Class. 
 Book 
 
 COPYRIGHT DEPOSIT 
 
A SYSTEM 
 
 OF 
 
 MIDWIFERY, 
 
 INCLUDING THE 
 
 DISEASES OF PREGNANCY AND THE PUERPERAL STATE. 
 
 / BY 
 WILLIAM LEISHMAN, M.D., 
 
 REGIUS PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF GLASGOW; PHYSICIAN TO THE 
 
 UNIVERSITY LYING-IN HOSPITAL; FELLOW AND LATE VICE-PRESIDENT OF THE 
 
 OBSTETRICAL SOCIETY OF LONDON; CORRESPONDING MEMBER OF THE 
 
 OBSTETRICAL SOCIETY OF EDINBURGH, AND OF THE 
 
 OBSTETRICAL AND GYNAECOLOGICAL SOCIETY 
 
 OF BERLIN, ETC., ETC., ETC. 
 
 SECOND AMERICAN FROM THE SECOND AND REVISED ENGLISH 
 
 EDITION 
 
 WITH ADDITIONS BY 
 
 JOHN S. PA KEY, M.D., 
 
 OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL; VICE-PRESIDENT OF THE OBSTETRICAL 
 SOCIETY OF PHILADELPHIA, ETC. 
 
 PHILADELPHIA: 
 
 HENRY C. LEA. 
 
 18 7 5. 
 

 Entered according to Act of Congress, in the year 1875, 
 
 By HENRY C. LEA, 
 
 In the office of the Librarian of Congress, at Washington, D. C. 
 
 SHERMAN & CO., PRINTERS, PHILADELPHIA. 
 
o- 
 
 EDITOR'S PREFACE. 
 
 In preparing for the press the Second American Edition of Dr. 
 Leishman's System of Midwifery the Editor has added such notes only 
 as he believed would make the book more useful to the profession 
 in this country. The additions are distinguished from the text by 
 being inclosed in brackets, [ — P.], and will be found chiefly in the 
 chapters on the Use of the Forceps, Lactation, and the Puerperal Dis- 
 eases. A chapter on Diphtheria of Puerperal Wounds has been added, 
 and a few new illustrations have been introduced, representing the 
 principal modifications of Obstetrical Instruments generally employed 
 in this country. 
 
 The Editor trusts that these additions will increase the usefulness of 
 a work of which the value is attested by the simultaneous exhaustion 
 of both the English and American Editions. 
 
 J. S. P. 
 1513 Arch Street, Philadelphia, 
 December, 1875. 
 
PREFACE TO THE SECOND EDITION. 
 
 The success which has attended the publication of this Work may, 
 it is hoped, be accepted as an indication that it has, in some degree, 
 fulfilled the purpose with which it was designed. 
 
 In the present Edition, many errors have been corrected, and no 
 effort has been spared to render it more worthy of the approbation 
 which has been accorded to it. The chief alterations will be found in 
 the Physiological Section — in regard to which the Author is under 
 great obligation to his colleague, Professor Allen Thomson — and in the 
 chapters on Puerperal Fever, which have been re-written, with the 
 view of giving greater prominence to the doctrine of septicemic 
 infection. 
 
 The assistance of Dr. Gavin P. Tennent has again been invaluable, 
 and especially so in the rearrangement of a Copious Index. 
 
 11 Woodside Crescent, Glasgow, 
 October 1st, 1875. 
 
PREFACE TO THE FIRST EDITION. 
 
 The Author's object in this Work has been to furnish the Students 
 and Practitioners a Complete System of the Midwifery of the present 
 day. Its claim to a title so ambitious may be questioned. 
 
 Of English Text-Books, some of the very best have long been out 
 of print; some are out of date; and others arc mere Handbooks, in 
 which the subject is, however ably, but cursorily treated. In our 
 language, scarcely a modern work exists which can be compared with 
 those of Cazeaux and Scanzoni. This is the Author's apology for an 
 attempt in which, while he does not presume to emulate those authors, 
 he ventures to hope that the fruit of some earnest labor, but too scant 
 leisure, may not be held unworthy of consideration. 
 
 There are, he believes, few modern works of approved merit, whether 
 British or Foreign, with which the Author has not made himself 
 familiar; nor has he scrupled to avail himself from these sources, of 
 what seems to him, at any point, to contribute to the elucidation of the 
 subject. In no case, it is hoped, has this been done without ample 
 acknowledgment. 
 
 The meagreness of statistical details, references, and illustrative 
 cases, is a part of the original plan, adopted with the view, as far as 
 the subject will admit, of maintaining the narrative form. 
 
 To several of his colleagues, to many professional friends, and, 
 especially, to Dr. Gavin P. Tennent, for assistance in passing the work 
 through the press, the Author is under obligations which he cannot 
 too warmly acknowledge. 
 
 4 Montague Place, Glasgow, 
 July 1st, 1873. 
 
CONTENTS. 
 
 CHAPTEE I. 
 
 INTRODUCTORY. 
 
 History of Midwifery — Hippocratic Era — Arabian School — Ambroise Pare — Mau- 
 riceau — English Midwifery — Objections to the Practice of Midwifery considered 
 — Comparative Anatomy of the Pelvis — The Pelvis a Tube through which the 
 Product of Conception Passes — Parturition in the Primates; in the various 
 Paces — The Erect Posture the Main Cause of Comparative Difficulty in the 
 Human Species — The Human Pelvis a Curved Canal — Separation of Pelvic 
 Articulations during Labor — Midwifery Defined, 17 
 
 CHAPTER II. 
 
 THE PELVIS. 
 
 Oslnnominatum : Sacrum: Coccyx — The Pelvis as a Whole : " True " and " False " 
 — Difference between Male and Female Pelvis: at Brim; in Cavity; and at 
 Outlet — Pelvic Articulations: (a) Pelvi-lumbar ; (b) Sacro-Coccygeal ; (c) Sac- 
 roiliac; (d) Symphysis Pubis; (e) Obturator Ligaments; (/) Sacro-Sciatic 
 Ligaments — Inclination of Pelvis — Axis of of the True Pelvis — Brim or Inlet 
 — Cavity — Outlet — Pelvic Diameters— Pelvic Angles — Development of Pelvis 
 — Certain Soft Parts connected with Pelvis ; Obturator Internus and Pyriformis 
 Muscles; " Floor » of Pelvis, 33 
 
 CHAPTER III. 
 
 FEMALE ORGANS OF GENERATION. 
 
 A. External. Labia; Perineum; Hymen, etc. — Erectile Tissue — The Vagina — 
 
 Glands of the External Organs— Abnormal Conditions — Mammary Glands. 
 
 B. Internal. The Uterus : Situation of; Divided into Body and Cervix; Axis 
 
 of Unimpregnatcd Uterus ; Cavity of; Fundus; Surfaces and Borders ; Serous 
 Covering of — Broad Ligaments; Round Ligaments; Vesico-Uterine Folds — 
 The Fallopian Tubes — Parovarium — Folds of Douglas — Equilibrium of the 
 Uterus, 48 
 
 CHAPTER IV. 
 
 female organs of generation (Continued). 
 
 Of the Proper Tissue of the Uterus — Of the Mucous Layer : its Structure and Glands, 
 in the Body and Cervix — Bloodvessels of the Uterus — Lymphatics and Nerves 
 — Malformations and Abnormal Conditions— The Ovaries : their Structure — 
 
Vlll CONTENTS. 
 
 The Graafian Vesicles and their Development — The Ovum — Phenomena of 
 Ovulation — Formation of the Corpus Luteum — The Corpus Luteum of Preg- 
 nancy distinguished, 67 
 
 CHAPTEE V. 
 
 MENSTRUATION AND CONCEPTION. 
 
 The "Rut" of Mammalia: Analogy between this and Menstruation — The First 
 Menstrual Period: Statistics of Duration of a " Period "—Quantity of the 
 Discharge — Menstruation a Hemorrhage : Non-Coagulability of — Source of 
 the Menses: various Theories regarding : is from the Mucous Membrane of the 
 cavity — Pouchet's Theory examined ; is the Mucous Membrane shed ? — Views 
 of Kolliker, Coste, etc. — Duration of Childbearing Epoch — Cause of Men- 
 struation — Conception — Composition of the Semen — Spermatozoa and their 
 development — " Sperm Cells " — The function of the Germinal Vesicle ; " Germ 
 Cells " — How does the Semen reach the Ovum? 87 
 
 CHAPTER VI. 
 
 DEVELOPMENT OF THE OVUM. 
 
 Formation of the Embryo-cell — Cleavage of the Yolk — Development of Blasto- 
 dermic Vesicle — "Serous" and "Mucous" Layers — The Area Germinativa 
 and Primitive Trace — Formation of the Embryo ; of the Umbilical Vesicle and 
 Omphalo-mesenteric Vessels; of the Amnion; of the Allantois and Umbilical 
 Vessels; of the Chorion — The Liquor Amnii — The Vitriform Body — The 
 Decidua : what is it? — Decidua Vera; Eeflexa ; Serotina — Early connection 
 of Ovum with Decidua — The Umbilical Cord : Vessels; Gelatin of Wharton, 
 etc. — Knots on Cord — The Placenta in Birds: in Non-Placental Mammals: 
 in Ruminants: in Man : Maternal and Foetal Surfaces of: Maternal Circula- 
 tion in : Curling Arteries: Sinuses: Veins — Foetal Portion: Arteries: Tufts 
 or Villi : Veins — Functions of the Placenta — Structure of Villi, . . 101 
 
 CHAPTER VII. 
 
 DEVELOPMENT OF THE EMBRYO AND FOETUS. 
 
 Demonstration of Embryonic Structures — Characteristics and Development of the 
 Foetus at the termination of each Month of Pregnancy, from the third onwards 
 — Dimensions of Mature Children — Of the Presentation and Attitude of the 
 Child in the Womb— Causes of Cranial Presentation : theories of " Physical 
 Gravitation," " Volition," and " Reflex Action " — The Foetal Cranium : 
 Sutures: Fontanelles: Diameters — Definition of the term "Vertex" — Func- 
 tions of the Foetus: Circulation: Respiration: Nutrition: Secretion, . 120 
 
 CHAPTER VIII. 
 
 PREGNANCY : SIGNS OF PREGNANCY. 
 
 Pregnancy — The Gravid Uterus : Muscular fibres of: Muscular layers — Change in 
 fibres after delivery — Development and Anatomical Relations of Uterus at 
 various stages of Pregnancy — Signs of Pregnancy — Suppression of the Cata- 
 menia — Digestive Disorders: Morning Sickness: Salivation — Kiestein — 
 Changes in the Mammae : Pain: Enlargement: Secretion of Milk: Areola: 
 Changes in Nipple, and in Glandular Follicles : Secondary Areola — Enlarge- 
 
CONTENTS. IX 
 
 ment and External Appearance of Abdomen : Flattening in early months : 
 Change in the Appearance of Umbilicus: Diagnosis of other Abdominal 
 Tumors— Vaginal Examination: Color: Digital Examination: Vaginal 
 Pulse, 144 
 
 CHAPTER IX. 
 
 signs of pregnancy (Continued). 
 
 Changes in the Os and Cervix Uteri : Progressive Softening of: Characters of at 
 Various Stages — Position of Os in Relation to Pelvic Walls — Practice of the 
 "Toucher" — Examination per Anum — Quickening: Ecetal Movements Ob- 
 served ; («) by the Mother, (b) by the Accoucheur — Ballottement or Repercus- 
 sion — Foetal Pulsation — Funic Souffle — Uterine Souffle : Theories as to its Pro- 
 duction — Stethoscopic Examination of Foetal Movements — Signs divided into 
 Certain and Probable — Tabular Resume of the Signs of Pregnancy, . 159 
 
 CHAPTER X. 
 
 DURATION OF PREGNANCY — SUPERFCETATION. 
 
 Duration of Pregnancy : in Cows and Mares : in Women — Protracted Preg- 
 nancy : Cases of — Difference in Rate of Development — Mode of Calculating 
 the Probable Time of Delivery: Calculation from last Menstruation to be cor- 
 rected by Period of Quickening — Superfcetation : to be distinguished from 
 Superfecundation — Proofs of the latter — Twin Pregnancy in relation to this 
 Subject — Cases — Conclusions, . . . , . „ , . .176 
 
 CHAPTER XI. 
 
 PLURAL* PREGNANCY — EXTRA-UTERINE PREGNANCY. 
 
 Plural Pregnancy — Mode of Impregnation — Twins: Disposition of the Mem- 
 branes and Placenta in : Diagnosis of : Relation of to Superfcetation — Triplets, 
 etc. — Extra- Uterine Pregnancy — Varieties of: Ovarian: Tubal: Tubo- 
 Ovarian: Abdomino-Tubal: Tubo-Uterine, etc.: Abdominal — Causes of Extra- 
 Uterine Pregnancy — Development of the Ovum and its Coverings — Sympathy 
 of the Uterus — Symptoms — Progress of in Different Varieties : Rupture of the 
 Sac: Peritoneal Inflammation: Discharge of Foetal Debris — Terminations — 
 Treatment, 190 
 
 CHAPTER XII. 
 
 abnormal development. 
 
 Molar Pregnancy — False Moles : from Vagina : Membranous Dysmenorrhoea : 
 Fibrous and Hemorrhagic Casts of Uterus — True Moles : Fleshy Moles : Hy- 
 datidiform Moles — Their Pathology, Diagnosis, and Treatment — Diseases of the 
 Placenta, and their Effects — Missed Labor — Diseases of the Foetus — Infra- 
 Uterine Fractures and Amputations: Efforts at Reproduction — Monsters, 205 
 
X CONTENTS. 
 
 CHAPTEK XIII. 
 
 DISEASES OF PREGNANCY. 
 
 I. Disorders of the Digestive Functions — Excessive Vomiting: Treatment 
 of: Question of Induction of Premature Labor in — Anorexia — Gastrodynia — 
 Pyrosis — Constipation — Diarrhoea — II. Disorders of Respiration — Dysp- 
 noea—Cough — III. Disorders of the Circulation— Condition of the Blood 
 in Pregnancy: Diminution of Blood-Corpuscles : Proportional Alteration in 
 Fibrin and Albumen — Supposed resemblance of the Phenomena of Pregnancy 
 to those of Chlorosis — Administration of Iron in Pregnancy — Plethora — 
 Varicose Veins — Haemorrhoids — Thrombus of the Vagina, . . . 218 
 
 CHAPTER XIV. 
 
 diseases of pregnancy (Continued). 
 
 IV. Disorders of Secretion and Excretion — Ptyalism — Interference with 
 Function of Kidneys and Bladder — Retention : Mechanical or from Paralysis 
 — Albuminuria : State of the Blood in : Peculiarities of the Puerperal Form: 
 Connection of with Puerperal Convulsions : Symptoms, Prognosis, and Treat- 
 ment — The Phosphatic Diathesis in Pregnancy — Leucorrhcea and Granular 
 Vaginitis — Ascites — Dropsy of the Amnion — Hydrorrhea — V. Disorders 
 affecting Locomotion — Pelvic Articulations : Relaxation of: Inflammation 
 of— VI. Disorders affecting the Nervous System— Affections of the 
 Special Senses — Effect on the Moral and Intellectual Faculties — Abdominal and 
 Uterine Pain— VII. Displacements of the Gravid Uterus — Prolapsus — 
 Anteversion and Anteflexion: Symptoms and Treatment of — Retroversion; 
 how caused originally: Chronic and Acute Forms : Symptoms and Treatment 
 of each : Operation for the Reduction of — Oblique Displacements, . . 232 
 
 CHAPTER XV. 
 
 LABOR AND ITS PHENOMENA. 
 
 Causes of Labor — Maturity: Antagonism between certain Groups of Uterine 
 Fibres: Brown-Sequard's Theory : Labor coincident with the Tenth Menstrual 
 Period — Forces by which Delivery is effected : Nervi-motor Functions of the 
 Uterus: Effect of Emotional Causes: Reflex Function of the Spinal Cord: 
 Peristaltic Action : Auxiliary Force in the Muscles of Expiration — Stages 
 of Labor— Preparatory Stage— First Stage: Labor Pains; their Effects on 
 the Maternal Pulse and on the Uterine Souffle: False Pains: Mechanism of 
 the Dilatation of the Os ; the Bag of Waters ; Effect of Longitudinal Fibres : 
 Termination of First Stage in Rupture of Membranes : Rigor : Show— Second 
 Stage : Change in character of the Pains ; the " Caput Succedaneum :" Action 
 of Voluntary Muscles : Dilatation of the Perineum : Birth of the Head and 
 Trunk— Third Stage : "Dolores Cruenti :" Separation and Expulsion of the 
 Placenta ; Mechanism of this, ........ 252 
 
 CHAPTER XVI. 
 
 MANAGEMENT OF NATURAL LABOR. 
 
 Duties of the Accoucheur — Preliminary Arrangements — False Pains and their Treat- 
 ment — Armamentarium of the Accoucheur — Position of the Woman during 
 
CONTENTS. XI 
 
 Labor — Digital Examination : Points to be examined — The Patient not to take 
 to bed during the First Stage — Preparation of the Bed, etc. — Abdominal 
 Muscles to be called into play during the Second Stage — Management of the 
 Anterior Lip of the Os — Obstacles arising from Rigid Os ; and from Non- 
 Rupture of Membranes — Use of Stethoscope — Views regarding Support of 
 Perineum — Treatment if Laceration is threatened — Causes of Laceration — 
 Birth of the Head — Passage of the Trunk — Treatment of Suspended Animation 
 in the Child — Ligature of the Cord — Management of the Third Stage: Crede's 
 Method — Application of Abdominal Bandage — Treatment of the Woman after 
 Delivery, 268 
 
 CHAPTER XVII. 
 
 THE MECHANISM OF LABOR. 
 
 Ideas which Labor involves — Difficulty and Importance of the Subject — Historical 
 Sketch: Views of Sir Fielding Ould ; of Smellie; of Saxtorph ; of Solayres de 
 Renhac ; and of Naegele — Natural and Faulty Presentations — Cranial Presen- 
 tations : Occipito-Anterior and Occipito-Posterior Varieties — First Posi- 
 tion: Pelvic Obliquity: Occipito-Frontal Obliquity, or Flexion: the Head 
 "at the Brim :" Examination of Fontanelles and Sutures — Rotation ; Causes of 
 — The "Presentation" or "Presenting Point" — The Caput Succedaneum — 
 The Chin leaves the Chest — Further Descent and Birth of the Head — Obliquity 
 at the Outlet — Moulding — External Rotation or Restitution of the Head — 
 Second Position: the Converse of the First — Third Position — Resume of 
 Mechanism in Occipito-Anterior Positions, 284 
 
 CHAPTER XVIII. 
 
 mechanism of labor (Continued). 
 
 Occipito-Posterior Positions — The Third [Fourth] Cranial Position ; Rotates 
 into the Second, or may terminate with forehead forwards — The Fourth [Fifth] 
 Position ; Rotates into the First, or may terminate with Forehead forwards — 
 Artificial Rectification of these Positions [Sixth Position] — Comparative Fre- 
 quency of the Four Cranial Positions. 
 
 Face Presentations — Distinction between "Obstetrical" and "Anatomical" 
 Face — Mento-Posterior and Mento-Anterior Varieties— Fourth Position: 
 Mechanism of— Third Position — First Position ; Rotates into the Fourth 
 — Second Position : Rotates into the Third — Relative Frequency of the Facial 
 Positions — Operative Interference in — Irregular Presentations — Tabular Com- 
 parison of Cranial and Facial Positions, 303 
 
 CHAPTER XIX. 
 
 PELVIC PRESENTATIONS. 
 
 The Practice of the Past — The Pelvis a Natural Presentation — Dorso-Anterior and 
 Dorso-Posterior Positions — Breech Presentation ; Four Positions of — First 
 Position of the Breech: Rotation: Passage of the Buttocks: Descent and 
 Birth of the Shoulders: Difficult Progress of the Head, and Mechanism of its 
 Expulsion — Second Position of the Breech — Third Position of the 
 Breech : Birth of the lower portion of the Trunk, and of the Shoulders i 
 
Xll CONTENTS. 
 
 Kotation of the Face backwards, and Mechanism of the Birth of the Head; 
 Exceptional Terminations— Fourth Position of the Breech— Special Kisk 
 of Pelvic Presentations — Diagnosis and Peculiarities — Knee and Footling Cases 
 — Management of Pelvic Presentations — Nature of Assistance to be Rendered — 
 Use of the Fillet, Yectis, and Blunt Hook — Indiscriminate Dragging on the 
 Lower Limbs to be avoided — Treatment of Case where Arms pass up along- 
 side Head — Management of the Funis — Indications of impending Death of the 
 Child — Manipulation for effecting speedy Delivery of the Head — Use of the 
 Forceps, 324 
 
 CHAPTER XX. 
 
 transverse presentations: complicated presentations. 
 
 Transverse Presentations — The Arm or Shoulder the Presenting Part — Causes 
 of — Signs of, before and during Labor — Premature Rupture of the Membranes 
 to be avoided^-Dorso-Anterior and Dorso-Posterior Positions — Determination 
 of exact Position by Observation of the Hand — Probable Course of an Unaided 
 Case — Occurrence of Spontaneous Evolution — Spontaneous Expulsion — Methods 
 of Operative Assistance : Period of Labor to be selected : Cephalic Version : 
 Podalic Version : Method of Combined External and Internal Manipulation: 
 Special Difficulties — Procedure Modified if Child Dead— Compound or Com- 
 plicated Presentations — Hand and Head— Hand and Feet, etc.— General 
 Management of these, .......... 341 
 
 CHAPTER XXI. 
 
 FUNIS PRESENTATION. 
 
 " Presentation " and " Prolapse" of the Cord — Relation of the Funis to other Pres- 
 entations — Causes of — Symptoms of at Various Stages of Labor — Great Danger 
 to Child— Treatment: at first Expectant: avoid Rupture of the Membranes : 
 Reposition by the Fingers : by Mechanical Appliances : Various Repositoria 
 described: Postural Method : Use of the Forceps : Turning, . . 355 
 
 CHAPTER XXII. 
 
 PREMATURE EXPULSION OP THE OVUM. 
 
 Classification — Abortion ; Definition of — Causes : in General Health : from Reflex 
 Irritation: from Diseases of the Ovum: from Action of Oxytoxics: from Af- 
 fections of Neighboring Organs : from Mechanical Violence — Tendency to 
 Repeated Abortion — Symptoms ; at various Periods— Precursory Symptoms : 
 Pains : Hemorrhage— To be distinguished from Delayed Menstruation— Signs 
 of Death of the Foetus — Distinction to be drawn between "Threatened" and 
 " Inevitable " Abortion — Retention of the Ovum — Expulsion of the Placenta — 
 Treatment: Preventive: Prevention when Abortion Threatened — Expulsion to 
 be Promoted when Inevitable — Management of Haemorrhage, and of the Pla- 
 centa: Placental Forceps — Treatment of a Woman after Abortion — Prema- 
 ture Labor — Special Causes— Treatment, 367 
 
 CHAPTER XXIII. 
 
 HEMORRHAGE before delivery. 
 
 "Unavoidable" and "Accidental" Haemorrhage — Placenta Previa; Central 
 and Lateral : Original Idea as to the nature of: Views of Roederer and Rigby 
 
CONTENTS. Xlll 
 
 — Causes of Placental Presentation — Symptoms :. Hemorrhage before and 
 during Labor : Examination from the Vagina : Occasional Termination by- 
 Expulsion of the Placenta, with Cessation of Haemorrhage : Symptoms and 
 Termination of the " Lateral " Variety — Treatment: General Measures: Use 
 of the Plug or Tampon : Evacuation of the Liquor Amnii by Puncture of the 
 Membranes or Placenta — Turning in Placenta Prsevia : Passage of the Hand 
 through the Placenta at one time Practiced: Usual Method of Operation — The 
 Bi-Polar Method — Artificial Extraction of the Placenta: Simpson's Statistics 
 — Partial Separation of the Placenta: Barnes's Views — General Conclusions as 
 to Treatment — Accidental Hemorrhage; more serious than is generally 
 supposed — Site of the Placenta — Symptoms — Treatment — Use of Styptics in 
 both Forms of Haemorrhage, . . . . . . . ' . 386 
 
 CHAPTEE XXIV. 
 
 HAEMORRHAGE AFTER DELIVERY. 
 
 Haemorrhage in the Third Stage of Labor — Abnormal and Ketained Placenta, and 
 Irregular Uterine Contraction, as Causes of Flooding — Post-partum Hemor- 
 rhage — Causes; General and Local — Symptoms; of External and Internal 
 Haemorrhage: Examination of the Abdominal "Walls: Examination by the 
 Vagina : General Symptoms : Symptoms which indicate the Approach of 
 Death — Treatment; Prevention: Treatment during the Hemorrhage: Pres- 
 sure and Friction over the Uterine Kegion — Effects of Bandaging — Effect of 
 Passing the Hand into the Uterine Cavit}' — Application of Cold, should not be 
 Continuous — Astringents to Internal Surface — Galvanism — Ergot — Treatment 
 by Plugging abandoned — Views in regard to Compression of the Abdominal 
 Aorta — Application of the Perchloride of Iron and other Styptics : Objections 
 to, and Arguments in favor of this Procedure — Dr. Barnes's Process — Treat- 
 ment directed to the General Condition of the Patient — Effects of Rest and 
 Position — Reaction to be avoided after severe Flooding — Transfusion : The 
 "Mediate" and " Immediate " Processes: Dr. Aveling's Apparatus; Injec- 
 tion of Defibrinated Blood, and of Saline Solutions, ..... 404 
 
 CHAPTER XXV. 
 
 INVERSION OF THE UTERUS. 
 
 Varieties of Inversion : Three Stages of the Ordinary Variety — Inversion of the 
 Unimpregnated Uterus — Inversion usually occurs during the Third Stage of 
 Labor — Causes: Dragging upon the Cord: Shortness of the Cord : Irregular 
 Contraction of the Uterus — Connection of this Accident with Hour-Glass Con- 
 traction — Effects of Paralysis of the Fundus — Mechanism of the Displacement 
 — Symptoms: Peculiar Violence of the Shock: Haemorrhage: Absence of Tu- 
 mor in Hypogastrium — To be distinguished from a Fibrous Polypus — Sensibil- 
 ity and Occasional Contractility of the Tumor — Modes of proving the Absence 
 of the Uterus from its Normal Situation — Recurrence of Haemorrhage in 
 Chronic Inversion — Treatment: Ordinary Method of Replacement : Manage- 
 ment of the Placenta if still Adherent: Management of more Difficult Cases: 
 Compression of Tumor: Depaul's Instrument — Chronic Inversion: Mont- 
 gomery's Method of Reposition: Constriction of the Os must be Overcome: 
 Effects of Sustained Elastic Pressure — Division of the Stricture : Removal by 
 the Ecraseur — Thomas's Operation as substitute for removal, . . . 418 
 
XIV CONTENTS. 
 
 CHAPTER XXVI. 
 
 RUPTURE OF THE UTERUS. 
 
 Rupture during Pregnancy — Rupture during Labor — Partial or Incomplete Rup- 
 ture — Site, Extent, and Direction of the Laceration — Reason of the Compara- 
 tive Frequency of Cervical Rupture — Is Rupture less common in Primiparae? 
 — Effect of the Duration of Labor — Causes — A. Mechanical : Sex ; Pelvic De- 
 formity ; Faulty Presentation ; Pressure upon the Cervix ; Operative Vio- 
 lence ; Effect; Violent Uterine Action — B. Reflex: Excitement of Cervix, 
 etc. — C. Pathological: Cancer; Rigidity of the Os ; Thinning or Partial 
 Atrophy; Softening; Fatty Degeneration — Symptoms — Premonitory: Local- 
 ized Pain increased during Labor — Signs of Rupture: Pain; Haemorrhage; 
 Shock; Recession of the Presenting Part — Laceration involving the Vagina — 
 Treatment — Preventive Measures : Delivery by the Forceps or b}' Perforation 
 — Extraction of the Placenta — Hernia of the Intestine — If Foetus has escaped 
 into the Peritoneal Cavity, Turning recommended : Gastrotomy is, however, 
 to be preferred — Further Management of the Case — Treatment of Rupture of 
 the Uterus in various Stages of Pregnancy, 430 
 
 CHAPTER XXVII. 
 
 DEFORMITIES OF THE PELVIS. 
 
 Importance of the Subject — Classification of Deformities — Causes — Diseases affect- 
 ing the Pelvis : Rachitis: Malacosteon — Rickets and Malacosteon contrasted : 
 Nature of the Brim Deformity characteristic of Each — Possibility of Yielding 
 in a Malacosteon Pelvis — The Obliquely Distorted Pelvis — Deformities of the 
 Cavity : Flattening of the Sacrum : Funnel-shaped Pelvis — Distortion of the 
 Outlet : Approximation of the Tuberosities of the Ischia : Projection Forwards 
 of the Coccyx : Anchylosis of the Sacro-coccygeal Articulation — Masculine 
 Type of Pelvis — Infantile Type — Effect of Muscular Action in producing 
 Pelvic Distortion— Spondylolisthesis — Pelvis JEquabilker-justo-Major, and 
 justo-Minor — Obstruction from Exostosis, O.-teo-Sarcoma, and other tumors, 
 and from Fractures of the Pelvis, and Morbus Coxarius — Symptoms — Measure- 
 ments of the Pelvis: Pelvimeters — Examination by the Fingers — Effects of 
 Distortion — Difference between "Impaction" and "Arrest" — Treatment — 
 Prevention — Circumstances which call for the Forceps, Turning, Craniotomy — 
 Use of the Forceps in Deformed Pelvis — Caesarian Section, . . . 443 
 
 CHAPTER XXVIII. 
 
 THE FORCEPS. 
 
 History of the Forceps — Chambei-len's Forceps — Invention of the Pelvic Curve — 
 The Short Forceps: Cases to which it is Applicable — Reasons for preferring the 
 Straight Forceps in most Cases — Forceps in Use in America— Circumstances 
 in which the Forceps is Required — Application of the Forceps : Conditions 
 essential to safety: Degree of Dilatation of the Os : Is it necessary to feel an 
 Ear ? Membranes to be ruptured : Blades to be applied to the Sides of the- 
 Head : Forceps to be applied in the Opposite Oblique Diameter to that occupied 
 by the Head of the Child — The Operation : Introduction of the " Lower " and 
 " Upper" Blades in the First Cranial Position — Application to the other Cra- 
 nial Positions, 460 
 
CONTENTS. XV 
 
 CHAPTER XXIX. 
 
 the forceps (Continued). 
 
 Action of the Forceps: 1, by Compression; 2, by Traction; 3, by Double-Lever 
 Action — Mode of Extraction: Management and Direction of the Handles at 
 various Stages of Delivery — Delivery by the Forceps in Occipito-Posterior 
 Positions : Rotation by the Forceps : Extraction with the Forehead Forwards 
 — The " Long Forceps " — Reasons for Preferring the Pelvic Curve in this Ope- 
 ration — Description of the Instrument — Cases in which the Long Forceps is 
 applicable — Directions for the Operation : Blades to be applied to the Sides of 
 the Pelvis: Mode of Introduction of the Lower and Upper Blades: Relation 
 of the Blades to the Surface of the Cranium — Use of the Forceps in Presenta- 
 tions of the Face — Procedure when the Head is retained after Expulsion of the 
 Trunk — Modifications of the Instrument : Ziegler's, Radford's, and other For- 
 ceps, 479 
 
 CHAPTER XXX. 
 
 THE VECTIS; FILLET; BLUNT HOOK; ETC.: DECAPITATION. 
 
 Discovery of the Vectis by Roonhuysen : Mode of Using the Vectis — Cases to 
 which it may be Applied — The Fillet ; a Contrivance of Ancient Origin ; 
 Applicable chiefly to Breech Cases — The Blunt Hook — The Crotchet : Pre- 
 cautions necessary in the Use of the Crotchet: The Guarded Crotchet — Use of 
 two Crotchets — Decapitation ; Various Instruments for : Description of the 
 Operation : Extraction of the Trunk : Subsequent Extraction of the Head by 
 the Various Methods of the Forceps, Crotchet, or Cephalotribe, . . 500 
 
 CHAPTER XXXL 
 
 TURNING. 
 
 Various Methods of Turning: Turning as practiced by the Ancients: Podalic 
 Version — Circumstances which call for and Conditions favorable to the Opera- 
 tion : The Operation in Detail : Choice of Hands : Introduction of the Hand : 
 Passage of the Os : Seizure of a Foot or Knee — Circumstances which render 
 Turning Difficult: Difficulty in Seizing the Foot — Child to be Turned For- 
 wards — Management of the Case after Version — Pelvic Version — Cephalic 
 Version — Turning in Contracted Pelvis: Degree of Distortion which may 
 admit of Turning — Turning contrasted with the Long Forceps, and. as a Sub- 
 stitute for Craniotomy — Special Difficulties — Bimanual or Bipolar Version : 
 Processes of Wigand, Lee, and Braxton Hicks, 510 
 
 CHAPTER XXXII. 
 
 EMBRYOTOMY. 
 
 Conditions which warrant the Operation — Craniotomy : consists of Various Stages 
 — Perforation: Varieties of Perforators: Method of, and Precautions to be 
 Observed in Perforating — Cranial Contents to be Broken Up and Dislodged — 
 Traction to be now Employed — Use of the Crotchet : where to Fix it : Dangers 
 of — The Guarded Crotchet — The Craniotomy Forceps — Removal of the Vault 
 of the Cranium — Protection of the Maternal Tissues — Davis's Osteotomist — 
 
XVI CONTENTS. 
 
 The Scalp to be Preserved — Turning after Craniotomy — Canting the Base, after 
 Eemoval of the Flat Bones, .and bringing the Face Downwards — The Cepha- 
 lotribe: French and English Models — Cephalotripsy the Final Stage in the 
 Operation of Craniotomy — Details of the Operation — May the Cephalotribe be 
 used as a Tractor? — Subsequent Extraction of the Trunk — Craniotomy in 
 Breech Delivery, after the Passage of the Trunk — Embryulcia: Evisceration 
 of the Foetus: applicable chiefly to Impacted Transverse Presentations — Van 
 Huevel's Forceps Saw — Dr. Barnes's process of Cranial Section by the Ecra- 
 seur, 526 
 
 CHAPTER XXXIII. 
 
 HYSTEROTOMY and allied operations. 
 
 History of the Operation of Hysterotomy — Cases in which it is Justifiable: Mater- 
 nal Mortality : Different Results in British and Continental Practice — Conditions 
 favorable to Success — The Operation and its Details: Duties of the Assistants: 
 Closure of the Wounds — After-Treatment — Causes of Fatal Result — Effect of 
 Cold in preventing Peritonitis — Repeated Success of the Operation in the same 
 Cases — G-astrotomy : Cases in which the Operation is required — The so-called 
 Vaginal Caesarian Section— Symphysiotomy : History and Nature of this 
 Operation : Objections to it — Stoltz's Operation of Pubiotomy — Tabular State- 
 ment showing the Degree of conjugate Contraction at the Brim which may be 
 supposed to indicate respectively the Operations of the Long Forceps, Turning, 
 Embryotomy, and the Caasarian Section, ....... 545 
 
 CHAPTER XXXIV. 
 
 induction or premature labor. 
 
 History "of the Subject — Nature and Scope of the Operation — Viability or Non- 
 Viability of the Child — Conditions which justify the Operation — Various 
 Methods of Provoking Uterine Action: Ergot: Puncturing the Membrane: 
 Separation of the Membranes by Hamilton's Method : Dilatation of the Cervix 
 by Tents : Introduction of an Elastic Bougie or Catheter into the Uterus : 
 Plugging or Distending the Vagina: The Method of Kiwisch by the Vaginal 
 Douche: Cohen's Method by Irttra-uterine Injections: Dr. Barnes's Process, 
 consisting of a " Provocative " and an " Accelerative " Stage : Galvanism : Ir- 
 ritation of the Breasts — Anatomical and Physiological Fitness of the Parts — 
 Constitutional Influences, .......... 558 
 
 CHAPTER XXXV. 
 
 labor obstructed by maternal soft parts. 
 
 Rigidity of the Os : Use of Belladonna : Forcible Distension : Incision of Os Oc- 
 cluded — Effects of Uterine Displacement — Abnormal Conditions of the Vulva 
 and of the Vagina: Rigidity : Persistent Hymen : Cicatrices from Sloughing : 
 Treatment of these Conditions — Vaginal Thrombus — Uterine Polypus : Man- 
 agement of, where it obstructs Labor — Ovarian Tumors — Fcecal Accumulation 
 in the Rectum : Rectocele — Distension of the Bladder : Cystocele — Stone in the 
 Bladder an Occasional Impediment — Hernial — Other Tumors which may im- 
 pede Labor — Malignant Disease of the Canal, 570 
 
CONTENTS. XV11 
 
 CHAPTER XXXYI. 
 
 OBSTRUCTION DEPENDING ON THE STATE OF THE OVUM. 
 
 Hydrocephalus: Diagnosis of: Management of such Cases — Spina Bifida — Obstruc- 
 tion from Ascites, Hydrothorax, and Distension of the Bladder — Gaseous Dis- 
 tension from Putrefaction — Tumors springing from the Foetus — Anchylosis of 
 the Joints, and Intra-uterine Fracture — Premature Closure of the Sutures — 
 Unusual Development of the Foetus — Special Difficulties in Plural Pregnancy: 
 Locked Twins — Monsters which impede Delivery ; The Siamese Twins, and 
 other Similar Cases — Shortness of the Umbilical Cord as an Obstacle — Dorsal 
 Displacement of the Arm — Thickness and Persistence of the Membranes, 582 
 
 CHAPTER XXXVII. 
 
 UTERINE INERTIA. AND PRECIPITATE LABOR. 
 
 Irregularities in the Progress of Labor ; often due to Intestinal Derangement — 
 Inertia : Influence of Temperament, Climate, Age, Emotion, Excessive Dis- 
 tension, Premature Rupture of the Membranes, etc. — Influence of Irregular 
 Uterine Action ; Uterine Tetanus — Wigand's Classification : Different Grades 
 and Varieties of Inertia — Treatment of Inertia ; if from Over-distension or 
 Displacement of the Uterus ; if from Intestinal Derangement — Various Modes 
 of Exciting Reflex Uterine Energy — Stimulants as a rule to be avoided — Use of 
 the Forceps in Inertia — Ergot ; its Natural History, and Physiological Effects : 
 Rules for its use in Midwifery — Other Oxytoxic Agents — Precipitate Labor: 
 Causes obscure : Apparent Connection with Menstrual Excitement — Labor may 
 be Precipitate from Deficient Resistance — Danger of Rupture and Laceration 
 of the Uterus — Tendency to Post-partum Haemorrhage — Treatment: Empty 
 Bowels : Opium : Sources of Reflex Irritation to be carefully avoided, . 594 
 
 CHAPTER XXXVIII. 
 
 THE PUERPERAL STATE : LACTATION. 
 
 Management of the Puerperal State — The Lochia : Nature and Source of — After- 
 pains : Treatment of — The Lacteal Secretion : Milk Fever : Colostrum — The 
 Child to be put to the Breast at Fixed Intervals — Agalactia — Galactorrhea : 
 Two varieties of — Management of Lactation — Effects of Over-feeding — Dura- 
 tion of Lactation — Effects of Menstruation and Pregnancy upon Lactation — 
 Disorders of Lactation — Inflammation and Abscess of the Mamma : Effects of: 
 Treatment — Excoriation and Fissure of the Nipples : Prevention of; Treat- 
 ment of, . .607 
 
 CHAPTER XXXIX. 
 
 THE NEWLY BORN CHILD. 
 
 Management of the Cord — Clothing — Cleanliness — Light and Air — Colostrum : Im- 
 proper use of Laxatives — The Mother to Nurse if Possible — Selection of Hired 
 Nurses; their Diet and Regimen — Causes of Difficulty in Sucking — Congenital 
 Malformations — The Excretory Functions — Diarrhoea: Simpleor " Catarrhal," 
 and Inflammatory or " Dysenteric " Varieties : Treatment of Each — Constipa- 
 tion: Management of — Icterus Neonatorum — Thrush — Artificial Feeding: 
 
XV111 CONTENTS. 
 
 Substitutes for Breast-Milk: Cow's Milk, Diluted and Sweetened: Nursing- 
 Bottles: Nurse to be procured if Child does not Thrive: Other Articles of 
 Diet ; Liebig's Food for Infants — Weaning — Dentition, . . . 626 
 
 CHAPTER XL. 
 
 PHLEGMASIA DOLEXS. 
 
 The Puerperal State in its Relation to Disease — Phlegmasia Dolens : Nomen- 
 clature — Causes ; after Labor and when Unconnected with Delivery — Symp- 
 toms : Premonitory Signs : Pain : White Swelling : Tension : Heat : Constitu- 
 tional Symptoms : The Limb Pits on Pressure during Convalescence : Loss of 
 Power in the Limb — Morbid Anatomy: Character of the Effused Fluid : Plug- 
 ging of the Veins ; State of the Lymphatics — Pathology: Milk-leg: Angeio- 
 leucitis : Crural Phlebitis : Experiments of McKenzie and H. Lee : Views of 
 Tilbury Fox : Review of the Pathology of the Subject — Treatment ; Is Blood- 
 letting justifiable? Blisters: Bandaging: Is Contagion Possible? General 
 Treatment to be directed as a rule to a Condition of Debility : Tonic Regimen : 
 Antiseptic Remedies — Cause of Protracted Convalescence, . . . 642 
 
 CHAPTER XLI. 
 
 PUERPERAL INSANITY. 
 
 Nomenclature — Normal Effect of Pregnancy on the Mind — Insanity associated 
 with Pregnancy, Labor, or Lactation — True Puerperal Insanity : Pathological 
 Theories : Connection of Puerperal Insanity with Albuminuria — Puerperal 
 Mania: to be distinguished from Phrenitis : is essentially a Disease of Exhaus- 
 tion — Symptoms: Significance of a Rapid Pulse : Violence: Delusions — Prog- 
 nosis — Puerperal Melancholia : Distinguishing Characteristics : Probable Ter- 
 minations — Treatment: Prevention: Bloodletting to be Avoided: Manage- 
 ment of the Digestive Functions: Emetics: Vascular Sedatives: Nervous 
 Sedatives; Opium, Hyoscyamus, Chloral, etc. : Diet and Regimen: Seclusion 
 and Restraint: Treatment during Convalescence: Tendency to Recurrence 
 after Subsequent Labors, 658 
 
 CHAPTER XLII. 
 
 PUERPERAL ECLAMPSIA. 
 
 Definition — Connection between Eclampsia and Acute Bright's Disease — Eclampsia 
 from other Morbid Conditions — Effects of Pregnancy on the System — Period 
 of Explosion — Symptoms : Premonitory Signs ; (Edema, Albuminuria, Cephal- 
 algia, etc. — Phenomena of the Fit: Period of Tonic and Clonic Convulsions, 
 and of Coma — Pathology : Albuminuria : Decomposition of Urea, and Forma- 
 tion in the Blood of Carbonate of Ammonia : Effects of Pressure on the Renal 
 Veins : Detection of Albumen in the Urine — Morbid Anatomy — Effect of La- 
 bor Pains — Maternal and Foetal Mortality — Prognosis: in Eclampsia Gravi- 
 darum, Parturentium, et Puerperarum — Treatment: Prophylaxis: Use of 
 Acids: Purgatives and Diuretics : Induction of Premature Labor : Treatment 
 during the Fit: Bloodletting; Chloroform; Chloral: Obstetrical Treatment 
 at Various Stages of Labor; Acceleration; Rupture of the Membranes ; Use 
 of the Forceps, 672 
 
CONTENTS. XIX 
 
 CHAPTER XLIII. 
 
 PUERPERAL EEYER AND ALLIED AFFECTIONS. 
 
 Perplexing Nature of the Subject — Puerperal Fever : Does a Specific Puerperal 
 Poison really exist? — Should the term "Puerperal Fever" be retained? — 
 Metria — Physiological Peculiarities of the Puerperal State — Puerperal Septi- 
 caemia — Mode of Septic Poisoning — Connection with certain Zymotic Influ- 
 ences; Erysipelas, Small-Pox, Scarlet Fever, etc. — Connection with Post- 
 partum Inflammations — Puerperal Peritonitis ; May exist independently 
 of Puerperal Fever: Symptoms of an Ordinary Attack; of the more Severe 
 form — False Peritonitis — Puerperal Metritis ; of less Frequent Occur- 
 rence : Symptoms — Uterine Phlebitis; Symptoms at first Obscure: Sec- 
 ondary Abscesses in the Later Stage: Tissues chiefly involved — Vaginitis; 
 Sthenic and Asthenic — Inflammation of the Uterine Lymphatics, . . 687 
 
 CHAPTER XLIY. 
 
 puerperal fever, etc. (Continued). 
 
 Question of Contagion — Septicemic Infection — Other Specific Poisons — Are Inflam- 
 matory Cases Contagious ? — History of Epidemics — Symptoms of Puerperal 
 Fever — Morbid Anatomy : Malignant and other Varieties Contrasted : Lesions 
 of other Organs : Pathological Appearances no Indication of the Virulence of 
 the Attack — Evidence of a Change of Type in Puerperal Fevers — Treatment : 
 All Varieties to be Treated as if Contagious : Recorded Results of Bloodletting 
 and Purging: Gooch's Treatment: Connection of Metastatic Inflammation 
 with Thrombus and Embolism : Uterine Phlebitis : Purulent Formations ; 
 Effect of Emetics; Calomel and Opium; Turpentine; Blisters and External 
 Applications; Tonic and Stimulant Treatment: Tapping the Peritoneum: 
 Prophylactic Treatment : Cleanliness : Use of Antiseptics, . . . 701 
 
 CHAPTER XLV. 
 
 DIPHTHERIA OF PUERPERAL "WOUNDS. 
 
 Prevalence during the past five years — Symptoms — Those which precede the out- 
 break — Digestive System — Pain and Abdominal Tenderness — Pulse and Res- 
 piration — Temperature — Countenance — Mental Condition — Local Symptoms — 
 False Membrane on Wounds — Joint Complications — Diagnosis and Prognosis 
 — Pathological Anatomy — Nature — Causes — Treatment: Quinia: Opium: 
 Local Remedies : Cauterization of Diphtheritic Wounds : Vaginal and Intra- 
 uterine Injections : Prophylaxis, ........ 719 
 
 CHAPTER XLVI. 
 
 PELVI-PERITONITIS : SUDDEN DEATH IN PUERPERAL PERIOD : ANAESTHESIA. 
 
 Pelvi-Peritonitis — Inflammation of the Uterine Appendages— " Fulness," 
 " Hardness," and " Tumor " — Pelvic Cellulitis : Anatomy of the Pelvic Cellu- 
 lar Tissue — Bernutz on Pelvi-Peritonitis — Diagnosis of Pelvic Cellulitis and 
 Pelvi-Peritonitis — Engorgement of the Uterus — Detection of Pus: Fluctuation 
 — Treatment : Alleviation of Pain : Application of Leeches, Poultices, Fomen- 
 
XX CONTENTS. 
 
 tations, etc. : Methods of Promoting Absorption ; Mercury; Iodine; Counter- 
 irritation ; The Operative Treatment of Abscess — Peri-uterine Hematocele — 
 Sudden" Death in Puerperal Period: Embolism of Pulmonary Artery — 
 Arterial Embolism — Entrance of Air into Veins — Anaesthesia : Various 
 Anaesthetic Agents : Effects of Chloroform on the Blood, and on the Progress 
 of Labor : Disadvantages of Chloroform : Modern Practice, . . . 730 
 
 APPENDIX, 745 
 
 INDEX, 753 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. 
 
 1. Pelvis of the female guinea-pis:, . ....... 
 
 2. The same; showing the separation of the bones during parturition, 
 
 3. Diagram showing the direction in which the uterine contents gravitate 
 
 in the Mammalia generally, ........ 
 
 4. Diagram showing the oscillatory movement referred to (Matthews 
 
 Duncan), ........... 
 
 5. External surface of right os innominatum, ..... 
 
 6. Internal surface of the same bone, ....... 
 
 7. Sacrum and coccyx — internal surface, ...... 
 
 8. 9. Male and female pelves contrasted, as seen from before (Quain), . 
 10, 11. Male and female pelves contrasted, as viewed in the axis of the brim 
 
 (Quain), ............ 
 
 12. Internal surface of female pelvis, showing — 1, 2, greater and lesser saero 
 
 sciatic ligaments; 3, 4. greater and lesser gaps or foramina, 
 
 13. Diagram showing the inclination and axis of the true pelvis, . 
 
 14. Diagram showing the axis of the parturient canal, .... 
 
 15. Interior of pelvis, showing the ischial planes, . . . . 
 
 16. Outlet of the female pelvis, ........ 
 
 17. Infantile pelvis, ........... 
 
 18. External organs, partially dissected (Kobelt), ..... 
 
 19. Showing the relative position of the pelvic organs, .... 
 
 20. Dissection of the lower half of the female mamma during the period o 
 
 lactation (Luschka), ......... 
 
 21. Structure of a lobule of the mammary gland, ..... 
 
 22. Ultimate glandular vesicles of the mamma, ..... 
 
 23. Diagram showing relative position of the pelvic viscera (A. Farre), 
 
 24. Profile section of the uterus, ........ 
 
 25. Lateral section of the uterus, ........ 
 
 26 The os uteri, ........... 
 
 27. Pelvic organs in situ, viewed in the axis of the brim (after Schultze), 
 
 28. Anterior view of the uterus and its appendages (Quain), . 
 
 29. Posterior view of the uterus and its appendages (Quain), . 
 
 30. Diagrammatic view of the uterus and its appendages as seen from behind 
 
 (Quain), . 
 
 31. Utricular glands of uterus (E. H. Weber), 
 
 32. Utricular gland of the uterus (Coste), ...... 
 
 33. Kelation of utricular glands to muscular tissue of uterus (Coste), 
 
 34. Termination of utricular glands on mucous surface of uterus (Coste), 
 
 35. Utricular orifices of uterus (Sharpey), ...... 
 
 36. Double vagina and uterus (after Busch), ...... 
 
 37. Bifid uterus, 
 
 38. Diagram showing the layers of the Graafian vesicle, and the contained 
 
 ovum, . 
 
 39. Diagrammatic representation of the ovum, as it escapes from the Graafian 
 
 vesicle, ............ 
 
 40. Development of Graafian vesicles in the sow, ..... 
 
 41. Ovary dissected, to show the structure of the Graafian vesicle at variou 
 
 stages (Coste), 
 
 42. Structure of the corpus luteum (Coste), ..... 
 
 43. The corpus luteum of simple ovulation, ...... 
 
 44. Corpus luteum in the third month of pregnancy (Montgomery), 
 
 PAGE 
 
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 77 
 
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 84 
 
XX11 
 
 LIST OF ILLUSTRATIONS. 
 
 FIG. 
 
 45. 
 46. 
 47. 
 
 48. 
 49, 
 52. 
 53. 
 54. 
 55. 
 56. 
 57. 
 58. 
 59. 
 60. 
 61. 
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 96. 
 
 97. 
 
 98. 
 
 99. 
 100. 
 101. 
 102 
 103 
 104 
 105 
 106 
 107 
 108 
 109 
 
 Corpus luteum in the sixth month of pregnancy (Montgomery 
 Corpus luteum at the period of delivery, ..... 
 Tumefaction of the uterine mucous membrane during menstruation (after 
 
 Coste), 
 
 Spermatozoa and vesicles of evolution, .... 
 
 50, 51. Successive stages of the cleavage of the yolk, 
 External surface of the ovum, showing the area germinativa 
 Diagram showing the earliest formation of the embryo, . 
 Diagram showing early stage of development, . 
 Further development of the ovum, ..... 
 
 Development in a more advanced stage, .... 
 
 Completion of the amnion, and formation of the umbilical cord, 
 Diagram showing Hunter's theory as to the formation of decidui 
 Formation of decidua ; first stage;, ..... 
 
 Formation of decidua completed, ..... 
 
 Flap of decidua reflexa turned down, disclosing the ovum, 
 Foetal surface of the placenta, ...... 
 
 Maternal surface of the placenta, ..... 
 
 Section of the placenta, ....... 
 
 Foetal villi of the placenta, ...... 
 
 Ultimate foetal villus, highly magnified, .... 
 
 Ovum opened, and embryo partly dissected, . 
 
 The same embryo, further dissected, .... 
 
 Posterior view of branchial apparatus, etc., 
 
 Posterior view of fcetal heart, ...... 
 
 Dissection of an ovum in situ, about the fortieth day, 
 Attitude of the foetus in utero, ...... 
 
 Uterine cavity at the fifth month, ..... 
 
 Upper surface of fcetal cranium, ..... 
 
 Diameters of the fcetal cranium, ..... 
 
 Circulatory apparatus in the foetus, ..... 
 
 Diagram illustrating Groodsir's theory of foetal nutrition.. 
 Fibre-cells of the unknpregnated and gravid uterus contrasted 
 External muscular layer of uterus, ..... 
 
 Internal muscular layer of uterus, ..... 
 
 Degeneration of fibre-cells after delivery, 
 
 Diagram showing development of uterine cavity (after Schultze) 
 
 Areola, and secondary areola of pregnancy (seventh month), 
 
 Cervix uteri (primiparse), twenty-fourth week, 
 
 Cervix uteri (pluriparae), twenty-fourth week, . 
 
 Cervix uteri (primiparse) thirtieth week, .... 
 
 Cervix uteri (pluriparae), thirtieth week, .... 
 
 Cervix uteri (primiparse), at full term, .... 
 
 Cervix uteri (pluriparae), at full term, .... 
 
 To calculate the duration of pregnancy (after Schultze), . 
 
 Diagrammatic representation of partition in twin pregnancy (1st variety). 
 
 Twin pregnancy (2d variet} 7 ), ...... 
 
 Hydatidiform degeneration of ovum, .... 
 
 Intra-uterine amputation and attempted reproduction, . 
 Retroflexion of the womb about the 16th week (Schultze), 
 Retroversion about the 12th week (Schultze), . . . 
 Parturient canal completed by the obliteration of the os and 
 Distension of the perineum (after Hunter), 
 Alleged inversion of placenta in the third stage, 
 Normal position of the placenta in the third stage, . 
 Mode of digital examination, ...... 
 
 Cranial planes as they engage in the brim, 
 
 First cranial position, ....... 
 
 Internal lateral surface of pelvis, ..... 
 
 Lateral obliquity of the head advancing in the axis of the bri 
 
 The head approaching the outlet. First position, . 
 
 First position as seen from above (Schultze), . 
 
 Diagrammatic representation of successive stages of the first position, 
 
 Second cranial position, . . . . . . 
 
 85 
 
LIST OF ILLUSTRATIONS, 
 
 XX111 
 
 position, 
 
 del 
 
 of th 
 
 FIG. 
 
 110. Second cranial position at the outlet, 
 
 111. Third cranial position, 
 
 112. Fronto-anterior termination of the third 
 
 113. Fourth cranial position, 
 
 114. Fourth cranial position at the outlet, 
 
 115. Diagram showing successive stages of rotation and 
 
 facial position, . 
 
 116. First position of the breech, 
 
 117. Birth of the breech, .... 
 
 118. Birth of the shoulders, 
 
 119. Arm displaced upwards, . 
 
 120. Birth of the head 
 
 121. Fourth position of the breech, . 
 
 122. Artificial delivery of the head in breech 
 
 123. Transverse presentation — Dorso-anterior 
 
 124. Transverse presentation — Dorso-posterioi 
 
 125. Spontaneous expulsion. First stage, 
 
 126. Spontaneous expulsion. Second stage, 
 
 127. Spontaneous expulsion. Third stage, 
 
 128. Case of complicated presentation, 
 
 129. Braun's repositorium, 
 
 130. Cells of fatty and healthy decidua, . 
 
 131. Placental forceps, .... 
 
 132. Dr. Aveling's apparatus for transfusion, 
 
 133. Partial inversion (after Matthews Dunca 
 
 134. 135, 136. Successive stages of inversio ut 
 
 137. Thomas's method of reducing chronic 
 
 Thomas), 
 
 138. Rachitic pelvis, 
 
 139. Malacosteon pelvis, . . 
 
 140. Isabel Redman's case, 
 
 141. Obliquely distorted pelvis, 
 
 142. Flattening of the sacrum, . 
 
 143. Funnel-shaped pelvis, 
 
 144. Exaggerated sacral curvature, . 
 
 145. Pelvic exostosis, .... 
 
 146. Baudelocque's calipers, and Coutouly's pi 
 
 147. Lumley Earle's pelvimeter, 
 
 148. Manual pelvimetry (Ramsbotham), . 
 
 149. Sketch of Chamberlen's forceps (Rigby), 
 
 150. Straight forceps for ordinary use, 
 
 151. Davis's forceps, ..... 
 
 152. Hodge's forceps, .... 
 
 153. Wallace's forceps, .... 
 
 154. Smith's forceps, .... 
 
 155. Elliot's forceps, .... 
 
 156. Robertson's forceps, .... 
 
 157. Simpson's forceps, .... 
 
 158. Introduction of the lower blade, 
 
 159. Introduction of the upper blade, 
 
 160. The forceps applied, .... 
 
 161. Forceps for application at the brim, . 
 
 162. Curve of abnormal promontory, 
 
 163. Introduction of long pelvic-curved force] 
 164 Diagram, showing various stages in the introduction of 
 
 (lower blade), ....... 
 
 165. Introduction of the first bl^de in the dorsal position 
 
 166. Introduction of the second blade in the dorsal position 
 
 167. Instruments introduced and locked in dorsal position, 
 
 168. Long forceps applied, 
 
 169. Ziegler's forceps, 
 
 170. Radford's forceps, 
 
 171. The vectis, .... 
 
 172. Whalebone fillet, 
 
 e uterus 
 
 n th 
 
 (after 
 
 the long forceps 
 
 first 
 
 PAGE 
 
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XXIV 
 
 LIST OF ILLUSTRATIONS. 
 
 FIG. 
 
 173. The blunt hook, 
 
 174. The crotchet, .... 
 
 175. Podalic version, 
 
 176. Turning by the noose or fillet, . 
 
 177. Malacosteon pelvis, . 
 
 178. Bimanual version : first stage, . 
 
 179. Bimanual version: second stage, 
 
 180. Bimanual version : third stage, 
 
 181. Simpson's perforator, 
 
 182. Hodge's craniotomy forceps, 
 
 183. Guarded crotchet, 
 
 184. Craniotomy forceps, . 
 
 185. Osteotomist, .... 
 180. Meigs's craniotomy forceps, 
 
 187. Braun's eranioclast, . 
 
 188. Simpson's omphalotribe, 
 
 189. French cephalotribe, 
 
 190. Dr. Matthews Duncan's cephalotribe 
 
 191. Hysterotomy, .... 
 192 Barnes's uterine dilators, . 
 
 193. Uterine polypus as an obstacle to delivery 
 
 194. Ovarian tumor obstructing delivery, 
 
 195. Double-headed monster, . 
 
 196. Double monster, .... 
 
 197. Head represented descending directly in the axis of the brim, 
 
 198. Head represented descending in the position described by Naegele, 
 
 199. Lateral obliquity of the head advancing in the axis of the brim, 
 
 504 
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 746 
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 747 
 
A SYSTEM OF MIDWIFERY, 
 
 CHAPTEE I. 
 
 IKTRODTJCTOBY. 
 
 HISTORY OF MIDWIFERY — HIPPOCRATIC ERA — ARABIAN SCHOOL — AMBROISE PARE - 
 — MATJRICEAU — ENGLISH MIDWIFERY — OBJECTIONS TO THE PRACTICE OF MID- 
 WIFERY CONSIDERED— COMPARATIVE ANATOMY OF THE PELVIS — THE PELVIS 
 AS A TUBE THROUGH WHICH THE PRODUCT OF CONCEPTION PASSES — PARTU- 
 RITION IN THE PRIMATES: IN THE VARIOUS RACES — THE ERECT POSTURE THE 
 MAIN CAUSE OF COMPARATIVE DIFFICULTY IN THE HUMAN SPECIES — THE 
 HUMAN PELVIS A CURVED CANAL — SEPARATION OF PELVIC ARTICULATIONS 
 DURING LABOR — MIDWIFERY DEFINED. 
 
 The History of Midwifery is to the student of that art a subject not 
 only interesting, but also in some degree instructive. To trace from 
 their earliest development, whether in the crude ideas of ancient times, 
 or in the hasty generalizations of an epoch not far distant from our own, 
 the growth and maturity of theories which we now believe to be in 
 accordance with the truth, is indeed in itself an attractive pursuit ; and 
 the student has his reward in the thorough mastery he thus obtains 
 over details, which can scarcely be eifected by the mere dogmatism of 
 ordinary teaching. 
 
 For various and evident reasons, however, the history of the obstetric 
 art cannot be embraced fittingly within the limits which must be fixed 
 for matter purely introductory to the study of a great practical subject. 
 Not even in outline, then, will a consecutive history of midwifery be 
 attempted ; but, as reference will in the sequel be not unfrequently 
 made to the doctrines and practice of the past, a few sentences may 
 here be devoted to the consideration of the midwifery of certain epochs, 
 in view of the influence which these may be supposed to exercise on the 
 practice of the present day. 
 
 From the earliest records, more or less authentic, which seem to throw 
 light upon the subject, it would appear that the practice of midwifery 
 was in the first ages entirely in the hands of women. If we may judge, 
 however, from the fact that a law was passed in Athens, at a very early 
 period, by which women were absolutely prohibited from practicing 
 
 2 
 
18 INTRODUCTORY. [CHAP. 
 
 physic in any of its branches, we are entitled to assume that the art 
 had not in the main prospered in their hands. It is in the Hippocratic 
 writings that we find the first trace of a profound intellect and a truly 
 scientific mind being applied to the observation of the phenomena of 
 parturition. The works, indeed, on this subject, which are attributed 
 to Hippocrates, are, for the most part, passed over as unauthentic by 
 modern critics ; but there can at least be no doubt that they were 
 written before Aristotle, at the latest, we may assume, about 400 B. C. 
 The head, according to this authority, is the only natural presentation ; 
 and when the child either lies across or presents by the feet, the woman 
 cannot be delivered. Observe the effect of this aphorism. The head 
 being thus assumed to be the only presentation in which the natural 
 forces could effect delivery, it follows, as the natural corollary of this 
 proposition, that one of the chief aims of operative midwifery must be 
 to convert breech and footling as well as transverse presentations into 
 presentations of the head. The contemplation of such a state of prac- 
 tice is too horrible to dwell upon. His graphic illustration of the 
 olive in the neck of the oil jar is familiar to all, and demonstrates to 
 perfection that it can, in its long diameter, be easily passed through; 
 but, he adds, if the long diameter of this oval body be thrown across, 
 either the bottle will break or the olive will be crushed. It is strange, 
 indeed almost incredible, that, having recognized the form of the foetus 
 while in the womb, as his simile clearly shows, he should have failed 
 to perceive that an oval body, be it olive or foetus, may pass by either 
 end of its long diameter. Overlooking this fact, he established a rule 
 of practice, which obtained in after ages, as there is every reason to 
 believe, for a period little short of 2000 years, at what expense of 
 maternal and foetal life it is impossible to compute. From this early 
 period we must also date the operation of Craniotomy, for the per- 
 formance of which quite intelligible rules are given. 
 
 This error of Hippocrates was corrected by Celsus in the first century 
 of the Christian era, and even, to some extent, at a much earlier date 
 by Aristotle; but it is to the former that the credit in this matter is 
 usually ascribed by the commentators, as his words are clear and free 
 from ambiguity. Tins is manifest from the following sentence alone, 
 extracted from the instructions given by him for the management of 
 transverse cases : " Medici vero proposition est, ut eum manu dirigat, 
 vel in caput, vel etiam in j)edes y si forte aliter compositus est." 
 
 Some four or five hundred years later, a careful compilation of all 
 that had been written up to that time on the subject of midwifery was 
 made by iEtius. Among the untoward circumstances detailed as 
 causes of difficult labor, he mentions a narrow pelvis, the presence of 
 polypi, and obliquity in the position of the womb. He states, further, 
 that an anchylosis of the ossa pubis at their point of junction is a 
 fertile cause of difficult labor, by preventing the separation which 
 would otherwise, he supposes, occur; and that distension of the rectum 
 or bladder may constitute a mechanical impediment to delivery. He 
 observes also, that difficult labor is due as well to a faulty condition 
 of the child as to the maternal parts. If the child, or any of its parts, 
 were unduly large, labor was presumed to be impeded by the fact that 
 
I.] MIDWIFERY AMONG THE ANCIENTS. 19 
 
 the motions and leaping of the ehild (supposed, even in comparatively 
 modern times, to contribute greatly to its delivery) was thereby inter- 
 fered with. Many other points of interest and of practical importance 
 are referred to by him, one or two of which may be noticed. We have 
 here, for example, in a chapter, " De Foetus Extractione ac Exsec- 
 tione," which he takes from Philumenus, the first indication of the 
 speculum vaginae, in an instrument which he recommends for the 
 purpose of separating the external parts, in order to bring the cause of 
 obstruction into view. We have also a perfect description of the 
 crotchet (uncinus attractorius) ; and in his description of a method of 
 delivery by the application of two crotchets — one to each side of the 
 head — we cannot fail to observe that the mechanical principle of the 
 midwifery forceps was not only then adopted in practice, but was 
 thoroughly understood by the author, and brought him very near to 
 the discovery of the forceps of modern times. And, finally, we have 
 here the operation of turning in cases of difficult cranial presentation 
 recommended, in terms which place it beyond a doubt that the pro- 
 cedure indicated is in all respects identical with what of late years has 
 been introduced in similar cases, as a novelty and an improvement in 
 modern practice. The credit of the discovery and demonstration of 
 the Fallopian tubes was claimed by Galen, but there is no doubt that 
 they were described at a still earlier period than the epoch now in 
 question by Rufus Ephesus, who lived in the reign of Trajan (circa 
 A. D. 110). The last writer on this subject of the old Greek school was 
 Paulus iEgineta, to whose works little originality can be attributed. 
 
 The favor in which literature and the sciences were held by the 
 Arabs evidently exercised a most beneficial influence in the development 
 of the Arabian School of Midwifery. The name of Rhazes, a physician 
 of Bagdad towards the end of the ninth century, is associated with the 
 discovery of the fillet. About a hundred years later a very remarkable 
 and voluminous series of works on midwifery and allied subjects was 
 given to the world by Avicenna, a physician of Ispahan. His works 
 consist for the most part in a confirmation of the leading views of the 
 Greek school, and as they enjoyed an extraordinary popularity in 
 Europe, as well as in Asia, it was by this channel mainly that the errors 
 of the ancients were diffused throughout the world. The fundamental 
 error of Hippocrates he adopts in a modified degree. All presentations, 
 says he, save the head, are preternatural : the head ought, therefore, to 
 be reduced, in all such cases, into the natural position, but, should this 
 be impracticable, we may deliver by the feet. He recommends in 
 certain cases the use of the fillet, which, when used for extraction, is 
 to be fixed over the head ; and, should this fail, the forceps is to be 
 applied to the head and extraction then attempted, while as a last 
 resource only are the perforator and crotchet to be employed. 1 A 
 reference to this passage makes it perfectly clear that the instrument 
 alluded to is essentially the midwifery forceps ; while the fact that the 
 author nowhere describes the instrument as a novelty warrants us in 
 
 1 See the chapter, " De regimene ejus, cujus partus tit difficilis causa magnitudi- 
 nis foetus." 
 
20 INTRODUCTORY. [CHAP. 
 
 the belief that, about the tenth century, or possibly at an earlier period, 
 the use of this important instrument was familiar to the Arabian 
 physicians. In the works of a later writer, oi' the eleventh or twelfth 
 century, 1 the forceps then used in midwifery is described and delineated. 
 It is represented under two different forms, the misdach and the 
 almisdaGh. In the Arab original in the Bodleian Library at Oxford 
 to which Smellie refers in his learned introduction, the former of these 1 
 is described as straight and the latter as curved, but in the Latin version 
 both are described as circular and full of teeth. 
 
 From this period, until the discovery oi' the art of printing in the 
 middle of the fifteenth century diffused a knowledge of the writings of 
 the ancients throughout the civilized world, our art seems to have made 
 but little progress. Indeed, wo may even say with truth, that after 
 the decline of learning in the East, the art of midwifery, as practiced in 
 Europe, was far interior to what obtained among the Arabians and even 
 among the later Grecian writers. This we may easily understand if 
 we reflect that Hippocrates was the text-book in the hands of all, and 
 that his errors continued to influence the practice of midwifery until 
 the dawn of science, after the dark ages of our art, dissipated in some 
 measure the mists of ignorance and superstition. 
 
 In 1518, Dr. Linacre, physician to Henry VI 11, obtained, through 
 his interest with Cardinal Wolsey, letters-patent constituting a corporate 
 body of regular physicians in London. This foundation of the Royal 
 College oi' Physicians of England marks the period at which midwifery, 
 for tin 1 first time in this country, was brought within the domain of 
 science. It must be confessed, however, that the earliest efforts of 
 English authors contributed but little to the advancement of the art, as 
 founded upon true scientific principles. The first English work on the 
 subject was a translation ofEucharius Rodian, by \h\ ftaynalde, under 
 the title of " The Byrthe of Mankynde." 2 That this work was held in 
 no little repute on the Continent is evident from the fact that it had 
 been translated from the original High Hutch, not only into Latin, but 
 also into Hutch, French, Spanish, and other languages. Ami yet, when 
 we examine it critically, we find that, except as a literary curiosity, it 
 scarcely merits our attention. Not only does he indorse the famous 
 blunder of Hippocrates, by saying that we should turn the child to the 
 natural position even when the feel present, but he boldly promulgates 
 another error when he says that when the child presents in the natural 
 way by the head, the face and foreparts of the foetus are towards the 
 foreparts of the mother. In most other respects his views are but 
 copies from the ancient writers. The same remark may be made with 
 reference to the productions of his contemporaries, as we find doctrines 
 which are essentially the same promulgated in the collections of mono- 
 graphs, memoirs, and reproductions from ancient and modern sources, 
 known as the " Gynseciorum Commentaria," a collection familiar to all 
 who have studied this subject with care. A very superficial study of 
 this compilation will suffice to show that even the more flagrant errors 
 of the ancients were still systematically taught; and therefore arc we 
 
 1 Albueasis or Alsaharavius. 2 London, 15(55. 
 
I,] AMBROISE PARE. 21 
 
 bound to conclude that the Hippocratie aphorism of turning, by the 
 head in breech presentation had, up to this period, been all but univer- 
 sally adopted in European practice, even although that error had been 
 to a great extent corrected by the later Greek and the Arabian writers. 
 It is not, then, too much to assert, as we have done, that the blunder of 
 Hippocrates, so frequently alluded to, was the rule of practice for little 
 less than 2000 years after his death. 
 
 In this collection, however, there is one work which we must mention 
 with more respect — that of the illustrious Ambroise Pare" — of whom 
 Smellie says no more than is his due when he terms him "the famous 
 restorer and improver of midwifery." The revival of anatomical study 
 under Vesalius, and the numerous dissections which had been made of 
 pregnant women by him and by his follower Columbus, had already 
 corrected many of the anatomical and physiological errors, which, being 
 time-honored, were therefore considered to be respectable, and were 
 generally admitted to be true. The belief in these doctrines being thus 
 sapped by the logic of facts, the whole rotten superstructure began to 
 crumble away, and from this epoch modern midwifery may be said to 
 have had its origin. It required a mind of no ordinary power and 
 energy to be the pioneer in this new path ; but it requires no critical 
 analysis of the work of Pare to show that the great surgeon was a 
 great master, and that scientific Midwifery as well as Surgery had at 
 last found a fitting modern exponent. Pare advises turning by the feet 
 in difficult cranial presentations; but if this cannot be done, he recom- 
 mends craniotomy, or delivering by the 4 crotchet, — which instrument he 
 directs us to fix, by the method of JEtius, in the orbit or mouth, or below 
 the chin. He frankly confesses, that although he has carefully studied 
 the position of the foetus in utero, he has been unable to come to a 
 satisfactory conclusion as to what is to be considered the normal posi- 
 tion ; while, as regards the causes of difficult labor, he dilates at some 
 length, and on the whole with considerable accuracy. After pointing 
 out with great clearness the serious nature of the impediment caused 
 by cicatrices, the result of former midwifery accidents, he enumerates 
 the various positions of the foetus which interfere with or prevent 
 delivery, and concludes by noting the bad effects of a premature escape 
 of the waters, and of uterine inertia. 
 
 At this period, the Parisian school was undoubtedly the first in the 
 world; and as all the leading surgeons there practiced midwifery, the 
 practice as well as the theory of obstetrics became rapidly developed. 
 Guillemeau, surgeon to the French king, and a pupil of Ambroise Pair, 
 further developed the theories of his master; but the book which seems 
 to have exercised the greatest influence was the remarkable one of 
 Mauriccau, " Sur les Maladies des Femmes grosses, et de ccux qui sont 
 accouchees." This author gives by far the best account which, up to 
 his day, had appeared of the phenomena of labor as observed by the 
 accoucheur. He criticizes with some asperity the views of Columbus, 
 which, however, we find to be, at least as regards the position of the 
 child in the womb, infinitely more correct than his own. The following 
 are his conclusions on this point: Up to the seventh or eighth month, 
 the child is situated in the centre of the womb, the head being towards 
 
22 INTRODUCTOKY. [CHAP. 
 
 the fundus and the face looking directly forwards. About this period 
 an important change takes place in its position, which, if it happens 
 sooner, is attended with danger. The weight of the head and upper 
 part of the infant having now become relatively greater, it causes the 
 child to turn forwards (/aire la culbute en devant), so that the face is 
 now turned directly backwards to the promontory of the sacrum. This 
 doctrine is simply an amplification of the views of Hippocrates on this 
 point; and it must be admitted, even in the present day, that the 
 greater relative frequency of breech and irregular presentations in cases 
 of premature delivery, lends some apparent confirmation to the idea. 
 He repudiates the idea formerly entertained, that the child, by its own 
 instinctive or automatic movements, aided in any way in effecting its 
 expulsion, and recognized not only the contractility of the uterine 
 tissue, but also the supplementary expulsive force which is derived 
 from the muscles of the abdominal walls, these acting, as he shows, 
 with greater effect upon the rounded back and nates of the child than 
 they could upon the head, did the head present. Mauriceau seems also 
 to have some indistinct and inaccurate idea of the rotation which occurs 
 in the pelvis; for, after stating that, in footling cases, it is necessary 
 that the face in its descent should look backwards, he gives directions 
 for turning the child during its descent, unless this has already taken 
 place, so as to make the heels look directly forward. 
 
 Any one who may wish to pursue this subject further will find 
 ample and most interesting material in the works of Peu, Dionis, 
 Deventer, La Motte, Puzos, Roederer, Levret, and others. In many 
 of these, new errors are developed, such, for example, as the undue 
 importance given to uterine obliquities by Deventer and his followers, 
 who supposed them to be a frequent cause of tardy labor. The re- 
 discovery of the midwifery forceps by the Chamberlens, about the 
 middle of the seventeenth century, marks another and most important 
 epoch ; but this will fall to be more particularly considered when we 
 come to discuss the forceps and its uses. 
 
 The interesting subject of the mechanism of parturition was inaugu- 
 rated little more than a hundred years ago by Sir Fielding Ould, of 
 Dublin, and this, too, is another important era in the history of mid- 
 wifery. To trace the successive steps, from the faint glimmering of 
 the truth which perplexed the shrewdness of Ould, and baffled the 
 astuteness of Smellie, to the full development of the modern theory as 
 it was laid before the scientific world in the celebrated essay of Naegele, 
 would lead us upon ground which for the present we must avoid. In 
 the sequel, and at the proper place, such of the historical facts as are 
 essential to the comprehension of this subject will be briefly noted. 1 
 
 It seems, on first sight, a paradox that the practice of midwifery 
 should involve, in the human species, the supervision of a function 
 which is purely physiological, and should be claimed by its professors 
 as an important branch of the healing art. So difficult, indeed, has 
 this problem been of solution, that many, from Rodericus a Castro 
 
 1 For a critical analysis of this subject, see an essay by the author " On the 
 Mechanism of Parturition." London, 18G4. 
 
I.] OBJECTIONS TO THE PRACTICE OF MIDWIFERY. 23 
 
 downwards, have asserted that the practice of the art was derogatory to 
 professional dignity, and an unnecessary interference with a natural 
 process. " Obstetriciam artem nee exercui nee exercere volo," wrote 
 one of these ; and there is reason to believe that the words find an echo 
 even now. We need scarcely pause to refute the former of the two 
 objections. We presume we may hold it as proved that, from the very 
 earliest times, women required and obtained assistance at the period of 
 delivery. This assistance was afforded, as we have already seen, by 
 persons of their own sex ; and that there is a fitness in this no one will 
 gainsay. If we may judge, however, from the Athenian laws, we may 
 assume that the practice of obstetrics did not prosper in the hands of 
 women ; but it must be confessed that there is evidence enough in the 
 works of Arsinoe and Cleopatra to prove that some of them, at least, 
 were quite familiar with the doctrines and practice of their age. And 
 it must be conceded further, in these days when women are knocking 
 so loudly, and with such importunity, at the portals of professional 
 recognition, that if the mantle of Mesdames La Chapelle and Boivin 
 could be made to fall on the shoulders of their sisters of the present 
 generation, female delicacy would be saved many a rude shock, and the 
 cause of science would in no sense suffer. But what do they say who 
 repudiate the general practice of the art? Women, they assert, should 
 in their hour of need be attended by women, and only in the case of 
 difficulty or danger should the male accoucheur be summoned. The 
 answer to this simply is, that the assistance of the latter would, under 
 such cireu instances, be of no value whatever, as without a knowledge 
 of the healthy or normal standard, which can only be attained by the 
 constant observation of the natural process, ignorance, not skill, would 
 be called upon to act. To the full as rational would it be to ask him 
 to compute distance or space who had no knowledge of the standards 
 of lineal measurement or capacity. Certainly, in the present day, Men 
 are required for the practice of midwifery, skilled in medicine and the 
 applied sciences, and who do not think of their dignity, any more than 
 of their ease and comfort, when their services are in this matter required. 
 
 In regard to the other objection, we must, of course, admit that 
 parturition is a physiological function. But, in the discharge of this 
 function, there exist in the human species peculiar conditions which 
 exercise, as compared with the lower animals, a special influence upon 
 the progress and issue of labor. What these conditions are will be 
 best understood by a reference to one or two points in comparative 
 anatomy, which reveal certain analogies, the appreciation of which 
 will clear away many difficulties, and a knowledge of which is, in 
 point of fact, almost essential to the student of midwifery. 
 
 At an early period of mammalian development, two rods or bars of 
 cartilage may be observed passing, more or less obliquely, from the 
 dorsal towards the ventral surface of the embryo near its caudal ex- 
 tremity. 1 The two parts are separated at their dorsal extremity, where 
 they embrace the vertebral column ; while in front, in most cases, they 
 meet and form a symphysis. This is the primitive pelvis. As the 
 
 1 See Flower's " Osteology of the Mammalia." London, 1870. 
 
24: INTRODUCTORY. [CHAP. 
 
 process of development goes on, the cartilage of each side, widening to 
 a great extent superiorly, ossifies from three centres, by the union of 
 which the os innominatum is formed, the two lower segments — ischium 
 and pubis — leaving a gap between them, the obturator or thyroid fora- 
 men. If we except the Cetacea and Sirenia, in which the pelvis is 
 almost rudimentary, these characteristics are common to the whole 
 mammalia. The innominate bones are firmly united above to the 
 sacral vertebra?, and usually below to each other at the symphysis ; and 
 this union, firm as it is, is greatly strengthened by a double ligament- 
 ous union of considerable strength between the sacral and caudal ver- 
 tebra? on the one hand, and the ischia on the other. This is familiar 
 to anatomists as the greater and lesser sacro-sciatic ligaments, which 
 are sometimes replaced by bone — as in the sloth. 
 
 The mammalian pelvis, then, by the union of the two innominate 
 bones and the sacrum, forms, with some exceptions, a complete circle 
 or girdle of bone; or, in other words, a short canal or tube, which has 
 two outlets. Of these, the anterior is called the inlet or brim, which is 
 marked more or less distinctly by a line which runs from the top of 
 the symphysis pubis to the first sacral vertebra. The axis of this is — 
 owing chiefly to the obliquity of the innominate bones — probably 
 never parallel to the vertebral column, but diverges from it, more or 
 less widely, according to what is termed the " inclination" of the brim. 
 The outlet looks backwards or downwards according to the position of 
 the animal, and is bounded in the dorso-ventral diameter by the caudal 
 vertebra? on the one side, and the lower margin of the pubic symphysis 
 on the other, and laterally by the great sacro-sciatic ligaments (or bones) 
 and the converging borders of the ischia. As the planes of brim and 
 outlet are never quite parallel, the axis of the pelvis is consequently 
 more or less of a curve. 
 
 A careful study of the form, and extent of development, in the 
 various mammalian groups, shows clearly that, as in other parts of the 
 skeleton, the ever-watchful provision by nature of means to an end is 
 here strikingly exemplified. In the Cetacea, where there are no pelvic 
 limbs, the pelvis is composed of two slender bones ununited inferiorly, 
 the chief use of which seems to be to afford an attachment for the crura 
 of the penis and clitoris. In the Armadillo, it is strong and powerful, 
 to aid in the support of the exo-skeleton. In the Carnivora, the ilium 
 and ischium are in a straight line and of nearly equal length, the pelvis 
 being thus elongated and narrow. The symphysis is long, includes 
 part of both pubis and ischium, and, in adult animals of this class, is 
 usually closed by anchylosis. In the Seals, the pelvis is small and of 
 a different form from the terrestrial Carnivora, the ilia being small, 
 and the ischia and pubes long and slender. The symphysis is small 
 and loose, admitting of being widely separated during parturition. 
 
 In many of the Insectivora, the symphysis is absent, the bones being 
 widely separated in the middle line. The pelvis of the mole, for 
 example, is long and narrow, and its axis is nearly parallel with the 
 vertebral column. The ischium, as well as the ilium, is united to the 
 sacrum by anchylosis, and the brim is so narrow that, there being no 
 union at the symphysis, the pelvic viscera lie external to the cavity, 
 
I.] COMPARATIVE ANATOMY OF PELVIS. 25 
 
 and parturition takes place beneath rather than through the pelvic canal. 
 In the Rodentia the pubes and ischia are always largely developed, flat 
 and diverging posteriorly, while the symphysis is long and usually 
 osseous. The Guinea-pig is an exception, as here the union remains 
 ligamentous, and admits of free opening during labor. 
 
 In the order Ungulata, the Pecora or true ruminants are character- 
 ized chiefly by the great development of the ischial tuberosity, forming 
 a well-marked conical process which is diverted outwards on each side. 
 The symphysis is long, and includes a considerable portion of the ischia, 
 and large epiphyses are observed, forming the articulating surfaces. 
 These parts ultimately become fused by anchylosis. In the Perisso- 
 dactyla, the greater expansion of the ilia, as seen in a marked degree in 
 the skeleton of the elephant, indicates, at first sight, an approach to the 
 human type; but the narrowing of the pelvis at the level of the acetab- 
 ula, and the comparatively small ischial and pubic portions, at once 
 dispel the illusion. 
 
 The Edentata have the pelvis more or less elongated, and the ischia 
 largely developed. In almost all, the ischia are directly connected 
 with the vertebral column by one or more osseous bridges, the single 
 one in the sloth passing from the ischial spine, and thus representing 
 the lesser sacro-sciatic ligament. This is carried to the greatest extent 
 in the Armadillos, where a long unyielding tube is formed by the 
 coalescence of the ilium and ischium on the one hand, and a consider- 
 able number of sacral and pseudo-sacral vertebras on the other. In 
 most of the Edentates, not only the sacro-iliac articulations, but also 
 the symphysis pubis, are anchylosed. 
 
 The Marsupiata and Monotremata are characterized by the great 
 development of the ischia and pubes, and the development in the tendon 
 of the external oblique muscle of the " marsupial" bones. 
 
 The facts here cited will suffice to show that the pelvis, in the various 
 groups into which the mammalia have been divided, is formed so as to 
 suit the requirements of the individual. The mode of locomotion, be 
 it leaping, running, or swimming, is revealed to the anatomist by an 
 examination of the pelvic bones, and in every case it will be seen that 
 the preponderance of ilium, ischium, or pubis, is due to the necessity 
 which exists for certain mechanical arrangements, by which alone can 
 the required muscular power be effectively applied to the bony levers. 
 The pelvis is also an efficient support to the organs which are usually 
 contained within it, and especially to those which are connected with 
 the function of generation. 
 
 The obstetrician, however, looks at the pelvis from a different point 
 of view. In it he sees the osseous canal through which the product 
 of conception must pass in the act of parturition. He sees in it also 
 the protecting framework which shields the generative viscera from 
 the effects of shock or injury. And, above all, he studies it as a structure 
 which, if abnormal, may seriously obstruct the process of parturition. 
 Let us look, then, for a moment, before quitting the subject, and from 
 this standpoint, at the pelvis of the mammalia. Throughout the whole 
 series, irrefragable evidence is afforded that the pelvis is' designed with 
 a direct reference to the propagation of the species; and we find more- 
 
26 
 
 INTRODUCTORY, 
 
 [chap. 
 
 Fig. 1. — Pelvis of the female guinea-pig. 
 Fig. 2.— The same ; showing the separation of the 
 bones during parturition. 
 
 over, that, on the approach of labor, certain modifications of structure 
 which then occur clearly prove that nature prepares the parts before- 
 hand for the new function. Thus, in the Chevrotains, a group of little 
 
 deerlike animals, formerly as- 
 sociated with the musk-deer, 
 the ischia in the males join the 
 elongated sacrum by ossi fi ca- 
 
 o ... 
 
 tion of the sacro-sciatic liga- 
 ments, but in the females the 
 latter retain their normal ex- 
 tensile texture. In the prolific 
 guinea-pig, again, 1 the pelvis is 
 long and laterally compressed, 
 the passage being much nar- 
 rower than the diameter of the 
 head of the mature foetus. 
 About three weeks before par- 
 turition, the interpubic liga- 
 ments become soft and extensile, 
 sothatduring labor the innomi- 
 nate bones separate from each 
 other at the symphysis, the 
 sacro-iliac joint thus becoming on each side a hinge. After this process, 
 the symphysis quickly returns to its normal or former state, and in a 
 few days presents only a little thickness and mobility. The young of 
 the guinea-pig are far advanced at birth ; some of the deciduous teeth 
 are shed in utero, and they run about and begin to eat soon after they 
 see the light. 
 
 In the cow, as the period of parturition approaches, a relaxation of 
 the pelvic ligaments also occurs, but the process here is different. 2 The 
 gradual upward curve and posterior projection of the ischia causes the 
 well-marked dorsal projection of their tuberosities, which appear promi- 
 nently on the rump, projecting on each side and above the coccygeal 
 vertebra?. By this elevation of the ischia, the sacro-sciatic ligaments 
 become a means of support to the pelvis, so that their action is, as 
 compared with the corresponding structure in the human pelvis, as it 
 were inverted. As the period of utero-gestation approaches its termina- 
 tion, these ligaments, as well as those of the sacro-iliac joint, become 
 relaxed to such an extent that the sacrum is observed to sink down- 
 wards between the innominate bones, so that the ischial tuberosities 
 become very prominent, and relatively elevated. The object of this is 
 manifestly to render parturition easier. Did this, indeed, not occur, 
 there can be little doubt that in the cow, as in some other ruminants, 
 the difficulties of labor which occasionally arise would be of much more 
 frequent occurrence. It is interesting to observe, as the probable cause 
 of dystochia in those animals, that, owing to the greater curve of the 
 
 1 Owen. 
 
 2 Todd'* 
 Pelvis. 
 
 " Comparative Anatomy and Physiology of the Vertebrates." 
 Cyclopaedia of Anatomy and Physiology." Supplement. 1859 
 
 Art. 
 
I.] COMPARATIVE ANATOMY OF PELVIS. 27 
 
 sacrum, the axis of the pelvis is necessarily more strongly curved than 
 usual, and in this respect approximates to the human type. 
 
 If we now turn to the Primates, we shall be able to show, by a com- 
 parison of the human race with those of the mammalia which stand 
 nearest to it in the scale, that the process of childbirth must be more 
 difficult and more obnoxious to serious hindrance than in any — even 
 the highest — of the other mammalia. In all the Simiina, the ilium is, 
 as compared with man, much elongated. " Each os innominatum in 
 the adult male gorilla," says Owen, " is one foot three inches in length, 
 that of man being seven inches and a half; the breadth of the ilium 
 is eight inches and a half, that of man being six inches." In the 
 lower forms — as the baboons and monkeys — the ilium is even longer, 
 relatively to the other bones of the pelvis, than is here described. The 
 ilia are nearly in a straight line with the vertebral column, and the 
 inferior rami of the ischia are directed almost horizontally inwards, 
 entering into the formation of the pubic symphysis, which, in the 
 ape tribe generally, may be more properly called the ischio-pubic sym- 
 physis. The form of the cranium is the familiar and ready test, not 
 only in distinguishing between man and the lower animals, but also 
 between the various races of mankind. It is peculiarly interesting to 
 us, however, to observe that a careful examination of the pelvis will 
 also supply the same and as reliable information. The chief peculiari- 
 ties of structure which are exhibited in the case of the highest of the 
 Simiina have just been noticed. In addition, we observe that the 
 depth both of the true and false pelvis is much greater than in the 
 human race, that the sacrum is much narrower, especially in the chim- 
 panzee, that the ischial spines are more closely approximated, and, 
 above all, the antero-posterior measurements at the brim prevail greatly 
 over the transverse. 
 
 Were we to compare the highest Ape with the lowest Man, we would 
 find the following broad points of distinction. In the Ape, a pelvis 
 with the brim much more inclined, its antero-posterior exceeding its 
 transverse measurement ; a bending of the pelvic brim at the ilio- 
 pectineal eminence forming an angle of about 120°, called the Mo-pubic 
 angle — a characteristic which, without exception, distinguishes the 
 lower animals possessing pelves ; a marked elongation of the ilia ; and 
 a parallelism of the symphysis with the vertebral axis. In Man, less 
 inclination of the brim, and a constant preponderance of the transverse 
 over the antero-posterior diameter ; the boundaries of the brim here 
 alone in the animal kingdom on one plane ; great expansion of the ilia, 
 as compared with their length ; and the symphysis forming an angle 
 with the vertebral column. The import of this great gap in develop- 
 ment is evident, and has its explanation in the adaptation of man alone 
 of all created beings to the fully erect posture. 
 
 The descriptive anatomy of the human pelvis will form the subject 
 of another chapter. We shall here glance only at its special functions, 
 in so far as they may be held to differ from those of the lower animals. 
 In all the other mammals the habitual and only natural position or pos- 
 ture of the animal is prone, — the dorsal surface being superior, the ventral 
 inferior. In those in which pelvic limbs exist, the weight of the pos- 
 
28 INTRODUCTORY. [CHAP. 
 
 terior or pelvic portion of the trunk alone is transmitted through the 
 pelvis to the cotyloid cavities, and thence transferred to the heads of 
 the thigh-bones. In Man, the whole weight of the body above the 
 pelvis is directly transmitted to it by the imposition of the last lumbar 
 vertebra, on the base of the sacrum, from which again it is transferred, 
 when the body is erect, to the femora, and in the sitting position, to the 
 tuberosities of the ischia. To enter upon an analysis of the mechanical 
 laws upon which this depends would be suitable to a work on animal 
 physics, but we must here confine ourselves to such points only as are 
 germain to our subject. 
 
 The sacrum — which is relatively much broader and stronger in man 
 than in any of the lower animals — is the part which receives the weight 
 of the trunk, the centre of gravity being, according to Weber, 8.7 milli- 
 metres above the sacro-lumbar joint, or just above the pelvic arch. It 
 has been compared by Cruveilhier to a wedge, by others to the key- 
 stone of an arch, and by Sir Charles Bell to the heel of a mast, — the 
 base of the vertebral column being fixed so that the interval between 
 the innominate bones may be looked upon as the step in which the 
 vertebral mast is socketed and mortised. In any case we may consider 
 the weight as being transmitted from the sacro-iliac joints in one of 
 two directions: in the erect posture, it passes through the irregular, 
 thick, and curved buttresses which are formed by this portion of the 
 ilia directly to the cotyloid cavities; in the sitting posture it passes, on 
 a posterior plane, from the same joints almost directly downwards to the 
 tuberosities of the ischia. The sacrum is thus described as forming the 
 common culminating point of two arches — viz., the cotylo-saeral or 
 standing arch, and the ischio-sacral or sitting arch. The extremities of 
 these arches are prevented from starting outwards, not by abutments as 
 in the ordinary architectural arch, but by connecting links or ties, which 
 are represented in the cotylo-saeral arch by the horizontal rami of the 
 pubes, and in the ischio-sacral by the united isehio-pubic rami. This 
 complicated arch acts also by preventing inward pressure, in the erect 
 posture, by the head of the femur; while shock is in a great measure 
 obviated by the oblique manner in which the sacrum is placed — the 
 sacro-sciatic ligaments preventing the movements of the coccyx upwards 
 and backwards, while the ilio-lumbar ligaments prevent the correspond- 
 ing motion of the base of the sacrum downwards and forwards. 1 The 
 expanded external surfaces of the ilia give attachment to the mass of 
 the glutei muscles, more powerful, for obvious reasons, in man than in 
 any other animal. 
 
 But the pelvis has, in addition to the elaborate mechanical functions 
 above shortly alluded to, a new and special function thrown upon it in 
 Man. This is the support of the pelvic viscera, including the organs 
 of generation. These latter being larger and heavier in the female, 
 and, in view also, no doubt, of the requirements of the pregnant state, 
 nature here makes special provision for their accommodation, in the 
 greater capacity and modified form to which we shall afterwards advert. 
 
 1 Dr. Matthews Duncan, in bis " Researches on Obstetrics'' (p. 55), shows more 
 correctly, that the weight is transferred from the sacrum to the cotyloid cavity, not 
 directly, hut indirectly through the agency ot the posterior ilio sacral ligaments. 
 
I-] 
 
 COMPARATIVE ANATOMY OF PELVIS, 
 
 29 
 
 Fig. 3. 
 
 Diagram showing the direction 
 in which the uterine contents grav- 
 itate in the Mammalia generally. 
 
 In the lower animals, the abdominal viscera, and, to some extent, also, 
 the pelvic viscera, are supported by the lower abdominal wall. The 
 contents of the pregnant uterus, therefore, gravitate downwards in the 
 direction of the arrow in the figure, and, under no circumstances, does 
 the weight of the uterine contents press into 
 the cavity of the pelvis. Even in the 
 Simiina, where the erect posture is to some 
 extent assumed, the greater inclination of 
 the pelvic brim prevents the gravitation of 
 the uterus and its contents into the true 
 pelvis. In a pregnant woman, on the other 
 hand, not only are the pelvic viscera proper 
 supported by the structures which form the 
 floor of the pelvis, but some support is indi- 
 rectly afforded to the abdominal viscera 
 under certain circumstances. In the preg- 
 nant state, the uterus and its contents gravi- 
 tate to a considerable extent downwards 
 and backwards in the axis of the brim. 
 
 The necessity which thus exists for efficient 
 pelvic support to these parts has not been 
 
 overlooked. Were the pelvis a simple tube, with the inlet looking 
 upwards, and the outlet downwards, it is obvious that no efficient sup- 
 port could be afforded. But the tube, far from being straight, is in a 
 woman strongly curved — so strongly indeed, that a line drawn so as 
 to represent the axis of the brim and the long axis of the uterus (which 
 we may here assume to be identical) will not fall within the plane of 
 the outlet at all, but behind it, somewhere about the centre of the 
 coccyx. By this curve in the pelvic axis, the lower part of the sacrum, 
 the coccyx, the sacro-sciatic ligaments, the levatores ani and coccygei 
 muscles, and the fascial and soft structures form a firm floor, by which, 
 in a normal and healthy condition of the parts, perfect support is given 
 to the structures of which we have spoken. But this manifest advan- 
 tage is obtained at the price of increased difficulty in the act of parturi- 
 tion. This difficulty is, no doubt, to a very great extent, compensated 
 for by the development of the subpubic arch, a peculiarity of the 
 human species which is but imperfectly developed in the lower animals. 
 Without this, indeed, and that shortness of the symphysis in women 
 which admits of its widest development, labor would be always diffi- 
 cult and often impossible. 
 
 The function of the pelvis being thus in every case a complicated 
 one, is so in the human female in an especial degree. The unyielding 
 nature of the structure, essential to the effectual support of the trunk, 
 and the curving of its cavity for the reasons above stated-, render child- 
 bearing in this instance exceptionably liable to dangers of various kinds, 
 and thence arises the necessity for that thorough training which can 
 alone engender confidence and develop skill. 
 
 The comparative facility with which parturition is effected in the 
 lower races of the human species has also been used as an argument 
 against the practice of midwifery. In reference to this objection, on 
 
30 INTRODUCTORY. [CHAP. 
 
 which we need not dwell, there can be little doubt that the effect, in 
 certain classes of society, of modern and luxurious habits, exercises no 
 inconsiderable influence upon the physiological phenomena of parturi- 
 tion. As regards the difference between the races, many very interest- 
 ing facts have been revealed by the researches of Vrolik, Weber, and 
 others, but there is still in this direction a wide field for original 
 investigation. The facts which already have been disclosed point to 
 the important conclusion that there subsists in the various races a 
 remarkable coincidence between the prevailing form of the skull and 
 the diameters of the pelvic brim, and that, consequently, the adaptation 
 of the foetal skull to the pelvic passage during labor must be greatly 
 facilitated. Weber's conclusions, drawn from the observation and 
 measurements of a considerable number of specimens, are, that we may 
 admit, as the general rule, subject however to numerous exceptions, that 
 the oval shape is most common in Europeans, the round shape in the 
 American aborigines, the square shape in the Asiatic or Mongolian type, 
 and the oblong in the Negro races. As regards the assumed facility of 
 labor in those races, there is every reason to believe that this has been 
 greatly exaggerated, and that cases of dystochia, though comparatively 
 rare, are yet not unfrequent. If the pelvis were the same in size and 
 proportion in them as in Europeans, the inferior cranial development 
 would afford an obvious explanation of the alleged fact of habitually 
 easy labors. So far, however, from this being the case, we have just 
 seen that the form of the pelvis corresponds to the shape of the head. 
 An examination of Negro, Bushman, and other pelves, shows in many 
 instances a remarkable degradation of type, such as a vertical direction 
 of the ilia, and their elevation at the posterior-superior spines, narrow- 
 ness of the sacrum, and acuteness of the subpubic angle. An occa- 
 sional peculiarity in some of the lower races, and one which appears 
 even more to approach to the ape type, is the preponderance of the con- 
 jugate over the transverse diameter of the brim. But they who have 
 asserted that the lower races referred to simulate in this respect apes 
 rather than Europeans have gone too far, as is clearly proved by the 
 measurements given in Wood's admirable article on the Pelvis in Todd's 
 Cyclopaedia, already quoted. From this it appears, that while the 
 transverse may, in the higher Simiina, measure less than the conjugate 
 diameter by one and a half to two inches, the difference in cases of 
 oblong pelvis in negroes is merely fractional, and that the type is in 
 every case far more closely allied to the European than to the Simian, 
 where the conformation of the pelvis is such, even in the highest forms, 
 that its marked peculiarities are appreciated at a glance. 
 
 Whether the pelvic articulations in women are, or are not, divaricable 
 during parturition, is a question obviously of great practical importance 
 to the accoucheur. Involving, indeed, as it does, practical considera- 
 tions, this is a subject, the study of which might here be considered 
 premature. But, in view of the facts which have just been stated in 
 relation to the comparative anatomy of the pelvis, this vexed question 
 may, we believe, be noticed with more advantage at this stage than at 
 any other. In so far as a study of the physiological phenomena of 
 labor in the lower animals can throw light upon the subject, we have 
 
I.] MOBILITY OF PELVIC ARTICULATIONS. 31 
 
 already seen that separation may take place to a very considerable 
 extent at the symphysis, as in the guinea-pig, or at the sacroiliac joint, 
 as in the cow. So far, then, analogy points to the possibility of such a 
 separation. Besides, anchylosis of either one joint or the other, com- 
 mon as it is in the lower animals, is known to be, in the human species, 
 an extremely rare occurrence. 
 
 Actual observation, again, by men of such undoubted authority, 
 among many others, as Par6, Levret, and Smellie, has proved, beyond 
 all possibility of doubt, that in women who have died during the par- 
 turient period, separation of the bones, now at the symphysis and again 
 at the sacro-iliac joints, has been seen and recorded. Few practitioners 
 of extended experience have failed to observe that women occasionally 
 complain, it may be either before or after labor, of pain in the neigh- 
 borhood of these joints, difficulty or inconvenience in walking, and, 
 more rarely, a grating or crepitant feeling, arising obviously from an 
 unwonted motion of the articulating surfaces upon each other; from 
 which we may conclude that separation may, to some extent at least, 
 occur. Cases such as have been detailed by Soemmerring — where the 
 bones at the sacro-iliac joint have been found separated to the extent of 
 an inch — have been supposed to be the result of disease and deposit of pus. 
 
 Admitting, then, that some separation does occasionally occur, are 
 we to assume that this is to be held as morbid or abnormal, or admitted 
 as one of the essential physiological phenomena of human parturition ? 
 It is, we suppose, now universally believed that, during the last months 
 of pregnancy, the cartilaginous and other structures forming these joints, 
 to be hereafter described, become softened, as if by serous infiltration. 
 The synovial membranes, indistinct before, now become capable of 
 demonstration; and, more important, perhaps, than all, the tissues 
 become thickened, while the ligaments of the joints are relaxed. The 
 effect of such thickening must, of necessity, be, like ivy roots in a wall, 
 to force the bones asunder and, consequently, to increase the pelvic 
 diameters. If, however, there is, as has been asserted, a yielding much 
 more extensive than this, such motion may be assumed to occur in one 
 of two ways; either by a separation of the pubes, involving a hinge 
 motion at the sacro-iliac joint, as in guinea-pigs, or by a movement of 
 the sacrum between the ossa innominata, involving a hinge motion of 
 the symphysis, as in the cow. As regards the first of these, a careful 
 examination of the circumstances under which it may occur, would 
 seem to indicate that a separation of the pubic bones to the extent even 
 of an inch would add very little to the diameters of the brim, and 
 would contribute least of all to the smallest or conjugate diameter. 
 The analogy which the frequent yielding of the symphysis seems to 
 reveal, gave rise, about the end of the last century, to an operation 
 consisting in the artificial section of the symphysis in cases of obstruc- 
 tion at the brim — a mode of procedure which Dr. Matthews Duncan 
 seems to think has been in these days too completely consigned to 
 oblivion. 
 
 The other method in which the pelvic capacity may be increased by 
 a movement of these joints, is by the motion of the sacrum between 
 the ossa innominata, somewhat as it has been shown to occur in the 
 
32 
 
 INTRODUCTORY. 
 
 [CHAP. 
 
 cow. 1 From what has already been said, it may be inferred, that to 
 compare the sacrum either to a wedge or a keystone is very far from 
 accurate. We have seen that this bone, besides its union with the 
 sacrum by means of intervening cartilage, is maintained in its position 
 by the ilio-lumbar and sacro-sciatic ligaments — the former preventing, 
 or rather strictly limiting, along with other forces, the downward and 
 forward movement of the promontory ; while the latter limits, in like 
 manner, the upward and backward motion of the coccyx. Now, these 
 ligaments share in the general relaxation of the pelvic structures towards 
 the end of gestation ; and thereby we may assume, that the movement 
 or oscillation on its transverse axis, of which the sacrum is capable, and 
 which is said by Zaglas to be about a line in the unimpregnated con- 
 dition, is, in the last months of pregnancy, considerably increased. The 
 manner in which this oscillation of the sacrum takes place in different 
 positions of the woman is clearly shown by Zaglas. " In the erect 
 position, the promontory of the sacrum is not in the position of greatest 
 projection into the brim of the pelvis, but the reverse; and, conse- 
 quently, the apex is in its forward 
 fig. 4. position, diminishing the outlet and 
 
 relaxing the sacro-sciatic ligaments. 
 When the body is bent forward, on 
 the other hand, the base of the sac- 
 rum is protruded into the brim, the 
 apex is tilted upwards, the sacro- 
 sciatic ligaments put on the stretch, 
 and the outlet of the pelvis conse- 
 quently enlarged. These move- 
 ments take place, ordinarily, both 
 in man and woman, in defecation, 
 etc., but in her they are of greatest 
 interest and importance in the func- 
 tion of parturition. 7 ' 2 The backward 
 motion of the coccyx has also the 
 effect of producing lateral widening 
 of the pelvis, by bringing a wider part of the base of the sacrum between 
 the ilia. This, of course, supposes some gliding motion in the sacro- 
 iliac articulation, or, at least, yielding of the parts. The experiments 
 of MM. Giraud and Ansiaux seem to show that, in contracted pelves, 
 the movements take place to an even greater extent, as if nature were 
 doing her utmost to obviate the disastrous effects of pelvic deformity. 
 Dr. Matthews Duncan, in his admirable essay on this subject, points 
 out, with great clearness, the very remarkable manner in which these 
 alterations correspond with the phenomena of the progress of the child 
 in parturition. In the first stage of labor, for example, when the head 
 is passing through the brim, the woman prefers the standing, sitting, 
 or reclining posture, in which the brim of the pelvis is, as we have 
 seen, kept open at the expense of the outlet (see Fig. 4) ; but in the 
 second stage she bends her body forwards, draws up her legs, and calls 
 
 1 Barlow. Monthlj* Journal of Medical Science, January, 1854 
 
 2 Matthews Duncan. Op. cit, p. 142. 
 
 Diagram showing the oscillatory movement 
 referred to. (Matthews Duncan.) 
 
II.] THE PELVIS. 33 
 
 into action the abdominal muscles, which act by tilting up the sym- 
 physis ; in a word, her posture and voluntary efforts are now precisely 
 those which may most effectively increase the conjugate diameter of 
 the outlet by tilting back the coccyx. To the motion of the sacro- 
 coccygeal joint, which is universally admitted, we need not at present 
 specially advert. 
 
 From these and other facts disclosed up to the present time we con- 
 clude: 1st. That, in the last months of pregnancy, a marked relaxa- 
 tion and softening of the pelvic articulations takes place. 
 
 2d. That, as the result of this modification in structure, an in- 
 creased, though limited, mobility is permitted, which tends to facilitate 
 labor. 
 
 3d. That in addition to the movement of the sacrum on its transverse 
 axis, as above noted (and which may be considered as peculiar to the 
 human species), the manner in which the joints yield is probably very 
 similar to what obtains in the case of the cow. The sacrum acts in 
 this case as a wedge separating the ossa innominata and causing the 
 symphysis to open with a hinge motion, while, during the violent efforts 
 of labor, the whole sacrum may probably be driven backwards to a 
 trifling extent. Separation of the bones at the symphysis is occasionally 
 observed, but this is probably the exception, while the other is the rule. 
 The development of the synovial membranes seems, when taken along 
 with the above facts, to warrant the conclusion arrived at by Lenoir, 
 " that the articulations of the pelvis proper should not be considered 
 as amphiarthroses, but as arthroses" 
 
 The word " Midwifery," it is proper here to state, is employed in 
 this work in the more extended sense in which it is used by Rigby and 
 other English authors, and not in the limited sense which is implied 
 by the French accouchement, and the German Geburtshiilfe. It signifies, 
 therefore, that Science and Art, which has for its object the manage- 
 ment of woman and her offspring during Pregnancy, Labor, and the 
 Puerperal State. 
 
 CHAPTER II. 
 
 THE PELVIS. 
 
 OS INNOMINATUM : SACRUM: COCCYX — THE PELVIS AS A WHOLE: "TRUE 7 ' AND 
 "FALSE" — DIFFERENCE BETWEEN MALE AND FEMALE PELVIS: AT BRIM; 
 
 IN cavity; and at outlet — PELVIC articulations: (a) PELVI-LUMBAR ; 
 
 (b) SACRO-COCCYGEAL ; (c) SACRO-ILIAC ; (d) SYMPHYSIS PUBIS ; (e) OBTURATOR 
 LIGAMENTS; (/) SACRO-SCIATIC LIGAMENTS — INCLINATION OF PELVIS — AXIS 
 OF THE TRUE PELVIS — BRIM OR INLET — CAVITY — OUTLET— PEL VTC DIAM- 
 ETERS — PELVIC ANGLES DEVELOPMENT OF PELVIS CERTAIN SOFT PARTS 
 
 CONNECTED WITH PELVIS; OBTURATOR INTERNUS AND PYRIFORMIS MUSCLES; 
 " FLOOR " OF PELVIS. 
 
 The Pelvis, as has already been observed, is composed in Man, as 
 in almost all the other Mammalia, of three parts : 1st, an os innomina- 
 
 3 
 
34 
 
 THE PELVIS. 
 
 [CHAP. 
 
 Fig. 5. 
 
 External surface of right os innominatum. 
 
 turn, formed by the union of three principal pieces, the ilium, ischium, 
 and pubis, and some other epiphysial parts, the complete fusion of 
 which into one mass is only complete about the twentieth year ; 2d, 
 the sacrum ; and 3d, the coccyx. 
 
 The Os Innominatum on its external 
 surface exhibits the remarkable ex- 
 pansion of the ilium which constitutes 
 one of the distinguishing features of 
 the human race. This large surface 
 serves to give attachment to the pow- 
 erful glutei muscles. Its superior 
 margin is called the crest of the ilium ; 
 the projections at 1 and 2 the ante- 
 rior, and those at 3 and 4 the poste- 
 rior spinous processes. The acetabu- 
 lum, a deep cavity for the reception of 
 the thigh-bone, also called the coty- 
 loid cavity, with its synovial depres- 
 sion and pit for the reception of the 
 round ligament, is shown in the cen- 
 tre of the figure. 5 marks the pecti- 
 neal or ilio-pectineal eminence, a point 
 of some importance in midwifery; and 
 the other parts indicated are, 6, the 
 symphysis pubis ; 7, the tuberosity of the ischium ; 8, the thyroid or 
 obturator foramen ; and 9, the spine of the ischium, which divides the 
 great posterior gap into the greater and lesser sciatic notches. 
 
 In the view of the internal surface of the innominate bone, the figures 
 1 to 9 indicate the same parts as in the preceding cut ; 10 is the iliac 
 fossa ; 11, the ilio-pectineal line or brim of the true pelvis ; 12, auricu- 
 lar cartilaginous surface of the sacro-iliac joint; 13, rough tubercu- 
 lated surface for the posterior sacro-iliac ligaments ; 14, spinous process 
 of the pubis, terminating the crest of the pubis and the ilio-pectineal line. 
 The relative position of the rami of the ischium and pubis, and other 
 points familiar to the anatomist, are clearly shown in both figures. 
 
 The Sacrum is an irregular wedge-shaped or triangular bone, formed 
 by the fusion of five vertebra?, and is more or less curved, with the con- 
 cavity forwards, the base of the triangle being upwards. It is placed 
 below the last lumbar vertebra, above the coccyx, and between the ossa 
 innominata, and forms the upper and back part of the pelvis. It is in 
 man stronger, and relatively larger, than in any other animal, this 
 characteristic being specially marked in the female. The external or 
 posterior surface is convex and rough, and there are four, and some- 
 times five, processes placed below each other in the median line, repre- 
 senting the spines of the original vertebra?. On either side, four 
 foramina are observed, through which the posterior sacral nerves pass 
 from the cauda equina, which is contained in a longitudinal canal, the 
 continuation of that of the vertebral column. Below the last spinous 
 process, is a triangular opening, which is the termination of the verte- 
 bral canal, and of which the lateral margins terminate in a pair of 
 
II.] 
 
 BONES OF PELVIS, 
 
 35 
 
 tubercles. These, which project downwards, and articulate with the 
 cornua of the coccyx, are known as the sacral cornua. A row of tuber- 
 cles is seen on the inside, and another on the outside of the foramina, — 
 corresponding to the articulating and transverse processes of the 
 vertebrae. 
 
 The pelvic or anterior surface (Fig. 7) is concave from above down- 
 wards, and slightly so from side to side, and is much smoother than 
 the posterior. Four foramina, larger than those above described, are 
 
 Fig. 7. 
 
 Internal suiface of the same bone. 
 
 Sacrum and coccyx — internal surface. 
 
 provided for the transit of the anterior sacral nerves ; and between the 
 foramina are four ridges, indicating the boundaries of the original 
 vertebral constituents of the bone. 
 
 Laterally, there is presented anteriorly an uneven surface of consider- 
 able size, covered in the recent state with cartilage, and corresponding 
 to the iliac articulating surface shown at 12, Fig. 6. This is called 
 from its shape the auricular surface ; and behind it there is an extremely 
 rough and uneven surface for the attachment of the posterior sacro-iliac 
 ligaments. Below and behind this, the irregular surface gives attach- 
 ment to the sacro-sciatic ligaments. 
 
 The oval surface of the sacrum, which, looking upwards and for- 
 wards, represents the base of the bone, is articulated, through the 
 medium of the interarticular disk, with the last lumbar vertebra; 
 while its narrow inferior extremity, transversely oval, is jointed with 
 the superior surface of the coccyx. 
 
 The Coccyx , the rudiment of the caudal vertebrae, generally consists 
 of four small vertebral pieces tapering downwards to a point. It 
 derives its name from a fancied resemblance to a cuckoo's beak, and is 
 placed so as to continue, anteriorly and posteriorly, the curve of the 
 sacrum. An oval surface (covered with cartilage and furnished with a 
 synovial membrane) articulates with the apex of the sacrum ; and this 
 union is strengthened by two small processes which project upwards to- 
 
36 THE PELVIS. [CHAP. 
 
 meet the cornua of the sacrum. Not only is the sacro-coccygeal joint 
 a perfect hinge, but the various bones of which the coccyx is composed 
 also admit of some motion in early life the one upon the other. In 
 adult life these bones are generally anchylosed, and the sacro-coccygeal 
 joint is, in males generally, and in females occasionally, lost, so that 
 the sacrum and coccyx are firmly joined together. 
 
 The superior mobility of the coccyx in women is universally admit- 
 ted as an important mechanical advantage in the process of parturition, 
 the aiitero-posterior diameter of the outlet being by this resiliency 
 increased, under ordinary circumstances, by an inch or even more. 
 Usually, during the childbearing period, the parts are in the condition 
 of complete mobility as regards the sacro-coccygeal joint, and yielding 
 also between the first and second bone of the coccyx, while the last 
 three bones are united. 1 In this respect, however, great irregularities 
 exist, and sometimes, even in women who are still young, complete 
 anchylosis is observed. The result of this is, of course, a very consid- 
 erable impediment to delivery, and many cases are recorded where, 
 during the use of instruments, or even in the course of ordinary labor, 
 a fracture of the bones thus anchylosed has occurred. Premature fusion 
 of this articulation, and malformation of the coccyx are conditions by 
 no means very uncommon. The usual form assumed in the latter case 
 is projection forwards, encroaching upon the conjugate diameter of the 
 outlet; but a projection of the coccyx backwards has also been noticed 
 by the writer and others, a condition which is interesting as an ana- 
 tomical peculiarity, but is rather favorable than obstructive to the 
 course of natural labor. In cases of fracture, care must be taken, dur- 
 ing the reparative process, to prevent union in such a position as to 
 constitute a possible impediment to delivery in subsequent labors. 
 
 The Pelvis as a Whole. — The Pelvis is thus formed by the union of 
 several pieces, the articulations or points of junction being, in front, 
 the symphysis pubis, and, behind, the sacro-iliac and sacro-eoccygeal 
 joints. These articulations are greatly strengthened by certain liga- 
 mentous structures which will be presently described. 
 
 It is divided into two parts by a line, the various parts of which are 
 in man alone on the same plane. This, known as the ilio-pectineal line, 
 marking the brim or inlet of the pelvis, runs on each side from the 
 symphysis pubis outwards, upwards, and inwards, forming an irregu- 
 larly oval constriction of the osseous canal. Various points in the 
 course of this line, which divides the superior or false from the inferior 
 or true pelvis, are of special interest to the obstetrician. In the middle 
 line anteriorly is the symphysis pubis. Diverging right and left from 
 this point, are the pubic crests, terminating in the pubic spines. The 
 finger, on being passed around, next touches the pectineal or ilio-pec- 
 tineal eminence, then the ilio-sacral articulation, and finally the pro- 
 jection known as the promontory of the sacrum. This last point is of 
 paramount importance, as the degree of projection which forms the 
 
 1 Cazcaux assorts that the sacro-coccygeal articulation ossifies generally before 
 the first and second bones become united. If this is correct, the mobility in these 
 cases must manifestly be impaired. 
 
II.] 
 
 MALE AND FEMALE PELVIS CONTRASTED. 
 
 37 
 
 Fig 
 
 promontory exercises a most important influence on the progress of a 
 case of labor. 
 
 The true pelvis, then, includes the whole of that part of the structure 
 which is below the brim as far as the outlet, the space comprised be- 
 tween the two being the cavity. Each of these parts requires careful 
 and separate consideration ; but, before passing to this part of the sub- 
 ject, it is advisable that the striking contrast between the male and 
 female pelvis, having an obvious relation to the function of parturition, 
 should be noticed. 
 
 The female differs from the male pelvis, in the first place, by the 
 comparative slenderness of the bones, as is well seen in the rami of the 
 ischium and pubis, and also by the greater smoothness of the surfaces 
 to which muscles are attached. The chief points of distinction, as 
 viewed from before, are 
 well shown in Figs. 8 
 and 9, in both of which 
 the numbers 1 and 2 
 represent the extremi- 
 ties of the widest trans- 
 verse diameter of the 
 upper or false pelvis ; 
 3 and 4 are the acetab- 
 ula, right and left ; 5, 
 5, the thyroid or obtu- 
 rator foramina ; and 6, 
 the subpubic angle or 
 arch. The differences 
 exhibited are those 
 which exist between 
 an ordinary male and 
 female pelvis in mid- 
 dle age : in neither case 
 is there anything ex- 
 aggerated or unusual. 
 The greater distance in 
 Fig. 9 between the ace- 
 tabula, the wider and 
 shallower true pelvis, 
 the triangular form of 
 the obturator foramen, 
 the greater width be- 
 tween the tuberosities 
 of the ischia, and the 
 greater span of the 
 subpubic arch, are the 
 chief points which at a glance show it to be a female pelvis. The last- 
 mentioned point of distinction is very characteristic in well-formed 
 pelves, the angle in males being no more than 75° to 80°, while in the 
 female it reaches from 90° to 100°. 
 
 Viewed from above and in front, at right angles to the brim of the 
 
 Male and female pelves contrasted, 
 
 (Quain.) 
 
38 
 
 THE PELVIS. 
 
 [CHAP. 
 
 Fig. 10. 
 
 Fig. 11. 
 
 true pelvis, the contrast is scarcely less marked. In the lower of the 
 two figures showing this view, the further peculiarities of the female 
 pelvis are evidenced by the greater expansion of the ilia, the minor 
 
 degree of projection of 
 the promontory of the 
 sacrum, and the mark- 
 ed general increase in 
 the diameters. In the 
 cavity, the most note- 
 worthy feature of the 
 female pelvis is the 
 diminution in the per- 
 pendicular depth, the 
 symphysis being in the 
 male nearly double the 
 depth, while the sac- 
 rum is shorter as well 
 as broader, and placed 
 so as to offer a more 
 ample concavity. It 
 will also be noticed, 
 in looking downwards 
 and backwards, as is 
 shown in Figs. 10 and 
 11, that three projec- 
 tions are seen — poste- 
 riorly the sacrum and 
 coccyx, and on either 
 side the converging 
 ischial planes, culmi- 
 nating in the ischial 
 spines. These projec- 
 tions, encroaching, as 
 they manifestly do, on 
 certain measurements of the lower parts of the pelvis, have, as will be 
 explained afterwards, a very important bearing upon the mechanical 
 laws which govern the process of parturition. 
 
 If, again, we look at the bony outlet, we find here also three projec- 
 tions, posteriorly the sacrum and coccyx, and at the sides the ischial 
 tuberosities. Between the latter is the subpubic angle, while between 
 them and the sacrum on each side is the irregular sacro-sciatic gap, 
 partly closed, as we shall see presently, by powerful ligamentous struc- 
 tures, and much more spacious in the female than in the male. 1 These, 
 the main features which enable us to distinguish between the male and 
 
 i The greater expansion of the ilia, and divergence of the cotyloid cavities, give 
 the chief peculiarities to the female figure, in regard to which the ancient Greek 
 sculptors are probably not far from the truth in representing their ideal of female 
 beauty as measuring a third more across the hips than the shoulders, while these 
 measurements are reversed in the case of Apollo. The same peculiarity occasions 
 the peculiar swinging gait, which is the more marked in a woman the broader the 
 pelvis is in proportion to her height. 
 
 Male and female pelves contrasted, as viewed in the axis of the 
 brim. (Quain.) 
 
II.] PELVIC ARTICULATIONS. 39 
 
 female pelvis, having now been noticed, we shall advert in future to 
 the female pelvis alone. 
 
 The ligaments and articulations which bind the various parts of the 
 pelvis together may now be briefly noticed. 
 
 a. Pelvi-lumbar Articulation. — In addition to the intervertebral disk, 
 and the ligaments which are strictly analogous to those existing between 
 the vertebras above, attention must here be paid to the sacro-vertebral 
 and ilio-lumbar ligaments. The former passes, expanding as it descends, 
 obliquely from the tip of the transverse process of the last lumbar ver- 
 tebra, to the depressed lateral part of the base of the sacrum ; the latter 
 horizontally between the tip of the transverse process of the last lumbar 
 vertebra and the posterior margin of the iliac fossa, where it somewhat 
 expands. 
 
 b. Sacvo- coccygeal Articulation. — An anterior and posterior ligament, 
 and an intervertebral disk, are here found as in the more perfect verte- 
 bras. There is observed besides in women, and in a lesser degree in 
 the male sex, a synovial membrane, described by Cruveilhier, and 
 which converts this into a perfect hinge joint, the structure and mobility 
 of which become, as has already been mentioned, much more obvious 
 in the latter stage of pregnancy. 
 
 c. Sacro-iliac Articulation. — The bones are here joined by a twofold 
 union ; in the first place, by the cartilaginous auricular surfaces which 
 are seen anteriorly when the parts are forced asunder, and from which 
 the name synchondrosis is often given to the joint. Generally, these 
 surfaces are closely united ; but in pregnant women, and, probably, 
 under certain other circumstances, an indistinct synovial cavity may be 
 demonstrated, admitting, as there is every reason to believe, of a certain 
 amount of motion. This union is greatly strengthened by the posterior 
 sacro-iliac ligaments, consisting of strong irregular bands of fibres which 
 pass from the overhanging portion of the ilium to the contiguous rugged 
 projections on the lateral surface of the sacrum. One of these bands, 
 extending downwards from the posterior superior iliac spine to the 
 third or fourth piece of the sacrum, in a direction different from the 
 other fibres, is known under the name of the oblique sacro-iliac liga- 
 ment. An anterior sacro-iliac ligament is also described, but is of 
 little anatomical importance. 
 
 d. The Symphysis Pubis. — This joint is, like the previous one, also 
 effected by fibro-cartilaginous plates and ligaments. The two cartilages 
 are thicker in front where they come into contact with each other, and 
 thinner posteriorly, so as to leave a space which is, as in the other 
 joints just described, lined by a synovial membrane. During preg- 
 nancy, an effect is produced upon this joint precisely similar to what 
 has been stated to occur in the sacro-iliac joints, but it is in this case 
 even more marked. The articulation is materially strengthened by 
 the ligaments which surround it, named respectively posterior, superior, 
 anterior, and inferior pubic ligaments. Of these, the posterior is a layer 
 of fibres of little strength ; the superior is connected with a band of 
 fibres which arises from the spine of the pubis, and conceals the irregu- 
 larities of the crest of the same bone ; the anterior is a layer of irregular 
 fibres passing across from one side to the other, and crossing obliquely 
 
40 
 
 THE PELVIS. 
 
 [CHAP. 
 
 Fig. 12. 
 
 the corresponding fibres from the other side, and the inferior, triangu- 
 lar, or subpubic ligament is so thick, and so formed by its attachments 
 to the rami of the pubic bones as to give smoothness and roundness to 
 the subpubic angle, and thereby to facilitate the passage of the foetus. 
 e. The Obturator Ligaments. — These structures, which are more cor- 
 rectly described as membranes, close almost entirely the obturator 
 foramina, giving attachment externally and internally to the obturator 
 muscles, and leaving only a small aperture in its upper and outer part, 
 which serves to transmit the obturator vessels and nerve. 
 
 /. Sacro-sciatic Ligaments. — These are two in number, longer in the 
 female than in the male, and become, to some extent, relaxed during 
 labor. The posterior, or great sacro-sciatic ligament (Fig. 12, 1), 
 
 which is placed in the inferior and 
 posterior part of the pelvis, is broad 
 and triangular in shape, and extends 
 from the inner surface of the ischial 
 tuberosity, which is the apex of the 
 triangle, to the side of the coccyx 
 and sacrum, as far as the posterior 
 inferior spine of the ilium. This 
 extensive attachment constitutes the 
 base. The fibres of the apex expand, 
 so as to send a falciform process up- 
 wards and forwards, along the margin 
 of the ischial ramus, to join the fibres 
 of the obturator fascia. 2 is the ante- 
 rior or small sacro-sciatic ligament, 
 which is both shorter and thinner 
 than the other, and is also of a some- 
 what triangular shape. Its fibres are 
 directed forwards and outwards ; the 
 fibres constituting its base are blended 
 with those of the larger ligament ; and 
 its apex is attached to the spine of the 
 ischium. By means of these struc- 
 tures, which are ossified in some of the lower animals, it will be observed 
 that the sacro-sciatic notches are converted into foramina, great and 
 small sacro-sciatic ; 3 and 4. Through the former of these, the pyri- 
 form muscle, the great sciatic nerve, and the ischiatic vessels and nerves 
 pass, while the latter admits of the exit from the pelvis of the obturator 
 interims muscle and the pubic vessels and nerve. 
 
 The obstetrician may look upon these ligaments as discharging a 
 double function. They act, as has already been mentioned, by pre- 
 venting the displacement of the apex of the sacrum upwards and back- 
 wards, — an accident wdiich, without their aid, the very oblique position 
 of that bone would in the erect posture be likely to engender; and 
 therefore, in this sense, they strengthen the sacro-iliac articulation. 
 But, in addition to this, they close in, in some measure, the large 
 irregular opening which constitutes the outlet of the pelvis ; forming, 
 at the same time, the framework of those soft structures which consti- 
 
 Internal surface of female pelvis, showing 
 — 1, 2, greater and lesser sacro-seiatic liga- 
 ments; 3, 4, greater and lesser gaps or for- 
 amina. 
 
II.] 
 
 INCLINATION OF THE PELVIS. 
 
 41 
 
 Fig. 13. 
 
 tute the floor of the pelvis — which exercise a very important influence 
 on the progress of labor, and which act also by affording an efficient 
 and elastic support to organs which would otherwise be liable to fre- 
 quent displacement downwards. 
 
 In addition to the ligaments above described, there are others, some of 
 them — as those of the hip-joint — of great importance; but as they have 
 no special obstetrical interest, their description may here well be omitted. 
 
 Inclination of the Pelvis. — If we place the articulated pelvis on a 
 table, so as to bring the tip of the coccyx and the ischial tuberosities 
 into the same horizontal plane, the brim of the pelvis will be found to 
 look upwards and slightly forwards. This was at one time supposed 
 to be the actual position in the erect posture ; and many persons now 
 living may remember to have seen articulated skeletons in which the 
 pelvis was so placed. Hence the term "horizontal," which use and 
 wont has attached to the upper of the two rami of the pubis. JNaegele 
 was the first clearly to show, not only that this was an error, but that 
 it was a very gross one, 1 and that the pelvis was, in the normal position, 
 inclined forwards to such an extent that the plane of the brim met the 
 horizon at an angle of 60° or more (Fig. 13, a). The same observer, 
 after examining a large num- 
 ber of well-formed female 
 bodies, concluded, further, 
 that the average height of 
 the promontory of the sacrum 
 above the upper margin of 
 the symphysis pubis is about 
 3} inches, and that a line 
 drawn from the tip of the 
 coccyx to the lowest part 
 of the symphysis, formed 
 with the horizon at b an 
 angle which varies greatly, 
 but which may be stated, as 
 an average, at about 11°. 
 In reference to this, however, 
 it must be borne in mind, 
 that the recession of the 
 coccyx implies a movement 
 downwards as well as back- 
 wards, and that, conse- 
 quently, this angle will be 
 rendered still more acute 
 during the passage of the child. The axis of the brim of the pelvis, 
 then, is a line, c d, which passes upwards and strongly forwards, while 
 that of the bony outlet is directed downwards and slightly backwards. 
 The axis of the cavity is usually described as the perpendicular of a 
 line drawn from the middle of the symphysis pubis to the centre of the 
 sacro-coccygeal curve. 
 
 \« 
 
 Diagram showing the inclination and axis of the 
 true pelvis. 
 
 Das Weibliche Becken," etc. Carlsruhe. 1825. 
 
42 
 
 THE PELVIS. 
 
 [CHAP. 
 
 Fig. 14. 
 
 Axis of the True Pelvis. — If the bony pelvis were a simple cylinder, 
 the demonstration of its axis would be a very simple matter. All that 
 would then be necessary would be to make a section, perpendicular to 
 its walls, when the axis of the cavity would be shown to be a line inter- 
 secting the plane represented by this section, and equidistant from every 
 part of the cylinder wall. The same simplicity of description will not, 
 however, suffice in the case of the irregular and curved pelvic cylinder. 
 What is known as the "curve of Carus" was at one time generally 
 supposed to represent the axis of the pelvis. This curve is described 
 in the following manner: The compasses are opened to the extent of 
 2J inches : one point is placed upon the central point of the posterior 
 surface of the symphysis, while with the other a curve is drawn from 
 the plane of the brim to the plane of the outlet, the segment of the 
 circle thus indicated being assumed to represent the axis of the pelvis. 
 A mere superficial observation of the human pelvis will serve to show 
 that neither this nor the segment of any circle can truly, or even ap- 
 proximately, represent the axis in question. 
 
 Although not absolutely free from technical objection, we may assume 
 
 that the following more modern view 
 brings us much nearer the truth : If 
 we produce the lines in the above dia- 
 gram, which represent the planes of 
 the brim and outlet, to their point of 
 intersection in front of the symphysis 
 at o, and from this common centre 
 draw an infinite number of radii pass- 
 ing through the pelvic cavity ; each 
 of these radii may be held to represent 
 the plane of that portion of the cavity 
 through which it passes. If we then 
 draw a line which shall pass through 
 the geometrical centre of each of these 
 planes, that line will be found to be a 
 curve, which coincides very closely 
 with the axis of the true pelvis, which 
 is the segment of no circle, and which 
 has been described as an irregular para- 
 bola. One point must here, however, 
 be noted — that as the terminal planes 
 or radii will be modified by the motion 
 of the coccyx during labor, so in like 
 manner will the inferior portion of the 
 curve be proportionally altered. This 
 is indicated in the diagram, where the 
 line cf marks the parabolic curve or 
 assumed true pelvic axis. 
 
 We must here be careful in drawing 
 a distinction between the axis of the 
 outlet of the bony pelvis, and that axis which represents the direction 
 in which the child is born. In considering the latter, it is essential 
 
 Diagram showing the axis of the 
 parturient canal. 
 
II.] INTERIOR OF PELVIS. 43 
 
 that the soft parts forming the floor of the pelvis should be looked upon 
 as constituting the posterior and inferior boundary of a continuation 
 of the pelvic canal. These parts, which extend from the tip of the 
 coccyx to the posterior commissure of the vagina, are subjected during 
 delivery to an amount of stretching for which nature makes due pro- 
 vision. The sphincter of the anus is dragged asunder, the perineum 
 distends in all directions in a manner apparently incompatible with the 
 integrity of that structure, until ultimately, at the moment of expulsion, 
 the fourchette is driven downwards and carried forwards to such an 
 extent, that a line drawn from the subpubic angle to the edge of the 
 distended perineum, shows the plane of the outlet of the completed 
 pelvic canal to look, not downwards, but almost directly forwards (Fig. 
 14, a b). The line e, perpendicular to, and meeting the centre of this 
 plane, is then the axis of expulsion. The tendency of that part of the 
 child which is first born is to move upwards and forwards under the 
 pubic arch, and in front of the symphysis, in continuation of the curve 
 indicated in the diagram by dotted lines. 
 
 Let us now look more closely at the various parts of this tube which 
 attract special notice, viz., the Brim, the Cavity, and the Outlet. The 
 Brim presents (Fig. 11, p. 38) an irregular oval appearance, the long 
 diameter of the oval being from side to side. It has been found on an 
 average to measure in the antero-posterior or conjugate diameter, ap, 
 which is taken from the promontory of the sacrum to the upper edge 
 of the symphysis pubis, 4 J inches. Its greatest transverse measure- 
 ment, 1 1, is 5J inches. In addition to these, there is also described an 
 oblique diameter, extending from the sacro-iliac synchondrosis on each 
 side to a point near the ilio-pectineal eminence on the other. This 
 measures 5 inches, and it must be remembered that these diameters 
 take their name "right" (r o), or "left" (I o), oblique according to the 
 sacro-iliac synchondrosis from which they spring. 1 
 
 It will thus be observed that, in the skeleton, the transverse is the 
 longest diameter of the three, but, when the soft parts are in situ, this 
 is not the case, as the iliacus muscle overlaps the brim, so as to 
 diminish the transverse while it scarcely encroaches upon the oblique 
 diameter. The effect of this is that the oblique is practically the longest 
 diameter, a fact which we find of great interest and importance when 
 we study the relation of the diameters to the foetal head. 
 
 The Cavity of the pelvis is the whole tube between the brim and the 
 outlet. As a general rule, the deeper the cavity the more difficult is 
 the labor, for in this case the pelvis approximates in its formation to 
 the male type. If the diameters are proportionally enlarged, labor 
 may be, it is true, quite easy; but the rule undoubtedly is that, in the 
 case of the tall handsome woman with dignified gait and carriage, the 
 probability of a difficult labor is much greater than in the short, wide- 
 
 1 In regard to this there unfortunately exists some discrepancy. The diameters 
 are named right and left, as in the text, by the best English and German writers, 
 but some eminent French and American authors have named them from the coty- 
 loid cavity, thus inverting the meaning of the terms. 
 
44 
 
 THE PELVIS, 
 
 [CHAP. 
 
 Fig. 15. 
 
 Interior of pelvis, showing the ischial planes. 
 
 hipped woman, in whom the swinging, or (to put it less gallantly) the 
 
 waddling motion of her sex is more 
 obvious. The cavity, as a single 
 glance will show (Fig. 16), is deep 
 posteriorly and shallow anteriorly. 
 The average depth of the symphysis 
 pubis gives the anterior depth at 1 J 
 inches. The height of the planes of 
 the ischia which corresponds to the 
 middle depth may be stated as about 
 3J inches. The depth posteriorly 
 may be set down, if we measure 
 directly from the promontory of the 
 sacrum to the tip of the coccyx, as 
 4J inches, which, if we follow the 
 curve of the sacrum, will be in- 
 creased to about 5 J inches, the former 
 of these measurements making no 
 allowance, however, for the yielding 
 of the coccyx. Three diameters are 
 also taken in the case of the cavity 
 as representing its width : the conju- 
 gate, from the centre of the symphysis pubis to the upper margin of 
 the third sacral vertebra, 5J inches ; the transverse, from a point cor- 
 responding to the lower margin of the acetabulum on one side to the 
 corresponding point on the other, 5 inches ; and the oblique, from the 
 centre of the great sacro-sciatic foramen on one side to the foramen 
 ovale on the other, 5J inches. 
 
 Looking now at the internal surface of the pelvic canal in a section 
 such as is here shown, we may observe that the lateral wall is divided 
 into two parts by a not very obvious line of demarcation (a b) leading 
 downwards and backwards, from the ilio-pectineal eminence to the 
 spine of the ischium. That part of the ischium which is in front of 
 this looks slightly forwards, that which is behind slightly backwards. 
 These are the anterior and posterior inclined planes of the ischium, sup- 
 posed by Desormeaux, Tyler Smith, and many others, to determine 
 the rotation of the head in the mechanism of parturition. To this, 
 however, we shall return. 
 
 While the brim or inlet of the pelvis is directed, as we have seen, 
 upwards and forwards in the erect posture, that of the outlet, owing to 
 the curve formed by the axis of the cavity, looks backwards, and, when 
 the coccyx is extended, almost directly downwards. 
 
 The conjugate diameter of the outlet (Fig. 16) extends from the 
 lower margin of the symphysis pubis to the tip of the coccyx, and may 
 be set down as 5 inches. In many cases the measurement is much less 
 than this, and in any case the diameter may be increased to the extent 
 of an inch or even more by the mobility of the coccyx during labor. 
 The transverse, from one tuber ischii to the other, is about 4| inches ; 
 and the oblique, from the middle of the lower edge of the great sacro- 
 
II.] 
 
 PELVIC DIAMETERS. 
 
 45 
 
 sciatic ligament on one side to the point of union between the ischium 
 and pubis on the other, also 4f inches. 
 
 The facts which are brought out by those figures are chiefly these : 
 (a) That the transverse measurement of the pelvic tube becomes pro- 
 gressively diminished from above downwards, being greatest at the 
 brim and smallest at the outlet. This is due, as a single glance down- 
 wards in the axis of the brim 
 will show, to the gradual 
 approximation of the ischia 
 (Fig. 11). (6) That the con- 
 j ugate diameter is, on the con- 
 trary, increased from above 
 downwards, in consequence 
 of the recession or curve of 
 the sacrum, progressively 
 from brim to outlet, if we 
 allow for the bending back 
 of the coccyx. These facts, 
 which are associated with a 
 remarkable rotation which 
 the child undergoes during 
 labor, are moreclearly shown 
 when, as in the following table, the figures above noted are brought 
 into juxtaposition. Along with these, a few of the more important of 
 the many measurements which have been made of the female pelvis 
 are also set down in inches, according to the average of the most recent 
 and approved observations. 
 
 Outlet of the female pelvis. 
 
 MEASUREMENTS OF THE FEMALE PELVIS. 
 
 1. Circumferential measurement of the brim, 
 
 2. Between widest part of iliac crests, .... 
 
 3. " Anterior superior spines of ilium, 
 
 4. " Front of symphysis and sacral spines, 
 
 True Pelvis. 
 Brim, . 
 Cavity, 
 Outlet, 
 
 Conjugate. Transverse. 
 
 . o-i- 5 
 
 . 5 2 4| 
 
 17 
 
 10| 
 
 10i 
 
 7 
 
 Oblique. 
 5 
 
 [4|] 
 
 All the measurements given in this table are, it must be remembered, 
 those of the skeleton — no allowance being in any case made for the 
 soft parts ; and to them we may add another measurement, which has 
 an important bearing on practical considerations arising from the study 
 of a certain class of pelvic deformities. This is the sacro-cotyloid 
 diameter, which is about 3 J inches in a well-formed pelvis, and is rep- 
 resented by a line drawn from the centre of the sacral promontory to 
 the region above the cotyloid cavity. The encroachment of the psoas 
 and iliacus muscles, with investing and other structures, reduces the 
 
 1 The oblique diameters of the cavity and outlet are placed in brackets, as, not 
 being taken from fixed bony points, they are of comparatively little importance. 
 
 2 When coccyx forced back. 
 
46 THE PELVIS. [CHAP. 
 
 transverse diameter of the brim by about half an inch, while the other 
 diameters of the brim, as well as of the cavity and outlet, are only 
 reduced by an eighth to a quarter of an inch at the most. The oblique 
 diameters are least of all affected ; but, owing to the presence of the 
 rectum on the left side, the left oblique diameter is slightly shorter 
 than the right. These facts have to be borne in mind in the course of 
 examinations which are made with a view of estimating the capacity 
 of the pelvis in its various parts, — a question often of vital import in 
 the practice of midwifery ; and in such investigations it is also useful 
 to know that the distance from the lower edge of the symphysis to the 
 promontory of the sacrum is about half an inch more than the conju- 
 gate of the brim. In regard to the measurements numbered 2, 3, and 
 4 in the table, if these are to be estimated by measurements in the 
 living body, from two to three inches must be added for the tegumen- 
 tary and other external structures. 
 
 In addition to the angles which have already been described as formed 
 with the horizon by the planes of the brim and outlet, and measuring 
 respectively 60° and 11° (Fig. 13), and the subpubic angle, there are 
 several others which should not be overlooked. The sacro-vertebral 
 angle is that which the sacrum forms with the upper portion of the 
 vertebral column, and is estimated as 117° in the male, and 130° in 
 the female. This remarkable contrast serves to show that there is no 
 gain whatever in capacity by a sudden recession of the sacrum, and 
 that they who have assumed that in the female there is a more abrupt 
 recession of the sacrum, are as much in error as those who have de- 
 scribed the female sacrum to be more curved than the male. The 
 symphysis forms with the horizon an angle of 35° to 40° in the erect 
 posture; while the ischium forms with the ilium, or rather with the 
 imaginary line leading downwards and forwards, and representing the 
 mean direction of that bone, an angle of 110° to 115°. This latter is 
 called the ilio-ischial angle? 
 
 Development of the Pelvis. — From birth to the age of puberty, the 
 pelvis differs in many respects, besides mere size and state of ossifica- 
 tion, from the same part in the adult. At birth, the iliac fossa? are flat, 
 and have their surfaces directed more forwards. The symphysis is 
 short. The sacrum is very narrow, and on this account the transverse 
 measurements are relatively smaller than the conjugate; while all the 
 diameters are extremely small, and so insufficient for the reception of 
 what are known as pelvic organs, that these parts are for the most part 
 lodged in the abdominal cavity. This contributes, no doubt, to the 
 abdominal prominence which is so familiar in the newly born. The 
 sacrum is very flat, and there is also very little approximation of the 
 inner surfaces of the ischium, which gives to the sides of the pelvis a 
 general appearance of parallelism not existing in the adult. A very 
 general idea prevails among the best modern writers that the inclination 
 of the brim is considerably increased as compared with the adult. 
 This has been stated by Cruveilhier and Burns, and even more decid- 
 edly by Cazeaux. " The sacrum," says the latter, " is so flat and so 
 
 1 For a complete and exhaustive aVniv>nstration of these and other points alluded 
 to, see Mr. Wood's Essay, Art. "Pelvis " in Todd's Cyclopaedia. 
 
II.] FLOOR OF THE PELVIS. 47 
 
 elevated, that a horizontal line drawn from the upper part of the pubis 
 will pass below the coccyx." Mr. Wood, however, has given the 
 weight of his authority in favor of another view, and states it as the 
 result of his careful observations, made by sections when the soft parts 
 were in situ, that he has always found the tip of the coccyx " as low as 
 the lower border of the symphysis pubis." Such a serious discrepancy 
 can only be accounted for by supposing that a different mode of obser- 
 vation has been adopted. 
 
 The child, it must be remembered, is not as yet structurally fit for 
 the erect position, and therefore maintains for many months after birth 
 a posture similar to that which it assumes in the womb, with the thighs 
 flexed upon the abdomen, and the symphysis tilted upwards. To 
 measure the pelvic angles of the child, with the view 
 of comparing them with those of the adult, it is es- FlG - 17 - 
 
 sential that the child should be placed in such a posi- 
 tion as may, without violence or rupture of tissue, 
 coincide as nearly as possible with the erect posture, 
 and if this is done the pelvis will usually be found to 
 present the appearance shown in Fig. 17. From this 
 point of view Cazeaux is possibly correct ; but if a 
 section be made through a child in the position which 
 it instinctively adopts, the relative position of parts, 
 as described and figured by Mr. Wood, will probably 
 under these circumstances be confirmed. The other distinctive char- 
 acteristics of the infant pelvis are also shown in the figure, in which, 
 moreover, the general resemblance to the type of the Simiina may 
 afford some pleasing suggestions to the disciples of Darwin. 
 
 According to Burns, it is not until the tenth year that the transverse 
 comes to exceed the conjugate measurement. There is, however, noth- 
 ing which would enable us to distinguish with even an approach to 
 certainty between the male and female pelvis until the period of puberty 
 approaches, when nature, availing herself of the plastic nature of these 
 bones, due to their tardy ossification, moulds the parts, in full view of 
 the important physiological function which is about to be instituted, 
 so that the marked characteristic features of the female pelvis are now 
 rapidly developed. 
 
 Hitherto we have looked at the pelvis as an osseous and ligamentous 
 structure. Connected in the most intimate manner with it, however, 
 there are certain soft structures which cannot properly be included in a 
 description of the organs of generation, and which fall therefore to be 
 considered' in this place. The fan-shaped iliacus muscle forms, along 
 with the psoas on each side, a sort of cushion, which, besides giving 
 proper support to other viscera, forms a rest for the gravid uterus, and 
 an effectual protection for it against shock. It encroaches, as we have 
 seen, upon the transverse, without materially lessening the oblique 
 diameter, and this encroachment is more marked when the muscles are 
 in a state of contraction. On each side of the cavity, there are two 
 muscles covering in to a great extent the great sciatic and obturator 
 gaps. These are the pyriformis and obturator internus muscles, to the 
 contraction of which the rotation of the foetal head which takes place 
 
48 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 within the cavity was supposed by Flam and of Strassburg to be due. 
 The dimensions of the cavity are further reduced by the rectum and 
 bladder, and by the cellular tissue, which, when overcharged with fat, 
 may form a barrier to the progress of labor, rendering its course more 
 tedious. 
 
 The perineal strait, open in the skeleton, is occupied by firm con- 
 tractile tissues, which form a floor for the support of the pelvic, and, 
 indirectly, of the abdominal viscera. This floor consists of two mus- 
 cular layers. Of these, the internal layer, formed by the levator ani 
 and cocci/geus, has its concavity directed upwards, and has been named, 
 not inappropriately, by Meyer the "pelvic diaphragm." The external 
 layer, with its concavity downwards, is formed of the muscles of the 
 perineum, known to anatomists as the sphincter ani, transversus perinei, 
 ischio- caver mosus, and sphincter vagince. The pudic vessels and nerves, 
 cellular tissue, the pelvic aponeurosis, an intermuscular aponeurosis, 
 and the skin, complete this floor, which at the time of delivery becomes 
 thin and distends to a very considerable extent. In the ordinary state, 
 the measurement from the coccyx to the posterior commissure of the 
 vulva is a little more than three inches ; but, during labor, the disten- 
 sion is such that it is increased to 5, 6, 6J inches, or even more, by the 
 stretching of the parts, and by overcoming the tonic contraction of the 
 sphincter. 
 
 CHAPTER III. 
 
 FEMALE ORGANS OF GENERATION. 
 
 A. External: labia; perineum; hymen, etc. — erectile tissue — the va- 
 
 gina — GLANDS OF THE EXTERNAL ORGANS — ABNORMAL CONDITIONS — MAM- 
 MARY GLANDS. 
 
 B. Internal: the uterus: situation of; divided into body and cervix, 
 
 AXIS OF UNIMPREGNATED UTERUS; CAVITY OF; FUNDUS; SURFACES AND 
 BORDERS — SEROUS COVERING OF — BROAD LIGAMENTS; ROUND LIGAMENTS; 
 VESICO-UTERINE FOLDS — THE FALLOPIAN TUBES — PAROVARIUM — FOLDS OF 
 DOUGLAS — EQUILIBRIUM OF THE UTERUS. 
 
 The Organs of Generation in the female include — besides the Uterus, 
 Ovaries, and other parts situated internally — the Vagina, Vulva, and 
 Mons Veneris. These latter being, more properly, external organs, 
 anatomists have divided the whole into External and Internal Organs. 
 
 External Organs of Generation. — Immediately over the symphysis 
 pubis, above, and in front of the opening of the vulva or pudendum, is 
 a firm cushion-like eminence, about two inches in depth and three 
 inches transversely. This, which is called the Mons Veneris, varies in 
 prominence according to the conformation of the pubes, and the amount 
 of adipose and cellular tissue in it and the contiguous parts. After 
 
III.] THE PERINEUM. 49 
 
 puberty, it is covered with hair, and is abundantly furnished with 
 sebaceous follicles, which were supposed by Moreau to contribute in some 
 measure to the dilatation of the external parts at the moment of delivery. 
 Continuous with this structure, extending downwards and backwards, 
 and becoming gradually thinner in their course, are two rounded folds 
 of integument, which, diverging from each other, leave in the median 
 line an elliptical interval between them. These, are the labia majora, 
 labia externa, or labia pudendi. They present an external surface, 
 lined with skin similar to that of the mons veneris, and an internal 
 surface covered with mucous membrane, which is the commencement of 
 the genito-urinary tract. Behind, the thinner margins unite, forming 
 the posterior commissure of the vagina. The fourchette, or framidum 
 pudendi, is a transverse fold in front of this, which resembles and has 
 been aptly compared to the continuation of the skin at the roots of the 
 fingers, and is very generally torn in first labors. The depression 
 between the fourchette and the commissure is named the fossa navicu- 
 laris. Between the skin and superficial fascia of the labia there exists 
 a purse-shaped sac, which has been described by M. Broca as analogous 
 to the dartos tunic of the scrotum. This sac is filled with fat and cel- 
 lular tissue, is the receptacle occasionally of hernia, and to it have been 
 traced the terminal fibres of the round ligament of the uterus. 
 
 The perineum extends from the posterior commissure to the anus, 
 and is usually about an inch and a half in length. It is made up of 
 highly distensible cellular tissue, and has been said to contain some 
 yellow elastic tissue. It is undoubtedly susceptible of great distension 
 during labor, without, under ordinary circumstances, any risk of rup- 
 ture. 
 
 On separating the labia majora, the labia minora or nymphaz are 
 brought into view. These are two thick mucous folds, somewhat 
 resembling the comb of a cock, about an inch and a half in length, 
 having their origin on the inner surface of the labia majora, and 
 becoming wider as they pass upwards and forwards, converging towards 
 the clitoris, with the prepuce of which they are continuous. The 
 clitoris is a small erectile tubercle, situated somewhat above the level 
 of the lower margin of the symphysis pubis. Like the penis of the 
 male, it has a suspensory ligament, two crura, two corpora cavernosa, 
 and a glans, but has no corpus spongiosum nor urethra. Two muscles, 
 corresponding to the ischio-cavernosus, are in the female called "erec- 
 tores clitoridis." The vestibule is a small triangular space, bounded 
 above by the clitoris, below by the urethra, and on either side by the 
 diverging nymphse. It is about an inch in length, is smooth on the 
 surface, and is specially important as a guide to the finger of the 
 accoucheur in the introduction of the catheter — an operation which 
 should always be performed, if possible, without exposing the patient. 
 The meatus urinarius is indicated by a small projection, easily dis- 
 covered by the finger, immediately beneath the vestibule, and in front 
 of the vaginal entrance. The catheter being laid along the palmar 
 surface of the forefinger, its point is guided towards the projection just 
 mentioned, when, if the other extremity is gently depressed, it will 
 usually pass in without the slightest difficulty. When the parts are 
 
 4 
 
50 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 distorted by disease, or by the tumefaction which occurs after labor, it 
 is often necessary to expose the patient before the instrument can be 
 introduced. The urethra is about one inch to one inch and a half in 
 length, highly distensible, and, in the unimpregnated state, almost 
 straight. In young children, what may be called the urinary parts of 
 the vulva are prominent, and it is not till the approach of puberty that 
 the genital portion is observed to predominate. 
 
 Behind and beneath the meatus, is the orifice of the Vagina, varying 
 greatly in appearance and in dimension in young girls, in those who 
 are no longer virgins, and in those who have borne children. In vir- 
 gins, it is generally closed to a considerable extent by a thin fold of 
 the mucous membrane called the hymen, which was at one time sup- 
 posed to be the "seal of virginity/' but which may be ruptured by 
 many causes other than coitus. Its usual form is crescentic, with the 
 concavity upwards, closing in the posterior, and to some extent the 
 lateral portions of the opening ; but it may present itself under various 
 other forms. It has been frequently observed, for example, to be cir- 
 cular, with a small perforation in the centre; or cribriform, with sev- 
 eral perforations, as in a medico-legal case which the writer was called 
 upon to examine ; or infundibuliform, or offering rarer peculiarities. 
 In some instances, the closure is complete. But, whether complete or 
 partial, or under whatsoever form it may present itself, the first effects 
 of coitus are generally sufficient to rupture this fragile partition. In 
 rare cases, however, its texture is so firm and resistant, that penetration 
 is rendered impossible until the structure has been divided by the 
 scalpel; and in cases of complete closure, where there is no question of 
 coition, the operation may be necessitated from its being a barrier to 
 the menstrual flow. 
 
 When the hymen is absent, small projections, called caruneulce myrti- 
 formes, generally about three or four on each side, are noticed on the 
 margins of the opening. These were generally supposed to be the 
 remnant of the ruptured hymen ; but, as they have been found to exist 
 along with the hymen, this must be looked upon as open to doubt. 
 
 Bloodvessels are supplied in abundance to all parts of the external 
 generative organs, and in certain situations the masses of venous plex- 
 uses which are termed erectile tissue are found in considerable quantity. 
 The accompanying cut, from Kobelt, shows these structures carefully 
 dissected. Besides the erectile parts already mentioned, there are, on 
 either side of the vaginal orifice, two large leech-shaped masses, a, called 
 bulbi vestibuli, which are about an inch in length, and are connected 
 with the crura of the clitoris and the rami of the pubis, covered inter- 
 nally by the mucous membrane, and embraced on the outside by the 
 fibres of the constrictor vaginse muscle. A small plexus — the pars 
 intermedia of Kobelt — has direct vascular connection with the bulbs. 
 These erectile tissues receive their blood from the internal pudic 
 arteries. 
 
 The Vagina is a membranous and highly dilatable tube, which serves 
 to connect the vulva with the uterus. It is situated in the true pelvis, 
 between the bladder and rectum anteriorly and posteriorly, and the 
 levatores ani muscles at the sides. Its axis is a curve, which corre- 
 
III.] 
 
 THE VAGINA. 
 
 51 
 
 sponds in some degree to that of the pelvis ; and, in consequence, its 
 anterior is shorter than its posterior wall, the former being about four, 
 and the latter five or six inches in length. It is narrowest at the vulva, 
 where it is embraced by the constrictor vaginae muscle, and widest at 
 its middle part, where it is extended transversely, owing to its being 
 compressed by the organs before and behind. The thickest part of the 
 
 Fig. 18. 
 
 External organs, partially dissected. (Kobelt.) 
 
 tube is its anterior wall, where it is intimately connected with the 
 bladder, and with the urethra, which is, as it were, imbedded in it. 
 Its connection with the levatores ani muscles and the rectum is much 
 looser, which admits of easy dilatation, and which also accounts for the 
 fact that the rectum is rarely dragged down in uterine displacements, 
 while the bladder is, from its closer connection, almost invariably 
 altered in its relations. In the upper part of its posterior surface, it is 
 separated from the rectum by a double fold of serous membrane, which 
 forms a pouch of the peritoneal cavity. 
 
 The external surface of the vagina is composed mainly of dense 
 areolar tissue, beneath which there are two indistinct layers of muscu- 
 lar fibres of the unstriped variety, the external being disposed longi- 
 tudinally, while the internal are circular in their direction. Around 
 the tube, a layer of loose erectile tissue has been found, which is most 
 distinct at the lower part. Internally, it is lined throughout by mu- 
 cous membrane, w T hich is covered with epithelium of the squamous 
 variety, and is continuous in one direction with the skin and in the 
 other with the mucous membrane of the uterus. Along the anterior 
 and posterior walls, the membrane is slightly raised in the middle line, 
 so as to form a ridge similar to the raphe in other parts. These ridges 
 are called columnce rug arum ; and, at right angles to them, the mem- 
 brane is thrown into numerous transverse folds (rugce), which are always 
 
52 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP. 
 
 more distinct in those who have not borne children, and which are 
 obviously destined to facilitate the dilatation of the parts. 
 
 The upper part of the vagina embraces the neck of the uterus, which 
 projects into the cavity from above, and in front. The vaginal mucous 
 membrane is consequently reflected over the neck of the uterus some 
 
 way above its mouth, the point of reflection 
 
 being 
 
 higher 
 
 on 
 
 the 
 
 Fig. 19. 
 
 Showing the relative position of the pelvic organs. 
 
 posterior wall ; and it has been observed that the connection between 
 the membranes and the subjacent uterine tissue is very firm close to the 
 mouth of the womb, and is much less so as it approaches the point of 
 reflection. This admits of the complete dilatation of the uterus, and 
 the consequent obliteration of the neck. The other tissues of the 
 vagina are continuous, or at least very closely united, with the corre- 
 sponding tissues of the uterus. A reference to Fig. 19 will serve to 
 show that the vagina terminates in a cul-de-sac above and behind the 
 uterus, and that at this point its wall is for some distance in direct rela- 
 tion with the peritoneal cavity, a fact of no little practical importance. 
 The cul-de-sac of peritoneum with which it is in contact is termed the 
 recto-vaginal pouch, and sometimes the pouch of Douglas. 
 
 Further, the vagina may be considered as the organ of copulation in 
 women • and as the canal which is destined to transmit the menstrual 
 discharge, and, in case of pregnancy, the product of conception. It is 
 abundantly supplied with vessels and nerves. The blood supply is 
 
III.] THE VAGINA. 53 
 
 derived from the vaginal and other branches of the internal iliac artery, 
 and returns by means of corresponding veins, after forming at each 
 side a vaginal plexus. The nerves have been traced to two sources, 
 the hypogastric plexus of the sympathetic system, and the fourth sacral 
 and pudic nerves of the spinal system. 
 
 The external organs of generation are furnished with numerous 
 glands of various kinds, which have been very fully described by MM. 
 Robert and Hugnier. The latter divides the glands of the vulva and 
 entrance of the vagina into sebaceous and muciparous follicles. The 
 sebaceous variety is met with in great abundance over the whole of the 
 parts from the genito-crural folds to the clitoris and nymphse. Those 
 of the nymphse are exclusively sebaceous, and they all find their func- 
 tion in the secretion of an oily fluid, which maintains the elasticity, 
 moisture, and sensibility of the parts, prevents them from adhering, 
 and, above all, protects them from the irritating action of the urine. 
 The muciparous follicles differ essentially in their situation, and in the 
 nature of the fluid which they secrete. Although here and there they 
 are isolated, as a general rule they are found in groups. One such 
 group of eight or ten follicles is found imbedded in the mucous mem- 
 brane of the vestibule. Another is observed in the immediate neigh- 
 borhood of the meatus urinarius, their orifices being extremely minute, 
 and opening for the most part below the aperture of the meatus, upon, 
 or close to, the little tubercle already described. A third group is 
 described as external to these, and situated on either side of the urethra ; 
 and a fourth, the orifices of which have been observed on each side of 
 the vaginal opening, at the root of the hymen or carunculae myrti- 
 formes. 
 
 Under the muciparous class, two compound or conglomerate glands 
 were long ago described by Bertholin, and more recently by anatomists 
 under the name of the vulvo-vaginal glands. They are also called the 
 glands of Duvernay, and are in many respects analogous to Cowper's 
 glands in the male. They are about the size of a small bean, variable 
 in form, and of a reddish-yellow color. Their development is said to 
 proceed, pari passu, with that of the ovaries, reaching the maximum 
 during the child bearing period, and being comparatively insignificant 
 in youth and old age. They are situated one on each side, at the 
 entrance of the vagina, beneath the superficial fascia, with their inner 
 surface united to the vagina by areolar tissue, and the outer surface in 
 relation with the constrictor muscle of the vagina. Each of the lobes 
 of which the gland is composed gives origin to a little duct, all of which 
 conduits ultimately unite at the internal and upper part, to form a com- 
 mon excretory duct, which proceeds horizontally forwards as far as the 
 vaginal orifice, where it terminates within the nymphse, and external to 
 the hymen or carunculae myrtiformes. The orifice is very small and 
 valvular, and is often only to be discovered with difficulty ; but its 
 situation is usually indicated by an increased vascularity at the point 
 whence it emerges. These glands secrete a fluid resembling that which 
 is found in the prostate in the male, which is increased in quantity 
 during coition, and is said to be expelled in jets, as occasionally occurs 
 with the contents of the salivary duct. By lubricating the parts it 
 
51 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 facilitates coition, and by preserving their moisture probably tends to 
 maintain their extreme sensibility. 
 
 The appearance and anatomical relations of the external organs of 
 generation vary greatly according to age, and in consequence of vene- 
 real indulgence, or of childbearing. At birth, the nymphse project 
 beyond the level of the labia majora, and the parts in general look more 
 forward than in the adult. When puberty approaches, hair appears on 
 the pubes, the nympha? disappear between the labia, and the parts look 
 downwards, so that in the erect posture nothing can be seen from before 
 except the mons veneris ; whereas, in the child, the upper parts of the 
 vulva are distinctly visible. The labia are symmetrical, thicker above 
 than below, closely applied to each other, and of a fresh rose color on 
 their mucous surfaces. Venereal indulgence, and still more, pregnancy 
 and childbearing, modify, in a great measure, the appearance here 
 described. The hymen is ruptured and replaced by the carunculse 
 myrtiformes. The labia lose their regularity, and become of a more 
 dingy hue on their mucous surface. The nymphae come again into 
 view, partly by separation of the labia, and partly in consequence of 
 hypertrophy of their tissue, while their vivid rose tint becomes replaced 
 by a darker shade of color. In some cases the hypertrophy is very 
 remarkable, and when so, is usually unequal on the two sides. This 
 is said to be very common among Hottentot women, where the nymphse 
 often become enormously enlarged. In women who have borne children 
 the fourchette is usually ruptured, and the vaginal orifice remains large 
 and irregular. The vagina again, which in virgins presents the appear- 
 ances already described, may now lose, to a great extent, its rugae; and 
 the deepening of its color is by some supposed to be a not unimportant 
 sign of pregnancy. In women of advanced age, the vagina becomes 
 contracted, being again thrown into folds, and greatly diminished in 
 calibre. Its orifice shares in the contraction, the nymphre shrink, and 
 the labia majora come once more into proximity, while the glandular, 
 erectile, and other special tissues become atrophied. In a word, the 
 characteristics of childhood are again in a great measure restored. 
 
 Abnormal conditions, constituting some form or other of congenital 
 malformation, are occasionally met with in the external organs. The 
 labia may be imperfect or rudimentary, preserving in this respect the 
 foetal condition of the parts; they may be developed on one side only; 
 or they may present the appearance of several folds. In cases of 
 deficiency of the lower part of the abdominal wall and of the bladder, 
 along with separation of the symphysis pubis, the labia are imperfectly 
 formed and set wider apart than usual. The posterior commissure of 
 the vaginal orifice may be hypertrophied and pushed forwards so as to 
 cover the aperture. The labia are, in some instances, adherent along 
 the median line, to such an extent that an opening is left sufficient only 
 for the passage of the urine. Induration and hypertrophy such as to 
 constitute elephantiasis has also, although rarely, been noticed. Entire 
 absence of the clitoris, unassociated with any other form of malforma- 
 tion, is very rare. It is sometimes so small that it can with difficulty 
 be discovered, and in these cases it might be erroneously supposed to 
 be absent ; but it may be assumed that, unless other parts, such as the 
 
III.] MAMMARY GLANDS. 55 
 
 nymphse, are absent, the clitoris is only rudimentary. This organ is 
 much more frequently enlarged, generally, no doubt, as the result of 
 disease, but sometimes it is a pure hypertrophy of the normal tissues, 
 when it may approach the dimensions of the penis and constitute one 
 of the so-called forms of hermaphroditism. An extreme development 
 of the nymphse — common, as we have seen, in certain races — may 
 occasionally be met with as a peculiarity of structure ; and cases are 
 even recorded where they have been found increased to two or even 
 three pairs. 
 
 The folds of which the hymen is composed, ordinarily thin and 
 fragile, are occasionally developed to such an extent as to prevent 
 sexual congress ; while, in some cases, it completely closes the mouth 
 of the vagina, preventing not only coition and impregnation, but also 
 menstruation, and, for the latter reason, if not for the former, rendering 
 an operation necessary — which is usually a very simple one. Another 
 condition of these parts which may call for operative interference, is 
 what has been called vaginismus, where there exists such spasmodic 
 contraction as prevents proper sexual contact, dilatation with or without 
 the use of the scalpel being in such cases often found necessary. Con- 
 genital absence of the vagina is by no means of very rare occurrence. 
 In extreme cases, the whole organ is wanting — the vulva terminating 
 abruptly at the point where the vagina, in the ordinary condition of 
 parts, commences. In others, a portion of the tube exists, but ends in 
 a cul-de-sac at some distance from the os uteri ; while, in another class, 
 there is a narrow canal, sufficient only for the passage of the menstrual 
 fluid. In many of these cases, free incision may be found necessary, 
 in order, by giving egress to the menstrual discharge, to relieve the 
 serious symptoms which arrest of that important function is apt to 
 engender. 
 
 A vertical septum occasionally exists, constituting the phenomenon 
 of double vagina, in which, if complete, there is a hymen to each tube. 
 More frequently, however, the septum is incomplete — either commenc- 
 ing at the vulva and terminating so as. to leave the tube single at its 
 upper part, or, conversely, commencing at the upper part and stopping 
 short of the mouth of the vagina. In the latter case, we would expect 
 it to be associated with double uterus. Transverse membranous septa 
 also exist as congenital malformations, but much more frequently as 
 the result of inflammatory action, or of the accidents of previous labors. 
 
 Many of the conditions above detailed may give rise to serious im- 
 pediments, either to delivery, to impregnation, or to the proper per- 
 formance of the menstrual function, and, in consequence, delicate, and 
 even dangerous operations may under such circumstances be required. 
 
 Mammary Glands. — Intimately associated with the function of the 
 reproductive system, are the glands, the presence of which serve to 
 distinguish the class Mammalia. On this account, several modern 
 writers have, with perfect propriety, included these organs in a descrip- 
 tion of the external parts of generation. When they are fully devel- 
 oped in a woman, they extend from the third to the sixth or seventh 
 rib, and from the side of the sternum to the axilla, the left breast being 
 generally the larger of the two. The nipple (niamilla) projects about 
 
56 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP. 
 
 the level of the fourth rib from near the centre of the gland, and is, in 
 the virgin, of a rose pink color. It is surrounded by a ring of similar 
 hue (areola) varying in tint with the complexion of the individual. 
 On the surface of this, several small tubercular projections are visible, 
 on each of which are the orifices of several glands. 1 The tissue of the 
 nipple is very rich in bloodvessels, and contains muscular fibres of the 
 non-striated variety with a certain amount of erectile tissue, the surface 
 being covered with papillae, which are highly sensitive. The tumes- 
 cence of the nipple, which occurs under irritation, is usually attended 
 with a pleasurable sensation. 
 
 The bulk of the breasts, and what gives to them their smooth and 
 moulded form, is chiefly fat, which, except at the nipple and areola, 
 where the gland is contiguous to the surface, lies beneath the skin, and 
 dips down into the intervals between the lobes and lobules of which 
 the gland is composed. Each of these lobes is inclosed in a distinct 
 cavity {loeulus, Fig. 20, 4), has a separate excretory duct, and is sub- 
 divided again and again into smaller lobes, and ultimately into termi- 
 
 Fig. 20. 
 
