases of the Uterine 
 
 System, - do. do. 
 
 Lodge's Pauley's Lisfranc on Dis- 
 ease of Uterus, - - do. do. 
 
 Waller, Lisfranc and Ingleby on Dis- 
 eases of the Uterus, - - do. do. 
 
 Warrington's Duparcque on Diseases 
 
 of the Uterus, - - - do. do. 
 
 Maladies des Femmes, par M. 
 
 Nauche, - two do. 
 
 Maladies des Femmes, par Chambon, do. do. 
 
 Boivin et Duges, Sur les Maladies 
 
 de 1'uterus et des ses annexes, - do. do, 
 
 Boivin, Recherches sur une des causes 
 les plus frequentes et la moins 
 con'nue de l'avortement, &c. do. do. 
 
 Boivin, Sur l'hemorrhagie, - do. do. 
 
344 
 
 Boivin, Sur une Cas d'absortion du 
 placenta, - 
 
 Dewees on Children, 
 
 Eberle on Children, 
 
 Underwood on Children, 
 
 Parkman's Rilliet & Barthez, on Dis- 
 eases of Children, 
 
 Billiard on Diseases of Infants, 
 
 Davis on Hydrocephalus, - 
 
 Evanson & Maunsell on the treat- 
 ment of Diseases of Children, 
 
 Combe on Children, 
 
 Capuron Sur les Maladies des Infans, 
 
 Ticknor's Mother's and Nurse's 
 Guide, - - 
 
 Warrington's Nurse's Guide, 
 
 Moreau's Midwifery, Velpeau's Human Ovology, 
 and Sir Astley Cooper on diseases of the female 
 breast, and on the anatomy of the breast, have been 
 ordered for the Library. 
 
 one 
 
 do. 
 
 do. 
 
 do. 
 
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 ILLUSTRATIONS. 
 
 Moreau's Obstetric Plates, coloured, framed, and 
 varnished, (folio) in number, - - 60 
 
 Maygrier's (Doane's Edit.) Plates of Midwifery 
 Illustrated, pasted on boards and varnished, 80 
 
 Davis' Obstetric Atlas — bound lithographic 
 plates, ----- 44 
 
 Ramsbotham's Parturition Illustrated, 52 plates and 
 142 figures. 
 
 Boivin & Duges' finely coloured plates, represent- 
 ing the principal morbid alterations of the uterus and 
 its appendages, - - - - 41 
 
 The eighty plates of Maygrier, and the hundred 
 and one finely coloured plates of Moreau, and Boivin 
 
& Duges, are so displayed upon the walls of the 
 study that they are constantly in view for reference, 
 in illustration of midwifery, and most of the diseases 
 of the uterus. 
 
 The Cabinet of Obstetric Anatomy at present con- 
 sists of 
 
 Female pelvis, containing the genital organs in 
 situ — two specimens. 
 
 Uterine organs, in connexion with each other, 
 but detached from the pelvis — one specimen. 
 
 Ovum, entire at 7 months—one specimen. 
 
 Uteris, which contained the above-mentioned 
 ovum — laid open that its internal surface may give 
 some idea of the mode of connexion of uterus and 
 ovum, during gestation — one specimen. 
 
 Uterus, ruptured at its cervix, during labour, the 
 woman having died undelivered — one specimen. 
 
 Uterus, with surface principally lined with fibrous 
 vegetations, resembling cauliflower excrescence — - 
 one specimen. 
 
 Uterus, containing two fibrous tumours at the 
 fundus of the cavity — the surfaces of these tumours 
 so arranged as to resemble one tumour split into two 
 equal parts — one specimen. 
 
 Uterus, as seen ten days after delivery, and seven 
 days after attack of metro-peritonitis— two specimens. 
 
 Hard polypus, with portion of a long pedicle — 
 one specimen. 
 
 Ova and fetuses, from six weeks or earlier up to 
 ninth month, complete — several specimens. 
 