 Dissection of the lower half of the female mamma during the period of lactation. (Luschka.) 
 
 nal lobules. Within the latter, by a process of cell development, and 
 multiplication of nuclei, the milk is eliminated from the surrounding 
 vessels. The fluid, on the rupture of the cells, passes into the terminal 
 ramifications of the ducts; which by their junction form larger canals 
 termed galactophorous ducts. The milk being thus brought from the 
 various lobes, these ducts, from fifteen to twenty in number, converge 
 
 1 These appearances are materially altered after impregnation. See Signs of 
 Pregnancy. 
 
III.] 
 
 AMMARY GLANDS. 
 
 57 
 
 towards the areola, beneath which they become considerably dilated 
 into sinuses, 6, which serve as temporary reservoirs for the milk against 
 the period of suckling. Between this and the nipple, the ducts again 
 become contracted, 5, and proceed from the base of the nipple towards 
 its summit without communicating, each discharging its contents by a 
 special orifice. The walls of the tubes and sinuses are composed of 
 areolar tissue, with longitudinal and circular elastic filaments. Irrita- 
 tion of the nipple, either by the contact of the child or otherwise, 
 causes a relaxation of the orifices, and at the same time, contraction of 
 the walls of the sinuses, which may be looked upon as a reflex action, 
 and which causes the milk to flow abundantly. Not unfrequently, a 
 spasmodic contraction takes place independently of any special excite- 
 ment, the result being the involuntary expulsion and loss of the milk. 
 The well-known sympathy which subsists between the glands and other 
 organs, such as the stomach and uterus, may give rise to similar phe- 
 nomena; while that which exists between the breasts of each side often 
 results in the spasmodic emptying of one gland while the child is at 
 the other. 
 
 'The lacteal vessels are lined throughout by a mucous membrane, 
 continuous at the nipple with the common integument, and which is 
 invested by a tessellated epithelium. They are accompanied in their 
 whole course by numerous lymphatics, which are connected intimately 
 with those of the axilla and other neighboring parts. These lym- 
 phatics are believed to take up the watery portion of the milk, and it is 
 supposed to be by their action that frictions are beneficial in cases where 
 we wish to diminish or arrest the secretion of milk. They receive their 
 
 Fig. 21. 
 
 Fig. 22. 
 
 .^V^v 
 
 K^ 
 
 Structure of a lobule of the mammary 
 gland. 
 
 Ultimate glandular vesicles 
 of the mamma. 
 
 blood from the internal mammary, axillary, and intercostal arteries. 
 The veins form round the nipple a circle or plexus, which is usually 
 called the cir cuius venosus of Haller. In the latter months of preg- 
 nancy, the pressure of the gravid uterus tends, as Mr. Nunn has pointed 
 out, to increase from mechanical causes the quantity of blood in these 
 vessels, and thus to promote the secretion of the gland. 
 
 Fig. 21, from Henle, represents a section from a small lobule of the 
 gland, magnified 60 diameters. 1, shows the stroma of the connective 
 tissue which supports the glandular structure ; 2, terminal ramuscule 
 
58 FEMALE ORGANS OP GENERATION. [CHAP. 
 
 of one of the gland tubes ; 3, glandular vesicles. Fig. 22 shows several 
 of the glandular vesicles, magnified much more highly, about 200 
 diameters. The secreting epithelial cells which line the vesicles are 
 here represented, while the cavities contain a certain number of milk 
 globules. 
 
 In the male, the mammary gland exists, but is rudimentary. Various 
 anomalies in structure have been met with, such as two or three nipples 
 on one gland, or an additional mamma or even mammae. In the latter 
 case, the supernumerary glands are usually near their ordinary site, 
 but sometimes they have been found in a distant part of the body — as 
 the axilla, thigh, or back. 
 
 The Internal Organs of Generation. — These are the Uterus, 
 the Fallopian Tubes, the Ovaries, with various ligamentous and other 
 structures intimately connected with them. 
 
 The Uterus, when unimpregnated, and at mature age, is, situated 
 deeply within the true pelvis, between the bladder and the rectum in 
 front and behind, and intimately connected at its lower part, as we 
 have already seen, with the vaginal wall. The function which it has 
 to discharge, is to receive the product of conception after it has passed 
 through the Fallopian tube, and to maintain it within its cavity until, 
 at maturity, it is expelled. The usual comparison of it to a pear, 
 flattened from before backwards, gives one a very correct idea of its 
 form. It is a hollow organ, with remarkably thick walls; and is so 
 placed in the centre of the pelvis, that its upper part looks upwards 
 and forwards, and its lower or vaginal part downwards and backwards. 
 It is generally assumed, as sufficiently correct for all practical purposes, 
 although by no means absolutely accurate, that its axis corresponds 
 with that of the pelvic brim, or, in other words, that its axis, if carried 
 downwards, would pass at the same time backwards, and cut the horizon 
 at an angle of 30°. 
 
 The uterus is divided into two parts : the body, which is much 
 broader ; and the neck, which is nearly as long as the body, but much 
 narrower. The point of division between these two parts is frequently 
 indicated externally by a slight constriction. 
 
 Till about the fourteenth or fifteenth year, this organ is of small size, 
 but a considerable increase takes place at the period of puberty. In 
 women who have borne children, its volume is permanently increased, 
 although it is sometimes found in advanced age to have resumed in 
 some measure the appearance presented in early life. It is temporarily 
 increased in size during a menstrual period ; but if examined during 
 the interval, the virgin uterus will be found to weigh on an average 
 about 500 grains, and to measure, in length three inches, in breadth 
 about two inches, and in thickness (i. e., from before backwards) one 
 inch. Its situation varies according to age. In the foetus it is alto- 
 gether above the brim, but from this position it gradually descends 
 after birth, although it is not till the tenth year or even later that the 
 fundus falls to the level of the brim plane. The uterus is, when healthy 
 and normal, united with the surrounding parts by means of certain 
 structures to be described presently. The nature of this union is essen- 
 
III.] 
 
 THE UTEKUS. 
 
 59 
 
 tially lax, admitting of pretty free movement in all directions, which 
 may easily be tested by the finger, and which enables it to accommo- 
 date its position according to the degree of distension of the neighbor- 
 ing hollow viscera. This laxity admits too of the free expansion of 
 the uterus during the course of pregnancy, but unfortunately it may 
 also give rise to certain displacements which will be duly considered 
 in the proper place, in so far as these have a bearing upon the practice 
 of midwifery. These displacements are prolapse or jwociclentia ; ante- 
 version and anteflexion; retroversion and retroflexion; and lateral dis- 
 placements ; terms which require no explanation. 
 
 The axis of the virgin uterus must, therefore, be constantly chang- 
 ing, now backwards and now forwards, according as vesical or rectal 
 distension prevails. It is thus a matter of no little difficulty to deter- 
 mine what may be regarded as the normal axis of the uterus, and in 
 all attempts which have been made by anatomists with this view, it 
 has been usual to consider the parts to be in their normal relative posi- 
 tion when the bladder and rectum are each moderately distended. The 
 opinion which is usually adopted, and which is founded on estimates 
 of this nature, is, as has been said, that the axis of the uterus is iden- 
 tical with the axis of the pelvic brim. It is admitted that, in many 
 cases, and especially in those in which the vagina is very short, the 
 fundus falls more or less backwards so as to bring the uterine axis 
 more into a line with that of the vagina, while in some cases the uterus 
 is curved so that the body forms an angle with the neck. 
 
 This bending of the uterine axis, instead of being admitted as an 
 exception, is recognized by many of the best authorities as the normal 
 position of the womb, a view which careful personal observations leads 
 us to confirm. It is a point of 
 
 great importance, in making fig. 23. 
 
 examinations on the living sub- 
 ject, that it should be clearly 
 recognized that the finger, on a 
 digital examination, approaches 
 the os uteri in a direction cor- 
 responding to the axis of the 
 vagina, which frequently forms 
 nearly a right angle with the 
 uterus. If this is overlooked, 
 error is sure to creep into our 
 calculations, as has evidently 
 been the case in certain instances 
 of inaccurate description of the 
 anatomical relations of the 
 womb. The opinion here ex- 
 pressed as to the position of the 
 womb is in accordance with that 
 of Kohlrausch, as shown in his 
 plates, and is confirmed by Dr. 
 A. Farre in his admirable essay 
 in the Cyclopaedia of Anatomy and Physiology, from which the diagram 
 
 Diagram, showing relative position of pelvic viscera. 
 (A. Farre.) 
 
60 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP. 
 
 (Fig. 23) is taken. According to these able observers, when the blad- 
 der b and the rectum c are moderately distended, the fundus of the 
 uterus is directed upwards and forwards, and the neck downwards and 
 very slightly backwards towards the orifice of the rectum. The relative 
 heights of these parts are determined, it is assumed, by two lines : the 
 one, a — a, being drawn from the lower border of the symphysis pubis 
 to the promontory of the sacrum, to mark the height of the fundus; 
 and the other, b — 6, carried from the same point anteriorly to the lower 
 margin of the fourth sacral vertebra behind, to mark the plane of the 
 orifice of the uterus. The line c — c indicates the axis of the body of 
 the uterus. The representation, therefore, given in Fig. 23, is, as re- 
 gards the position of the womb, probably nearly correct, subject, of 
 course, to numerous modifications, in consequence of its mobility, and 
 the influence exercised upon it by neighboring organs. 
 
 The interior of the uterus corresponds in some measure with its ex- 
 ternal surface. It is divided into two parts by a constriction not far 
 below its middle, indicating the point at which the cavity of the cervix 
 ends, and that of the body begins. This constriction, which is the 
 usual cause of the difficulty experienced in passing the instrument 
 known as the uterine sound, is called the os uteri internum, the orifice 
 communicating with the vagina being named the os tinccje, os externum, 
 or, more generally, the os uteri. In a profile section (Fig. 24) the an- 
 
 Fig. 24. 
 
 Fig. 25. 
 
 ^^W 
 
 Profile sectipn of the uterus. 
 
 Lateral section of the uterus. 
 
 terior and posterior walls are shown to be almost in apposition, this 
 being, however, more complete at the internal os o. From this point 
 the cavity of the body extends upwards to the fundus, while that of the 
 cervix reaches downwards, and terminates at the external 
 
 os. 
 
 The 
 
 neck of the uterus is divided, as will be observed, into two portions, 
 upper and lower, by the point of reflection of the vaginal mucous mem- 
 
III.] 
 
 THE UTERUS. 
 
 61 
 
 brane, the lower part being called the vaginal part of the cervix. 
 Viewed thus, the os is composed, as may be noticed, of two lips, a, an- 
 terior, and p, posterior, of which the former is generally described as 
 the longer. This, however, which is more apparent than real, is caused 
 by the position of the uterus as regards the pelvis, which brings the 
 anterior lip lower in the vagina, and thus makes it seem longer than it 
 really is in reference to the long axis of the organs. The vagina 
 reaches somewhat higher on the posterior than it does on the an- 
 terior lip. 
 
 If we now make a transverse section as shown in the accompanying 
 diagram (Fig. 25), it is to be noticed, in the first place, that the cavity 
 of the cervix, as well as that of the body, is expanded from side to side, 
 owing to the approximation of the anterior and posterior walls as shown 
 in the previous figure. The cavity of the cervix then is, being some- 
 what flattened from before backward, irregularly fusiform. Its lining 
 membrane presents a peculiar appearance, being thrown into irregular 
 folds, which branch laterally from a raphe or median line, in a direc- 
 tion generally upwards. This arborescent appearance has given rise to 
 the name under which it is known to anatomists, the arbor vitce uterinas, 
 and it has been observed that, in the uteri of very young children, 
 these folds are traced much higher than in the internal os, which is 
 their limit in the adult. The cavity of the body is from this point of 
 view triangular in shape, smooth on its surface, and having three open- 
 ings leading into it, one at the internal os or apex of the triangle, and 
 one at each angle of the uterus, leading right and left into the Fallopian 
 tubes. Some rare instances of congenital absence of this cavity have 
 been recorded: what is more common is adhesion of the walls in old 
 age. 
 
 The os uteri, as felt by the finger, or as seen through the speculum, 
 is a transverse opening or slit, which, in the virgin, and in the ab- 
 sence of structural disease, is perfectly 
 smooth. In these circumstances, the 
 aperture is closed, but the depression 
 between the lips is easily felt, and is 
 precisely similar, in the impression it 
 communicates to the finger, to the sen- 
 sation experienced when the finger is 
 applied to the tip of the nose. In this 
 case the cartilages represent the firm 
 tissue of the lips, while the vertical in- 
 terval between them corresponds to the 
 transverse slit which constitutes the os. 
 
 The characteristics above described are those of the virgin, or, as 
 Dr. Tyler Smith more correctly calls it, the " nulliparous " uterus. 
 During pregnancy, the organ is enormously distended, and the ana- 
 tomical relations of the contiguous parts are greatly disturbed. After 
 delivery, the parts contract, and regain in a great measure their original 
 appearance and condition, but they nevertheless retain features of dis- 
 similarity which generally enable the observer, on a careful examina- 
 tion, to distinguish the uterus of a woman who has been a mother. The 
 
 Fig. 26. 
 
62 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 chief points of distinction are as follows : The weight of the organ is 
 increased, according to Meckel, to about an ounce and a half; the 
 fundus and body are rounded externally ; the cavity of the body loses 
 its triangular shape, and becomes much larger relatively to the cervix, 
 the os internum being agape. The arborescent folds of the cervix are 
 in a great measure obliterated, or at least are rendered indistinct, and 
 the os externum is patent. The differences in the latter are, from the 
 fact of its being of easy access to the finger, of special importance, and 
 consist mainly in an enlargement of the parts, and an irregularity in 
 the surface of the lips, which are now no longer smooth, but puckered 
 round the edge of the os, and often nodulated on the surface. These 
 irregularities are due to slight lacerations of tissue which occur during 
 delivery. They are always more marked in women who have borne 
 many children, where the lips are not unfrequently divided into lobes 
 by shallow furrows, representing these lacerations, and which radiate 
 from the os as from a centre. These fissures are generally observed 
 at the sides or angles of the os, and are, according to Cazeaux, much 
 more marked on the left than on the right side. 
 
 The uterus, then, as may be inferred from what has been said, pre- 
 sents a fundus, more or less rounded according as the woman has or 
 has not borne children, two borders laterally, and an anterior and 
 posterior surface, of which the latter is the more convex. It consists 
 of three constituent layers : a serous or investing coat ; a mucous or 
 lining coat ; and an intermediate thick layer of fibro-muscular structure 
 constituting the proper tissue of the uterus. Each of these requires 
 special and very careful consideration. 
 
 The Sei*ous Coat — Along with this, we shall consider certain structures 
 very intimately connected with it, which are described as the Ligaments 
 of the Uterus. The great serous membrane, which invests almost the 
 whole of the abdominal viscera, is also reflected over the greater part 
 of the womb. Passing backwards over the fundus of the bladder, the 
 peritoneum becomes reflected upwards on the anterior surface of the 
 uterus from a point which in the virgin uterus is about midway between 
 the os externum and internum, a space being thus left (see Fig. 19) 
 through which direct communication may take place between the uterus 
 and the bladder. This may occur as an accident in midwifery practice, 
 constituting a vesico-uterine fistula, as in a case reported by the writer. 1 
 From the front to the back of the uterus, the membrane now passes 
 over the fundus, and investing the whole of the posterior surface with 
 the exception of the vaginal portion, reaches downwards behind the 
 vagina, in the manner already described, to form the pouch of Douglas. 
 The manner in which the uterus is thus embraced by the peritoneum in 
 its course from before backwards is peculiar. Instead of investing the 
 lateral parts of the organ in the same manner as the anterior and 
 posterior walls, it is stretched from side to side of the pelvis, forming, 
 in fact, a double layer of peritoneum, in the centre of which the uterus 
 is confined. These folds, intimately connected on either side with 
 
 1 Glasgow Medical Journal, 1862. 
 
III.] 
 
 RELATIVE POSITION OF PELVIC ORGANS. 
 
 63 
 
 important organs to be presently described, are the broad ligaments of 
 the uterus. 
 
 Looking from above downwards in the axis of the brim, it will be 
 noticed that the broad ligaments, with the uterus, u } form a partition or 
 
 
 
 Fig. 27. 
 
 
 Pelvic organs in silu, viewed in the axis of the hrim. (After Schultze.) 
 
 curtain, dividing the cavity of the pelvis into two parts, anterior and 
 posterior, of which the anterior is occupied mainly by the bladder, b, 
 
 Fig. 28. 
 
 Anterior view of the uterus and its appendages. (Quain.) 
 
 and the pouch which separates it from the womb, and the posterior by 
 the rectum, r, and the pouch of Douglas. It will also be observed 
 
64 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP. 
 
 that the greater convexity, and, indeed, the bulk of the uterus, projects 
 into the posterior of the two cavities. The attachment of the broad 
 ligament is in point of fact to the anterior lip of the lateral border of 
 the womb. 
 
 If, therefore, the uterus and the broad ligament are viewed from 
 before, as in Fig. 28, the fundus and body of the uterus are indeed 
 indicated, as well as the situation of other parts to be mentioned im- 
 mediately, and the relation which they all bear to the vagina ; but the 
 parts themselves are only to be distinctly demonstrated by turning our 
 attention to the posterior surface of the pelvic partition, as shown in 
 Fig. 29, where the posterior wall of the uterus has been removed, in 
 
 Fig. 29. 
 
 Posterior view of the uterus and its appendages. (Quain.) 
 
 order to show the interior of the organ. The peculiar structure of the 
 cavity of the cervix, the anterior lip of the os, and the anterior wall of 
 the vagina are also shown, as also the triangular space bounded infe- 
 riorly by the ovary and its ligaments, which, from a fanciful resem- 
 blance to a bat's wing, has been called ala vespertilionis. 
 
 It is thus very apparent that the effect of the broad ligament is to 
 maintain the uterus in its central position as regards the pelvic cavity, 
 and to prevent its displacement downwards, while it admits of very 
 free antero-posterior movement, corresponding to the distension of the 
 bladder or rectum. 
 
 Between the two layers which constitute the broad ligament, and 
 occupying each a fold more or less distinct, are the following structures : 
 the round ligament (see Fig. 27), a cord-like bundle of fibres, partly 
 muscular, and about four and a half to five inches in length, which has 
 its course on each side from the angle of the uterus, first upwards and 
 outwards, and then forwards and a little inwards to the internal ingui- 
 nal ring. Passing, like the spermatic cord in the male, through the 
 inguinal canal, and invested by a peritoneal sheath called the canal of 
 Nuck, its fibres expand and are lost in the mons veneris, some of them 
 having been traced to the purse-shaped cavity in the labia majora 
 already described. According to Madame Boivin, the ligament of the 
 right side is a little shorter and thicker than the other. Two small 
 
III.] LIGAMENTS OF UTERUS. 65 
 
 semilunar folds are seen on this aspect, which are formed by the peri- 
 toneum in its passage from the uterus to the bladder, and which limit 
 laterally the pouch existing between these two organs. They are called 
 the vesico-uterine ligaments. The uterus is generally observed to be a 
 little more to the right than to the left side ; and it is asserted by 
 Schultze that in the normal position it is somewhat twisted on its axis, 
 so as to turn the anterior surface a little to the right. On this obser- 
 vation is grounded a theory which Schultze has propounded as to the 
 position of the child in the womb. All this is shown in Fig. 27. 
 
 Reverting now to the posterior surface of the broad ligament, we 
 find several parts which are of the highest physiological importance. 
 At the upper or free margin of the broad ligament, and occupying a 
 portion of the space between its layers, there extends from each angle 
 of the uterus a thick cord, between three and four inches in length, at 
 first nearly straight in its direction, but in its outer half pursuing a 
 somewhat tortuous course, especially in young subjects. This is found, 
 on dissection, to be traversed in its whole extent by a canal of small 
 diameter, and is familiarly known to anatomists as the Fallopian tube 
 [oviduct). It is composed in a great measure of muscular tissue of the 
 non-striated variety, which is disposed in layers, an external one of 
 longitudinal, and an internal of circular fibres. Along with this is 
 areolar tissue, the whole being embraced by the peritoneum in the 
 manner described. The canal is lined with mucous membrane, with 
 an epithelium of the columnar and ciliated variety, continuous at one 
 extremity with the mucous membrane of the uterus, and at the other 
 with the inner surface of the peritoneum — a unique example of a mu- 
 cous being continuous with a serous membrane, and of a serous cavity 
 which is not absolutely a closed sac. The tube is small, and its cavity 
 narrow at the uterine end, barely permitting the passage of an ordinary 
 bristle, but it becomes dilated in its course outwards, and ultimately 
 expands into the trumpet-shaped extremity from which it derives its 
 name {tuba). The mucous membrane lining the canal is disposed in 
 longitudinal folds, so that in a transverse section of the structure the 
 cavity presents a stellated appearance. The mouth of the tube has a 
 very irregular and fringed margin, hence its name of fimbriated ex- 
 tremity — the fimbria? being arranged in a circular manner, and sur- 
 rounding the orifice, which looks downwards in the direction of the 
 ovary. With this organ it is in fact connected by the elongation of 
 one of the fimbria?. When the ovum comes to maturity within the 
 ovary, that portion of the organ from which it is about to escape by 
 dehiscence is firmly grasped by the fimbria? (morsus diaboli), and the 
 ovum is received into the oviduct, and by it conducted to the uterus, 
 where it is retained and developed, or whence it is discharged, according 
 to circumstances. 
 
 Leading from the inner extremity of the ovary — an organ to be 
 hereafter described — is a dense cord, composed mainly of fibro-areolar 
 tissue, but containing also muscular fibres. This is the ligament of the 
 ovary, which is also, like the round ligament and the Fallopian tube, 
 firmly united to the angle of the uterus at a point behind and below 
 the latter, and is about an inch and a half in length. The parovarium, 
 
 5 
 
66 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 or organ of Rosenmiiller (Fig. 30, p o), is situated between the layers 
 of the broad ligament, and can usually be brought into view by holding 
 up to the light that portion of the ligament which is between the outer 
 part of the ovary and the Fallopian tube. According to the observa- 
 
 FlG 
 
 Diagrammatic view of the uterus and its appendages as seen from behind. (Quain.) 
 
 tions of Kobelt and Follin, the parovarium is usually composed of from 
 seven to ten tubules, which are convoluted and end in a cul-de-sac, all 
 converging towards the tube through which the vessels of the ovary 
 pass. These tubes exist at all ages, but are more distinct in children, 
 and still more so in the foetus. In no instance have they been found 
 to have an orifice, but there seems good reason to believe that they 
 correspond to the epididymis of the male, more especially the coni 
 vasculosi, and are therefore the vestiges of the upper part of the 
 Wolffian bodies of the embryo. It is more than likely that the little 
 cysts so frequently found in this situation, which are usually pedicu- 
 lated, have some anatomical connection with the parovarium. From 
 the back of the uterus on each side, crescentic folds of peritoneum pass 
 backwards towards the rectum (Fig. 27). They are more marked 
 than the vesico-uterine folds, previously described, and are called the 
 posterior or recto-uterine ligaments, or folds of Douglas, as they mark 
 the upper boundary of the pouch with which the name of this anato- 
 mist is associated. 
 
 That muscular fibres exist between the layers of the broad ligament 
 is a question no longer open to doubt ; and there seems good reason to 
 believe, from the researches of Rouget and others, that this is only a 
 portion of a continuous envelope of muscular fibres, embracing the 
 uterus, Fallopian tubes, and ovaries. These fibres are believed to 
 exercise an important physiological function, in bringing all the struc- 
 tures into harmonious action, and more especially in insuring the pre- 
 cision with which the fimbriated extremities of the Fallopian tubes 
 grasp the ovaries. 
 
 The uterus is thus — by means of its ligaments and other auxiliary 
 structures — so suspended in the cavity of the true pelvis as to admit, as 
 has been shown, of tolerably free movement ; and, at the same time, to 
 
IV.] MUCOUS MEMBRANE OF UTERUS. 67 
 
 restrict its mobility within certain limits. The movement of the body 
 from side to side is curtailed effectively in a healthy state of the parts, 
 by the broad ligament, while displacement backwards is prevented by 
 the vesico-uterine folds and the round ligament, and movement in the 
 contrary direction by the recto-uterine ligaments. Undue importance 
 must not, however, be attached to the function of these structures as 
 ligaments ; for it is very obvious that other parts (and in an especial 
 degree the vagina) aid them in holding the uterus thus in suspension. 
 The general laxity of all these tissues, however, which nature permits 
 in view of the higher function of the uterus, is very apt, under disturb- 
 ing influences, to give rise to displacements which have already been 
 named, but the consideration of which belongs more properly to the 
 department of gynaecology. It may, however, be observed that the 
 symptoms of these displacements are, in a great measure, mechanical, 
 and the direct result of the loss of equilibrium — as those, for example, 
 which arise from pressure on the bladder or rectum, and the pain in 
 the groin frequently experienced in retroversion, which is assumed by 
 Cazeaux to arise from tension of the round ligament. 
 
 In the interval between the two layers of the broad ligament, and 
 associated with the other structures above described, there is found a 
 considerable quantity of loose and extensible cellular tissue. This 
 admits of the complete alteration in the anatomical relations of the parts 
 which occurs during pregnancy, and which is further provided for by 
 the manner in which the uterus is attached to its serous investment. 
 The nature of the connection is firm at the fundus, and lax at the sides, 
 where the peritoneum may be moved by the finger to and fro upon 
 the subjacent tissue of the organ. The manner in which the neigh- 
 boring parts accommodate themselves to the distension of the womb 
 during pregnancy will fall to be considered in a subsequent chapter. 
 
 CHAPTER IV. 
 
 FEMALE OKGANS OF GENEKATIO^ (Continued). 
 
 OF THE PROPER TISSUE OF THE UTERUS — OF THE MUCOUS LAYER ; ITS STRUC- 
 TURE AND GLANDS, IN THE BODY AND CERVIX — BLOODVESSELS OF THE 
 UTERUS — LYMPHATICS AND NERVES — MALFORMATIONS AND ABNORMAL CON- 
 DITIONS — THE OVARIES : THEIR STRUCTURE — THE GRAAFIAN VESICLES AND 
 THEIR DEVELOPMENT — THE OVUM— PHENOMENA OF OVULATION — FORMATION 
 OF THE CORPUS LUTEUM — THE CORPUS LUTEUM OF PREGNANCY DISTIN- 
 GUISHED. 
 
 The Proper Tissue, which lies immediately beneath the peritoneum, 
 and which constitutes the greater part of the walls of the uterus, is very 
 dense in structure, and, except during pregnancy or a menstrual period, 
 is of a grayish color in section, and displays numerous bloodvessels, 
 
68 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 some of them of considerable size. It is thickest at the middle of the 
 body and at the fundus, thinnest at the Fallopian tubes, and is com- 
 posed throughout of bundles of muscular fibres of the plain variety. 
 These fibres in the unimpregnated condition are interlaced, disposed 
 very irregularly in bands and layers, and mixed with fibro-areolar tissue, 
 which is more abundant near the external surface. As in the case of 
 other hollow viscera, the muscular elements may be described as con- 
 sisting of an external layer, the fibres of which have a general longi- 
 tudinal direction, and of an internal or circular layer. From the 
 irregular manner, however, in which, in the unimpregnated uterus, the 
 bundles of fibres are disposed, and the intimate union which subsists 
 between them, this seems on the first glance to be somewhat of a forced 
 analogy. And it would probably remain so, were it not that during 
 pregnancy the stratification of the muscular tissue becomes much more 
 distinct, so as to render the comparison quite justifiable, a fact which 
 will be brought out more clearly afterwards. Anatomists usually 
 divide this tissue into three layers, external, intermediate, and internal. 
 3fucous Membrane. — The very existence of this membrane was long 
 disputed, the obvious reason being that it differs so much from other 
 mucous membranes, that physiologists, with some show of reason, 
 refused to admit the analogy. More modern and more exact observa- 
 tions, however, leave no doubt in these days as to the propriety of 
 classifying it as it is here named. The descriptions which are usually 
 given of this membrane by anatomists are very meagre, and in some 
 respects inaccurate; this may serve as our warrant for examining its 
 structure and functions a little more in detail than under other circum- 
 stances might have been necessary. Although often described as a thin 
 membrane, it is, on the contrary, probably the thickest mucous mem- 
 brane in the body, constituting, according to M. Coste, in the cavity, 
 about one-fourth of the entire thickness of the organ. In this situation, 
 it is of a reddish tint, but in the cervix, where it is much thinner, it is 
 paler in color, the thinning occurred somewhat abruptly at the os inter- 
 num. It is firmly adherent to the subjacent muscular tissues, and can- 
 not, in consequence of the sparseness of the submucous cellular tissue, 
 be made to glide upon the part which it covers. The surface of the mem- 
 brane is smooth, and abundantly studded over with minute dots, which 
 are found on closer examination to be the orifices of numerous utricular 
 glands, which run through the entire thickness of the membrane in a 
 direction perpendicular to its surface. Fig. 31 represents a part of the 
 cavity of the uterus which shows in section — a, the orifices of the glands, 
 and d, the glands themselves. They were believed by Weber, and 
 are here represented, as being, at the commencement of pregnancy, 
 greatly convoluted, and sometimes bifurcated at the extremities. The 
 more recent and exact observations of M. Robin show, however, that 
 when in situ, they are rather undulated than convoluted, that they 
 are never spiral, although, as in Fig. 32, they may appear so when 
 separated, and never bifurcating. During pregnancy and menstruation, 
 they become greatly enlarged, and sometimes cross each other, an ap- 
 pearance which in all probability has led to the idea of a division of 
 the tube. They are simple utricular glands, parallel to each other, 
 
IV.] 
 
 MUCOUS MEMBRANE OF UTERUS. 
 
 69 
 
 ending in a cul-de-sac, and permeating the entire membrane. They 
 are lined by nucleated ovoid epithelial cells, their walls being finely 
 granular, and very firmly adherent to the tissue which intervenes 
 between them. Their length measures exactly the thickness of the 
 
 JSmm 
 
 Fig. 31. 
 
 MB 
 
 >MM,&kt?$ 
 
 mnmmw^^- 
 
 l 
 
 Utricular glands of uterus. (E. H. Weber.) 
 
 mucous membrane, and is least, therefore, where the' membrane be- 
 comes thinner, on its approach to the os internum and the orifice of the 
 Fallopian tubes. " If we except that of the stomach/' says M. Robin, 1 
 
 Fig. 32. 
 
 Fig. 
 
 Utricular gland of the 
 uterus. (Coste.) 
 
 Relation of utricular glands to muscular 
 tissue of uterus. (Coste.) 
 
 " there is no mucous membrane more rich in glandular follicles than 
 that of the uterus." In the pig and some other animals the epithelial 
 cells which line the glands are ciliated. 
 
 In the unimpregnated uterus, in an intermenstrual period, the utric- 
 ular glands are not very easily seen ; but if their sections are treated 
 with acetic acid or concentrated tartaric acid, and viewed by transmit- 
 ted light, they can generally be made out. They terminate quite 
 abruptly at the inner margin of the muscular coat, the point of junc- 
 tion being very distinctly indicated by the muscular fibres running at 
 right angles with the tubes. The glands were supposed by Sharpey 
 to penetrate the muscular tissue, but this view is now generally re- 
 garded as an erroneous one. Their abrupt termination is well shown 
 by a reference to Fig. 33. In the same preparation, which was taken 
 
 De la Muqueuse Uterine. Paris, 1861. 
 
70 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP. 
 
 from the uterus of a young girl who had committed suicide in the 
 intermenstrual period, is also shown the general direction of the fibres 
 composing the proper tissue of the uterus, p, as compared with the 
 course of the tubules from the free surface of the mucous membrane at 
 m. At a the tubes are cut across, and shown obliquely in section, and 
 the course of the bloodvessels which accompany them is also indicated 
 between m and the adjacent part of the muscular tissue. 
 
 Fig. 34, also taken from Coste's beautiful plates, shows a detached 
 portion of the mucous membrane in the same case. Little funnel- 
 shaped depressions are shown at a, into which the orifices of the tubes 
 open. The actual glandular orifices are distinctly shown elsewhere on 
 the surface of the membrane. From one portion, the epithelium has 
 been stripped off, so as to show the termination of the tubes free and 
 floating. But what is most distinctly shown here, is the perfect net- 
 work of vessels which surrounds the orifices, which is always to be 
 observed most distinctly at those seasons when the functional activity 
 of the uterus is excited. 
 
 Fig. 35 is a small portion of the mucous membrane as observed after 
 recent impregnation. This specimen is represented as viewed upon a 
 
 Fig. 34. 
 
 Fig. 35. 
 
 Termination of utricular glands on 
 mucous surface of uterus. 
 
 Utricular orifices of 
 uterus. (Sharpey.) 
 
 dark ground, and also shows the orifices of the uterine glands, in most 
 of which, as at 1, the epithelium remains, and in some, as at 2, it has 
 been lost. 
 
 The mucous membrane is smooth on its surface, which is composed 
 of columnar and ciliated epithelium. Cruveilhier describes it, how- 
 ever, as presenting indistinct papillae, while some earlier physiologists 
 insist that it is studded with free villi : errors which have probably 
 had their origin, as M. Robin assumes, in the extremities of the gland- 
 ular follicles becoming liberated from their epithelial attachment by 
 post-mortem change, and which find in analogy an apparent corrobora- 
 tion in the condition of the membrane as observed in the uterine 
 cornua of some mammalia. During pregnancy, the epithelium becomes 
 transformed ; it loses all trace of the vibratile cilia, and the cells are 
 changed from the columnar to the pavement variety. 
 
IV.] BLOODVESSELS OF UTERUS. 71 
 
 Berres 1 was the author of the erroneous hypothesis that the villi of 
 the placenta plunged into these glands to be there bathed in materials 
 destined for the foetal blood, a view which was afterwards supported by 
 Bischoif, 2 but which now receives little if any support. M. Coste 3 was 
 undoubtedly the first who gave a complete description of the mucous 
 membrane during menstruation and the various stages of pregnancy. 
 To him the merit is also due of having first demonstrated, what is now 
 all but universally admitted, that the maternal covering of the ovum 
 (decidua), of which we shall have more to say, is not a new formation, 
 as Hunter taught, but is the mucous membrane itself, altered and 
 modified to suit the circumstances of the case. The views of Coste have 
 received the most remarkable confirmation by the subsequent observa- 
 tions of Richard, and by the still more recent researches of Robin. 
 
 The mucous membrane of the uterine cavity is continuous at the 
 angles with that which lines the Fallopian tubes. At the internal os, 
 it becomes much thinner, with fewer glands, and loses many of its 
 special characteristics as it passes into the cavity of the cervix. The 
 presence of the folds, which give to it in this situation an arborescent 
 appearance, has already been noticed. The extent of the inner surface 
 of the cervix is thus greatly increased, an arrangement which not only 
 admits of free dilatation of the parts, but also furnishes a greatly in- 
 creased secretory surface. It has been computed by Dr. Tyler Smith 
 that, in a well-developed virgin uterus, the follicles of the cervix 
 (gJandulce NabotJd) are not less in number than ten thousand. These 
 glands secrete a clear tenacious fluid, which is alkaline in reaction, and 
 which is often seen on vaginal examination to occupy the os externum, 
 and they are liable during pregnancy to a very remarkable hypertro- 
 phy. The mucus which lubricates the parts during delivery is mainly 
 derived from this source, and in certain morbid conditions it is greatly 
 increased in quantity, when it is either secreted of an acid reaction, or 
 loses its alkalinity, and also its transparency, by contact with the acid 
 mucus of the vagina. The cavity of the cervix is lined with an epithe- 
 lium which in its lower half is squamous like that of the vagina. 
 About midway between the outer and inner os, it assumes the charac- 
 teristics of the ciliated and columnar epithelium of the cavity. 
 
 The uterus is supplied with blood from two sources. The ovarian 
 arteries have their origin, like the spermatic in the male, from the 
 aorta, at a point a little below the renal arteries. Passing over the 
 psoas muscles, and occupying a fold in the peritoneum, which is indi- 
 cated in Fig. 27, they pass between the layers of the broad ligament — 
 forming what have been described as the ovario-pelvic ligaments. 
 They follow, in their passage towards the ovary, an extremely tortuous 
 course, which admits of free distension during pregnancy without any 
 risk of diminution of their calibre. Giving off branches to the ovary 
 and round ligament, they now pass inwards to join the uterine arteries 
 on each side. These latter spring from the interior division of the in- 
 
 1 Medicinische Jahrbiicher des K. K. (Esterreich. Staates. Wien, 183^ 
 
 2 Traite du developpement de l'homme, etc., 1845. 
 
 3 Histoire du developpement des Corps Organises. Paris, 1847. 
 
72 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 ternal iliac, pass between the layers of the broad ligament downwards 
 towards the neck of the uterus, then upwards, pursuing, like the 
 ovarian arteries, a very tortuous course, and, giving off numerous 
 branches to the uterus, effect a union with the ovarian. Frequent 
 anastomoses take place, and the branches may be seen to lie in little 
 canals or channels on the surface of the womb, before they penetrate 
 more deeply. The veins correspond to the arteries just named, and 
 are of considerable size. They form plexuses, which communicate 
 freely, and during pregnancy their calibre becomes enormously in- 
 creased. Within the substance of the uterus, the ramifications of the 
 arteries retain their spiral form, but become straighter as they approach 
 the mucous membrane, where fine branches surround the utricular 
 glands, and ultimately form, as has been shown (Fig. 34), a fine net- 
 work on the free surface of the membrane. The veins which convey 
 the returning current are, at their origin, of small size, but become 
 much larger within the substance of the womb, attaining during preg- 
 nancy a size so considerable that they are designated the uterine sinuses. 
 The cervix is very much less vascular than the body and fundus. 
 
 Numerous lymphatics, which are fully developed only during preg- 
 nancy, have been traced to the uterus. Some doubt still exists, how- 
 ever, as to the precise source of the nervous supply. All agree that the 
 chief supply is from the sympathetic system, — the hypogastric, renal, 
 and inferior aortic plexuses being all believed to contribute. An idea 
 generally entertained is, that the sacral nerves send some filaments to 
 the cervix, but this has been denied by Dr. Snow Beck, 1 who failed in 
 his dissections to discover any single filament proceeding from this 
 source. M. Jobert has asserted, again, that no nerves whatever are 
 sent to the vaginal portion of the cervix ; but this has been warmly 
 refuted by M. Boulard. There can be no doubt that the presence in 
 the cervix of filaments from a cerebrospinal source, or the absence 
 from its vaginal portion of all nerves whatever, are both observations 
 which, if confirmed, would tend to throw some light on certain phys- 
 iological and pathological facts. 
 
 While, as a rule, in the Mammalia, the vagina is single, the contrary 
 is the case as regards the womb. In the female human embryo, the 
 uterus is formed by the median fusion of the lower parts of the ducts 
 of M tiller — which are the efferent tubes of the rudimentary generative 
 apparatus. These meet together inferiorly, become gradually united 
 from below upwards, and ultimately form a single cavity by the ab- 
 sorption of the partition between the two, so that there is a stage in 
 development, at which the human uterus is composed of two separate 
 and distinct tubes. It follows, from the manner in which they become 
 united, that there is a series of subsequent stages at which the partly 
 developed organ may be termed uterus bicollis — when the necks are 
 still separate; bieorporeus — when the union has reached the os inter- 
 num; bifundalis — when the fundus alone is divided; biangularis ; 
 and, finally, the uterus simplex — the highest or perfect human form. 
 In the other Mammalia, the process is so far identical, but may be 
 
 1 Philosophical Transactions, 1846. Part II, p. 219. 
 
IV.] UTERINE MALFORMATIONS. 73 
 
 arrested at any stage to form the uterus natural to the group to which 
 the individual belongs. In the Marsupials, not only are the uteri 
 separate, but also the vaginas. In a large number of the Rodents, the 
 vagina is single, and into its fundus two distinct uterine cavities open 
 by separate apertures ; while, in some, there is a partial separation of 
 the vagina for about a third of its length. The commencing union of 
 the cervix is shown in some groups of the same order — as the MuridaB 
 — where there is a very short common cavity. The confounding of 
 the two uterine cavities may be traced in various progressive stages by 
 an examination of the internal organs of certain of the Carnivora, the 
 Ruminants, the Ungulata, the Edentata, and the Simiina ; but even in 
 women there still remains in the angles of the uterus a trace of the 
 original bifurcation. 
 
 This reference to the development of these parts, and, for the analogy, 
 to their condition in the lower animals, will be found to throw light 
 upon certain cases of malformation or peculiarity of structure in the 
 human subject, which apparently consist, for the most part, of a simple 
 arrest of development. Taking the particulars above noted as a basis 
 of classification, we may adopt the division in regard to those abnor- 
 malities which Dr. A. Farre, in his essay on the uterus, 1 has selected 
 as the best. Of this section of his admirable monograph, the following 
 remarks are in great part an abstract. 
 
 Group 1. Complete absence of the uterus, both of the ducts of 
 Miiller being imperfect or undeveloped. In the cases of total absence 
 of uterus which have been recorded, it seems certain that, in a very 
 large proportion at least, something of a rudimentary organ existed in 
 the fold of the peritoneum lying behind the bladder, and representing 
 the broad ligament. They usually occur under the form of two hollow 
 rounded cords, or bands of uterine tissue, extending upwards towards 
 the ovaries. The vagina may be absent or rudimentary, as also the 
 Fallopian tubes ; but it is interesting to observe that the ovaries may 
 be perfect in these cases — a fact easy of explanation, when we remem- 
 ber that the ovary is formed out of a separate portion of blastema from 
 the Wolffian bodies and duct of Miiller. 
 
 Group 2. One uterine cornu only may retain the imperfect condition 
 last described, while the second develops, so that we now have what 
 has been called the uterus unicornis. In this condition, which repre- 
 sents the type of the normal condition in birds, both ovaries may be 
 found perfectly developed. 
 
 Group 3. When development progresses in both cofnua, and these 
 do not, as under ordinary circumstances, unite, various peculiarities 
 result, which cause the uterus to assume, according to the degree of the 
 malformation, a type which is lower or higher in the animal scale. 
 " The marsupial type/' says Owen, " is repeated in one of the rarer 
 anomalies of the female organs in the human species." This, indeed, 
 is an anomaly so rare and peculiar, that it has only been observed as 
 coexistent with other malformations, — such as fissure of the abdomi- 
 nal and pelvic walls ; but what is more frequently met with is the form 
 
 1 " Cyclopaedia of Anatomy and Physiol ogy." Art. " Uterus." 1859. 
 
74 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP, 
 
 shown in Fig. 36, where the two uterine halves meet, and are united 
 by a commissure of true uterine tissue, which represents the fundus 
 uteri. The higher this commissure reaches, the more does the womb 
 approach to the normal type. In the figure there are two vagi me, two 
 orifices, and two uterine cavities. 
 
 In the case shown in Fig. 37, there is but one vagina. The os also 
 is single, as is the cavity of the cervix, the bifurcation commencing 
 
 Fig. 36. 
 
 Fig. 37. 
 
 Double vagina and uterus. (After Busch.) 
 
 Bifid uterus. 
 
 about the os internum. The angle at which the cornua unite varies in 
 different cases — which is accounted for, as is pointed out by Rokitansky, 
 by the height at which the uniting commissure is situated. 
 
 Group 4. In this, the external form of the uterus differs but little 
 from the normal character. The breadth of the organ is greater, es- 
 pecially at the fundus, where a depression in the middle line indicates 
 the situation internally of a vertical septum, which more or less com- 
 pletely divides the uterine cavity into two halves, and constitutes the 
 uterus biloGularis. The extent of this septum may vary from a mere 
 ridge to a complete partition, which may even invade the vagina. 
 
 These several deviations from the normal form of the uterus will 
 influence more or less the function of the organ. Menstruation may, 
 it is true, in a large proportion of cases, be scarcely affected ; and this 
 function will be normally discharged whenever the ovaries are perfect 
 and a normal channel exists. In those rarer cases, however, in which 
 the uterus is rudimentary, there may be perfect ovaries, and atresia 
 either of the cervix or of the vagina, with the result, if a uterine cavity 
 exists, of an accumulation of the discharge, and attendant symptoms of 
 considerable severity. If, on the contrary, there be no cavity, the 
 menstrual molimen may then be relieved by the occurrence of vicarious 
 discharges. As regards the influence exercised by such anomalies 
 upon impregnation, much will depend upon the condition of the 
 vagina, and also of the Fallopian tube, for if either of them are 
 closed, impregnation is of course impossible. If, however, they are 
 
IV.] THE OVARIES. 75 
 
 open, it is quite possible for impregnation to occur even in a uterus 
 unicornis. 1 
 
 Great difficulty and danger may arise, in such cases, during the prog- 
 ress of gestation. In the case, for example, which is referred to in the 
 footnote, death took place from rupture of the sac in the third month, 
 the termination being thus very much what one would expect in a case 
 in which the development of the ovum goes on in the Fallopian tube, 
 instead of in the cavity of the womb. In the cases of the uterus 
 bicornis and bilocularis, either side of the uterus may become separately 
 or alternately the seat of gestation, or twins may be simultaneously 
 developed, one on each side. There is, indeed, no good anatomical 
 ground for absolutely rejecting the doctrine of superfoetation as a possi- 
 bility in such cases. When there is a double vagina, coition usually 
 takes place by one canal, so that successive pregnancies may be looked 
 for on the same side. The effects produced on the act of parturition 
 by such anomalies as have been cited, have probably been exaggerated. 
 Rokitansky has indeed shown that the axis of expulsion may, as in the 
 one-horned variety, be so directed as to place the forces at an obvious 
 disadvantage; but it may be assumed that, if the anomaly has been 
 of such a grade as to admit of complete intra-uterine development, 
 there will not likely be any impediment during delivery, which may 
 not be surmounted by the application of ordinary principles. 
 
 Cases in which the arrest of development has taken place after birth, 
 are to be placed in a special category. At the ordinary period of 
 puberty, the signs which indicate sexual maturity do not appear, 
 while the uterus is found still to present the characters peculiar to 
 infancy or childhood. In these cases, which are almost certainly pro- 
 ductive of sterile marriages, there is often an absence of the vaginal 
 portion of the cervix ; and the other infantine conditions of the womb 
 may be exhibited in every particular, such as the exaggeration of the 
 forward curve, which, in a smaller degree, we have indicated as the 
 normal adult condition, the persistence, within the cavity, of ruga?, 
 similar to those of the cervix, and the thinness of the parietes. 
 
 Of the Ovaries. — Projecting on either side from the posterior surface 
 of the broad ligament, and invested with a special fold of its posterior 
 layer, are the important organs within which is elaborated that which 
 the woman contributes to the propagation of her species, analogous 
 therefore in this, as in other respects, to the testicles of the male. They 
 are connected (see Figs. 27, 28, and 29) with the uterus by a special 
 ligament already described, and also through the Fallopian tubes, to 
 one of the fimbriae of which they are permanently adherent. In shape, 
 the ovary is a flattened oval. It varies greatly in size, according to 
 age, and in different individuals of a similar age; but it may be set 
 down as, on an average, about eighty grains in weight, and* an inch 
 and a half in extreme length. From the manner in which it is em- 
 braced by the peritoneum, it is free on two sides, and on the posterior 
 border, and attached to the broad ligament by a kind of mesentery 
 
 1 See a remarkable case by Kokitansky, the preparation of which is in the Vienna 
 Museum. (Pathological Anatomy — Syd. Soc, vol. ii, p. 277.) 
 
76 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 along the anterior border only, where, between the layers, the vessels 
 and nerves enter. The nature of the relation subsisting between the 
 ovary and the peritoneum has of late been a subject of much interest to 
 physiologists, and the observations of Waldeyer 1 certainly now leave 
 no room for doubt that anatomists have been in error in describing the 
 ovary as invested by the peritoneum in the same manner as the other 
 viscera. The structure of the peritoneum proper ceases abruptly at a 
 fold near the hilus, and quite visible to the naked eye. This fold 
 surrounds the ovary in such a way that the greater portion of its free 
 surface consists, not of the peritoneum, but of a special layer, continuous 
 with the peritoneum, presenting, on microscopic examination, a pris- 
 matic epithelium instead of the laminated form which exists in the 
 serous membranes. This prismatic epithelium is intimately connected 
 with the origin of the ova. The ovary attains its greatest size after 
 puberty, and is, up to this period, smooth on the surface. During 
 pregnancy, the position of the organ is completely changed ; but in the 
 unimpregnated condition it will be found lying deeply in the lateral 
 posterior part of the pelvic cavity, covered by the small intestines, and 
 to some extent by the Fallopian tube of the same side. Beneath the 
 outer covering, a dense layer of the stroma, somewhat white in color 
 from a sparseness of bloodvessels, binds the proper structure of the 
 organ together, giving support and protection to it, and to the impor- 
 tant structures which it contains; this is the tunica albuginea. The 
 bulk of the organ beneath this is composed of highly vascular tissue of 
 a pinkish color, which is called the stroma of the ovary. The stroma 
 is composed of a dense fibro-nuclear tissue, through which bloodvessels 
 ramify from the base of the ovary towards its surface. 
 
 The Graafian Vesicles. — If a longitudinal section is made through a 
 mature and healthy ovary, these vesicles are brought into view, im- 
 bedded in the stroma and varying considerably in size. In number 
 and in situation, they differ greatly according to age. In infants and 
 young children, the ovary is found to be composed, within the tunica 
 albuginea, of two distinct portions, — one internal, corresponding to the 
 stroma in the mature organ, and the other external, of considerable 
 thickness and density. It is in the latter, or peripheral portion alone, 
 that, at this time, the Graafian vesicles are to be found, in enormous 
 numbers, but as yet of small size and in a rudimentary condition. As 
 puberty approaches the distinction between the peripheral and central 
 portion of the stroma becomes gradually less marked. Some of the 
 vesicles enlarge and, according to Schron, retreat in the first instance 
 towards the centre of the ovary. When puberty is attained, a certain 
 number of them enlarge, and those which have attained the greatest 
 size approach the surface. A few of them are from ^th to £th of an 
 inch in diameter, or even more; but the great majority remain much 
 smaller. Their number is also greatly diminished as compared with 
 those existing in the ovaries of children, so that we may assume that a 
 large proportion is absorbed. This number is still, however, very con- 
 siderable, and has been computed by Henle at 36,000 in each ovary of 
 a girl of eighteen. The ova, which are contained within these Graafian 
 
 1 Eierstock und Ei. Leipzig, 1870. 
 
IV.] 
 
 STRUCTURE OF GRAAFIAN VESICLE, 
 
 77 
 
 vesicles, being comparatively small, occupy in the case of the more 
 developed vesicles a small space only, the rest of the vesicle being filled 
 with fluid. Before puberty the ovaries are smooth on the surface, but 
 they subsequently become scarred, wrinkled, and furrowed, in conse- 
 quence of the share which they take — as we shall see immediately — in 
 the phenomena of ovulation. 
 
 The Graafian vesicle is usually described as consisting of two coats 
 and a granular epithelial layer, three special coverings in all ; but in 
 point of fact, there does not appear to be any distinct membrane lining 
 the Graafian vesicle. This, indeed, is merely ovarian stroma in its 
 finest form ; while, as regards the vascular layer usually described, its 
 existence is more than doubtful, although in its developed state, a net- 
 work of bloodvessels runs near the surface of the vesicle. 
 
 The Ovum, in the mature condition of the Graafian vesicle, lies near 
 its surface, and is imbedded in the membraria granulosa ; a layer of 
 peculiar nucleated and granular cells, which surrounds the whole of 
 
 FiCx. 38. 
 
 Diagram showing the layers of the Graafian vesicle, and the contained ovum. 
 
 the interior of the vesicle, and is thickened at that part where the ovum 
 is imbedded in it (proligerous disk of V. Baer). This is shown in the 
 accompanying diagram. 
 
 If the surface of the ovary be punctured, while a mature Graafian 
 vesicle is projecting, and the contents of the latter pressed out, a small 
 spherical body may be observed, if care be taken, covered with granu- 
 lar matter in greater or less quantity. It is more opaque than the 
 medium in which it is suspended, and is remarkably constant in 
 size — being about y-j-o^h of an inch in diameter. It is comprised of 
 the following parts : 
 
 a. A thick transparent envelope, which was called by Baer, the dis- 
 tinguished discoverer of the ovum in the Mammalia, the Zona pellucida. 
 As this refers only to its appearance, many physiologists prefer to call 
 it the vitelline membrane, or membrane of the yolk. This membrane 
 completely surrounds the ovum, and to all appearance is impervious. 
 It presents at least no distinct aperture or micropyle such as is observed 
 in some animals, and has been by some supposed to exist in the human 
 ovum. 
 
 b. The Yolk. — The cavity inclosed by the zona pellucida is filled 
 with a substance, which is viscid and faintly granular, and which 
 
78 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 readily escapes when the sac is ruptured. It can scarcely be described 
 as a fluid, as it retains its spherical form after rupture of the sac, and 
 may, according to Bischoff, be broken into segments. It has no in- 
 vesting membrane other than the zona pellucida. 
 
 c. The Germinal Vesicle. — In the middle of the yolk, in the earliest 
 stage, and in contact, in adults, with some part of the periphery of the 
 investing membrane, a little vesicle is found, apparently, when seen in 
 the more opaque medium in which it is suspended, quite transparent 
 and colorless. This is the germinal vesicle — first described in the ova 
 of birds by Purkinje, and discovered in the Mammalian ovum by 
 Coste and by Wharton Jones. It is slightly oval, about 7 J()th of an 
 inch in diameter, and surrounded by a very thin membrane. A more 
 careful examination of it when removed from the yolk shows that it is 
 not absolutely transparent, but contains a few scattered granules, and, 
 in addition : 
 
 d. The Germinal Spot of Wagner, which may be seen close to some 
 point or other of the inner surface of the wall of the germinal vesicle. 
 It is probably formed by the aggregation of cells and granules which 
 give to it a greater opacity than characterizes the contents of the vesicle. 
 It measures about jg'pth to o^pth of an inch. 
 
 Although it is generally understood that the ovum is always to be 
 found on the side of the vesicle next the surface of the ovary (Fig. 38), 
 recent investigations have shown very clearly that this is by no means 
 universal, and would almost seem to point to the conclusion that the 
 contrary is the rule, and that, in the majority of Graafian vesicles, we 
 are more likely to discover it on the side which lies towards the centre 
 of the organ. 
 
 The ova begin to be formed at a very early period, and are already 
 to be found in great numbers in the superficial layer of the rudimentary 
 stroma of the human ovary as early as the fourth month of intra-uterine 
 life. But their first origin is even at an earlier period. The germinal 
 vesicle is the part of the ovum first formed, and it appears to arise by 
 involution from the superficial layer of germinal cells. One or more 
 of these cells, becoming larger than the rest, sink into the stroma and 
 soon become surrounded by a single layer of nucleated cells. This 
 constitutes the commencement of the membrana granulosa, and repre- 
 sents therefore the Graafian vesicle. As development proceeds, a small 
 quantity of protoplastic yolk surrounds the germinal vesicle, and the 
 cells of the membrana granulosa increase in number and assume more 
 of the appearance of a cellular lining. The cells accumulate round the 
 simple ovum so as to form the proligerous disk, and a space begins to 
 be apparent between this and the rest of the membrana granulosa, 
 within which the fluid of the vesicle afterwards accumulates. The 
 ovum grows by the increase of the yolk round the germinal vesicle, 
 the protoplasm becoming granular; and, finally, the yolk and germinal 
 vesicle are inclosed by the external firm vesicular membrane, known 
 as the zona pellucida. 
 
 These, then, are the parts of which the mature ovum, prior to im- 
 pregnation, consists. On the approach of puberty, as has been seen, 
 several Graafian vesicles, each containing an ovum, approach the sur- 
 
IV.] PHENOMENA OF OVULATION. 79 
 
 face of the ovary. As they increase in size, they form little projections 
 beneath the investing membrane. In those animals where several ova 
 are simultaneously fecundated — as in the sow (Fig. 40) — there may be 
 
 Fig. 39. Fig. 40. 
 
 Diagrammatic representation of the ovum, as it Development of Graafian vesicles 
 
 escapes from the Graafian vesicle. in the sow. 
 
 observed on the surface of the ovary a number of little cystic growths; 
 but, in the human species, where the fecundation of more than one 
 ovum at a time is exceptional, the Graafian vesicles, as a rule, come to 
 maturity one by one, or in small numbers. 
 
 The changes which take place during the maturation and discharge 
 of the ova, and which are associated with the "rut" in many of the 
 lower Mammalia, and with menstruation in women, constitute the 
 phenomena of Ovulation. These changes are manifested, not only in 
 the Graafian vesicle, but also in all the component parts of the internal 
 generative system. 
 
 It has already been observed that the development of the Graafian 
 vesicle is due, in a great measure, to the increase in its fluid contents. 
 While this is taking place, the vascularity is notably increased, not 
 only in the vesicle itself, but in the contiguous portion of the ovary, 
 and, in some degree, throughout the whole of the organ. The walls 
 of the follicles become thickened, except at the part where rupture 
 is about to take place, and a certain amount of blood is said to be 
 effused into the cavity. This has frequently been observed (although 
 even that has been disputed) in the sac of ruptured follicles ; but the 
 researches of Pouchet — whose views are confirmed by Farre — seem to 
 show that an actual sanguineous discharge may take place into the fol- 
 licle, at a period prior to its rupture. According to Pouchet, the effect 
 of this discharge is, mechanically, to force the ovum towards that part 
 of the ovisac which is next the surface, — it being, before this, generally 
 found on the deep or distal side. 
 
 An increased vascularity is now observed, externally, over the salient 
 portion of the vesicle, and the tissues become, about the centre of the 
 projection, more and more thinned, until, at last, they yield — the ovum 
 then escaping by a process analogous to dehiscence. The rupture takes 
 place in a small spot where the bloodvessels previously are wanting. 
 This is similar to the larger band of non-vascular tissue which exists in 
 the ovicapsules of birds. Towards this non-vascular spot the neighbor- 
 ing vessels converge in considerable numbers, causing the appearance 
 we have just referred to. Assuming the theories above mentioned to 
 be correct, the bursting of the vesicle is due, not merely to an augmen- 
 tation of its fluid contents, but to a thickening of its internal layer, 
 
80 FEMALE ORGANS OF GENERATION. [CHAP. 
 
 which becomes at the same time irregular in outline and yellowish in 
 color; and also to an effusion of blood, which has been termed the 
 menstruation of the follicle. 
 
 This evolution of the ovum is accompanied by important changes in 
 various parts besides the ovary. In so far as the uterus is concerned, 
 these changes will come to be considered under menstruation. At 
 present, it need only be observed that the Avhole of the internal genital 
 organs become engorged. The Fallopian tube loses its pale color in- 
 ternally, and often becomes of a violet hue from extreme congestion. 
 This is more marked towards the fimbriated extremity, which com- 
 pletely embraces that portion of the ovary where the mature vesicle is 
 about to give way. The ovum is thus received into the Fallopian 
 tube, but the rupture which admits of the dehiscence does not termi- 
 nate the series of changes of which the ovary is the seat. 
 
 Before attempting a description of these changes, however, we must 
 consider for a moment the conditions under which rupture of the Graa- 
 fian vesicle occurs, and the laws which determine this rupture. 
 
 The celebrated experiments of Bischoff, as detailed in his well-known 
 work, 1 have supplied most of the facts upon which, even at the present 
 day, the conclusions of physiologists on this subject are based. From 
 these, and from the corroborative results obtained by subsequent ob- 
 servers, it is clear that ova may, in the Mammalia, as in animals lower 
 in the scale, be discharged from the ovary independently of sexual in- 
 tercourse, or of any kind of influence from the male. 2 In other words, 
 sexual contact or excitement is not, as the earlier observers, down to 
 Barry, believed, the one essential determining cause of the discharge of 
 ova. From experiments on rabbits, which were conducted by Coste, 
 it seems, however, more than probable that sexual congress may pre- 
 cipitate a rupture which, but for the excitement, would have been de- 
 layed. The immediate cause which leads to a rupture is thus somewhat 
 obscure, but Ave recognize the fact that the occurrence is intimately 
 associated with the maturation of the ovum, of which, in women, the 
 periodic menstrual flow is the external manifestation. 
 
 We have already seen that the internal layer of the Graafian vesicle 
 presents a yellow color previous to its rupture, becomes wavy in out- 
 line, and is very considerably thicker. This change of color has been 
 shown by Farre to be due to the presence of very minute oil-granules, 
 which give to the structure a yellow hue, — hence the name given to 
 the follicle during the period of decline — the corpus luteum. After 
 rupture, a laceration, fissure, or scar, marks, on the surface of the ovary, 
 the spot whence the ovum escaped, and a longitudinal section, made 
 through the ovary in this situation, will generally bring the yellow 
 body into view. At first, its distinguishing characteristics are but 
 faintly shown ; and it is this fact which caused Raciborski to assert 
 that the corpus luteum was not found before rupture. Undoubtedly, 
 however, the first stage of its formation is while the ovum is still 
 within the vesicle; but it is only after rupture that the change in color 
 becomes quite distinct, — a change w r hich Raciborski supposed to be due 
 
 1 Beweis der von der Begattung unabhangigen periodischen Reifung und Loslo- 
 sung der Eier, etc. 1844. 
 
 2 See Raciborski " De la ponte period i que chez lafemmeetles Mammiferes." 1844. 
 
IV.] 
 
 THE CORPUS LCIEUM. 
 
 SI 
 
 to an absorption of coloring matter from the blood-clot which fills the 
 cavity. "Whether it is due in part to this, or wholly to a further de- 
 velopment of oil-granules in the internal layer, as Coste supposed, the 
 result is the yellow tint, which may be recognized from without, or. 
 more distinctly, on sectiou. If the laceration has produced an opening 
 of sufficient size, the clot which occupies the cavity may escape along 
 with the ovum; but, if not, it is retained and absorbed. The folding of 
 the internal layer now becomes much more distinct, so that the internal 
 surface of the vesicle resembles cerebral convolutions on a minute 
 scale. According to Coste, this plication is due in great measure to 
 retraction of the external coat, but this does not seem by any means 
 clear, seeing that the convolutions become quite as distinct in those 
 cases where the diameter of the whole vesicle is not diminished. It is 
 much more likely that the plication is mainly due to the rapid increase 
 in the cells of the membrane, which, being confined within a limited 
 space, is thus necessarily thrown into folds. In every case, the cavity 
 of the vesicle becomes rapidly encroached upon, the furrows between 
 
 Ovary dissected, to show the structure of the Graafian vesicle at various stages. (Coste.) 
 
 the convolutions become deeper, and the result is that the follicle now 
 presents, in a section, a stellated appearance, which is more or less 
 marked according to the stage at which the corpus luteum has arrived. 
 The various changes above alluded to are shown in Fig. 41. taken from 
 (Teste's atlas, which represents an actual dissection, made at the Morgue, 
 of the ovary of a young woman who had committed suicide towards 
 
82 
 
 FEMALE ORGANS OF GENERATION. 
 
 [CHAP. 
 
 the end of a menstrual period. It must here be noted, however, that 
 the most recent observations have failed to demonstrate the layers of 
 the Graafian vesicle which Coste has so distinctly indicated. 
 
 The ovary is partly dissected, to show the situation of the ova; and 
 also the structure of the Graafian vesicles, and the changes which they 
 undergo after rupture. Most of the vesicles are turgid, tending to pro- 
 trude, and indicated by the network of vessels on their walls. Three 
 of them are open. 
 
 1. The vesicle to the left in the figure is intended to demonstrate the following 
 peculiarities: 
 
 g g. The granular membrane, which covers the whole internal surface of the 
 Graafian vesicle. 
 A thickened portion of this — granular disk — showing: 
 
 o. The Ovum surrounded by the cells of the disk, and situated, as is usual, im- 
 mediately before rupture, on the side next the peritoneum. 
 i i. Internal layer of the Graafian vesicle, showing a rich vascular network, not 
 only on the flaps which are turned back, but also in the interior of the 
 vesicle, through the granular membrane. 
 e e. External (vascular) layer, vascular like the former. 
 
 2. The open Graafian vesicle in the centre of the figure has broken spontaneously 
 at the point v, and has allowed its ovum to escape. The nipple-shaped part of the 
 granular membrane, in which the ovum was imbedded, has escaped along with it. 
 
 g. Layer of granular membrane, which has not been dragged out with the 
 
 ovum. 
 i. Internal layer of the Graafian vesicle, forming numerous folds, which are 
 
 the earliest of the modifications through which this layer passes in the 
 
 formation of the Corpus Luteum. 
 e. External layer of the Graafian vesicle, retracted (sic Coste) on the former. 
 
 3. The third Graafian vesicle, to the right, has been artificially pierced to show 
 how the ovum, while escaping, drags with it that portion of the granular mem- 
 brane in which it is lodged. 
 
 g. Portion of the granular membrane, escaping by the opening made in the 
 
 Graafian vesicle. 
 ce. Ovum lodged in the thickened nipple-like projection of this membrane. 
 
 Coste denies the presence, as a 
 
 Fig. 42. 
 
 Structure of the corpus luteum. (Coste.) 
 
 rule, of a blood-clot within the 
 Graafian vesicle. He asserts that 
 the vesicle, after rupture, becomes 
 filled with a gelatinous matter, 
 which is slightly tinged with the 
 coloring matter of the blood. This 
 he shows in Fig. 42, where the 
 ovary is divided in its whole 
 length to exhibit the organization 
 of the corpus luteum. The prep- 
 aration was taken from a woman, 
 the mother of several children, 
 who died from poison a few days 
 after menstruation. The body was 
 exhumed and examined a week 
 after death. No ovum was found 
 in the uterus, nor in the Fallo- 
 pian tube. An open corpus lu- 
 teum, of considerable size, is shown 
 in the lower part of the figure. 
 a. Internal laver of the Graafian 
 
IV.] STRUCTURE OF CORPUS LUTEUM. 83 
 
 vesicle, plicated and having commenced that hypertrophy which con- 
 verts it into corpus luteum. 
 
 b. Plastic semitransparent matter, which occupies the centre of the 
 corpus luteum, adheres intimately to the internal surface of the con- 
 volutions, and moulds itself upon them. To the right, this matter is 
 left in its place ; on the left it has been detached, to show the subjacent 
 convolutions and the impression which they leave upon it. 
 
 c. An old corpus luteum, from a preceding menstruation, probably 
 the one before last. 
 
 Graafian vesicles — some intact, others open, and in various stages of 
 development, are seen in other parts of the ovary. 
 
 The description given, up to this point, applies to all corpora lutea, 
 whether associated with pregnancy or not. It is therefore scarcely 
 necessary to add that Haller was in error when he stated that " the 
 corpus luteum is the effect of pregnancy alone. 77 The demonstration 
 of this error caused many hastily to assume that the corpus luteum 
 was, under no circumstances, a sign of pregnancy, and was, in conse- 
 quence, of no medico-legal value — an unfortunate mistake, which has 
 been productive of much confusion, as there certainly are points of 
 difference which enable us, with care, to distinguish between the two 
 varieties. 
 
 The corpus luteum which is found when there has been no impreg- 
 nation, runs something like the following course from the point at 
 which we left it. It shrinks rapidly, the retractility of the outer coat 
 being apparently the chief agent in its contraction. The contiguous 
 surfaces of the convolutions become pressed together, and their free 
 surfaces gradually approach across the cavity, so as rapidly to cause its 
 obliteration. The vascularity of the vesicle, and of the stroma of the 
 ovary, becomes notably diminished, the ovisac loses its yellow color, 
 and becomes white — all these changes occurring in about twenty-five 
 or thirty days, so that, on the approach of another menstrual period, 
 the cavity is reduced to a comparatively small size. At this stage, its 
 appearance, as represented in Fig. 43, a, is very characteristic, the rays 
 which proceed outwards from the central cavity showing the point of 
 junction of the convolutions. Several other vesicles are shown, of the 
 ordinary size before enlargement. From this stage, the stellate re- 
 mains of the vesicles gradually diminish in size, and retreat towards 
 the centre of the stroma, to give place to others, until at last they are 
 obliterated. Sometimes, they soften so rapidly, that they are com- 
 pletely reabsorbed before the folds of the internal layer have actually 
 come in contact or contracted adhesions. 
 
 Widely different is the state of matters where the ovum has been 
 impregnated. In this case, the functional activity of the uterus is, in 
 a measure, shared by the ovaries, and manifests itself in an increased 
 vascularity, which, instead of disappearing, as at the end of a menstrual 
 period, is maintained, more or less, during the whole course of the 
 pregnancy. It is, probably, in consequence of this, that the corpus 
 luteum of pregnancy goes through a series of transformations, so much 
 more elaborate, and extending over a period the duration of which is 
 so much longer. Taking the duration of an unimpregnated follicle as 
 
84 
 
 FEMALE ORGANS OE GENERATION. 
 
 [CHAP, 
 
 about two months to complete obliteration, the corpus luteum which 
 accompanies pregnancy may be said to last usually for thirteen or 
 fourteen months, while traces of it may be found at a still later period. 
 Such a history involves the idea of special structure and modified 
 development, and this a study of the facts amply corroborates. When 
 pregnancy succeeds or accompanies the phenomena of ovulation, the 
 earlier changes are the same as those already described; but instead of 
 softening and rapidly shrinking, as in the former case, the inner coat, 
 or ovisac, continues to develop in thickness, and deepens in color, in 
 
 Fig. 43. 
 
 Fig. 44. 
 
 The corpus luteum of simple ovulation. 
 
 Corpus luteum in the third month 
 of pregnancy. (Montgomery.) 
 
 consequence of an increase in the number of oil-granules in its sub- 
 stance. There does not seem, in the first instance at least, to be any 
 contraction whatever of the external membrane. On the contrary, 
 there is some reason to believe that, at this stage, it often yields, so as 
 to admit of an increase in the entire diameter of the vesicle, and, in- 
 deed, if we admit Coste's description to be correct, when he describes 
 the corpus luteum of pregnancy to be " as large as the ovary itself," 
 this can only be accounted for in the manner described. The size of 
 the ruptured follicle varies considerably, but it occupies, usually, during 
 the first four months, about a fourth, a third, or a half of the entire 
 ovary. During the period immediately succeeding impregnation, rapid 
 hypertrophy of the inner coat goes on, and it becomes folded together 
 into convolutions as before. The material being abundantly supplied, 
 while the development still continues, causes the convolutions to be 
 firmly pressed together, while their free surface encroaches upon the 
 cavity. At the end of two months, the condensation of the hyper- 
 trophied tissue of the ovisac will be found to have imparted to the 
 follicle a considerable amount of solidity, which is quite obvious when 
 it is pressed by the finger. Bloodvessels run through it, from the cir- 
 cumference towards the centre, marking, probably, the situation of the 
 original folds. These latter are no longer distinct, and are so com- 
 pressed laterally that the layer has now the appearance of a very thick 
 yellow coat surrounding the diminished cavity, which is up to this 
 time, according to Montgomery, usually circular in form, as shown in 
 
IV.] 
 
 THE CORPUS LUTEUM, 
 
 85 
 
 Fig. 44. The cavity here represented is, however, exceptional, and 
 subject to much variety. 
 
 The blood-clot which originally occupied the cavity, or, if we choose 
 to adopt the view of Coste, the tinged lymph which is effused after 
 rupture, undergoes certain metamorphoses, which ultimately result in 
 the formation of a milk-white coat which lines the cavity, taking the 
 place, as it were, of the original granular membrane. This membrane, 
 which is also shown in Fig. 44, is fibrous in structure, and extremely 
 tough. Occasionally, the cavity is obliterated at the fourth month, but 
 generally it will still be found perfectly distinct, although much reduced 
 in size, up to the sixth month of pregnancy (Fig. 45). The walls 
 continue gradually to approach nearer to each other, the white lining 
 membrane becomes thinner, and, folded into plaits, which, radiating 
 outwards, are seen to intermingle with the yellow color of the ovisac. 
 The outer boundary of the vesicle now becomes irregular in outline, 
 
 Fig. 45. 
 
 Corpus luteuni at the 
 sixth month of preg- 
 nancy. (Montgomery.) 
 
 Corpus luteum at the period of 
 delivery. 
 
 and complete obliteration of the cavity ensues, a white stellated cicatrix 
 in the midst of the yellow mass marking where its walls came into 
 contact. This is shown in Fig. 46, the original drawing of which was 
 taken by Montgomery from a woman who had died of inflammation 
 of the uterus two days after mature delivery. Up to this time, and 
 often for some weeks afterwards, numerous vessels radiate through the 
 corpus luteum, as may be proved by injection. This vascularity is 
 now markedly diminished, while, at the same time, the characteristic 
 yellow color becomes fainter in hue. It is often not till four or five 
 months have elapsed that all trace of the corpus luteum has disap- 
 peared, a trace of the tough white membrane being then, it may be, 
 still indicated by a very faint star-like scar in the stroma of the ovary. 
 As the facts above set forth are of some medico-legal, as well as 
 obstetric importance, they may be briefly summarized as follows : 
 
86 FEMALE ORQANS OF GENERATION. [CHAP. 
 
 What is called the corpus luteura is due to a deposit of yellow fatty 
 matter in, and hypertrophy of, the internal layer of the Graafian vesicle 
 (ovisac). 
 
 The formation of a corpus luteum always succeeds the rupture of a 
 Graafian vesicle. 
 
 Up to a certain point the changes in the Graafian vesicle are uniform, 
 and have no relation to pregnancy. The corpus luteum of pregnancy 
 may, however, be distinguished in its subsequent course, by its higher 
 development and longer duration, its hardness, its vascularity, and, at 
 a later stage, by the formation of the white lining membrane, and large 
 central stellate cicatrix. 
 
 The presence in the ovary of a corpus luteum is no evidence of preg- 
 nancy, unless the characteristics last indicated are distinct and une- 
 quivocal — under which circumstances it is a certain sign. 
 
 With reference to the above conclusions, it may be remarked that 
 much confusion has arisen from the employment loosely of the terms 
 "true" and "false," as applied to the corpus luteum, in so far as they 
 are assumed to imply a distinction, which proves or disproves the 
 occurrence of pregnancy. " There is as little reason," says Farre, with 
 justifiable emphasis, " for the use of the last term as there would be for 
 denominating a child a false man. . . . These terms actually represent 
 the same body, only in different stages of growth or decay." 
 
 During the whole of the childbearing period of a woman's life, 
 the ripening and dehiscence of the Graafian vesicles are of periodic 
 occurrence. In those animals in which plural births are the rule, several 
 vesicles ripen and discharge their contents at, or near, the same time ; 
 but in man this is exceptional, and we thus find that one vesicle only, 
 as a rule, ripens at a time, bursts, discharges its contents, and rapidly 
 shrinks as it retires towards the centre of the ovary ; to give place in 
 their turn, in a normal condition of the parts, to a constant succession 
 of vesicles, which, one by one, run a similar course after discharging 
 their ova. There is every reason to believe, further, that during preg- 
 nancy and suckling, while the uterine functions are in abeyance, those 
 also of the ovary are temporarily arrested, in so far as the development 
 of new Graafian vesicles is concerned, — the whole generative force 
 being, as it were, turned into other channels. 
 
 The numerous lacerations which, in consequence of repeated ruptures, 
 take place on the surface of the ovary, leave, in the process of healing, 
 corresponding cicatrices. On this account the smoothness of surface is 
 soon lost, and it becomes more and more fissured and wrinkled, until, 
 towards the end of the childbearing epoch in a woman's life, the ovary 
 is so irregular on the surface, as to warrant the comparison which 
 Raciborski has instituted between it and the kernel of a peach. After 
 this, the organ becomes atrophied, and, like the uterus and other parts, 
 is restored, in some measure, to the form which it presented in early 
 life. 
 
V.] MENSTRUATION AND CONCEPTION. 87 
 
 CHAPTEE V. 
 
 MENSTRUATION AND CONCEPTION. 
 
 THE " EUT " OF MAMMALIA: ANALOGY BETWEEN THIS AND MENSTRUATION — THE 
 FIRST MENSTRUAL PERIOD: STATISTICS OF DURATION OF A "PERIOD." — QUAN- 
 TITY OF THE DISCHARGE — MENSTRUATION A HEMORRHAGE : NON-COAGULA- 
 BILITY OF — SOURCE OF THE MENSES : VARIOUS THEORIES REGARDING : IS FROM 
 THE MUCOUS MEMBRANE OF THE CAVITY — POUCHET'S THEORY EXAMINED; IS 
 THE MUCOUS MEMBRANE SHED? — VIEWS OF KOLLIKER, COSTE, ETC. — DURATION 
 OF CHILDBEARING EPOCH — CAUSE OF MENSTRUATION — CONCEPTION — COMPOSI-^ 
 TION OF THE SEMEN — SPERMATOZOA AND THEIR DEVELOPMENT — "SPERM- 
 CELLS " — THE FUNCTION OF THE GERMINAL VESICLE ; " GERM-CELLS " — HOW 
 DOES THE SEMEN REACH THE OVUM ? 
 
 There is, in the animal kingdom generally, a certain periodicity in 
 the phenomena which attend the maturation of the Ovum. In the 
 Mammalia, there always is a period of excitement, in which the whole 
 generative apparatus more or less participates ; succeeded by a period 
 of rest, of longer or shorter duration, according to the group or species, 
 during which the organs involved are in a state of complete or com- 
 parative quiescence. The first marks the period at which the ovum is 
 ready for impregnation ; during the latter sexual congress, is, as a rule 
 ineffectual. This term of excitement, which is accompanied by general 
 and local symptoms to be noticed presently, is called, in mammals 
 lower in the scale than man, the rut or oestrus. 
 
 There is not the slightest doubt that, in those animals, the escape of 
 the ova from the ovary, and their passage down the Fallopian tube, 
 are facts which coincide with the oestrus. The female then manifests 
 an instinctive desire for copulation, and is generally said to be at this 
 time " in season " or " in heat.' 7 The pudendum is congested and 
 swollen, and the glands in this region pour out an abundant secretion, 
 which, by its odor, attracts the male. This secretion, unless in those 
 animals which come nearest to man in the scale, is very seldom even 
 tinged with blood. In some cases, as was demonstrated by Bischoff in 
 the case of the roe, the rut occurs only at intervals of a year, about the 
 month of August. It is only at this period that the ovaries of the 
 female contain ripe ova; and, what is of even higher physiological 
 interest, the semen of the male is elaborated then and then only, so 
 that impregnation is doubly impossible, save with a view to the birth 
 of the young at that time of the year when they may be most easily 
 reared. But, in many animals, the maturation and dehiscence of the 
 ova occur with much greater frequency, and it is probable that food, 
 domestication, and careful tending, may modify the return of those 
 periods. 
 
88 MENSTRUATION AND CONCEPTION. [CHAP. 
 
 In women, during the period of ovulation, there are, as has already 
 been shown, certain essential phenomena which are, so far, almost 
 identical with what we observe in other mammalia. But there is here 
 a special phenomenon superadded, which is in fact the external mani- 
 festation of what we know to be taking place internally. This consists 
 in a discharge from the uterus of nearly pure blood, which lasts usually 
 for several days. It is called the " catamenial " or " menstrual " dis- 
 charge, as it occurs very constantly at intervals of a month ; the occur- 
 rence being, in its course, usually designated as menstruation. 
 
 A very warm discussion has been maintained for many years as to 
 whether the " rut " and " menstruation " are to be held as analogous. 
 Up to a certain point, the analogy is admitted by all ; but it must be 
 conceded that, between the two, distinctions and even contrasts are 
 found, on careful examination, to arise, which seem to challenge the 
 truth of the assertion which many have made, that the phenomena are 
 •physiologically identical. Without expressing any confident opinion 
 as to this quwstio vexata, we may here mention the chief points, in ad- 
 dition to the sanguineous discharge, in which they differ. Impregna- 
 tion takes place during the excitement of the rut, while as a general 
 rule it occurs in women about a week after menstruation, during the 
 period of rest. Again, there succeeds to the rut a period of inappe- 
 tence, when not only does the female refuse the male, but in some cases 
 no semen is, as we have seen, secreted ; in the human species there is, 
 strictly speaking, no period of inappetence, not even excepting the 
 period of the menstrual discharge, so that at any time impregnation 
 may occur. Great as these differences undoubtedly are, and even if we 
 admit that they destroy the identity of the acts, they are scarcely suffi- 
 cient to warrant us in rejecting the analogy ; for, although the subject 
 is still obscure, a more accurate knowledge of the time occupied by the 
 descent of the human ovum may show that the above points of con- 
 trast are more apparent than real. 
 
 Menstruation is familiarly termed by women the " courses," " monthly 
 illness/ 7 or " period." It is not to be looked upon as an isolated act, 
 but as one of the important series of phenomena which occur during 
 ovulation ; and as such it requires special and careful attention. Its 
 first appearance is associated with the other signs of puberty. The 
 approach of this is indicated by an alteration in the form of the pelvis, 
 and a consequent change in figure and gait ; by the growth of hair on 
 the pubes, the rapid development of the mammae, the greater projection 
 of the nipple, and the deeper color of the areola. These physical 
 modifications are generally associated with very characteristic moral 
 changes. A frank romping manner gives place to one more timid and 
 gentle, and the loud voice and ringing laughter of childhood is replaced 
 by subdued tones and bashful reserve. A Graafian vesicle now for the 
 first time comes to maturity, and projects on the surface of the ovary, 
 which is embraced by the fimbriae of the Fallopian tube, while the 
 whole of the organs, including the uterus, become highly congested. 
 
 According to Boerhaave, the first menstruation is accompanied with 
 a certain amount of fever, as the result of the excitement of the genital 
 organs. The girl complains of lassitude, hypogastric fulness, lumbar 
 
V.] STATISTICS OF MENSTRUATION. 89 
 
 and sacral pains, slight itching and tumefaction of the external geni- 
 tals, and a painful swelling of the mammae. Not unfrequently, hysteria, 
 chorea, and other nervous disorders, manifest themselves, — generally 
 in a mild form. After a few days, a mucous discharge, more or less 
 abundant, is observed; this becomes tinged with blood, and after a 
 time is found to be almost pure blood, to be again replaced by a tinted, 
 and finally by a clear discharge, closely resembling that which at first 
 showed itself. The previous symptoms disappear with the menses, 
 which may have lasted a week ; and she is restored to perfect health, 
 but with an indescribable something in manner and appearance which 
 marks the transition into womanhood. Such symptoms as are above 
 detailed, on the authority of Boerhaave, as accompanying a first men- 
 struation, are generally slight in degree, the discharge often appearing 
 during sleep, or at any other time, without anything whatever of the 
 nature of premonitory symptoms. Very often, for a period or two, 
 some of the same symptoms are experienced, at intervals of a month, 
 without any flow of blood. These indicate preliminary or abortive 
 attempts on the part of nature, — the Graafian vesicles being probably, 
 as yet, not perfectly mature ; but there is little reason to doubt, that 
 the first maturation of a vesicle is, as a rule, coincident with the first 
 menstrual discharge. 
 
 The initiation of this period of a woman's life is believed to be 
 hastened by hot climates, by residence in towns, and the habits which 
 are there contracted, and by constitutional vigor ; while cold tempera- 
 tures, country residence, and a feeble and delicate temperament, retard 
 the act. In a certain number of cases, menstruation is postponed to a 
 period of life much more advanced than usual. We read, for example, 
 of a case in which a woman who had married at twenty-seven, men- 
 struated for the first time two months after her eighth labor ; and of 
 another who had no discharge until after her second marriage, at the 
 age of forty. Numerous cases of premature menstruation are also on 
 record, where menstruation has actually appeared during infancy, and 
 where the external appearances and sexual desires of maturity have 
 been manifested at a very early age. In a case cited by Cams, a child 
 menstruated at the age of two years, became pregnant at eight, and 
 lived to an advanced age. Such cases are, of course, extremely rare ; 
 but of more frequent occurrence are those instances in which women 
 become pregnant without ever having menstruated ; while it is by no 
 means an uncommon thing for a woman who is nursing, to become 
 pregnant again before the menses have returned, such facts indicating, 
 as Cazeaux observes, that menstruation plays a secondary part in the 
 phenomena of ovulation. 
 
 Putting such exceptional cases aside, as irregular and abnormal, we 
 at once recognize the fact, that the time of a first menstruation varies 
 greatly, according to climate, constitution, and the kind of life which 
 is led. In so far as climate is concerned, the influence exercised by it, 
 while quite marked, is by no means so considerable as was once be- 
 lieved, and may be represented by a period of three years at the fur- 
 thest between the extremes, which we may suppose to exist in the 
 Hindoo and the Esquimaux. At one time, ideas were entertained on 
 
90 
 
 MENSTRUATION AND CONCEPTION. 
 
 [CHAP. 
 
 this subject which more correct observation has shown to be absurd, 
 and to no one are we more indebted than to Mr. Roberton, of Man- 
 chester, for clearing away the errors which were long promulgated on 
 these points. The following table, which shows the period of the first 
 menstruation in 8983 cases, is the result of a very careful analysis of 
 the most reliable statistics which have been published in Europe on 
 this subject. 
 
 Some idea is here given of the variation in the different countries of 
 Europe, and shows the very small proportion of cases in which men- 
 struation first appears under ten or over twenty-two years. The period, 
 as will be observed, varies very considerably, about the age of sixteen 
 being the time at which it most frequently shows itself in this country. 
 At any age, however, between twelve and twenty, the function may be 
 established, without any peculiarity whatever in the attendant symp- 
 toms or deterioration of the general health ; but if beyond these limits, 
 it may be looked upon as exceptional and irregular, although even 
 then, as in the cases alluded to, the health may in no way suffer. 
 
 Age. 
 
 England, j France. 
 
 Germany. 
 
 Norway. 
 
 Russia. 
 
 Total. 
 
 Roberton, Brierre de 
 Lee, White- Boismont, 
 head, and Raciborski, 
 Murphy. Bouchacourt. 
 
 Osiander. 
 
 Faye. 
 
 Lebrun. 
 
 Under 10, 
 
 10 to 13, 
 
 11 " 12, 
 
 12 " 13, 
 
 13 " 14, 
 
 14 " 15, 
 
 15 " 16, 
 
 16 " 17, 
 
 17 " 18, 
 
 18 " 19, 
 
 19 " 20, 
 
 20 " 21, 
 
 21 " 22, 
 Over 22, 
 
 14 
 
 64 
 
 103 
 
 278 
 
 595 
 
 1034 
 
 1178 
 
 1307 
 
 714 
 
 531 
 
 213 
 
 104 
 
 18 
 
 17 
 
 16 
 
 41 
 
 138 
 
 209 
 
 258 
 
 355 
 
 411 
 
 349 
 
 287 
 
 190 
 
 102 
 
 66 
 
 31 
 
 23 
 
 3 
 
 8 
 
 21 
 
 32 
 
 24 
 
 11 
 
 18 
 
 10 
 
 8 
 
 1 
 
 1 
 
 4 
 
 4 
 
 13 
 
 14 
 
 20 
 13 
 13 
 6 
 8 
 3 
 o 
 
 1 
 
 15 
 
 27 
 
 35 
 
 13 
 
 6 
 
 2 
 
 1 
 
 30 
 
 105 
 
 241 
 
 494 
 
 865 
 
 1424 
 
 1650 
 
 1727 
 
 1060 
 
 765 
 
 337 
 
 188 
 
 54 
 
 43 
 
 Total, 
 
 6170 2476 
 
 137 
 
 100 
 
 1.00 
 
 8983 
 
 Once established, the menses should return with periodic regularity 
 during the whole childbearing epoch. The recurrence of the discharge 
 is always attended with local, and generally with constitutional, symp- 
 toms. The latter are identical with those which accompany the first 
 menstruation, only less in degree, and constitute what has been termed 
 the menstrual molimen. The only circumstances which normally arrest 
 this function of the uterus are the occurrence of pregnancy and lacta- 
 tion, during which the ovarian and uterine functions are generally in 
 complete abeyance. If, under other circumstances, it should disap- 
 pear during the childbearing epoch, it is regarded as an indication of 
 some morbid condition, usually constitutional, and which declares itself 
 
V.] QUANTITY OF THE DISCHARGE. 91 
 
 as a rule by the presence of other symptoms. It may last from one to 
 eight days, eight being, according to Brierre de Boismont, the most 
 common, and, strange to say, seven the least so. The following is, ac- 
 cording to the same observer, the duration in days arranged in the 
 order of frequency in which each day is selected : 
 
 8 : 3 : 4 : 2 : 5 : 1 : 6 : 10 : 7. 1 
 
 The catamenial period and interval together occupy a period of a 
 month of four weeks, or twenty-eight days. This is the rhythm of the 
 act in such a large proportion of cases, that we may set it down as the 
 rule ; but it is a rule to which we find constant exceptions, a few days 
 more or less than the limit here mentioned being of constant occurrence, 
 much greater irregularities, indeed, being quite compatible with perfect 
 health. It is by no means rare to find a woman who menstruates once 
 in six weeks or once in a fortnight, without any inconvenience what- 
 ever. In all cases, it is the continuance of the flow which mainly de- 
 termines the duration of the interval or intermenstrual period. In 
 some, and under the influence of morbid conditions, a leucorrhoeal dis- 
 charge takes the place of the ordinary menstrual flow ; and, in others, 
 the molimen is relieved by a discharge of a hemorrhagic nature from 
 some other surface. Both of these conditions, although essentially 
 pathological, are, nevertheless, in not a few instances, beneficial in their 
 action. 
 
 The amount of the discharge is very variable even in the same 
 woman, and very different opinions have been formed as to what is to 
 be considered a normal quantity over the whole period. The obvious 
 difficulties in the way of such an investigation have hitherto prevented 
 anything like a reliable estimate. That of Hippocrates, which we 
 have on the authority of Galen, assumes eighteen ounces to be lost at 
 each period, but this has not been confirmed, even proximately, by 
 any modern observer. Meigs put it down at four to six ounces, Dehaen 
 at three to five, and Farre at two to three ; and there can be no doubt 
 that these figures give a more accurate idea, and that Farre is probably 
 correct when he says " that a discharge, amounting to six or more 
 ounces in the aggregate, will generally produce for the time sensible 
 effects upon the constitution, such as general pallor, and some feeble- 
 ness of the muscular system. " 
 
 In regard to the nature and influence of the menstrual discharge, 
 very incorrect and even fabulous opinions were entertained. Pliny 
 assures us that the presence of a menstruating woman blights vegeta- 
 tion, turns wine sour, and produces a number of other and similar 
 effects ; and in some districts, even at the present day, traces of this 
 superstition are to be found. The peculiar odor which was described 
 by De Graaf, and which has been compared by some French physiol- 
 ogists to that of the marigold, is a very usual characteristic of the 
 discharge ; but it is scarcely necessary to add that, in the absence of 
 any morbid condition, neither this nor any other quality of the dis- 
 
 1 De la Menstruation : par A. Brierre de Boismont. Paris, 1842. 
 
92 MENSTRUATION AND CONCEPTION. [CHAP. 
 
 charge can produce deleterious results. During the height of the 
 period, it is composed, as the researches of Donne, Pouchet, Letheby, 
 and others have abundantly proved, almost entirely of pure blood, 
 mixed with a certain quantity of mucus. During the periods of in- 
 vasion and decline the mucus predominates, the color being in direct 
 proportion to the number of blood-corpuscles, which are seen by the 
 microscope, mixed with epithelial scales and with mucous corpuscles 
 from the cervix. 
 
 There is one striking peculiarity which serves to distinguish this 
 from ordinary hemorrhagic discharges — its want of coagulability. This 
 was at one time supposed to be of itself sufficient evidence that it was 
 not blood, or was blood deprived of its fibrin ; but no doubt now re- 
 mains that the arrest of coagulation depends upon the mixture of the 
 acid secretion of the vagina with the still fluid blood as it escapes from 
 the os, which not only maintains the fibrin in solution, but also renders 
 it difficult of chemical detection. When the quantity is excessive, con- 
 stituting the affection known as menorrhagia, nothing is more common 
 than to find clots discharged, the blood being then so far in excess as 
 to neutralize the acid in the vagina. And, besides, it has been proved 
 that if the blood be collected as it escapes from the os, and before it 
 mixes with the mucus, it is coagulable and alkaline in reaction. These 
 facts suffice to prove that the discharge is a hemorrhage. 
 
 Source of the Menstrual Discharge. — There are few subjects in phys- 
 iology which have given rise to more discussion than this. Some ob- 
 servers have seen blood oozing from the surface of the vaginal mucous 
 membrane, while others have traced it to the os and cervix uteri ; and 
 on isolated observations such as these, theories on the subject have 
 been founded. Admitting the facts upon which these theories have 
 an unsubstantial basis, we recognize in them nothing more than ex- 
 amples of vicarious menstruation, a term which has been applied to 
 those cases in which the menstrual molimen is relieved by a discharge 
 through an unwonted channel. That the menstrual discharge has its 
 true source in the mucous membrane wdiich lines the cavity of the 
 uterus is a fact which admits of no doubt, and has been proved to 
 demonstration, by examination of the uteri of women who have died 
 during a period ; by accumulation of blood within the cavity in cases 
 of atresia of the cervix or of the vagina; and, finally, by the examina- 
 tion of cases of chronic inversion of the uterus, which offer peculiar 
 facilities for the study of the subject. 
 
 In our view of ovulation, those of the essential phenomena of the 
 process which have their seat in the uterus and its lining membrane, 
 were left for consideration at this place. In point of fact, we may 
 assume that menstruation itself is essentially one of these phenomena, 
 which are mutually dependent on each other. Along with the enlarge- 
 ment of the ovary and Fallopian tubes already described, a very con- 
 siderable enlargement, involving an increase in weight, takes place in 
 the uterus. Its vascular apparatus becomes developed and injected 
 in an unusual degree. This is especially marked in the case of the 
 mucous membrane, on the surface of which, under the epithelium, the 
 
▼••] 
 
 SOURCE OF THE MENSTRUAL DISCHARGE. 
 
 93 
 
 vascular network already described becomes very distinct where the 
 vessels surround the orifices of the utricular glands. The glands them- 
 selves are also visibly enlarged, 
 
 Tumefaction of the uterine mucous membrane during 
 menstruation. (After Coste.) 
 
 and any difficulty which may 
 arise in demonstrating them 
 while the uterus is at rest, now 
 no longer exists. The mem- 
 brane becomes increased in 
 thickness, its color is deepened, 
 and the temperature of the 
 whole womb is raised. The 
 result of these changes is that 
 the membrane becomes hyper- 
 trophied to such an extent that 
 it is thrown into convolutions, 
 which are soft, pressed together, 
 and project into the cavity so as 
 to fill it completely, its walls 
 being thus no longer smooth 
 but wrinkled. (Fig. 47.) M. 
 Coste, whose conclusions are 
 based upon no inconsiderable 
 number of such observations, says that, save as a pathological product, 
 no such pseudo-membranous exudation exists, as has been described by 
 physiologists of repute. 
 
 A closer examination of the surface shows that, at this period, it is 
 dotted over with minute specks, which a low magnifying power proves 
 to be small drops of blood occupying the orifices of the utricular glands, 
 from which they may be dislodged by gentle compression of the walls. 
 This, however, does not determine the ultimate source of the haemor- 
 rhagic flow, and it is around this part of the subject that the greatest 
 difficulties have arisen. 
 
 That it is not a secretion, in the proper acceptation of the term, as 
 was once believed, is a postulate which the analysis of the discharge 
 enables us to affirm. We need not therefore address ourselves to the 
 refutation of an exploded theory. The view entertained by Coste, is 
 that it is a transudation through the walls of capillary vessels, chiefly 
 venous, or in other words (if we do not misunderstand him) that a con- 
 siderable haemorrhage takes place in this manner, without any breach 
 whatever in the walls even of the smallest vessels, a conclusion which 
 all physiological analogy forbids us to accept. That there may be 
 permanent vascular orifices through which the blood escapes during the 
 menstrual period is an idea which has found favor in the eyes of some 
 eminent physiologists, among others Dr. Far re. Nor is this so fanciful 
 a view as one might be disposed at first to consider it. If there are 
 permanent orifices, it may indeed be asked, why is there not continuous 
 haemorrhage? And in reply, it may be assumed, hypothetically of 
 course, that these orifices are, during the intermenstrual period, closed 
 by the contractility of the tissues which surround them ; but that the 
 increased vascularity, tumefaction, and relaxation of all these parts, 
 
94 MENSTRUATION AND DISCHARGE. [CHAP. 
 
 which coincide so constantly with the other phenomena of ovulation, 
 admit of a welling forth of pure blood through apertures which now, 
 under the special circumstances, become patent, and which, the apogee 
 of the period having passed, forthwith commence to close, to open 
 afresh on the approach of the next menstruation. 
 
 The theory, however, which perhaps of all others has attracted in 
 recent times the greatest amount of attention, is that which is associated 
 chiefly with the name of M. Pouchet, and to this theory some of the 
 ablest of our English writers have given their adhesion. Pouchet — if 
 we mistake not — supposed that the whole, or at least the greater part 
 of the mucous membrane (not the epithelium merely) is shed at each 
 catamenial period ; and that its separation from the subjacent tissues 
 involves the rupture of vessels, whence the menstrual flow. This, 
 however, would involve a very different appearance of the internal 
 surface of the uterus, from that which has been above described as 
 occurring at this time, and which we believe to be substantially correct. 
 A separation of a membrane so thick and so important Avould, in fact, 
 be capable of obvious anatomical demonstration ; and if it could be so 
 demonstrated, we would at once have, in the trunks of the vessels which 
 must of necessity be ruptured, the source, clear and unequivocal, which 
 we are endeavoring to trace. The separation of the mucous membrane 
 of the uterus, under the name of decidua, which occurs in women at the 
 moment of delivery ; and the occasional occurrence of what is known 
 as membranous dysmenorrhea, when, in certain morbid conditions, 
 the whole membrane is actually exfoliated, and shed either piecemeal 
 or entire, are facts which have seemed to M. Pouchet sufficient to 
 establish an analogy, on which, mainly, his theory is based. The 
 mucous membrane, he says, is deciduous not merely at the termination 
 of pregnancy, or as a consequence of an exceptional morbid action, but 
 at each menstrual period. No such separation takes place in the lower 
 animals, and in this distinction we find revealed at once the source of 
 the menstrual discharge, and the reason why, in the human species, 
 haemorrhage is superadded to the ordinary phenomena of " rut." In- 
 genious as this theory may be, and interesting as the facts undoubtedly 
 are which its promoter has brought to bear upon it, it is one, we think, 
 which requires closer investigation. 
 
 If M. Pouchet could show us the exfoliated membrane, and the raw, 
 bleeding surface which its removal necessarily involves, as he might 
 do in membranous dysmenorrhea, or in women who have died shortly 
 after delivery, his theory would be established, and the question for- 
 ever set at rest. But in this he has scarcely succeeded. Opportuni- 
 ties of examining the bodies of women who die during a menstrual 
 period are, no doubt, rare ; but, a sufficient number of such examina- 
 tions have been made by Coste, and, more recently, by Kundrat and 
 Engelman, to show what is the usual condition of the parts. In a 
 certain number of cases, no doubt, something approaching to complete 
 exfoliation does occur, but even Pouchet himself is forced to admit that 
 these cases are exceptional. His ultimate conclusion seems to be that 
 the membrane desquamates, not during menstruation, but in the inter- 
 val. This, however, abandons all the advantage which he gained from 
 
V.] CAUSE OF MENSTRUATION. 95 
 
 the analogy which he so ingeniously established. For there can be no 
 comparison between a desquamation occurring when the functional 
 activity of the womb is in abeyance, and one which is uniformly asso- 
 ciated with its highest functions ; although an analogy might fairly 
 enough have been traced between the birth of the decidua, in the final 
 act of parturition, and the shedding of the same membrane in connec- 
 tion with a process which is held to be, up to a certain point, prepara- 
 tory to the reception and development of the ovum. 
 
 The separation of the membrane from the subjacent structures would 
 certainly, if occurring during menstruation, account satisfactorily for 
 the discharge; but, even if it were established that an intermenstrual 
 exfoliation did occur, this would, in no sense whatever, account for the 
 periodical phenomena of menstruation. Dr. Tyler Smith states, that, 
 having had several opportunities of examining the uteri of women who 
 had died during menstruation, he found that the appearances presented 
 were similar to those which are observed after abortion. "In each of 
 those cases," he says, " I found the mucous membrane of the body of 
 the uterus either in a state of dissolution, or entirely wanting." In 
 one case — of which he gives a drawing in his "Manual" — he found 
 that " in the cervical canal the mucous membrane was perfect, but at 
 the os uteri internum it ceased as abruptly as though it had been dis- 
 sected away with a knife above this point. Blood was oozing at 
 numerous points, from broken vessels in the submucous tissue." In a 
 microscopic examination of this case, in which he was assisted by Dr. 
 Handfield Jones, no traces of the epithelium or utricular glands could 
 be found. Now, if Dr. Tyler Smith founds his belief in the exfoliation 
 theory, on such cases as this, he goes much further than Pouchet him- 
 self, in attempting to prove, w r hat that physiologist does not, that the 
 separation of the membrane occurs during menstruation. Speaking 
 with that respect for his views to which such an eminent observer is 
 entitled, we are inclined to assume that Dr. Tyler Smith w r as mistaken, 
 and that the case was either a very exceptional one, or that he mistook 
 shedding of the epithelium for separation of the entire membrane. 
 
 We believe that, in all probability, the views of Kolliker, which 
 have been recently, in some degree, confirmed by Robin, point to a 
 more correct conclusion than any of the theories above stated. These 
 distinguished histologists believe, with Coste, that the mucous mem- 
 brane becomes thickened during menstruation. They hold, however, 
 that the blood escapes from ruptured superficial capillaries, the epithe- 
 lium covering the mucous membrane of the body being, in great part, 
 thrown off. The interesting observations of Robin, as to the structure 
 of the utricular glands, make it more than likely that -a considerable 
 portion of the discharge comes from these ; but that it comes from the 
 surface of the membrane as well, and probably, to a trifling extent, 
 from that of the Fallopian tubes, we may consider as certain. There 
 can be little doubt, however, that a certain change does take place in 
 the epithelium during menstruation. Independent observers have 
 shown, for example, that, as during pregnancy, so also at this time, 
 the epithelium is deprived of its vibratile cilia. Farre has occasionally 
 observed, in an injected uterus, that the capillary vessels, which form 
 
96 MENSTRUATION AND CONCEPTION. [CHAP. 
 
 so fine a network upon its inner surface, are " denuded, and hanging 
 forth in detached loops." Such observations, taken along with the 
 fact that epithelial cells, and a certain amount of debris, are found 
 mingled with the catamenial discharge, suffice, we think, to prove that, 
 during menstruation, the flow of blood is from the mucous membrane 
 of the cavity, and that certain changes in, and probable loss of the 
 epithelium, are associated with the flow. 
 
 The view above expressed has received recent confirmation from the 
 interesting observations of Kundrat, above referred to. As the result 
 of microscopic researches in the case of women who were either men- 
 struating or pregnant at the time of their death, he concludes that a few 
 days before the menstrual flow is established, a proliferation of the 
 cells of the interglandular tissue takes place, by which that portion of 
 the mucous membrane which lies nearest the cavity becomes infiltrated 
 with newly formed round cells. When the capillary vessels rupture, 
 these cells have already passed through a stage of cloudy swelling and 
 fatty degeneration, and it is this superficial portion of the mucous mem- 
 brane which is thrown off during the continuance of the discharge, and 
 for some days after its cessation. To this extent, then, we hold it to 
 be established that the mucous membrane of the uterus is shed at each 
 menstrual period ; and that Pouchet's theory, as corrected by more 
 modern research, is not so wide of the truth as it at first appears. 
 
 The menstrual, or childbearing epoch of a woman's life ranges on 
 an average from twenty-five to thirty years, ceasing most frequently 
 between the ages of forty-five and fifty. So long as the woman enjoys 
 perfect health, the appearance of the discharge should be at regular in- 
 tervals, of which the normal duration is twenty-eight days. Some 
 women, however, as is well known, menstruate every three or every 
 six weeks, and we are only justified, practically, in looking upon such 
 cases as abnormal, when the general symptoms are such as to call for 
 interference. Irregularities occur, too, as we have already seen, fre- 
 quently enough during the first months of menstruation; and we find 
 also that, as the catamenial climacteric or change of life approaches, the 
 cessation of the menstrual function does not occur abruptly, but after 
 marked premonitory symptoms. At this period of her life, a woman 
 becomes subject to many hysterical and other minor ailments, from 
 which she may previously have enjoyed an entire immunity. A period 
 may, possibly for the first time, pass without discharge. On the next 
 occasion, an increased quantity seems as it were to compensate for the 
 omission which nature had made. Intervals of longer duration may 
 now succeed, intervals which bear no relation to former menstrual 
 epochs, until after a certain number of fitful and capricious efforts on 
 the part of the uterus to relieve itself as before, the catamenia finally 
 cease ; the uterus becomes less in size, and the ovaries shrink so rapidly, 
 that they become wrinkled on their external surface, so as to resemble, 
 as Raciborski says, the kernel of a peach. The only normal exceptions 
 to regular menstruation are pregnancy and lactation ; but even these 
 are by no means regular in their occurrence, as we occasionally meet 
 with cases where women continue to have their periods for some time 
 after conception, and frequently with others where, during lactation, 
 
V.] THE SEMINAL FLUID. 97 
 
 menstruation goes on with perfect regularity. Any menstrual irregu- 
 larity, however, occurring during the period of a woman's life which 
 we are here considering, and independent of pregnancy, is to be looked 
 upon as an abnormal state, which calls for treatment with a view to 
 the maintenance of her health. These, and other menstrual disorders, 
 constitute a class of diseases to the treatment of which the physician 
 has constantly to address himself. 
 
 The cause of menstruation is a question which has given rise to a 
 great deal of useless discussion, and to not a few baseless theories. 
 Without broadly asserting that the two phenomena stand to each other 
 in the relation of cause and effect, we are, in the present state of our 
 knowledge, entitled to assume that the periodical discharge depends 
 upon corresponding changes in the ovary, associated with the matura- 
 tion of a Graafian vesicle. This is proved by the examination of the 
 ovaries of women w T ho have died during menstruation, when the ap- 
 pearances already described are generally to be found; by the almost 
 invariable cessation of menstruation when the ovaries have been re- 
 moved; 1 and by the facts which a careful examination of the phenomena 
 of the "rut" of the lower animals discloses. Why the act should 
 recur at periods so regular and constant, is a question which we need 
 scarcely attempt to answer. That, in one animal, a single Graafian 
 vesicle should come to maturity each month, in another, a cluster ripen 
 simultaneously, and, in a third, that evolution should occur at intervals 
 of a year, are facts which display a marvellous accordance with the pur- 
 poses of nature in regard to the propagation of species, but they are 
 facts, too, the ultimate cause of which will continue to baffle the specu- 
 lation of the astutest intellects. 
 
 Conception, Fecundation, and Impregnation, are terms all of which 
 imply fruitful contact of the male and female elements, so that a new 
 organism comes into existence. The fecundating principle which is 
 contributed by the male is secreted by the testes at the age of puberty, 
 and is known as the semen or seminal fluid. At the time of sexual 
 contact, the excitement of the erectile tissue is such, that, acting through 
 the medium of a ganglionic centre, which is supposed to be situated in 
 the lower portion of the spinal cord, it culminates in an orgasm, during 
 which certain muscular fibres are called into a reflex and convulsive 
 action. The semen is thus ejaculated with considerable force by the 
 fibres of the vasa deferentia, and by the special muscles which sur- 
 round the vesicula? seminales and the prostate gland, its regurgitation 
 towards the bladder being prevented, according to Kobelt, by the 
 tumefaction of the verumontanum which occurs during the period of 
 erection. It is thus thrown for the most part into the upper part of 
 the vagina, and over the os and vaginal portion of the cervix; but it is 
 well known to medical jurists that this, although highly favorable to 
 impregnation, is not essential. On the contrary, there are perhaps few 
 
 1 Percival Pott's well-known and often-quoted case, corroborated by similar ob- 
 servations by Cazeaux, Oldham, and others, was long held as conclusive evidence 
 that menstruation in the absence of the ovaries was impossible. A sufficient num- 
 ber of cases have, however, been reported on good authority to show that, excep- 
 tionally, periodic sanguineous discharges may go on in the absence of the ovaries. 
 
 7 
 
98 MENSTRUATION AND CONCEPTION. [CHAP. 
 
 physicians of experience who have not met with cases where women, 
 believing themselves safe, have permitted a certain amount of sexual 
 contact without penetration, and have thus become pregnant. All, in 
 fact, that seems to be essential is contact of the seminal fluid with the 
 pudendum, which is further proved by observations of pregnancy coin- 
 cident with perfect hymen. 
 
 The semen is a thick, glutinous, whitish fluid, albuminous, heavier 
 than water, and emitting a peculiar odor. If subjected to exami- 
 nation by a considerable magnifying power, it is found to consist of a 
 number of little oval, flattened bodies, which in man are not more than 
 %-qqq of an inch in width, furnished with long filiform tails, which 
 taper gradually to the finest point. A lashing undulating motion is 
 imparted to these bodies, for a certain time after death or ejaculation, 
 varying according to circumstances from several hours to several days. 
 This brisk and constant movement, which has led Kolliker to compare 
 them to ciliated cells, gave rise to the erroneous opinion that they were 
 
 animalcules, hence the name which 
 they still retain, Spermatozoa. Besides 
 these bodies, there are observed cer- 
 tain minute round and granular masses, 
 varying in number, but always fewer 
 in ripe semen than the Spermatozoa 
 themselves. These are what were 
 originally termed by Wagner, " semi- 
 nal granules," but which have been 
 shown by his subsequent researches, 
 and by those of Kolliker, Leuckart, 
 
 Spermatozoa and vesicles of evolution. etc., to be Cells within which the Sper- 
 
 matozoa are developed, and are now 
 termed vesicles of evolution. These again are generally found to be 
 inclosed in groups of from three to seven within parent cells (Fig. 48, 
 b b), but each vesicle of evolution is destined for the development of a 
 single spermatozoon, as is shown in a mature specimen at c. The indi- 
 vidual spermatozoa escape thereafter by rupture of the containing vesi- 
 cle, and may now (a) exhibit their characteristic movements. Some- 
 times, rupture of the vesicles of evolution takes place without absorption 
 of the parent cell, when the appearance produced is that shown at d, 
 where a bundle of spermatozoa is seen, their number corresponding to 
 that of the original vesicles. It is only, it may be observed, by careful 
 examination of the semen in the testes, epididymis, and other portions 
 of the tract, that these several stages may be traced. These elements 
 of the semen are found to float in a limited quantity of clear perfectly 
 homogeneous liquid. Direct experiment on the ova of the Amphibia 
 has proved that it is in the spermatic particles and not in this fluid 
 that the fecundating principle resides. If the spermatozoa are absent, 
 therefore, as in debility, disease, or old age, impregnation is impossible, 
 and it is their absence in the semen of hybrids that renders these ani- 
 mals sterile. 
 
 The Ovum at the stage at which we left it, was escaping, or about 
 
V.] CONTACT OF OVUM WITH SPERMATOZOA. 99 
 
 to escape, from a ripe Graafian follicle. It is then composed of the 
 following parts (see Fig. 39, p. 79): 
 
 a. Of a thick transparent membrane, which completely surrounds it, 
 and exhibits no trace of vascularity — the zona pel lucida of Baer, or 
 vitelline membrane of Coste : 
 
 b. Of a granular yolk contained in this vesicle : 
 
 c. Of the germinal vesicle of Purkinje : 
 
 d. Of the germinal spot of Wagner. 
 
 The Germinal Vesicle, as the period of dehiscence approaches, moves, 
 as we have seen, towards the periphery of the yolk, both it, and the 
 germinal spot within it, being so placed, as to be as near as possible to 
 the point where rupture is about to occur, as if to seek the fertilizing 
 influence of the male. Since Bischoff actually demonstrated the pres- 
 ence of spermatozoa on the ovaries of bitches and rabbits, in whom 
 congress had been permitted at the proper period, few physiologists 
 question the possibility of impregnation occurring while the ovum is 
 yet in the ovary ; and indeed, if true ovarian pregnancy is possible, 
 — which some doubt, — it is only in this way that impregnation can, in 
 these cases occur. It has been generally assumed, however, that a 
 rupture of the walls of the Graafian vesicle could alone permit of such 
 impregnation ; but if we may so far judge from analogy, what has 
 recently been divulged in reference to the penetration of the walls of 
 bloodvessels by the white corpuscles of the blood, and their consequent 
 transformation into pus-cells, we may at least admit the possibility that 
 particles endowed with such mobility may penetrate the attenuated 
 walls of a Graafian vesicle, even before rupture. 
 
 The germinal vesicle has been designated by some physiologists the 
 germ-cell, and the vesicle which contains the spermatozoon the sperm- 
 cell, it being assumed that the fertilizing product of the latter made its 
 way through the walls of the ovum, and intermingled with the con- 
 tents of the former. In the osseous fishes, and in some animals lower 
 in the scale, it has been shown that a minute opening (micropyle) exists 
 in the zona pellucida, which has been supposed by Dr. Allen Thomson 
 to facilitate the fecundation of ova possessed of very thick external 
 coverings. No reason other than this exists for the belief, which some 
 have entertained, that a similar aperture in the Mammalia facilitates 
 the introduction of the spermatozoa. There are many reasons for be- 
 lieving frhat the germinal vesicle, or germ-cell, plays an important part 
 in conception, but what precise share it takes in the process is hitherto 
 undetermined. 
 
 The cessation of the characteristic movements of the spermatozoa 
 marks the termination of the period during which their fertilizing in- 
 fluence may be exercised. The duration of the period will, therefore, 
 obviously depend upon the circumstances under which the semen is 
 placed. Its admixture, at the time of ejaculation, with the prostatic 
 fluid and the secretion of Cowper's glands, and, subsequently, with the 
 vaginal and uterine secretions, are obviously circumstances which tend 
 to preserve the spermatozoa, by furnishing a medium in which they 
 may freely float : an absence of these conditions would necessarily cur- 
 tail their vitality. Although we may assume it as possible that im- 
 
100 MENSTRUATION AND CONCEPTION. [CHAP. 
 
 pregnation may occur in'the ovary, it by no means follows that it can 
 occur nowhere else. But it is certain that the contact between the 
 male and female elements must almost always take place, if not in the 
 ovary, at some point between it and the upper third of the uterine 
 cavity. Bischoff affirms that, by the time the ovum reaches the lower 
 end of the Fallopian tube, its capacity for impregnation is lost, and 
 experiments which have been made, by tying the Fallopian tubes in 
 the lower animals before copulation, so far corroborate this view, which 
 is now generally entertained. There can at least be little doubt that 
 in the great majority of cases among Mammalia, and most probably in 
 the human subject, it is in the upper half, or third, of the Fallopian 
 tube that the meeting of the ovum with the semen takes place. 
 
 How, then, do the spermatozoa reach the ovum? It cannot for a 
 moment be doubted that the spermatozoa must make their way upwards, 
 in Man, as in the lower animals, from the vagina, to that point where 
 they meet the ovum. 1 There are various possible agencies by means 
 of which this movement may be effected : 1st. By the action of the 
 spermatozoa themselves, which may undoubtedly determine a motion, 
 although it is difficult to conceive why such motion should be in a 
 definite direction. It is highly improbable, therefore, that this is the 
 sole motive. 2d. By the action of the vibratile cilia. This will 
 account, no doubt, for the movement from the middle of the cervix 
 upwards ; but in cases where impregnation has resulted from contact 
 without penetration, the absence of cilia between the vulva and the 
 cervix must leave the movement along this part of the tract to the 
 operation of some other agency. 3d. Muscular peristaltic contractions 
 may also act by propelling the semen in a definite direction. There 
 are various parts of the course which the semen must traverse to which 
 one or other of these forces may be more applicable, but it is more than 
 likely that muscular peristaltic action is the chief moving power. 
 
 The absence of the vibratile cilia during a menstrual period may 
 raise a difficulty as to the acceptance of one of the above theories, most 
 likely to suggest itself to those who entertain the strongest views as to 
 the identity of the rut and menstruation. But, in regard to this it 
 must be observed, that the period at which impregnation is most likely 
 to occur is some days after, or shortly before, menstruation ; in the one 
 case, the changes in the epithelium of the uterine mucous membrane 
 not having yet commenced, and, in the other, a sufficient period having 
 elapsed to admit of its reparation. Another channel through which, 
 in exceptional cases, the spermatozoa may work their way up, is one 
 which, on the authority of Mauriceau, De Graaf, and Baudelocque, 
 Cazeaux assumes to result from a bifurcation of the Fallopian tube 
 near its uterine extremity, the new canal passing through the uterine 
 walls, and opening near the internal os. As modern anatomists make 
 no mention of such a canal, we may assume its existence to be doubtful ; 
 and even if we admit it, its only physiological importance would be 
 the possibility of the arrest of the ovum there, and the formation of 
 
 1 Some speak of the "ovum" only after impregnation, and term it "ovule" 
 prior to this. 
 
VI.] DEVELOPMENT OF THE OVUM. 101 
 
 what has been called by the older writers " Graviditas in substantia 
 uteri. " 
 
 A sketch of the development of the ovum, from the period of im- 
 pregnation onwards, will be reserved for the following chapter. 
 
 CHAPTEE VI. 
 
 DEVELOPMENT OF THE OVUM. 
 
 formation of the embryo-cell — cleavage of the yolk — development of 
 the blastodermic vesicle — " serous " and "mucous" layers — the 
 area germinativa and primitive trace — formation of the embryo ; 
 of the umbilical vesicle and omphalo-mesenteric vessels ; of the 
 amnion; of the allantois and umbilical vessels; of the chorion — 
 the liquor amnii — the vitriform body — the decidua ; what is it? 
 dec1dua vera ; reflexa ; serotina — early connection of ovum with 
 decidua — the umbilical cord : vessels ; gelatin of wharton, etc. — 
 knots on cord — the placenta — in birds: in non-placental mammals : 
 in ruminants: in man: maternal and fcetal surfaces of: maternal 
 circulation in: curling arteries: sinuses: veins — fcetal portion: 
 arteries : tufts or villi : veins — functions of the placenta — struc- 
 ture of villi. 
 
 The development of the ovum in the Mammalia, and especially in 
 Man, is, as regards its earlier stages, a subject still involved in no 
 little obscurity. The important results which have sprung from the 
 studies in comparative physiology, associated with the names of V. 
 Baer, Rathke, Bischoff, Remak, Kolliker, and many others of scarce 
 inferior merit, enable us, with a certain amount of confidence, to fill up 
 gaps in an account of human development, which the very rare oppor- 
 tunities afforded of examining human ova would probably never have 
 revealed, but which the application of strict analogical reasoning enables 
 us to supply. On these principles, the following sketch is based. No 
 attempt will, however, be made to follow the development of individual 
 organs ; but merely to indicate, in what appears to the writer to be the 
 simplest possible manner, the mode in which the envelopes of the 
 embryo are evolved, and the provision which, in successive stages of 
 growth, is made for its nutrition. 
 
 The disappearance of the germinal vesicle is one of the earliest 
 changes which has been observed. This is not necessarily associated 
 with impregnation, but is rather a sign of the complete maturation of 
 the ovum. Modern physiologists indeed appear to believe that, as a 
 rule, it has nearly, if not entirely, disappeared at the time of the rup- 
 ture of the Graafian vesicle. The formation, however, in its place, of 
 the new embryo-cell, which, having been demonstrated in many animals, 
 
102 
 
 DEVELOPMENT OF THE OVUM, 
 
 [CHAP. 
 
 is assumed to take place also in the human species, and the changes 
 which immediately occur in the yolk, are undoubted results of the 
 fecundating process, and of the penetration of the walls of the ovum 
 by the spermatozoa. In the outer half of the Fallopian tube, the ovum 
 is believed to have already undergone some of these changes. There 
 can be little doubt, at least, that, even thus early, the germinal vesicle 
 and its spot can no longer be distinguished, and the external surface of 
 the ovum is still covered with some of the granulations in which, within 
 the Graafian vesicle, it was imbedded. The yolk becomes more com- 
 pact, and, as it were, condensed. In the inner half of the tube, the 
 granulations have disappeared, and their place is occupied, on the ex- 
 ternal surface of the ovum, by a thin albuminous layer, which is anal- 
 ogous to the white of the egg in birds. This albuminous layer, like 
 the subjacent zona pellucida, becomes, in the first instance, thicker, and 
 there now commences that most remarkable series of changes prepara- 
 tory to the formation of the embryo, known as the segmentation, or 
 cleavage of the yolk. 
 
 The first step in this process consists, as is shown in Fig. 49, of the 
 fission of the mass of the yolk into two equal portions, by a deep 
 
 Fig. 49. 
 
 Fig. 50. 
 
 Fig. 51. 
 
 Successive stages of the cleavage of the yolk. 
 
 furrow on either side, which ultimately, by uniting in the centre, com- 
 pletes the division. These again, by a repetition of the process, become 
 subdivided, so that four spheres are now observed to occupy the cavity 
 of the zona pellucida. Each of these divisions of the yolk proceeds, 
 pari passu, with a corresponding duplication of the " embryo cell," 
 already referred to. After precisely the same fashion, the spherules 
 become still further subdivided into 8, 16, 32, 64, and so on, until, on 
 the arrival of the ovum at the uterine extremity of the Fallopian tube, 
 the yolk presents the appearance shown in Fig. 51, which has been 
 well compared to a mulberry. It is from this germ-mass that the whole 
 organization of the embryo is gradually evolved. In Mammalia, the 
 process of segmentation affects the whole mass of the yolk, which is 
 protoplasmic. But there are great differences in this respect in other 
 animals. In Birds and Reptiles, the cicatncula, or white spot, lying 
 on the side of the yolk which floats uppermost, alone undergoes this 
 process. A distinction is, therefore, to be made between the ova of 
 these animals in which the yolk is entirely segmented, and is therefore 
 germinal, and those in which a part only is directly germinal and 
 another is nutritive. 
 
 Having arrived in the uterine cavity, the ovum, on examination, 
 
VI.] 
 
 THE BLASTODERMIC VESICLE. 
 
 103 
 
 Fig. 52. 
 
 ^^. 
 
 appears as if the whole of the granular germ-mass had been absorbed. 
 And to some extent, no doubt, a process of solution or absorption has 
 taken place, the centre of the cavity being again occupied by a fluid 
 which is limpid and transparent. A more careful examination shows, 
 however, that a large proportion of the granules become condensed 
 towards the inner surface of the zona pellucida, assuming the form of 
 true cells, of a hexagonal or pentagonal appearance from the pressure 
 which they exercise upon each other. While these changes are going 
 on, a rotatory movement of the yolk takes place, during which, possibly 
 by centrifugal attraction, the cells retreat from the centre towards the 
 circumference, and ultimately form a new membrane. This spheroidal 
 vesicle within the zona pellucida, 
 is the structure out of which, step 
 by step, the entire embryonic struc- 
 tures are evolved. It is the blasto- 
 dermic vesicle of Bischoff and Coste. 
 
 From the shape of the cells of 
 which it is originally composed, the 
 ovum now presents the appearance 
 shown in Fig. 52, which indicates 
 also a considerable increase in size, 
 owing to the rapid augmentation of 
 its fluid contents by absorption from 
 the uterus, and the simultaneous de- 
 velopment of the blastodermic vesi- 
 cle, which now exhibits great and 
 independent vital energy. At one 
 point of its surface, a certain num- 
 ber of the original segmentary masses and cells form, by their aggre- 
 gation, the appearance which is represented in the same figure. This, 
 which is at first round, and subsequently becomes oval, is recognized 
 by its whitish opaque appearance. It is called the area germinativa, 
 and constantly increases in size by the development of fresh cells, and 
 by and by splits into two layers, a division which rapidly extends 
 throughout the whole blastodermic vesicle. The external of these two 
 layers was originally called the " serous," the internal the "mucous" 
 layer. As our object is to enter upon this subject only in so far as is 
 essential to a knowledge of the points in development which are of 
 special obstetric interest, we shall here refer to these two layers only. 
 There is another layer, however, intermediate between the two, which 
 further subdivides as evolution advances, a knowledge of which is 
 essential to a thorough description of the various organs. This was 
 first called the "vascular" layer, but there are many points in reference 
 to it which are still under consideration, and in a measure involved in 
 obscurity. This seems to be an additional reason why, even at the 
 risk of a charge of inaccuracy here and there, we should not enter upon 
 the difficult subject of the intermediate layer. 
 
 The area germinativa, at first homogeneous in appearance, soon 
 shows in its centre a clear space, called the area pellucida, bounded by 
 a denser layer of cells, which are manifestly more opaque. The first 
 
 External surface of the ovum, showing the area 
 germinativa. 
 
c 
 
 104 DEVELOPMENT OF THE OVUM. [CHAP. 
 
 appearance of definite embryonic structure is a shallow groove lying 
 lengthwise in the area pellucida. This is the primitive trace, the earliest 
 
 indication of the cerebro- 
 spinal canal. If viewed in 
 section, this groove (Fig. 
 53 a) is seen to lie between 
 two lateral eminences called 
 the lamince dorsales (c c), 
 
 Diagram showing the earliest format^ of the embryo. which We here demonstrate, 
 
 as it illustrates a law in de- 
 velopment, of which, in the evolution of special organs, we find many 
 illustrations. This diagram, after Remak, is the only one in the series 
 in which the middle layer is indicated, showing at o the first trace of 
 the vertebral column, and at p p the subdivision of this layer, indicat- 
 ing the origin of the pleuro-peritoneal cavity. The lowest in the figure 
 is the mucous layer. In the development of the tube of which the 
 groove is the trace, the lamina? dorsales rise, and, folding together, meet 
 in the middle line, and there unite. Consequently the cutaneous or 
 corneal layer (Hornblatt of Kolliker) secretes from a portion of its sur- 
 face elements which, within the tube, ultimately become the cerebro- 
 spinal nervous centre. Among other instances of this method of de- 
 velopment by involution, the formation of the lens and vitreous body, 
 in the construction of the eye, is a striking example, both the cuticle 
 and these structures being originally portions of the same external or 
 corneal surface. 
 
 The albuminous layer having now disappeared, and the zona pellncida 
 having in great part lost its thickness, the formation of the embryo be- 
 comes more distinctly manifested by a rolling or folding inwards both 
 of the sides and of the extremities of the area germinativa. At this 
 stage, the embryo has the appearance of a curved gutter, with a larger 
 (cephalic) and a smaller (caudal) extremity. A glance at the diagram 
 (Fig. 54) will show that its external or epidermic surface is continuous 
 with the external or serous layer (s) of the blastodermic vesicle. About 
 this period, the blastodermic vesicle becomes divided into two parts, as 
 is indicated by the horizontal dotted line in this and the following 
 diagram, the lower portion being embryonic, and the large cavity above 
 forming the umbilical vesicle (u). The embryonic portion constantly 
 increases, while the umbilical vesicle progressively diminishes, as if the 
 development of the former took place at the expense of the latter: this 
 is made clear in the series of diagrams. The two small projections (a a) 
 show the earliest stage of the formation, by a process of involution, of 
 the amnion, an important structure, the further development of which 
 will be traced presently. The blastodermic vesicle, then, is surrounded 
 by the zona pellucida z. It is itself composed of two layers, the ex- 
 ternal or serous (s), which is continuous with the external surface of 
 the embryo, and from which the amnion is developed ; and the internal 
 or mucous (m), which subsequently subdivides as we have seen. If we 
 look, however, at the mucous layer, in its original and simplest form, 
 we may assume that the umbilical vesicle and the intestinal surface of 
 
VI.] 
 
 THE AMNION AND CHORION. 
 
 105 
 
 the embryo are identical and continuous, both being derived from the 
 same layer. 
 
 In Fig. 55, the same parts are shown in a more advanced stage of 
 development. The embryonic portion of the blastodermic vesicle is 
 more defined, and of larger size, and the umbilical vesicle is diminished 
 in a corresponding degree, while the communication between the two 
 
 Fig. 54. 
 
 Fig. 55. 
 
 Diagram showing early stage of 
 development. 
 
 Further development of the ovum. 
 
 is rendered more distinct. The first indications are now shown on the 
 latter of a vascular system. This is the omphalo-mesenteric system, or 
 circulation of the yolk, from which is formed ultimately the portal 
 circulation of the foetus. The umbilical vessels spring, as we shall 
 see, from another source. The amnionic folds (a a) are now seen to 
 project more over the embryo. 
 
 The next step in the process of development is shown in Fig. 56, in 
 which the whole ovum shows an increase in size. The amnionic folds 
 project so far that they are nearly in contact, the embryo being thus 
 inclosed in a sac, which has as yet an opening at a a. About this 
 period, a very important structure, the allantois, makes its first ap- 
 pearance under the form of a small pear-shaped vesicle (p), which 
 springs from the mucous layer, near the caudal extremity of the 
 embryo. This little organ has, as we shall find, a most important 
 part to play in providing an apparatus, and channel of communication, 
 whereby the circulation and respiration of the foetus may be efficiently 
 maintained. This vesicle, in Birds, reaches a very considerable size, so 
 much so as completely to surround the yolk sac, so that, through the 
 shell and its membrane, it comes into actual relation with the external 
 air. In those mammals, in whom the placenta (an organ to be here- 
 after described) surrounds the ovum, the allantois has in like manner 
 a considerable development; but, in the human race, where its function, 
 though not less important, may be said to be comparatively of a tem- 
 porary nature, it never reaches any considerable size. It is originally 
 hollow, and is the receptacle for the secretion of the Wolffian bodies, 
 and subsequently for that of the true kidneys when formed. It is not, 
 however, correct to suppose that it gives origin to the urinary bladder, 
 but its pedicle, the urachus, forms the suspensory ligament of the 
 bladder, and may be traced in adult life. At a very early period of 
 
106 
 
 DEVELOPMENT OF THE OVUM. 
 
 [CHAP. 
 
 its formation, vessels make their appearance upon it, and shortly after 
 this (probably in a few days) it becomes elongated and, as it were, 'pro- 
 jects these vessels, which are the umbilical arteries and veins, towards 
 the surface of the ovum, with which it comes into contact at that part 
 where the placenta is about to form. It is not, indeed, until this has 
 taken place that the outer of the two foetal envelopes may probably be 
 said to be completed. 
 
 The foetal covering here alluded to is the chorion, which may thus be 
 considered as composed of the external or serous layer, with the remains 
 — should these still exist — of the zona pellucida on its external, and 
 some portions of the allantois on its internal surface. The Chorion 
 thus constituted, becomes abundantly supplied with vessels from the 
 allantois, which soon pervade it in its whole extent, as is shown in the 
 accompanying diagram (Fig. 57). Prior to this, small projections have 
 
 Fig. 57. 
 
 Fig 56 
 
 Development in a more advanced 
 stage. 
 
 Completion of the amnion, and formation of the 
 umbilical cord. 
 
 appeared on the external surface of the chorion, which are the rudi- 
 ments of the long shaggy villi with which the ovum is seen to be covered 
 in abortions occurring in the early weeks of pregnancy. The allantois 
 having now fulfilled its function, dwindles to a mere cord, within 
 which a minute vesicle may be detected by careful examination, as 
 representing the original cavity. It is probable that the allantois 
 forms about the tenth clay after impregnation, and runs its course in a 
 few days more ; so that it is not to be wondered at, that some physiol- 
 ogists have doubted its existence in the human race, seeing that its 
 limits have not been clearly demonstrated. Analogy, however, enables 
 us confidently to assume that, without it, there could be no vascularity 
 of the chorion, a condition which would involve a speedy arrest of 
 development. At first, it carries two arteries and two veins ; but the 
 vein of the right side becomes obliterated about the fifth or sixth week, 
 so that there are found from this period till the time of birth, two 
 umbilical arteries and one umbilical vein. 
 
VI.] THE AMNION AND CHORION. 107 
 
 After the formation of the allantois, the umbilical vesicle rapidly 
 shrinks, and is often seen, in abortions at the sixth week, under the 
 form of a vesicle no larger than a pea, connected with the small intes- 
 tines of the embryo by means of a long and narrow 7 pedicle ; and its 
 flattened yellowish vestige may with care be detected much later, lying 
 not far from the place of implantation of the umbilical cord into the 
 placenta, between the chorion and amnion. (See Fig. 71.) The om- 
 phalo-mesenteric vessels atrophy, along with the organ to which they 
 belong; and the communication which existed between the vesicle and 
 the alimentary canal, becomes more and more curtailed, and ultimately 
 obliterated. There can be no doubt, however, that in the earliest stages 
 of the development of the ovum, and up to the period of the formation 
 of the allantois, the embryo derives its chief nourishment from the 
 whitish-yellow fluid, which is contained in the umbilical vesicle, and 
 which has been found to contain numerous fatty cells and globules. 
 But, with the formation of the allantois and the vascularity of the 
 chorion, the necessity for nutrition from this source ceases, and the 
 umbilical vesicle, which at one time formed the greater part of the 
 bulk of the ovum, now withers, and ultimately disappears. 
 
 At the same time that this dwindling of the umbilical vesicle takes 
 place, the development of the amnion goes on with considerable rapidity. 
 In Fig. 57 the completed process of involution, which results in the 
 formation of the cavity of the amnion, is shown, as are the earlier stages 
 in the preceding diagrams. The amnion thus forms a close cavity or sac, 
 which consists of two layers, and is contractile; and in which, hence- 
 forth, the foetus floats freely, protected by the fluid which it contains, 
 from shock and external influences. By the absorption of the original 
 amnionic folds, at the point where they come into contact (see the dot- 
 ted line below a), the amnion becomes completely detached from that 
 portion of the serous layer of the blastodermic vesicle, which we have 
 shown to enter into the formation of the chorion. The amnion thus 
 forms a sheath for the umbilical cord, and from the margins of the 
 ventral aperture or umbilicus, is continuous, as it has been from the 
 first, with the surface of the embryo. When completed, it constitutes 
 the internal membrane of the ovum; and from its inner surface there 
 exudes, a liquid (liquor amnii) which is essential to the safety and fur- 
 ther development of the embryo, — not by affording it nourishment, to 
 any extent, but by the mechanical support and protection which it con- 
 stantly maintains. The liquid consists of water, holding in solution a 
 small quantity of albumen and salts. It is at first limpid, but, towards 
 the end of pregnancy, it becomes of a higher specific gravity, and is 
 often milky, or of a darker color, with numerous albuminous flakes. 
 When the hue is greenish, or dark in shade, this is probably due to 
 the escape of the contents of the bowel. The quantity of the liquid 
 varies extremely, and that, too, without apparent cause ; and while its 
 actual quantity may be said to augment during the whole period of 
 gestation, it is generally admitted that, relatively to the size of the 
 foetus, it increases during the first half of pregnancy, and diminishes 
 from that time onwards. In addition to the protection of the foetus 
 
108 DEVELOPMENT OF THE OVUM. [CHAP. 
 
 from shock, which must manifestly be exercised to the greatest advan- 
 tage during the early months, the liquor amnii gives room for the 
 movements of the foetus, which we cannot doubt to be essential to its 
 proper development, and for changes in position or posture, in obedi- 
 ence to the laws of gravity. It protects, also, the umbilical cord from 
 pressure; and, during labor, prevents the walls of the contracting 
 uterus from pressing prematurely on the surface of the child, while it 
 safely and expeditiously effects the mechanical dilatation of the os. 
 Finally, omitting, for the present, the possibility of its being a source 
 of nutriment, it is of great assistance to the accoucheur, — preventing 
 the firm contraction of the uterus upon the child, and so facilitating, in 
 many ways, both manual and instrumental operations. 
 
 External to the amnion, the interval between it and the chorion is 
 occupied by a soft and gelatinous substance, to which Velpeau gave 
 the name of vitriform body ; and imbedded in which is found the re- 
 mains of the umbilical vesicle. The long pedicle of the umbilical vesi- 
 cle penetrates the cord, by an aperture in its sheath. The closure of 
 the amnionic cavity, the formation of the allantois, and the connection 
 thus ultimately established between the embryo and the exterior of the 
 ovum, complete the essential parts of the ovum. The latter now 
 consists — 
 
 a. Of the Embryo. 
 
 b. Of the Liquor Amnii, in which it is suspended. 
 
 c. Of the membrane of the Amnion, which is the internal membrane 
 of the ovum, is continuous with the external surface of the embryo, 
 and forms a sheath to the umbilical cord. The pedicle of the umbili- 
 cal vesicle passes through an aperture in this sheath. 
 
 d. Of the Urachus or pedicle of the Allantois, and other parts which, 
 together, form the Umbilical Cord. 
 
 e. Of a space between the amnion and the chorion, containing the 
 remains of the vitriform fluid and of the Umbilical Vesicle. 
 
 /. Of the Chorion, — the external envelope of the ovum. 
 
 These parts, although deriving, no doubt, the supply of material 
 necessary for their growth from the parent, are strictly of embryonic 
 origin, or spring from parts which take their rise in connection with 
 the embryo or the peripheral membranes of the ovum. Other struc- 
 tures, however, are simultaneously developed, which may be regarded 
 as in whole or in part maternal. 
 
 The outermost of the three coverings of the ovum, one which, ac- 
 cording to every hypothesis hitherto advanced, must be looked upon as 
 purely maternal in its origin, is the decidua. The theory originally 
 propounded by Hunter, and adopted by the great bulk of physiologists 
 of the early part of the present century was simply this : The conges- 
 tion and excitement coincident with impregnation, caused, on the inner 
 surface of the uterus an exudation of a new formation of the nature of 
 coagulable lymph, which closed the orifices of the Fallopian tubes, 
 leaving only one opening, corresponding to the internal os. The ovum, 
 on its arrival in the uterine cavity, was assumed to push this mem- 
 
VI.] 
 
 FORMATION OF THE DECIDUA, 
 
 109 
 
 Diagram, showing Hunter's 
 theory as to the formation of 
 decidua. 
 
 brane before it, so that the decidua became naturally divided into two 
 parts, that which adhered to the uterine surface 
 [decidua vera, a), and that which invested the 
 ovum (decidua reflexa, b). Subsequent ob- 
 servation having shown that a portion of 
 membrane, identical in its structure with 
 these, was found behind the ovum, — between 
 it and the uterine wall, — this was regarded as 
 a formation subsequent to the arrival of the 
 ovum, and was named the decidua serotina. 
 This theory owed its general acceptance to 
 the fact, that it afforded an explanation of 
 what had frequently been observed in abor- 
 tions — that the complete ovum was found to 
 be inclosed in a pouch, which was shed from 
 the uterus, and which thus derived its name. 
 The view universally adopted by modern 
 physiologists is, however, quite different from this. 
 
 We have already seen in our notice of the mucous membrane of the 
 uterus, as observed in women who have died during menstruation, that 
 it is at these periods greatly hypertrophied and congested, and, in con- 
 sequence, thrown into convolutions. (See Fig. 47.) Up to a certain 
 point the changes after impregnation are identical with those which 
 accompany the menstrual molimen. According to Robin, the colum- 
 nar and ciliated epithelium is partly exchanged, during the progress 
 of pregnancy, for the tessellated variety, and partly desquamated. 
 Sharpey and Weber found that the decidua vera was, allowing for the 
 changes above mentioned, identical in structure with the mucous mem- 
 brane of the uterus ; and, especially, that the characteristic tubular 
 glands were abundant, and much more distinct than in the unimpreg- 
 nated condition. By others, the orifices of the Fallopian tubes were 
 found to be free. As regards the decidua reflexa, greater difficulties 
 had to be surmounted. If this portion of the membrane be examined 
 at an advanced period of pregnancy, it is found to be thin and trans- 
 parent, if indeed it can be separated from the decidua vera; and it 
 then presents no trace whatever of the tubular glands. At an earlier 
 period, the glands are found to be absent in the central or more promi- 
 nent portion only, becoming more distinct, however, as we approach 
 its point of contact with the decidua vera. In fact, we may assume, 
 with Coste, that the views of Bischoff are, on this subject, incorrect, 
 and that, on its first formation, the decidua reflexa is identical in its 
 structure with the decidua vera. All this points irresistibly to the 
 conclusion that the decidua is nothing else than the uterine mucous 
 membrane, altered to suit the requirements of the case. 
 
 The main difficulty which, on this view, will suggest itself to the 
 student of physiology, is to account for the manner in which the ovum 
 gets behind the mucous membrane. Here we must be content with 
 theory; but it is a theory founded directly on the facts which modern 
 physiology has revealed, and certainly preferable to that of Hunter, 
 more especially as accounting for the existence of the decidua serotina. 
 
110 
 
 DEVELOPMENT OF THE OVUM 
 
 [CHAP. 
 
 Fig. 59. 
 
 I 
 
 IHi 
 
 Formation of clecidua; first stage. 
 
 The ovum, on its arrival in the uterine cavity, is for a certain time 
 free from all adhesion. Probably, it becomes arrested in one of the 
 
 sulci between the convolutions into 
 which the mucous membrane is 
 thrown, and there it contracts ad- 
 hesions, at the point where the 
 placenta will presently be formed. 
 On either side of it, there now rise 
 projections of the mucous mem- 
 brane (Fig. 59), as we have seen 
 to occur in the formation of the 
 amnion, and in that of the organs 
 of special sense: the folds meet in the centre, and the evolution is com- 
 plete, a (Fig. 60) being the decidua reflexa, b the decidua vera, and c 
 the decidua serotina. The villi, which at this time are abundantly de- 
 veloped on the surface of the 
 ovum, are assumed by some 
 to be received into the ori- 
 fices of the uterine glands, 
 and, indeed, Sharpey actu- 
 ally found this to take place 
 in the case of the bitch. The 
 simple fact of extra-uterine 
 pregnancy seems, however, 
 sufficient to show that, al- 
 though this may occur, it is 
 by no means essential as a 
 step in development. But, 
 whatever view we may be inclined to take of the theory, the facts are 
 these: if we open the uterus of a woman, about the fifth week of preg- 
 nancy, we find, almost certainly, a tumor in the neighborhood of the 
 fundus, and projecting into the cavity of the uterus. The Fallopian 
 tubes are open, and the membrane which covers the tumor is continu- 
 ous, and identical in structure, with that which lines the uterine cavity, 
 the glands being probably more distinct near its base. The tumor, on 
 being incised, discloses a cavity containing an ovum. All this seems 
 to indicate that the modern theory is, at least, more likely to be correct 
 than any hitherto advanced. 
 
 If, in the course of such an examination as has just been indicated, 
 the cavity be carefully opened, and a flap turned down, the ovum, quite 
 uninjured, may then be observed, sometimes bathed in blood when 
 bloodvessels have been injured. Its external surface will be seen 
 bristling with villi, and on the inner surface of the everted flap, small 
 depressions or lacunae may be noticed, into which the villi dip, and by 
 means of which, no doubt, material is obtained for the time from the 
 circulation of the mother. If, again, we cautiously remove the ovum 
 and wash out the cavity, we shall find that the lacunse on the side of 
 the decidua serotina are much deeper and more numerous. This marks 
 the place at which the placenta is about to form. 
 
 If we look again at Fig. 61, we may observe that in the most pro- 
 
 Formation of decidua completed. 
 
VI.] 
 
 THE UMBILICAL CORD. 
 
 Ill 
 
 Fig. 61. 
 
 jecting part of the ovum, which is the centre of the everted flap, the 
 membrane has become thin and exsanguine; and here, even at this 
 early period, we would probably look in vain for the tubular glands. 
 This is the commencement of another and an important change which 
 goes on, pari passu, with the develop- 
 ment of the placenta. Those villi of 
 the chorion which pass towards the cle- 
 cidua serotina are more and more de- 
 veloped, and become imbedded in the 
 latter, the two together forming the 
 placenta, an organ to be immediately 
 described. So soon as this new con- 
 nection is thoroughly established, the 
 
 villi over 
 
 the remaining surface of tl 
 
 ic 
 
 Flap of decidua reflexa turned down, dis- 
 closing the ovum. 
 
 ovum diminish or cease to grow in the 
 same proportion; and, as the ovum ex- 
 tends, they become thin and scattered 
 over that side of the chorion which is 
 most distant from the placenta, and are 
 ultimately absorbed, the external sur- 
 face of the chorion being then perfectly smooth. With this, the decidua 
 reflexa loses its vascularity, the vessels becoming obliterated from the 
 centre of the projecting part towards the circumference. As development 
 progresses, the ovum steadily increases in size, and the cavity which 
 exists between the two layers of decidua becomes, in consequence of this, 
 encroached upon, until, about the third month, the two come into con- 
 tact, and the whole of the uterine cavity is then occupied by the foetus 
 and its membranes. It is impossible after this stage to distinguish or 
 separate the decidua vera from the decidua reflexa, which has led Dr. 
 A. Farre to think it probable that the decidua reflexa, after becoming 
 extremely attenuated, ultimately disappears entirely. We do not doubt, 
 however, that although it may become very thin, it may with care be 
 traced. 
 
 Let us now turn again to the interior of the ovum, the essential 
 parts of which were completed by the formation of the allantois. The 
 elongation of the pedicle of the allantois, and the obliteration of its 
 cavity takes place with great rapidity, and, at the same time, the cord 
 becomes greatly increased in length. From this period onwards, the 
 Umbilical Cord consists of the following parts : the amnionic sheath, 
 which entirely surrounds it, save at one point, where a small slit gives 
 egress to the pedicle of the shrunken umbilical vesicle ; the two umbilical 
 arteries and the umbilical vein, which form the greater portion of the 
 bulk of the cord ; that portion of the pedicle of the umbilical vesicle, 
 which extends from the umbilicus to the point of exit; and lastly, the 
 remains of the pedicle of the allantois. By means of the villi of the 
 chorion, acting, as Professor Owen has observed, like the spongioles of 
 a plant, nutriment is extracted from the maternal soil in which it is 
 imbedded, each vascular tuft being, as it were, an independent centre 
 of respiration and nutrition. But, with the complete establishment of 
 the umbilical communication — for it cannot as yet be termed a "cord" 
 — these functions become localized in the human race, and there now 
 
112 DEVELOPMENT OF THE OVUM. [CHAP. 
 
 begins to form, at the point, probably, where the allantois first touched 
 the wall of the ovum, an important special organ of connection, the 
 Placenta, in which externally the umbilical cord terminates. The 
 Umbilical Cord, being composed of the elements above detailed, con- 
 ducts the foetal blood from the bifurcation of the abdominal aorta to 
 the placenta by its two arteries, and brings back the same blood by 
 means of its single vein, it having meanwhile undergone certain changes. 
 The obliteration of the umbilical vesicle soon admits of the closure of 
 the aperture alluded to, and thus reduces the contents of the cord to 
 the vessels above mentioned, and the loop of bowel which still protrudes 
 by the umbilical orifice. This communication between child and pla- 
 centa varies considerably in length. At first, it is short, and is also 
 thick in proportion to the size of the ventral aperture, but soon becomes 
 considerably elongated. Even at. the termination of pregnancy, how- 
 ever, great varieties are observed, it being in some instances no more 
 than a few inches in length, and in others extending to five feet or even 
 more. Its average length, at the full time, may be assumed to be 
 somewhere about twenty inches. The vessels, which are devoid of 
 valves, and which give off no branches in the cord, are disposed in 
 regard to each other, in a manner somewhat peculiar. Firmly bound 
 together by a tenacious substance called the gelatin of Wharton, the 
 quantity of which determines in a great measure the thickness of the 
 cord, the vessels are invariably twisted like the handle of a basket. 
 This does not take place in an irregular manner; on the contrary the 
 twist is, nine times out of ten, from right to left, and, invariably, the 
 vein forms as it were a centre or axis, around which the arteries are 
 arranged in an irregularly spiral form. This twisting, which has been 
 observed as early as the second month, is supposed to depend partly 
 upon the movements of the foetus, and partly upon a more rapid growth 
 of the arteries than of the other tissues of the cord. On an average, 
 the cord is about the thickness of the little finger. Many anomalies 
 have been observed in its formation. One artery; three arteries; and 
 even three veins have been met with, without anything untoward hav- 
 ing occurred, in any stage of the case, in the course of pregnancy. 
 
 When the cord is too long, knots have frequently been observed 
 upon it. These are, doubtless, due to the movements of the foetus, and 
 are much more likely to occur if, along with great length of the cord, 
 there is an excess of the liquor amnii. It is easy to understand how, 
 under such circumstances, the foetus might float through a large loop, 
 and a knot be the immediate or ultimate result. It is conceivable that 
 danger might arise from this, in the course of labor, should any me- 
 chanical complication tend to draw the knot tighter; but all experience 
 seems to show, that these knots are not to be looked upon as dangers, 
 unless under such very exceptional circumstances. 
 
 The cord is of very considerable strength, as a general rule, as is 
 shown in cases where: — often in error — considerable force is brought to 
 bear upon it, in attempts to remove the placenta when this organ is 
 retained. At other times, a very moderate tension will suffice to break 
 it. It is firmly adherent, at its foetal extremity, to the abdominal walls 
 of the child, and, at the placenta, it is found to be intimately con- 
 
VI.] THE PLACENTA. 113 
 
 nectecl with the tissues of the chorion. Externally, its connection with 
 the amnionic sheath is of slighter character, and this is more particu- 
 larly to be observed near the placenta, where the amnion often passes 
 off from it near to the point of its insertion, and thus forms a sort of 
 infundibuliform investment, which has been noticed by many authors. 
 Nerves and lymphatics have been described as appertaining to the 
 umbilical cord ; but these, if present, are so difficult to trace that their 
 existence is very generally doubted. 
 
 The Placenta. — The ovum is, as we have seen, supplied with nutri- 
 ment, in the first instance, directly from the contents of the umbilical 
 vesicle, through the channel of communication which exists between it 
 and the intestinal canal ; subsequently, in all probability, through the 
 medium of the omphalo-mesenteric circulation ; and, at a still later 
 period, before the formation of the allantois, through the villi of the 
 chorion, by imbibition. When, through the agency of the allantois, 
 the umbilical vessels have been projected to the walls of the ovum, a 
 more direct means of communication is at once established. In the 
 lowest Mammalia, which are hence called ^non -placental," no further 
 change takes place in this respect — the whole periphery of the chorion 
 exchanging elements with the maternal parts, as in the early human 
 ovum — until the period of birth. In many of the higher Mammalia, 
 as in the Ruminants, certain portions of the surface of the ovum con- 
 tract with the superimposed maternal parts more intimate adhesions, 
 while other parts become comparatively deprived of their villi. An 
 increase of tissue at these points gives rise to the formation of " cotyle- 
 dons," which may be looked upon as so many miniature placentae, the 
 structure of the uterus, forming the cotyledons, being in these animals 
 permanent. Many other and interesting varieties arc observed, among 
 which we may mention the diffused placenta of the mare and pig, and 
 the zonal placenta of the Carnivora. In man, however, and the higher 
 orders, the mass is confluent and concentrated at one spot, and thus 
 forms the single connective organ which is known as the Placenta. 
 
 The disappearance of the villi over the remaining portion of the sur- 
 face of the chorion, concentrates within the new organ the functions of 
 nutrition and respiration, which it has thenceforth to discharge. A 
 study of its structure is of peculiar interest to the obstetrician, as any 
 diseased or other condition which may affect the due performance of 
 its functions, must necessarily exercise an important influence on the 
 healthy and normal development of the embryo. In many of the 
 animals in whom a placenta exists, that portion which is derived from 
 the ovum may be readily separated from the part which is of maternal 
 origin ; but, in the human placenta, no such separation is in any way 
 possible, so intimately are the two elements incorporated together. We 
 must, nevertheless, look upon the placenta as composed originally of 
 two distinct parts or layers, which are accordingly named the matwnal 
 and foetal portions of the placenta. 
 
 The maternal portion is developed out of that part of the uterine 
 mucous membrane to which the ovum attached itself on its arrival in 
 the uterus. In other words, it is the decidua serotina. No sooner has 
 its formation commenced, than the bloodvessels in the corresponding 
 
 8 
 
114 DEVELOPMENT OF THE OVUM. [CHAP. 
 
 region of the uterus become notably enlarged, the arteries retaining 
 their characteristic spiral form, while the diameter of the venous trunks 
 becomes so much increased, that they are now called sinuses. In the 
 earlier stages of formation, the maternal and foetal vessels are easily 
 seen to run in distinct structures, which may be separated artificially 
 from one another, without rupture of any of the vessels. But, as the 
 placenta becomes more consolidated, the interweaving of the two sets of 
 structures becomes more intimate, by the thinning out of the interven- 
 ing material, while the villous ramification of the foetal part, becoming 
 more and more extended, is accompanied by a corresponding inflection 
 of the maternal structure and vessels over every part of the villous 
 surface; so that, at last, there is produced so complete a combination 
 or interlacing of the two as to make it quite impossible to separate 
 them, or even to distinguish accurately the confines between the struc- 
 ture which was originally foetal and villous, and that which was ma- 
 ternal, or decidual and venous. Numerous observations have proved 
 this, but none more distinctly than the experiments of Bonami, to 
 which we shall immediately refer. Before doing so, however, it is 
 necessary to observe that, on separating a placenta from its uterine 
 attachment by cautiously drawing the parts asunder, it becomes obvious 
 that a special tissue intervenes. This has been described as separating 
 into two thin gelatinous layers, consisting when in situ of interlacing 
 lamellae, adhering at certain points only of their surface, and thus 
 forming cells which may be shown on gently drawing the parts asunder. 
 This is the interplaeental or inter liter o -placental tissue. 
 
 Bonami demonstrated so far the structure of the placenta by colored 
 injections as follows: He injected — 
 
 1st. Red, from the iliac and ovarian veins : 
 
 2d. Blue, from the uterine arteries : 
 
 3d. White, from the umbilical vein : 
 
 4th. Yellow, from one umbilical artery, the other being tied to pre- 
 vent the regurgitation from the anastomosis, which would otherwise 
 have occurred. 
 
 Careful observation and dissection then disclosed the following facts : 
 that numerous red vessels were visible through the amnion on the foetal 
 surface of the placenta; that red and blue vessels, the former straight 
 and the latter spiral, were seen to pass in great numbers through the 
 utero-placen tal tissue, and to penetrate the placenta; and, finally, that 
 a white and yellow network was distinctly seen on the uterine surface of 
 the placenta. As no escape of the injected fluids had taken place into 
 the intermediate tissues, the facts speak for themselves. 
 
 Before proceeding to consider the more minute structure of the pla- 
 centa, some general description of the physical characters of the mature 
 organ may here be given. On its removal from the body, it is found 
 to be a soft spongy mass, about twenty ounces in weight, and seven and 
 a half inches in its greatest width. These are, of course, average di- 
 mensions, as it varies greatly in size; and, on the same principle, it is 
 described as being three-fourths of an inch thick in the centre, and one- 
 eighth to one-fourth of an inch at the margin. It is usually somewhat 
 oval in form, and the umbilical cord is inserted in the centre of its 
 
VI.] 
 
 STRUCTURE OF THE PLACENTA. 
 
 115 
 
 foetal surface. It may be situated at any portion of the uterine surface, 
 even over the os, but its usual site is the neighborhood of the fundus. 
 It presents for observation an internal or foetal, and an external or 
 uterine surface. 
 
 The internal surface (Fig. 62) is smooth, and is covered by the am- 
 nion, through which the vessels are distinctly seen to divide and sub- 
 
 Fig. 62. 
 
 Foetal surface of the placenta. 
 
 divide before plunging into the tissue beneath. The external or uterine 
 surface (Fig. 63) is very different from the former. It is slightly 
 rough on the surface, giving a peculiar granular impression to the 
 finger, very familiar to every obstetrician. It is, moreover, divided 
 into irregular lobes, which may be easily torn or separated from each 
 other. Indeed, examined from this side, the substance of the pla- 
 centa may be said to be brittle. This surface is covered, as has been 
 shown, by a thin layer of utero-placental tissue, through which, with 
 some care, and by floating the placenta in water, the oblique passage of 
 the veins from the uterus may be detected. The margin is continuous 
 throughout with the membranes; the foetal portion with the chorion, 
 and the maternal with the decidua. 
 
 Peculiarities in the structure of the placenta, and in the manner of 
 its connection with the umbilical cord, are not very uncommon. What 
 is known as battledore placenta is one of the most common of these, the 
 cord being then attached, not to the centre, but to the margin of the 
 placenta, giving it something of the form from which it has derived its 
 name. In other cases, although much more rarely, small lobes or 
 cotyledons are found detached from the general mass, as in a case fig- 
 
116 
 
 DEVELOPMENT OF THE OVUM 
 
 [CHAP. 
 
 ured by Dubois; while in twin cases certain modifications are observed 
 which are essential to the dual development, but which will fall more 
 naturally to be considered under the section relating to plural preg- 
 nancy. 
 
 The structure of the placenta being thus complicated, it is not to be 
 wondered at that great difficulties have been encountered in determin- 
 ing what is the nature of the communication which there takes place 
 between the foetal and maternal circulating systems. An opinion long 
 obtained that there was a direct commingling of the two currents, and 
 that blood passed from the uterine arteries directly to the foetus, and, 
 
 Fig. 63. 
 
 Maternal surface of the placenta. 
 
 after there yielding a portion of its vital constituents, returned again by 
 the uterine veins. The earliest attempts at injection being no doubt 
 unskilfully executed, seem to have encouraged this belief. Modern 
 physiologists have long since dispelled this illusion, and the experiments 
 of Bonami above cited demonstrate, along with others, that there is a 
 maternal and a foetal circulation, each being distinct from the other as 
 regards continuity of current down to its uttermost conduits. The 
 vessels of the two systems are, however, in intimate contact throughout, 
 as is made obvious at once by anatomical demonstration, and by a 
 knowledge <of the physiological necessities of the case. What, then, is 
 
VI.] 
 
 CIRCULATION IN THE PLACENTA. 
 
 117 
 
 the nature of the contact which permits of an interchange of material 
 between the two? 
 
 In attempting to answer this question, and to describe the minute 
 structure of the placenta, it must be admitted that there are still many 
 points in regard to which differences of opinion exist, and some diffi- 
 culties which have yet to be explained. To enter upon a full consid- 
 eration of these would ill accord with the expressed object of this work, 
 but a general view of the case, as adopted by the best authorities, may 
 here be briefly epitomized. The vessels which are seen to pass through 
 the utero-placental tissues are, with an important exception to be noticed 
 afterwards, of two kinds, arteries and veins. The former, the " curl- 
 ing arteries'' of the uterus, as they are generally called, are of mod- 
 erate size; they do not anastomose much, nor are their ramifications 
 very numerous, and they retain, within the placenta, in a certain de- 
 gree, their spiral disposition. The veins are somewhat larger, straight 
 
 Fig. 64. 
 
 Section of the placenta. 
 
 in their direction, and with numerous anastomoses. Some have sup- 
 posed that the connection between these veins and arteries was of the 
 nature of a simple capillary circulation; but the researches of Eeid, 
 Weber, and Goodsir, have shown that their connection is of a special 
 character, and offers the strongest possible contrast to a capillary sys- 
 tem. According to them, the blood is conducted by the curling arte- 
 ries into large irregular cells or sinuses, the walls of which are thin, and 
 composed of the lining membrane of the maternal vascular system 
 only. These sinuses communicate freely with each other, and from 
 them the blood is returned to the uterus through the veins which are 
 seen to pass through the utero-placental tissue. In fact, a considerable 
 
118 
 
 DEVELOPMENT OF THE OVUM 
 
 [CHAP. 
 
 portion of the bulk of the placenta, when the organ is replete with 
 blood, is said to be composed of a great venous cavity, which dips so 
 deeply into the chorion as to attain its foetal surface, but which is more 
 distinctly seen in the tissue of the decidua. A large coronary vein has 
 been described by Jacquemier and Meckel as existing near the margin 
 of the placenta. It is, they say, rarely complete, but presents in its 
 course frequent interruptions, where the continuity is maintained by 
 subdivision and anastomosis: but as their observations on the subject 
 have not been confirmed by recent research, we may assume that the 
 existence of such an arrangement is doubtful, certainly not constant. It 
 is proper to add that the presence of a great venous cavity within the 
 placenta has quite recently been seriously called in question. 
 
 On the foetal side, the vessels, on reaching the placenta, divide at 
 once into large branches which are distinctly seen through the amnion. 
 If this membrane be detached, which may easily be effected, as shown 
 in the upper part of Fig. 62, both arteries and veins are observed to 
 divide on the surface of the chorion. They then subdivide again and 
 again, always dichotomously, and plunge into the thickness of the lobes. 
 Here the arteries communicate freely with each other, so that if we in- 
 ject one umbilical artery, the injection will return by the other. If, 
 however, we tie the other, a successful injection will return into the 
 umbilical vein, while the color of the injection will be observed on the 
 uterine surface of the placenta. If we trace the arteries to their ulti- 
 mate ramifications, we find that they are divided into innumerable tufts, 
 fringes, or villi, which form in fact the bulk of the foetal placenta. 
 Each tuft is occupied by one or more capillary loops, and the current, 
 after passing through these loops, returns by the affluent canals, form- 
 ing by their union the umbilical vein. The vessels of this capillary 
 system differ from other capillaries in their greater size, their calibre 
 being such as to admit of several blood-corpuscles passing abreast of 
 each other. Throughout the whole placenta, the villi are found to 
 project in the form of fringes into the placental sinuses, or, in other 
 words, into the large venous cavity which is formed in the placenta 
 
 Fig. 65. 
 
 Fcetal villi of the placenta. 
 
 by the union of these sinuses. Each fringe is thus bathed in maternal 
 blood, and the foetal blood passing through each loop parts with its 
 carbonic acid and receives oxygen in exchange, precisely as occurs in 
 the branchiae of aquatic animals. And, further, as was first shown by 
 
VI.] 
 
 VILLI OF THE PLACENTA. 
 
 119 
 
 Reid, a certain number of the foetal villi pass through the placenta, 
 and dip directly into the larger sinuses of the uterus itself. 
 
 Reid believed further, and his view 
 is very generally accepted, that each 
 tuft, in projecting into the placental 
 cavity, pushed before it the lining mem- 
 brane of this cavity, so that each foetal 
 villus had a special maternal investment. 
 It is to be observed, however, that among 
 English physiologists, Dr. A. Farre 
 combats this view, and that both Coste 
 and Robin are opposed to it. They be- 
 lieve that the walls of the uterine vessels 
 are eroded and perforated by the villi, 
 so that the walls of the latter are in di- 
 rect contact with the blood of the mother. 
 It will be observed, however, that either 
 view of the case is sufficient to confirm 
 the views first enunciated by the Hunt- 
 ers, that there is no commingling of the 
 two systems. The accompanying illus- 
 trations refer to the arrangement and 
 structure of the foetal 
 
 Villi. 
 
 Ultimate foetal villus, highly magnified. 
 
 In Fig. 
 6Q, the cellular covering which covers 
 the villus is shown, except at its distal 
 portion, where it has been removed to 
 show the looped vessels. 
 
 It must be remembered that the oxygenation of the foetal blood is 
 not the only function of the placenta; but that through this channel 
 also, material is supplied for the building up of the foetal tissues, and 
 effete matter is removed. The observations of Goodsir on this point, 
 which are of the greatest possible interest, are corroborative of the views 
 of Reid. These will be noticed when we come to speak of the nutrition 
 of the foetus. 
 
 The formation of the placenta commences in the latter part of the 
 second month, and within a few weeks it acquires its essential charac- 
 teristics. Small bloodvessels, for the special nourishment of the organ, 
 pass from the uterus ; but neither nerves nor lymphatics have been, as 
 yet, satisfactorily traced. It is proper to add, that although the view 
 which has been given of the structure of the placenta is that almost 
 universally entertained, some physiologists have denied the existence 
 of a sinus system. The names of Velpeau, Radford, Ramsbotham, 
 and Madge may be mentioned as holding more or less confidently the 
 latter view ; but of late the contribution in refutation of the Hunterian 
 theory which has attracted most attention is the Essay which Dr. 
 Braxton Hicks presented to the Obstetrical Society in 1873. 
 
120 DEVELOPMENT OF THE EMBRYO AND FOETUS. [CHAP. 
 
 CHAPTER VII. 
 
 DEVELOPMENT OF THE EMBRYO AND FCETUS. 
 
 DEMONSTRATION OF EMBRYONIC STRUCTURES — CHARACTERISTICS AND DEVELOP- 
 MENT OF THE FCETUS AT THE TERMINATION OF EACH MONTH OF PREGNANCY, 
 FROM THE THIRD ONWARDS — DIMENSIONS OF MATURE CHILDREN — OF THE 
 PRESENTATION AND ATTITUDE OF THE CHILD IN THE WOMB — CAUSES OF 
 CRANIAL PRESENTATION: THEORIES OF "PHYSICAL GRAVITATION," " VOLI- 
 TION, " AND "REFLEX ACTION" — THE FCETAL CRANIUM: SUTURES: FONTA- 
 NELLES : DIAMETERS — DEFINITION OF THE TERM "VERTEX" — FUNCTIONS OF 
 THE FCETUS : CIRCULATION : RESPIRATION : NUTRITION : SECRETION. 
 
 The term Foetus is, according to usage, not applicable to the product 
 of conception, until the termination of the third month of gestation. 
 Till then it is termed the Embryo. A study of the formation of the 
 various embryonic structures is a subject which, in so far as human 
 development is concerned, is beset with many difficulties. Viewed, 
 however, in the light which comparative physiology has thrown upon 
 it, our knowledge of the various organs of which the individual is 
 composed, and of their growth from primal elements, may be considered 
 as tolerably complete. The opportunities which arise of examining 
 the bodies of women who die in the earliest stages of pregnancy are so 
 few, that a very peculiar interest attaches to such reliable descriptions 
 and representations as have hitherto been made. Among all these, 
 none perhaps have received more unqualified commendation than the 
 well-known drawings of Coste, from which the representations which 
 follow have chiefly been taken. To attempt a demonstration, or even 
 a narrative of the development of individual organs, is only suitable to 
 a systematic treatise on Embryology. A very superficial description 
 will serve our purpose here, and may suffice to show, more clearly than 
 is possible by any means other than actual dissection, the relations 
 which the various parts of the ovum bear to each other, and to the 
 maternal structures with which they are in contact. 
 
 The accompanying representation of the product of an abortion about 
 the twenty-fifth to the twenty-eighth day, shows the embryo and its 
 membranes partly dissected, and magnified about seven times and a 
 half. The Chorion, which has been opened in its whole extent, is 
 recognized by its villi externally, and the numerous bloodvessels on its 
 internal surface. Above, and to the left, is seen the umbilical vesicle, 
 w r ith the branches of the omphalo-mesenteric vessels coursing upon it. 
 It lies, as has already been shown, between the chorion and the amnion, 
 and its long narrow r pedicle bearing the vessels is seen to pass into the 
 umbilical cord, and, finally, to terminate at the summit of the single 
 
VII.] 
 
 STRUCTURE OF THE EMBRYO. 
 
 121 
 
 curve which marks the commencement of the intestinal convolutions. 
 The right omphalo-mesenteric artery is close below the intestinal canal, 
 and included in the rudimentary mesentery. The left omphalo-mesen- 
 teric vein (v) is passing towards where the stomach is beginning to 
 
 Fie. 67. 
 
 Ovum opened, and embryo partly dissected. 
 
 develop, to discharge itself into the common trunk of the umbilical 
 veins. This is the commencing vena portse. The amnion (m wi) has 
 been freely opened to allow the embryo to escape, the caudal extremity 
 being still within its cavity. The manner in which it is reflected to 
 form the sheath of the umbilical cord is very clearly shown. The 
 umbilical cord is opened in its whole extent to show its contents, in- 
 cluding the canal of the urachus (pedicle of the allantois), which 
 extends from the caudal extremity of the alimentary canal, closely ac- 
 companied by the umbilical vessels, and terminates at w in a cul-de-sac. 
 On either side are the umbilical arteries and veins, the arteries spring- 
 ing from the lower part of the aorta, and the veins passing upwards, to 
 unite before entering the liver and mix their contents with the general 
 circulation, at the point of confluence (o), beneath the heart. The vein 
 of the left side, which may be observed passing through the centre of 
 
122 
 
 DEVELOPMENT OF THE EMBRYO AND FOETUS. [CHAP. 
 
 Fig. 68. 
 
 the mesentery, is the permanent one, and is already much larger than 
 its fellow of the right side, which has been cut across at p p. The 
 heart (h), with its four cavities and the aortic bulb, is separated from 
 the liver by an imperfect diaphragm. The Wolffian 
 body of the right side (w) is shown passing from 
 the heart to the inferior extremity of the intestine. 
 Along its outer margin runs its excretory duct, 
 which opens, along with its fellow of the other 
 side, into the cloaca behind the rectum. The 
 greater relative size of the cephalic extremity of 
 the embryo is a striking peculiarity which at 
 once attracts attention. The rudimentary eye 
 (a) is remarkable, chiefly in respect of its lateral 
 position. In front of it is the right nasal fossa, 
 and below it, at e, is the earliest trace of the in- 
 ternal ear. The large bucco-nasal cavity, with 
 the three branchial arches beneath it, also attract 
 special notice. 
 
 Fig. 68 shows the same embryo magnified eleven 
 times, carefully dissected, and seen from before. A 
 portion of the intestinal convolution and of the 
 mesentery has been removed, along with the an- 
 terior thoracic and abdominal walls, and the um- 
 bilical cord, so as to bring into view the most of 
 the Wolffian bodies on each side, and the heart. 
 
 This representation shows more clearly the 
 lateral position of the eyes (a), and the distance 
 between the nasal fossa? (/), which are seen to 
 communicate with the buccal cavity by a simple 
 furrow. Between a and / are the rudiments of 
 the superior maxillary bones. There is complete 
 absence of all trace of palate. The position of 
 the auricles, ventricles, and aorta, and the relation 
 which these parts bear to each other at this age, 
 are also more obvious from this point of view. 
 Hidden to some extent by the heart, and sepa- 
 rated from it by an incomplete diaphragm, is the 
 liver (I), which is of equal size on the right and 
 left side, and presents a fissure on its lower surface; it covers and con- 
 ceals the stomach. The vessel which is seen in section within this 
 fissure (m), is the common trunk of the umbilical veins. To the left, 
 within the curve of the intestine (i), is the left omphalo-mesenteric vein 
 (v), the one which, being permanent, ultimately becomes the vena 
 porta?. Below the alimentary canal, and within the mesentery, is the 
 right omphalo-mesenteric artery (o). 
 
 Extending downwards from the lower surface of the liver to the 
 caudal extremity of the embryo, are seen on either side the Wolffian 
 bodies, with their excretory ducts close to their external borders. The 
 white band running along their inner margin is the rudiment of the 
 internal generative organs. Between these parts is the divided mesen- 
 
 4 
 
 The same embryo, further 
 dissected. 
 
VII.] 
 
 STRUCTURE OF THE EMBRYO. 
 
 123 
 
 Fig. 69. 
 
 tery, connected inferiorly with the alimentary canal (i). Immediately 
 below this, the transverse slit shows a section of the cavity of the ura- 
 chus, while the vessels which along with it form the umbilical cord are 
 seen to surround it, the veins being below the arte- 
 ries. It will be observed that one vein is already 
 smaller than the other, and would ultimately have 
 become obliterated. The buds or rudiments of the 
 superior and inferior extremities are quite distinct; 
 p is the common orifice of the genito-urinary system. 
 
 Fig. 69 shows the branchial apparatus, rudimen- 
 tary lungs, stomach, and liver, from behind. Above, 
 is the inferior maxilla, the two lateral halves of 
 which have already united in the middle line. Be- 
 tween this and the superior branchial arch is the 
 rudiment of the tongue. From above downwards 
 are the first, second, and third branchial arches, sepa- 
 rated from each other by slits or apertures {branchice). 
 Into the pharyngeal cavity which is thus exposed, 
 the branchial apertures, the oesophagus, and the 
 glottis open. The origin of the glottis is an oval 
 eminence with a slit, which is indicated at b : c c are 
 the rudimentary lungs pressed against the oesopha- 
 gus, the right being lower than the left: (s) the 
 stomach, at this period vertical in direction, and 
 forming, with the oesophagus and alimentary canal, 
 a nearly straight tube : ( I) the liver, formed on either 
 side of two nearly equal lobes, with a large furrow 
 accommodate the stomach. 
 
 In Fig. 70 the heart is seen from behind. The 
 preserved in order to show the relation, in size and position, which 
 they bear to the heart, (a a) Auricles, the right being 
 evidently more developed than the left, (v v) Ven- 
 tricles, the left larger than the right. 
 
 Posterior view of bran- 
 chial apparatus, etc. 
 
 between them to 
 
 ungs have been 
 
 The 
 
 large vessel in the centre is the trunk common 
 
 Posterior view of foetal 
 heart. 
 
 to the omphalo-mesenteric, umbilical, and azygos 
 veins. That to the right in the figure is common 
 to the superior azygos vein (superior cava of the adult), 
 and the inferior of the right side; the smaller trunk 
 to the left is common to the azygos, superior and in- 
 ferior, of the left side. 
 
 (ce) Section of oesophagus. 
 
 The woman from whom the drawing (Fig. 71) was taken was, as 
 may be inferred from the structure of the os and cervix, pluriparous. 
 She committed suicide about the fortieth day of pregnancy, and her body 
 was subsequently examined at the Morgue in Paris. The anterior 
 wall of the uterus has been divided vertically in its whole length, and 
 the uterus thus laid open. " The cavity of the uterus," says Coste, 
 " was partly occupied by a sort of soft fluctuating tumor, caused by 
 the presence of the ovum at this point. This tumor had externally all 
 the appearance and the organization of the mucous membrane which 
 
124 
 
 DEVELOPMENT OF THE EMBRYO AND FOETUS. [CHAP. 
 
 lined the uterus in the rest of its extent, and was situated on its pos- 
 terior surface in the space between the two Fallopian tubes. The 
 tumor produced here by the presence of the ovum did not yet occupy 
 the whole cavity of the uterus. About the lower third of this cavity 
 was free, so that the interior of the uterus might be reached from the 
 canal of the cervix without encountering any resistance. The internal 
 orifices of the Fallopian tubes were, as well as that of the cervix, per- 
 fectly permeable, which was proved in the clearest manner by the ob- 
 servation of the orifice of the left tube, through which the ovum had 
 passed on its way to the uterus." In order to demonstrate the struc- 
 ture and relation of the parts, a circular incision was first made 
 through the decidua reflexa, and the flap thus formed was turned down 
 towards the internal os. On its inner or everted surface (d), the lacunae 
 
 Fig. 71. 
 
 Dissection of an ovum in situ, about the fortieth day. 
 
 are seen, which have already been described as existing at this period 
 of pregnancy for the reception of the villi of the chorion. The ovum 
 itself was then opened by a crucial incision, and the flaps of the chorion 
 (c c) turned aside, so as to show the amnion (a). Through the walls of 
 the latter membrane, the embryo is seen floating freely in the liquor 
 
VII.] GROWTH OF THE FCETUS. 125 
 
 amnii. The short and thick umbilical cord is observed passing from 
 its ventral surface to that part of the surface of the chorion where the pla- 
 centa would afterwards have been found. The situation of the umbili- 
 cal vesicle in the cavity between the chorion and the amnion (a point 
 which the student has occasionally some difficulty in understanding) 
 is here very satisfactorily shown, and also the long pedicle which pene- 
 trates the umbilical cord, and through which communication with the 
 intestinal cavity of the embryo is still for a time kept up. The amnion 
 is not yet of sufficient size to fill the cavity of the chorion, which still 
 contains a portion of the vitriform substance (magma reticule of Vel- 
 peau). This substance gradually disappears as the ovum increases in 
 size, becomes compressed, and ultimately is reduced to a layer of ex- 
 treme thinness when the amnion and chorion come into contact, when 
 all but a trace of the umbilical vesicle disappears. 
 
 After the development of the placenta is completed, and the villi of 
 the free surface of the chorion have been absorbed (as some suppose, 
 by a process of fatty degeneration), not only does the cavity between 
 the chorion and the amnion disappear, but that which exists between 
 the decidua vera and the decidua reflexa is also gradually encroached 
 upon by the growth of the embryo. When these membranes finally 
 adhere, that cavity, too, is obliterated; and now, for the first time, the ) 
 product of conception may be said to occupy the whole cavity of the ^ 
 uterus. These changes are completed in the course of the third month. 
 
 At this period, the foetus measures, in length, from five to six inches, 
 and weighs about four ounces; and the development of its limbs and 
 other parts has advanced to such an extent, that the external parts 
 may be said to be completely formed. The head, although still, rela- 
 tively, of great size, is so in a much less degree than at an earlier 
 period. The various cavities are completely closed. The formation 
 of the palate, and the completion of the superior maxillary bones, has 
 divided the bucco-nasal cavity. The branchial arches have disappeared 
 as early as the fifth week, with the exception of one fissure which has 
 developed into the external ear. The umbilical cord is already longer 
 than the embryo, has assumed its characteristic spiral form, and is at- 
 tached considerably below the middle point of the vertical measure- 
 ment of the child. Previous to this, a loop of intestine occupied a 
 portion of the cord, but this is now included, by contraction of the 
 umbilicus, within the abdominal cavity. When that condition is per- 
 manent, umbilical hernia is the result. The globe of the eye is seen 
 through the eyelids, and the pupillary membrane may be seen filling 
 up the aperture of the iris. The nails have commenced to form, but 
 are very thin, and almost membranous. The sexes are distinct. 
 
 At the end of the fourth month 1 the length of the foetus will be found 
 to have increased to from 6J to 7| inches, and its weight to nearly 9 V 
 ounces on an average. On examining the head, the fontanelles are 
 found to be of great size, and the sutures apart. Hair makes its ap- 
 pearance on the scalp, in the form of a slight down, which may also 
 
 1 The expression, "at the month," is very loosely employed by many wri- 
 ters. When weeks are not mentioned, it is used in this work as meaning the com- 
 pletion of the calendar month of the pregnancy. 
 
12G DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 
 
 be noticed, in a still more delicate form, on the general surface. Fat 
 begins to be deposited in the subcutaneous tissue. The muscular 
 movements are brisk, although they may not yet have been recognized 
 by the mother ; and, in abortions which take place at this epoch, the 
 movements are not only vigorous at the moment of birth, but may 
 continue for several hours afterwards. 
 
 With the completion of the fifth month, the length of the body will 
 
 V usually be found to have increased to from 8 to 10 inches, and its 
 weight to from 10 to 12 ounces, or even more. 
 
 At six months, it is from 11 to 12J inches, and weighs something 
 
 ' more than a pound avoirdupois. The growth of the hair has consider- 
 ably advanced, and, in addition to that on the scalp, the eyebrows and 
 eyelashes are also beginning to form. On the surface of the body, the 
 cutaneous structure now becomes more distinct, and the cutis vera and 
 epidermis may usually, on careful dissection, be separated. The invari- 
 able wrinkling of the surface is the result of the minute quantity of 
 subcutaneous cellular tissue which is developed up to this time, in pro- 
 portion to the other structures. In the male, the scrotum is very small 
 and empty. The nails are already solid. 
 
 \y In the course of the seventh month the foetus is from 12J to 14 inches 
 in length. The bulk becomes, from this period, steadily increased, by 
 the deposition of subcutaneous cellular tissue, and the development of 
 various organs ; but as the extent of this varies very greatly in differ- 
 ent cases, it is difficult to say what should be stated as the average 
 weight of this period. The bones of the cranium, — in which the pro- 
 cess of ossification has already considerably advanced, — become more 
 prominent, and the intervals between them less. It is usually said, 
 that about this time the pupillary membrane disappears ; but this is a 
 question in regard to which very considerable discrepancy of opinion 
 has arisen. Velpeau denied the existence of the membrane in the 
 human species at any period, but the opinion usually entertained in 
 regard to this point, is that which we have mentioned, — that it exists 
 during pregnancy, up to the termination of the seventh month, and 
 then disappears. More modern observations have, however, shown 
 that it is incorrect to suppose that this membrane is lost at the time 
 mentioned, but that it loses its vascularity in a great measure, and is 
 so transparent that great difficulty is experienced in its demonstration. 
 "In every instance/' says Mr. Jacob, 1 "where I have made the exami- 
 nation, I have found the membrana pupillaris existing, in a greater or 
 less degree of perfection, in the newborn infant, — frequently perfect, 
 without the smallest breach, sometimes presenting ragged apertures in 
 several places, and, in other instances, nothing existing but a remnant 
 hanging across the pupil like a cobweb. I have even succeeded in in- 
 jecting a single vessel in the membrana 'pupillaris of the ninth month." 
 The eyelids now commence to open, and the testicles to descend in the 
 scrotum . 
 
 By the end of the eighth month, the increase in the bulk of the child 
 and its general plumpness become very obvious, and this is shown still 
 
 1 Cyclopaedia of Anatomy and Physiology. Art. " Eye." 
 
VII.] THE FCETUS IN UTERO. 127 
 
 more clearly by taking its weight and measurement as before, when it 
 will be found that whereas the longitudinal measurement has not in- 
 creased beyond 17 inches, and is probably less, its weight will have 
 reached 4 to 5J pounds. The skin is now red in color, is no longer 
 wrinkled, and is covered with down. Upon its surface is observed, in 
 greater or less quantity, little masses of curdy or sebaceous matter, — 
 a substance which is not of new formation, although it has become 
 much more abundant. It may be noticed as early as the fifth month. 
 The scrotum now contains one testicle, usually that of the left side. 
 v On the birth of the child at the termination of pregnancy, it will be 
 'found to measure from 19 to 24 inches, and to weigh about 100 to 130 
 ounces (say, on an average, about 1\ pounds avoirdupois). The um- 
 bilicus was at one time believed to mark, at the full term, the middle 
 point of the body, but the careful observations of Moreau and Olivier 
 d'Angers show that this is not the case, but that the middle point is 
 generally about three-fourths of an inch above the umbilicus. With 
 the complete development of the child, there is, of course, increased 
 thickness of the nails, and a considerable addition to the adipose tissue, 
 which sometimes, indeed, is so considerable in quantity, as to raise the 
 weight of the infant considerably above what has been set down as the 
 average, and that without any corresponding increase in its length. 
 
 Many fables have been narrated as to children which have been born 
 weighing 20 to 30 pounds, and being 3J to 4 feet long. Twelve pounds 
 is looked upon as a very great and unusual weight for a child at birth, 
 but there are in this country few practitioners of experience who have 
 not seen one or more such cases. In 4000 cases in the Maternite 
 Madame Lachapelle only found one child which weighed 13J pounds. 
 Dr. Rigby says that Sir Richard Croft delivered a living child 15 
 pounds in weight. Mr. Owens delivered a woman of a stillborn 
 child 1 which weighed 17 pounds 12 ounces. Another case of a still- 
 born child which was said to weigh 19 \ pounds is given by Cazeaux, 
 but the weight was not taken by himself, and he seems to admit a 
 doubt of it. Putting aside increased dimensions from disease, the 
 above may be received as the extremes of authentic cases. It must be 
 remembered, however, on the other hand, that many children, even at 
 the full term, weigh much less than the average ; but it is a recognized 
 fact that, if the child be mature, it rarely survives if it weighs less 
 than 5 pounds at birth, although its chance is considerably greater, if 
 a child of that weight be born prematurely. Female children weigh 
 and measure less than males, and on this point it is said by Burns that 
 12 males are as heavy as 13 females. An interesting observation has 
 been made by Dr. Guy, that " the mean weight of the bodies of still- 
 born children, exceeds the weight of such as have lived one day, by 
 from about \ to somewhat less than J-." In the last months, the size 
 of the placenta becomes greatly reduced in proportion to the develop- 
 ment of the child; thus, at the sixth month, it is nearly half the weight 
 of the child, while at the full term it is but a sixth or a seventh. 
 
 There are few matters of higher importance, with reference to the 
 
 1 Lancet, 1835. 
 
128 
 
 DEVELOPMENT OF THE EMBRYO AND FGETUS. [CHAP. 
 
 relation which the foetus bears to enveloping and contiguous structures, 
 than precision of nomenclature. At the same time, all who have had 
 experience of the matter will confess that such precision, in regard to 
 words which, in their vulgar acceptation, have a more extended signifi- 
 cation, is a matter of no little difficulty. To obviate, as far as possible, 
 any confusion which may arise, we shall here attach to the three words 
 "attitude," "presentation," and "position," a definite meaning to which 
 we shall adhere in the sequel as closely as possible; and it may further 
 be remarked that a clear understanding on this subject has saved 
 German authors from many of the errors and perplexities into which 
 English writers have fallen. By the attitude or posture of the foetus in 
 utero (Haltung) is meant the relation which its head, trunk, and limbs 
 bear to each other; by presentation (Lage) is implied the relation of 
 the long axis of the child to that of the uterus ; while the word position, 
 in its strict and limited obstetrical sense (Stellung), indicates the relation 
 which definite parts of the foetus bear to the anterior, posterior, or lateral 
 regions of the abdominal or pelvic cavities. The varieties of a given 
 presentation, according to the relation which the lowest or presenting 
 part of the child bears to the pelvic canal, constitute the most familiar 
 use of the last-named term. 
 
 Presentation and Attitude of the Child in the Womb. — The shape of 
 the womb being during the whole course of pregnancy more or less 
 oval, the foetus is found to assume from the earliest period a correspond- 
 ing presentation and attitude. In the early months of pregnancy, while 
 the embryo still floats freely in the liquor amnii, and the envelopes of 
 the ovum have not as yet come into contact with the uterine walls, the 
 coincidence of the embryonic with the uterine ovoid is not an essential 
 
 condition ; but, even thus early, the 
 FlG - 72 - ovoid form is being assumed, as is shown 
 
 by the bending forwards, which ap- 
 proximates the cephalic to the caudal 
 extremity. In this attitude, the devel- 
 opment of the trunk and extremities 
 proceeds, and, even at a period when 
 there is still room for the foetus to 
 stretch itself, and extend its limbs, we 
 find it constantly with back and neck 
 bent, and limbs drawn up and flexed. 
 This attitude of the foetus becomes more 
 marked as pregnancy advances; and, 
 ultimately, at the full term, it is very 
 constantly to be observed, as is shown 
 in the accompanying diagram, with the 
 vertebral column bent forwards, the chin 
 inclined upon the sternum, the thighs 
 strongly bent upwards on the belly, the 
 knees bent, and the dorsum of the foot 
 Attitude of the foetus in utero. inclined towards the shin-bone. The 
 
 arms, more or less apart, are bent at the 
 elbows, and the forearms are crossed or folded on the breast. In such 
 
VII.] CAUSES OF CEPHALIC PRESENTATION. 129 
 
 a posture the child best adapts itself to the shape of the cavity in which 
 it is inclosed, and which it pretty nearly fills. 
 
 In no fewer than 96 per cent, of the cases of children born at the 
 full term, the head of the child is turned — as in the figure — downwards 
 towards the cervix of the uterus. The investigation of the causes 
 which give rise to this law in gestation has long attracted the attention 
 of obstetric writers. But, much as has been written on the subject, and 
 ingenious as are many of the theories which have been advanced, it 
 must be confessed that the problem has not yet been clearly solved. 
 Few have prominently noticed the fact above mentioned, that the ovoid 
 form of the foetus is assumed while it is yet the embryo, and before it 
 has been subjected to any influence arising from contact with the uter- 
 ine walls. Manifestly, however, there is a cause, — subsidiary it may 
 be, — which acts thus early on the embryo, to insure its safety at a 
 later stage. But the point which, to the exclusion of others, has at- 
 tracted, in this matter, the greatest amount of attention, is the pre- 
 sentation of the child, and the causes which lead to the inferior situation 
 of the head in such an enormous preponderance of cases. 
 
 The earlier theories which were propounded are more curious than 
 instructive. It was very commonly assumed by the older writers that, 
 in the early months, the head was normally uppermost, and that the 
 sickness of early pregnancy w r as caused by an irritation of the diaphragm, 
 produced by the hair on the scalp. It was, further, believed that about 
 the seventh month the presentation became inverted, and that now, for 
 the first time, the head was normally beneath. 
 
 Of all the theories which have been advanced to account for the 
 presentation of the head, none attracted so much attention, or gained 
 so much credence, as that which led to the opinion that it was due 
 simply to physical gravitation. The foetus, it was said, being suspended 
 by its centre, in the liquor amnii, by means of the umbilical cord, its 
 heavier, or cephalic, extremity must, of necessity, gravitate downwards; 
 and this view was strengthened by the fact, that the point of suspen- 
 sion was not the centre, but actually nearer the caudal extremity. It 
 was obvious to those who refused to accept of this theory, that however 
 it might be held as applicable to the first weeks of pregnancy, such 
 a mechanism could have no share in producing or maintaining the 
 presentation, after the cord had attained a length equal to the diameter 
 of the ovum; and, further, if the theory were correct, that gravitation 
 would be more likely to induce cephalic presentation in the early weeks 
 of labor than at any other time. Every one knows, they argued, that 
 on the contrary, it is not at the beginning, but at the end, of pregnancy 
 that this is most constantly observed, and, therefore, the idea in ques- 
 tion is wrong. Dubois, who took a prominent position in opposing 
 the gravitation theory, further disproved it by some interesting experi- 
 ments, which he made by plunging foetuses in water, and suspending 
 them by the umbilical cord, when he found that it was not the head, 
 but the scapula, or back, which hung downwards, and first touched the 
 bottom of the vessel. And to these arguments it might be added, that 
 the placenta is not always attached to the fundus — which situation could 
 alone admit of such gravitation; and again, that, in the lower animals, 
 
 9 
 
130 DEVELOPMENT OF THE EMBRYO AND FOZTUS. [CHAP. 
 
 the theory of gravitation would place the head at the fundus, whereas, 
 here also, we find the head turned to the os. In women, moreover, 
 who maintain the horizontal position during the whole course of preg- 
 nancy, the cranial presentation is as constant as in other cases. 
 
 An ingenious plea in favor of gravitation, as a cause of the ordinary 
 presentation, has more recently been advanced by Dr. Matthews Dun- 
 can, who energetically controverts the opinions of Dubois, Simpson, 
 and Scanzoni, and who insists, with much propriety, that, in deciding 
 this point, we should always remember that, while the mother is in the 
 erect posture, or when she is lying on her back, the uterus is far from 
 vertical ; that, on the contrary, it is only when the trunk is inclined to 
 the horizon, at an angle of 30°, that the uterus can be said to be ver- 
 tical ; and that the mature foetus is only horizontal when the woman 
 lies upon her side. Dr. Duncan's arguments are of too controversial 
 a character to be usefully epitomized ; but they must be referred to with 
 the respect which they merit, and which they will always command. 
 
 The name of Dubois is, in this particular matter, associated with a 
 theory, the evidence in favor of which is, we must admit, singularly 
 inconclusive. M. Dubois supposed that, in obedience to some instinc- 
 tive impulse, or act of volition, certain movements were, towards the 
 end of pregnancy, executed by the foetus, with the object of bringing 
 the head into the lower segment of the uterus. This renowned obstet- 
 rician derives his chief argument from the harmony which he believed 
 to exist between the object which nature had in view, and the means 
 which she adopts, with a view to secure it. It is more than likely that 
 Dr. Tyler Smith is correct when he surmises that, " had he (Dubois) 
 written after the reception of Dr. Marshall Hall's great discovery of 
 the spinal or physical movements, as distinct from the cerebral or 
 psychical motor actions of the animal economy, he would probably 
 have referred the motor powers of the foetus to reflex action, instead of 
 to instinct or volition." 
 
 The late Sir James Y. Simpson, in a series of admirable papers on 
 this subject, has attempted to prove that the presentation of the foetus is 
 due, in the first instance, to a succession of reflex or " adaptive" move- 
 ments, and that, when it has once assumed the usual presentation, it is 
 maintained in it, when displacement is threatened, by a repetition of 
 similar reflex acts, which rarely fail to insure its reposition. It is in 
 this way, and on this principle, that violent foetal movements succeed 
 such changes in the maternal posture as may lead to the displacement 
 of the foetus ; and he adds, further, that in cases of long cord, and in 
 those in which the quantity of liquor amnii is much above the average, 
 such movements on the part of the foetus are more frequent, and are of 
 greater violence than usual. These last statements are certainly open 
 to doubt. Cazeaux attaches great weight to the form of the uterus, as 
 mechanically inducing the presentation of the foetus in the last months 
 of pregnancy, the broader or breech end of the foetal ovoid being nec- 
 essarily turned towards the fundus, and the smaller, or cephalic end 
 consequently directed to the os. Some consider the child as composed 
 of two ovals, one formed by the head, and the other by the trunk and 
 limbs, and that corresponding to these, the outline of the uterus is 
 
VII.] 
 
 CAUSES OF CEPHALIC PRESENTATION. 
 
 131 
 
 observed to consist of a portion of two ovals, as may be seen by look- 
 ing again at Fig. 72. 
 
 It mast be remembered, however, with reference to these various 
 theories, that it is only in cases at the full term that the head presents 
 in 96 per cent. ; and, with regard to most of the observations which 
 have been made, that they have reference mainly to cases occurring at 
 this period. It is universally admitted, that the earlier the period of 
 the pregnancy, the less constant is the presentation of the child. The 
 following table, founded upon the observations collected by Professor 
 
 Period of Pregnancy. 
 
 Total 
 Cases. 
 
 Presentations of 
 
 Percentage of 
 
 Head 
 Presentations. 
 
 Shoulder. 
 
 Breech. 
 
 Head. 
 
 Before end of sixth month, . . . 
 During seventh month, .... 
 During eighth and ninth month, . 
 At full term of gestation, . . . 
 
 121 
 
 119 
 
 96 
 
 100 
 
 5 
 6 
 2 
 1 
 
 52 
 
 31 
 
 22 
 
 3 
 
 65 
 82 
 
 72 
 96 
 
 52 in 100 
 68 in 100 
 76 in 100 
 96 in 100 
 
 Dubois, at the Maternity Hospital of Paris, has been constructed by 
 Simpson, and is, as he says, sufficient to prove "that the position (pre 
 sentation?) of the foetus, with the head lowest, and over the os uteri, 
 does not begin to be assumed till about the end of the sixth month, 
 and that it is taken up with increasing frequency and certainty fro or 
 that period onwards, to the full term of pregnancy." It must be no- 
 ticed, however, with reference to this table, that, whereas the returns 
 for the first, second, and fourth lines, have reference to children born 
 during the specified period, whether alive or dead, the figures in the 
 
 third line, of children born during 
 the eighth and ninth month, refer 
 
 Fig. 73. 
 
 only to children born dead. 
 
 The reason of the greater variety 
 of presentation in the early months 
 is sufficiently obvious. Not only is 
 the child at this period smaller rel- 
 atively to the cavity which is pre- 
 pared for it, but the form of the 
 cavity itself is such, as compara- 
 tively to encourage changes of the 
 presentation. Until the sixth month, 
 the cavity of the cervix not ha vino; 
 been as yet encroached upon, in the 
 process of development, the child 
 is contained in the cavity proper of 
 the uterus, or rather of the body of 
 the uterus. Most anatomists agree 
 that, up to this period, the cavity is 
 round, and not oval, so that, as in 
 
 the annexed diagram (Fig. 73) a foetus of five months may move much 
 more freely in any direction than is possible at the full time, when it 
 is closely embraced by the pyriform or ovoid womb. 
 
 Uterine cavity at the fifth month. 
 
132 DEVELOPMENT OF THE EMBRYO AND F03TUS. [CHAP. 
 
 It must be confessed, however, that the causes which lead to the pre- 
 sentation of the head constitute a subject still shrouded in no little ob- 
 scurity. The fact being clearly established, we see no need to pin our 
 faith exclusively upon a single theory, particularly as it is more than 
 probable that most, if not all of them, point to individual causes which, 
 acting successively, or in concert, produce the effect which we have been 
 considering. No theory quite satisfactorily accounts for the fact that the 
 embryo assumes its ovoid form at so early a date of development. We 
 know, of course, what Harvey first taught, that " all animals, while they 
 are at rest or asleep, fold up their limbs in such a way as to form an oval 
 or globular figure.' 7 This has been ascribed by modern physiologists 
 to the greater muscular tone and contraction of the flexor as compared 
 with the extensor muscles; but, dating from a period of development 
 antecedent to the formation of muscles properly so called, it is question- 
 able whether even this will throw much light upon the point in question. 
 In regard to the theory of gravitation, as originally promulgated, it is 
 now sufficiently obvious that suspension by the cord cannot be the 
 cause of the usual presentation at the end of pregnancy. It would be 
 too much, however, to assume that gravity exercises no influence upon 
 the foetus; indeed, the experiments of Matthews Duncan and Cazeaux 
 point to a directly opposite conclusion. On the whole, however, we 
 incline to the idea of reflex action, as affording the most reasonable 
 theory which has yet been promulgated; but, far from shutting out the 
 hypothesis of gravitation, we can conceive nothing more likely than 
 that the vital force and the physical law act harmoniously together here, 
 as elsewhere, at the bidding of nature. 
 
 When the foetus is abnormally situated in the womb, the walls of 
 this organ yield, and adapt themselves to the altered circumstances of 
 the case. The bent posture is, however, always maintained, and the 
 foetal ovoid is only distorted, in a marked degree, when the violent 
 pressure of the contracting walls acts upon a misplaced foetus. It is in 
 the ordinary presentation that the ovoid is most regular and marked, 
 the larger pole being upwards, and occupying the expanded fundus, 
 while the smaller is turned towards the vagina. If we take the 
 longest, or bipolar measurement of the ovoid, at twelve inches, the 
 broadest part of the larger end, from the lumbar region to the sole or 
 edge of the foot, will usually be found to be about eight inches, and to 
 correspond to the greatest transverse measurement of the cavity. Ob- 
 viously, therefore, any marked alteration in the attitude or presentation 
 of the child implies distorton of the outline of the womb. The fact of 
 the smaller or cephalic end being only some four and a half inches in 
 its larger or occipitofrontal measurement, has led to the idea which 
 has been frequently expressed, w T ith reference to the mechanism of de- 
 livery, that the child thus placed was a wedge, and that the smaller 
 end dilated the parts for the passage of the larger breech. Nothing 
 can, in point of fact, be more erroneous than this, or more likely to 
 lead to serious practical blunders. For we find that, when the large 
 end presents at the os, labor, far from being retarded, often advances, 
 up to a certain stage, with unusual ease and rapidity, a fact which is 
 owing to the plastic nature of the structures of which it is composed. 
 
VII.] THE FCETAL CRANIUM. 133 
 
 If it were, in any sense, a wedge, the head, or apex of the wedge, would 
 never fail to follow the breech at once, and with ease. But as it does 
 not, and is often extracted only after much suffering, and at great risk 
 to the child, we cannot admit the simile to be a happy one. The fact 
 is, that the smaller end of the ovoid is the really formidable structure 
 in the act of parturition, from its comparatively unyielding nature, — 
 due to the special means which are adopted for the protection of the 
 important nervous centre, upon the integrity of which the life of the 
 infant depends. When the head has passed in safety, it is rarely, in- 
 deed, that there is any difficulty in the birth of the other parts. To 
 the obstetrician, therefore, one of the most important practical points 
 in the study of his art is the thorough comprehension of the foetal 
 cranium, and more especially of its relation to the pelvis, and to the 
 other maternal structures which have already been described. 
 
 The Foetal Cranium. — The bones which compose the cranium and 
 face are found, at the period of delivery, to have reached different stages 
 of development. With a view, no doubt, to the perfect protection of 
 the important organs at the base of the brain,* the bones which form 
 the base of the cranium, and the greater part of the face, are already 
 so fused together as to admit of little or no movement. It is different, 
 however, with the flat bones of the vault. The subjacent parts of the 
 great nervous centre, being less essential to life, admit, with perfect 
 impunity, of a certain amount of compression ; and, in order that full 
 mechanical advantage may be taken of this circumstance, the ossification 
 of the flat bones is comparatively imperfect. The various parts of 
 which the cranium is composed are, of course, familiar to every student 
 of anatomy. It will suffice, therefore, to notice those points only which 
 are of special obstetrical interest. 
 
 The Sutures are, first, the sagittal, which runs along the vertex, from 
 the anterior to the posterior fontanelle. In continuation of this, there 
 runs forwards a suture, which is peculiar to early life, and which is de- 
 scribed by some writers as a part of the sagittal suture. This, which 
 divides the frontal bone into two equal parts, is usually named the 
 frontal suture. The coronal suture marks the line of demarcation be- 
 tween the frontal and parietal bones ; while the lambdoidal suture runs 
 outwards and dowmvards, from the posterior fontanelle, separating the 
 posterior margin of the parietal from the occipital bone, and having 
 thus the appearance of a bifurcation of the sagittal suture posteriorly, 
 it presents some resemblance to the Greek letter from which it takes 
 its name. At the base of each parietal is the suture which unites it to 
 the corresponding temporal bone. 
 
 The ossification of the bones, at all these points of contact, is so in- 
 complete, as to admit of very considerable motion ; and in some situa- 
 tions, — as at the sagittal suture, — the bones overlap each other to such 
 an extent that, by reducing certain diameters, a great mechanical 
 advantage accrues in the act of parturition. The angles of the bones 
 are the points at which the development is least advanced, and it is 
 here that certain gaps are left, where membrane only intervenes be- 
 tween the scalp and the brain, and through which the pulsations of the 
 latter may be observed. These gaps are called the Fontanelles. The 
 
13-i 
 
 DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 
 
 largest, the great or anterior fontanelle, or bregma (Fig. 74, a), is 
 irregularly lozenge-shaped, of considerable size, and easily recognized 
 by the finger during labor. The larger portion of it is in front of the 
 coronal suture, whence it is sometimes continued forwards, almost to 
 the root of the nose. The posterior fontanelle (p) is very much smaller, 
 and is triangular in shape. As the occiput is almost always turned 
 forwards, it is this fontanelle which the finger usually touches in an 
 examination during labor; but in well-developed crania, and more 
 especially where overlapping of the sutures has taken place, it scarcely 
 merits the name of a fontanelle, but is rather a point at which the 
 lambdoidal and sagittal sutures meet. In a digital examination, it is 
 of importance that the accoucheur should be able at once to distinguish 
 between these fontanel les, for it is mainly by marking their situation 
 that he is enabled to recognize the exact position of the head. At first, 
 the student will find some difficulty in ascertaining this, but a little care 
 and attention will soon enable him to overcome the trifling difficulty ; 
 and he will find it useful, when in doubt, to run his finger round the 
 gap, and count the sutures which run into it : in the case of the ante- 
 rior fontanelle, these are four in number, and, in that of the posterior, 
 three only. The tumefaction of the scalp, which is so common an oc- 
 currence in difficult labor, may render such an examination difficult; 
 but in the absence of this, the only circumstance which might mislead 
 him, on a hurried examination, would be the presence of the irregular 
 bones, called ossa triquetra. Some writers describe lateral fontanelles 
 at the inferior angles of the parietal bones, anteriorly and posteriorly ; 
 but these are so covered in by the temporal muscles, that it is only 
 under very exceptional circumstances that their observation can be of 
 any practical moment. 
 
 It must now be obvious that a correct knowledge of the size of the 
 cranium, and the relation which it bears to the pelvis in its various 
 
 Fig. 74. 
 
 Upper surface of foetal cranium. 
 
 Diameters of the foetal cranium. 
 
 diameters, must in no small measure be our guide to intelligent and 
 skilful practice. Numerous measurements have been taken of the 
 foetal cranium, for the most part between points arbitrarily selected. 
 It is, however, only the most important of these diameters with which 
 
VII.] MEASUREMENTS OF FCETAL CRANIUM. 135 
 
 the memory need be charged, viz., the occipito-frontal, the occipito- 
 mental, and the biparietal; and, in addition to these, we shall mention 
 only the trachelo-bi^egmatic and the fronto-mental. 
 
 The Occipito-frontal, or long diameter of the oval cranium, is an 
 imaginary line, extending from the frontal eminences anteriorly to the 
 occiput posteriorly. It is somewhat doubtful what some authors mean 
 in this case by " the occiput/ 7 but there is no doubt that most modern 
 writers, who are exact in the matter, describe it as terminating at the 
 summit of the occiput, or, in other words, at the posterior fontanelle. 
 If, during labor, the attitude of the head in relation to the trunk were 
 the same as in an adult in the erect posture, this would doubtless be 
 correct. But if we recall the fact, that the chin of the child is applied 
 to the sternum, and that the occiput passes into the pelvis considerably 
 in advance of the forehead, it seems more correct to adopt the view of 
 Cazeaux and some others, and draw our line (Fig. 75, a b) to the 
 occipital protuberance. The actual measurement, it is true, is only 
 fractionally greater, but the line indicated is certainly more nearly in 
 coincidence with the plane of the pelvic brim and the upper part of the 
 cavity, than that which is usually described. 
 
 The Occipito-mental is the largest of the cranial diameters, and 
 exceeds that just described, if we make an allowance for an average 
 amount of moulding, by about an inch. It is thus of great importance 
 with reference to the mechanism of parturition, and is represented in 
 the figure by the line o m, drawn from the point of the chin to the 
 posterior fontanelle. The Biparietal diameter (b b, 74) extends #ans- 
 versely from one parietal protuberance to the other. The Trachelo- 
 bregmatic, t t, is from the posterior extremity of the anterior fontanelle 
 to the anterior margin of the foramen magnum ; and the Fronto-mental, 
 b m, from the level of the frontal eminences to the point of the chin. 
 Most of these diameters will be increased or diminished in direct pro- 
 portion to the amount of pressure to which the head is subjected, and 
 the consequent degree of moulding which it undergoes. It is, on that 
 account, extremely difficult to state averages. But, besides, the recog- 
 nized differences which subsist between male and female crania, not to 
 speak of the varieties depending on race, still further increase the diffi- 
 culty. Taking, however, the average of male and female crania in 
 Europe, the following measurements probably come very near the 
 truth, — if at the same time we make due allowance for average mould- 
 ing, which, if we are to estimate the size of crania at the moment of 
 birth, must certainly be done. 
 
 Average Measurement of Male and Female Crania. 
 
 Occipito-frontal diameter, ........ 4§ inches. 
 
 Occipito-mental " ....... C>£ " 
 
 Biparietal " 3 J " 
 
 Trachelo-bregmatic " ....... 3^ " 
 
 Fronto-mental " . . . . . . . 3£ " 
 
 It is scarcely necessary to add, that these measurements refer to cases 
 in which the head is born in the occipitoanterior position. In other 
 cases of abnormal or unusual position, the moulding will be modified 
 
136 DEVELOPMENT OF THE EMBRYO AND F03TUS. [CHAP. 
 
 to suit the requirements of the case, and the diameters will thereby be 
 relatively altered. The same remark applies to circumferential measure- 
 ments, which are usually stated, as regards the occipito-frontal circum- 
 ference, as about fourteen inches, and for the occipito-mental as sixteen 
 inches. According to Dr. Tyler Smith, "the ordinary presenting cir- 
 cumference, which passes under the occiput, and round the parietal 
 bones to a little behind the bregma, is about eleven and a half inches." 
 
 In descriptions of foetal crania, and of cranial positions, the term 
 "vertex" is constantly adopted by English and American writers. 
 Unfortunately, however, this is one of several terms which are so 
 loosely used, that it is necessary to give a definition before venturing 
 to employ them. It is described in. Todd's Cyclopedia as synonymous 
 with the anterior fontanelle; by Dr. Ramsbotham, as a point a little 
 in front of the posterior fontanelle ; by Smellie, as the whole space 
 between the two; and by Schmidt, as a point midway between the 
 anterior and posterior fontanelle. Of all these, the most usual de- 
 scription is that which places the vertex in or close to the posterior 
 fontanelle. The expression " crown " or " vertex" implies that portion 
 of the head which is highest in the erect posture. If so, the vertex 
 can neither be the anterior nor posterior fontanelle, but a point inter- 
 mediate between the two, varying somewhat according to the peculiar 
 formation of different crania, so that it is difficult to determine the 
 exact point. If it were absolutely necessary to describe it as such, we 
 should probably closely approach the truth by placing it with Schmidt 
 at a ^oint midway between the two fontanelles. But if we consider 
 the infinite varieties which obtain in the relative situation of the two 
 fontanelles, as regards the pelvic axes, so that any one point of the 
 sagittal suture may in certain cases present, it then becomes obvious 
 that to the term vertex we must attach a more extended signification, 
 if we would avoid complicated systems of classification. On these 
 grounds we prefer the definition of Smellie, and shall use the term 
 vertex as including the sagittal suture in its whole length, and on either 
 side that portion of the parietal bone (once called os verticis) which lies 
 between the suture and the protuberance. 
 
 Functions of the Foetus. — The Foetus being, during the whole period 
 of its intra-uterine life, separated from the outer world, and immersed 
 in a liquid medium, those functions which, after birth, are discharged 
 under the usual atmospheric conditions, and in consonance with the 
 ordinary laws of nutrition, fall to be performed after a fashion adapted 
 to the peculiar circumstances of the case. We find, therefore, that, in 
 the absence of aerial respiration, certain special modifications of the cir- 
 culatory apparatus have been adopted, with the view of affording that 
 gas to the blood, and that nutritive material to the frame, without 
 which life within the womb would be a physical impossibility. A 
 knowledge of this subject is essential both to the physiologist and to 
 the accoucheur ; and it is only in the light of such knowledge that 
 certain morbid phenomena and faults of development can be under- 
 stood, and possibly, in some instances, obviated. 
 
 The life of the foetus is maintained by an intimate union between the 
 maternal and foetal circulatory systems, a union in which, although 
 
VII.] 
 
 CIKCULATION IN THE FCETUS. 
 
 137 
 
 Fig. 76. 
 
 there is no junction of the two currents, there is ample provision for 
 the mutual interpenetration of gases and fluids, and also for the inter- 
 change of cell elements. We do not allude now to the laws which regu- 
 late the development of the early embryo, but to the union which sub- 
 sists after the development of the organs of connection which have 
 already been described, and which exist in almost all the Mammalia. 
 The lungs of the foetus are, up to the moment of birth, apparently 
 rudimentary. We say " apparently/' because, although in point of 
 size and texture they present little resemblance to the organs of respi- 
 ration, when that function has once been established, they are in the 
 mature foetus already perfect in structure, and only await inflation to 
 become the important organs, the function of which only ceases with 
 life. In the adult, and dating from birth, the circulation is usually 
 described as consisting of two tracts, mutually dependent upon, and 
 yet in a sense distinct from, each other, the systemic and pulmonary 
 channels, through which the whole column of blood continuously and 
 successively flows. In the foetus, however, 
 the function of the lungs being impossible, 
 that portion of the circulatory current which 
 is associated with the function of aerial res- 
 piration is diverted from its course by special 
 conduits, which join the circuit at a more 
 advanced point, the pulmonary system being 
 thus practically nil, although its apparatus 
 is fully prepared against the moment of 
 birth. From the systemic vessels, again, 
 blood passes to the placenta by the umbilical 
 arteries, and returns by the umbilical vein 
 to join the general venous system of the 
 child. As the other functions of the foetus 
 depend chiefly upon the modifications of 
 what we know as the adult apparatus, we 
 may here describe these shortly. 
 
 The Foetal Circulation. — The blood which 
 returns from the placenta by the umbilical 
 vein (Fig. 76, d) is charged with oxygen 
 derived from the mother, so that the term 
 "venous blood " is here, in its ordinary 
 sense, inapplicable. After passing through 
 the umbilicus, the vessel divides. A por- 
 tion of its contents enters the liver, along 
 with the blood which is being returned 
 from the intestines by the vena portse (g), 
 and, after circulating in that organ, enters 
 the vena cava at h. The greater portion of 
 it, however, passes direct to the vena cava, 
 by the ductus venosus (a), which joins the 
 main trunk at a point a little lower than the hepatic vein. The blood, 
 being thus mixed with the systemic venous current, arrives at the heart 
 much more feebly oxygenated than it was at the umbilicus, and passing 
 
 Circulatory apparatus in the foetus. 
 
138 DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 
 
 into the right auricle, is directed by the Eustachian valve towards the 
 foramen ovale, a special aperture through which the blood from the 
 inferior cava is transmitted to the left auricle. From this point the 
 current passes to the left ventricle, and from thence, as in the adult, to 
 the aorta, almost the whole of this supply proceeding to the head and 
 superior extremities by the three great vessels of the aortic arch, to 
 return again to the right auricle by the superior cava. Although a 
 mixture of the two currents from the vena? cava? must, to some extent, 
 inevitably occur, the blood of the superior vein passes, almost in its 
 entirety, through the tricuspid valve into the right ventricle, and thence 
 to the commencement of the pulmonary artery. The condition of the 
 lungs not being such as to receive this large column of blood, another 
 special structure, the ductus arteriosus (r) is interposed, through which 
 the current is diverted, and conducted directly into the descending 
 aorta. Along with a little blood from the left heart, this column passes 
 downwards to the lower part of the body, most of it going to the placenta 
 by the umbilical arteries, from whence, charged with oxygen, it again 
 returns to the vena cava inferior. It will be observed that three 
 special conduits thus exist; two of them, the foramen ovale and ductus 
 arteriosus, being designed with the direct object of diverting the circu- 
 lation from the lungs, while the other serves to connect the vena cava 
 with the umbilical vein. In addition to these, which are completely 
 obliterated after birth, there are the umbilical arteries, which are per- 
 manent in a portion of their course, forming the internal iliac and 
 superior vesical arteries. 
 
 The Lungs enter upon their function immediately upon the birth of 
 the child, and when anything occurs to prevent the speedy occurrence 
 of the respiratory act, the child is stillborn. The sudden inflation of 
 the lungs which thus occurs, and the arrest of the placental circulation, 
 consequent upon the separation of that organ from the mother, give 
 rise to immediate changes in the direction of the current, which are the 
 first steps in the obliteration of the special foetal structures which have 
 been described. The essential phenomenon is the transference of the 
 seat of respiration from the placenta to the lungs. By the consequent 
 development or unfolding of the pulmonary vessels, a vacuum is created, 
 which draws the blood from the right ventricle directly, and for the 
 first time, into the pulmonary circuit. The aorta, lacking thus the 
 important source of supply which it had hitherto derived from the 
 ductus arteriosus, sends a diminished supply of blood in a feeble stream 
 to the umbilical arteries, thus encouraging the stasis of the blood in the 
 foetal portion of the placenta. This causes a diminution, and soon a 
 complete cessation, of the flow of blood outwards through the umbilical 
 arteries, and of its return through the umbilical vein. When the left 
 auricle is sufficiently supplied, by the return of the blood from the lungs 
 through the pulmonary veins, the foramen ovale is closed by the pressure 
 of the blood upon its valve, the closure being further encouraged by 
 the diminution in the supply of blood to the right auricle, which is the 
 necessary result of the arrested circulation in the umbilical vein. These 
 facts make it clear how important it is for the mechanism of the circu- 
 lation, that the establishment of aerial respiration should besimultane- 
 
VII.] RESPIRATION IN THE FCETUS. 139 
 
 ous with the arrest of the placental circulation. It is only upon the 
 complete establishment of the pulmonary circulation, that the distinc- 
 tion between arterial and venous blood can, with perfect propriety, be 
 drawn. There is no longer a mingling of the two currents, and they 
 now assume within their proper vessels the physical characteristics which 
 serve to distinguish them. 
 
 The time at which the obliteration of the foetal apertures takes place, 
 and the order in which they close, are facts of some medico-legal im- 
 portance. Effective closure, if not obliteration, of all of them, will 
 generally be found to have occurred by the ninth day, although they 
 may remain patent for twelve or fifteen days, or even longer, without 
 any inconvenience to the child. The umbilical arteries are usually 
 impermeable from the second day, owing to contraction and thickening 
 of their walls ; the umbilical vein and ductus venosus always close after 
 the arteries, generally about the sixth or seventh day. The ductus 
 arteriosus and foramen ovale are the last to be obliterated, but rarely 
 remain permeable longer than the period above stated. In regard to 
 the latter, it has been said that, while it is the last to close, it is the 
 first to contract. In the embryo, there is but one auricular cavity; 
 but, about the third month, a semilunar valve, containing fleshy fibres, 
 marks the first growth of the partition which ultimately separates the 
 right from the left auricle. Permanence of the aperture may constitute 
 the affection known as Cyanosis. Dr. Tyler Smith is of opinion that 
 the closure of the foetal apertures is, in a great measure, due to the 
 mechanical effect of the inflation of the lungs; and there can be little 
 doubt, we believe, that this contributes to the result, by the pressure 
 which is exercised, in the one direction, by the left bronchus, upon the 
 ductus arteriosus, and, in the other, by the displacement downwards 
 of the liver, upon the umbilical vein and ductus venosus. The changed 
 position of the heart also tends to the closure of the foramen ovale. 
 Another very marked result of the alteration in the circulating system — 
 one which acts somewhat more slowly — is the thickening of the walls, 
 and augmentation in the capacity, of the left heart, which, prior to 
 birth, is subordinate to the right heart in both of these particulars. In 
 three or four weeks this change is very obvious. 
 
 The blood of the mature foetus does not differ materially from that 
 which occupies the vessels after birth ; but, owing, no doubt, to the 
 comparatively imperfect arterialization which takes place in the pla- 
 centa, and the manner in which the two systems mingle, there is not 
 observed that contrast in color which enables us to distinguish arterial 
 from venous blood. As regards the blood of early embryonic life, few 
 opportunities occur in which it can be examined ; but, from what has 
 been observed, it would appear that it is of a dark color, coagulates 
 feebly, is deficient in fibrin, and becomes but little reddened on ex- 
 posure to the atmosphere. 
 
 Respiration. — From what has just been said, in reference to the 
 course of the circulation of the blood in the foetus, it will be obvious 
 that the respiratory function must be carried on in the placenta — the 
 most important of whose functions, indeed, is that of an intra-uterine 
 lung. We need not pause here to discuss exploded theories, as to the 
 
140 DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 
 
 source from which oxygen is derived by the foetus. The researches of 
 Bisch off proved that, even in the embryo, respiration by means of the 
 branchial fissures is impossible, and that, in point of fact, these struc- 
 tures have no connection whatever with this function, as was at one 
 time erroneously supposed by Geoffroy Saint-Hilaire and others. Two 
 facts stand out prominently : first, that a constant supply of oxygen 
 is necessary to the life of the foetus ; and, second, that that supply 
 cannot be obtained directly from the air. Whence, then, is it derived ? 
 
 The full description, which was given in a former chapter, of the 
 structure of the placenta, may suffice for an answer to this question, in 
 so far as regards that period of intra-uterine life during which the 
 placenta exists. But, for the period of embryonic life, some further 
 description is required; and, indeed, there is still, in regard to this 
 point, some necessity for extended research. M. Serres has described 
 two periods — the first of these, which he terms the period of branchial 
 respiration, exists down to the time when the placenta is formed. He 
 assumes that, among the villi of the chorion, there are a certain number 
 (villosites branchiales) which dip into the lacunae of the decidua reflexa, 
 and are there bathed in a special fluid, from which the supply of oxygen 
 is derived until, in the course of development, the second, or placental 
 period arrives. To what extent, if at all, this theory may be admitted 
 as correct, it is at present impossible to determine; nor would it serve 
 any good purpose to enter here upon the discussion of this, or any 
 mere physiological speculation. We shall at once, therefore, assume, 
 as facts hitherto observed entitle us, that from the earliest period at 
 which the necessity of a respiratory function may arise, the essential 
 supply of oxygen is derived from the mother, and passes through the 
 external surface of the ovum, the villi of the chorion, or the villi of 
 the placenta, according to the stage of actual development. The func- 
 tion of respiration involves the interchange of gases; but whether this 
 interchange takes place in consonance with the laws which regulate 
 interpenetration of fluids, or by passing through some intermediate 
 vehicle, as is presumed by Serres, the source of the supply may, in all 
 cases, be assumed to be the same. In point of fact, the respiration of 
 the foetus bears the strictest analogy to the branchial respiration of 
 fishes, in which a membranous structure only is interposed between 
 the blood and the liquid from which the oxygen is to be derived. In 
 the placenta, as we have seen, the parts are so disposed as to bring as 
 large a portion as possible of the two systems, maternal and foetal, into 
 contact. 
 
 That, in consequence of this contact, the blood undergoes important 
 and vital changes is proved by many facts, pathological and otherwise. 
 To compress the cord, is to cause the certain death of the foetus; but 
 more significant even than this is the fact, that after death from this 
 cause, the physiological phenomena of apnoea are invariably developed. 
 There exists, also, a marked respiratory antagonism between the 
 placenta and the lungs. So long as the placental circulation is still 
 uninterrupted, the newborn infant may live without pulmonary respi- 
 ration ; but, so soon as it breathes strongly, the blood no longer passes 
 by the cord, or if it persists to a certain extent, it may at once be stopped 
 
VII.] NUTRITION OF THE FGETUS. 141 
 
 by ligature. But if the child has not breathed, it is always wrong to 
 tie a pulsating cord until aerial respiration has been set up. Finally, 
 the respiratory function of the placenta has been proved by analysis of 
 the blood from the umbilical arteries and veins, that in the vein always 
 showing a comparative abundance of oxygen, although, as already 
 mentioned, the quantity of the gas is not sufficient to establish that 
 marked difference in color, which enables us so readily to distinguish 
 between ordinary arterial and venous blood. 
 
 Nutrition. — This function is intimately associated with that of res- 
 piration. All modern physiologists admit that the nutritive supply 
 comes from the mother, but the exact manner in which it is absorbed, 
 and the proportion in which it passes through various channels and 
 media are points which have given rise to endless disputes, and many 
 hypotheses. It is certain that the nutritive material cannot, at all 
 stages of embryonic and foetal development, pass through the same 
 course in its way from mother to child ; and, in truth, our knowledge 
 of the history of development prepares us for the admission that the 
 plan of nutrition must differ materially according to the stage at which 
 the fertilized ovum has arrived. Even at the very earliest stage, while 
 it still moves freely in the Fallopian tube, absorption from maternal 
 sources may take place by endosmose through its external envelopes, 
 which also admit of penetration by the fertilizing sperm of the male. 
 But, in addition to this, there is a store of material, which we have 
 reason to believe is in a great measure nutritive, contained in the um- 
 bilical vesicle. The quantity of this, and the proportion which it bears 
 to the size of the embryo, is at first very great, but as changes succeed 
 each other within the ovum, in the manner already described under the 
 head of development, the relative quantity dwindles, and the reservoir 
 itself becomes ultimately absorbed, after being drained of its contents. 
 The connection of the umbilical vesicle with the rudimentary intestine, 
 the chemical composition of its contents, and, more significant still, the 
 establishment in its walls of bloodvessels proceeding from the foetus, 
 suffice to prove this position. After the development of the allantois, 
 vessels are carried from the embryo to the chorion : the villi of the 
 latter become enlarged and vascular, implant themselves in the decidua, 
 and thus bring foetal vessels and foetal blood into the closest contact 
 with the mother. Some have even believed that the villi plunge into 
 the utricular follicles, and thence derive their pabulum. 
 
 With the formation of the placenta, this contact becomes localized, 
 and at the same time, owing to the peculiar structure of that organ, is 
 greatly increased in extent. Through the delicate membranes which 
 separate the one system from the other, and in addition to the gaseous 
 supply which constitutes the respiratory function of the placenta, there 
 pass incessantly, in fluid form, materials which go to the building up 
 of the foetal tissues. But it is not alone by a mere endosmose, or by 
 mutual interpenetration, that this nutritive function is carried on, but 
 by a process of intermediate cell-growth, in the course of which, 
 materials are elaborated, with the express object of foetal nutrition. 
 Goodsir's theory on this point is illustrated by the accompanying dia- 
 
142 DEVELOPMENT OF THE EMBRYO AND F03TUS. [CHAP. 
 
 gram (Fig. 77). His observations led him to the conclusion that the 
 blood, in the vessels of the mother, is separated from that in the ves- 
 sels of the foetus, by the intervention of two distinct sets of nucleated 
 cells. One of these, c, belongs to the maternal 
 Fig. 77. portion of the placenta, lies in contact with, 
 
 and external to the ultimate maternal vessels, 
 and is probably designed for the separation 
 from the blood of the mother of the materials 
 destined for the foetus. The other layer,/, lies 
 between the membrane of the foetal villus and 
 the wall of the vascular loop which it contains, 
 the object of these cells being to receive the 
 Diagram illustrating Goodsir's material which has been elaborated on the other 
 theory of foetai nutrition. s \ ( ] e ^ Between the two there is a space, d, into 
 which the materials secreted by one set of cells 
 is poured, in order that it may be absorbed by the other. In this way, 
 it is probable that not only are materials passed from the mother to the 
 foetus, but that, through the same agency, effete or excrementitious 
 matters are transferred from the foetal to the maternal blood. 
 
 Another source from which nutriment may be drawn is the liquor 
 amnii. Substances introduced into the stomach or blood of the female 
 have been found in this medium, as well as in the foetus and placenta, 
 and its analysis has proved it to contain albumen, osmazome, and salts. 
 Besides this, newly born calves have been kept alive by fresh amnionic 
 fluid during a period of fifteen days. This being the case, many theo- 
 ries have been advanced, with the view of proving that nutritive ma- 
 terial passed by this channel from the mother to the foetus. The mam- 
 mary glands, the genital organs, and the alimentary canal, have all 
 been upheld as constituting the mediate channel of communication ; 
 but there can be little doubt that such communication, if it occur at 
 all, is most likely to take place through the entire cutaneous surface. 
 This idea is confirmed in an especial manner by the observations of 
 Brugmans, who found, on removing the embryo from the amnionic 
 pouch in living animals, that the lymphatic vessels of the skin were in 
 an engorged condition, while those of the intestines, the functions of 
 which had yet to be established, were found to be empty. If we admit 
 that these facts establish the belief of nutrition through the liquor 
 amnii, we see no reason to doubt what Scanzoni asserts, that a similar 
 absorption may take place through the Avails of the umbilical cord, and 
 that this would be a more direct way than any to the main channel of 
 the foetal circulation. Beyond all doubt, however, the main source of 
 nutritive supply to the foetus is the placenta, while the liquor amnii 
 may be looked upon as an auxiliary medium, through which, possibly, 
 certain special elements may be admitted. 
 
 Secretions. — The secretions of the foetus are similar in their nature to 
 those which are found after independent existence has been established, 
 but are, according to the period of development, in a more or less 
 rudimentary condition. It is necessary to mention here three only, the 
 Bile, the Urine, and the Meconium. 
 
VII.] FCETAL SECRETIONS. 143 
 
 The Liver is, in proportion to the size of the foetus, and in com- 
 parison with the same organ in adult life, a viscus of great size. Prior 
 to the fifth month, its structure is soft and pulpy, and the gall-bladder 
 has the appearance of a white cord ; but about this period the secretion 
 of the bile commences, the characteristic structure of the liver becomes 
 developed, and the gall-bladder begins to distend. Besides acting as 
 an assimilating organ, by preparing materials for the blood and the 
 tissues, its proper secerning function is to separate the hydrocarbona- 
 ceous portion of the protein compounds, and this function it discharges 
 in the foetus, with special and increasing energy, after the placenta has 
 been fully formed, most physiologists being of opinion that it is by 
 this channel, and not through the placenta, that the carbon and other 
 effete materials are chiefly removed. At the end of the seventh month, 
 the gall-bladder will usually be found distended with bile, and a con- 
 siderable quantity of its contents, charged with carbon, makes its way 
 into the intestine. 
 
 The name meconium is that which has been given to the excremental 
 materials which are contained in the alimentary canal of the foetus. 
 Up to the third month, the inner surface of the canal presents a slight 
 moisture, but about this period the stomach and duodenum contain a 
 small quantity of whitish albuminous fluid. At the beginning of the 
 sixth month the contents of the small intestine will be found to have 
 assumed a deep yellow color, owing to the admixture of bile, which 
 gradually becomes darker in hue as pregnancy advances. The meco- 
 nium now enters the great intestine, and ultimately, about the end of 
 the term, occupies the rectum in considerable quantity, from whence it 
 is ejected in presentations of the breech, and under various other cir- 
 cumstances which need not be here detailed. The meconium, then, is 
 the result of a mixture of foetal bile with the material secreted by the 
 mucous membrane of the digestive canal. 
 
 The Urine is secreted at an early period of intra-uterine life, when 
 the structure of the kidneys is already very considerably advanced. 
 It was at one time supposed that the bladder communicated directly, 
 by the urachus, with a cavity in the allantois, which thus constituted 
 a reservoir for the urine. The allantois, however, in man at least, no 
 longer exists as a cavity at the period when the kidneys form and the 
 secretion of urine begins, so that we are forced to believe that the 
 urine must be evacuated into the amnionic cavity, a fact which seems 
 to have been established bv the discovery of urinary materials in the 
 liquor ainnn. 
 
144 PREGNANCY. [CHAP, 
 
 CHAPTER VIII. 
 
 PREGNANCY : SIGNS OF PREGNANCY. 
 
 PREGNANCY — THE GRAVID UTERUS: MUSCULAR FIBRES OF: MUSCULAR LAYERS — 
 CHANGE IN FIBRES AFTER DELIVERY — DEVELOPMENT AND ANATOMICAL RELA- 
 TIONS OF UTERUS AT VARIOUS STAGES OF PREGNANCY — SIGNS OF PREGNANCY: 
 SUPPRESSION OF THE CATAMENIA — DIGESTIVE DISORDERS: MORNING SICKNESS : 
 SALIVATION — KIESTEIN — CHANGES IN THE MAMMAE: PAIN: ENLARGEMENT: 
 SECRETION OF MILK : AREOLA: CHANGES IN NIPPLE, AND IN GLANDULAR FOL- 
 LICLES : SECONDARY AREOLA — ENLARGEMENT AND EXTERNAL APPEARANCE 
 OF ABDOMEN : FLATTENING IN EARLY MONTHS: CHANGE IN THE APPEARANCE OF 
 UMBILICUS : DIAGNOSIS OF OTHER ABDOMINAL TUMORS — VAGINAL EXAMINA- 
 TION : COLOR: DIGITAL EXAMINATION : VAGINAL PULSE. 
 
 While the ovum undergoes, in the progress of its development, the 
 changes which have been detailed, the organism of the mother is also 
 the seat of important anatomical changes and physiological phenomena. 
 Among these, the changes which occur in the uterus naturally attract 
 very considerable attention. 
 
 The Gravid Uterus, when we compare it with the unimpregnated 
 organ, presents alterations, not only in magnitude, but in structure. 
 Nothing could be more erroneous than the idea of the old physiologists 
 that its development was a mere distension, similar to what takes place 
 when we inflate an india-rubber bottle. There is, on the contrary, an 
 increase in the quantity of its tissue, whereby its weight is progressively 
 increased up to the end of pregnancy ; and there is, moreover, an 
 alteration in the tissues of which it is composed, raising its structure, 
 so to speak, to a higher physiological level. The changes which the 
 mucous membrane undergoes have already been incidentally referred 
 to in connection with the formation of the decidua. In regard to the 
 tissue proper of the uterus, we have found it, in the unimpregnated 
 state, to be composed of interlacing fibres, which are somewhat irregu- 
 larly disposed. Had no opportunity ever existed of examining them 
 in a gravid womb, it would perhaps have been held a bold speculation 
 to maintain that these fibres are muscular elements of the non-striated 
 variety. In the present state of histological science, nothing is more 
 clearly demonstrated than that this is the case, even if the expulsive 
 contractions of the uterus had not pointed to a similar conclusion. 
 This is indicated with great distinctness in the accompanying illustra- 
 tion (Fig. 78), where a, a, are nucleated fibre-cells from the unimpreg- 
 nated uterus. Their embryonic or undeveloped condition shows in 
 marked contrast with cells from the gravid uterus, which are shown 
 in 6, b, c, c, and c, at different stages of development. 
 
 These fibres, which constitute so large a portion of the bulk of the 
 womb, have, from the time of Vesalius, been described by anatomists 
 
VIII.] 
 
 THE GRAVID UTERUS. 
 
 145 
 
 as forming layers; but the contradictory statements made on this sub- 
 ject by the earlier anatomists serve to show FlG 78 
 what may very easily be seen by examin- 
 ing the uterus for ourselves, that the fibres 
 are far from being regular and distinct in 
 their course. This is more especially the 
 case with regard to the unimpregnated 
 uterus ; but when conception has occurred, 
 and the fibres have reached the higher 
 stage of development figured above, not 
 only are the fibres themselves more dis- 
 tinct, but their disposition in layers be- 
 comes more apparent. It must be con- 
 fessed, however, that not even the careful 
 dissections of Hunter and Madame Boivin, 
 nor the microscopic researches of Kolliker, 
 have as yet clearly demonstrated what is 
 the exact arrangement of these layers. It 
 may be asserted, no doubt, in general 
 terms, that the fibres are irregularly dis- 
 posed in this, as in the other hollow viscera, 
 so as to form an external or longitudinal, 
 and an internal or circular group ; but 
 when we come to look at the actual draw- 
 ings upon which these statements are based, 
 we cannot fail to be struck with the fact 
 that, as regards the outer layer, a very 
 small proportion only of the fibres can be 
 truly described as longitudinal. The ac- 
 companying cut (Fig. 79) shows the poste- 
 rior surface of the uterus, from which the 
 peritoneum has been carefully removed, 
 so as to exhibit the external layer of the 
 muscular tissue. It will be observed that 
 the fibres appear to proceed from the sides 
 of the uterus, where they are continuous 
 with those which pass along the round 
 ligament, the broad ligament, the ligament 
 of the ovary and the Fallopian tube. Their 
 direction therefore is, in the main, trans- 
 verse, and when they reach the middle line 
 some of them pass across, interlacing with 
 their fellows of the other side; while a 
 certain number, according to Cazeaux, turn 
 upwards and downwards, after interlacing, 
 to form the band of longitudinal fibres which 
 is shown in the figure, and which is continu- 
 ous with numerous powerful bundles pass- 
 ing over the fundus. A somewhat similar „., „ , *. \ * * 
 
 j. . . . ■, . n libre-cells of the unimpregnated and 
 
 disposition is seen on the anterior surface. gra vid uterus contrasted. 
 
 10 
 
146 PREGNANCY. [CHAP. 
 
 The inner layer, as described by William Hunter, and before him, 
 though much less accurately, by Ruysch, is that which corresponds to 
 the circular layer of the other viscera. It is thin, and composed of 
 groups of fibres, the general direction of which is transverse, but ar- 
 ranged at either angle of the uterus, in a concentric manner, around 
 the orifices of the Fallopian tubes, as shown in Fig. 80. Other groups 
 
 Fig. 79. Fig. 80. 
 
 External muscular layer of uterus. Internal muscular layer of uterus. 
 
 encircle the middle of the body of the uterus, while others again are 
 described as forming a sort of sphincter surrounding the os uteri. 
 Between these two layers, a third or middle layer is generally described 
 by modern anatomists, as being of considerable strength and thick- 
 ness, with numerous bundles, flattened, and running in all directions 
 in the substance of the or^an. These interlace freely, and surround 
 the vessels of the uterus, so that, when the organ is in a state of con- 
 traction, these vessels must be notably diminished in their calibre. 
 Indeed, there is every reason to believe that it is mainly by their agency 
 that haemorrhage is prevented after the separation of the placenta, the 
 ruptured and gaping orifices of the utero-placental vessels being there- 
 by closed. 
 
 Inseparably connected with the subject which we are now consider- 
 ing, is that of the involution of the uterus, or that process whereby the 
 organ returns, after delivery, to a size and structure approaching that 
 of the unimpregnated state. That the uterus, in a short time, is reduced 
 in weight, from about twenty -four ounces to two, involves the certainty 
 that rapid absorption takes place under very special conditions. How 
 this takes place has been indicated by many physiologists, but by none 
 has it been demonstraed so clearly as by Kolliker. The enormous fibre- 
 cells which exist at the termination of pregnancy, are now huddled 
 together in contraction, and, their function being over, absorption takes 
 place, under favorable conditions, with great rapidity. They become 
 the seat of rapid atrophy, and fatty degeneration, and the whole mass 
 of the muscular tissue becomes soft and friable. The separation of 
 individual fibres for microscopic examination is, on this account, not 
 easy ; but if successfully removed, they will be found as represented in 
 Fig. 81, where the appearance presented by them a fortnight after de- 
 
vin.] 
 
 THE UTERUS DURING PREGNANCY. 
 
 147 
 
 livery is shown at a. About the fourth week, the development of new 
 fibres in various stages b, may also be observed. A large portion of 
 the fatty and disintegrated matter is removed by the vagina in the 
 lochial discharge; and a proportion still larger is probably absorbed 
 into the circulation, and discharged ultimately from the system by the 
 ordinary excretory channels. The latter has been supposed to contrib- 
 ute to the formation of the caseous matter in the milk first secreted. 
 
 That portion of the peritoneum which invests the uterus and neigh- 
 boring parts, is evidently so disposed in the unimpregnated state, as to 
 admit of free extension during pregnancy. ' It is in this way that the 
 
 Fig. 81. 
 
 Fig. 82. 
 
 Degeneration of fibre-cells after 
 delivery. 
 
 Diagram, showing development of uterine cavity. 
 (After Schultze.) 
 
 broad, as well as the anterior and posterior ligaments unfold themselves, 
 as the uterus slowly develops, until, at last, they entirely disappear. 
 But it is not by a mere mechanical process such as this, that the serous 
 covering of the womb adapts itself to the exigencies of the pregnant 
 state, but, in addition, by an actual hypertrophy of its tissue. Were 
 the former alone the case, the extension thus furnished would not be 
 possible without thinning of the membrane; but as we invariably find 
 that, at the very end of pregnancy, the membrane in question is as 
 thick as before, we infer, that in this case, as in large hernia? and cer- 
 tain other morbid conditions, the serous, as well as the muscular and 
 mucous coats of the womb, undergo marked hypertrophy. 
 
 The development of the ovum within the womb, the various stages 
 of which we have traced, is necessarily accompanied by a corresponding 
 increase in the volume of the uterus, and by marked changes in its 
 anatomical relations. In the shape of the organ there is, from the first 
 weeks, a marked alteration in respect of the antero-posterior flattening ; 
 and, as the pregnancy advances, the general form approaches more a 
 
148 PREGNANCY. [CHAP. 
 
 spheroidal than a pear shape. From the twelfth to the twenty-fourth 
 week, the cavity assumes more and more of a rounded appearance, but 
 still retaining a certain amount of the antero-posterior flattening, and 
 its length is also somewhat greater than its width ; but, speaking in 
 general terms, the cavity of the uterus may, at the last-named period, 
 be described, as it is shown in the diagram (Fig. 82), as circular. Dur- 
 ing the remaining sixteen weeks of gestation, the rounded shape of the 
 uterine cavity becomes changed into an oval, so that at the end of preg- 
 nancy the womb is about twelve inches long, nine broad, and eight 
 I from before backwards. This change is brought about, as has gener- 
 ally been believed, by an invasion of the canal of the cervix, which 
 takes place now for the first time, and which acts from above down- 
 wards. The numbers 30, 36, and 40, are supposed to represent, by 
 the dotted lines, the extent to which, at these weeks, the uterine cavity 
 has increased at the expense of the cervix. The crosses mark upon 
 the uterine wall the site of the original os internum. To this subject, 
 and more particularly to the state of the os and cervix as a sign of preg- 
 nancy, we shall revert. 
 
 These alterations in the form of the uterus, must needs be accom- 
 panied by changes, no less marked, in its situation and anatomical rela- 
 tions. During the first twelve weeks of gestation, the womb remains 
 within the true pelvis, or cannot, at least, be felt above the pubes ; 
 although, on pressing the fingers somewhat deeply, it may be readily 
 discovered. Seeing that the fundus is originally very near the level of 
 the brim, it follows that the considerable increase in bulk which these 
 weeks bring must find room in another direction. We find, therefore, 
 that the development, under the circumstances, goes on in a downward 
 direction, and that the os and cervix are discovered, on examination, 
 to be much nearer the floor of the pelvis than they were before impreg- 
 nation. It thus obeys, so far, the laws of gravity, and the weight of 
 the intestines resting upon the fundus may, in some measure, contribute 
 to the result. The progress of foetal growth soon renders it impossible 
 for the uterus and its contents to remain longer within the pelvis; and 
 if under peculiar circumstances, it be so, the safety, both of mother and 
 child, is immediately endangered. The presence of the rectum on the 
 left side is assumed by many to be the cause of a change in the ana- 
 tomical relations of the uterus, which very generally takes place, and 
 which consists in a deviation of the fundus to the right side. In the 
 course of the fourth month, the fundus can usually be felt by the fin- 
 ger of the accoucheur, above the pubes. The level which it attains 
 at various periods of pregnancy depends upon the condition of the ab- 
 dominal walls, and upon many other circumstances which render exact 
 statements upon this subject impossible. Very generally, it will be 
 found to have attained the level of the umbilicus some time in the 
 course of the sixth month. About the thirty-sixth or thirty -seventh 
 week, it reaches the level of the xiphoid cartilage ; but between this 
 time and the end of pregnancy, it falls downwards and forwards, pre- 
 paratory to the phenomena of parturition. 
 
 In rising from the pelvis, and going through the succeeding stages 
 of its development, it is easy to understand how the uterus, with a ten- 
 
VIII.] EARLY SIGNS OF PREGNANCY. 149 
 
 dency towards the right side, will be still more encouraged in its move- 
 ment in that direction, by the prominence of the vertebral column in 
 the middle line. Or, if we reject the theory of the influence exercised 
 by the rectum, we still see, in the relations which subsist between the 
 expanding uterus and the vertebra?, a sufficient cause for deviation 
 from the middle line. And it is certain that, in a large proportion of 
 cases, this deviation is to the right side. 1 If we reflect that the line 
 which represents the axis of the uterus, is nearly coincident with the 
 axis of the brim of the pelvis, and remember the marked projection 
 of the lumbar vertebra?, we shall have no difficulty in appreciating the 
 causes which lead to the uterus being in immediate contact with the 
 anterior abdominal wall, so that it is a rare occurrence when we find 
 any portion of the intestines intervening between the abdominal and 
 uterine walls in this situation. At the termination of pregnancy, then, 
 the uterus, with the ovaries, Fallopian tubes, and other structures 
 closely applied to its sides, occupies a great part of the abdominal cav- 
 ity. Its usual relations are as follows : in front with the vagina, the 
 neck and posterior wall of the bladder, and the anterior abdominal 
 wall ; behind, with the rectum and the promontory of the sacrum 
 below, and the mesentery and the intestines above ; on the right, by 
 the caecum and the right abdominal wall ; and, on the left, by the 
 sigmoid flexure of the colon, and, usually, the great bulk of the small 
 intestines. 
 
 Signs of Pregnancy. — The development of the womb, and that, al- 
 ready described, of the germ which it contains, constitute the essential 
 anatomical and physiological phenomena of the pregnant state. Asso- 
 ciated with it, however, and dependent upon its continuance, are nu- 
 merous other manifestations, which have their seat in organs so remote, 
 that it is difficult, in many cases, to trace the sympathy which exists 
 between them and the special organs of generation. There is, in point 
 of fact, no single function of the whole economy which may not be 
 affected by the operation of a cause which has its centre in the genera- 
 tive organs, and which radiates thence throughout the entire system. 
 Consequently, phenomena are frequently observed in distant organs, 
 which are certainly not associated in function with the womb ; but so 
 constant is the occurrence of these phenomena, that they have come to 
 be familiarly looked upon as among the early symptoms of pregnancy. 
 More important are the symptoms which have their cause and seat in 
 the generative organs ; but in the observation even of these, there are, 
 as in the case of the others, so many sources of fallacy, so many pit- 
 falls of error, that obstetrical writers have uniformly, and with obvious 
 propriety, made a study of the signs of pregnancy, — one of the most 
 prominent objects to which it is desirable that the attention of the 
 student in this department should be drawn. We can conceive no 
 
 1 It has been held, among the causes which have been advanced to account for 
 this displacement to the right, that the weight of the placenta gave rise to it, — it 
 being more frequently, according to Levret, on the right side. The presence of the 
 descending colon on the left, the habitual use of the right hand in preference to the 
 left, and the habit of lying on the right side during sleep, are a few among the many 
 reasons which have been propounded to account for the phenomenon. 
 
150 SIGNS OF PREGNANCY. [dlAP. 
 
 subject in regard to which a mistake might so utterly ruin a young 
 man's hopes, than the determination, in delicate or doubtful cases, of 
 this question of pregnancy. An obvious pregnancy overlooked, be- 
 cause the idea has never crossed the mind, is bad enough ; and we have 
 known a practitioner of thirty years' standing blister the abdomen in 
 the ninth month, under the idea that he was treating a morbid growth. 
 But what is far more inexcusable, is the culpable rashness of those 
 w r ho, without irrefragable evidence of the existence of pregnancy, 
 would venture — as has been done in high quarters — to brand a woman 
 with the stigma of dishonor. To enable the practitioner to avoid these, 
 and similar errors, the symptoms which indicate pregnancy have been 
 arranged, with a view, more especially, of assigning to each its actual 
 diagnostic value, and determining the period at which, in the course of 
 a pregnancy, it is available. We shall find that the number of symp- 
 toms which are of themselves conclusive as evidence of pregnancy is 
 very limited; but the other, and more numerous group, constitute an 
 important chain of circumstantial or corroborative links, which, under 
 ordinary circumstances, enable us to admit the strongest probability of 
 an event which may be either dreaded or longed for. The convictions 
 of a woman whose most earnest desire is to be a mother, and the pas- 
 sionate asseveratious of another whose chastity is called in question, 
 are disturbing elements which tend to throw us out in our calculations, 
 and must always be taken cum grano. 
 
 In classifying the signs of pregnancy, various plans have been 
 adopted, but what seems more rational, and what certainly is much 
 more satisfactory than any attempt at rigid classification, is to take up 
 the symptoms, as nearly as may be, in the order in which they are 
 manifested. The earliest of all the symptoms have their seat in the 
 generative organs, but are of little value from a practical point of view, 
 inasmuch as they consist in physiological and anatomical manifestations 
 which are almost entirely beyond our ken. It is certain that the fer- 
 tilized ovum, on its arrival within the cavity of the uterus, finds that 
 organ in a condition suitable for its reception. Probably the condi- 
 tions which we have seen to exist, in ordinary healthy menstruation, 
 as regards the tissues of the womb, are, under the special circumstances 
 of conception, prolonged, and ultimately pass, by a series of develop- 
 mental changes, some of which have been described, into those which 
 are characteristic of the more advanced stages of pregnancy. Or, sup- 
 posing even the uterus to be quiescent, and not under the influence 
 either of a past or of an impending menstrual molimem, we may as- 
 sume that one of the earliest effects of impregnation is a marked con- 
 gestion and hypertrophy of all the uterine structures ; changes which, 
 though easily enough demonstrated after death, are not so easily ap- 
 preciated during life, and are in reality of little actual diagnostic value. 
 Still, the increased weight and heat of the uterus, the increased resis- 
 tance in the upper and anterior wall of the vagina, — due, it has been 
 said, to a slight anteversion of the womb usual at this period, — may, 
 along with other symptoms, excite in the mind of the experienced 
 practitioner suspicions which, under other circumstances, might not 
 have arisen. 
 
VIII.] SUPPRESSION OF CATAMENIA. 151 
 
 Suppression of the Catamenia is generelly the first symptom which 
 attracts the attention of a woman who admits to herself the possibility 
 of impregnation. Although this undoubtedly is a remarkably constant 
 occurrence, it is by no means invariable. It has, however, a special 
 interest, apart from its value as a sign of pregnancy, in the fact that it 
 is' from the last appearance of the menstrual flow that women are in 
 the habit of calculating the period at which the birth of a mature 
 child will probably take place. What detracts more especially from 
 its value as an evidence of impregnation, are the remarkable aberra- 
 tions which, under such circumstances, not unfrequently occur. It is 
 far from bejng a very uncommon occurrence that, during the early 
 months of pregnancy, the catamenia, or at least a periodical sanguin- 
 eous discharge, makes its appearance much as usual. Cases in which 
 this occurs up to the fifth or sixth month, are of much less frequent 
 occurrence; and fewer still are the instances in which, from the begin- 
 ning to the end of pregnancy, the menstrual discharge apparently goes 
 on as usual. Probably, Moreau is correct in assuming that, in these 
 cases, the source of the discharge is not the same as in ordinary men- 
 struation ; but, as regards the import of the symptom, this is a mere 
 speculation, and of no practical significance. Cases are on record also 
 in wdiich women menstruated only during pregnancy, menstruated for 
 the first time after impregnation had taken place, or became pregnant 
 without ever having menstruated at all. The last case, which is ex- 
 tremely rare, is analogous to what takes place in those instances in 
 which women who are nursing again become pregnant, without ever 
 having menstruated since the previous accouchement. The converse 
 of these cases, and what goes still further to lessen the value of the 
 suppression of the catamenia as a sign of pregnancy, is to be found in 
 the very numerous examples which occur in every-day practice, of pa- 
 tients in whom the discharge is suppressed, as the result of certain 
 morbid conditions affecting, more or less directly, the generative 
 organs. A similar result may obtain, and that even more frequently, 
 in those instances in which the suppression is the result of constitu- 
 tional causes, in themselves apparently quite independent of the gen- 
 erative functions. And, in a few rare cases, there is a suppression of 
 the menstrual discharge without any appreciable cause, local or gen- 
 eral ; but it cannot be doubted that in these the only peculiarity is, that 
 the cause is hid from us. It should be remembered, as a fact of by no 
 means very rare occurrence, that newly married women may cease to 
 menstruate during several periods, as a result apparently of mere sexual 
 excitement unconnected with impregnation. It is in the highest de- 
 gree probable that these deviations from the normal standard, are due 
 to unusual conditions of the ovary, which in one class of cases we may 
 venture to assume as being unduly stimulated to attempts at ovulation, 
 during a period at which that function should naturally be in abey- 
 ance ; while in another class, its function is arrested by causes which 
 may act upon the ovary, either specially through the generative appa- 
 ratus, or constitutionally through the general system. 
 
 The Digestive Organs are, during a pregnancy, the seat of various 
 derangements of function, evidently depending on the sympathy which 
 
152 SIGNS OF PREGNANCY. [CHAP. 
 
 subsists between these upon the one hand, and the womb on the other. 
 Although the exact period at which such symptoms develop themselves 
 varies greatly, there is scarcely a single case of pregnancy, in which, at 
 some time or other, symptomatic digestive disorders do not manifest 
 themselves. The most frequent of all is nausea, generally accompanied 
 with vomiting, and this symptom being of much more frequent occur- 
 rence in the morning than at any other time of the day, has given rise 
 to the name morning sickness. 
 
 In the absence of any special cause which might give rise to nausea 
 or vomiting, and if the general health apparently remains good, this 
 sign is sometimes of considerable value. It is generally, however, to 
 the early months that this nausea is limited, and it usually terminates 
 \J or is mitigated about the time that the fundus may be observed above 
 the pubes, having commenced probably about the fourth or fifth week. 
 The period of development, and the duration of this symptom, are 
 subject to great irregularities ; in one case, it may be, beginning with 
 the first days of pregnancy, and continuing to the last, while in others 
 it does not commence until an advanced period, when local irritation 
 of the stomach is more likely to be the cause. AVe have seen cases in 
 which, at first, morning sickness was as marked as usual, to this suc- 
 ceeded a period of immunity, extending over several months, the 
 nausea returning with great discomfort to the patient during the last 
 weeks, being probably due in the first instance to sympathy, and in 
 the latter to the effect of proximity of the organs. Associated with 
 the more familiar symptoms of morning sickness, are others which 
 also have their origin in the digestive system, such as heartburn, 
 pyrosis, epigastric pain, and troublesome eructations. Repugnance to 
 various articles of diet, which possibly were relished before pregnancy, 
 or a longing for unusual, and even deleterious or disgusting substances, 
 such as occurs in chlorosis, are by no means unusual symptoms. The 
 symptoms manifested during one pregnancy are no sure criterion of 
 their probable form in another ; for we often find that a woman, who 
 has suffered intensely in her first pregnancy from these digestive dis- 
 orders, is on subsequent occasions remarkably free from them ; nay, 
 it may happen that women, who have never had morning sickness, 
 complain of it for the first time on the occasion of a fifth or sixth 
 pregnancy. All the affections alluded to constitute, when excessive, 
 morbid conditions, and as such fall to be considered as disorders of 
 pregnancy. 
 
 Salivation, although not a symptom of any practical importance, is 
 occasionally so marked in degree as to constitute a prominent feature 
 in the case. In this, there seems to be a special glandular sympathy 
 manifesting itself in a hypersecretion, which may last during the whole 
 term of pregnancy. Under the same category of phenomena which 
 have their origin in the glandular system, we may here notice certain 
 changes in the urine which, since the time of the ancients, have attracted 
 attention as symptomatic of the pregnant state. About thirty years 
 ago, a number of observers directed their attention to the investigation 
 of this subject, but the person whose name is most intimately associated 
 with it is M. Nauche, by whom the name Kiestein was given to the 
 
VIII.] CHANGES IN THE MAMM^. 153 
 
 substance referred to. From the numerous observations which have 
 been made, by him and others, it would appear that the period of 
 pregnancy at which this has been discovered varies considerably ; that 
 it is certainly not present in all cases of pregnancy ; and that it has 
 been discovered in certain morbid conditions which have no relation 
 to the pregnant state. This, of course, reduces the value of Kiestein 
 as a sign of pregnancy to a low level ; but there can at the same time 
 be no doubt whatever, that in a large proportion of cases the substance 
 may be discovered. When the urine is fresh from the bladder, there 
 is no appearance whatever which would enable us to distinguish it 
 from the ordinary excretion. About the third day, or sooner, it com- 
 mences to lose its transparency, and becomes hazy, as if mucus were 
 suspended in it, and, shortly afterwards, distinct traces may be seen, 
 on the surface, of the formation of a pellicle, which is at first thin and 
 transparent, but subsequently becomes much thicker and more opaque. 
 About the third or fourth day, the distinctive characters of this pellicle 
 usually reach their greatest intensity, and little flocculent portions then 
 commence to detach themselves from its under surface, and sink through 
 the liquid to the bottom of the vessel. The whole pellicle ultimately 
 goes through this process, and becomes thus transformed into a whitish 
 deposit which gravitates to the bottom, as did the flocculi first detached. 
 The original pellicle is then replaced by another, which contains, as 
 indeed may the first one, crystals of triple phosphate; the liquid be- 
 comes more turbid, until, finally, the appearances characteristic of 
 pregnancy become lost in the process of putrefaction. Kiestein, then, 
 first makes its appearance in the urine, under the form of a cloud, like 
 cotton in suspension, which is due to the aggregation of little globules 
 which exist in the urine when passed. These subsequently unite, rise 
 to the surface, and constitute the pellicle which we have described. 
 It is said that, when Kiestein is present in the urine, it persists from 
 the end of the first month until delivery ; but the observations of 
 Cazeaux throw much doubt on this assertion, as regards the last six 
 weeks, for he tells us that he examined in 1849 the urine of fifteen 
 women at this stage of pregnancy, without discovering any trace of it. 
 Chemical and microscopical researches seem to show that Kiestein is 
 a new formation, and is an azotized substance, and that it presents 
 itself under the form of minute globules. Whether the theory usually 
 entertained in regard to it, that it is the result of an excretory function 
 of the kidneys, peculiar to the circumstances of the case, is a question 
 which we must in the meantime leave in doubt; but it must be 
 admitted that there are several facts firmly established in physiology, 
 which, from an analogical point of view, give some confirmation to the 
 hypothesis. 
 
 Changes in the Mammce. — The Mammae are, from an early period, 
 the seat of certain symptoms and changes, which are justly looked upon 
 as of great importance. When we reflect on what their proposed func- 
 tion is, we cannot marvel that, even thus early, they become the seat 
 of changes, which are evidently designed with the view of elaborating, 
 and otherwise preparing, these important structures against the time 
 when they will be called upon to discharge the function in question. 
 
154 SIGNS OF PREGNANCY. [CHAP. 
 
 The earliest indications which are given by the mammae of the existence 
 of pregnancy, are certain vague sensations, which are described by the 
 woman as of fulness and weight, but which not unfrequently amount 
 to considerable uneasiness, and even acute pain. This points to the 
 awakened activity of the organs, further evidence of which is soon 
 shown in a considerable increase of volume, due obviously to the greater 
 afflux of blood, which dates from the earliest weeks, and which mani- 
 fests itself at a more advanced period, by the presence of large blue 
 veins, which may be seen coursing under the skin, more conspicuously 
 in women of a blonde complexion. To the touch, the gland seems 
 harder than usual, and here and there may often be felt clusters of 
 enlarged milk vessels, which give the impression of knotting. Towards 
 the end of pregnancy, or, if the distension is extreme, at a much earlier 
 period, silvery white lines are seen upon the surface of the breast, 
 radiating from the nipple as from a centre. These arise from disten- 
 sion of the cutaneous structures, and yielding of the corium at some 
 points, so as to give facility to the expansion due to the growth of the 
 gland. 
 
 The secretion of milk in the breasts has very generally been supposed 
 by the vulgar to be an infallible sign of pregnancy, either past or exist- 
 ing. Nothing can be more erroneous than such a conclusion ; but, at 
 the same time, the presence of milk in the ducts is, when taken along 
 with other signs, often of very considerable importance. It is proper 
 to mention, however, that not only is milk in the breasts no certain 
 sign of pregnancy, but numerous cases are recorded by Montgomery 
 and others, where the breasts of young women who had never been 
 pregnant, and of old women past childbearing, have yielded milk in 
 sufficient abundance to suckle a child. A striking case of this nature 
 was narrated to the writer by Dr. Livingstone, the renowned African 
 traveller, who had so investigated the circumstances as to eliminate 
 even the possibility of doubt. A native woman was delivered of twins, 
 and not being constitutionally very robust, was unable to nurse both, 
 whereupon the grandmother, a woman of sixty, took one infant, when, 
 after repeatedly placing it to the breast, the secretion was so abundantly 
 established, that she proved an excellent nurse. Nay, more than this, 
 there have been cases in which the gland in the male has secreted milk 
 in considerable abundance. 
 
 Surrounding the nipple, and circumscribed by a circle of about three- 
 fourths of an inch radius from its centre, the skin presents, in the adult 
 and unimpregnated condition, a peculiar' appearance, which consists 
 chiefly in an increased depth of color. It is thin and delicate, and 
 presents to the eye the semblance of a structure intermediate between 
 skin and mucous membrane. From its surface, small glandular emi- 
 nences, varying in number from twelve to twenty, or more, may be 
 seen to project slightly. This area, which is called the A?-eoIa, is the 
 seat during pregnancy of changes which are frequently of the greatest 
 importance in strengthening the presumptive proof which may already 
 exist ; but it must always be remembered that changes, closely resem- 
 bling those which we are about to describe, may be produced by causes 
 which have their seat in the generative system, but which are hide- 
 
VIII.] THE AREOLA. 155 
 
 pendent of pregnancy ; and, moreover, that as the changes are to a 
 considerable extent permanent, it is in first pregnancies that they have 
 the greatest diagnostic value. The following are the appearances 
 referred to: If the breast be carefully examined about the ninth week, 
 a considerable increase in the size of the nipple will almost always be 
 observed, this structure having become turgid, and, as it were, erect. 
 Simultaneously with this, or closely succeeding it, there is a deepening 
 in the color of the areola, an increase in its diameter, and a greater 
 prominence and development of the follicles which stud its surface. It 
 participates, obviously, in the increased vascularity of the nipple, and 
 becomes, like it, moist and turgid. The alteration in color, which is 
 due to this turgescence, takes place in all cases ; but it is only in women 
 of dark complexion that the characteristic changes of the areola are to 
 their fullest extent manifested. In these, there is an actual deposit of 
 pigment, and the depth of the color is, towards the termination of the 
 pregnancy, not unfrequently such as to present a most striking and 
 peculiar appearance. Examination of the follicles has shown that they 
 are possessed of excretory ducts, through which their secretion may, 
 under certain circumstances, be expressed. 
 
 At a period not earlier than the fifth month, there may generally be 
 observed, in women in whom the areola is deep in color, some trace of 
 
 Fie. 83. 
 
 
 
 
 Areola, and secondary areola of pregnancy (seventh month). 
 
 what Montgomery has described under the name of secondary areola, 
 and to which he attaches great diagnostic significance, amounting, 
 indeed, in his opinion, to a certainty of pregnancy independent of other 
 signs. This secondary areola, which immediately surrounds the other, 
 
156 STGNS OF PREGNANCY. [CHAP. 
 
 is, even when most distinct, very faint in color, and has been well 
 compared to the effect produced by drops of water falling upon a tinted 
 surface, and discharging the color. An attempt has been made in the 
 accompanying cut (Fig. 83), to indicate the various appearances 
 referred to. 
 
 The pigmentary deposit, on which the appearance of the areola of 
 pregnancy in a great measure depends, is not in every case limited to 
 the situation in question. In a large proportion of cases, a dark line, 
 about a quarter of an inch in width, may be observed running along 
 the middle line of the abdomen, from the symphysis to the umbilicus, 
 and occasionally extending from thence as far as the ensiform cartilage. 
 A dark-colored disk, occupying and surrounding the umbilicus, was 
 occasionally observed by Montgomery, and is described by him under 
 the name of the "umbilical areola;" and brownish streaks, analogous 
 to the silvery lines in the breasts, are not uncommonly to be seen in 
 the abdominal walls, running parallel to each other, and generally 
 curved, with the convexity towards the groins. These streaks lose 
 their color, but do not disappear after delivery, and are therefore of 
 some importance in determining the question of previous pregnancy. 
 As an occasional concomitant of pregnancy, there has also been ob- 
 served a more general discoloration of the skin, so much so, indeed, as 
 to give rise, in one case at least, to the suspicion of existing disease of 
 the suprarenal capsules. In the case in question, the whole forehead, 
 and part of the cheeks, neck, and breast, were deeply tinged of a yel- 
 lowish-brown color; but within a few w r eeks after the birth of the 
 child this had completely disappeared, nor was there at any time the 
 slightest symptom, in addition to the discoloration, to encourage the 
 belief in the existence of the disease of Addison. In other instances, 
 discoloration of the skin during pregnancy has been found to be due 
 to the presence of 'pityriasis versicolor. 
 
 The appearance of the abdomen, although a very conspicuous sign of 
 pregnancy, can only be admitted as such on the careful exclusion of 
 certain sources of fallacy. For not only may solid tumors of various 
 kinds give rise to appearances very similar, but fluid accumulations, 
 such as ovarian cysts or dropsical effusions, or even distension of the 
 bladder, may delude the unwary into a hurried and erroneous diagno- 
 sis. It behooves the observer, therefore, to be careful how he admits 
 this point in evidence. Cessation of the menses, with abdominal en- 
 largement, would almost certainly be admitted by an expectant mother 
 and her friends as proof sufficient ; but it sometimes falls to the duty 
 of the medical attendant to dispel such illusions. Passing over, for the 
 moment, the evidence to be derived in such cases by the practice of 
 palpation, a certain amount of information may be obtained by the eye 
 alone, in examining the abdomen in the various stages of pregnancy. 
 
 As we have already seen, the uterus, during the early w r eeks of 
 pregnancy, instead of rising upwards, into the abdominal cavity, actually 
 falls downwards towards the floor of the true pelvis. This fact gives 
 rise to the earliest modification in the outline of the abdomen, which 
 consists, not in an enlargement as might have been expected, but in a 
 dragging downwards of the umbilicus, and a flattening of the hypogas- 
 
VIII.] EXTERNAL APPEARANCE OF ABDOMEN. 157 
 
 trie region. This fact has been long recognized, and, although its im- 
 portance has been exaggerated, its expression is embodied in the old 
 French proverb, quoted by all writers, " Ventre plat, enfant il y a.' 7 
 Actual abdominal enlargement dates from about the thirteenth or 
 ''fourteenth week, but so much depends upon the figure of the woman, 
 the number of children she has borne, the presentation of the child, 
 and the quantity of liquor amnii, that the mere study of the abdominal 
 outline would, in so far as uterine development is concerned, rarely 
 afford us reliable information. Another observation which should be 
 made, consists in a careful examination of the umbilicus. During the 
 first three months, the depression of the navel is, if altered at all, some- 
 what deeper than usual. On the expiry of this period, it regains its 
 original appearance. In the course of the fourth month, it becomes 
 less hollow than before conception, and, from this time, the depth of 
 the cavity becomes gradually diminished until, about the seventh 
 month, it becomes completely effaced, and is on a level with the sur- 
 rounding skin. Nor do the changes of the umbilicus cease here, for 
 during the two last months the umbilicus protrudes beyond the sur- 
 face, being, as it were, inverted by the pressure which is brought to 
 bear on the inner surface of the abdominal wall by the distending womb. 
 This is a pretty constant sign, and is certainly the most important to 
 be derived by an ocular observation of the abdominal wall ; but simi- 
 lar phenomena may be caused by ascites and tumors. 
 
 In so far as external appearance is concerned, there is scarcely any 
 variety of solid tumor connected with subjacent organs, nor even any 
 tumor, due to fluid or gaseous distension, which may not, under cer- 
 tain circumstances, give rise to the suspicion of pregnancy. It is rarely, 
 in practice, that the differential diagnosis of such affections presents 
 any great difficulty; but there are cases in which difficulties undoubt- 
 edly exist, when recourse must be had to percussion and palpation, to 
 remove such doubts as may arise. Such an examination enables us to 
 determine the shape and limits of the tumor, and the relation which 
 it bears to the bowels and other surrounding parts. Nothing is here 
 of such importance as the consistency of the tumor. The extreme 
 hardness of uterine fibroids, on the one hand, and the yielding softness 
 of gaseous or fluid distension on the other, represent the extremes; 
 between which endless varieties exist. But the uterus, when distended, 
 communicates to the hand a feeling so peculiarly its own, as to enable 
 any one possessed of the requisite tactus eruditus to pronounce on the 
 subject almost with certainty. This feeling consists in a certain elasticity 
 which, although it may be simulated, is different from that which is 
 communicated by any other form of abdominal tumor. Besides this, 
 the practice of palpation seems, in some cases, actually to cause a cer- 
 tain amount of feeble, painless contraction in the womb, which, when 
 distinctly felt, is of the highest diagnostic value ; but it must be re- 
 membered that these symptoms prove only that it is the uterus which 
 we are touching, and are no evidence of pregnancy. If, however, we 
 are convinced that the elastic tumor contains a solid movable body, 
 there is scarcely any room for doubt. In cases where, from unusual 
 thickness of the abdominal walls, or from some other cause, palpation 
 
158 SIGNS OF PREGNANCY. [CHAP. 
 
 gives obscure results, the history of the tumor, and, especially, the 
 situation in which it was first observed, are points which may have 
 special value. If ovarian, the tumor will have been observed, in the 
 first instance, in either groin ; if from the spleen or liver, the history 
 will be of a growth developing from above downwards, instead of the 
 globular uterine swelling, first observed in the middle line behind the 
 symphysis, which steadily increases in an upward direction, and the 
 nature of which is probably revealed by other important symptoms, 
 some of which have already been detailed. In those cases, in which 
 the tumor is proved to be the uterus — but the fact of pregnancy is still 
 in doubt — there is always the possibility of the cavity being distended 
 by other contents, such as intra-uterine polypi of various forms, dis- 
 tension of the cavity with gas (physometra), or a similar fluid disten- 
 sion (hydrometra). Actual difficulty, even in exjjerienced hands, and 
 error in diagnosis, are most likely to occur in those cases in which 
 pregnancy coexists with some of the morbid affections above alluded 
 to. We may have, for example, clear evidence of ovarian disease — a 
 tumor, Ave shall suppose, partly cystic and partly solid, springing from 
 either groin, and slowly increasing in size. In such an instance, on 
 the occurrence of pregnancy, the abdominal tumor will increase with 
 much greater rapidity ; but, one cause of abdominal enlargement 
 having already been established, the possibility of a coexisting cause 
 may quite slip out of notice, and thus very serious mistakes have, 
 in some cases, actually been made. When we come to consider the 
 diseases and complications of pregnancy, we shall find that there are 
 many other morbid conditions which, when associated with it, tend 
 greatly to obscure the diagnosis. 
 
 Vaginal Examination. — Important information, either positive or 
 negative, is afforded at all stages of pregnancy by a vaginal examina- 
 tion. In the early months, the descent of the uterus causes an appar- 
 ent shortening of the vagina, and an increase in its width from side 
 to side ; but from the end of the third month till towards the end of 
 gestation, — when, as we shall see, the womb again falls downwards, — 
 the extension of the vagina upwards results in an elongation and a 
 consequent proportional narrowing of its diameters. There is clear 
 evidence here also of increased activity of the circulation, correspond- 
 ing to that which we have found to exist in the internal genital organs. 
 It takes the form^ in this situation, of a venous engorgement, which is 
 due, in part at least, to obstruction, caused by pressure of the gravid 
 womb, and is indicated by a more or less livid color of the mucous 
 membrane — very different from the rose color of the unimpregnated 
 state. This ocular examination of the parts, although it may thus 
 reveal a sign which is far from being the least important, is, for obvi- 
 ous reasons, a method of research which cannot be generally adopted 
 in the practice of midwifery, so that we have to depend here upon the 
 results which are afforded by an examination conducted, under the 
 bedclothes, by the finger. 
 
 Under the head of digital examination, the first symptom which 
 often comes under our observation is one which is due to the increased 
 vascularity of the parts to which reference has just been made, and 
 
IX.] CHANGES IN THE CERVIX UTERI. 159 
 
 consists in strong pulsations, which are obviously due to enlargement 
 of the vaginal arteries. This, which is a sign of no great importance, 
 has been described by Osiander under the name of vaginal pulse. During 
 the later months, it is by no means unusual to find the mucous mem- 
 brane hypertrophied and covered with small granulations or papillary 
 projections, which are supposed to be the result of an abnormal devel- 
 opment of the mucous follicles, and which are, certainly, often accom- 
 panied by an augmented mucous secretion. The chief, and in many 
 cases, the sole object of vaginal examination is to ascertain the condi- 
 tion and anatomical relations of the inferior segment of the uterus ; 
 and, more especially, the state of the os, and of that portion of the 
 cervix which projects into the vagina. In those early weeks, during 
 which the uterus descends within the cavity of the true pelvis, the 
 descent is accompanied by a certain amount of anteversion, which ena- 
 bles the experienced accoucheur, as early as the sixth week, to recognize 
 in the anterior vaginal cul-de-sac a fulness or slight resistance, which 
 is absent in the normal and un impregnated condition of the parts. As 
 pregnancy advances, this becomes more distinct, although higher, until 
 the most depending part of the fcetus can be distinctly felt through the 
 anterior uterine wall. 
 
 CHAPTER IX. 
 
 SIGNS OF PREGNANCY (Continued). 
 
 CHANGES IN THE OS AND CERVIX UTERI: PROGRESSIVE SOFTENING OF: CHARAC- 
 TERS OF AT VARIOUS STAGES — POSITION OF OS IN RELATION TO PELVIC 
 WALLS — PRACTICE OF THE "TOUCHER" — EXAMINATION PER ANUM — QUICK- 
 ENING: FCETAL MOVEMENTS OBSERVED; (a) BY THE MOTHER, (b) BY THE 
 ACCOUCHEUR — BALLOTTEMENT OR REPERCUSSION — FCETAL PULSATION — FUNIC 
 SOUFFLE — UTERINE SOUFFLE : THEORIES AS TO ITS PRODUCTION — STETHO- 
 SCOPIC EXAMINATION OF FCETAL MOVEMENTS — SIGNS DIVIDED INTO CERTAIN 
 AND PROBABLE — TABULAR RESUME OF THE SIGNS OF PREGNANCY. 
 
 It is from the observation of the Os and Cervix Uteri that the 
 most important information is derived in the course of a vaginal exam- 
 ination ; for not only does this give us indications of pregnancy at a 
 very early stage, but it enables us in many instances to judge, proxi- 
 mately at least, of the stage which the pregnancy has attained. From 
 a very early period of gestation, a difference takes place in the firmness 
 and resistance of the cervical tissue, which is due, in the first instance, 
 to the congestion and hypertrophy of which this, as well as the other 
 portions of the uterus, are, immediately after conception, the seat. But 
 in addition to this, there is a special change, which a few careful exami- 
 nations by the finger will enable any one to recognize, and which is 
 admirably described by Cazeaux. " Towards the end of the first 
 month, " he says, " one may already discover that, in addition to the 
 
160 SIGNS OF PREGNANCY. [CHAP. 
 
 first general modification, that portion of the lips of the os which is 
 situated most inferior] y, or rather most superficially, begins to soften. 
 This appears to be rather an oedematous condition of the mucous mem- 
 brane, than an actual softening of the tissue proper of the lips, so that, 
 in pressing slightly upon the thick and softened membrane, the finger 
 at once perceives its fungous softness, but seems immediately after- 
 wards to reacli the tissue proper of the neck, which still retains its 
 normal consistence. The sensation thus conveyed closely resembles 
 that which we obtain if we press with the finger upon a table, which 
 is covered with a thick and soft cloth. It is not till towards the ter- 
 mination of the third month, or the beginning of the fourth, that the 
 entire thickness of the lips of the os is softened, to the extent of two 
 or three millimetres. From the fifth month, the softening extends 
 from below upwards, and, at the sixth, reaches the centre of the vaginal 
 portion of the cervix. During the three last months, it invades, step 
 by step, the superior part, until it reaches the internal os, so that at 
 the end of pregnancy, the neck is so soft, in the case of certain women, 
 that I have often observed that students had great difficulty in dis- 
 tinguishing it from the walls of the vagina." This, according to the 
 distinguished accoucheur, from whom we have quoted, should be looked 
 upon as a very important sign of pregnancy, and is very constant in 
 its occurrence, unless it be in cases where the tissue of the cervix is 
 the seat of pathological alterations. 
 
 The shape of the os and cervix also undergoes, during the advance 
 of pregnancy, some very remarkable changes. The os very early loses 
 the form of a transverse slit, and becomes more circular in form, while 
 the comparative softness of the tissue admits sometimes of the intro- 
 duction of the point of the finger. This becomes much easier as preg- 
 nancy advances ; and the softening process described by Cazeaux ex- 
 tends, so that, by the sixth month, it is occasionally possible, even in 
 primiparse, to introduce the point of the finger. A reference to the 
 diagram already shown (Fig. 82, p. 147) indicates the manner in which, 
 according to the ideas originally entertained by Desormeaux, and by his 
 followers to the present day, the canal of the cervix becomes invaded, 
 in the march of development, by a process of encroachment from 
 above downwards, dating from the sixth month, or, according to some, 
 even earlier. Nothing, we may say, could be more simple or more 
 easy of comprehension, than this process of invasion according to a 
 fixed and definite law. 
 
 It requires, however, no very extensive study or observation of the 
 facts to show that no such simple description will afford a satisfactory 
 explanation of the facts as they come under observation in practice. 
 A shortening, or apparent shortening, of the vaginal portion of the 
 cervix is, more especially in primiparse, undoubted ; but are we enti- 
 tled to accept this observation as conclusive, or even as corroborative, 
 evidence of the views of Desormeaux ? No one, we should imagine, 
 can hesitate, on reflection, to answer this query in the negative ; but 
 yet we can scarcely doubt that this has been accepted by many as suffi- 
 cient evidence of the doctrines to which they subscribe. 
 
 This theory, although so convenient in its simplicity, is one which 
 
IX.] CHANGES IN THE CERVIX UTERI. 161 
 
 many writers both of the past and the present century have found it 
 impossible to adopt ; but, unfortunately, of the dissenters, no two seem 
 to have reached precisely the same conclusions. In fact, this, so far 
 from being a simple matter which admits of clear demonstration by a 
 few strokes of the pencil, is at the present day a subject which urgently 
 requires renewed and careful examination. In rejecting, as we may 
 safely do, the theory of Desormeaux as applicable to all cases, it still 
 remains for consideration whether it is applicable to any case whatever. 
 
 In reviewing the observations of those who, at different epochs, have 
 formed opinions hostile to the views commonly entertained, among 
 whom we may mention Weitbrecht (1750), Stoltz (1826), and Matthews 
 Duncan (1868) — one thing becomes abundantly clear, that no single 
 description will serve for all cases ; and another becomes scarcely less 
 obvious, that the process in pluriparse differs materially from that in 
 the case of primiparaa. The softening process above described, involv- 
 ing, as it necessarily does when complete, the disappearance of the 
 characteristic hardness and resistance of the vaginal portion of the 
 cervix, alters so thoroughly, in so far as the sense of touch is con- 
 cerned, the apparent anatomical relations of the parts, that we must 
 recognize in this, at least, a possible source of error. Stoltz and 
 Cazeaux suppose that the shortening of the canal of the cervix takes 
 place without any yielding of the os internum, the os internum and os 
 externum being approximated in consequence of the softening of the 
 tissues. In other words, they suppose that the width of the canal of 
 the cervix is increased at the expense of its length ; but as this idea is 
 somewhat fanciful, we need not dwell upon it. The figures here given 
 represent the views which, at the present day, are being generally 
 accepted, and are borrowed, with slight modifications, from Schultze. 
 
 In so far, then, as primiparse are concerned, the views of Schultze 
 seem to confirm those of Desormeaux, except that the latter believed 
 the invasion of the cavity of the cervix to date from a still earlier 
 period. In Figs. 84, 86, and 88, the conditions indicating the primi- 
 paraB os are clearly indicated ; but, as regards the period at which the 
 resistance of the os internum is first overcome, the researches of Stoltz, 
 and the more recent observations of Matthews Duncan, not only throw 
 doubt on the views formerly entertained, but go a long way to disprove 
 them. Indeed, the belief is now steadily gaining ground that, even in 
 primiparse, it is only during the last fortnight that the encroachment 
 upon the canal of the cervix takes place, Duncan, indeed, believing 
 that its dilatation is only effected by the painless uterine contractions 
 of the last few days of pregnancy. 
 
 Practical investigation of the matter is unfortunately beset with no 
 little difficulty, for not only are the opportunities of post-mortem ex- 
 amination few, but the circumstances are such, in most cases, as to 
 render crucial observations in the living subject impossible without the 
 risk of inducing premature labor. Our belief is that all cases do not 
 follow the same law ; but we have had no difficulty in convincing our- 
 selves that, even in the last days of pregnancy, when the feel of the os 
 externum and the apparent proximity of the presenting part w T ould 
 seem to imply that the entire canal of the cervix was lost, there some- 
 
 11 
 
162 SIGNS OF PREGNANCY. [CHAP. 
 
 times exists a canal between the os externum and a point considerably 
 higher, a canal which crosses from before backwards the axis of the 
 presenting part, so as to give one the idea of a valvular opening into 
 the uterine cavity. It is proper to add that dissections and drawings 
 from nature seem to corroborate this view. 
 
 As regards the process in pluriparse (Figs. 85, 87, and 89) there is 
 less difference of opinion, and we find that the ideas entertained by 
 Schultze, and represented in the diagram referred to, differ very little 
 from those promulgated by Stoltz and Cazeaux, and corroborated by 
 the more extreme views of Matthews Duncan. The softening process 
 attacks the tissue of the cervix in a manner precisely similar to that 
 which obtains in the case of primiparae. There is in this case, how- 
 ever, a gaping external orifice, which admits easily, even earlier than 
 the twenty-fourth week, the point of the finger. From this period 
 onwards, till about the thirty-sixth week, the only change which takes 
 place is, that the cavity of the cervix becomes more and more accessible 
 to the finger, which slips into it, as Cazeaux says, as into a thimble. 
 The mechanical effect of previous pregnancy seems to be that the 
 cavity proper admits of easy and ample distension, so that no call is 
 made upon the cavity of the cervix until the termination of pregnancy 
 approaches. Even in those instances in which the cavity of the cervix 
 is most easily permeable by the examining finger, the os internum is, 
 in pluriparae, often found quite impassable at the thirty-seventh week, 
 or even later. From this period, however, a very rapid shortening of 
 the cervix takes place until, at the fortieth week, as in primiparae, the 
 cervix is in a manner effaced. But there remains to the last, instead 
 of the thin, smooth, and almost membranous margin of the os in primi- 
 parae, an irregular nedematous lip which is in the highest degree char- 
 acteristic, and which is not wholly lost even during the first stage of 
 labor. There is represented in the diagrams (Figs. 85, 87, and 89) — 
 which may be compared with the adjoining figures — the distinguishing 
 features of the pluriparous os, as observed from the vagina. 
 
 The description, then, which is usually given of the state of the os 
 during the various stages of pregnancy is applicable only to the case of 
 those within whom a foetus is, for the first time, being developed. Rapid 
 as is the process by which the uterus is reduced in size after delivery, 
 it never completely regains its virgin state. The os and cervix are the 
 parts which show most distinctly the peculiarities which attach to those 
 who have already borne children; and, in the course of a digital 
 examination, this peculiar feature comes prominently under our notice. 
 This method of examination, therefore, enables us not only to recognize 
 the stage of the pregnancy, but also to distinguish between first and 
 subsequent pregnancies — due regard being had to the manner in which 
 the cervix is developed in the two classes of cases. 
 
 The situation of the os uteri, relatively to the walls of the pelvis, is 
 another point which is disclosed in the course of a vaginal examination. 
 This is, however, of more importance in conveying information as to 
 the stage of pregnancy than in regard to the fact of its existence ; but, 
 as it may, under certain circumstances, become an important point in 
 evidence, its omission here would be improper. We have already seen 
 
IX.] 
 
 CHANGES IN THE CERVIX UTERI. 
 
 163 
 
 that, in consequence of the growth downwards of the uterus, the os is, 
 in the first instance, displaced in the same direction ; and, as we believe, 
 somewhat backwards, this movement corresponding to the slight ante- 
 
 DlAGRAMS SHOWING THE KELATION WHICH THE CANAIi OF THE CERVIX 
 
 bears to the cavity of the uterus during pregnancy. 
 (After Schultze.) 
 
 Primipar^e. 
 Fig. 84. 
 
 PLTJRIPAR.E. 
 Fig. 85. 
 
 Twenty-fourth week. 
 
 Fig. 86. 
 
 Fig. 87. 
 
 Thirtieth week. 
 
 At full term. 
 
 flexion to which reference has already been made. The escape of the 
 uterus from the true pelvis, and the subsequent and rapid upward 
 development of its body, soon causes a corresponding movement upwards 
 
164 SIGNS OF PREGNANCY. [CHAP. 
 
 of the os, which thus seems to follow the fundus, in proportion to its 
 development, steadily upwards in the pelvis from the tenth to the 
 thirty-seventh week, when it attains the highest point, and is reached 
 by the finger sometimes with a little difficulty. With the descent of 
 the uterus in the last weeks, it again sinks downwards, and, at the same 
 time, moves backwards ; so that, though lower, it is not more within 
 reach of the finger. This final movement corresponds to the falling 
 downwards and forwards of the fundus, mention of which has already 
 been made. Sometimes the head descends to an unusual degree in the 
 pelvis, and, in such cases, may push before it the anterior segment of 
 the uterus. From this cause a difficulty occasionally arises, which may 
 even give rise to the suspicion of congenital absence of the os ; but a 
 careful examination by the finger, in the direction of the hollow of the 
 sacrum, will rarely fail to disclose the position of the os — the difficulty 
 being, of course, greater in first than in subsequent pregnancies, owing 
 to the membranous thinness which the lips of the womb frequently, in 
 these cases, assume. 
 
 In the practice of the toucher, or digital examination of the vagina, 
 skill and experience are of paramount importance; and as it is by 
 practice alone that the required dexterity can be attained, it behooves the 
 student to avail himself of every opportunity which may arise for add- 
 ing to his store of experience. With this view, some uniform scheme 
 or method of examination should be adopted. A long finger is doubt- 
 less an advantage, but the advantage is by some writers greatly exag- 
 gerated. The index finger may alone be used, but some prefer to use 
 two, by which we no doubt gain something by the greater length of 
 the second finger. This advantage, however, is frequently counter- 
 balanced by the increased pain which the examination gives the woman, 
 causing her to shrink and draw away from the hand of the accoucheur. 
 The finger should be passed forward from the situation of the coccyx 
 over the anus and the posterior commissure of the vagina. It may 
 seem almost too ridiculous to suppose that the anus should in such an 
 examination be mistaken for the vagina, but the knowledge of the fact 
 that the mistake has been committed will suffice to prevent the student 
 from a similar error. The finger should be well oiled or smeared with 
 lard, with the object in all cases of facilitating introduction, and in a 
 certain class of cases to protect the finger. Notice is to be taken, as a 
 matter of routine, of the state of the perineum, labia, and other parts. 
 The condition of the vagina and rectum, and of the pelvic walls, must, 
 in like manner, not be overlooked, for, in all questions bearing upon 
 pregnancy, the state of these parts must have a special interest, and the 
 timely recognition of anything abnormal may have the effect of avert- 
 ing a calamitous result. In the actual examination of the os and cervix, 
 some assistance will occasionally be derived from the use of the hand 
 over the surface of the abdomen, by which the fundus may be steadied 
 and the os pressed downwards more within the reach of the finger. 
 In conducting such investigations as we have been referring to, the 
 strictest caution must in every instance be exercised in order to obviate 
 the possibility, which exists in every case, of premature labor being 
 induced bv rude and careless hands. The amount of irritation neces- 
 
IX.] MOVEMENTS OF THE CHILD. 165 
 
 sary to excite the uterus to contraction varies greatly in different cases, 
 but we cannot doubt that incautious interference, more especially with 
 the os and cervix, may incite contraction, and cause the loss of the 
 product of conception. 
 
 In the investigation of uterine diseases unconnected with pregnancy, 
 it is often proper to institute an examination per anum. In the prac- 
 tice of midwifery, and the diagnosis of pregnancy, such a mode of ex- 
 amination is very seldom necessary. Cases, however, do now and 
 again occur, in which, owing, it may be, to excessive tenderness of the 
 parts, or to partial obliteration of the vagina, the result of sloughing, 
 we may be obliged to have recourse to this expedient. Or, again, it 
 may be necessary for the proper examination of tumors, which exist as 
 complications of pregnancy, and which are connected with the poste- 
 rior part of the pelvis. And, in one other group of cases, we are 
 recommended by Montgomery to examine thus, " when, for any par- 
 ticular reason, it is thought desirable to ascertain whether the uterus is 
 enlarged within the first two months of supposed pregnancy/ 7 Under 
 any circumstances, however, this mode of examination is so repulsive 
 to the woman that, with that consideration for her feelings which should 
 always sway us, we instinctively shrink from proposing it, unless the 
 circumstances be such as to render it absolutely essential. 
 
 Quickening. — The period of quickening is that at which the mother 
 becomes for the first time conscious of the movements of the foetus 
 within her womb. They who at one time believed that the ascent of 
 the uterus from the pelvis to the abdominal cavity took place suddenly, 
 and was not a simple process of gradual evolution, held, naturally 
 enough, the view that the quickening was this assumed sudden motion. 
 Every woman now knows that it is due to the actual movements of the 
 living child, which are at this period first communicated to her senses. 
 The sensation, however, does not represent the first movements of the 
 child, for they are seldom perceived by the mother earlier than the 
 sixteenth week, whereas, in abortions at a much earlier period, vigor- 
 ous movements are often observed after the expulsion of the embryo. 
 Nor is it an uncommon thing, in the course of an abdominal examina- 
 tion by the hands and the stethoscope, to feel or to hear slight move- 
 ments which we can only suppose to be exercised by the foetus, and 
 that too at a time when the mother may still be in doubt as to the fact 
 of her pregnancy. 1 The time usually stated as that of quickening is 
 about the middle of pregnancy, or four and a half calendar months. 
 This belief, although only a popular one, is sufficiently wide of the 
 truth to call for correction. It is difficult, however, to fix upon a 
 period as a safe average, as we know that the time of quickening may 
 
 \ It is now generally believed that the mother cannot be conscious of the foetal 
 movements until the uterus comes in contact with the abdominal walls. It is then 
 for the first time possible that the sensation can be transmitted by sensory fibres of 
 the cerebrospinal system ramifying: in the abdominal parietes. This theory ac- 
 counts, as it appears to us, quite satisfactorily, for the phenomena which exist ; for 
 we cannot doubt that the limbs of the child must strike the uterine walls at an 
 earlier period than they are perceived by the mother, and it is not to be expected 
 that the sensation could be communicated through the few filaments which reach 
 the uterus from the cerebrospinal system, as these are confined to the os and cervix. 
 
166 SIGNS OF PREGNANCY. [CHAP. 
 
 vary from the end of the second to the eighth month. In a very large 
 majority of cases, about the seventeenth week may be assumed as the 
 period at which women feel the first feeble flutterings which to them 
 indicate the vitality of their offspring. In some instances, the move- 
 ment is more decided, even at this time, but the rule is that it is at 
 first very faint, and gradually becomes stronger in proportion as the 
 development of the foetus progresses. In the later months, the foetal 
 movements become so vigorous, that they may cause the woman actual 
 pain, and have been known to cause her to cry out; and, at this stage 
 of pregnancy, the movements which are perceived are due to brisk 
 flexion and extension of the joints of the lower limbs, the sensation 
 being in some instances due to smart kicks, and in others to a continu- 
 ous movement, such as might be caused by the passage of the knee 
 along the inner uterine wall. Important as this sign is to the accou- 
 cheur, and all-important as it is to the woman, it is nevertheless one 
 in regard to which we must always be cautious, as there are fallacies 
 which may lead astray even those women who have previously borne 
 children, and who may thus be supposed to be familiar with the sen- 
 sation in question. The conditions which may give rise to such erro- 
 neous impressions are rapid movements of gas in the intestines, irregu- 
 lar contraction of the muscles of the bowels, or even of the muscles 
 which form part of the abdominal walls; and the pulsatile movements 
 of an aneurism, or of a large artery, which, being communicated to a 
 tumor within the abdomen, may very readily deceive a woman who 
 already suspects that she is pregnant. Such cases are so frequent, that 
 we must always be careful in receiving as evidence the mere statement 
 of the woman. 
 
 We have hitherto spoken only of the active movements of the foetus, 
 as observed by the mother. But these movements receive, as evidence 
 of pregnancy, a vastly increased significance, if, in addition, the accou- 
 cheur is able to convince himself of their reality, which he generally 
 can succeed in doing by careful abdominal palpation. The nature of 
 the tumor, its symmetry, and its elasticity, will already have prepared 
 him for the corroborative evidence which he expects, and a very ordi- 
 nary skill will prevent him from being misled by any disturbing influ- 
 ences, such as may deceive the woman. He is conscious of the presence 
 under his hand of a solid body, contained within an elastic tumor. Pie 
 presses this body from side to side, and in various other directions, 
 with the almost certain effect, if the child be alive, of causing such 
 movements as, from the fifth month onwards, will place the question 
 of pregnancy beyond the possibility of doubt. His eye, meanwhile, 
 may follow many of the more violent of these movements, the abdominal 
 wall forming from time to time distinct projections, corresponding to 
 the subjacent portion of the limb or body of the foetus, so that the out- 
 line of the abdomen is for the moment distorted, the projecting part 
 often suddenly changing its site before it sinks dovm again within the 
 liquor amnii. But even here we are not safe from error, as, in some 
 instances, movements closely resembling those of pregnancy have been 
 observed by the accoucheur. The only condition, how r ever, which 
 
IX.] BALLOTTEMENT. 167 
 
 might mislead any one using ordinary care, is that which arises from 
 spasmodic action of the abdominal muscles. 
 
 An interesting example of this occurred several years ago in the 
 Glasgow Royal Infirmary, in one of the wards at that time under the 
 care of the writer. This woman was thirty -two years of age. She had 
 been married for several years, but had had no children. She had been 
 admitted on account of bronchitis, and was highly hysterical. She 
 stated that she was pregnant, an assertion which at first attracted little 
 attention, but as she stated subsequently that she had been pregnant 
 for fourteen months, the case was looked upon with some interest by 
 the gentlemen attending the clinique. The symptom upon which she 
 founded her belief was the motion of the child, which she said she felt 
 frequently and quite strongly. On examination, a tumor was observed 
 in the abdomen, somewhat to the left of the middle line, reaching as 
 high as the umbilicus, and not at all unlike the gravid uterus at the 
 sixth month. When the hand was placed over this and held steadily 
 for a little, distinct jerking movements were noticed, which, for the 
 moment, seemed to have some resemblance to such as might be caused 
 by a foetus in utero. A little further examination soon showed the 
 true nature of the case ; the tumor was tympanitic on percussion, and 
 nothing like the outline of the uterus could be felt; the os, on vaginal 
 examination, was found to have none of the characteristics of preg- 
 nancy ; the stethoscope gave a negative result. And to make things 
 certain, the woman was put under the influence of chloroform, when 
 the tumor completely disappeared, and the suspicious movements 
 ceased. The case w r as one of " phantom tumor," with spasmodic con- 
 traction of the abdominal muscles; but no amount of reasoning could 
 shake the patient's belief in her pregnancy, and she left the hospital 
 in the full conviction that she was sixteen months gone with child, 
 and that in the course of the succeeding month she would give birth to 
 a child in an unprecedented condition as to development. 
 
 Ballottement. — An important sign of pregnancy is also to be found, 
 under certain special conditions, in the passive movements which may 
 be imparted to the foetus. This sign has been called by some English 
 writers " Repercussion," but is more familiarly known under the French 
 designation " Ballottement," which is certainly the more appropriate 
 of the two. The following is the manner in which this test is usually 
 applied : The woman is placed in a position which is intermediate 
 between reclining and standing, and a very convenient plan is to have 
 her shoulders supported behind, while she sits on the edge of the bed, 
 with her feet upon the ground. The fundus uteri is then steadied by 
 one hand, while the index finger of the other is introduced in the usual 
 way into the vagina, with the palmar surface upwards. The finger 
 thus placed is then brought into contact with the anterior segment of 
 the uterus, near the cervix, where the presenting head of the child will 
 generally be most easily felt. A smart jerk is given upwards, and the 
 finger then kept perfectly steady, in its original situation, when, if the 
 attempt be successful, it will be found that the foetus, which had risen 
 up in the liquor amnii, in obedience to the impetus which had been given 
 to it, falls, in a few seconds, back into its original place, and seems to 
 
168 SIGNS OF PREGNANCY. [CHAP. 
 
 poise itself upon the tip of the finger, communicating to it the peculiar 
 sensation from which the test derives its name. 
 
 Although the posture above indicated is that in which the sign of 
 ballottement is most readily recognized, it is by no means the only 
 position in which it may be made out. A precisely similar sensation, 
 indeed, is communicated when the woman lies upon her back, or even 
 (although more rarely) when she occupies the ordinary obstetrical 
 position on the left side. The same effect may also be produced in the 
 course of abdominal palpation, about the fifth or sixth month, when, 
 if the woman is placed upon her side, in the horizontal position, and 
 one hand passed beneath the projection, there will be felt, if the ab- 
 dominal walls are not too thick, some portion of the body of the foetus 
 resting upon the hand. This, not un frequently, may be displaced, and 
 will return upon the fingers precisely in the same manner, and on the 
 same principle, as when the examination is conducted in the usual way. 1 
 
 The sign of ballottement establishes the presence, in a fluid medium, 
 of a solid body. This body must obviously be, on the one hand, of 
 sufficient size to be perceptible to the sense of touch, and on the other, 
 of a size considerably less than the cavity which contains it. It is 
 clear that, unless these conditions are fulfilled, the sign is not available 
 for the purposes of diagnosis. Of this proposition it is an obvious 
 corollary, that it is only during a certain period of a pregnancy that 
 ballottement can be distinguished. Before the fourth month, the size 
 of the embryo is so small that it is impossible to produce the move- 
 ment; but from this epoch till about the seventh month, it becomes 
 more and more distinct. For a few weeks after this it may still be 
 observed, although with greater difficulty ; but, during the last six 
 weeks, this method of examination gives no result whatever, in con- 
 sequence of the great size of the child, and the extent to which the 
 uterine cavity is filled by it. For a similar reason, it is not available 
 in twin pregnancy. The only exceptions to this rule are cases in which 
 the quantity of liquor amnii is greater than usual. Ballottement, in 
 the hands of an experienced practitioner, may be looked upon as a 
 certain proof of pregnancy; but by the inexperienced it is never to be 
 relied upon, without strong corroborative evidence of some kind. The 
 conditions requisite for its production are all fulfilled, it must be re- 
 membered, in the case of calculus in the bladder, when the solid body 
 may be displaced with ease in its fluid medium. Anteversion of the 
 womb, too, has, on a hurried examination, given rise to sensations 
 closely resembling those of ballottement. In admitting, therefore, that 
 ballottement is a certain sign of pregnancy, we do so, we repeat, with 
 the reservation that it is so in experienced hands alone. 
 
 Foetal Pulsation. — By far the most important of all the signs of preg- 
 nancy, is that which is associated with the name of Mayor of Geneva, 
 who was the first to discover that the heart of the foetus could be heard 
 
 1 Considerable attention has been given of late } T ears, more particularly on the 
 Continent, to the importance of abdominal palpation in the diagnosis of pregnane}' ; 
 and there is no doubt that in this way, and under favorable circumstances, the pre- 
 sentation, and even the position of the child may, with tolerable accuracy, be ascer- 
 tained. 
 
IX.] FCETAL PULSATION. 169 
 
 beating through the abdominal and uterine walls. This discovery was 
 announced in 1818, but attracted little notice until several years later. 
 The period at which these sounds become audible in the course of preg- 
 nancy, is subject to considerable variation. It is certain that, as a 
 general rule, it is not till the fifth month that they can be detected ; 
 but many trustworthy observers have asserted that they have heard 
 them in the course of the fourth month, and even as early, in some few 
 cases, as the eleventh week. This latter statement is generally looked 
 upon with incredulity ; but there can be no doubt but that occasionally 
 the sounds may be heard in the fourth, third, or second, or even in the 
 first week of the fourth month. On an average of a large number of 
 cases, the eighteenth week may be stated as about the period at which 
 we may expect to hear it. 
 
 These pulsations are much more frequent than those of the mother, 
 and are, like them, distinctly double. They, of course, lack the volume 
 of the maternal sounds, and are further enfeebled by the distance from 
 the ear, and by the low density of the intervening media. The fre- 
 quency of the beats is increased by the foetal movements, and may thus 
 be found to vary at different times ; but it generally ranges from 130 
 to 160 in a minute. Some interesting observations made by Steinbach 
 and Frankenhauser seem to show that the heart's action is more rapid 
 in females, in the proportion, as they say, of 144 to 131. The pulse 
 of the mother has no marked influence upon that of the child. It is 
 scarcely possible, therefore, for any one who takes note of this frequency 
 in the beats, to mistake them for maternal pulsations, which might, of 
 course, under various anatomical and pathological conditions, be pro- 
 duced in any tumor under examination. The only case in which the 
 possibility of difficulty can be admitted is where the maternal pulse is 
 unduly accelerated by the existence of fever, or by some more transient 
 cause ; so that, in practice, it is well to adopt the simple precaution of 
 placing the finger upon the mother's wrist at the moment we are mak- 
 ing the stethoscopic examination, when, if there is obvious dichronism, 
 we are sure of our diagnosis ; while, on the contrary, if there is an ap- 
 proach to synchronism in the two pulses, caution is clearly indicated. 
 
 The pulsation of the foetal heart is never heard over the whole sur- 
 face of the abdomen, but, on the contrary, over an area which is always 
 limited. This site varies with the presentation and position of the 
 child, and it is often only after prolonged exploration that a point is dis- 
 covered where the sounds are clearly audible ; and, as w T e have already 
 shown that the presentation of the child is more constant the nearer 
 it is to the end of pregnancy, it follows that the earlier the period at 
 which the examination is conducted, the greater will be the variety in 
 the site at which auscultation has a successful result. It is usual, with 
 a view" of saving time and trouble, to adopt a uniform plan in conduct- 
 ing this investigation, beginning always at the point at which the 
 sound, for well-known reasons, is most frequently to be distinguished. 
 The child, as is known, lies in the womb, in a very large majority of 
 cases, with the head downwards, and the back forwards and to the left, 
 some portion of the back part of the trunk being thus brought into 
 contact, almost invariably, with the uterine wall, somewhat to the left 
 
170 SIGNS OP PREGNANCY. '[CHAP. 
 
 of the middle line. If we place the stethoscope over any portion of 
 the uterus other than this, the layer of amnionic fluid which lies be- 
 tween our ear and the heart of the foetus cuts off all acoustic commu- 
 nication ; whereas, at the point just named, there is continuity of solid 
 tissue, and through that the sound is conducted. The extent of the 
 area over which the sounds are heard depends, in a great measure, on 
 the quantity of the liquor amnii, being greatest when it is scanty, while, 
 with much liquid, a small portion only of the foetal trunk comes into 
 contact with the uterine wall, and the area is thus proportionally 
 small. The point, therefore, at which we have the best chance of at 
 once catching the sound, is about midway between the umbilicus and 
 the symphysis pubis, and somewhat to the left side. If the child is in 
 what will be described afterwards as the second cranial position, the 
 back being thus forwards and to the right, we may expect to hear the 
 sound at a corresponding point to the right of the middle line. In 
 dorso-posterior positions, whether of the head or of the breech, the 
 convexity of the spinal column being turned backwards sometimes con- 
 stitutes a difficulty in auscultation, as is also created by an unusual 
 quantity of the liquor amnii (dropsy of the amnion), and by various 
 abnormal presentations of the child. If, however, an examination 
 conducted with due care at any time after the fifth month, and in the 
 course of which the whole of the abdominal surface has been carefully 
 explored, fails to detect the foetal pulse, this, of itself, is very strong 
 evidence, either that pregnancy does not exist, or if it has existed, that 
 the foetus is dead. 
 
 It is generally believed to be possible to determine, by means of 
 stethoscopic examination, the existence of a twin pregnancy by the 
 following peculiarities : that, in twin pregnancies, the two hearts are 
 heard beating at opposite points of the abdomen, and that they are 
 frequently not synchronous in their action. If the latter point can 
 be conclusively established by the simultaneous examination of two 
 observers, the case is clear ; but in regard to the mere existence of 
 pulsation at two opposite points of the abdomen, this cannot be ad- 
 mitted as satisfactory proof. It has by some been asserted that the 
 distinction is easy, and that, when we have pulsation at two points, in 
 a single pregnancy, the sounds reach their greatest intensity midway 
 between the two ; whereas, in a twin pregnancy, examination in the 
 intermediate area gives a negative result. This, if true, would be a 
 sure and easy test ; but we are perfectly certain it is not to be relied 
 upon, although it may represent the general rule. Still taken along 
 with the shape of the abdomen, and the results of careful palpation, 
 pulsation at two points is an important symptom in the diagnosis 
 of twins, which are generally placed to the right and left in the 
 womb. 
 
 Funic Souffle. — Dr. E. Kennedy has described another stethoscopic 
 sound, which is synchronous with the foetal heart. " In some cases," 
 says he, " w r here the uterus and the parietes of the abdomen were 
 extremely thin, I have been able to distinguish the funis to the touch 
 externally, and felt it rolling distinctly under my finger, and then, on 
 applying the stethoscope, its pulsations have been discoverable, remark- 
 
IX.] UTERINE SOUFFLE. 171 
 
 ably strong ; and on making pressure with the finger for a moment 
 on that part of the funis which passed towards the umbilicus of the 
 child, I have been able to render the pulsations less and less distinct, 
 and even, on making the pressure sufficiently strong, to stop it alto- 
 gether." This assertion of Dr. Kennedy's has been vigorously con- 
 troverted in Germany ; but even admitting the description to be abso- 
 lutely correct, the observation is one, as has been well observed by Dr. 
 Tyler Smith, " which can hardly be of practical use, because when the 
 abdominal and uterine walls are so thin as to permit us to feel the pul- 
 sation of the funis through them, the other auscultatory signs of preg- 
 nancy, and the evidence obtained by palpation, must already have set 
 the question at rest; and except under such circumstances, it must be 
 very difficult to discover the funicular souffle." 
 
 Uterine Souffle. — The " bruit de souffle," " placental souffle," and 
 Uterine Souffle, arc among the most familiar of the designations which 
 have been applied to another and an important auscultatory sign, which 
 was originally discovered, in 1823, by M. de Kergaradec, but for 
 whom, also, the more important observation of M. Mayor would have 
 been overlooked. The various names by which the souffle is described 
 point pretty clearly to the well-known fact, that speculations as to its 
 nature and its cause have given rise to various theories, which display 
 the existence of very contradictory opinions. All agree that the sound 
 is maternal, not foetal, as its rhythm corresponds to that of the mater- 
 nal heart. The universal acceptation of the term " souffle" shows that, 
 in regard to the nature of the sound, observers are at one. But, in so 
 far as its seat and mode of production are concerned, great divergence 
 of opinion has existed. 
 
 The Uterine Souffle, as, for reasons to be stated presently, and fol- 
 lowing Dubois, we prefer to call it, is distinguishable at an earlier 
 period than the foetal pulsation. Dr. Kennedy, who has given much 
 attention to this, as to the other signs of pregnancy, maintains that he 
 has heard it as early as the tenth week ; but usually, it is not till the 
 sixteenth week, or even later, — or, in other words, until the uterus is 
 accessible to the stethoscope, — that it can be made out. These remarks 
 apply to examination through the abdominal walls; for, if the metro- 
 scope of M. Nauche be used, it is possible that it may be heard at a 
 somewhat earlier period. An occasional characteristic of the sound is 
 that it is not constant. It may be distinctly audible at one moment, 
 and may disappear the next, to return again in a short time, — these 
 changes taking place without any appreciable cause. In some cases, 
 it is heard over the whole abdomen ; while, in others, it is confined 
 within a limited boundary, usually in the region of the groin. Gen- 
 erally it is heard, in advanced pregnancy, over the whole of the lower 
 part of the uterus, but not over the fundus, nor in the lumbar region ; 
 but, in the earlier months, it may be heard over the symphysis, or 
 wherever the uterus is accessible to the stethoscope. In regard to tone 
 and pitch, the varieties are endless, — presenting, in fact, from the soft 
 whiff to the musical cooing or rasping sound, all the peculiarities of 
 aneurismal or cardiac murmurs ; and what is not a little remarkable, 
 
172 SIGNS OF PREGNANCY. [CHAP. 
 
 it varies in this respect, not only in different individuals, but in the 
 same individual at different times. 
 
 If the observations be made during a labor pain, a very striking 
 effect is often found to be produced by the contraction of the uterine 
 fibres, the sound becoming, in the first instance, louder, more sibilant, 
 or even musical, and then, at the height of the pain, becoming lost — to 
 return, as it passes off, in the inverted order of the tones, as the pres- 
 sure on the vessels is relaxed. It seems to have no fixed relation to 
 the site of the placenta, and it certainly gives no reliable evidence, as 
 might, perhaps, have been expected, as to where the placenta is 
 situated in the uterus. The uterine souffle as a sign of pregnancy, is, 
 no doubt, extremely valuable, and is to be distinguished from any 
 other arterial sound by the absence of impulse, and its persistence in 
 every posture; but it must, on no account, be admitted as a certain 
 sign. For, the attention which has of late years been given to the 
 diagnosis of ovarian tumors has shown that one of the more constant 
 signs of a pathological uterine tumor, and which goes far to distinguish 
 it from a similar structure which has sprung from the ovary, is the ex- 
 istence of a souffle, which has the closest possible resemblance to the 
 souffle of the pregnant womb. 1 Under no circumstances is the uterine 
 souffle to be held as proof of the life of the child. 
 
 A certain number of observers were long of opinion that the sound 
 which we are now considering was caused by pressure on the great 
 arterial trunks which lie in the posterior part of the pelvis. This 
 must at once be admitted as a possible cause of such a sound, seeing 
 that pressure on vessels in any situation may produce a souffle. But 
 that this is not the case in pregnancy, seems to be proved by the fact, 
 that such a change of posture (the prone position, for example), as 
 would remove the uterus for the time being from the neighborhood of 
 the vessels, never has the slightest effect in arresting the souffle. The 
 view which was entertained by M. Kergaradec himself in regard to 
 the production of the sound, was that it was produced in the utero- 
 placental vessels, and on this account he named it the " bruit placen- 
 taire." That it is not so, is now universally admitted, and the idea 
 was, indeed, completely refuted by the discovery that the sound is 
 heard at so many various sites, and still more conclusively by the 
 observations which have been made after delivery, and which have 
 proved that not only may the sound be heard after the birth of the 
 child, but even after the placenta has been expelled. 
 
 The theory which owes its origin to Dubois is as follows. This 
 distinguished accoucheur assumed that the blood, in passing from the 
 uterine arteries to the uterine veins or sinuses, presented characters 
 precisely analogous to those which constitute aneurismal varix, or which 
 produce the souffle in erectile tissues. In all of these cases, as he 
 observes, we have arterial branches discharging their blood directly 
 into veins, the more rapid current joining a more sluggish one ; and 
 
 1 Many believe this to be due merely to pressure on neighboring large vessels. 
 Sometimes it is so ; but we are persuaded that the cause of the sound is generally in 
 the uterine walls. 
 
IX.] UTERINE SOUFFLE. 173 
 
 this, he adds, " is undoubtedly the cause of the murmur and the bruit 
 de souffle which is so remarkable in aneurismal varix and erectile 
 tissues/' His conclusion is that, very probably, the same causes within 
 the uterine walls produce the same results. A theory somewhat similar 
 to that of Dubois has been advanced by Corrigan, with the additional 
 suggestion that the sounds are modified by pressure of the foetus against 
 the uterine walls. De la Harpe believed that the sound was due simply 
 to the multiplicity of currents of blood within the uterine walls : the 
 sound from each vessel being, by itself, inaudible, but the aggregation 
 of many giving rise to the familiar sound. Finally, there is the view 
 of Scanzoni, who holds that the blood during pregnancy is in a chlo- 
 rotic state, and that the sound is due mainly to causes which have 
 their seat in the composition of the blood, and are accompanied by 
 murmurs analogous to those with which we are familiar in the case of 
 chlorotic women. The ingenious theory of Dubois may, no doubt, in 
 some particulars, be inaccurate ; but the opinion now generally enter- 
 tained of the cause of the bruit is — that it has its origin in the uterine 
 walls, and neither in the vessels external to them, nor in the placenta 
 within them, and that, therefore, the views of Dubois and Corrigan 
 are, in all probability, very near the truth. 
 
 As has already been observed, the movements of the foetus may 
 occasionally be observed, by means of the stethoscope, at a very early 
 period. This mode of investigation, which we owe to the younger 
 Naegele, is one which is surrounded by so many difficulties and sources 
 of fallacy that, important as it seems to be, it is never likely to be of 
 any great practical worth. The possibility, however, which is un- 
 doubted, of thus recognizing foetal movements at a time when the other 
 evidence must be very inconclusive, is a point not to be lost sight of. 
 Possibly this, as well as the other stethoscopic sounds, might be early 
 recognized by the use of the Metroscope, a modification of the stetho- 
 scope, which was devised by Nauche with the view of directly auscul- 
 tating the uterus from the vagina, but which has fallen into disuse. 
 
 The Signs of Pregnancy consist, then, of a few which are Certain, 
 and of a considerable number which are Probable or Presumptive. 
 The certain signs are : 
 
 1. The Sounds produced by the Pulsations of the Foetal Heart. 
 
 2. The Active Movements of the child, distinctly felt by a skilled 
 person. 
 
 3. The Passive Movements, in which consists the sign of Ballotte- 
 ment. 
 
 If any one of these signs is made out, the woman is incontestably 
 pregnant. But, in regard to the negative evidence which is afforded 
 by their absence, this can only be admitted as proof that the woman is 
 not pregnant when the other signs are wanting: the absence of one is 
 only sufficient to warrant a doubt. To the three certain signs given 
 above, we might, perhaps, add a fourth, — the secondary areola of Mont- 
 gomery ; but, as this is open to doubt, and is only to be observed in a 
 limited number of cases, we include it among the probable signs. 
 
174 
 
 SIGNS OF PREGNANCY. 
 
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176 DURATION OF PREGNANCY. [CHAP. 
 
 It is quite unnecessary that the latter should be again enumerated. 
 Singly they are of no value; but, when a considerable number of them 
 are simultaneously observed, in cases where pregnancy is expected, as 
 in married women, the evidence thus afforded is tacitly admitted as 
 complete. For such a diagnosis the medical attendant should not be 
 held responsible; but if it turns out, after all, to be a mistake, he will 
 find that, in accounting for the blunder, a large share of the blame will 
 lie at his door. For a certain opinion, such as one would be warranted 
 in giving upon oath in a court of justice, no combination of merely 
 probable signs will suffice. In addition to these, however imposing 
 their array, we must, in every case, have one at least of the certain 
 signs, before we can, with.all confidence, assert that the woman bears a 
 living child. 
 
 If the child is dead, it is obvious that two out of the three signs are 
 no longer available ; but, in these cases, there may still be ballottement, 
 or there may be present signs which are held to indicate the death of 
 the foetus, and which will be noticed in their proper place. The ques- 
 tions may be put to us: Is pregnancy probable in this case? or, Can 
 you say with perfect confidence that the woman is not pregnant? The 
 reply to such questions must be given with the greatest caution, and 
 will depend very much on the correct appreciation of the various 
 probable signs, and the exact value which attaches to each, or to each 
 group of such signs. In most cases of doubt, some period will be given 
 as the probable or possible time from which, if existing, the pregnancy 
 must date ; and it will be upon a careful analysis of the signs proper 
 to such period of pregnancy as may thus be indicated, that our opinion 
 will, in the end be formed. With a view of facilitating such an 
 investigation, the preceding table has been drawn up, in which is given 
 the average period at which the various signs are available. 
 
 CHAPTEK X. 
 
 DURATION OF PREGNANCY— SUPERFCETATION. 
 
 DURATION OF PREGNANCY : IN COWS AND MARES : IN WOMEN — PROTRACTED PREG- 
 NANCY : CASES OF — DIFFERENCE IN RATE OF DEVELOPMENT — MODE OF CALCU- 
 LATING THE PROBABLE TIME OF DELIVERY : CALCULATION FROM LAST MEN- 
 STRUATION TO BE CORRECTED BYPKRIOD OF QUICKENING — SUPERFCETATION : 
 TO BE DISTINGUISHED FROM SUPERFECUNDATION — PROOFS OF THE LATTER — 
 TWIN PREGNANCY IN RELATION TO THIS SUBJECT — CASES — CONCLUSIONS. 
 
 The Duration of Pregnancy is a subject which, in so far as regards 
 the human race, is enveloped in no little obscurity. Our chief diffi- 
 culty arises from the fact, that it is only in a very small number of 
 cases that the date of fertile coitus can be accurately ascertained ; and, 
 further, in the majority of these, it is probable that the data are open 
 
X.] STATISTICS. 177 
 
 to doubt.- For example, when an unmarried girl says she is pregnant 
 from a single coitus, may we not suspect that she does so to palliate her 
 fault, as she can no longer conceal her shame ; and the more closely, 
 indeed, Ave investigate this class of cases, the more convinced do we 
 become that many instances of so-called pregnancy from a single act 
 should not be admitted in evidence. The proof, however, which is 
 afforded by undoubted cases of this nature, and that which is derived 
 from other sources, is sufficient to show that there is a considerable dif- 
 ference in the duration of pregnancy, consistent with maturity of the 
 foetus and a normal state of the pregnancy from first to last. 
 
 In the Mammalia generally, one coitus, coinciding, as it does, with 
 the period of rut, is generally followed by conception. This admits of 
 observations of an exact kind in the case of many of our domestic ani- 
 mals ; by means of which, indeed, much of, what is known in this do- 
 main of physiology has been, in a great measure, established. In 1819, 
 M. Tessier submitted to the Academie des Sciences at Paris the result 
 of a series of investigations of this nature, which are of some interest 
 as illustrating by the light of comparative physiology the question 
 which we are now considering. The observations were, in fact, insti- 
 tuted with the object of determining the possibility of protracted ges- 
 tation in the human race. The following are the leading results : 
 
 Of 140 Cows : 14 calved between the 241st and the 266th day. 
 
 53 " " 269th " 280th " 
 
 68 " " 280th " 200th " 
 
 5 " " 290th " 308th " 
 
 The extreme difference between the births, in an animal in which ges- 
 tation is only a little more protracted than in women, being thus 67 
 days. An extended series of observations of a similar nature, and 
 yielding similar results, was conducted by the late Lord Spencer : 
 
 Of 102 Mares 
 
 3 foah 
 
 d on the 
 
 
 311th day. 
 
 
 1 
 
 " 
 
 u 
 
 
 314th " 
 
 
 1 
 
 " 
 
 n 
 
 
 325th " 
 
 
 1 
 
 (< 
 
 a 
 
 
 326th " 
 
 
 2 
 
 (t 
 
 u 
 
 
 330th « 
 
 
 47 
 
 si 
 
 between 
 
 the 
 
 340th and the 350th day 
 
 
 25 
 
 n 
 
 u 
 
 « 
 
 356th " 360th " 
 
 
 21 
 
 a 
 
 a 
 
 t 
 
 360th " 377th " 
 
 
 1 
 
 a 
 
 on the 
 
 
 394th day. 
 
 The extremes in this case embracing a period of no less than 83 days. 
 Of course, as regards the cases in which the birth took place much 
 earlier than the ordinary period, it may be said that they were examples 
 of premature delivery ; but even if, by striking them off, we remove this 
 possible fallacy, there still remains a sufficiency of facts to prove that, 
 in those animals, there is considerable latitude as to the exact day at 
 which labor may be anticipated. And, if this be the case in animals, 
 where sexual excitement is in abeyance during the whole period of 
 gestation, is it not even more likely to obtain in the case of women, in 
 whom sexual excitement persists, and who are exposed to moral and 
 social influences, and to diseases, one and all of which may act as dis- 
 turbing influences, and thus cause irregularities in the period of deliv- 
 
 12 
 
38th ' 
 
 ' —260 to 2ii6 
 
 30th < 
 
 < —267 to 273 
 
 40th " —274 to 280 
 
 41st < 
 
 ' —281 to 287 
 
 42d « 
 
 ' —288 to 294 
 
 43d « 
 
 ' —295 to 301 
 
 178 DURATION OF PREGNANCY. [CHAP. 
 
 ery ? And, in point of fact, this has been shown to be the case by 
 numerous examples which have been carefully noted by experienced 
 observers. The usual method of determining the approximate duration 
 of pregnancy, it being impossible to fix the date of conception, is to 
 make the calculation from the last day on which the menstrual dis- 
 charge was observed. It was upon this principle, and selecting those 
 cases only in which this starting-point could be exactly determined, 
 that Dr. Merriman conducted his investigations, with the results which 
 are quoted in almost every work on obstetrics. Of the 150 mature 
 births observed by him — 
 
 5 were delivered in the 37th week — 255 to 259 davs. 
 
 16 " " 
 
 2i " » 
 
 46 " " 
 
 28 " " 
 
 18 " 
 
 11 " « 
 
 5 " " 44th, the latest being the 306th day. 
 
 In this most interesting and reliable table a difference is shown 
 between the extremes of 51 days. The following table, of no less than 
 500 cases, by Dr. James Reid, is of no less interest, and is calculated 
 like that of Merriman from the last day of menstruation. 
 
 Of the 500 cases — 
 
 23 were delivered in the 37th week — 255 to 259 days. 
 
 48 " " 
 
 81 " " 
 
 131 " " 
 
 112 " 
 
 63 " " 
 
 28 " " 
 
 the difference between the extremes being in this case no less than 60 
 days. 
 
 The results yielded by these two tables prove that, calculating in 
 this manner from the last day of the last menstruation, considerable 
 variations in the duration of pregnancy seem to occur. But such 
 seeming variations must be viewed with caution. Our calculation is not 
 here, as in cows and mares, from the very day and hour of coition, 
 but is made in full knowledge of the fact that conception may have 
 occurred on any one day of a period extending over more than three 
 weeks. Such conclusions as may be admitted, upon an analysis of the 
 cases of single coitus in the human species which are on record, tend 
 to show pretty clearly that, although the range is less than in the 
 lower animals, there is an undoubted variation within certain limits. 
 Dr. Reid, in the series of papers from which the above table was taken, 
 gives an analysis of 43 cases of single coitus which he had collected ; 
 but as we entertain grave doubts of the accuracy of such tables, for 
 reasons already stated, we refrain from quoting it in extenso. Accord- 
 ing to it, delivery took place in from 260 to 300 days, a range of no 
 
 38th ' 
 
 ' —260 to 266 
 
 39th « 
 
 < —267 to 273 
 
 40th ' 
 
 ' —274 to 280 
 
 41st " —281 to 287 
 
 42d ' 
 
 « —288 to 294 
 
 43d " -295 to 301 
 
 44th « 
 
 ' —302 to 308 
 
 45 th ' 
 
 < —309 to 315 
 
X.] IRREGULAR CASES. 179 
 
 less than 40 days, and the average duration of gestation is shown to be 
 about 275 days. 
 
 The facts above cited seem to show that the question of the duration 
 of pregnancy is one which is of the highest importance not only in an 
 obstetrical, but in a legal sense; and it is indeed upon the facts established 
 by scientific and obstetrical research, and the opinions which are 
 founded upon them, that the laws bearing upon the subject have been 
 framed, and are interpreted in courts of law. One of the most inter- 
 esting cases of this kind on record is the well-known Gardner peerage 
 case, of which the following is a brief outline: 
 
 " Lord Gardner parted from his wife on board of his ship on the 30th of January, 
 1802, and, having proceeded to the West Indies, did not see her again until the 11th 
 of July following. Lady Gardner had been living in open adulterous intercourse 
 with a Mr. Jadis, and on that account his lordship obtained a divorce after his re- 
 turn, and subsequently contracted a second marriage. The case came before the 
 House of Lords in 1825, when Allan Legge Gardner, the son of Lord Gardner, by 
 his second wife, petitioned to have his name inscribed as a peer on the Parliament 
 Boll. Another claimant, however, appeared in the person of Henry Fenton Jadis 
 or Gardner, who alleged that he was the son of Lord Gardner, by his first, and sub- 
 sequently divorced wife. He was proved to have been born on the 8th of Decem- 
 ber, 1802, and the question in view of the above facts simply was (as the. possibility 
 of the pregnancy dating from July was not put forward) whether a child born 311 
 days from possible intercourse, could have been the child of the -deceased Lord 
 Gardner. The medical evidence, as, unfortunately, it too often is in such cases, was 
 very contradictory, but is particularly interesting as bringing out the opinions of 
 the greatest obstetrical authorities of the day. Sir C. Clarke, Dr. Gooch, and Dr. 
 Davis, stated their belief that forty weeks (280 days) is never exceeded, while on 
 the other hand, Drs. Blundell, Conquest, and Granville asserted that the period 
 was in some cases undoubtedly exceeded, and to such an extent that they were war- 
 ranted in admitting the possibility of the claimant, Henry Fenton Jadis, having 
 been a ten and a half months' child. Their lordships found that the elder claim- 
 ant was illegitimate, arid that, consequently, the son of the second marriage was 
 Lord Gardner. It must be admitted, however, that the moral evidence in this case 
 had probably more weight than the medical." 
 
 Since this decision, the attention of the profession has been much 
 more carefully directed to this subject, and probably no one at the 
 present day would venture to assert that 280 days is the ultimum tempus 
 pariendi which some legal authorities suppose it to be. Were we able 
 to date from the moment of conception, which under no circumstances 
 is possible to us, Ave could soon collect sufficient data to guide us in 
 future. But we must not forget that, even in those cases in which the 
 calculation is made from a single coitus, the time of insemination does 
 not necessarily mark the time of fecundation, and there is good reason 
 to believe, from what has been observed in the lower animals, that 
 some days may elapse before the fertilizing principle encounters the 
 ovum. [This opinion is sustained by the fact, that spermatozoids 
 have been seen in motion on the surface of the ovary, eight days after 
 intercourse (Flint, Jr.) Dr. S. R. Percy discovered them alive in 
 the mucus issuing from the os uteri eight days and a half after the 
 last coitus. — P.] Then, again, if we date from menstruation, Ave must 
 admit the possibility of irregular menstruation prior to impregnation, 
 in which case conception may occur six weeks or more after the last 
 menstruation. And if we admit this, as Ave tacitly do in cases of mar- 
 ried Avomen Avho carry the child longer than usual, Ave are bound in 
 
180 DURATION OF PREGNANCY. [CHAP. 
 
 common fairness to allow the same argument to those who wish to 
 prove the possibility of protracted pregnancy. The following instance, 
 from the writer's case-book, will serve to illustrate this : 
 
 u Mrs. P., who before had borne one child, ceased to menstruate on the 11th of 
 September. On the 23d of December, she had slight haemorrhage and other symp- 
 toms of threatened abortion. Nothing solid came away, and she was confined 
 strictly to bed until all the symptoms had disappeared. Previous to this she had 
 had morning sickness. In the course of the month of February, she felt motion, 
 but did not note the date. Development went on as usual, and she enjoyed excellent 
 health. 
 
 " On the 17th of July I visited her, being somewhat astonished at the duration of 
 the pregnancy. On examination I felt the outline and feet of the child quite dis- 
 tinctly, the latter moving vigorously in the right hypochondriac region, where the 
 movements had subjected the mother to much annoyance The os uteri was patent, 
 so as to admit the point of the finger, and was quite cushiony and soft. The ^ervix 
 was short, but quite perceptible. The presenting part could not be reached by the 
 finger. On the 22d of July, 314 days from the last menstruation, a male child was 
 born of average size and quite healthy." 
 
 In this case menstruation was habitually irregular, and there was 
 often an interval of six weeks between the periods. If we assume 
 therefore that impregnation occurred immediately before a menstrual 
 period, after an interval of six weeks (42 days), this would make the 
 duration of pregnancy exactly 273 days. 
 
 The following case is of a somewhat similar nature, but is further 
 interesting as affording an illustration of what we believe to be in 
 many cases an essential element in determining the probable duration 
 of pregnancy. The sensation of quickening is generally, as has been 
 observed, perceived by the mother a little before the middle of preg- 
 nancy, and should always be accurately noted, if possible. Were this 
 done in every case, it would serve to correct errors which may arise 
 from calculations based exclusively on the last menstruation. Had it 
 been done in the following instance, some trouble and anxiety might 
 have been saved ; and the same remark might possibly apply with equal 
 force to many of the so-called examples of protracted gestation : 
 
 Mrs. M., who had previously borne eight children, ceased to menstruate on the 
 13th of September. For some months after this she suffered much from spasmodic 
 asthma, which seemed to be associated with the pregnancy, of the existence of which 
 she was for some time doubtful. The movements were said to be less vigorous on 
 this than they had been on former occasions, but in all other respects she progressed 
 very favorably, the asthma becoming much less in proportion to the advance made 
 in the pregnancy. The calculated time having long passed, and a more careful 
 questioning having been adopted, it was found that quickening dated/rom thefirst 
 week in March at soonest. Only one menstruation had occurred since her former 
 pregnancy. 
 
 July 24th. — On examination, the os is found to be patent. A few pains have 
 occurred. Head easily reached and presenting. 
 
 July 31st. — Child born at 5 a.m., 322 days from the last menstruation. 
 
 If impregnation had not occurred in this case, we may suppose it 
 possible, if not probable, that the second menstrual period after the 
 former confinement would have taken place between six and seven 
 weeks after the first, and that impregnation had occurred immediately 
 before it — say on the 24th of October, or 280 days before birth. 
 
 The last case which we shall cite in illustration of this subject is one 
 of special interest, inasmuch as it is calculated from a single coitus 
 
X.] PROBABLE MAXIMUM. 181 
 
 under circumstances which leave no room for doubt as to the facts, and 
 in which the pregnancy was unusually prolonged: 
 
 The subject of the case in question, Mrs. R., had previously had seven children, 
 one having been a transverse presentation, and several having been delivered with 
 the forceps. Her general health being indifferent, she dreaded greatly another 
 pregnancy, and on that account absented herself from her husband's bed. In the 
 month of March the latter went on a visit to the country, where Mrs. E. visited 
 him for a single night, circumstances having arisen which obliged her to go to the 
 Continent, where she remained for two months. The date of this visit was the 2d 
 of April, and before her return home she was convinced by previous experience 
 that she was pregnant. The date of the last menstruation was a little uncertain, 
 but was about the 27th of March. To the astonishment of every one who knew the 
 circumstances, the pregnancy continued far beyond the ordinary limits, until, on 
 the 22d of January, she was delivered of a very large male child weighing 12 lb. 3 
 oz , 295 days from what we believe to have been beyond all doubt a solitary coitus. 
 An interesting point in the case was the great size of the child, indicating, as it 
 might be, that it had been retained within the womb beyond the ordinary period of 
 maturity. 
 
 Many writers, among them Scanzoni, maintain, and some observa- 
 tions seem to confirm their view, that the rate of intra-uterine develop- 
 ment is not always the same; and that children born mature at an 
 earlier period than usual are to be described as exceptional (Graviditas 
 Prceeox), while the contrary class of cases are those in which, develop- 
 ment being slow, maturity is not reached until a period considerably, 
 beyond the average (Graviditas Serotina). 
 
 The facts just stated furnish a general confirmation of the observa- 
 tions of those whose conclusions are embodied in the tables which we 
 have given. The maximum, according to Peid, is 393 days, as deduced 
 from his cases of single coitus; our own case above quoted is 295 ; and 
 Merriman's maximum of 306 days from the last menstruation will, if 
 calculated from the probable time of conception, give about the same 
 result. In Scottish Law, and in the French Code, the period of 300 
 days is fixed as the utmost possible limit, and in Prussia 301, so that 
 in these countries the child of a woman who is delivered 302 days after 
 the death or proved absence of her husband is declared illegitimate. 
 Difficult as it is, and always must be, to fix precisely the limit, we are 
 inclined to think that these laws are just; for while it is the object of 
 the law, from one point of view, to protect the innocent offspring from 
 the brand of illegitimacy, if it be possible to do so, it is in like manner 
 the duty of those who administer the law, not rashly to confer the posi- 
 tion and privileges of legitimacy upon the fruit of adulterous intercourse. 
 In English Law, no period or limit is fixed, and cases, when they arise, 
 fall to be decided in the light of the medical evidence of experts, and 
 of the moral and collateral aspects of the case. In America, a more 
 liberal view is taken, to judge from some legal decisions which are 
 quoted by Taylor, where paternity was held to be proved in two cases, 
 the duration of the pregnancy from coition being shown in one to be 
 313, and in the other 317 days. It is possible that the American 
 views on this subject may have received their color from the extreme 
 views entertained by one of the most eminent obstetricians in that coun- 
 try, Dr. Meigs, of Philadelphia, who has expressed a belief that gesta- 
 tion might continue for a year, or even more. 
 
182 DURATION OF PREGNANCY. [CHAP. 
 
 With reference to what has been said as to the probability of 300 
 days being a liberal interpretation of a law of nature, it must not be 
 forgotten that some very able obstetricians in this country have ex- 
 pressed a contrary opinion. The names of Simpson and Murphy are 
 a sufficient guarantee that the cases cited by them, on which they found 
 their opinion that pregnancy may be prolonged considerably beyond 
 the period named above, are free from the suspicion of careless investi- 
 gation ; but, on the whole evidence before us, we conclude that the 
 extreme cases must be disallowed, as the sources of fallacy are too 
 numerous to warrant us, without clear evidence, to sanction the exten- 
 sion of the possible limit. 1 
 
 Speaking in general terms, pregnancy may be stated as lasting, under 
 ordinary circumstances, for nine calendar months, — from 273 to 276 
 days, according to the length of the months which intervene. But, as 
 we are ignorant of the date of conception, and can only make the above 
 calculation under very exceptional circumstances, some other mode has 
 to be adopted in practice. It is a matter of some importance to the 
 practitioner, and one on which his comfort in no small measure depends, 
 to be able to forecast his obstetrical engagements ; and this subject is, 
 on that account, to him one of special interest. A long series of careful 
 examinations, conducted by independent observers, seems clearly to 
 show that the period of impregnation is usually about a week after the 
 cessation of a menstrual period. A ready method of reckoning, which 
 is founded on this belief, is recommended by many German authors, 
 and is very generally practiced by nurses in this country. It consists 
 in taking the date of the last menstruation, reckoning three months 
 back, and adding seven days. For example, a woman has ceased to 
 menstruate on the 8th of June ; three months back (or nine months 
 forwards), gives the 8th of March; to this add seven days = 15th of 
 March, which will be found, in a large number of cases, to be within a 
 few days of the actual time of delivery. 
 
 For greater exactness, as well as for the purposes of general scientific 
 accuracy, it is better to make the calculation in such a manner as may 
 
 1 Some reliable information, in regard to this subject, may, as we believe, be 
 derived from the observation of pregnancy in Jewish women. The author is 
 mainly indebted to a very able physician and accoucheur of that persuasion for the 
 following information. Among Jews the sexes are separate during menstruation, 
 and for seven clear days thereafter. The shortest period allowed for menstruation 
 is rive days, even should it last only for an hour or two, so that the minimum period 
 of separation every month is twelve days; and, in anything approaching menorrha- 
 gia, of course much longer. This law is observed by the vast bulk of the Jewish 
 women : the exceptions are very few. After the period of separation, whatever that 
 may be. the woman, besides an ordinary bath for cleansing purposes, must take what 
 is called the "bath of purification." She simply dips in this, but does not wash. 
 This gives a fixed day, from which a Jewish woman reckons, as she knows the 
 day she went to the bath, and calculates accordingly. Any one who may have an 
 opportunity of making observations in this direction, will find, 1st, that Jewish 
 women calculate more accurately as to the duration of pregnancy ; 2d, that, ac- 
 cording to their experience, the duration of pregnancy seems to be rather less 
 than is usually supposed; and 3d (although this has less to do with the subject 
 more immediately under consideration), that, as has been observed by a late writer 
 in Germany, this frequent and protracted abstention from sexual intercourse may 
 be admitted as a possible cause of the undoubted vitality of the Jewish race. 
 
X.] 
 
 METHOD OF CALCULATING. 
 
 183 
 
 enable us to compare one case with another, and at the same time 
 reduce possible error to a minimum. This is done by calculating in 
 each case 280 days, or ten lunar months, from the last menstruation, 
 which is equivalent (by deducting seven days) to nine calendar months 
 from the assumed date of conception. This calculation, simple as it is, 
 implies a certain amount of trouble, to reduce which various tables 
 have been constructed. Such tables, however, as are given by Naegele, 
 or by Murphy, after Dr. Ryan, are too elaborate to be of any real 
 practical every-day use, and to read them requires almost as much 
 trouble as to make the original calculation in each case. A much 
 more useful and satisfactory one is the following, which is very easily 
 read, and from which the calculation necessary may be made in a few 
 seconds. 
 
 Around the circle are arranged, in their order, the months in the 
 year, with the number of days in each. The number placed below 
 each month gives the number of days which must be added to the 
 
 Fig. 90. 
 
 To calculate the duration of pregnancy. (After Schultze.) 
 
 nine preceding months in order to make up 280 days. If the month 
 of February in a leap year is included in a pregnancy, it is estimated 
 by the number in brackets. 
 
 We reckon, in order to find the next 280 days from the starting- 
 point (the last day of menstruation), nine months forwards (or, more 
 simply, three months backwards), and add to the date thus reached the 
 number standing below the name of that month. 
 
 Example 1. — Last menstruation, the 10th of February, count three 
 months back = November 10th -f 7 — November 17th (in leap year, 
 November 10th + 6 = November 16th). 
 
 Example 2. — Last menstruation, 24th March, = 29th December, == 
 280 days. 
 
184 DURATION OF PREGNANCY. [CHAP. 
 
 Example 3. — Last menstruation, 30th September, 1863, = July 7th, 
 1864, = 280 days. 
 