 Uterus and appendages, with portion of perito- 
 neum. The body of the uterus is in a scirrhous state. 
 The orifice represents the ulcerated condition, after 
 the removal, by ligature, of a small cauliflower ex- 
 crescence. In the peritoneal attachments are to be 
 
 30* 
 
346 
 
 seen parieties of two abscesses, one of which opened 
 externally into the vagina ; the other into the cavity of 
 the abdomen, causing fatal peritonitis — one specimen, 
 (in spirits,) presented by late pupil, Dr. James Mit- 
 chell, of Philadelphia. 
 
 Organs of generation in the female fetus ; presented 
 by late pupil, Dr. Thomas Wood, of Ohio — one spe- 
 cimen. 
 
 Dried pelvis, representing normal and abnormal 
 sizes and proportions — three specimens. 
 
 Fetal skeleton, mounted — one specimen. 
 
 Fibrino-sanguineous masses, which have been sup- 
 posed to be abortions; the study of which, may cor- 
 rect some false impressions heretofore entertained re- 
 specting certain cases of supposed abortion ; several 
 of these have been presented to the proprietor. 
 
 The Cabinet of Instruments contains specimens of 
 every thing necessary for the practitioner of Mid- 
 wifery, as well as a variety of those used in the treat- 
 ment of the diseases of women. A suitable number 
 of these will be placed in the hands of the gentlemen 
 having the privilege of the room, that they may be- 
 come familiar with the articles, and the mode of ap- 
 plication and use. 
 
 One or more obstetric machines, and models of 
 fetus, as well as labour beds, and forceps, veetis, &c, 
 will be accessible at all reasonable periods to' the 
 members of the class or classes having the privilege 
 of the study ; and it is the intention of the subscriber 
 to add to the various departments of the means of 
 reference or illustration, as far as practicable, in pro- 
 portion to the number of his pupils. 
 
 With this view, orders have been given for a spe- 
 cimen of every new and approved obstetric instru- 
 ment as it may appear ; and instructions directed to 
 a bookseller to supply the library with a copy of any 
 valuable work which may be published on mid- 
 wifery, and diseases of women and children. 
 
347 
 
 As it is the wish of the subscriber to enlarge his 
 cabinet of specimens, illustrating the anatomical, 
 physiological, and pathological departments of ob- 
 stetric medicine, he hereby announces to his former 
 pupils, and his friends generally, who may be dis- 
 posed to contribute specimens, with appropriate de- 
 scriptions, that their favours will be gratefully re- 
 ceived and suitably acknowledged. 
 
 PLAN OF INSTRUCTION. 
 
 The room is open daily from an early hour in the 
 morning until 10 o'clock P. M. On Thursdays it is 
 not accessible until 11 A. M. At all other periods 
 except this, every facility is furnished for prosecuting 
 the study of the various departments of Obstetric 
 Medicine. 
 
 The subscriber devotes one hour each day for five 
 days in the week, at the room, in giving practical in- 
 structions in obstetrics and the diseases of women 
 and children. 
 
 During the session of public lectures, regular ex- 
 aminations are made on the subject, at least once 
 each week. 
 
 Four courses of Demonstrations of the anatomy 
 of the female organs of generation, of the mechanism 
 of labour, simple, manual, and instrumental, together 
 with the mode of preparing the bed> and the patient, 
 &c, are given in the lecture-room. 
 
 These courses will commence at S o'clock in the 
 morning of the first Monday in March, in June, in 
 September, and in December, and continue regularly 
 five times a week until completed. The interval be- 
 tween the completion of one course and the commence- 
 ment of the other is filled up by lectures on diseases 
 of women and children, in the same manner, except, 
 
348 
 
 perhaps, during August, and a recess of a few days 
 in October. 
 