 Example 4. — Last menstruation, 31st May, 1863, = March 7th, 
 1864, = 280 days. 
 
 The last example shows how to proceed when, at the end of the 
 month, there may be a doubt as to the calculation. 
 
 The 31st of February is equivalent to the 3d of March, which + 4 
 == 280 days. 
 
 An equally simple calculation may be made when, in medico-legal 
 investigations, we want to calculate backwards from the day of birth 
 to the probable cessation of the menses 280 days previously. In this 
 case, we count three months forwards, and subtract the number stand- 
 ing under the birth-month. 
 
 Example 1. — Birth, 31st October, = Menses, January 31st, — 7 — 
 January 24th, or 280 days. 
 
 Example 2.— Birth, 20th April, = Menses, July 20th, — 6 = 
 July 14th, = 280 days. 
 
 Impregnation may take place at any time during an intermenstrual 
 period. It is believed, however, that the time at which it most fre- 
 quently occurs is about seven days after the last menstruation, and that 
 the epoch next in point of frequency is immediately before the succeed- 
 ing menstrual period. It will be observed that we have thus a range 
 of three weeks within which impregnation may occur, even when the 
 menstruation is quite regular, and this fact serves to explain, as we 
 believe, the great majority of those cases in which a woman appears to 
 carry the child for three weeks beyond the calculated time. Indeed, 
 when a woman goes one week beyond the 280 days, we have come to 
 look upon it in practice as by no means unlikely that she will carry 
 her child for fourteen days more. 1 
 
 The errors which arise from this method of calculation are of such 
 frequent occurrence, that we find it of great advantage, when practica- 
 ble, to correct this observation by another, as has already been inci- 
 dentally observed — to wit, the quickening. In regard to this sign of 
 pregnancy, there certainly exists much self-deception on the part of 
 women, and, moreover, it is, as Dr. Reid remarks, seldom that they 
 can tell us the exact day on which they first feel it. The vulgar be- 
 lief is that the period when it is first felt indicates the middle of preg- 
 nancy, or four and a half calendar months ; but the opinion of the most 
 experienced accoucheurs is that it is, as a rule, perceived about the end 
 of the fourth calendar month, or about a fortnight before the middle of 
 the term. About the seventeenth or eighteenth week, therefore, may 
 be set down as the most usual period. Its value, as a sign of the dura- 
 tion of pregnancy is unfortunately much diminished by the long period 
 during which it may for the first time be experienced ; but, still, its 
 value is very considerable in this way, that, if we have a case to deal 
 with of apparently protracted pregnancy, it is unlikely that any con- 
 
 1 This term of 280 days is of special interest from another point of view, as 
 marking the tenth menstrual period from conception. (See " Causes of Labor," 
 Chapter XV.) 
 
X.] SUPERF(ETATION. 185 
 
 siderable error should arise both from the quickening and the menstru- 
 ation in the same case. By this precaution, therefore, the risk of mis- 
 calculation is certainly diminished. 
 
 When, as is usual in midwifery practice, the services of the accoucheur 
 are engaged beforehand, he should, for his own satisfaction, uniformly 
 ascertain the date of the last menstrual flow, and not be content with 
 the scanty information usually given that she expects her confinement 
 " early in the year," or " about the middle of June/' Having ascer- 
 tained the fact and noted it, he must then inquire as to the quickening, 
 and if the information is sufficiently clear, he must note that also. Or, 
 if the woman has not yet arrived at the period of her pregnancy when 
 this sign manifests itself, she must be requested to make an accurate 
 note of her quickening, with a view to the subsequent information of 
 her medical attendant. With the facts thus disclosed before him, he 
 may then, by an application of the principles already laid down, make 
 a calculation which, with ordinary care and discrimination, will rarely 
 mislead him. 
 
 Superfoetation. — It is generally, although not universally, admitted 
 by those who have devoted most attention to the subject, that it is quite 
 possible for one impregnation to succeed another, in the same pregnancy, 
 within a certain limited period, and it is all but proved that, in this 
 manner, twin pregnancies do occasionally occur. This is, however, not 
 superfoetation, but merely superfecundation; the essential distinction 
 between the two being, according to Scanzoni, that the former must 
 be held as occurring after the period at which the decidua vera and 
 decidua reflexa come into close contact. Under the head of Superfe- 
 cundation we must class cases, of which many are on record, of women 
 who have borne twins of different colors, after having had connection 
 successively with a negro and a white man. Scanzoni, who rejects the 
 idea even of superfecundation, explains such cases on the principle 
 that children sometimes resemble the father, and, at other times, the 
 mother, both in features and complexion. In twin pregnancies, one 
 child occasionally resembles the father, while the other resembles the 
 mother. It seems, on this ground, quite possible to him that all that 
 is necessary for the production of a black child and a white one is 
 cohabitation between a black man and a white woman ; or, what is 
 vastly more common, a white man and a black woman. It is quite 
 certain that the orifice of the Fallopian tube remains, during the early 
 months of pregnancy, quite patent; and that the mucous plug in the 
 os internum does not hermetically close the cavity. In fact, the ana- 
 tomical conditions are such that, but for the fact that the maturation 
 of ova does not usually go on during pregnancy, the difficulty would 
 rather be to discover why superfecundation was not more common. 
 Physiologically, the real impediment lies in this fact, that the highest 
 function of the ovary remains in abeyance from the period of concep- 
 tion till some time after delivery. If, therefore, ovulation should ex- 
 ceptionally go on — which Dr. Matthews Duncan supposes may be 
 indicated by exceptional instances of menstruation during pregnancy — 
 there is no difficulty in admitting the possibility of superfecundation 
 under such circumstances. 
 
186 SUPERF(ETATION. [CHAP. 
 
 It is otherwise with Superfoetation, the possibility of which has been 
 vigorously opposed by Wagner, who termed it a physiological impossi- 
 bility ; and by most of the modern English writers, among whom we 
 may mention Drs. Ramsbotham and Churchill. The idea implied is, 
 that a woman who already bears within her womb a living foetus may, 
 at a stage of pregnancy more or less advanced, again conceive, and thus 
 carry simultaneously the fruit of two conceptions, between which there 
 must be a considerable interval. A careful analysis of the so-called 
 cases of superfoetation, and especially of the older cases, shows conclu- 
 sively that, in most of them, the phenomena were quite consistent with 
 the idea of ordinary twin pregnancy. Numerous cases are on record 
 where, abortion having taken place, one twin has then been expelled, 
 while the other has gone to the full time. Others, again, occasionally 
 occur in which a mature child and a small withered one are born 
 together. But it needs no argument to show that, although instances 
 such as these may excite surprise among the ignorant, they are quite 
 in keeping with what is known of the physiology of twin pregnancy. 
 A number of the recorded cases are so obviously to be accounted for 
 in this way, that we are almost tempted to refer, without any further 
 investigation, all such to the same category. But an impartial con- 
 sideration of the numerous examples which have been advanced in 
 support of superfoetation will not permit such a summary treatment of 
 the subject. 
 
 Among the cases frequently quoted, is one which was published in 
 the Transactions of the College of Physicians. 
 
 " Mrs. T., an Italian lady, who was married to an Englishman, was delivered of 
 a male child at Palermo, on the 12th of November, 1807 ; and on the 2d of February, 
 1808, she was delivered of a second male child." Both children were said to huve 
 been born perfect, but a careful analysis of the whole facts as disclosed, seems to 
 show that the case in all probability comes under the class of twin pregnancies. 
 Certain doubtful circumstances regarding the first infant, coupled with the fact of 
 its early death, seem to point to the conclusion that it was born immature. 
 
 Dr. Mobus of Dieburg reports a similar case, the narrative of and 
 remarks upon which we take from Taylor's well-known work on 
 Medical Jurisprudence. 
 
 " A healthy married woman, about thirty-five years of age, was safely delivered 
 of a girl on the 16th of October, 1833. The child is described as having been well 
 formed, and having borne about it all the signs of maturity. This woman, it is to 
 be observed, had previously had several children in a regular manner. Soon after 
 her delivery, and the expulsion of the placenta, she felt, on this occasion, something 
 still moving within her. On examination, the mouth of the uterus was found com- 
 pletely contracted, and the organ itself so drawn up as to render it difficult to be 
 reached; but the motions of a second child were still plainly distinguishable 
 through the parietes of the distended abdomen. Her delivery was not followed by 
 the appearance of discharge (lochia) or by the secretion of milk. The breasts re- 
 mained flaccid, and there was no fever. On the 18th of November, thirty-three 
 days after her first confinement, this woman, while alone and unassisted, was sud- 
 denly delivered of another girl, which, according to Dr. Mobus, was healthy, and 
 bore no sign of over -maturity about it. The reporter alleged that this case most 
 unequivocally establishes the doctrine of superfoetation. The two births took place 
 at an interval of thirty-three days, and the two children were, it is stated, when 
 born, equally well-formed and mature ; but Dr. Mobus did not see the second child 
 until twenty-four hours after birth. This may, however, have been a twin case, in 
 which one child was born before the other. Dr. Mobus considers that the first child 
 
X.] ALLEGED EXAMPLES. 187 
 
 was born at the usual period of gestation, it being described as mature; and that 
 the other, thirtj'-three days after that period, having been, in his view, conceived 
 so many days later than the first child. If, however, we imagine, that in this, as 
 it often happens in twin case*, one twin was more developed than the other, and 
 that the more developed was the first expelled ; or that it is not always easy to com- 
 pare the degree of development in two children, when one is born before the other, 
 and the two are not seen together, we shall have an explanation of the facts, with- 
 out resorting to the hypothesis of a second conception after so long an interval. 
 As to the signs of over-maturity alluded to, they are not met with. If we are to 
 believe authentic reports, a child born at the thirty-ninth week cannot be distin- 
 guished from one born at the forty-third or forty-fourth week, and children born 
 at the full period vary much in size and weight. A longer time may be required 
 to bring children to maturity in some women than in others; and in a woman with 
 twins, it is well known that two children may arrive at the same degree of maturity 
 within different periods — one requiring perhaps several weeks longer than the other 
 for its full development." 
 
 In a most interesting paper by Dr. Bonnar of Cupar-Fife, 1 a number 
 of cases are given in which children, born in wedlock, succeeded each 
 other with very unusual rapidity. The question of superfcetation is 
 here looked upon from a different point of view, in reference more 
 particularly to the period after parturition, at which the female pro- 
 creative organs are again capable of exercising their functions. Dr. 
 Bonnar gives three cases, all occurring in families of rank and posi- 
 tion ; but we do not think it necessary to repeat the names, as some of 
 the parties are still alive. In these cases, there intervened between the 
 two deliveries 182, 174, and 127 days, and all the children were suffi- 
 ciently developed to be reared, and, without exception, to reach ma- 
 turity. How are we to explain these facts? We know that impreg- 
 nation may occur within a very short period of delivery, long before 
 the mucous membrane has gone through the process described by M. 
 Robin, and been restored to its normal state. But, in the case last 
 mentioned, this would only give about four calendar months from an 
 impregnation assumed to date from six days after the last delivery, an 
 age at which it would not be possible to rear the child, even upon the 
 assumption of its being a case of so-called graviditas prwcox. If we 
 reject this theory, and yet admit the facts which we believe to be be- 
 yond question, there is only one other way of accounting for them, and 
 that is to admit the possibility of superfcetation. 
 
 Now, in regard to much of what has been urged in evidence against 
 the possibility of superfcetation, it must be admitted that it is either 
 irrelevant or inconclusive. Many, even of those who admit the prob- 
 ability, within certain limits, of superfecundation, assume that a new 
 conception is impossible — say in the second or third month — on account 
 of mechanical impediments which exist so soon as the decidua is formed. 
 We know, of course, that the complete development of the decidua 
 reflexa is a barrier to the formation of another embryo within the 
 pouch thus constituted, or, in other words, of an ordinary twin preg- 
 nancy; but the researches of Coste most conclusively show, as has 
 already been mentioned, that neither the Fallopian tubes nor the 
 cavity of the cervix are closed so as to prevent communication between 
 the vagina and the ovary. Or, to speak more plainly, there is no me- 
 
 1 Edinburgh Medical Journal. January, 1865. 
 
188 SUPERFOETATION. [CHAP. 
 
 chanical, nor, if the function of the ovary be not arrested, is there any 
 physiological impossibility that a new ovum might be fertilized, at any 
 period prior to that at which the decidua vera and the decidua reflexa 
 come into contact, and be developed in a special decidual sac. But 
 some of the last cited, if they are to be taken as cases of superfoetation, 
 would seem to point to a new impregnation at a period later than that 
 at which the two decidual layers come into contact ; a difficulty which 
 is ingeniously got rid of by Dr. Matthews Duncan, who says, " if we 
 suppose, in an instance of this kind, that the first child is born prema- 
 turely, but within the limits of viability, we thus gain two months; 
 and, if impregnation may take place between two and three months 
 after conception, we have thus four or five months of interval accounted 
 for between the births of successive viable infants." 
 
 It is admitted on all hands that superfoetation may take place in cases 
 of extra-uterine pregnancy. This, taken in connection with the facts 
 hitherto ascertained with reference to menstruation during pregnancy, 
 seems to indicate pretty clearly that the function of the ovaries is not 
 necessarily interfered with in the course of gestation ; but, at the same 
 time, cases of this nature must be considered as standing by themselves 
 and not affecting directly the ordinary question of superfoetation. 
 
 [It cannot be said that superfoetation is generally admitted as possi- 
 ble after an extra-uterine conception. Women have repeatedly con- 
 ceived while carrying a child, developed outside of the uterus, but we 
 are aware of no facts which prove that a uterine impregnation is pos- 
 sible, between the time that the misplaced conception occurs, and the 
 complete restoration of the woman from the pseudo-puerperal con- 
 dition, which follows the death of the child and the false labor, which 
 occur at or near term in extra-uterine pregnancy. 
 
 The history of extra-uterine pregnancy, contrary to the opinions ex- 
 pressed by the author, appears to show that the function of the ovaries 
 is interfered with during the course of gestation. It is only after the 
 completion of this, and the restoration of the woman to the non-puer- 
 peral condition, that she can conceive while carrying an extra-uterine 
 child.— P.] 
 
 An example of this is reported by Montgomery, in which, while the 
 product of an extra-uterine gestation remained encysted within the 
 abdomen, the woman bore three children, one of whom lived. A simi- 
 lar case has been recorded by Dr. Steigertahl ; and another still more 
 interesting by M. diet, of Lyons, in which a woman died suddenly, 
 and, upon dissection, an extra-uterine foetus of five months was found 
 in the abdomen, while a foetus of three months occupied the uterus. 
 
 In another group of cases, of which many are on record, a second 
 impregnation takes place, and development goes on within the un- 
 occupied cavity of a double uterus. Of these, few present features of 
 greater interest than one which was brought under the notice of the 
 author by Dr. J. Harris Ross, of Brighton. It was embodied by him 
 in his graduation thesis at the University of Glasgow in 1871, and 
 was subsequently published in the Lancet. The following is Dr. Ross's 
 report : 
 
X.] 
 
 IMPREGNATION IN DOUBLE UTERUS. 189 
 
 "Mrs. C , the subject of these remarks, is a woman aged thirty-three. She 
 
 has been married fourteen years ; and, previous to the circumstance [ am about to 
 relate, had been delivered of six children. With the last three I was the medical 
 attendant; but had never before had the opportunity of examining the uterus, as 
 the child on each occasion was quite at the outlet of the vagina when I arrived at 
 her house. With the exception of once (when she was prematurely delivered of a 
 seven months' child) the labors were all natural, and she always made a good 
 recovery. 
 
 "She sent for me in May, 1870, as she had considerable haemorrhage. She told 
 me that she was pregnant, and that she had not menstruated since the previous 
 February. On examination, I found the os uteri very flaccid and partially open, 
 and another opening close to the left of it, which I supposed to be an excavated 
 ulcer, and the cause of the haemorrhage. As she objected to the use of the spec- 
 ulum. I ordered her to keep the recumbent posture, and to use an astringent injec- 
 tion, which 1 sent her, together with some tonic medicine In a few days thehsemor- 
 rhage ceased, and she got about her household duties until July 16th. 
 
 " On the morning of that day she sent for me in a great hurry. 1 found her with 
 strong labor pains; and on making an examination, I found a bag of membranes 
 protruding from the uterus, which ruptured during my examination. After this 
 the pains left her. I saw her several times in the course of the day, but the pains 
 did not return until about nine o'clock in the evening, when they were of a very 
 feeble character. On examination at this time I found another bag of membranes 
 protruding, which I ruptured, as I thought it might stimulate the uterus to con- 
 tract. A head then presented, and, after some time, the pains being very feeble, a 
 foetus was expelled. On again examining, a leg presented, and after awhile I de- 
 livered her of a second* i'oet us, and then of a double placenta — that is, one with two 
 cords. The children were, I should judge, of nearer six than five months' growth. 
 After I had removed the placenta, the patient exclaimed^. ' I am sure there is 
 another, Mr. Ross,' — meaning another child. As the uterus felt rather bulky, I 
 introduced my hand into the vagina, and my finger into the uterus, to make sure, 
 but found the cavity quite empty. At this time the second opening in the uterus 
 was plainly to be felt. The whole course of this labor was very different from her 
 other ones ; the pains were very feeble, and the labor unduly long : this I attributed 
 to her having twins. 
 
 "About a week afterwards, the patient again declared that she had another 
 child in the womb; but I pooh-poohed it, as I had madesuch a careful examination 
 after delivery, that I felt certain that I could not have left one behind. She, however, 
 persisted in her statement. One day I went to see her, and my hand being very 
 cold, I placed it upon her abdomen, when I plainly felt the movements of a child, 
 and on applying my stethoscope the foetal heart was quite audible. On exam- 
 ination per vaginam, the two openings could distinctly be felt, when it at once 
 dawned upon me that I had got a case of double uterus, with both sides impreg- 
 nated at the same time. On introducing a sound into the apertures, there was no 
 doubt they both opened into a cavity or cavities, but, as she was still pregnant, I 
 did not then push the matter further. When laid flat upon her back the tumor 
 in the abdomen was decidedly more to the right than the left side. As there was 
 now no doubt about her being pregnant, 1 told her to send for me direct^ she was 
 in labor. 
 
 " She went on well until the morning of October 31st, when she sent for me at 
 6 a.m. On my arrival, I found the head on the perineum, with the membranes 
 protruding. I ruptured them, and delivered her of a female child of full growth 
 in about a quarter of an hour afterwards. On examining the uterus (after removal 
 of the placenta) I could get my thumb into one opening, and, by a little manipula- 
 tion, my finger into the other, and could distinctly feel a septum between them. 
 She slated that she had menstruated three times since her miscarriage of twins in 
 July. Both mother and child made a good recovery." 
 
 The conclusions, then, with reference to this subject, at which we 
 think we are justified in arriving are, — 1st, That in regard to Super- 
 fecundation, this is a phenomenon the existence of which there is no 
 reason to doubt; 2d, That in so far as cases of double uterus and extra- 
 uterine pregnancy are concerned, Superfoetation is established beyond 
 question ; and 3d, That with respect to other cases (to which alone, 
 
190 PLURAL PREGNANCY. [CHAP. 
 
 perhaps, the term Superfoetation should properly be applied), a large 
 number of recorded cases are merely twin pregnancies. A strong pre- 
 sumption is, therefore, established that, up to the period when the 
 decidua reflexa comes into contact with thedecidua vera, and, probably, 
 until the two have become intimately adherent, there is a possibility 
 of a new impregnation. Beyond this period we believe it to be 
 impossible. 
 
 CHAPTER XL 
 
 PLURAL PREGKAXCY— EXTRA-UTERINE PREGNANCY. 
 
 plural pregnancy — mode of impregnation — twins: disposition of the 
 membranes and placenta in: diagnosis of: relation of to superfceta- 
 tion — triplets, etc. — extra-uterine pregnancy — varieties of: ovarian: 
 tubal: tubo-ovarian : abdomino-tubal : tubo-uterine, etc.: abdomi- 
 nal — CAUSES OF EXTRA-UTERINE PREGNANCY — DEVELOPMKNT OF THE OVUM 
 AND ITS COVERINGS — SYMPATHY OF THE UTERUS — SYMPTOMS — PROGRESS OF IN 
 DIFFERENT VARIETIES : RUPTURE OF THE SAC: PERITON EAL INFLAMMATION : 
 DISCHARGE OF FC3TAL DEBRIS — TERMINATIONS — TREATMENT. 
 
 The term Plural Pregnancy may be held to include all cases in 
 which two or more germs are fertilized, simultaneously or nearly so, 
 and are together developed within the uterine cavity. The products 
 of conception in these cases are termed twins, triplets, quadruplets, etc., 
 according to their number. It has been observed that certain women 
 are peculiarly prone to plural conceptions ; that those, for example, 
 who have once borne twins are much more likely to carry two children 
 again than those who have not. Whether such pregnancies are or are 
 not the result of separate acts of insemination, is a question in regard 
 to which we cannot venture beyond conjecture. Many facts, such as 
 the birth of twins of different color, have been observed, which seem 
 to show that successive acts within a limited period may be the cause 
 of the impregnation of separate ova. But it is in the highest degree 
 improbable that this is always the case, for there is no reason to believe 
 that, if the semen comes into contact at the same time with two mature 
 ova, one only is to be fecundated, and the other passed over. Indeed, 
 in cases of double yolk, where twin pregnancy occasionally arises, it is 
 apparent that what may suffice to fecundate one germ, can scarcely fail 
 similarly to act upon the other. We shall not pause here to consider 
 whether or not we are to explain the fact of the frequent unequal de- 
 velopment in multiple pregnancies by the doctrine of superfecu Delation, 
 but nothing is so common in this class of cases as to find one child well 
 developed and vigorous, while another is weak and puny. 
 
 Twin Pregnancies occur once in about 75 to 80 cases, and triplets 
 certainly not oftener than once in 5000. Cases where the number of 
 
XI.] TWIN PREGNANCY. 191 
 
 children is greater are extremely rare. It was for long doubtful 
 whether two embryos which were being simultaneously developed 
 belonged to the same or different ova, and whether, in the last case, 
 these ova proceeded from the same ovary. Modern research has in 
 reference to these points established the following propositions : 1st, 
 that two yolks are occasionally found in a single ovum ; and that the 
 germs contained in them are probably simultaneously fertilized : 2d, 
 that two ova may exist within a single Graafian vesicle, from which, 
 on its maturity, they may escape and be fertilized, together or suc- 
 cessively : 3d, that two ova may be formed within two Graafian vesicles 
 in the same ovary, or one in each ovary, the latter of w T hich is proved 
 by the simultaneous occurrence of pregnancy in each cavity of a double 
 uterus (see Dr. Ross's case, quoted in Chap. X), and by the existence of 
 two corpora lutea, in the same stage of development. 
 
 The following varieties of twin pregnancy, — the distinction between 
 which depends on the arrangement of the membranes, cord, and pla- 
 centa, — are those which are generally observed in practice. The essen- 
 tial difference between them depends, as a little careful examination 
 will show, upon whether two ova have been separately impregnated, or 
 a single ovum has contained two germs.. 
 
 The cases which occur most frequently are those in which two dis- 
 tinct ova are impregnated, whether they come from separate ovaries, 
 from two Graafian vesicles in one ovary, or from a single Graafian 
 vesicle. Each of these becomes imbedded in the mucous membrane of 
 the uterus, and the decidua reflexa rises round it in the usual way. In 
 the process of growth, the two tumors approach each other and come 
 into contact, forming thus a partition between the two cavities, which 
 originally consists of six layers, the decidua, chorion, and amnion, 
 proper to each embryo. It would seem, however, according to the 
 observations of Guillemot and others, that the decidua forms a very 
 thin layer in the partition, or is absorbed, so that the partition at 
 maturity consists of four layers only, consisting of the amnion (3 3) 
 and the chorion (2 2) on each side, the whole mass being enveloped in 
 a single decidua (1 1). In these cases the placenta?, developed, as will 
 be remembered, on the maternal and foetal sides, from the decidua and 
 chorion respectively, are sometimes completely separated, the one from 
 the other. In other instances, again, they are fused together into a 
 single mass, or are united by a sort of membranous bridge. But, as a 
 rule, in spite of this continuity of tissue, there exists no vascular com- 
 munication between the two. 
 
 In another class of cases, which are of comparatively rare occurrence, 
 there is a chorion (Fig. 92, 2 2) common to both embryos, each, how- 
 ever, being inclosed in its own amnion (3 3), the common decidua 
 (1 1) surrounding the whole, as in the former case. In these instances 
 there is a single placenta, and very frequently ramifications exist be- 
 tween the branches of the two cords. There can be no doubt that here 
 there must have been impregnation of two germs within a single 
 ovum ; or, in other words, they are cases of double yolk. 
 
 It occasionally occurs that two embryos exist in a common amnionic 
 cavity, — a fact which it is difficult to explain on any other hypothesis 
 
192 
 
 PLURAL PREGNANCY. 
 
 [CHAP. 
 
 than that they originally belonged to the former class, and that the 
 amnionic partition in Fig. 92 is absorbed in the course of development. 
 If we could admit that the doctrine propounded by M. Serres was 
 correct, — that the amnion exists, in the first instance, as an independ- 
 ent vesicle, and that, subsequently to its complete development, the 
 foetus comes into contact with it, and depresses its surface so as to 
 envelop itself in a double layer, as takes place in the case of the serous 
 membranes and the viscera which they invest, — we might be able to 
 
 Fig. 91. 
 
 Diagrammatic representation of 
 partition in twin pregnancy (1st 
 variety). 
 
 Twin pregnancy (2d variety). 
 
 explain the occurrence. In the present state of our knowledge, how- 
 ever, on the subject of Ovology, we are at a loss to account for the 
 presence of two embryos in one amnionic sac on any other theory than 
 that which we have mentioned. But we cannot agree witli those who 
 pronounce it to be impossible, or irreconcilable with the views of de- 
 velopment which have been given in an earlier section of this work. 
 For, while we are constrained to admit the improbability, we cannot 
 subscribe to the impossibility, of the development of two embryos on a 
 continuous surface of the germinal membrane, — both being included 
 within the cavity formed, in the usual way, by the amnionic folds. 
 The two cords have generally been observed, in these cases, to spring 
 from separate points of the placenta; but they have been found, in a 
 few rare instances, to spring from a common trunk, which bifurcates at 
 a variable distance from the placental surface. In the cases of twin 
 pregnancy in which one fetus is deprived of an important part of its 
 body, it has been frequently found along with a perfect twin in the 
 same amnionic sac. 
 
 A fourth variety of twin conception is that which has been described 
 by Olivier and others, under the name of monstrosity by inclusion. 
 This consists in the presence within an otherwise perfect foetus of the 
 elements, more or less distinct, of another, which may be situated 
 either within the abdominal cavity, or beneath the skin — usually in 
 the neighborhood of the perineum or scrotum. 
 
 It is often possible, during the currency of a pregnancy, more espe- 
 cially during the weeks immediately preceding delivery, to recognize 
 the presence of twins. Generally speaking, when there is, as is usual, 
 a foetus on either side of the uterus, the shape of the organ is less 
 globular than usual, and there is more enlargement in the direction of 
 the sides. The woman may complain of movement at separate points 
 
XI.] RARER VARIETIES. 193 
 
 of the abdomen, — an observation which, although far from being con- 
 clusive evidence of the presence of twins, seems to be, in certain cases, 
 of some practical value as a symptom. If the abdominal wall be thin, 
 it may also be possible for the accoucheur to perceive these movements 
 by palpation, and, in the course of the same examination, even to recog- 
 nize the presence of a second foetus. There is greater distension of the 
 abdomen, and an aggravation of such symptoms as are the result of 
 pressure on neighboring organs. The pulsation of the two foetal hearts 
 may be heard at different points on the abdominal surface. Ballotte- 
 ment is not practicable. The uterine souffle is unaltered. These signs 
 are, however, often vague and unsatisfactory, even in those cases in 
 which a suspicion of twin pregnancy has arisen ; and, in the majority 
 of instances, the fact of the plural pregnancy is only recognized in the 
 course of labor. 
 
 Whether as the result of superfecundation, or simply of unequal de- 
 velopment, cases are very frequently met with in which the infants are 
 of different size. In others, the growth of one foetus is arrested, and 
 it dies. The results, in such cases, vary considerably, being influenced 
 by various circumstances, among which we may assume that the mode 
 of disposition of the membranes is not the least important. In a cer- 
 tain number of cases, the dead foetus is retained, but there being no 
 access of external air, no putrefactive change takes place. It becomes 
 hard, withered, and mummified, and in this state it may be born with 
 the mature foetus at the termination of pregnancy. This may happen 
 whatever may be the nature of the partition between the two, and even 
 as some believe, in the cases in which they are in a single amnionic 
 cavity ; but it is, we apprehend, likely that Baudelocque is correct, 
 when he assumes that, in the latter, the death of one necessarily places 
 the life of the other in great jeopardy. In other instances, the dead 
 foetus acts as a foreign body, or in some other way incites the uterus to 
 contract, the result being usually the expulsion of the living and the 
 dead ; or the dead foetus is expelled, and the uterine action being 
 arrested at this point, the living one is retained, and ultimately fully 
 developed. This can, for reasons which a moment's reflection will 
 render obvious, only take place when each foetus is enveloped in a 
 complete series of membranes. If there be a common chorion, and, 
 a fortiori, if there be a common amnion, the expulsion of one necessa- 
 rily involves the expulsion of the other. In yet another group of 
 cases of this nature, both are retained ; but when labor comes on, the 
 mature and living child only is expelled, while the withered foetus 
 remains behind, and may possibly occupy the womb for a very con- 
 siderable period. The cause of the death of one foetus in these cases 
 is not well understood, but, probably, they who believe it to be due to 
 some form of degeneration of the placenta or the membranes, or to some 
 disease in the foetus itself, are correct in their supposition. 
 
 It has been observed, with reference to multiple pregnancies, that 
 they frequently terminate before the full period of gestation has been 
 reached. This we may assume to be due to the over-distension of the 
 uterus, which excites it to contraction at a period somewhat earlier than 
 
194 EXTRA-UTERINE PREGNANCY. [CHAP. 
 
 usual. As a rule, both children are generally expelled in the course 
 of the same labor, in some instances without even a pause in the uterine 
 effort. This is, however, far from being invariable, as it is not uncom- 
 mon for the action to cease, and to return again in eighteen, twenty- 
 four, or even forty-eight hours, when the uterus is thrown anew into 
 periodic contractions, and the labor goes on in a perfectly regular and 
 normal manner. In very rare cases, the interval between the two births 
 may extend to a period of weeks, or even of months ; and there can 
 be no doubt that many of these cases have given rise, on erroneous 
 grounds, to a belief in the theory of superfoetation, the error arising 
 from the fact that the immaturity of the first child is overlooked. 
 
 It is unnecessary to make further mention of the other varieties of 
 multiple pregnancy, as the observations which have been made may be 
 held mutatis mutandis, as applicable to these also. To judge from the 
 few cases in which observations have been made, it would appear to be 
 rare that each foetus, the number being more than two, is inclosed in 
 its own complete sac. Several cases of triplets, are, for example, re- 
 corded, in which one had a special sac, while the other two had a com- 
 mon amnion. In regard to the possible retention of one or more 
 of them, we may well suppose, to judge from analogy, that any con- 
 ceivable combination of the numbers is in this respect possible. The 
 practical bearing of plural pregnancy on the progress of labor will be 
 noticed hereafter. 
 
 Extra-uterine Pregnancy. — Although the cavity of the womb is the 
 site which nature has specially prepared for the development of the 
 fruit of conception, it occasionally happens that it goes through its 
 characteristic phases of development elsewhere. Generally, in these 
 cases, its growth is arrested at a stage considerably short of maturity ; 
 but many instances have occurred in which the full period of gestation 
 has been reached, and some in which it has been considerably exceeded, 
 although the cavity of the uterus was entirely empty, as in the virgin 
 state. The ovum is, as has been shown, developed within the ovary in 
 the Graafian vesicle; and what has been observed in the lower animals 
 leads us to conclude that, while yet it occupies that situation, and even 
 before the rupture of the vesicle has occurred, impregnation may take 
 place. On the bursting of the vesicle, the germ is received into the 
 infundibulum or pavilion of the Fallopian tube, and is thence con- 
 ducted slowly through the entire length of the tube, until it reaches 
 the uterine cavity, where its subsequent development progresses until 
 the moment of delivery. Such we know to be the law of nature. Con- 
 stituting an exception to this law, the ovum may, however, be arrested 
 at any point of its course, and there, taking root as it were, the vital 
 processes of development go on, up to a certain point, as actively and 
 as efficiently as if the ovum had passed on to its usual site. In other 
 cases it may deviate from its normal channel, and escaping between the 
 fimbria? of the Fallopian tubes, falls into the cavity of the peritoneum, 
 to some portion of which membrane it attaches itself. These are the 
 circumstances which constitute extra-uterine pregnancy, and cases as 
 they occur are classified more or less elaborately according to the ana- 
 tomical relations which the ovum assumes in its unwonted situation. 
 
XI.] TUBAL PREGNANCY. 195 
 
 The usual division is into Ovarian, Tubal, and Abdominal cases, with 
 many subdivisions, the more important only of which will be noticed. 
 
 The existence of Ovarian pregnancy has, by Mayor, Velpeau, and 
 others, been absolutely denied. The denial seems, however, to have 
 been founded on the assumption, which we believe to be unwarranted, 
 that impregnation is mechanically impossible without rupture of the 
 Graafian vesicle. But, even if rupture has taken place, it is not incon- 
 ceivable that a fertilized ovum should remain, and become, at least 
 partially, developed within the Graafian vesicle. This is what has been 
 termed the "internal" variety of ovarian pregnancy, as distinguished 
 from the " external" form, in which the ovum is attached to the surface 
 of the ovary. It is probable that, while the latter may more properly 
 be classed as " abdominal," or " tu bo-ovarian," it is the former alone 
 which should receive the name of "ovarian" pregnancy; but it must 
 be confessed that, in this sense, internal or true ovarian pregnancy 
 involves an assumption which, among modern physiologists, receives 
 little support. 
 
 Of all the varieties of extra-uterine gestation, the most common, by 
 far, is the Tubal, which, for the reasons, already stated, is precisely 
 what we would anticipate. The ovum is, in its descent towards the 
 cavity which awaits it, arrested, it may be at any one point of its 
 course, and there contracts adhesions, forms its membranes and pla- 
 centa, and is thus surrounded, in lieu of a uterus, with a sac which is 
 formed of the dilated and hypertrophied walls of the Fallopian tube. 
 For greater precision in description, various names have been assigned 
 to such pregnancies, according to the exact point at which the arrest 
 of the ovum takes place. Those quite at the fimbriated extremity of 
 the tube, which either are originally, or come to be in course of time, 
 in contact both with tube and ovary, are termed tubo-ovarkm. Where, 
 again, the ovum is stopped at the point where the tube first narrows, 
 the fimbriae having relaxed their hold on the ovary, the development 
 may take place partly within the tube, where the placenta will probably 
 be situated, and partly bulging into the abdominal cavity, in which 
 direction the growth mainly advances. To this variety the name tubo- 
 abdominal has been given. Between this and the uterine wall is the 
 situation at which the ordinary and most common form of tubal preg- 
 nancy occurs. Several varieties have been described of cases in which 
 the ovum has its seat in the immediate vicinity of the uterine cavity, 
 of which the most important and interesting is the utero-tubal, where 
 the ovum lodges in that portion of the tube which passes through the 
 walls of the uterus. The development in such a case may be partly 
 within the uterus and partly within the tube; or, when a little more 
 external, it may develop actually within the parenchyma of the uterus, 
 and, if projecting into the cavity, may be invested with a covering of 
 muscular fibres derived from the uterus itself. This is, probably, the 
 Graviditas in substantia uteri of the older writers. 
 
 Among the rarer varieties is that, of which an example is given by 
 Burns, in which the placenta is found in its normal situation within 
 the uterus, and the foetus within the Fallopian tube ; and, still more 
 rare are those of which Hunter, Horfmeister, and Patuna have given 
 
196 EXTRA -UTERINE PREGNANCY. [CHAP. 
 
 illustrations, in which the foetus has been found in the abdominal 
 cavity, and the placenta in the uterus — the two being connected by a 
 cord which ran from the placenta for some distance within the Fallo- 
 pian tube, and then perforated it to join the foetus. These latter cases 
 have been called utero-tubo-abdominal ; and, in reference to them, it is 
 in the highest degree probable that they were originally cases of tubal 
 pregnancy, in which the placenta had been developed within the uterus, 
 while the foetus had escaped into the peritoneum by rupture of the 
 walls of the sac in which it had been contained. Another rare form 
 has been described as subpcritoneo -pelvic ; in which it is assumed that 
 the ovum, having been unable to enter the external orifice of the tube, 
 has got between the folds of the broad ligament, and there developed 
 itself. It has been justly observed that, if this variety does occur, a 
 more favorable result may be anticipated than in the other forms ; 
 beeause, in such a situation, the debris of a dead foetus may be more 
 easily and more safely removed. 
 
 In Abdominal Pregnancy, the fertilized ovum escapes the grasp of 
 the fimbriae, and falls into the cavity of the peritoneum, to any portion 
 of which membrane it may in fact become attached. We may thus 
 find it firmly incorporated with the broad ligament, the intestines, the 
 colon, and any other parts to which continuity of tissue permits its 
 access. The essential physiological difference between an abdominal 
 case and the other varieties of extra-uterine pregnancy is that, in the 
 former, the ovum is without any special covering which can correspond 
 to that which, under other circumstances, it derives from the tube or 
 other investing structure. It grafts itself, so to speak, upon the 
 peritoneal surface of some viscus, or of the abdominal wall; and if it 
 is subsequently covered with any special covering, that must be the 
 result, physiologically, of special evolution, or, pathologically, of in- 
 flammatory action. 
 
 Little has been hitherto discovered which enables us to come to a 
 satisfactory conclusion, in regard to any of the above varieties, as to the 
 Causes of extra-uterine gestation. Many have believed that a shock or 
 fright, or a blow on the lower part of the belly may, should this chance 
 to coincide with the moment of conception, give rise to it, and they 
 ground this belief on facts which women have from time to time com- 
 municated. No single observation affords, however, to this theory, 
 even the shadow of a proof, and the so-called evidence on which it 
 rests, may perhaps be attributed without impropriety to that love of 
 the marvellous which exists in so many minds. We cannot doubt that 
 certain pathological conditions might furnish the cause; and, in some 
 instances, the existence of such pathological conditions has been estab- 
 lished. Inflammatory action of any kind, induration, pressure exer- 
 cised by morbid growths, spasm of the muscular fibres of which the 
 tube is so largely composed — so as to cause stricture — are a few of a 
 hundred conditions which might be specified as possible causes of the 
 phenomenon. The fact is, however, that in most of the cases in which 
 a careful examination has been made, the course of pregnancy so alters 
 the anatomical conditions of the chosen site, that it is impossible to 
 come to any satisfactory conclusion as to the original condition of the 
 
XI.] POSSIBLE CAUSES. 197 
 
 parts. Some very curious phenomena have been observed, showing 
 that the ovum is sometimes very erratic in its course. How otherwise 
 are we to explain the facts observed in Dr. Oldham's cases, in which 
 there was a distinct corpus luteum on one side, and tubal pregnancy on 
 the other? for we must accept, as Dr. Tyler Smith says, in reference to 
 one of these cases, one of three explanations. "The unimpregnated 
 ovule might have been swept by the cilia of the peritoneum from the 
 right ovary to the fimbriated extremity of the left tube; this would be 
 similar to what occurs in the Amphibia, in which the ova always 
 traverse the abdomen to reach the oviduct. Or the left tube may have 
 reached over to the right ovary and have taken up the ovule. Accord- 
 ing to the third explanation it might be that the ovule has descended 
 the right tube, entered the uterus, and then ascended through part of 
 the left tube by an antiperistaltic action, or by the ciliary currents 
 which move from below upwards." The view which Dr. Smith pre- 
 ferred in regard to the case in question was the third ; while Dr. Old- 
 ham and Mr. Wharton Jones were inclined to accept rather the second 
 of the explanations offered. It is possible that some cases of extra-uterine 
 pregnancy may owe their origin to some such peculiarities in the evolu- 
 tion of the ovule. 
 
 In every form of extra-uterine pregnancy, the ovum forms its own 
 membranes, and goes through the various phases of evolution in all 
 respects as if the pregnancy were normal. It is therefore in every 
 case covered by its own amnion and chorion, without which, indeed, 
 further development were impossible. For, if we reflect on the man- 
 ner in which the main circulation of the embryo is established through 
 the agency of the latter membrane, we cannot by any possibility agree 
 with those who have maintained that in abdominal pregnancies there 
 is no chorion. So far all cases are alike. But in regard to the further 
 coverings of the foetus which, external to those just named, are of 
 maternal origin, and correspond to the decidua and the uterus, great 
 differences exist according to the class of extra-uterine pregnancy to 
 which each case is to be referred. It is probable that in tubal preg- 
 nancy the mucous membrane may form, as in ordinary cases, a special 
 envelope strictly analogous to the decidua ; but, whether we take this 
 view of the case or not, it is clear that, in every instance, the sac within 
 which is contained the foetus and its special structures, is composed 
 of the mucous, muscular, and serous layers of the Fallopian tube, which 
 become distended, and at the same time hypertrophied, as the ovum 
 grows. In true ovarian pregnancy, if such indeed exist, the sac must 
 consist originally of the walls of the Graafian vesicle, and externally of 
 the special coverings of the ovary itself; but, in the compound forms, 
 the sac may be partly tubal and partly ovarian, or partly tubal and 
 partly uterine, the covering depending simply in each case upon the site 
 at which the ovum becomes arrested. 
 
 Cases of Abdominal pregnancy differ materially from all others in 
 this respect, and stand on that account in a class by themselves. The 
 ovum is not in this variety arrested at any point of the canal through 
 which nature intended it to pass ; but escapes altogether from that 
 canal and falls naked into the great abdominal cavity, without any 
 
198 EXTRA-UTERINE PREGNANCY. [CHAP. 
 
 special covering whatever, unless it be some remains of the granular 
 disk in which it was imbedded. Here, in the early stage at least, there 
 can be no special covering, nor connection with the maternal parts 
 other than mere juxtaposition, the result of gravity or some other 
 accidental circumstance. If the ovule has not, prior to this, been 
 fertilized, it will no doubt rapidly disappear, and be absorbed with the 
 secretions of the peritoneal surface. But, if on the other hand, an 
 independent vitality has been communicated to it by conception, it 
 bears the life which it contains to some point accidentally selected, and 
 having there grafted itself upon the subjacent part, the essential contact 
 between the maternal and foetal systems is established, and the subse- 
 quent stages of development ensue. There can thus be, in the first 
 instance, no sac whatever; and although it is not impossible that a 
 special sac might be developed from the peritoneal surface, as under 
 ordinary circumstances takes place from the mucous membrane of the 
 uterus, no facts have hitherto been observed to show that the ovum in 
 abdominal pregnancy has any sac external to the chorion. But, should 
 rupture of the membranes of the ovum occur, the embryo, which usually 
 escapes into the abdominal cavity along with the liquor amnii, instantly 
 becomes a foreign body; and, by exciting inflammatory action, pro- 
 vokes the development of coagulable lymph. This, under favorable 
 circumstances, may form a sac around the ovum, inclosing it now in 
 a special cavity, and protecting the rest of the peritoneal surface from 
 the dangerous effects of extensive inflammation, which would inevitably 
 ensue from the prolonged contact of the foetal remains. 
 
 Whatever the site may be, abdominal or otherwise, at which the 
 fertilized ovum takes up its position, the speedy result is a marked 
 increase in the vascularity of the contiguous parts. If, for example, it 
 becomes adherent to the peritoneal surface of any portion of the bowel, 
 the bloodvessels of that part will at once become the seat of a marked 
 and wonderful hypertrophy. What were before minute twigs now 
 become large venous trunks, and the arterial supply is of course pro- 
 portionally augmented. The vessels being projected from the embryo 
 to the chorion by means of the allantois, the vascularity of that mem- 
 brane is at once established. Those of its villi which belong to the 
 visceral surface undergo marked development, and contract still closer 
 adhesions with the peritoneum. The whole of the tissues become at 
 this point enormously developed, and thus the placenta is formed, 
 within which the interchange of gases and materials goes on smoothly 
 and, for a time, safely. 
 
 During the development of an extra-uterine foetus, certain changes 
 more or less marked have been noticed to take place in the uterus at 
 an early period of the pregnancy. These changes, in so far as they 
 have hitherto been observed, seem to be identical with the preparatory 
 process of which the uterus is the seat at the time of impregnation, 
 and prior to the descent of the ovum. They consist in a marked in- 
 crease in the size of the organ, in an equally marked increase in its 
 vascularity, and in the characteristic thickening and hypertrophy of 
 the mucous membrane, which is the first stage in the formation of the 
 decidua. These symptoms are, however, of brief duration. The 
 
XI.] SYMPTOMS. 199 
 
 uterus, not receiving the expected stimulus which would have been 
 afforded by the ovum on its arrival, falls into a state of quiescence, its 
 bulk and circulation being speedily restored, or nearly restored, to the 
 normal standard. 
 
 The symptoms of extra-uterine pregnancy are far from being defi- 
 nite and distinct. Just at first, the changes which have been men- 
 tioned as occurring in the uterus would, no doubt, tend to suggest the 
 idea of an ordinary pregnancy. The woman may, at this time, enjoy 
 perfect health, disturbed only by some of the sympathetic digestive 
 disorders which are so familiar. No reliance can be placed on the ces- 
 sation of the menses as a sign, as, from the narrative of recorded cases, 
 it would appear that the discharge ceases in about the same proportion 
 of cases as it persists, while, in another class, irregular uterine haemor- 
 rhage seems to be looked upon, if coincident with the early symptoms 
 of pregnancy, as having a certain diagnostic value. Very generally, 
 from an early period of the pregnancy, abdominal pain is complained 
 of. This may take the form of an intermitting pain ; but it is generally 
 constant, and confined to a certain limited region, which may be any 
 one point on the abdominal surface. As the case advances and the 
 ovum grows, considerable discomfort may be caused by pressure, exer- 
 cised by the tumor directly or indirectly on neighboring organs; 
 causing, for example, if the tumor should encroach upon the pelvic 
 cavity, difficulty in defecation and micturition. Morning sickness, 
 and the various changes which have their seat in the breasts, are of 
 usual occurrence ; and, as the case goes on, a tumor may be felt which 
 resembles, more or less closely, the gravid uterus, but which is fre- 
 quently more irregular in outline, and situated more to one side than 
 in the middle line. At the proper time, quickening takes place, and 
 is soon succeeded by the pulsation of the fetal heart. Should suspicion 
 have arisen as to the nature of the case, it is probable that the absence 
 at this time of the characteristics which are revealed in ordinary preg- 
 nancy by a vaginal examination might throw considerable light on the 
 case. 
 
 [A careful study of the clinical histories of a large number of cases 
 of extra-uterine pregnancy, appears to show, that the symptoms of this 
 accident are not so vague, as the statements of the author would lead 
 us to believe. During the first few weeks after conception, there may 
 be no symptoms to attract the attention of either the patient or her 
 friends. Sooner or later, however, often at the end of the fourth week, 
 often not until the end of the second month, the woman is seized with 
 a violent pain, usually described as colic, and situated in the hypogas- 
 tric region, generally on one side. This pain is very severe, and often 
 produces profound prostration, with pallor, cold, clammy perspiration, 
 feeble or nearly imperceptible pulse, and even syncope. It is generally 
 associated with marked, and even very great tenderness in the lower 
 part of the abdomen, which has led some to mistake this condition for 
 peritonitis. After a period of variable duration, from a few hours to 
 one or two days in most cases, the severity of the pain diminishes or 
 it may disappear entirely. The calm, however, is deceitful, for sooner 
 or later another paroxysm sets in, and pursues the same course that 
 
200 EXTRA -UTERINE PREGNANCY. [CHAP. 
 
 the first did. These attacks of pain continue to recur at intervals, 
 until rupture occurs, or until after the fifth or sixth month of gestation. 
 They sometimes continue to term. 
 
 Appearing before the pain, with it, or immediately after it, is another 
 very characteristic symptom. This is metrorrhagia. The quantity of 
 blood lost varies from a slight discharge to an exhausting haemorrhage. 
 
 The occurrence of these two symptoms in a woman, who is herself 
 firmly convinced that she is pregnant, should always lead to the suspi- 
 cion of extra-uterine pregnancy. If in addition to these a decidua 
 should be discharged en masse or in pieces, or symptoms of rupture 
 supervene, the diagnosis is almost absolute. Even thus early an extra- 
 uterine tumor can be discovered. At the end of the third month the 
 child has been detected by ballottement. 
 
 After the foetal heart can be heard, all doubts about the woman being 
 pregnant are removed. It will now be found that the foetal tumor is 
 developed upon one side, that its contents are very superficially situated, 
 and that in some, but not all cases, the sac is immovable. By vag- 
 inal examination the uterus is found to be displaced. The os is gen- 
 erally carried forwards and upwards, so that it is often pressed against 
 the symphysis pubis, or the anterior abdominal wall, some distance 
 above the pubis. It is often reached with great difficulty, or cannot 
 be found at all. At the same time an elastic or fluctuating tumor 
 forms in the pelvis behind the uterus. This retro-uterine fulness with 
 anterior displacement of the womb should always lead to the suspicion 
 that the child is being developed outside of the uterus, providing the 
 existence of pregnancy has been established. Another important 
 symptom is the small size of the uterus, which, while it becomes more 
 or less enlarged, is not developed in proportion to the duration of the 
 gestation. Great care has, however, to be exercised in making this 
 examination, to avoid being misled by the condition of the os and 
 cervix. During this stage the spasmodic pains and metrorrhagia, so 
 often present during the first three or four months of gestation, are 
 likely to have ceased. — P.] 
 
 If the pregnancy goes on without accident or hindrance till the 
 period which marks the ordinary limit of gestation, pains come on, 
 which are periodic, and which are described by women who have 
 already borne children as precisely similar to ordinary labor pains. 
 " These pains," says Burns, " usually begin in the sac, and then the 
 uterus is excited to contract and discharge any fluid it contains." This 
 uterine effort, at the end of the ninth month, is a physiological fact of 
 surpassing interest, and seems to us to afford strong corroborative evi- 
 dence of the correctness of that theory which supposes that the cause 
 of labor has its seat neither in the foetus nor in the uterus, but is, 
 probably, to be found in the ovary, and is generally to be looked for 
 at the tenth menstrual period after impregnation. In weighing the 
 symptoms in a doubtful case, a fact which has already been mentioned 
 in reference to the question of superfoetation should be borne in mind, 
 viz. : that a second (uterine) pregnancy is quite possible ; and, indeed, 
 a most striking case is quoted by Montgomery from Primrose, in 
 which a woman went to the ninth month of her seventh gestation, 
 
XI.] SYMPTOMS. 201 
 
 when labor came on as on former occasions, although, ultimately, it 
 turned out that there was a prior abdominal pregnancy. 
 
 The cases, however, in which extra-uterine pregnancy is prolonged 
 till the ninth, or even the eighth month, form a very small proportion 
 of the whole. It is, in point of fact, an unusual occurrence when de- 
 velopment in such a case continues beyond the fourth or fifth month ; 
 but, on the other hand, cases are on record, which are apparently au- 
 thentic, in which the life of the foetus was prolonged within the 
 abdomen for several months beyond the ordinary period. M. Desei- 
 meris, whose memoir on this subject is justly considered as of great 
 value, states that rupture occurs in more than three-fourths of all 
 cases ; that, in the tubo-uterine variety, it takes place, as a rule, before 
 the end of the second month ; in tubal, in the fourth month ; later in 
 ovarian pregnancy ; and, in abdominal pregnancy, not till the eighth 
 or ninth month. The usual crisis, then, in all such cases, which may 
 arrive sooner or later in their course, is rupture of the sac and of the 
 fcetal membranes, or of the latter alone in abdominal pregnancies. 
 
 The symptoms which follow rupture of the sac are of extreme gravity, 
 and the result invariably is that the life of the woman is placed in 
 great jeopardy. The rupture is frequently preceded by severe pains, 
 which may continue for several hours. A sudden cessation of these 
 pains is then observed to coincide with a notable diminution in the 
 size of the tumor. This is succeeded almost immediately by pallor, 
 dimness of vision, vomiting, syncope, and other symptoms which indi- 
 cate profuse internal haemorrhage. To these succeed loss of pulse, 
 clammy sweat, convulsions, and death — or, the bleeding being arrested, 
 the patient rallies and escapes the immediate danger of haemorrhage. 
 
 If, after rupture of the sac, the haemorrhage is limited in extent, or 
 if something occurs to check it by favoring the coagulation of the 
 blood, death may not be immediate, but may, nevertheless, take place, 
 as the result purely of haemorrhage, after an interval of some days : 
 whereas, if the flow of blood be effectually barred, the patient may 
 rally, and the symptoms of impending dissolution may disappear. But 
 the danger which has thus been averted is forthwith succeeded by 
 another equally grave. The foetus, the amnionic fluid, and the effused 
 blood, arouse violent peritoneal inflammation, which rapidly runs its 
 course, generally with a fatal result. Should the powers of nature be 
 of sufficient energy to overcome this second assault, the effect of the 
 inflammatory action is rather beneficial than otherwise, for the foetus 
 now becomes inclosed in a sac, which is formed from coagulable lymph, 
 and which effectually shuts it out from the rest of the abdominal 
 cavity. Within the new cavity, a process of disintegration or modified 
 decomposition goes on in the greater number of cases. 
 
 [The views of the author in regard to the supervention of peritonitis 
 after rupture of the cyst are in accordance with those which have been 
 generally believed for many years. Clinical experience has shown, 
 however, that peritonitis and consequent encystment of the escaped 
 child, rarely follow rupture of the sac. Indeed, it so seldom happens, 
 that Rogers, of New York, who has specially investigated this subject, 
 is inclined to believe that it never occurs. Even when the woman 
 
202 EXTRA-UTERINE PREGNANCY. [CHAP. 
 
 lives for several days, and presents all the symptoms of peritoneal in- 
 flammation, that membrane is found pale and perfectly free from lymph 
 at the autopsy. The accident is almost invariably fatal, but death is 
 due to shock and anaemia. The process of elimination described by 
 the author applies to cases in which the child has died in an unrup- 
 tured cyst. — P.] 
 
 The presence of the foetal debris -excites anew inflammatory action, 
 extending probably to contiguous viscera, between which and the sac 
 adhesions may be established. To this succeeds ulcerative absorption, 
 resulting in the establishment of fistulous openings in the direction of 
 the hollow viscera, or externally through the abdominal walls ; or per- 
 foration may take place a second time into the peritoneal cavity, with 
 little hope of any result other than a fatal one. But, if the perforation 
 take the direction first mentioned, we may have, for weeks or months, 
 portions of the more indestructible foetal structures, bones, teeth,. and 
 the like, discharged through the abdominal wall, the vagina, the rectum, 
 the bladder, or even the stomach ; and, if there be more than one fistu- 
 lous opening, we may have portions successively or simultaneously 
 discharged through two or more of the channels which have been 
 enumerated. While the discharge of debris is going on, the inflam- 
 matory action in the interior of the cyst continues, and is probably 
 aggravated by the admission either of the external air, or of the con- 
 tents of the hollow viscera into which the opening takes place. Irri- 
 tative fever of a severe type is thus often set up, and to this, those 
 women who have been so fortunate as to escape the dangers already 
 specified may succumb. 
 
 In some instances, the course and termination of extra-uterine preg- 
 nancy is very different to what has been detailed. The pressure of 
 the tumor may be productive of such annoyance and pain, or may 
 interfere so seriously with the functions of neighboring organs, that 
 the woman sinks and dies without any rupture having occurred; or 
 even, in so far as can be ascertained, without the death of the foetus 
 having preceded that of the mother. Or, as in another class of recorded 
 cases, the child may die before rupture of the membranes has occurred, 
 a result which we must look upon as favorable in the progress of these 
 cases. For the first result of this is the arrestment of placental circula- 
 tion, the dwindling of the enlarged vessels on the mother's side, and 
 the consequent abatement in the risk from haemorrhage to which the 
 woman is subjected. Under such exceptional circumstances, it is quite 
 possible that no rupture of the original sac may occur. The foetus will 
 then be retained without the occurrence either of haemorrhage or peri- 
 toneal inflammation, but ultimately its remains will most likely be 
 extruded by a similar process, and through the same channels as in the 
 cases above mentioned. In some remarkable instances, the irritation 
 caused by the presence of a dead foetus has been so inconsiderable as to 
 permit of its residence for many years within the abdominal cavity, 
 without causing any alarming symptom. It is probably in such cases 
 that the putrefactive process undergoes the peculiar modifications which 
 are manifested either by a withering or mummifaction of the foetus, or 
 by a change which seems to be closely allied to adipocire. In many 
 
XI.] TREATMENT. 203 
 
 of the recorded cases in which the fetus has been retained for an 
 unusually long period, the sac would appear to have become the seat 
 of calcareous deposit, which, by thickening and strengthening its walls, 
 may be supposed at once to protect the foetus from external violence, 
 and, at the same time, to protect the external parts, by rendering its 
 rupture practically all but impossible. Burns mentions a case in which 
 he had known the foetus retained for twenty years, and there have been 
 instances in which it has been retained for a much longer period. 
 Women, in some of these cases, have repeatedly become pregnant, and 
 have been delivered of healthy children at the full time without dis- 
 turbing the retained ovum. 
 
 In regard to the Treatment of extra-uterine pregnancy, much must in 
 every case depend on the stage of development and the other circum- 
 stances of the case. In so far as the early weeks are concerned, it is 
 obvious that, accurate diagnosis being impossible, treatment can only 
 be palliative, or directed against symptoms, the import of which we can 
 only guess at. At a stage somewhat more advanced, precision in 
 diagnosis is scarcely more easy ; although, could we only be certain of 
 this, we cannot doubt that the resources of modern surgery might avail. 
 If the sac were lodged in the pelvis, interference would very probably 
 take place with the functions of the bladder and rectum, requiring close 
 attention to the state of the bowels, and perhaps frequent mechanical 
 aid for the relief of the bladder. The attacks of pain, which are of such 
 frequent occurrence in all the forms, will be most certainly and satisfac- 
 torily removed by anodyne applications and by opiate suppositories or 
 enemata, strict rest in the recumbent posture being at the same time 
 enjoined, with careful attention to the digestive and other functions. It 
 has been suggested by Cazeaux that, even at this early period, attempts 
 should be made, by bleeding to syncope, or by electric shocks passed 
 through the abdomen, to destroy the life of the foetus. Were this prac- 
 ticable, it would be sound treatment, in view of the probabilities of 
 the case, to cut short the existence of the foetus; but we apprehend 
 that the result looked for cannot, with any confidence, be counted upon. 
 It has also been recommended to perforate the sac by trocar from the 
 vagina, should this be practicable, a step to which Scanzoni lends his 
 powerful advocacy ; and we see no reason to doubt the propriety, in 
 many cases, (if only diagnostic difficulties were overcome) of exhaust- 
 ing the liquor amnii by means of the aspirator. 
 
 When the period of expulsive effort arrives, it comes to be a question 
 whether in any case we may interfere with a view to the relief of the 
 patient by immediate delivery. The cases, doubtless, in which operative 
 interference may be resorted to, with the greatest prospect of success, are 
 those in which the foetus is felt through the vagina, and the nature of 
 the case is distinctly made out; and, an additional argument in favor 
 of operation will doubtless be afforded by proof of the life of the child. 
 Besides there is always the chance that the case may be one of those 
 which have been described as subperitoneo-pelvie. The operation, if 
 resolved upon, consists in an incision through the vaginal walls, and 
 the removal, by forceps or otherwise, of the foetus. By having recourse 
 
204 EXTRA-UTERINE PREGNANCY. [CHAP. 
 
 to this procedure, the lives of infants have been, in a considerable 
 number of instances, preserved ; but as a general rule, the mother has 
 succumbed. 
 
 If the pregnancy has reached the eighth month, and the life of the 
 foetus is indicated by the usual signs, and, if the sac can be reached only 
 through the abdominal walls, it is of course, possible to anticipate 
 rupture, and to extract, by gastrotomy and incision of the sac, a living 
 foetus. To this operation the name of Laparotomy has been given, and 
 to its performance few obstacles or difficulties would seem to arise. 
 But if we balance the hope of the child's life against what is almost 
 the certainty of the mother's death, — which even under the most favor- 
 able conditions, must be the state of the case, — there are, perhaps, few 
 contingencies in surgical or obstetrical practice in regard to which the 
 sense of responsibility will be more keenly felt. It is so far satisfactory 
 to know, that recent experience has dispelled what was at one time 
 believed to be the chief difficulty on the maternal side, viz., the removal 
 of the placenta; and, indeed, it is now universally admitted that, if we 
 perform the operation at all, we only augment the danger to the mother 
 by any attempt to detach the placenta from the site to which it is 
 adherent. There are cases in which this operation may be the only 
 chance of the mother's life, and we are certainly entitled to hope that 
 the great success which has of late years followed the operation of 
 ovariotomy may point to the possible saving of lives which have hitherto 
 been yielded up as hopeless. And, perhaps, a day may come when 
 diagnostic skill being more certain, an early extra-uterine pregnancy 
 may be removed and ligatured with as great a prospect of success as 
 an ovarian cyst. Incases where a living mature child has escaped by 
 rupture of the sac into the abdominal cavity, we need have no difficulty, 
 for here the analogy is complete between the case in question and one 
 in which a living child has similarly escaped through a uterine rupture ; 
 and, by the operation in these circumstances, the risk to the mother 
 will be little aggravated, while the life of the child may probably be 
 saved. 
 
 [The operation of gastrotomy to save a living and viable child 
 cannot be too strongly condemned, unless the cyst has previously 
 ruptured. A careful investigation of this subject has convinced the 
 editor, that considering the child's and mother's lives of equal value, 
 more human beings will be saved by trusting to nature, and meeting 
 indications as they arise than by opening the abdominal cavity to pre- 
 serve the life of the child. — P.] 
 
 In the case of a woman who has carried for one or more years, an 
 extra-uterine foetus, which causes her great suffering, or which is ob- 
 viously undermining her general health, the question of operation may 
 also suggest itself, although in a different form. The rule which must 
 here guide us is, in addition to the state of her health, the possibility 
 of reaching the tumor from the vagina; for, unless we were convinced 
 of the existence of adhesions to the anterior or lateral abdominal 
 walls, an operation in this direction would, we conceive, seldom be 
 warranted. 
 
 The duty of the surgeon will, however, in most cases, be confined to 
 
XII.] MOLAR PREGNANCY. 205 
 
 carefully watching and cautiously assisting in the separation of the 
 foetal debris. Should one or more fistulous openings exist in the 
 abdominal walls, the vagina, the perineum, or the rectum, the nature 
 and extent of the cavity of the sac may be carefully explored through 
 them. By the aid of sponge-tents, the apertures may be safely dis- 
 tended, and any loose portion removed; care being always taken not to 
 drag rudely such fragments as may be adherent to the walls of the 
 sac, as, by doing so, the sac might be ruptured, and peritonitis ensue. 
 [These openings are more rapidly and more safely enlarged with the 
 knife. This operation is one of little more gravity than opening a large 
 abscess. — P.] If the communication has taken place in the direction 
 of the bladder, it may be necessary to remove them by one of the opera- 
 tions for lithotomy ; or, by dilatation of the urethra, as was done by Pro- 
 fessor G. H. B. McLeod in a case which he communicated, many years 
 ago, to the Medico-Chirurgical Society of Glasgow. While the separa- 
 tion of the remains of the foetus is thus promoted, in any way which ex- 
 perience may suggest to us as consistent with safety, the general health 
 of the woman must be carefully attended to, her strength being sus- 
 tained by nourishing food and suitable stimulants, while any tendency 
 to hectic or irritative fever must receive its appropriate treatment. 
 
 CHAPTER XII. 
 
 ABNOKMAL DEVELOPMENT. 
 
 MOLAR PREGNANCY — FALSE MOLES : FROM VAGINA : MEMBRANOUS DYSMENORRHCE A : 
 FIBROUS AND HEMORRHAGIC CASTS OF UTKRUS — TRUE MOLES : FLESHY MOLES : 
 HYDATIDIFORM MOLES — THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT — 
 DISEASES OF THE PLACENTA, AND THEIR EFFECTS — MISSED LABOR — DISEASES 
 OF THE FCETUS — INTRA-UTERINE FRACTURES AND AMPUTATIONS : EFFORTS AT 
 REPRODUCTION — MONSTERS. 
 
 There are, in addition to the peculiarities of development already 
 noticed, certain others which deserve special notice in a systematic 
 treatise, but which, nevertheless, are not unfrequently passed over as 
 of no moment. There is every reason to suppose that these peculiarities 
 have their origin, in a large proportion of instances, in actual disease 
 of the ovum ; but whether this is, or is not, the primary cause of the 
 affections in question, no doubt can, in the present state of pathological 
 knowledge, be admitted, as to the frequent coincidence of disease or 
 degeneration of the ovum, either with arrest of development, or with 
 the transference of developmental energy to structures which are merely 
 subsidiary. The result of this is the occasional expulsion from the 
 
206 ABNORMAL DEVELOPMENT. [CHAP. 
 
 uterus of substances, the nature of which it is not always easy to deter- 
 mine, and the origin and pathology of which have often been misunder- 
 stood. These substances are generally termed Moles. 
 
 It must be made clear, however, from the outset, that all solid mat- 
 ters discharged from the uterus are not moles, properly so called. In 
 other words, all such discharges are not the result of impregnation, — a 
 fact which is of obvious medico-legal importance, and which imposes 
 upon us the necessity of drawing a careful distinction between " true " 
 and "false " moles. The matters which are discharged from the virgin, 
 or which are independent of impregnation, and which might be mis- 
 taken for the result of conception, form but few varieties, and constitute 
 what are termed, with questionable propriety, False Moles. Under this 
 designation may be included bodies, Avhich are composed mainly of 
 the squamous epithelium of the vagina, thrown off in the form of 
 flakes, or tubular casts ; and which may either be expelled singly, or 
 form, by their union, masses of greater or less bulk, but seldom of any 
 considerable size. A careful examination of these by the microscope, 
 or even by the eye, will generally obviate the possibility of error; but 
 as regards the following, the unwary may easily be misled. It is a fact 
 familiar to every physician, that the most obstinate and intractable form 
 of painful menstruation, or Dysmenorrhoea, is the membranous variety, 
 in which the mucous membrane of the uterus is shed at each catamenial 
 period, either in shreds of various size, or in the form of a single mass, 
 forming a complete cast of the uterine cavity. In some rare instances, 
 this occurs also independently of menstrual disorder. It may readily 
 be conceived, that in such a case, accompanied, as it generally is, with 
 haemorrhage and sustained expulsive effort, a suspicion of pregnancy 
 and early abortion might arise in the mind, — the membrane in question 
 being mistaken for the decidua, from which the embryo has escaped 
 unobserved. In such a case, however, the true nature of the substance 
 discharged may be disclosed by remembering that such an occurrence 
 is not unusual at a menstrual period, and by obseving that all the usual 
 and familiar signs of pregnancy are absent. It is, moreover, much 
 less substantial in its texture, and more easily torn than the decidua, 
 which has, under such circumstances, according to Montgomery, "a 
 soft, rich, pulpy appearance, deep vascular color, and numerous well- 
 developed utricular follicles or crypts, and foramina for the reception 
 of the nutrient vessels from the uterus, which are always so distinctly 
 observable. In one point, however, the dysmenorrhoea] membrane 
 resembles the decidua, — having its inner surface smooth, and the outer 
 unequal ; but it is of a ragged, shreddy appearance, unlike that of the 
 healthy uterine decidua, and is, moreover, entirely destitute of the little 
 cotyledonous sacculi described as an essential character in the latter 
 structure." No trace of anything analogous to the transparent mem- 
 branes of the ovum is to be discerned within it, nor does it contain a 
 reflected layer, forming an inner pouch. When perfect, it presents 
 three openings, — -one for each Fallopian tube, and one at the points of 
 connection with the cervix uteri. 
 
 A third variety of false mole has been described as occurring under 
 
XII.] TRUE MOLES. 207 
 
 certain conditions of functional derangement of the uterus, more espe- 
 cially when this is accompanied with some form of inflammatory action. 
 In it, the substances expelled are of a fibrinous appearance externally, 
 of a firm consistence, and varying greatly in size, but frequently pre- 
 senting the form of a cast of the uterine cavity. Most frequently these 
 are composed of blood-clots, which have become condensed and altered 
 in appearance by their decolorization externally. In certain cases, 
 they appear to be composed partly of clot and partly of lymph; while 
 in others, which have been carefully observed, it would appear that a 
 membranous cast has been surrounded by an outer layer of condensed 
 coagulation. 1 
 
 The True Moles differ from the above essentially in this, that they 
 are in every instance the result of conception, in which, generally, the 
 embryo has been blighted, and yet development of the membranes has 
 progressed with abnormal activity. In the investigation of these cases, 
 it is of importance to remember what Smellie tells us. "Should the 
 embryo die," he says, "(suppose in the first or second month) some 
 days before the ovum is discharged, it will sometimes be entirely dis- 
 solved, so that when the secundines are delivered there is nothing more 
 to be seen. In the first month, the embryo is so small and tender that 
 the dissolution will be performed in twelve hours ; in the second month, 
 two, three, or four days will suffice for this purpose." If this is the 
 case when the ovum is expelled shortly after the death of the embryo, 
 it need not astonish us that Avhen it is retained for a considerable period 
 all trace of embryo has disappeared, while the membranes are so de- 
 generated or metamorphosed that it is only with difficulty that the 
 true nature of the case can be recognized. 
 
 Of the highest interest and importance in reference to this subject, 
 and more especially to the question of etiology, are the hemorrhagic 
 discharges of which the ovum is the seat. In addition to the direct 
 effect, which must spring from the sudden abstraction of blood either 
 from the foetal or maternal vessels connected with the ovum, the blood 
 which flows from the ruptured vessels very frequently exercises a me- 
 chanical influence in the separation of contiguous parts with the most 
 disastrous results. Blood may thus be interposed by the rupture of 
 the utero-decidual vessels, and so cut off the only maternal supply pos- 
 sible for the early embryo. Or, at a later stage, haemorrhage from the 
 utero-placental vessels may so engorge the parenchyma of the placenta, 
 as to cause apoplexy of that organ, an affection which we shall have 
 occasion hereafter to mention. Again, the extravasation may take 
 place between the chorion and the clecidua reflexa, or even within the 
 amnion, destroying the embryo and giving rise to abortion. Particular 
 attention has been given by Scanzoni to the various forms of apoplexy 
 of the ovum, a subject which is of interest to us at this stage, as a 
 cause not only of death of the embryo, and of abortion, but also of the 
 
 1 These formations are fully described and admirably depicted by Dr. A. B- 
 Granville, in his admirable monograph on Abortion and the Diseases of Menstrua- 
 tion. 
 
208 ABNORMAL DEVELOPMENT. [CHAP. 
 
 formation of true moles, when abortion does not at once ensue. His 
 conclusions as to the progress and termination of the haemorrhage are as 
 follows : 
 
 " 1. If the flow of blood is simply from the utero-placental or utero- 
 decidual vessels, and the quantity is inconsiderable, this does not suffice 
 to separate the ovum in the greater part of its circumference, or by 
 mechanical pressure to arrest its further development ; so that blood 
 effused between the uterine walls and the decidua, or even between the 
 two layers of the latter, may be either completely or, at least, partially 
 reabsorbed, and the pregnancy may reach its normal termination. 
 
 " 2. But if the quantity of the effused blood is considerable, the 
 ovum is separated from the uterine walls either entirely or to a great , 
 extent, and is compressed by the voluminous coagulum, and more or 
 less flattened ; such compression actually causes bursting of the mem- 
 branes (of which Dubois narrates a case), when abortion is the usual 
 result. 
 
 " 3. The same is the result when the foetus dies through rupture of 
 its own vessels and the placental haemorrhage thus induced. Here 
 also the abortive ovum is expelled, the rapidity with which the abor- 
 tion occurs depending especially on the occurrence of simultaneous 
 uterine haemorrhage. 
 
 "4. The ovum may, as is much more rarely the case, remain with 
 the dead foetus for a considerable time in the uterine cavity ; the coagu- 
 lum undergoes certain changes, which are also observable in extrava- 
 sation in other parts of the body, and so gives occasion for the origin 
 of the formation known under the name of Fleshmole." 
 
 The Fleshy Mole (Mole Carnosa) is probably formed in part from 
 coagula and in part from the membranes of the ovum, which undergo 
 a species of degeneration by some such series of changes as the follow- 
 ing : The effused blood becomes in the first instance decolorized by 
 rupture of the blood-corpuscles and absorption of their coloring matter. 
 This decoloration takes place from the centre towards the circumfer- 
 ence. The fibrin, as Scanzoni supposes, becomes transformed into 
 cellular tissue, by means of which communication is established between 
 the external lining of the ovum on the one hand, and the inner surface 
 of the uterine wall on the other, — so that the further development of 
 the structures thus in apposition is rendered possible. We may as- 
 sume that in these cases complete separation of the ovum cannot have 
 taken place, otherwise the death of the whole structures of the ovum 
 would have rendered its expulsion inevitable. And, as the connection 
 between the uterus and the ovum is most firm at that part where the 
 placenta has either formed or is about to form, the probability is that 
 the vascular supply sent to the ovum through this channel is never 
 entirely cut off. On the establishment of new and more extensive 
 adhesions, the blood supply is at once augmented, and the membranes 
 and effused coagula become intimately bound together into a mass, 
 through which vessels freely run, and which becomes hypertrophied 
 to a very considerable extent. It would appear that, at least under 
 certain circumstances, the chief seat of the carneous degeneration is the 
 
XII.] THE HYDATIDIFORM MOLE. 209 
 
 decidua vera; for, it is certain that in many of the cases which have 
 been most carefully examined, the structure of the chorion has been 
 distinctly recognized by its villi, although the membrane itself had 
 undergone some considerable thickening. The villi in these cases have 
 been found to consist of molecular masses and fat-cells. The amnion' 
 undergoes little change, and may be found adhering to the inner sur- 
 face of the chorion, and containing within its cavity a certain quantity 
 of bloody fluid, in which will be found what remains of the embryo. 
 The rudiments of the embryo are, however, frequently very indistinct, 
 unless the pregnancy should chance to have been more advanced than 
 usual; and, indeed, difficulty will frequently be experienced in tracing 
 even the remains of the cord, although the chorion and amnion may 
 be tolerably distinct. The nature of the case will nevertheless usually 
 be recognized on a careful examination, by the discovery of the villi 
 of the chorion ; and Scanzoni asserts further that in the cases examined 
 by him he has never failed to discover the enlarged villi by the agency 
 of which the placenta was already going through the earliest stage of 
 its formation. While in all these cases the diseased membranes go 
 on increasing in bulk, they are of course rendered quite unfit for the 
 discharge of their primary functions, so that the contained embryo, if 
 its death has not preceded the degeneration, must speedily succumb. 
 " When the growth of the ovum," says Rigby, " proceeds after the 
 destruction of the embryo, it increases very rapidly in size, much more 
 so than would be the case in natural pregnancy, so that the uterus, 
 when filled with a mole of this sort, is as large at the third month as 
 it would be in pregnancy at the fifth." As the development of the 
 mole goes on, it increases in density as well as bulk, and the growth 
 may continue for three or four months, until its presence within the 
 uterus awakens expulsive efforts, when it is speedily expelled, present- 
 ing the characteristics just detailed. 
 
 Cases occasionally occur in which fatty degeneration is the most 
 conspicuous characteristic of a mole; but this we may merely mention 
 as a variety of the fleshy form ; and the same remark may be made in 
 regard to what has been described by the German authors as " Stein- 
 mole" a yariety which seems to attend a retention of the mole within 
 the uterus for an unusually long period ; and which implies, as its 
 name indicates, a calcareous degeneration of what was, in all proba- 
 bility, originally an ordinary fleshy mole. With reference to such 
 cases, it may, however, be remarked, that such calcareous masses are 
 to be cautiously received as evidence of mole pregnancy, unless the 
 characteristics of the latter are clearly manifested. For we know that 
 fibroid tumors of the uterus are also subject, although rarely, to a simi- 
 lar degeneration ; and it is quite within the bounds of possibility that 
 an error of some magnitude might here be committed, seeing that these 
 concretions are sometimes spontaneously separated from the uterus, 
 and discharged through the vagina. 
 
 The Hydatidiform Mole. — The bodies which form the distinguishing 
 feature of these moles were long supposed to be true hydatids, formed 
 in, and discharged from the uterus. More careful examination showed, 
 
 14 
 
210 
 
 ABNORMAL DEVELOPMENT. 
 
 [CHAP. 
 
 Fig. 93. 
 
 K) 
 
 Hydatidiform degeneration of ovum. 
 
 however, that they were not, like true hydatids, closed sacs within one 
 
 another, but that the vesicles were arranged 
 in a manner quite different from this, each 
 saccule growing from another, in regard to 
 which it is either sessile, or connected by 
 a pedicle of varying length. In this man- 
 ner cyst grows out of cyst, and the pedicles 
 do not unite them with principal stems, 
 but with each other, so that, as Metten- 
 heimer and Barnes have shown, it is in- 
 correct to compare them, with Gooch, to 
 currants, or, with Cruveilhier, to a bunch 
 of grapes. The arrangement is very well 
 shown in the annexed representation of a 
 mass of these bodies which had been ex- 
 pelled from the uterus. The vesicles vary 
 considerably in size, from a walnut down- 
 wards, according to the development which 
 they have attained, or the distance at which 
 they are situated from the parent cyst, from 
 which they originally spring. Not u infre- 
 quently, when they escape unexpectedly, 
 they are brought under the notice of the 
 practitioner floating in a basin of water, 
 and discolored with blood ; and under 
 these circumstances the graphic description of Gooch is singularly 
 applicable, for they then resemble very closely a mass of " white cur- 
 rants floating in red currant juice." 
 
 Although the exact mode in which the vesicles constituting the hyda- 
 tidiform mole are formed is not yet clearly fixed to the satisfaction of 
 all, there is one point in which all modern authorities are agreed, viz., 
 that they spring from the villi of the chorion. It is also admitted 
 that in this, as in the fleshy mole, we have no new formation, but 
 simply an alteration and degeneration of previously existing structures. 
 But when we come to consider the pathological process by which this 
 alteration is effected, Ave find that considerable differences of opinion 
 exist. The views on this subject originally propounded by Metten- 
 heimer in 1850, in Mullens Arehiv, and which have been indorsed 
 in this country by Paget and Barnes, are those which are generally 
 entertained. The villi of the chorion, as has been pointed out by 
 modern physiologists, grow normally by a process of gemmation, bud 
 springing from bud in successive stages of growth. Under the influ- 
 ence of perverted development, these buds, or the elementary cells of 
 which each villus is composed, take on a new action, and become trans- 
 formed into vesicles, which vary in size, and to which attaches the 
 power of repeating the process of chorion development, still in a per- 
 verted sense, until the so-called hydatidiform mass is formed. Gierse 
 is of opinion that the change consists in hypertrophy of the normal 
 structures found in the chorion villi, with secondary oedema ; and Dr. 
 
XII.] THE HYDATIDIFORM MOLE. 211 
 
 Graily Hewitt urges that the vesicular transformation is a consequence, 
 and not a cause , of the death of the embryo, and that it is therefore 
 nothing more than a degeneration of structures arrested in their develop- 
 ment. We fail to see, however, that the death of the embryo, prior to 
 the formation of the cysts, is in any way incompatible with the theory 
 of Mettenheimer ; indeed, we cannot but think it extremely probable 
 that in this, as in the case of fleshy moles, it is the developmental force 
 diverted by the death of the embryo into an unwonted channel which 
 is the great cause of the activity of the degenerative process. And, 
 moreover, this is all the more likely to take the form of cystic degen- 
 eration on account of the peculiar anatomical conditions under which 
 the villi of the chorion, and more especially those of the placenta are 
 produced. The period within which hydatidiform degeneration may 
 originate does not probably extend beyond the tenth week, for it is 
 during that period that the activity is greatest in the growth and 
 multiplication of the villi ; and, at a later stage, when bloodvessels 
 have largely occupied the bulk of the villi, it would appear that they 
 are no longer capable of undergoing that form of degeneration. A 
 certain dropsical condition, or secondary oedema, as Gierse describes it, 
 of the membranes, is probably an essential part of the degeneration in 
 question, and may serve to account for the constant supply of the fluid 
 which fills the sacs. Although the special activity in the development 
 of the villi which ultimately would have formed the perfect placenta, 
 might naturally be expected to attract thither the morbid action, ex- 
 perience has shown that this is not invariably the case. 
 
 An important question has arisen as to whether a portion of placenta, 
 retained at the full term, can take on hydatidiform change. This has 
 been answered in the affirmative — among others, by Montgomery and 
 Ramsbotham — but all recent writers dispute the conclusion. In the 
 majority of cases, an examination conducted with every care shortly 
 after expulsion fails to detect any trace whatever of the embryo, although 
 in some instances a foetus has been discovered, and this is, doubtless, 
 what has led to the erroneous conclusion referred to. The explanation 
 of the facts as observed is to be found in the fact that, here, growth is 
 limited to the chorion and the degenerated villi, and that the uterus is 
 filled with an enormous mass of cysts which have sprung from this 
 source, so that the cavity of the amnion and its contents are almost 
 inevitably obliterated. The destruction of the embryo is, for this 
 reason, much more complete than in the fleshy variety of mole. 
 
 In regard to the symptoms of this form of mole, they are at first 
 identical with the ordinary signs which are supposed, in the first three 
 months, to indicate pregnancy. The usual symptoms, and more 
 especially those which have their seat in the mamma, then become 
 indistinct and perplexing. The patient is ill at ease, her appetite and 
 digestion become impaired, and her feelings are quite different to those 
 which attended former pregnancies. So soon as the degenerative 
 process has been thoroughly established, the increase in the bulk of the 
 uterus goes on with very unusual rapidity, and it has been noticed to 
 expand irregularly, and more in a lateral than in the usual upward 
 direction. When the period arrives at which the conclusive proofs of 
 
212 ABNORMAL DEVELOPMENT. [CHAP. 
 
 pregnancy should, under ordinary circumstances, be distinctly mani- 
 fested, the absence of foetal pulsation and ballottement may arouse 
 suspicion as to the nature of the case. But at a period even earlier 
 than this, watery and sanguineous discharges, mixed or separately, may 
 occur, the former being due to the bursting of distended vesicles, which 
 have probably been submitted to considerable pressure. It occasionally 
 happens that, along with these discharges, a few vesicles only, or a 
 larger proportion of the mass, escape, which at once reveals the nature 
 of the case. There is, in addition, another symptom to which we would 
 call special attention, and which we have found of the highest impor- 
 tance in practice in the diagnosis of this affection. This consists in a 
 peculiar doughy, boggy feeling, which is revealed on palpation, and 
 which we take to be in the highest degree characteristic, more especially 
 if we take along with it the absence of that irregular hardness which 
 indicates the prominences of the foetus. The term " dense" which we 
 find generally used to describe the feeling of the uterus in this condition 
 is, we apprehend, singularly inappropriate. " Tense/' again would 
 represent correctly enough the effect of the rapid distension ; but the 
 sensation yielded by palpation, which we have had the opportunity of 
 thoroughly testing in several cases, is, we are persuaded, more correctly 
 described above, than by either of the terms specified. 
 
 The existence of moles of this nature is seldom prolonged beyond the 
 sixth month, when repeated haemorrhage, and over-distension of the 
 uterus, entailing probably a partial separation of the placenta, will 
 usually have excited uterine contraction. The effect of these con- 
 tractions, when once thoroughly aroused, is to effect the complete 
 separation of the entire ovum, which insures the safety of the woman 
 by the arrest of the haemorrhage. It would seem, however, that under 
 certain special circumstances, fortunately of rare occurrence, the con- 
 nection between the uterus and the ovum is so firm that a portion only 
 of the fruit of conception is expelled. "In such cases," says Scanzoni, 
 " portions of the ovum remain behind in the uterine cavity for a con- 
 siderable time, on account of their firmer connection with the inner wall 
 of the uterus. These may give rise to profuse and long-continued 
 floodings, as we have seen in one of our cases occurring in the gynaeco- 
 logical clinique at Prague, where an exhausting haemorrhage, which had 
 continued for some months after the expulsion of a vesicular mole, was 
 first arrested on the removal by the hand of the remainder of the ovum, 
 which had remained behind in the cavity of the uterus." 
 
 What is, however, of more frequent occurrence when the whole of 
 the ovum is not at once expelled, is that the case turns out to be one of 
 twin pregnancy, in which the membranes of one embryo only have 
 become the seat of the degeneration in question. Doubtless, under 
 such circumstances, the uterus, after expelling a large hydatidiform 
 mass, will not cease in its efforts until the whole of its contents have 
 been expelled; but, a certain number of cases have been recorded, in 
 which, after such an event, a fully developed child has been expelled 
 after an interval of a few months, a fact which is only reconcilable 
 with the idea above expressed. This is said by Montgomery to have 
 occurred at the birth of the celebrated anatomist Beclard. The most 
 
XII.] DISEASES OF THE OVUM. 213 
 
 recent observations on this subject seem to indicate that examples of 
 this nature are by no means of nn frequent occurrence, which obviously 
 shows that we should exercise caution in the treatment of such cases, 
 lest we destroy the living germ while removing the dead. 
 
 The treatment of all such cases will of course depend on the urgency 
 of the symptoms. So long as they are moderate in severity, and are 
 not such as to call for immediate action, our course of treatment must be 
 purely expectant, more especially as there will almost always be an 
 element of doubt in the diagnosis. But, so soon as profuse, watery, 
 and hemorrhagic discharges shall indicate serious danger to the woman, 
 we must not delay until interference is a mere dernier ressort, but act 
 promptly, and in the manner most likely to empty the uterus speedily 
 of its contents. In several cases of hydatids, we have found the ergot 
 of rye act quite satisfactorily, and effect expulsion without difficulty ; 
 as, indeed, it usually does when the uterus has reached a certain degree 
 of distension. We recommend, therefore, that in the first instance, 
 this drug should be employed; but if, as often happens, it fails to ex- 
 cite uterine effort, we must then resort to other means. A sound or 
 catheter has been introduced into the womb, and successfully used so 
 as to break up the mass, and separate it as far as possible from its 
 uterine attachments; but we regard it a safer as w T ell as a more 
 satisfactory method, to dilate the os and cervix by means of Barnes's 
 bags or other similar appliances, so as to introduce the hand, and 
 remove at once the whole mass. The dilatation of the os and cervix by 
 means of sponge-tents would also have the effect of exciting the uterus 
 to contraction, and would have the further advantage of checking 
 haemorrhage. Galvanism has also been recommended ; the object, of 
 course, in each and all of these modes of procedure, being to empty 
 the uterus safely as well as quickly. Nothing special need be said 
 in reference to the treatment of the fleshy mole, as in that case the 
 diagnosis is much more difficult. Although the unexpected arrest of 
 development, and the general, constitutional disturbance, with the ces- 
 sation of such of the signs 01 pregnancy as may previously have been 
 present, may indicate the probability of this affection, it is seldom that 
 its nature is recognized until the carneous mass, with the blighted 
 ovum, has been expelled. 
 
 There is yet another group of cases in which the pathological 
 phenomena are also to be found in a portion of the ovum, but which 
 occur at a later period of pregnancy than those which we have just 
 been considering. In these instances, development goes on uninter- 
 ruptedly until the placenta has been fully formed ; and it is to diseases 
 of that organ that the death of the foetus is then due. Among the 
 affections of the placenta which may have this result, is Apoplexy of 
 the Placenta, in which blood is effused, by rupture of vessels, into the 
 parenchyma of the organ, exactly as takes place in the lung, and with 
 a similar result as regards the respiratory function. Another affection 
 which, as we have already seen, is apt to attack the tissue of the fleshy 
 mole, is Fatty Degeneration. Recent researches show that, at a more 
 advanced period of gestation, the same pathological change is apt to 
 invade the tissue of the placenta, and so to alter its structure as to 
 
214 ABNORMAL DEVELOPMENT. [CHAP. 
 
 interfere seriously with, and ultimately to arrest, the development of 
 the embryo. The cause of this fatty degeneration has been very care- 
 fully investigated by Barnes, Priestly, and others; and the conclusion 
 at which they seem to have arrived is, that the fatty molecules are the 
 result of a low form of placentitis — being either thrown out, primarily, 
 as inflammatory exudations, or formed, secondarily, of inflammatory 
 products, which subsequently degenerate into fat-particles. Placentitis 
 is another affection which may cause intra-uterine death — the inflam- 
 matory process, in these instances, attacking the organ, and in extreme 
 cases leading to hepatization, induration, abscess, and the other termi- 
 nations of the inflammatory state. The morbid action is generally 
 confined to a limited portion of the organ, or to a few lobules, and 
 extends from the maternal towards the foetal surface of the placenta. 
 There is reason to believe that morbid adhesion of the placenta may 
 have its origin in placentitis ; and, in connection with it, hypertrophy 
 of the decidua serotina has not unfrequently been observed. General 
 oedema, or dropsy of the placenta, is another affection of the organ 
 which has been carefully observed by Meckel and Gierse. The appear- 
 ances are here altered to those which are characteristic of oedema in all 
 soft tissues; swelling, paleness in color, and serous infiltration, being 
 the leading features which an examination of the tissue reveals. "This 
 must not/ 7 as Simpson well remarks, " be confounded with the white, 
 blanched, and merely anaemic state of the placenta, often observable 
 in cases where the child has died of peritonitis, or other foetal diseases, 
 and been retained in utero for some time subsequently ; and it is patho- 
 logically very different also from the stearoid or fatty degeneration." 
 
 Hypertrophy of the placenta, cartilaginous and calcareous degenera- 
 tion, ramollissement, and atrophy, are all affections which have been 
 specially observed. In many of the affections above enumerated, there 
 seems to be a tendency to return in subsequent pregnancies ; and it may 
 be held as an established fact, that such has been the case in many of 
 those instances of repeated abortion which cause so much disappoint- 
 ment to the mother. Under the influence of these degenerations, the 
 nutrition of the placenta may, for a time, go on uninterruptedly. Soon, 
 however, its function is interfered with, and the safety of the foetus 
 becomes compromised. The general rule, in such circumstances, un- 
 doubtedly is, that the uterus is excited by the foreign body to active 
 contraction, and abortion is the result. But, in a certain number of 
 instances, the decreased vitality of the placenta is maintained, while the 
 embryo becomes shrivelled and attenuated to an extraordinary degree, — 
 under which conditions it may be retained until the full term of 
 gestation is reached, and then discharged. This latter result is more 
 likely to occur in twin than in single pregnancies — the placenta of the 
 one foetus being diseased, and the other, remaining healthy; and it is 
 probably under such circumstances that with a fully-formed child, a 
 shrunken foetus is sometimes expelled — giving rise, erroneously, to a 
 suspicion of super foetation. The dead foetus, in these instances, is 
 generally flattened by the pressure which is exercised upon it by the 
 other in the course of its development. 
 
 An extremely rare and curious phenomenon has been occasionally 
 
XII.] DISEASES OF THE FCETUS. 215 
 
 observed, in which, the foetus remaining in utero, labor does not come 
 on at the usual time; and the remains of the foetus may be retained for 
 a considerable period, or discharged piecemeal by the vagina, without, 
 for a time, at least, seriously affecting the health of the mother. This 
 has been called Missed Labor, and is alluded to by Dr. Tyler Smith in 
 his admirable Manual, in which he gives the history and illustration 
 of a case which occurred in the experience of Dr. Oldham. 
 
 The Umbilical Cord may also, like the placenta, be the seat of certain 
 anomalies, or morbid affections, which may cause the untimely death of 
 the foetus. Under the former class, may be ranged cases of true knots 
 on the cord, and twisting of it round various parts of the child, which 
 may possibly be attended with fatal results; and, under the latter, may 
 be mentioned inflammation of the cord, or of any of its parts, and 
 cystic degeneration, which was first described by Ruysch, and has been 
 mentioned by subsequent writers, although it is probably of very rare 
 occurrence. 
 
 Diseases of the Foetus. — Having now considered the chief morbid 
 conditions which affect the various parts of the ovum, including the 
 placenta, we may at this place advert, with propriety, to certain diseases 
 to which the foetus itself is liable. With few exceptions, the foetus may 
 be said to be subject to the same diseases as are observed after birth. 
 Among the most frequent are the affections of the nervous system which 
 give rise to haemorrhages ; or which consist primarily in inflammatory 
 affections, from which spring secondary effects, attended with very 
 serious results to the mother as well as to the child. Haemorrhages 
 into the substance of the foetal brain are very rare; but it is not so 
 much so in regard to discharges which take place behind the membranes 
 or on the surface of the brain. These affections when observed, and 
 when unconnected with obstructed delivery, have usually been found 
 associated with placental apoplexy or obstruction of the cord. Of all 
 the results of inflammatory action in this situation, the most familiar is 
 chronic hydrocephalus, in which the quantity of serum effused within 
 the cranium is often so great as not only to cause a certain amount of 
 atrophy of the encephalon, but also an increase in the size of the head, 
 so considerable as to form a serious obstacle to delivery. Convulsions 
 may attack the foetus while it is yet in the womb, and cases have been 
 observed in which convulsions on the part of the mother were com- 
 municated to the child. The probable cause of these, in most instances, 
 is arrest of the circulation, which causes the foetus to die of apnoea, — of 
 which convulsive action is a frequent symptom. Although the lungs 
 are as yet of very small size, it would appear that they are occasion- 
 ally, though very rarely, the seat of inflammation ; but pleurisy and 
 tuberculosis are of much more frequent occurrence than pneumonia. 
 Acute and chronic peritonitis, whether general or partial in extent, is 
 met with much oftener than the above. This affection may be accom- 
 panied with effusions, which are identical in appearance and general 
 characteristics with those which are so frequently observed after birth ; 
 and, according to the type of the inflammatory action, they may take 
 the form, either of coagulable lymph, by means of which the viscera 
 may be glued together, or of a fluid effusion, the quantity of which 
 
216 ABNORMAL DEVELOPMENT. [CHAP. 
 
 may become enormous, and may cause the death of the foetus either 
 before or after birth, or may even render delivery difficult. It would 
 appear from certain researches made by Simpson in reference to this 
 affection, that it is not unfrequently associated with syphilitic disease 
 of the mother. Diseases of the liver and of the spleen, many of them 
 associated with the same constitutional disorder, have also been fre- 
 quently observed ; and, more rarely, affections of the alimentary canal, 
 with which may be classed cases of Ascarides and Taenia, these entozoa 
 having been repeatedly found in the intestines of the unborn. Conges- 
 tion, cystic degeneration, and other affections of the kidney, as well as 
 various affections of the ureter, have occasionally been noticed ; and 
 the same may be said with reference to cardiac diseases, examples of 
 which, including peri- and endocarditis, have also been noted. Va- 
 rious diseases of the skin are observed in children born either prema- 
 turely or at the full time, including the characteristic eruption of certain 
 febrile diseases, such as variola, which may be contracted from the 
 mother within the uterus ; or, what is much more wonderful, which 
 may be communicated through the mother to the child, she herself 
 remaining unaffected. Erythema, pemphigus, and other forms of skin 
 disease, are very frequently to be received as evidence of the existence 
 of syphilitic disease, in one parent or in both. 
 
 Fracture of the bones of the foetus is an affection which is usually 
 the result of violence from without; but a sufficient number of cases 
 have been observed to establish the fact that, independently of any 
 such accident, intra-uterine fracture may occur. Some of the recorded 
 instances of this are of the most extraordinary nature. Chaussier, for 
 example, tells us of one case in which there were forty-three, and 
 another in which there were no fewer than one hundred and thirteen 
 fractures of the bones of the foetus, facts which it is difficult to conceive, 
 unless under the supposition that extensive disease of the bones existed. 
 But, a more extraordinary phenomenon still is the occurrence within 
 the womb of what has been described as spontaneous amputation. 
 Haller, and many physiologists after him, supposed that these were 
 cases of simple arrested development, but that this cannot be the case 
 in every instance is proved by the discovery within the uterus of the 
 missing part. The fact of this spontaneous amputation having, at a 
 more advanced period, been clearly established by irrefragable evidence, 
 the question which next presented itself for solution was the manner in 
 which such a separation within the uterus could by any possibility take 
 place. To this, the reply given by Chaussier, Billard, and other writers 
 of that period, was that the only manner in which it could be accounted 
 for was to suppose that the parts separated had been the seat of gan- 
 grene, and that spontaneous amputation had taken place at the line of 
 demarcation between the living and dead issue. The discovery in 
 several cases of the amputated part, which had not undergone any 
 decomposition, soon proved that this theory was quite erroneous, and it 
 is to Montgomery that we owe what is now generally believed to be the 
 correct explanation of what was long a pathological problem. Mont- 
 gomery's view, which has, since he wrote, received the most ample 
 confirmation, was that the intra-uterine section was effected, either 
 
XII.] INTRA-UTERINE AMPUTATION. 217 
 
 by constriction exercised by the cord, or by special bands consisting 
 originally of organized lymph, such as is usually elaborated under the 
 influence of inflammatory action. These bands or threads having be- 
 come fixed round a limb, their compressive power becomes daily 
 augmented, on the one hand, by their own contractions, and, on the 
 other, by the growth of the body within their grasp. In the majority 
 of cases, the complete separation of the limb is not effected, and it is 
 only partially divided. But if the processes of contraction and growth 
 continue, the supply of blood to the distal part of the limb is first 
 diminished and then cut off; and, ultimately, the nutrition of the bone 
 being similarly interfered with, it becomes brittle, and probably breaks 
 off short at the point of constriction. A most interesting observation, 
 which we owe to Simpson, in connection with this subject, is the occur- 
 rence in these instances of an attempt on the part of nature to remedy 
 the deficiency by a process of reproduction which is familiar low in the 
 animal scale, but of which, as we ascend, nature avails herself less and 
 less. When, in a case of this kind, as he shows by reference to a con- 
 siderable number of cases, separation in utero occurs, a stump is found 
 which offers certain peculiarities in appearance. " Two points of the 
 skin, or rather of the subcutaneous tissue, are found adherent to the 
 ends of the ulna and radius, and present a depressed or umbi Heated, 
 form, particularly when the forearm is flexed and moved, and the 
 fissures of the skin run in converging lines to these two points as 
 centres. Midway, and a little in front of these two points, the rudi- 
 ment of the regenerated extremity is situated in the form of a raised 
 cutaneous fold, or fleshy mass, or tubercle, and having on its surface 
 one, two, or more smaller projections or nodules, furnished with minute 
 nails." In illustration of this, the appended engraving is given, repre- 
 senting the stump of the left 1 forearm of a foetus of -the seventh month, 
 preserved in the Obstetric Mu- 
 seum of the University of Ed in- fig. 94. 
 burgh. There are five small 
 rudimentary fingers tipped with 
 minute nails, in the usual posi- 
 tion on the end of the stump. 
 
 Deviations from the ordinary 
 process of development fre- 
 quently give rise to results 
 which constitute Monstrosities. 
 The subject of monsters, how- * / 
 
 ever, although it might fairly / 
 
 enough be discussed here, is 
 
 One Of SUch magnitude that We Intrauterine amputation and attempted 
 
 must needs pass it by, as it is reproduction. 
 
 quite impossible to give to it 
 
 even the briefest notice in a work such as this. Those who would pursue 
 the subject may refer to the magnificent Traite de Teratologic by Geof- 
 frey Saint-Hilaire, and to other works where the subject is fully and 
 
 1 It is somewhat remarkable that this accident generally occurs on the left side. 
 
218 DISEASES OF PREGNANCY. [CHAP. 
 
 exhaustively treated. The Anencephalic, Cyclocephalic, and other 
 varieties, which consist in the absence of portions of the cranium and 
 subjacent parts, are interesting chiefly, from a purely practical point of 
 view, as being likely to puzzle any one who, on making a digital ex- 
 amination during labor, might chance to touch such a formation. 
 While the double monsters are, as we shall see, interesting in their 
 practical bearing, as being certain to be attended with difficult labor, 
 the whole subject of monstrosities and malformations is, however, here 
 quite beyond our grasp. 
 
 CHAPTER XIII. 
 
 DISEASES OF PREGNANCY. 
 
 I. DISORDERS OF THE DIGESTIVE FUNCTIONS — EXCESSIVE VOMITING : TREATMENT 
 OF: QUESTION OF INDUCTION OF PREMATURE LABOR IN — ANOREXIA — GASTRO- 
 DYNIA — PYROSIS— CONSTIPATION — DIARRHCEA. II. DISORDERS OF RESPIRATION 
 — DYSPNOEA — COUGH. III. DISORDERS OF THE CIRCULATION — CONDITION OF 
 THE BLOOD IN PREGNANCY: DIMINUTION OF BLOOD-CORPUSCLES: PROPOR- 
 TIONAL ALTERATION IN FIBRIN AND ALBUMEN — SUPPOSED RESEMBLANCE OF 
 THE PHENOMENA OF PREGNANCY TO THOSE OF CHLOROSIS — ADMINISTRATION 
 OF IRON IN PREGNANCY — PLETHORA — VARICOSE VEINS — HAEMORRHOIDS — 
 THROMBUS OF THE VAGINA. 
 
 Many of the symptoms which have already been detailed as indi- 
 cative of pregnancy are such as, under ordinary circumstances, would 
 be regarded as pathological phenomena, and would be classed as Dis- 
 eases, or at least as Disorders. But, under the special circumstances 
 attending the pregnant state, which implies the development of a 
 function purely physiological, these symptoms, which are in a great 
 measure the result of sympathetic or reflex irritation, are naturally 
 looked upon as physiological indications of a natural process. So 
 long, at least, as they are confined within moderate limits, it is usual 
 either to treat them by means of mild palliative measures, or to disre- 
 gard them altogether, provided the general health does not seem to be 
 in any serious degree affected. A very small amount of practical 
 experience suffices to show that great differences exist, consistently with 
 a perfectly healthy pregnancy, in the gravity of the symptoms which 
 are manifested; a woman, in one case, being scarcely exposed, during 
 the whole period of her pregnancy, even to discomfort; while, in 
 another, with an equally happy result, disagreeable symptoms of one 
 kind or another have been well-nigh incessant. The difficulty, there- 
 fore, is where to draw the line, and to determine what cases demand 
 treatment, and in what others interference is to be avoided. These 
 remarks apply especially to the abnormal digestive phenomena which 
 so invariably attend pregnancy, and to certain other symptoms which 
 may be referred to the same category. There are, as is well known, 
 many other symptoms, which are exceptionally attendant on gestation, 
 
XIII.] DIGESTIVE DISORDERS. 219 
 
 and which, when present, are essentially pathological from the first. 
 The whole subject, therefore, of the diseases of pregnancy, is one to 
 which careful attention should be given ; by the student, in the first 
 instance, that he may be able to appreciate the significance of the 
 symptoms which he may observe; and, by the practitioner, that he 
 may be able, in case of need, so to manage a pregnancy with prudence, 
 as to avert such dangers as may be foreseen and avoided. There is 
 good reason to believe that a sound knowledge of the morbid phenom- 
 ena of pregnancy may enable us not only to avert dangers the nature 
 of which is now well understood, but to discover, in the future, means 
 whereby the dangers and diseases of development may be combated, by 
 agents not yet at our command, and the risks of childbed be thus 
 lessened both to mother and child. 
 
 A study, however superficial, of diseases of the womb, or of menstrual 
 derangements shows clearly that a sympathy, of a very intimate kind, 
 exists between the uterus and the nervous and digestive systems; a 
 sympathy which a knowledge of the origin and distribution of the par 
 vagum and sympathetic nerves might already have led us to expect. 
 We cannot wonder, then, that, during pregnancy, when the function 
 of the uterus is so exalted, this sympathetic action should also be ex- 
 aggerated. The symptoms manifested are infinite in their variety, 
 according to the constitution of the individual ; but so deceptive and 
 erratic are they in their mode of development, that we can place no 
 dependence on them as a guide to the probable progress of a given case. 
 There are instances, and these by no means unfrequent, in which the 
 constitution is actually improved by the occurrence of pregnancy ; and 
 cases are even observed in which the downward course of lingering and 
 wasting disease is arrested by conception, and is held in abeyance during 
 its continuance. There are, on the other hand, extreme cases, in which 
 the life of the woman is actually in danger, not from any acute or 
 organic disease, but from the great functional disturbance which, in 
 these peculiar instances, pregnancy provokes. The time at which such 
 symptoms as merit the name of pathological phenomena manifest them- 
 selves varies very considerably. Some have their origin in the early 
 months, and such will usually be found, on careful examination, to be 
 purely sympathetic; while those, on the other hand, which do not call 
 for attention and treatment till towards the end of the term of gesta- 
 tion, will be found, as a rule, to be due to some pressure, or mechanical 
 interference with the functions which are disturbed. 
 
 Most modern writers, in considering systematically the disorders of 
 the pregnant state, have adopted either the classification of Desormeaux, 
 or some modification of it. Following their example, we propose to 
 divide the affections in question into the following groups : 
 
 1. Disorders of the Digestive Functions. 
 
 2. Disorders of Respiration. 
 
 3. Disorders of the Circulatory System. 
 
 4. Disorders of the Secretions and Excretions. 
 
 5. Disorders affecting Locomotion. 
 
 6. Disorders affecting the Nervous System. 
 
 7. Displacements of the Gravid Uterus. 
 
220 DISEASES OF PREGNANCY. [CHAP. 
 
 I. Disorders of the Digestive Functions. — Vomiting, or rather " morn- 
 ing sickness/' is, as has already been stated, one of the most constant, 
 as it is one of the earliest of the signs of pregnancy. Indeed, it may 
 be said that, owing to the intimate sympathy which has been spoken 
 of as existing between the uterus on the one hand, and the stomach on 
 the other, almost all pregnant women are affected with it more or less. 
 Sometimes, this symptom manifests itself almost immediately after con- 
 ception, — almost always in the course of a few weeks, — and it generally 
 continues till the period of quickening has been reached. So long as 
 the vomiting is moderate, it is best not to interfere ; and, indeed, an 
 impression very generally prevails, to which Puzos and others have 
 given expression, that it is a salutary symptom, and midwives have an 
 aphorism that "a sick pregnancy is a safe one." But in some cases, 
 the sickness goes to a very great extent, the woman being constantly 
 nauseated, and the stomach rejecting almost everything, solid or fluid, 
 which it receives. In some of the worst of these cases, it is a matter 
 of constant astonishment how it is possible for the vital powers to be 
 sustained, as everything seems to be ejected almost as -soon as it is 
 swallowed. Of course, in all such, a certain portion of the food must 
 be retained ; or the stomach rapidly absorbs a portion before its con- 
 tents are voided. As a rule, the symptom is most violent, and most 
 frequently calls for treatment in the case of primiparse ; but it occa- 
 sionally happens that a woman, who has previously been pregnant 
 without any very marked digestive disorder, may, on a subsequent 
 occasion, undergo the misery of this affection to the fullest extent. 
 There exists, moreover, a great variety in the amount of pain or dis- 
 comfort to which the act of vomiting gives rise, — some women simply 
 emptying the stomach, without pain or effort, as in the vomiting which 
 is symptomatic of brain disease, while others suffer pain and exhaustion 
 from the excessive retching, to an extent which leads us to marvel how 
 it is possible, under such continued spasmodic action, for the uterus to 
 remain quiescent, and to retain its contents. Even in the extreme 
 cases, the emaciation is by no means in proportion to the severity of 
 the symptoms, and the development of the fetus goes on as steadily as 
 if the system were quite unaffected by any disturbing influence. 
 
 In the cases which are most intractable, the matters ejected are often 
 mixed with bile, the breath is fetid, and the patient complains of severe 
 epigastric pain. The latter has been relieved by the application of a 
 small blister to the epigastrium, which may be dressed with morphia. 
 The experience of all, however, who have tried opiates seems to be 
 against their use at least by the mouth. Sometimes, quite suddenly, 
 and without any treatment whatever, the symptoms cease, after having 
 attained their maximum of intensity; but in other cases they persist, 
 and, if not relieved, reduce the woman to the last stage of exhaustion, 
 when nature at last interferes for her relief by the occurrence of spon- 
 taneous abortion, — a fact which has been generally received as an indi- 
 cation of the treatment which we should adopt in extreme cases. There 
 is scarcely any form of rational treatment which has not been tried, 
 with a view to the alleviation of this distressing symptom. We shall 
 only mention here, however, such remedies as have been commended 
 
 
XIII.] TREATMENT OF VOMITING. 221 
 
 by the best authorities, or have seemed to us to be the most reliable. 
 Narcotics, as a rule, are worse than useless. When the symptoms are 
 slight, and confined to a simple aggravation of the ordinary morning 
 sickness, — under which some women are vastly more impatient than 
 others, — the remedies employed should be of the mildest possible nature, 
 and in many cases some bitter infusion, or a cup of strong tea before 
 rising in the morning has quite a decided effect. In several instances, 
 we have known the nausea to be greatly relieved, and the vomiting 
 entirely checked by breakfasting in bed, and not rising for some little 
 time afterwards. In some, food is only retained w T hen cold ; and in 
 others, nothing will lie on the stomach but what is hot. Ice will some- 
 times check it; and bismuth, in doses of eight or ten grains, has been 
 said by Cazeaux to have a good effect. It will be obvious from these 
 facts that the management of the diet is an important part of treatment, 
 but One which will often perplex us sadly. 
 
 The strictest attention must be paid to the state of the bowels, and 
 marked benefit is often derived, in cases where they are sluggish in 
 their action, from a gentle dose of some such mild laxative as Carls- 
 bad salts, Pulna water, or the phosphate of soda. There is, perhaps, 
 no class of remedies which is attended with such beneficial results as 
 effervescing draughts, among the best of which may be mentioned the 
 granular effervescing citrate of magnesia. On the Continent a favorite 
 remedy is the "potion de Riviere," which is prepared and given in the 
 following manner, so that the effervescence actually occurs within the 
 stomach : 
 
 R. 1. Acid. Citric, gr. xxxvj. 
 Syr. Simp., ^j. 
 Aquae, t ^ij. S. 
 
 2. Potass. Bicarb., gr. xxxvj. 
 
 Aquas, ^iij. S. 
 
 Sig. A tablespoonful of each to be taken successively. 
 
 Calumba and soda is a favorite combination with some; and hydro- 
 cyanic acid, or creasote, may be tried, although their usual effect is not 
 to be depended upon. Salicin has also been mentioned : and the salts 
 of cerium have been used and strongly recommended by Simpson, but 
 in so far as our experience goes, with no better effect than the other 
 means which have been mentioned. Should there be much exhaustion 
 of the patient's strength, stimulants must be employed; and, indeed, 
 these, when taken in moderate quantities, and in an effervescing form, 
 such as champagne, or brandy and soda-water, seem almost to exercise 
 a specific influence. In some cases, pepsin is a very valuable addition 
 to other modes of treatment. Sometimes, when such of the above 
 measures as may have been selected are totally devoid of effect, we 
 stumble fortunately on some agent which may chance to have the de- 
 sired effect, even though it be of the simplest possible character. Of 
 such a nature is milk and lime-water, and barley-water; indeed, in 
 reference to the latter, we have seen such striking instances of its 
 efficacy, in which it has been retained by the stomach when all else 
 has been rejected, that we have come to look upon it as among the 
 most valuable agents which we have at command. Lumbar pain is 
 
222 DISEASES OF PREGNANCY. [CHAP. 
 
 sometimes associated with the vomiting of pregnancy, and it is possible 
 that this may depend upon that slight form of uterine inflammation to 
 which Burns refers as a cause of obstinate vomiting. This affords, at 
 least, a rational explanation of the effect of fomentations, hot baths, 
 and if the patient be plethoric, of leeches applied to the loins, in arrest- 
 ing the vomiting in this class of cases. A beneficial effect is also de- 
 rived from the use of belladonna, applied either to the abdomen, as 
 recommended by Bretonneau, or administered in the form of pessaries. 
 In some cases, where the irritability of the stomach seems merely to 
 be increased by food and drink, it will be proper for us to sustain the 
 powers of nature by nutritive enemata ; and, availing ourselves, 
 further, of the possibility of ingestion by the skin, we may give warm, 
 baths, to which gelatinous matter, in any form, may be added ; or 
 inunction, by means of cod liver, or other oil, may be practiced. 
 
 But, failing all other means, the question remains for solution, 
 whether we are warranted in imitating what nature occasionally effects 
 by her own efforts, by inducing the premature expulsion of the fcetus. 
 We shall not pause here to consider, as some have done at great length, 
 the moral aspects of this important practical question. The idea in- 
 volved is death to the foetus, in order either to avoid risk to the mother, 
 or to save her life, when that is in immediate and urgent danger; and 
 no right-minded man can decide in such a case, without feeling that a 
 grave moral responsibility rests upon his decision. We apprehend 
 that when it is a mere question of freeing the woman from the risk of 
 a contingent, though not imminent danger, we are in no case warranted 
 in sacrificing the life of the child, and we must therefore dissent from 
 the conclusions of those who would sanction such a proceeding in any 
 condition of the mother short of extreme peril. The conclusion at 
 which Cazeaux and others have arrived is, that under no circumstances 
 are we justified in inducing premature labor for the relief of the vom- 
 iting of pregnancy; but to this we cannot assent, although we admit 
 that the cases which would warrant the operation are of extremely rare 
 occurrence. That such cases do occur we cannot doubt ; but let the 
 young practitioner be assured that a lifelong experience will scarcely 
 bring such a case under his observation, and let him beware, therefore, 
 lest, by exaggerating to himself the importance of the symptoms, he 
 may, in his anxiety, be led into error. For his guidance, we would 
 call attention to the following facts : 
 
 1. Cases have been recorded in which death has undoubtedly been 
 the result, during pregnancy, of vomiting, and of the inanition conse- 
 quent upon it. Two examples of this are narrated by M. Dance, in 
 the Archives Generates for 1827, where the vomiting began with preg- 
 nancy and terminated fatally, — in the one case at three, and in the 
 other at three and a half months. Dubois met with twenty fatal in- 
 stances in thirteen years, and Tyler Smith alludes to two cases "in 
 which the induction of premature labor artificially was so long delayed 
 that the patient died before abortion could be induced." Burns, on 
 the other hand, says that " he has never known vomiting, purely de- 
 pendent on pregnancy, end fatally;" and a similar observation is made 
 by Desormeaux. 
 
XIII.] ANOREXIA. 223 
 
 2. Numerous cases are recorded in which the operation was success- 
 fully performed, with immediate relief of the symptoms. Such in- 
 stances, however, while they afford proof of the safety of the operation, 
 are not to be admitted as, in any sense, arguments in favor of the prac- 
 tice ; moreover, the result alluded to is far from being invariable. 
 
 3. Instances have occurred, in the experience of almost every prac- 
 titioner, in which the symptoms, although of great severity, spontane- 
 ously ceased, and the labor reached a happy termination ; and not 
 a few are recorded, on excellent authority, which show that, at the 
 last moment, and in the most desperate case, the vomiting may cease, 
 and an equally satisfactory result ensue. In illustration of this, 
 we may cite the following example, which occurred in the practice of 
 Dubois : 
 
 "A young German lady, two and a half months pregnant, had vomited almost 
 incessantly from the first fortnight of her pregnancy. For six weeks she vomited 
 every few minutes, and the smallest spoonful of fluid set up at once the most 
 energetic contractions of the stomach. She was excessively emaciated and feeble: 
 her breath was very fetid. In a word, the symptoms were so grave that M. 
 Dubois called in Chomel. The prognosis of both was almost hopeless, and they 
 left the lady, in the belief that she had but a few days to live. Two days after 
 the consultation, the patient was seized with severe diarrhoea, and from that 
 moment the vomiting ceased, and never returned. She could then take and retain 
 some nourishment, the quantity of which was gradually increased until she re- 
 gained her strength and full digestive powers." 
 
 This woman, then, after being so near death that two such men 
 considered it a hopeless case, made a perfect recovery, and carried her 
 child to the full term. Dubois gives quite frankly, the details of 
 tw r o similar cases, in which he proposed abortion. In both the women 
 refused and went to the full term. 
 
 A review of facts such as these should certainly lead us to use the 
 greatest possible caution, when the question of premature labor comes, 
 in such cases, under our consideration. It is unfortunate that the 
 great majority occur in the early months of pregnancy, — a fact which 
 increases our responsibility. For, if it were essentially a disease of the 
 last, instead of the first weeks, we might provoke labor with less 
 hesitation, as we would then have a viable child, instead of an embryo 
 whose expulsion involves its death. The special circumstances which 
 attend each case should be taken anxiously into consideration, and our 
 verdict must depend mainly upon these, but in full view of the expe- 
 rience of the past. 
 
 Among the other disorders of digestion to which pregnancy gives 
 rise, Anorexia is sometimes prominent. The lack of appetite, amounting 
 occasionally to actual disgust and loathing, is most marked in the 
 early months, although not confined to that period. It is to be met by 
 very careful attention to the normal functions, and by regulation of diet. 
 The effect of tonics, although occasionally good, is not to be depended 
 on ; and it must always be remembered, in reference to the treatment 
 of this and other disorders of the same class, that although we may 
 mitigate symptoms and deaden sensibility within certain limits, w r e 
 cannot annihilate the sympathy upon which the manifestation of these 
 phenomena depends. It is far from unusual for the appetite to become 
 
224 DISEASES OF PREGNANCY. [CHAP. 
 
 depraved in a manner similar to what occurs in chlorosis ; and this, in 
 an aggravated form, constitutes the affection known as Pica. What 
 usually occurs in healthy pregnancy is, that the appetite is altered but 
 not depraved, milk, fresh fruits, succulent vegetables, and other articles 
 of diet easy of digestion being the form of " longing" which prevails. 
 But when this takes a morbid direction, we find the desire for such 
 substances replaced by a craving for raw rice, soap, chalk, cinders, slate 
 pencil, and even substances more disgusting. If the morbid longing be 
 for such matters as may be prejudicial to health, they must of course be 
 withheld, even by forcible means should this be necessary. It is, how- 
 ever, usual and is certainly judicious, to humor the tastes as far as is 
 possible, as they not unfrequently point to the class of diet which agrees 
 best with the patient. 
 
 Gastrodynia and Pyrosis, if present in any marked degree, must be 
 treated by precisely the same means which we would adopt in the same 
 affection occurring in other circumstances; and for this purpose bismuth, 
 calumba, and antispasmodics, combined if necessary with minute doses 
 of opium, may be prescribed. In heartburn and acidity, Dinneford's or 
 Hendry's fluid magnesia, or the effervescing citrate or bicarbonate of 
 potash, may be- administered in each case with every prospect of at 
 least temporary relief to the symptoms. Constipation is a very frequent 
 concomitant of pregnancy, and is due to the pressure which is exercised 
 by the pregnant womb upon the bowels, thus not only reducing its 
 calibre, but also paralyzing to some extent its muscular fibres. In other 
 cases, there is a want of bile, and they who hold that there is dur- 
 ing pregnancy a pseudo-ana?mic state of the system, attribute the 
 irregularity of the bowels to the same causes which operate in the early 
 stage of chlorosis. In any case, whatever the cause may be, constipation 
 is of constant occurrence, and women who were not previously of a 
 costive habit frequently require laxatives during the whole course of 
 their pregnancy. If clay-colored stools indicate that the function of 
 the liver is interfered with, a few grains of blue pill given occasionally 
 will often do much good. In the opposite condition of diarrhoea, which 
 is by no means unfrequent, we must be careful to discriminate the na- 
 ture of the case before pushing astringent treatment too far. If it de- 
 pends upon fecal accumulation, or upon the presence of irritating matter 
 in the alimentary canal, the first step in the treatment must be to clear 
 out the bowels by castor oil, and then to exhibit, if necessary, such 
 astringents as the nature of the case seems to call for. 
 
 II. The Disorders of Respiration, which accompany pregnancy, are 
 by no means numerous. Dyspnoea is an affection which is very common 
 in the later months, and is then due to the mechanical pressure exer- 
 cised in the direction of the diaphragm by the expanding womb. Pest, 
 careful attention to the digestive functions, and such arrangement of 
 the dress as may tend to encourage thoracic, and relieve diaphragmatic 
 respiration, are the obvious and sole means by which this affection is 
 to be combated. In the last weeks, the falling down of the womb 
 which then occurs, will generally be found, by relieving the diaphragm 
 from pressure, to put an end completely to the discomfort from which 
 the patient suffers. Dyspnoea may, however, exist at any period of 
 
 
XIII.] DISORDERS OF RESPIRATION. 225 
 
 pregnancy ; and, when it occurs in the earlier months, it is probably 
 due to sympathetic irritation communicated through the nerves. We 
 have known the dyspnoea under these circumstances to be very harass- 
 ing, and in one instance it was accompanied during the first five months 
 with severe spasmodic asthma in the case of a lady who never suffered 
 from that affection either before or since. Antispasmodics are obviously 
 indicated in such a case, and, in the instance in question, great benefit 
 was derived from a combination of chloroform with bromide of potas- 
 sium. Cough, the result apparently of mere sympathetic irritation, is 
 also an accompaniment of pregnancy in no small number of cases. It 
 may be found to be associated with congestion of the base of the lungs, 
 or with some more serious affection of these organs. As a rule, it 
 exists independently of any ascertainable pulmonary disorder, but is, 
 nevertheless, frequently spasmodic, and at times so violent as to re- 
 semble hooping-cough ; and in these cases it may induce abortion. 
 Some combination of sedatives and antispasmodics would be the best 
 form of treatment for such a case — the symptoms of which are often 
 specially troublesome during the night — and by promoting sleep, may 
 prevent exhaustion and constitutional disturbance. 
 
 III. Disorders of the Circulatory System. — Careful analyses have been 
 performed in order to determine the condition of the blood during the 
 pregnant state. Among these, the researches of MM. Anclral and 
 Gavarret are conspicuous for the care with which they were conducted, 
 and the interest which attaches to the results they disclose. They 
 showed clearly that the plethoric condition of the circulation, which 
 had been believed in by past generations of practitioners (and which 
 was often treated by the ever-ready lancet), did not exist; and not 
 only this, but that the condition which was to be observed in the greater 
 proportion of cases was more of an anaemia than a plethora. The fact 
 is that, as a rule, an examination of the blood of a woman who is 
 pregnant discloses alterations in the relative proportion of its con- 
 stituents, which are closely analogous to what we may observe in 
 ansemia from any cause. In the earlier months of pregnancy, it would 
 appear that the blood deviates little from the normal standard, that the 
 corpuscles are present in their usual number, and that the fibrin and 
 albumen are scarcely altered in the proportion which they bear to the 
 other constituents, the former being, if anything, rather diminished. 
 In the later months, however, the blood is characterized by a remarkable 
 diminution in the number of corpuscles, and a considerable increase in 
 fibrin, while the proportion of albumen suffers no marked disturbance, 
 what little change there is being, however, a diminution. An estimate 
 has been made by the same observers, according to which they assume, 
 that if w 7 e suppose the average number of corpuscles in the blood of 
 healthy women who are not pregnant to be represented by the number 
 125, the average in women towards the end of pregnancy is probably 
 not more than 115. If, in like manner, we take 300 as representing 
 the physiological average of the fibrin, the proportion of that constituent 
 up till about the sixth month may be set down at 250, while from this 
 period onwards, during the last three months of gestation, it steadily 
 
 15 
 
226 DISEASES OF PREGNANCY. [CHAP. 
 
 increases in quantity, and reaches as high in extreme cases as 480. 
 These physiological phenomena accord perfectly with the small clot 
 and bivffy coat which has been so generally observed while practicing 
 venesection in the course of a pregnancy. The interpretation however, 
 which was formerly attached to this, was that the appearance was due 
 to an inflammatory condition of the blood, and was consequently 
 evidence that the practice which was being adopted was rational and 
 judicious ; but now, a more correct knowledge of true physiological 
 principles enables us to recognize that such an appearance is quite 
 compatible with the alterations which have been mentioned. In 
 addition to the facts above noted as the result of analytical research, it 
 has been further established more recently that the quantity of iron, as 
 we would naturally expect from the loss of red corpuscles, is decidedly 
 diminished. 
 
 Many of the symptoms of pregnancy, it must be admitted — such as 
 somnolence, weight in the head, flushing, ringing in the ears, and 
 vertigo — bear a striking resemblance to those which indicate plethora. 
 As the lancet has, however, in this country fallen into disuse, it is 
 unnecessary to repeat that such- symptoms are no indication whatever 
 of bleeding. There is, indeed, much reason to believe that the errors 
 of a former generation have in this, as in some other respects, led to 
 the absolute rejection of what is a powerful agent in the treatment of 
 disease, and that in avoiding one extreme we have gone to the other. 
 We cannot doubt, however, that in the treatment of the pregnant state 
 the change has had a beneficial result, for with the blood in such a 
 state as it is now demonstrated to be in the later months of pregnancy, 
 no one, even in former times, would have thought of bleeding in an 
 ordinary case of gestation. The analogy between pregnancy and 
 chlorosis is most elaborately argued and worked out by Cazeaux, who 
 goes so far as to assume that the system during pregnancy is in a state 
 closely resembling amemio-chlorosis, and that the treatment of preg- 
 nancy should in a great measure be based on a knowledge of this fact. 
 "An animal diet," he says, " and the administration of chalybeates 
 have for many years seemed to me to be as useful against the functional 
 disorders of pregnancy as against those of chlorosis." 
 
 We cannot, we confess, bring ourselves to admit, as Cazeaux seems 
 to do, that an affection identical with chlorosis is a usual and normal 
 condition of pregnancy. To do so would be to admit that a pathological 
 state is the normal accompaniment of a physiological function, a view 
 which we are certainly not prepared to accept. That the phenomena 
 are so far identical has been proved, but there are other explanations 
 which may be offered, more in accordance with such analogies as may 
 be drawn from known physiological and pathological laws. We may, 
 for example, accept it at least as possible that the demand which is, 
 under the circumstances of pregnancy, made upon the mother to sup- 
 ply the material necessary for the rapid development of the infant 
 which she carries, may of itself cause what we are accustomed to con- 
 sider a deterioration in the constitution of the blood. And yet this 
 so-called deterioration may, for aught we know, be a wise provision of 
 
XIII.] CONDITION OF THE BLOOD. 227 
 
 nature against the time when this demand shall suddenly cease. In- 
 deed, although we have little fancy for theories in support of which we 
 have no facts to advance, we do think that it is by no means improba- 
 ble that the vital engine is, for a special purpose, worked at a low 
 power during the last months of pregnancy. In this way at least, the 
 tendency to post-partum inflammatory action may be diminished, as it 
 is only by degrees, after labor, that the blood regains its normal and 
 healthy composition. Or, again, this pseudo-chl orotic state may be in 
 a great measure induced by inadequate nourishment, the result of the 
 nausea and anorexia which so frequently occur. But, whatever the 
 cause of the alteration of the blood may be, it is very doubtful whether 
 iron can with propriety be administered in most cases of pregnancy. 
 In certain cases in which special circumstances have induced us to pre- 
 scribe it, we have found that its effect was less satisfactory than usual; 
 and that it did not allay digestive disorders, but rather, from its ten- 
 dency to increase the sluggish action of the bow T els — which is so fre- 
 quently a complication of pregnancy — seemed, in some cases at least, 
 to aggravate them. 
 
 In thus opposing the view that pregnancy should be treated as a 
 disease, when it presents what we recognize as its normal condition, we 
 must guard ourselves from the possibility of misconception. There are 
 cases, undoubtedly, in which the symptoms are such that we are bound 
 to look upon them as cases of chlorosis ; nay, we may go further, and 
 admit that such cases are by no means of very rare occurrence. Cir- 
 cumstances render it highly probable that many of the signs of preg- 
 nancy are intimately associated with the diminution of the blood-cor- 
 puscles already alluded to, but it seems somewhat curious that these 
 symptoms are often present during pregnancy, while the healthy ruddy 
 complexion of the patient discourages the idea of chlorosis. In ac- 
 counting for this, we must bear in mind, as Scanzoni observes, " that 
 there is a form of chlorosis in nOn-pregnant women, in which the 
 patients, in spite of the fact that the relative quantity of blood-corpus- 
 cles has undergone diminution, preserve a quite healthy color, so that 
 it is conceivable that, in pregnant women also, the pale color of the, 
 general surface is no pathognomonic sign of a diminution of the blood- 
 corpuscles." To this we would only add, that it consists with the ex- 
 perience of all that pallor is quite as frequent in the early as in the 
 late months of pregnancy, although in the former case the alteration 
 in the relative proportion of the blood-corpuscles is as yet scarcely if 
 at all disturbed. 
 
 In a certain number of instances, however, the deterioration of the 
 blood takes place at an unusually early period, and, running its course 
 with great rapidity, leaves the woman, before many weeks have passed, 
 in a state in which all the symptoms of chlorosis in its higher grade 
 may be manifested; and those symptoms are all the more marked 
 when the chlorosis has preceded conception. In all such cases, the 
 course of gestation is more or less disturbed by the characteristic 
 symptoms of the disease, and an influence is not unfrequently exercised 
 upon the duration of pregnancy by the occurrence of exceptionally 
 
228 DISEASES OF PREGNANCY. [CHAP. 
 
 violent symptoms, which may give rise to premature delivery. The 
 experience of those who have devoted most attention to this subject 
 seems to show that no hurtful influence is exercised by chlorosis in the 
 progress of labor, but that a common result is that convalescence is 
 greatly protracted, and that there exists an increased tendency to 
 haemorrhage. In which case also, it has been remarked that there is 
 an increased liability to diseases which are the sequela? of labor, such 
 as phlegmasia dolens ; and, in the case of epidemic metria, that disease 
 is apt, when it attacks a chlorotic woman, to assume some one of its 
 more rapid and fatal forms. The treatment of the chlorosis of preg- 
 nancy is to be conducted on the same principles as under other circum- 
 stances. It will thus consist mainly in careful attention to the general 
 health, special attention being given to the diet, which should in all 
 cases be generous, and contain a considerable proportion of animal 
 food. Stimulants in some form are also indicated, the red wines of 
 Bordeaux, Burgundy, and Hungary, being perhaps superior to all 
 others in the treatment of this class of diseases. In this respect, how- 
 ever, tastes as well as constitutions vary considerably, but, as a rule, 
 the milder stimulants will be found to suit better than those of greater 
 alcoholic strength, unless, indeed, sinking, or even collapse, the result, 
 it may be, of some form of haemorrhage, should call for more energetic 
 measures. The only class of medicines which stand prominently in 
 advance of others in the treatment of chlorosis are of course the various 
 preparations of iron, which should therefore in every case be tried. If 
 the bowels are constipated, the iron should be combined with a laxa- 
 tive; but our own impression is, as has already been observed, that it 
 is, as a rule, less efficacious in pregnancy than under other circum- 
 stances. 
 
 Plethora, in its wider sense, is a comparatively rare affection of preg- 
 nancy. Local Plethora or congestion is of course common enough, 
 and is the result generally of mechanical pressure, exercised either upon 
 the organs affected or upon venous trunks. A certain number of cases 
 do, however, actually occur in those whose temperament renders them 
 liable to hyperemia. In those instances, the symptoms of pregnancy 
 are different from such as are ordinarily observed, but are by no means 
 rendered more bearable. In fact, the vertigo, ringing in the ears, 
 flushing, and severe headache greatly aggravate the discomfort of the 
 woman. If these indications are disregarded, and the symptoms un- 
 checked, nature may relieve herself by the spontaneous occurrence of 
 haemorrhage; and, if the flow of blood should take the direction of the 
 utero-placental, or utero-decidual system, a very natural result will be 
 the premature expulsion of the foetus or embryo. The treatment 
 proper to such cases will consist, in the milder form, of simple regula- 
 tion of the diet and mild laxatives. We must not here, as in the chlo- 
 rotic cases, encourage our patient to use animal food with freedom ; but, 
 on the contrary, we must enjoin abstinence, complete if need be, from 
 such articles of diet, and even from the milder stimulants, — light soups, 
 cooling drinks, and a large share of vegetables being substituted for 
 more stimulating materials. Our object here is to keep the supply in 
 
XIII.] PLETHORA. 229 
 
 proper balance with the assimilative powers, so as to reduce the ten- 
 dency to hypersemia ; and our efforts in this direction with be greatly 
 aided by the use of laxatives, of which the salines are the best for the 
 purpose, beginning, perhaps, in the first instance with a more active 
 cathartic. When the symptoms are so severe as to lead us to appre- 
 hend serious results, such as convulsions, we may fearlessly have re- 
 course to bloodletting, which may be practiced from the arm in the 
 usual way ■ or, if there be evidence of a special determination of the 
 blood in any one direction, such as the brain, the kidneys, or the 
 womb, local abstraction of blood by leeches or cupping-glasses may in 
 these instances be preferred. In such cases the bleeding must be fol- 
 lowed by the general treatment above indicated, which should be 
 rigorously maintained, it may be continuously, or at such intervals as 
 seem necessary, during the whole course of the pregnancy. 
 
 The pressure which, during the pregnant state, is exercised upon 
 venous trunks, gives rise to a number of symptoms which are thus due 
 to a cause purely mechanical. Among the more common of these is a 
 varicose condition of the veins of the legs and lower part of the trunk, 
 which, when trifling, may be disregarded, but, when severe, should be 
 treated by bandages, the pressure of which must be carefully regulated. 
 Should this condition of the veins have preceded impregnation, the 
 symptoms may be so severe as to suggest to the mind the possibility of 
 relief by some operation with a view to a radical cure. It need 
 scarcely be said, however, that, under the circumstances of pregnancy, 
 the chance of a favorable result from any such operation is extremely 
 improbable ; and, moreover, the immediate effect of the operation might 
 be to disturb the progress of gestation. Haemorrhoids spring from the 
 same mechanical cause as the preceding affection, and are besides very 
 greatly aggravated by the habitual constipation which is of such fre- 
 quent occurrence during pregnancy. However severe the suffering 
 may be to which they give rise, there are scarcely any circumstances 
 which would warrant us in excising, ligaturing, or otherwise operating 
 with a view to the cure of this troublesome affection. Nor is it proper 
 even to apply leeches to the part, if it be true, as has been asserted, 
 that these may cause abortion ; and, besides, Desormeaux tells us that 
 he has never known the application of leeches to, or incision of, these 
 tumors in pregnancy attended with any durable amelioration in the 
 symptoms. The treatment of haemorrhoids must consist, therefore, in 
 measures which are purely palliative. If they are painful, sponging 
 with warm water, or fomenting with sponges wrung out of hot water 
 and applied successively as hot as can be borne, is often attended with 
 the greatest possible relief and comfort. Of local applications, nothing 
 perhaps is superior to the well-known Unguentum Gallse cum Opio. 
 Where haemorrhage is a prominent symptom, it may be necessary to 
 employ more active astringents, but what is more useful is cold injec- 
 tions, which may be quite freely used without risk. 1 It is doubtful 
 
 1 Cazoaux recommends the administration every night of a full enema, to be 
 given cold, and when this has been evacuated, a second is to be given, about a fourth 
 of the bulk of the first : the latter to be retained. 
 
230 DISEASES OF PREGNANCY. [CHAP. 
 
 whether cold hip-baths are advisable, as the risk in that case of excit- 
 ing uterine action is increased. 
 
 We have already observed, as a sign of pregnancy, the distended con- 
 dition of the small veins of the vagina, which gives rise to an alteration 
 of the color of the part to a different tint. If the pressure be unusually 
 great, these veins may assume a varicose appearance, but if this only is 
 the result, no interference is necessary, and the inconvenience is but 
 trifling. In another and more severe class of cases, rupture of the dis- 
 tended vessels takes place, and the result is the formation of a livid 
 tumor, usually limited in extent, and situated for the most part in one 
 or other of the labia. This tumor constitutes a Thrombus of the 
 vagina. Its appearance, which is usually sudden, is attended with con- 
 siderable pain, and its immediate cause, in many instances, is to be 
 traced to blows, falls, or violent efforts of any kind. It is very variable 
 in its course and termination, and may end by resolution like a throm- 
 bus in any other situation, in which case it is of very short duration. 
 It may terminate also in rupture, which gives exit to the pent-up 
 blood, and may thus give relief and lead to a speedy cure; or the 
 haemorrhage may be so excessive as to cause great apprehension, and it 
 has even terminated in death. In other cases, suppuration and gan- 
 grene have been the immediate effects, and from the latter process a 
 fatal result has also ensued. The condition of the parts during preg- 
 nancy renders this affection more serious than when it is independent 
 of the process of gestation, and it is not until delivery has taken place 
 that we can look for cure. This is, however, by no means always the 
 case, for the relaxation which then occurs facilitates the further effusion 
 of blood, and we may therefore have, immediately after delivery, a 
 serious increase in the bulk of the tumor. For a similar reason, throm- 
 bus is occasionally developed for the first time after labor, and in these 
 cases there is more danger of its acquiring a considerable size. 
 
 The treatment of vaginal thrombus is a point of great nicety and 
 importance. In those cases in which there seems to be a tendency 
 towards resolution, and in which the density of the tumor becomes 
 increased while its bulk diminishes, no active interference is called for, 
 and our duty is simply to watch the progress of the case, lest circum- 
 stances should arise to call for prompt action. In cases, on the other 
 hand, where the tumor is of large size, so as to fill a considerable 
 portion of the pelvis, and form an obstacle to the functions of surround- 
 ing parts ; or when it is fluctuating throughout, showing that it contains 
 a vast reservoir of fluid blood, and when there is reason to believe that 
 the haemorrhage into the tissues is still going on ; or, again, when there 
 is pointing and other evidence that at any moment spontaneous rupture 
 may occur — and in all these cases evidence that the vital powers are 
 on the wane — we cannot hesitate, but must act by at once incising 
 and giving vent to the effused blood. The two groups of cases above 
 cited are extremes, but there is another, forming probably the largest 
 number of all, which may be supposed to occupy a place intermediate 
 between them. In this class, while the symptoms are neither such 
 as to make us confident in the approach of resolution nor to cast 
 aside as injudicious the idea of further delay, we are constrained to 
 
XIII.] THROMBUS OF THE VAGINA. 231 
 
 wait, with varying hope and apprehension, as long as the health of 
 the woman will admit of it, until the features of the case become so 
 marked in one direction or another that our course of procedure is 
 definitely fixed. A special class of cases are those in which a thrombus 
 during labor threatens to be an actual impediment to its progress, and 
 in which for that reason, irrespective of others, it may be necessary to 
 operate. 
 
 In all cases in which incision has been determined upon, we must in 
 the first place take care to make the aperture a free one, for if a small 
 opening only is made, nothing will escape but fluid blood, and all the 
 clots, which constitute probably the greater portion of the bulk of the 
 tumor, will be left behind. If the clots are adherent, or firmly inclosed 
 in the interstices of the tissues, care must be taken in dislodging them, 
 lest we should unnecessarily give rise to fresh haemorrhage. As regards 
 the point of the tumor at which we are to operate, we must, in the 
 first instance, be guided by the fact whether or not there is any indica- 
 tion of pointing, and, if so, our choice must fall upon the site so indicated. 
 But if there be no pointing, and seeing that the thrombus is very 
 generally situated in the labia, and has thus a cutaneous and a mucous 
 surface, the question arises through which of these is the incision to be 
 made. On this point, most of those who have written on the subject 
 are agreed that to make, the opening from the cutaneous side gives the 
 patient the best chance. The freer exit for the discharges, the protec- 
 tion of the wound from the lochial and other irritating fluids, and the 
 improbability of there being in future labors a cicatrix which might 
 again give way, are among the reasons which have been urged in favor 
 of this mode of procedure. The inflammation which usually supervenes 
 upon the operation must be combated by appropriate means, such as 
 strict cleanliness, and appropriate lotions and injections. The prog- 
 nosis of all such cases is far from favorable. " Of sixty-two cases," 
 says M. Deveux, " which have come to my knowledge, the women died 
 in twenty -two, either during pregnancy, or labor, or afterwards. And, 
 with the exception of one case, all the children of these twenty-two 
 women died." 
 
232 DISEASES OF PREGNANCY. [CHAP. 
 
 CHAPTEK XIV. 
 
 DISEASES OF PREGNANCY (Continued). 
 
 IV. DISORDERS OF SECRETION AND EXCRETION — PTYALISM — INTERFERENCE WITH 
 FUNCTION OF KIDNEYS AND BLADDER — RETENTION : MECHANICAL OR FROM 
 PARALYSIS — ALBUMINURIA: STATE OF THE BLOOD IN : PECULIARITIES OF THE 
 PUERPERAL FORM : CONNECTION OF WITH PUERPERAL CONVULSIONS ! SYMP- 
 TOMS, PROGNOSIS, AND TREATMENT — THE PHOSPHATIC DIATHESIS IN PREG- 
 NANCY — LEUCORRHCEA AND GRANULAR VAGINITIS — ASCITES — DROPSY OF THE 
 AMNION — HYDRORRHEA. V. DISORDERS AFFECTING LOCOMOTION — PELVIC 
 articulations: relaxation of: INFLAMMATION OF. VI. DISORDERS AF- 
 FECTING THE NERVOUS SYSTEM — AFFECTIONS OF THE SPECIAL SENSES — EFFECT 
 ON THE MORAL AND INTELLECTUAL FACULTIES — ABDOMINAL AND UTERINE 
 PAIN. VII. DISPLACEMENTS OF THE GRAVID UTERUS — PROLAPSUS — ANTEVER- 
 SION AND ANTEFLEXION : SYMPTOMS AND TREATMENT OF — RETROVERSION | 
 HOW CAUSED ORIGINALLY: CHRONIC AND ACUTE FORMS: SYMPTOMS AND 
 TREATMENT OF EACH: OPERATION FOR THE REDUCTION OF — OBLIQUE DIS- 
 PLACEMENTS. 
 
 IV. Disorders of Secretion and Excretion. 
 
 Ptyalism, which has already been mentioned as a concomitant of 
 pregnancy, is occasionally excessive, and may thus give rise to such 
 annoyance as to cause the woman to apply for relief. It has generally 
 been observed as an affection of the first weeks of pregnancy only, and 
 rarely lasts more than two months : if it be excessive, or of longer 
 duration than usual, it may be relieved by the use of gum arabic, 
 tamarind-water, ice, or some gentle astringent. 
 
 The Function of the Kidneys is not, as a rule, in any way disturbed 
 by gestation. 1 It is, however, otherwise as regards the Bladder, which, 
 from its situation, is peculiarly liable to be affected in its function by 
 the pressure to which it is subjected. Annoyance from this source is 
 seldom experienced in the early months of pregnancy, but, in the last 
 weeks, when the uterus has fallen downwards, as is usually the case 
 prior to delivery, the pressure then brought to bear upon the neck of 
 the bladder, which is compressed between the head of the child and 
 the symphysis, may give rise to intolerable annoyance, for the relief of 
 which, prompt action is frequently required. In many cases, the 
 woman is able to relieve herself perfectly by placing herself on her 
 knees and elbows, when, the weight of the child being transferred to 
 the fundus of the womb, the mechanical obstacle is at once removed, 
 
 1 The formation of Kiestein has already been referred to. See " Signs of Preg- 
 nancy." 
 
 
XIV.] ALBUMINURIA. 233 
 
 and she is able to micturate without difficulty. The cases in which the 
 greatest amount of difficulty exists are those which are accompanied by 
 anteflexion of the womb, when the pressure upon the bladder is for 
 obvious anatomical reasons more severe. Complete retention of urine 
 is occasionally the result, and, in such a case, the bladder may become 
 enormously distended, and, in an unnaturally elongated form, may 
 reach as high as the umbilicus ; and, indeed, cases have been recorded 
 in which death has taken place from rupture of the bladder, and escape 
 of the urine into the peritoneal cavity. Fortunately, however, it is 
 only on rare occasions that the retention is complete, but it is by no 
 means unusual for the practitioner to be summoned to relieve the almost 
 constant irritation from which the woman suffers, in consequence of the 
 difficulty which she experiences in her efforts to empty the bladder. 
 If this difficulty is not relieved by change of posture during the act, 
 an abdominal bandage, carefully adjusted, and worn so as to give sup- 
 port to the uterus, will often be productive of the most satisfactory 
 results. But, failing such means, it will be necessary, in some instances, 
 to use the catheter, and in this manner to relieve the bladder. With 
 the ordinary female catheter, considerable difficulty may often be ex- 
 perienced, as it is too straight and too short to be adapted to the 
 altered anatomical relations of the urethra and bladder; and, indeed, its 
 use is not free from risk. It is, therefore, much better to use an elastic 
 catheter, by means of which the operator will, even in cases of complete 
 retention, rarely fail to effect his purpose. In cases where the com- 
 pression is comparatively trifling, it may act in another way, by inducing 
 paralysis of the sphincter vesica?, and a constant escape of the urine 
 drop by drop. In one case, this was observed by Scanzoni as early as 
 the third, and disappeared entirely so soon as the uterus had risen out 
 of the pelvis in the fourth month. Catheterism may be employed as 
 often as is necessary; and the catheter may be left in for several hours, 
 while the woman lies quietly on her back, should the symptoms not 
 yield to the simple emptying of the bladder. Sometimes, in the last 
 months, she experiences a smarting or more severe pain, in micturating, 
 which has been found to depend, in many instances, upon a catarrh of 
 the bladder, or at least of its neck ; under which circumstances, whitish 
 flakes and purulent matter in the urine will disclose the nature of 
 the case, for the treatment of which, the only safe means which can 
 be adopted are baths, bland drinks, and emollient applications. This 
 affection may be associated with spasm of the neck of the bladder, 
 which may also exist independently of any local disease, the irritation 
 which causes it being sometimes due to pressure, and at other times to 
 a reflex irritation starting from the uterus. 
 
 The existence of Albuminuria as a disease of pregnancy, was first 
 discovered by M. Rayer, and in this country was brought under the 
 notice of the profession by Dr. Lever. Previous to this, there can be 
 no doubt that many cases were set down simply as instances of oedema, 
 due to pressure (the (Edema Gravidarum of the old writers), which 
 were, nevertheless, caused by the presence of albumen in the urine, or 
 by the changes in the kidneys upon which that symptom usually 
 depends. Under ordinary circumstances, the presence of albumen in 
 
234 DISEASES OF PREGNANCY. [CHAP. 
 
 the urine is looked upon as symptomatic of very serious organic disease, 
 and experience abundantly shows that we have only too good reason to 
 look forward in such cases with somewhat gloomy anticipations as to 
 the future. There are, however, exceptional instances, such, for exam- 
 ple, as arise in the course of scarlatina, in which our prognosis is vastly 
 more favorable. A knowledge of these facts has given rise to numerous 
 speculations as to the nature and exact import of the symptom, when it 
 is observed in the course of pregnancy. The question, in fact, is — are 
 we to consider the albuminuria of pregnancy as indicative of serious 
 disease of the kidneys; or are we, on the other hand, to look upon it 
 as an exceptional symptom of pregnancy, and one to the disappearance 
 of which after delivery we may confidently look forward ? In consider- 
 ing, in the light of modern investigation, what answer should be given 
 to this query, we note, in the first place, the fact that the albumen in 
 the blood is somewhat diminished during pregnancy. Along with this 
 we have the researches of Blot and Litzinann, who, by a series of inde- 
 pendent observations, have shown that albumen exists in the urine in 
 more than twenty per cent, of pregnant women ; and in the case of 
 primiparse, the percentage is considerably higher even than this. If 
 Ave were to admit, therefore, that albumen in the urine was here a 
 pathognomonic sign of equal significance with that which occurs inde- 
 pendently of gestation, we must conclude that the mortality of preg- 
 nancy and childbed would be thereby in a very great degree augmented. 
 But, as experience shows us the contrary, we are thus, on the very 
 threshold of the inquiry, forced to admit that the albuminuria of preg- 
 nancy is comparatively an innocuous disease. 
 
 That childbed mortality is, directly or indirectly, increased in some 
 measure by the presence of albumen in the urine, and the associated 
 phenomena, is a fact which no one in these days will gainsay. Among 
 the phenomena here alluded to are puerperal convulsions, a subject to 
 which we shall, at a later period, have occasion specially to refer, as the 
 affection in question is one upon which the most serious results not un- 
 frequently ensue. This is, in fact, one of the most interesting and 
 practically important points in connection with the subject; to the 
 demonstration of which Simpson contributed in no small measure, by 
 establishing the intimate association which exists between convulsions 
 and albuminuria. But, the unhappy results which frequently attend 
 this complication fortunately do not indicate the ordinary course of an 
 uncomplicated case of albuminuria in pregnancy. The frequency with 
 which this alteration of the urine is to be observed, as has been shown 
 by the observations of Blot and Litzmann already referred to, is suffi- 
 cient to prove that a large proportion of cases are unattended by any 
 marked symptoms, and, therefore, we may assume, run their course 
 without the nature of the case being so much as suspected. And, more- 
 over, this idea receives the strongest possible confirmation from the 
 fact which experience has fully disclosed, that, in the majority of cases 
 in which albumen is actually detected in the urine by chemical exami- 
 nation during gestation, the general health is little if at all affected, 
 and the normal constitution of the urine is restored within a short 
 period after delivery. 
 
XIV.] TREATMENT OF ALBUMINURIA. 235 
 
 The symptoms of this affection are, then, in the mildest cases, either 
 such as to attract no attention, or are confounded with those which 
 naturally arise from, or are associated with, the pregnant state. When, 
 however, dropsical effusion takes place, — which is not, like that which 
 has already been alluded to as the result of mere mechanical pressure, 
 confined to the lower limbs, but affects more or less extensively the 
 whole body, — our suspicion should be at once aroused, and a careful 
 examination instituted, when the presence of the abnormal element in 
 the urine will usually be detected. In extreme cases, the legs are enor- 
 mously swollen, and the vulva and vagina tumefied; and the charac- 
 teristic puffiness of the face, with swelling of the upper limbs and of 
 the abdominal walls, indicate still more clearly the nature of the case. 
 The urine is scanty, of high specific gravity, and may become solid 
 on boiling. In the worst cases, and especially in those in which con- 
 vulsions occur, there is considerable headache, dimness of vision, and 
 amaurosis, — which latter sometimes conies on quite suddenly, imme- 
 diately before a fit. The blood poisoning, which gives rise to these 
 epileptiform seizures, consists, as the observations of Christison and 
 others have conclusively shown, in the presence in the blood of urea, 
 which is not eliminated in consequence of the perverted condition of 
 the renal function. It has been demonstrated experimentally, that 
 placing a ligature on the renal veins, and thereby disturbing the 
 balance of the circulation in the kidneys, causes the appearance of 
 albumen in the urine. From this the inference has been drawn, that 
 the albuminuria of pregnancy was due to the pressure exercised by 
 the gravid uterus. That this is the case in many instances we cannot 
 doubt, but at the same time we are inclined to believe that the expla- 
 nation has been too readily accepted as the solution of every case. 
 The fact of its greater frequency in primiparae and in twin pregnancy, 
 where the pressure is obviously greater, no doubt lends confirmation 
 to the view alluded to ; but, on the other hand, instances occasionally 
 occur in which, at an early period of pregnancy, albumen may be de- 
 tected before any such pressure as would account for it on the above 
 hypothesis could by any possibility occur. "In such cases," says Dr. 
 Tyler Smith, "the disease appears to me to depend upon reflex irrita- 
 tion of the kidneys by the gravid uterus, similar to the irritation of 
 the salivary glands, the mammae, thyroid, etc., and not upon mere 
 pressure alone." If the symptoms continue unchecked, the general 
 health of the patient becomes seriously compromised. The anaemia 
 and waxy pallor which is so characteristic of the more advanced stages 
 of Bright's disease now become manifest. This is supposed by modern 
 pathologists to be due, mainly, to the poisoning of the blood by the 
 urea, which takes the place in that fluid of the lost albumen ; while, 
 by subsequent decomposition, the urea is converted into ammonia, 
 which has been detected in the blood and in various secretions. 
 
 The existence of puerperal albuminuria, is, as a rule, only recognized 
 during the last months of pregnancy. It by no means follows, how- 
 ever, that this marks the period at which it is first present in the urine. 
 On the contrary, we may be certain that its recognition is often deferred 
 to that period, simply because the symptoms have not been such as to 
 
236 DISEASES OF PREGNANCY. [CHAP. 
 
 attract particular attention. There is too good reason to believe, indeed, 
 that, even in cases where the symptoms ought to have excited suspicion, 
 the idea has never been entertained until the occurrence, during labor, 
 of violent convulsions, for the first time directs attention to the fact. 
 The greatest variety exists in the progress and duration of the disease. 
 In some of the cases which have been most carefully noted, the presence 
 of the albumen has not been constant, but has either oscillated in regard 
 to quantity, or has ceased completely for days, to return again, — thus 
 repeatedly intermitting during a considerable period. In others, the 
 affection appears to gain ground as the pregnancy advances, and ulti- 
 mately to culminate in that form of granular degeneration of the kidney 
 which constitutes the disease of Bright. There are, of course, cases in 
 which women who are already the subjects of Bright's disease become 
 pregnant, and in whom all the symptoms suffer aggravation. But what 
 we refer to at present exclusively are those cases in which, at some 
 period in the course of a pregnancy, albuminuria makes its appearance 
 for the first time. The instances in which no serious kidney lesion 
 exists, constitute, happily, the great majority. In such, the albumen 
 usually disappears shortly after delivery ; but, in others (as we not 
 unfrequently see after scarlatina), the albumen persists for many months, 
 although the general symptoms are not necessarily severe. Much in- 
 formation may be derived, in doubtful cases, from a microscopic exam- 
 ination of the urine ; and in this way, too, our prognosis will, in a 
 great measure, be formed, as the presence of tube-casts, and their mi- 
 croscopic characters, will often reveal the nature and stage of the renal 
 degeneration, should it exist. Headache, sickness, and the various 
 forms of digestive disorder which are so frequently associated with 
 pregnancy, are, under the influence of albuminuria, often greatly 
 aggravated ; and there can be no doubt that the morbid alteration in 
 the blood gives rise, as has been observed by M. Blot and by Tyler 
 Smith, to dangerous haemorrhage during or after labor. 
 
 In reference to the question of treatment, it is obvious that it must 
 be of no small importance to ascertain, as early as possible after its 
 development, the presence of the albumen. More especially is it of 
 importance to be possessed of this information, in order that we may 
 adopt such measures as may remove, or at least mitigate, the symptoms, 
 before the period of labor arrives, at which experience teaches us to 
 dread the occurrence of convulsions, and the alarming results which 
 spring from uremic poisoning. In every case in which the symptoms 
 point in that direction, including even the minor forms of oedema, it is 
 well, as a matter of routine in practice, to test the urine for albumen. 
 Its presence may, doubtless, be discovered in many cases in which no 
 other symptoms exist, and the health of the woman is excellent. If so, 
 the treatment will consist in careful regulation of the diet and of the 
 functions, and in occasional observations of the urine, with the view of 
 obtaining the earliest possible information of any morbid change. If 
 the case is one wholly due to pressure, no serious symptoms whatever 
 may be manifested, and the case may continue until the end of preg- 
 nancy, with the result of a happy labor and perfect recovery. If the 
 general system seem to participate in the morbid process, and there is 
 
XIV.] TREATMENT OF ALBUMINURIA. 237 
 
 lumbar pain and general febrile excitement, great relief will frequently 
 follow the application of a few leeches to the loins, to be followed by 
 diligent fomentation. Antiphlogistic treatment of any kind, more 
 especially in such cases as are not observed until the disease has made 
 some progress, must be resorted to with the greatest caution. For it must 
 be remembered that the disease is one of debility, and implies impov- 
 erishment of the blood — a condition which calls more for a tonic treat- 
 ment and a generous diet. Baths of various kinds are often useful, 
 being at once grateful to the feelings of the patient and likely to pro- 
 mote the function of the skin. The use of diuretics has also been rec- 
 ommended ; but, if used, these agents should be employed cautiously, 
 and in the mildest form. In a case which came under our observation 
 lately, a lady aged thirty-four, pregnant for the first time, had oedema 
 of the ankles about the beginning of the sixth month, when a trace of 
 albumen was discovered — the urine being very scanty, high-colored, 
 and loaded with lithates. The treatment adopted was the bitartrate of 
 potash, with Rochelle salts and benzoic acid, which kept the symptoms 
 somewhat in abeyance, and manifestly improved the function of the 
 kidney. The general health did not deteriorate, but the general dropsy 
 increased, the quantity of albumen in the urine fluctuating considerably. 
 All went on well, but, in the last stage of a tedious labor, the patient 
 was seized with a most violent epileptiform attack. She was at once 
 delivered with the forceps, made a good recovery, and in six weeks all 
 trace of albumen had disappeared. In the above case, the benzoic acid 
 was given, as recommended by Frerichs, with the view of neutralizing 
 the ammonia which forms in the blood from the decomposition of the 
 retained urea. 
 
 [We have frequently derived great advantage from the use of digitalis 
 and acetate of potash in the albuminuria of pregnancy. The digitalis 
 should always be given in infusion. Alcoholic preparations of this 
 drug do not by any means possess the diuretic properties which belong 
 to the infusion. If there is anaemia, the acetate of potash should be 
 given with Basham's mixture, with which it combines well. The latter 
 may be prepared according to the following formula: 
 
 R. Tinct. Ferri Cblor., fgiij. 
 Liq. Ammoniae Acet., f^iij. 
 Acid. Acetic, t^xv. 
 01. G;iultherige, gtt. v. 
 Syr. Aurantii cort., f^j. — M. 
 
 Sig. Dose one to two drachms three times daily. — P.] 
 
 The significance of albuminuria during pregnancy has been viewed 
 by some as of such serious import as to warrant the induction of prem- 
 ature labor ; but to such an opinion, in so far as ordinary cases are 
 concerned, we are unable to subscribe. So serious, however, is the 
 probable issue of a case in which the quantity of albumen, the degree 
 of oedema, and the general condition of the patient, tend to indicate 
 the highest grade of severity in the symptoms, that we may be quite 
 justified in entertaining gravely the propriety of such a course. But, 
 in such circumstances — and the remark applies equally to all cases in 
 which the question of premature delivery may arise — it is proper not 
 
238 DISEASES OF PREGNANCY. [dlAP. 
 
 finally to resolve upon such a step without, if possible, obtaining the 
 sanction and approval of some colleague in whose opinion we may have 
 confidence. 
 
 Dr. Tyler Smith has pointed out, as an occasional accompaniment of 
 pregnancy, the habitual occurrence of a large quantity of triple phos- 
 phate in the urine, which, under the circumstances, is of high specific 
 gravity, and has an alkaline reaction. The same observer has noticed, 
 further, that in some cases in which this phosphatic diathesis has been 
 found to exist, fatty degeneration of the placenta had occurred in suc- 
 cessive pregnancies. The treatment of such cases consists in the use of 
 the mineral acids, opiates, rest, and a nutritious regimen. 
 
 A hypersecretion of the mucous membrane of the vagina constitutes 
 a troublesome form of leueorrhcea, which is of frequent occurrence 
 during pregnancy. A certain degree of this increase in the action of 
 the glandular structures is to be looked upon as an ordinary accompa- 
 niment of pregnancy, due to the increased vascularity which is insepa- 
 rable from gestation, and which manifests itself, as we have already 
 seen, in a change in the color of the membrane. This, of course, re- 
 quires no treatment beyond ordinary attention to cleanliness. But the 
 quantity of the discharge is occasionally excessive, and varies greatly 
 in its appearance, being in one case clear, in another milky, and in a 
 third yellow and creamy like ordinary pus. Such a condition is found 
 occasionally to be associated with a growth of papillary projections on 
 the surface of the membrane, which are sometimes as large as small 
 peas, but more generally very minute and spreading over the whole 
 vagina, giving to it a granular appearance. This is what has been 
 called vaginitis granulosa, an affection accompanied with irritation and 
 uneasiness, amounting in some instances to pretty severe pain, or, what 
 is even worse, intolerable itching of the parts. The latter symptom 
 may give occasion, even during sleep, to rubbing and scratching of the 
 vulva, which may cause ultimately severe excoriation, and much suf- 
 fering. When circumstances render it probable that a specific cause 
 exists, we must of course be on our guard against mistaking gonor- 
 rhoea! or syphilitic discharges for that which we are now considering; 
 and, in cases where the diagnosis may be difficult, the presence of con- 
 dylomata and other unequivocal specific appearances will serve to re- 
 move all doubt. Generally, when the affection is due to pregnancy, 
 even the most profuse discharges rapidly disappear after delivery, and 
 seldom attract any notice after the lochia have ceased to flow. Cases, 
 however, occasionally occur in which such a discharge, originally ap- 
 pearing during pregnancy, lasts during the convalescence after labor, 
 and ends in an obstinate and troublesome vaginal leueorrhcea. The 
 treatment of this affection must necessarily be confined within certain 
 limits, so that sometimes palliation is the most we can hope for. Cau- 
 terants, or strong injections, cannot be employed, lest they should in- 
 duce premature labor, and even the simplest injections must, if used, 
 be employed with the greatest possible caution, as it is well known 
 that repeated injections, even of tepid water, will often suffice to induce 
 uterine contractions. The resources at our command are, on this ac- 
 count, extremely limited, and in most cases must consist in cleanliness, 
 
XIV.] LEUCORRHCEA. 239 
 
 warm baths, and emollient applications. Medicated pessaries of various 
 kinds, such as those which are made with tannin, or with alum and 
 catechu, may also be used with safety and with every prospect of suc- 
 cess. If there is much irritation or itching, the ingredients may be 
 varied at w r ill to meet these indications. 
 
 General dropsy, as symptomatic of, or coincident with puerperal 
 albuminuria, has already been fully noticed. There are other forms, 
 however, of dropsical disease which require attention, among which 
 are ascites, dropsy of the amnion, and the affection known as hydror- 
 rhcea, each of which calls for special remark. Ascites is a form of 
 dropsy, familiar to the physician, which takes the form of effusion 
 within the peritoneal cavity, and which is of frequent occurrence 
 during pregnancy. Sometimes it is developed at an early stage of 
 gestation, in which case we should look upon the symptoms with con- 
 siderable apprehension, as experience has shown that the result is. not 
 unfrequently, fatal to child or mother, or to both. It is rare, however, 
 that it develops itself before the fifth month, and if the patient reaches 
 the termination of the sixth month without ascites, it is unusual for 
 the symptom to manifest itself for the first time after that period. A 
 certain amount of effusion may take place within the peritoneal cavity 
 without attracting any special attention, but as pregnancy advances, 
 the amount of distension is out of all proportion to the stage which 
 has been reached. Examination by the usual process of palpation 
 discloses the fact, in the same manner as under ordinary circumstances, 
 but the site of the chief effusion is varied somewhat in consequence of 
 the presence of the distended uterus. On that account, fluctuation will 
 be perceived most distinctly in the hypochondriac regions, and especi- 
 ally on the left side. The distension, as the case goes on, continues to 
 increase, to such an extent as to press injuriously upon the diaphragm 
 and disturb the functions of the thoracic organs, while the amount of 
 mechanical pressure is further shown by the projection of the umbili- 
 cus, which often takes the form of a protrusion several inches in length, 
 and as translucent as the scrotum in hydrocele. The abdominal walls 
 become cedematous and pit on pressure, and if the case is still un- 
 checked, the whole body becomes enormously swollen, while the blue 
 lips, labored breathing, and rapid feeble pulse show how much the 
 general functions are disturbed. In the course of such a case, the 
 diagnosis of pregnancy is seriously interfered with, and it may be im- 
 possible to make out the presence either of a solid body or a distended 
 uterus; and, besides, there is good reason to believe that, the uterus 
 being separated to a greater or less extent from the abdominal walls, 
 the sensation of quickening is deferred to an advanced period of ges- 
 tation, or in some cases is never felt at all, although the child is alive 
 and vigorous. The worst cases of all are those in which ascites is 
 complicated with dropsy of the amnion, when the prognosis is very 
 unfavorable. 
 
 Caution must be exercised in the treatment of puerperal ascites, in 
 so far as the use of drugs is concerned. It would appear, indeed, that 
 not only is the free use of purgatives and diuretics prejudicial to the 
 pregnancy, and apt to bring on labor, but also that those agents have 
 
240 DISEASES OF PREGNANCY. [CHAP. 
 
 very little effect, in such cases, in checking the advance of the malady. 
 We ought, however, always to try them before resorting to other 
 measures; but, should they fail, and the distension be such as to 
 threaten the life of the woman, we have no choice left save between 
 paracentesis and the induction of premature labor. In deciding be- 
 tween these two modes of procedure, we must be guided by the pecu- 
 liarities of individual cases. The operation of paracentesis will be pre- 
 ferred in all such as may show a reasonable prospect of thus relieving 
 the woman and allowing the pregnancy to run its course, thereby 
 saving both mother and child. It must be remembered, however, that 
 the operation is very frequently succeeded by uterine contractions, so 
 that the very measure which is adopted with a special view to the 
 safety of the child, may possibly be the cause of its expulsion. In 
 regard to the operation itself, it is clear that we cannot, without incur- 
 ring the risk of wounding the gravid womb, operate in the ordinary 
 situation ; so that another site must be selected. Scarpa operated in 
 the left hypochonder, and Ollivier punctured on several occasions the 
 protruding umbilicus with an ordinary lancet, and either of these 
 modes of procedure might be adopted in cases where the operation had 
 been, after due consideration, resolved upon. We confess, for our 
 part, that, seeing the frequency with which premature labor has fol- 
 lowed spontaneously upon the operation of paracentesis, and the risk 
 of peritonitis which the woman must run as a consequence of it, we 
 look with more favor on the induction of premature labor as the proper 
 measure to resort to in extreme cases. The nearer such a case ap- 
 proaches to the full term of gestation, the less need we hesitate in 
 adopting this course; but even when it involves the certain loss of the 
 child, we believe that the most judicious course would be to adopt this, 
 in preference to paracentesis. 
 
 Dropsy of the Amnion. — There is, as has already been observed, a 
 very great variety, consistently with quite normal gestation, in the quan- 
 tity of the liquor amnii. It is, therefore, a matter of no little difficulty 
 to determine the point at which the quantity becomes abnormal, but 
 we shall probably not be w r ide of the truth if we put down the limit at 
 from two to three pints ; so that, if the quantity should exceed this, the 
 case may be held to come under the category of dropsy of the amnion. 
 In extreme cases, from thirty to forty pints of fluid have escaped from 
 the uterus. It was at one time generally believed that this form of 
 dropsy was associated with some special morbid condition. It has 
 been supposed, for example, to be due to inflammation of the amnion, 
 constitutional syphilis, or to some diseased condition of the foetus; but, 
 although all these theories are possible, none of them have up to this 
 period been demonstrated. It seldom has been observed before the 
 fifth month, and is much more frequent in twin pregnancies. 
 
 If any difficulty should be found in distinguishing between ascites 
 and dropsy of the amnion, attention to the following points, which are 
 laid down by Cazeaux as diagnostic, will generally enable us to make 
 the distinction, if the cases are uncomplicated ; but it must not be for- 
 gotten that the two affections may coexist. In ascites, the urine is 
 scanty and thick, and the lower limbs and genitals are cedematous. 
 
XIV.] HYDRORRHEA. 241 
 
 There is also fever and constant thirst. It is difficult, if not impossi- 
 ble, to recognize the outline of the uterus, and in the course of our ex- 
 amination by palpation, distinct fluctuation is to be detected. In 
 dropsy of the amnion again, there is normal urine and little thirst. 
 The lower limbs are often perfectly free from oedema, or if it be present, 
 it is so to a comparatively small extent. The rounded form of the dis- 
 tended uterus can generally be made out, but the fluctuation is very 
 deepseated and obscure. There is rarely any umbilical projection, 
 and if so, it is not transparent. The distension from dropsy of the 
 amnion is sometimes enormous, and may threaten death by apnoea, by 
 interfering with the function of the lungs. The natural relief which 
 has, in such cases, followed upon spontaneous rupture of the mem- 
 branes and the escape of the fluid, points very clearly to the only 
 method of treatment upon which we can rely; for, whatever may be 
 the opinions entertained with reference to ascites, there can be no doubt 
 that, in the affection we are now considering, the only operative pro- 
 cedure applicable to cases where life is in danger is the induction of 
 premature labor by rupture of the membranes. If the symptoms are 
 not urgent, and the distension not excessive, careful attention to all the 
 functions is the only mode of procedure which can be adopted, seeing 
 that diuretics and purgatives are of no avail, and, besides, that the 
 pregnancy may possibly come to a satisfactory termination. The result 
 of this affection is very serious as regards the life of the child, but sel- 
 dom implicates that of the mother, nor, indeed, as a general rule, does 
 it seriously aifect her health. The natural result is spontaneous prem- 
 ature expulsion. 
 
 Hydrorrhea. — In this singular affection, which has also been called 
 " false waters," a discharge of fluid takes place from the uterus, the 
 amnionic sac remaining entire, and the phenomenon being neither 
 preceded, nor necessarily followed, by uterine contractions. This occurs 
 pretty frequently towards the end of pregnancy, and even although the 
 quantity of fluid discharged may have been considerable, and lead to 
 the idea that premature rupture of the membranes had occurred, labor, 
 when it eventually occurs, is found to be accompanied in the first stage, 
 as usual, by the formation of the " bag of waters." The circumstances 
 under which the discharge occurs vary considerably. In some cases 
 it has an obvious connection with some powerful effort or accidental 
 violence, while in others it comes on while the patient is at perfect rest, 
 or even during sleep. In one case the discharge may occur as a gush, 
 in another it may escape guttatim; or, it may come on in either of 
 these ways, and then, ceasing completely, may again and again return. 
 The discharge is in the first instance at least, attended by no pain, but 
 in those cases in which the quantity is large, and the escape sudden, 
 uterine contractions are apt to supervene, and premature delivery thus 
 to ensue. 
 
 The cause and source of a serous and usually colorless discharge 
 which comes from the uterus during pregnancy, and is not the liquor 
 amnii, are points of considerable interest, and to account for the phe- 
 nomenon many theories have arisen. The only one, however, which 
 it is necessary to mention here, as it is that which is almost universally 
 
 16 
 
242 DISEASES OF PREGNANCY. [CHAP. 
 
 accepted, is that the affection arises from a secretion which has its 
 source in the inner surface of the uterus, and which, in proportion to 
 its quantity j separates the coverings of the ovum from their uterine 
 attachments. A pouch is thus formed between the decidua and the 
 womb, which gradually increases as more fluid becomes effused, until, 
 making its way downwards towards the cervix, it finds a mode of exit, 
 the fluid then escaping into the vagina and making its appearance 
 externally. The treatment consists in enjoining strict rest in the 
 horizontal posture in order to reduce this risk to a minimum ; and, if 
 the gush has been sudden and the quantity large, it will also be proper, 
 with the same object, to give an opiate in some form, to allay possible 
 uterine excitement. The only practical mistake which might be made 
 in such a case would arise from an error in diagnosis, for if we believed 
 the discharge to indicate rupture of the membranes, we might, naturally 
 enough, rather encourage the coming on of labor, believing that to be 
 inevitable. 
 
 V. Disorders affecting Locomotion. — Attention has already been 
 directed to the fact, now fully recognized, although long disputed, that 
 a relaxation of the various pelvic articulations is an essential and 
 physiological accompaniment of the pregnant state. This consists in a 
 thickening of the cartilaginous, and a softening and relaxation of the 
 ligamentous structures surrounding the articulations in question. Along 
 with this, there is a greater afflux of blood to the parts, and the more 
 perfect structure of the joints at these times, — as shown, for example, 
 in the increased secretion of synovial fluid, — indicates that nature 
 makes, as it were, an attempt to establish here what exists in so many 
 of the lower animals. The amount of motion which is thus permitted 
 is, with the exception of the sacro-coccygeal joint, very trifling in normal 
 cases, for were it otherwise the power of locomotion would be seriously 
 interfered with. A certain number of rare instances have, however, 
 been recorded, which suffice to show that the articulations may be 
 relaxed in an unusual degree, and thus a morbid condition ensue. 
 Cases have, indeed, been examined by Morgagni, Hunter, and others, 
 in which the separation between the pubic bones at the symphysis ex- 
 ceeded an inch, and in such cases great increase of the synovial secretion 
 has been observed. The woman complains first of pain and uneasiness, 
 which is aggravated on walking, or even by a trifling movement of 
 the trunk. From being intolerable, locomotion becomes impossible; 
 and, on careful examination of the joints, movement, attended with 
 synovial crepitations, may sometimes be induced. Absolute rest should, 
 as a matter of course, in all such cases, be strictly enjoined, for every 
 movement either of the trunk or lower limbs will increase the morbid 
 mobility, and by accustoming the joints to move, will render a cure, 
 which cannot be looked for till after labor, vastly more tedious. After 
 labor — the severity of which this affection will rather tend to mitigate 
 — a similar course of treatment must be persevered in, to encourage the 
 parts to resume their former condition. This will also be promoted by 
 firm bandaging round the pelvis, so as to bring the ossa innominata 
 more firmly together, and by the use, it may be, of some more rigid 
 mechanical support, such as the steel girdle devised by Martin of Berlin 
 
 
 
xiv.] pain. 243 
 
 We have known, under such circumstances, locomotion rendered im- 
 possible for many months after delivery. Inflammation of the pelvic 
 articulations is another occurrence which may call for attention, but 
 cases of this affection are extremely rare. 
 
 Locomotion, which is, with few exceptions, somewhat impeded in 
 the last months of pregnancy, may be rendered extremely painful, or 
 at least very uncomfortable, by many of the affections which Ave have 
 been considering. Cases, for example, of relaxation of the abdominal 
 walls in pluriparse and the anteversion of the womb, which often' ac- 
 companies it, are often attended with this inconvenience, which, under 
 such circumstances, may be greatly relieved by the use of an abdominal 
 bandage, so adjusted as to support the displaced womb. 
 
 VI. Disorders affecting the Nervous System. — The extent to which 
 these may be multiplied by classification is almost illimitable. We 
 shall here, however, confine our attention to a few only, leaving the 
 more important of them to be discussed in a future chapter, and passing 
 over such as may be treated on general principles. The functions of 
 each of the organs of special sense may be disturbed during pregnancy, 
 and we may therefore meet with cases of deafness, aversion to certain 
 odors or perfumes which may previously have been deemed agreeable, 
 dimness of vision, and even amaurosis, and, as regards the sense of 
 taste, peculiarities in this respect are among the most familiar accom- 
 paniments of the pregnant state. Vertigo, flushings, syncope, and even 
 itching of the skin, in the absence of any cutaneous irritation, must 
 also be referred to the same class. Nor do the moral and intellectual 
 faculties escape, in all cases, without suffering material disturbance. 
 The subject of mental alienation in the puerperal state will hereafter 
 be more fully discussed, but there are minor degrees of aberration, 
 both moral and intellectual, which do not amount to, or even approach 
 insanity, but which are by no means of rare occurrence during gesta- 
 tion. Affection may, in this way, be replaced by unaccountable antip- 
 athy, a trusting disposition by jealousy, or a temper which can scarcely 
 be ruffled by wanton irritability. Amusing cases are even narrated, 
 in which an inverse process was the result, and in which whole house- 
 holds learned to hail with pleasure the pregnancy of the lady of the 
 house, which was divulged to them by unwonted gentleness of manner 
 and genial cheerfulness. u It is not uncommon," as Burns says, " to 
 find women very desponding during pregnancy, and much alarmed 
 concerning the issue of their confinement." This affection, closely 
 resembling a similar state occasionally attendant upon disordered men- 
 struation, amounts, when extreme, to melancholia, and seems, in both 
 cases, to have its origin in an irritation which, starting from the uterus, 
 operates reflexly through the nerves. Cheerful society, and careful 
 attention to the diet and bowels, constitute, along with other similar 
 measures, the only treatment proper to such a case. 
 
 Pain, unconnected either with uterine contraction, or with inflam- 
 mation, and referable to any one point in the abdomen, is an occur- 
 rence which occasionally, from its severity, calls for interference. In 
 a certain number of such cases, there, no doubt, is, as Scanzoni points 
 out, an abnormal tenderness of the womb, which many have attributed 
 
244 DISEASES OP PREGNANCY. [CHAP. 
 
 to rheumatism of that organ, during which either the whole womb, or 
 a limited portion of it, may be the seat of very acute pain. When this 
 is the seat of the pain, it is usually referred to the hypogastric region ; 
 but there are many other instances in which pain of an equally acute 
 character is experienced in other regions. Pain in the groins has thus 
 been supposed to be caused by dragging on the round ligaments, which 
 will be best relieved by an abdominal bandage and the horizontal 
 posture. Pain in the lumbar region has, in like manner, although on 
 what ground it is not clearly shown, been attributed to stretching of 
 the broad ligaments. Pain and cramps in the thighs are most distress- 
 ing accompaniments of pregnancy, and are due, in part to pressure on 
 the sacral nerves, and in part to a reflex action, starting, most likely, 
 from the uterus, but probably, in some instances, from the bowels. 
 The abdominal walls also seem, in some cases, to be the seat of acute 
 and almost constant pain. This occurs during the last months of 
 pregnancy only, and is generally confined to a limited space on the 
 abdominal surface — so that it is often difficult to convince the patient 
 that it does not mark the seat of some severe local inflammation. All 
 such painful affections as we have alluded to must be treated, during 
 pregnancy, by the agency of measures which are merely palliative, and, 
 in point of fact, palliation is the most that experience of such cases 
 teaches us to anticipate. Warm baths in all cases, laxatives in the case 
 of cramps, rest and local applications for the relief of the pain, are the 
 only agents which, in most instances, can be employed ; for opiates and 
 other anodynes are very generally contraindieated, in so far as their 
 internal administration is concerned. Among external applications, 
 may here be mentioned the soap and opium liniment, chloroform with 
 tincture of aconite, and belladonna plasters. In the worst cases, morphia 
 may be resorted to, in the form of suppository or subcutaneous injection. 
 The increased sensibility of the uterus is, in some of these cases, asso- 
 ciated with particularly active foetal movements ; and, very often, pain, 
 which has been relieved or deadened, is again awakened by a sudden 
 movement, a sneeze, or a cough. 
 
 VII. Displacements of the Gravid Uterus. — Certain displacements or 
 dislocations of the womb, which are of frequent occurrence in the un- 
 impregnated state, exist also, although more rarely, during pregnancy. 
 The reason of the comparative infrequency is to be found in the fact 
 that, while in all probability impregnation takes place in some instances 
 of uterine displacement, the general effect of the subsequent develop- 
 ment of the uterus in the course of pregnancy is to reduce the disloca- 
 tion, and thus to avert the disastrous consequences of its persistence. 
 As a rule, however, marked flexion or version of the unimpregnated 
 organ is a barrier to pregnancy. 
 
 Ln the affection known as Prolapsus or Procidentia, conception may 
 occur, and that even in cases where the uterus projects externally. But 
 while prolapsus frequently precedes impregnation, the details of some 
 cases would seem to show that sometimes the prolapse succeeds the 
 conception, the uterus descending instead of ascending as the develop- 
 ment progresses, while the further growth of the organ takes place 
 without its ever rising into the abdominal cavity. Examples of this 
 
XIV.] ANTEVERSJON AND ANTEFLEXION. 245 
 
 have been recorded by Portal, and by others whose statements we can- 
 not permit ourselves to call in question. In some of these instances 
 development has gone on entirely within the true pelvis. Up to a 
 certain point, the uterus may no doubt occupy this situation without 
 causing any symptoms of discomfort, and this in fact is what takes 
 place, as we have seen, in the first three months of normal pregnancy. 
 But, should any mechanical impediment prevent its further expansion 
 in the direction of the abdomen, or should any other cause induce its 
 prolonged sojourn in the pelvis, the pressure which is exercised upon 
 the bladder and rectum interferes seriously with their functions, and 
 the case goes on, with great suffering to the patient, until nature relieves 
 herself by expelling prematurely the contents of the womb. Those 
 instances in which it is reported that pregnancy went on uninterruptedly, 
 must, we presume, have been cases in which the cavity of the pelvis 
 presented very unusual dimensions. In some of them the uterus pro- 
 jected partially, but the most extraordinary of all, are those in which 
 prolapsus has been complete, the gravid uterus lying in the form of a 
 huge tumor between the thighs of the mother ; and, incredible though 
 it may seem, it has been asserted that under such circumstances, preg- 
 nancy has reached its normal termination without any special danger 
 either to mother or child. The usual result is that abortion occurs 
 before the end of the fifth month, as in cases narrated by Levret, 
 Capuron, and others. The treatment will consist mainly in careful 
 attention to the functions of the bladder and rectum, and in watching 
 the progress of the case. When the prolapse has preceded pregnancy, 
 and circumstances point to the possibility of an occurrence such as we 
 are now considering, we should watch the case carefully as the period 
 approaches at which the uterus should rise above the brim, and, if 
 necessary, afford it some aid by careful manipulation, as was done by 
 Scanzoni in two cases. Should the organ appear externally, similar 
 efforts should be made, failing which, it must be supported by an ex- 
 ternal bandage. But, so soon as dangerous symptoms manifest them- 
 selves, or the bowels or bladder are so obstructed as to render defeca- 
 tion or micturition impossible, our course of procedure is clearly to act 
 promptly, in such manner as may seem most judicious, with a view to 
 the immediate expulsion of the contents of the uterus, for to allow such 
 a pregnancy to continue would be to compromise the life of the mother 
 as well as that of the child. 
 
 Anteversion and Anteflexion. — These forms of displacement are of 
 rare occurrence during the early months of pregnancy. This is what 
 an observation of the anatomical relation which the organ bears to the 
 j)elvic walls would have led us to anticipate ; and, as Kiwisch has well 
 observed, any such tendency which might exist is obviated further by 
 pressure, directed upwards against the fundus by distension of the 
 bladder, and downwards against the vaginal portion by repletion of the 
 rectum. Cases have, however, been occasionally observed, giving rise 
 to symptoms indicating obstruction to the action of the bowels and 
 bladder. The digital examination which such symptoms suggest 
 reveals at once the nature of the case, the cervix being high in the 
 
246 DISEASES OF PREGNANCY. [CHAP. 
 
 hollow of the sacrum, while the fundus forms a rounded tumor in the 
 roof of the vagina in the direction of the bladder. In such a case, the 
 patient should be directed to lie on her back as much as possible; and, 
 when the period arrives at which the uterus no longer finds accommo- 
 dation within the pelvis, the fundus will rise upwards, and will thus 
 spontaneously relieve any uneasiness to which the displacement may 
 have given rise. This is the natural issue of such a case; but it is 
 quite possible that, in some instances, the dislocation may be reduced 
 by careful pressure upwards of the fundus by the finger, but this should 
 only be attempted should the severity of the symptoms warrant any 
 interference. In the latter months of pregnancy, anteversion is of 
 more frequent occurrence, and is then associated with the phenomenon 
 of pendulous abdomen. It is observed almost always in the case of 
 multipara, in whom the abdominal walls have been subjected to 
 repeated distension, and in those, it is said, in whom the inclination 
 of the pelvis is greater than usual. In direct proportion to the degree 
 of displacement is the amount of pressure to which the bladder is sub- 
 jected, and, consequently, the degree of discomfort to which it gives 
 rise by impeding the flow of urine. In some instances, the abdominal 
 wall not only projects forwards, but hangs downwards, and to those 
 cases the term anteflexion is more applicable than anteversion, as the 
 axis of the uterus is then bent in a greater or less degree. In extreme 
 cases, the walls of the abdomen have been observed to hang down as 
 far as the knees, but it seems likely that in most of these there is an actual 
 hernia of the womb, owing to a separation of the recti muscles, between 
 which it protrudes. This form of displacement may, as we shall have 
 occasion hereafter to observe, cause difficulty in the process of parturi- 
 tion, by misdirecting the expulsive force ; but, in every case, the treat- 
 ment is the same, and consists in an endeavor to raise the fundus by a 
 bandage, supplying in this way the support which the abdominal wall 
 should afford ; and, in addition, attending to the function of the bladder, 
 remembering always that the greater the displacement of the womb, 
 the greater is the corresponding elongation of the bladder. That organ, 
 indeed, in some cases, loses all traces of a spheroidal form, and assumes 
 the shape of an elongated pouch, which is bent over the symphysis, 
 and which, therefore, can only be conveniently emptied by the use of a 
 long elastic catheter. 
 
 Retroversion and Retroflexion of the gravid uterus are much more 
 dangerous both to mother and child than displacements in the contrary 
 direction. The distinction between the two varieties depends simply, 
 as the names imply, upon whether the long axis of the uterus is bent 
 or straight, and in each the fundus of the uterus occupies more or less 
 completely the recto-vaginal pouch of the peritoneum. We believe, 
 however, that the distinction which is usually drawn between retro- 
 version and retroflexion, whether occurring in the unimpregnated state 
 or during gestation, is more apparent than real. The majority of cases 
 will be found in fact, on careful examination, to be neither exactly the 
 one nor the other, but a condition intermediate between the two, in 
 which the axis of the uterus is neither straight, nor abruptly bent at 
 
XIV.] RETROVERSION. 247 
 
 the os internum like the neck of a retort, but forms the arc of a circle, 
 the imaginary centre of which varies very greatly. 
 
 As — although, probably, in a very limited number of cases — im- 
 pregnation may take place of an ovum contained in a womb, the fun- 
 dus of which is displaced backwards, it is proper to notice here briefly 
 the causes which have been assumed, and to a certain extent have been 
 demonstrated, to lead originally to this displacement. It has been 
 supposed, and we believe with good reason, that there is often an un- 
 usual mobility of the uterus in the direction which leads to the dis- 
 placement we are now considering. This is due to a morbid relaxation 
 and lengthening of the round ligaments and vesico-uterine folds, which 
 thus admit in the first instance of a movement of the fundus back- 
 wards, encouraged by repletion of the bladder, and still more by over- 
 distension, arising either from carelessness or from any other cause. 1 
 The effect of the combined action of these two causes is to induce a 
 certain amount of displacement, which other circumstances may tend to 
 aggravate or complete. While the uterus is in its normal position, it 
 is impossible that distension of the rectum can cause retroversion, but 
 so soon as the causes above detailed, or others to be mentioned presently, 
 have acted so far as to press the fundus backwards towards the promon- 
 tory of the sacrum, then this new force comes into play, the fecal masses, 
 as they descend, gradually forcing the fundus further and further down 
 into the pouch of Douglas, until a marked case of retroversion or re- 
 troflexion is the result. The other causes alluded to as auxiliary 
 forces, are the downward pressure exercised by the abdominal viscera, 
 and the existence of fibroid growths in the posterior uterine wall. At 
 any stage impregnation is possible, and it is easy to understand how, 
 in such a case, a comparatively slight displacement may be converted 
 into one in which the fundus fills the hollow of the sacrum, and may 
 actually reach as far down as the coccyx. Before long, however, the 
 limited space, within which, in this position of the uterus, the devel- 
 opment of that organ goes on, becomes filled, and the pressure upon the 
 bladder and rectum calls immediate attention to the case. An exami- 
 nation discloses the altered anatomical relations of the parts. The os 
 and cervix will generally be found about the level of the subpubic 
 angle, or somewhat above it; while, behind this, and about the same 
 
 1 With a view to the elucidation of the subject, Scanzoni made a series of most 
 interesting observations both in the living and the dead. He found, in the first 
 place, that distension of the bladder always caused a certain amount of displacement 
 backwards of the fundus. " We found,'' he says, " when we artificially filled the 
 bladder in dead bodies, that the duplicatures of the peritoneum passing from the 
 uterus to the bladder, stretched themselves in direct proportion to the distension of 
 the bladder, so that when the bladder was filled and distended as far as possible, 
 this stretching reached to such an extent that it was impossible, without considera- 
 ble effort, to force the fundus of the uterus backwards for more than a few lines, as 
 its attachment to the posterior wall of the bladder was much more firm than when 
 that viscus was empty. A very different result ensued when we, in the first in- 
 stance, cut the round ligaments and the peritoneal duplicatures above alluded to, 
 and then filled the bladder. In this case, by a moderate distension, the fundus uteri 
 was strongly displaced backwards, and the vaginal portion forwards, so that it de- 
 pended upon our will, by the injection of a greater or less quantity of fluid into the 
 bladder, to induce a higher or lower grade of retroversion." — Lehrbuch der Geburts- 
 hilfe. 
 
248 
 
 DISEASES OF PREGNANCY. 
 
 [CHAP. 
 
 level, a firm rounded tumor is felt, apparently occupying the recto- 
 vaginal pouch, and pressing forwards the posterior wall of the vagina. 
 (Fig. 95.) On examination by the rectum, — into which two fingers 
 are to be passed as high as possible, — the same tumor is felt through 
 the anterior wall, but in this method of observation, considerable diffi- 
 culty will often be experienced in passing the finger, owing to the great 
 pressure to which the bowel is subjected. Backward displacement of 
 the gravid womb has generally been observed in the third or fourth 
 month of pregnancy, but cases are recorded by Smell ie, Bartlett, and 
 
 Fig. 95. 
 
 Retroflexion of the womb about the 16th week. (Schultze.) 
 
 others, in which it was observed as late as the fifth or even the seventh 
 month. It is more than likely, however, that, in those instances, what 
 Scanzoni describes as partial retroflexion was mistaken for complete 
 dislocation of the organ. The partial retroflexion here referred to 
 would be more accurately described as a peculiarity in the shape of the 
 uterus, in consequence of which its posterior wall forms a tumor which, 
 owing to some peculiarity in the position of the child, projects into the 
 recto-vaginal pouch, and thus resembles an ordinary case. Assuming 
 that this does actually take place, the occurrence is possible at a much 
 more advanced period of pregnancy, when the development upwards of 
 the remainder of the uterus would probably enable us, without much 
 difficulty, to recognize the nature of the case. 
 
 Of much more frequent occurrence than that which we have just 
 described, and which we may call the chronic form, is the acute retro- 
 version of pregnancy. (Fig. 96.) The affection occurs suddenly, but 
 it is most likely that there is a pre-existing minor degree of displace- 
 ment, which gives rise to a further and sudden change in the position 
 
XIV.] 
 
 ACUTE RETROVERSION. 
 
 249 
 
 of the womb, sufficient to cause complete retroversion. Immediately 
 upon the occurrence of this dislocation, or within a very short period, 
 the woman complains of severe dragging pain, which is accompanied 
 by a new sensation, as of a foreign body in the pelvis. This gives rise 
 to painful and fruitless expulsive efforts, with increase of the pain 
 
 Fig. 96. 
 
 Retroversion about the 12th week. (Schultze.) 
 
 around the entire pelvis, and great difficulty in emptying the bladder 
 and the rectum. These symptoms are usually attended with faintness, 
 nausea, and vomiting, and other general symptoms of even greater 
 severity ; and, unless the reposition of the organ be speedily effected, 
 this state of matters gives rise to complete retention of urine and ob- 
 struction of the bowels, which may, in their progress, result in rupture 
 of the bladder, stercoraceous vomiting, ileus, and such symptoms as 
 precede a fatal result. In many cases, — perhaps in most of those in 
 which the incarceration of the organ is prolonged, — there is congestion 
 and thickening of the uterine walls, and this may sometimes amount 
 to actual inflammation of the organ, which becomes exquisitely tender, 
 and thus aggravates greatly the sufferings of the patient. 
 
 The natural termination of a case such as this involves great risk to 
 the mother, and almost certain death to the child. For, although in 
 its further development the womb may possibly take an upward direc- 
 tion, and the symptoms be thus spontaneously relieved (and such cases 
 are on record), the usual result unfortunately is, that the increase of 
 the uterus gives rise to the more serious symptoms above detailed, 
 which can only be relieved by arrest of development, or by expulsion 
 of the foetus. Nothing can, therefore, be more obvious than the neces- 
 sity which exists for prompt action in the w r ay of treatment. Should 
 
250 DISEASES OF PREGNANCY. [CHAP. 
 
 the congestion of the womb be marked, benefit will be derived in the 
 first instance from the use of warm baths and injections, and local or 
 even general bloodletting ; and, when these measures have had time 
 to act, attempts are then to be made to effect the reposition of the 
 organ, taking care, of course, in the first place, that the bladder and 
 rectum have been thoroughly emptied. 
 
 The woman having been placed in the ordinary midwifery position, 
 with the nates projecting over the edge of the bed, or on her elbows and 
 knees, the index and middle fingers, previously well oiled, are introduced 
 into the rectum, so as to bear against the tumor, 1 and an effort is then 
 to be made by means of steady pressure in the axis of the brim, to push 
 the fundus beyond the promontory of the sacrum. It will be observed, 
 should it be found possible to displace the fundus to any extent, that 
 the movement takes place not directly towards the promontory, but 
 rather towards the sacro-iliac synchondrosis of either side; and, as we 
 cannot tell beforehand to which side it will incline, although the prob- 
 abilities are in favor of the right, we must, in the first instance, push 
 directly upwards. But, should the fundus obviously tend to move in 
 the direction of one sacro-iliac joint in preference to the other, the 
 direction of the pressure must then be altered, in order to accommodate 
 it to the tendency thus exhibited. If the compression of the rectum 
 is such as to prevent the introduction of the fingers to a proper height, 
 Kiwisch suggests that we should substitute the handle of a silver spoon 
 or of a sound for the finger. Should a first attempt at reposition fail, 
 we may pause and endeavor, by means of repeated injections, cold 
 or warm, still further to reduce, if possible, the intumescence of the 
 womb. The patient may then be brought fully under the influence of 
 chloroform, and the attempt renewed in a different posture, when, in 
 many instances, the dislocation will be happily reduced, the womb 
 being occasionally restored to its normal position, as in the case of 
 its inversion, with a snap or jerk. Should difficulty occur in the intro- 
 duction of the finger into the rectum, it will be proper to make an 
 attempt by the vagina, although in this case, as a little reflection will 
 show, the attempt will be made at a greater mechanical disadvantage 
 than when the rectum is selected. Failing all these methods, we may 
 attempt to dislodge the fundus by the introduction, as high as is pos- 
 sible, into the rectum of an elongated air-bag, such as those invented 
 by Barnes for dilating the os and cervix in inducing premature labor. 
 These bags have a long tube fitted at the end with a stopcock, and 
 through this the injection, either of air or of water, causes a graduated 
 pressure which acts continuously, and at the same time effectively, upon 
 the displaced fundus, so as gradually to effect its reposition. 
 
 All attempts at reduction having failed, the best mode of procedure 
 is to adopt only such measures as are necessary for the relief of the 
 bladder and the rectum, so long as the symptoms are not so severe as 
 to call for immediate action. But should the emptying of the bladder 
 
 1 Scanzoni recommends that the thumb of the same hand should be introduced 
 into the vagina, mainly with the object of elevating the perineum, and thus allow- 
 ing the examining fingers to pass higher. 
 
XIV.] OBLIQUE DISPLACEMENTS. 251 
 
 become impossible, or should any other symptom develop itself which 
 may be held to imply that the life of the mother is in imminent danger, 
 there then remains for us no resource but to imitate nature, and to 
 induce, without delay, the premature expulsion of the foetus. Of the 
 many methods by means of which, as we shall have occasion again to 
 observe, it is possible to induce premature labor, that which is most 
 applicable to the present case is the rupture of the membranes. For, 
 the immediate effect, which is thus produced by the sudden evacuation 
 of the liquor amnii, is to reduce the diameter of the uterus, and thus 
 to afford partial relief during the period wdiich intervenes between the 
 operation and the commencement of uterine action. It is, however, by 
 no means an easy matter in every case to effect this rupture, more espe- 
 cially when the os is tilted up behind the symphysis, and is only reached 
 with difficulty, and it may be found necessary on that account to intro- 
 duce a catheter, with an opening at the extremity, through which a wire 
 may be passed, and having reached the membranes, to thrust the wire 
 through and thus effect our purpose. But it may happen, unfortunately, 
 that the os is displaced upwards to such an extent that it is impossible 
 to reach it, or at least to pass anything through it, and in such circum- 
 stances we have no alternative, if the life of the mother is in obvious 
 danger, but to puncture that portion of the uterine wall which lies 
 lowest, and thus give vent to the amnionic fluid, and afford relief to the 
 patient. It is of course safer, under such circumstances, to puncture 
 from the vagina than from the rectum, but the latter operation has been 
 successfully performed, effusion into the peritoneal cavity having been 
 prevented, by leaving the canula in situ until the risk of further effusion 
 had passed. The uterus being thus relieved of its fluid contents, may 
 now be replaced without much difficulty, unless adhesions should chance 
 to have occurred, and then awakened expulsive effort will speedily 
 relieve the organ of its solid contents. Where reposition of the uterus 
 has been successfully effected, labor may go on without any further 
 accident or hindrance, but in some few instances it would seem that a 
 tendency to relapse remains. This must therefore be guarded against, 
 by insisting upon strict rest on the side, and, by the frequent use of 
 the catheter and enemata, to prevent such mechanical pressure from 
 the bladder and rectum as might encourage a recurrence of the dis- 
 placement. 
 
 Oblique Displacements of the uterus have been insisted upon by some 
 writers as exercising an important influence on the progress of preg- 
 nancy. We know already that the long axis of the gravid uterus does 
 not correspond with the middle line of the body. It is quite possible, 
 therefore, that when this normal obliquity is exaggerated, the os may, 
 for a time, be prevented from dilating by the altered axis of the ex- 
 pulsive force. Such displacements, however, seem to have had their 
 origin in a great measure in the imagination of those who have sought 
 to reduce the art of midwifery to a series of geometrical propositions, 
 and are certainly not of sufficient practical importance to require more 
 particular attention. 
 
 In addition to the diseases of pregnancy which we have described, 
 
252 LABOR AND ITS PHENOMENA. [CHAP. 
 
 there are others, chiefly constitutional, which exist both during and 
 after labor, the consideration of which we shall, therefore, in the mean- 
 time, defer. 
 
 CHAPTER XV. 
 
 LABOK AND ITS PHENOMENA. 
 
 CAUSES OF LABOR — MATURITY: ANTAGONISM BETWEEN CURTAIN GROUPS OF 
 UTERINE FIBRES: BROWN-SEQUARD'S THEORY: LABOR COINCIDENT WITH 
 THE TENTH MENSTRUAL PERIOD — FORCES BY WHICH DELIVERY IS EFFECTED: 
 NERVI -MOTOR FUNCTIONS OF THE UTERUS: EFFECT OF EMOTIONAL CAUSES: 
 REFLEX FUNCTION OF THE SPINAL CORD: PERISTALTIC ACTION: AUXILIARY 
 FORCE IN THE MUSCLES OF EXPIRATION — STAGES OF LABOR — PREPARATORY 
 STAGE — FIRST STAGE: LABOR PAINS; THEIR EFFECTS ON THE MATERNAL 
 PULSE AND ON THE UTERINE SOUFFLE: FALSE PAINS: MECHANISM OF THE 
 DILATATION OF THE OS ; THE BAG OF WATERS ; EFFECT OF LONGITUDINAL 
 FIBRES: TERMINATION OF FIRST STAGE IN RUPTURE OF MEMBRANES : RIGOR: 
 SHOW — SECOND STAGE: CHANGE IN CHARACTER OF THE PAINS : THE "CAPUT 
 SUCCEDANEUM :" ACTION OF VOLUNTARY MUSCLES: DILATATION OF THE 
 PERINEUM: BIRTH OF THE HEAD AND TRUNK — THIRD STAGE: "DOLORES 
 CRUENTI:" SEPARATION AND EXPULSION OF THE PLACENTA; MECHANISM OF 
 THIS. 
 
 The first point which, in considering the subject of labor, attracts 
 our notice, is one which has given rise to many interesting physiologi- 
 cal speculations. We refer to the causes which lead to the occurrence 
 of delivery, in almost all cases in which the course of pregnancy is 
 undisturbed, at a certain fixed period, calculated from the assumed 
 date of conception. In ancient times, the idea prevailed that the foetus 
 was itself the principal agent in effecting its birth, breaking the mem- 
 branes, and opening up the womb in its efforts to reach the external 
 world, after the same fashion as the chick when escaping from the 
 thraldom of the egg. The advance of physiological science generally, 
 and more especially the discovery and demonstration of the contrac- 
 tility and muscular structure of the uterus, while they showed clearly 
 enough how erroneous this opinion of the ancients was, did not dis- 
 close, and as yet have not clearly revealed, what is the determining 
 cause of uterine contractions at the period alluded to. There exists, 
 say some, a natural antagonism between the muscular fibres of the 
 body of the uterus and those of the cervix ; and, so long as the oblit- 
 eration of the cervix is not effected by the progress of development 
 towards the end of gestation, the tonic contraction of the fibres of the 
 body is not sufficient to overcome the resistance offered by the cervix. 
 But, so soon as the process of dilatation has entirely invaded the cer- 
 vix, — a change which is only complete with the termination of preg- 
 
XV.] CAUSES OF LABOR. 253 
 
 nancy, — the fibres of the body for the first time prevail, and the con- 
 tractions assuming a rhythmical method of action, gradually increase 
 in intensity until they result in real labor pains. Others, and among 
 them Dubois, recognizing the exact analogy which subsists, in regard 
 to the distribution of muscular fibres and nerves, between the uterus 
 and the other hollow viscera, and assuming that in the uterus, as in 
 the rectum and bladder, contraction may be awakened by irritation of 
 the cervix (to which alone, as we have already seen, the nerves of 
 animal life are supposed to have access), believe that in these facts the 
 secret is revealed. They hold that complete obliteration of the cervix 
 involves the highest grade of physiological development to which its 
 fibres can attain, and that the sphincter fibres are then for the first 
 time fully susceptible of external influences, communicated to them 
 through cerebrospinal nerves. And they conclude that, in this manner, 
 the first excitation reaches the cervix, and thus contraction of the whole 
 organ ensues. 
 
 A most ingenious theory has been founded by M. Brown-Sequard on 
 the result of certain experiments which he performed by tying the 
 trachea of pregnant animals, in whom he had previously destroyed the 
 lower portion of the spinal cord. The immediate result of the apncea 
 thus artificially induced, was the occurrence of uterine contractions, 
 which disappeared on relaxing the ligature, and returned again on 
 repeating the experiment. This is due, says the experimenter, to the 
 contact of venous blood with the muscular fibres, the irritability of 
 which is highly exalted during pregnancy. He explains the earliest 
 uterine contractions on the same principle. The large size of the uterine 
 sinuses insures the presence in the substance of the uterus of a large 
 quantity of venous blood, and so soon as the muscular fibre reaches, at 
 the termination of pregnancy, its highest point both of irritability and 
 of development, it becomes for the first time excited to contraction. 
 The immediate result of this is to empty, in a great measure, the sinuses 
 of blood ; but so soon as the rhythmical relaxation occurs, the venous 
 blood again gains access to the irritable fibres, and anew excites them 
 to contraction. 
 
 Whatever view we may be inclined to assume in reference to the 
 cause of labor, there can be no doubt that it is coincident with the 
 maturity of the foetus. Gradual relaxation of the anatomical connec- 
 tions between the uterus and the ovum, is another undoubted phenom- 
 enon w . £ icli immediately precedes birth, and it was in this that Simpson 
 believed the determining cause to reside. And, finally, Dr. Tyler Smith 
 has suggested — and argues with great ability in favor of the theory — 
 that the cause of labor is to be found in the ovary. " It is allowed by 
 all observers," says Dr. Smith, "that labor has a tendency to occur, 
 and does occur, in a great proportion of cases, in the fortieth week from 
 the last menstruation ; and it is equally allowed that impregnation is 
 generally effected just after the catamenial period. It is also made 
 out by the record of a considerable number of cases in which a single 
 coitus occurred, that gestation lasts, on an average, about 275 days 
 from the actual date of impregnation. These dates make the average 
 duration of pregnancy approach 280 days from the last catamenial 
 
254 LABOR AND ITS PHENOMENA. [CHAP. 
 
 period, and the oecnrrence of parturition, is on the average, very nearly 
 a multiple of a single catamenial period." We confess that the argu- 
 ments which this author advances in support of his theory, seem to us 
 in a great measure to warrant the conclusion at which he has arrived ; 
 but, while we admit that it is probable that a presiding influence 
 springs from the ovary at the period of the natural menstrual molimen, 
 we by no means wish to commit ourselves to the opinion that it is the 
 sole cause. 
 
 Whatever we may assume the cause of labor to be, the immediate 
 effect of its operation is to rouse the latent energy of certain Forces, 
 by means of whose active co-operation the delivery of the woman is 
 effected. The prime force, to which the others are merely subsidiary, 
 is, as is well known, the contraction of the muscular fibres of which the 
 uterus is, to such a large extent, composed. That these contractions 
 are of very considerable power, is proved, not merely by the resultant 
 of the force, as shown in the expulsion of the foetus, but also palpably 
 to the senses by the contraction which may be seen and felt through 
 the abdominal walls, and by the effect which is produced on the hand 
 when introduced into the uterine cavity. Dr. Matthews Duncan has 
 computed this force as equivalent to a pressure of 3 lbs. on the square 
 inch. 
 
 In considering the Nervi-motor functions of the uterus, we observe, 
 in the first place, that volition exercises no direct influence whatever 
 on the contraction of the uterine muscular fibre ; although, as we shall 
 see, it presides over what will be afterwards described as the auxiliary 
 forces. In cases of cerebral paralysis, and when the action of the will 
 has been completely suspended by chloroform, we find that uterine 
 contractions are quite undisturbed. Nay, stranger still, we know that, 
 in some instances, contractions may occur after death, giving rise to 
 post-mortem delivery. There are cases, at least, in which this phenom- 
 enon is due to actual contraction of the fibres ; but we must be careful 
 to draw a distinction between these and cases of expulsion, which have 
 occurred some days after death, and which have been found to be due 
 either to rigor mortis, or to pressure from the development of gas in the 
 process of putrefaction — a condition which gives rise to other strange 
 phenomena familiar to the student of medical jurisprudence. 
 
 Certain emotional causes produce an effect on the uterine contractions 
 which it is not easy to account for. Few occurrences are more familiar 
 to the accoucheur than the effect which his arrival frequently produces 
 upon the progress of labor, by causing a complete temporary cessation 
 of all uterine effort* On the other hand, sudden mental emotion of 
 any kind may, by augmenting the force and frequency of the expulsive 
 action, sometimes influence the progress of labor in a marked degree; 
 and this has been observed to occur upon the threat of using instruments, 
 or upon the exhibition of the forceps. Causes, then, which, being psy- 
 chical, have their origin in the cerebrum, may act either by increasing 
 or by arresting uterine effort. 
 
 The spinal marrow exercises upon the uterus a very obvious and 
 important influence. There is, in the first place, a direct or centric 
 action, in which the motor nerves are excited by a communication 
 
XV.] NERVI-M0T0R FUNCTIONS OF THE UTERUS. 255 
 
 starting from the nervous centre ; and it is in this way that ergot and 
 other oxy toxics act, being conveyed to the cord by the circulation, and 
 there producing an effect which is transmitted to the uterus, where it 
 takes the form of muscular action. In this manner, too, many diseased 
 conditions of the blood produce an effect, as is well known, by acting 
 on the cord, and giving rise to different varieties of puerperal eclampsia ; 
 and in this way even plethora, or anaemia, may exercise an influence on 
 the dynamic force of the womb. But of much greater importance, and 
 of higher physiological interest, is the diastaltic, or reflex function of 
 the cord, which chiefly presides over the motor functions of the uterus. 
 One of the most familiar instances of this is the uterine contraction 
 which ensues upon the irritation of the nipple by the contact of the 
 child. The impression is, in this case, conducted to the spinal centre, 
 and being thence reflected to the uterus, forthwith acts upon its con- 
 tractile fibres ; indeed, so constant is this occurrence, that it is admitted 
 in practice as a valid reason for putting the child to the breast at an 
 early period after delivery. A similar effect may be produced, although 
 with less certainty, by an irritation of a similar kind starting from the 
 stomach, rectum, or any other part of the alimentary canal; from the 
 ovary, or from any structure in the immediate vicinity of the uterus; 
 and, finally, from the direct irritation of the organ itself, which may 
 be effected in various ways, the most reliable of which is irritation of 
 the os and cervix, or of the internal surface in the case of haemorrhage. 
 The very extensive nervous sympathy which thus exists between the 
 uterus and so many distant parts, shows pretty clearly that its nervous 
 functions are, during pregnancy and the puerperal state, greatly in- 
 creased. What is known, up to the present titne, in reference to the 
 uterine nerves, is by no means very satisfactory ; but the result of most 
 modern investigations in regard to these nerves, which are only to be 
 traced with the greatest difficulty, seems to confirm the view originally 
 adopted by Dr. R. Lee, that they undergo, during pregnancy, con- 
 siderable enlargement, — an enlargement, however, which appears to 
 have its seat mainly in the neurilemma. This subject is one which has 
 given rise to a deal of acrimonious discussion, and is still beset with 
 difficulties which have only been partially overcome. It was stated 
 in a former chapter that twigs of the sacral nerves, passing to the os 
 and cervix, constitute the channel of communication between the cord 
 and the uterus, but that the rest of the nerves are derived from the 
 ganglionic system. When, therefore, nervous force is reflected upon 
 the uterus from the cord, it passes by the nerves in question, and 
 reaches in the first instance the cervix and os. In this situation plex- 
 uses are found, to the formation of which the spinal and ganglionic 
 systems contribute, and through these the force is transmitted to ter- 
 minal fibres in the body of the organ, where it excites immediate and 
 effective contraction. 
 
 It is well known that the hollow viscera, which are supplied in 
 whole or in part by the ganglionic nerves, contract, when irritated, after 
 a fashion peculiar to such structures. The contraction, instead of being 
 limited to the immediate vicinity of the point of irritation, is propa- 
 gated in a definite direction in rhythmical waves, successive groups of 
 
256 LABOR AND ITS PHENOMENA. [CHAP. 
 
 fibres being thus excited so as to constitute the phenomenon commonly 
 known as peristaltic action. The uterus forms no exception to this 
 general law, and its peristaltic or ganglionic motor action was observed 
 and described by Harvey and William Hunter, and by every physiol- 
 ogist of note since their day. The manner in which peristaltic uterine 
 action occurs is, as Wigand has taught, in so far as the contractions of 
 labor are concerned, as follows : The earliest contractions always take 
 place at the neck, which grows tense. From this point, the vermicular 
 action extends gradually upwards in the direction of the fundus, from 
 whence it again returns towards the os, obvious mechanical advantages, 
 of which we shall speak presently, being attendant upon this method 
 of action. Uterine expulsive action is thus a composite force, which 
 is partly diastaltic and partly peristaltic. Physiologists have sought, 
 by many ingenious experiments on the lower animals, to ascertain what 
 is the precise share which is to be attributed to the reflex function of 
 the spinal cord in producing the phenomena of labor. These experi- 
 ments have usually taken the form of section of the spinal cord at a 
 certain level, or destruction of the lower part of the cord ; and it has 
 been found that the latter procedure has produced the most decided 
 effect in arresting uterine action. In most of these cases, however, it 
 would seem that the peristaltic action remained, and that there was 
 still sufficient expulsive force left to effect delivery. In some cases, 
 it would almost seem as if destruction of the lower part of the cord 
 put an end to all uterine action, but there are obvious sources of fallacy 
 connected with such a method of investigation which render it neces- 
 sary to exercise great caution before coining to a positive conclusion. 
 It is, indeed, a- very difficult question, and one which still remains for 
 solution, whether or not, all connection with the nervous system of 
 animal life being cut off, peristaltic contraction remains possible ; for 
 it must not be forgotten that, however thoroughly we may destroy the 
 lower half of the spinal cord, there still remains, in the connections 
 which subsist between the sympathetic system and the upper part of 
 the cord, a possible, though circuitous route, through which the impor- 
 tant influence of the cord may still, although more feebly, be exercised. 
 In making the assertion that the will has no influence directly upon 
 the contraction of the womb, we must not be understood as implying 
 that the will exercises no influence on the progress of labor. For we 
 shall see immediately that there is a stage of labor at which the volun- 
 tary muscles are brought into play as an auxiliary force, and that the 
 woman instinctively avails herself of their aid. The diaphragm and 
 the abdominal muscles are the chief agents of this new power, and 
 everything therefore which gives a fixed point for the efficient action of 
 the semuscles, indirectly gives great assistance in the progress of labor. 
 It is this which causes a woman instinctively to arrest respiration, in 
 order to admit of the efficient action of the diaphragm, and for the 
 same reason she will eagerly employ the means which are afforded her, 
 by towels tied to the bedpost, or footstools in the bed, to fix the trunk 
 so as to bring the whole power of the expiratory muscles into play. 
 A minor degree of voluntary expulsive effort, which is in all respects 
 similar, is that which attends difficult defecation. Haller attributed 
 
XV.] STAGES OF LABOR. 257 
 
 to the abdominal muscles the chief share of the expulsive efforts, but 
 that this is obviously wrong is shown by the fact that in feeble wo- 
 men, in whom the voluntary muscular system is very poorly developed, 
 the delivery is not only effected as easily as in others, but actually in 
 many instances, with greater ease ; and, moreover, complete anaes- 
 thesia, which has a most marked effect on the voluntary muscles, 
 scarcely affects in any marked degree the progress of delivery. An- 
 other auxiliary force exists, in an advanced stage of labor, in the 
 action of the muscles which constitute the floor of the pelvis, and in 
 the contraction of the muscular fibres which enter into the composition 
 of the vaginal walls. In the lower animals, as is well known, the 
 comparatively feeble contractile efforts of the uterine cornua bring the 
 young successively to the os uteri, when, powerful and violent propul- 
 sive efforts being awakened in the vagina, they are promptly expelled. 
 In those animals, therefore, we may look upon the vagina rather than 
 the uterus as the great organ of parturition. What occurs in the human 
 species is precisely similar, only that here the vaginal contraction is 
 subordinate to the uterine, while in rabbits and such like the converse 
 is the case. That the vaginal expulsive force is by no means incon- 
 siderable is shown by the manner in which the placenta is expelled, 
 and still more, by what involves a more powerful muscular effort, — the 
 expulsion of the head in cases of presentation of the breech. In regard 
 to the share which is taken by the muscles at the floor of the pelvis, 
 this, too, is in all probability considerable, and constitutes, no doubt, 
 the "reflected force" of which Solayres de Renhac speaks in his ad- 
 mirable essay. 
 
 The Stages of Labor. — Writers, in considering the physiological 
 phenomena of labor, have uniformly adopted the plan of dividing its 
 progress into various stages. Some have multiplied these stages to an 
 extent which is absurd, as the subject is thus rendered more perplexing 
 instead of being made easy of comprehension to the student. The 
 familiar classification of Desormeaux, according to which labor is 
 divided into three stages, is that which is adopted here. 
 
 1st. From the beginning of labor until complete dilatation of the os 
 uteri is effected. 
 
 2d. From full dilatation of the os till the birth of the child. 
 
 3d. The complete separation and expulsion of the placenta. 
 
 In considering the First Stage of labor, some little difficulty is 
 experienced in determining the exact moment from which labor is to 
 be dated. Long before symptoms of actual labor manifest themselves, 
 certain preliminary processes are gone through, and to this some 
 writers have with propriety attached the name of the Preparatory 
 Stage. The falling down of the womb, which occurs in the last weeks 
 of pregnancy, may be mentioned as perhaps the earliest of those changes. 
 This, as has already been stated, is usually attended with a marked 
 relief of such symptoms as arise from pressure upwards; but these are 
 often replaced by such as are the result of pressure in the contrary 
 direction, so that dysuria and irritation of the lower bowel now become 
 familiar symptoms. If an examination is made at this period, the 
 head will be found to have descended in the pelvis, and the condition 
 
 17 
 
258 LABOR AND ITS PHENOMENA. [CHAP. 
 
 of the os characteristic of the stage of pregnancy will at the same 
 time be disclosed. The ligaments also of the pelvis become more 
 relaxed and elastic, and the articulations somewhat less firm. The first 
 contractions of the womb at the commencement of labor are either 
 painless, or accompanied with discomfort so slight, as scarcely to attract 
 the attention of the patient. Even thus early, however, the contrac- 
 tions may be perceived by the hand of the accoucheur, if he make 
 an examination through the abdominal walls ; and they are often 
 accompanied with such an amount of pain as to lead a woman who has 
 previously borne children to look for the speedy occurrence of labor. 
 It is by no means a rare occurrence for this class of pains to recur again 
 and again, night after night, keeping the patient in a constant state of 
 expectancy and apprehension. Usually, however, the period soon 
 arrives Avhen the pains become more severe, and return at regular 
 periodical intervals, when the contractions, as observed through the 
 abdominal walls, will be found to be much firmer than those of the 
 earlier period. 
 
 A Pain in midwifery is used as synonymous with the expression 
 "contraction," the one symptom depending directly upon the other. 
 When, at the commencement of labor, the uterus is thrown into con- 
 traction, the cervix being, as we have seen, first affected, and then the 
 fundus, the muscular fibres, after remaining in a state of contraction 
 for a brief period, relax, — as is usually the case in non-striated muscle, 
 it being only exceptionally capable of sustained effort. During the 
 whole period of a healthy labor, therefore, pain and pause alternate, the 
 former being at first of short duration, and coming on at long intervals; 
 but as the case progresses, the pains become longer and more severe, 
 and the pauses shorter and shorter, until, at the final effort, one pain 
 succeeds another with such violence and rapidity that the periods of 
 rest or pause are almost obliterated. When a pain comes on, it may 
 in many cases be observed that the fundus, which, is usually displaced 
 to the right, moves toward the middle line, so as to bring the expul- 
 sive force to act in the direction in which it can be most efficiently 
 employed. If we, at this stage, make a vaginal examination, we find, 
 in primipara?, that the os and .cervix are so far obliterated, that the 
 margin of the former is a thin, circular, and almost membranous ring, 
 which represents that portion of the uterus. Against this apparently 
 unyielding ring, the membranes are firmly pressed during the continu- 
 ance of a pain ; and, as the amnionic fluid necessarily takes the direction 
 in which there is least resistance, it is found that at this moment the 
 difficulty of reaching the presenting part is increased by the augmen- 
 tation in the quantity of the imposed stratum of liquid, and by the 
 tension to which this gives rise. Soon, however, the rigid margin 
 becomes softer and more tumid, a condition which, in pluriparse, exists 
 from the first, and the os yields slowly under the influence of successive 
 pains, so that we are able during the intervals of perfect rest to hook 
 the finger into the os, and to feel distinctly the presenting part. 
 
 It is interesting to observe the effect which is produced on the 
 mother's pulse by the occurrence of a pain. If, placing a finger upon 
 it, we note, during an interval of rest, the number of beats, and con- 
 
XV.] EFFECT OF PAINS ON THE PULSE. 259 
 
 tinue the observation, we shall find that, with the commencement of 
 the pain, its frequency is increased, and that, continuing to rise, it 
 attains its maximum along with the pain ; while with its subsidence, 
 the pulse falls, and on its complete cessation is found to have returned 
 to its original rate. This observation, as Hohl points out, may be use- 
 fully employed as a test to gauge the efficiency of the pains, for the 
 more marked and rhythmical this variation of the pulse, the more 
 effective is the pain which it at once accompanies and indicates. " When, 
 however," he says, "the rapidity of the beats subsides before approach- 
 ing the maximum, the pain is too weak ; or when the rapidity rises by 
 sudden starts, the pain is a hurried one, and in either case its effect will 
 be imperfect." He assumes that, in an efficient pain of average dura- 
 tion, the increase and diminution of the pulse for each quarter of a 
 minute may be put down as follows : 
 
 18. 18. 20. 22 : 24. 24. 22. 18. 
 
 It would thus appear that the frequency of the maternal pulse attains 
 its maximum during the first half of the second minute: but it must be 
 understood, in making observations, based upon this, that it applies to 
 average pains only, and that towards the termination of labor, when 
 the systemic excitement is intense, the pulse from that cause is often 
 so accelerated that any observation of the kind is impossible. If aus- 
 cultation be practiced during the pains, we often find that the foetal 
 pulsations are somewhat accelerated, but the effect of a pain tends 
 rather to obstruct than to facilitate the observation of the feetal heart. 
 The uterine souffle, however, undergoes, almost invariably, marked 
 modifications. The situation having been ascertained at which that 
 sound may most distinctly be made out, auscultation is sustained during 
 the continuance of a pain, or of a succession of pains, when the follow- 
 ing modifications are observed. The approach of a pain is heralded by 
 a rushing sound, which may indicate muscular action, movement of the 
 amnionic fluid, or movement of the child. Along with this, there is a 
 marked increase in the distinctness of the souffle, which is raised in 
 tone and in pitch, and may even become vibrating or musical. Up to 
 a certain point this increases in intensity; but, as the pain approaches 
 its acme, the sound becomes as it were more and more distant, and then 
 — when the moment of greatest contraction is attained — very faint, or 
 altogether inaudible ; while, as the pain goes off, it passes again through 
 those changes in an inverted order, until the tone proper to the period 
 of rest is restored. 
 
 We must be prepared in every case for the occurrence of what are 
 called false pains, in which, although there may be uterine contraction, 
 it is not of a proper kind. The pain in such cases may be severe enough, 
 but it is spasmodic and variable in character, and, instead of beginning 
 in the cervix and extending upwards, as in a true labor pain, it com- 
 mences usually in the fundus or body, and is attended with no symp- 
 toms indicating progress towards delivery. These pains, which are re- 
 ferred to the region of the fundus, and not to the loins as in normal 
 labor, probably depend upon some irritation, having its origin, in a 
 large proportion of cases, in some derangement of the digestive system. 
 
260 LABOR AND ITS PHENOMENA. [CHAP. 
 
 The leading characteristics, then, of what, for the sake of distinction, 
 we call true labor pains, are uterine contractions, which commence at 
 the os, and thereby prevent, by the constriction of its sphincter fibres, 
 the descent of the umbilical cord, or of such parts of the foetus as might 
 impede delivery. These contractions are accompanied with pains, 
 which may begin in front and pass round to the sacrum, but which are 
 generally referred mainly to the lumbar and sacral regions. 
 
 From an early stage of labor, the tissues are prepared for their new 
 function, by a profuse secretion from the vagina and cervix of a thick 
 colorless mucus, Avhile the parts from which it Hows become softer and 
 more cushiony. This discharge, which is occasionally tinged with 
 blood, is frequently mixed with little semi-solid albuminous masses, 
 and is very obviously provided by nature for the purpose of lubricating 
 the parts, and thus facilitating the progress of the foetus along the canal 
 through which it has to pass. Upon the quantity of this secretion, the 
 ease of the labor undoubtedly depends in no small degree; not by its 
 lubricating action alone, but because its appearance involves a soften- 
 ing and general preparedness of the tissues, dependent upon the un- 
 loading of the congested vessels. There is no sign upon which, as in- 
 dicating the probable duration of a case of labor, the accoucheur looks 
 with more confidence than this ; and from a copious secretion and re- 
 laxed condition of the parts, he augurs an easy and speedy labor, while 
 from a dry, constricted, and rigid vagina, he learns that in all prob- 
 ability a lingering exhausting labor will lead to a tardy delivery. 
 
 The phenomenon which essentially attaches to that stage of labor 
 which we are now considering, is the dilatation of the os and cervix, 
 and it has, on that account, been called by some the "stage of dilata- 
 tion." From what has already been said with reference to the nature 
 of uterine contraction, it is evident that the effect of each individual 
 pain, when efficient, must be to contribute to the opening or dilatation 
 of the os. And, further, it must be obvious that, while the membranes 
 are intact, the presenting part of the child can play but a trifling part 
 in the mechanism of distension. The more attention we give to this 
 subject, the more must we admire the admirable adaptation of means 
 to an end which nature has in this instance adopted, where the object 
 is, as we must remember, not only the expulsion of a solid body through 
 a certain channel, the integrity of which must be preserved, but its ex- 
 pulsion in such a way as may least endanger its independent vitality. 
 It is for that purpose, doubtless, that the membranes are thus preserved. 
 
 The first efficient contraction having probably resulted in an opening 
 of the cervix to a trifling extent, and the tissues being sufficiently re- 
 laxed to admit of satisfactory progress, we are enabled to trace the pro- 
 cess of dilatation through all its subsequent stages. When the os has 
 so far yielded, the membranes, which are here separated from their 
 uterine attachment, commence to protrude in the form, first of a watch- 
 glass, and then of the extremity of a pouch or bag, which has been 
 termed the " bag of waters." Following the operation of a very ob- 
 vious law already alluded to, this phenomenon implies, primarily, an 
 attempt, consequent on the uterine contraction, on the part of the waters, 
 to escape in the direction in which resistance is least. The special 
 
XV.] TERMINATION OF THE FIRST STAGE. 261 
 
 function, however, of this bag is to effect the further dilatation of the os, 
 and we can conceive no means which could be more admirably adapted 
 to this object than the graduated fluid pressure which is thus brought 
 to bear upon the os equally in its whole circumference. It constitutes, 
 in fact, in its action during a pain, a hydrodynamic force acting at once 
 safely and powerfully upon the whole of the os. But another effect of 
 this action is of even higher physiological interest, for in it we observe 
 a means by which the head of the child is protected from all pressure 
 during the first stage. If we make an examination, in the interval 
 between the pains, when the os is moderately dilated, we can generally 
 feel quite distinctly, through the membranes, the head, or other pre- 
 senting part, and are able to distinguish, for example, the different 
 sutures and fontanelles. A pain then comes on ; but, instead of the 
 head being driven downwards against the still rigid os, it recedes, and 
 the bag of waters takes its place in effecting that dilatation which, when 
 premature rupture of the membranes occurs, must of necessity be per- 
 formed by the head itself. And the result, when that occurs, is, as 
 every one knows, protracted labor and increased risk to the child. As 
 the termination of the first stage approaches, the protrusion of the bag 
 of the membranes becomes more and more marked ; and as, at the same 
 time, the pains 'usually become more violent, it often excites our aston- 
 ishment that rupture is so long delayed, and we look for its occurrence 
 at every pain. The bag by this time forms in the vagina a tumor of 
 considerable size, and, in some cases, where the membranes are un- 
 usually resistant, this tumor completely fills the vagina, and even pro- 
 trudes externally, a condition which, as we shall have occasion after- 
 wards to notice, constitutes a serious impediment to delivery. In such 
 cases, the bag of waters, having performed the duty for which it was 
 designed, is no longer of any use, and may, under ordinary circum- 
 stances, be ruptured without hesitation. 
 
 This purely mechanical force, although we believe it to be the chief, 
 is certainly not the only one which is brought to bear in the course of 
 the process of dilatation. For we cannot doubt that it is powerfully 
 assisted by the contraction of the longitudinal fibres of the uterus, 
 which tend to drag the margin of the os upwards at the same time that 
 the fluid is being forced downwards, and some have gone so far as to 
 believe that it is mainly by their agency that the dilatation of the os 
 is effected. Without crediting this latter assumption, we may look 
 upon these longitudinal fibres as antagonistic, in their action, to the 
 circular fibres which surround the os so as to form a sort of sphincter. 
 While we admit such an action as this, we must not overlook the fact, 
 which has already been demonstrated, that the arrangement of the uterine 
 muscular fibres is extremely irregular. Were the number of longitu- 
 dinal fibres which are directed towards the cervix greater, and were 
 the arrangement of a circular sphincter more distinct, we might more 
 readily accept this as the main dilating power; but knowing what we 
 do of the irregularity of these structures, we can only accept of it as a 
 subsidiary force. There is yet another method by which, according to 
 some, the dilatation of the os may be aided. It is assumed by those 
 who hold the view alluded to, that there is, in addition to the forces 
 
262 LABOR AND ITS PHENOMENA. [CHAP. 
 
 above mentioned, an active dilating power which is resident in the os 
 itself — a power which acts, not only by opening the os, but also by 
 closing it, as has often been observed in retained placenta, and in 
 inversion of the uterus. We confess, however, that we cannot consider 
 as satisfactory the evidence which has hitherto been offered in support 
 of this theory. In cases in which rupture of the membranes precedes 
 dilatation of the os, the mechanism of the act is quite different, as in 
 that case the walls of the uterus are brought to bear directly against 
 the surface of the foetus, the head being forced, at each pain, against 
 the circumference of the os, which, at some risk, and by a slower 
 process, is thereby dilated. 
 
 A very frequent occurrence on the termination of the first stage is a 
 Rigor. This is a symptom which might very naturally excite alarm 
 in the mind of a young practitioner, more especially as it is sometimes 
 so violent as to shake the bed on which the patient lies. It is, however, 
 attended with no diminution of temperature, nor is it in any way 
 affected by the application of warmth to the surface. This rigor is in 
 fact a phenomenon purely physiological, and is similar to what is 
 observed upon dilatation of the other sphincters of the body, a familiar 
 example of which is afforded in the shudder which sometimes passes 
 over the body during the act of micturition. 
 
 Another familiar symptom is the slight discharge of blood which at 
 this moment frequently occurs, the ordinary discharge being mixed, or 
 at least streaked, with blood which proceeds from the rupture of small 
 vessels in the os consequent upon its extreme distension. This is what 
 midwives call a Show. But the crowning act of the first stage is rup- 
 ture of the membranes, which usually occurs at the height of a pain, 
 and is accompanied with a sudden gush of liquor amnii, usually pro- 
 pelled with considerable force, and with a sound which is often quite 
 audible to the attendants. If this gush of waters coincides, as it usually 
 does, with complete dilatation of the os, it marks the termination of 
 the first stage. Complete dilatation of the os must not be held at this 
 stage to imply that obliteration of it which converts the parturient 
 canal from the fundus uteri to the ostium vagina? into a continuous 
 tube, as shown in the figure which follows, for it is not till the second 
 stage has well advanced that such an amount of dilatation is effected. 
 Full dilatation at the termination of the first stage mean* merely such 
 as will permit of the further progress of the head. 
 
 The pains which accompany the first stage are of a character peculiar 
 to themselves, and are of a more teasing, worrying, and wearing nature 
 than the more severe agony which subsequently occurs. The chief 
 annoyance that the woman feels is from the fact that she fancies she is 
 making no progress, and the stage is, therefore, often to her wearisome 
 and tedious in the extreme. She questions her attendants again and 
 again as to the probable duration of her suffering, but this is a point 
 in regard to which we should be specially cautious in risking an opinion. 
 Nothing is so likely to mislead us in this respect as the apparent in- 
 tensity of the pain. For not only do certain women bear pain better 
 than others, but the same degree of uterine contraction may, in indi- 
 viduals of different nervous susceptibility, produce a very different 
 
XV.] 
 
 DURATION OF FIRST STAGE. 
 
 263 
 
 amount of actual suffering. The intensity of the pain, therefore, is not 
 always in proportion to the degree of contraction, and still less is it to 
 be held as a safe indication of its efficacy. 
 
 Fig. 
 
 Parturient canal completed by the obliteration of the os and cervix. 
 
 The duration of the first stage varies exceedingly, both in primiparse, 
 and in those who have had several children. Considerable difficulty 
 in determining this point arises also from the impossibility of fixing 
 the exact period at which this stage may be supposed to commence. 
 Assuming it, however, to date from the first sensible contractions, we 
 may assume that, with ordinary pains, and a normal condition of the 
 parts, full dilatation may be effected on an average in about six hours, 
 the time in primiparse being somewhat longer than in other women ; 
 but the stage may nevertheless last for one hour only, or for twenty- 
 four, without the occurrence, in either case, of a single symptom to 
 cause us the least anxiety. It has been frequently observed by the 
 most experienced accoucheurs that, in those instances in which the first 
 stage is tedious, the subsequent stages proceed with unusual rapidity. 
 Sometimes, cases in which there is unusual rigidity of the neck of the 
 womb come to an unexpected and rapid termination in consequence 
 
264 LABOR AND ITS PHENOMENA. [CHAP. 
 
 either of rapture of tissue or of sudden relaxation of the sphincter 
 fibres. 
 
 The Second Stage. — Upon the termination of the first stage, the 
 uterus gathers itself for further effort by tonic contraction around the 
 body of the child. The pains now undergo a remarkable change. 
 Not only do they continue to increase in frequency, duration, and 
 severity, but the whole character of the pain is altered. The woman 
 has now a consciousness of a solid body which has to be expelled, and 
 she therefore brings to bear upon it, half involuntarily, the action of 
 all such voluntary muscles as she has at command. The contractions, 
 at the same time, although actually more severe, are much more easily 
 borne, — and apparently for this reason, that the woman is now con- 
 scious that progress is being made. These are well termed " bearing 
 down," or expulsive pains, and this stage has therefore been described 
 by some writers as the propulsive stage of labor. Considerable resist- 
 ance may still be offered by the os uteri, when rigid, to the advance 
 of the head, and, if so, an oederaatous swelling, which is limited in its 
 circumference by the pressure of the os, forms on the presenting por- 
 tion of the scalp, and may attain a considerable development. This 
 is called the " caput succedaneum." The anterior lip of the os may 
 also become oedematous, in consequence of pressure between the ad- 
 vancing head and the pubis ; but, as a rule, it slips up after a time, 
 and the canal then becomes, for the first time, a continuous one. But 
 it is usually not until the head has escaped from the embrace of the os, 
 that the caput succedaneum forms, its size depending upon the degree 
 of resistance which is offered by the perineum, and by the other tissues 
 surrounding the ostium vaginae. This swelling is always more marked 
 in primiparse, and its exact situation on the scalp depends upon the 
 extent to which the movement of rotation, to be afterwards described, 
 has taken place. We now find that when the head is forced down 
 during a pain, the sutures overlap each other considerably, their situa- 
 tion being then indicated by a furrowed or wrinkled line on the scalp. 
 The whole auxiliary force, formerly alluded to as residing in the ab- 
 dominal and other muscles of expiration, now comes into play, and it 
 is a wise provision of nature that, however low the head may stand in 
 the pelvis, this seldom occurs until the dilatation of the os is complete; 
 for we may be pretty sure that, were it otherwise, laceration would be 
 of more frequent occurrence. Every means which may in this way 
 strengthen the expulsive effort is instinctively adopted. The respira- 
 tion is arrested, the limbs are fixed, and the woman presents the ap- 
 pearance of one who is undergoing a powerful struggle of muscular 
 strength and energy. The sound of the cry which she emits is also 
 indicative of violent effort; indeed, so characteristic is this, that it is 
 narrated of an old French accoucheur, that when he went to sleep 
 while attending an accouchement, he was always roused from his 
 slumbers by the altered nature of the patient's voice to a sense of his 
 impending duties. The muscles of the floor of the pelvis, and the 
 muscular fibres which enter into the composition of the vagina, aid 
 still further the propulsive efforts; while the expiratory muscles are 
 stimulated to redoubled energy, by a reflex action starting from the 
 
 
 
XV.] THE SECOND STAGE. 265 
 
 sensory nerves of the vagina. There is every reason to believe, more- 
 over, that the pressure exercised upon the uterus by the abdominal 
 muscles, constantly increasing as the over-distension of their fibres is 
 reduced, is a supplementary cause of the propulsive vigor of the uterus, 
 which is, by the contraction of the former, more actively stimulated. 
 Violent, however, as the propulsive efforts are, they are not attended 
 with that danger to the integrity of the parts which might, perhaps, 
 have been expected ; for so soon as they reach such a point as would 
 seem to endanger the latter, "the short gasp or cry is," as Tyler Smith 
 says, " exchanged for a cry which dilates the glottis, and the pain and 
 contraction subside. This cry is a motor action, excited by the emo- 
 tion of pain, and instantly relieves the uterus of all extra-uterine pres- 
 sure. Thus, the glottis may be compared to a safety-valve, which is 
 thrown open by emotion whenever the pressure becomes more than can 
 be borne with safety." The presenting part, which now approaches 
 the outlet of the vagina, soon presses directly upon the perineum, 
 which bulges downwards; and, at the height of a pain, when this 
 bulging is most marked, that part of the child which is to be first 
 born, presents itself at the vulva. This is admirably shown in the 
 accompanying engraving. The rectum now becomes flattened, and the 
 sphincter dilated, so that any fecal matter which may have been lodg- 
 ing there is unavoidably expelled. The margins of the anus being 
 dragged apart, the anterior wall of the rectum thus becomes, as it 
 were, a temporary portion of the perineum, as is shown in the figure, 
 while the perineum itself becomes more and more distended, for which 
 modification, indeed, its structure, and the nature of the attachment of 
 its muscles admirably adapt it. The hemorrhoidal veins are frequently 
 much distended, and the dilatation of the perineum goes on both lon- 
 gitudinally and transversely, in a progressive manner, proportionally 
 to the violence of each pain, with which the perineum projects as far 
 as is safe ; while, on the subsidence of the pain, the elasticity of the 
 perineal structures causes the head again to recede. 
 
 Alternately advancing and retiring in this way, but always gaining 
 ground, the head ultimately passes the distended aperture in a direction 
 forwards, under the pubic arch, the perineum now presenting the ap- 
 pearance of a thickened membrane. In many cases the head is arrested 
 by the cessation of a pain, just at the moment when its greatest diam- 
 eter is encircled by the circumference of the vulva, but it does not now 
 recede. This has been called the stage of "crowning," and may be 
 looked upon as favorable to the integrity of the soft tissues. A final 
 pain now brings the presenting part into the world, and this period, 
 which immediately precedes delivery, is that at which the suffering of 
 the woman reaches its highest pitch, — sometimes amounting to frenzy, — 
 and it is wisely and mercifully provided, in some codes of jurisprudence, 
 that any act of violence committed at this moment is viewed with 
 special leniency. Upon the birth of the head, the woman enjoys a 
 brief interval of relief, but the pains soon return, and complete the 
 delivery of the remainder of the child. The external parts, which 
 have become contracted around the neck upon the passage of the head, 
 are again dilated, and the shoulders are expelled. It will be found, 
 
266 
 
 LABOR AND ITS PHENOMENA. 
 
 [CHAP. 
 
 however, that it is not invariably the anterior shoulder, as is stated in 
 many works, which is first expelled ; for, in a very considerable number 
 of instances, that shoulder which lies towards the perineum takes 
 precedence in its passage into the world. During this stage, a slight 
 amount of laceration generally takes place, in the direction of the dis- 
 tended perineum, and in primiparae, indeed, the fourchette seldom, if 
 
 Fig 
 
 Distension of the perineum. (After Hunter.) 
 
 
 ever, escapes. The remainder of the infant then passes, and with it a 
 gush of blood and the rest of the amnionic fluid. The uterus now 
 contracts firmly on the placenta, and may be felt, as a hard globe, 
 above the symphysis ; while the abdominal walls become flaccid, and 
 the mother experiences a feeling of calm and perfect rest, which yield 
 to her, from the comparison, a sensation of delicious repose. 
 
 The Third Stage. — The final contractions of the second stage are 
 sometimes so violent as to expel the Placenta along with the child. 
 This, however, is an unusual occurrence, and what generally takes 
 place, when the case is absolutely left to nature, is as follows : The 
 child, on its birth, remains connected with the placenta by means of 
 the cord, which, for a time continues to pulsate. The latter being 
 divided, in the manner to be described in the following chapter, the 
 woman remains at perfect rest for an interval of about ten minutes or 
 a quarter of an hour, on the average. The uterus then begins sponta- 
 neously to contract upon the placenta, the expulsion of which organ 
 constitutes the Third Stage of labor. The pains of this stage, although 
 of the same expulsive nature as those which preceded it, are compara- 
 tively trifling, and are accompanied with more or less of the blood 
 which has escaped from the ruptured utero-placental vessels. They 
 were, on this account designated by the older writers dolores cruenti. 
 A few of these contractions is generally sufficient to effect the complete 
 separation of the placenta and its propulsion into the vagina, but the 
 feeble contractile power of the latter often renders it necessary to give 
 
XV.] 
 
 THE THIRD STAGE. 
 
 267 
 
 some assistance in the delivery. The placenta and the adhering mem- 
 branes being expelled, this final act terminates the labor. 
 
 The description originally given by Baudelocque as to the mechan- 
 ism of the birth of the placenta, has been adopted by almost all modern 
 authors, and the demonstration which has lately been given of it by 
 Schultze in his admirable Wandtafeln (see Fig. 99), is in every respect 
 confirmatory of the views of the great French obstetrician. The descrip- 
 tion given by them of the process is, that the placenta passes through 
 the vagina inverted, with its foetal or amnionic surface turned outwards, 
 
 Fig. 99. 
 
 Fig. 100. 
 
 Alleged inversion of placenta in the 
 third stage. 
 
 Normal position of the placenta in 
 the third stage. 
 
 an assertion which, in so far as the natural process is concerned, is 
 quite incorrect, That the placenta passes, in a large number of cases, 
 in the manner shown in the accompanying figure, is probably true 
 enough, but the reason is, that the practice of pulling on the cord is 
 resorted to with too great frequency in general practice. For if we 
 believe that the normal process is thus represented, it will seem rational 
 enough, when delay occurs, to pull gently towards the ostium vaginse 
 that portion which nature intends should first be born. In cases, how- 
 ever, which are left entirely to nature, it will almost invariably be 
 found that it is not the foetal surface but the edge of the placenta which 
 presents, and it is this part, overlapped it may be by the membranes, 
 which will be found to pass first both into the vagina and through the 
 vulva. This is the description which has been given by Lemser, 
 Cazeaux, and some others, and, more recently, Dr. Matthews Duncan 
 has, in a paper distinguished by his usual ability, put the matter in a 
 perfectly clear light. In his drawing, which we here reproduce slightly 
 
268 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 modified, the placenta is shown folded upon itself, with the detached 
 uterine surface turned towards the observer, " but the folds are," as he 
 observes, "according to the length of the passage, not transverse to it, 
 as inversion or presentation of the foetal surface imply." We are fully 
 persuaded that the observation of half a dozen cases, in which no inter- 
 ference with the cord is permitted, will convince any one of the truth 
 of these assertions. It will be shown presently that they involve some 
 points of practical importance. 
 
 The uterus may now be felt behind the pubes firmly contracted, and 
 on the maintenance of this tonic contraction depends mainly the safety 
 of the woman from the dangers of post-partum haemorrhage It some- 
 times occurs, however, that the rhythmical efforts persist, when the 
 womb may be felt in alternate stages of relaxation and contraction 
 without necessarily any particular loss of blood. 
 
 CHAPTEE XVI. 
 
 MANAGEMENT OF NATURAL LABOR. 
 
 DUTIES OF THE ACCOUCHEUR — PRELIMINARY ARRANGEMENTS — FALSE PAINS AND 
 THEIR TREATMENT — ARMAMENTARIUM OF THE ACCOUCHEUR — POSITION OF THE 
 WOMAN DURING LABOR — DIGITAL EXAMINATION : POINTS TO BE EXAMINED — 
 THE PATIENT NOT TO TAKE TO BED DURING THE FIRST STAGE — PREPARATION 
 OF THE BED, ETC. — ABDOMINAL MUSCLES TO BE CALLED INTO PLAY DURING THE 
 SECOND STAGE — MANAGEMENT OF THE ANTERIOR LIP OF THE OS — OBSTACLES 
 ARISING FROM RIGID OS ; AND FROM NON-RUPTURE OF MEMBRANES — USE OF 
 STETHOSCOPE— VIEWS REGARDING SUPPORT OF PERINEUM — TREATMENT IF 
 LACERATION IS THREATENED — CAUSES OF LACERATION — BIRTH OF THE HEAD 
 — PASSAGE OF THE TRUNK — TREATMENT OF SUSPENDED ANIMATION IN THE 
 CniLD — LIGATURE OF THE CORD — MANAGEMENT OF THE THIRD STAGE : CREDe'S 
 METHOD — APPLICATION OF ABDOMINAL BANDAGE — TREATMENT OF THE WOMAN 
 AFTER DELIVERY. 
 
 Having in the last chapter fully considered the various phenomena 
 attendant upon natural labor, the subject of the duties of the accou- 
 cheur remains for our consideration. It is fortunate that, in a very 
 large proportion of all cases, the various stages of labor are effected 
 by the unaided efforts of nature, in a manner which renders any 
 "assistance" on the part of the accoucheur, in the ordinary acceptation 
 of the term, quite unnecessary. Indeed, the duties which he has to 
 discharge might, in nineteen cases out of twenty, be performed as effi- 
 ciently and perhaps more agreeably to the feelings of the patient by a 
 thoroughly trained and intelligent nurse. But, in the twentieth case, 
 something may occur, — and it may be, quite unexpectedly — which sud- 
 denly demands special experience, operative skill, and a thorough 
 practical knowledge of the healing art. It is only, however, as has 
 
XVI.] PRELIMINARY ARRANGEMENTS. 269 
 
 already been observed in the introductory chapter, by a careful study 
 of the normal process, that it is possible for us to recognize speedily and 
 with precision deviations from the physiological standard; and this 
 reason alone would suffice as an apology for a branch of practice which 
 some look upon with disdain. But a more important reason still is to 
 be found in the fact that many of the dangers and complications of 
 labor arise so suddenly that, unless aid is at hand, the life of mother 
 or child, or of both, may be sacrificed ; for, as at present trained, it is 
 rare to find a nurse who has the skill requisite for the management 
 even of the more remediable complications of midwifery. 
 
 There are numerous points of detail which contribute greatly to the 
 comfort of the patient, in regard to which an intelligent nurse is usu- 
 ally well informed, and the management of which may be left in her 
 hands, if we have confidence in her ability. This, however, manifestly 
 applies only to the wealthier classes, who alone can command the 
 services of such skilled attendants; but, as the practice of the great 
 majority of professional men extends, more or less, in directions where 
 he has himself to discharge many of the duties which are more properly 
 those of the nurse, it is necessary that every young practitioner should 
 thoroughly understand what these are. And, in any case, the failure 
 of the nurse may devolve these duties upon him, so that it is of further 
 importance that he should be familiar with them, in order that he may 
 be able at once to detect incompetency, and to remedy its defects. 
 
 The judicious management of a case of labor may be held to include 
 certain preliminaries, in regard to which women, and more especially 
 primiparse, often require some advice. The systematic neglect of the 
 bowels which women so often practice, is likely, if persisted in, to be a 
 cause of much discomfort. A pregnant woman should therefore be en- 
 joined on no account, as the period of labor approaches, to neglect this 
 function. In most cases it is proper, by a laxative given at the outset 
 of labor, or by the administration of an enema, to make sure that the 
 lower bowel is empty; for, if this be neglected, the labor will be much 
 more disagreable to the accoucheur, and may also be unduly protracted. 
 If her health be tolerable, she must not be encouraged to consider her- 
 self an invalid, but should be recommended to take such moderate 
 exercise as may seem appropriate, while the tone and general vigor of 
 the system is maintained by a sufficient diet, which may be generous, 
 but not stimulating. During the last weeks of pregnancy, the descent 
 of the womb often renders a woman more capable of moving about, 
 from which " it would almost seem," as Rigby says, " that nature 
 intended she should use exercise at this period, and thus prepare her, 
 by increased health and strength, for a process which requires so much 
 suffering and exertion." 
 
 The perverted and irregular contractions, to which we have already 
 alluded under the name of " false pains," may cause the summoning of 
 the accoucheur long before his services as such are required. Those 
 pains will often, upon strict investigation, be found to depend upon 
 derangement of the bowels, or upon reflex irritation starting from some 
 other source ; and, in this, as in many other cases, the success of the 
 treatment will depend upon the intelligent appreciation of the cause. 
 
270 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 The uterus* may be the seat, as every one knows, of congestion, as well 
 as of neuralgic or rheumatic affections, the latter being of much less 
 frequent occurrence than was at one time supposed; and each of these 
 conditions may involve special or peculiar treatment. But, in most 
 cases, the treatment will consist in rectifying the state of the bowels, 
 and, thereafter, in allaying uterine irritation by the administration of 
 an opiate, which will generally at once arrest the spasms, and will also 
 procure refreshing sleep for the patient, of which she may for some 
 time have been bereft. Should any reliable evidence of congestion 
 exist, it may be advisable, when the period of natural labor is close 
 at hand, to reduce this by external fomentations, and by tartar emetic 
 combined with small doses of opium. For, in some such cases, it will 
 be found that an unusual rigidity or dryness of the parts exists, which, 
 if unaltered, will almost certainly act as an impediment to labor. By 
 mistaking false for real pains, we may, in our ignorance, allow the 
 woman to go on suffering that which we generally have it in our power 
 to alleviate. 
 
 The practitioner will often, to his great annoyance, be called to the 
 bedside of his patient, when, although labor may have commenced, the 
 period is yet distant at which his services will be required. Such a 
 summons should, however, be promptly obeyed. For, although in 
 most cases it will be time lost, it is of the greatest possible importance 
 that anything abnormal should be detected as early as may be in the 
 course of labor. We are then in a position leisurely to determine our 
 plan of procedure; and, should any operative assistance be required, 
 to select that period for it which is most favorable in the interests of 
 mother and child. We are able, moreover, when we have an early 
 opportunity of examining the case, to form an opinion, to which expe- 
 rience will lend confidence, as to the probable duration of the case, and 
 this enables us to leave the patient for a time, and to attend to such 
 other of our professional duties as may be most urgent. If the symp- 
 toms are such as to convince us that the woman is really in labor, we 
 should always make an examination before leaving. In proposing this, 
 especially in women who are in labor for the first time, we should 
 never forget the consideration which is due to the feelings of the patient, 
 whatever be her rank in life. For it cannot be otherwise, than that a 
 woman must look upon such an examination as is necessary, by a person 
 of the other sex, with apprehension, if not with abhorrence; but if the 
 necessity be first explained to her in a few kindly words, she will rarely 
 fail to appreciate the good feeling which prompts them, and will submit 
 without a murmur to whatever may be deemed essential to her safety 
 or comfort. A similar feeling should guide us in everything we do in 
 the practice of midwifery, and if so, we shall seldom fail to win the con- 
 fidence of our patient. To lay down, however, as some have attempted 
 to do, rules for the guidance of the young practitioner in this respect, is 
 simply absurd ; for, to tell a man of grave demeanor to look cheerful, 
 and a man of lively and jocund spirit to look grave, is to make both 
 artificial, and more like fools than rational beings — a state of matters 
 little likely to establish confidence or to engender esteem. 
 
 There are certain articles of his armamentarium which the accoucheur 
 
 
XVI.] POSITION OF THE WOMAN. 271 
 
 should look upon as indispensable, and should therefore carry with him 
 as a matter of coarse : these are an elastic catheter, a small vial of some 
 approved preparation of opium, and a similar quantity of the liquid 
 extract of ergot. To these may be added chloroform and sal volatile ; 
 and, if we are going to any distance, we should certainly take the for- 
 ceps, which does not occupy much room in the gig or saddle-bag, 
 whereas its absence may possibly cause many hours of delay, and in- 
 creased clanger. It is the duty of the nurse to provide narrow tape or 
 strong thread for tying the cord, and to have in readiness the abdominal 
 bandage, scissors, hot and cold water, and a supply of napkins; but, 
 as it will often fall to the lot of the medical attendant to see to these 
 preparations himself, he should, at least, be provided with such material 
 as may be depended upon for ligaturing the cord ; and we take it for 
 granted that he habitually carries with him scissors and a stethoscope. 
 For obstetric use, a stethoscope with an elastic stem is to be preferred. 
 He should also give a general glance around, and see that everything 
 is ready which may be necessary for the comfort or safety of the patient. 
 In making an examination, the most convenient position for the 
 accoucheur, as well as the patient, is that which is invariably adopted 
 in this country. The woman lies on her left side, with her back to 
 the examiner, and near the edge of the bed, which must, if necessary, 
 be previously so arranged as to admit of this. 1 The index and middle 
 finger of either hand — the right being usually preferred, although the 
 left has certain advantages — being then smeared with lard or oil, are 
 passed over the perineum, and gently into the vagina up to the os uteri. 
 It is usual to select a period of a pain for the examination ; but, if so, 
 
 1 " In the earliest periods of history, women appear to have been delivered in a 
 sitting posture, as is described in the first chapter of Exodus. This mode was re- 
 vived in comparatively modern times ; thus Ambrose Fare, in 1573, speaks of a 
 labor-chair, with an inclined back, which he preferred to a common bed. Labor- 
 chairs were brought into very general use upon the Continent in the beginning of 
 the last century by Deventer, and, although they have been in a great measure 
 discontinued in modern times, there are still some districts in Germany where they 
 continue to be used. It is a species of chaise percee, furnished with straps, cushions, 
 etc., by which the patient can fix her extremities, and thus enable the abdominal 
 muscles to act with the greatest power. In some remote parts of Ireland and also 
 of Germany, the patient sits upon the knees of another person, and this office of 
 substitute for a labor chair is usually performed by her husband. Labor-chairs, as 
 far as we are acquainted with their history, were never used in this country, nor 
 have they been used for the last century in France, where the patients are usually 
 delivered in the supine posture, on a small bed upon the floor, which has not inaptly 
 been termed lit de misere. A modification of the labor-chair is the labor-cushion, 
 first used by Unger, and afterwards by the late Professor von Siebold of Berlin, and 
 Professor Cams of Dresden ; it is a species of mattress, with a hollow beneath the 
 nates of the patient for receiving the discharges which take place during the labor. 
 The patient is compelled to lie upon her back during the greater part of labor, and 
 thus maintain the same position for some time, which must necessarily become irk- 
 some, and even painful to her. In this country and in Germany the patient is 
 delivered upon a common bed, prepared for the purpose as above mentioned; in 
 England she is placed upon her left side, the nates projecting to the edge of the bed, 
 for the greater convenience of the accoucheur ; in Germany — except in Vienna and 
 Heidelberg, where the English midwifery has in a great measure been introduced 
 by Boer and Naegele — the patient is delivered upon her back. In former times, 
 the supine posture was also used in this country, but for about a century the 
 position on the leftside has been preferred." — A System of Midwifery, by Edward 
 Eigby, M.D. 
 
272 
 
 MANAGEMENT OF NATURAL LABOR. 
 
 [CHAP. 
 
 the finger must not be withdrawn until we have examined the parts in 
 the state of repose also, for the protrusion of the bag of waters during 
 a pain makes it difficult to ascertain the presentation, without risking 
 premature rupture of the membranes by undue violence. The points 
 which one ascertains in the course of the examination are, in the first 
 place, the state of the vagina, whether it is soft, relaxed, and well 
 lubricated with mucus. In regard to the os uteri, we observe if it is 
 soft and dilatable, or rigid and unyielding, and to what extent it has 
 become dilated, if at all. Information is, further, obtained, as to 
 whether the membranes are ruptured ; whether we have to deal with 
 a natural presentation ; and if there is any pelvic deformity or morbid 
 growth which might impede the progress of labor. And, finally, we 
 may thus recognize at an early stage prolapse of the cord — a condition 
 which calls for constant care and anxiety, so long as the labor may 
 last. With this view, also, it is usual to make an examination at the 
 time of the rupture of the membranes, as it is at this moment that the 
 loop of the cord frequently descends ; and, besides, an examination 
 now enables us, more surely than before, to determine the position of 
 the presenting part. The mode of examination above described is 
 
 Fig. 101. 
 
 Mode of digital examination 
 
 represented in the accompanying figure, in which the examination is 
 being conducted with the right hand. In most cases one finger, as 
 here shown, will suffice, and this should always be attempted when the 
 examination seems to cause unusual pain. The student and young 
 practitioner should avoid making too frequent examinations, for, not 
 only does this irritate the parts, but it tends to remove, at each succes- 
 sive examination, a portion of the lubricating medium, upon the quan- 
 
XVI.] PREPARATION OF THE BED. 273 
 
 tity of which depends, in some measure, the satisfactory issue of the 
 case. The practice of previously smearing the finger with some bland 
 lubricant is resorted to on every occasion in which an examination is 
 found to be necessary, not so much to facilitate introduction — which 
 the abundance of mucus generally renders easy enough — as to supply 
 the place of any mucus which may be removed, and in a certain class 
 of cases to protect the finger. The operator should never omit, after 
 an examination, to address a word or two to the patient in a cheerful 
 tone; and, if the presentation be natural, and you are then able to 
 say so, she will always be gratified by hearing that "all is as it 
 should be." 
 
 So long as the os uteri is not fully dilated, or, in other words, so 
 long as the first stage continues, the patient should be encouraged to 
 believe that this is a stage which is merely preliminary to the act of 
 parturition ; and that, therefore, she should not lie in bed, but rather 
 walk about in the intervals between the pains, and take such light food 
 as she would under ordinary circumstances. If she can be induced to 
 occupy her attention, as far as possible, by any familiar occupation, 
 however trivial, it will be to her advantage, by relieving the tedium of 
 her suffering. If this cannot be done, her attendants should try, by 
 cheerful conversation, to beguile the time, and to divert her mind from 
 the gloomy apprehensions which are of frequent occurrence at this 
 period. The accoucheur should not remain in the room during this 
 stage unless there be any special necessity for it, although he may visit 
 it occasionally. To do otherwise would encourage her to expect assist- 
 ance at his hands, which it is not in his power to afford ; and, more- 
 over, his presence would to her seem to imply that he expected a speedy 
 termination of her sufferings. During this period, the woman is fre- 
 quently advised by ignorant attendants to press down, and with this 
 view footstools are placed at the foot of the bed, and towels are tied to 
 the bed-post, by means of which she may fix the trunk, and bring the 
 whole force of the expiratory muscles to bear. This acts most inju- 
 riously on the progress of the labor, for the stage is one of dilatation, 
 and not of propulsion ; and, if the muscles referred to are thus brought 
 prematurely into play, the voluntary expulsive force is fruitlessly ex- 
 pended before the stage arrives at which it may properly be employed. 
 Nothing, in fact, is more certain, than that any attempt, either on the 
 part of the woman, or, on the part of the practitioner, by forcible dila- 
 tation of the os, the administration of ergot, or the exhibition of stimu- 
 lants, to hurry delivery, must be strictly avoided in the course of the 
 first stage of a natural labor. And, even in cases where its duration 
 is prolonged far beyond the average, this of itself is no excuse for in- 
 terference, unless the general symptoms indicate that it is our duty to 
 accelerate the labor by such means as are within our reach — a state of 
 matters which is of rare occurrence. When the pains flag, it has often 
 been found that the administration of an enema for the purpose of 
 emptying the lower bowel, acts further as an efficient stimulant to 
 uterine contraction. 
 
 The pains usually become more severe as the termination of the first 
 stage approaches, and at this period it is advisable that the woman 
 
 18 
 
274 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 should go to bed, more especially if she has previously borne children, 
 as there is a risk of the sudden propulsion of the child immediately 
 upon the rupture of the membranes. Previous to this, the nurse pre- 
 pares the bed — which should not be too soft — by placing over it a 
 piece of india-rubber sheeting to protect it from the discharges. Upon 
 this a folded sheet, about two and a half to three feet in width, is 
 placed across that part of the bed upon which the pelvis of the woman 
 lies. By this simple arrangement, the sheet may be gradually pulled 
 through as it becomes soiled with successive discharges of liquor amnii, 
 or of blood, and at the end of the labor it is completely removed along 
 with the final discharges which accompany the birth of the placenta. 
 The ordinary night-dress which the patient wears, or rather that part 
 of it which is beneath her as she lies, should be rolled up above the 
 waist, and the lower part of the body covered with a petticoat which 
 opens all the way down, and she should then be covered with such 
 bedclothes as the season of the vear and her own feelings mav render 
 necessary. She lies on her left side, as has already been stated, with 
 her back to the practitioner, and her head consequently to his left hand ; 
 and one of the advantages of such a position is that she is not disturbed 
 by seeing such preparations as may be necessary for her assistance or 
 relief. It is by no means essential that she should occupy this posi- 
 tion continuously till the termination of labor. To do so would be 
 irksome in the extreme; so that she may be permitted to lie at will on 
 either side, or on the back, reverting necessarily to the left side when 
 any occasion may arise for renewed examination. 
 
 For reasons above stated, frequent examinations are always to be 
 avoided. From time to time, however, examinations may be instituted 
 with the view of ascertaining the rate of progress which is being made. 
 This has the further advantage of allowing the busy practitioner to ab- 
 sent himself from time to time, for such a period as he judges to be 
 quite safe; but, in this respect, he must always be cautious, as he will 
 be blamed if absent at the critical moment. In some cases, even in 
 prim i pane, a sudden and violent increase in the expulsive force un- 
 expectedly occurs, when, if the parts be soft and dilatable, the birth 
 may take place with extraordinary rapidity. All calculations as to the 
 probable period of delivery are very uncertain, and although experi- 
 ence gives a certain confidence to the opinion which may be formed, 
 we cannot be too cautious in expressing it; for, not only may it end 
 abruptly as we have seen, but, in other cases, labors, which up to a 
 certain point have advanced in a manner which seemed to render 
 speedy delivery almost a certainty, are suddenly suspended by failure 
 of uterine action, or by some other cause. The child may, under such 
 circumstances, actually be arrested on the very threshold of its en- 
 trance into the world. 
 
 So soon as rupture of the membranes has taken place, the sheet be- 
 neath the patient should be pulled by the nurse towards the edge of 
 the bed, so that she may rest on a dry portion, and avoid the discom- 
 fort of lying on a wet bed. The stage of propulsion now usually com- 
 mences, and it is quite proper, in many cases, to encourage the woman 
 to avail herself of the aid of the abdominal muscles. In most cases, 
 
XVI.] PROGRESS OF THE SECOND STAGE. 275 
 
 she will do this instinctively, and requires no instruction wiiatever ; but, 
 in others, there is a disposition to waste the force of the expiratory 
 muscles in cries, which are worse than useless, and it is in these cases 
 that encouragement should be given. In regard to the means already 
 referred to for fixing the trunk, the accoucheur will use his own discre- 
 tion as to how far they are to be permitted ; for, if the pains are of 
 more than usual violence, we must rather restrain than encourage her 
 efforts, while if, on the contrary, they are slow and inefficient, we may, 
 with perfect propriety, allow of any means which may act by increasing 
 the deficient propulsive force. At any time in the course of the labor, 
 but more especially, perhaps, about the commencement of the propulsive 
 stage, difficulty may arise from retention of urine, in consequence of 
 mechanical closure of the urethra. This requires the use of the cathe- 
 ter, which is to be employed with caution and with due reference, as 
 has already been mentioned, to the anatomical modifications which 
 attend pregnancy. The pressure consequent upon the descent of the 
 head, often gives rise to cramps in the thighs, a symptom which some- 
 times aggravates very greatly the suffering of the patient. We shall 
 not stop here to consider whether this is due to direct pressure upon 
 the large nervous trunks, or to a reflex action ; but, in regard to the 
 treatment of what is a troublesome complication, although not a dan- 
 gerous one, it can only be said that if emptying the bowels by an 
 enema, and warm friction of the thighs should fail to remove the spasm, 
 we can but try such other means of palliation as may occur to us, for 
 in all probability the patient will not enjoy complete relief, until the 
 termination of the labor has removed the cause which is responsible 
 for the symptom in question. 
 
 As the head descends in the pelvis, after the termination of the first 
 stage, it not unfrequently happens that the anterior lip of the os re- 
 mains in an oedematous condition, indicative of pressure of the anterior 
 uterine wall between the presenting part and the symphysis pubis. 
 This constitutes a very manifest impediment to the progress of the 
 labor. It has been said by some of the best authorities that under such 
 circumstances we should never interfere. "All attempts," says Rigby, 
 " to push it above the head are objectionable, because, in the first place, 
 the finger cannot reach sufficiently high to effect the object, and, there- 
 fore, the swelling descends again to its former situation ; and, secondly, 
 the efforts to push it up only tend to inflame it, and increasing the 
 swelling." To this we must demur. Any attempt, rudely or forcibly, 
 to push up the anterior lip, even when it exists as a manifest impedi- 
 ment, should certainly be avoided; but we are bound to add that, in 
 many cases, it may be pushed beyond the head with perfect safety, and 
 in this way the impediment to delivery may be at once obviated. The 
 swollen part should, during the interval between two pains, be gradually 
 and cautiously pressed up as far as possible beyond the head. If the 
 finger be removed, the tumor descends at once, as Rigby says ; but if 
 it be kept in position until the next pain comes on, the head will often 
 pass down, and the cervix be retracted upon it, precisely as occurs at 
 the moment of the passage of the head through the ostium vagina?, by 
 the action of the levatores ani muscles. This cannot be effected in 
 
276 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 every instance, bat the attempt, if cautiously performed, is free from 
 risk, and in a very considerable proportion of cases, is attended with 
 complete success. 
 
 The further progress of the labor brings the head, or other present- 
 ing part of the child, downwards, towards the floor of the pelvic cavity. 
 In a certain number of cases, it is, however, impeded in its progress by 
 mechanical hindrances, which it is in our power to remove. The mem- 
 branes, for example, may be so tough as to have resisted an ordinary 
 amount of force at the period at which they are usually ruptured ; or 
 they may be distended by a very unusual quantity of liquor amnii; in 
 either of which cases the bag of waters may constitute an impediment 
 to delivery, which can only be removed by artificial rupture, so as to 
 permit the descent of the head. In other instances, the os uteri pre- 
 sents a condition of abnormal rigidity, its margin being, at the acme of 
 a pain, hard, rigid, and tender. In former times, the practice univer- 
 sally adopted in such a case was bloodletting, and we do not for a mo- 
 ment doubt that the effect of the operation was to relax the rigidity, 
 and permit the descent of the head; but the cases in which we would 
 be justified in bleeding during labor are very limited. It is safer to 
 give tartar emetic in nauseating doses, which will be found to have an 
 equally beneficial effect, and one, at the same time, from which the sys- 
 tem can be more easily released than when, by misadventure, too much 
 blood has been abstracted. We have, however, in chloroform a far pref- 
 erable agent, which, in such cases, exercises a most powerful influence 
 upon the rigidity of the os. This we should never fail to avail our- 
 selves of in cases requiring operative interference. Chloroform, indeed, 
 in such instances, fulfils a threefold indication, by subduing the rigidity 
 we are speaking of, arresting voluntary movements, and allaying reflex 
 susceptibility. Of late, chloral hydrate has been extensively used for 
 the same purpose and with satisfactory results; and in France, bella- 
 donna has enjoyed a high reputation, which, however, is somewhat 
 doubtful. 
 
 The stethoscope should be employed from time to time during the 
 course of a tedious labor, to ascertain the vitality and vigor of the foetus, 
 for there are cases in which the life of the foetus may be compromised, 
 while that of the mother undergoes no risk whatever. Some, indeed, 
 have recommended that, in labor apparently the most uncomplicated, 
 the stethoscope should be frequently used, so that risk to the life of the 
 child may thus be reduced within the narrowest possible limits. 
 
 When the further progress of the case has brought the head to press 
 against the perineum, as is shown in Fig. 98, it distends or bulges that 
 structure outwards, or rather downwards, more and more during every 
 succeeding pain; and the position of the patient on the left side enables 
 us often to watch the process without her being aware of any exposure. 
 The axis of motion is now no longer downwards, but forwards in the 
 direction of the subpubic angle, as will be fully described in a subse- 
 quent chapter. A very usual practice at this stage, is to separate the 
 knees by means of a pillow or otherwise, so as to encourage, as far as 
 possible, the movement in this direction. This has, however, been 
 condemned by some of the best authorities, on the ground that labor 
 
XVI.] SUPPORT OF THE PERINEUM. 277 
 
 should be habitually retarded at this stage, an argument, the force of 
 which, we confess, we can scarcely admit. And this for two reasons : 
 first, because the position on the side, which involves apposition of the 
 knees, is singularly unfavorable to movement of the head in the direc- 
 tion which we have indicated as normal ; and, second, because, in a large 
 majority of cases, the separation gives the woman great relief, a fact 
 which is familiar to every experienced nurse. 
 
 The most important point, however, connected with this stage of the 
 process is, undoubtedly, the Support of the Perineum, — a mode of pro- 
 cedure which is recommended in some form or other by most writers 
 on obstetrics. Many years ago, our attention w T as, by an accidental cir- 
 cumstance, very particularly directed to this matter, and we published 
 some time afterwards a paper on the subject, 1 which w r as founded not 
 only on a careful clinical study of the phenomena of this stage of labor 
 when unaided, but also on a critical examination of the views entertained 
 by those who practice support of the perineum, and of the reasons which 
 swayed them. The points brought out were mainly these : 
 
 The earlier writers recommended only, in reference to this stage, the 
 free use of lubricants and emollients. About the middle of the last 
 century, Smellie advocated artificial dilatation of the external orifice of 
 the vagina ; Puzos, stretching of the parts along with lubrication ; and 
 Roederer, pressing of the perineum towards the sacrum : all these modes 
 of treatment differing greatly from the modern procedure. To whom 
 the practice of perineal support is originally due is a matter of doubt, 
 but, in the treatise published by Professor Hamilton of Edinburgh, in 
 1781, we find it mentioned as a distinct system, applicable alike to 
 natural labor and to that which is in any way abnormal. This author, 
 like Puzos, advocates the use of lubricants, and recommends us to 
 release the perineum when the head is being born, " by cautiously 
 sliding it back over the face and chin of the child. 7 ' From this time 
 writers have, in the main, agreed that, by a support of the perineum, 
 lacerations are to be prevented ; but they have not agreed as to what 
 " support" is, or to what extent it is to be practiced. It would carry us 
 far beyond the limits within which the subject must here be confined to 
 examine critically the views which are, or have been, entertained by 
 the most approved authorities on this point. We shall, on this account, 
 refer only, and that very briefly, to the opinions which are promulgated 
 by some of the authorities referred to. 
 
 Dr. Pamsbotham says, "As soon as the head has come to press on 
 the external parts, it becomes our duty to take our seat by the bedside, 
 and never to move from our position till the child has passed. This 
 we do to protect the perineum and to prevent laceration." . . . "Place 
 your elbow/' he continues, "against the bedstead, regarding it as a 
 fixed point, and allow the perineum to be forced against your hand." 
 Fortunately there are few, if any teachers of midwifery who go to 
 such an extreme in the recommendation which they give to their 
 students ; for we believe that support of this kind can scarcely fail 
 sometimes to bring about the very accident which we are striving to 
 
 1 Glasgow Medical Journal. January, 1860. 
 
278 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 avert. Dr. Tyler Smith pointed out many years ago, that pressure 
 upon the perineum is apt to excite the uterus to increased contraction 
 by a reflex action starting from the nerves which are distributed through 
 the former structure, and, on this ground he dissuades us from prac- 
 ticing systematic support. Churchill recommends very gentle and 
 careful support, and, in concluding his observations on this point, 
 informs us that it has been his lot to " witness more than one case 
 where rupture was owing to excessive and injudicious support." Den- 
 nian only sanctions support in first cases, while Naegele plainly says, 
 "under ordinary circumstances, any support of the perineum is un- 
 necessary." 
 
 It was a careful study of these opinions among others, along with a 
 thorough observation of the process in nature, which led us long ago to 
 condemn support of the perineum as irrational and useless in all cases, 
 and undoubtedly hurtful in some. It must be admitted, however, that 
 the method usually adopted, which consists in very gentle support, 
 with the view, mainly, of directing the head forwards, probably does 
 no harm ; the palm of the left hand, protected by a napkin, being laid 
 along the perineum, and pressed against it during a pain. Two points 
 must here, however, be borne in mind ; that the perineum must sooner 
 or later yield, and that support necessarily implies opposition to the 
 progress of the head. If, therefore, we admit support as a rule of prac- 
 tice we shall find ourselves opposing a natural process, and presuming 
 to teach nature a lesson. If any one will but take the trouble in a 
 single case to watch the admirable manner in which nature effects her 
 purpose in dilating the perineum, each pain increasing the dilatation 
 by a carefully graduated force, until at last the orifice permits the pas- 
 sage of the head, the observation will go further to convince the most 
 earnest advocate of the doctrine of support than any mere argument 
 can do. And be it remembered always, that, do what we may, rupture 
 of the perineum will, in a certain proportion of cases, as is admitted 
 by every one, occur. 
 
 The practice of perineal support, then, is, if very gentle, harmless. 
 Indeed, we are inclined to admit that, in some cases of deficient con- 
 tractile power, it may be beneficial, but in a way very different from 
 what the operator counts upon — by exciting more energetic propulsive 
 action. The practitioner, however, who never puts his hand to the 
 perineum will, we firmly believe, have fewer cases of ruptured perineum 
 in his practice than he who admits support in any form as applicable 
 to every case of labor ; while, if he adopts the advice of Ramsbotham, 
 as above quoted, he will, beyond all reasonable doubt, sometimes cause 
 the very accident which he is attempting to prevent. We do not 
 think, in reference to this subject, that we take an exaggerated view of 
 the case in looking upon it as a relic of " meddlesome midwifery," in 
 which we presume by irrational and bungling interference to dictate 
 to nature. 
 
 The proper management of this stage — which will be found to be 
 attended with results of the most satisfactory kind — consists in watching 
 the amount of pressure to which the perineum is being subjected. 
 This may be done effectively and easily by keeping a finger on the 
 
XVI.] LACERATION OF THE PERINEUM. 279 
 
 anterior margin of the perineum, which enables us, with a little practice, 
 to gauge with tolerable accuracy the degree of propulsive force which 
 is being exercised. Should this exceed the normal standard, so as to 
 imperil the integrity of the tissues, we must then order all aids to ex- 
 pulsive effort to be removed from the reach of the patient, and at the 
 same time encourage her to cry out lustily during the height of a pain, 
 or, in other words, to make free use of the safety-valve of the glottis. 
 Should circumstances render it expedient to oppose the advance of the 
 head with the view of rendering the process of dilatation more gradual, 
 this should be done, not by pressure on the perineum, but by pressure 
 exercised directly upon the head of the child, which is to be pressed 
 towards the hollow of the sacrum. But the effect even of such pres- 
 sure is in most cases doubtful, and the greatest possible care must be 
 exercised lest we divert the force which should be expended in the 
 direction of the pubic arch, and, by bringing it to bear directly upon 
 the perineum, thus enhance its risk of rupture. 
 
 In all first cases, the fourchette is slightly lacerated, but the rupture 
 seldom extends further. In cases in which there exists morbid rigidity, 
 cicatrices, or a diseased state of the parts, the rent may extend deeply 
 into the perineum, and even in extreme cases through the sphincter 
 into the anus. We must guard, however, against taking too serious a 
 view of such a laceration ; for what may seem at the moment of deliv- 
 ery to be a serious surgical lesion, turns out in the course of forty-eight 
 hours, and in consequence of the retraction of the parts, to be but a 
 trifling fissure. It is not, as a rule, by the passage of the head that 
 the most serious lacerations are effected ; they are often commenced by 
 this, but it is the passage of the shoulders which extends the rupture. 
 Sometimes, the perineum gives way under an amount of pressure which 
 is comparatively trifling, suddenly yielding in its whole extent like a 
 piece of wet parchment; and it is in regard to these cases that a sus- 
 picion has arisen as to the possibility of disease in the structure of the 
 parts. There is also an increased risk of perineal rupture in certain 
 forms of pelvic deformity — such as diminution in the trausverse diam- 
 eter of the outlet. This involves an approximation of the tuberosities 
 of the ischia, and an abnormal acuteness of the subpubic angle — con- 
 ditions which obviously must make the head pass further doivnwards 
 in the direction of the perineum, before it is possible for it to move 
 forivards under the arch. The unskilful use of instruments is also a 
 fertile cause of perineal rupture, and the same may be said of careless- 
 ness in operative manipulation. Certain rare cases are recorded in 
 which the child has actually passed through the perineum, by forcing 
 a passage through this structure and the anterior wall of the rectum, 
 while the posterior commissure of the vagina remained unruptured. 
 
 Eigidity of the perineum is an affection which sometimes causes a 
 very serious impediment to the completion of labor. If it be simple 
 rigidity, unconnected with any lesion, and accompanied with dryness 
 of the parts, the treatment applicable in the case of rigid os may be 
 tried here also, for there is no doubt that in such a case, warm baths, 
 tartar emetic, chloroform, or chloral hydrate, would have a beneficial 
 action ; and there is no reason that we can see why, in such cases, the 
 
280 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 old -fashion eel treatment by lubricants may not be useful. But there 
 are cases in which rigidity is the cause of rupture ; and when the lat- 
 ter is impending, we may occasionally be justified in making a slight 
 incision with a lancet, or tear with the finger-nail if possible, on each 
 side, as has been practiced by some of the most distinguished accouch- 
 eurs. In this case the laceration which attends the passage of the child 
 is, both in direction and in extent, a matter of very little importance. 
 This is an advice, however, that one is almost afraid to give to the 
 inexperienced, as there is much risk of its being improperly and unnec- 
 essarily resorted to. Cases in which, in the absence of structural dis- 
 ease, rigidity in this situation constitutes an impassable barrier to de- 
 livery are very rare; but they do occur, and, when present, may require 
 free lateral incisions. The treatment of perineal laceration will be re- 
 ferred to in another place. 
 
 When the passage of the head is completed, we should ascertain if 
 the cord is around the neck, and if so, it must be slipped over the 
 shoulders, or pulled down so as to protect the neck from injurious 
 pressure. One hand is to be placed over the fundus uteri, which is to 
 be gently pressed, and followed in its descent by the hand, — a practice 
 which tends to promote the speedy separation of the placenta, Unless 
 there are symptoms of threatened asphyxia in the child, or circum- 
 stances which demand immediate delivery, we should not in any way 
 interfere in the birth of the trunk, which will be naturally effected after 
 a short pause, generally counted by seconds. We must now place the 
 child in such a position as will enable it to breathe freely; and, should 
 efficient respiration not immediately ensue, — the best evidence of which 
 is a loud cry, — it will be our duty at once to adopt such means as are 
 best suited to excite respiratory action. The stimulus afforded by ex- 
 posure to the external air, along with certain centric causes arising 
 from deficient aeration of the blood, are generally sufficient to excite 
 the muscles which contribute to the act; but, should these fail, it will 
 be proper, by blowing on the face, a smart pat on the nates, or sprink- 
 ling with cold water, to set the function agoing without delay. Failing 
 this, the infant should be plunged into a basin of warm water, and 
 cold water plentifully dashed upon it as it is removed from the bath. 
 The tongue should be drawn forward, the mucus rapidly removed 
 from the fauces as far as is possible, and regular attempts at artificial 
 respiration persevered in so long as the slightest action of the heart 
 continues. In cases of suspended animation, the cord should not be 
 tied until it has ceased to pulsate, as there is a possibility, in such cir- 
 cumstances, of a certain amount of placental respiration. The child is 
 also threatened with asphyxia in cases where it is born along with the 
 unruptured membranes, and thus remains, after its separation, en- 
 veloped in its intra-uterine coverings and bathed in the liquor amnii. 
 In this case the membranes must be instantly ruptured, and aerial 
 respiration established. 1 
 
 1 In this case the child is said to be born with a "caul." It is supposed to be 
 indicative of good luck and prosperity, and in seaport towns the caul is carefully- 
 preserved, and is believed by the credulous to be a talisman which protects the 
 wearer from death by drowning. 
 
XVI.] LACERATION OF THE PERINEUM. 281 
 
 The infant being born, and having given proof of its independent 
 existence, our next duty is to ligature and cut the cord. The material 
 to be used as a ligature is a matter of no very great moment, provided 
 it be of sufficient strength, some preferring strong thread, and others 
 an agent which, while it compresses efficiently, is not so incisive as the 
 ordinary surgical ligature, by which the gelatin of Wharton is actually 
 cut. The material preferred by the latter is strong narrow tape, of 
 which the narrow red tape of national tradition affords a good example. 
 The ligature should be placed about two or three inches from the um- 
 bilicus, and should be drawn with sufficient tightness to prevent the 
 possibility of oozing. The knuckles should be brought together, 
 while the knot is being drawn, to steady the hands; for, were the liga- 
 ture to snap, in the absence of this precaution, the funis might be torn 
 from the umbilicus or its placental attachment, and thus give rise to 
 much trouble and some risk. The reason of applying the ligature at 
 such a distance from the umbilicus, is to leave room for another should 
 the first fail. It is usual to apply a second ligature on the placental 
 side of the first, and to cut the cord between the two ; but the advan- 
 tage of the additional one consists entirely in preventing the fluid con- 
 tents of the umbilical vessels from further soiling the bed-linen. In 
 reference to this, Dr. Dewees, who disapproves of the application of a 
 second ligature, observes that " the evacuation from the open extremity 
 of the cord will yield two or three ounces of blood, which favors the 
 contraction of the uterus and expulsion of the placenta." In the case 
 of twin pregnancy, a second ligature should always be applied, as the 
 cords occasionally communicate. The cord may be divided by a pair 
 of blunt scissors, for the more the Avails of the vessels are lacerated, 
 the less likely is subsequent haemorrhage to occur. 
 
 The child being separated and handed to the nurse, there only now 
 remains, to complete delivery, the third stage, or expulsion of the 
 placenta. If the directions above given have been observed, and the 
 fundus uteri followed by the hand, and firmly compressed at the ter- 
 mination of the second stage, little difficulty will be experienced in 
 regard to the speedy and satisfactory termination of the case. If we 
 do not feel that the uterus is firmly contracted behind the symphysis, 
 we may attempt by friction over the fundus to excite it to contraction ; 
 if, on the contrary, it is quite firm, the case may be left absolutely to 
 nature, when expulsion will usually occur in from ten to twenty 
 minutes. But what is, in its results, a much more satisfactory method 
 of procedure is to keep the hand upon the uterus, and to aid its con- 
 traction by means of firm pressure. This method of expression, or 
 squeezing the placenta and membranes out of the womb, has long been 
 practiced by some; but, fortunately, of late years, more particular 
 attention has been directed to it under the name of "Crede's method/' 
 so that this mode of managing the third stage is now becoming — as it 
 ought to be — very generally adopted. In this way, a very few minutes 
 will usually suffice for the passage of the placenta, its ultimate emer- 
 gence being effected by the action of the muscular fibres of the vagina 
 and perineum. Pulling on the cord should always, if possible, be 
 avoided. 
 
282 MANAGEMENT OF NATURAL LABOR. [CHAP. 
 
 [Credos method of delivering the placenta is best performed by 
 seizing the uterus, with the fundus in the hollow of the hand; the 
 four fingers being applied to the posterior, and the thumb to the an- 
 terior surface of the organ. The relaxation of the abdominal walls 
 enables the physician to do this readily, so that he has the organ 
 thoroughly under control. The uterus is then firmly compressed, 
 when the placenta is expelled, sometimes with a gurgling noise. This 
 method of delivering it is especially valuable during an epidemic of 
 puerperal fever, and when the- general practitioner has under his eare 
 diseases which he- fear- might be transmitted to his puerperal patient by 
 inoculation. — P.] 
 
 Should any unusual delay or special difficulty arise, it will then be 
 proper to pass a finger into the- vagina, using the cord a- a guide, in 
 order to ascertain whether or not the separation of the placenta is com- 
 plete. When, with a single finger, we can reach with ease the inser- 
 tion of the cord, we- may infer that the placenta, or at least the greater 
 part of it, i- in I he vagina, and under such circumstances we may 
 attempt to hook down it- edge, at the same time drawing gently on 
 the cord. But when we- find the cord passing up into the uterus be- 
 yond oiii" reach, the edge of the placental mass which presents at the os 
 uteri being alone accessible, we- know that the placenta, although possi- 
 bly completely separated, ha- not as yet been expelled from the uterus; 
 and, after pausing for a few minutes, we again endeavor, by forcible 
 compression applied by both hands to the fundus and sides of the 
 womb — the fingers being directed to the pubes — to awaken the dor- 
 mant uterine energy, to assist such pain- as may be present, or to imi- 
 tate them if absent. It will be necessary, however, in a certain num- 
 ber of instances, to assist nature in the- completion of the deliverance. 
 An intelligent apprehension of the manner in which the placenta is 
 naturally expelled, which is described in the preceding chapter, will 
 prevent us under such circumstances from doing, what is too common 
 in midwifery practice, viz., forcibly pulling on the cord. In a large 
 proportion of cases, the delivery of the placenta may doubtless by this 
 means be effected, it being hauled through like an inverted umbrella, 
 hut \\\<: amount of haemorrhage, at the time and afterwards, which 
 attends such a mode of procedure, is thus very unnecessarily increased. 
 The proper course is to pull down the presenting portion of the pla- 
 centa, using only such traction upon the cord as may assist us in effect- 
 ing this object. Our first efforts of extraction should be made in the 
 axis of the uterus, backwards and downwards. This is to be altered, 
 as soon as the placenta passes into the vagina, to a direction down- 
 wards and forwards, corresponding to the axis of that canal. Should 
 we fail in this attempt, or should there be danger of a portion only of 
 the placenta being removed, it will be proper to introduce cautiously 
 the hand into the uterus to such an extent as may be necessary for the 
 complete extraction of the mass; and, if it should then be found, as is 
 sometimes the case, that morbid adhesions exist, these must be broken 
 down in their whole extent, and the hand, if possible, not removed 
 until the entire placenta is brought with it. Irregular contraction of 
 the uterus may also prevent its expulsion, and of this a familiar variety 
 
XVI.] AFTER DELIVERY. 283 
 
 is described as "hour-glass" contraction, the organ being retained in 
 the upper segment by a constriction. 
 
 When the placenta is expelled, or has been extracted, it is well to 
 look at its uterine surface to see that no portion of it has been left be- 
 hind ; and it is also of importance, as it escapes from the external parts, 
 that the adherent membranes should pass along with it, as otherwise a 
 portion of them may be torn off and left behind in the uterus. With 
 this object in view, we are advised to twist or rotate the placenta as it 
 is passing the vulva, the membranes being thus twined into a sort of 
 rope which renders them less likely to tear. The uterus is now to be 
 examined, and we must satisfy ourselves of its existence in the form of 
 a firm tumor behind the pubes about the size of a child's head. The 
 prepared sheet being now pulled from beneath the woman, and with it, 
 as far as possible, the discharges, she may be allowed to lie on the 
 back, with the legs extended and the knees together. In this position, 
 the condition of the uterus may be still more satisfactorily ascertained, 
 and it is a good plan in practice to place the hand of the patient 
 over the uterus, and instruct her to press gently upon it occasionally, 
 which insures the expulsion of any clots which may be retained, and, 
 in the case of pluriparse, has an excellent effect in moderating after- 
 pains. So soon as we are satisfied with the contraction of the uterus, 
 and the woman has been made comfortable by the removal of the pet- 
 ticoat, and rolling down of the night dress which has thus been pre- 
 served from the discharges, a dry napkin is placed over the pudendum, 
 and the abdominal bandage applied. The object of this bandage, the 
 propriety of which has been disputed, is to afford the uterus and other 
 organs some support, as a substitute for what they have lost in the 
 sudden relaxation of the abdominal walls. If there is any tendency 
 to haemorrhage, it is usual to fold a towel in the form of a pad, and 
 place it beneath the bandage over the uterus, so as to exercise more 
 direct pressure over that organ. Another and subsequent use of the 
 bandage in the hands of a skilful nurse is the preservation of a woman's 
 figure, a matter to her of no little importance. Bandages are often 
 shaped, in which case they have sometimes a T bandage attached to 
 keep the napkin in contact with the external parts. In ordinary prac- 
 tice, nothing is better than a bolster cover, which, when pinned firmly 
 over the abdomen, serves the purpose admirably. 
 
 [There is considerable difference of opinion among American ac- 
 coucheurs in regard to the use of the binder. During the past ten 
 years some appear to be disposed to discard it. The truth appears to 
 be between the extremes in this, as in many other things. Patients 
 generally prefer to have a well-applied binder. It gives them comfort, 
 but unless properly adjusted it does more harm than good. The bene- 
 fits which follow its application are obtainable during the first few hours 
 after delivery. At this time it acts in precisely the same 'manner that 
 the bandage used in the operation of paracentesis abdominis does. 
 After the woman has become accustomed to the changes produced by 
 the discharge of the uterine contents, the bandage has done its work, 
 and may be removed. The widespread opinion among women that 
 it aids in restoring the original outlines of the figure does not call for 
 
284 MECHANISM OF LABOR. [dlAP. 
 
 its continued use. As a rule, compresses had better not be employed, 
 and the bandage should be thin enough to allow the uterus to be felt 
 through it. — P.] 
 
 So soon as the bandage has been applied, and the comfort of the 
 mother otherwise attended to, the nurse is at liberty to dress and 
 attend to the child. The patient must be strictly enjoined to maintain 
 the horizontal position, as fatal cases have occurred in women who had 
 imprudently assumed the erect posture shortly after delivery, and had 
 thus established such haemorrhage as immediately proved fatal. A 
 single glass of sherry or claret with water may be allowed ; but it is 
 truly astonishing how seldom this is necessary, so admirably is the 
 effort even of weakly women compensated for. It is advisable for the 
 practitioner not to leave the house too hurriedly, until he feels confi- 
 dent that all is well, and more especially, that there is no tendency to 
 post-partum haemorrhage. An excellent physiological method of 
 averting the latter, is to put the child early to the breast, which seldom 
 fails to excite reflex uterine contraction ; and this acts otherwise ad- 
 vantageously, although there is no milk in the breasts, by drawing 
 out the nipples. 
 
 CHAPTER XVII. 
 
 THE MECHANISM OF LABOR. 
 
 IDEAS WHICH LABOR INVOLVES — DIFFICULTY AND IMPORTANCE OF THE SUBJECT — 
 HISTORICAL SKETCH : VIEWS OF SIR FIELDING OULD ; OF SMELLIE ; OF SAX- 
 TORPH ; OF SOLAYRES DE RENHAC ; AND OF NAEGELE — NATURAL AND FAULTY 
 PRESENTATIONS — CRANIAL PRESENTATIONS — OCCIPITOANTERIOR AND OCCIPITO- 
 POSTERIOR VARIETIES — FIRST POSITION : PELVIC OBLIQUITY: OCCIPITOFRONTAL 
 OBLIQUITY, OR FLEXION: THE HEAD " AT THE BRIM :" EXAMINATION OF FON- 
 TANELLES AND SUTURES — ROTATION; CAUSES OF — THE "PRESENTATION," OR 
 " PRESENTING POINT" — THE CAPUT SUCCEDANEUM — THE CHIN LEAVES THE 
 CHEST — FURTHER DESCENT AND BIRTH OF THE HEAD — OBLIQUITY AT THE 
 OUTLET — MOULDING — EXTERNAL ROTATION OR RESTITUTION OF THE HEAD — 
 SECOND POSITION : THE CONVERSE OF THE FIRST — RESUME OF MECHANISM IN 
 OCCIPITOANTERIOR POSITIONS. 
 
 The primary idea of Labor comprises three secondary ideas : a body 
 which is to be propelled, a force by means of which the propulsion 
 is to be effected, and a passage through which it takes place. The 
 mechanism of birth thus includes, in its most comprehensive sense, all 
 mechanical questions which spring from the elaboration of these three 
 ideas. The various points connected with the anatomy of the parts, 
 and arising from a consideration of the various forces which contribute 
 to effect the expulsion of the child, having been already fully discussed 
 in preceding chapters, there remains still for careful study, the relation 
 
XVII.] PRELIMINARY CONSIDERATIONS. 285 
 
 which the body propelled bears to the canal during the different stages 
 of labor. It is in this higher though more restricted sense that the term 
 Mechanism of Labor is employed, and a study of this subject includes, 
 therefore, a thorough and critical examination of the physical laws 
 according to which the process of parturition is in the human race 
 effected. 
 
 A knowledge of this section of the subject has been fitly described 
 as the keystone of the art of obstetrics. For, without an intelligent 
 apprehension of the various doctrines involved, the practice of mid- 
 wifery is reduced to a mere handicraft, in which a certain amount of 
 manual dexterity may be attained, but which, under such circumstances, 
 is utterly unworthy of the dignity of a science. We cannot, therefore, 
 too earnestly nor too emphatically, urge upon the student the necessity 
 of mastering at the outset this important subject, upon which a great 
 part of what is to follow is founded. It is not by any means an easy 
 matter, just at first, clearly to understand the descriptions given in 
 books, or to follow at the bedside the process so described. This 
 demands sustained attention, and a perseverance which is apt to be 
 baffled by the peculiar circumstances under which the investigation is 
 conducted. We may here mention shortly what the chief difficulties 
 are, and how they may in some measure be avoided. 
 
 The most effective descriptions, and such as are most useful to the 
 student, are, undoubtedly, those in which unnecessary complication is 
 most scrupulously avoided, and in nothing is simplicity more essential 
 than in the various classifications of labor according to the position of 
 the child within the pelvis. A simple system ought, therefore, in every 
 case to be preferred : in regard to such as are more complicated, it has 
 been well observed that divisions and subdivisions may be multiplied 
 almost at will. The chief difficulty of the beginner arises from the 
 somewhat complex mental process through which alone he can deter- 
 mine the presentation and position of the child in any given case, — a 
 difficulty which the obstetric posture in this country somewhat increases. 
 For not only have we to figure to ourselves the child with its axis 
 inverted — standing, so to speak, upon its head, which is towards the 
 os uteri — but we have also to allow for the posture of the woman, lying, 
 as she does, horizontally, or with the long axis of her body at right 
 angles to that of the accoucheur. Some of this difficulty is avoided by 
 remembering that in almost all cases the right side of the child corre- 
 sponds to the right side of the mother ; that its back is turned to her 
 anterior or abdominal surface, and that its head is downwards in the 
 direction of the os. These are the first points which it is necessary 
 clearly to understand in regard to the anatomical relations of the child 
 in natural labor ; but, essential as such preliminary knowledge is, it 
 has no direct reference to what is known in modern times as the 
 mechanism of labor. 
 
 The facts just stated comprise well-nigh all that was formerly known 
 in reference to the child during labor, and their observation led to very 
 erroneous conclusions as to the manner in which its birth takes place. 
 Until 1741, it was, in fact, assumed that there was no special mechanism 
 of labor beyond the mechanism which attends any vital expulsive act, 
 
286 MECHANISM OF LABOR. [CHAP. 
 
 and that the passage of a fecal mass or a half-organized clot was as 
 little regulated by fixed mechanical laws as was the birth of the child. 
 The universal belief was, that the child lay in the womb with the face 
 directly backwards ; and that, in its descent through the pelvis, it 
 never altered this position in its course from the brim to the outlet, 
 u so that," to use the words of one of the writers of that period, "it 
 seems, when she lies upon her back, to creep into the world on its 
 hands and feet." As in regard to most great discoveries, so in this 
 instance was the development of more correct view T s a gradual process, 
 and the result of the investigations of successive observers. It was 
 from first to last a process, in the case at least of those who contributed 
 in any considerable degree to its advance, of close inductive reasoning, 
 according to which, step by step, during a period of about eighty years, 
 the subject gradually emerged from obscurity. Nothing tends so much 
 to impress upon the mind the great facts which have been disclosed in 
 the course of this investigation, as a narrative of the successive steps 
 by which the truth was ultimately attained ; and we shall, therefore, 
 here*call attention to the more important contributions which have from 
 time to time been made in this direction. 
 
 The honor of the first step in the process of demonstration is un- 
 doubtedly due to Sir Fielding Child, of Dublin, who published to the 
 world, about the date above mentioned, a statement to the effect "that 
 the breast of the child does certainly lie in the sacrum of the mother, 
 but the face does not ; for it always (when naturally presented) is 
 turned either to the one side or the other, so as to have the chin directly 
 on one of the shoulders." The idea here involved is the twisting of 
 the neck, so as to bring the long diameter of the head into parallelism 
 with that of the shoulders, the greatest diameter both of the head and 
 the trunk being thus arranged so as to avoid the limited antero-pos- 
 terior measurement of the brim. The step next in succession was 
 achieved by Sine! lie. This excellent obstetrician, whose work is still 
 deservedly ranked among the classics of English midwifery, confirmed 
 Child's observation that the long diameter of the head occupied the 
 transverse diameter of the brim, as it found, in that direction, the most 
 ample accommodation. But to this he adds, as the result of his own 
 observations, that the long diameter of the head rotates at the outlet into 
 the antero-posterior diameter, which his measurements, allowing for the 
 recession of the coccyx, clearly indicate as the best. In many respects, 
 the views enunciated in this admirable work come much nearer the truth 
 than some of a later date ; and its translation into several continental 
 languages brought the opinions of the author prominently under the 
 observation of the medical schools of Europe. From that time, indeed, 
 no writer of note in any language has failed to pay his tribute of ad- 
 miration to the importance of Smell ie's works, and the genius of their 
 author. 
 
 The work of Smellie found continental obstetrics in a most unfavor- 
 able state as compared with the English school, and provoked much 
 unfavorable criticism. Steadily, however, his ideas gained ground, 
 although considerably disturbed by the excitement of those who joined 
 with Levret in forming what we may term the geometrical school of 
 
XVII.] HISTORICAL SKETCH. 287 
 
 obstetrics, and who believed with their master " that labor was a purely 
 mechanical operation, and susceptible of geometrical demonstration." 
 The ultimate adoption by the most able continental obstetricians of the 
 views of Smellie undoubtedly preceded the brilliant results which a few 
 years later were disclosed, and for which we owe them so much. It 
 was admitted, as proved by Smellie, that there is a determinate relation 
 between the pelvis and the child's head during the whole time of labor. 
 But the point now for the first time disclosed, was that the head passes 
 into the pelvic cavity, in a position which corresponds neither to the 
 transverse nor the conjugate diameter, but is intermediate between the 
 two, or oblique. The names of Saxtorph of Copenhagen, and Solayres 
 de Renhac of Montpellier, are specially connected with the discovery 
 and announcement of this fact, which was published almost simultane- 
 ously by them about 1771. The discovery had, however, been made 
 at an earlier period by Berger, whose pupil Saxtorph had been not later 
 than 1759. Of this, indeed, there is internal evidence in Saxtorph's 
 works, who, far from claiming originality, says in a note to one of his 
 papers on this subject, "In a similar manner, Berger saw the true posi- 
 tion of the head in labor, and imparted it in his lectures." But, how r - 
 ever this may be, it is certain that, but for Saxtorph and Solayres, this 
 great truth would have remained unknown, possibly even to the present 
 day. We have elsewhere 1 stated and fully analyzed the views of these 
 distinguished observers, at a length which is here quite impossible. 
 We may state, however, in general terms, that the discovery with which 
 their names will always be connected, embraces the fact that the long 
 diameter of the head not only occupies in the pelvis an oblique diam- 
 eter, but that it occupies in the great majority of cases the right oblique 
 diameter? Solayres gives, further, an elaborate account of the mech- 
 anism of labor in the different cranial positions, and in this he is fol- 
 lowed by his pupil and enthusiastic admirer, the celebrated Baude- 
 locque; the tendency of both writers being to run into too great elabo- 
 ration in classification and description. Baudelocque seems in some 
 measure to have recognized the rotation which takes place in occipito- 
 posterior positions, the clear demonstration of which is certainly due to 
 Naegele, and the discovery of which is generally attributed to the same 
 writer. Between Baudelocque and Naegele, no name occurs, the men- 
 tion of which is essential to the elucidation of the subject in question. 
 
 In 1818, Professor JNaegele, of Heidelberg, published, on this sub- 
 ject, a small pamphlet, of insignificant appearance, which was, neverthe- 
 less, destined to exercise a greater influence, in regard to this question, 
 on the professional mind than all the ponderous tomes of the hundred 
 years immediately preceding. " No other work of equally small size," 
 as Dr. Tyler Smith well observes, " ever exerted greater influence upon 
 any branch of medicine than that of Naegele upon midwifery. It may 
 
 1 The Mechanism of Parturition. London, Churchill, 1864. 
 
 2 The student will carefully note the fact that, in this work, the two oblique di- 
 ameters take their name "right" or "left" from the sacro-iliac synchondrosis 
 from which they spring. This has already been stated in an early chapter, hut is 
 here repeated, as unfortunately, by some writers, the nomenclature of these diam- 
 eters is reversed. 
 
288 
 
 MECHANISM OF LABOR. 
 
 | ('II A I'. 
 
 be termed, indeed, the Euclid of Obstetrics j but it will nol have exe- 
 cuted its mission until every accoucheur, in each individual case coming 
 before him, entirely masters the position of the foetal head. Nothing 
 less than this should he aimed at by every obstetric practitioner. 
 Without in any way attempting to detract from the merit of Naegele, 
 a meril which will have its recognition so long as medical science has 
 a name, we believe that i\\^ views promulgated by him have been too 
 implicitly believed in and adopted by the majority of obstetric writers. 
 The translation of his essay by Rigby, and the enthusiastic defence by 
 the latter of every theory and doctrine which emanated from his master, 
 produced a powerful impression ; and, in point of fact, from thai time, 
 English writers have, with few exceptions, reproduced, without modi- 
 fication, and as demonstrated facts, the whole of the conclusions of the 
 great German obstetrician. Indeed, it is not too much to say, thai the 
 view generally entertained, even by the ablest writers, amounts t<> this, 
 that the subjeel had been so expounded by Naegele that there was noth- 
 ing further to demonstrate, that every problem and theorem was solved, 
 and that his conclusions were (o he accepted as an absolute solution of 
 all the difficulties and perplexities of the past. 
 
 Some have ventured, however, both in this country and abroad, to 
 demur to this, and to assert that the matter is not yet set at rest, and 
 that the ipse dixit, even of Naegele, is not to be admitted as infallible. 
 And, indeed, it* we rellect as to what w:is (he state of the subjeel when 
 
 he wrote, while acknowledging that there is that in his discoveries 
 
 which merits all the fame which attaches to his memory, we can scarcely 
 
 conceive it possible that one mind could so grasp all the details as to 
 
 make chaos order, and leave no point unassailable, no question unsolved. 
 In forming his conclusions, no one could be more earnest and faithful 
 
 in his observations of nature than Naegelej but, in some respects at 
 least, he was mistaken, and from some of his facts he drew erroneous 
 inferences. To him is due (he whole credit of showing, although he 
 exaggerates it, that the head lies in the right oblique diameter in a. 
 
 preponderance of cases such as had never been dreamed of. I le demon- 
 strated also, what vxvvy modern accoucheur has corroborated many 
 times in his own practice, the rotation which naturally ocours in oc- 
 ci pi to-posterior positions of the head. And he showed that, in ordi- 
 nary labor, the forehead does not rotate completely into (he hollow of 
 the sacrum, but still retains, in a certain degree, its oblique position. 
 Finally, he asserted, and is admitted by most systematic writers to have 
 proved, thai there exists, on the part of the head in its descent through 
 the pelvis, a bi parietal obliquity, according to which one ear is ap- 
 proximated to the corresponding shoulder. We accept, in general 
 
 terms, all liis conclusions, with the exception of the last, to the investi- 
 gation of which we have devoted much time and patience, and conclude, 
 
 unhesitatingly, with Velpeau, Cazeaux, Matthews Duncan, and many 
 
 others (the number of whom is constant ly increasing), that no such bi- 
 parietal obliquity as Naegele described exists as a normal phenomenon 
 of natural labor. 1 
 
 1 To examine critically the views of Naegele <>n this subject would involve Hi 
 introduction of controversial matter quite unsuitable to a systematic treatise. W< 
 
XVII.] 
 
 PRESENTATION. 
 
 289 
 
 Presentations* — The term " presentation " should, as has already been 
 stated, only l>e employed to express the relation which the long axis of 
 the child bears to the axis of the uterus ; and should never be confounded 
 with "position," which is used in another and more restricted sense. 
 We speak, therefore, of presentation of the head, of the breech, of the 
 shoulder, and so on, as representing the part which occupies the os uteri. 
 The presentations may be multiplied to any extent, as there is scarcely 
 a single point on the surface of the child's body which may not, under 
 certain circumstances, oiler itself at the os. In proceeding to the con- 
 sideration of the various presentations which il is necessary specially to 
 describe, and remembering the attitude of the foetus within the womb, 
 we recognize the Pact that il forms an irregular oval. By either end of 
 this oval, delivery may take place naturally, so that we may consider 
 ms Natural Presentations all the varieties known as cranial, breech, 
 knee,and footling cases. When thechild lies transversely, the shoulder, 
 
 Or some oilier part of the superior exl remil y, or, in oilier words, (lie 
 
 side of the oval, — presents ; and, as those cases can rarely be terminated 
 by the unaided efforts of nature, they may be termed Faulty Presenta- 
 tions. The following Table, which is given by Dr. Churchill, will give 
 some idea of the relative frequency of the various presentations, as de- 
 duced from the practice of different individuals: 
 
 Author. 
 
 Total number 
 
 Head Presen- 
 
 Breech Pre- 
 
 [nferlor 
 
 Superior 
 
 of Cases. 
 
 tations. 
 
 sentations. 
 
 Extremities. 
 
 Extremities. 
 
 Mud. Boivin, . . . 
 
 20,517 
 
 L9.810 
 
 872 
 
 288 
 
 80 
 
 Mud. Lachapelle, . 
 
 15,652 
 
 14,677 
 
 849 
 
 K 1V> 
 
 68 
 
 Dr. Joseph Clarke, . 
 
 10,887 
 
 9,748 
 
 61 
 
 184 
 
 48 
 
 \)\. iM.'iiiiiian, . . . 
 
 2,947 
 
 2,786 
 
 78 
 
 40 
 
 1!) 
 
 Dr. d run villc, . 
 
 640 
 
 619 
 
 •j 
 
 8 
 
 1 
 
 Edinburgh Hospital, . 
 
 2,452 
 
 2,225 
 
 17 
 
 8 
 
 4 
 
 Dr. Maunsel, . . . 
 
 889 
 
 786 
 
 — 
 
 21 
 
 l 
 
 Mr. Gregory, . . . 
 
 69] 
 
 645 
 
 II 
 
 7 
 
 1 
 
 Dr. Collins, .... 
 
 16,414 
 
 15,912 
 
 242 
 
 is? 
 
 40 
 
 Dr. Boatty, .... 
 
 L.182 
 
 1,105 
 
 28 
 
 ir> 
 
 I 
 
 M p. Lever, .... 
 
 4,666 
 
 4,266 
 
 59 
 
 29 
 
 12 
 
 Dr. Churchill, . . . 
 
 1,640 
 
 1,119 
 
 86 
 
 22 
 
 !) 
 
 Drs. MoClintockand | 
 
 llnrdy, .... | 
 
 6,684 
 
 5,815 
 
 1 10 
 
 r.l 
 
 26 
 
 Drs. Sinclair and \ 
 Johnston, . . . j 
 
 18,748 
 
 11,874 
 
 809 
 
 ISI 
 
 80 
 
 The enormous preponderance of cranial overall oilier presentations 
 renders a study of the former by far the most important. We shall, 
 therefore, in the first place, direct our attention to the different varieties 
 of cranial presentations. In respect of the difficulties which the student 
 will encounter, in his endeavor to master this subject, i( has already 
 
 feel, however, that Naegele's views have such a hold on British obstetrics, and d» v - 
 mand, as well us deserve, such earnest consideration, that we do not oonsider our- 
 selves justified in passing over with :> simple denial any statement to which he has 
 lent the weight of his great authority, we reproduce, therefore, in the form of an 
 A.ppendix, the reasons which have indue 
 
 point,. (Sec Appendix.) 
 
 P 
 
 id ii> to rejeot Naegele'a dictum on this 
 
 i'.» 
 
290 MECHANISM OF LABOR. [CHAP. 
 
 been confessed that these are not inconsiderable. But it is only at the 
 outset that real difficulty will be met with. With every case we observe, 
 and every minute we devote to the subject, what seems almost insur- 
 mountable at the first glance will melt away. More and more clearly, 
 as we grapple with the minor difficulties which now arise, do we discern 
 the great truths upon which the science and art of obstetrics depend. 
 Having once fairly mastered the subject, we can never forget it, and so 
 habitual and automatic will our observations become, that we shall find 
 ourselves unconsciously adding to our stock of knowledge, and storing 
 up valuable facts which will stand us in good stead in many an hour of 
 difficulty and danger. But, if the student, at this period of his career, 
 fails to acquire the requisite amount of knowledge which enables him 
 to perfect the iactus eruditus, he will most likely never rise beyond 
 mediocrity in obstetrical and scientific knowledge. Success after a 
 fashion he may reach, but his attainments will never much surpass 
 those of an intelligent midwife. Once more, therefore, we would urge 
 upon the beginner, with what emphasis and earnestness we can com- 
 mand, to lose no opportunity of acquiring sound knowledge on so im- 
 portant a subject. Without it, the practice of midwifery is weariness 
 and drudgery ; with it, it is a subject of constant interest, worthy of, 
 and affording ample scope for, the highest scientific acumen. 
 
 As the occipito-frontal or long diameter of the child's head may, in 
 a presentation of that part, lie at the brim of the pelvis in the conjugate, 
 oblique, or transverse diameter, or in any diameter intermediate between 
 these, the number of Cranial Positions may be multiplied to any con- 
 ceivable extent. Admitting the possibility of all of these, we at the 
 same time recognize the fact, which Solayres de Renhac has so clearly 
 demonstrated, that the occipito-frontal diameter of the head of a mature 
 child enters a normal pelvis in one or other of its oblique diameters. 
 This admits of but four cranial positions, depending upon the direction 
 in which the poles of that diameter are turned. In two, the occiput is 
 turned forwards ; and, in two, it is directed backwards : these are called 
 respectively Occipito-Anteriorand Occipito-Posterior. Four positions, 
 therefore, are described, which are termed First, Second, Third, and 
 Fourth : 
 
 f , r , p ... f Head in Right Oblique Diameter; 
 
 n^ DT ™ A^„r, D j Position, | forehead backwards. 
 
 Occipito- Anterior, ■{ ; -^ -, . T - ,,, ,. t^. 
 
 I Second Portion ' Head in Left Oblique Diameter ; 
 
 ^ second fosiaon, ^ f ore head backwards. 
 
 f Third Position i Head in Kight 0bli q uer>iametei ' I 
 Occipito-Posterior J ' * forehead forwards. 
 
 in ,. n -a- f Head in Left Oblique Diameter : 
 forehead forwards. 
 
 1 
 
 [American obstetrical authors and teachers generally describe six. 
 positions of the cranium, three of which are occipitoanterior and three 
 occipito-posterior. They are classified as follows : 
 
 f p . , n ., f Head in Ric;ht Oblique Diameter : 
 
 First Position. < * -u j v 1 j 
 
 | ' \ forehead backwards. 
 
 ~ . ! a , D ... f Head in Left Oblique Diameter : 
 
 Occipito-Anterior, \ Second Position, | foreh ead backwards. 
 
 Head in Antero-Posterior Diam- 
 eter ; forehead backwards. 
 
XVII.] FIRST CRANIAL POSITION. 291 
 
 OCCIPITO-POSTERIOR, 
 
 Fourth Position 
 
 >{ 
 
 Head in Right Oblique Diameter; 
 forehead forwards. 
 „.,,, n ... Head in Left Oblique Diameter ; 
 
 Fifth Position, | forehead forwar l s . 
 
 . ,-. r, ... r Head in Antero-Posterior Diam- 
 
 L Sixth Position, | eter . forehead forvyards.-P.] 
 
 First Position. — The head of the child, which occupies generally, 
 above the brim, a position approaching the transverse, with the face 
 to the right, assumes, as it enters the pelvis, in the great majority of 
 cases, what is called the First Position. The centre of the occiput is 
 turned towards the ilio-pectineal eminence on the left side, while the 
 forehead is directed to the right sacro-iliac synchondrosis. The long 
 diameter of the head thus lies in the right oblique diameter. So soon, 
 however, as the head encounters resistance in its descent towards the 
 cavity, its long diameter ceases to be parallel with the plane of the 
 brim, and nothing can be clearer and more obvious than the advantage 
 which is thus obtained. For this occipito-frontal obliquity not only 
 involves the passage of the occiput in advance of the forehead, in a 
 degree proportionate to the amount of resistance, but, involving as it 
 does a flexure of the neck, it thus enables the propulsive force to 
 operate at a greater mechanical advantage, so soon as the chin becomes 
 applied to the sternum. It is, in fact, the vis a tergo which causes the 
 obliquity, as is most admirably described by Solayres in his account of 
 the position which we are now considering. The propulsive forces 
 which impel the foetus so situated, are communicated, in the first in- 
 stance, to its vertebral column, the articulation of which with the base 
 of the skull is much nearer the occipital than the frontal pole of the 
 long diameter. This of itself, supposing the resistance to be equal all 
 round, would be sufficient to cause the occiput to take precedence of 
 the forehead ; but the movement is further encouraged by the curving 
 of the spinal column through which the force is transmitted. 
 
 No term in midwifery is more loosely used than the expression "at 
 the brim." In reference to this, we observe that the head, in passing 
 the brim, offers, first, the vertex, 1 then its transverse or biparietal 
 measurement, and, lastly, its long or occipito-frontal diameter, so that 
 although a considerable portion of the cranium has passed the brim, 
 and consequently occupies the cavity, it cannot be said to have cleared 
 the brim until the occipito-frontal diameter has passed. A reference 
 to Fig. 102 will render this more intelligible, the line A B there indi- 
 cating the biparietal plane, and that which is marked C D the occipito- 
 frontal plane, w T hich cannot pass the brim until the former has de- 
 scended some little way into the cavity. The occipito-frontal obliquity, 
 or flexion of the head, no doubt, disturbs in some measure the idea thus 
 expressed, but this, we believe, can only take place when the resistance 
 is considerable, and occurs at an earlier stage than usual. We hold 
 the head, therefore, to be "at the brim," in the proper sense of the 
 term, when the long diameter occupies its plane; but as this can only 
 be approximately ascertained, it cannot be held as a definition which is 
 
 1 For definition of this term, see p. 136. 
 
292 
 
 MECHANISM OF LABOR. 
 
 [CHAP. 
 
 practically satisfactory. It is better, however, than using the terra, as 
 many seem to do, without attaching to it any clear meaning whatever. 
 
 IG. 102. 
 
 Cranial planes as they engage in the brim. 
 
 While the head occupies the position indicated in Fig. 103, which 
 we assume to be at the brim — and in which flexion has not as yet 
 occurred — it is scarcely likely that what we have described as the first 
 stage of labor has, as yet, terminated, or even that the os has reached 
 such a degree of dilatation as to admit of a thorough vaginal examina- 
 
 FlG. 103. 
 
 First cranial position. 
 
 tion. In making such an examination at this time, the first point to 
 be remembered is the relation which the finger bears to the uterus and 
 its contents ; for most incorrect views will inevitably be adopted if we 
 overlook the fact that the axis of examination forms, with the axis of 
 the uterus and that of the brim, pretty nearly a right angle. The 
 part of the foetal cranium which is lowest in the pelvis, and which the 
 finger first touches, is the right parietal bone in the neighborhood of 
 its tuber. 1 But, if the finger be pushed farther back, so as to reach 
 
 1 This is one of the points upon which Naegele founded his belief in the exist- 
 ence of bi parietal obliquity. Our reasons for dissenting from this view are fully 
 given in the Appendix. 
 
XVII.] ROTATION. 293 
 
 the point on the surface of the foetal cranium through which the axis 
 of the brim may be presumed to pass, we shall find that this corre- 
 sponds to some point in the line of the sagittal suture, nearer to one or 
 other fontanelle in proportion to the degree of flexion. 
 
 The descent of the head is not, in the first part of its course, in a 
 direction which is identical with what has been described as the axis of 
 the pelvic canal. Its movement is, in fact, directly downwards and 
 backwards in the axis of the brim, until it approaches the floor of the 
 pelvis, and experiences the resistance to its advance arising from the 
 gradual approximation of the ischial planes. Upon the degree of 
 flexion depends entirely the extent to which the occiput is in advance 
 of the forehead. The further dilatation of the os uteri, and the rup- 
 ture of the membranes, now usually admit of more exact observation 
 by the finger, by which the sagittal suture will be found traversing the 
 pelvis obliquely in the right oblique diameter. In the posture in 
 which the woman is lying, therefore, we trace this suture downwards 
 and forwards for a short distance, to a point within easy reach of the 
 finger, where it divides into two branches. This indicates the posterior 
 fontanelle, which the pressure generally renders indistinguishable as a 
 fontanelle by approximation and overlapping of the bones. The two 
 branches are the lambdoidal suture. Following the sagittal suture in 
 the contrary direction, and with reference still to the posture of the 
 patient, the finger travels upwards and backwards towards the right 
 sacro-iliac synchondrosis. It requires some effort to reach the anterior 
 fontanelle, not only on account of its being situated posteriorly in the 
 pelvis, but on account of the flexion, which removes it farther from 
 our reach. Very generally, it can only be reached by subjecting the 
 woman to some pain ; but it is easily recognized by its size and shape, 
 and by the four sutures which run into it. If the right ear can be 
 reached behind the symphysis without causing unnecessary suffering, 
 the direction of its lobe at once reveals the position of the head. 
 
 In consequence chiefly of the approximation of the sides of the pelvis 
 which has been mentioned, the head now undergoes a change in its 
 position. This is effected by the movement which was described by 
 Smellie, and which is known as the rotation of the head. This rota- 
 tion, which is effected gradually, brings the antero-posterior diameter 
 of the head into, or nearly into, the conjugate of the pelvis, so that the 
 occiput looks forwards to the subpubic angle, and the forehead back- 
 wards to the hollow of the sacrum. The recession of the anterior lip 
 of the os beyond the advancing head admits of an easy examination of 
 this process, which an observer may demonstrate for his own satisfac- 
 tion by keeping his finger for a time in contact with the head. As he 
 does so, he will often observe, as the head advances and recedes with 
 successive pains, that the degree of rotation is greatest at the height of 
 a pain, while, as the pain passes off, the head resumes its former posi- 
 tion. The movement may thus be compared to that of a screw, the 
 action of which is alternately direct and reversed. That nature pro- 
 vides for this rotation of the head in labor is made manifest by an ex- 
 amination of the relative measurements of the brim, cavity, and outlet 
 of the pelvis. A question which has given occasion for much specula- 
 
294 MECHANISM OF LABOR. [CHAP. 
 
 tion is the mechanical cause of the rotation. The head, if maintaining 
 its original direction, would simply be arrested at the outlet of the 
 pelvis, its further progress, if of average size, being impossible. In 
 virtue of what law, then, does it so invariably rotate ? 
 
 Some have professed to recognize in the womb itself a rotatory power 
 (vis vertens) by means of which the rotation of Smellie was effected. 
 Others have studied most industriously the mode of action of the 
 various muscles which line the pelvis, believing that in this direction 
 the solution of the problem is to be found ; and by one accoucheur of 
 eminence — Flamand of Strassburg — it was supposed that the action of 
 the obturator internus and piriformis muscles was the cause upon 
 which the phenomenon in question depends. Modern investigation 
 has r however, proved that it is due to the nature of the opposing force 
 which exists at the floor of the pelvis. If we look at the internal 
 lateral surface of the pelvic cavity, as it is here represented, we observe 
 that the tip of the ischial spine is the point which encroaches farthest 
 upon the transverse measurement of the pelvic canal. The head, 
 therefore, as it descends in the right oblique diameter, in the position 
 which we are now studying, arrives at the floor of the pelvis with the 
 occiput in front of the left ischial spine, and, as a consequence, the 
 forehead behind the right spine. Rotation backwards of the occiput 
 or forwards of the forehead is thus effectually prevented. As the pro- 
 pulsive stage advances, the occiput is conducted downwards and for- 
 wards by the inclined plane formed by that portion of the ischium 
 which is in front of and inferior to its spine, and by the obturator in- 
 ternus muscle ; while on the other side of the pelvis, and on a higher 
 level, the forehead is directed by the yielding sacro-sciatic ligaments 
 towards the hollow of the sacrum. These two surfaces, then, are in- 
 clined planes which constitute the female screw, while the male screw 
 is represented by the child's head ; and we fully agree with Dr. Tyler 
 Smith, that "the key to the pelvic mechanism, in an obstetric sense, 
 may be said to be the spinous processes of the ischia." Some writers, 
 it may be here observed, describe a posterior inclined plane of the 
 ischium, which is separated from the anterior by an imaginary line 
 leading from the spine of the ischium in the direction of the ilio-pec- 
 tineal eminence. (See Fig. 15, p. 44.) This they suppose to act, in 
 reference to the forehead, as the anterior plane does with the occiput. 
 No such action can, however, be performed by this plane, as the fore- 
 head impinges upon the spine and margin of the great notch, and is at 
 once conducted to the ligaments along which it glides. 
 
 We have already used the term " Presentation " in its broader signi- 
 fication. There is, however, another sense, in which it is employed by 
 all British and American obstetricians, which here calls for some spe- 
 cial notice, as there unfortunately obtains, in regard to this, as well as 
 other terms in English midwifery, the objection that each writer is left 
 to attach to it his own meaning. The presentation, in the second and 
 more limited sense, is not the part of the child but the actual " point " 
 on its surface which presents ; and, if it be wished to express this cor- 
 rectly, we do not know of a more accurate definition of the term than 
 that given by Professor Hodge of Philadelphia, who describes it as 
 
XVII.] 
 
 OSCILLATION OF THE HEAD. 
 
 295 
 
 - that portion of the foetal ellipse which is recognized toward the centre 
 of the canal of the pelvis and vagina." This is practically the same as 
 that of Dr. Matthews Duncan — " that point on the surface of the 
 child's head through which the axis of the developed pelvic canal 
 passes." But, while admitting these to be mathematically more cor- 
 rect, we must own to a preference for the meaning which is attached 
 to the word by Dr. Tyler Smith, who defines it as " that portion of the 
 foetal head felt most prominently within the circle of the os uteri, the 
 vagina, and the ostium vaginae, in the successive stages of labor." 
 When the dilatation of the os uteri proceeds with unusual slowness, 
 owing to rigidity, or premature rupture of the membranes, the caput 
 succedaneum forms upon the scalp. Under such circumstances, that 
 swelling will be found to occupy, altogether or mainly, the right pari- 
 
 FiG. 104. 
 
 Fig. 105. 
 
 Internal lateral surface of pelvis. 
 
 etal bone. This is, however, no evidence of biparietal obliquity, as 
 the swelling occurs in obedience to the laws of gravity, in the direction 
 of the vagina, where the resistance is least. It is only, however, under 
 circumstances of exceptional resistance, that the swelling alluded to 
 becomes developed at this stage. 
 
 While the head is undergoing the rotatory process above described, 
 no change whatever takes place in the parallelism which exists between 
 its transverse diameter and the plane of the brim. Qua the cavity of 
 the pelvis, the right side is certainly lower, but this is a very different 
 matter from what is asserted by the followers of Naegele. 1 So soon as 
 
 1 This is roughly indicated in the diagram here given. Fig. 105 shows the great 
 amount of lateral obliquity, in reference to the horizon, of the head advancing in 
 the first position in the axis of the brim, the centre of the sagittal suture being 
 exactly midway between the promontory of the sacrum and the symphysis pubis. 
 It shows, also, how, during the whole of this stage of labor, the right parietal pro- 
 tuberance may be described, in general terms, as the part which first meets the 
 
296 MECHANISM OF LABOR. [CHAP. 
 
 a certain amount of rotation has occurred, the vertex descends quite to 
 the floor of the pelvis. The head now becomes exposed to a set of 
 forces quite distinct from those which have, up to this time, been the 
 sole cause of its movements. The tissues which form the floor of the 
 pelvis, although they yield, to some extent, before the advance of the 
 head, constitute by their resiliency an opposing force which, while it 
 effectually bars the further advance of the head in that direction, deter- 
 mines a motion which is the resultant of this and the force from above, 
 and, being intermediate in its direction between these, is consequently 
 downwards and forwards. Solayres called this a reflected force, and 
 describes the mechanism in the following graphic terms : " Hujus 
 motus rationem haud immerito contuleris cum ea, quse nucleus pre- 
 mentes digitos fugit." An illustration of this is familiar to every 
 schoolboy who has propelled a cherry-stone fresh from the fruit, by 
 pressing it between his fingers. 
 
 As the forehead of the child has, in its course along the back part of 
 the cavity, to traverse a curve which is of much greater extent than 
 the posterior surface of the pubis, we would anticipate what actually 
 does take place, — viz., that the chin, before the completion of the 
 movement of rotation, leaves the breast, and that the anterior pole of 
 the occipito-frontal diameter descends, as regards the brim-plane, con- 
 siderably in advance of the other, — this motion being again reversed, 
 at a more advanced stage, as we shall see presently. The successive 
 changes which thus occur in the obliquity of the long diameter are 
 well expressed by Dr. Murphy, when he says that the head may, in 
 the course of labor be described as "oscillating on its transverse 
 measurement." 
 
 From the time at which the head comes under the influence of the 
 reflected force of Solayres, its general direction is altered, and now cor- 
 responds pretty closely with the axis of the vagina. The vagina, or 
 what, in its altered anatomical relations, we may more appropriately 
 call the lower portion of the parturient canal, has a curve for its axis, 
 which we have already demonstrated (p. 42) as continuous with the 
 axis of the bony pelvis. The general direction of this is downwards 
 and forwards, so that the head may be assumed now to move in a 
 direction which forms an approach to a right angle with its original 
 course. The pressure of the head upon the perineum gradually effects 
 the dilatation of the terminal portion of the canal. The left division 
 of the os frontis, in the immediate vicinity of the fontanelle, or the 
 contiguous portion of the parietal bone, presses upon the coccyx, which 
 moves backwards to the extent of an inch, in order to permit of the 
 passage of the child. If the pelvis is at all under the average in point 
 of size, the frontal region is arrested at the apex of the sacrum, and the 
 occipital end of the lever is again driven downwards, so as to press 
 
 finger, or as lowest in the pelvis, advancing, as it does, in the direction of the 
 dotted line, parallel to the axis of the brim. If the head were in the transverse 
 position, the sinking of the parietal protuberance would be still more decided. 
 
 A B. The plane of the brim, meeting the horizon at an angle of 60° at A. 
 
 CD. The axis of the brim, passing through the centre of the sagittal suture and 
 the coccyx, and meeting the horizon at D, at an angle of 30°. 
 
XVII.] THE HEAD AT THE OUTLET. 297 
 
 upon and distend the perineum. If, however, the parts be ample, and 
 the perineum not unduly resistant, this does not occur, and the whole 
 bulk of the head follows the curve of the sacrum at every pain, obviously 
 attempting to effect an exit immediately under the pubic arch. 
 
 From the above description, it is apparent that the occipito-mental 
 or longest diameter of the child's head is never at any time thrown 
 across the pelvis. The moment now approaches, however, at which a 
 new movement must be executed, that of extension, and it is difficult 
 at first to see how this can be effected without the extreme diameter 
 being turned into the conjugate of the outlet. Nature fortunately does 
 not attempt this movement until the occiput is passing upwards in 
 front of the symphysis pubis in the act of birth. The motion of exten- 
 sion is the reverse of the flexion which has been mentioned as one of 
 the earlier mechanical phenomena of labor. The oscillations which 
 the head in its course undergoes on its transverse axis are — first, flexion ; 
 then partial extension prior to rotation ; then flexion, if the forehead 
 be arrested at the apex of the sacrum ; and finally, the movement of 
 exaggerated extension, which is only completed with the birth of the 
 head. The occipito-mental diameter is not at any moment thrown 
 across, and is only released when its occipital pole is born. The occi- 
 put, vertex, forehead, face, and chin successively sweep over the dis- 
 tended perineum, the head continuing its curved axis of motion, and 
 being born upwards and forwards in front of the mons veneris. 
 
 Before Naegele wrote, it was universally believed that the head was 
 born with its antero-posterior measurement accurately corresponding 
 to the conjugate diameter of the outlet. A considerable number of 
 modern obstetricians still hold this view, and it is certain that, in a 
 large number of instances, the head is so born. The Heidelberg pro- 
 fessor taught, however, that the head did not pass into the world after 
 this fashion, but that there existed at the outlet a certain amount of 
 pelvic obliquity, as the forehead did not rotate altogether into the 
 hollow of the sacrum ; and he showed, in addition, that a certain 
 degree of biparietal obliquity is maintained, according to which the 
 right parietal protuberance is, in the first position, born in advance of 
 the left, so that the caput succedaneum is at this stage formed upon 
 the superior and posterior quarter of the right parietal bone, close to 
 the posterior fontanel le. That both of these obliquities generally occur, 
 in what we may call a typical case of normal parts and moderate peri- 
 neal resistance, we believe; but, in asserting that they are essential phe- 
 nomena, such as are the movements of Flexion, Rotation, and Exten- 
 sion, the celebrated author committed an error which his followers have 
 but too faithfully copied. For these obliquities are of comparatively 
 trifling importance, and should never have been bracketed with the 
 other and really important movements. Until he has fully mastered 
 the latter, we should advise the student to take no note of these obliqui- 
 ties. The most recent writers on the subject (Kuneke, Hodge, and 
 Duncan) all dispute the conclusions of Naegele and argue in favor of 
 the parallelism, or, as they term it, " Synclitism," of the biparietal 
 and cervico-bregmatic planes of the child's head, with the planes of the 
 pelvis and the vagina. With reference to the observations of Professor 
 
298 
 
 MECHANISM OP LABOR. 
 
 [CHAP. 
 
 Hodge, it may be remarked that he, his celebrated predecessor Dewees, 
 and, we may add, the American obstetrical school generally, have long 
 repudiated many of the doctrines of Naegele which are still taught in 
 English text-books. Fig. 106 shows the relation which the head, 
 when about to pass in this position, bears to the pelvic structures. 
 
 The head approaching the outlet. 
 First position. 
 
 First position as seen from above. 
 (Schultze.) 
 
 No sooner is the head born than another rotation takes place, — the 
 face of the child turning spontaneously to the right thigh of the mother. 
 This is due to the manner in which the shoulders descend. In Fig. 
 107 we are looking downwards into the cavity of the uterus. It will 
 be observed that the broad, or transverse, diameter of the shoulders 
 and of the breech occupies the left or opposite oblique diameter to that 
 in which the anteroposterior measurement of the head is descending. 
 Upon the birth of the head, the shoulders encounter the same difficulty 
 from the ischial spines ; and, as the rotation must be such as to bring 
 the anterior shoulder, as it did the occiput, under the pubic arch, the 
 left, or posterior shoulder revolves into the hollow of the sacrum. This 
 movement of the shoulders takes place, therefore, in a direction which 
 is the re verse of the previous rotation of the head; so that we may 
 with perfect propriety, look upon the head as resuming the oblique 
 position which it originally held in reference to the pelvis. It has, on 
 this account, been well called the movement of Restitution. There is 
 another phenomenon which should not here be overlooked, inasmuch 
 as it exercises no inconsiderable influence on the progress of labor. This 
 is the moulding of which the head is susceptible, without any risk to the 
 child. The amount of moulding is, of course, proportionate in a great 
 
XVII.] 
 
 SECOND CRANIAL POSITION. 
 
 299 
 
 measure to the resistance, but the head, when born, presents in every 
 instance, a shape which gives it a peculiar, elongated appearance, and, 
 in cases where the caput succedaneura is much developed, this is still 
 further exaggerated. The moulding and pointing of the occipital region 
 is the Hinterhaiqrtspitze of the Germans ; and the form presented is, 
 as will be shown in the sequel, very different from that which is pro- 
 duced in occipito-posterior positions. As soon as the shoulders have 
 escaped, the mechanical difficulties of delivery may be said to have ter- 
 minated ; for the extent to which the parts have been dilated during 
 the birth of the head, will have rendered them more than sufficient for 
 the egress of the parts which remain. The Placenta escapes edgewise, 
 folded as formerly described, and not inverted, as is usually asserted. 
 
 We have, in the above description of the first position, gone pretty 
 fully into detail, in order that the other three positions may be more 
 easily understood. We would recommend the student, before attempt- 
 ing any practical investigation of the facts which have been set forth, to 
 follow the description with the bones in his hand, — by which means 
 only can he thoroughly understand the subject, to the extent which is 
 essential as a preliminary to the intelligent examination of the phe- 
 nomena of actual labor. 
 
 The figure here shown indicates, diagrammatically, the various posi- 
 tions which the child occupies during the successive stages of labor, as 
 
 Fig. 108. 
 
 Diagrammatic representation of successive stages of the first position. 
 
 just described. The representation is supposed to be of a woman from 
 whose body the right half has been removed, leaving the foetus alone 
 untouched. 
 
 Second Position. — This is the converse of the First. As the head 
 
300 
 
 MECHANISM OF LABOR. 
 
 [chap. 
 
 enters the brim of the pelvis, the occiput is turned towards the right 
 ilio-pectineal eminence, the forehead being directed to the left sacro- 
 iliac synchondrosis. This, therefore, like the first, is an occipito- 
 anterior position, the only difference being that it occupies the left 
 oblique diameter instead of the right. It is the left side of the head 
 which presents, and the neighborhood of the left parietal protuber- 
 ance is, therefore, the part which the finger first reaches in a digital 
 examination. The sagittal suture corresponds to the left oblique 
 diameter, so that when the woman is on her left side, the finger passes 
 upwards and forwards, to reach the posterior fontanelle, and down- 
 wards and backwards to reach the anterior. The occipital pole of the 
 
 Fig. 109. 
 
 Fig. 110. 
 
 Second cranial position. 
 
 antero-posterior diameter of the child's head is, as in the first position, 
 driven downwards in advance of the other. It glides, during the ro- 
 tation w r hich succeeds, in a direction downwards and forwards, along 
 the ischial plane on the right side, towards the subpubic arch, while- 
 
 the forehead moves from left to 
 right, along the left sacro-sciatic 
 ligaments, towards the hollow of 
 the sacrum. The head, after com- 
 plete rotation and sufficient dis- 
 tension of the perineum, ap- 
 proaches the orifice of the partu- 
 rient canal, in a position which 
 generally approximates that shown 
 in the annexed figure (Fig. 110), 
 in which a certain amount of left 
 obliquity still exists, and the left 
 parietal protuberance is a little in 
 advance. The face, upon its birth, 
 turns tow r ards the left thigh of the 
 mother, while the shoulders, after 
 passing the brim in the right 
 oblique diameter, are rotating so 
 as to bring the left shoulder under 
 
 Second cranial position at the outlet. tne V U ® lG arc h- 
 
XVII.] RECAPITULATION. 301 
 
 With reference to this external rotation of the head, it must here 
 be remarked, — and the observation applies equally to first and second 
 positions — that the rotation described, in each case, while the rule, is a 
 rule which admits of exceptions. It is, no doubt, true, that an obser- 
 vation of the external rotation of the head may generally be received 
 as evidence — confirmatory, or the reverse — of the diagnosis which we 
 may previously have formed as to its position in the pelvis. But 
 this is by no means invariable, as sometimes, in undoubted first posi- 
 tions, the face rotates to the left, and in second, to the right ; the 
 direction of the movement in each of these cases being a continuation, 
 by the shoulders, of the same screw motion previously performed within 
 the pelvis by the head. Occasionally, as Naegele admits, and probably 
 in cases where the diameters are greater than usual, the shoulders pass 
 in the transverse diameter, and there is no rotation at all ; while in 
 cases rarer still, as is described by Schmitt, "the face of the born head 
 turns itself, first to the one side and then to the other, as if to ask of 
 nature in what direction the descent of the shoulders could best take 
 place." 
 
 Once more let us recapitulate the various movements which the head 
 undergoes in the two Occipito- Anterior positions above described, and 
 note very briefly their mode of action as mechanical aids to labor. 
 
 The general direction followed by the head of the child from the 
 brim to the floor of the pelvis, is that of the axis of the brim. The 
 longer diameter of the oval formed by the head occupies one or other 
 oblique diameter, as it finds in these the longest measurement. 
 