 Three classes of pupils are accommodated by this 
 arrangement, viz. : — One, consisting of gentlemen 
 who wish to make themselves thoroughly acquainted 
 with the principles of Obstetrics and the diseases of 
 women and children, by the use of the library, by 
 pictorial illustrations, by anatomical specimens, and 
 by constant attendance upon demonstrations and lec- 
 tures on these subjects, with appropriate recapitu- 
 latory examinations ; these are regarded as Room 
 Pupils, and can enter as such, during any period of 
 their medical studies under the regulations pre- 
 scribed. 
 
 Another class consists of those who enter for the 
 lectures merely, and who have no access to the room 
 except during the hours appropriated to the lectures. 
 
 The third class consists of advanced students, or 
 graduates in medicine, who are desirous of acquiring 
 practical experience in attending upon pregnant, par- 
 turient and puerperal women, under the supervision 
 of the subscriber, as Accoucheur to the Philadelphia 
 Dispensary and Nurse Charity. 
 
 Such gentlemen are regularly instructed in the du- 
 ties of the accoucheur, and closely exercised upon 
 obstetric models in the manner of preparing the bed 
 and the patient, as well as in tact in diagnosis of 
 presentation and position of the fetus, the use of the 
 hand, for manual, and of the various instruments, for 
 instrumental deliveries. In connexion with this 
 course of exercises, they are admitted to the Obstet- 
 ric Clinic every Thursday morning, at which they 
 have such cases of pregnancy as apply for aid, dis- 
 tributed to them for attention, under the supervision 
 of the subscriber as Accoucheur. 
 
 Gentlemen who attend the lectures on, diseases of 
 women, or who obtain the privilege of the study as 
 Room Pupils, and are at the same time associated 
 
349 
 
 with any of the District Physicians of the Dispen- 
 sary, or "of the Guardians of the Poor, are at liberty 
 to consult with the subscriber in reference to any 
 case of disease peculiar to females, which may have 
 been assigned to them, provided such consultation 
 be made with the approbation of the physician under 
 whose care they are visiting the patient. These con- 
 sultations are made at the study at the close of a 
 lecture, or at the bedside, if desired, whenever the 
 leisure of the subscriber will permit. 
 
 The Annual Introductory Lecture is given at 
 8 o'clock in the evening of Wednesday following 
 the first Monday of November of each year. 
 
 TERMS 
 
 For pupils who enter for the privilege of Room, 
 Obstetric demonstrations and examinations in Mid- 
 wifery, preparatory to graduation or otherwise, dur- 
 ing the term of regular courses of public lectures in 
 the Schools, - - - $15 00 
 
 For pupils who enter for the entire year, enjoying 
 the above privileges, and in attendance upon the 
 course of practical lectures on diseases of women 
 and young children, during the recess of public lec- 
 tures, - . . $35 00 
 
 For graduates, or advanced students, who wish to 
 attend upon cases of pregnancy and parturition, under 
 the care of the subscriber, as Accoucheur to the Phi- 
 ladelphia Dispensary and Nurse Charity, including 
 a course of close preparatory exercises upon the ob- 
 stetric machine, &c, during three months, $20 00 
 
 For pupils who enter for an entire year, with all 
 the privileges above specified, including a course of 
 practice, for three months, (the period at which such 
 pupils are permitted to enter on practice, being at 
 the discretion of the teacher,) - $50 00 
 
350 
 
 Pupils who enter for attendance upon the lectures 
 merely, during the year, - - $20 00 
 
 The fees in all cases to be paid in advance, and in 
 money current in Philadelphia. 
 
 Pupils in entering their names and obtaining 
 tickets will please specify the town, county, and state 
 in which they reside, the name of their preceptor, and 
 the school to which they are attached, or at which 
 they intend to graduate. 
 
 JOSEPH WARRINGTON, M. D., 
 
 No. 229 Vine Street, Franklin Square. 
 
 Philadelphia, 2d mo., Feb. 1842. 
 
 Note. — Hours at Room, 341 Market street, 8 to 
 9 o'clock, A. M., (except Thursdays,) at home, 229 
 Vine street, 3 to 4, P. M. 
 
 DEC ip;-: 
 
LIBRARY OF CONGRESS 
 
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