 By the antero-posterior obliquity of the head, not only is the occipito- 
 mental diameter prevented from lying, by any possibility, across the 
 pelvis, but the occipital pole of the occipito-frontal is so depressed that 
 a further and obvious mechanical advantage is gained. This is other- 
 wise called Flexion of the head. 
 
 Rotation is a movement of the head upon its perpendicular axis, 
 according to which its longer diameters are moved into, or nearly into 
 the conjugate of the pelvis, which is at this stage the most ample. This 
 is mainly effected by the anterior ischial planes, and the yielding of the 
 sacro-sciatic ligaments. 
 
 The movement of extension is that which occurs at the moment of 
 birth, its most important object being to admit of the passage of the 
 great occipito-mental diameter without injury to the perineum. It is, 
 like flexion, a movement of the head on its transverse diameter. The 
 chin leaves the sternum of the child as it descends through the pelvis, 
 a certain amount of flexion again occurring if there is much resistance 
 at the apex of the sacrum, but it is only when its head is passing the 
 external parts that the exaggerated movement occurs to which the name 
 Extension has par excellence been given. The general direction of the 
 movement, from the time the head reaches the floor of the pelvis, is 
 downwards and forwards, but the head follows the parabolic curve of 
 the axis of the passage. 
 
 The obliquity (pelvic) of the head at the outlet is probably due to 
 the position of the shoulders ; the biparietal obliquity is accounted for 
 by the head still retaining something of its original parallelism to the 
 
302 MECHANISM OF LABOK. • [CHAP. 
 
 plane of the brim. Neither is of much importance, but the latter, by 
 permitting one parietal protuberance to precede the other, diminishes, 
 to a slight degree, the circumferential measurement of the ostium 
 vaginae at the moment of its greatest distension. 
 
 The external rotation of the head is caused by the rotation of the 
 shoulders in the opposite oblique diameter to that which was occupied 
 by the head. As the result of this is to restore the head, by a move- 
 ment on its perpendicular axis, to its original position, it has been 
 called the movement of Restitution. 
 
 [Third Position. — The occipito-pubic position is very rare, but Ma- 
 dame Boivin, Radford, Dewees, Hodge, and others have met with 
 examples of it. The occiput is found directly behind the pubis. "When 
 the head presents in this position, its cervico-bregmatic diameter is 
 in the conjugate, and the biparietal in the transverse diameter of the 
 brim. The occipito-mental of the child's head, as in the other cranial 
 positions, coincides with the axis of the brim. In most cases this posi- 
 tion is spontaneously converted into a first or second, owing to the 
 projection of the lumbar vertebrae and upper portion of the sacrum. 
 If this does not occur, the first pains produce flexion of the head, im- 
 mediately after which descent commences. The biparietal diameter 
 will readily pass through the transverse of the pelvis, but as there is 
 but little difference between the cervico-bregmatic of the child's head 
 and the conjugate of the Superior Strait, this may occasion some delay. 
 When the head has once passed the brim, however, the progress is com- 
 paratively rapid, as no rotation is necessary. The occiput takes its posi- 
 tion under the arch of the pubis, after which the mechanism of the birth 
 of the head is the same as in the first and second positions after rota- 
 tion has occurred. 
 
 There may be some delay in the birth of the shoulders, as these are 
 apt to occupy a transverse position in the cavity of the pelvis, and their 
 wide diameter to be consequently opposed to the short diameters of the 
 outlet. Finally, however, one shoulder rotates and comes forward under 
 :he arch, after which the labor proceeds as in a first or second posi- 
 tion.— P.] 
 
XVIII.] THIRD CRANIAL POSITION. 303 
 
 CHAPTER XVIII. 
 
 MECHANISM OF LABOR (Continued). 
 
 OCCIPITO-POSTERIOR POSITIONS — THE THIRD CRANIAL POSITION; ROTATES INTO 
 THE SECOND, OR MAY TERMINATE WITH FOREHEAD FORWARDS — THE FOURTH 
 POSITION; ROTATES INTO THE FIRST, OR MAY TERMINATE WITH FOREHEAD 
 FORWARDS — ARTIFICIAL RECTIFICATION OF THESE POSITIONS — COMPARATIVE 
 FREQUENCY OF THE FOUR CRANIAL POSITIONS. 
 
 FACE PRESENTATIONS — DISTINCTION BETWEEN "OBSTETRICAL" AND "ANATOM- 
 ICAL" FACE — MENTO-POSTERIOR AND MENTO-ANTERIOR VARIETIES — FOURTH 
 POSITION : MECHANISM OF — THIRD POSITION — FIRST POSITION ; ROTATES INTO 
 THE FOURTH — SKCOND POSITION; ROTATES INTO THE THIRD — RELATIVE 
 FREQUENCY OF FACIAL POSITIONS — OPERATIVE INTERFERENCE IN — IRREG- 
 ULAR PRESENTATIONS — TABULAR COMPARISON OF CRANIAL AND FACIAL 
 POSITIONS. 
 
 In the two remaining, or Occipito-Posterior positions, the head lies 
 as in the former, in one or other of the oblique diameters, so soon 
 as it fully occupies the brim. The reversal, however, of the frontal 
 and occipital poles of the long diameter of the head here renders 
 necessary the application of mechanical principles, which in some 
 respects differ very widely from those which have been explained as 
 accounting for the phenomena attendant upon delivery in the occipito- 
 anterior positions. This becomes to some extent obvious upon an 
 examination of the cranium itself, and by a comparison of the broad 
 unyielding forehead with the pointed compressible occiput. But, if we 
 observe further the relation which the pelvic cavity bears to possible 
 movements of flexion and rotation, it will at once become apparent that 
 in these positions nature has difficulties to overcome in comparison 
 with which those attending the occipito-anterior positions are probably 
 trifling. What these special difficulties are, we shall attempt to show, 
 noting carefully, at the same time, the means which nature adopts to 
 overcome the impediments which thus arise. 
 
 Third [Fourth P.] Position. — The head in this case enters the brim 
 of the pelvis in the right oblique diameter, with the forehead turned 
 towards the left ilio-pectineal eminence, and the occiput to the right 
 sacro-iliac synchondrosis, as shown in the accompanying figure. On a 
 digital examination, it is the left parietal bone which the finger touches, 
 in the neighborhood of its protuberance, at a point usually a little an- 
 terior to that reached in the second occipito-anterior position. With 
 reference to the posture of the woman, the sagittal suture is traced 
 downwards and forwards, where it ends in the large lozenge-shaped 
 anterior fontanelle; while, in the contrary direction, it may be followed 
 
804 MECHANISM OF LABOR. [CHAP. 
 
 upwards and backwards to where it terminates in the posterior fonta- 
 nelle. This point is of paramount importance in the diagnosis of the 
 position, for when, in any case, we find that the great fontanelle is 
 within easy reach of the examining finger, our suspicions should at 
 once be excited, and the nature of the position carefully ascertained. 
 
 So soon as the head becomes engaged in the brim, one of two things 
 may occur. In the one case, the occiput is driven, by the propulsive 
 force communicated through the spinal column, downwards in advance 
 of the forehead, as in occipitoanterior cases ; in the other, the occiput 
 is arrested, and the force being thus transferred to the frontal pole of 
 
 Fig. 111. 
 
 Third cranial position. 
 
 the long diameter, that pole precedes the other in its descent. Whether 
 the forehead or the occiput thus descends, there is, in the great majority 
 of cases, no barrier to the termination of the labor by the unaided 
 efforts of nature, although such cases are more or less protracted. 
 When the head, therefore, is placed in the third position, the labor may 
 terminate in two ways, either by rotation into the second position, or 
 by the forehead passing under the pubis. As the former is the rule, 
 and the latter a somewhat rare exception, we shall first consider the 
 mechanism according to which, in the great majority of cases, such 
 labors terminate. 
 
 The natural termination of the third position is by a movement 
 which in extent far exceeds the ordinary rotation of the head. The 
 facility with which this occurs depends in no small measure upon the 
 capacity of the pelvis. For nothing is more essential as a preliminary 
 to this movement, than an easy descent of the occiput in the direction 
 of the right sacro-sciatic ligaments; whereas, any difficulty which may 
 exist, from peculiar formation, or contraction of any of the diameters, 
 by arresting this initiatory movement, favors the descent of the fore- 
 head. The more marked the flexion of the head, therefore, and the 
 nearer the posterior fontanelle to the examining finger, the greater is 
 the confidence with which we anticipate a natural and satisfactory 
 rotation. If, as is frequently the case, the head descends quite to the 
 floor of the pelvis before rotation has occurred, depression of the occiput 
 and corresponding recession of the forehead are still the signs which 
 
XVIII.] THIRD CRANIAL POSITION. 305 
 
 point towards rotation. For, in this situation, the forehead, which 
 occupies the anterior inclined plane of the ischium on the left side, 
 cannot, on account of the approximation of the ischial spines, rotate 
 directly in the same pelvic plane. It is essential, therefore, that the 
 forehead should be elevated above the spine of the ischium, and the 
 antero-posterior diameter of the head thus shortened in reference to the 
 pelvic planes. This is precisely what is effected by flexion at this 
 stage ; and if we watch the process with the finger, we observe, in the 
 first instance, that the anterior fontanelle recedes from our finger in the 
 direction of the horizontal ramus of the pubis. The posterior fonta- 
 nelle descends and comes within easy reach, until the flexion is so 
 complete that the occipito-mental diameter approaches the axis of the 
 brim. A rotatory or screw motion of the head now becomes manifest, 
 the forehead moving upwards and backwards on the left, and the 
 occiput downwards and forwards on the right side of the pelvis during 
 a pain ; and the head resuming its former position during the interval. 
 Presently, and often in the course of a single pain, it performs a rota- 
 tion equal in extent to the quadrant of a circle ; and if we now make 
 an examination, we find that the head occupies what was described in 
 the last chapter as the second cranial position. In its normal and 
 natural course, therefore, the third position rotates into the second. 
 
 The rotation thus effected is remarkable not only in regard to the 
 extent, but also in respect of the mechanism by which it is effected. If 
 the mechanism were identical with what obtains in the occipito-anterior 
 varieties, the forehead would, in every case, be directed by the ischial 
 spine over the left ischio-pubic ramus towards the subpubic arch. But 
 the mechanical result of pressure transmitted through the vertebral 
 column is the same in all cases where the pelvic resistance is equal on 
 all sides. The occiput being thus pressed down, the forehead. rises as 
 has been described, and the chin is approximated to the sternum. A 
 point is presently reached at which the whole forehead has risen above 
 the level of the ischial spine, and the rotatory movement commences. 
 The occiput, on the other side, is beneath the right spine, and approaches 
 the centre of the pelvis, being directed downward and forwards, on the 
 right side, by the corresponding margin of the sacrum and coccyx, and 
 the sacro-sciatic ligaments. This is probably the cause of the first 
 effort at rotation, but as soon as the forehead passes sufficiently far back 
 to impinge upon the posterior ischial plane, it at once glides along this 
 to the sacro-iliac synchondrosis, and the rotation is complete. After- 
 wards — the presenting point being as before a portion of the left parietal 
 bone — the case goes on as if it had been from the first a second position, 
 the only difference as affecting the progress of the labor being that that 
 process has now to commence — should it be required — which consists 
 in moulding of the parts, and which, under other circumstances, would 
 already have been in some measure effected. From what has been said, 
 it will be understood that the earlier and the more easy is the descent 
 of the occiput, the more uninterrupted and satisfactory is the course of 
 the labor : in such cases there is in fact no special difficulty, and no 
 additional danger either to mother or child. But, in cases in which the 
 forehead continues to descend, the difficulty of rotation is greatly 
 
 20 
 
306 MECHANISM OF LABOR. [CHAP. 
 
 enhanced, for in that case the preliminary flexion involves the necessity 
 of the occipitofrontal diameter being thrown across the pelvis; and if 
 the measurements generally are small, this can only be effected with 
 considerable difficulty, a difficulty which is increased by a certain degree 
 of moulding, and the formation of the caput succedaneum in an unusual 
 situation. But, even these cases will usually terminate as second posi- 
 tions, more especially if a certain amount of assistance be afforded in a 
 manner to be hereafter described. 
 
 In a small proportion of cases, but certainly much more frequently 
 than Naegele and his followers would have us suppose, the rotation 
 above described does not take place. The forehead, in these instances, 
 sinks ' low T er and lower in the pelvis, and the anterior fontanelle 
 approaches still more closely to the ostium vaginae. A very useful 
 practical distinction was drawn by Dr. Uvedale AY est, of Alford, a 
 veteran practitioner, who has devoted much earnest thought to the 
 subject now in question. Dr. West, recognizing the flexion of the head 
 as an essential element in rotation, proposed that those cases in which 
 the frontal pole of the long diameter remains high, all of which end by 
 rotation, should be called bregmato-cotyloid, while the others, which 
 terminate, or threaten to terminate, with the forehead forwards, should 
 be designated fronto-cotyloid, — a simple distinction of unmistakable 
 importance. 
 
 When the head assumes this fronto-cotyloid position in a well- 
 marked degree, we may be pretty sure that it will end with the fore- 
 head forwards instead of the occiput. But we must not too hastily 
 adopt this conclusion, as cases have been observed in which, at the last 
 moment, when the part presenting had already shown itself at the 
 external aperture, the forehead spontaneously moved up, and delivery 
 was effected, after rotation, in the usual way. The attention of the 
 accoucheur, should he have omitted to notice it previously, may be 
 attracted by the fact that the labor is progressing in an unsatisfactory 
 manner, and that the progress made is quite out of proportion with the 
 expulsive force; and, on examination, he now recognizes the nature of 
 the case with which he has to deal. At this time, the orbits and nose 
 may be easily felt behind the pubis, and as labor progresses the fore- 
 head comes into view. Cazeaux says that the superciliary arch may 
 sometimes be seen, and that on one occasion he saw the upper eyelid. 
 Under the influence of powerful uterine contraction, the occiput is now 
 driven downwards, the head executing thus tardily its movement of 
 flexion. The perineum becomes distended to a dangerous extent by 
 the posterior part of the head. This cannot be relieved, as in the 
 ordinary position, by the movement forward of the occiput, to which 
 the forehead offers no resemblance in shape. The presenting part 
 moves, therefore, somewhat upwards, and to the left, until the occiput 
 passes over the strongly distended perineum. The final movement is 
 performed by an extension of the head — the nape of the neck, pressed 
 against the anterior margin of the perineum, being the centre upon 
 which the revolution occurs which brings the forehead, nose, mouth, 
 and chin, successively from beneath the pubic arch. The motion at 
 this point is precisely analogous to what obtains in first and second 
 
XVIII.] 
 
 THIRD CRANIAL POSITION. 
 
 307 
 
 positions, where the centre of the motion is the subpubic angle, and 
 the forehead and face sweep forward over the perineum. There is 
 certainly in all such cases an increased risk of perineal laceration. The 
 various stages in the mechanism of delivery in this position are shown 
 iii the accompanying diagram. (Fig. 112.) 
 
 Another possible termination of occipito-posterior positions consists 
 in a movement of extension, or rotation of the head on its transverse 
 axis, by which the case is changed into a presentation of the face. And, 
 
 Fig. 112. 
 
 Fronto-anterior termination of the third position. 
 
 moreover, as a rotation such as this would bring the chin forwards — 
 which is, as we shall show, in a face presentation, a quite favorable 
 position — we may assume that such an occurrence would be rather a 
 favorable termination than otherwise to the cases which Dr. West 
 terms fronto-cotyloid. 
 
 Fourth [Fifth P.] Position. — The head, in this position, enters the 
 brim of the pelvis in the left oblique diameter. The forehead is turned 
 towards the right ilio-pectineal eminence, and the occiput to the left 
 sacro-iliac synchondrosis, as shown in Fig. 113. On a digital exami- 
 nation, it is the right side of the head which the finger touches. The 
 sagittal suture, in reference to the posture of the woman, is traced down- 
 wards and backwards to where it terminates in the posterior fontanelle, 
 while, in the contrary direction, the finger follows it upwards and for- 
 wards to the anterior fontanelle. The opinion is very generally enter- 
 tained that, in the fourth position, the engagement of the head is more 
 difficult, and its rotation slower than in the third. It is impossible to 
 avoid the conclusion that this is due, in a great measure, if not entirely, 
 
308 
 
 MECHANISM OF LABOR, 
 
 [CHAP. 
 
 to the rectum, which, by encroaching upon the left oblique diameter, 
 renders it less capacious than the right. The fourth position being the 
 converse of the third as the second is of the first, we find the descrip- 
 tion of the one will serve, mutatis mutandis — reading right for left, and 
 
 Fig. 113. 
 
 Fourth cranial position. 
 
 so forth — in every respect for the other. It may thus terminate in two 
 ways, according as the occiput or the forehead descends. In the former 
 case, the occiput passes below the left, and the forehead above the right 
 ischial spine, so that the fourth position rotates into the first in the natural 
 
 and normal course of such a case, 
 and ends with the occiput under 
 the pubic arch as usual, the right 
 side of the head thus being, during 
 the whole course of the labor, the 
 lowest in the pelvis. In this, as 
 in the third position, a certain 
 number of cases terminate with 
 the forehead under the pubis, the 
 mechanism, in each case, being pre- 
 cisely similar, the occiput usually 
 passing over the fourchette, where- 
 upon the forehead, nose, and chin, 
 sweep successively, backwards and 
 downwards, from behind the pubic 
 symphysis. The position of the 
 foetal head in reference to the out- 
 let of the pelvis is shown in the 
 engraving. If we admit the pos- 
 sibility of conversion of a third 
 position into a face case by rota- 
 tion on the transverse axis of the 
 head, Ave must also admit it in the case of the fourth position. And 
 it is worth noticing that such a rotation would directly, and without 
 further change, convert the position which we are now speaking of 
 into that position of the face which is most frequent in its occurrence. 
 In all cases in which the forehead is born forwards, the ordinary pro- 
 
 Fourth cranial position at the outlet. 
 
XVIII.] FOURTH CRANIAL POSITION. 309 
 
 cess of moulding is reversed, and the head presents a very remarkable 
 appearance, owing to the flattening of the occipital, and bulging of the 
 frontal regions. 
 
 The comparative difficulty which arises from the situation of the 
 rectum constitutes, therefore, as it would seem, the only practical dis- 
 tinction between third and fourth positions. All observers seem to 
 have agreed in this, — that, in the fourth, the rotation takes place as a 
 rule, and probably, on account of this very difficulty, on a higher level 
 as regards the pelvis ; and that, if it descends to the floor of the pelvis 
 with the forehead still directed towards the right obturator foramen, 
 the chances of rotation at this more advanced stage are less than in the 
 third. Rotation, at an early stage of labor, before it is yet practicable 
 to ascertain the actual position of the head with anything like certainty, 
 is probably of much more frequent occurrence than we have any idea 
 of. Few things are more familiar to the experienced accoucheur than 
 a rotatory or rolling movement of the head, which he observes either 
 during a pain or an interval, while it is still high in the pelvis. This 
 is due partly to uterine action, and partly to the movements of the 
 foetus, and we have no doubt that, by this means, many unnatural and 
 faulty positions are rectified even after labor has commenced; and we 
 are further entitled to assume that in this way many ocoipito-posterior 
 positions are rectified at such a stage that their detection is rendered 
 impossible. It should always be remembered that the dorso- or occipito- 
 anterior position of the child is the natural one, and that according to 
 which the irregular oval which it forms is most conveniently disposed. 
 
 Recognizing, as we now do, the natural termination of third and 
 fourth cases as second and first respectively, -a very important practical 
 point arises, which may perhaps be most conveniently discussed at this 
 place. This is the possibility of rectification by artificial means of 
 occipito-posterior positions, which are about to terminate, or threaten 
 to terminate, with the forehead towards the pubis. No possible doubt 
 can exist as to the fact that the position of the head may be, and often 
 has been changed by the operations of the accoucheur. In confirma- 
 tion of this assertion, we have the evidence of the most eminent obstet- 
 ricians. More than a century ago, Smellie, after having repeatedly 
 but in vain attempted to drag the head through in a case of this kind, 
 bethought him of trying to turn the face backwards into the hollow of 
 the sacrum. Success attended his first attempt — a result which " gave 
 him great joy," and opened his eyes to a new field of improvement "in 
 the method of using the forceps in this position." Clarke, Burns, and 
 others, stated that rectification could be brought about in many cases 
 by the use of the finger alone. Among accoucheurs of our own day, 
 Drs. Murphy and West have emphatically expressed their views in favor 
 of the feasibility of this proceeding. 
 
 As regards the period of labor at which rectification may be effected, 
 we find that many writers assume, or at least imply, that the operation 
 may be performed at any stage. The fact is, however, that the head 
 cannot in ordinary circumstances be rotated until it has reached that 
 stage of the labor where nature as a rule spontaneously induces the 
 rotation, so that it will often be a matter of difficulty to say what share 
 
310 MECHANISM OF LABOR. [CHAP. 
 
 in the movement we are to award to nature and what we may claim 
 as the result of oar operative interference. The conclusion with refer- 
 ence to the subject at which we have arrived is that we may succeed in 
 amending the position of the head in two classes of cases. In the first 
 of these, the head is free at the brim, or at least has not as yet encoun- 
 tered any serious pelvic resistance ; and here rotation may be effected 
 by the forceps in a manner which will be more particularly alluded to 
 when we come to speak of the uses of that instrument. In the second 
 class of cases referred to, the head has reached the floor of the pelvis, 
 where we have natural rotatory forces operating in our aid ; but no 
 attempt, while the head is in a situation intermediate between these 
 two, is likely to be attended with success. 
 
 The forceps is quite inapplicable to the class of cases last mentioned, 
 for reasons which are obvious. The surest and safest guidance is to 
 be found in a careful study of the mechanism by which nature at 
 this stage effects the rotation. And if we do so, it will soon become 
 apparent that it is only by imitating or assisting nature that we can 
 hope for success. If we attempt simple rotation, the ischial spines 
 interpose a barrier which it is impossible to surmount; but, if we, on 
 the other hand, take nature for our guide, and assist her in the direc- 
 tion which she indicates, we must employ our whole efforts in promoting 
 the preliminary flexion of the head, which has been fully explained in 
 the description of the third position. With this in view, then, we 
 should press the forehead upwards, in the direction of the ilio-pectineal 
 eminence, on the side in which it lies. This is done most effectively by 
 bringing two fingers to bear upon it and pressing in the direction 
 indicated during a pain. This, in the first instance, will probably have 
 little effect in displacing the forehead, but if we can only succeed in 
 preventing its further descent, we thus transfer in some measure the 
 propulsive force to the occiput, and in a greater or less degree encour- 
 age the essential movement of flexion. After a time, the effect of this 
 will probably become manifest in a recession of the frontal pole of the 
 long diameter. But, should the effort fail, we may, as Dr. West sug- 
 gests, attempt to pull down the occiput by means of the instrument 
 called the vectis, while continuing the pressure with the fingers as 
 before. By one or other method, or by a combination of both, we may 
 often succeed in effecting the natural flexion of the head, until the fore- 
 head is high enough to pass above one ischial spine and the occiput low 
 enough to pass beneath the other, when nature herself will effect the 
 actual rotation, and may be left to complete the labor without any 
 further interference. Madame Boivin seems to have entertained the 
 belief that, in the third position, something may be gained by emptying 
 the rectum so as to facilitate rotation into the second ; and that, as 
 regards the fourth, a distended rectum is rather an advantage than 
 otherwise, inasmuch as it would tend to prevent the movement of the 
 occiput into the hollow of the sacrum, and so indirectly encourage the 
 rotation into the first position, which we desire to promote. 
 
 [Sixth Position. — In this position the occiput is directed to the 
 sacrum and the forehead to the pubis. It is very rare. Dewees met 
 with three, and Meigs with two cases. In most instances it is sponta- 
 
XVIII.] OCCIPITO-POSTERIOR POSITIONS. 311 
 
 neously converted into a fourth or fifth position, owing to the convexity 
 of the occiput, which constantly tends to throw the head to the right 
 or left side of the projection formed by the junction of the sacrum and 
 lumbar vertebras. When the position persists, the eervico-bregmatic 
 diameter of the head is in the conjugate of the superior strait, and the 
 biparietal in the transverse. Flexion being completed, the head 
 descends without rotation until the occiput is delivered, after which 
 backward extension of the head brings the forehead and face into the 
 world as in fourth and fifth positions which terminate in posterior 
 rotation. 
 
 Either shoulder may come under the arch of the pubis, after which 
 the mechanism of delivery is similar to that of the third position. In 
 the former case, however, the occiput rotates forwards, and in the latter 
 backwards, to effect this. — P.] 
 
 While the four positions which have now been described are all 
 which we think it necessary to specify in detail, there can be little 
 doubt that, under exceptional circumstances, others may be met with. 
 The accidental position, for example, of the head in the conjugate or 
 transverse diameters of the brim has, in the opinion of many approved 
 authorities, warranted them in adding four more, making eight posi- 
 tions in all. We apprehend, however, that the mechanism, in such 
 rare instances as may be met with of conjugate or transverse as primary 
 positions, does not call for any special description, and that to admit 
 them would be unnecessarily to complicate a subject already beset with 
 sufficient difficulties. Both of the positions indicated would, in a normal 
 pelvis, inevitably be resolved into one or other of those which have 
 been described, and would thus terminate according to the laws which 
 we have attempted to elucidate; while, if they were the result of ab- 
 normal disproportion of the parts, they would come under the influence 
 of special laws, which it is no part of our object at present to explain. 
 We take no notice, it will be observed, of premature birth or putridity 
 of the foetus, in which the child may pass in any diameter; but even 
 here the tendency is to follow the natural course. 
 
 We have now to consider the subject of the Comparative Frequency 
 of the cranial positions. It may be considered that this ought to have 
 been referred to at a somewhat earlier stage. We have, however, pur- 
 posely postponed it until now, as considerations arise, in reference to 
 points not yet fully determined, which can only be understood by those 
 who are in possession of the facts which have been detailed in this and 
 the preceding chapter. It is to be regretted that no inconsiderable dif- 
 ferences of opinion, on many of the points referred to, have arisen in 
 consequence of the views of Naegele having been implicitly received, 
 while yet they have obviously lacked confirmation. 
 
 From the time of Smellie, the first position has been universally 
 admitted as that which is by far the most frequent. Until the publi- 
 cation of Naegele's celebrated essay, there was a similar unanimity 
 among obstetricians as to the second position being next in point of 
 frequency to, and in all respects the converse of the first ; but the effect 
 of his researches upon the minds of all modern practitioners has been 
 to modify greatly, and in most cases entirely to overthrow, the conclu- 
 
312 
 
 MECHANISM OF LABOR. 
 
 [CHAP. 
 
 sions of his predecessors on this point. In order to avoid a mass of 
 statistical details, we shall only attempt here to compare the conclusions 
 of Naegele, and of those who agree with him, with the results attained 
 by some modern observers who differ from him more or less widely. 
 It is beyond doubt that his original doctrines are, to the present day, 
 more fully believed in this country than in France, America, or even 
 in Germany ; and this is obviously due to the fact that many of our 
 most eminent accoucheurs have taught and still teach these doctrines, 
 while some believe that they have confirmed their accuracy by subse- 
 quent research. All this is shown in the following tabular analysis; 
 but it is therein further made .evident that there are many men of un- 
 doubted talent and experience who decline to accept the evidence even 
 of Naegele as of greater weight than that of their own senses. The 
 following table shows the percentage of each of the four cranial positions, 
 as deduced from the published statistics of the observers quoted : 
 
 
 First 
 Position. 
 
 Second 
 Position. 
 
 Third 
 Position. 
 
 Fourth 
 Position. 
 
 Not 
 Classified. 
 
 Naegele, 
 
 Naegele, the younger, 
 Simpson and Barry, . 
 
 Dubois, 
 
 Murphy, 
 
 Swayne, 
 
 70. 
 
 64.64 
 
 76.45 
 
 70.83 
 
 63.23 
 
 86.36 
 
 ' '.29 
 2.87 
 
 10.18 
 9.79 
 
 29. 
 32.88 
 22.68 
 25.60 
 16.18 
 1.04 
 
 ' '.58 
 
 .62 
 4.42 
 
 2.8 
 
 1. 
 
 2.47 
 
 By means of this tabular arrangement, we see at a glance the extent 
 to which, apparently, one observer differs from another, but we must 
 look a little closer at the figures to discover their true import, In the 
 first place, we may observe that the two Naegeles regarded the second 
 and fourth positions as so exceptional that they did not include them at 
 all in their system of classification, contenting themselves with the as- 
 sertion that, when present, there were either some special circumstances 
 which induced the irregularity, or that the observations w T ere not made 
 sufficiently early in the labor. The elder Naegele, indeed, says that, to 
 positions of the third kind, those of the face come next in point of fre- 
 quency, while the second is classed by him with the conjugate variety as 
 rarest of all. The younger Naegele, again, who, while he enters into 
 statistical details much more deeply, repeats and corroborates his father's 
 doctrines, lays himself open in more than one place to criticism, in respect 
 of the manner in which he disposes of his statistics to suit his own views. 
 He states, for example, that his conclusions are based on 3795 cases of 
 cranial presentation, but instead of placing these fairly under the four 
 heads which constituted essentially the classification of the German 
 school, he coolly says : "After deducting 94 cases, in which the original 
 position of the head could not be made out on account of various cir- 
 cumstances, we have 3701 carefully observed cases of cranial presenta- 
 tion." Now, these 94 cases form nearly two and a half per cent, of 
 the whole, and if divided, as we cannot doubt they ought to have been, 
 between the positions numbered second and fourth, would have brought 
 the statistics of Naegele very near to those of Dubois, whose observations 
 
XVIII.] STATISTICS OF CRANIAL POSITIONS. 313 
 
 accord perhaps as closely as those of any other with the prevailing ideas 
 of the present day. 
 
 The statistics of Simpson and Barry confirm the conclusions of 
 Naegele more closely than any others ; but it will be observed that a 
 certain percentage of second and fourth presentations is admitted, which 
 becomes more marked in the figures of Dubois. 
 
 The conclusions arrived at by the two observers whose names are 
 placed last upon the list, indicate a startling discrepancy witli the 
 results given above, and are of themselves sufficient to show that the 
 doctrines of Naegele are by no means definitely settled. Dr. Murphy's 
 conclusions are the result of a careful personal observation, in the 
 Dublin Lying-in Hospital, of sixty-eight cases of cranial presentation, 
 in which he found the second position to occur as frequently as the 
 third. His conclusions may at first seem to be less satisfactory than if 
 they had been based upon a larger number of observations ; but, at the 
 same time, we must admit that the results obtained by so able and ex- 
 perienced an accoucheur as Dr. Murphy, should be held as more likely to 
 be correct than when the observations on which statistics are founded 
 are intrusted in a great measure to others. The experience of Dr. 
 Swayne shows a larger number of cases of first position than any other 
 observer, and in other respects his deductions are still more strikingly 
 opposed to the idea generally received. Reverting to the opinion held 
 before Naegele, he believes that in point of frequency the second comes 
 after the first, and that the fourth is more frequent than the third, an 
 opinion in which he is supported by Professor Millar of Louisville. In 
 the table above given we have avoided extremes, or we could have given 
 statistics which have been offered in proof of assertions which are, as 
 regards the views of Naegele, more contradictory still. 
 
 In attempting to reconcile statements so conflicting, we cannot fail 
 to become convinced of the fact that, even in the most experienced 
 hands, it is no easy matter to determine the position of the head in 
 the early stage of labor. It is not to be conceived that all the ob- 
 servers above quoted can be right. It is equally clear that nature 
 must have some law, according to which the head of the child enters 
 and passes through the pelvis of the mother. But is it in our power to" 
 determine what is this law of nature, and in what this or that observer 
 has erred? Can we so reduce the law to statistical results, as to place 
 the matter forever on the basis of irrefragable evidence ? He would 
 be a bold man who, in the present state of the art, would venture to 
 answer these queries in the affirmative. For our part, we are con- 
 vinced that there is ample room for renewed observation and research ; 
 but unless a man can bring to bear upon the subject a mind un warped 
 by prejudice or preconceived ideas, his testimony will be of little avail. 
 Take by way of example of this, the second position. Who has not 
 been summoned again and again, to the bedside of a woman in labor, 
 to find the head in the lower third of the pelvis, and in the position 
 in question ? In such a case the disciple of Naegele would probably 
 record in his note-book, a A case of third position, in which rotation 
 had occurred before my arrival." He is driven to this conclusion, if 
 he adopts Naegele's theory, but yet, as regards the individual case, the 
 
314 MECHANISM OF LABOR. [CHAP. 
 
 evidence is Naegele's and not his. Or, again, if quite early in labor he 
 finds the head undoubtedly in the second position, he classifies it las 
 irregular, and assumes the presence of some of the "various circum- 
 stances" in which only, says Naegele, this position can occur. To.be 
 candid, however, we must admit of the possibility of a mistake which 
 is the converse of this, and which would be committed by him who 
 should rank every case as second, without any reference to the stage at 
 which the first examination is made. It must, we think, be manifest, 
 that correct conclusions on this subject can only be based upon a large 
 number of observations, in which the position of the head is ascer- 
 tained in every case at the beginning of the labor, or before it expe- 
 riences any pelvic resistance further than that which is due to gravity. 
 
 Granting that the first position is by far the most frequent, occurring, 
 as it does, in nearly 70 per cent, of all cranial presentations ; and, 
 granting further, as we do, that Naegele's discovery — that the third is, 
 as a primary position, next to the first in point of frequency — is correct, 
 we are persuaded that both second and fourth cases occur more fre- 
 quently than is generally supposed, — certainly much more frequently 
 than Naegele would have us believe. We are inclined to think that, 
 by striking an average between the percentage yielded by the statistics 
 of Dubois and Murphy respectively, we should come very near the 
 truth. 
 
 The proportion thus deduced stands nearly as follows : 
 
 First Position. Second Position. Third Position. Fourth Position. 
 
 67 10 20 3 
 
 The second cranial position is, in all respects, both as regards pelvis 
 and cranium, the exact converse of the first, and it is difficult to account 
 for its comparative infrequency on any other ground than the presence 
 of the rectum on the left side. It is somewhat strange that Naegele 
 should reject this theory as improbable, as it is very obviously in favor 
 of his argument that all cases, almost without exception, lie originally 
 in the right oblique diameter ; but perhaps we should, instead of being 
 surprised at this, take it as evidence of his impartiality. Whether the 
 rectum may, or may not, have an influence in determining the original 
 position, it is clear that it bears practically on the progress of labor, 
 especially if distended. But, even should it be empty, it is conceivable 
 that the thickness of the coats of the bowel may tend to make a tight 
 fit tighter. 
 
 The proportion of occipito-posterior positions which end with the 
 face to the pubis is, for obvious reasons, very difficult to determine. It 
 is not to be wondered at, perhaps, that great difference of opinion exists 
 as to the proportion of cases which perform the usual rotation back- 
 wards; but it is a little astonishing that the actual number of cases 
 ending with the face forwards should be overlooked or misunderstood. 
 Naegele did not believe in the face-to-pubis termination of such cases, 
 except under peculiar circumstances, — such as a small head or a large 
 pelvis, — but there are probably few accoucheurs of large experience, 
 who take the trouble to observe what passes under their eyes, but have 
 met with such cases, there being no peculiar circumstances whatever to 
 
XVIII.] FACE PRESENTATIONS. 315 
 
 account for them. Drs. Simpson and Barry came to the conclusion 
 that, in the third position, spontaneous rotation occurred in 96 per 
 cent.; while, still more recently, Dr. West found that in 481 cases 
 observed by himself, 15 third cases were born, or were about to be born, 
 with the forehead in advance ; but these included, it must be remem- 
 bered, cases in which he rectified artificially the position of the head, 
 on the assumption that, had he not interfered, they would certainly 
 have terminated with the face to the pubis. In regard to rotation in 
 the fourth position, the number of cases observed is so small that no 
 reliable data are to be found ; but the impression generally prevails, 
 that spontaneous rotation, in such cases, is effected with greater diffi- 
 culty, and the tendency to fronto-anterior termination is thus propor- 
 tionally increased. 
 
 ■Face Presentations. — The only other varieties of possible presenta- 
 tion of the cephalic extremity of the child which it is necessary hereto 
 consider are the various positions of the Face. These occur about once 
 in 230 cases. The causes which lead to this unusual occurrence are 
 not well understood, but the initiatory movement which results in the 
 position can only be, as is obvious, a movement of extension which, at 
 an early stage of labor, or prior to its occurrence, is substituted for the 
 usual movement of flexion occurring during labor in the ordinary posi- 
 tions of the cephalic extremity. In other words, and to take the most 
 simple view of the matter, cranial are converted into facial positions by 
 a simple movement of the head on its transverse axis. As, in this and 
 other respects, there is a very close analogy between the mechanism of 
 face and vertex presentations, we introduce the subject of the former at 
 this place from a conviction that it will be much more easily under- 
 stood if studied along with the ordinary cranial positions. 
 
 In pursuing the analogy which exists between the face and the vertex, 
 we note, in the first place, that the " obstetrical " differs from the 
 " anatomical " face in including the forehead. The long diameter of 
 the face, therefore, which extends from the centre of the forehead 
 between the frontal protuberances to the tip of the chin, corresponds 
 to the occipitofrontal diameter; and, in like manner, the transverse 
 diameter, from one malar bone to the other, corresponds to the bi- 
 parietal measurement of the cranium. We observe, further, in looking 
 closely at the facial oval, that the pointed chin represents the occiput, 
 while the forehead is, in each position, the broad end of the long 
 diameter. A premature and exaggerated movement of extension of 
 the head having thus, as we conjecture, converted a cranial into a facial 
 position, we find that in its descent and birth, it follows the same me- 
 chanical laws as those which govern the vertex. Movements are thus 
 executed, which in every stage correspond to those already described, 
 with this important distinction, that the relation which they bear to the 
 trunk of the child is in some respects reversed. This will become 
 apparent as we proceed. The face, like the head, and for similar 
 reasons, descends into the pelvis with its long diameter in one or other 
 of the oblique diameters of the brim. There are thus four positions in 
 which we may find the face, according as the presentation may have 
 been originally a cranial position of the corresponding number. It 
 
316 . MECHANISM OF LABOR. [CHAP. 
 
 will be observed, however, as a most important distinction, that the 
 numbers of the Mento- Anterior variety do not correspond to the oc- 
 cipitoanterior of the cranium. Each presentation as numbered is, we 
 repeat, supposed to be produced from the corresponding cranial position, 
 by a simple movement on its transverse axis. 
 
 M ENTO-POSTERIOR, 
 
 Mento- Anterior, 
 
 v , D ... f Face in Ri<rbt Oblique Diameter 
 
 Jb irst Position, { r , ,=?. -, H 
 
 ' I ioreliead lorwards. 
 
 Second Position, \ F " ce ] n L * ft 0bl ^ ue Di « meter 
 
 ' ( ioreliead forwards. 
 
 rm • 7 r> -j- f Face in Ri<rbt Oblique Diameter 
 
 iliird Position, { .. , . P , \ 
 
 ' ( Ioreliead backwards. 
 
 xt, , 7 D ... f Face in Left Oblique Diameter 
 
 Jbourth Position, < ,. , -, T , M . 
 ( ioreliead backwards. 
 
 The chin, in all these positions, being looked upon as the mechanical 
 equivalent of the occiput, it follows that the Mento-Anterior varieties 
 in which the front of the child is turned forwards, are the natural 
 terminations of all face cases. This, indeed, is the case in a much 
 stricter sense than in presentations of the cranium, for reasons which 
 will appear presently. We shall, therefore, in the first instance, con- 
 sider these two positions ; and, as the fourth is the one which occurs 
 most frequently, we shall commence with it. 
 
 Fourth Position of the Face. — Although it is not the usual course in 
 these cases, we are entitled to assume it as possible that this position 
 may be produced from the fourth of the cranium by a movement on its 
 transverse axis, which brings the chin towards the right ilio-pectineal 
 eminence, the head being extended so as to bend the occiput towards 
 the nape of the neck. The long diameter, indicated by the direction 
 of the nose, lies in the left oblique diameter, with the forehead towards 
 the left sacro-iliac synchondrosis. The finger, on an examination, first 
 reaches the right malar bone, which is the part deepest in the pelvis, 
 and the presentation itself is made out by feeling the nose, mouth, and 
 other features, care being taken not to injure these delicate parts by 
 rough and careless manipulation. The long diameter descends ob- 
 liquely, with the chin in advance, in proportion to the degree of resist- 
 ance. The caput succedaneum will be found to involve the right malar 
 bone, the right angle of the mouth, and the parts immediately adjoin- 
 ing. When the face reaches the floor of the pelvis, the chin is directed 
 by the right ischial spine downwards and forwards, along the corre- 
 sponding anterior ischial plane, while the forehead glides along the left 
 sacro-sciatic ligaments towards the hollow of the sacrum, precisely as 
 in the second cranial position. Having reached the perineum, and 
 probably still retaining a certain degree of pelvic obliquity, the chin 
 now moves forward under the pubic arch. The perineum becomes 
 distended, and the chin having moved sufficiently forwards to release 
 the mental pole of the occipito-mental diameter, the emergence of the 
 head takes place by a movement of flexion, the face being born forwards 
 and upwards as the nose, forehead, vertex and occiput successively 
 sweep over the perineum — all of which takes place with no greater 
 difficulty than in an ordinary cranial position. The shoulders having 
 descended in the right oblique diameter, the right shoulder is lowest 
 
XVIII.] VARIOUS FACIAL POSITIONS. 317 
 
 and in front. This part, therefore, is, in its turn, rotated from left to 
 right, along the anterior plane of the left ischium, while the left shoulder 
 retreats into the hollow of the sacrum ; and in this position they pass, 
 as has already been fully described, under cranial positions, a corre- 
 sponding movement of restitution being at the same time performed 
 by the head. The trunk and breech follow as under ordinary circum- 
 stances. 
 
 Third Facial Position. — In this the mechanism is precisely similar 
 to that which has just been detailed. The face, however, lies in the 
 right oblique diameter, the forehead being to the right sacro-iliac syn- 
 chondrosis, and the chin in the direction of the left ilio-pectineal emi- 
 nence. The left side of the face is lowest in the pelvis, and it is on 
 this that the caput succedaneum forms. The chin descends, and rota- 
 tion takes place as in the former case, only in the contrary direction, 
 the details of the process being in every respect similar. 
 
 First Facial Position. — In this, and in the remaining position, the 
 prominence of the chin is turned backwards. Following the method 
 which we have adopted with the view of maintaining as closely as pos- 
 sible the analogy subsisting between facial and cranial cases, we ob- 
 serve that the Mento-Posterior positions correspond closely with the 
 fourth and third cranial. As in the mento-anterior variety, we may 
 accept the chin as representing the occiput. The First Facial Position 
 is produced from the first of the head, by a movement of extension. 
 Its long diameter corresponds, therefore, to the right oblique diameter 
 of the pelvis, the chin being directed to the right sacro-iliac synchon- 
 drosis, and the centre of the forehead towards the left ilio-pectineal 
 eminence. The chin thus occupies the position where the occiput lies 
 in a third cranial position. The part which is lowest in the pelvis, 
 and which the finger feels from the vagina through the anterior walls 
 of the uterus, is the right malar bone. If the os is sufficiently dilated, 
 we may feel through it the bridge of the nose. Carrying the finger, in 
 reference to the position which the woman occupies, downwards and 
 forwards, we may reach the forehead, the frontal suture indicating the 
 path from the bridge of the nose to the anterior fontanelle ; w r hjle, by 
 passing it in the opposite direction, upwards and backwards, we may feel 
 the ridge of the nose, and the mouth, where the alveolar ridge may be 
 distinguished, and ultimately reach the chin. Should the resistance of 
 the os, at this stage, be such as to cause the development of a caput 
 succedaneum, it will be found to occupy the upper half of the right 
 side of the face, and will generally, to some extent, involve the eye. 
 
 With regard to this position, the same observation may be made as 
 in regard to the third of the cranium, — that it may terminate in two 
 ways : with the chin towards the hollow of the sacrum ; or, by a rota- 
 tion forwards, which, by bringing the chin upon the right anterior 
 ischial plane, converts it into the fourth position, already fully described. 
 Although Smellie, and many writers of merit since him, describe cases 
 of facial presentation in which the chin passes into the hollow of the 
 sacrum, and is born over the perineum, it is only with difficulty that 
 we can admit — for reasons which will be detailed afterwards — a bare 
 possibility of such a termination of labor by the natural efforts. The 
 
318 
 
 MECHANISM OF LABOR. 
 
 [CHAP. 
 
 head, therefore, adopts a course very similar to what obtains in third 
 cases of the cranium. As in the one case the occiput, so in the other 
 the chin descends, prior to rotation, somewhat in advance of the fore- 
 head. The fronto-mental diameter being, however, more than an inch 
 less than the occipitofrontal, the same degree of obliquity is not neces- 
 sary as an essential preliminary to rotation. And it is fortunate that 
 it is so, for the head is already so strongly extended that a further 
 extension seems all but impossible. In the course of the rotation, the 
 chin comes in front of the right ischial spine, while the forehead moves 
 upwards and backwards towards the left sacro-iliac synchondrosis, and 
 the case is thus converted into what we have already described as the 
 fourth position of the face. The rotation, therefore, which converts 
 
 Fig. 115. 
 
 Diagram showing successive stages of rotation and delivery in the first facial position. 
 
 the first facial into the fourth is, if we read "chin" for "occiput," 
 essentially the same as occurs when the third of the vertex rotates into 
 the second. Less obliquity of the long diameter of the face being re- 
 quired, the rotation of the face takes place with greater ease, which is 
 another reason why we should look upon this as the only natural termi- 
 nation of that position of the face which is the result primarily of a 
 movement of extension of a head occupying the first position of the 
 vertex. The accompanying diagram (Fig. 115) shows the various 
 stages alluded to. 
 
 Second Facial Position. — In this, which is the converse of the first, 
 the face is in the left oblique diameter, with" the chin to the left sacro- 
 iliac synchondrosis, and the forehead to the right ilio-pectineal eminence. 
 
XVIII.] VARIOUS FACIAL POSITIONS. 319 
 
 The chin, therefore, lies in the direction which the occiput occupies in 
 the fourth cranial position, and the part which is lowest in the pelvis is 
 the left malar bone. The normal and almost invariable termination of 
 such a case is a rotation analogous to what is observed in the fourth 
 position of the vertex. The chin in this way becomes applied to the 
 left anterior ischial plane, along which it glides as in what we have 
 described as the third facial position, so as to bring it under the arch 
 of the pubis, where the labor is terminated in the usual way. 
 
 The relative frequency in the occurrence of the various positions of 
 the face might not unnaturally admit of considerable difference of 
 opinion. For, if the ordinary positions of the cranium, which are so 
 familiar to us, still admit of doubt in this respect, it is not to be 
 wondered at, that doubt may still attach to this rare and, as some term 
 it, faulty presentation. If we are correct in assuming, what is very 
 generally admitted, that presentations of the face are the result, in the 
 corresponding positions of the vertex, of a simple movement of the 
 head on its transverse axis, the numbers which we have attached to the 
 various facial positions have a special significance in indicating the 
 original position of the head. But there the numerical correspondence 
 ceases. For, the more closely we look at the relation which the one 
 presentation bears to the other, the more obvious does it become that 
 the chin is mechanically the analogue of the occiput, and that, there- 
 fore, the anterior surface of the foetus is turned forwards in all face 
 cases which are to be regarded as normal. In cranial positions on the 
 contrary, the back is, as a rule, turned forwards. This, while it so 
 far destroys the analogy between the two classes of cases, establishes 
 between them more important practical points of resemblance ; for our 
 object is, in any assistance which we may consider ourselves justi- 
 fied in offering, to bring the occiput forward under the pubic arch in 
 cranial positions, so in these also we may use what means we can, with 
 the view of aiding in a similar way the descent and precedence of the 
 chin. The aphorism of Roederer might, in fact, if we substitute the 
 word "mentum" for " occiput 7 ' be admitted as the leading principle 
 upon which nature conducts all such labors. " Indifferens est quisnam 
 sit capitis positio, modo pars conica atque arctissima, mentum nempe, 
 descendat." 
 
 In point of relative frequency, therefore, we must speak with some 
 caution. No doubt can exist with reference to the fact that the third 
 and fourth, or men to-anterior, positions are the natural terminations of 
 all face cases. In what proportion of these, third and fourth positions 
 of the cranium have become directly transformed, as we have conjec- 
 tured, into the corresponding facial positions, it is, and probably from 
 the rarity of the cases always will be, impossible to determine. That 
 such a transformation is possible, no one can deny ; that it is proba- 
 ble, we will venture to assert. And, moreover, should it so occur, the 
 change of a fronto-anterior position of the cranium into a mento-anterior 
 of the face must be looked upon as a much more favorable termination 
 of a labor, than the tedious process already described which, in a cer- 
 tain proportion of such cases, brings the occiput over the fourchette 
 before the face can pass from under the pubis. It is on this ground, 
 
320 MECHANISM OF LABOR. [CHAP. 
 
 indeed, that we have considered ourselves justified in taking note of 
 these as distinct positions, and not merely as stages in the course of the 
 other two. 
 
 If we take into consideration, moreover, the enormous preponder- 
 ance of cases in which the cranium or vertex presents with the forehead 
 backwards, we readily admit that it is much more than probable that 
 the men to-posterior positions are, in the earlier stages of labor, the 
 usual positions of the face. The fact again that the first position of the 
 cranium occurs in nearly 70 per cent, of the four varieties of these cases, 
 suffices to account, on the principle of rotation, for the preponderance at 
 the moment of delivery of fourth over third facial positions. But the 
 fact recorded by Naegele, that the preponderance alluded to amounts 
 only to twenty-two fourth, as against seventeen third, facial positions 
 can only be accepted as confirmatory of his statements as to the fre- 
 quency of the various vertex presentations, by supposing that the third 
 position of the cranium is, as we have assumed, not unfrequently con- 
 verted by simple extension into the corresponding position of the face. 
 Otherwise, the disproportion would be much greater ■ between the two 
 mento-anterior terminations than he assumes. 
 
 That mento-posterior positions may terminate as such in a large 
 pelvis, or in cases of premature delivery, we may admit as possible. 
 But, if we consider carefully what this termination implies, in the 
 case of an ordinary pelvis and a fully developed head, we find it im- 
 possible to conceive a degree of extension which would involve such 
 compression and moulding of the head, as would bring the occiput 
 into relation with the dorsal vertebra? before the chin could reach the 
 posterior commissure of the vagina. We believe, therefore, that the 
 cases upon which the assertions of Smellie and others are founded 
 must have been of the exceptional nature above referred to. And, 
 if such cases do occur, the mechanism at the moment of birth of the 
 head must be the arrest of the chin at the fourchette, and a movement 
 of flexion which, while relieving the head from its constrained position, 
 brings the mouth, nose, forehead, and vertex successively in a back- 
 ward direction from beneath the pubic arch. 
 
 All presentations of the face were at one time supposed to be ab- 
 normal and dangerous. This belief gave rise to different methods of 
 operative interference, which were devised with the view of rectifying 
 the presentation. Of these, the operation of turning found special 
 favor in the eyes of the older accoucheurs, who did not scruple, as a 
 matter of routine, to introduce the hand, and turn in all cases in which 
 the presentation was recognized at a period sufficiently early in the 
 labor. Till the beginning of the present century, indeed, this was the 
 mode of procedure which received the sanction of the most eminent 
 authorities. The attention which about this time was directed to the 
 subject of scientific obstetrics soon showed how erroneous was this view, 
 and how greatly increased was the risk both to the mother and child 
 by the operation of turning. But the idea of necessary interference of 
 some kind had got too firm a hold of the professional mind to be at 
 once dispelled, and we therefore find substitutes for the discarded oper- 
 ation sanctioned by the authority of some great names. We find, for 
 
XVIII.] MENTO-POSTERIOR POSITIONS. 321 
 
 example, that it was recommended by Dr. J. Clarke, to allow the face 
 to descend into the cavity of the pelvis, and then by steady pressure 
 exercised upon the presenting malar bone during a pain, to push the 
 face into the hollow of the sacrum, and allow the occiput to descend. 
 That Dr. Clarke may have succeeded, as he says, in such cases, we 
 must not doubt; but we confess to great skepticism as to the feasibility 
 of such a proceeding under ordinary circumstances, and we have little 
 doubt, if we did succeed, the risk to the child would be rather in- 
 creased than lessened. 
 
 Until it had been demonstrated by Naegele, accoucheurs were quite 
 ignorant of the rotation which occurs in the great majority of face 
 cases, whereby, in mento-posterior cases, the" chin spontaneously comes 
 forward under the pubis. It was therefore a totally erroneous impres- 
 sion of the nature of these labors which led Baudelocque to suggest, 
 and so many of his followers to adopt, an operation which is scarcely 
 less objectionable than turning. In recommending the operation re- 
 ferred to, he directs us to pass the finger through the os, and along the 
 anterior wall of the uterus over the forehead, and then, rupturing the 
 membranes, attempt to drag down the occiput. This he naturally 
 conceived to be better than to leave the case to nature, believing as he 
 did that all mento-posterior cases could only terminate as such. These 
 and all other similar modes of procedure were at once thrown aside 
 when the fundamental errors from which they sprang were removed 
 by the industry and genius of Naegele. 
 
 In face presentations, as they occur in actual practice, we believe the 
 safest rule for our guidance is to avoid interference as far as possible. 
 In occipi to-posterior positions of the cranium, we have recommended 
 interference in such cases only as threaten to terminate with the fore- 
 head in advance, and the same rule should guide us in our manage- 
 ment of the face. When the chin is originally forwards, or has already 
 rotated, no interference whatever is required. It is usually recom- 
 mended, however, in the mento-posterior positions, to aid the rotation, 
 either by hooking the finger into the mouth, and making cautious 
 traction in the proper direction, or by some other mode of manual in- 
 terference, with the view of bringing the chin towards the pubic arch, 
 as the face is about to emerge from the pelvis. It is doubtful, how- 
 ever, whether such interference should be sanctioned as the proper 
 routine procedure. So many delicate points have here to be attended 
 to — the direction of the pressure, the time for operation, and the like 
 — that w T e incline to the belief that nature should, in the great majority 
 of instances, be trusted to. For, if the practitioner of average expe- 
 rience can have but a few cases to observe in the course of a lifetime, 
 it is scarcely to be expected that he can attain such special skill as to 
 act with unfailing precision. While, however, we can bear personal 
 testimony to the possibility of operative rectification of these positions, 
 we would, in ordinary cases of this nature, certainly prefer to watch 
 carefully the process which nature is adopting, and act only in such 
 instances as she may seem to be calling for assistance. 
 
 It may be necessary, in facial as well as in cranial positions, to give 
 
 21 
 
322 MECHANISM OF LABOR. [CHAP. 
 
 assistance by manual or operative interference in cases in which delivery 
 is delayed, although the parts are normally situated. Such aid as, 
 under the circumstances, it may seem necessary to afford, is to be em- 
 ployed in each case on the same principles. The only points which 
 are here to be remembered as distinctive, arise from the facts — that in 
 facial position, the vessels of the neck are, in consequence of the pecu- 
 liar position, subjected to very unusual pressure, and that the adjacent 
 maternal organs are also likely to be compressed by the manner in 
 which the child's head is doubled back. Both of these conditions 
 should lead us, therefore, to watch the progress of such a case some- 
 what more strictly than usual, in order, if possible, to detect the 
 earliest indications of abnormal obstruction to delivery, and so soon 
 as this may arise, to relieve it without delay. The forceps, for exam- 
 ple, may be employed in such cases, at a period somew 7 hat earlier than 
 is considered necessary in cranial positions, in proportion exactly to 
 the imminence of the danger which we apprehend. Should it, how- 
 ever, occur that the head descends to the floor of the pelvis, and yet 
 no effort is made in the way of rotation, it will be proper to aid the 
 movement in question, having first carefully ascertained the position 
 of the face, and calculated the direction in which our efforts should be 
 applied. Persistent mento-posterior cases may possibly, as has already 
 been said, terminate as such, if the child be premature or putrid, or 
 the pelvis of unusual capacity; but if, owing to the disproportion of 
 parts, or some other special cause, rotation should not be effected, the 
 inevitable result is such obstruction as may be called insurmountable; 
 and in these instances the crotchet and the perforator may be required 
 before the relief of the woman is effected. 
 
 [If rotation cannot be effected by the measures recommended by the 
 author, it is doubtful whether the obstruction should "be called insur- 
 mountable," and the perforator resorted to without a trial of another 
 measure. In November, 1873, the editor read a paper before the 
 Obstetrical Society of Philadelphia, on "The Use of the Hand to cor- 
 rect unfavorable Presentations and Positions of the Head during Labor." 
 In this was related a case of face presentation, with the chin behind and 
 to the right side, seen in consultation with Dr. Elliot Richardson. 
 The face was almost at the inferior strait. All attempts to flex the 
 head, to rotate the chin in front, or to deliver by traction with the 
 forceps failed. The woman was completely exhausted, and there seemed 
 to be no alternative but to perform craniotomy. Before resorting to 
 this, however, I passed my whole hand into the pelvis, and placed the 
 thumb over the brow and the fingers over the superior maxillary bone, 
 " and pushing forcibly upwards, the head was easily raised above the 
 brim of the pelvis. It was then flexed without any difficulty, and a 
 mento-posterior of the face was converted into an occipitoanterior of 
 the vertex." Wallace's forceps were promptly applied, and a few 
 minutes later we had the satisfaction of delivering a living child. 
 
 To successfully perform this manipulation the woman should be 
 completely under the influence of an anaesthetic. When the patient 
 is thoroughly relaxed by ether, " it is very surprising what can be 
 
XVIII.] MENTO-POSTERIOR POSITIONS. 323 
 
 done by forcibly pushing the head upwards. Not only does the child 
 ascend, but if the lower segment of the uterus has been carried with 
 the head into the cavity of the pelvis, it may be lifted with its contents 
 above the pelvic brim, where the latter become movable and easily 
 manipulated. Both in the pregnant and unimpregnated woman, the 
 degree of stretching and movement of which the generative organs are 
 capable when the patient is completely anaesthetized, appears very 
 remarkable to one who has never employed this important agent in 
 such cases.' 7 
 
 For further information in regard to this subject, the reader is referred 
 to the paper alluded to, which was published in the American Journal 
 of Obstetrics for May, 1875. It is not to be supposed that the measure 
 here described will always prove successful, but the happy result of the 
 case alluded to, warrants the hope that it will sometimes obviate the 
 necessity of resorting to the perforator, the most horrible of all obstetric 
 instruments. — P.] 
 
 Although but four positions are above described, it may be said of 
 face, as of cranial positions, that there is no possible diameter of the 
 brim which may not be occupied, in some case or other, by the long 
 diameter of the face. And, in regard to the situation of the parts after 
 they have descended in the cavity of the pelvis, it may be further noted, 
 that certain intermediate or modified presentations may possibly occur. 
 Brow presentations, for example, are described by many writers, and, 
 in so far as we may judge from comparative measurement and mechan- 
 ism, are to be admitted as possible. They must, however, be always 
 looked upon as of the most unfavorable nature, and one of the most 
 formidable objections to Baudelocque's operation was the risk of thus 
 converting an unfavorable presentation into one which was, perhaps, 
 even more so, should the attempt at artificial rectification be arrested 
 midway in its course. A thorough knowledge of the mechanism of 
 ordinary labor will be the best guide to the management of any such 
 exceptional cases as may offer themselves in the course of practice. 
 
 We have attempted throughout, in the description which has been 
 given of the four positions of the face, to indicate the strong analogy 
 which exists between them and the ordinary positions of the cranium, 
 which are so familiar to all. The prominence of the chin, therefore — 
 be it once more remarked — is the analogue of the occiput. This is 
 more clearly shown in the following tabular statement, which is drawn 
 up with the view, not only of showing the relation between facial and 
 cranial positions, but also of enabling the student to store the facts 
 in his memory, in such a form as may be most available for prac- 
 tical emergencies in any presentation of the cephalic extremity of the 
 child. 
 
324 
 
 PELVIC PRESENTATIONS. 
 
 [CHAP. 
 
 Tabular Arrangement of the Presentations and Positions 
 of the Cephalic Extremity of the Foetus. 
 
 Occipito- 
 anterior I 
 Positions. 
 
 Cranium or Vertex. 
 
 I I. In Right Oblique Diam- 
 eter ; forehead to right 
 sacro-iliac synchondro- 
 sis. 
 
 Occipito- , 
 Posterior 
 Positions.! 
 
 II. In Left Oblique Diam- 
 eter ; forehead to left 
 sacro-iliac synchondro- 
 sis. 
 
 till. In Right Oblique Di- 
 ameter ; forehead to- 
 wards left ilio-pec- 
 tineal eminence. Usu- 
 ally rotates into the 
 second. 
 
 IV. In Left Oblique Diam- 
 eter ; forehead towards 
 right ilio-pectineal emi- 
 nence. Usually rotates 
 into the first. 
 
 Mento- 
 posterior 
 Positions. 
 
 Mento- 
 anterior 
 Positions 
 
 Face. 
 
 I. In Right Oblique Di- 
 ameter ; forehead to- 
 wards left ilio-pecti- 
 neal eminence. Ro- 
 tates into the fourth. 
 
 II. In Left Oblique Diam- 
 eter ; forehead to- 
 wards right ilio-pec- 
 tineal eminence. Ro- 
 tates into the third. 
 
 III. In Right Oblique Di- 
 
 ameter ; forehead to 
 right sacro-iliac syn- 
 chondrosis. 
 
 IV. In Left Oblique Diam- 
 
 eter ; forehead to left 
 sacro-iliac synchon- 
 drosis. 
 
 In Cranial Positions, therefore, the third rotates into the second, and 
 the fourth into the first; while in Facial, the second rotates into the third, 
 and the first into the fourth. 
 
 CHAPTEE XIX. 
 
 PELVIC PRESENTATIONS. 
 
 the practice of the past — the pelvis a natural presentation — DORSO- 
 
 ANTERIOR AND DORSO-POSTERIOR POSITIONS — BREECH PRESENTATION; FOUR 
 POSITIONS OF — FIRST POSITION OF THE BREECH : ROTATION: PASSAGE OF THE 
 BUTTOCKS: DESCENT AND BIRTH OF THE SHOULDERS: DIFFICULT PROGRESS 
 OF THE HEAD, AND MECHANISM OF ITS EXPULSION — SECOND POSITION OF THE 
 BREECH — THIRD POSITION OF THE BREECH : BIRTH OF THE LOWER PORTION 
 OF THE TRUNK, AND OF THE SHOULDERS: ROTATION OF THE FACE BACKWARDS, 
 AND MECHANISM OF THE BIRTH OF THE HEAD; EXCEPTIONAL TERMINATIONS 
 — FOURTH POSITION OF THE BREECH — SPECIAL RISK OF PELVIC PRESENTATIONS 
 — DIAGNOSIS AND PECULIARITIES — KNEE AND FOOTLING CASES — MANAGEMENT 
 OF PELVIC PRESENTATIONS — NATURE OF ASSISTANCE TO BE RENDERED — USE 
 OF THE FILLET, VECTIS, AND BLUNT HOOK — INDISCRIMINATE DRAGGING ON THE 
 LOWER LIMBS TO BE AVOIDED — TREATMENT OF CASE WHERE ARMS PASS UP 
 ALONGSIDE HEAD — MANAGEMENT OF THE FUNIS — INDICATIONS OF IMPENDING 
 DEATH OF THE CHILD — MANIPULATION FOR EFFECTING SPEEDY DELIVERY OF 
 THE HEAD — USE OF THE FORCEPS. 
 
 Although the writer of the obstetrical memoranda which were 
 attributed to Hippocrates recognized the oval position of the child in 
 
XIX.] PELVIC PRESENTATIONS. 325 
 
 the womb, and illustrated the impossibility of delivery in cross birth 
 by the graphic simile of the olive in the neck of an oil jar, he strangely 
 enough, as has already been mentioned, omitted to perceive the full 
 force of his illustration. For, as every oval has two ends, he ought to 
 have concluded that the fetal oval could pass naturally with either of 
 these in advance, as the olive might be extracted from the jar. Failing 
 to observe this, however, the ancients believed that presentations of the 
 pelvic extremity were abnormal, and should in all cases be rectified by 
 artificial aid. The result of such a mode of practice as this points to — 
 which obtained throughout a period of several centuries — is looked at 
 by the modern obstetrician with horror, on account of the fearful sacri- 
 fice of human life which such a procedure must have involved. There 
 is nothing, indeed, in the history of Midwifery comparable to this; 
 and the idea of turning by the head in all cases of pelvic presentation 
 is one so repugnant to every principle of the science and art of obstetrics, 
 that it is difficult to conceive by what perversion of reason a blunder 
 so fearful could have been perpetrated. Certain it is that, until the 
 revival of anatomy by Vesalius, and even for some time after the art 
 of printing had been discovered, the practice recommended in pelvic 
 presentations was that which has just been indicated as dating from the 
 time of the ancients. 
 
 It is to Ambroise Pare that we owe the correction of this monstrous 
 error, and from his day these presentations have always been recognized 
 as natural. Although much more dangerous to the child, they are 
 attended with no increase of risk to the mother. While, however, we 
 prefer to consider presentations of the pelvic extremity as natural, it 
 must be noted that many writers have thought it necessary to classify 
 them as preternatural, an opinion which has given rise to much con- 
 troversy, an analysis of which would serve no good or useful purpose. 
 The pelvic end of the foetus is made up of certain anatomical elements 
 which may present themselves in various combinations. The ordinary 
 presentation is that in which the foetus preserves its usual intra-uterine 
 attitude, with the limbs flexed, but with its axis inverted, so that the 
 presenting part is the breech. If, however, the inferior extremities 
 become separated from the trunk, and thus occupy the inferior segment 
 of the uterus, we may have other presentations which fall under the 
 same category, such as presentation of the knees or of the feet, or of one 
 knee or one foot. The classification, therefore, of possible positions 
 may be multiplied by a little ingenuity to such an extent as to render 
 the subject an extremely complicated one, and its study a wearisome 
 task. Here, again, we owe much to the indefatigable industry of 
 Naegele. For it was he who first showed that, although we may sub- 
 divide the positions ad infinitum, all pelvic presentations may, in so far 
 as the mechanical phenomena of labor are concerned, be reduced to two 
 classes according as the dorsal or abdominal surface of the child is 
 turned forwards within the womb. We shall now proceed, therefore, 
 to the description of the positions of the breech, which will suffice for 
 all possible presentations of the pelvic extremity. Certain peculiarities 
 attach to cases of knee and footling birth, which, being of a practical 
 nature, will receive a brief notice in the proper place. 
 
326 PELVIC PRESENTATIONS. [CHAP. 
 
 The structures which form the breech of the child are of a much 
 softer and more yielding nature than the cranium, and are, therefore, 
 within certain limits, more plastic and susceptible of adaptation to the 
 parts through which they have to pass. Parturition is not the less on 
 that account governed by fixed mechanical laws, according to which the 
 parts enter, pass through, and emerge from the pelvic and parturient 
 canal. To the consideration of these we now pass. In presentation of 
 the breech we find no less marked a preference for the oblique diame- 
 ters than in the case of the cranium, so that the child assumes a position 
 with its back or belly forwards, and turned at the same time either to 
 the right or to the left. The two main divisions of all such cases then 
 are, according to Naegele and subsequent observers, dorso-anterior and 
 dorso-posterior positions, the former being more frequent in the pro- 
 portion of three to one. As each of these implies a possible position 
 of the transverse or long diameter of the breech in either oblique diam- 
 eter of the maternal pelvis, we may here, as in cranial and facial cases, 
 detail four positions of the breech as follows : 
 
 Dorso- Anterior, 
 
 DORSO-POSTERIOR, 
 
 ( „. , D ... f Breech in Left Oblique Diameter; 
 
 1 rirst Position. < , ~. , , . „ ^ , ' 
 
 J ' [ left trochanter forwards. 
 
 \ c 7 D •,• ( Breech in Right Oblique Diameter ; 
 
 1 second Position. < . ,, , \? *. * j 
 
 I. - l right trochanter forwards. 
 
 /rm • ■, n •,• [Breech in Left Oblique Diameter ; 
 
 Third Position, < . . . , , , „ 1 , 
 
 ' ( right trochanter forwards. 
 
 j? .47 p '4' f Breech in Right Oblique Diameter ; 
 
 I £* OlLVtll A Sit 1071. "\ l n. , 1_ j /» T 
 
 ^ ' ( left trochanter forwards. 
 
 The breech is recognized, on a digital examination, by the ischial 
 tuberosities, between which the genital organs, male or female, may be 
 distinguished. As the parts are, however, frequently much distorted 
 by the formation of the caput succedaneum, it is not always so easy for 
 the beginner to recognize the presentation as he may perhaps imagine. 
 He may, in a hurried and imperfect examination, very readily mistake 
 the tuber ischii, which his finger first touches, for the prominence of 
 the shoulder, and the female genital organs for the fold of the axilla. 
 It is well, therefore, that in every case he should make a leisurely ex- 
 amination, in order to insure the accuracy of his diagnosis. The 
 genitals, occupying a situation between two osseous prominences, one 
 of which is usually considerably lower than the other, can scarcely be 
 mistaken ; and, in the case of the male, the scrotum is generally tume- 
 fied. But if any doubt should arise, this is set at rest if, in addition to 
 the parts named, he recognize the anus, the point of the coccyx, and the 
 unequal osseous surface of the back of the sacrum. To this last point 
 Cazeaux attaches considerable importance. At the commencement of 
 labor, or even before it has come on, it may be possible to recognize a 
 breech presentation by palpation of the abdominal tumor, which, when 
 the walls of the belly are thin and relaxed, enables us to recognize the 
 general outline of the child, with the rounded resistant cephalic ex- 
 tremity turned towards the fundus and inclined a little to either side. 
 The pulsations of the foetal heart are heard on a somewhat higher 
 
 
XIX.] FIRST POSITION OF THE BREECH. 327 
 
 level, near the umbilicus. The absence in the vagina of the firm and 
 smooth globular head, which generally occupies the lower segment of 
 the uterus, would further corroborate such observations as the above. 
 The presentation is, at this stage, higher than usual, and often beyond 
 the reach of the finger ; but, in knee and footling cases, the knee or 
 heel may be felt lying against the most dependent part, and retreating 
 before the pressure of the finger. In its general shape and external 
 appearance, the uterus is not sensibly altered. 
 
 Presentation of the pelvic extremity is by no means a rare occur- 
 rence, as it is met with once in about 45 mature births ; and in prema- 
 ture delivery it is, for reasons formerly stated, much more frequent. 
 In 80 cases observed by Dubois, 54 were ordinary breech positions, 
 and in 26 the feet descended in advance. Madame Lachapelle only 
 saw the knees presenting once in 3445 instances of labor, and in the 
 statistics of the Lying-in Hospitals of Wurzburg and Prague, we find 
 but one case in 9274. The breech is, however, not only the most 
 frequent, but the most favorable of the pelvic presentations. For al- 
 though at first sight it might appear that a footling or knee might, on 
 the principle of the wedge, be a more favorable arrangement mechani- 
 cally, an observation of the whole process at once shows that this is 
 not the case. The broad breech, increased in bulk by the flexion of 
 the thighs, performs a most important function in dilating the passages 
 for the safe and rapid progress of the head, during the latter and more 
 critical period of the labor ; and as it is very evident that this will be 
 more effectively done by the breech than by the footling presentation, 
 the former is, from a mechanical point of view, undoubtedly the most 
 favorable. 
 
 First Position of the Breech. — Of all the possible positions of the 
 pelvic extremity this is the most common. In it, the transverse or 
 long diameter of the breech occupies the left oblique diameter of the 
 brim, so that, as the back of the foetus is turned forwards, it is the left 
 ischial tuberosity which is lowest in the pelvis, and upon which the 
 finger impinges on examination. The position is shown in the accom- 
 panying engraving. Backwards, and in the direction of the left sacro- 
 iliac synchrondrosis, another similar projection is reached, and between 
 the two, in a direction corresponding to the right oblique diameter, is 
 a sulcus or depression, in which may be recognized, from before back- 
 wards, the coccyx, the anus, and the external genital organs. In pro- 
 portion to the resistance offered to the breech in its descent, there is an 
 increase in its obliquity, which brings the left buttock still more in 
 advance, precisely as occurs in the descent of the occiput. When the 
 breech reaches the floor of the pelvis, therefore, it is the left hip and 
 posterior surface of the left thigh which comes upon the anterior ischial 
 plane of the right side, while the right hip passes behind the left 
 ischial spine, and comes into contact with the sacro-sciatic ligaments 
 of the same side. 
 
 A rotation now takes place which is in every respect analogous to 
 the cranial rotation already described, the left buttock gliding down- 
 wards, forwards, and to the left, along the ischial plane and the obtu- 
 
328 
 
 PELVIC PRESENTATIONS. 
 
 [CHAP. 
 
 First position of the breech. 
 
 rator interims, while the right buttock performs the corresponding 
 
 movement from left to right 
 fjg. 116. towards the hollow of the sa- 
 
 crum. There is not in this case 
 — as a comparison of the rela- 
 tive measurements will show — 
 the same imperative necessity 
 for rotation which obtains in 
 the case of the head. But, in 
 its birth, it follows the same 
 mechanical law, with this dif- 
 ference only, — that the rotation 
 is, in the case of the breech, 
 more rarely complete into the 
 antero-posterior diameter than 
 occurs when the head is the 
 presenting part. It might be 
 supposed, following the analogy 
 of the mechanism of the occip- 
 ito-anterior positions of the 
 vertex, that the left buttock 
 passed upwards and forwards 
 under the pubic arch, while the 
 right swept over the perineum. 
 Such, however, is not the usual mechanism of the process. The left 
 buttock, indeed, moves forwards to the arch, but at this point it is 
 arrested and forms a centre, upon which the right buttock describes 
 the arc of a circle, from before backwards on the distended perineum, 
 so that, in the act of birth, it takes precedence of the left, which passes 
 immediately afterwards. The long diameter still preserves to the last 
 a certain amount of its obliquity, so that the right buttock is directed 
 a little to the left of the middle line, and, so soon as it has passed, the 
 feet and knees slip down, and with the movement of extension of the 
 thighs the lower part of the trunk is born. The belly of the child 
 thus lies towards the right thigh of the mother. No marked move- 
 ment of restitution occurs at this stage, because the shoulders are de- 
 scending in the same oblique diameter as was occupied by the breech. 
 If, however, the trunk of the child does not participate in the rotation 
 of its pelvis, a certain degree of restitution may occur to relieve the 
 twisting of the vertebral column. 
 
 The thorax now occupies the pelvic cavity. The superior extremi- 
 ties, if normally situated, are in contact with the anterior and lateral 
 parts of this region of the trunk. The long diameter of the shoulders, 
 occupying like the breech the left oblique diameter, descends under the 
 influence of successive pains. When the resistance of the pelvic floor 
 is fully encountered, a movement is executed in every respect similar 
 to that which is observed in the passage of the breech. The left 
 shoulder comes forward towards the summit of the pubic arch, but is 
 there arrested, so that the right sweeps over the perineum, and is born 
 
XIX.] 
 
 BIRTH OF THE BREECH. 
 
 329 
 
 in advance of its fellow, as shown in Fig. 118. It happens, not un- 
 frequently, that one or both of the arras slip up during the descent of 
 the trunk, and become applied to the sides of the child's head (see Fig. 
 119), an accident which, in a pelvis below the average in its measure- 
 ment, may give rise to considerable obstruction and delay. The origi- 
 nal attitude of the head with reference to the trunk, in all breech cases, 
 
 Fig. 117. 
 
 Birth of the breech. 
 
 is with the chin flexed towards the sternum, which permits of the ex- 
 pulsive force being communicated to the trunk to the greatest mechani- 
 cal advantage. Any movement of extension which may occur, tends 
 not only to disturb the conditions upon which a speedy labor depends, 
 but may also, by allowing the hands to slip between the chin and the 
 sternum, and thence to the side of the head, interpose a very serious 
 barrier to the accomplishment of the labor, more especially if, as some- 
 times happens, one becomes locked behind the head, and between it 
 and the pubis. 
 
 As the shoulders are passing through the outlet of the pelvis, the 
 head descends in the right oblique diameter. The point of essential 
 distinction between pelvic and cephalic presentations becomes manifest 
 at this stage. In the latter, the difficulty terminates with the birth of 
 the head and the passage of the shoulders, but in the former it is widely 
 different. The passage of the breech is not attended with any special 
 difficulty ; nor is the passage of the shoulders long delayed. But, in- 
 stead of the difficulty ceasing with the birth of these parts, it becomes 
 increased, and the really anxious and critical time of the labor now 
 begins. For not only has the most unyielding part of the foetal oval 
 still to pass, but it has to pass under circumstances which necessarily 
 imperil the life of the child. Beyond a certain point, indeed, delay in- 
 
330 
 
 PELVIC PRESENTATIONS. 
 
 [CHAP. 
 
 volves death to the child, so that the skilful management of this stage 
 may be said to be one of the most important practical duties of the 
 accoucheur. A cause which, at this moment, increases the risk, is the 
 failure of expulsive force. This does not imply so much a failure of 
 
 Fig. 118. 
 
 Birth of the shoulders. 
 
 expulsive action as that, the uterus being now nearly empty, its pro- 
 pulsive energy is brought to bear upon the head at great mechanical 
 disadvantage ; and it is difficult to see how, but for the contraction of 
 the vagina, and of the muscles at the floor of the pelvis, nature could 
 ever complete a case of pelvic presentation. In the position at present 
 under consideration, the head descends with the forehead turned to- 
 wards the right sacro-iliac synchondrosis, and a little in advance. The 
 occiput is turned towards the left ilio-pectineal eminence, and after 
 rotating towards the subpubic arch, is there arrested until the chin, 
 nose, forehead, and vertex sweep successively forwards and upwards 
 over the distended perineum. Fig. 120 shows the head in this position 
 immediately prior to the final act which terminates the second stage of 
 labor. 
 
 Second Position of the Breech. — In this, the position is also dorso- 
 anterior ; but, instead of occupying the left as in the position above de- 
 scribed, the pelvis descends in the right oblique diameter. It is there- 
 fore the right ischial tuberosity which presents, and the right buttock 
 which descends in advance as far as the pubic arch, being directed to- 
 wards it by the anterior inclined plane on the left side of the pelvis. 
 The left hip sweeps over the perineum, and the shoulders descending 
 in the right, and the head in the left oblique diameters, are successively 
 expelled by a mechanism which is in all respects identical with that 
 
XIX.] 
 
 SECOND POSITION OF THE BREECH. 
 
 331 
 
 which obtains in the first position, only in the contrary direction as re- 
 gards the various rotatory and other movements. At first it seems 
 
 Fig. 119. 
 
 Arm displaced upwards. 
 
 strange that this should be less frequent than the first position, and 
 that nature should prefer the left oblique diameter in breech cases to 
 
 Fig. 120. 
 
 Birth of the head. 
 
 the right ; and this too would almost seem to throw doubt upon the 
 opinion we have expressed that she prefers the right oblique in cranial 
 
332 PELVIC PRESENTATIONS. [CHAP. 
 
 presentations, in order to avoid the left, which is encroached upon by 
 the rectum. But, even here, if we watch the case to a termination, we 
 find nature apparently guided in a majority of cases by the selfsame 
 law. For, as we have already seen, the really critical and important 
 moment of a breech case is that during which the head passes through 
 and out of the pelvis; and it is on this account that in the more com- 
 mon first position the head is in the favorable diameter ; whereas, in 
 the second, the head descends in the left, which is, as statistics would 
 seem to show, more dangerous to the child, probably because detention 
 of the head is more likely to occur. 
 
 Third Position of the Breech. — Of 161 cases occurring at Heidelberg, 
 121 had the back, and 40 the belly of the child turned forwards. This 
 gives as nearly as possible a preponderance in favor of the two first 
 positions, already set down at three to one. The two Dorso-Posterior 
 positions, then, are of comparatively rare occurrence. 
 
 In the Third Position, which occurs less frequently than any of the 
 others, the breech lies in the left oblique diameter, which, as the back 
 is turned towards the vertebral column of the mother, brings the right 
 tuber ischii to the front, and deeper in the pelvic cavity. When it 
 reaches the floor of the pelvis, the corresponding buttock glides along 
 the right ischial plane, and attains the summit of the pubic arch, where 
 it is arrested until the left ischium sweeps over the perineum, when 
 the belly of the child is born towards the mother's left thigh. The 
 shoulders descend in the same oblique diameter, and are expelled 
 pretty much as in a dorso-anterior position. The head then enters the 
 pelvis in the right oblique diameter, with the occiput towards the right 
 sacro-iliac synchondrosis. In the great majority of cases, the termina- 
 tion of this position is by a rotation which brings the occiput from the 
 sacro-iliac synchondrosis to the obturator foramen on the right side, 
 and the forehead from the obturator foramen to the sacro-iliac syn- 
 chondrosis on the left side. In a word, the rotation is the same which 
 converts a third into a second position of the cranium. This rotatory 
 movement has, in some cases, been observed to take place at an earlier 
 period in the labor. When that occurs, the movement takes its direc- 
 tion from the original rotation, which brings the right buttock in 
 advance. It passes then, from right to left, into the conjugate, and a 
 little beyond it, and ultimately continues the movement in the same 
 spiral direction, until the belly of the child looks almost directly back- 
 wards. The trunk, in this case, participates in the rotation of the 
 breech ; but if it does not so participate, the head itself, when subjected 
 to the resistance of the pelvis, performs the extensive rotation which 
 we have described. Whatever may be the course of labor in this 
 position, the natural termination is a rotation into the second position. 
 The head, therefore, whether the vertex or the breech presents, rotates, 
 as a rule, from the third position into the second. 
 
 Cases are occasionally observed in which the rotation above described 
 does not take place, and the head comes into the world with the occiput 
 turned backwards. The usual course in such a case is, that the head 
 descends in the pelvis in a strong state of flexion, with the forehead 
 and occiput turned to the anterior and posterior extremities, respectively, 
 
XIX.] 
 
 FOURTH POSITION OF THE BREECH, 
 
 333 
 
 of the right oblique diameter. The usual movement of rotation brings 
 the occiput along the right sacro-sciatic ligaments towards the hollow 
 of the sacrum, and the forehead from left to right, under the subpubic 
 arch. The original motion of flexion is then continued, so as to bring 
 the face, forehead, and vertex, in succession, from behind the symphysis, 
 while the occiput, around which as a centre, this movement has been 
 executed, is the last part to escape. It would also appear, from cases 
 which are recorded upon good authority, that the head in this position 
 may escape by a movement which is not one of flexion, but of exten- 
 sion. The occiput, in those rare instances, would seem to have preceded 
 the forehead in its descent; the chin rests upon the lower part of the 
 symphysis, and the occiput, vertex, forehead, and face successively 
 emerge over the perineum, the 
 depression between the chin and 
 
 the trachea 
 upon which 
 
 being the centre 
 
 the movement of 
 extension occurs. 
 
 Fourth Position of the Breech. 
 — Of the two dorso-posterior 
 positions of ..the breech, it is this 
 which is more frequently met 
 with. The long diameter of 
 the hips occupies the right ob- 
 lique diameter of the brim, so 
 that, while the child sits, as it 
 were, upon the brim of the pel- 
 vis, its anterior surface looks 
 forward, and to the right. The 
 left trochanter is towards the 
 left ilio-pectineal eminence, and 
 it is consequently the left tuber 
 ischii which is forwards, and 
 stands lowest in the pelvis. The 
 breech and shoulders descend 
 as in the third position, each 
 performing the same limited amount of rotation and external restitu- 
 tion ; the head then arrives in the pelvis, in the left oblique diameter, 
 the chin being in front of the right, and the occiput behind the left 
 ischial spine. The head then rotates, under ordinary circumstances, 
 from the fourth position into the first, the occiput travelling, as in the 
 corresponding positions of the vertex, from the left sacro-iliac synchon- 
 drosis, onwards along the left side of the pelvis, until it arrives at the 
 subpubic angle, where it is arrested, and the face, forehead, and vertex 
 sweep, as in the preceding presentation, forwards over the distended 
 perineum. The same exceptional cases may also occur as in the third 
 position, and we should therefore be prepared for the possible occur- 
 rence either of complete rotation before the head descends to the brim, 
 or of one or other of the occipito-posterior positions which have been 
 described. 
 
 All presentations of the breech tend therefore, as has been shown, 
 
 Fourth position of the breech. 
 
334 PELVIC PRESENTATIONS. [CHAP. 
 
 to terminate more irregularly than those of the head. The birth of the 
 nates is perhaps attended with even less difficulty than when the head 
 precedes, but the real difficulty is the speedy and safe passage of the 
 latter. And it is indeed remarkable, not only in regard to the first 
 position, but also the fourth, or more frequent of the dorso-posterior 
 positions, that the head, in its descent by the normal path, avoids that 
 oblique diameter which is contracted by the rectum. But whether this 
 occurs or not, pelvic presentations are attended by special and greatly 
 increased risk. This is much more so, however, in regard to knee and 
 footling cases, than when the breech presents in the ordinary way. 
 This is brought out very clearly by the statistics of 71,578 cases col- 
 lated by Dr. Rigby from various sources. The nates presented once in 
 every 78 cases, and the feet once in 108.5 : of the nates cases the child 
 was born dead in the proportion of 1 to 3.8, and in the footling births 
 1 to 2.8. Knee presentations are so rare that they need not be taken 
 into consideration. 
 
 Something must here be said in reference to the diagnosis of knee 
 and footling cases, but as regards the mechanism according to which 
 labor under such circumstances is accomplished, no special description 
 is necessary, as it differs in no material respect from what has been 
 described in regard to the breech. The mechanism of all pelvic pre- 
 sentations is, in other words, essentially the same. Very little can be 
 recognized with certainty, until the rupture of the membranes enables 
 us to distinguish the various parts. The form of the bag of waters, 
 upon which some have laid great weight in a diagnostic point of view, 
 may certainly give rise to suspicion, although it can never by itself be 
 of much importance. In all pelvic presentations, it is, as a rule, more 
 pointed, and projects further into the vagina. In footling cases, the 
 bag is long and sausage-shaped, and through it the foot or feet may be 
 felt. When the membranes ultimately give way, the discharge of the 
 liquor amnii does not take place with such a gush as in cranial positions, 
 but on the other hand it is more continuous, and the drainage more 
 complete. In cranial presentations, the head, acting like a ball-valve, 
 hinders the liquor amnii from escaping, except in small quantities, in 
 the intervals between the pains; but, when the irregular pelvic extremity 
 presents, a more complete escape is permitted, which, by bringing the 
 uterus to bear more powerfully and directly upon the surface of the 
 child, no doubt increases the risk in all such cases. The foot is very 
 liable to be mistaken by beginners for the hand, for although any one 
 could distinguish between the two with the eyes shut, if he could bring 
 the whole of his ten fingers to bear upon it, it is a very different matter 
 when he attempts to recognize a part which can only be reached by a 
 couple of fingers, and that possibly with difficulty. The length of the 
 digits, and the mobility of the thumb as compared with the great toe, 
 will prevent the possibility of doubt when we can recognize these points, 
 but under circumstances of unusual difficulty, this may be impracticable. 
 No single anatomical feature of the foot is, in difficult cases, so charac- 
 teristic as the prominence of the heel. The dorsal surface of the hand 
 may be mistaken for the instep and the fingers for the toes, but on the 
 other side of the joint there is nothing in the hand which can be com- 
 
XIX.] MANAGEMENT OF PELVIC PRESENTATIONS. 385 
 
 pared to the projection of the heel. If, therefore, we can pass one finger 
 over the dorsum of the foot, and another over the heel, which enables 
 us to grasp the extremity of the limb like the head of a crutch, we may 
 be perfectly confident that it is a foot and not a hand with which we 
 have to deal. And we would here observe, parenthetically, that this 
 is one of many points, in regard to which the young practitioner should 
 lose no opportunity of perfecting the tactus eruditus ; for a mistake here, 
 which is acted upon by operative or other interference, may bring dis- 
 credit upon him, and, what is worse, may directly lead to the most 
 disastrous results for his patient. The determination of the position 
 from a single foot is a matter in reference to which some doubt may 
 exist. The general direction of the toes will however indicate the 
 abdominal surface of the child, and if both feet should present, this is 
 much more certain. We may, however, have to wait for the descent 
 of the breech before we can be certain to which of the four positions it 
 is to be referred. A single foot should always, if possible, be identified 
 as right or left, which is very easily done, if it be sufficiently within 
 reach, by placing the palm of the hand to the sole of the foot in the 
 same manner as is pursued in identifying a single hand, as will be more 
 particularly described afterwards. 
 
 The risk to the mother in presentations of the pelvic extremity is in 
 no way increased; for, admitting that the opinion generally expressed 
 in regard to the tardy completion of the first stage is correct, we may 
 assume that this is compensated for by the comparative ease with 
 which the child makes its way through the passage. But the figures 
 already quoted, which are confirmed by the experience of every one, 
 show only too clearly that the risks to which the child is exposed are 
 enormously increased. It is equally certain, — as, indeed, is further 
 indicated by the figures alluded to, — that the risk is not the same in 
 all cases of pelvic presentation alike, but is greatly increased in those 
 cases in which the thighs are extended, and not flexed upon the trunk. 
 The cause of this is to be found, as has already been observed, in the 
 inefficient manner in which the canal is thus dilated for the passage of 
 the head, which delays the completion of the labor at the critical mo- 
 ment when, all being born but the head, it is arrested in the pelvis 
 until the life of the infant is destroyed by suffocation. In an ordinary 
 breech labor, the more complete dilatation of the parts reduces this risk 
 to a considerable extent, but even under the most favorable circum- 
 stances the risk is, as compared with cranial births, enormously in- 
 creased. And it is none the less certain that, by prompt and skilful 
 measures, the accoucheur will often have the gratification of saving 
 lives which, if left to nature, would have inevitably been sacrificed. A 
 thorough knowledge of the mechanical phenomena above detailed, is 
 the first essential qualification which may lead to skill and judicious 
 management in the treatment of all cases of pelvic presentation. In 
 order thoroughly to understand the subject, however, we must view it 
 under various aspects. While we have no difficulty, for example, in 
 recognizing that, in many instances, assistance is necessary, we must 
 not overlook the fact that injudicious interference is bad. We have to 
 consider, therefore, not only what to do, but what not to do; for, an- 
 
336 PELVIC PRESENTATIONS. [CHAP. 
 
 fortunately, many errors in practice have been committed, and as some 
 have had the sanction of great names, it is doubtful whether on this 
 subject sound practical views are entertained as invariably as they 
 ought to be. 
 
 Long after the preposterous idea of Hippocrates, alluded to in the 
 beginning of this chapter, was exploded, views erroneous, but erroneous 
 in a minor degree, obtained in reference to the treatment of presenta- 
 tions of the pelvic extremity of the child. We thus find Williams, 
 Hunter, and Smellie bringing down the feet when the breech presents 
 at the beginning of labor; and we cannot wonder that this mode of 
 procedure extended into the present century, although it has now hap- 
 pily long fallen into disuse. The errors of the present day are thus 
 rather of the nimia diligentia category than the grosser blunder allnded 
 to; but, in regard to the presentations which we are now considering, 
 it may with truth be said, that the subject is one which demands care- 
 ful attention at the hand's of every one who would be an accoucheur 
 and not a midwife, not less than the more familiar positions of the 
 cranium. 
 
 It may be inferred from what has already been said, that the duties 
 and responsibilities of the accoucheur are, in the case of a pelvic pre- 
 sentation, greatly increased. In a cranial case, while all goes well, we 
 look to the issue without a shadow of apprehension ; and we absent 
 ourselves, from time to time, without any consciousness of neglecting 
 or evading a duty. But, when the pelvis presents, all is altered in this 
 respect. The risk, be it again repeated, is a fetal, and not a maternal 
 one ; but, as we cannot tell the moment at which our assistance may 
 be required, we must be much more strict and continuous in our at- 
 tendance ; and, so soon as the breech has descended in the pelvis, we 
 must not leave the bedside of our patient until the delivery has been 
 completed. This assiduity, on our part, does not involve, of necessity, 
 any interference with the natural process. On the contrary, many 
 cases will terminate happily without any aid afforded ; so that we have 
 two important points before us for solution in every case : whether we 
 are to interfere at all; and, if so, how, and at what time? 
 
 Having fully satisfied ourselves of the exact position of the foetus, 
 and thus recognized the manner in which the mechanism will probably 
 be conducted, we simply wait and watch the issue. If nature takes 
 the ordinary course, and the breech descends, whatever its original 
 position may have been, in a satisfactory manner, we do not presume 
 to interfere, by in any way hastening or aiding the labor. At this 
 moment, there is no special risk to the child, and, indeed, the slower 
 the dilatation. of the passage, the more effectual is that dilatation likely 
 to be, and the safer and more rapid the subsequent birth of the head. 
 So soon as the buttocks and lower limbs are born, we know that the 
 critical period approaches ; and some anxiety is not unnaturally felt as 
 to the subsequent progress of the case, as a condition now comes into 
 operation, constituting one of the special dangers of pelvic births. 
 This is compression of the umbilical cord, which, as the thorax ap- 
 proaches the ostium vagina?, becomes jammed between the pelvic wall 
 
XIX.] OPERATIVE ASSISTANCE. 337 
 
 and the unyielding cranium — a state of matters which, if complete and 
 continuous, rapidly destroys the child, by interrupting the placental 
 circulation. We should, at this stage, pull down a loop of the cord, 
 thus obviating the probability of obstructed circulation by over-stretch- 
 ing, and at the same time guide it, if possible, in the direction of either 
 sacro-iliac synchondrosis — where the risk of pressure is least — choosing, 
 if choice there be in the matter, that sacro-iliac synchondrosis which 
 corresponds to the side of the child's head. Much useful information 
 as to the prospects of the case is afforded by grasping the cord with the 
 finger, so as to feel its pulsation. So long as this remains quite vigorous, 
 the case is to be left entirely to nature; but we must repeat the obser- 
 vation frequently, as the descent of the head may expose the cord quite 
 suddenly to fatal pressure — a fact which it is of the highest importance 
 immediately to recognize. The persistence or failure of funic pulsation 
 are, in fact, the chief indications as to the necessity for operative 
 interference. 
 
 Exceptional circumstances, no doubt, may arise to call for assistance 
 at a stage even earlier than that which we are describing. Long de- 
 tention of the breech within the cavity, owing to disproportion of the 
 foetal or maternal parts, or to inertia uteri, may call for action at an 
 unusual period, on the same general principles as obtain in the case of 
 obstructed cranial labor. Tiie operative procedure proper to breech 
 cases is, however, peculiar ; and, if we fail, by the use of ergot or other- 
 wise, to arouse the dormant energy of the uterus, or should w r e recognize 
 an obstruction which natural efforts cannot overcome, we must be pre- 
 pared to act with a view to speedy delivery. The forceps, being specially 
 constructed for application to the foetal head, is not available. The 
 vectis, however, applied over the flexure of one thigh, while the hand 
 of the operator is applied to the other, may possibly succeed ; and the 
 blunt hook is an instrument which has been frequently recommended 
 in the management of such cases. No one can doubt the mechanical 
 power of these, and especially of the blunt hook ; but the danger of 
 bruising, and even lacerating, the parts of the foetus is not inconsidera- 
 ble, so that such means should, if possible, be avoided. When the 
 child is dead, and much force has to be employed, the blunt hook, and 
 even the crotchet may be applied — the use of which instruments will 
 be more particularly detailed when we come to consider obstetric in- 
 struments and their use, under a special section. By the fingers alone, 
 introduced over the groin upon the flexure of the thighs, the breech, in 
 a very considerable proportion of ordinary cases, may be drawn down 
 under the pubic arch, the operator remembering always, and imitating, 
 as far as possible, the natural mechanism of the act. This is in all 
 cases to be preferred as the safest ; but, should it fail, a second mode 
 is still available, which is much safer than, and therefore to be pre- 
 ferred to, any variety of instrumental delivery. What is required for 
 the operation is a handkerchief, or, what we have found even more 
 satisfactory, a skein of cotton yarn. One end of this is to be passed 
 between the thighs and the abdomen, in the flexure of the groins, to 
 the corresponding point on the other side, where it is to be seized and 
 
 22 
 
338 PELVIC PRESENTATIONS. [CHAP. 
 
 pulled down. 1 Id this we have a powerful fillet so adjusted that we 
 may use a very considerable traction force without any risk of injury. 
 It is sometimes possible — and the more so when the breech is high in 
 the pelvis — to break up the presentation, by pulling down one leg. 
 Should we employ this subsequently, for the purpose of traction, great 
 care must be taken not to use too much force, otherwise dislocation or 
 fracture may be readily enough produced. 
 
 The rule, however, is, as has been said, that we should interfere in no 
 way whatever until the breech and low r er part of the trunk have been 
 born, when we direct our attention assiduously to the state of the cord. 
 When the breech is born, and the legs lie between the thighs of the 
 mother, and in footling cases, even before the passage of the breech, an 
 almost irrepressible desire may possess the accoucheur to grasp the limbs 
 and to bring the labor to a rapid termination. Such, it is to be feared, 
 is not unfrequently the practice of those who have not taken some pains 
 to master the mechanism of pelvic births. In many cases, doubtless, 
 the result may be what is desired, but the hasty termination of the 
 labor is thus purchased at an increased risk to the child. For the 
 result of thus forcibly dragging down the body of the child is to sepa- 
 rate, unless the uterine contractions are unusually strong and continuous, 
 the chin from the sternum, against which it has been hitherto applied. 
 The consequent extension of the head may thus result in a faulty posi- 
 tion ; or, if the traction be continued, it may descend without under- 
 going the natural movement of rotation proper to the original position. 
 The possible result of this is only too obvious, and arises from the fact 
 that under such circumstances the child's head is delayed in the pelvis 
 longer than if we had left the case to nature, and thus, at the moment 
 of all others at which speedy delivery is desired, the head is detained, 
 and the child is suffocated, owing to the blundering ignorance of the 
 operator. But this is by no means the only manner in which his mis- 
 placed energy may defeat its own ends, for the separation of the chin 
 from the sternum leaves a gap into which the hands are liable to slip 
 from their position in front of the thorax, and from thence again to the 
 sides of the head, which may thus, in a tight pelvis, be jammed at the 
 brim. This, then, is an obvious error in practice which the young 
 practitioner should carefully avoid, and in regard to which midwives 
 should be specially instructed and cautioned. 
 
 The posture of the hands, and even of the arms, by the side of the 
 head is an occurrence which, quite independently of unskilful inter- 
 ference, may spontaneously take place. Under all circumstances, it 
 is an unfortunate complication, and requires, when recognized, imme- 
 diate attention. So soon therefore, as the lower half of the trunk has 
 been born, and the cord has been looked to, we pass up the finger to 
 ascertain the relative position of the arms. Should these be in the pos- 
 ture of which we have just spoken as the natural one, no interference 
 whatever is required, but if they are applied to the sides of the head, 
 
 1 In cases where this cannot easily be done, an elastic catheter, or some instru- 
 ment'of the nature of that which is used for plugging the posterior nares, might be 
 advantageously employed. 
 
XIX.] BIRTH OF THE HEAD. 339 
 
 it will be proper to bring them clown singly. Selecting that one which 
 is most within reach, a finger is to be hooked over the humerus, close 
 to the elbow-joint, when the arm is to be gently drawn forwards, so as 
 to cause the forearm to sweep over the anterior surface of the child. If 
 dragged down roughly, and without any reference to direction, fracture 
 of the humerus may occur, as has indeed often taken place in the hands 
 of the ignorant or unskilful. The one arm being released, the head 
 will probably descend a little further, and the other, coming thus more 
 within reach, is to be treated in the same manner. We must be careful, 
 during the passage of the shoulders, that the perineum is neither dis- 
 tended in such a manner, nor in such a direction, as to endanger its 
 integrity. The head, after the birth of the shoulders, now occupies 
 the cavity of the pelvis, and the face, in almost all cases, will be found 
 to have rotated into the hollow of the sacrum. 
 
 This is the stage of greatest clanger, and that at which the life of the 
 child is most frequently lost. Consequently, this is the moment which 
 requires the most constant attention, and at which assistance has gen- 
 erally to be afforded. The powers of nature are, in a certain propor- 
 tion of cases, quite sufficient to complete the delivery, so that even 
 here there exists no necessity for operative interference as a point of 
 routine duty. We must, still, therefore, be guided by the circum- 
 stances of the case, and no single sign affords us more reliable informa- 
 tion as to the urgency of the symptoms, than, as before, the funic pul- 
 sation. The cord, however, now becomes exposed to more powerful 
 pressure, and, at the same sime, the function of the placenta is seriously 
 interfered with, if not wholly arrested. The absence, in breech cases, 
 of the not inconsiderable quantity of liquor amnii which remains in 
 ordinary presentations till the last, allows of the firm compression of 
 this organ between the head of the child and the uterine walls ; and, 
 even should not this take place, the great contraction of the uterine 
 vessels permits of but a scanty supply of maternal blood for the oxy- 
 genation of that of the foetus. This, then, may truly be called a crit- 
 ical moment, in which, although placental respiration has all but ceased, 
 aerial respiration is as yet impossible. A life trembles in the balance, 
 and a few minutes at furthest will decide its fate. Impending death 
 from asphyxia is indicated in such cases, not only by a failure in the 
 circulation of the cord, but by failure of the heart's action as observed 
 by the stethoscope, and by convulsive movements of the respiratory 
 muscles. Such spasmodic attempts to fill the lungs with air are of the 
 nature of reflex actions, excited probably by the contact of carbonated 
 blood with the nervous centres. They indicate, therefore, impending 
 suffocation, and call for immediate action. It is assumed, of course, 
 that before matters have gone so far as this, we have in readiness such 
 restoratives as may be approved of, hot and cold water, and the forceps 
 — everything in fact which may be requisite, whether for the delivery 
 of the child, or its restoration should it be born, as frequently occurs, 
 in a state of suspended animation. 
 
 When the signs just mentioned indicate that the moment for opera- 
 tion has arrived, w T e must act without a moment's delay, a few seconds 
 making all the difference between success and failure, life and death. 
 
340 
 
 PELVIC PRESENTATIONS, 
 
 [CHAP. 
 
 The body and shoulders must not be grasped and pulled directly down- 
 wards, as is sometimes done. To do so would probably defeat our ob- 
 ject, by pulling down the occiput towards the pubic arch, instead of 
 favoring the natural movement of flexion ; and, besides, forcible trac- 
 tion of the neck is by no means free from the risk of causing instant 
 
 Fig. 122. 
 
 Artificial delivery of the head in breech cases. 
 
 death by injury to the spinal marrow. The following simple manoeuvre 
 answers admirably in ordinary cases; and will rarely fail to release the 
 head. The body of the child rolled in a napkin is laid along the right 
 forearm, which is then carried upwards between the thighs, so as to 
 bring the back of the child quite towards the abdomen of the mother. 
 Very gentle traction is all that is necessary to combine with this move- 
 ment, in order to permit the extraction of the head, which is mainly 
 effected, indeed, by the flexion of the neck which is thus encouraged. 
 Should this fail, the same movement may be combined with extractive 
 force, applied directly to the head by one or two fingers in the child's 
 mouth, or what is better and safer, two fingers applied to the superior 
 maxilla, one on either side of the nose. Some of the best authorities 
 recommend a simple method by which all traction on the neck is 
 avoided. In this, which is represented in the annexed engraving, two 
 fingers of the left hand are introduced, as above described, while the 
 occiput is pushed upwards behind the symphysis by the corresponding 
 fingers of the right hand: the movement of flexion essential to de- 
 livery is in this way effected, while the face and forehead are drawn 
 forwards along the distended perineum. By such a proceeding, some 
 have succeeded in establishing respiration, even before the head was 
 born, and with this object in view, Dr. Bigelow has recommended the 
 use of a flat flexible tube, which is to be passed within the vagina into 
 the mouth of the child. All these manoeuvres must be varied, in cases 
 
XX.] TRANSVERSE PRESENTATIONS. 341 
 
 of occipito-posterior and other exceptional positions, in accordance with 
 the natural mechanism of each case. 
 
 If, however, the resistance is unusually great, we must, in preference 
 to dragging upon the neck, apply the forceps without delay to the sides 
 of the child's head, and thus complete the delivery. If the child does 
 not at once breathe, the usual means described under suspended anima- 
 tion must be adopted and persevered in, so long as the slightest chance 
 remains of preserving the life of the infant. Any exceptional circum- 
 stances which may constitute impediments to delivery, must be man- 
 aged on general principles ; and, in extreme cases, it may even be 
 necessary to perforate behind the ear, and allow the contents of the 
 cranium to escape. Should the child be dead, many of the precautions 
 above detailed will of course be unnecessary. 
 
 CHAPTEE XX. 
 
 TRANSVERSE PRESENTATIONS: COMPLICATED 
 PRESENTATIONS. 
 
 transverse presentations : — the arm or shoulder the presenting part — 
 causes of — signs of, before and during labor — premature rupture 
 of the membranes to be avoided — dorso- anterior and dorso-poste- 
 rior positions — determination of exact position by observation of 
 the hand — probable course of an unaided case — occurrence of spon- 
 taneous evolution — spontaneous expulsion — methods of operative 
 assistance: period of labor to be selected: cephalic version: poda- 
 lic version: method of combined external and internal manipula- 
 tion: special difficulties — procedure modified if child dead — 
 compound or complicated presentations — hand and head — hand and 
 foot, etc. — general management of these. 
 
 In the Cross Birth of Hippocrates, the axis or long diameter of the 
 foetal oval is thrown across the womb — the most unfavorable position 
 which could by any possibility be selected. There is scarcely a point 
 on the surface of the trunk of the body in regard to which we may say 
 that its presentation at the os uteri is impossible, and it is not to be 
 wondered at, therefore, that some writers have described an infinite 
 variety of Transverse Presentations. Experience has, however, shown 
 that, whatever may be the case with a premature or putrid foetus, the 
 presentation of a mature and living child, which has unfortunately 
 assumed this position, is generally a presentation of the arm and 
 shoulder from the first. And, moreover, in the exceptional instances in 
 which some portion of the dorsal, thoracic, or abdominal surfaces pre- 
 sents, it has been found that these are usually converted into shoulder 
 or arm presentations by the descent sooner or later of those parts. For 
 these reasons, and for this additional one — that the mechanism in all 
 
342 TRANSVERSE PRESENTATIONS. [CHAP. 
 
 transverse cases is essentially the same — cases of cross birth may be 
 considered solely as arm presentations ; and, when these have been 
 fully described, it will be found that little remains to be specified in 
 regard to the other possible presentations of the trunk. In point of 
 fact, it is to presentations of the arm or shoulder alone that the terms 
 "faulty" or "preternatural" are properly applicable. According to 
 the elaborate statistics of Dr. Churchill, the superior extremities enter 
 the pelvis in advance of the rest of the foetus once in 231f cases. 
 
 The Causes of transverse presentation are, although obscure, probably 
 somewhat less so than in the case of the breech. Any fault or deformity 
 in the structure of the pelvic brim, which may act by preventing the 
 descent of the head into the cavity, may turn aside, towards the iliac 
 fossa, that extremity of the foetal ovoid, when the shoulder may slip 
 down and take its place. In like manner, an unusual quantity of 
 liquor amnii may, by destroying the ovoid form of the uterus, indi- 
 rectly encourage the displacement in question ; while uterine obliquity, 
 and premature expulsion of the foetus are also admitted by most writers 
 as circumstances which may possibly act in a similar manner. The 
 unfortunate tendency to a recurrence of this, in women who have 
 already had a child or children presenting by the superior extremity, 
 would almost seem to indicate that some anatomical peculiarity of the 
 parts may be the cause ; and it was this which led Wigand to suppose 
 that the form of the uterine cavity was the determining cause, and that, 
 in those cases in which cross birth occurred, the transverse diameter 
 of the uterus was in the first instance augmented, the long diameter of 
 the cavity being thus relatively diminished. 
 
 There are signs which, when distinct, may lead us, before the occur- 
 rence of labor, to suspect the existence of a transverse presentation; 
 but, until the presenting part comes within reach of the finger, it is 
 generally a matter of considerable difficulty to form a confident opinion. 
 The increased attention which has of late — more particularly in the 
 German schools — been given to the study of abdominal palpation 
 promises, however, to add precision to our diagnosis in this and other 
 similar conditions where the pregnancy is sufficiently advanced and the 
 abdominal walls are not unusually thick. In most cases, the belly of 
 the woman is peculiar in shape, and elongated in a transverse direction ; 
 and, if the abdominal walls are lax and thin, we may recognize a tumor 
 in each iliac fossa, one of which is more resistant and spheroidal, and 
 the continuity between which may be established on palpation. It is 
 sometimes possible to distinguish the hand, elbow, or shoulder, through 
 the anterior wall of the uterus, from the vagina ; but, generally speak- 
 ing, when we discover the presenting part in this situation, the most 
 we can say is that we feel a part which resembles the shoulder. Such 
 an observation, however, associated w T ith careful abdominal palpation, 
 may point to a quite definite conclusion. The stethoscope gives us no 
 reliable information ; but there are cases, as Cazeaux observes, in which 
 our diagnosis receives confirmation from this source. " If," he says, 
 "the vaginal examination has resulted in the recognition of a portion 
 of the foetus which is of small bulk, and if we perceive the pulsations 
 of the heart in the hypogastric region, we may almost certainly con- 
 
XX.] SIGNS OF TRANSVERSE PRESENTATION. 343 
 
 elude that it is the superior extremity. If we heard the heart at the, 
 level of the umbilicus, it would in all probability be a leg." It hap- 
 pens, even more frequently in transverse than in breech presentations, 
 that it is impossible to reach any portion of the fetus with the finger 
 alone in the earlier stages of labor; but, in some of these, the nature 
 of the case will be recognized by introducing a portion of the hand. A 
 marked effect of the height at which the foetus stands, is slow, and 
 comparatively painless dilatation of the os ; and, when the bag of waters 
 forms, it is, as in the case of the breech, very different in shape from 
 that which precedes the head. In transverse presentations, the shoulder 
 is the part which usually offers itself at the os uteri ; but, as a consid- 
 erable period often elapses before it comes within easy reach of the 
 finger, it is often not recognized until labor has made some progress — 
 a fact which bears in an unfortunate manner, as we shall see, upon the 
 ultimate issue of the case. 
 
 It is, indeed, of the very highest importance that, if we have to deal 
 with a cross birth, we should recognize the presentation as soon as it is 
 possible to do so ; so that the moment we discover a shoulder, an arm, 
 or a hand, we should not desist until we have exactly, and to our per- 
 fect satisfaction, ascertained the position of the child. The prominence 
 of the shoulder may be confounded with that of the tuber ischii, but 
 may readily be distinguished by the absence of a similar tuber, at a 
 little distance, with the genital organs between : and, should this nega- 
 tive evidence not be deemed sufficient, the finger passed towards the 
 axilla, so as to feel the ribs, will remove, if they can be reached, such 
 doubts as may remain. Care must be taken, in such manipulation as 
 may be necessary, to avoid rupturing the membranes ; for, so long as 
 the child is not forced down upon the brim, and these remain intact, 
 they are probably fulfilling their normal function of dilating the os, a 
 process Avhich should not, if possible, be interfered with. But, should 
 the membranes be ruptured, or the shoulder be forced downwards into 
 the cavity of the pelvis, and if we are still in doubt, it will be proper 
 cautiously to pull down the arm and hand, which enables us not only 
 to make snre of the presentation, but to recognize the particular position 
 by a simple method to be hereafter described. There is no evidence 
 that this procedure has any bad effect upon the progress of the case or 
 otherwise, and the unanimous opinion of the most experienced accouch- 
 eurs is that, if carefully done, it is quite free from risk. But, even if 
 a certain amount of risk necessarily attached to the operation, we would 
 be perfectly justified in incurring it, in preference to attempting the 
 management of the case without certain knowledge as to the position of 
 the child. Some difficulty might occur in distinguishing the parts if 
 not within easy reach. The manner in which the hand is to be made 
 out under such circumstances has already been referred to in the pre- 
 ceding chapter; but if, as will generally be observed, the arm hangs 
 down into the vagina, there can be no difficulty whatever in distin- 
 guishing it from the lower extremity even by the inexperienced. The 
 anatomical characters of the knee and elbow would enable us to dis- 
 tinguish also between these parts in the unlikely event of such a diffi- 
 culty arising. 
 
344 
 
 TRANSVERSE PRESENTATIONS. 
 
 [CHAP. 
 
 We have alluded to the caution to be exercised in manipulating, so 
 as to avoid premature rupture of the membranes. There is, however, 
 one advantage in this mode of procedure to which we have not alluded : 
 this is the possibility of rectification of the transverse position. This 
 has been observed by competent persons too often as a spontaneous 
 occurrence to admit of doubt as to its being an exceptionally fortunate 
 issue of the difficulties of such a case; but it must be manifest that no 
 such alteration in the axis of the child can occur when the waters have 
 drained away, and it is grasped firmly by the uterus and forced in part 
 into the cavity of the true pelvis. And not only this, but we know by 
 experience that the change may, in favorable circumstances, be effected 
 by a method, to be afterwards described as that of Dr. Braxton Hicks, 
 or, if the os is inaccessible by the finger, even more simply by external 
 manipulation alone, after the method of Wigand. 
 
 If we except certain complicated and unusual cases, to be afterwards 
 alluded to, we may refer all transverse presentations to two varieties, — 
 Dorso- Anterior and Dorso-Posterior — of which the former is more fre- 
 quent in the proportion of two to one. In dor so-anterior positions the 
 
 Fig. 123. 
 
 Fig. 124. 
 
 Transverse presentation. — Dorso-anterior. 
 
 Transverse presentation.— Dorso-posterior. 
 
 back of the child is, as in the corresponding positions of the pelvic 
 extremity, turned forwards. But, as the head may lie either to the 
 right or to the left, there are thus two varieties of this position, in one 
 of which, the head being to the left side of the mother, the right 
 shoulder presents ; while in the other, the head is to the right, and 
 consequently the left shoulder is the presenting part. These varieties 
 bear no relation whatever to the pelvic diameters. Nor, if we consider 
 that they are preternatural as regards the uterine diameters, can we 
 even admit that they bear any such possible or practical relation to 
 these, as would warrant us in placing them in the same category as the 
 presentations of the ends of the foetal ovoid which we have hitherto been 
 considering. There is here no question — primarily at least — of oblique, 
 transverse, or conjugate diameter, so that a separate description of the 
 two varieties of dorso-anterior position is quite unnecessary. The same 
 
XX.] DIAGNOSIS OF POSITION. 345 
 
 remark applies to the dorso-posterior position, which in like manner 
 offers itself for consideration under two varieties. In one, the head is 
 to the right, and the right shoulder presents ; in the other, the head is 
 to the left, and the left shoulder presents. As regards the two princi- 
 pal positions mentioned, as Avell as their varieties, it is unnecessary to 
 enter upon any elaborate description, as the management is in all cases 
 essentially the same. The nature of the operative procedure which, in 
 the great majority of instances, is necessary in the treatment of trans- 
 verse presentations, renders it important that we should begin by 
 ascertaining the exact position of the foetus. Indeed, should we make 
 a mistake in this particular, we know of a certainty that our error adds 
 to the maternal risk, which is already considerable. Of great impor- 
 tance, therefore, is it that we possess the power of discrimination between 
 the four positions which have been alluded to. 
 
 The points which we wish to ascertain are — to which surface of the 
 womb, anterior or posterior, is the Back of the child turned ? and to 
 which side, right or left, is the Head directed? To ascertain this by 
 passing the hand within and around the womb would of itself be a 
 serious operation ; but we have fortunately a safe and certain means by 
 which, under all ordinary conditions, we may at once determine the 
 exact relation which the child bears to the uterine walls, and so modify 
 our operative manipulations accordingly. The information in question 
 is to be derived from a careful examination of the arm which presents. 
 Prior, therefore, to any operation which we may find it necessary to 
 perform, with a view to the rectification of this faulty presentation, we 
 must pull down the arm, and carefully observe it, unless, indeed, our 
 examination of the presenting shoulder, and the parts beyond, should 
 have sufficed clearly to establish the position of the child. The point to 
 be first ascertained is, as to the presenting arm, whether it be right or 
 left. This is determined, in the simplest possible way, by the accouch- 
 eur placing the palm of his hand against the palm of the child's hand, 
 when if the thumbs correspond, so do the hands. For example, if he 
 employs, as most people do, the right hand, and finds the thumb of the 
 child correspond to his little finger, he knows that it is the left hand, 
 while if he finds them thumb to thumb, it is the right. This is a cer- 
 tain guide, and one in reference to which there is no possibility of fal- 
 lacy; but the information which is thus afforded is but limited, and 
 only indicates that we have to deal with one of two possible positions. 
 A more careful examination of the hand gives us complete and certain 
 information, so that we know exactly where to find the anterior and 
 posterior surfaces, and the head and the feet of the child. The following 
 rule is all that it is necessary to remember : the hand of the child being 
 supine, the Palm corresponds to the abdominal surface, and the Thumb 
 points to the Head. Here, however, there is a possible source of error, 
 which, if not avoided, \vill inevitably lead to wrong conclusions. For 
 a moment's consideration will suffice to show that, if we omit to make 
 sure that the hand is supine, we run the risk of its being pronated, 
 which, by turning the palm towards the back, and the thumb towards 
 the feet, may lead us to form an opinion which is, in every respect, 
 
346 TRANSVERSE PRESENTATIONS. [CHAP. 
 
 wrong. Before making the observation, therefore, be sure that the 
 hand is supinated — when error becomes impossible. 
 
 When the body of the child presents transversely at the brim of the 
 pelvis, the labor almost invariably requires at the hands of the accouch- 
 eur the assistance of art. Indeed, it may be said that, if the pelvis 
 be normal, and the foetus living, mature, and of average size, it is im- 
 possible for the woman to be relieved by the unaided efforts of nature. 
 The progress, and termination of such a case would probably be as 
 follows : After a tedious first stage, in which the dilatation of the os is 
 unsatisfactorily effected, the membranes rupture, and the arm descends 
 into the pelvis, either primarily, or, when the shoulder originally pre- 
 sents, after the labor has made some further advance. When this 
 occurs, the pains become much more severe and strong, and with each 
 succeeding effort the shoulder is forced down, and wedged into the 
 cavity of the pelvis. The head being situated, however, to one side, 
 and the breech to the other, progress beyond a certain point is mani- 
 festly impossible, so that when the utmost degree of moulding is at- 
 tained of which those parts are susceptible, and the base of the wedge 
 has entered the pelvis as far as the mechanical conditions will permit, 
 no amount of uterine or other propulsive effort can produce the slightest 
 effect. Left to nature, and attended with powerful uterine action, such 
 a case must ere long involve the life of the child, not less by the great 
 and continuous pressure on the neck and other vital parts, than by the 
 implication, from the same cause, of the placental circulation. The 
 actual degree of the pressure is further shown by the tumefaction of 
 the limb which hangs down into the vagina, or protrudes partially from 
 the ostium vaginse. The sufferings of the mother are in no way alle- 
 viated by the death of the child, but, on the contrary, every minute of 
 such fruitless effort renders her position more and more precarious. 
 The continued pressure on the soft parts of the parturient canal may 
 destroy in this way the vitality of the portions most exposed to its 
 influence, when sloughing, more or less extensive, will occur, from the 
 effects of which, coupled with the prostration and exhaustion which 
 gradually wear out her powers of constitutional endurance, her suffer- 
 ings are terminated by death. Or, at any stage of the labor, rupture 
 of the uterus may occur, and a similar result will, almost inevitably, 
 ensue. 
 
 Under certain circumstances, however, — such as a putrid or imma- 
 ture foetus, or a pelvis of unusual size, nature may relieve herself by a 
 spontaneous process of delivery. One of these processes is associated 
 with the name of Denman. This distinguished obstetrician found that, 
 under conditions similar to those above noted, what he termed sponta- 
 neous evolution occasionally occurred. In those cases, the shoulder, or 
 point of the wedge, did not maintain its position in the pelvis, but 
 moved upwards, during the continuance of the pains, towards the brim 
 of the pelvis, on that side which the head originally occupied, the head 
 itself moving in a corresponding direction in the iliac fossa. This 
 ultimately made way for the nates, which descended towards the floor 
 of the pelvis, when labor terminated as in a case which had been from 
 the first a presentation of the breech. This observation of Denman's 
 
XX.] 
 
 SPONTANEOUS EVOLUTION. 
 
 347 
 
 was hotly, controverted by some of the most eminent obstetricians of 
 the day, with the ultimate result, however, of establishing the correct- 
 
 Fiu. 125. 
 
 Spontaneous expulsion. First stage. 
 
 ness of his views. The controversy, moreover, by directing general 
 attention to the phenomena of spontaneous delivery, resulted in a 
 
 Fig. 126. 
 
 Second stage. 
 
 thorough elucidation of the whole subject, from which it transpired 
 that there was another process, and one of more frequent occurrence, 
 
348 
 
 TRANSVERSE PRESENTATIONS. 
 
 [CHAP. 
 
 according to which a similar result ensues. The credit of first describ- 
 ing this is generally attributed to Dr. Douglas, of Dublin, who, to 
 distinguish it from the process of Denman, called it spontaneous expul- 
 sion. The mechanism of this differs essentially from the former, as 
 the shoulder, instead of ascending, continues to descend, until it be- 
 comes fixed against the subpubic arch, when it is arrested and forms 
 a centre, upon which the whole body of the child revolves. It is 
 obvious that such a mechanism as this can only be possible under the 
 same exceptional conditions which permit of spontaneous evolution. 
 For in this case the breech must pass the pelvic brim which is already 
 partly occupied with the base of the skull, an occurrence which is 
 manifestly impossible if the relative proportion of the parts, maternal 
 and foetal, are in accordance with the normal standard. The mode in 
 
 Fig. 127. 
 
 Third stage. 
 
 which the successive stages of the expulsion actually occur is shown in 
 the accompanying figures, in which is depicted the manner in which, 
 while the child revolves, the thorax, buttocks, and remaining shoulder 
 succeed each other in their passage over the distended perineum. All 
 being thus born but the head, the delivery of that part may either be 
 effected by the natural efforts, or with the assistance of the accoucheur 
 in the manner already fully described in the last chapter. The long- 
 continued ineffectual efforts of the uterus, resulting in complete atony 
 of its muscular structure, may at this stage cause the death of the 
 woman by haemorrhage so profuse that all our efforts are powerless to 
 arrest it, — an unhappy result which is more likely to occur in those cases 
 in which operative assistance has been too long delayed. 
 
 There are, perhaps, no cases occurring in the practice of midwifery 
 which call for more tact, judgment, and operative skill, than those 
 which are now under consideration. The object of all operative in- 
 
XX.] OPERATIVE INTERFERENCE. 349 
 
 terference is the rectification of a preternatural presentation, so as to 
 place the axis of the child in correspondence with the axis of the uterus, 
 and thus permit of delivery in consonance with the mechanical laws 
 which govern the normal process. Deliberately to leave the case to 
 nature, on the chance of the occurrence of spontaneous evolution or 
 expulsion, would be irrational in the extreme. For, although the risk 
 of operative procedure must not be under-estimated, we may be quite 
 certain that the danger which will accrue from delay is vastly greater, 
 inasmuch as the child's life is sacrificed, and that of the mother is 
 placed in imminent peril. It is scarcely possible in these days that, 
 in this or any other civilized country, a woman would be suffered to 
 die undelivered, for sooner or later assistance would be sure to reach 
 her. Such assistance, however, there is too good reason to believe, 
 may be afforded at a period when the vital powers have already begun 
 to flag, when the arm and shoulder are already wedged down in the 
 pelvis, and when the life of the child has long been destroyed. All 
 these circumstances increase very greatly the gravity of the case, and 
 may often lead us to despair as to its ultimate issue ; but, whatever 
 the difficulties may be, the educated accoucheur must be prepared to 
 cope with them, and to act in every case, even the most desperate, in 
 such a manner as may at least give the mother what chance human 
 skill can afford her. No one point, therefore, is of such importance as 
 this, — that we should recognize the position at the earliest possible 
 moment. If we have the good fortune to do so early in the labor, we 
 may look upon the case with calm self-reliance, knowing that the issue 
 lies in a great measure in our hands. No pressure having at this time 
 compromised the life of the infant, w T e hear its heart beating vigorously, 
 and we may possibly feel it move ; while the maternal parts have as 
 yet been subjected to no mechanical violence. No details are requisite 
 to prove that, in the two classes of cases referred to, the prospect of 
 success is very different, and we therefore repeat that nothing, in point 
 of importance, is to be compared with an early recognition of the case. 
 This enables us, moreover, to select the time at which we may act with 
 the greatest probability of success. 
 
 The choice thus afforded us must be taken advantage of with dis- 
 crimination, and in full view of the facts which have been detailed. 
 The responsibility which devolves upon the accoucheur in such a case, 
 renders it essential that his services should be at command on any 
 emergency, such as the arrival of the moment favorable for operation 
 somewhat earlier than he might perhaps have been prepared to expect. 
 For, as will presently be made apparent, this period may be of short 
 duration, and if it be not taken advantage of, the case may pass very 
 rapidly into another category in which the risk to mother and child is 
 greatly increased. It is of the first importance, as has already been 
 mentioned, that the integrity of the membranes should be preserved as 
 long as is possible. Any clumsiness or violence of manipulation during 
 the course of an ordinary vaginal examination, may thus, by causing 
 the escape of the waters, not only permit of the descent of the abnormal 
 presentation, but may, by complete evacuation of the liquor amnii — 
 upon the same principle as in pelvic presentations — bring the uterine 
 
350 TRANSVERSE PRESENTATIONS. [CHAP. 
 
 walls into immediate contact with the surface of the child. This is all 
 the more likely to occur if we examine during a pain, so that we should 
 carefully avoid examination at this moment, or at least conduct it with 
 special caution. The patient is to be confined strictly to the horizontal 
 posture, but so long as the child is alive, the os but partially dilated, 
 and the presenting part still high, it is better to wait than to attempt 
 a forcible dilatation of the os, which would most likely involve a rup- 
 ture of the membranes. This is the period, however, at which an 
 attempt at rectification may be made with considerable prospect of 
 success, if we combine the use of the finger internally with the external 
 manipulation of Wigand, according to the method recommended and 
 practiced by Dr. Braxton Hicks. After having ascertained the exact 
 position of the child, or at least the side to which the head is turned, 
 this may be effected by pressing the shoulder upwards from the vagina, 
 while the head is pressed down towards the brim of the pelvis, and if 
 necessary retained there, by the other hand which is applied to the 
 surface of the abdomen. The process effected by this manoeuvre is 
 what is termed Cephalic Version. The same result has been success- 
 fully attained by Hamilton, Gooch, and others, by manipulation which 
 is purely internal, and by Wigand and Martin, by a method in which 
 the manipulation is exclusively external, but it is to the distinguished 
 obstetrician named above that we owe the combined method. 1 This 
 subject will be more fully noticed under the head of Turning in a 
 special chapter, so that we shall only mention here such points as are 
 incidental to the peculiar case which we are now considering. 
 
 The treatment, according to almost all authorities, which is most 
 applicable to transverse presentations, is the operation generally known 
 as Turning or Podalic Version, to be afterwards more particularly de- 
 scribed. Should this operation be determined upon from the first, the 
 condition of the membranes is of even greater importance than before; 
 and the state of matters which is most favorable to its successful per- 
 formance is to be found when the os is in such a condition, as regards 
 dilatation or dilatability, as to permit the passage of the hand, should 
 that be necessary, while, as yet, the liquor amnii has not escaped. 
 Waiting patiently till full dilatation has been attained, or till rupture 
 of the membranes takes place, increases in no way, as we have seen, 
 the risks of the case. But, so soon as either event occurs, we at once 
 proceed to the operation by introducing the hand, seizing the feet, and 
 bringing them towards the os uteri, whence the shoulders will recede — 
 under such circumstances at least — without difficulty. The mode pre- 
 viously detailed of ascertaining the position of the child by observation 
 of its hand must here be practiced if necessary, as the result of an error 
 in this respect, or a haphazard introduction of the hand within the 
 womb, will greatly increase the risk to the mother which attends the 
 operation, even when most skilfully performed. The position of the 
 child being ascertained, the palm of the child's hand will indicate the 
 abdominal surface, to which the hand of the operator should always be 
 
 1 See Dr. Braxton Hicks's Memoir, " On Combined External and Internal 
 Version."— London, 1864. 
 
XX.] TREATMENT. 351 
 
 directed, while by pushing the hand in the contrary direction to that 
 in which the thumb points, the feet will most easily be attained, and 
 at a minimum of risk. In this case also, the method of combined 
 version is equally applicable as for cephalic version. And it requires 
 no argument to show that, if it be practicable thus to effect the object 
 in view, an operation which consists in the introduction of one, or at 
 most tw r o fingers into the uterine cavity, must involve less risk than 
 necessarily attends the ordinary procedure of turning by the feet. 
 That it is practicable, we have had several opportunities of demon- 
 strating, and it is without any hesitation, therefore, that w T e recommend 
 that this method should in the first instance be tried in every case, and 
 the more severe operation only in those instances in which the former 
 fails. As in cephalic version, it is better to attempt rectification so 
 soon as the os has sufficiently dilated to admit the finger, and to permit 
 an accurate diagnosis. With the escape of the waters, the mobility of 
 the foetus is, for obvious reasons, diminished. 
 
 The following, from Dr. Hicks's published cases, is a striking instance 
 of how, even under most unfavorable circumstances, combined version 
 may be practiced with perfect success. 
 
 " Mrs. M , admitted into Mary Ward in April, 1861. The antero-posterior 
 
 diameter of pelvic brim measured only two inches and one-eighth, which had 
 caused her labor to be accomplished with the greatest difficulty; embryotomy being 
 employed on the last occasion, although brought on at the seventh month. Labor 
 was induced on 13th April last, in the seventh month of this her fourth pregnancy, 
 by puncturing the membranes. Pains came on in about sixty hours, after which 
 they continued to increase for twenty-four hours, at intervals of five minutes. The 
 os uteri was then about the size of half a crown, still unyielding, scarcely admitting 
 two fingers. The liquor amnii still existed in small quantities, draining slowly 
 away. The shoulder presented, the head being to the right side, the breech to the 
 left, but both approaching the fundus, the child being somewhat doubled on itself. 
 As it was of much importance to rectify the presentation before the os dilated, so 
 that the presenting part might not be driven lower down, and as the footling pre- 
 sentation seemed, with so narrow a brim, and a small soft head, to give the best 
 chance for the life of the foetus, I decided on attempting podalic version. The 
 patient was put under the influence of chloroform. The left hand was introduced 
 into the vagina, with two fingers through the os, and the presenting part pushed in 
 the direction of the head, while the right hand pressed down the breech from with- 
 out. The foetus did not glide round in the uterus very easily, for it was tightly 
 clamped by it, and every movement within or without produced uterine action, con- 
 sequently it required a little patience; but by varying the position and direction of 
 the outside pressure, the foot was at last drawn into the os by two fingers. The 
 chloroform was discontinued, and after about half an hour, slight expulsive pains 
 appearing, gentle traction was made upon the child. It was not long before the os 
 dilated and the child was brought down during the pains. Some detention of the 
 head took place at the brim, in consequence of the very narrow antero-posterior 
 diameter, and the child's life was lost. The mother did very well." 
 
 The really difficult cases, and those in regard to which apprehension 
 will naturally arise, are those in which we have to act after the shoul- 
 der has descended in the pelvis, and when the body of the child is 
 tightly embraced by the womb. No attempt should be made under 
 any circumstances to replace the hand and arm, should these have pro- 
 lapsed ; and it Avill generally be proper, before proceeding to operate, 
 to allay the excited irritability of the uterus, which shows a spasmodic 
 tendency to contract under the slightest stimulus. Of various means 
 at our command, that which is most suitable for this purpose is chloro- 
 
852 TRANSVERSE PRESENTATIONS. [CHAP. 
 
 form, and if the patient be well brought under its influence, it is won- 
 derful to what extent we succeed, in some instances, in relaxing the 
 parts, so as to admit of the easy passage of the hand. In every case, 
 however, such an operation is attended, as compared with one performed 
 at an earlier stage of the labor, with greatly increased risk, the danger 
 being in direct proportion to the amount of resistance encountered in 
 an attempt to pass the hand. The condition of the bladder and rectum 
 should, as a matter of course, be ascertained, and, if necessary, those 
 viscera emptied before any attempt is made at rectification. A peculiar 
 and special resistance may proceed from the state of the os, which, if 
 rigid, may constitute a barrier to the passage of the hand. In this case, 
 if the waters have escaped, and the probability of its dilatation within 
 a given time is thus a matter of great uncertainty, we must endeavor 
 to dilate the os, either by the finger in a manner which will be after- 
 wards described, or by means of some such mechanical appliance as 
 Barnes's bags, and then proceed in the usual way. We may be sum- 
 moned to cases in which, although the wedging of the shoulder is com- 
 plete, clear evidence is afforded us of the death of the child. The proof 
 of death may consist either in the signs of actual putrefaction, when the 
 skin will peel off the presenting part, in the observation of a flaccid and 
 pulseless funis, which is not unfrequently prolapsed in these cases, and 
 in the absence of foetal pulsation and movement; of which signs the 
 first two may be regarded as certain, while the last is to be accepted 
 with caution. Our procedure here is to be modified by the fact that 
 we have now no longer the interest of the child, but that of the mother 
 alone to look to, so that our object simply is to deliver her in such a 
 manner as may subject her to the smallest possible risk. We make no 
 attempt, therefore, in this case, to turn, but at once reduce the bulk of 
 the child by evisceration, or bisect its long axis by decapitation, and 
 then proceed to extract it in the manner which may seem safest and 
 best. 
 
 In a very few cases, in which the special circumstances favorable to 
 such an occurrence are present, it may be obvious that the case is about 
 to terminate spontaneously, according to the methods of Douglas or 
 Den man. This will be recognized in each case by careful examina- 
 tion, — more especially during the pains, — which will enable us to make 
 out that the process of revolution is being gradually effected. Delay is, 
 under such circumstances, quite proper, more especially when the child 
 is dead; in which case, indeed, we might assist the process materially 
 by the aid of the crotchet or blunt hook. With reference to the more 
 frequent of the two processes, Dr. Douglas says, " If the arm of the 
 foetus should be almost entirely protruded, with the shoulder pressing 
 on the perineum; if a considerable portion of its thorax be in the hol- 
 low of the sacrum, with the axilla low in the pelvis; if, with this dis- 
 position, the uterine efforts be still powerful, and if the thorax be forced 
 sensibly lower during the pressure of each successive pain, the evolu- 
 tion may, with great confidence, be expected." 
 
 Compound or Complicated Presentations. — In addition to the various 
 presentations already described, there are many others, of rare, though 
 possible occurrence, in which certain parts, anatomically distinct from 
 
XX.] COMPLICATED PRESENTATIONS. 353 
 
 each other, come together towards the os uteri. Most of these presen- 
 tations are varieties, more or less distinct, of transverse presentation ; 
 but in some, again, the coincidence of the long axis of the child with 
 that of the uterus is maintained. We shall only mention here one or 
 two of the many possible compound presentations. When the hand 
 and head present together, the mechanism of natural delivery is, of 
 course, complicated to the extent of the diameter of the arm. In a 
 pelvis of large, or even of ordinary dimensions, there is nothing to 
 prevent a satisfactory termination of the labor; but, if the pelvic 
 diameters should chance to be ever so little out of proportion, the pres- 
 ence of the arm may make all the difference in the world, and suffice 
 to jam a head which would probably have passed, under the ordinary 
 conditions, with very little more difficulty than usual. Nay, even 
 when a hand presents on either side of the head, there is nothing abso- 
 lutely to prevent the birth of the child, which has, in fact, been 
 observed to pass, under such circumstances, without any marked diffi- 
 culty whatever ; so that, in both of these instances, we have to deal 
 with conditions very different to those which obtain in cross-births. 
 But the chance of delay and protracted suffering is sufficient warrant 
 for us, in such cases, to attempt a rectification of these presentations, if 
 only this can be effected without incurring the risk of making matters 
 worse. What we wish to do is to push the arm upwards, so as to allow 
 the head to descend, and alone to occupy the cavity of the pelvis. In 
 making such an attempt, however, we must be particularly careful not 
 to displace the head ; for, if the result of our interference were to be 
 that the head was moved from the brim to the iliac fossa, and the 
 shoulder thus permitted to descend, we would, in plain language, find 
 that we had converted a comparatively favorable presentation into one 
 of the most unfavorable which it is possible to conceive. For this rea- 
 son, it is generally better to avoid all such attempts until the head has 
 entered, or is becoming engaged in the pelvic brim. If we then use 
 ordinary caution in our manipulation, we may attempt, without hesi- 
 tation, to effect our object by pressing the prolapsed limb steadily up- 
 wards ; and, along with this, we should try to retain the head against 
 the brim, in such a manner as to prevent the slipping down of the 
 arm, until the uterine efforts have caused the head to descend so far 
 that this is no longer possible. This latter indication has been success- 
 fully fulfilled by combining external with internal manipulation, and 
 that in a manner which would encourage us to repeat the manoeuvre 
 on any occasion which might occur. 
 
 The Feet and Hands, or one of each may present, and thus consti- 
 tute what may be termed an unusual variety of transverse presentation. 
 It is a common occurrence, in this variety, to find prolapse of the funis 
 as a further complication, and one unfortunately which will add in no 
 small degree to our perplexity. As we could scarcely expect in such 
 a case to replace both limbs, and as prolapse of the cord of itself in- 
 volves very serious danger to the life of the foetus, the very obvious 
 and proper procedure is to draw down the inferior extremity, and thus 
 complete podalic version. For, if we leave it to nature to select by 
 which of the poles of its long diameter the child will descend, it is 
 
 23 
 
354 
 
 TRANSVERSE PRESENTATIONS, 
 
 [CHAP. 
 
 more than probable that the shoulder will slip down, and the difficul- 
 ties of the case will then be very greatly aggravated. Or, as is still more 
 likely, the upper and lower limbs will together become wedged into the 
 pelvis, and the progress of the labor be as effectually barred as in the 
 ordinary transverse position. If the mobility of the foetus within the 
 womb is as yet not seriously interfered with, no great difficulty will be 
 incurred in the operation, and as the child revolves, its arm will leave 
 the vagina and follow the head in its movement towards the fundus. 
 But, if the child is so firmly grasped by the womb as to render the 
 operation unusually difficult, the woman must be put under the influ- 
 ence of chloroform, and a fillet attached by a running noose above the 
 ankle (see chap, xxxii), when steady traction upon this, combined 
 with pushing up the arm, and with the further aid of external manip- 
 ulation, to be afforded by an assistant, will usually effect the version. 
 Should the cord have formed one of the elements of the original pres- 
 entation, great attention must be paid to it, in order, if possible, that 
 it should retreat into the uterine cavity along with the superior ex- 
 tremity ; failing which, it should be guided into that part of the pelvis 
 where it is least likely to be exposed to injurious pressure. The case, 
 otherwise, is to be managed as an ordinary footling presentation, and 
 delivery slowly or rapidly effected according to the urgency of the symp- 
 toms and the other attendant circumstances. 
 Positions more complicated still may be, although rarely, encountered. 
 
 Fig. 128. 
 
 Case of complicated presentation. 
 
 We may have, for example, the Hand and Foot presenting along with 
 the Head, or we may have, as in the case which is represented in the 
 accompanying engraving, a presentation of the Head, Hand, Foot, and 
 
XXI.] PROLAPSE OF THE CORD. 355 
 
 Cord. All such cases are to be managed on similar principles by the 
 performance of podalic version. In the case in question, the whole of 
 the presenting parts were tightly jammed in the pelvis, the child firmly 
 embraced by the uterus, and the cord flaccid and pulseless, before it 
 was brought under our observation. The woman had previously borne 
 several children at the full term. Although greatly exhausted by a 
 fruitless labor of many hours' duration, her pulse was of tolerable 
 strength ; and it was resolved, after the administration of some stimu- 
 lants, at once to proceed to the operation. Version was, however, in 
 this instance, effected with extreme difficulty, in the manner above de- 
 scribed, by the hand and the fillet. When the child was born, it was 
 found to assume, as if from imperfect cadaveric rigidity, the attitude 
 which it had occupied within the womb. This was so characteristic 
 that a cast was taken, of which the drawing is a tolerably correct rep- 
 resentation. Other presentations, in addition to those enumerated, may, 
 as we have said, be met with, but the above will suffice to indicate the 
 general principles upon which the treatment of all such is to be based. 
 All cases of transverse and complicated labor are attended with 
 greatly increased risk as regards the child ; and, even under the most 
 favorable circumstances, with a considerable addition to the dangers 
 which women undergo in childbed. In the former class, it has been 
 found that, even including those cases in which the most skilful assist- 
 ance has been afforded, more than half of the children perish, while, 
 as regards the mother, the deaths are about one in nine. The fatality 
 in both depends, in a very great measure, as all experience has shown, 
 upon the period or stage of the labor at which assistance is first afforded. 
 
 CHAPTER XXI. 
 
 FUNIS PKESENTATION. 
 
 "PRESENTATION" AND "PROLAPSE" OP THE CORD — RELATION OF THE FUNIS TO 
 OTHER PRESENTATIONS — CAUSES OF — SYMPTOMS OF AT VARIOUS STAGES OF 
 LABOR— GREAT DANGER TO CHILD — TREATMENT: AT FIRST EXPECTANT: 
 AVOID RUPTURE OF THE MEMBRANES: REPOSITION BY THE FINGERS: BY 
 MECHANICAL APPLIANCES: VARIOUS REPOSITORIA DESCRIBED: POSTURAL 
 METHOD : USE OF THE FORCEPS : TURNING. 
 
 Some writers have, without any obvious advantage, drawn a distinc- 
 tion between " presentation " and "prolapse" of the umbilical cord. 
 By the former term is implied those cases only in which a portion of 
 the cord is situated in the lowest part of the amnionic cavity, so that 
 it may be felt from the vagina; either through the inferior portion of 
 the uterine wall, or through the membranes, when the finger can be 
 passed by the os. Prolapse, again, is restricted to cases in which, after 
 
356 FUNIS PRESENTATION. [CHAP. 
 
 the rupture of the membranes, a loop of the cord passes into the 
 vagina, or even hangs from the vulva, — in both cases preceding that 
 portion of the child's body which presents at the os uteri. Such a 
 distinction as this is, in so far as classification is concerned, obviously 
 useless, seeing the prolapse is merely a more advanced stage, and an 
 almost inevitable sequence, of the presentation. 
 
 At the beginning of labor, the funis may present alone at the os, 
 and may be felt to occupy the bag of waters before the child has de- 
 scended ; or, what is more usual, it descends along with the cranium, 
 nates, shoulder, or any other part of the fetus, becoming prolapsed 
 only when the membranes give way. Presentation of the cord is an 
 occurrence which, although not very frequent, is so hazardous, as re- 
 gards the life of the child, that we cannot pass it by without careful 
 attention. Considerable discrepancy exists as to the frequency of its 
 occurrence, and it has been variously stated by competent and expe- 
 rienced observers at from 1 in 37 to 1 in 382. There can be little 
 doubt that it often occurs without its being recognized, — in those cases 
 chiefly in which the loop is small, and the prolapse consequently 
 trifling. This may, in some measure, seem to account for the discrep- 
 ancy alluded to; but we may confidently accept of the statistics care- 
 fully compiled by Dr. Churchill, — which, on a total of 90,983, give 
 one case of funis presentation in 282, — as indicating, approximately at 
 least, the state of the case. It is in cranial presentations that prolapse 
 of the cord most frequently occurs, — a fact which depends wholly upon 
 the great preponderance of these as compared with the other presenta- 
 tions. Considered, however, relatively to transverse, breech, and the 
 rarer presentations, we find that it is most frequent with the shoulder, 
 then with the breech, and, in point of fact, is more likely to occur in 
 any other presentation (relatively to its actual frequency) than in 
 cranial cases, where the ball-valve formed by the head is, as we shall 
 show, less likely than any other part to admit of the descent of the 
 coil. Scanzoni brings out the following as the result of his experience: 
 
 Funis presenting once in 304 cranial cases. 
 " " " 32 face cases. 
 
 " " " 21 presentations of pelvic extremity. 
 
 " " " 12 transverse presentations. 
 
 The Causes of funis presentation vary according to the presentation 
 of the child, and are also influenced by other circumstances. Among 
 the predisposing causes, an unusual quantity of liquor amnii is a con- 
 dition which, by separating the uterine walls from the surface of the 
 foetus, must certainly encourage the displacement in question ; and it is 
 mentioned by Scanzoni that, in more than a third of the cases observed 
 by him, an unusual quantity of liquor amnii existed. Probably the 
 larger the quantity the more likely would be the descent of the cord ; 
 so that in cases of Dropsy of the Amnion we might anticipate the 
 probability of such a displacement. In the case of a cord of unusual 
 length, the conditions are also such as singularly to favor its gravita- 
 tion downwards, either prior to the rupture of the membranes, or during 
 the escape of the waters, when the loop suddenly slips down along with 
 the gush of fluid. In cases where the placenta is inserted near the os, 
 
XXI.] CAUSES. 357 
 
 and the cord lies, consequently, in its immediate vicinity, the danger 
 of prolapse must manifestly be increased, and will, on the contrary, be 
 reduced, the further the site of the placenta is from the lower segment 
 of the womb. It is doubtful whether a pelvis of unusually large size 
 favors, as some have supposed, the descent of the cord ; in fact, we are 
 inclined to believe, that so far from this being the case, the unusual 
 depth in the pelvis of the presenting part, in these cases, is more likely 
 to prevent the accident, by a firmer contact than usual with the inferior 
 part of the uterine cavity. But it is otherwise with a narrow pelvis, 
 and more especially in such instances as show marked contraction at 
 the brim. In these, the descent of the presenting part, and the occu- 
 pancy by it of the inferior part of the womb, are mechanically hindered, 
 to such an extent that the cord is either forced down by the uterine 
 contractions into the bag of waters, or, upon the escape of these, is 
 carried past the arrested head by the impulse of the momentary torrent. 
 Cases of this kind have been recorded by Mr. Roberton, of Manchester, 
 who has paid particular attention to the subject. 
 
 There is, probably, no cause which acts more decidedly in producing 
 this unfortunate situation of the cord than the presentation of the child. 
 The more thoroughly the lower region of the womb is occupied by the 
 corresponding portion of the child, the less likely is prolapse to occur; 
 and we find, therefore, that the less effectively this condition is main- 
 tained, there is, in direct proportion, increased danger to the cord. In 
 the case of the cranial positions, a very superficial observation of the 
 facts of the case will suffice to show how admirably adapted these are 
 to the mechanical prevention of the displacement in question. It is 
 true, indeed, that it is not the head which, in the first stage of labor, 
 presses during a pain upon the os, and it might be assumed, as by no 
 means improbable, that the cord should slip down into the interval 
 between the membranes and the head. But a more close attention to 
 the mechanism of a labor-pain, — which has been fully described in a 
 previous chapter, — shows that nature, apparently, provides against such 
 a movement on the part of the cord, by commencing the contraction in 
 the cervix, from whence it passes upwards, and thus, by a sort of inverted 
 peristaltic action, maintains the relative position of the parts, which is 
 only likely to be disturbed, under such peculiar circumstances, as have 
 been above detailed. So soon as rupture of the membranes permits of 
 the immediate application of the head to the circumference of the os, 
 the same action, beginning in the sphincter fibres of the cervix, and 
 exercised equally upon the spheroidal cranium, still more effectually 
 prevents displacement. 
 
 It is widely different in the other presentations of the child, which 
 we may here consider together. In the case of the face, the conditions 
 approach more closely to those of cranial presentations than to any 
 other; and we thus find, as we might have anticipated, in the table 
 quoted above from Scanzoni, that these are, next to the cranial posi- 
 tions, the most favorable. As regards presentation of the nates, we 
 have here also a rounded mass, occupying the lower segment of the 
 uterus, in a manner which in most cases is sufficient to maintain the 
 position of the cord. That its descent occurs in a much larger relative 
 
358 FUNIS PRESENTATION. [CHAP. 
 
 proportion of cases than in cranial positions, is to be accounted for by 
 various circumstances. We cannot fail to observe, in the first place, 
 that there is not the same regularity in the circumference of the pre- 
 senting breech as in the case of the head. There are thus, necessarily, 
 various points at which the contact between the uterus and the present- 
 ing mass is comparatively insufficient, so that the cord may easily glide 
 down at those points where the resistance is least. We can easily con- 
 ceive it possible that, in this manner, a loop of the cord may pass down 
 over the genitals in the interval between the nates, and make its appear- 
 ance in the vagina, or externally. Should the presentation be one of 
 the knees or feet, the conditions favorable to a descent of the cord are 
 even more exaggerated. It is in transverse presentations, however, 
 that the cord most frequently descends along with, or in advance of, 
 the presenting part. There is, in this case, but little to prevent the 
 displacement in question; and neither the shoulder nor the arm can be 
 looked upon as, in any sense, the mechanical equivalent of the cranium. 
 And what makes matters worse, in the case of cross birth, is the prox- 
 imity, in every case, of the umbilicus to the os uteri, which must still 
 further multiply the conditions favorable to displacement. But, of all 
 possible cases, those in which prolapse or presentation of the funis is 
 most likely to occur are what have been described in the preceding 
 chapter as complicated presentations, — such as hand and head; hand 
 and foot; head, hand, and foot; and the like, — in which the conditions 
 favoring prolapse reach their maximum. 
 
 Sudden rupture of the membranes, with the accompanying gush of 
 waters, has been placed by some in the first rank as a determining 
 cause of prolapse of the funis. This is claiming for the phenomenon 
 in question too important a position. No one can deny that "pro- 
 lapse" of the cord usually takes place at this moment, but the deter- 
 mining cause of the displacement has, probably, in almost all these 
 cases, been previously in operation, and has already induced a descent 
 of the cord as fir as, prior to the moment of rupture, is possible. It 
 may, no doubt, happen that, under special circumstances, such as 
 abundance of the liquor amnii, a loop of the cord may be carried down 
 past the presenting part along with the fluid ; but the usual occur- 
 rence, we apprehend, is that the prolapse at the moment of rupture is 
 merely a more advanced and complete stage of previous displacement. 
 
 The Symptoms by which this accident is to be recognized vary ac- 
 cording as the membranes are intact or ruptured. In the former case, 
 the diagnosis is attended with considerable difficulty, inasmuch as we 
 can only be guided by the sense of touch through the membranes 
 or the thin uterine walls. It is quite possible, at this stage, to mistake 
 the inequalities which are presented by the fingers and toes for the 
 irregularities due to the twisting of the cord; and, in such cases, the 
 only sign upon which we can confidently rely is the observation of the 
 umbilical pulse. This is, however, not always easily made out, unless 
 we are able to compress the cord between the finger and the presenting 
 part of the child. And, even when we do feel pulsation, we must be 
 cautious not to mistake the pulsation due to enlarged maternal vessels, 
 which are to be distinguished by the synchronism of the latter with 
 
XXI.] SYMPTOMS. 359 
 
 the radial pulse. It is, then, unequivocal foetal pulsations only which 
 are to be accepted under those circumstances as satisfactory evidence of 
 the displacement which we are now considering. Whatever doubt 
 may exist as to the nature of the case is at once dispelled by rupture of 
 the membranes, when the loop of the cord escapes into the vagina, or 
 may even pass so far down as to come into sight at the orifice of the 
 vagina. But, should the coil be small, or any other circumstance pre- 
 vent its prolapse, no difficulty will be met with in perfecting the diag- 
 nosis, as the cord may now be felt distinctly, rolling beneath the finger, 
 and its pulsation may be ascertained by compressing it directly be- 
 tween the fingers ; while the fingers and toes, should these parts have 
 given rise to doubt, may, by a similar method of examination, be read- 
 ily distinguished. There is one possible, though, perhaps, scarcely 
 probable source of error, against which the inexperiened observer must 
 here be on his guard. It occasionally happens that, in extensive rup- 
 ture of the uterus, a coil of the small intestine passes through the 
 aperture into the uterus, and even into the vagina ; and, although the 
 presence of the mesentery and the absence of pulsation should in such 
 cases obviate the possibility of mistake, the sensation which the bowel 
 yields bears such a resemblance to the cord that an opinion might rashly 
 be formed, which might lead, in practice, to the most disastrous results. 
 Several cases, at least, have been recorded in which this blunder has 
 been committed, with the most discreditable and unfortunate issue. 
 
 As regards the mother, there is no risk whatever in a presentation of 
 the funis. Experience has, however, shown that, of all possible pres- 
 entations, not even excepting trans'verse cases, nothing is more fatal 
 to the life of the foetus. Of all cases, and without any reference to the 
 fact of assistance being rendered, it is certain that considerably more 
 than one-half of the children are lost, which is sufficient to show that 
 the treatment or management of the cord, in these cases, during labor, 
 is necessarily one of the most important points which can possibly arise 
 in the course of practice. What we desire to effect is the protection of 
 the cord from such pressure as may arrest the circulation, or, in other 
 words, to avert, if it be possible, from the child, the danger of death 
 from asphyxia. We have already seen, in reference to presentations of 
 the pelvic extremity, that the chief cause of increased mortality in these 
 cases is pressure on the cord, and the same remark obviously applies 
 with equal force to all cases of transverse or other presentations in 
 which podalic version is practiced. But, unless there should be pro- 
 lapse, the danger is confined to the later stage of labor, during which 
 the cord is subjected to pressure between the head and the pelvic walls. 
 If the cord presents originally, the vessels are obviously subjected to 
 a more prolonged and continuous pressure, so that the danger is con- 
 siderably increased. When, in any case, the labor pains are frequent, 
 violent, and of long duration, the chance of the child's life is small, 
 unless delivery should be effected with unusual rapidity; but if, on the 
 contrary, the pains are moderate, and of short duration, the foetus has 
 time to rally, during the intervals, from the effects of the partial 
 asphyxia which attends each uterine effort, and the cumulative effect 
 of pressure is in a measure avoided. We must, how T ever, even under 
 
360 FUNIS PRESENTATION. [CHAP. 
 
 the most favorable circumstances, look with serious apprehension, as 
 regards the interests of the child, upon all cases of funis presentation, 
 and we would do well to make a point in all such instances of inform- 
 ing the friends of the patient of the precise danger which we anticipate. 
 Many circumstances, other than those already mentioned, modify the 
 danger of individual cases, but, in all, the continuousness and the de- 
 gree of the pressure are the points upon which the gravity of each par- 
 ticular instance depends. If it should so happen, therefore, that the 
 cord occupies a position in which it is exposed to comparatively little 
 pressure, the chance of the case is greater: and to this Naegele draws 
 attention, and points out that when the cord presents with the head in 
 the ordinary or first cranial position, the life of the child is much more 
 likely to be spared when it lies towards the left sacro-iliac synchon- 
 drosis, the point at which it is least likely to be subjected to injurious 
 pressure. 
 
 Treatment. — Unless the case is otherwise abnormal, so as to call for 
 operative interference in the interests of the mother, we of course leave 
 to nature all cases in which we have unequivocal evidence of the death 
 of the child. We must, however, be careful in admitting want of pulsa- 
 tion in the cord as satisfactory evidence of the death of the foetus. If 
 the cord be perfectly flaccid, and is examined continuously, during the 
 occurrence of several successive pains, without any pulsation being dis- 
 cerned, we can have no doubt that all hope of the child must be aban- 
 doned. But, should the examination have been made hurriedly, during 
 the occurrence of a pain, we may abandon a remediable case while 
 there is yet hope, as it has frequently been observed, in such cases, that 
 pulsation is for a long period arrested during the pains, and returns in 
 each succeeding interval. As a rule, then, we should examine during 
 an interval as well as a pain; and it is only the continuous absence of 
 pulsation which is to be admitted as evidence of death. In almost all 
 other cases, it is proper for the accoucheur to afford some assistance ; 
 and in all, without exception, in which we presume that the child is 
 alive, we must watch with constant attention the progress of the labor, 
 so as to afford at the proper moment such aid as may be applicable to 
 the exigencies of the case. The indications of treatment which are to 
 be observed are, either the entire relief of the cord from pressure, or its 
 removal to where it will be subjected to the minimum of compressing 
 force. While there are special cases in which little or no interference 
 is required, or indeed justifiable, these form a very small proportion of 
 the whole. The great majority, therefore, are those in which assistance 
 of some kind or other is essential, and in many of them the skill and 
 perseverance of the operator will be taxed to the utmost. The exact 
 circumstances under which the displacement may occur, are of such 
 infinite variety, that it were endless to attempt to lay down rules which 
 may serve for the guidance of the operator in every case. There is, in 
 point of fact, perhaps no contingency in the practice of midwifery in 
 which sound judgment and self-reliance are so essential; but we are, 
 nevertheless, enabled in the light of the experience of the most distin- 
 guished accoucheurs, to lay down certain general principles, upon which 
 the management of presentation and prolapse of the funis is to be based. 
 
XXI.] TREATMENT. 361 
 
 Should the cord be felt through membranes as yet unbroken, or 
 through the uterine wall from the vagina, our treatment must be essen- 
 tially expectant. It must not be imagined that integrity of the mem- 
 branes is, under all circumstances, a guarantee that the cord is safe 
 from injurious pressure, but so generally is this the case, that we are 
 always bound to assume that upon nothing does the issue of the case 
 so much depend as the prolonged retention of the waters. In cases, 
 the termination of which is intrusted to the natural efforts, this is, 
 indeed, of paramount importance ; and, in all, we look upon the danger 
 as imminent only, and not in actual operation, so long as the sac of the 
 membranes prevents the prolapse of the cord. Nothing, therefore, can 
 be more obvious than that we must exercise the greatest possible cau- 
 tion in such manipulations as Ave may deem necessary, with the view 
 of subjecting the membranes to no such violence as might cause their 
 rupture prematurely. In a word, the preservation of the membranes 
 is, in all cases in which we may be fortunate enough to discover the 
 cord before their rupture, a point of primary importance. For this 
 reason, also, it is far better to leave the presentation in doubt than to 
 run any risk of rupture of the sac in our anxiety to be correct in our 
 diagnosis ; and, on the same ground, it stands to reason that no attempt 
 should be made to replace the cord at this particular stage, or even to 
 guide it into those parts of the pelvis at which it will be exposed to 
 least pressure. So long as the waters are retained, we may be confident 
 that the cord is at least under more favorable conditions than could be 
 afforded it by any remedial or operative procedure which we might think 
 proper to adopt. In cases, therefore, in which the bag of the waters 
 occupies the vagina after the termination of what is usually called the 
 first stage, we do not act as we would under ordinary circumstances by 
 rupturing the membranes; but, on the contrary, we look upon the 
 exceptional persistence of the membranes as of good augury in regard 
 to the. child in all cases in which we have already recognized the funis. 
 The longer, in fact, the liquor amnii is retained, the shorter will be the 
 final stage during which pressure more or less severe must be encoun- 
 tered ; and, other things being equal, the less proportionally will be the 
 risk to the life of the child. Persistence of the bag of the waters up 
 to the moment at which the head is being born is perhaps the case of 
 all others in which nature is most likely to secure a happy result. Such 
 cases, however — and along with them may be classed instances in which 
 the capacity of the pelvis is greater than usual — are not frequently met 
 with ; but, when they do occur, we would be quite justified in simply 
 watching the progress of the case, and only interfering when the symp- 
 toms become more threatening, or the conditions are such as to render 
 .prolonged compression of the cord a matter of certainty. 
 
 The cases which are of most usual occurrence in practice, and those, 
 too, which are the most favorable in their results, are where the head 
 and the cord present together. In cases in which this complicated pres- 
 entation has been early recognized, when the membranes are complete 
 and the os as yet but little dilated, it has occasionally been observed 
 that the presenting cord has passed up out of reach, and the head de- 
 scends alone as in an ordinary case. The possibility of such a satis- 
 
362 FUNIS PRESENTATION. [CHAP. 
 
 factory result would of itself suffice to warrant us in endeavoring, by 
 all means, to preserve the integrity of the membranes, but the result 
 is not, as will be understood, one upon which we can, in any circum- 
 stances depend. It has been asserted upon good authority, however, 
 that the conditions which render such an occurrence most likely are a 
 small loop of cord, which is situated higher than usual and to one side 
 of the os, and when the projecting bag of the membranes is embraced 
 by the lower segment of the womb with unusual force. When the 
 cord descends along with the head, the risk is not so great to the child 
 as in other complicated presentations, of which the cord forms an ele- 
 ment; for, although the actual compression is greater, it is of much 
 shorter duration than in breech and footling cases, and moreover, the 
 danger ceases the moment respiration is rendered possible by the birth 
 of the child's head. And, in addition to this, the possibility of suc- 
 cessful reposition of the cord is much greater on account of the more 
 thorough adaptation of the spheroidal head to the cavity through which 
 it has to pass. If, on the other hand, we have to deal with the pelvic 
 extremity, the cord, when replaced, is more likely to prolapse anew, and 
 in every such instance the chance of prolonged compression is much 
 enhanced. No doubt, the actual pressure is, in the first instance, less 
 than when it descends along with the head, but we must in such a case 
 look forward, not only to a longer continuance of pressure, but, in ad- 
 dition, to the same ultimate compression from the head, at a period 
 when, from long-continued interruption to the placental circulation, 
 and by the operation of other causes, the life of the child is already in 
 imminent danger. 
 
 When that stage is reached at which the dilatation of the os is what 
 we call complete, the membranes being as yet unruptured, it may oc- 
 casionally be a matter of some difficulty to determine upon what prin- 
 ciple we are to proceed in the management of the case. We know 
 that the danger is greater in first than in subsequent pregnancies, and 
 in mature than in premature deliveries; but, beyond this we have 
 nothing, in addition to the facts already mentioned, which may guide 
 us, further than a correct appreciation of general principles. If, upon 
 examination, we find that the cord still pulsates, we may perhaps use 
 a little more freedom with the finger, in order to ascertain the proba- 
 ble extent of the coil, and the exact nature of the presentation, but, 
 with this exception, we must generally content ourselves by watching 
 the progress of the case. As the head descends, we should try, if it be 
 possible, — and still acting with the greatest caution, — to guide the cord 
 towards that sacro-iliac synchondrosis which corresponds to the side of 
 the cranium ; and in pelvic presentations it will also be proper to act 
 upon the same principle by directing it to that synchondrosis which 
 may correspond to the antero-posterior measurement of the breech, 
 with the view in each case, of placing the cord at that point of the 
 pelvic circumference at which the pressure will probably be least. 
 
 With the rupture of the membranes, the cord will usually prolapse, 
 to an extent proportionate to the size of the coil which precedes or ac- 
 companies the presenting part. This is the stage which we will gen- 
 erally select to attempt the Reposition of the cord. With this object 
 
XXI.] METHODS OF REPOSITION. 363 
 
 in view, we bring the points of the index and middle fingers to bear 
 upon the coil in the interval between the pains, and thus endeavor to 
 push it upwards, beyond the presenting part, into the cavity of the 
 uterus. The process, when the coil is large, will resemble somewhat 
 the procedure applicable to the reduction of a large hernia, by succes- 
 sively replacing portions of the cord until the whole has been reduced, 
 remembering always that, to be effectual, reduction must be complete, 
 and that, if ever so small a portion be left down, pressure may be as 
 fatal as if w T e had never attempted the operation. But, with the actual 
 reposition of the cord, our difficulties do not cease. The reduction of 
 the prolapse may be easy enough, but the real difficulty consists in 
 maintaining it in its new position. The finger must, on this account, 
 not be hurriedly withdrawn ; on the contrary, we should, by contin- 
 uous support, endeavor to retain it within the cavity until the child 
 descends somewhat further, and forms, by its presenting part, a plug, 
 which renders impossible, from its bulk, the renewed descent of the 
 funis. The finger should, with this object, be cautiously removed 
 during a pain, when the conditions referred to are, of course, present 
 in the highest possible degree, so that, if the operation is successful, the 
 labor will now be completed without any further risk than attends an 
 ordinary case. For the reasons already stated, success will more fre- 
 quently attend our efforts when the head of the child presents, as this 
 part more thoroughly fulfils the conditions of an effective plug. Un- 
 fortunately, how r ever, in a large proportion of cases, this manoeuvre will 
 fail, and the cord will descend again and again, under the impulse of 
 the uterine contractions. It was, probably, this unsatisfactory result 
 which induced some noted authorities to recommend a more thorough 
 method of reposition, by carrying the cord upwards towards the fundus 
 of the womb, and endeavoring to suspend it over the limbs of the child, 
 or at least to press it completely beyond the head, into the hollow 
 formed by the neck. Both of these modes of procedure have been 
 repeatedly resorted to, and sometimes with success; but the difficulties 
 which attend the operation in each case are such that, in the greater 
 number of instances, we will fail utterly in our endeavor to maintain 
 the cord in its improved position. 
 
 This acknowledged and, in some instances, insuperable difficulty has 
 given rise to much mechanical ingenuity. The object in view is to 
 devise an instrument by means of which the funis may safely be re- 
 turned to the upper part of the uterus, and, if necessary, retained there. 
 Of such as have hitherto been invented, those which are the most sim- 
 ple in construction seem to have succeeded best. Michaelis recom- 
 mended that a large-sized gum-elastic male catheter should be used, to 
 the eye of which the prolapsed cord is attached by a ligature, which is 
 to be loosely drawn so as to avoid compression. The stilet is then 
 introduced, and the catheter, carrying with it the cord, is steadily 
 pushed up in the direction of the fundus, where it may be left, the 
 stilet being withdrawn, until the completion of labor. The contri- 
 vance of Dr. Roberton is, with a trifling modification, the same as this. 
 A simple piece of flat whalebone has been preferred by some, and is as 
 simple and as convenient as the other. Perhaps if we w r ere to express 
 
364 
 
 FUNIS PRESENTATION. 
 
 [CHAP. 
 
 a preference for one form over another, that used by Dr. Braun for 
 many years in his Klinik at Vienna might be selected as combining 
 simplicity and efficiency in the highest degree. It is made of gutta- 
 percha, and is used as is shown in the accompanying figure. It is 
 about sixteen inches in length, and has, about two inches from the 
 rounded extremity, an aperture of sufficient size 
 fig. 129. to allow the passage of a loop of tape or worsted, 
 
 which, after being carried round the cord, is 
 brought over the extremity of the instrument, 
 and is then pulled so as to grasp the cord firmly 
 without subjecting it to dangerous compression. 
 The apparatus is then pushed as high as is possi- 
 ble in the direction of the fundus uteri, and is 
 allowed to remain until the further descent of 
 the head in the pelvis presents an effectual bar- 
 rier to the prolapse of the cord. When we are 
 convinced that this stage has been reached, the 
 instrument is to be drawn down with a wrig- 
 gling or shaking movement, by which the loop 
 passes over the point, and the cord is left behind, 
 while the whole apparatus is removed. Kiwisch 
 effected the same purpose by fixing the point cut 
 from a large catheter upon the extremity of an 
 ordinary uterine sound; and we have tried with 
 success, an instrument of French construction, 
 made of two parallel pieces of whalebone, of 
 Braun'srepositorium. which the one slides upon the other, and has a 
 sort of hook at the end by means of which the 
 cord may be confined or released at will. The principle of the opera- 
 tion is in every case the same, and the varieties above mentioned are 
 but a few of a large number which practical difficulty has suggested to 
 different operators. We cannot, however, depend even upon the best 
 of them for reliable and satisfactory results, and, in fact, we find that 
 many experienced operators prefer the fingers in all ordinary cases; 
 while Tyler Smith informs us that even Michaelis has abandoned his 
 ingenious instrument for the use of the finger. Be this as it may, we 
 should always try, when the fingers fail, what we can do with a reposi- 
 torium, hastily constructed though it may be from such materials as are 
 at hand. The success attained by others is ample warrant for perse- 
 vering efforts in this direction. 
 
 The Postural Method of treatment has from time to time attracted 
 attention during the last thirty years, and is associated chiefly with the 
 names of Bloxam, Thomas of New York, and Dyce of Aberdeen. 
 When this plan is adopted, the woman is placed upon her elbows and 
 knees, so as to raise the pelvis above the level of the fundus uteri, and 
 thus to take advantage of the law of gravity. That a certain amount 
 of advantage is thus gained may be admitted, and it would appear 
 that in practice the results have been in a measure satisfactory. We 
 cannot, however, anticipate such results as the supporters of this pro- 
 cedure seem to claim for it. The posture in question will doubtless 
 
XXI.] GENERAL CONSIDERATIONS. 3G5 
 
 tend so far to the gravitation of the cord towards the fundus, but it 
 must at the same time cause the head to retreat from the lower segment 
 of the uterus, and thus remove what we are accustomed to regard as 
 the most effectual barrier to prolapse, for, when a pain comes on, 
 gravity is a mere feather-weight in comparison with the power of 
 uterine contraction. This may possibly explain why it has not been 
 attended with more marked success. We should not hesitate to avail 
 ourselves of the postural method in any case of difficulty, and it is 
 quite possible that by combining the instrumental with the postural 
 method as has been suggested by Dr. Barnes, more favorable results 
 may ensue than have hitherto followed the use of either separately. 
 
 So long as vigorous pulsation shows that the life of the child is not 
 in immediate danger — and this we should also ascertain by ausculta- 
 tion of the foetal heart — we must not cease in our efforts to prevent the 
 cord from descending into the pelvis along with the presenting part. 
 McClintock and Hardy recommend that the woman should be made to 
 lie upon the side opposite to that on which the protrusion has taken 
 place. In addition to the means above detailed, the expedients which 
 have been devised are endless. Among these may be mentioned 
 partial plugging of the uterine orifice, after reposition, by a piece of 
 sponge; and the inclosure of the coil of the funis, when unusually 
 large, within a bag of some kind, the whole being then returned to the 
 uterus and left there. 
 
 It is universally admitted that a certain number of cases do occur in 
 which reposition of the cord is a practical impossibility, or would be 
 attended with unwarrantable risk to the mother. Of such a nature 
 are those cases — by no means of unfrequent occurrence — in which the 
 accident is not recognized until the head has already descended far into 
 the pelvis. For the management of such conditions no definite rules 
 can be given; all will depend upon the peculiar circumstances of each 
 individual instance. We must be guided mainly by the following 
 general considerations : 
 
 1. We must ascertain whether or not the child lives ; for it must be 
 obvious that a negative answer to this question bars all further action 
 on our part. When the cord, therefore, is flaccid and pulseless in the 
 interval between the pains, and the pulsation of the foetal heart cannot 
 be made out, we leave the case absolutely to nature, as we know that 
 there is no danger to the mother, and we need no longer act in the 
 interests of the child. 
 
 2. No conceivable circumstances will warrant us in subjecting the 
 mother to any considerable risk. Practically, in an uncomplicated case, 
 she is perfectly safe, so that to endanger her on the mere chance, or 
 even probability, of saving her child, would be worse than absurd. It 
 is, perhaps, true that there is no operative procedure whatever which is 
 not attended with some increase of risk, be it ever so little. But, from 
 a moral as well as a practical point of view, we must draw the distinc- 
 tion between slight and serious risk, and upon this distinction treat- 
 ment will, in many instances, be based. The principle must, however, 
 remain a general one, for the gradations between the two extremes are 
 
366 FUNIS PRESENTATION. [CHAP. 
 
 infinite, and each case should thus be decided on its own merits, and in 
 full view of the whole facts. 
 
 3. When reposition is impossible, the simplest and safest mode of 
 procedure is to guide the cord, as has already been stated, towards that 
 part of the pelvic wall where it is least likely to be subjected to severe 
 pressure ; and, of all possible situations, the direction of that sacro-iliac 
 synchondrosis which corresponds to the side of the child's head, if it be 
 a cranial presentation, is perhaps the most favorable. The pulsations 
 of the foetal heart, and those of the funis, must now be carefully watched, 
 as representing the condition of the child, and indicating the approach 
 of imminent danger ; and upon these observations will chiefly depend 
 our future course of action. So long as the pulsations are tolerably 
 strong, we are justified in leaving the process to nature ; and in the case 
 of a woman who has previously borne children, or in whom the pelvis 
 is of larger dimensions than usual, the perilous stage of the labor will 
 often be safely passed, and the child born alive; whereas, in the con- 
 trary conditions of a prim i para, or a narrow pelvis, the chances of a 
 favorable result are comparatively small. 
 
 4. When a failure of the circulation is indicated by the stethoscope 
 or the finger, our course of action will be suggested, in a great measure, 
 by the stage at which the labor has arrived. If, in an ordinary cranial 
 position, the os is fully dilated, and the circumstances are otherwise 
 favorable for the operation, we need have no hesitation whatever in 
 applying the forceps, and completing the delivery as rapidly as possible. 
 In the case of the breech, the fillet or blunt hook may be used, with the 
 view of expediting labor; but these, or other operations, are only to be 
 attempted when the conditions are generally favorable, and the risk to 
 the mother is not great. 
 
 5. The question of turning, in funis presentations, demands, as a 
 disputed point in obstetrics, some special attention. In the early part 
 of the present century, the operation seems to have been held in pretty 
 general esteem, but in more recent times the other and safer modes of 
 operative procedure are, when practicable, usually preferred. It must 
 not, however, be supposed that the operation so warmly supported by 
 Mauriceau is to be, under all circumstances, condemned. There are, 
 in the first place, instances in which the operation must be performed 
 in the interest of the mother, no less than in that of the child, and in 
 respect of which, therefore, there can be no hesitation. Of this nature 
 are cases of shoulder presentation and placenta praevia, both of which 
 conditions are apt to be complicated with descent of the cord. Here 
 we scarcely take the cord into consideration, so clear are the other indi- 
 cations ; or, if we do, it is only to admit it as of secondary importance, 
 but, at the same time, as an additional circumstance which calls for 
 speedy action, so soon as the proper period shall arrive for the perform- 
 ance of the operation under the most favorable conditions. But, while 
 such cases are clear, it is otherwise when, in a cranial presentation, the 
 question of turning offers itself for our consideration in the interests of 
 the child alone, other modes of procedure being impracticable. The 
 opinion generally entertained is, that under the circumstances to which 
 we allude, we are rarely warranted in turning, — a view which we 
 
 
XXII.] PREMATURE EXPULSION OF THE OVUM. 367 
 
 believe to be, in the main, correct. That there are exceptional instances, 
 however, in which, after other means have failed, we may be justified 
 in performing the operation in question, we cannot dispute. There is 
 perhaps no one point in regard to presentation of the funis which calls 
 for more careful consideration and judicious balancing of the special 
 circumstances of individual cases. A capacious pelvis, a yielding and 
 moderately dilated os, and other conditions favorable to the operation 
 itself, afford strong presumption that turning may be effected without 
 any great risk to the mother. The period may not have arrived at 
 which the idea of forceps can be entertained, and yet the child is in a 
 state of immediate peril, so that the question may simply be: Are we 
 to act, or are we to leave the child to its fate? Here, experience, and the 
 habitual caution which matured experience engenders, can be the only 
 safe guides. We repeat, however, our conviction that cases do occa- 
 sionally occur in which we would be justified in turning at once. We 
 must not forget, while forming our resolution, that the operation does 
 not necessarily, even under the most favorable circumstances, relieve 
 the child from danger. For, the operation being performed, there is 
 still the critical period of the passage of the head, during which, although 
 everything be done which skill can achieve, the child, already enfeebled, 
 may succumb from the renewed pressure on the cord. 
 
 CHAPTER XXII. 
 
 PREMATURE EXPULSION OF THE OVUM. 
 
 CLASSIFICATION — ABORTION ; DEFINITION OF — CAUSES : IN GENERAL HEALTH : 
 FROM REFLEX IRRITATION : FROM DISEASES OF THE OVUM : FROM ACTION OF 
 OXYTOXICS : FROM AFFECTIONS OF NEIGHBORING ORGANS : FROM MECHANICAL 
 VIOLENCE — TENDENCY TO REPEATED ABORTION — SYMPTOMS ; AT VARIOUS 
 PERIODS — PRECURSORY SYMPTOMS: PAINS: HEMORRHAGE — TO BE DISTIN- 
 GUISHED FROM DELAYED MENSTRUATION — SIGNS OF DEATH OF THE FCETUS — 
 DISTINCTION TO BE DRAWN BETWEEN "THREATENED" AND "INEVITABLE" 
 ABORTION — RETENTION OF THE OVUM — EXPULSION OF THE PLACENTA — TREAT- 
 MENT : PREVENTIVE : PREVENTION WHEN ABORTION THREATENED — EXPULSION 
 TO BE PROMOTED WHEN INEVITABLE — MANAGEMENT OF HAEMORRHAGE, AND 
 OF THE PLACENTA: PLACENTAL FORCEPS — TREATMENT OF A WOMAN AFTER 
 ABORTION — PREMATURE LABOR — SPECIAL CAUSES — TREATMENT. 
 
 Although the usual period of utero-gestation is about ten lunar 
 months, the ovum may be expelled at any time by premature uterine 
 action, the result of the operation of certain causes which we shall have 
 to consider. Abortion, in the sense now ordinarily attached to the 
 term, is the name which is applied to the occurrence, when it takes 
 place before the eighth lunar month ; while Premature Labor occurs 
 
368 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 during the last three months of gestation. Many writers have confined 
 the term "abortion" to the first sixteen weeks, and apply the word 
 lliscarriage to the period between that and the twenty-ninth, but it is 
 more convenient to adopt the simpler classification, which has the fur- 
 ther advantage of allowing the familiar expressions "non-viable" and 
 " viable" to be used, as applicable to the foetus, in connection with the 
 periods of abortion and premature labor respectively. Miscarriage is 
 a term familiar to women, and is used by them as synonymous with 
 abortion in the wider sense in which we prefer to use the latter. 
 
 Strictly speaking, Abortion may take place at any moment subse- 
 quent to conception. Should the one supervene immediately upon the 
 other, or within the first few weeks, no symptom is likely to be mani- 
 fested which would attract particular attention, and the blighted ovum 
 in such cases might be as impossible of detection as the ovule which is 
 thrown off at a menstrual period. If the ordinary catamenial period, 
 in a woman previously regular, should pass, her suspicions may be 
 aroused ; but, if a discharge manifests itself in a few days thereafter, it 
 is assumed that the period has been delayed, and this may be held fur- 
 ther to account for the increase in the quantity, and of the pain which 
 accompanies it, as compared with the symptoms attendant upon the 
 ordinary menstrual flux. In point of fact, it is rare that the abortions 
 of the first three or four weeks from the assumed date of conception 
 attract such attention as to be brought under the notice of the medical 
 attendant. Even during the course of the second month, the symptoms, 
 although more distinct, may be overlooked ; and the woman who is 
 seized with considerable discharge, and uterine pains of a periodic 
 character in the seventh or eighth week, may be quite unaware that 
 one of the clots which have been expelled contains the immature ovum. 
 To the earliest abortions, the ancients gave the name of Effluxion. 
 When it is said, therefore, that abortion occurs most frequently from 
 the eighth to the twelfth week, we assume that the earlier abortions 
 are not taken into consideration, for in truth we have no means whereby 
 the number of the latter may be even approximately computed. 
 
 The liability to abortion is undoubtedly greater in the early months 
 of pregnancy, when the union between the chorion and the decidua is 
 of a lax character, so as to admit readily of haemorrhage into the space 
 between them, with the result of cutting off the temporary communica- 
 tion which exists between the mother and child before the formation of 
 the placenta. Fortunately, however, the earliest and most frequent 
 abortions are not attended with much risk, as the ovum usually escapes 
 entire ; and the haemorrhage which accompanies them, and which pro- 
 ceeds from the vessels of the decidua, is rarely such in extent as to 
 cause any great alarm. In the latter part of the abortion period, — the 
 sixth and seventh lunar months, — the symptoms manifested and treat- 
 ment required are so analogous to what obtains at the full time, that 
 few special directions are necessary for their proper management. It 
 is quite otherwise, however, in regard to abortions which occur in the 
 middle period, — say from the tenth to the eighteenth or nineteenth 
 week. In these cases we have special danger to dread, and, if possible, 
 to avert, which separate this from any other period of abortion. These 
 
XXII.] CAUSES. 369 
 
 dangers are dependent upon special conditions which it is necessary 
 carefully to observe and to understand, and the most important of them 
 is the alteration in the vascular relations between the maternal and 
 foetal systems, connected with the formation of the placenta. 
 
 The Causes of abortion must, before we go further, engage our atten- 
 tion. These are very numerous, and, being both general and local, 
 may act in a very variable manner in inducing the premature action of 
 the uterine fibres upon which the expulsion depends. Many obvious 
 causes are to be traced to the general health or temperament of the 
 mother. In so far as the familiar affections which so frequently attend 
 early pregnancy are concerned, — such as sickness, faintness, salivation, 
 and the like, — and which, when extreme, are considered among the 
 diseases of pregnancy, it has always been observed that these are very 
 rarely the cause of abortion. The most common of all, — sickness, — 
 is, even in the worst cases, little liable to be followed by premature ex- 
 pulsion. " It is," as Dewees says, " a remark as familiar as it is well 
 grounded, that very sick women rarely miscarry;" aud when we see, in 
 some instances strong and apparently plethoric women miscarry, who 
 have not been sick, we may feel inclined to share the general impression 
 that sickness is a safeguard, and probably keeps down morbid irrita- 
 bility or rigidity of the uterine fibre. With these exceptions, however, 
 it may be assumed that whatever deteriorates the general health of the 
 mother is apt to produce abortion, or, at least, to place the woman in 
 such a condition that she is more susceptible to the influence of other 
 causes which may then come into play. Any serious disease, whether 
 acute or chronic, may be the direct cause; and the general symptoms 
 which accompany the original disease may be greatly aggravated by 
 the occurrence in question. Many febrile disorders are extremely liable 
 to lead to abortion, more especially small-pox and scarlatina; and in 
 too many of these cases there is a fatal issue. Of chronic diseases, 
 none, perhaps, exercise a more marked influence than syphilis, which 
 actually seems to poison the ovum, and is certainly associated, in many 
 instances, with various forms of disease and degeneration, of which it 
 is the seat. But it is not from the mother alone that such influences 
 proceed ; for the ovum may be infected by the poisoned spermatic fluid 
 of the male; and, in some cases stranger still, it would appear as if the 
 woman were a mere conductor of the contagious principle — of which 
 one of the most familiar instances is that which is narrated of his own 
 case by Mauriceau. This distinguished accoucheur tells us that, shortly 
 before he was born, his mother had the misfortune to lose the eldest of 
 her three sons by small-pox, and that in spite of her condition, as wo- 
 men will do, she tended him with constant and tender care. Mau- 
 riceau was born the day after his brother's death, and, although his 
 mother, neither then nor subsequently, presented the slightest symp- 
 toms of the disease, he had on his body at his birth, five or six un- 
 doubted variolous pustules. 
 
 Reflex irritation, from a variety of sources, is one of the most fre- 
 quent causes of premature expulsion of the ovum. The irritation may 
 start from any part of the alimentary canal, and in those instances the 
 
 24 
 
370 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 nature of the case may be revealed by the existence of dyspepsia, diar- 
 rhoea, dysentery, or intestinal worms. In cases of protracted or inju- 
 dicious nursing, it may have its origin in the nipple, by irritation of 
 the mammary nerves, as was conclusively shown by Dr. Tyler Smith. 
 But, besides such distal sources of irritation, reflex action may, un- 
 doubtedly, be induced by direct irritation of the vagina, as in plug- 
 ging; or by irritation of the uterus itself, as is effected, in fact, by the 
 contact of a dead or diseased ovum. Illustrations of this variety of 
 case might be indefinitely multiplied. " We may consider," says Tyler 
 Smith, " abortion from reflex action as being, in some points of view, 
 comparable with spasmodic asthma, or any other exci to-motor disease. 
 From certain irritating causes, an excitable condition of the excito- 
 motor arcs concerned in parturition is induced. This state of excita- 
 bility once produced, slight causes, which would, in healthy subjects, 
 produce no disturbance whatever, are sufficient to produce morbid or 
 spasmodic parturition. This excitability is not suddenly reached. It 
 requires that the nervous arcs, whether mammary, rectal, or other, 
 should be irritated for a considerable time, when an excitable, charged, 
 or polar state of the uterine nervous system seems to be produced. The 
 period preceding a case of reflex abortion 'may be likened to the time 
 preceding an epileptic attack." When the reflex irritation has its ori- 
 gin in the ovaries there is a tendency to the separation of the ovum at 
 what would have been a menstrual period, — a fact which taking the 
 identity of the decidua and the mucous membrane as a matter of un- 
 doubted certainty, seems to confirm the views of those who hold that 
 menstruation involves a periodical discharge of that membrane. This 
 particular cause seems, moreover, to occur, for the most part, in those 
 who have suffered, before impregnation, from some form of dysmen- 
 orrhea. 
 
 Abortion is clearly associated in some cases with certain diseases of 
 the ovum. These have already been incidentally referred to in speak- 
 ing of the diseases to which the embryo is subject. That fatty degen- 
 eration of the chorion and placenta has a marked and decided influence, 
 seems at least to have been established beyond doubt in the admirable 
 researches of Dr. Barnes. The particular variety of this degeneration 
 which exercises the most undoubted influence upon the ovum in in- 
 ducing premature expulsion consists in a metamorphosis of portions of 
 the maternal and fetal structures of the placenta. This may occur at 
 any period of intra-uterine life, and the appearances presented by the 
 cells of the decidua in the healthy and degenerated placenta are indi- 
 cated in the figure, where the two are similarly magnified and shown 
 in juxtaposition. It is unnecessary to follow the minute and interest- 
 ing series of changes which have been traced in reference to this form 
 of degeneration. It seems, however, to be clearly proved that it is 
 frequently induced by constitutional syphilis. The decidua, placenta, 
 and other parts of the ovum are, like all other vital textures, liable to 
 congestive and inflammatory affections, which may arrest the vitality 
 of the foetus, either by inducing some of the various forms of degener- 
 ation, or by causing sanguineous effusion into the tissue of the placenta, 
 
XXII.] 
 
 CAUSES. 
 
 371 
 
 Cells of fatty and healthy decidua. 
 
 which has occasionally been found to contain purulent deposits. When 
 the blood effused is considerable in quantity, it constitutes what Cru- 
 veilhier has described un- 
 der the name of Apoplexy 
 of the Placenta, which by 
 interrupting the circula- 
 tion, may cause death of 
 the foetus, and, conse- 
 quently, inevitable abor- 
 tion, although the foetus 
 may be retained in utero 
 for a considerable time, 
 while the degenerated 
 structures of the ovum 
 undergo further change. 
 Any of the numerous dis- 
 eases to which the foetus 
 is liable may cause its 
 death, and it is believed 
 that twisting or knotting 
 of the cord, either upon 
 
 itself or round the neck of the child, may have a similar result. Like 
 the placenta, and other tissues of the ovum, the cord too is subject to 
 special diseases, in the course of which its function is destroyed. Be- 
 sides this, the facts stated by Mauriceau, Stein, and others, seem to 
 prove that the cord, when too short, may be so dragged upon as to 
 endanger its integrity. 
 
 Among the causes of abortion we must not omit to mention those 
 agents to which the name of Oxytocics has been given. The more 
 familiar of them are the ergot of rye, borax, and savin, which, with 
 some others, exercise an undoubted effect upon the muscular tissue of 
 the uterus. The nature of their action is not thoroughly understood ; 
 but it is certain that ergot, and probable that the others, exercise a 
 marked influence upon the spinal cord. Through this channel, then, 
 we may infer that the oxytocic influence passes, which incites the uterus 
 to contraction. The uterus is, however, not nearly so obnoxious to the 
 action of these agents as when the organ is fully distended, either at the 
 end of pregnancy, or from any other cause. A similar action is pro- 
 duced by carbonic acid, as has been abundantly proved by the records 
 of cases of accidental or intentional poisoning. A precisely similar 
 effect follows the retention of carbonic acid in the blood in asphyxia — 
 a condition under which expulsion of the ovum has very frequently 
 been found to occur. Of the five hundred Arabs who were suffocated 
 in the caves of Dahra, in 1845 — as is said, by the orders of the Due de 
 Malakoff — a considerable proportion were women ; and of these many 
 who were pregnant were found to have aborted ; and other instances of 
 a similar nature have also been recorded. The same fact has been 
 proved experimentally by the researches of Dr. Brown-S£quard, who 
 further believes, as we have already stated, that the oxytocic action of 
 carbonic acid is the determining cause of labor at the full term, excit- 
 
372 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 ing, by the direct contact of venous blood, the irritable uterine fibre to 
 contract. Emotional causes, such as joy, grief, anger, and the like, may 
 produce an effect precisely similar. In some cases of auto de fe, and 
 other barbarous acts in which the victim perished at the stake, abortion 
 has also taken place, partly, as is probable, the result of fear, and partly 
 by the action of asphyxia. 
 
 Certain affections of neighboring organs may produce the premature 
 expulsion of the ovum. In many of these cases, it would seem as if 
 the cause was a purely mechanical one. Tumors, adhesions which 
 bind down organs that ought naturally to rise with the uterus, and 
 anything, in fact, which may mechanically hinder the development of 
 that organ, may act in the same way. Displacement of the uterus 
 itself may act in the same manner ; and we have known cases of uterine 
 retroversion, for example, in which abortion had occurred several times, 
 and in which an ovum only reached maturity after the displacement 
 upon which the abortion depended had been cured by appropriate 
 treatment. 
 
 Premature expulsion of the ovum may also follow the occurrence of 
 accidents or mechanical violence of any kind, such as falls and blows, 
 and these cases are important, as the symptoms which accompany abor- 
 tion differ in them from the other cases previously detailed. Such 
 causes may act in either of two ways : by an effect produced on the 
 organs or tissues of the mother, or by injury to the foetus which may 
 cause its death. It has been denied by some authors that the latter is 
 a possible cause, so admirably has nature provided against the effects 
 of accident and shock. We do not speak now, of course, of extreme 
 violence, but of such only as may afterwards operate as a cause of 
 abortion. The following case, given by Cazeaux, is conclusive as to 
 this: " A young woman, six months pregnant, while groping in the 
 dark in her room, struck the abdomen violently against a table. 
 During the night the movements of the child became suddenly very 
 violent, then diminished, and the following day were no longer felt. 
 Two days afterwards she was delivered of a dead child, which pre- 
 sented on the back an ecchymosis as large as the palm of the hand." 
 Burdach gives the case of a woman who, in the sixth month of preg- 
 nancy, had received a blow on the lower part of the belly, of sufficient 
 violence to fracture the forearm and the leg. The child was carried 
 to the full time, and the fracture was found at birth to have united at 
 an angle. The effect of such accidents as tell directly on the maternal 
 parts is more obvious. Nothing, however, is more astonishing than 
 the amount of violence which women may suffer with perfect impunity, 
 in so far as pregnancy is concerned. Falls from windows, giving rise 
 to severe contusions and fracture of the limbs, have repeatedly occurred 
 to women who were pregnant, without causing abortion. The late Dr. 
 Pagan used to tell of an instance in which his coachman drove right 
 over a woman who was in the eighth month of pregnancy, inflicting 
 upon her very serious injuries. His master, thinking that premature 
 delivery must of necessity follow, caused frequent inquiries to be made, 
 and found ultimately that the pregnancy was in no way disturbed, and 
 that the woman was delivered of a healthy child at the full time. The 
 
XXII.] SYMPTOMS. 373 
 
 slowness with which the uterus responds, in many instances, even to 
 considerable irritation, is familiar to those who have had occasion to 
 induce premature labor ; and the fatal result, in cases of criminal abor- 
 tion, is, no doubt, mainly due to the amount of violence which is resorted 
 to, in the hope of exciting the contractions which milder measures have 
 failed to induce. 
 
 A disposition which is exactly the opposite of this exists in some 
 women, who, so to speak, abort upon the slightest provocation. That 
 in many of those cases of habitual abortion, there is some anatomical 
 or physiological cause upon which the phenomenon depends is more 
 than probable ; and in all those instances in which there exists a me- 
 chanical impediment of any kind, it may follow impregnation periodi- 
 cally, almost as a matter of course. But, putting such aside for the 
 moment, there are other, and by no means rare, instances in which we 
 can only account for the repeated abortions by supposing that the 
 uterus has contracted an inveterate habit. It is, perhaps, one of the 
 most familiar observations in obstetrical practice, that a woman who 
 has previously aborted is much more liable to a repetition of the acci- 
 dent than one who has never been pregnant, or who, if previously 
 pregnant, has carried her children to the full term. And, when abor- 
 tion has occurred in several successive pregnancies, we look upon a 
 recurrence of that condition with some apprehension. In such cases, 
 it is very generally observed that the tendency to separation of the 
 ovum is greatest at a certain period of pregnancy ; and every accouch- 
 eur of any experience can recall cases in which successive ova were 
 thrown off at exactly the same age, as calculated from the presumed 
 period of conception. It would thus seem as if, in those cases in which 
 no obvious cause can be detected, there was some perverted condition 
 of the uterine fibre, as regards irritability, which prevented dilatation 
 of the viscus beyond a certain point, analogous to what obtains in 
 morbid irritability of the bladder, when the desire to micturate occurs 
 long before even moderate distension has taken place. And in the 
 latter case, too, habit has something to do with it, and resisting the call 
 has sometimes, at least, a beneficial effect. In the case of the womb, 
 however, voluntary resistance has no effect, and so the act goes on re- 
 peating itself if unchecked. 
 
 If those above detailed embrace the chief, they are far from repre- 
 senting all the causes which may possibly lead to premature expulsion. 
 This would require a special treatise. Enough has, however, been said 
 to enable us to apply the principles of treatment, which, without a 
 knowledge of the etiology of this subject, w T e could by no possibility 
 attain. 
 
 Symptoms. — These vary somewhat according to the cause and the 
 period of pregnancy. One of the most constant symptoms of all cases 
 is pain, but in some instances the expulsion seems to be accompanied 
 with little pain or even discomfort. In very early abortions, — the 
 " Effluxio" of the ancient writers, — the pain may be no more than that 
 which attends an ordinary menstrual period. The seat of the pain is 
 usually the lumbar, sacral, and hypogastric regions, but it may extend 
 to the groins and down the thighs. A trifling increase in the amount 
 
374 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 of the catamenial pain, and the presence of some solid masses along 
 with the discharge, may be the only symptoms which attract attention, 
 and are not unnaturally mistaken for those which accompany a delayed 
 menstrual period, when the ordinary functions of the parts are shortly 
 resumed as before. At a more advanced period the symptoms are, as 
 might be expected, more marked. The occurrence is then frequently 
 ushered in by a rigor, followed by an increase of temperature, some 
 increase in the frequency of the pulse, thirst, and sometimes nausea, 
 even when this has not been present before. Other and more vague 
 symptoms, such as palpitation, cold extremities, dimness of vision, and 
 dark rings surrounding the eyes, have also been noticed. A cold un- 
 easy feeling about the pubes, with more or less of weight in the same 
 region, according to the size of the embryo — which may also be ex- 
 perienced in the coxal region — is looked upon, and with justice, as a 
 characteristic and important sign. Lumbar pain and vesical tenesmus 
 are also of frequent occurrence. If they should have been present, 
 there is a cessation of what are recognized as the breeding symptoms : 
 morning sickness is no longer complained of, and the mammae usually 
 become flaccid, although the pain in these glands is sometimes con- 
 siderably increased. 
 
 Those symptoms are in their nature precursory, but are soon suc- 
 ceeded by increase in the lumbar pain, which becomes periodic, and 
 extends to the hypogastric region. If the fundus can be distinguished 
 behind the pubes, it will now be felt to contract, indicating the com- 
 mencement of uterine expulsive effort. If a discharge of a hemor- 
 rhagic nature has not previously taken place, that symptom will now 
 be observed ; the amount of the discharge varying very greatly — 
 depending, no doubt, on the extent to which the ovum has become 
 separated from its attachments. An examination should now be made 
 by the finger ; but this must be conducted with great caution, as any 
 roughness of manipulation might make matters worse, by exciting the 
 uterus to more energetic action, or, possibly, by rupturing the thin sac 
 which contains the liquor amnii and the embryo. The os and cervix 
 will be felt to be softened to an extent commensurate with the period 
 at which the pregnancy is presumed to have arrived ; and, in addition, 
 the os will be found more or less patent. 
 
 In the earlier periods of pregnancy, we may have some little difficulty 
 in making out whether the woman is pregnant or not. In many cases, 
 therefore — in unmarried women for example — we must be very cautious 
 in expressing an opinion on this point, however suspicious the symptoms 
 may appear to be. According to Madame Lachapelle, the following 
 points are of importance in establishing a distinction between the two. 
 If the case be one of abortion, the os is more or less open ; haemorrhage 
 usually precedes the pains, and gives them no relief; but, on the con- 
 trary, they become more severe as the case advances. If, on the other 
 hand, the case be one of delayed menstruation, the os is nearly closed, 
 or is at most very slightly opened : the pains precede the haemorrhage, 
 and are diminished upon its occurrence, or may entirely cease when it 
 is thoroughly established. These points are, no doubt, of importance, 
 but are to be received in evidence with caution. Certain other rules 
 
XXII.] SYMPTOMS. 375 
 
 are given with the view of enabling us to distinguish between a clot 
 and an ovum in a digital examination at the os uteri, but these are of 
 little if any practical importance, seeing that both a clot and the ovum 
 may, and often do, present simultaneously. 
 
 As the case progresses, and the rhythmical uterine contractions con- 
 tinue and increase in energy, the os dilates still further. For reasons 
 which are obvious, the dilatation is often very tedious. At the period 
 of pregnancy at which abortion occurs, the cavity of the cervix is, as 
 will be remembered, not at all invaded by the process of distension to 
 which the cavity of the uterus proper is subjected. Naturally, there- 
 fore, its distension by the uterine efforts is effected under circumstances 
 of comparative mechanical disadvantage. The conditions at least are 
 widely different from the termination of the period of gestation, when 
 the circumference of the external os is the only point against which the 
 uterine efforts are directed; and, although the dimensions of the body 
 which is to pass are to be taken into consideration, the wonder is that 
 the difficulty of dilatation is not more universally marked. The rup- 
 ture of the membranes is somewhat irregular in its occurrence, but if 
 these remain intact, they will often be found to protrude in a manner 
 similar to what obtains in labor at a more advanced period. In the 
 course of the first few weeks, the ovum is generally expelled entire, 
 which, indeed, is a most favorable occurrence, and the cause of the fact 
 that the abortions of that period are comparatively free from danger to 
 the mother. When the membranes rupture, the embryo is expelled, 
 and may be followed at a variable interval by the secundines. Or the 
 latter may be retained for a longer period, to give rise to symptoms 
 and difficulties which will require for their management all the skill 
 and judgment which we have at our command. 
 
 As a general rule, the death of the foetus precedes the uterine con- 
 tractions which cause its expulsion. In other cases, again, the foetus 
 is born in such a condition as would seem to indicate that it had only 
 perished while undergoing the process of expulsion ; and, in a third 
 class, chiefly the result of accidents, it is expelled alive, and may move 
 briskly for a few hours after its birth. 
 
 It not unfrequently occurs that the symptoms which indicate the 
 death of the foetus are separated by a considerable interval from those 
 which accompany the expulsive phenomena. When the former, the 
 more important of which have already been detailed, have been distinct 
 and unequivocal, the sequela?, or external manifestations of abortion, 
 are always to be looked for, usually after an interval of some days. 
 When the woman has received an injury, or has otherwise been sub- 
 jected to violence, the ovum may, if it be a very early abortion, be 
 expelled almost immediately. If, however, it has attained any size, a 
 certain interval must elapse, when, upon the death of the child, a simi- 
 lar but more gradual result will ensue, the mechanism of the expulsion 
 being essentially the same as in the other case. It is in the cases in 
 which the cause has been one rapid in its operation that the child is 
 most frequently born alive. Whatever the cause may originally have 
 been, if it acts by first destroying the life of the foetus, the latter plays 
 the part of a foreign body, and, as such, excites the uterus to contract. 
 
376 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 "The living foetus," says Rigby, "obeys the law of organic life; the 
 dead foetus those of gravity. When once the child has ceased to exist, 
 it acts like any other mass of inanimate matter;" and this too is the 
 reason why the feeling of weight is so frequent, and upon the whole so 
 reliable a symptom in the more advanced periods at which abortion 
 may occur. 
 
 The symptoms of abortion call in every case for careful observation 
 and attentive consideration. The most important practical point which 
 may arise is the following : No doubt, we shall suppose, is entertained 
 as to the fact of pregnancy, while the symptoms are clearly those of 
 abortion. But are the symptoms those of threatened abortion only, or 
 do they imply that the loss of the ovum is inevitable? In the former 
 case, we must do all we can to avert the expulsion; in the latter, we 
 do all in our power to promote it; hence the importance, nay, the ne- 
 cessity of recognizing the special symptoms which enable us to distin- 
 guish the one class of cases from the other. If we are called to a case 
 of abortion at the onset of the symptoms, we may assume that the loss 
 of the ovum is seldom inevitable unless it is dead. Nothing, there- 
 fore, short of clear evidence of the death of the foetus will warrant you 
 in abandoning all effort to save it. The danger depends for obvious 
 reasons upon the extent to which separation has taken place between 
 the ovum and the u'erus. Whether the ruptured vessels are decidual 
 or placental, the maternal vascular supply for the nutrition and respi- 
 ration of the foetus is more or less restricted by the rupture of the con- 
 necting vessels. No symptom, therefore, is of greater importance, than 
 the amount of haemorrhage which has occurred, as this may be held to 
 indicate with tolerable certainly the extent of the separation and rup- 
 ture of the tissues from which the blood flows. The quantity of the dis- 
 charge is much more important than its duration, so that, whereas in the 
 former case, we despair of the issue, or at least look forward with much 
 apprehension, in the latter we will often meet with instances in which 
 a moderate or trifling amount of discharge may persist for many days 
 without the slightest effect being produced in arrestment of the process 
 of gestation. Profuse haemorrhage, then, recurring, at short intervals, 
 and accompanied with pallor, vomiting, and a tendency to syncope, 
 indicates extensive separation of the ovum, and proportionate gravity 
 in the nature of the case. 
 
 Uterine contractions may not only be present, but may persist for a 
 considerable time ; but we should never on this account alone place the 
 case in the "inevitable" category, as the symptoms sometimes subside 
 spontaneously, and often under appropriate treatment. Rhythmical 
 uterine contraction, however, is always a most alarming sign, and more 
 than sufficient to cause anxiety ; but the significance of this as an 
 isolated symptom will chiefly depend on the vigor and continuance of 
 each successive pain. Of greater importance is the condition of the os. 
 If this is agape, with some portion of the ovum already protruding, 
 prevention is out of the question. If even we fail to reach any por- 
 tion of the ovum, and the os is widely patent, we recognize in that 
 fact, evidence which, if not conclusive, is at least presumptive of abor- 
 tion ; while, on the contrary, if the os is but slightly dilated, and the 
 
XXII.] RETAINED PLACENTA. 377 
 
 cavity of the cervix has as yet been but little encroached upon, our 
 hopes of a favorable issue are greatly strengthened. 
 
 One of the worst indications possible is in the discharge of the liquor 
 amnii, and in fact, when we can be sure that this has taken place, we 
 mav abandon all hope of tiding over the emergency. Evidence of 
 rupture of the membranes must, however, be cautiously received. The 
 assertion of the patient on a point such as this may go for nothing. 
 The observations of an intelligent nurse are, of course, of greater value; 
 but we must be cautious even then, as the possibility of hydrorrhoea 
 and discharges from other sources must be admitted and disposed of 
 before we can speak with confidence. If, with discharge of the waters, 
 we have a gaping os, profuse haemorrhage, and obliteration of the cer- 
 vix uteri, the case may be given up, and our efforts directed into a new 
 channel, with the view of expediting the process which, under more 
 favorable circumstances, it would have been our duty to oppose. With 
 intact membranes, closed os, trifling haemorrhage, and moderate or irreg- 
 ular uterine contractions, our prognosis may be favorable, but is to 
 be expressed with caution, as graver symptoms may at any moment 
 supervene. 
 
 In most cases of abortion, the expulsion of the ovum is slow, and it 
 thus happens that the ovum, or a portion of it, is sometimes delayed 
 for days in the orifice of the os. In so far as danger from haemorrhage 
 is concerned, the death of the foetus some time prior to its expulsion is 
 an advantage, as the utero-placental vessels atrophy, and there is thus 
 little danger of haemorrhage — less even than in labor at the full time. 
 Or, if the supply of blood be continued as before, it is misapplied, and 
 results in the morbid development of the parts and the formation of 
 a mole. In some cases, again, the death of the ovum is not followed 
 by its expulsion, but it is retained for many weeks, or even months. 
 At a very early period, the delicate tissues of the embryo are dissolved 
 in the liquor amnii, and are said then to form a gummy solution. At 
 a later period, it shrivels or dries up like a little mummy, and may 
 remain unaltered in this condition during the remainder of its sojourn 
 in the womb. In other cases, it assumes the saponaceous and withered 
 appearance, without any putrefactive odor, so graphically described by 
 Devergie, which is apparently analogous to that variety of putrefactive 
 change which the same eminent medical jurist has described under the 
 name of adipocire. In these cases, the woman may experience but 
 little uneasiness, or may be perfectly unconscious of anything unusual. 
 She and her attendants may suppose that the ovum had passed unde- 
 tected, until, after a long interval, a mass escapes from the vagina, 
 with or without pain, an examination of which at once reveals the 
 nature of the case. 
 
 Apart from the danger arising from haemorrhage before abortion, the 
 peculiar circumstances which attend the Expulsion of the Placenta are 
 of the highest importance, and differ in many essential particulars from 
 the corresponding phenomena of labor at the full time. " In all cases, 
 the placenta is retained much longer after the expulsion of the child 
 in abortion, than in labor at the full time." Thus wrote Burns, and 
 his assertion is undoubtedly correct ; but we must here make a distinc- 
 
378 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 tion between the different epochs of abortion. In the first and second 
 month, the placenta being undeveloped, the ovum is generally expelled 
 entire, with little risk to the woman. In the course of the fifth and 
 sixth month, the mode of expulsion of the foetus does not materially 
 differ from what obtains in birth at the full time, except that there is a 
 greater tendency to retention of the placenta and its attendant dangers. 
 It is to the middle term of the abortion period, therefore, that our 
 attention requires more particularly to be directed — say from the 
 eighth to the eighteenth week. During this period, the placenta forms 
 a close anatomical connection with the uterine tissues and with the 
 maternal vascular apparatus, connections which are often to be severed 
 only with the greatest difficulty. The uterine contractions suffice, in 
 many instances, to burst the ovum and discharge the foetus, and when 
 the cord breaks or is tied, uterine action ceases. But, instead of a 
 speedy recurrence of the pains, and a natural and unaided expulsion of 
 the placenta, the uterus remains quiescent, the os closes, and the pla- 
 centa, with the membranes, is retained, sometimes for hours only, but 
 often for a much longer period, extending to eight or ten days, or even 
 more. The absence of pain, and other symptoms of importance, may 
 induce the woman to believe that she is perfectly well, and we may on 
 this account have some difficulty in convincing her of the necessity 
 which exists for perfect rest. A return of the pains, after a very 
 variable interval, marks a renewed attempt on the part of the uterus 
 to rid itself of its contents. If a considerable time should have elapsed, 
 the os will have closed so firmly that a tedious process, which is con- 
 ducted at great mechanical disadvantage, is necessary for its dilatation. 
 This process is often attended with alarming haemorrhage, as it is only 
 now that the utero-placental vessels are being severed, and this haemor- 
 rhage may only cease upon the expulsion or extraction of the placental 
 mass. 
 
 Should there be no effort at expulsion, the placenta will usually be- 
 come the seat of putrefactive changes, a condition which will be mani- 
 fested by the occurrence of a dark and fetid discharge. Under the 
 influence of this, the structures may be broken up and discharged 
 piecemeal ; but the process is always tedious, and may be accompanied 
 by low fever, in consequence of which the woman may become reduced 
 to a condition which may excite considerable alarm, and there is of 
 course the danger of what fortunately does not often occur in such 
 cases, viz., blood poisoning through the uterine veins. A similar con- 
 dition, as regards discharge and general symptoms, may also supervene 
 in those instances in which the membranes rupture, and the foetus, as 
 well as the placenta and membranes, is retained, the access of atmos- 
 pheric air in this as in the former case giving rise to putrefactive de- 
 composition. It is said that, in some cases, absorption of the placenta 
 occurs, and in this way the uterus may get rid of its contents. " In 
 cases of twins," says Burns, " after one child is expelled, either alone 
 or with its secundines, the discharge sometimes stops, and the woman 
 continues pretty well for some hours, or even for a day or two, when a 
 repetition of the process takes place, and, if she has been using any 
 exertion, there is generally a pretty rapid and profuse discharge. This 
 
XXII.] PREVENTIVE TREATMENT. 379 
 
 is one reason, amongst many others, for confining women to bed for 
 several days after abortion. The second child may, however, be 
 retained till the full time." 
 
 There is one other point which is of great value in estimating the 
 gravity of the symptoms of what is supposed to be retained placenta 
 after abortion. The accoucheur may have had no opportunity before 
 this of personally ascertaining the facts of the case, and may therefore 
 be grievously misled by the details with which he is furnished. Noth- 
 ing is of greater importance in the earlier abortions than that all clots 
 and solid matters which may escape should be carefully preserved for 
 examination ; but, unfortunately, this is seldom done. We may thus 
 be in no small measure perplexed by the doubt whether the imper- 
 fectly formed placenta and embryo, or the placenta alone remain be- 
 hind. The history which we may receive from the woman or her 
 attendants must therefore be cautiously received, as quite circumstantial 
 details are sometimes given of the expulsion of the embryo, and yet the 
 issue of the case may show that the presumed ovum can have been 
 nothing but a clot, the layers of which may have appeared to resemble 
 the membranes which inclose the product of conception. Important 
 information is almost always to be derived from a careful inspection of 
 the discharges, and all clots should be washed and carefully examined 
 with a view to the discovery of shreds of membrane, fragments of pla- 
 centa, or structures which show, more unequivocally still, the nature 
 of the case. 
 
 Treatment. — The treatment of abortion may be arranged under two 
 heads : 1st, to prevent it when this is possible ; and 2d, to favor expul- 
 sion when this is inevitable, — under which we may include the man- 
 agement of the placenta. 
 
 The Prevention of abortion may, as a practical question, be presented 
 for our consideration under various forms. In the case of the woman 
 who has aborted on several occasions successively, our treatment is, in 
 the strictest sense, preventive, and must be commenced long before 
 actual symptoms of abortion are manifested. In regard to this par- 
 ticular branch of treatment, while there are certain general principles 
 upon which the management of all cases must be based, there are, at 
 the same time, special considerations, which must not be lost sight of, 
 as applicable to individual cases. A careful investigation of the causes 
 which may have induced, on former occasions, the premature expulsion 
 of the ovum, will sometimes point to the special considerations alluded 
 to. There is a great tendency, in those cases of repeated abortion, to 
 the separation of the ovum at the same period of gestation. This law 
 operates with great force in cases in which there is no cause in the con- 
 stitution of the mother, nor disease in the ovum, to which it can be 
 attributed ; so that, in some instances, the uterus actually seems, as it 
 has often been expressed, to have contracted a habit of periodical abor- 
 tion. The general principles then, which guide us have their origin 
 in this fact, and the treatment of every case is more or less based upon 
 it. The object is, if it be possible, to tide over the period of former 
 abortions; and, when this can be successfully effected, the pregnancy 
 will often progress, and reach the full time, without the occurrence of 
 
380 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 a single bad symptom. If we can only succeed in breaking the 
 habit, — be the ultimate result of the pregnancy what it may, — we have 
 achieved something in the way of success ; and we have known more 
 than one instance in which the result of treatment was, in the first 
 place, to transfer the period of abortion from the third to the fifth 
 month, and on the occasion of the next pregnancy, a repetition of the 
 same treatment was attended with the most satisfactory results possible. 
 
 In effecting our object, in the circumstances now under consideration, 
 rest must be placed first among the remedial agencies in which we may 
 trust. The strictness with which we enjoin rest will depend, in a 
 great measure, on the number of previous abortions, and the extent to 
 which preventive measures have already been adopted. In the worst, 
 or most obstinate cases, nothing will do short of absolute confinement 
 to bed, in the recumbent posture. When the woman has aborted but 
 once or twice, it is by no means necessary that absolute rest should be 
 so strictly enforced; but, in every case, the chief care is to be directed 
 to the period at which previous accidents occurred. Something will 
 depend on the effect which want of exercise may have on the general 
 health, and if any deterioration should be observed in that direction, it 
 becomes a matter of consideration, whether we are not doing more 
 harm than good by the course we are adopting. And, moreover, there 
 are many cases in which the circumstances of the patient render it, for 
 her, an impossible matter to abstain from all physical exertion ; and 
 there are other cases, again, in which we have to take into considera- 
 tion the amount of energy which exists in the temperament of the 
 patient, as it is clear that the woman who leads a life of irrepressible 
 energy will require more restraint than one who is languid and disin- 
 clined to exertion. There are other causes which, no less than physical 
 exertion, must be avoided, as far as is practicable. Among them are 
 emotional causes, and any local irritation which might, by any possi- 
 bility, act reflexly in the direction of the uterus. Irritations of the 
 skin, bladder, or alimentary canal, are of this nature, and even such 
 distal irritation as toothache has been known to act in a similar man- 
 ner. A careful inquiry into the circumstances which attended former 
 abortions should always be made; and, if it is found that diarrhoea, 
 vesical irritation, or any similar affection, was a prominent symptom, 
 as these sometimes are, it will be proper narrowly to watch, and if 
 necessary to rectify, the function which may thus have been disturbed. 
 Separation a tlioro is in most cases proper, and in some indispensable; 
 and, if necessary, the patient should be cautioned against the effects of 
 tight lacing. 
 
 In women who are constitutionally weak, or apparently cachectic, a 
 tonic treatment is, in addition to the precautions just mentioned, held 
 to be proper. Some Spas, chiefly chalybeate, enjoy a certain reputa- 
 tion in such cases, and tepid or cold sea-bathing, both before and after 
 conception, has been strongly recommended by Mr. White, of Man- 
 chester. But, while the general health of the woman is thus attended 
 to, we must not overlook any special constitutional causes which may 
 be in operation. The most important of these is undoubtedly syphilis, 
 and the best chance of success in dealing with such cases is — whether 
 

 XXII.] TREATMENT. 381 
 
 the mother or father, or both, be affected — to bring them gently under 
 the influence of mercury before coitus is again permitted. An examina- 
 tion of the structures expelled in former abortions may seem to call for 
 certain special means of treatment in addition to the general course of 
 procedure above indicated. Diseases of the placenta or membranes act 
 upon the foetus mainly by interfering with the oxygenation of the blood. 
 It has been proposed, therefore, that an attempt should be made to 
 introduce a superabundance of oxygen into the maternal blood, — an 
 indication which it has been attempted to fulfil by inhalations of oxygen, 
 or by the exhibition of such substances as contain a large proportion of 
 oxygen in a state of feeble combination. It was with this object that 
 Dr. Bower prescribed nitric acid, and Sir James Simpson the chlorate 
 of potash. In the case of other diseases of the ovum or foetus, such as 
 meningitis or peritonitis, mercury and other drugs have been prescribed 
 on an analogous principle, in the hope of affecting the foetus through 
 the maternal circulation, but so many difficulties are in the way of 
 correct diagnosis in such cases, that little can be hoped for in the way 
 of successful treatment. Indeed, with the single exception of the treat- 
 ment of syphilis by mercury, we can place but little reliance on the 
 medicinal treatment of habitual abortion, beyond what is administered 
 with the view of giving tone to the system, or allaying constitutional 
 disturbance. We must not, however, even where nature seems to defy 
 us, in any case despair of success. Dr. Young, of Edinburgh, tells, in 
 his lectures, of a case in which the patient actually miscarried thirteen 
 times, and yet bore a living child the fourteenth time. In the most 
 obstinate cases, a year's marital separation should be enjoined. 
 
 The prevention of abortion extends, although in a somewhat differ- 
 ent sense, to the treatment of cases in which the symptoms of impend- 
 ing abortion have already manifested themselves. Having taken due 
 cognizance of the symptoms which enable us to decide whether or not 
 the loss of the ovum is inevitable, and being persuaded that there is 
 room for hope, the efforts of the accoucheur will chiefly be directed to 
 the expulsive contractions of the uterus. The success of his treatment 
 will in fact depend upon the power which the remedies he may em- 
 ploy will exercise upon this function of the uterus. Should any source 
 of irritation exist, he must at once attempt to remove or to allay it. 
 Bloodletting was at one time very generally employed in all cases, but 
 is applicable only to those in which there is great arterial excitement, 
 and a tendency to plethora. In these days, indeed, few practitioners 
 would risk more than a few leeches to the perineum, and even that 
 under very exceptional circumstances. The most perfect quiet of body 
 and mind is more important perhaps than anything else. The patient 
 should lie on her back on a hard mattress, and be kept cool. She 
 should change her position as seldom as possible, for any exertion 
 however slight will often be attended with a gush of blood. Her food 
 should be light and easy of digestion; and not only stimulants, but 
 animal food should in most instances be forbidden to her. Hemor- 
 rhage is one of the alarming symptoms which we desire to arrest if it 
 be possible, and on this account it is well to give the food cold, or at 
 least cool. Caution must, however, be exercised, in the use of ice, 
 
382 PREMATURE EXPULSION OF THE OVUM. [CHAP. 
 
 either internally or externally, for if, as is sometimes done, all the 
 food is iced, and, in addition, cold affusion and injection resorted to, 
 we may excite reflex action of the uterus, and thus defeat our ultimate 
 object, although we may arrest the haemorrhage. With the view of 
 arresting uterine action, nothing can be compared with opium, which 
 is indeed our sheet anchor. This has succeeded even in cases where 
 the discharge was alarming, and the os open to a considerable extent. 
 To secure the full advantage of its sedative action, it must be given in 
 full doses, so that forty minims of the Liquor Opii Sedativus in two 
 doses, at an interval of twenty minutes, may be given in most cases 
 without the slightest hesitation. This preparation has, we believe, the 
 advantage which Rigby claimed for it over the other preparations of 
 opium, that its sedative effect is more sure, and that it produces less 
 irritation and derangement of the stomach and bowels. In other cases, 
 again, in which it may be inadvisable to give opium by the mouth, an 
 ordinary enema of starch with a drachm of laudanum will be preferred ; 
 and, in point of fact, the possibility of having a local in addition to a 
 constitutional effect, when it is administered in this way, will probably 
 cause many to make choice of the method. Chloral, by the mouth or 
 by injection, has also been employed with success. We must never 
 despair so long as a chance remains of saving the ovum, bearing in 
 mind that evidence of the death of the foetus is an immediate warrant 
 for suspending all operations which have for their object the retention 
 of the product of conception. It is a safe and good rule, however, 
 that so long as we are not sure that the foetus is dead, we should act as 
 if it were living. 
 
 When violent pains, profuse haemorrhage, discharge of the liquor 
 amnii, and progressive dilatation of the os, show that abortion is in- 
 evitable, the treatment differs widely from the above, as the object of it 
 now is to promote instead of to prevent expulsion. In the course of 
 this process, however, there are so many steps to be gone through, that 
 it often requires great nicety and discrimination to conduct a case to a 
 successful issue, which implies the safety and speedy recovery of the 
 mother. In the first three months the less we interfere the better. 
 For, in these instances, as has been seen, the ovum often escapes entire, 
 which is the most favorable occurrence possible ; while, if we interfere 
 too much in the way of careless manipulation, we run the risk of rup- 
 turing the membranes, discharging the liquor amnii, and thus causing 
 a protracted retention of the whole or part of the ovum. The only 
 symptom which is likely even thus early to call for energetic treat- 
 ment is haemorrhage. It is unusual at this period for loss of blood 
 to be a cause of much danger or alarm ; but if it should be so, we 
 should not hesitate to plug the vagina. Of the various modes of plug- 
 ging none is more simple or more effective than that which is recom- 
 mended by Dr. Dewees. He advises that a piece of soft sponge, of 
 sufficient size to fill the vagina without producing uneasiness, should 
 be wrung out of pretty sharp vinegar, and introduced into the passage 
 up to the os uteri : the blood in filling the cells of the sponge coagu- 
 lates rapidly, and forms a firm clot, which completely seals up the 
 vagina without producing any of those unpleasant effects which follow 
 
XXII.] MANAGEMENT OF THE PLACENTA. 383 
 
 upon the insertion of a napkin rolled up for that purpose. There is 
 this to be said in reference to the action of the plug, that while it 
 may be looked upon as universally applicable in all cases of alarming 
 haemorrhage, when all hope of saving the ovum has been abandoned, 
 we should, if possible, avoid it in all other cases. It is an undoubted 
 source of reflex contraction, and may thus precipitate labor in a hope- 
 ful case. If properly applied, the plug may be left for a considerable 
 time without interference, and may often be expelled with the'ovum. 
 If removed, and the haemorrhage continues while the os is still con- 
 tracted, there is no course open to us but to renew the plug, and this 
 may always be done with the less hesitation, as it is well known that 
 the risk of internal haemorrhage during the period of abortion is very 
 trifling, and has rarely been observed earlier than the sixth month. 
 
 As in the case of other haemorrhages, astringents are frequently given 
 in abortion, sometimes with good effect. It is, however, in the earlier 
 abortions in which this is most marked, when acetate of lead, gallic 
 acid, and the mineral acids, may often be given with advantage. The 
 more advanced the pregnancy, the less can we rely on ordinary astrin- 
 gents ; so that we must then resort to oxytocics, with the view of 
 exciting uterine contractions of such force as may expel the ovum, or 
 such portion of it as may be retained. A simple enema, or one con- 
 taining turpentine, will often serve as a powerful incentive to uterine 
 action. If the abortion is one of the sixth month, we may sometimes 
 be justified, when the haemorrhage is alarming, in rupturing the mem- 
 branes, as in an ordinary case of accidental haemorrhage towards the 
 end of pregnancy — a mode of treatment which was recommended by 
 Puzos. More probably, even then, we would make choice of plug- 
 ging, in preference to a mode of procedure which must even further 
 remove any small chance of saving the ovum which might exist. 
 
 It is the Expulsion of the Placenta, however, in regard to which the 
 greatest difficulty is often incurred. If that period of pregnancy has 
 been reached at which tins organ is distinct, the main difficulty would 
 seem to arise from the firm anatomical connection which subsists be- 
 tween the uterus on the one hand, and the placenta on the other. If, 
 therefore, the whole ovum is not expelled entire, as is usual in the 
 early weeks, the effect of the uterine contractions will probably be to 
 rupture the membranes, and discharge the embryo or foetus through the 
 cervix, which has been sufficiently dilated for this purpose. The action 
 then ceases, the os closes, and the placenta is retained : so that here the 
 analogy between abortion and labor at the full time ceases. 
 
 This being the state of matters, we can do nothing but wait. The 
 contracted state of the os prevents the introduction of the ringer, and 
 ergot is often of little or no use; so that unless the haemorrhage is 
 alarming, the safest course is to preserve an expectant attitude. When, 
 after an interval of hours or days, as the case may be, haemorrhage re- 
 curs, with pains more or less distinct, indicating further separation of 
 the placenta and renewed uterine efforts, we must carefully observe the 
 symptoms which are being developed, and manage the case accordingly. 
 The haemorrhage may be so profuse as to require the plug, while we 
 wait for the dilatation of the os. While this process is slowly being 
 
384 
 
 PREMATURE EXPULSION OF THE OVUM. 
 
 [CHAP. 
 
 Fig. 131. 
 
 effected, Ave may find that a portion of the placenta occupies the cervix, 
 and can already be reached with the finger. Great caution should here 
 be exercised ; and, if the haemorrhage is not alarming, it may be set 
 down as a rule, that we should abstain from interference until there is 
 some clear evidence of entire separation of the placenta, or until the 
 os has reached a stage of more advanced dilatation ; and, even then, 
 should all be going on favorably, it will be better to leave the process 
 to nature, than to interfere, with the view merely of accelerating a 
 process which nature is satisfactorily effecting. If we interfere prema- 
 turely, we incur the danger of removing from the os a portion only of 
 the placenta, upon which the closure of the os may again occur ; and, 
 besides this, the flow of blood may thereby be actually increased, as 
 the portion removed may have served as a natural plug. 
 
 When the os is pretty well dilated, or when severe flooding calls for 
 prompt action, the immediate removal of the placenta is of course our 
 first object. With this in view, the finger is to be cautiously passed 
 round the protruding portion, and, if necessary, another finger may be 
 introduced into the os. If we can thus succeed in 
 getting a hold of the placenta upon which we can 
 rely, it may be extracted entire ; but a rude or un- 
 skilful mode of manipulation may entirely frustrate 
 our efforts by leaving behind a portion of what we 
 wish to extract whole. It is impossible to lay down 
 rules for the skilful performance of this manoeuvre, 
 which can only be taught by experience; but we 
 have no doubt that more reliance is to be placed 
 upon the fingers than upon instruments, as a general 
 rule. Levret recommended the injection of a pretty 
 powerful stream of warm water, by means of a 
 syringe, into the uterus, on the same principle as is 
 adopted for the removal of wax or foreign bodies 
 from the ear ; but the danger of intra-uterine in- 
 jection, which modern practice has revealed, will 
 probably deter most operators from adopting this 
 plan. The placental forceps was devised by the 
 same authority with the object of grasping and 
 removing a retained placenta. Since then many 
 varieties of this instrument, some of them most in- 
 genious, have been constructed. Among others, Dr. 
 Dewees recommended a wire crotchet, which he had used with good 
 effect; and this, variously modified, has been not unfrequently em- 
 ployed since his time. It must be confessed, however, that, whatever 
 ingenuity may be exhibited in the construction of these, the fingers 
 are almost always to be preferred ; and, if instruments are tried, they 
 should only be used as auxiliary to the safer means of ordinary ma- 
 nipulation. 
 
 Should such attempts be attended only with failure, we must again 
 plug, with the view of effectually restraining the loss of blood, which 
 soon tells upon the pulse ; and the only other resource which remains 
 to us is the use of ergot, or some other oxytocic agent. Upon ergot, 
 
 Placental forceps. 
 
XXH.] PREMATURE LABOR. 385 
 
 however, we must not depend, for the smaller the bulk of the uterine 
 contents, the less is it to be relied upon ; but we are not, on that account, 
 to be deterred from administering it, since it frequently exercises a 
 remarkable influence upon the uterine fibre, even independently of 
 pregnancy — as we have seen more than once in the case of uterine 
 fibroids, where the physiological effect of the drug was an important 
 element of diagnosis. 
 
 Under ordinary circumstances, abortion is attended with but little 
 risk to the mother, and the cases in which her life is placed in jeopardy 
 are, therefore, relatively rare. Without taking into consideration the 
 numerous instances in which abortion actually takes place, and is never 
 recognized as such, this termination of pregnancy is of such frequent 
 occurrence that the difficulties and dangers above described are only 
 too familiar to the busy practitioner. I)r. Whitehead of Manchester 
 made this a point of special investigation, and found that out of two 
 thousand pregnant women, who had applied to the Manchester Lying- 
 in Hospital, the total number of their abortions amounted collectively 
 to one thousand two hundred and twenty-two. Thirty-seven out of 
 every two hundred mothers had aborted before they had reached the 
 age of thirty, and among those of a more advanced age the proportion 
 of abortions was very much higher. It is, in point of fact, a rare thing 
 for a woman to pass the greater part of the childbearing epoch in 
 wedlock, without having aborted once, or oftener — which, along with 
 the facts above cited, will suffice to show how enormous must be the 
 loss of foetal life in the a^retrate. 
 
 The treatment after abortion is a question of considerable importance; 
 but, unfortunately, it is often a difficult matter to persuade a woman of 
 the necessity which exists for the exercise of ordinary prudence and 
 care. Under favorable circumstances, all that may be necessary is 
 confinement to bed for a few days, and avoidance of fatigue and exer- 
 tion for some time thereafter ; but, in other cases, more strict treatment 
 may be necessary. Should retained fragments of placenta give rise 
 again to haemorrhage, the patient must not be permitted to rise until 
 all trace of this has ceased; and, if her general health has materially 
 suffered, a course of chalybeate tonics, change of air, tepid sea-baths, 
 and the like, must be resorted to, with a view of restoring the health. 
 The great danger accruing from neglect of these precautions is not so 
 much to be evinced in immediate effect as in the more remote results; 
 and we are convinced, from long experience, that no more fruitful 
 source of menstrual disorder or of chronic uterine disease exists, than 
 what arises from a want of due precaution at this critical period of a 
 woman's existence. 
 
 But little of a special nature remains to be said of Premature Labor, 
 which occurs only during the last three months of gestation — at a 
 period, therefore, at which the child is held to be " viable." A vulgar 
 idea very generally prevails, that children born at the eighth month 
 are reared with more difficulty than those which are prematurely ex- 
 pelled at the seventh ; but careful observation has clearly shown, what 
 reason and analogy would have led us to conclude, that the further 
 removed from the natural term of pregnancy is the period of delivery, 
 
 25 
 
386 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 the less chance is there of rearing the child. Many of the causes which 
 have been enumerated as inducing abortion may also operate similarly 
 at this more advanced period of pregnancy, but there are undoubtedly 
 other special causes which may also be mentioned. The most impor- 
 tant of these latter is over-distension of the womb, from whatever cause 
 this may arise. Plural pregnancy, dropsy of the amnion, and hydror- 
 rhea, are all causes of this nature ; and the immediate result of their 
 operation is that the uterus attains, at a period much earlier than is 
 usual or normal, that degree of distension which is characteristic of 
 completed gestation. The symptoms and treatment of premature, labor 
 differ in no essential particular from what obtains at the full term. If 
 the dilatation of the os is somewhat tardy, a commensurate mechanical 
 advantage is gained in the ease with which the fetus passes through 
 the parturient canal. There is, however, without doubt, a greater ten- 
 dency to retention of the placenta, although in a much less degree than 
 in the course of the abortion period ;■ and, the nearer the delivery is to 
 the natural term of gestation, the more strictly identical are the symp- 
 toms with those of mature birth. 
 
 CHAPTER XXIII. 
 
 HEMORRHAGE BEFORE DELIVERY. 
 
 "UNAVOIDABLE" AND "ACCIDENTAL" HEMORRHAGE — PLACENTA PREVIA; 
 CENTRAL AND LATERAL: ORIGINAL IDEA AS TO THE NATURE OF: VIEWS OP 
 RCEDERER AND RTGBY — CAUSES OF PLACENTAL PRESENTATION — SYMPTOMS : 
 HEMORRHAGE BEFORE AND DURING LABOR: EXAMINATION FROM THE VA- 
 GINA: OCCASIONAL TERMINATION BY EXPULSION OF THE PLACENTA, WITH 
 CESSATION OF HEMORRHAGE : SYMPTOMS AND TERMINATION OF THE " LATERAL" 
 VARIETY — TREATMENT: GENERAL MEASURES: USE OF THE PLUG OR TAM- 
 PON : EVACUATION OF THE LIQUOR AMNII BY PUNCTURE OF THE MEMBRANES 
 OR PLACENTA — TURNING IN PLACENTA PREVIA: PASSAGE OF THE HAND 
 THROUGH THE PLACENTA AT ONE TIME PRACTICED : USUAL METHOD OP 
 OPERATION — THE BIPOLAR METHOD — ARTIFICIAL EXTRACTION OF THE PLA- 
 CENTA: SIMPSON'S STATISTICS — PARTIAL SEPARATION OF THE PLACENTA: 
 BARNES'S VIEWS — GENERAL CONCLUSIONS AS TO TREATMENT — ACCIDENTAL 
 HEMORRHAGE ; MORE SERIOUS THAN IS GENERALLY SUPPOSED — SITE OF THE 
 PLACENTA — SYMPTOMS — TREATMENT — USE OF STYPTICS IN BOTH FORMS OF 
 HEMORRHAGE. 
 
 While haemorrhage prior to delivery is, as has just been shown, 
 the rule in cases of premature expulsion of the ovum — a rule which 
 indeed, at certain periods of abortion, admits scarcely of an exception — 
 it is otherwise with labor at the full term. With the exception of the 
 trifling hemorrhagic discharge constituting, at the termination of the 
 first stage, what the midwives call a " show/' any loss of blood which 
 
XXIII.] PLACENTA PREVIA. 387 
 
 precedes the birth of the child when mature, is in its nature abnormal. 
 In practice, a certain number of cases are found to occur in which, in 
 consequence of abnormal conditions, a serious loss of blood cccurs be- 
 fore birth, so serious as in many instances to imperil the life both of 
 the mother and her child. All cases of haemorrhage before labor do 
 not, however, as will clearly be shown in the sequel, depend on the 
 same cause; and, in consequence, the treatment applicable to each 
 varies in relation to the cause which produces it. Dr. Rigby in his 
 admirable essay on this subject, published now nearly a hundred years 
 ago, divided cases of haemorrhage which occur in the last three months 
 of gestation into those which are " unavoidable' 7 and those which are 
 " accidental." Of the two, the former is the more important, and is 
 familiarly known under the name of Placenta Prsevia; while the acci- 
 dental form is due to the operation of causes which are similar in their 
 nature, and in their mechanism, to the discharges which occur in 
 abortion. 
 
 Placenta P?'cevia, or Placental Presentation, as it has also with per- 
 fect justice been termed, implies that the placenta, instead of occupy- 
 ing its usual site in the neighborhood of the fundus uteri, is the lowest 
 or most dependent part of the uterine contents, and occupies, wholly or 
 partly, the passage through which the child has to pass. When it is 
 attached to the entire circumference of the cervix, it is called "com- 
 plete" placenta praevia, or Placenta Centralis; while, if it is adherent 
 to a portion only of this area, it is usually designated as "partial" pla- 
 centa praevia, or Placenta Lateralis. Such peculiar situation of the 
 placenta necessarily involves its detachment from the subjacent uter- 
 ine tissues with which it is in contact. This may take place, either 
 gradually, in proportion as the cervix expands in the latter months of 
 pregnancy, or more suddenly, when the mechanism of the first stage 
 of labor tears asunder those attachments in the course of the uterine 
 contractions which effect dilatation of the os. In either case, the 
 haemorrhage from gaping vessels is in the strictest sense of the term 
 " unavoidable," as it is impossible for the child to be born without 
 haemorrhage of the most alarming description. There are, on this ac- 
 count, few of the dangers of midwifery which the accoucheur dreads 
 more ; and Naegele was probably right when he said that " there is no 
 error in nature to be compared with this, for the very action which she 
 uses to bring the child into the world, is that by which she destroys 
 both it and the mother." 
 
 The idea entertained by the ancients, and which (with the exception 
 of those of Portal and Gifford) was taught in all works on midwifery 
 down to about 1766, — when Roederer's Elementa Artis Obstetricice 
 was published, — was that in these cases the placenta was originally 
 attached at its usual site, and that it only fell down to the lower part 
 of the uterus after it had been entirely separated. Roederer, in the 
 work above referred to, gave as complete and succinct a description of 
 placental presentation as is to be found in any modern work on ob- 
 stetrics, and drew, moreover, a distinction between central and lateral 
 implantation of the placenta. The work of Rigby, published a few 
 years later, but which contains no reference whatever to the observa- 
 
388 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 tions of Rcederer, is more familiar to English writers, and certainly 
 was the first to bring a correct knowledge of the subject under the 
 notice of English obstetricians, whatever may be the weight of the 
 author's claims to originality. 
 
 The Causes of placental presentation are but little understood. The 
 fertilized ovum grafts itself, as is well known, generally, upon some 
 portion of the uterine mucous membrane, not far distant from the ori- 
 fice of the Fallopian tube along which it has descended. It has been 
 presumed that, as the connection between the chorion and the decidua 
 is — prior to the development of the placenta — continuous over the 
 whole of their contiguous surfaces, the actual site of the placenta may 
 correspond to any point in the circumference of the ovum. The tumid 
 and convoluted condition of the mucous membrane which obtains 
 during menstruation, and for some days afterwards, is obviously well 
 suited to the arrestment of the fertilized ovum, a body already endowed 
 with independent vitality, and prone to adhere to any surface from 
 which may be derived the pabulum on which the maintenance of that 
 vitality must necessarily depend. Exceptional circumstances may, 
 however, occur to permit of the descent and ultimate escape of a fertil- 
 ized ovum; and we may, therefore, infer that the ovum may, in any 
 such case, be arrested near the cervix, and there go through the series of 
 physiological changes upon which the formation of the embryo de- 
 pends. The occurrence of extra-uterine pregnancy shows that contact 
 with the membrane which is specially prepared for its reception is by 
 no means essential to development of the ovum. There is nothing, 
 therefore, extravagant in the assumption, that it may take root at a 
 point of the uterine mucous membrane distant from the site which it 
 ordinarily selects. It has even been held that the impregnation of the 
 ovule may take place as low in the uterus as the cervix; and, if it be 
 so, this will no doubt serve to explain the phenomenon in question. 
 But, even if we suppose the ovule to be impregnated before its arrival 
 in the uterus — which is, as is believed, the usual course — there are 
 many special circumstances which may account for its occasional gravi- 
 tation towards the cervix before contracting adhesions. If, for exam- 
 ple, its descent is, relatively to the menstrual period, later than usual, it 
 may find the mucous membrane no longer tumefied and convoluted to 
 the same extent as before ; and there can be no doubt that a smooth 
 and flat surface would be more likely to permit of such gravitation 
 than the other condition of the membrane already referred to as charac- 
 teristic of a menstrual period. The probable result of such a case 
 would be loss of the ovum ; but it is at least possible that it might yet 
 be arrested in its descent, and graft itself upon a surface to which it is 
 accidentally contiguous, as when it falls upon the peritoneum in ab- 
 dominal pregnancy. All such speculations are, however, merely theo- 
 retical ; for it must be confessed that, in so far as the etiology of pla- 
 centa previa is concerned, nothing definite is known. 
 
 In the early months of pregnancy, there are no Symptoms which 
 enable us to recognize the condition in question ; and, if hemorrhage 
 should take place, it will probably be followed by abortion, in the 
 course of which nothing would occur likely to direct our attention to 
 
XXIII.] SYMPTOMS OF PLACENTA PREVIA. 389 
 
 the peculiar nature of the case. At any period more advanced than 
 that at which abortions generally take place, a sudden attack of haemor- 
 rhage, more profuse than usual, and for which no definite cause can be 
 assigned, should always excite our suspicion, as it must neeessarily 
 demand our attention. Such haemorrhages, dependent upon placental 
 presentation, usually occur in the course of the last three months of 
 pregnancy ; and the nearer the pregnancy is to its natural termination, 
 the more profuse is the discharge likely to be. If this symptom should 
 be of earlier occurrence than usual, the quantity will probably be slight, 
 and, under favorable circumstances and judicious treatment, will speedily 
 cease. After an uncertain interval, and often at what would have been 
 the next menstrual period, the symptoms will, however, return with 
 increased violence. Repeated haemorrhages of this kind, becoming 
 progressively more alarming, ultimately attract attention, and call for 
 assistance. The loss of blood in these cases probably depends upon 
 the gradual development of the cavity of the cervix, which becomes 
 further encroached upon with every day of advancing pregnancy. 
 
 If at this stage we make an examination, we shall probably find that 
 the os and cervix are somewhat peculiar to the touch. This peculiarity 
 consists in a doughy feeling, due to the unusual thickness of the cervix, 
 which is necessarily permeated with large vessels for the placental cir- 
 culation. And this feeling is further exaggerated by the presence of 
 the placenta itself, between the finger and the presenting part, depriv- 
 ing the latter of its feeling of firmness and resistance. If the os is 
 sufficiently dilated to permit the passage of the finger, the character- 
 istic spongy tissue of the placenta may alone be felt ; or, if the case 
 should be a lateral and not a central one, we may feel the edge of the 
 placenta projecting at one side of the os uteri, and, possibly, the bag 
 of membranes with the presenting part of the child at the other. If 
 the flooding has been very severe, we may feel the detached surface of 
 the placenta, which is lacerated and stringy to the touch ; and we may 
 even discover, in some instances, where the separation has been exten- 
 sive, a portion of the organ protruding into the os, or, through it, into 
 the vagina. In presentations of the breech or shoulder, which usually 
 remain high in the pelvis, the detection of placenta praevia is more 
 difficult, partly on this account, and partly because the placenta can 
 less easily be felt than when it is between the finger and the resistant 
 structures of the cranium. 
 
 There is another class of cases, in which no symptoms whatever 
 occur until the uterine contractions at the commencement of labor in- 
 terrupt, for the first time, the continuity of the utero-placental vessels. 
 Here the gush of blood is sometimes so fearful, as to cause immediate 
 syncope, and in some cases the death of the woman before assistance 
 can reach her. Haemorrhage before labor, therefore, has this advan- 
 tage, — that it enables us to recognize the nature of the case at a period 
 sufficiently early to adopt precautionary measures, with a view to the 
 patient's safety. From the commencement of labor, the symptoms in 
 the two varieties are identical. Each successive pain tends still fur- 
 ther to the separation of the placenta from its cervical attachments, 
 and consequently to increase the haemorrhage, so that, up to a certain 
 
390 HAEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 stage, the more advanced the labor, the more imminent is the danger; 
 and, if left to themselves, such cases almost necessarily prove fatal. It 
 is here that the important practical distinction is drawn which enables 
 us, even without a digital examination, to distinguish between Una- 
 voidable and Accidental haemorrhage, and which led Rigby to adopt 
 this useful classification. In the former, remissions may occur between 
 the pains, but with each contraction the flow of blood is increased ; 
 while, in the latter, the descent of the head bars the egress of blood, 
 the source of the discharge being higher in the uterus, as will be shown 
 by and by, when we come to notice this special variety of flooding. 
 
 It has been said that haemorrhage before labor is more likely to occur 
 in cases of central than of lateral placenta praevia ; and if we were to 
 draw an inference from the anatomical relation of the parts, we would 
 be quite prepared to accept the correctness of this conclusion. Practi- 
 cal experience has, however, shown that we cannot depend on this, and 
 that many cases of central implantation present no symptoms whatever 
 until these are developed by the occurrence of labor. 'It sometimes, 
 though rarely, happens that the effect of the uterine contractions is to 
 separate the placenta either from its cervical attachments or from its 
 entire uterine connection, so that the haemorrhage is comparatively 
 trifling. In some of these instances, the detached placenta has been 
 propelled into the vagina, and the foetus then descending so as to 
 press upon the orifices of the gaping vessels, has protected the woman, 
 from that time onwards, from the further effects of alarming haemor- 
 rhage. This has suggested a mode of treatment of these cases which 
 will be mentioned at the proper place, and which is not without 
 strenuous advocates at the present day. Another rare termination of 
 central placenta, of which cases have been recorded by Portal and 
 others, is the birth of the child through the placenta. A case of this 
 nature occurred in the practice of Mr. White, of Heathfield in Sussex, 
 and is given by Rigby. The placenta was " centrally attached to the 
 os uteri, when, in consequence of two or three powerful pains, the head 
 was forced through, tearing it quite across. The child was born dead, 
 but the mother did well." Such natural terminations of placenta 
 praevia are so rare, that not only do we place no reliance on them, but 
 we do not even allow them to enter into our calculations in determining 
 the mode of procedure which is to be adopted. It has even happened 
 that in these cases children have been born alive; but it is obvious that 
 the life of the child must, almost of necessity, be sacrificed. This is a 
 further reason for not trusting to nature in the circumstances now 
 under consideration. 
 
 More confidence may, at times, be placed in the efforts of nature, 
 when the case is a partial one, and the placenta situated laterally with 
 respect to the os. As the placenta may be implanted upon any part of 
 the internal surface of the uterus, a considerable variety of cases of 
 partial placenta praevia may present themselves. In those cases in 
 which the placenta spreads over a large portion of the cervix — and it 
 has been observed that it is generally of greater superficial size than 
 when it is developed at the fundus — the same treatment which is held 
 to be applicable to central cases will be indicated. But, in the instances 
 
XXIII.] PARTIAL PLACENTA PREVIA. 391 
 
 in which the bulk of the placenta is above the cervix, and a small por- 
 tion only is implanted on that part, it is quite possible that, although 
 labor may be ushered in by profuse flooding, the head may be permit- 
 ted to descend, when it will act as a plug, and the natural powers will 
 effect a safe delivery as regards both mother and child. And, a fortiori, 
 when the placenta can only .be reached by the finger with some diffi- 
 culty, this fortunate issue of the case is the more likely to occur; and, 
 in fact, such cases should rather be looked upon as occupying a place 
 intermediate between the " unavoidable" and "accidental" category. 
 As is the case with regard to many other of the accidents of midwifery, 
 there seems to be a proclivity to the recurrence of placenta previa in 
 those who have once been the subject of it ; and another and stranger 
 fact has also been noticed by Rigby, Saxtorph, Naegele, and others, 
 viz., that at certain periods this accident seems of more frequent occur- 
 rence than at others. The last-named authority, in remarking on this, 
 states "that in some years, placental presentation was so frequent that 
 it seemed as if it were almost epidemic." 
 
 Treatment. — The occurrence of hemorrhage in the last months of 
 pregnancy is of itself sufficient to warrant, and indeed demands, an 
 immediate vaginal examination. Should the existence of the symptoms 
 already detailed reveal the presence of the placenta at the os, the future 
 management of the case becomes at once a matter involving no little 
 anxiety. It has already been remarked that the earlier the period of 
 pregnancy at which flooding first takes place, the less is the immediate 
 risk. The treatment of such cases differs but little, as Rigby well 
 remarks, from that of an ordinary case of abortion. The indications, 
 in fact, are the same, viz., to stop the discharge, and allay any disposi- 
 tion to uterine contraction. At the same time, no effort must be spared 
 to prevent, if it be practicable, further separation of the placenta. 
 
 Nothing is, perhaps, of such importance as rest. The patient should 
 be placed in a bed which is as hard as is compatible with comfort. 
 With the view of keeping her cool, the temperature of the room must 
 be attended to, and the bedclothes should be light. The bowels mav 
 be managed by gentle saline laxatives or enemata, and the patient 
 should not be permitted to raise her shoulders ; nor, for a certain time 
 after an attack, should she ever be allowed even to move in bed more 
 than is absolutely necessary. The food at first should be of the lightest 
 possible description, such as milk, arrowroot, and the like, and should 
 be given cool. Such restricted regimen cannot be persevered in for any 
 length of time, so that we must soon introduce soups, fish, chicken, and 
 more nourishing material generally into the dietary. The use of 
 stimulants, except in so far as they may be necessary in the stage of 
 depression, consequent on severe flooding, must be forbidden. Under 
 such treatment, and with the mind as well as the body at perfect rest, 
 the best chance is afforded the woman of reaching the full term of ges- 
 tation. The probable result of haemorrhage, in placenta previa prior 
 to the seventh month is, as has been said, abortion. But, when gesta- 
 tion is further advanced, and the foetus has reached the period of 
 viability, we endeavor to avert premature delivery as long as is pos- 
 sible, in order to give the child the best possible chance. But we do 
 
392 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 this in the interest of the mother also, and not exclusively in that of 
 the child. Of the operative remedial measures which may be adopted, 
 none is so frequently resorted to as turning, and the nature of the 
 operation is such that it may always be effected with greater ease to the 
 operator, and less risk to the woman, the nearer the case is to the full 
 term. 
 
 When haemorrhage and vaginal examination have revealed the nature 
 of the case, at any time during the last three months of gestation, we 
 should inform the patient and her friends of the certainty of a recur- 
 rence of the flooding sooner or later. The number of the attacks, and 
 the period which may elapse between them, are points on which we 
 dare not venture an opinion. In one case, the flow may be almost 
 continuous, or have remissions only ; and, in another, there may be but 
 one or two attacks, and these not seldom corresponding to menstrual 
 periods. But the great peril, in every case, lies in this — that we can 
 never foresee the moment when a torrent of blood may be poured out 
 in such abundance, that the life of the woman is placed in instant jeop- 
 ardy, and may be sacrificed before assistance can reach her. Particular 
 directions should therefore be given, in order that no time be lost in 
 summoning assistance. It is, moreover, of the highest possible impor- 
 tance that a skilful nurse should be in constant attendance, to whom 
 the accoucheur may give instructions as to the method of plugging — 
 the materials for which should be kept prepared and constantly at 
 hand. 
 
 The use of the vaginal plug or tampon, as applicable to the treatment 
 of abortion, has already been described. The proceeding in this case 
 is precisely similar, and the material recommended on the authority of 
 Dewees will here suit the purpose equally well. The object of plugging, 
 if practiced before labor has commenced, is simply to prevent the flow 
 of blood, without there being any ulterior object, as regards further 
 operative procedure, in view. This is effected partly by preventing 
 the external flow, and partly by compressing the placenta between the 
 plug and the presenting part of the child, and thus artificially damming 
 up the source from which the blood has escaped. Although, as already 
 remarked, the sponge is to be preferred on various grounds, it, and the 
 coagulated blood which accumulates in its interstices, are so prone to 
 decomposition, that it cannot well be retained beyond a few hours. In 
 such cases, then, as it may seem advisable to maintain compression of 
 the placenta for a longer period, it may be better to plug with slips of 
 lint, tow, or some other similar substance; or, better still, by an india- 
 rubber bag, which, after its introduction, may be distended either with 
 water or with air. Braun's Colpeurynter is a contrivance of this nature. 
 The plug must not, however, be used rashly in those cases in which 
 the haemorrhage is as yet trifling, and in which, consequently, we are 
 justified in temporizing, in the hope of preserving the child; for ex- 
 perience, derived from the treatment of abortion cases, has clearly shown 
 that the irritation of the plug is pretty sure, sooner or later, to excite 
 uterine contraction. Where labor pains, however feeble, have already 
 manifested themselves, or where the urgency of the symptoms precludes 
 the hope of conducting the case to maturity, this particular action of 
 
XXIII.] TREATMENT OF PLACENTA PRiEVIA. 393 
 
 the plug is rather an advantage, as, by stimulating the uterine fibres, 
 the os is more rapidly and effectually dilated. Astringents, local and 
 general, have been tried in every possible way in these cases, but it 
 must be confessed that their action is not even in the slightest degree 
 to be depended upon ; a result which will not excite wonder if the 
 purely mechanical cause of the haemorrhage be kept in mind. 
 
 When the flooding does not occur until labor has declared itself at 
 the termination of pregnancy, or when, at any period, the haemorrhage 
 is so profuse, and the general symptoms so urgent as to demand ener- 
 getic action in the presence of a great emergency, our duty is to encourage 
 contraction, and to complete delivery as soon as possible. With this 
 object prominently in view, various modes of treatment have been rec- 
 ommended, to each of which it is necessary specially to advert. In a 
 large proportion of the cases in which the os is as yet undilated to any 
 extent, the only justifiable mode of procedure is to arrest the haemor- 
 rhage by plugging, and, at the same time, to favor uterine contraction 
 by every means at our command. Plugging is, however, as will be 
 observed, in all cases of placenta prsevia, a mere temporary expedient, 
 which is employed with a view to ulterior proceedings. 
 
 Evacuation of the liquor amnii by puncture of the membranes is a 
 practice of great antiquity. The object of this in the present instance 
 is to develop uterine energy, which usually becomes increased when its 
 walls are thus relaxed ; while, at the same time, being of smaller bulk, 
 it acts with greater energy. The cases to which this mode of procedure 
 seems more particularly applicable, are those instances in which the 
 placenta is situated more or less laterally, or, in other words, those in 
 which the membranes can be reached before the os has become dilated, 
 and without much risk of rupture of tissue. Its use, however, has not 
 been confined to such cases, but has been recommended and practiced 
 by Deventer, Deleurye, Smellie, and, more recently, by others, who, 
 in cases of central implantation, puncture the placenta by a trocar or 
 otherwise, with the result of arresting the haemorrhage. Rupture of the 
 membranes is also applicable to all cases in which it is found expedient 
 to induce premature labor, that is to say, if it can be effected with safety; 
 but, if not, of coui'se other means must be adopted to rouse the uterus 
 to activity. Dr. Barnes says, " The puncture of the membranes is the 
 first thing to be done in all cases of flooding sufficient to cause anxiety 
 before labor. It is the most generally efficacious remedy, and it eon 
 always be applied. 9 ' The italics are his, indicating the emphasis with 
 which he makes the statement, but in so far as our experience enables 
 us to judge, we cannot indorse his assertion. And, moreover, we cannot 
 but think that such a procedure as he describes of guiding a stilet or 
 quill along the finger to the membranes must necessarily cause, for a 
 tiuie at least, an increase in the bleeding in central cases, as it certainly 
 must a complete and violent separation of the placenta in a part of its 
 circumference. The contraction of the uterus may be further promoted 
 by the action of ergot and the other oxytocics. Evacuation of the 
 liquor amnii and the use of ergot are, it must be remembered, open to 
 this objection, that, by such treatment, the difficulty of the operation 
 of turning is greatly increased, should that operation eventually be 
 
394 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 found necessary ; but if the operation for separation of the placenta is 
 to be preferred, as is recommended by Dr. Barnes, this objection has 
 no force. 
 
 The operation of turning, which will be more particularly described 
 in another chapter, is that to which most modern authorities, with some 
 distinguished exceptions, give the preference in the treatment of cases 
 of placental presentation. So long as this operation is looked forward 
 to as one suitable to an individual case, not only must rupture of the 
 membranes not be practiced, but every means should be adopted which 
 is likely to preserve their integrity. We shall not here anticipate the 
 details of the ordinary operation of turning, but notice only those modi- 
 fications of the operation which are rendered necessary by the peculiar 
 anatomical conditions of the case. Two methods have been suggested. 
 That to which Dr. Rigby has lent the weight of his authority, consists 
 in forcing the hand through the tissues of the placenta into. the amni- 
 onic cavity, and then completing the operation in the usual way. Dr. 
 Dewees urges the following cogent and unanswerable objections against 
 this procedure : 
 
 " 1. In attempting this, much time is lost that is highly important 
 to the patient, as the flooding unabatingly, if not increasingly, goes on. 
 
 "2. In this attempt, we are obliged to force against the membranes, 
 so as to carry or urge the whole placentary mass towards the fundus of 
 the uterus ; by which means the, separation of it from the neck is in- 
 creased, and, consequently, the flooding augmented. 
 
 " 3. When the hand has even penetrated the cavity of the uterus, 
 the hole which is made by it is no greater than itself, and, consequently, 
 much too small for the foetus to pass through without a forced enlarge- 
 ment; and this must be done by the child during its passage. 
 
 " 4. As the hole made by the body of the child is not sufficiently 
 large for the arms and head to pass through at the same time, they 
 will consequently be arrested ; and if force be applied to overcome this 
 resistance, it will almost always separate the whole of the placenta from 
 its connection with the uterus. 
 
 " 5. That, when this is done, it never fails to increase the discharge, 
 besides adding the bulk of the placenta to that of the arms and head of 
 the child. 
 
 " 6. When the placenta is pierced, we augment the risk of the child; 
 for, in making the opening, we may destroy some of the large umbilical 
 veins, and thus permit the child to die from haemorrhage. 
 
 " 7. By this method we increase the chance of an atony of the uterus, 
 as the discharge of the liquor amnii is not under due control. 
 
 " 8. That it is sometimes impossible to penetrate the placenta, espe- 
 cially when its centre answers to the centre of the os uteri ; in this in- 
 stance much time is lost that may be very important to the woman." 
 
 These and similar arguments, and the experience of modern practice, 
 have resulted in a general, if not invariable, preference for the second 
 method of performing the initiatory stage of the operation of turning. 
 The origin of the procedure referred to is generally attributed to 
 Portal. The hand, in this case, is to be passed, not through, but by 
 the side of the placenta, choosing, if it be possible to ascertain the fact, 
 
XXIII.] TREATMENT OF PLACENTA PRiEVIA. 395 
 
 that side to which the placental adhesions are least extensive. It is 
 very rare that the attachment is equal in extent all round; and, of 
 course, if there is any point of the circumference to which the placenta 
 is not adherent, that place should be selected for the passage of the 
 hand. The usual precautions are to be adopted for preventing rupture 
 of the membranes, and the hand is to be carried high into the uterus 
 between it and the membranes, until the situation of the feet is ascer- 
 tained, when the fingers are thrust through them, the feet seized, and 
 the operation completed in the usual way. During the course of this 
 procedure, — which is often easier of execution than under ordinary 
 circumstances, owing to the relaxed state of the uterus, the result of 
 haemorrhage, — the arm of the operator acts as a plug, which effectually 
 restrains external haemorrhage. When the feet are brought down into 
 the vagina, the breech and trunk of the child forcibly compress the 
 placental mass ; and in this way one plug is replaced by another more 
 efficient still. The action of the womb should be aided by an external 
 bandage, or by firm pressure, at this period, over the fundus, and a full 
 dose of ergot may be administered, with the view still further of 
 insuring efficient contraction. If the child is still alive, or if there is 
 no evidence of its death (in which case we should act as if it were alive), 
 delivery must be effected as rapidly as is consistent with the safety of 
 the mother. With its birth, the critical period of danger will have 
 passed, and the uterus will now contract firmly upon, and shortly expel 
 the mass of the placenta which is left behind. 
 
 When the accoucheur is summoned at the commencement of labor, 
 on account of the alarming flooding, he will probably find that the os 
 is not sufficiently dilated to permit of the operation of turning with a 
 reasonable prospect of safety. His first duty at this stage is to arrest 
 the haemorrhage, until such time shall arrive as the condition of the 
 parts may warrant him in proceeding to the operation. This can only 
 be effected by the action of the plug, which is to be introduced in the 
 manner above described. Or, what is more effectual still, strips of lint 
 may be introduced, one after the other, through the speculum, as by 
 this means the vagina can be more thoroughly packed. As the pressure 
 of the plug is apt to interfere with the action of the bladder, it will be 
 well to see that the viscus is empty before its introduction. A still 
 more effectual method of plugging may at this stage be practiced by 
 means of the fiddle-shaped water-bags, which we owe to the ingenuity 
 of Dr. Barnes. A certain amount of dilatation is necessary for the 
 successful application of these ; but if the os is of sufficient size to admit 
 the point of the finger, it will then be practicable to pass a bag of small 
 size. This may then be distended with water in the manner described 
 by the inventor, and a firm elastic plug is thus formed, which serves 
 the double purpose of preventing any escape of blood, and, at the same 
 time, of mechanically dilating the os by a safe and graduated method 
 of pressure. The exchange of the small bag for one of larger size may, 
 after an hour or so, be effected without much risk, if the operator is 
 dexterous ; and, in this way, such dilatation of the os may be effected 
 as will admit the passage of the fingers, and subsequently of the hand. 
 
396 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 But, whether we make use of the vaginal or cervical plug, the object is 
 to dilate the os, with the view of subsequent operative procedure. 
 
 It is to be remembered that extensive dilatation of the os is by no 
 means essential to the successful performance of the operation of turn- 
 ing. The method of combined external and internal manipulation, 
 which has already been referred to in. the chapter on Transverse Pres- 
 entations, and which will be more particularly described, affords a 
 mode of procedure which is by no means difficult, and which is cer- 
 tainly safer to the mother. To effect this, the passage of one or two 
 fingers through the os is all that is necessary; and in so far as placenta 
 prsevia is concerned, we are convinced that this method is peculiarly 
 applicable, and will ultimately, in a great measure, displace the more 
 familiar operation. 
 
 "The conditions favorable for turning are," says Dr. Tyler Smith, 
 "a dilated or dilatable state of the os uteri; the retention of the liquor 
 amnii, or a moderately relaxed state of the uterus; a pelvis of average 
 capacity ; the absence of dangerous exhaustion, or a temporary cessation 
 of the haemorrhage." Nothing is of greater importance than that the 
 operation should be attempted as early as possible, for there can be no 
 doubt that the great mortality which attends these cases is due in no 
 small degree, to an injudicious expectant treatment, while the precious 
 moments pass during which alone we can save the patient's life and 
 that of her child. It may sometimes be necessary, when the case does 
 not come under observation until this more advanced and critical stage, 
 to delay the operation, and to plug, until the woman is rallied by free 
 stimulation from the state of incipient collapse into which she has fallen. 
 In this, as in all other cases of prostration from haemorrhage, brandy 
 given along with opium will effect the object in view as well perhaps 
 as any other combination of stimulants which it is possible to prescribe. 
 When, in such cases, the pulse and general appearance show that the 
 woman has rallied, the operation may be commenced, and conducted 
 with the special precautions which the circumstances demand. 
 
 In some cases of partial placenta prsevia, the operation of turning 
 may not be required ; but if in such the haemorrhage is still alarming, 
 after the head has descended so as to occupy a fully distended os, the 
 labor may be completed by the application of the forceps. 
 
 Artificial Extraction, and Artificial Separation of the Placenta — for 
 it is proper to draw a distinction between the two — are operations which 
 were suggested by what has occasionally been observed as a natural 
 termination of placenta prsevia, viz., the birth of the placenta or its 
 expulsion into the vagina in advance of the child, with cessation of the 
 haemorrhage. Imitating this, Drs. Wood, Radford, and Simpson, tried 
 what had previously been done in a few cases, to separate and extract 
 the placenta, in the hope of speedily arresting the haemorrhage, and 
 thus insuring the safety of the mother. Simpson, with his usual and 
 indefatigable industry, collated a table, in which cases are given show- 
 ing the results to the mother in instances of turning. Contrasted with 
 this, is another series of cases, in which the placenta was expelled nat- 
 urally or removed artificially before the birth of the child. The fol- 
 
XXIII.] TREATMENT OF PLACENTA PREVIA. 397 
 
 lowing represents in a tabular form, the results of his elaborate sta- 
 tistics : 
 
 Cases. Maternal Deaths. 
 
 Turning, 654 180, or 27.48 per cent. 
 
 Extraction or Expulsion, . . 140 . . 10, or 7.14 per cent. 
 
 Such an issue as is represented by these figures is by no means, how- 
 ever, a fair representation of the comparative risk attendant upon the 
 two operations. On the contrary, by grouping together the cases in 
 which natural expulsion had occurred with those in which the removal 
 had been accomplished by operative interference, the value of the com- 
 parison is lost, as it must be evident that expulsion is less likely to be 
 attended with a fatal result than those cases in which the parts are torn 
 asunder by an operation which, how r ever gently performed, implies a 
 rupture of tissue by violence, involving the integrity of large vascular 
 trunks. Although the figures are to this extent unreliable, it must be 
 admitted that the cases upon which they are founded show quite clearly 
 that separation of the placenta, whether natural or artificial, is accom- 
 panied in a large proportion of cases with an abatement, dependent upon 
 the arrest of hemorrhage, of the more alarming symptoms. " Paradox- 
 ical as it may appear," says Simpson, " there are sufficient grounds and 
 facts for believing that, when the placenta is separated slightly and 
 partially, the chance of fatal haemorrhage to the mother is greater than 
 when the disunion of the organs is entire and complete." 
 
 It would serve no good purpose to follow the discussion to which 
 Simpson's views as to the source of the haemorrhage in placenta praevia 
 gave rise. These are essentially the same as were held by his prede- 
 cessor, Dr. Hamilton, that the blood flowed not from the uterine, but 
 from the placental orifices of the ruptured vessels, a point which, 
 although of high physiological interest, must not divert our attention 
 from the more important practical questions upon which it has but an 
 indirect bearing. We must not omit to mention that the operation of 
 extraction is, as regards the child, extremely unfavorable in its ultimate 
 results — more so, certainly, than turning, if performed at the proper 
 time. In this, also, Simpson's statistics are likely to mislead, if not 
 carefully analyzed. Again, grouping together indiscriminately cases 
 of expulsion and extraction, he finds that, in 141 cases, the child was 
 saved in 33, and, as the result as regards the child was not stated in a 
 considerable number of the remaining cases, it may be assumed that the 
 actual number of children born alive was somewhat larger than is 
 above stated. But here again the same source of fallacy comes into 
 j^lay, and, in point of fact, it may be assumed that the statistical results 
 of spontaneous expulsion and artificial extraction should be carefully 
 separated, otherwise the figures are very apt to encourage errors in 
 practice. When the foetus is born by the efforts of nature, it has often 
 been found to be expelled by the same pain which brings the placenta 
 into the world, or at least follows it within a very few minutes, a result 
 extremely improbable in artificial extraction. Dr. Simpson's own tables 
 point conclusively to this fact, and in those cases in which the interval 
 between the birth of the placenta and that of the child was more than 
 ten minutes, he gives but one instance, occurring in the practice of Mr. 
 
398 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 Perfect, in which the child was born alive. Unless then it could be 
 proved that a speedy delivery of the child could be depended upon after 
 extraction of the placenta, that operation cannot be looked upon with 
 favor, in so far at least as the interests of the child are concerned. 
 
 But, should we even resolve upon the operation of extraction, the 
 difficulties of the case do not terminate with the completion of that 
 operation. Thus we find that, of the entire number of 86 cases given 
 by Simpson in his tables, delivery was effected by turning in 25 in- 
 stances, and by other modes of operative procedure in 7, while in 9 the 
 mode of delivery is not specified. This leaves 45 cases only in which 
 the delivery was completed by the natural pains, and we may confi- 
 dently conclude that, if w r e could separate the cases of spontaneous 
 expulsion, the issue of the operative cares would appear still more un- 
 favorable. The inference which was drawn from Simpson's elaborate 
 papers on this subject, and the interpretation which indeed seemed to 
 attach to them, was that the author wished to supersede the old opera- 
 tion of turning by that of artificial separation. We might think it 
 necessary to say something more in refutation of such a conclusion, were 
 it not that the practice has never commanded general support, save under 
 exceptional circumstances. And, moreover, a careful reperusal of Simp- 
 son's facts, arguments, and conclusions, seems very clearly to show that, 
 whatever opinions may have been entertained by that distinguished 
 accoucheur when he submitted his views to the Medico-Chirurgical 
 Society of Edinburgh in 1844, those were materially altered before his 
 death. This appears even more clearly from the " Lecture Notes," by 
 which the reprint of his selected obstetrical works recently edited by 
 Dr. J. Watt Black is prefaced. 
 
 We shall now refer to the mode of partial separation, which has of 
 late years received a considerable amount of support. It is intimately 
 associated with the name of Dr. Barnes, whose writings on the subject 
 of placenta previa are among the most valuable of the many contribu- 
 tions to obstetrical literature which we owe to the distinguished obstetric 
 physician of St. Thomas's Hospital. The effect of the uterine contrac- 
 tions, and consequent dilatation of the os, is, as he has shown, to sepa- 
 rate the placenta in concentric rings from below upwards, vessel after 
 vessel being thus opened, and the haemorrhage proportionally increased. 
 So soon as the separation has reached a certain height, the passage of 
 the head may become possible, while yet an amount of placenta suffi- 
 cient to discharge the function of the organ may remain attached. Dr. 
 Barnes maintains that the complete separation of the placenta as 
 recommended by Simpson is impracticable. "In by far the greater 
 number of cases," he says, " the placenta extends higher than the 
 meridian of the uterus, often reaching the fundus. The fingers are not 
 long enough to reach even half way towards the further margin of the 
 placenta. The diameter of the placenta is nine or ten inches ; the fin- 
 gers will barely reach three inches. In the greater number of cases, 
 therefore, in which the directions prescribed have been followed, the 
 placenta has not been wholly detached, and the result, when successful, 
 cannot be attributed to an operation which was not performed." As- 
 suming this fact to be correct, and supposing, therefore, that to insure 
 
XXIII.] TREATMENT OF PLACENTA PREVIA. 399 
 
 vom'plete separation of the placenta, the whole hand must be passed into 
 the uterus, he adds that this operation " is even more severe than turn- 
 ing, which does not require the hand to be passed through the cervix." 
 Here he obviously refers to the bipolar method. There is, he infers, a 
 zone or line around the lower part of the uterine cavity above which 
 spontaneous detachment and haemorrhage do not occur, and below which 
 alone separation and unavoidable haemorrhage take place. 
 
 On this hypothesis, then, the real period of danger is that during 
 which the placenta is being separated from the cervical zone, and Dr. 
 Barnes maintains with great confidence that this is the mode of action 
 in many of the cases which have been narrated of spontaneous cessa- 
 tion of the flooding, the real facts being misinterpreted by the observer. 
 In a case which recently occurred in the experience of the writer, the 
 facts observed seemed strongly to corroborate the idea thus suggested, 
 in regard to which he had previously been more than skeptical. A 
 young woman, pregnant for the second time, had had several attacks 
 of haemorrhage prior to the expiry of her pregnancy. With the first 
 labor pains another gush took place, and shortly after this she was first 
 seen and examined by him. He found the os sufficiently dilated to 
 admit a single finger, and the placenta completely surrounding the 
 orifice. During several successive pains it was observed that the quan- 
 tity of blood was for such a case very trifling, and it was on that ac- 
 count resolved to leave the case for a time to nature, with the view of 
 observing what course nature would adopt. Materials were prepared 
 for plugging the moment this should seem to be necessary, and the 
 case was anxiously watched. Soon afterwards pains came on of great 
 violence, and in rapid succession, but there was only one short period 
 of about a minute and a half, during which the haemorrhage was 
 alarming, which suddenly ceased upon the rupture of the membranes. 
 Upon an examination the head was now felt descending, and the 
 woman was shortly afterwards safely delivered of a living child. She 
 made an excellent recovery. 
 
 Whatever may be the method of treatment upon which it is resolved 
 to act, the first difficulty generally is to effect the dilatation of the cer- 
 vix with the least possible chance of haemorrhage. Dr. Barnes, be- 
 lieving that the tardy separation of the placenta from what he terms 
 the " orificial zone " of the uterus is the main cause of haemorrhage, 
 recommends that, if rupture of the membranes, which is his first pro- 
 cedure, should fail, we ought at once to separate the whole of that part 
 of the placenta which is adherent to the zone in question. The de- 
 tails which he gives are as follows : "Pass one or two fingers as far as 
 they will go through the os uteri, the hand being passed into the va- 
 gina if necessary ; feeling the placenta, insinuate the finger between it 
 and the uterine wall ; sweep the finger round in a circle, so as to sepa- 
 rate the placenta as far as the finger can reach ; if you feel the edge of 
 the placenta where the membranes begin, tear open the membranes 
 freely, especially if these have not been previously ruptured; ascertain 
 if you can what is the presentation of the child before withdrawing 
 your hand. Commonly some amount of retraction of the cervix takes 
 place after this operation, and often the haemorrhage ceases. ... If 
 
400 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 uterine action return so as to drive down the head, it is pretty certain 
 there will be no more haemorrhage; you may leave nature to expand 
 the cervix, and to complete the delivery. The labor, freed from the 
 placental complication, has become natural." Failing this, he then 
 advocates the use of his hydrostatic dilators, which at once expand the 
 os, and arrest the bleeding. These bags, which we have had occasion 
 repeatedly to use, and which we have ventured to suggest as applicable 
 to the plugging and dilating of the os prior to turning, admirably serve 
 the purpose of dilatation. After an hour or half an hour, the bag may 
 be withdrawn, and if then the uterus remains inactive, with a contin- 
 uance of the haemorrhage, or if the presentation turns out to be trans- 
 verse, or otherwise abnormal, which is very common in placenta pre- 
 via, the operation of turning is then to be resorted to by the bipolar 
 method. On a total of 69 cases treated by Dr. Barnes on this princi- 
 ple, the percentage of maternal deaths was only 16.66. 
 
 The various methods above described may be conveniently epitom- 
 ized for practical purposes in the following propositions, in which it is 
 attempted to give its proper value to each : 
 
 1. That the Evacuation of the Liquor Amnii is specially applicable 
 to cases of lateral or partial placenta praevia, and other cases in which 
 the membranes can be easily reached; and to cases in which the feet us 
 is immature. 
 
 2. That Ergot and other oxytocics may be administered, but it is to 
 be remembered that both these and evacuation of the liquor amnii act 
 so as to render the operation of turning more difficult. 
 
 3. That Plugging is called for at various stages, and may be applied 
 either in the vagina or in the os uteri. It is a mere temporary expe- 
 dient, and, in the case of turning, is an almost essential mode of pre- 
 liminary treatment. 
 
 4. That extraction of the placenta, although not so impracticable as 
 Dr. Barnes supposes, is not to be resorted to unless the circumstances 
 be very exceptional, as when the operation of turning is impossible, 
 and that of separation has failed. 
 
 5. That Separation of the placenta, which has sometimes been con- 
 founded with Extraction, is a much more justifiable procedure than 
 the latter. It may be performed in all cases in which the condition of 
 the parts or the state of the mother prohibit turning; but the evidence 
 in its favor is not as yet sufficiently clear to warrant us in abandoning 
 the older operation of turning. That it arrests haemorrhage in a con- 
 siderable proportion of cases is admitted, but until a more extended 
 experience shall corroborate the conclusions of Dr. Barnes, it would 
 be unwise to admit them as proved. Statistics in such a case are of 
 little value, and this Dr. Barnes himself frankly admits. 
 
 6. That the operation of Turning is that in which the great majority 
 of experienced practitioners still place the greatest confidence. If the 
 percentage of maternal deaths under this treatment is, as Simpson says, 
 as high as 27.48, including all cases indiscriminately, we are certainly 
 bound to conclude that in those instances in which the patient is under 
 treatment from the first, the results will be very much more favorable. 
 If the plug bars the haemorrhage, as it generally does when properly 
 
XXIII.] ACCIDENTAL HEMORRHAGE. 401 
 
 applied and carefully watched, that stage of the process must be ad- 
 mitted as effectual. But it is not to be forgotten that the operation of 
 turning is one which involves special risks, of which laceration of the 
 os and cervix, terminating in uterine phlebitis, is not the least, and that, 
 therefore, we must weigh well the responsibilities we undergo before 
 we reject all other modes of procedure in favor of this operation as it 
 is usually performed. The risk, however, has been greatly modified 
 by the introduction of the bipolar method of version. 
 
 The so-called Accidental Haemorrhage differs in many essential par- 
 ticulars from the unavoidable variety commonly called placenta praevia. 
 The designation is, of course, more an arbitrary than a philosophical 
 one; but as it is one generally intelligible to English readers, we shall 
 not attempt to change it. In this case also, there is haemorrhage before 
 delivery, but there is a most important clinical distinction to be drawn 
 between the two. In the last three months of pregnancy the anatomical 
 connection which subsists between the uterus and the placenta becomes 
 more feeble, so that the one is more easily separated from the other. 
 The wonder then is, not that the separation does in rare instances occur, 
 but that it does not occur more frequently. In accidental haemorrhage, 
 the placenta is attached to the uterus at its normal site. 
 
 What the causes are which, in such circumstances, lead to a separa- 
 tion of the placenta are but little known or understood, but it has been 
 observed that the separation rarely occurs in the young and robust; 
 while, in those who have borne many children, or in whom any cause 
 may have led to constitutional feebleness, it is relatively of more fre- 
 quent occurrence. If, in such cases, the flooding is to be looked upon 
 as a symptom of constitutional depravity, that of itself renders the 
 case a grave one; but another source of hidden danger is that the 
 haemorrhage is often concealed. Placental separation indeed occurs; 
 blood is insinuated between the membranes and the uterus; obvious 
 shock and even collapse is produced ; and yet no single drop of blood 
 escapes externally, while laceration of the uterine wall has occurred 
 from the over-distension of the cavity by a haemorrhage such as this. 
 In other cases, again, the placenta has remained adherent at its margin, 
 while an enormous quantity of blood has been effused between the uter- 
 ine wall and the body of the placenta. It would appear that, in many 
 cases, the separation of the placenta takes place in the centre and not 
 at the margin, and that the blood makes its way towards the margin, 
 and thence frequently beneath the membranes, until it makes its ap- 
 pearance externally. These are the cases which, although by no means 
 so treacherous or so dangerous as the former, are generally described 
 as accidental haemorrhage. In some of them, the general symptoms 
 are as severe as those which accompany a case of placenta praevia, and 
 in others are much more grave than the actual external flow would 
 seem to account for. Sickness, pallor, dimness of vision, and fatal 
 prostration may thus rapidly supervene in a case of this nature, before 
 even the symptom of flooding has attracted any particular attention. 
 
 Accidental haemorrhage may occur either before or during labor. 
 The great diagnostic feature which, according to all authorities, from 
 Rigby downwards, enables us to distinguish, during labor, between it 
 
 26 
 
402 HEMORRHAGE BEFORE DELIVERY. [CHAP. 
 
 and unavoidable haemorrhage, is that, in the latter, the effect of a pain 
 is to increase the flooding, by still further separating the placenta; in 
 the accidental form of haemorrhage, the presenting part descends during 
 a pain, and thus, by plugging the cervix, stops the external flow. 
 
 [It is not every case of this sort that is attended with a discharge of 
 blood externally, and these "concealed accidental haemorrhages" are 
 probably not so rare as authors represent them to be. Dr. William 
 Goodell, of Philadelphia, has analyzed one hundred and six examples 
 of this accident. The most prominent symptom is collapse. This is 
 alarming from the very first, and carries "dismay into the heart of 
 the bystander." The skin becomes cold ; is bedewed with a clammy 
 perspiration. The pulse is feeble and flickering, and the patient suffers 
 from difficulty of breathing, sighs and retches frequently, and finally 
 faints. At the same time the woman has an agonizing pain, with a 
 sense of distension in the uterus as if it were bursting. The labor pains' 
 are very feeble or entirely absent. This while there is no sign of haemor- 
 rhage externally, but some time after the effused blood has become co- 
 agulated a watery discharge may take place from the vagina. This is 
 generally supposed to be the liquor amnii, but upon examination the 
 membranes are found to be intact, proving that the fluid is the liquor 
 sanguinis, which has worked itself outwards between the membranes 
 and the uterus. In some instances the blood after a time begins to 
 flow from the vagina. Some authors, among whom are Levret, Hopff, 
 Leroux, and Baudelocque, have attached great importance to the de- 
 velopment of an " accessory tumor" of the uterus, the result of bulging 
 of the walls from the accumulated blood. This is not a constant symp- 
 tom. It occurs when the margins of the placenta remain adherent. 
 This assemblage of symptoms is certainly very striking, and when they 
 appear in women who were previously perfectly healthy, they are cal- 
 culated to excite the utmost alarm upon the part of both the patient 
 and her friends. 
 
 The accident is liable to be mistaken for rupture of the uterus, from 
 which it can be distinguished by the fact that in concealed haemorrhage 
 the size of the abdomen continues to increase, while in rupture it dimin- 
 ishes, especially if the child escape into the abdominal cavity. In rup- 
 ture the head recedes from the os, or the bag of waters becomes flaccid 
 if it have not broken ; though rupture is rare until after this occurs. 
 In concealed haemorrhage the bag continues tense. In rupture, the 
 pains, until the moment of the accident, have generally been unusually 
 violent, when they cease suddenly. In concealed haemorrhage they are 
 very feeble or entirely absent from the first. 
 
 Dr. Goodell, to whose admirable description of this accident we are 
 indebted for the above facts, mistook it for a severe attack of " cramp 
 colic." The diagnosis may be very difficult, but the fact that the 
 woman is pregnant is of considerable importance, while the syncope of 
 the mother, and failure of the fcetal circulation would point to the 
 true cause of the symptoms. A serous discharge from the vagina, the 
 membranes remaining intact, is a symptom of great value, and sets all 
 doubts at rest. — P.] 
 
 Many writers seem to pass over these cases, as if they were of little 
 
XXIII.] ACCIDENTAL HAEMORRHAGE. 403 
 
 importance, and were as nothing beside the more interesting physio- 
 logical speculations which arise from a consideration of placenta prsevia. 
 In point of fact, however, they are extremely fatal to the child, and 
 highly dangerous to the mother, so that their management involves, in 
 some instances, no less anxiety than placenta prsevia itself. In so far 
 as Treatment is concerned, the first step in accidental haemorrhage is,i>^ 
 undoubtedly, to rupture the membranes, so as to give egress to the 
 liquor amnii. This, by removing the strain on the uterine walls from 
 within, has a well-known tendency to promote vigorous expulsive 
 action on the part of that organ. It is, besides, the most efficient safe- 
 guard which it is possible to procure, for a pain not only plugs the os, 
 by forcing down the foetus, but, what is more important, it compresses 
 the placenta between the uterus and the child, and, by the same action, 
 mechanically closes the mouths of the vessels from which the blood has 
 flowed. Friction, ergot, and if there be much depression, stimulants, 
 may also be used, with the object of encouraging uterine action in those 
 cases in which it is feeble or absent. But these means may fail to excite 
 efficient uterine action, and the expulsion of the uterine contents, upon 
 which alone we can depend for the safety of the mother. Should this f 
 be the case, our next step, after indulging, in the absence of actual 
 haemorrhage, in a reasonable amount of expectancy, should be to dilate 
 the cervix gradually, by means of Barnes's bags, and to complete de- 
 livery by the operation of turning, in which the bipolar method should 
 always, if it be practicable, be preferred. The previous evacuation of 
 the liquor amnii will, no doubt, render the manoeuvre of turning more 
 difficult than it would otherwise have been ; but, on the other hand, 
 as it is failure of uterine action which calls for the latter operation, the 
 atony of the uterine walls will generally compensate for the absence of 
 those conditions wdiich are usually held to be favorable to the perform- 
 ance of the operation of turning. The greatest possible care should, 
 in every case, be taken to avoid precipitation in the course of the 
 manipulation, and thus to preserve the integrity of the tissues of the 
 cervix. 
 
 The peril of the woman does not necessarily terminate, either in 
 unavoidable or accidental haemorrhage, with the birth of the child, or 
 even with the expulsion or extraction of the placenta. The uterine 
 fibres may remain in such a paralyzed condition that flooding may still 
 go on from the patent orifices of the uterine vessels. In such an emer- 
 gency it may, therefore, be necessary to apply some powerful styptic to 
 the bleeding surface, with the view of arresting the jjost-partum haemor- 
 rhage, an object which, in the case of placenta prsevia, may be most 
 effectually attained by swabbing the cervical zone with perchloride of 
 iron, alum iron, or some other astringent; but, in the case of the 
 accidental variety, it may be necessary, in order to reach the bleeding 
 surface, cautiously to inject the cavity of the uterus with the same 
 powerful agents. Another source of anxiety in all these cases, even 
 when the immediate dangers of the haemorrhage and operation have 
 been surmounted, is the risk of puerperal pyaemia and the allied affec- 
 tions, to the development of which such patients are peculiarly prone. 
 
404 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 CHAPTEE XXIV. 
 
 HAEMORRHAGE AFTER DELIVERY. 
 
 hemorrhage in the third stage of labor — abnormal and retained pla- 
 centa, and irregular uterine contraction, as causes of flooding — 
 post-partum hemorrhage — causes: general and local — symptoms: 
 of external and internal hemorrhage : examination of the abdomi- 
 nal walls : examination by the vagina : general symptoms ! symptoms 
 avhich indicate the approach of death — treatment: prevention: 
 treatment during the hemorrhage : pressure and friction over the 
 uterine region — effects of bandaging — effect of passing the hand 
 into the uterine cavity — application of cold, should not be continu- 
 ous — astringents to internal surface — galvanism — ergot — treat- 
 ment by plugging abandoned — views in regard to compression of the 
 abdominal aorta — application of the perchloride of iron and other 
 styptics: objections to, and arguments in favor of this procedure — 
 dr. barnes's process — treatment directed to the general condition 
 of the patient — effects of rest and position — reaction to be avoided 
 after severe flooding — transfusion: the "mediate" and "imme- 
 diate " processes : dr. aveling's apparatus ; injection of defii3rinated 
 blood, and of saline solutions. 
 
 Although haemorrhages which precede the expulsion of the placenta 
 are not, properly speaking, post-partum, we shall, for convenience sake, 
 consider them here. The proper management of the placenta, with 
 the object mainly of preventing haemorrhage, has already been ex- 
 plained in the chapter on the Management of Labor; but there are 
 some other important matters which are still left for consideration, and 
 as some of these have strong analogies with true post-partum haemor- 
 rhage, it has been thought better to include them in this section of our 
 subject. Retention of the placenta, and consequent haemorrhage, may 
 be the result of mismanagement, but, independently of this, there are 
 other causes, over which we have little or no control. If the circum- 
 stances attending the labor are in all respects normal, the placenta is 
 probably separated entirely, either during the birth of the child, or in 
 the course of the dolor es cruenti which follow it. In a certain number 
 of instances, however, the placenta is not separated in this manner; 
 owing, in one class of cases, to some anatomical peculiarity in the form 
 of the placenta, in a second to atony, in a third to irregular contrac- 
 tion of the womb, and in a fourth to what has been described as morbid 
 adhesion. 
 
 Cases of abnormal placenta, in which the organ is divided, or has 
 detached cotyledons, are of such rare occurrence that no practical im- 
 portance can be supposed to attach to them. A full account of these is 
 
XXIV.] RETAINED PLACENTA. 405 
 
 given, with beautiful illustrations, in a recent work by Hyrtl. 1 Should 
 atony of the uterus be the cause, we must attempt without delay to ex- 
 cite uterine contraction by friction, cold applications, or ergot. In 
 such a case, we have a double cause of haemorrhage in operation, — an 
 absence of the contractile force upon which the closure of the bleeding 
 vessels depends, and a mechanical hindrance to that contraction in the 
 presence of the placenta. Of irregular contractions of the uterus,* that 
 which is most frequently spoken of is " hour-glass " contraction, in 
 which a spasmodic stricture of certain fibres of the uterus divides the 
 organ into two cavities, within the upper of which the placenta is im- 
 prisoned. True placental adhesion depends, again, on actual disease 
 of the decidua or placenta, or, at least, on the presence of morbid prod- 
 ucts which are the result of antecedent disease. 
 
 In all these cases, the treatment is the same, and consists in the 
 speedy removal of the placental mass, or masses. If there is a loss of 
 expulsive force, the hand is to be passed, w r ith the usual precautions, 
 into the uterine cavity, so as to grasp the whole placenta. A pause 
 should, however, be made here until contraction takes place, which is 
 to be further aided by the pressure of the hand on the walls of the ab- 
 domen, so that, if possible, the placenta and the hand may be expelled 
 together. If this is not done, the placenta may indeed be extracted, 
 but, in such a case, flooding of the true post-partum variety can hardly 
 fail to take place from the flaccid organ. If the so-called hour-glass 
 contraction should be found to exist, the efforts of the operator must, 
 in the first place, be directed to the stricture, which has to be over- 
 come before the extraction of the placenta can be safely effected. There 
 is no doubt, however, that hour-glass contraction is of much less frequent 
 occurrence than is generally supposed. It is a familiar expression, 
 and is apt to be employed loosely, as representing all forms of irregu- 
 lar uterine contraction in which the extraction of the placenta is a 
 matter of difficulty. When the uterus contracts irregularly, this ma- 
 terially affects the process of separation of the placenta, besides mechan- 
 ically hindering its extraction. The gradual insinuation of the hand 
 into the womb, and the introduction of one or two fingers into the 
 contracted portion, so as gradually, by gentle but sustained efforts', to 
 overcome the morbid spasm, or other condition, which is indirectly the 
 cause of the haemorrhage, is the treatment which is applicable to such 
 a case. It requires no great force to wear out a spasm of this nature, 
 and although at first it may be almost tetanic in its rigidity, it will 
 gradually yield, and, by permitting the passage of the hand, admit of 
 the easy removal of the placenta. When the cause of haemorrhage is 
 the adhesion of a partially separated placenta, it is sometimes necessary 
 to introduce the hand, and forcibly strip the organ from its uterine 
 attachments. This peeling process, which must be conducted very 
 slowly and steadily, will often occupy a considerable time ; but, fortu- 
 nately, the cases in which the operation is required are of rare occur- 
 rence. It would appear, that in some of these instances at least, the 
 uterine tissue, with which the placenta is in such intimate connection, 
 
 1 Die Blutc;efasse der menschlichen Nachs:eburt. Wien. 1870. 
 
406 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 is morbidly soft and friable, so that the operator runs the double risk 
 of leaving behind adherent portions of a placenta, the bulk of which 
 has been removed, and of injuring the uterine walls, which are no 
 longer, in their structure, such as to admit of even ordinary force. Do 
 what we may, portions of placenta are sometimes left behind, which 
 may require to be removed as the causes of subsequent haemorrhage, or 
 which may afterwards be spontaneously discharged, — a result which 
 may, although very unjustly, be set down to the discredit of the ac- 
 coucheur. Such retained masses have been removed, when unusually 
 adherent, by the wire- rope £craseur. 
 
 In so far as the ordinary and normal condition of the placenta is 
 concerned, the best safeguard against the haemorrhage in question is the 
 proper management of the placenta during, and subsequent to, the birth 
 of the child. This has already been described in another section of this 
 work. 
 
 True Post-partum haemorrhage is an alarming and sometimes, in its 
 effects, an appalling occurrence. When, in the course of labor, every- 
 thing has passed as favorably as could be desired, the child is born 
 alive, and the mother is apparently well, we naturally anticipate, as 
 experience has taught us, a happy issue to the case. But the termina- 
 tion of labor, the real hour of trial to the mother, maybe the beginning 
 for her of a new and unforeseen peril. One of the essential physiological 
 phenomena of labor is, as has been shown, the efficient contraction of 
 the uterus during and after the birth of the child. This is nature's 
 almost invariable safeguard. At times, unhappily, the uterine fibres 
 which close the bloodvessels are relaxed, and blood pours forth with an 
 impetuosity proportionate to the calibre and relaxation of the vessels, 
 deluging the woman with blood, and reducing her in extreme cases to a 
 condition of collapse which may be the immediate forerunner of death. 
 So fearful is the torrent, in the worst cases, that, before we even have 
 time to arrange our plan of treatment, our patient lies dead before us. 
 The more experience one has of the practice of midwifery, the more do 
 we dread the occurrence of this form of haemorrhage, which we can 
 seldom foresee, and which is therefore all the more appalling, since we 
 have seen no occasion to nerve ourselves and to prepare for an approach- 
 ing emergency. 
 
 Causes. — A certain number of cases are, no doubt, due to slovenly 
 practice, a neglect of those details which should be matter of routine in 
 every case. But, while such causes may generally be avoided by ordi- 
 nary skill and attention, there are other instances where the causes upon 
 which the flooding depends are comparatively little, and sometimes not 
 at all, within our control. One of the most important and, at the same 
 time, most common cause of post-partum haemorrhage is uterine inertia. 
 It may be that in these cases the uterine effort is simply exhausted, and 
 complete atony is the immediate sequel of labor. Anything which may 
 have tended to reduce the vital powders may lead to this. In women 
 who have long suffered from wasting diseases, whose constitution may 
 have been exhausted by many rapidly succeeding pregnancies, or in 
 whom the vital energies have been in a measure sapped by a long- 
 continued or complicated labor, we see illustrations of those conditions, 
 
XXIV.J CAUSES. 407 
 
 which are predisposing causes of haemorrhage after labor. No small 
 proportion of the fatal cases seem to have occurred in women who were 
 the subjects of the more advanced stage of Bright's disease, or of any 
 similar disease which exercises a deteriorating influence on the compo- 
 sition of the blood, increasing the watery at the expense of the corpus- 
 cular elements. It has been observed that, when the labor is unusually 
 rapid, either from violent expulsive effort or deficient resistance, there 
 is a tendency to post-partum flooding. It would appear, therefore, 
 that a condition of safety is gradual emptying of the uterine cavity. 
 In this way the fibres have time to contract to the enormous extent 
 which is essential to the effectual closure of the vessels ; whereas, sadden 
 contraction, although possibly efficient enough as regards delivery, 
 cannot maintain itself, and is often followed by subsequent intermittent 
 periods of relaxation, during which flooding is almost sure to occur. 
 This, no doubt, is the reason why, after delivery by the forceps, and 
 in some other obstetrical operations, flooding is more frequently ob- 
 served, — an excellent and sufficient warrant for the strict observance of 
 the obstetric aphorism, that we should empty the womb in operative cases 
 as slowly as possible, and allow it to contract upon the child as it is 
 being expelled. Sometimes, however, anxiety for the life of the child 
 and other circumstances may lead us, for what may seem good reasons, 
 to disregard this maxim ; but, in doing so, we should always admit into 
 our calculations the fact that, in avoiding one danger, our pilotage may 
 cause us to make shipwreck on another somewhat more remote. 
 
 Fibroid growths connected with the uterus, and especially fibroid 
 polypi are, if present, almost certain causes of haemorrhage after labor. 
 It is well known that haemorrhage is one of the earliest and most con- 
 stant symptoms of this affection in the nn impregnated state, and it is 
 not therefore to be wondered at that the proclivity to flooding should 
 be more marked at the critical period which immediately succeeds 
 delivery. This symptom may be caused in two ways, either by haemor- 
 rhage from the mucous surface of the tumor, or by the mechanical 
 interference which it exercises in preventing the proper closure of the 
 venous orifices in the wall of the uterus. 
 
 Another affection may here be mentioned as an undoubted cause, and 
 which, although it has not the slightest pathological affinity with the 
 tumor just described, may be, and has by very experienced observers 
 been, mistaken for it. We allude to inversion of the uterus. The 
 symptoms of this, which will be more fully noticed in another place, 
 are indeed such as, under ordinary circumstances, could scarcely be 
 mistaken. In the one, we have a tumor generally ovoid in shape, con- 
 nected with a pedicle which we can trace up to the os or beyond it to 
 its intra-uterine attachment ; in the other, we have also an ovoid tumor, 
 but which ends abruptly by a more extensive attachment, within easy 
 reach of the finger. In the former case, we find the distal extremity 
 of the tumor encircled by a ring, formed by the os uteri more or less 
 contracted ; in the latter, there is no such constriction. But this, be it 
 remembered, applies only to the diagnosis of complete uterine inversion, 
 which must pass, slowly or more rapidly, through various stages before 
 it becomes complete, and at any one of these it may be arrested. In 
 
408 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 other words, there may be partial as well as complete inversion, and it 
 is the former condition only which is likely to be mistaken for a polypus. 
 In a case which, many years ago, came under our notice, there was a 
 rounded tumor narrowing towards its upper part and tightly embraced 
 by the os, and it was this condition which led to an erroneous diagnosis. 
 In a precisely similar case, one of the best known and most distinguished 
 accoucheurs in Britain made a similar error, but fortunately discovered 
 his mistake, just as he was about to remove the tumor by the ecraseur, 
 by the pain which the patient complained of, and which he knew by 
 experience was a most unusual symptom in manipulating polypi. Let 
 us beware, therefore, of mistaking a partially inverted uterus for a 
 polypus which is protruding from the uterine cavity. 
 
 The Symptoms of post-part urn haemorrhage are flooding, or the general 
 symptoms to which it gives rise, or both of these combined. In by 
 far the greater number of instances, the external discharge is at first, 
 and throughout the whole course of the case, the most alarming, as it 
 is the most palpable sign. It may immediately succeed the birth of 
 the child, or may precede or follow the expulsion of the placenta. The 
 quantity of the discharge is very variable, and upon this will depend, 
 in a great measure, the opinion which we may form as to the gravity of 
 the case. Generally, symptoms, more or less distinct, of uterine inertia 
 will be manifested. The firm tumor which we are accustomed to feel 
 behind the pubes loses its distinct outline, and becomes less perceptible 
 to the touch ; or may disappear altogether, so that we can perceive 
 nothing but softness and flaccid ity. We may then feel parts, such as 
 the projection of the last lumbar vertebra and the promontory of the 
 sacrum, which we know to be separated from the fingers by the tissues 
 of the womb. If the inertia or atony of the uterus is complete, this 
 condition is persistent, and on introducing the hand into the cavity, 
 which may generally be effected with ease, we find that the uterine 
 walls are soft throughout, and, as Cazeaux graphically describes it, 
 " folded together like a piece of old linen/' Such a condition, should 
 it precede the separation of the placenta, may exist without haemor- 
 rhage; but, if the third stage of labor has been completed, flooding is 
 inevitable. In many of these cases, however, it will be to the observer 
 a matter of wonder that the haemorrhage should not be more profuse. 
 Sometimes there are efforts on the part of nature to effect uterine con- 
 traction, when the hand, in the hypogastric region, may detect alter- 
 nate relaxation and contraction of the organ, the latter periods being 
 accompanied with the expulsion of such blood as may have accumu- 
 lated within the cavity during the former. This disposition to rhyth- 
 mical action on the part of the uterus is not to be looked upon with 
 unnecessary apprehension, unless the actual flow of blood, or the general 
 symptoms, are grave. 
 
 The absence of alarming external haemorrhage is a negative symp- 
 tom, which may divert the attention of the inexperienced from the true 
 nature of the case. In some of these cases, bleeding may be going on 
 internally to an extent which may rapidly place the woman in a posi- 
 tion of extreme peril. The continuous absence of the uterine tumor, 
 and the formation, subsequently, of an extensive and soft abdominal 
 
XXIV.] SYMPTOMS. 409 
 
 swelling, progressively increasing in size, will, along with the general 
 symptoms which rapidly develop themselves, soon indicate what is 
 going on. The conditions under which such symptoms may manifest 
 themselves, are — first, a state of the uterus which admits of easy dila- 
 tation ; and, second, anything which mechanically impedes the external 
 flow, Any displacement of the flaccid womb which may close the ex- 
 ternal orifice mechanically, is sufficient, in the first instance at least, to 
 check the flow in the direction of the vagina, Subsequently, the occlu- 
 sion of the orifice with a clot, which will form a more effective plug if 
 the os and cervix should be in any degree contracted, and at an earlier 
 period, the pressure of the wholly or partially detached placenta, may 
 in this way form a barrier which, under ordinary circumstances, would 
 speedily be swept away, but which, in the utterly flaccid and dilatable 
 condition of the uterus, may be sufficient for the development of the 
 phenomena in question. Sometimes, this process of distension is ac- 
 companied with great agony, which is not the result of attempted con- 
 traction of the organ, but of the morbid phenomenon of over-distension, 
 an indication which is not (infrequently noticed in distension of the 
 other hollow viscera. If the hand of the operator is now introduced 
 into the cavity of the womb, he will recognize still more clearly the 
 condition of matters, and he will find his fingers entangled in an enor- 
 mous mass of clots, with which, and with fluid blood, the cavity is 
 distended to an extent which may equal the size of the organ at the 
 natural period of mature gestation. 
 
 The general symptoms which indicate post-partum haemorrhage may 
 exhibit themselves equally in external and internal haemorrhage. They 
 are, unfortunately, familiar to all experienced practitioners; but, as 
 symptomatic of the accidents we are now considering, they are, for 
 obvious reasons, of greater importance in those instances in which the 
 haemorrhage is internal. In the worst cases, the symptoms are truly 
 appalling, and in the course of a very few minutes the loss of blood 
 may be so enormous as to plunge the woman, almost without warning, 
 into a state of fatal syncope. In cases which, though less desperate, 
 are scarcely less alarming, the woman may, with or without previous 
 abdominal pain, and with or without external haemorrhage, experience 
 a feeling of faintness associated with marked pallor. The vision be- 
 comes dim, and she calls out that she can no longer see; vomiting fre- 
 quently occurs ; and the extremities and general surface of the body 
 become cold and bedewed with a clammy perspiration. The pulse 
 becomes rapid, small, or imperceptible; and the paleness becomes so 
 marked, so greatly exceeding all others, that Dr. Tyler Smith has 
 called it " Puerperal Pallor." In some cases, however, the effect on 
 the circulation is such as to produce, in the first instance, what is 
 familiar to surgeons as the " hemorrhagic pulse," a symptom which is 
 apt to mislead the inexperienced. This is a bounding and apparently 
 full pulse; but, if its character be more carefully tested, it is found to 
 be remarkably compressible, and soon, with a continuance of the flood- 
 ing, merges into the more familiar condition of feebleness and imper- 
 ceptibility. 
 
 Such symptoms are manifestly indicative of a state of extreme peril, 
 
410 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 and, if prompt and skilful treatment be not speedily afforded, are too 
 often the precursors of death, which may be preceded by dilatation of 
 the pupil, hysterical paroxysms, or even by convulsions. It has fre- 
 quently been observed that the amount of blood lost is not a safe cri- 
 terion of the danger ; for not only are we apt to be deceived in regard 
 to the amount of internal haemorrhage, but there is the greatest pos- 
 sible variety in the symptoms which, in different women, attend a loss 
 of a precisely similar amount; and it may be added that it is not in- 
 variably the strong and robust who bear haemorrhage best, or recover 
 most rapidly from its effects. In those cases in which haemorrhage 
 after labor is due to a laceration more or less extensive of the os, or of 
 any other portion of the parturient canal, the symptoms are rarely 
 such as to excite alarm. The dangers to which such occurrences give 
 rise are of a different nature, and do not manifest themselves till a later 
 stage. 
 
 Treatment. — There are, perhaps, few practical questions involving 
 more anxious consideration than this. The young practitioner may 
 find an illustration in the first case of midwifery which he is summoned 
 to attend. He has no time for reference to books, no moment even 
 during which he may appeal to his memory for facts which have escaped 
 it ; and he must, therefore, be fully prepared by a thorough acquaint- 
 ance with the subject, or he is unable to cope with so great an emergency. 
 The principles on which all treatment depends, demand, then, his care- 
 ful attention. 
 
 It is perhaps scarcely possible to attach too great importance to the 
 prevention of post-pa rtu in haemorrhage. Much will depend upon a 
 proper management of the various stages of labor, retarding the action 
 when this has a tendency to be precipitate, promoting it when the pains 
 are feeble, and acting otherwise as has been recommended in the chap- 
 ter on the management of labor. The importance of never leaving a 
 woman until you are satisfied with the uterine contraction after delivery 
 will, in view of the circumstances above stated, now become more mani- 
 fest. We can never be sure of the case unless we are satisfied on this 
 point. There are certain points here, however, which, if not under- 
 stood, might result in the nirnia diligentia of the tyro. First, it must 
 ever be borne in mind that each case of labor is accompanied in its 
 last stage with a certain amount of haemorrhage, and this is not unfre- 
 quently considerable, without being accompanied, either then or sub- 
 sequently, with any other symptoms which should excite alarm. A 
 second circumstance which may cause needless alarm is the gush of 
 liquor amnii, mixed or colored with blood, which immediately follows 
 the birth ; and a third consists in what we very frequently observe, a 
 certain amount of alternate contraction and relaxation which may seem 
 to resemble, in some degree, the conditions above described. An erro- 
 neous inference, drawn from these observations, we have known to lead 
 to treatment which was energetic enough certainly, but quite unneces- 
 sary, and, moreover, not unattended with risk. Caution must, there- 
 fore, be exercised, lest, by giving undue prominence to one symptom 
 without reference to the others, needless panic and improper interfer- 
 ence is the result. 
 
XXIV.] TREATMENT. 411 
 
 There are cases in which the history of previous labors, no less than 
 the circumstances attendant on that which is going on, indicate, at least, 
 the probability of a similar result, and in such it is always proper 
 towards the end of the second stage, or at least before the extraction of 
 the placenta, to administer ergot with the object of insuring efficient 
 contraction ; and the same agent may be used in all cases in which, 
 after the expulsion of the placenta, there is a tendency to atony. More- 
 over, we would do wrong, knowing what we do of the effect produced 
 upon the uterus by excitation of the nipples, were we to omit to have 
 the child placed early to the breast. These means, along with the 
 application of the abdominal bandage, and the other details which have 
 previously been fully described, constitute what is called preventive 
 treatment. 
 
 The course of procedure, to be adopted in actual presence of the 
 emergency, is the real question which may task our knowledge, our 
 nerve, and our ingenuity to the utmost. The object which, before all 
 others, we have in view, is to promote uterine contraction, and if we 
 fail in this, we fail utterly. Of the various methods which we have at 
 command, that which is invariably first employed is manual pressure 
 exercised upon the fundus of the uterus, and also upon its lateral walls, 
 by attempting to grasp the whole organ. In doing this, we do not so 
 much depend upon the effect of such mere mechanical compression, as 
 upon the more indirect action whereby the uterus is excited to contract, 
 a result which is further encouraged by circular friction exercised over 
 the fundus of the organ. The effect of the abdominal bandage at this 
 moment certainly is to aid contractile effort, by affording a substitute 
 for the support which has been lost by the inevitable relaxation of the 
 abdominal walls. The bandage is, however, no advantage, but the 
 contrary, when it prevents us from ascertaining and, when necessary, 
 continually watching the condition of the uterus and its relation to the 
 abdominal walls. It is best to have it loosely attached, so as to admit 
 of easy removal and reapplication, and by placing one or more folded 
 towels over the hypogastric region, the compression of the uterus is kept 
 up continuously, and is not temporary or intermittent as that of the 
 hand necessarily must be. Should this not be immediately followed 
 by satisfactory uterine contraction, the hand should be passed into the 
 vagina, so as to ascertain the condition of the uterus more exactly. 
 Sometimes the irritation of the cervix which is thus caused, results, 
 with the aid of the external hand, in the action so much desired ; but 
 should the organ remain in a state of complete atony, the hand must 
 be passed into the cavity, in order still further to stimulate contraction 
 by contact with its internal surface. When the hand is so passed, it 
 should be moved about w T ithin the womb, so as to collect, as far as 
 possible, within the palm, the clots which occupy the cavity. This 
 movement will generally suffice to awaken uterine action ; but in every 
 case we must be careful not to remove the hand except during sensible 
 contraction, w T hen the uterus may be permitted, as it were, to expel the 
 hand, and with it the retained clots. 
 
 The reflex effect of cold in producing uterine action is often well 
 marked. This may be applied either to the abdominal or thoracic 
 
412 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 walls, to the vulva, or by injection to the rectum or vagina. It has 
 often been observed, even in cases in which the action of this powerful 
 agent was at first marked, that its continuous action is not to be depended 
 on. However effectual, therefore, it may seem in the first instance, 
 when applied suddenly by the douche or otherwise, the action should 
 not be sustained ; otherwise an effect the reverse of beneficial is apt to 
 be produced. The injection of the uterine cavity with iced water, or 
 the application to the inner uterine surface of a piece of solid ice is, 
 under circumstances of emergency, quite justifiable, and has often 
 proved efficacious. The alternated action of heat and cold has been 
 found more useful than sustained cold, the latter agent acting in two 
 ways as an astringent and an excitor of uterine action. M. Evrat 
 recommended the use of a peeled lemon, which he introduced into the 
 cavity of the uterus and then squeezed, so as to project the acid juice 
 upon the bleeding surface. A sponge wrung out of vinegar and other 
 astringents have, in the same way and for the same purpose, been intro- 
 duced, and the effect of such applications has not un frequently been to 
 rouse the uterus from its dormant condition. Galvanism has also been 
 employed with good effect, and may always, if immediately available, 
 be tried. In cases in which clots again form within the cavity of the 
 womb, these should be removed, as by presenting a mechanical impedi- 
 ment to feeble contraction they encourage a continuance of the flooding; 
 and, as before stated, it is well to allow the hand and the clots to be 
 simultaneously expelled by uterine action, should it be possible to 
 arouse the organ to such an effort. 
 
 In the worst cases, little dependence can be placed in the use of ergot, 
 for before sufficient time has elapsed to admit of the physiological action 
 of the drug, the patient may be dead. If employed, it is to be given 
 in full doses, and at as short intervals as is possible. The stomach will, 
 however, often reject it, as indeed, when the patient is in a state of 
 extreme collapse, it will reject anything solid or fluid which may be 
 swallowed. This is not to be looked upon as in itself an unfavorable 
 occurrence, as it has often been observed that violent retching is attended 
 with uterine action, so much so indeed that some practitioners have 
 actually prescribed ipecacuanha with the view of obtaining its emetic 
 effect. Plugging, as a method of treatment, is of ancient origin, and 
 has been advocated in modern times by Leroux and others who adopted 
 his opinions; but, as it has proved inefficacious, it has been abandoned. 
 The mode of action must obviously have been, whether the plug was 
 applied in the vagina or within the womb, to convert external into 
 internal haemorrhage, and in no sense, therefore, to benefit the patient. 
 The last attempts of this nature which have been made would seem to 
 have consisted in the introduction within the uterus of Gariel's air 
 pessary, which was then distended in the hope of compressing the 
 
 bleeding vessels, an effect which a more correct knowledge of the con- 
 
 ... . 
 
 dition of the uterus will not permit us to count upon. 
 
 The flaccid condition of the abdominal walls which immediately 
 
 succeeds delivery, enables us, without difficulty, to press upon, and 
 
 more or less effectually arrest the flow of blood through, the aorta. In 
 
 desperate cases, therefore, the compression of this great vessel has been 
 
XXIV.] USE OF STYPTICS. 413 
 
 practiced, in order to arrest the torrent which continues to pour from 
 the uterine vessels ; but the practice has by some been violently opposed 
 on theoretical grounds. Baudelocque maintained continuous pressure 
 upon the aorta for several hours, and imagined that in this way there 
 was at least a gain of time, during which ergot and other agents might 
 act, and the strength of the woman be restored. The most weighty 
 objection to the practice is obvious, in the fact that the source of the 
 haemorrhage is not so much in the curling arteries as in the venous 
 sinuses, so that aortic compression cannot be supposed to exercise a 
 very decided effect. But there is, moreover, another objection which 
 has been urged, viz., that it is scarcely possible to compress the aorta, 
 without at the same time subjecting the vena cava to more or less 
 pressure, so that directions have been given whereby the pressure is to 
 be directed to the left side of the vertebras, in order to avoid the vena 
 cava. Cazeaux believes that the result of such compression of the vena 
 cava should be looked upon as rather a favorable condition than other- 
 wise; and we are certainly inclined to agree with him in thinking that, 
 in the worst cases, the volume of blood can only be accounted for by 
 supposing that it proceeds, by regurgitation, from the great venous 
 trunks. Two methods of compression of the aorta have been recom- 
 mended ; in the one, the vessel is compressed through the abdominal 
 walls, and in the other the hand is passed into the uterus, and the 
 vessel closed — as is assumed, more effectually — by pressure through 
 the posterior uterine wall. While it must be confessed that the results 
 of this procedure have not been such as to encourage us to look upon 
 it wjth anything like confidence, there still seems to be in it a ray of 
 hope, to which, w T hen all else may have failed us, we cannot close our 
 eyes. By all means, therefore, let aortic compression be tried. There 
 is certainly no evidence upon which we can rely, that the practice has 
 ever been productive of harm, while many believe that it, at least, 
 arrests temporarily the rapid downward tendency which is so charac- 
 teristic of a considerable proportion of such cases. 
 
 The application, not of astringents merely, but of powerful Styptics, 
 to the inner surface of the uterus, is a mode of treatment which has, 
 during the last few years, attracted considerable attention in this coun- 
 try. The procedure is not a new one, and even as regards the styptic 
 salts of iron, which are, undoubtedly, the best, they were originally 
 used by D'Outrepont, and also by Kiwisch, who, upwards of twenty- 
 five years ago, strongly supported this method of treatment. The 
 action of such powerful agents is looked upon by most practitioners 
 with considerable apprehension, and that it is so, is not, perhaps, to be 
 wondered at. Nothing is more unjustifiable than such a procedure, 
 unless, in the first instance, other means have been tried, and have 
 failed to arrest the flow of blood ; but in the presence of a great danger 
 and instant peril, the objections to the application of styptics have less 
 force. We do not wish in any way to undervalue these objections; 
 but even admitting their validity, and viewing the operation in the 
 light of a desperate remedy, the facts which are given by Kiwisch, and 
 recently, in this country, by Dr. Barnes, are such as to afford us much 
 
414 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 encouragement, and warrant us, in cases of emergency, in availing 
 ourselves of this method of treatment. 
 
 It is proper, however, to notice here the dangers which may arise 
 from the injection of perchloride of iron, which have been very fairly 
 put by Dr. Barnes, who is the chief supporter in this country of the 
 bold employment of the more powerful styptics. The perchloride 
 produces immediate coagulation of any blood with which it may be 
 brought in contact, but the danger to be dreaded is, that such coagula- 
 tion might extend further ; and, should coagula be carried to the centre 
 of circulation, death would be the probable, if not the inevitable, result. 
 Immediate death has followed the injection of even a few minims into 
 a nsevus, and in one such case which is quoted by Dr. Barnes, " ex- 
 amination showed that the point of the syringe had penetrated the 
 transverse facial vein, and that the blood in the right cavity of the 
 heart had been immediately coagulated." Several cases have occurred 
 on the Continent, and at least one in England, in which an injection 
 of the perchloride has resulted in death by peritonitis, caused by the 
 passage of a portion of the injection through the Fallopian tube. It is 
 not to be forgotten that a similar result has followed the injection of 
 fluids which are comparatively innocuous; but the possibility of such 
 a result must, under no circumstances, be lost sight of. Forcible in- 
 jection of the uterine cavity should never be attempted. Were it 
 possible thoroughly to sponge the inner surface of the uterus in an 
 efficient manner, this, no doubt would be preferable; but, as it would 
 be all but impossible thus to bring the styptic solution into actual 
 contact with the bleeding surface, some other means must be adopted. 
 We are ignorant, it must be remembered, of the extent, or even the 
 exact site of the surface from which the blood flows ; and, moreover, 
 the cavity is so occupied with fluid and clotted blood, that we could 
 not hope, by any mere process of sponging the actual surface of the 
 mucous membrane, effectually to reach it. It would be necessary there- 
 fore, as a preliminary measure, to wash out the uterus. Dr. Barnes 
 says, however, that the conditions inseparable from a recent delivery, 
 are a relaxed and patent condition of the os, which would readily admit 
 of an escape into the vagina of any fluid injected in excess, so that the 
 conditions are, in all respects, different from what has obtained inmost 
 of the fatal instances recorded where injection has been practiced in an 
 unimpregnated, and sometimes in a displaced, uterus. 
 
 The following is the course recommended by Dr. Barnes: "You 
 have the Higginson's syringe adapted with an uterine tube eight or 
 nine inches long. Into a deep basin or shallow jug, pour a mixture of 
 four ounces of the Liquor Ferri Perch loridi Fortior of the British Phar- 
 macopoeia, and twelve ounces of water. The suction-tube of the syringe 
 should reach to the bottom of the vessel. Pump through the delivery- 
 tube two or three times to expel air, and insure the filling of the appa- 
 ratus with the fluid before passing the uterine tube into the uterus. 
 This, guided by the fingers of the left hand in the os uteri, should be 
 passed up to the fundus. The injection should then be effected slowly 
 and steadily, when you will find the fluid come back into the vagina 
 mixed with coagula caused by the action of the fluid. The haemostatic 
 
XXIV.] TRANSFUSION. 415 
 
 effect of the iron is produced in three ways : first, there is its direct 
 action in coagulating the blood in the mouths of the vessels ; secondly, 
 it acts as a poAverful astringent on the inner membrane of the uterus, 
 strongly corrugating the surface, and thus constringing the mouths of 
 the vessels ; thirdly, it often provokes some amount of contractile ac- 
 tion of the muscular wall.' 7 All facts hitherto recorded seem to show, 
 that we have in this an almost certain means of arresting uterine haemor- 
 rhage, and Dr. Barnes insists that we should not defer its application 
 too long, but resort to it without hesitation so soon as the ordinary 
 means have received a fair trial. To wait until the vital powers are 
 all but exhausted is certainly not giving the measure fair play ; but 
 we apprehend we would only be justified in having recourse to such a 
 procedure after the inefficacy of the other means has been thoroughly 
 proved. 
 
 [While there is no reason to doubt the efficiency of intra-uterine 
 injections of the salts of iron in post-partum haemorrhage, and while 
 the editor has seen the undiluted solution of the subsulphate used with- 
 out any bad results, it cannot be denied that death has followed as a 
 consequence of this method of treatment. For this reason Professor 
 J. D. Trask, of Astoria, Long Island, in a paper published in the 
 American Journal of Obstetrics for February, 1875, proposes to resort 
 to intra-uterine injections of iodine, a measure originally proposed by 
 M. Dupierris, of Havana, Cuba. M. Dupierris used half an ounce of 
 the tincture of iodine diluted with an ounce of water. The condition of 
 one of the patients whose history is related was certainly desperate, but 
 the injection arrested the haemorrhage, and she finally recovered. — P.] 
 
 In the course of any treatment which may be adopted, the general 
 condition of the patient must of course receive earnest and continuous 
 attention. The tendency to syncope must be combated by free stimu- 
 lation by brandy, or by brandy and opium in combination, upon which, 
 we confess, we place even more reliance. The frequently repeated ob- 
 jection to opium in such cases is, that it is an agent which arrests uterine 
 action, and therefore should be avoided when our object is exactly the 
 contrary of this. And the objection holds good in so far as very large 
 doses of opium are concerned; but if the dose be a moderate one, and 
 combined with brandy or some other stimulant, it will always be 
 found, if it acts at all, to act in a beneficial manner by rallying the 
 patient from collapse, and either thus indirectly, or, it may be, by a 
 more direct action, exciting the uterus to contract. The patient should 
 always be placed upon her back with the pelvis high and the head low. 
 The object of this is, not only to take advantage as far as is possible 
 of the law of gravity as a haemostatic, but also to prevent that lateral 
 bagging which is apt to take place in a relaxed uterus in the ordinary 
 obstetrical position. Perfect rest and the recumbent posture are essen- 
 tial, not only at the time of the haemorrhage, but for a considerable 
 period thereafter. All danger does not cease with the arrestment of 
 haemorrhage, or even with uterine contraction ; so that all these meas- 
 ures must be insisted upon as safeguards against the recurrence of the 
 peril with which the patient has been menaced. If it be a rule never 
 to leave a patient, even after natural labor, without satisfying ourselves 
 
416 HEMORRHAGE AFTER DELIVERY. [CHAP. 
 
 of the state of the uterus, how much more important must it be to 
 watch the case in which haemorrhage has already caused us anxiety, 
 and in which there is always a tendency to its return. Flooding may, 
 in some instances, only become alarming when some time has elapsed 
 after delivery ; but in most of them it will be found to be due to the 
 retention within the womb of a portion of the placenta or membranes, 
 or of clots which have prevented the thorough closure of the cavity. 
 
 The tendency to syncope should, in all cases, be combated as far as 
 is in our power ; nor, in a condition of great depression, should the 
 patient be permitted to yield to the drowsiness which overtakes her, 
 as this may prove as fatal as that which is the result of exposure to 
 intense cold. The period of convalescence after severe haemorrhage is 
 one which may require great care and management. There is, above 
 all, a tendency to reaction, which may manifest itself in the form of 
 precordial oppression, severe headache, and throbbing of the carotids, 
 which injudicious treatment, either by alcoholic stimuli or improper 
 articles of diet, may increase to symptoms more serious still. The 
 bulk of the blood which has been removed must be replaced gradually, 
 and with caution; and although the tolerance of stimulants is, during 
 the haemorrhage and in presence of the symptoms of collapse, some- 
 times truly marvellous — when brandy seems to produce no more effect 
 on the brain than as much pure water — it is quite otherwise when the 
 immediate danger has passed and the patient begins to rally. When 
 the symptoms which indicate reaction subside, it may be necessary to 
 persevere, by means of generous diet, old wine, and tonics, for many 
 weeks, or even months, before the system recovers from the fearful 
 state of depression into which it has been thrown. 
 
 There are cases in which the arrest of haemorrhage, although com- 
 plete, seems to have come too late, the recuperative forces of nature 
 having been too seriously compromised. There remains in these cases 
 a state of utter prostration in which there seems to be no tendency to 
 rally, an irritable stomach, a continued tendency to syncope, and an 
 apparent arrestment even of the function of assimilation. Such a state 
 of matters can only terminate in one way, unless we can induce a rally, 
 and the feeble hold which the patient has on life is gradually, but too 
 surely relaxed. These are the cases in which, however desperate the 
 circumstances, the operation of transfusion has succeeded, and we hope 
 may often again succeed in rescuing the woman from the very jaws of 
 death. This operation may be performed in various ways. The simplest 
 process is that of immediate transfusion by some such simple apparatus 
 as has been recommended by Dr. Aveling. 1 This is described as con- 
 sisting " of two small silver tubes, to enter the vessels, and of an india- 
 rubber tube by which they are united, and which has in its centre an 
 elastic receptacle, holding about two drachms. It is without valves, 
 and is simply a continuous pipe with an expanded portion in the 
 middle. By its means, the vessels are, as it were, extended from one 
 to the other, and a supplementary heart is added to regulate the cir- 
 culation." Air is got rid of by first pumping water or a saline solu- 
 
 Obstetrical Transactions, vol. vi, p. 133, 18G5. 
 
XXIV.] 
 
 TRANSFUSION. 
 
 417 
 
 tion through it, and then seeing that it is quite full of blood before the 
 tube is inserted into the recipient vein. 
 
 In what has been called, in contradistinction from the other, the 
 mediate process, the blood is first received in a vessel, in which it is 
 
 Fig. 132. 
 
 Dr. Avcling's apparatus for transfusion. 
 
 kept at the proper temperature, and it is thence injected by means of a 
 syringe, different varieties of which have been devised by Drs. Little, 
 Richardson, and Graily Hewitt. In addition to the difficulty which 
 attends the exclusion of air, another and no less formidable one con- 
 sists in the tendency of the blood to rapid coagulation. It has been 
 attempted, with the view of obviating the latter, to inject the defibri- 
 nated blood only, the blood being received in an open vessel, rapidly 
 stirred so as to promote coagulation, and then filtered. In a considera- 
 ble number of cases, this process has been attended with successful 
 results, sufficient at least to prove that the presence of fibrin is not 
 essential ; but the preponderance of professional opinion is decidedly 
 in favor of the " immediate" process. It has been proposed by Dr. 
 Richardson, as a corollary to certain well-known experiments and con- 
 clusions of his, to prevent coagulation by the mixture with the pure 
 blood of ammonia in the proportion of three drops to each ounce; and 
 with the same object in view, Dr. Braxton Hicks has used the phos- 
 phate of soda. Some, arguing from the effects which have been known 
 to follow the injection of a simple saline solution into the blood in the 
 collapse of cholera, have advocated a similar mode of procedure in 
 hemorrhagic collapse. The quantity to be introduced is much greater 
 than when blood is used, and the following is the formula for the 
 preparation of a solution which has been used by Dr. Little : 
 
 Chloride of Sodium, 60 grains. 
 
 Chloride of Potassium, ...... 6 " 
 
 Phosphate of Soda, R " 
 
 Carbonate of Soda, . . . . . . . 20 " 
 
 Distilled Water, . 20 ounces. 
 
 Perhaps the simple apparatus and process of Dr. Aveling is the best 
 for ordinary purposes which has hitherto been devised, and from its 
 
 27 
 
418 INVERSION OF THE UTERUS. [CHAP. 
 
 simplicity of construction, it may be used by any one possessed of 
 moderate dexterity. The operation has not been confined to cases of 
 post-partum haemorrhage, but has also been employed in placenta 
 previa, when the patient was too prostrated to survive delivery unless 
 previously rallied. The successful performance of transfusion may, 
 although followed by a rally, be again succeeded by renewed flagging 
 of the circulation, and a recurrence of the original symptoms. In this 
 case, it would be quite proper to repeat the injection. Professional 
 attention has of late years been so thoroughly awakened to the im- 
 portance of this procedure, that there exists in the minds of many 
 experienced practitioners a strong hope, and some confidence, that 
 obstetric mortality may in this way be in some measure reduced. 
 
 CHAPTER XXV. 
 
 INVERSION OF THE UTERUS. 
 
 VARIETIES OF INVERSION:' THREE STAGES OF THE ORDINARY VARIETY — INVER- 
 SION OF THE UNIMPREGNATED UTERUS — INVERSION USUALLY OCCURS DURING 
 THE THIRD STAGE OF LABOR — CAUSES: DRAGGING UPON THE CORD: SHORT- 
 NESS OF THE CORD: IRREGULAR CONTRACTION OF THE UTERUS — CONNECTION 
 OF THIS ACCIDENT WITH HOUR-GLASS CONTRACTION — EFFECTS OF PARALYSIS 
 OF THE FUNDUS — MECHANISM OF THE DISPLACEMENT — SYMPTOMS: PECULIAR 
 VIOLENCE OF THE SHOCK: HAEMORRHAGE: ABSENCE OF TUMOR IN HYPOGAS- 
 TRIUM — TO BE DISTINGUISHED FROM A FIBROUS POLYPUS — SENSIBILITY AND 
 OCCASIONAL CONTRACTILITY OF THE TUMOR — MODES OF PROVING THE ABSENCE 
 OF THE UTERUS FROM ITS NORMAL SITUATION — RECURRENCE OF HAEMORRHAGE 
 IN CHRONIC INVERSION — TREATMENT: ORDINARY METHOD OF REPLACEMENT : 
 MANAGEMENT OF THE PLACENTA IF STILL ADHERENT : MANAGEMENT OF MORE 
 DIFFICULT CASES : COMPRESSION OF TUMOR : DEPAUL'S INSTRUMENT— CHRONIC 
 INVERSION: MONTGOMERY'S METHOD OF REPOSITION: CONSTRICTION OF THE 
 OS MUST BE OVERCOME: EFFECTS OF SUSTAINED ELASTIC PRESSURE — DIVISION 
 OF THE stricture: REMOVAL BY THE ECRASEUR. 
 
 Inversion of the Womb has already been referred to in the pre- 
 ceding chapter as one of the causes of haemorrhage after delivery. 
 There are, in addition to this, other circumstances, of no less impor- 
 tance, which render the subject one demanding, at our hands, special 
 and careful consideration. Although the accident is by no means of 
 frequent occurrence, it is not to be supposed that, on that account, it is 
 to be treated as one of minor consequence. On the contrary, it in- 
 volves so many practical questions, and is, moreover, a subject in 
 regard to which so much misapprehension has existed, and still exists, 
 that it is necessary to devote somewhat more of space to its considera- 
 tion than its importance might, in the first instance, seem to warrant. 
 
 The idea essentially involved in the term " Inversion of the Womb" 
 
XXV.] 
 
 VARIETIES OF INVERSION. 
 
 419 
 
 Fig. 133. 
 
 is an abnormal condition of that organ, in which, in extreme cases, the 
 whole organ is turned inside out. As has already been remarked, such 
 a displacement, must, in becoming complete, pass through a variety of 
 stages ; and as, at any one of these stages, the 
 inversion may be arrested, it is possible to 
 imagine an almost infinite number of varieties 
 of inversion. We shall, however, only men- 
 tion four. Of these, the first is not generally 
 described, but is said by Dr. Matthews Dun- 
 can to be " not rarely observed after delivery." 
 The condition of the parts is as shown in this 
 diagram (Fig. 133), and consists, therefore, in 
 an inversion of the inferior segment of the 
 uterus only. This variety, although, proba- 
 bly, not uncommon, is of no great practical 
 importance, as it will rectify itself without 
 assistance. It is otherwise with the three 
 varieties which are figured diagrammatically 
 in Figs. 134, 135, 136. All these are, as 
 will be observed at a glance, merely stages in 
 the progress of the same accident, which is 
 
 the true Inversio Uteri of authors, and which differs from the other 
 and less important variety, in commencing at the fundus. It is quite 
 possible that the variety represented in Fig. 133 might, as in the other 
 case, terminate in complete inversion ; but the experience of all goes 
 to show that the ordinary course is — first, one of Depression of the 
 Fundus (Fig. 134); second, one of Partial (Fig. 135); and, third, one 
 
 Partial inversion. (After 
 Matthews Duncan.) 
 
 Fig. 134. 
 
 Fig. 135, 
 
 Fig. 136. 
 
 Successive stages of inversio uteri. 
 
 of Complete Inversion (Fig. 136). In a stage more advanced still, 
 the inverted womb may protrude from the vulva, — a condition which 
 necessarily involves at least partial inversion of the vagina, which is 
 dragged down by the womb. 
 
 Although essentially one of the accidents of midwifery practice and 
 usually occurring in the course of delivery, there are cases in which 
 the uterus becomes inverted independently of the pregnant state. Most 
 
420 INVERSION OF THE UTERUS. [CHAP. 
 
 of those are instances in which there is either a polypus within the 
 cavity, or a fibroid growth in the walls of the uterus, which, by acting 
 in a manner as foreign bodies, excite the organ to contractile and ex- 
 pulsive action, terminating in inversion. It is a disputed point, 
 whether inversion of the normal and unimpregnated uterus is, in any 
 other circumstances, possible. On this point Dr. West says, " Inver- 
 sion of the uterus, the turning of the organ inside out, is an accident 
 clearly impossible in the natural condition of the unimpregnated 
 woman, — it being obviously essential for its occurrence that the organ 
 should have attained a certain size, and that its walls should be com- 
 paratively yielding." This opinion is adopted by Matthews Duncan 
 and others; but Dr. Tyler Smith believes, on the other hand, that the 
 unimpregnated uterus may invert itself, under the influence of irregu- 
 lar contraction. We are not aware that any case has been recorded in 
 which the evidence of inversion, under such circumstances, is not open 
 to doubt, more or less strong. At the same time, we must confess that 
 we agree with Tyler Smith's conclusion. It is certainly true, as he 
 says, "that the unimpregnated and virgin uterus, particularly under 
 irritation, possesses more motor power than is generally attributed to 
 it ;" and we can see no physiological reason which can warrant us in 
 assuming such an inversion to be impossible. Many years ago, we 
 had occasion to assist at the post-mortem examination of a young 
 woman who had died of fever, and who had suffered previously to her 
 death from severe flooding. The uterus was found completely in- 
 verted, and of very little, if any, greater size than the normal unim- 
 pregnated standard. There was neither polypus nor fibroid growth. 
 This case corroborates strongly the assertion of Tyler Smith, and, at 
 least, proves that previous enlargement of the organ, and a yielding 
 condition of its walls, are not, as West supposed, essential. There 
 cannot be the slightest doubt that the presence of a polypus, or of any- 
 thing else, within the cavity of the uterus, must so far encourage inver- 
 sion, both mechanically and physiologically. In the above case, there 
 may have been a clot ; but, whether or no, it, and other cases of an 
 allied nature, seem to show that inversion of the unimpregnated uterus, 
 independent of polypus, or any other similar condition, may occur. 
 
 Causes. — The occurrence of uterine inversion, coincident, as is to be 
 feared, very frequently, with the practice of dragging upon the cord 
 after the termination of the second stage of labor, has led not unnat- 
 urally to a prevalent belief that this was the usual cause of the acci- 
 dent in question ; and it has also been supposed to be due, in some 
 instances, to spontaneous dragging by a funis which is either too short, 
 or has been rendered so by twisting round some part of the child. 
 According to these ideas, the uterus must be looked upon as a passive 
 agent, the fundus or site of placental attachment being mechanically 
 displaced in a direction downwards, and ultimately through the os and 
 into the vagina. That a certain number of cases are thus produced, 
 most observers will probably admit; but the conclusion arrived at by 
 all who have paid, in recent times, most attention to the subject, is, 
 that the importance of this, as a cause, has been in every way exagge- 
 rated. A strong pull at the cord, while the uterus is in a state of 
 
XXV.] CAUSES. 421 
 
 flaccidity or complete atony, may doubtless — and especially if the pla- 
 centa be morbidly attached — at once turn the organ inside out. In- 
 deed, if such flaccidity were the normal condition of this stage, it would 
 be a matter of wonder that the accident should not invariably accom- 
 pany every effort in this direction, did we not observe that nature here 
 interposes her authority, and effectually guards the woman, as we shall 
 see, from the effects of operative mismanagement. Nothing, as a mo- 
 ment's reflection will show, is so certain, so effectual a safeguard 
 against inversion, as regular and symmetrical contraction of the whole 
 uterus. It is fortunate, therefore, that a very usual effect produced by 
 pulling upon the cord is a contractile action of this nature, by which, 
 for the time being, depression or introcession of any part of its walls is 
 rendered impossible. Be it observed, however, that this observation 
 applies to regular contraction only. 
 
 The uterus does not, in every instance, follow the method of regular 
 contraction. On the contrary, it not unfrequently is the seat of irregu- 
 lar contractions, which affect certain portions only of the walls, while 
 other parts are left in a temporary condition of relaxation or atony. 
 One form of this has already been mentioned as a cause of retention of 
 the placenta by what is familiarly known as " hour-glass" contraction 
 of the uterus, and otherwise as " encysted placenta." It would seem 
 as if, in the opinion of many, this was the only form of irregular uterine 
 contraction, whereas there can be little doubt that an infinite variety of 
 such irregularities may exist. It is, in fact, among such abnormal 
 conditions that the true cause of ordinary cases of inversion is to be 
 sought. Many of the older writers recognized the presence of such 
 contractions as we now allude to; and one of the earliest observations 
 in this direction was, that a frequent site of this localized inertia is that 
 portion of the uterus upon which the placenta happens to be implanted. 
 The important bearing w T hich this has upon the cause and mechanism 
 of hour-glass contraction was clearly pointed out by Levret, although 
 altogether overlooked by many subsequent writers. "The neck of the 
 uterus/' says Madame Lachapelle, "is often inert, although the fundus 
 is contracted ; sometimes the reverse happens, and it is then that the 
 placenta, inclosed in the uterus, appears to be encysted in it." As the 
 nature of these and other abnormal conditions of contraction is more 
 exactly ascertained, the relation which they bear to inversion of the 
 uterus comes into view. All modern observers agree in the observa- 
 tion that a local uterine paralysis, involving, as a matter of course, 
 more or less irregular contraction, occurs more frequently at or near 
 the site of the placenta than in any other part of the uterus. As this 
 is the part which, by its introcession or depression towards the centre 
 of the uterine cavity, forms the first stage of inversion, the coincidence 
 of the displacement with the site of local paralysis has drawn special at- 
 tention to the fact. Rokitansky, in his work on Pathological Anatomy, 
 says on this point : " We must here mention a very singular circum- 
 stance, which may, on account of the consequent danger, become im- 
 portant, and may even be misunderstood in post-mortem examinations; 
 it is paralysis of the placental portion of the uterus, occurring at the 
 same time that the surrounding parts go through the ordinary processes 
 
422 INVERSION OF THE UTERUS. [CHAP. 
 
 of reduction. It induces a very peculiar appearance. The part which 
 gave attachment to the placenta is forced into the cavity of the uterus 
 by the contraction of the surrounding tissue, so as to project in the shape 
 of a conical tumor, and a slight indentation is noticed at the correspond- 
 ing point of the external uterine surface." Whether the words which 
 we have placed in italics represent or not the real cause of the first stage 
 of displacement is a question not as yet definitely settled. Matthews 
 Duncan, in his essay on this subject, maintains that the uterus cannot 
 itself effect introcession, and that it must, on that account, in every 
 instance, be commenced by a force external to the uterus. In the case 
 of dragging upon the cord, we have a force of this kind acting from 
 below 7 ; and, as regards spontaneous inversion, he assumes that we have 
 a cause of a similar nature acting from above in the mechanical condi- 
 tions of the abdomen, which are called into play, and which take the 
 effective form of what is familiarly known as " bearing-down" effort. 
 
 Whatever may be the view entertained, as to the initiatory process 
 by which spontaneous uterine inversion is effected, numerous authentic 
 facts attest that such an occurrence takes place by the operation of 
 causes which may be at once abnornal and spontaneous. So soon as 
 the stage of depression has been established, as represented in Fig. 134, 
 the further progress of the case admits of easy explanation. The 
 analogy which at this stage exists between inversion and an ordinary 
 case of " hour-glass" contraction has not failed to attract the attention 
 of many of the more eminent writers on this subject. In both, we find 
 the region of the fundus in an abnormal condition of atony, but the 
 parts below are in a state of more or less efficient contraction. A 
 stimulus to sustained and active contraction is afforded by the presence 
 within the cavity of a tumor. " The annular contraction of the body 
 of the uterus grasps," says Tyler Smith, " the introcedent fundus as it 
 would a foreign body, and carries it downwards for expulsion through 
 the os uteri, the os itself being at this time either in a state of inertia, 
 or actively dilated, just as at the end of the second stage of labor. After 
 the inverted uterus has passed through the dilated os uteri, this part 
 of the organ becomes contracted, preventing reinversion from taking 
 place. Thus there is, first, the depression of the fundus uteri, with 
 annular or hour-glass contraction of the body of the uterus, and dilata- 
 tion of the os uteri. Next, there is intussusception of the fundus by 
 the body of the uterus. Lastly, complete inversion occurs, with con- 
 traction of the os uteri upon the inverted organ. If we wished to 
 describe this action in three words, they would be — introcession — intus- 
 susception — inversion" (see Figs. 135, 136). 
 
 It must not be supposed that, by thus supporting the doctrine of 
 spontaneous inversion, the production of the accident by artificial or 
 violent causes is ignored; still less, that any support is given by impli- 
 cation to the improper practice of pulling upon the cord with the view 
 of effecting separation of the placenta. It will be inferred from what 
 has already been said, that there are two classes of cases, in one of 
 /which the uterus is completely, and in the other partially paralyzed. 
 Inertia, therefore, in some form or another, is an essential concomitant 
 of all cases of inversion. In complete atony of the organ, uterine 
 
XXV.] SYMPTOMS. 423 
 
 activity can take no part in the displacement, although bearing down 
 or abdominal effort may ; but, in the other variety, where, as has been 
 shown, local paralysis has its usual seat about the fundus, uterine effort 
 is the efficient cause in all cases of spontaneous inversion, and in those 
 in which the displacement is artificially produced, there is every reason 
 to believe that there must be, so to speak, a consenting action on the 
 part of the uterus, which then acts in unison with the force which is 
 applied. If any further evidence were held to be necessary to establish 
 the fact of such an occurrence, it is to be found in the instances which 
 have been put on record of post-mortem inversion, which can only thus 
 be satisfactorily explained. 
 
 Symptoms. — Inversion generally takes place shortly after the birth 
 of the child, and before the placenta has been expelled. The patient 
 being thus under the immediate observation of the accoucheur at the 
 moment of the occurrence of the accident, the first symptom which will 
 in all probability attract his attention is a condition indicating shock, 
 out of all proportion to the circumstances even of a lingering or exhaust- 
 ing labor. The violence of the shock, and the disturbance of the 
 nervous system which accompanies it, bear no relation to the degree of 
 the inversion. We would naturally expect that, in the stage of depres- 
 sion or introcession, the symptoms would not be so severe as in the 
 more advanced stages ; but in respect of these latter, it has been ob- 
 served that the amount of shock attendant upon intussusception and 
 complete inversion is as great in the one case as in the other. The 
 degree of constitutional disturbance depends, however, in a great meas- 
 ure, upon the amount of haemorrhage, and this again upon the extent to 
 which the placenta has become separated. In all cases in which com- 
 plete separation of the placenta may have occurred, the haemorrhage is 
 alarming, and may be so severe as to place the life of the patient within 
 a few minutes in most imminent peril. But if the contraction of the 
 cervix is firm, it may be by this in some measure controlled. 
 
 The occurrence of such symptoms is accompanied by an unusual 
 condition of parts, as examined through the abdominal walls. In the 
 stage of depression we may feel the outline of the uterus, but it is no 
 longer a spheroid, for its centre presents a cuplike depression which 
 can be distinctly felt by the fingers. In the more advanced stage, 
 however, the hard tumor which the uterus should in normal circum- 
 stances form behind the pubes is absent, nor is there in its place any 
 such condition of general tumidity as might indicate a flaccid organ 
 distended with blood. The uterus has, in fact, passed beyond the reach 
 of the finders in this direction. If we now make a vaginal examina- 
 tion, the nature of the case is at once revealed. A firm rounded tumor 
 is here felt, which may also protrude externally. If to this the placenta 
 is still partially or entirely adherent, there is of course no possibility 
 of error, but when the placenta has become separated, no inconsiderable 
 perplexity and difficulty may arise. 
 
 The distinction between a fibroid polypus and a partial inversion has 
 already been alluded to under the head of post-partum haemorrhage. 
 In addition to what was then remarked, we need only observe here 
 that, in some cases, the sense of touch affords little reliable information, 
 
424 INVERSION OF THE UTERUS. [CHAP. 
 
 as there is in this respect such variety in the texture both of polypi and 
 inverted uteri, that the most skilled observer could scarcely by this 
 alone distinguish between the two. The really important point in 
 diagnosis is this, that polypi, owing to the narrowness and length of 
 the pedicle, can generally be moved much more freely, and may be 
 twisted to a greater extent on their long axis without giving rise to any 
 particular pain. Any attempt which may, on the other hand, be made 
 to twist the tumor which is formed by an inverted uterus, is attended 
 with considerable pain, and can, moreover, be effected only within the 
 narrowest limits. If there is any inherent contractility in the tumor, 
 this at once shows that it is the uterus. If the inversion is complete, 
 the continuity of the vagina with the lateral walls of the tumor enables 
 us by the finger to recognize the nature of the case; but when the 
 intussuscepted fundus is tightly grasped by the os and its diameter at 
 this point thereby reduced, the resemblance to a fibroid polypus is 
 greatest, and it is here that the tests of immobility and sensibility may 
 be most usefully applied. The nature of the case may be still more 
 conclusively demonstrated by such modes of examination as may prove 
 the absence of the uterus from its normal situation. On this point, 
 Barnes recommends that we should pass one or two fingers into the 
 vagina to the root of the tumor, and then press down the fingers of the 
 other hand behind the symphysis. If in doing this we can make the 
 fingers meet, and feel from the outside the funnel of the inverted uterus, 
 our diagnosis will be confirmed. Or, again, we may pass a finger into 
 the rectum so as to get its point above the root of the tumor, and then 
 pass a sound into the bladder, with its point turned backwards, so 
 as to meet the finger in the rectum, which, if it can be effected, will 
 equally show that the uterus is absent from its usual situation, and 
 consequently, by inference, that the tumor in the vagina is the uterus. 
 
 Simple prolapsus or procidentia, when occurring immediately after 
 labor, may also be mistaken on a careless or cursory examination for 
 inversion, but more careful observation will at once in such cases dis- 
 close the real nature of the case, as soon as the depression correspond- 
 ing to the os and the orifice itself is recognized in the centre of the pro- 
 jecting tumor. 
 
 The symptoms above enumerated are those of an ordinary case of 
 uterine inversion incurring in the course of labor, and do not of course, 
 apply in all respects to the other and rarer varieties. Assuming it for 
 the moment as proved, that inversion of the unimpregnated organ is a 
 possible occurrence, it is undoubtedly so rare that little or nothing 
 can be said as to its symptoms; but we may assume that haemorrhage, 
 pain, and nervous shock will be among them, and that the diagnosis 
 may be unusually difficult. There may be cases again, in which the 
 presence of a polypus is established, and yet inversion may occur, the 
 two conditions thus coexisting, although the former has in all proba- 
 bility been the direct cause of the latter. There are yet other instances 
 in which inversion may succeed delivery, and yet not follow so closely 
 upon it as under ordinary circumstances it does. Possibly, in such the 
 initiatory stage of depression has alone been produced during labor, and 
 this again has been transformed into one or other of the more advanced 
 
XXV.] TREATMENT. 425 
 
 stages by irregular contractions, or modifications of what are known as 
 after-pains. It would appear as if occasionally the symptoms, at the 
 time of the inversion, were not so marked as usual ; for there can be 
 no doubt that the accident has sometimes been altogether overlooked 
 at the time of labor, and only discovered long after. When the woman 
 recovers from the immediate effects of inversion, she may regain her 
 health and strength as if nothing ailed her, and be able to follow her 
 ordinary avocations. But, in such cases, the original symptom of 
 haemorrhage will, sooner or later, return, and, by its periodic recur- 
 rence — corresponding often, as might be anticipated, to catamenial 
 periods — saps the strength and undermines the health of the patient. 
 These constitute cases of Chronic Inversion. 
 
 Treatment. — Whatever the stage may be at which inversion of the 
 uterus is recognized, our duty is to reduce the dislocation of the fundus 
 without unnecessary delay. If we were fortunate enough to discover 
 what has happened immediately, there would probably be but little 
 difficulty in effecting the reposition, as we would then find the os in a 
 state of relaxation. This period is, however, of brief duration, and is* 
 followed by contraction of the os, which grasps the organ firmly, and 
 in this way adds very greatly to the difficulty of the operation. 
 
 If the placenta is still adherent, it is a question whether we should 
 at once separate it. The advantage of the procedure is, that the fundus 
 will undoubtedly be more easily reduced than when its bulk is increased 
 by the presence in its immediate neighborhood of the mass of the pla- 
 centa ; while, on the other hand, the obvious disadvantage of separa- 
 tion is to encourage haemorrhage by rupturing the utcro-placental 
 vessels. Both methods of treatment have been adopted, but it is cer- 
 tain that neither of them can be held as appropriate to all cases. Re- 
 position along with the placenta is, in fact, only applicable to those 
 cases in which the os is relaxed, and is all but impracticable in the 
 other class of cases, where we may find it difficult enough to return the 
 fundus alone through the stricture formed by the os. Practically, the 
 question may be said to stand thus : return the placenta if you can, or 
 attempt to return it, if you can see a reasonable prospect of doing so 
 without the exercise of undue force ; otherwise, separate the placenta 
 at once, and do not waste time which may be of inestimable value in 
 the interests of your patient. To remove the placenta from its attach- 
 ments, insert the finger beneath the edge, and gradually strip it from 
 the entire surface to which it is adherent. The diminished size, and 
 at least partially contracted condition of the uterus, lessen to a con- 
 siderable extent the danger which we would naturally anticipate from 
 haemorrhage ; but the risk is still sufficient to render it imperative 
 that we should make no delay at this stage, but proceed at once to the 
 reduction. 
 
 The method which is usually recommended is to bring the points of 
 the fingers together, and to apply the apex of the cone thus formed 
 firmly to the centre of the displaced fundus, which is by this means to 
 be steadily pushed upwards in the axis of the pelvis, so as to carry the 
 fundus through the ring formed by the contracted os. Due caution 
 must, of course, be exercised in regard to the amount of force which is 
 
426 INVERSION OF THE UTERUS. [CHAP. 
 
 employed, as it is possible by violence to inflict very considerable injury 
 upon the uterine tissue. So soon as the fundus passes through the os 
 in the process of rein version, it must be followed upwards by the 
 finger, to render the operation complete. While this is being effected, 
 the organ is to be steadied, as far as is practicable, by the hand which is 
 placed upon the abdomen, and the operator must, in addition to this, 
 be careful to direct the force to one side or other, so as to avoid the 
 sacral promontory. 
 
 When a certain time, even a single hour, has elapsed since the dis- 
 placement has taken place, the difficulties of the operation may be 
 considerably increased ; and when this has extended to days, it will 
 naturally become more difficult still. The effect of the strangulation 
 of the neck of ihe tumor is to cause general tumefaction of the parts 
 beneath, so that it will often be necessary to compress the organ from 
 side to side, in order to curtail its dimensions in that direction before 
 attempting actual reduction. By this manoeuvre a difficulty, which 
 may at first seem insuperable, will sometimes be overcome. By the 
 ordinary procedure, by means of the fingers, the reposition of the uterus 
 has been found by some operators to be so difficult that instruments 
 have been used which, being of less bulk, are presumed to offer certain 
 mechanical advantages. Of such a nature is the baton repoussoir of 
 Depaul ; but to this it may fairly be objected that the gain is probably 
 more than counterbalanced by increased risk ; and it must be confessed, 
 in this, as in many other operations in midwifery, that the more expe- 
 rienced and skilful the accoucheur, the more does he prefer his fingers 
 to mechanical aids, however ingenious. 
 
 When the fundus has passed to a certain distance within the os, it 
 has very frequently been observed that the same muscular action of the 
 uterus which originally contributed to the dislocation of the organ now 
 comes into play as an auxiliary to reposition, and it is not uncommonly 
 observed that the ultimate complete restitution of the fundus is effected 
 by a sudden jerk or snap, which is often quite audible to the bystanders. 
 In those instances, however, in which inertia of the organ is persistent, 
 it will be necessary to pass the hand quite within the cavity, until we 
 are convinced that its anatomical relations are completely re-established. 
 Nor is it proper, at this moment, and at once, to withdraw the hand. 
 We should rather act here as we would do in a case of encysted pla- 
 centa, or of post-partum haemorrhage, in which the hand is introduced 
 for the removal of the uterine contents ; and it is, therefore, advisable 
 to allow it to remain in contact with the uterine walls, and to act with 
 the other hand, in concert w T ith it, through the abdominal walls, so as 
 to excite the organ to efficient and symmetrical contraction, which is a 
 safeguard both against haemorrhage and a repetition of the displace- 
 ment. 
 
 There is another class of cases, in which the difficulties are still more 
 formidable than any which have hitherto been described. It may be 
 assumed that the longer the standing of the case the more serious will 
 be the obstacles to reduction, until it reaches the condition to which 
 the name Chronic Inversion has been given. Where, it may be asked, 
 may we assume acute inversion to end and chronic inversion to begin? 
 
XXV.] CHRONIC INVERSION. 427 
 
 The only rational reply to this question with which we are acquainted, 
 is that which is given by Dr. Barnes in his recent work : " I would 
 distinguish the cases in this way : inversion is recent so long as the 
 physiological process of involution of the uterine tissues is going on. 
 When this process is complete, and the uterus has returned to its ordi- 
 nary condition, the inversion is chronic." In all cases of unusual 
 difficulty, whether recent or chronic, the process of taxis, recommended 
 by Montgomery, McClintock, and other distinguished practitioners of 
 the Irish School, may be attempted. The idea here is to regard the 
 inversion as a hernia, and to replace that part first which comes down 
 last. The neck of the tumor is to be firmly grasped, and pushed up- 
 wards, continuous pressure being thus maintained upon the contracted 
 os. If the cervix can be insinuated within the lips of the os as the 
 latter relaxes, the rest of the tumor is to be treated in a similar way, 
 until at last the fundus returns to its place in the usual sudden manner. 
 
 It was at one time generally supposed that, when a few hours had 
 been permitted to elapse, inversion might be looked upon as irreducible. 
 The results of modern practice have, however, clearly demonstrated 
 that such an idea is quite untenable; and it may now be confidently 
 asserted, that no condition short of inflammatory adhesion of the parts 
 will warrant such a conclusion, whatever the duration of the case may 
 be. The great point to be kept before us, and against which all opera- 
 tive effort is to be directed, is the contracted state of the os. However 
 hopeless, therefore, on a cursory examination, the case may seem to be, 
 we may be confident that sustained effort will, in the end, overcome the 
 resistance. But, to be effectual, it must be continuous; and we have 
 only to reflect upon the fact that Tyler Smith succeeded thus in reducing 
 an inverted uterus of ten years' standing, and that a number of cases 
 are on record of a similar kind, to encourage us, even under the most 
 unpromising circumstances, in diligent and untiring effort. 
 
 Pressure effected by means of the hand of the operator, although 
 perfectly safe, cannot be maintained for a sufficiently long period, and 
 is thus inapplicable to the class of cases which we are now considering. 
 The very obvious danger which would attend the use of any solid 
 material, has led to the employment of air or water bags, which are to 
 be introduced into the vagina, and gradually distended. This elastic 
 pressure is, when properly applied, perfectly safe, and can usually be 
 borne by the woman without much uneasiness. In Tyler Smith's case, 
 above referred to, the details of which will be found in the Medico- 
 Chirurgical Transactions for 1858, the pressure was kept up for more 
 than a week; and, in many other cases, a similar process has been 
 attended with equally satisfactory results. The mode of action in 
 these seems to be that continuous although indirect pressure is thus 
 brought to bear upon the os. At first, this is as ineffectual, or even 
 more so, than the previous efforts, which have already been made with 
 the view of effecting reduction by manual interference ; but, in the end, 
 the long-continued pressure wears out the spasm, the os yields, and 
 reinversion occurs. 
 
 In those instances in which it is said that the organ has been spon- 
 taneously restored to its normal condition, as in a case narrated by 
 
428 INVERSION OF THE UTERUS. [CHAP. 
 
 Baudelocque, it is certain that a spontaneous relaxation of the os must 
 have occurred, and it is probable that, along with this, the inverted 
 organ had been subjected to some pressure in its new situation from 
 permanent or temporary causes. The theory that a spontaneous re- 
 duction may take place in consequence of tonic contraction of the Fal- 
 lopian tubes and of the broad or round ligaments, appears to us to be 
 in the highest degree improbable. The condition, of all others, essential 
 to replacement is, we repeat, relaxation of the os. There may be cases, 
 however, in which even sustained elastic pressure may fail to effect the 
 object which we have in view, although we have every reason to believe 
 that such must be of rare occurrence. But, even under such circum- 
 stances, our resources are far from being exhausted, and various methods 
 have been adopted for overcoming the difficulty in individual cases, 
 which it would be impossible to describe here. The idea of section of 
 the constriction must have often suggested itself; but Dr. Barnes was 
 probably the first to carry a case to a successful termination by this 
 operation. 1 The proceeding, as described by him, is as follows : " Draw 
 down the uterine tumor by means of a loop of tape slung round the 
 body, so as to put the neck of the tumor upon the stretch ; then, with 
 a bistoury, make a longitudinal incision about half an inch long, and 
 a quarter of an inch deep, on either side, into the constricting os ; then 
 reapply the elastic pressure. Next day, try the taxis, and reapply 
 the elastic pressure if necessary. Elastic pressure alone, or aided by 
 this operation, will, I am convinced, overcome every case of inversion, 
 except when fixed by inflammatory adhesions." Another, and proba- 
 bly a safer, process has also been suggested, by which the incisions in 
 the os are increased in number, but made much more superficial. 
 
 Cases have been met with in which menstruation has gone on regu- 
 larly from the surface of an inverted uterus ; and, indeed, observation 
 of such instances has thrown some light upon the source of the men- 
 strual discharge. In such cases, leucorrhoea, and the presence of a 
 tumor within the vagina, may be the only symptoms, but the almost 
 invariable rule is repeated flooding, and that to such an extent as to 
 bring the patient into a condition of immediate clanger. Failing all the 
 means already detailed — in the practice of which it has been assumed 
 that full advantage has been taken of chloroform, an invaluable agent 
 in all cases of uterine spasm — is there any other method which we may 
 adopt for the relief of a woman who may be dying before our eyes from 
 the effects of this accident? 
 
 The only possible remedy in such a case is removal of the inverted 
 uterus, as this alone can be expected effectually to check the haemor- 
 rhage. The objections to such a procedure are sufficiently manifest; 
 for not only is the case one of mutilation, by which the woman is un- 
 sexed, but it is one the immediate risk of which is very great. Still, 
 the operation has been repeatedly performed with success, and the 
 woman has enjoyed perfect health for many years thereafter. In the 
 only case which has come under our observation, the patient, who was 
 operated upon about nine years ago, is still alive, and in perfect health ; 
 
 1 Medico-Chirurgical Transactions, 1869. 
 
XXV.] 
 
 REMOVAL BY THE ECRASEUR. 
 
 429 
 
 and it is worth remarking, in addition, that she has never menstruated 
 since, but that the menstrual molimen is apparently relieved by peri- 
 odical or vicarious leucorrhoea. If, therefore, the doom of a patient 
 seems fixed if we decline to interfere, we should have no hesitation in 
 resorting to a measure so extreme as the removal of the organ ; and, 
 of course, at the present day the operator would select the ecraseur in 
 preference to the older methods of ligature or excision. The best in- 
 strument for the purpose is the wire-rope ecraseur of Braxton Hicks, 
 which may be used either with fine wire twisted into a rope as recom- 
 mended by the inventor, or with a single strong wire as is recommended 
 by Barnes. The responsibility which attaches to an operation such as 
 this cannot fail to w r eigh upon the operator ; and he will, therefore, at 
 once recognize the necessity, before finally committing himself to this 
 course, of making himself sure on two points : first, as to the accuracy 
 of his diagnosis; and, second, that the tumor is beyond all doubt irre- 
 ducible. Until we can form a confident opinion in regard to both 
 these matters, we cannot, in any case, conscientiously proceed to ope- 
 ration ; and it must also be borne in mind that the more perfectly has 
 our knowledge of the accident become developed, the more completely 
 has the operation for removal of the organ fallen into disuse and 
 disfavor. 
 
 [Extirpation of the uterus under these circumstances is frequently 
 fatal. About one-third of all the cases end in death. It is besides a 
 mutilation, from which the patient and her surgeon naturally revolt. 
 Prof. T. G. Thomas has proposed and successfully practiced another 
 
 Fig. 137. 
 
 Thomas's method of reducing chronic inversion. (After Thomas.) 
 
 method of cure in a very obstinate case of chronic inversion, in which 
 Professors Miller of Kentucky, and Parvin of Indiana, as well as him- 
 self had failed in effecting reduction after prolonged and repeated efforts. 
 Under these circumstances Prof. Thomas proposed to reduce the 
 displacement by making an incision in the abdominal wall, and stretch- 
 
430 RUPTURE OF THE UTERUS. [CHAP. 
 
 ing the cervical constriction. For this purpose the patient is to be 
 thoroughly etherized, when an assistant passes his hand into the vagina, 
 and seizing the inverted fundus, lifts it up so that the cup-shaped de- 
 pression can be felt against the abdominal wall. An incision about 
 two inches long is then made in the median line; all the precautions 
 recommended by ovariotomists being carefully observed, so that no 
 blood is admitted into the peritoneal cavity. The peritoneum being 
 opened, the operator then replaces the hand of his assistant with his 
 own in the vagina, as is shown in the figure. He then stretches the 
 constricted cervical ring with an instrument resembling a glove- 
 stretcher. After this is completely dilated, the inversion is to be re- 
 duced by one of the various methods of taxis. — P.] 
 
 CHAPTER XXVI. 
 
 KUPTTJKE OF THE UTERUS. 
 
 RUPTURE DURING PRKQNANCY — RUPTURE DURING LABOR— PARTI AL OR INCOM- 
 PLETE RUPTURE — SITE, EXTENT, AND DIRECTION OF THE LACERATION — REASON 
 OF THE COMPARATIVE FREQUENCY OF CERVICAL RUPTURE — IS RUPTURE LESS 
 COMMON IN PRIMIPAR.E ? — EFFECT OF THE DURATION OF LABOR — CAUSES — A. 
 MECHANICAL : SEX ; PELVIC DEFORMITY; FAULTY PRESENTATION ; PRESS URE 
 UPON THE CERVIX ; OPERATIVE VIOLENCE; ERGOT; VIOLENT UTERINE ACTION 
 — B. REFLEX: EXCITEMENT OF CERVIX, ETC. — C. PATHOLOGICAL: CANCER; 
 RIGIDITY OF THE OS; THINNING OR PARTIAL ATROPHY; SOFTENING; FATTY 
 DEGENERATION — SYMPTOMS — PREMONITORY: LOCALIZED PAIN INCREASED 
 DURING LABOR — SIGNS OF RUPTURE: PAIN: HEMORRHAGE ; SHOCK; RECESSION 
 OF THE PRESENTING PART — LACERATIONS INVOLVING THE VAGINA— TR EAT- 
 MENT — PREVENTIVE MEASURES: DELIVERY BY THE FORCEPS OR BY PERFORA- 
 TION — EXTRACTION OF THE PLACENTA — HERNIA OF THE INTESTINE — IF FCETUS 
 HAS ESCAPED INTO THE PKRITONEAL CAVITY, TURNING RECOMMENDED: GAS- 
 TROTOMY IS, HOWEVER, TO BE PREF ERRED— FURTHER MANAGEMENT OF THE 
 CASE — TREATMENT OF RUPTURE OF THE UTERUS IN VARIOUS STAGES OF 
 PREGNANCY. 
 
 Rupture of the Uterus, at all times one of the most appalling acci- 
 dents of midwifery, is also the most fatal ; and is the more terrible, as 
 in many cases it can neither be foreseen nor averted. The elaborate 
 statistics for which we are indebted to Dr. Churchill, show the acci- 
 dent to have occurred in 85 out of 113,138 cases of labor — about 1 in 
 1331. Although rupture almost invariably occurs in the course of 
 labor, it is not always so, as a certain number of well-authenticated 
 cases have been put on record, in which rupture occurred at various 
 periods in the course of pregnancy, in the absence of any uterine ac- 
 tion whatever. Some of these cases have been the result of violence, 
 
XXVI.] PARTIAL RUPTURE. 431 
 
 and a considerable number seem to have followed over-exertion of some 
 kind. But there are others in which no such cause can have been in 
 operation, as in a case published in the Medical Repository, by Mr. 
 Scott of Bromley, in which a woman in the sixth month, was awakened 
 from sleep by a sudden pain about the umbilicus, which was soon suc- 
 ceeded by collapse and death. On examination after death, a rupture 
 was discovered at the fundus, through which the foetus, enveloped in its 
 membranes, had escaped into the abdominal cavity. It would proba- 
 bly be impossible, in many of these cases, to distinguish between this 
 accident and rupture of the sac of an extra-uterine pregnancy, as the 
 symptoms are, in the two cases, almost identical. The very rarity of 
 spontaneous rupture has not unfrequently given rise to suspicion of 
 foul play in such cases, and the question has, therefore, a medico-legal 
 significance, in reference chiefly to criminal abortion; but there will 
 probably be little difficulty in recognizing a spontaneous rupture at 
 this stage, as it is generally at the fundus, while criminal injuries are 
 more frequently discovered in the region of the os and cervix. Be- 
 sides, the nature of the injury is so different, that the appearance of 
 a spontaneous rent and a violent laceration could scarcely be mis- 
 taken ; and, moreover, there often is to be found, as the cause of these 
 ruptures, a diseased condition of the structures of the womb. Rup- 
 tures during the course of pregnancy may occur as early as the third 
 month, but are more frequent, the more advanced is the development 
 of the foetus. 
 
 By far the greater number of cases occur during labor, and it is to 
 these that attention must be more particularly directed. The lacera- 
 tion in these cases generally involves the entire thickness of the uterine 
 walls, but there are exceptions to this rule. In some, the rent is found 
 to have extended through the mucous membrane and proper tissue of 
 the uterus, and to have been arrested by the peritoneum, which remains 
 intact. The mobility and distensibility of the peritoneum upon the 
 subjacent uterine tissue in some measure encourages this ; and it is, 
 therefore, at the lower portion, where the connection of the peritoneum 
 is looser, that this has been more frequently observed. The result of 
 such cases, although often fatal, is not so much to be despaired of as 
 when the laceration is complete ; but a very probable result would be 
 the effusion of blood between the peritoneum and the tissues beneath, 
 and the consequent formation of periuterine hematocele. In many of 
 these instances, it is most likely that the fact of laceration is not recog- 
 nized at all at the time of its occurrence. Another rare variety of rup- 
 ture consists in numerous fissured lacerations of the external surface 
 of the tissue proper of the uterus, immediately beneath the peritoneum, 
 which may give rise, as in the other case, to subperitoneal haemor- 
 rhage ; while in other instances, the peritoneum itself is the only part 
 which is lacerated, the uterine tissues escaping altogether. 
 
 Any part of the uterus may be the seat of laceration, while the rent 
 in the tissues may take any direction, and, in extent, may be limited 
 only by the size of the organ itself. It may thus be either longitudinal 
 or transverse ; and may, in the first case, correspond to the entire length 
 of the uterus, and, in the latter, the laceration may extend completely 
 
432 RUPTURE OF THE UTERUS. [CHAP. 
 
 around the uterus, thus dividing it into two. Both of these are extreme 
 cases : the rent is generally much more limited in extent. Considerably 
 more than half of all the ruptures at the full time occur in the region 
 of the cervix, generally at that part which marks the junction between 
 the uterus and the vagina. Next in point of frequency comes the body ; 
 and last of all, the fundus, which is, as we have seen, the site preferred 
 in early pregnancy. One of the most remarkable monographs on this 
 subject is one which was published, in 1848, in the American Journal 
 of Medical Science, by Dr. James D. Trask, and is based on an analy- 
 sis of over four hundred cases. The following represents the propor- 
 tion of cases in the various situations named, as deduced from his sta- 
 tistics : 
 
 Ruptures of the cervix, ..... 55 per cent. 
 " " body, . . . • . . .36 " 
 " " fundus, 9 » 
 
 The reason of the comparative frequency of rupture at the cervix is 
 afforded by a moment's consideration of the mechanism of the dilata- 
 tion of the os, which has been fully detailed in reference to the prog- 
 ress of the first stage of labor. The os, as was explained, is dilated 
 by the combined action of the longitudinal fibres of the uterus and the 
 bag of waters, or, in the absence of the latter, by the presenting part 
 of the child ; so that we cannot wonder that the usual seat of rupture 
 is where the greatest amount of force is brought to bear. Trifling rup- 
 tures of the vaginal portion of the cervix, commencing at its margin, 
 are among the most common of the minor accidents of midwifery. 
 But, even when lacerations of this part are more extensive, the rent 
 does not necessarily involve the peritoneum, so that the gravity of the 
 case will depend chiefly upon whether or not that membrane is injured. 
 In some rare instances, the laceration extends into the bladder, and in 
 others, rarer still, the whole vaginal portion of the cervix has been 
 separated, in the form of a ring, which has been born with the child. 
 Lacerations of the cervix alone are very common, and generally take 
 a vertical direction. They are said to occur more frequently on the 
 left than on the right side. 
 
 It was at one time generally supposed, and it is even now stated by 
 many writers, that there is less liability to rupture in first than in sub- 
 sequent pregnancies. A more correct observation of such statistics as 
 bear on that subject, — among which those of Churchill and Trask are 
 best known, — shows that this is not the case, but that there is, if any- 
 thing, a preponderance of primiparous cases. The error has arisen 
 from comparing first with all other labors ; but, if we compare first 
 with second, third, fourth, and so on, individually, but not collectively, 
 the result will be found to be as we have said. Another view, all but 
 universally held, was that the accident was a common result of pro- 
 tracted labor; and it is, indeed, not unnatural to suppose that this 
 should be the case ; but there is, perhaps, no one point which is brought 
 out more strikingly in Dr. Trask's cases than that the actual duration of 
 labor has little or nothing to do with it. In 104 out of 147 cases rup- 
 ture occurred within twenty-four hours of the commencement of labor. 
 
XXVI.] CAUSES. 433 
 
 It must, however, be remembered that the usual course of a protracted 
 case is failure of the pains ; so that, although we may fairly assume that 
 long-continued effort would endanger tissues weakened by exhaustion, 
 nature here arrests the pains, and thus interposes for the protection of 
 the parts, vigorous action being only restored when she has had time 
 to recruit her exhausted powers. 
 
 Causes. — Whatever views may be entertained in regard to the two 
 conditions above alluded to, there can be no doubt that anything which 
 mechanically impedes the course of labor, is an undoubted cause of rup- 
 ture of the uterus. The sex of the child thus plays, as might be ex- 
 pected, an important part, as is shown by the statistics of the Dublin 
 Lying-in Hospital, extending over a long period, from which it would 
 appear that, in nearly 70 per cent, of all the cases of rupture, the sex 
 was male. Trask's cases show, no less clearly, that pelvic deformity, 
 or disproportion is another important cause, which had been proved to 
 exist in 74.74 per cent, of his cases. For the same reason, faulty pres- 
 entations, which are an impediment to labor, may be the direct cause 
 of uterine rupture ; thus, in 303 cases given by Trask, of all presenta- 
 tions, 16 were presentations of the shoulder. Forcible compression of 
 the neck of the womb between the head of the child and the pelvic 
 walls is supposed by Dr. Murphy to play an important part in inducing 
 rupture of the womb, so that if it is pinched anteriorly against the ilio- 
 pecti neal line, or posteriorly upon the promontory of the sacrum, ante- 
 rior or posterior lacerations of the cervix are to be explained by the 
 mechanical action of the fundus and the longitudinal fibres. 
 
 Although we have every reason to believe that the more accurate 
 knowledge of modern times has had a marked effect upon the results 
 of modern practice, it must still be admitted that operative violence 
 cannot be overlooked as a cause of rupture of the uterus. We do not 
 here refer to such cases as occur in consequence of causes of a patho- 
 logical nature, to which we shall again advert, where the accoucheur is 
 often unjustly blamed ; but to those in which errors of judgment, or 
 rashness in operative procedure, lead to this disastrous result. The 
 most common of all midwifery operations, for example, may, in any 
 case, be attended with extensive laceration ; for, if we apply the for- 
 ceps -without due consideration, and careful observation of the state of 
 the os, we may readily rend those tissues and destroy our patient. In 
 the same way, clumsy manipulation in turning may, at any stage of 
 that operation, in a moment plunge a satisfactory case into the category 
 of hopelessness ; and so, in a hundred different ways, operative incom- 
 petency may, in the attempt to shield the woman from danger, only 
 precipitate her doom. The improper administration of ergot has, there 
 is only too good reason to believe, been attended with a similar result 
 in no insignificant number of cases, where that powerful drug has been 
 given in tedious cases, without any reference whatever to the amount 
 of mechanical resistance which has to be overcome ; and we rather 
 think, that if the truth were known, — which for obvious reasons, is 
 often withheld, — this, as a cause of uterine rupture, would stand promi- 
 nently forward. Professor Bedford of New York has in his museum 
 four wombs ruptured by the improper use of ergot. A preternatural 
 
 28 
 
434 RUPTURE OF THE UTERUS. [CHAP. 
 
 violence in the uterine contractions, even when associated with no 
 marked resistance beyond what is perfectly normal, may also induce 
 rupture by the actual impetuosity of the propulsive effort; but such 
 cases, in the absence of morbid excitement of some kind, are probably 
 very rare. When such morbid excitability does exist, it is astonish- 
 ing, however, by what trifling causes violent action may be set up. It 
 is by no means rare, that the slight irritation of the cervix which 
 occurs in the course of an ordinary vaginal examination, arouses, by a 
 reflex act, an amount of expulsive effort which may thus lead to rup- 
 ture from a cause apparently so simple. Examples of this kind have 
 been from time to time recorded, but cases which are centric in their 
 origin are, undoubtedly, of far more frequent occurrence. Rupture 
 has occasionally taken place, or has been extended, during straining 
 at stool. 
 
 Special attention has of late years been directed to certain patho- 
 logical conditions, upon which there can be no doubt that rupture of 
 the uterus occasionally depends. It is in these cases mainly that, in 
 the most skilful hands, and with every possible attention, ruptures 
 quite unexpectedly occur; and in such the practitioner may be cruelly 
 and unjustly blamed. This, indeed, is by no means the least impor- 
 tant of the considerations, which invest this part of the subject with a 
 special interest. Some of the pathological conditions referred to also 
 act, like the class of cases already mentioned, mechanically. Of this 
 nature is cancer of the uterus, which generally attacks the os and 
 cervix, and, unfortunately, in some instances, proves no bar to concep- 
 tion. The nature of the disease, even when it has not passed to the 
 more advanced stages, renders the affected tissues so undilatable, that 
 laceration, under the influence of efficient uterine contraction, is almost 
 inevitable ; and, in more extreme cases, the only safeguard may be 
 Craniotomy or the Caesarian Section. Cases of extreme rigidity of 
 the os and of the more external parts of the parturient canal, are by 
 no means of rare occurrence in practice; and, if they should chance to 
 be accompanied with, or complicated by, violent uterine effort, rup- 
 ture may not unlikely occur. There are, however, other conditions in 
 which laceration may take place quite independently of excessive mus- 
 cular action, or even in the absence of such action, as the history of 
 uterine ruptures during pregnancy and before labor seems to show, and 
 the interesting researches of Dr. Murphy at the Dublin Lying-in Hos- 
 pital, clearly demonstrate. " Thinning, or partial atrophy of the uterus, 
 is not an unfrequent cause," says Dr. Murphy ; " four examples of this 
 
 morbid change presented themselves to our notice When a 
 
 change of this kind takes place, the symptoms are often very obscure. 
 There may be a very severe laceration without any severe pains, or any 
 of those prominent symptoms that often precede the accident. You can 
 appreciate what would be the effect of ergot of rye, if it were given to 
 increase pains rendered feeble from this morbid condition of the ute- 
 rus. Softening is another pathological cause of laceration. The fibrous 
 tissue seems to be the first tissue affected ; the mucous membrane may 
 then be involved, but the peritoneum generally escapes. This morbid 
 change may be only slight, affecting a few of the uterine fibres ; or it 
 
XXVI.] SYMPTOMS. 435 
 
 may be extensive, converting the affected portion of the uterus into a 
 putrid mass. Thus we have found a kind of aneurismal sac formed 
 in the parietes of the uterus, in consequence of a partial rupture of the 
 uterine fibres; no symptoms of laceration showed themselves during 
 labor, nor did any appear until several hours afterwards, when the sac 
 burst. In the same manner may be explained some of those obscure 
 cases of sudden and fatal haemorrhage some days after delivery. Dr. 
 Collins relates one in which the patient was seized with violent flood- 
 ing on the fifth day after delivery. She died in an hour; and, on dis- 
 section, it was discovered that a patch of the uterus, of about the size 
 of a shilling, had given Avay, corresponding to the projection of the 
 sacrum." 
 
 Recent observations tend to show that that process of fatty degenera- 
 tion which, as we have shown, is so essential a phenomenon of the 
 normal process of involution (see Fig. 130, p. 371), sometimes takes 
 place prematurely ; and, if so, it can be readily understood how such 
 an occurrence — under the circumstances, of course, a pathological one — 
 must essentially contribute to the risk of rupture. And there can be 
 little doubt, as Tyler Smith observes, "that in cases where the uterus 
 is feebly developed, or weakened by disease and exhausted action, the 
 contractions of the abdominal muscles must contribute to the rupture 
 of the organ, by urging the head or presenting part of the child 
 through the os uteri." 
 
 Symptoms. — The causes of rupture of the uterus being so various, it 
 will excite no astonishment that the symptoms are far from being uni- 
 form. Very violent and tetanic uterine contraction, under circum- 
 stances which, for the time at least, render it impossible that labor 
 can make much progress, will always excite our apprehension, and 
 may seem to call for such means as we have at our command for mod- 
 erating excessive action. But, the powers of nature are such that, even 
 in the most unpromising circumstances, the dreaded result seldom en- 
 sues. The significance of the premonitory symptoms is, however, 
 greatly increased if, along with contractions of this nature, the woman 
 complains of pain of an unusual intensity; and, if the site of such pain 
 should correspond to a point where it had been complained of before 
 labor, our fears will be proportionally increased. We cannot, how- 
 ever, trust to premonitory symptoms. Indeed, in the great majority 
 of cases, we have not even the benefit of such obscure signs as have 
 been mentioned, and thus the climax of the case is attained while we 
 are quite unprepared for a casualty so dreadful. 
 
 As a general rule, the symptoms which denote actual rupture of the 
 uterus are well marked. At the height of a pain, a sudden and excru- 
 ciating pang may occur. This is sometimes accompanied with a snap 
 which may be audible to the patient and even to those about her. The 
 pain suddenly ceases, and is almost instantly followed by alarming 
 prostration and shock, which is modified, more or less, by the charac- 
 teristic symptoms of haemorrhage. This may be altogether internal, or 
 may be indicated by a gush of blood from the vagina, according to the 
 portion of the uterus which has been the seat of the rupture. The 
 countenance becomes pallid, with a fearful expression of alarm and 
 
436 RUPTURE OF THE UTERUS. [CHAP. 
 
 anxiety ; the face is bedewed with a clammy sweat, and the extremities 
 and general surface become cold. The stomach ejects its contents, 
 and at once throws off anything which may be swallowed; and it has 
 sometimes been noticed, after protracted retching, that the matter vom- 
 ited is of the color and appearance of coffee-grounds. The respiration 
 becomes labored, and the pulse becomes rapid, feeble, irregular, and 
 ultimately imperceptible. Simultaneously with these symptoms, the 
 signs of the life of the foetus disappear. In some cases, the occurrence 
 of rupture is not marked either by acute pain or by the other symp- 
 toms above enumerated ; and the dangerous condition of the patient 
 may only become apparent after a considerable period has elapsed, it 
 may be hours, or even days. These are, for the most part, eases in 
 which the rent is comparatively trifling in extent, and, if it should so 
 happen that the entire thickness of the uterine tissues has not been in- 
 volved, the ordinary expulsive contractions may go on, although prob- 
 ably modified in degree. 
 
 A very usual and significant symptom is recession of the head of the 
 child, which may have come to press on the perineum, or even to dis- 
 tend the vulva, and come distinctly into view. If, along with symp- 
 toms such as have been described, the head suddenly recedes towards 
 the upper part of the pelvis or passes beyond the reach of the finger, 
 we can have little doubt as to the nature of the occurrence. We must 
 here warn the young practitioner against an error into which he may 
 fall, and which may cause him a considerable amount of unnecessary 
 anxiety; for it not unfrequently happens, towards the termination of 
 the second stage of labor, that the head suddenly and unexpectedly 
 recedes, on the termination of a pain, to a much greater extent than is 
 usual. Such an occurrence, however, need cause no alarm, as it is due 
 to a mere temporary relaxation of the uterine walls, and is usually the 
 forerunner of more efficient contractile efforts, under the influence of 
 which the child is rapidly brought into the world. Complete recession 
 of the presenting part, in rupture of the uterus, usually indicates that 
 the child has passed or is passing through the uterine walls into the 
 cavity of the abdomen, through the parietes of which the various parts 
 of the child may be distinguished. In some cases, it would appear 
 that the sudden cessation of pain was the only symptom of any im- 
 portance, and it is worth remembering that this has been mistaken for 
 inertia, and ergot administered. 
 
 There is a class of cases which, although not strictly speaking rup- 
 tures of the uterus, have so important an analogy to the latter that 
 it seems proper to mention the subject here. These are ruptures or 
 lacerations of the vagina. Lacerations of the lower part of the vagina 
 are usually situated in its posterior wall, and, if they involve the super- 
 ficial structures, they constitute the accident formerly described as Rup- 
 ture of the Perineum. There are instances, however, in which the 
 rupture of the tissue is very extensive in so far as the vagina is con- 
 cerned, and in which, nevertheless, the external tissues of the perineum 
 remain quite uninjured, such cases proving both tedious and trouble- 
 some, although, as compared with rupture of the uterus, they are com- 
 paratively trivial. The lacerations to which allusion is here more par- 
 
XXVI.] TREATMENT. 437 
 
 ticularly made, in reference to uterine rupture, are those in which the 
 head of the foetus, after passing the os, pinches in and compresses a zone 
 of the vagina. The uterus in its contractile efforts pulls upon this 
 fixed ring, precisely as happens when the cervix is similarly compressed, 
 the result being a tear, which is transverse in its direction, and may 
 extend circularly around the entire vagina. It is important to know 
 that, in such cases, the whole of the uterus and the upper part of the 
 vagina has been expelled by the natural efforts, which has given rise to 
 the charge of malapraxis. It has been denied by some that the uterus 
 could in this way rend its ligaments ; but recorded and perfectly au- 
 thentic cases now clearly show that not only may the round and broad 
 ligaments be torn asunder in this way, but that they may even be rup- 
 tured as a mechanical effect of spontaneous inversion. Lacerations 
 involving both vagina and uterus are not uncommon, and it is proba- 
 bly difficult in some of these instances to determine for certain in which 
 of the two textures the rupture has had its origin ; but there can be 
 no doubt that lacerations, either of the cervix uteri or of the upper 
 part of the vagina, must, in consequence of their intimate anatomical 
 relations, be very apt to extend from the one to the other. A consid- 
 erable haemorrhage could scarcely fail in such cases to be a prominent 
 symptom. 
 
 Treatment. — It is scarcely necessary to observe that, if there be any 
 possible means whereby we may succeed in preventing this accident, 
 such must necessarily be by far the most important point relative to 
 treatment. But, unfortunately, the cases in which prevention is possi- 
 ble are rare ; or, rather, the indications which demand preventive 
 treatment are so obscure in their nature that it is difficult to tell, on 
 the one hand, whether we are called upon to interfere, and, on the 
 other, whether, having interfered, the safety of the patient may fairly 
 be attributed to our conduct in the case. The latter point is perhaps 
 the most difficult of all. We recognize, let us suppose, a serious me- 
 chanical impediment to delivery, which coexists with violent and long- 
 continued uterine effort, and which may seem to imperil the integrity 
 of the uterine tissues. We operate, by the forceps, turning, or other- 
 wise, and speedily relieve the patient; but when are we entitled to say 
 that such prompt and decisive action on our part has actually averted 
 a great calamity ? We may, indeed, be perfectly certain that a well- 
 considered and definite plan of treatment, in accordance with which 
 operative assistance is afforded or withheld, will reduce rupture of the 
 uterus to a minimum, as is well shown by the statisticts of large lying- 
 in hospitals, where this accident is one of those least frequently met 
 with. It cannot, however, on the other hand, be doubtful that a need- 
 less dread of rupture, which inexperience is certain to exaggerate, leads 
 in some instances to operative interference, which may be perfectly un- 
 necessary, although the operator does not fail to congratulate himself 
 on a fortunate issue, which he fancies to be due to his prescience and 
 skill. 
 
 Apart from this, there are, however, certain conditions upon which 
 an intelligent preventive treatment may be founded. The occurrence, 
 for example, in the course of gestation, of acute pain, referable to some 
 
438 RUPTURE OF THE UTERUS. [CHAP. 
 
 particular part of the uterus has often been known to precede rupture 
 in the part affected, which is believed in these instances to have been 
 the seat of local or limited metritis. Should any suspicion, therefore, 
 of this be entertained, it will be proper to adopt such means as may 
 seem suitable with the view of subduing the morbid action which is 
 assumed to exist. One, and by no means the least important, of the 
 objects which the accoucheur has in view in inducing premature labor 
 in cases in which there must be disproportion of parts at the full time, 
 is to avert the danger of rupture which fruitless uterine effort might in 
 any case produce. And he will, in like manner, feel himself impelled 
 to prompt and energetic action, when the expulsive effort of the uterus 
 is morbidly in excess. In some of these cases, the contractions attain 
 a tetanic violence, which seems at every moment to imperil the integrity 
 of the uterine tissues ; and, if the period should not have arrived at 
 which we may assist delivery by artificial means, we must then have 
 recourse to such treatment as may subdue this violence, — of which 
 opium, chloroform, and chloral hydrate are, in these days, the most 
 familiar examples. In certain cases of extreme urgency it may be 
 necessary to enlarge the orifice of the vagina by lateral incision of the 
 perineum ; and, if we are certain that the child is dead, and it is 
 making but slow progress under very violent uterine propulsion, we 
 are justified in lessening the bulk of the head by the operation of 
 craniotomy. In so far as the forceps is concerned — and the remark 
 applies with still greater force to turning — we must not be astonished 
 if any attempt at operative assistance should excite the organ to more 
 violent contraction still, and thus defeat its own object. What con- 
 stitutes morbid or excessive uterine action can of course only be learned 
 by experience. 
 
 The treatment of actual rupture, however desperate the circumstances 
 may seem, calls for every possible attention, not only in the interests of 
 the child — which may often be saved — but in that of the mother, who 
 may, even in unpromising cases, rally from the effects of the injury and 
 ultimately recover. We must not, therefore, accept the dictum of 
 Smellie, that the accident is an absolutely hopeless one. All the best 
 authorities are agreed that a speedy removal of the child affords the 
 mother the best chance even when, the child being dead, this is done 
 without any reference whatever to its condition other than considered 
 as a foreign body. If the head of the child is still in the pelvic cavity, 
 and thus within reach, it may be possible, although very rarely, to grasp 
 and deliver it by the forceps ; and, it need scarcely be said, that if this 
 can easily be done, it ought to be preferred as the method which is at 
 once easiest and safest. As, however, in a large proportion of such 
 cases, rupture is associated with more or less of pelvic disproportion, 
 the usual practice is to perforate, and then to extract by the crotchet or 
 craniotomy forceps, after having evacuated the contents of the cranium. 
 This operation is, under such circumstances, attended with special dif- 
 ficulties, which may render its performance a matter of difficulty or 
 impossibility. Instead of being, as in most other cases, firmly held in 
 position by the uterus, the foetus is apt to pass upwards on the slightest 
 pressure towards the abdominal cavity ; and, if the rupture be a trans- 
 
XXVI.] VARIOUS METHODS OF TREATMENT. 439 
 
 verse one, such pressure is apt to increase it; while, again, if a portion 
 of the foetus has already passed into the peritoneal cavity, the remainder 
 may thus be propelled in the same direction. It has been recom- 
 mended, therefore, in order to obviate these difficulties, to use the per- 
 forator so as to press the head back towards the hollow of the sacrum 
 by directing the handles forwards as much as is possible in the direction 
 of the subpubic angle. Success in an attempt such as this will be 
 more probable if we avail ourselves of the aid of an assistant, whose 
 duty it should be to maintain the child in the position which it occupies, 
 by sustained and judicious pressure exercised through the abdominal 
 walls. 
 
 If we succeed in this way in effecting delivery of the child, we may 
 then encounter another, and probably a more serious difficulty, in the 
 extraction of the placenta. This organ, in a large proportion of cases, 
 will be found to have escaped through the gap in the uterine parietes 
 into the abdominal cavity, and, if contraction has subsequently taken 
 place to any considerable extent, the aperture may thus be so reduced 
 that great difficulty will be encountered in any attempt to draw it 
 down. Too much caution cannot here be observed with the view of 
 avoiding further laceration and extension of the wound. Were we to 
 attempt to force the hand through the opening in order to seize the 
 placenta, this would almost certainly occur. It is better, therefore, to 
 use the cord as an extractor, and to pull the placenta towards the 
 opening and then cautiously through it, and in this way complete the 
 delivery. A prolapse or hernia of a portion of the intestine through 
 the wound is by no means an unfrequent complication of such cases, 
 and it is a matter of doubt in many instances whether we should or 
 should not attempt to replace the protruding intestine. In so far as 
 the risk of strangulation is concerned, this is a matter of trifling im- 
 portance, for the usual situation and direction of the rupture, and the 
 relation which it bears to the uterine fibres, render it a very unlikely 
 matter that strangulation should occur ; and, apart from the chance of 
 a recurrence of the prolapse, it may fairly be doubted whether the risk 
 of displacing the clots and again disturbing the wound will not do 
 more harm than good, — as recovery has taken place even when a con- 
 siderable coil of intestine has passed through the wound and occupied 
 the vagina. 
 
 In a very considerable proportion of cases of rupture of the uterus, 
 it is impossible to deliver by the natural channel, on account either of 
 pelvic deformity, contraction of the os, or escape of the child into the 
 abdominal cavity. In the first case, our course of procedure will depend 
 upon the degree and extent of the deformity ; and, in the second, the 
 rigidity may possibly be overcome by the use of chloroform, or even by 
 incision of the tissues of the os, our object being, in every case in which 
 the child remains in the uterine cavity, to deliver, if it be possible, per 
 vias naturales. But, in the third case, when the child has escaped from 
 the uterus, and lies among the intestines in the abdominal cavity, our 
 treatment must be essentially different. So hopeless were such cases at 
 one time generally regarded, that some of the most eminent accouch- 
 eurs — Denman among others — recommended that we should not in any 
 
440 RUPTURE OF THE UTERUS. [CHAP. 
 
 way interfere, but leave the case to nature, as it has happened that 
 women, even under such desperate circumstances, have recovered, the 
 child ultimately being discharged piecemeal by the ulcerative process, 
 as in cases of extra-uterine pregnancy. In several cases in which rup- 
 ture of the uterus and escape of the child into the peritoneal cavity had 
 occurred, delivery has been effected and the woman saved by the opera- 
 tion of turning, the hand being passed through the rupture, the feet of 
 the child seized and brought down, and the delivery completed in the 
 usual way. The fortunate result of these cases gave rise to a very 
 general impression that this was the method of treatment most suitable 
 for such cases ; but the gross results of the operation have turned out 
 so unsatisfactory that a very general and growing belief now exists 
 that, whatever may have been the result in rare and favorable instances, 
 the chances of the woman are by this procedure rather diminished than 
 increased. Dr. Barnes believes, and with some reason, that the cases 
 alluded to were chiefly examples of rupture of the vagina, the rent of 
 which is not contractile, and it is certain that it would scarcely be pos- 
 sible to deliver in this way, in an ordinary case, without displacing the 
 clots, increasing the rent, and thus exposing the woman anew to the 
 danger of increased haemorrhage and redoubled shock. If it is to be 
 performed at all, it seems to us to be applicable only to such cases as 
 present a cervical rupture of considerable size, and in which the general 
 condition of the woman is unusually favorable. 
 
 The statistics of Dr. Trask, and the experience of later years, have 
 very much modified the views previously entertained by competent 
 authorities on the subject of gastrotomy in those cases of uterine rupture 
 in which the child is in. the peritoneal cavity. The dangers of such a 
 course are manifest. There is increased shock, and the special risk 
 which attaches to all cases in which the cavity of the peritoneum is 
 opened ; and, in addition to this, we may take into consideration the 
 natural repugnance which is entertained by the patient's friends to such 
 an operation, so long as another is in any way practicable. It must 
 certainly be confessed that, in so far as it has been possible to institute 
 a comparison between turning and gastrotomy in cases in which the 
 child is outside of the uterus, the presumption is entirely in favor of 
 the latter. The results of turning, and of removal through the rupture 
 and the vulvo-uterine canal, are, according to Trask, as unfavorable to 
 the mother as when we abandon the case absolutely to nature. But, 
 in those in which the operation of gastrotomy has been preferred, the 
 results have been much more favorable, about two-thirds of the cases 
 collated by Trask having been saved. We must be very cautious, 
 however, in admitting such figures as representing the true facts of the 
 case, as we cannot but believe that many fatal cases are, for reasons 
 which are sufficiently obvious, suppressed. This is the reason why 
 here, as well as elsewhere in this work, comparative tabular statements 
 are omitted as likely to lead to misapprehension and false hopes. The 
 safety of the child is in all such cases a secondary matter ; but it may 
 be admitted, as an element of the case for our consideration, that, where 
 the operation of gastrotomy has been promptly performed, the child 
 has occasionally been saved. On the whole evidence, then, we must 
 
XXVI.] LAPAROTOMY. 441 
 
 pronounce in favor of gastrotomy when the child is in the peritoneal 
 cavity, of turning when it has remained in the cavity of the uterus, 
 and of the forceps or perforation where the head can be easily reached 
 within the pelvis. 
 
 The operation of gastrotomy, or Laparotomy, is simply the first stage 
 of what will afterwards be more particularly described as the Caesarian 
 Section. A longitudinal incision having been made in the middle line, 
 below the umbilicus, with those precautions which the modern opera- 
 tion of Ovariotomy has made familiar to us, the child is to be at once 
 removed, along with the placenta and such clots as may be within 
 reach. The wound should then be closed in the usual way, and a full 
 opiate administered, while the patient is ordered to be kept in a state 
 of perfect quiet, both of body and mind. Some difficulty may possibly 
 arise, both before and after the operation, as to the use of stimulants. 
 The condition of shock and general depression, and the state of the 
 pulse may, on the one hand, indicate that we should not withhold them ; 
 but, on the other, our apprehension of the dreaded, though inevitable 
 peritonitis is such, that we shrink from any treatment which might 
 tend to aggravate the inflammatory action, upon the degree and extent 
 of which the life of the patient will depend, more, perhaps, than upon 
 anything else. It is, in fact, impossible, in this particular, to lay down 
 rules for our guidance; so that we must act, to the best of our judg- 
 ment, as the exigencies and peculiarities of an individual case may seem 
 to indicate ; but, it will probably be necessary, in most cases, to rally the 
 patient in some degree from the shock which has attended the accident, 
 before proceeding to perform the operation which we may have selected. 
 
 In those cases in which rupture has occurred in the course of preg- 
 nancy, the treatment will, in some measure, depend upon the stage of 
 pregnancy. In so far as rupture in the early months is concerned, 
 something must be allowed for the difficulty of diagnosis, as it would 
 be difficult, in such a case, to know whether it was a rupture of the 
 uterus, or of the cyst of an extra-uterine pregnancy. This distinction 
 is not, however, one of any great practical importance, as the treatment 
 in the two cases is probably identical, and there seems no reason to 
 doubt that, in this case, the best chance would be to leave all to nature, 
 in the hope that, by the ordinary process of ulceration, the foetus may 
 ultimately be discharged. When the rupture takes place in the later 
 months of pregnancy, the conditions are quite different, and the indica- 
 tions of treatment are more those of rupture during labor. If we are 
 certain that the foetus has escaped from the uterus, there must be no 
 hesitation here as to the advisability of laparotomy. For, with an os 
 firmly closed, it would be futile to attempt dilatation of it and the 
 cervix as a preliminary to thrusting the hand through the uterus into 
 the abdominal cavity, so that we cannot here even think of turning. 
 Some have recommended, when the child is still within the uterus, a 
 forced dilatation of the os, and even excision, to be followed by turn- 
 ing ; but we very much question whether, even here, it would not be 
 preferable to perform laparotomy, and extract the child from the womb 
 by enlarging the laceration, should it be necessary. Under circumstances 
 such as these, many w T ould probably prefer trusting to nature. 
 
442 DEFORMITIES OF THE PELVIS. [CHAP. 
 
 CHAPTER XXVII. 
 
 DEFORMITIES OF THE PELYIS. 
 
 IMPORTANCE OF THE SUBJECT — CLASSIFICATION OF DEFORMITIES — CAUSES — DIS- 
 EASES AFFECTING THE PELVIS: RACHITIS: MALACOSTEON : RICKETS AND 
 MALACOSTEON CONTRASTED: NATURE OF THE BRIM DEFORMITY CHARACTER- 
 ISTIC OF EACH— POSSIBILITY OF YIELDING IN A MALACOSTEON PELVIS — THE 
 OBLIQUELY DISTORTED PELVIS — DEFORMITIES OF THE CAVITY: FLATTING OF 
 THE SACRUM: FUNNEL-SHAPED PELVIS — DISTORTION OF THE OUTLET: AP- 
 PROXIMATION OF THE TUBEROSITIES OF THEISCHIA: PROJECTION FORWARDS 
 OF THE COCCYX: ANCHYLOSIS OF THE SACRO-COCCYGE AL ARTICUL VTION — MAS- 
 CULINE TYPE OF PELVIS — INFANTILE TYPE — EFFECT OF MUSCULAR ACTION IN 
 PRODUCING PELVIC DISTORTION — SPONDYLOLISTHESIS — PELVIC .EQUABI LITER- 
 JUSTO-MAJOR, AND JUSTO-MINOR — OBSTRUCTION PROM EXOSTOSIS, OSTEOSAR- 
 COMA, AND OTHER TUMORS; AND FROM FRACTURES OF THE PELVIS, AND 
 MORBUS COXAR1US — SYMPTOMS— MEASUREMENTS OF THE PELVIS: PELVIME- 
 TERS — EXAMINATION BY THE FINGERS — EFFECTS OF DISTORTION — DIFFERENCE 
 BETWEEN "IMPACTION" AND "ARREST" — TREATMENT — PREVENTION — CIR- 
 CUMSTANCES WHICH CALL FOR THE FORCEPS, TURNING, CRANIOTOMY — USE OF 
 THE FORCEPS IN DEFORMED PELVIS — C.ESARIAN SECTION. 
 
 Before passing to the more particular consideration of Operative 
 Midwifery, it is proper that we should in the first instance turn our 
 attention to the important subject of Pelvic Deformity; upon which 
 condition a very large proportion of all midwifery operations depends. 
 The first point which may be regarded as essential to the mastery of 
 this important subject is, beyond all doubt, a correct appreciation of 
 the normal standard, or, in other words, an accurate knowledge of the 
 anatomy of the female pelvis. Upon this also, as we have already 
 seen, hangs the whole theory of the mechanism of parturition ; but, so 
 soon as deformity of any kind disturbs the relations which subsist be- 
 tween the various pelvic diameters, it converts the harmonious whole 
 of a normal pelvis into discordant elements, to which it is impossible 
 to adapt such laws as under ordinary circumstances guide our action. 
 If the art of obstetrics stopped short here, it would have little claim 
 indeed to the dignity of a science. No point, however, within the area 
 of our subject has attracted more of the attention of those to Avhose 
 genius and industry we are under the deepest obligation ; and the 
 light which their experience and investigation has thrown on it, 
 enables us in these days to look upon the deviations from the normal 
 standard to which we have alluded with more of confidence than ap- 
 prehension. For the occurrence of difficulties more or less formidable, 
 then, we must be prepared; and nothing will suffice for an intelligent 
 and satisfactory appreciation of these, short of an intimate knowledge 
 
XXVII.] CAUSES. 443 
 
 of the causes upon which pelvic deformities depend, and the practical 
 contingencies which they involve. Many attempts have, from time to 
 time, been made to classify and reduce these morbid conditions into 
 genera and species, but they have been attended for the most part, in 
 so far as practical results are concerned, with but indifferent success. 
 Many of the best authorities, whom we shall in this matter attempt to 
 follow, abandoning any such scheme, have therefore attached to the 
 conventional phrase, " pelvic deformity," a signification somewhat be- 
 yond what its etymology would seem to imply, so as to include, as we 
 shall see, certain cases in which no deformity in the strict sense of the 
 term exists, and yet in which the mechanical requirements of natural 
 labor cannot possibly be assumed to exist. Many of the familiar terms 
 arising from the systems of classification alluded to will be employed 
 in the sequel, but only so far as may be necessary to meet the exigencies 
 of formal description. 
 
 The Causes of pelvic distortion are various; but by far the most 
 important of these are the diseases known as Rachitis and Malacosteon, 
 which, although closely allied in respect of the morbid conditions 
 upon which they depend, are, nevertheless, to be carefully distinguished 
 in regard to the difficulties which they engender, and the effects which 
 they produce on the course of parturition otherwise natural. An elab- 
 orate consideration of the pathological conditions, symptoms, and 
 progress of these diseases is altogether foreign to a work such as this ; 
 but there are certain points of similarity, and still more of contrast 
 between the two, a knowledge of which is essential to a correct appre- 
 ciation of the subject in all its bearings, and to which, therefore, it is 
 necessary that we should at this place briefly advert. One of the most 
 essential, and, in regard to our subject, one of the most important 
 points of distinction between rachitis and malacosteon is, that while 
 the former is a disease of childhood, the latter is a disease of adult life ; 
 and it is only necessary to compare the form, and degree of inclination 
 of the pelvis of an infant (see Fig. 17) with that of the adult, to see 
 that the effect which must inevitably be produced in the two cases, by 
 a yielding of the osseous structures, can only be attended with results, 
 as regards the measurements and form of the pelvis, which of them- 
 selves would suffice to establish a marked distinction. Such differences 
 in form as results from the operation of this cause — to which we shall 
 more particularly refer — are by no means the only features which fix 
 our attention in this direction. 
 
 Rachitis or Rickets is, as we have said, a disease of infancy and 
 childhood, which very rarely comes on after the age of puberty. It is 
 attended from the first by a marked cachexia, which the best authori- 
 ties seem to regard as identical with that of scrofula ; but the first 
 symptom which clearly points to the nature of the case, is the yielding 
 of the bones, which soon gives rise to more or less of deformity in 
 those parts of the skeleton which have most to do with the support of 
 the body — namely, the spine, pelvis, and lower limbs. The chief 
 morbid alteration upon which these phenomena depend is a diminution 
 of the earthy constituents of the bones ; but the change goes much fur- 
 ther than this, and involves corresponding alterations in the animal 
 
444 DEFORMITIES OF THE PELVIS. [CHAP. 
 
 portion, and thinning of the dense or laminated texture, with a conse- 
 quent predominance of the cancellated structure, and the formation of 
 certain new and semi-solid products. Some bones suffer more than 
 others, and even some parts of the same bone may be affected to a com- 
 paratively greater extent. The amount of deformity which is thus 
 produced will obviously depend, in a great measure, upon the extent 
 to which the disease exists, and the continuance of the morbid condi- 
 tions referred to ; but it is generally observed that the deformity is not 
 confined to any particular part of the osseous framework, but affects it 
 generally, the more conspicuous symptoms being spinal curvature and 
 flexion of the bones of the leg. With the distortion in these regions 
 we have here nothing particular to do ; but, as regards the pelvis, there 
 is almost always more or less deformity caused by the weight of the 
 trunk, which is thrown upon the bones of the pelvis from the spinal 
 column through the sacrum. Another important point of special 
 interest to us is that rachitis is usually accompanied with arrest of 
 growth, which, although most marked in the lower limbs, and thus 
 imparting dwarfishness to the frame, is also to be noticed in the pelvis, 
 which is often, on this account, abnormal in respect of size as well as 
 of distortion. We shall not further follow the symptoms and progress 
 of such cases. It will suffice to observe that the general tendency is 
 towards recovery, which is first indicated by an amendment of the gen- 
 eral health, disappearance of the cachectic symptoms ; and, with more 
 inclination for muscular action, a steady amelioration in the morbid 
 condition of the bones, in which the phosphatic deficiency is gradually 
 improved. Ultimately, the health and strength are permanently re- 
 stored, but the period of restoration merely fixes the bones for life in 
 the distorted position. Judicious treatment during the period of con- 
 valescence no doubt often modifies the amount of ultimate deformity; 
 but such treatment is usually directed to the spine and lower limbs, 
 while the pelvis comes in for a much smaller share of attention. The 
 accoucheur should always remember that the existence of spinal curva- 
 ture is no evidence of antecedent rickets, a consideration which may 
 be of importance, chiefly with reference to questions of prognosis. 
 
 Malacosteon, or Osteomalacia, is much rarer than the preceding, and 
 is essentially a disease of adult life. The process of ossification has, 
 we may suppose, been satisfactorily accomplished ; and then come on, 
 for the first time, the morbid conditions upon which the distortion 
 depends. Although in this case, as in that of rickets, the most usual 
 occurrence is a disproportion between the earthy and animal con- 
 stituents of the bones, their whole structure suffers considerable altera- 
 tion. It is more frequently observed in females than in males; while 
 in rickets there docs not seem to be any preference for sex. The 
 general symptoms which accompany malacosteon are, from an early 
 period of the case, very grave. It usually runs a rapid course, mani- 
 fests no tendency to repair, defies all attempts at treatment, and, sooner 
 or later, has a fatal result. The disease may affect the whole skeleton, 
 or may be limited to several bones, or to one; and it would appear 
 that the pelvis at least rarely escapes. It would also seem to involve 
 the entire texture of the affected bones more equably than rickets. 
 
XXVII.] MALACOSTEON. 445 
 
 Softening: of the bones is the usual characteristic, but it may occasion- 
 ally be attended with brittleness, to which the term Fragilitas Ossium 
 has been applied. Mollities Ossium is not, therefore, to be accepted 
 as absolutely synonymous with Malacosteon. 
 
 In contrasting these two morbid conditions, the first point of im- 
 portance to be noticed is that, in rickets, we are dealing, not with 
 disease, but with the effects of disease, the pelvis being, in fact, often 
 more dense in structure than if it never had occurred; while, in mala- 
 costeon, we have actually existing and progressive disease. From this 
 arises a practical point, which may be noticed here, although with no 
 intention to exaggerate its importance. This is the possibility of some 
 yielding of the bones of the diseased pelvis, so as to admit of parturi- 
 tion, or of operative assistance which would otherwise be unavailable. 
 A case of this kind is given by Osiander, who, being about to perform 
 the Caesarian section in a malacosteon pelvis, made a final attempt 
 by the hand — an attempt which, owing to such relaxation as is here 
 described, actually succeeded. 
 
 The condition and circumstances of the patient at the period of the 
 occurrence are such as to exercise a very important influence on the 
 nature of the distortion. Rickets, in most cases, comes on before the 
 child has begun to walk, so that the most likely mechanism of distor- 
 tion in these instances is a force acting through the spinal column, as 
 we have already observed, upon a pelvis which, in comparison with 
 the adult model, has a greater inclination and a conjugate diameter 
 exceeding the transverse. In malacosteon, on the other hand, the 
 patient may walk or stand during the process of softening, and the 
 
 Fig. 13S. 
 
 Rachitic pelvis. 
 
 weight of the whole trunk is thus transmitted to the heads of the thigh- 
 bones. This difference in the nature of the forces or mechanism of 
 pelvic deformity is well shown in the characteristic features of rachitic 
 and malacosteon pelves. In a typical case of the former variety there 
 is, as shown in Fig. 138, a marked projection forwards of the sacrum 
 by the operation of the cause above alluded to. This is by far the most 
 frequent of all the varieties of deformity which have been described. 
 It may (as shown in the figure) or may not be associated with flatten- 
 ing of the anterior wall, and projection backwards of the symphysis 
 
446 
 
 DEFORMITIES OF THE PELVIS. 
 
 [chap. 
 
 
 pubis, but the effect, in every case, is a more or less marked diminu- 
 tion of the conjugate diameter of the brim. Different varieties of this 
 distortion have been described as " masculine," " heart-shaped," and 
 "figure of eight" deformities of the brim ; all of which are, as will be 
 
 Fig. 139. 
 
 Malacosteon pelvis. 
 
 observed, mere modifications of the same condition, and all of which 
 partake of the character of elliptical distortion. In malacosteon again, 
 the general characteristic of the deformity is angular, and is due to 
 antero-lateral displacement of the pelvic walls by pressure exercised 
 upon the acetabula. This is indicated in a typical form by the rostrated 
 variety shown in Fig. 139, where the conjugate diameter is increased 
 at the expense of the transverse and oblique. 
 
 Endless varieties and combinations of these two may occur, so that 
 the distinction between a rickety and a malacosteon pelvis is only to be 
 
 Fig. 140. 
 
 Isabel Redman's case. 
 
 accepted with the qualification that some cases partake of the charac- 
 teristics of each. Thus, in the case of Isabel Redman, operated upon 
 
XXVII.] VARIETIES. 447 
 
 by Dr. Hall, the conjugate and oblique diameters were both involved, 
 constituting a very serious modification of distortion in this situation. 
 These are, of course, mere illustrations of possible variations, which 
 might be infinitely multiplied ; but it is to be remembered that a con- 
 siderable number of cases have been met with in which an undoubtedly 
 rickety pelvis presented all the more prominent characteristics of mala- 
 costeon deformity. 
 
 In so far as the true malacosteon pelvis is concerned, it has been well 
 observed by Stanley that there is no diminution in the actual circum- 
 ferential measurement of the brim, and that the bones are of their 
 natural bulk and proportion, so that " if their various doublings were 
 unfolded " the pelvis would be restored to its normal dimensions and 
 form. In rickets, however, this does not usually apply, owing, as has 
 already been observed, to the partial arrest of development which 
 obtains during the course of the disease. 
 
 In the majority of cases of pelvic deformity, there is a want of sym- 
 metry, one side being affected to a greater extent than the other. This 
 is due to a variety of causes, probably one of the most important being 
 the alteration of the centre of gravity in consequence of spinal curvature. 
 A very peculiar and extreme variety of this kind is that which was so 
 fully described by Naegele in his memoir on the subject as the "pelvis 
 oblique- ovata" or Obliquely Distorted Pelvis. In these very interest- 
 ing cases, there is anchylosis of the sacro-iliac articulation on the affected 
 side, which is flattened and its development arrested, as is shown in the 
 figure. Half of the sacrum is imperfectly developed, and the oblique 
 distortion is such that the whole of that bone is carried towards the 
 
 Fig. 141. 
 
 Obliquely distorted pelvis. 
 
 affected side, while the sacro-iliac synchondrosis of the sound side is 
 brought nearly opposite to the pubic symphysis.. 
 
 Deformities of the cavity of the pelvis may either be associated with 
 some of the above, or may exist independently. One of the best known 
 of these, and which is by no means an uncommon cause of impaction 
 
448 
 
 DEFORMITIES OF THE PELVIS. 
 
 [CHAP. 
 
 of the head within the cavity, is " flattening" of the sacrum as here 
 shown. The normal recession of that bone being wanting, the conju- 
 gate diameter of the cavity is proportionally curtailed, and the move- 
 ment of rotation rendered im- 
 FlG - 142 - possible. 
 
 In other cases, the diameters 
 of the pelvis are diminished from 
 above downwards, so as to con- 
 stitute what has been designated 
 and described as the "funnel- 
 shaped" pelvis. An example of 
 this, from an original drawing of 
 such a case, is shown in Fig. 143, 
 in which the gradual approxi- 
 mation of the ischial planes is 
 greatly exaggerated, and the flat- 
 tening of the sacrum contributes 
 to the reduction of the conjugate 
 diameter. Sometimes the curve 
 of the sacrum is too great or too 
 abrupt, as in the case represented 
 in Fig. 144. This, however, might perhaps be supposed to come more 
 within the category of distortion of the outlet, although it may, we 
 apprehend, be fairly considered as contributing to both. 
 
 Distortion of the outlet is necessarily involved in many of the varie- 
 
 Flattening of the sacrum. 
 
 Fig. 144. 
 
 Funnel-shaped pelvis. 
 
 Exaggerated sacral curvature. 
 
 ties which have been described. The general effects produced in mala- 
 costeon are, then, a narrowing of the transverse diameter, chiefly by 
 approximation of the acetabula. This implies, as a reference to Fig. 
 139 will more clearly show, a diminution of the corresponding diame- 
 ters of the cavity and outlet, which brings the tuberosities of the ischia 
 nearer to each other, and thus reduces the subpubic angle, so that the 
 
XXVII.] . VARIETIES. 449 
 
 head must descend further in the direction of the perineum, before it 
 can pass under the subpubic arch. And, in like manner, a diminution 
 of the conjugate diameter at the outlet will materially impede the birth 
 of the head. An abrupt curve of the sacrum, as shown in the accom- 
 panying figure, will have this effect, and if there should be, as has been 
 observed, anchylosis of the sacro-coccygeal articulation, the difficulties 
 of the case will thereby be materially increased. When the deformity 
 is confined to this part of the pelvis, it has been observed that approxi- 
 mation of the ischial tuberosities is quite as frequent as conjugate con- 
 traction. 1 
 
 The masculine type of pelvis has already been mentioned in refer- 
 ence to the deformities which exist at the brim. An extension of this 
 to the cavity and outlet constitutes a very serious impediment to labor. 
 In such cases, we may have the bones of the pelvis thicker, heavier, 
 and more marked with muscular attachments, the cavity deeper — as is 
 more particularly shown by the greater depth of the pubic symphysis, 
 — and the subpubic angle rendered more acute by an approximation 
 of the ischial tuberosities. Or, again, we may have an infantile type 
 of pelvis, in which, from arrest of development, with or without rickets 
 in other parts, the inclination of the brim is greater, and-the transverse 
 diameter relatively less than is normal, while the whole pelvis is smaller 
 than it should be. 
 
 It is a fact familiar to every surgeon, that the action of the muscles 
 plays a most important part in producing distortion of a rickety skele- 
 ton ; but it would appear that this cause of pelvic deformity has not re- 
 ceived anything like general attention at the hands of obstetric writers. 
 The following observations on this point are borrowed from Dr. Mur- 
 phy : " In the motions of the body, there are two sets of muscles con- 
 nected with the pelvis to be considered, each having a distinct office to 
 perform. One set, passing anteriorly and posteriorly, between the pelvis, 
 and the thigh-bones, keeps the pelvis fixed to its position ; these, there- 
 fore, would act very powerfully in distorting the softened bone to which 
 they are attached, but would manifestly produce a much greater effect 
 when the body is upright and the pelvis is made a centre of motion, 
 as in the adult pelvis, than when the body is bent forwards, and moves 
 less upon the pelvis, as in the child. Such we find to be the case : the 
 lower portion of the sacrum and the coccyx is bent, nearly at a right 
 angle, by the great gluteal and pyramidal muscles, and close up the 
 outlet. Anteriorly, the effect is not so apparent in the adult pelvis, 
 because it is counteracted by the acetabula and ischio-pubic rami being 
 pressed in towards the centre; but still the edges of these rami are 
 more everted, and the pubic arch itself, immediately beneath the sym- 
 physis, is wider than it ought to be. The other set of muscles are 
 those that maintain the body in its erect position ; posteriorly the 
 dorsal ; and, anteriorly, the abdominal muscles. The tendency of the 
 former is to draw the sacrum towards the spine, and thus to increase 
 the projection of the promontory; the effect of the latter is to draw 
 
 1 For an exhaustive account of the difference between malacosteon and rickety 
 pelves, embodying the researches of Meyer r of Zurich, see an article by Dr. Mat- 
 thews Duncan in the Edinburgh Medical Journal for April, 1856. 
 
 29 
 
450 DEFORMITIES OF THE PELV1.S. [CHAP. 
 
 the ilium more upright, and to render it more irregular. The action 
 of these muscles will therefore explain the character of some of the 
 distortions in the adult pelvis. In the infant pelvis, their influence is 
 modified by the altered position of the body. In this case, the weight 
 from above presses down upon the thigh-bones, and tends to separate 
 them more from each other; the muscles, therefore, passing between 
 them and the pelvis, will draw outwards that portion of the pelvis to 
 which they are attached ; hence the ischio-pubic rami are more sepa- 
 rated, and the tubera of the ischia more apart than natural ; but the 
 distance of the thigh-bones being increased, the coccyx can still be 
 drawn forwards by the muscles attached to it; consequently the outlet 
 is much more open than it ought to be, and the abruptly-curved sacrum 
 becomes the only impediment to the escape of the head." 
 
 It will be understood that the varieties of pelvic deformity above 
 described are far from embracing all that might be adduced, as our 
 object has been to avoid complication by simplifying the subject as far 
 as is consistent with a correct appreciation of the facts which may be 
 supposed to bear upon practice. Some of the rarer deformities are 
 figured in Moreau's atlas. There are still, however, one or two con- 
 ditions which, although not strictly pelvic deformities, are very prop- 
 erly considered along with them. Among these we may first mention 
 deformity due to disease of the lower portion of the spinal column, 
 in which curvature, or other displacement of the bones, may prove as 
 effectual a bar to natural delivery as the more common varieties of de- 
 formity at the brim. Of this nature is the affection which has been 
 described under the name of Spondylolisthesis, when the last lumbar 
 vertebra slips downwards and forwards, and directly encroaches on the 
 conjugate of the brim. 
 
 Nor can Ave omit to mention two other varieties of peculiarity in 
 conformation, in each of which the shape of the pelvis, and relative 
 measurements of its parts, are perfectly normal. The former of these, 
 which has been termed the pelvis cequabiliter-justo-major, implies a 
 pelvis which is symmetrically increased in all its diameters. Although 
 such a conformation as this must necessarily act by facilitating labor, 
 by the comparative ease with which it admits of the passage of the 
 child, it is not to be regarded as a favorable condition. On the con- 
 trary precipitate labor is always, and with good reason, looked upon 
 with apprehension, as experience teaches us that, when moderate and 
 normal resistance on the part of the pelvic walls is wanting, violent 
 and rapid dilatation of the soft textures of the canal necessarily takes 
 place, to the danger of their integrity at any part from the os uteri to 
 the vulva ; and there are, in addition to this, other dangers, which will 
 afterwards be more particularly described. The only advantage which 
 may accrue from such a pelvis occurs, according to Churchill, in face 
 presentations. To this we may perhaps add occipito-posterior posi- 
 tions of the cranium, and, in the absence of all assistance, transverse 
 presentations, as it would naturally favor spontaneous expulsion or 
 evolution. The pelvis cequabiliter-justo-minor — the other variety re- 
 ferred to — is the converse of this. We have here also a perfectly- 
 shaped pelvis ; but all the diameters are less than is usual, so that a 
 
XXVII.] 
 
 VARIETIES. 
 
 451 
 
 Fig. 145. 
 
 special impediment must in every such case exist, in a degree propor- 
 tionate to the extent of the symmetrical deformity. What makes this 
 a condition more unfavorable than we might at first suppose, is the 
 absence of any possible compensation in one direction for a deformity 
 existing in another. We thus find that the moulding process is of 
 much less avail here than where, for example, we have a moderate 
 degree of conjugate contraction, with an ample measurement in the 
 transverse, in which latter direction the head may, by compression, 
 elongate itself, and thus, by changing its shape, pass the obstacle, after 
 a certain amount of delay. 
 
 We may here consider the effect which is produced by certain sur- 
 gical diseases or accidents which may prove impediments, more or less 
 insuperable, to normal parturition. These are in their nature various, 
 and, in their extent, offer every variety from a slight encroachment 
 upon a single diameter to complete blocking up of the true pelvis. 
 Osteosarcoma and Exostosis are two 
 of the most important of these affec- 
 tions, and may constitute, if of any 
 size, an impediment which renders 
 delivery by the natural channel quite 
 impossible. These tumors may take 
 their origin from any part of the osse- 
 ous tissue of the pelvis; but the situa- 
 tion from which they most frequently 
 spring is the upper third of the sa- 
 crum, encroaching therefore upon the 
 brim and cavity by spreading from 
 this centre. Care must be taken, by 
 examination through the vagina, and, 
 if necessary, through the rectum, not 
 to mistake these for abnormal con- 
 traction of the brim, due to projection 
 of the sacral promontory. This is 
 an error which has been committed, 
 and which would probably be in most cases avoided by external meas- 
 urement of the pelvis ; and, if it should, in the course of such an 
 examination, be discovered that the measurements in question were 
 normal in extent, the presumption of exostosis would be increased. 
 The absolute hopelessness, in the case of an exostosis of large size, of 
 delivering by the vagina will appear by a reference to this familiar 
 figure. Cancerous disease of the pelvic bones, resulting in the devel- 
 opment of tumors of greater or less consistency, may be a serious me- 
 chanical impediment to the course of labor, besides being a condition 
 which involves the life of the mother. These may spring from any 
 part of the pelvis, and will probably develop in the direction in which 
 there is least resistance, so that, if they have their origin in the inner 
 surface, they can scarcely fail seriously to reduce the diameters of the 
 pelvis in the same manner as the benign tumors previously described. 
 
 The projection from certain portions of the pelvis of osseous spiculse 
 was made the subject of very painstaking investigation by Kilian, who 
 
 Pelvic exostosis. 
 
452 DEFORMITIES OF THE PELVIS. [CHAP. 
 
 found that a common situation of such spiculse is the margins of the 
 various symphyses. It is not difficult to foresee the effect of such 
 sharp thorn-like projections if they should chance to spring from the 
 sacro-iliac synchondrosis, or from any other part of the brim of the 
 pelvis ; and, indeed, in such cases, — which are fortunately very rare, — 
 scarcely anything could be looked for but laceration of the uterus and 
 possible rupture. It would appear to be a general belief, that bony 
 growths from the pelvis are in some way associated with the gouty or 
 rheumatic diathesis. Partial ossification of the sacro-sciatic ligaments 
 has been sometimes observed, and, when this takes place, the peculiarity 
 would, no doubt, be suggestive of the natural condition in some of the 
 lower animals. From these, from the other ligamentous structures, 
 and from the periosteum, tumors of the fibrous or fibro-sarcomatous 
 variety may spring, which, when constituting an apparent deformity in 
 the pelvis, have sometimes been successfully removed in the course of 
 labor. Any attempt at the removal of the purely bony tumors is out 
 of the question, but cases have occurred in which the texture of these 
 tumors was so loose, and so entirely composed of weak cancellated 
 structure, as to admit of being crushed or broken down, either by the 
 foetal head or the manipulations of the accoucheur. 
 
 Fractures of the pelvis are occasional causes of pelvic deformity, — 
 either from the union of the fractured bones in a distorted position, or 
 from the irregular development of callus in the direction of the pelvic 
 cavity, the diameters being thereby reduced. Projections of this kind 
 have been observed, in which the pelvic diameters involved were re- 
 duced to the extent of one and even two inches. Very considerable 
 deformity of the pelvis may also be the result of Morbus Coxarius, 
 which has gone on to dislocation and anchylosis; or of fracture or dis- 
 location of the head of the bone 1 , — the effect being due, in such cases, 
 to the distorted condition of the limb acting, in all probability, on a 
 pelvis which is morbidly softened, or at least in a constitution which 
 is impaired. 
 
 Symptoms. — These may, to a great extent, be inferred from what has 
 been said in reference to the causes from which pelvic deformities are 
 believed to arise. In marked cases, involving considerable deformity — 
 such as may be due to Rachitis — the general distortion of the skeleton 
 will point to the pelvis as a part of the solid framework of the body 
 which can hardly be expected to have escaped. But an obvious rickety 
 condition of the skeleton is no evidence whatever, either of the degree 
 or of the nature of the deformity. It is necessary, therefore, in such 
 instances, if we desire to gain an accurate knowledge of the nature of 
 the case, to observe with great care the actual pelvic measurements, 
 both externally and internally. The conjugate diameter is that which 
 in most instances we are anxious to determine, and, in so far as this 
 may be inferred from measurement in the living subject, it may be 
 approximately ascertained by the use of Baudelocque's Calipers, which 
 are here shown. By this, and making a deduction of about three 
 inches for the soft parts, the measurement from the posterior sacral 
 spines to the anterior surface of the pubic symphysis should be about 
 seven inches. Such a method of examination as this is so manifestly 
 
XXVII.] 
 
 PELVIMETRY. 
 
 453 
 
 open to the operation of disturbing causes, that little reliance can be 
 placed on inferences which are drawn from it alone, so that various 
 instruments have been devised, and a great amount of mechanical in- 
 genuity has been expended, on the construction of an internal pelvime- 
 ter. One of the earliest instruments of this kind was the pelvimeter 
 of Coutouly, which closely resembles in its form the rule used by shoe- 
 
 FlG. 146. 
 
 Baudelocque's calipers, and Coutouly's pelvimeter. 
 
 makers in measuring the length of the foot, and consists of two parts, 
 one of which slides in a groove in the other. A limb projects from 
 the extremity of each of these at right angles to it. The instrument is 
 introduced beneath the arch of the pubis, and pushed onwards until 
 the extremity touches the sacral promontory. It is held in this posi- 
 tion, and the pubic portion is then slid forwards until it touches the 
 posterior surface of the pubic symphysis. The distance of the sacrum 
 from the pubic bones is indicated by the extent to which the anterior 
 portion is thus drawn out, which is read off in inches marked on the 
 stem. The total length of this instrument, which is also represented 
 in Fig. 146, is about eleven inches. 
 
454 DEFORMITIES OF THE PELVIS. [CHAP. 
 
 An immense number of pelvimeters have since then been invented. 
 That which is shown in Fig. 147, as designed by Dr. Lumley Earle, is 
 probably one of the best and simplest : it is to be introduced into the 
 vagina with the shorter of the two limbs turned towards the pubis ; 
 and, on the extremity reaching the level of the brim, as ascertained by 
 the finger, along which it is carefully guided, the handles are pressed 
 together, and their divergence read off on the scale which is between 
 them. The objection to all such internal instruments is, that they are 
 difficult of application so as to insure accurate results, and besides not 
 altogether safe unless used with great caution. Coutouly's is, for 
 reasons which are quite obvious, inapplicable to cases in which the 
 woman is in labor, and, indeed, to cases of pregnancy, so that in the 
 very instances in which we are most anxious for exact information, it 
 is practically valueless. Dr. Earle's is, no doubt, from this point of 
 view, to be preferred. But even when, in the absence of pregnancy, 
 we may wish to ascertain the condition of the pelvis, it is by no means 
 an easy matter to use either the one or the other. 
 
 All such contrivances, indeed, as have hitherto been invented are 
 open to the objections which have just been stated. Many of the best 
 authorities have, on this account, absolutely discarded them, and prefer 
 the simpler method of investigation by the finger. The various methods 
 by means of which we may thus gain information have been admirably 
 described and illustrated by Dr. Ramsbotham. "Three methods," he 
 says, " are practiced : one is, by the introduction of the first finger of 
 the right hand within the vagina, so that the point should be carried 
 up to, and touch the sacral promontory, while the root of the finger is 
 applied exactly under the symphysis pubis, at the upper part of the 
 arch. It must be evident that this mode of inquiry will be of no avail 
 unless the pelvis be greatly distorted — considerably under three inches, 
 indeed, in the conjugate diameter. For the ordinary length of the 
 index finger along its inner edge is less than three inches ; and as the 
 oblique line from the promontory to the apex of the pubic arch exceeds 
 the direct line across, so if there be more than the space just mentioned, 
 the finger would not be able to reach the projection, and we should 
 consequently be in utter ignorance what amount of room existed. If 
 the pelvis be very small, the sacral promontory can be felt with ease; 
 but, even in that case, the dimensions of the direct conjugate diameter 
 is not afforded, but the length of the oblique line is given ; and it is 
 not always possible to calculate the difference between these two lines 
 accurately." 
 
 " Another mode which has been recommended is the introduction of 
 the whole left hand within the pelvis, with the outside or point of the 
 little finger touching the inner surface of the symphysis pubis, and the 
 first finger placed against the promontory of the sacrum. As every 
 man is aware what his hand measures across, it is supposed he will be 
 able to ascertain the transverse (conjugate?) diameter of the pelvis. 
 Thus, presuming the hand to be two inches and three-quarters wide, 
 which is the common average about the centre of the fingers, if, when 
 placed edgeways, it just fits the brim, the examiner will know that 
 the space is within three inches. Again, if he can only introduce three 
 
XXVII.] 
 
 MANUAL PELVIMETRY. 
 
 455 
 
 fingers instead of four, he will know that the pelvis does not measure 
 two inches, and probably not so much ; and, if he can only pass up 
 two fingers, closed together, he will be assured that there is not more 
 than an inch and three-eighths. But, on the contrary, if, in introducing 
 the whole hand, he be compelled to spread his fingers widely before he 
 can touch the sacral promontory, he will then be certain that the space 
 is more than three inches, probably four, or near it. But it is not always 
 easy to follow this mode of inquiry, because the child's head is generally 
 protruded somewhat into the pelvis, even when the brim is contracted ; 
 and we could not carry the hand up in this manner, and make the 
 accurate examination which we require to do, unless the brim as well 
 as the cavity were perfectly free and unoccupied. It might, perhaps, 
 be employed with advantage, provided the deformity was excessive." 
 
 Fig. 147. 
 
 Fig. 148. 
 
 Lumley Earle's pelvimeter. 
 
 Manual pelvimetry. (Kamsbotbam.) 
 
 " The third method I consider the best, and is the one I myself 
 adopt. Two fingers of the left hand are to be carried within the vagina ; 
 the extremity of the first finger is to be placed exactly behind the sym- 
 physis pubis, and the tip of the second against the sacral promontory. 
 (See Fig. 148.) By stretching the fingers in this way, we shall have 
 
456 DEFORMITIES OF THE PELVIS. [CHAP. 
 
 little difficulty in reaching the promontory of the sacrum, even when 
 the pelvis is of ordinary dimensions; and by withdrawing them in the 
 same position, we may measure off the distance between their extremi- 
 ties on the first finger of the right hand, or on a scale of inches, or with 
 the limbs of a pair of compasses; and, consequently, we arrive at an 
 accurate knowledge of the great dimensions of the pelvic brim. The 
 laxity of the vagina, and other soft structures, which almost invariably 
 attends the process of labor, will permit the fingers to be withdrawn 
 while extended ; and if the examiner uses sufficient care, they may be 
 kept perfectly steady until the space which they embrace be ascertained. 
 This mode Of proceeding possesses a great advantage over the other two, 
 inasmuch as we are able equally well to make our examination, whether 
 the head be occupying a part of the pelvic cavity, or whether it be still 
 detained quite above the brim ; for, even if it be engaged in the vagina, 
 one finger may be passed anterior to, and the other behind it, with 
 comparative ease." 
 
 It is only, however, after considerable experience that such arbitrary 
 methods of examination are of much value in diagnosis. Very marked 
 deformity is usually recognized easily enough, but the more important 
 question of the degree or amount of distortion is not so readily solved, 
 and will always require most careful and exact observation. It is upon 
 the latter, indeed, that the most important practical considerations 
 hinge ; and upon the result of such an investigation, be it right or 
 wrong, will depend whether, in a given case, we determine in favor of 
 operation by the forceps, turning, craniotomy, or the Caesarian section. 
 The actual measurements which relate to these operations will be more 
 particularly considered in the chapters which follow. 
 
 The effects, direct and indirect, of pelvic deformity, are often very 
 serious, and are usually to be observed, as might be anticipated, in 
 neglected or mismanaged cases. A common result of long-continued 
 pressure upon the tissues of the os and cervix is sloughing of these 
 parts, attended with irritative fever, and general symptoms even more 
 severe than this. The destruction of tissue which is involved in this 
 process may result in fistulous openings into the bladder or rectum, 
 requiring subsequent operative procedure for their cure. The deformi- 
 ties are, as is universally admitted, frequent causes of rupture of the 
 uterus, sometimes from actual bursting, violence of the pains, and, in 
 other cases, by pressure of the walls of the uterus against some part of 
 the brim of the pelvis. The great amount of pressure which is ex- 
 ercised in these cases is occasionally shown in a significant manner by 
 the moulding and alteration in shape of the child's head. This some- 
 times presents an indentation of the parietal bone from the pressure of 
 a projecting sacral promontory; and, under the influence of the same 
 cause, even fracture of the parietal bone has taken place. Another 
 marked effect, produced by the arrest of the child's head or other pre- 
 senting part, is the formation of a caput succedaneum of very unusual 
 size, in the observation of which a serious error may arise. The for- 
 mation of this swelling is a process of gradual development in the 
 direction of the vagina, and not of sudden growth : it may, therefore, 
 happen, that an inexperienced person, who feels that the actual surface 
 
XXVII.] TREATMENT. 457 
 
 of the scalp approaches nearer and nearer to the finger, may take this 
 as evidence of a gradual advance of the head, the passage of which may 
 nevertheless be absolutely barred. If, in consequence of this or any 
 similar error in judgment, the case is left too long to nature, the powers 
 of the woman progressively decline, and she soon reaches a condition 
 in which we act at a great disadvantage, and even with much appre- 
 hension as to the ultimate result. 
 
 In cases of extreme deformity, the head does not even engage in the 
 brim, so that the effect of the ordinary expulsive efforts is simply to 
 pinch or compress the lower segment of the uterus against the pelvic 
 walls, while the os is being slowly dilated by the bag of waters. When 
 the deformity is confined to the brim, and the promontory is not within 
 reach of the finger, the nature of such a case is probably sometimes 
 overlooked at first, as the examiner may conclude, from a simple ex- 
 ploration of the vagina by one finger, that everything is quite normal 
 and that the presenting part will descend presently. In other instances, 
 the obstruction being less in degree, the vault of the cranium passes 
 the plane of the brim, and the head is only arrested when its principal 
 diameters come to be involved ; and, in a third class of cases, the 
 obstacle being in the cavity or even at the outlet, labor goes on quite 
 naturally until the head reaches the particular plane at which the 
 obstruction exists. 
 
 There is one point, in reference to these cases, in which it is of much 
 importance that we should ascertain the relative condition of the parts 
 involved : this is best expressed by drawing a careful distinction between 
 the terms "impaction" and "arrest," which are sometimes used some- 
 what loosely, as if the expressions were synonymous. By impaction, 
 we should imply only such a condition of the head as consists in its 
 being actually jammed in the pelvis. In such a case, not only does 
 the head make no advance with the pains, but it does not recede during 
 the interval, so that it is immovable in both directions. In a case in 
 which the head is only arrested, however, there may be an equal impos- 
 sibility as regards the advance of the head ; but its recession during the 
 interval between the pains shows that the period of impaction has not 
 yet been reached — a point which may be of very considerable importance 
 in regard to the probable success or failure of a given operation. 
 
 Treatment — -The management of cases of pelvic deformity will be 
 treated of in detail when, in the subsequent chapters, the various opera- 
 tions are considered, the necessity for which arises in a great measure 
 from this particular cause. The accoucheur is occasionally consulted 
 in reference to such cases, at a time when the dangers of pelvic distor- 
 tion may be averted or modified. If it be a question as to marriage, 
 it may be a very difficult as well as a delicate matter to decide, in a 
 rachitic patient, between celibacy and the possible dangers of pregnancy ; 
 but, if the case should be put before us, we must simply advise accord- 
 ing to the facts revealed in the course of a thorough examination, when, 
 if there should be evidence of such distortion as would probably call 
 for the operation of craniotomy, it will be proper to withold our sanction 
 to a marriage under such circumstances. Another possible case, in 
 which prevention rather than treatment may require consideration, is 
 
458 DEFOKMITIES OF THE PELVIS. [CHAP. 
 
 when the woman is pregnant, and the evidence of extreme distortion is 
 clear ; or when, in previous pregnancies, labor has only been terminated 
 by the sacrifice of the child. In both of these instances, the question 
 which arises is that of the induction of premature labor, by which alone, 
 it may be, the safety of the mother can be insured. It is generally, 
 however, in the course of labor at the full time that the nature of the 
 case is disclosed, and prompt and decisive treatment called for. 
 
 Having endeavored to ascertain, approximately at least, the amount 
 of distortion, we must, in the first instance, decide whether, and if so, 
 to what extent, we should give nature a chance. In the minor degrees 
 of pelvic deformity, it is always proper to do so, if the strength of the 
 patient be not exhausted, and the uterine effort not unduly violent. 
 When the cranium is of moderate size, it frequently occurs that, even 
 in unpromising circumstances, the head becomes so moulded as to pass 
 with perfect safety both to mother and child, although probably after 
 a tedious labor. If the head is not actually impacted, we may have 
 the choice of three operations, — the forceps, turning, or craniotomy; 
 but when impaction has taken place, it is impossible to pass the hand, 
 and, therefore, turning is struck out of our calculations altogether. In 
 every case in which the head is in the cavity or at the outlet, the forceps 
 should be preferred, unless, indeed, there is clear evidence that the 
 head cannot pass without a reduction of its bulk, when any attempt of 
 this kind would be worse than useless. If, however, the head should 
 be at the brim, the use of the long forceps involves other and more 
 serious considerations, and is, indeed, generally regarded as an opera- 
 tion so dangerous that not a few of the most distinguished of modern 
 obstetricians have expressed a decided preference for turning over the 
 forceps, and even, under certain circumstances, for turning as compared 
 with craniotomy when the head is in this particular situation. The 
 general rules which are laid down for our guidance in the application 
 of the forceps in ordinary cases are, to a limited extent only, of avail 
 here. The altered conditions of a deformed pelvis, differing more or 
 less in every case, put such rules as serve for the normal pelvis com- 
 pletely out of the question. Instead, for example, of applying the 
 blades to the sides of the head, it is often necessary to apply them to 
 the forehead and occiput, and, in general terms, it may be said that our 
 duty is to apply them in the direction where we have most room, and 
 where we can get the firmest grip of the cranium. Thus, if the head 
 is arrested at the upper portion of the cavity, in consequence of projec- 
 tion of the sacral promontory, the sides of the head will probably be 
 strongly compressed in the reduced conjugate diameter. The insertion 
 of the blades of the forceps in such a direction would, therefore, be 
 practically a matter of great difficulty, if not impossibility ; so that the 
 operator should at once, and without hesitation, apply the blades to the 
 long diameter of the head in the'transverse of the brim. 
 
 If the head is at the brim, and the distortion not excessive, it will 
 be quite proper, as we conceive, to make a gentle attempt by the long 
 double-curved forceps, which should be of considerable strength in 
 construction, in order to gain an efficient hold, and to prevent slipping. 
 The operator, bearing in mind the immense power of such an instru- 
 
XXVII.] TREATMENT. 459 
 
 merit, will be excessively cautious in the amount of force which he em- 
 ploys, and will only persist if he observes some indication of yielding. 
 
 Putting, for the moment, out of the question what have been called 
 long-forceps cases, there are few points, of undoubted practical impor- 
 tance, in reference to which greater difference of opinion obtains, than 
 with regard to the proportion of cases in which we are justified in ap- 
 plying the forceps in the minor degrees of pelvic disproportion. When 
 we find one practitioner of experience using it only once in a hundred or 
 even in several hundred cases, and another, of equal, experience, in 
 every eight or ninth case, it is by no means easy to decide who is in 
 the right. For our part, we entertain a very confident belief that the 
 practitioner who uses the forceps in less than five per cent, of all his 
 cases exposes many of his patients to needless pain and increased risk, 
 and is pretty sure, in his practice, to lose more children in labor than 
 he ought. 
 
 When the decision lies between turning and craniotomy, we must 
 first be sure that, if we succeed in turning, the head can be got through 
 the contraction ; for it sometimes happens that, after turning, delivery 
 can only be accomplished by perforating behind the ear. It must, 
 therefore, be obvious, that it would be better to perforate, and deliver 
 at once, than to turn and then perforate, thereby subjecting the woman 
 to a twofold danger. We must also be able to displace the presenting 
 part without employing much force, so as to introduce the hand into 
 the uterus ; and it is certain that, when this cannot be done without 
 violence, it is better at once to desist. One of the most important 
 bearings of this interesting subject is whether the child is alive or not, 
 which may be ascertained by the stethoscope in the usual way. If it 
 is so, the possibility of saving the child, — which has sometimes been 
 done when the general condition seemed little to encourage the hope 
 of such a favorable result, — is the strongest possible inducement we 
 can have for choosing turning, giving the child the chance at least, 
 small though it may be, of which craniotomy necessarily deprives it. 
 
 Among the minor arguments which have been used in support of 
 this procedure, may be mentioned the repugnance with which one 
 naturally regards any operation which involves the mutilation of the 
 child, and the use of instruments instead of the hand. And, again, as 
 has very clearly been pointed out by Simpson, there is an undoubted 
 advantage in the manner in which "the transit of the cone-shaped head 
 of the child, through a somewhat narrow brim, is facilitated by the 
 narrow end of the cone (or bimastoid diameter of the head) being made 
 to enter and engage first in the contracted brim ; and the hold which 
 we obtain of the extracted body of the child enables us to employ so 
 much extractive force upon the engaged foetal head, as to make the 
 elastic sides of the upper and broader portion of the cone (or biparietal 
 diameter of the cranium) to become compressed, and if necessary in- 
 dented, between the sides of the contracted brim." Besides, the opera- 
 tion of turning, when it can be effected, even after some time, and with 
 some difficulty, is, there is good reason to believe, more safe to the life 
 of the mother than that of craniotomy ; so that, even when the child 
 is dead, it is often to be preferred. But, when the child is dead, and 
 
460 THE FORCEPS. [CHAP. 
 
 turning is unusually difficult, or impracticable, we must consent to 
 waive the objections which have just been stated, and substitute craniot- 
 omy without delay. This, then, is a question of great practical im- 
 portance, and is still receiving, at the hands of the ablest obstetricians, 
 the attention which it merits ; but the limits of this work preclude a 
 more extended analysis of the facts which bear upon the subject. 
 
 When the pelvic distortion is excessive, and more than one of the 
 diameters is encroached upon to a great extent, as has frequently been 
 observed in malacosteon pelves, it may be quite impossible to deliver 
 the woman by means of any of the operations which we have mentioned. 
 We ma} r , in such instances, have no resource but the desperate one of 
 the Caesarian section. What specific conditions may be held to justify 
 the performance of that particular operation, we shall afterwards at- 
 tempt to show; but, in regard to it, as well as the other methods of 
 operative procedure, it is well-nigh impossible to lay down hard-and- 
 fast rules, which may seem, in any strict sense, reliable, as for our guid- 
 ance. An attempt will, however, be made to state the measurements, 
 and other conditions, which are held, by the most competent authori- 
 ties, to be warrant for the preference of one operation over another. 
 
 The above remarks have had reference to cranial presentations only ; 
 but it is, of course, to be kept in view that any other presentation may 
 occur, and thus develop new and special considerations. An intelligent 
 combination of the general principles upon which such presentations 
 are to be managed, and an adaptation of these to the special circum- 
 stances of the case, will enable the well-informed practitioner to con- 
 duct such cases also in a skilful and creditable manner. 
 
 CHAPTER XXVIII. 
 
 THE FORCEPS. 
 
 HISTORY OF THE FORCEPS — CHAMBERLEN'S FORCEPS — INVENTION OF THE PELVIC 
 CURVE — THE SHORT FORCEPS : CASES TO WHICH IT IS APPLICABLE — REASONS 
 FOR PREFERRING THE STRAIGHT FORCEPS IN MOST CASES — CIRCUMSTANCES IN 
 WHICH THE FORCEPS IS REQUIRED — APPLICATION OF THE FORCEPS : CONDITIONS 
 ESSENTIAL TO SAFETY : DEGREE OF DILATATION OF THE OS : IS IT NECESSARY 
 TO FEEL AN EAR? MEMBRANES TO BE RUPTURED : BLADES TO BE APPLIED TO 
 THE SIDES OF THE HEAD: FORCEPS TO BE APPLIED IN THE OPPOSITE OBLIQUE 
 DIAMETER TO THAT OCCUPIED BY THE HEAD OF THE CHILD — THE OPERATION: 
 INTRODUCTION OF THE " LOWER" AND " UPPER" BLADES IN THE FIRST CRA- 
 NIAL POSITION — APPLICATION TO THE OTHER CRANIAL POSITIONS. 
 
 The subject of operative Midwifery, naturally commences by a con- 
 sideration of the great Prime Mover of Obstetrics, as the Forceps has 
 not inaptly been termed. It is scarcely possible to exaggerate the im- 
 
XXVIII.] EARLY INSTRUMENTS. 461 
 
 portance of this instrument, which is simple in construction, easy of 
 application, and marvellous in power; and, besides, the greater fre- 
 quency with which we avail ourselves of its aid, as compared with 
 other methods of instrumental and operative assistance, fully entitles 
 it, and its application in practice, to the prominent position in which 
 the subject is invariably placed. 
 
 No doubt can be entertained that the ancients discovered, and were 
 in the habit of using, an instrument which, in the principle of its con- 
 struction, is identical with the modern forceps. The period at which 
 the discovery was actually made will probably never be known. It 
 does not appear that the knowledge of the subject was general, even 
 among the most civilized communities, but it is certain that it was 
 well known to the early Arabian physicians. We thus find it men- 
 tioned by Avicenna, and more particularly described by Albucasis, 
 who lived about the eleventh or twelfth century. The latter describes 
 two kinds of forceps, the misdach and the almisdach, both being ac- 
 cording to the Latin version circular and full of teeth. It is worthy 
 of note that, in the Arab original, which Smellie seems to have seen in 
 the Bodleian library at Oxford, the misdach is described as straight, 
 and the almisdach as curved. This important discovery was, however, 
 completely lost sight of in the gloom of the dark ages, nor was it till 
 the middle of the seventeenth century that it was rediscovered and, 
 after a long interval of secrecy, introduced into practice. 
 
 The discovery w T as made, as Dr. Churchill has clearly made out, by 
 Dr. Paul Chamberlen prior to 1647, and was communicated by him to 
 his sons, who were also members of the profession. The secret seems,, 
 however, to have been greedily guarded by the Chamberlen family 
 for their own profit; and Dr. Hugh Chamberlen, who translated into 
 English Mauriceau's work on Midwifery, alludes to it in the preface 
 to that work as late as 1716. Referring to the use of the crotchet, he 
 says, " but I can neither approve of that practice, nor of those delays, 
 beyond twenty-four hours, because my father, brothers, and myself 
 (though none else in Europe as I know) have, by God's blessing and 
 our industry, attained to, and long practiced a way to deliver women 
 in this case without any prejudice to them or their infants; though all 
 others (being obliged, for want of such an expedient, to use the common 
 way) do and must endanger, if not destroy, one or both, with hooks.' 7 
 As a sort of apology for keeping it secret, he adds, " there being my 
 father and two brothers living that practice this art, I cannot esteem 
 it my own to dispose of nor publish it without injury to them." 
 
 The political troubles of his time obliged Dr. Hugh Chamberlen, on 
 two occasions at least, to fly the country and take refuge on the Con- 
 tinent, where he made various attempts to dispose of his invention. 
 His offer to sell it to the French Government was refused, chiefly 
 on account of the failure which had attended his efforts to deliver a 
 woman upon whom Mauriceau had resolved to perform the Caesarian 
 operation, and which was therefore a case, as we may assume, quite 
 unsuitable for the operation by the forceps. He was more successful, 
 however, in Holland, where he managed to. dispose of his secret to 
 
462 
 
 THE FORCEPS. 
 
 [CHAP. 
 
 Fig. in 
 
 Sketch of Chamberlen's for- 
 ceps. (Rigby.) 
 
 several practitioners, of whom the eminent Ruysch, the anatomist, 
 was one. From the Netherlands to Germany, where it was used by 
 Solingen, and ultimately to France, the secret 
 slowly spread, until it was a secret no longer^ 
 and was recognized in all its importance by the 
 most accomplished accoucheurs of the day. 
 Long before the operation had thus made its 
 way into notice on the Continent, the secret in 
 this country had undoubtedly oozed out in 
 some quarter; and, ultimately, the midwifery 
 forceps was described and figured by Chapman, 
 in his well-known work, as the instrument used 
 by the Chamberlens. A very interesting dis- 
 covery was made in the old manor-house of a 
 small estate near Maiden, in Essex, which 
 had been purchased by Dr. Peter Chamberlen 
 towards the end of the seventeenth century, 
 and which had remained in the family till 
 about 1715. In an old chest in one of the 
 rooms of this house, there was discovered, in 1818, a collection of ob- 
 stetric instruments, along with old coins, trinkets, and the like. Mr. 
 Cansardine, into whose possession these relics had fallen, gave an inter- 
 esting description of them in the Medico- Chirurgical Transactions , Vol. 
 IX. There were several pairs of forceps, showing apparently the 
 various stages of advancement through which the invention passed in 
 Chamberlen's hands before he reached what he believed to be perfec- 
 tion. Fig. 141) shows one of the most perfect of these, in which the 
 blades are fenestrated, and are so constructed as, when separately ap- 
 plied, to be articulated together at the shank by means of a pivot. 
 This instrument, as perfected by Giffard and Chapman, is essentially 
 the same as the forceps most frequently used at the present day, except 
 in so far as the lock is concerned. 
 
 Up to this time the handles of all the instruments were, as in the 
 French forceps to the present day, of iron, and the lock was either a 
 pivot, with or without a screw; a sort of mortice lock, like the blades 
 of a pair of scissors; or the blades were clumsily tied together, after 
 their adjustment, by means of a tape or cord. We are certainly indebted 
 to Smellie for the simple contrivance which is known as the English 
 lock, and also for the adaptation of wooden handles, which give a much 
 better hold and purchase. The principle upon which all forceps were 
 essentially constructed was to adjust the curve of the blades with refer- 
 ence only to the spheroidal shape of the child's head, so as to make sure 
 of securing an efficient hold without risk to the child. The difficulty 
 in the application of such an instrument as this, when the head was at 
 the brim or at the upper part of the cavity, led to another important 
 modification of the forceps, the credit of which is divided between 
 Levret and Smellie. It is most likely, however, that the French ob- 
 stetrician was the real inventor; but it is to be regretted, for the sake 
 of his reputation, that he made a secrect of it, as the Chamberlens, to 
 their lasting discredit, had done before. 
 
XXVIII.] SHORT FORCEPS. 463 
 
 The novelty in question consisted in the adaptation of a second curve 
 in the blades, with reference, in this instance, to the curved axis of the 
 pelvic canal. This is called the "pelvic curve/' and is the invariable 
 form of the French forceps of the present day; while, in this country, 
 the straight forceps lias been entirely abandoned by some of the most 
 eminent of our obstetrical authorities. This variety was originally con- 
 structed in order to overcome difficulties at the brim and high in the 
 cavity, and it is, therefore, to these that it is chiefly applicable ; although, 
 as has been said, many prefer this form in all cases, and allege that it 
 is easier in application, and safer both to mother and child. We do 
 not intend to enter at any length upon the controversy of single versus 
 double-curved forceps; but it is proper to mention that Dr. Barnes, i\w 
 latest English authority on the subject of operative midwifery, pro- 
 nounces, in yevy emphatic terms, in favor of the latter, in all cases, 
 whether at the brim, in the cavity, or at the outlet. For our part, 
 although we cannot subscribe to this doctrine, Ave are quite confident 
 as (o (he superiority of the pelvic curve in all cases where the head is 
 at the brim or high in the cavity. 
 
 Long and Short Forceps are described by all English writers as dis- 
 tinct varieties of the instrument, and are sold by the makers under these 
 names. The Short Forceps, as usually constructed, is an instrument 
 about eleven inches in length, the measurement from the lock to the 
 tip of the blades being a little over seven inches. Each blade is fenes- 
 trated, the aperture being destined, on each side, to receive the parietal 
 protuberances. The blades arc curved, so as to measure between their 
 widest part about three inches, and from tip to tip, when closed, not more 
 than an inch. This instrument when made without a pelvic curve, is 
 known as Smellie's forceps, and is still used in this country more fre- 
 quently than any other Conn. When it is applied to the child's head 
 within the pelvis, the handles should be about an inch apart. It is 
 scarcely necessary to observe, what is equally applicable to any variety 
 of forceps, that, the blades should be made of steel of the finest temper; 
 otherwise, they are constantly apt to slip over (he head by yielding of 
 the metal. The edges are highly polished, and bevelled off in every 
 direction with great care, so as to avoid the possibility of injuring the 
 scalp of the child or the soil parts of the mother. Covering the blades 
 with leather was once practiced, but this has now properly fallen into 
 disuse, as rendering the instrument more difficult of introduction, and 
 more likely to convey infection. Nor is the practice of covering them 
 with a, composition of gutta-percha to be commended; and, when 
 properly made, the clean, smooth metal is, on all accounts, to be pre- 
 ferred. The short forceps is suitable for the extraction of the head 
 from the outlet and lower part of the pelvis; but if the head is higher 
 in the cavity, this instrument, although it may still be used with diffi- 
 culty, is not to be recommended when one more efficient is at hand. 
 Its use should be limited to those instances in which it is possible, after 
 adjusting the blades, to close them while the lock is still quite clear of 
 the external parts, li' the lock passes within the; vulva, there is con- 
 siderable danger, — especially when the woman is under the influence 
 
464 THE FORCEPS. • [CHAP. 
 
 of chloroform, and is thus unable to give any evidence of particular 
 suffering — of pinching in some portion of the soft parts, and inflicting 
 serious laceration. 
 
 To obviate this risk, and at the same time to render the forceps 
 capable of more extended application, we have always advocated the 
 employment, in ordinary practice, of an instrument which is both longer 
 and stronger than the ordinary short forceps. Such an instrument as 
 this, which fulfils equally well all the purposes of the short forceps, is 
 also applicable to cases in which the head occupies the middle third of 
 the cavity, or even a little higher. In these latter cases, the lock is 
 still external, and the power of the instrument is considerably increased. 
 The handles are stronger, and the blades thicker, than in the ordinary 
 short instrument; for it is a fundamental rule, in the construction of 
 the midwifery forceps, that, for obvious mechanical reasons, w T e must 
 increase the strength in proportion to the length of the blades. And, 
 in doing so, it is also proper so to construct the handles as to give the 
 operator sufficient power; as no greater error can be committed than to 
 sacrifice power to elegance, or to a dislike to give the instrument a 
 formidable appearance. The following remarks by Dr. Barnes are so 
 apposite to this, that we quote them here. " It has been sought," he 
 says, " to make an instrument safe by making it weak. There can be 
 no greater fallacy. In the first place, a weak instrument is, by the 
 mere fact of its weakness, restricted to a very limited class of cases. 
 In the second place, if the instrument is weak it calls for more muscular 
 force on the part of the operator. Now, it is sometimes necessary to 
 keep up a considerable degree of force for some time, and not seldom 
 in a constrained position. Fatigue follows; the operator's muscles 
 become unsteady; the hand loses, its delicacy of diagnostic touch ; and 
 that exactly-balanced control over its movements which it is all-impor- 
 tant to preserve. Under these circumstances, he is apt to come to a 
 premature conclusion, that he has used all the force that is justifiable; 
 that the case is not fitted for the forceps, and takes up the horrid per- 
 forator; or he runs the risk of doing that mischief to avoid which his 
 forceps was made weak. The faculty of accurate gradation of power 
 depends upon having a reserve of power. Violence is the result of 
 struggling feebleness, not of conscious power. Moderation must ema- 
 nate from the will of the operator; it must not be looked for in the 
 imperfection of his instruments. The true use of a two-handed forceps 
 is to enable one hand to assist, to relieve, to steady the other. By 
 alternate action the hands get rest, the muscles preserve their tone, and 
 the accurate sense of resistance which tells him the minimum degree of 
 force that is necessary, and warns him when to desist." 
 
 It is, perhaps, natural that an operator should prefer that form of 
 forceps to the use of which he has been trained, and upon which he 
 knows, by experience, that he can thoroughly depend in times of danger 
 or difficulty. In confessing, however, a personal predilection for the 
 straight forceps, it is proper to observe that many of the most expe- 
 rienced and distinguished practitioners, both in this country and abroad, 
 express a decided preference for the pelvic curve. No English writer 
 
XXVIII.] 
 
 STRAIGHT FORCEPS. 
 
 465 
 
 Fig. 150. 
 
 has so emphatically pronounced against the straight variety as Dr. 
 Barnes, in his recent work. Personal experience, which is corroborated 
 by that of many able and experienced accoucheurs, prevents us from 
 perceiving the strength of his arguments, or the justice of his conclu- 
 sions ; and we object more particularly to the assertion that the straight 
 forceps is especially dangerous to the child. It may well be that the 
 pelvic curve in the hands of those skilled in its use is equally efficient. 
 That it is so, cannot, indeed, be doubted, and it is possible that, when 
 once adjusted, the danger of slipping is less when used by the inexpe- 
 rienced, but we conceive that such problematical advantages are more 
 than counterbalanced by the following : First, the blades are more 
 easily introduced, with reference to the position of the child's head, if 
 the operator has but one curve to think of; 
 second, the two blades being the same, no 
 mistake can possibly be made between the 
 upper and lower, or anterior and posterior 
 blade ; and third, that if it should be found 
 necessary to alter the position of the head 
 by rotation, this can only be effected by the 
 straight instrument. 
 
 The forceps, the use of which we recom- 
 mend to young practitioners, who generally 
 possess but one, is an instrument of a size 
 intermediate between the ordinary short 
 forceps and what will presently be described 
 as the long forceps. It is, as already men- 
 tioned, applicable for all the purposes of 
 the short forceps, but by means of it we are 
 able to operate quite as easily when the 
 great diameters of the head are on a level 
 with the middle plane of the pelvis. It is 
 fourteen inches in length, the blades to the 
 lock being nine, and the handles five inches. 
 The fenestras are four and a half inches in 
 length, and something less than an inch 
 and a quarter in the widest part. The dis- 
 tance between the blades in the widest part 
 of the curve is three inches, and at the tips 
 a little under an inch. The handles are 
 
 lengthened tO Secure a better hold. 1 Straight forceps for ordinary use. 
 
 1 It would appear that, in some quarters, the words "short" and "straight," as 
 applied to the forceps, are admitted as synonymous terms. This, or (what is only 
 too probable) some confusion in the text, seems to have led to the idea that the 
 author of this work upholds the use of the short forceps. This he would beg to 
 repudiate, and he refers to Fig. 150, and to its dimensions as now stated, in refuta- 
 tion of what has been imputed to him by critics, who in other respects were gener- 
 ous and indulgent to a fault. The instrument here described is, in point of fact, 
 identical, or nearly so, with what is known in Ireland as Beatty's forceps, and is 
 almost identical in measurement, although stronger in construction, with a straight 
 forceps described by Dr. G-raily Hewitt some years ago. The young obstetric prac- 
 titioner should have nothing to do with the short forceps, unless he should be so 
 circumstanced as to have nothing better at hand. 
 
466 
 
 THE FORCEPS. 
 
 [CHAP. 
 
 [The author's recommendation of the straight forceps will not be 
 generally adopted in America. It carries us back to the days when 
 Dr. Thomas C. flames, the first Professor of Obstetrics in the Univer- 
 sity of Pennsylvania, advised the numerous students whom he taught 
 to use no other than the short straight instruments of Haighton. If 
 wo were to accept Dr. Irishman's statements as correct, the earnest 
 teachings of Dr. Dewees, "the American Baudelocque ;" and of Dr. 
 Hodge, his illustrious successor in the University of Pennsylvania, 
 would pass for naught. The former of these great men introduced the 
 long double curved forceps into use in America. The latter modified 
 the instrument in a number of important particulars. 
 
 In this country the straight forceps are scarcely ever used. The late 
 Professor Charles 1>. Meigs recommended the short double curved in- 
 strument of Professor Davis, of London, and for a long time it was a 
 favorite with the graduates of the school in which the former taught. 
 The inventor of these forceps, however, expressly 
 1 '"•• 15L stated that they were only applicable to cases in 
 
 which the head was arrested at the outlet or in 
 the cavity of the pelvis, and that they could 
 not he applied at the brim. Davis's instru- 
 ment, or some modification of it, continues to 
 be relied on in most cases by many experienced 
 and successful practitioners. 
 
 One of the most important improvements of 
 this valuable instrument which has been made 
 by any American accoucheur, is that of Professor 
 Hodge, who has attempted to combine all the 
 advantages of the various suggestions of others, 
 while he rejected everything which he deemed 
 objectionable. This forceps, its inventor claims, 
 has the following advantages over those of 
 others : 
 
 1. Its weight is diminished (to seventeen 
 ounces avoirdupois) without any diminution of 
 its strength. 
 
 2. The pelvic curve is such that the perineum 
 cannot he dangerously pressed upon when the 
 instrument is applied at the superior strait, 
 while any loss of power which may result from 
 this increased curvature, is compensated for by 
 a bend of the handles in the opposite direction, 
 which preserves the direct line of traction. 
 
 3. The shanks are closely approximated, and 
 occupy nearly parallel lines, one anterior to the 
 
 other, until nearly at the point where they join the blades, when they 
 separate abruptly. Thus undue stretching of the vulva and the danger 
 of lacerating the perineum are prevented. 
 
 4. The blades are of nearly the same width in all their parts, so that 
 the fenestra? have the outline of an elongated oval rather than the 
 kt kite" shape of those of the French and English instruments. This 
 
 Davis's lb re ops. 
 
XXVIII.] 
 
 HODGE S FORCEPS. 
 
 467 
 
 not only secures a firmer bold on the child's head, but allows the pa- 
 rietal protuberances to jut through the opening, so that the blades 
 occupy no space in the cavity of the pelvis. 
 
 5. The surface of the blades which comes in contact with the child's 
 head is curved not only from the handle towards the extremity, but 
 likewise from side to side, as was suggested by Haighton. In this 
 manner the tissues of the child are always safe, as there is always a 
 flat surface in contact with them. 
 
 6. The cephalic curve is slight at the extremity of the blades, and 
 gradually increases as the shanks are approached for two-thirds of their 
 length, at which place the space between the blades is two inches and 
 a half. From this point the width diminishes quite rapidly until the 
 shanks are reached. In this manner the force employed is equally 
 distributed over the child's head, while the instrument is rendered less 
 
 Fig. 152. 
 
 Hodge's forceps. 
 
 liable to slip, because as the head is compressed it will tend to glide 
 deeper and deeper into the grasp of the blades. 
 
 7. The blades are united by Siebold's lock, which gives it all the 
 steadiness of the French, and is as easily adjusted as the lock of the 
 English instrument. 
 
 When made as directed by Professor Hodge, the whole length of 
 the instrument is sixteen inches. From the lock to the extremity of 
 the blades is nine and a half inches. The length of the blades proper, 
 
468 
 
 THE FORCEPS. 
 
 [chap. 
 
 Fig. 153. 
 
 in a direct line, is six inches. The extremities of the blades are half 
 an inch apart when the handles are in contact, while the greatest width 
 between the blades is two and one-half inches. 
 
 This instrument has been extensively employed in this country 
 through the influence of its eminent inventor. Still, the teaching of 
 the Jefferson Medical College has always been in favor of some form of 
 Davis's forceps. Professor Meigs, who so long occupied the chair of ob- 
 stetrics in that school, and who for so many years was the contemporary 
 teacher of Hodge, in Philadelphia, as has already been stated, recommend- 
 ed Davis's short double-curved 
 instruments to the large classes of 
 students which annually gathered 
 to be instructed by him. His suc- 
 cessor, Professor Ellcrslie Wal- 
 lace, has modified this instrument, 
 making one with substantially 
 Davis's blades and Hodge's han- 
 dles. The whole length of the 
 forceps in a direct line, from the 
 extremity of the blade to the end 
 of the blunt hook on the handle, 
 is fifteen inches. From the ex- 
 tremity of the blade to the lock 
 is eight and one-half inches. The 
 extremities of the blades are half 
 an i nch apart. The greatest width 
 of the space between these is about 
 one-third of the distance from the 
 shanks, and is two inches and a 
 half. The fenestra? have the oval 
 outline of the original Davis and 
 the Hodge forceps, but the shanks 
 are more closely approximated 
 than in the former instrument. 
 They are nearly parallel, and that 
 of the female, occupies a position 
 in front of that of the male blade. 
 This is an important change, and 
 insures the integrity of the peri- 
 neum, so that the instrument can 
 be applied high up in the cavity 
 of the pelvis or at the superior 
 strait, without endangering any of the mother's tissues. 
 
 The editor has used Professor Wallace's forceps for the past decade, 
 in both private and hospital practice, almost to the exclusion of the 
 eclectic instrument of the late Professor Hodge. When the head is 
 high up in the pelvic cavity, or at the superior strait, they are more 
 easy of application, and hold more firmly than the instrument of 
 Hodge. 
 
 Dr. Albert H. Smith, the eminent lecturer on Obstetrics at the 
 
 Wallace's forceps. 
 
XXVIII.] 
 
 SMITH S FORCEPS. 
 
 469 
 
 Fig. 154. 
 
 Nurse's Home in Philadelphia, in a discussion on the use of the obstetric 
 forceps at the Obstetrical Society in that city, in 1872, announced his 
 preference for the Davis forceps, because their grasp is more firm, and 
 they slipped less easily than Hodge's. In the American Journal of 
 Medical Sciences for July, 1869, he published a description of a modi- 
 fication of this instrument, which adapts it to cases in which the head 
 is high up in the cavity, or at the superior strait. The peculiarity of 
 the instrument is that it is made portable by a joint in the handles, by 
 which the forceps can be separated into two parts, and " one of the 
 handles can then be joined to a vectis, and the instrument used either 
 as a vectis or a blunt hook. A sepa- 
 rate pair of short handles is provided 
 for cases where the short forceps 
 would be preferable, as where no 
 compression is desirable. The con- 
 nection is made by means of a pivot 
 and socket joint about an inch below 
 the lock, adjusting very firmly and 
 readily by a spring-catch, raised in 
 separating them by means of a con- 
 cealed lever upon the inside of the 
 handle. The instrument is thus ren- 
 dered more portable without in the 
 slightest degree impairing its strength. 
 The blades are of the Davis pattern, 
 and the lock a simple button, proved 
 by experience to be the safest and 
 most readily adjustable of any in use. 
 The long handles for compression 
 permit an approach of the blades at 
 their widest part of two and a quarter 
 inches ; the short handles for traction 
 in ordinary cases only two and three- 
 quarter inches. The jointed handle 
 could be adapted to any pattern of 
 
 blade desired. The whole set, taken to pieces, can be put in a leather 
 bag nine inches in length and two and a half in width." 
 
 The late Prof. George T. Elliot, of New York, used and recom- 
 mended a forceps which is essentially a modification of the instrument 
 used by the late Sir James Y. Simpson. The total length of the speci- 
 men of Dr. Elliot's forceps, which we measured, is fifteen inches in 
 a direct line from the extremity of the handles to that of the blades. 
 From the lock to the end of the blades is nine inches. The greatest 
 distance between the blades is three and a quarter inches, while the 
 extremities of these are an inch apart. The blades are united by the 
 English lock, and the handles are composed of steel and wood. In one 
 handle is a bolt which, when screwed out by a burr in the handle, for 
 that purpose, limits the compression exerted by the instrument to any 
 extent desired by the operator. 
 
 In 1872, Prof. F. M. Robertson, of Charleston, South Carolina, 
 
 Smith's forceps. 
 
470 
 
 THE FORCEPS. 
 
 [CHAP. 
 
 published a description of the forceps which he uses, and which is in 
 reality a modification of Hodge's. The blades are those devised by 
 Hodge, except that the pelvic curve is slightly increased. The blunt 
 hook on the handles of Hodge's forceps has been abandoned, and the 
 latter, which are composed partly of steel and partly of wood, have 
 been reduced 2.3 inches in their length. The length of the shanks is 
 also reduced .5 of an inch, making the entire length of the instrument 
 from the extremity of the handles to that of the blades in a direct line 
 13.5 inches. 
 
 Dr. Robertson prefers that women should occupy the dorsal position 
 during childbirth, and the chief advantage which he claims for his 
 
 Fig. 155. 
 
 Fig. 156. 
 
 Elliot's forceps. 
 
 Eobertson's forceps. 
 
 modification of the forceps is that it can be applied without changing 
 the position of the patient. 
 
 The instruments of Hodge and Wallace were generally used in 
 Philadelphia until about five years since, when Dr. William F. Jenks 
 returned to this country after several years' sojourn in Europe. He 
 
xxviii.] Simpson's forceps. 471 
 
 brought with him a pair of Simpson's forceps, accurately made accord- 
 ing to the model of the famous Edinburgh Professor. Dr. Jenks's 
 persistent advocacy of this instrument induced many of his friends to 
 try it. The result is that it is rapidly growing into favor among Phil- 
 adelphia obstetricians. The total length of Simpson's instrument, 
 from the extremity of the blade to that of the handle, is thirteen and 
 one-half inches. The distance from the lock to the extremity of the 
 blade is eight and one-half inches in a direct line. The blades and 
 shanks are therefore of precisely the same length as those of Wallace's 
 forceps, but they are one inch shorter than the eclectic instrument of 
 Dr. Hodge. The extremities of the blades are an inch and an eighth 
 apart, the handles being in contact, or five-eighths of an inch more than 
 either Hodge's or Wallace's forceps. The greatest space between the 
 blades is three and a quarter inches, or three-quarters of an inch more 
 than that of the instruments of Hodge and Wallace, and one inch more 
 
 Fig. 157. 
 
 
 Simpson's forceps. 
 
 than the long forceps of Smith. The shanks are about two inches 
 long, and run parallel to one another three-quarters of an inch apart. 
 The blades are united by the English lock, which is made very loose, 
 so that the handles have considerable play. This facilitates locking. 
 The handles are composed of wood and steel, and at their upper ex- 
 tremity terminate in hollowed transverse projections or shoulders, 
 which enable the instrument to be firmly grasped. 
 
 This is a fair description of the various models of forceps now in 
 common use in America. Various other modifications are employed 
 by individual practitioners. Whichever one of these varieties may be 
 selected, it will fill the requirements under all ordinary circumstances ; 
 whereas, if the recommendations of the author are followed, the physi- 
 cian will be forced to have two pairs of forceps at hand, if he expects 
 to apply them at the superior strait. When supplied with Hodge's, 
 Wallace's, Smith's, or Simpson's instruments, the operator will find 
 the short forceps entirely unnecessary. Any one of these can be ap- 
 plied anywhere in the parturient canal. 
 
 Several things have to be taken into consideration in the selection 
 of a pair of forceps. From the descriptions of the various instruments 
 in use it will be seen that they may be divided into two distinct classes : 
 those which are forcible compressors, and those which have but little 
 power to diminish the size of the child's head. In this first class may 
 be included the instruments of Hodge, Robertson, Wallace, and Smith. 
 Of these, the last is the most poAverful compressor, as the space be- 
 tween the blades is only two and a quarter inches at its widest part, 
 while the instruments of Hodge, Robertson, and Wallace measure two 
 and a half inches in the widest part. On the other hand, the forceps 
 
•JL72 THE FORCEPS. [CHAP. 
 
 of Simpson and Elliot possess but little compressing power, the blades 
 of both having three and a quarter inches between them at their 
 widest point. Of those varieties which may be styled powerful com- 
 pressors the editor has always preferred the forceps of Professor 
 Wallace. The advantages of these are the ease with which they are 
 introduced, owing to the great pelvic curve, and the tightness of the 
 grasp. Of the second class, Simpson's instrument, when properly con- 
 structed, appears to us to be the best, and is the one which we now 
 US e._p.] 
 
 Cases requiring the use of the forceps are very variable in their 
 general features, but most of them may be referred to one or other of 
 the following groups. We may have, in the first instance, cases in 
 which everything is normal save expulsive power, which may utterly 
 fail as the period of delivery approaches: this failure of the vis a tergo 
 is familiarly known as " uterine inertia," and from it arises, more fre- 
 quently than from any other cause, the necessity for operative assist- 
 ance. In another group, the operation is rendered necessary by a minor 
 degree of pelvic deformity, at the outlet or in the cavity, — of which 
 flattening of the sacrum is an example, probably of more frequent 
 occurrence than is usually supposed. The application of the forceps, 
 when the head is at or above the brim, is less frequently required, 
 and is attended with special difficulties and dangers which will be duly 
 considered. Any mechanical obstruction, however, whether of the 
 hard or soft parts, including abnormal rigidity of any portion of the 
 parturient canal, may be an unmistakable warrant for operative assist- 
 ance. In occipi to-posterior positions, and in face presentation, the 
 forceps may be found necessary either for rectification or direct ex- 
 traction ; and, in convulsions, or any condition calling for speedy 
 delivery, it may also be necessary to use the forceps if the labor 
 has sufficiently advanced to admit of the safe application of the in- 
 strument. Some of the rarer circumstances calling for the forceps 
 have already been mentioned, such as certain exceptional cases of rup- 
 ture of the uterus, placenta prsevia, or funis presentation. In cases of 
 breech presentation, or after turning, it is frequently necessary to apply 
 the forceps, when the trunk has been born, in order to extract the head 
 from the soft parts and protect the child from suffocation. The instru- 
 ment being specially constructed for application over the spheroidal 
 cranium, is only applicable, as is evident, to a limited class of cases. 
 For other presentations, which may require operative assistance, special 
 mechanical aids must be sought. The necessity for operation by the 
 forceps arises more frequently in primipane than in women who have 
 already borne children. 
 
 [Under many of these circumstances it is an important and difficult 
 question to decide when to interfere. Authors generally point out the 
 circumstances which warrant resort to the forceps, but few of them give 
 any definite advice as to how long the powers of nature are to be trusted 
 in a case of delayed labor. Denman, however, was explicit upon this 
 point. His advice " that the head must rest immovable six hours 
 upon the perineum before the forceps be resorted to," has often been 
 quoted. This so manifestly limits the use of the instrument and cur- 
 
XXVIII.] USE OF THE FORCEPS. 473 
 
 tails the power of the physician to relieve his patient, that the advice 
 need not be refuted in this enlightened age. Others never resort to 
 the forceps until the pains have ceased and the patient begins to show 
 signs of exhaustion, becomes hot, thirsty, and has a rapid pulse; in 
 short, until febrile reaction sets in. Such advice is scarcely in advance 
 of the teaching of Denman, and indicates either ignorance of the value 
 and powers of the forceps, or timidity in their use. 
 
 We do not hesitate to assert that this instrument, when properly 
 applied and skilfully manipulated, by an educated and judicious phy- 
 sician, cannot possibly injure the mother. This fact cannot be too 
 strongly insisted upon. As regards the child, it must be acknowledged 
 that occasional injury may be inflicted upon its tissues. However, this 
 rarely occurs in the hands of an experienced and skilful operator. 
 Careless application of the instrument may be detrimental to both 
 mother and child, but properly and scientifically used, it shortens and 
 diminishes the suffering of the one, and may be the means of saving 
 the lives of either or both. 
 
 Therefore, instead of waiting in cases of delay until the mother shows 
 symptoms of exhaustion, or until auscultation shows that the child's 
 life is in jeopardy, the careful and educated physician will anticipate 
 and prevent danger. It is a notable fact that those who resort to forceps 
 most frequently are rarely compelled to use the perforator, and scarcely 
 ever deliver a stillborn child, or lose a mother in childbed. The late 
 Dr. William Harris, of Philadelphia, practiced obstetrics extensively 
 for forty-six years, and used the forceps in about one out of every seven 
 cases. For thirty years he did not lose a woman from labor or its im- 
 mediate effects. Dr. Hamilton, of Great Britain, uses the forceps in 
 one-seventh of his cases. He makes sure that the anterior lip of the 
 uterus recedes before the descending head, and then if labor does not 
 terminate spontaneously in two hours, he delivers with the forceps. 
 The results of this practice are, that in one series of seven hundred and 
 thirty-one consecutive confinements, there was not a single still birth. 
 This result is truly remarkable. The maternal mortality, though not 
 definitely stated, is said to have been satisfactory, That the mothers 
 were not injured by the use of the instrument, may be inferred from the 
 fact, that Dr. Hamilton did not have to use the catheter upon a puer- 
 peral patient, in his own practice, during a period of thirty years. 
 
 Dr. G. E. Francis, of Worcester, Mass., has recently reported a series 
 of three hundred confinements, in which the forceps were used in one 
 in every six cases. Of the three hundred women three died ; two from 
 unavoidable causes, pulmonary thrombosis and blood-poisoning from 
 erysipelas, and the other from exhaustion due to a a very long first 
 stage in which no interference was permitted," so that '" by the time 
 the os was dilated she was in a high fever." Of the three hundred 
 and one children born, the author states that all were alive excepting 
 four. One of these was destroyed by prolapse of the cord, one was a 
 monster, and one was supposed to have died before labor commenced. 
 The fourth appears to have been born alive, but it was premature, and 
 died in a few hours. These results are certainly all that could be 
 desired. 
 
474 THE FORCEPS. [CHAP. 
 
 In a discussion upon the use of the forceps before the Obstetrical 
 Society of Philadelphia in 1872, Dr. Albert H. Smith stated "that 
 he had long made it his rule in normal pelves never to allow his patient 
 to suffer long after the full dilatation of the os uteri had taken place." 
 
 The editor long since adopted for his guidance the rule never to wait 
 more than two hours after the progress of the labor had been arrested, 
 no matter whether the delay was due to inefficiency of the pains or 
 disproportion between the size of the head and the pelvis, and no mat- 
 ter in what part of the parturient passages the head is arrested, whether 
 it is at the superior strait, in the cavity, or at the outlet of the pelvis. 
 The results of not a small experience in both private and public prac- 
 tice, have only strengthened him in the belief that this rule of practice 
 is a proper one, and diminishes the dangers of both mother and 
 child.— P.] 
 
 A2iplication of the Forceps. — Before, in any case, making the slightest 
 attempt in this direction, we must be sure that neither the bladder nor 
 rectum are distended, and this caution is specially required as regards 
 the bladder, from which the contents must, if necessary, be withdrawn 
 by the catheter. An essential condition is, according to all authorities, 
 complete dilatation of the os, but some difficulty unfortunately seems 
 to exist in determining what we are to understand by " complete dilata- 
 tion." The cases which are undoubtedly most favorable for operation 
 are those in which the os is absolutely obliterated or drawn up beyond 
 the reach of the operator over the advancing head. But if we limit 
 the employment of the instrument to these cases alone, we shall certainly 
 withhold assistance in many in which we might deliver the woman 
 with perfect safety. Obliteration of the os, or actual continuity of^the 
 uterine with the vaginal canal, is no doubt desirable, but we must not 
 admit as true the statements of those who tell us that it is essential to 
 safety. To wait until the lip of the os can no longer be felt, as some 
 have said, is to wait for what may possibly never occur; and, in like 
 manner, if we accept the rule as perfectly correct that we are never to 
 pass the blades of the forceps within the uterus, we may allow the 
 period to pass at which we may, by prompt action, save the life of the 
 child. 
 
 Complete dilatation of the os is, indeed, in a sense, absolutely essen- 
 tial ; and it is certain that a greater degree of dilatation is necessary for 
 this than for any other of the operations for delivery. But complete 
 dilatation, in the sense which we would attach to the term, does not 
 imply that the anterior lip of the os has passed out of reach beyond the 
 head, but merely such dilatation as will admit of the safe passage of the 
 head. In many cases, then, we are justified in passing the blades 
 partly within the uterus, and we apprehend that Dr. Ramsbotham's 
 assertion is strictly correct when he affirms that the forceps may be 
 used in some cases in which as much as a third part of the circular 
 margin of the os uteri can be felt. There can be no doubt that, in a 
 considerable number of cases, recession or retraction of the os, and 
 especially of its anterior lip, does not occur immediately upon full 
 dilatation, nor, it may be, for a considerable period thereafter. 
 
 The possibility of feeling an ear has been very generally looked upon 
 
XXVIII.] CONDITIONS ESSENTIAL TO SAFETY. 475 
 
 as an important and, by some, as an essential condition, in the absence 
 of which we would never be justified in operating. That the ear may 
 often be reached with ease, when the other operative conditions are 
 fulfilled, is undoubted ; and, in cases in which we are only called in 
 when a large caput succedaneum has in sOme measure obliterated the 
 landmarks on the surface of the cranium, it is really important that 
 we should seek for and observe the ear, with the view of determining 
 the exact position of the head. But to accept this as a rule for our 
 guidance in every case, is both unnecessary and improper, as the ear, 
 in some cases in which we may hold the operation to be perfectly justi- 
 fiable, can only be reached with difficulty, or with an amount of violence 
 which may greatly aggravate the sufferings of the patient. To these we 
 might add other conditions, which have been prescribed as essential to 
 the safe performance of the operation, but which have deservedly fallen 
 into neglect. 
 
 The forceps must be applied directly to the surface of the child's 
 head, and it is therefore absolutely necessary that the membranes be 
 ruptured should this not have already spontaneously occurred. We 
 have been summoned with a view to delivery by the forceps in a case 
 in which it was stated that the os was fully dilated, although it turned 
 out that the os was still very slightly dilated and only reached with 
 difficulty in the posterior part of the pelvis, the thin uterine wall being 
 still extended over the surface of the scalp. Such a condition could, 
 with ordinary care, scarcely lead to an error in practice, but the possi- 
 bility of a mistake should nevertheless be borne in mind by the inex- 
 perienced. 
 
 If possible, but with exceptions to be afterwards noticed, the blades 
 should be applied to the sides of the child's head. To do this with 
 accuracy, it is necessary that the actual position of the head be made 
 out with perfect certainty. This may be ascertained, as has been ex- 
 plained in a former chapter, by a careful examination of the sutures 
 and fontanelles, and of the relation which these parts bear to the pelvic 
 canal ; and, as there are four possible cranial positions, we must first 
 be sure with which of them we have to deal, before we take the instru- 
 ment into our hands. It is only, as we have said, when exceptional 
 difficulties exist that we require to examine the ear. No one, there- 
 fore, is qualified to attempt delivery by the forceps unless he is familiar 
 with the laws which regulate normal parturition ; and there is, in fact, 
 no operation or contingency in midwifery practice, in which a thorough 
 knowledge of the mechanism of labor, in all its details, is so essential 
 as this. It is unnecessary to inform any one familiar with the details 
 of normal parturition, that the method of application will depend upon 
 the situation of the head. In proportion to the proximity of the head 
 to the external parts the movement of rotation will be found, in the 
 ordinary position, to have occurred ; and, therefore, the nearer it is to 
 the outlet, the more do we require to apply the blades in the transverse 
 diameter of the pelvis, in our endeavor to adjust them to the sides of 
 the head. When, however, the head is higher, its position is more 
 decidedly oblique, and, even at the outlet, a little of this obliquity still 
 obtains ; so that, to insure their application to the sides of the head, 
 
476 THE FORCEPS. [CHAP. 
 
 we must apply them in the opposite oblique diameter to that in lohieh the 
 child's head lies. 
 
 Having satisfied ourselves as to the position of the head, and that 
 the conditions exist which warrant the performance of the operation, 
 we prepare the forceps by warming and greasing the blades. The 
 patient, who lies in the ordinary midwifery position, should be carried 
 quite to the edge of the bed, so that her hips may even project a little 
 over it, and she is then to be brought, with due caution, under the 
 influence of chloroform. We should be perfectly satisfied with her 
 posture before commencing the operation, as to change her position 
 after one blade has been introduced is not free from risk. If the head 
 is at the outlet and resting on the perineum, the blades are to be in- 
 troduced so that the handles shall look forwards under the arch of the 
 pubis; if rotation has not yet occurred, and the head is consequently 
 in the lower part of the cavity, they will, with reference to the erect 
 posture, look doivnwards ; and, if the head is higher in the pelvis, they 
 will look more or less backwards in the direction of the perineum. If, 
 however, it is still high in the pelvis, or at the brim, we should use the 
 double-curved long forceps ; for, our object being to apply extracting 
 force in the axis of that part of the pelvis which the head occupies, we 
 must discard the straight forceps so soon as the shanks of the blades 
 come to press upon the fourchette. This we do for various reasons, 
 to be afterwards more particularly explained in connection with the 
 subject of the double-curved forceps, not the least of which is the 
 danger to the integrity of the perineal tissues which would accrue in an 
 attempt to pull the head backwards in a direction even approaching 
 to the axis of the brim. 
 
 Let us suppose the head to be in the position which in seventy per 
 cent, of cranial presentations it occupies, — in the right oblique diameter, 
 with the forehead towards the right sacro-iliac synchondrosis, and the 
 occiput to the left foramen ovale. The blades, in this case, are to be 
 passed in the direction of the left sacro-iliac synchondrosis and the 
 right foramen ovale, or, in other words, to the poles of the left oblique 
 diameter of the pelvis. With reference to the position of the woman, 
 we speak of the " upper" and " lower " blades. It is of no great im- 
 portance which of these blades is first introduced, but it is proper that 
 the operator should have a definite plan of procedure, which he may 
 adopt in every case. If he introduce, as we are in the habit of doing, 
 the lower blade first, he grasps one of the blades with the fingers of his 
 right hand as he would a catheter, and holds it for a moment diago- 
 nally across the breech of the woman, with the concavity of the blade 
 turned towards her, the point downwards and to the left, the handle 
 upwards and to the right. If thus held, it will correspond to the left 
 oblique diameter, and from this it should not deviate or twu'st in any 
 way during its introduction. Two or three fingers of the left hand, 
 which have been duly anointed, are then to be passed into the vagina, 
 over the left ischial tuberosity, in the direction of the corresponding 
 sacro-sciatic ligaments, with the palmar surface upwards, until the head 
 is reached. The blade is then passed along the fingers, and, if the os 
 is still distinguishable, it is to be carefully guided within it. If the 
 
XXVIII.] INTRODUCTION OF THE LOWER BLADE. 
 
 477 
 
 handle is now gradually depressed, and at the same time gently pushed 
 onwards, it will generally glide over the convex surface of the cranium 
 without the slightest difficulty or danger. Should the blade turn or 
 twist in the direction either of the hollow of the sacrum or of the fora- 
 
 FlG. 158. 
 
 Introduction of the lower blade. 
 
 men ovale, it is on no account to be replaced forcibly, but is to be par- 
 tially withdrawn by raising the handle, and reintroduced with greater 
 care. The handle is then carried towards the perineum, and intrusted to 
 an assistant while the introduction of the upper blade is being effected. 
 The operator should take the second blade with his left hand, so that 
 it diagonally crosses the breech as before, but with the point above and 
 to the right, and the handle downwards and to the left. The fingers 
 of the right hand are then passed in the direction of the right foramen 
 ovale until the head is reached, and along their palmar surface, which 
 is turned downwards, the blade is then to be introduced. The reason 
 for bringing the woman quite to the edge of the bed now becomes ob- 
 vious, as it is only in this way that the handle of the upper blade can 
 be sufficiently depressed to admit of its easy introduction. This blade 
 is introduced, as will be observed, in front of the lower blade, as it is 
 only in this way that the two parts of the forceps will lock. 1 The 
 hand is now to be steadily raised, when, under the direction of the 
 fingers, the blade will glide over the right side of the child's head. An 
 
 1 We have frequently observed that students who may be practicing these details 
 with the machine and phantom commit the error of passing the second blade with- 
 out any reference to the direction of the lock in the first. This error cannot possi- 
 bly be committed in practice if the directions here laid down are observed. 
 
478 
 
 THE FORCEPS. 
 
 [CHAP. 
 
 excellent guide during this part of the operation is derived from an 
 observation of the inner or metallic surface of the handle, which should 
 
 Fig. 159. 
 
 Introduction of the upper blade. 
 
 remain parallel with the corresponding surface of the lower blade, and 
 the earliest deviation of the blade from its proper course will be found 
 in an inclination of this surface to one side or another. Should this 
 
 Fig. 160. 
 
 The forceps applied. 
 
 occur repeatedly, after partial removal and reintroduction of the blade, 
 it may be advisable to withdraw the lower blade, and introduce it with 
 reference to the other, as there is the possibility of a mistake having 
 been committed as to the position of the head, and it is besides a mat- 
 ter of far greater importance to have the blades exactly opposite to 
 
XXIX.] THE FORCEPS. 479 
 
 each other, than to have them accurately adapted to the transverse 
 diameter of the head. The best test of a proper application of the for- 
 ceps is the perfect locking of the blades after their introduction. Fig. 
 160 shows the blades as adjusted for the first position, the head being 
 in the pelvic cavity, as is indicated by the direction of the handles. 
 The blades being separated by the transverse diameter of the head, the 
 extremities of the handles are about an inch apart. 
 
 When the head occupies the second cranial position, the blades are 
 to be applied to the poles of the right oblique diameter. The lower 
 blade is therefore introduced in the direction of the left foramen ovale, 
 from which point the handle is first directed upwards and to the left, 
 and then depressed downwards and to the right. The upper blade is 
 then introduced in the direction of the right sacro-iliac synchondrosis, 
 taking care that it is passed in front of the lower blade, and that the 
 metallic surfaces of the handles retain their parallelism as before. In 
 third positions, the forceps must be applied in exactly the same way as 
 when the head is in the first ; and in fourth presentations as for the 
 second. 
 
 CHAPTEE XXIX. 
 
 THE FOKCEPS (Continued). 
 
 ACTION OF THE FORCEPS : 1, BY COMPRESSION ; 2, BY TRACTION ; 3, BY DOUBLE-LEVER 
 ACTION— MODE OF EXTRACTION: MANAGEMENT AND DIRECTION OF THE HAN- 
 DLES AT VARIOUS STAGES OF DELIVERY — DELIVERY BY THE FORCEPS IN OC- 
 CIPITO-POSTERIOR POSITIONS: ROTATION BY THE FORCEPS: EXTRACTION WITH 
 THE FOREHEAD FORWARDS — THE " LONG FORCEPS " — REASONS FOR PREFERRING 
 THE PELVIC CURVE IN THIS OPERATION — DESCRIPTION OF THE INSTRUMENT — 
 CASES IN WHICH THE LONG FORCEPS IS APPLICABLE — DIRECTIONS FOR THE 
 OPERATION : BLADES TO BE APPLIED TO THE SIDES OF THE PELVIS : MODE OF 
 INTRODUCTION OF THE LOWER AND UPPER BLADES: RELATION OF THE BLADES 
 TO THE SURFACE OF THE CRANIUM — USE OF THE FORCEPS IN PRESENTATIONS 
 OF THE FACE — PROCEDURE WHEN THE HEAD IS RETAINED AFTER EXPULSION 
 OF THE TRUNK — MODIFICATIONS OF THE INSTRUMENT : ZIEGLER'S, RADFORD'S, 
 AND OTHER FORCEPS. 
 
 The forceps acts mechanically in three different ways in effecting the 
 object which we have in view : by compression, by traction, and by a 
 double-lever action. In so far as Compression is concerned, a certain 
 degree of this is essential, in order to grasp the head with the blades, 
 which otherwise would slip off, or would only be precariously main- 
 tained in their position, under certain circumstances, by the pressure of 
 the walls of the parturient canal. But, by compression, something more 
 
430 THE FORCEPS. [CHAP. 
 
 is implied than mere grasping; for by it, as is obvious from the yield- 
 ing nature of the sutures and fontanelles, the actual diameters of the 
 cranium may be materially diminished. It is to be remembered, how- 
 ever, that the forceps is usually applied to that portion of the cranium 
 which is least subjected to pressure, and that, therefore, as a rule, little 
 is to be gained by diminishing these diameters. We may, in fact, 
 assume that the pressure which is necessary to insure such a grasp of 
 the head as may render it impossible for the blades to slip under mod- 
 erate efforts, will effect all the compression which is desirable. Many 
 recommend that a piece of cord or tape should be firmly tied round the 
 handles in order to keep up sustained pressure on the cranium, and it 
 is for this that the depression near the extremities of the handles, 
 which is characteristic of all English forceps, is intended. This mode 
 of procedure is not to be commended, as such serious and sustained 
 pressure may endanger the life of the child. The power exercised by 
 the hands of the operator, if only the handles are of proper size, is 
 quite sufficient for our purpose, and being necessarily intermittent, is 
 free from the danger which attaches to continuous pressure upon struc- 
 tures so delicate and important as are contained within the cranium. 
 Sometimes, when it is necessary to use very considerable force, the full 
 extent of possible compression must be resorted to, but this more with 
 the view of maintaining a secure hold than of gaining much by mere 
 compression. In such a case, the corner of a towel which has been 
 dipped in water may be tightly bound round the handles at the depres- 
 sion alluded to, when the remainder of the towel being wrapped round 
 the handles will give a better hold and more power; but, when this is 
 done, the pressure should always be relieved during the intervals be- 
 tween the pains, or when at any other time we make a periodical pause 
 in our extractive efforts. The amount of compression which is safe 
 will depend in no small measure on the construction of the forceps ; 
 and, in an instrument, such as are many of those of French manufac- 
 ture, with an interval of half an inch only between the tips, the pressure 
 will certainly be attended with more risk than when these are, as they 
 should be, an inch or nearly so apart. This is done with the view of 
 avoiding — what is always dangerous — continuous pressure on the child's 
 head ; and, for the same reasons, if pains be absent, our efforts at ex- 
 traction should be intermittent so as to imitate as closely as possible 
 the normal process. 
 
 The forceps acts also by Traction ; but this force is not applied alone, 
 as in drawing a cork from a bottle, but in combination with the third 
 mode of action of the instrument, — viz., that of a Double Lever. The 
 forceps, as almost invariably constructed with the English or other 
 similar lock, is composed of two levers — the fulcrum of each being the 
 lock. This enables us, by a swaying movement of the hands, to apply 
 extracting force, partly by leverage and partly by traction, to each side 
 of the head successively, without the danger which attaches to the single 
 lever or vectis, where it is necessary to find a fulcrum in some part of 
 the pelvic wall. 
 
 When the blades have been adjusted to the satisfaction of the operator, 
 he now proceeds to the actual operation of extraction. As his object 
 
XXIX.] EMPLOYMENT FOR RECTIFICATION. 481 
 
 should, in most cases, be rather to aid than to supersede the natural 
 efforts, he must merely assist the pains should they be present, and 
 pause when his assistant informs him that the uterine action has ceased. 
 This leads us to observe, that, if it be practicable, the assistance of 
 another practitioner should always be obtained ; for not only is there 
 thus a division of responsibility, but the operator has the great advan- 
 tage of efficient and intelligent aid, to which he can trust for the man- 
 agement of chloroform, the steadying of the uterus, and many other 
 points of detail, which it is impossible to obtain at the hands of those 
 who are ignorant or inexperienced. 
 
 When the action of the uterine fibres has ceased — as in cases of 
 complete inertia — he should imitate nature by applying extracting force 
 at intervals corresponding to the ordinary duration of natural pains. 
 The handles should be grasped by both hands, two of the fingers of one 
 hand being passed up so as to impinge upon the head. The object of 
 this is to ascertain the earliest indication of slipping of the blades, 
 which is always more apt to occur when the distance between their 
 extremities is more than an inch. So soon as he feels that his fingers 
 are leaving the surface of the scalp under the influence of his efforts, he 
 knows that the instrument is losing its hold. The blades should then 
 be disarticulated and pushed back to their original position ; and, upon 
 renewed efforts, he makes use of a little more compression, thus striving 
 always to effect the dislodgement of the head with as little of actual 
 force as may be necessary. The force should be applied as nearly as 
 possible in the direction of the axis of that part of the pelvic canal 
 within which the head lies ; and the operator should act by combining 
 steady traction with a swaying motion of the handles from side to side. 
 
 If the head is by these efforts dislodged from the situation in which 
 it has been arrested, and moves downwards into a lower plane of the 
 pelvis, this may, in the presence of efficient pains, be all that is re- 
 quired, as nature will often in such cases complete the delivery. It is 
 better, however, at this stage, not to withdraw the blades, but merely 
 to disarticulate them, and, leaving them in contact with the head, 
 watch the result. If the head now moves satisfactorily with every 
 pain, they may be entirely withdrawn ; but, so long as there seems a 
 probability of further assistance being required, it is better to leave 
 them than to run the risk of having again to apply them at a more 
 advanced stage of the labor. If it is a case of inertia, or when there 
 is obvious obstruction at the outlet, our efforts must be continued at 
 intervals as before ; resting satisfied with a very gradual advance, and 
 never (unless under exceptional circumstances, when rapid extraction 
 is imperatively demanded) striving for a speedy termination of the 
 case, which might endanger the perineum, and the other soft structures 
 which nature in normal cases very gradually distends. 
 
 The direction which, in labor, the head naturally takes is always to 
 be kept in mind. As it descends, therefore, if it has originally been in 
 the cavity when the blades were introduced, the handles are to be 
 carried forwards under the arch of the pubis, and at the moment of 
 birth, are to be raised in front of the symphysis. It is at this moment 
 that precipitation or violence of any kind is so apt to lacerate the 
 
 31 
 
482 THE FORCEPS. [CHAP. 
 
 perineum, so that we •should, by every means in our power, closely 
 imitate the process by which nature so admirably effects the dilatation 
 of this structure. It is usual to practice what is called support of the 
 perineum, in forceps as in ordinary cases; but in such means, as a 
 preventive of laceration, we have, for reasons already stated, no con- 
 fidence whatever.. As the head passes from the cavity to the outlet, 
 the natural movement of rotation is not to be forgotten. It is not, 
 indeed, necessary that we should attempt artificially to produce this 
 rotation. Under the influence of the ordinary causes, nature will effect 
 it at the proper time, whereas we might only do harm by misplaced 
 efforts before that time has arrived. Still, it is proper that we should 
 watch the first indications of rotation, and, in our subsequent endeavors, 
 " humor" the blades so as in every way to encourage it. 
 
 The situation on the sides of the child's head which corresponds to 
 the blades, varies considerably, and will depend, in some measure, on 
 the degree of moulding, or elongation, which may have occurred. 
 When successfully applied, so as to obtain the best possible hold, the 
 tips of the blades will be found to have passed over the ears, and to 
 have grasped the soft parts of the cheek beyond the zygomatic arch. 
 In not a few cases 1 , however, and especially in those in which the for- 
 ceps has been used before the head has attained the perineum, they do 
 not reach so far, and in these the point attained will be marked by a 
 depression in the temporal region above the zygoma. Beyond the 
 depression just mentioned, the injury inflicted upon the soft parts of 
 the child should be very trifling, even in severe cases. A certain 
 amount of discoloration, from bruising, is sometimes noticed, but this 
 disappears in the course of a few days. 
 
 In the third and fourth, or occipi to-posterior positions, the difficulties 
 which we encounter are often much more formidable. These difficulties, 
 it is to be remembered, probably depend entirely on the faulty nature 
 of the position. Our first attempts, therefore, should be to remedy 
 these positions, by promoting the rotation which would bring the occi- 
 put forwards. Having failed in our attempts to induce this rotation 
 by the fingers, with or without the vectis, in the manner formerly de- 
 scribed (see Chap. XVIII), we should always try to effect rotation by 
 the forceps, previous to attempting direct extraction. Very special 
 care is here necessary, as a moment's consideration will show, to dis- 
 tinguish between the two occipito-posterior positions. If, for example, 
 we should mistake the third position for the fourth, we would apply 
 our rotating force so as to move the occiput from right to left in an 
 attempt to reduce it to a first position, with the result, if we moved 
 the head at all, of forcing it in the direction of the conjugate diameter, 
 and thus making matters worse, instead of better. If, however, we 
 are confident in our diagnosis, we have only to remember that third 
 positions rotate naturally into the second, and fourth into the first, 
 which at once points to the direction in which alone rotatory force can 
 safely be expended. Dr. Tyler Smith says that we should rotate during 
 the process of extraction ; but it is better that we should, in the first 
 place, attempt simple rotation, and then, if that fail, combine rotation 
 with extraction. If we succeed in effecting rotation, the case, left to 
 
XXIX.] 
 
 LONG FORCEPS. 
 
 183 
 
 we fail, it will 
 
 -a matter of difficulty 
 
 nature, will terminate in the usual way. But, should 
 be necessary to extract directly, without rotation 
 always, and sometimes of impossibility. 
 
 In delivering by the forceps, while the head remains in an occipito- 
 posterior position, care must he taken to conduct the operation with a 
 due regard to the manner in which nature effects delivery in such cases. 
 If we attempt to drag the head forwards under the pubic arch, we will 
 probably fail ; so that we should direct our efforts so as to get the occi- 
 put over the perineum, — as it is only in this way that the occipito- 
 mental diameter can be released, — and the forehead is then suffered to 
 sweep backwards from behind the symphysis. The great danger is rup- 
 ture of the perineum, which, in some instances, it will be almost im- 
 possible to avoid ; but, when the pelvis is of good size, the difficulties 
 attending delivery in such a posi- 
 tion are by no means so great as FlG - m - 
 might be supposed. 
 
 The Long Double-curved For- 
 ceps. — Whatever opinion may be 
 entertained as to the propriety of 
 employing the forceps with a 
 double curve in all cases, without 
 exception, we have no doubt that 
 the long forceps, as applicable to 
 cases where the head is at or 
 above the brim, can only be used 
 with safety when constructed on 
 this principle. The objection to 
 the long straight forceps in this 
 situation is pretty obvious, if we 
 reflect that extraction, exactly in 
 the axis of the brim, is impossi- 
 ble, as the line representing that 
 axis passes through the coccyx, 
 or even the lower part of the sa- 
 crum. It is not, indeed, until 
 the head has fallen well into the 
 cavity, that it may be supposed 
 to occupy a plane the axis of 
 which passes in front of the peri- 
 neum. Not even with the pelvic 
 curve can Ave pull directly in the 
 axis of the brim, but we are able 
 more nearly to approach to what 
 is desiderated, and, what is much 
 more important, to do so with 
 comparative safety. If the 
 straight forceps is used at the 
 brim, not only do we pull the head too much forwards, but we do so 
 to the imminent danger of the perineum, against which the shank of 
 the blades is pressed. And, if we overcome the first resistance, the 
 
 m 
 
 Forceps for application at the brim. 
 
484 THE FORCEPS. [CHAP. 
 
 widening of the blades as they descend exposes this structure to ever- 
 increasing danger as the child descends, for it is not till the head reaches 
 the lower third of the cavity that we can bring the handles forwards. 
 This risk to the perineum is, no doubt, much lessened, if we use an in- 
 strument in which the shanks are approximated for some distance, so 
 that the curve of the blades springs from a point several inches from 
 the lock, as in a modification of Beatty's forceps, which has been very 
 commonly used. 
 
 In the construction of this variety of long forceps, bearing in mind 
 the rule already laid down, our first point is to insure strength without 
 clumsiness. There is good reason to believe that the neglect of this 
 precaution has been the cause, in many instances, of the instrument 
 slipping again and again. There is no necessity for the blades, if of 
 proper material, to be of great thickness, but the handles should always 
 be large, of sufficient size, indeed, to be firmly grasped by both hands. 
 Endless varieties and modifications of the long curved forceps have 
 been devised, and it is but natural that every operator should prefer 
 his own. The instrument shown in Fig. 161, is somewhat similar to 
 what is known in this country as Simpson's forceps, which was adapted 
 by him from the pattern of that used by Naegele and other German 
 accoucheurs. The joints are made so loose as to admit of very slight 
 lateral motion or overlapping, and below the lock there are transverse 
 rests which give more power to the hands; "the long forceps/' as 
 Simpson observes, " being only properly used as an instrument of 
 traction, not of compression." The length of the instrument which 
 we have represented is sixteen and a half inches, bjeing ten and a half 
 inches from the lock to the tip of the blades, and six inches for 
 the handles. The measurements between the blades should be the 
 same as those of the medium-sized instrument above described, and 
 the fenestra? about five and a half inches in length. The instrument 
 is thus, as it is believed, both longer and of greater strength than those 
 which are generally employed by English practitioners. It is, we be- 
 lieve, inferior in efficiency to none, and, if used with due caution, equal 
 in point of safety to any. No one should, however, under any cir- 
 cumstances, take such an instrument into his hands without a sense of 
 responsibility much greater than attaches to the ordinary operation. 
 
 The long forceps, in the sense in which we employ the term, is 
 applicable to cases in which the head will not enter the brim or descend 
 beyond the upper part of the cavity. The cases which are held to 
 warrant its employment are chiefly those in which the head is arrested 
 at the brim by reason of moderate contraction of the conjugate diameter. 
 Great care must therefore be taken, in the first instance, to ascertain 
 the degree of deformity, and to make sure that the case is really one 
 in which the forceps may be used with a reasonable prospect of success ; 
 for, if not, nothing can be more irrational than to subject the woman 
 to the not inconsiderable risk which attaches to this operation, even 
 under the most favorable conditions. When the child is dead, and the 
 estimated difficulty in extraction is considerable, most accoucheurs 
 would prefer to deliver by craniotomy; but if, on the contrary, there 
 is evidence of the child being alive, nothing can be more repugnant to 
 
XXIX.] SCOPE OF LONG FORCEPS. 485 
 
 the feelings, than the idea of an operation which deliberately destroys a 
 life, and we will naturally prefer any procedure which may give the 
 child a chance. To yield too far to this inclination would, however, 
 be manifestly wrong, for the mere fact of the child's life need not enter 
 into the calculation when it is obvious that it must, sooner or later, be 
 sacrificed. Our whole attention, in such a case, should be centred in 
 the mother, in whose interests, therefore, we should decide upon that 
 operation which is likely to subject her to the least possible risk. 
 
 But it is not against craniotomy alone that the long forceps may be 
 balanced, for there are cases in which the question for decision is 
 between the forceps and turning, as will be better understood when 
 we come to consider the conditions under which we have recourse to 
 the latter operation. It has been said that the forceps is a " child's 
 operation," but we would take a very narrow and improper view of 
 the scope of the instrument did we conclude that it was always so, and 
 that it was inapplicable in the interests of the mother. The results of 
 craniotomy are, according to Churchill, about one maternal death in 
 five, and we may be sure that when the head is high in the pelvis the 
 figures will be more unfavorable still. Nothing can be more absurd, 
 therefore, than to assume that, in so far as the mother is concerned, 
 craniotomy and the long forceps stand to each other in the relation of 
 safety and danger; and yet it would almost seem that this was the 
 idea which prompted many, even in modern times, to declare in favor 
 of the former. 
 
 The operation by the long forceps is one to which, as a rule, a 
 considerable amount both of difficulty and danger is attached. This 
 arises from the peculiar circumstances of the case, as compared with 
 the ordinary forceps operation. There can scarcely be a stronger con- 
 trast than between a case requiring the application of the ordinary 
 forceps, when the head lies upon the perineum, and is arrested by 
 simple inertia, and one in which a contracted brim prevents the head 
 from entering the pelvic canal. In the one, we have the operation in 
 all its details so thoroughly within our control, that we almost cease 
 to look upon it with the slightest apprehension. In the other, we are 
 operating comparatively in the dark, and at great mechanical disad- 
 vantage ; we have to subject, to an extent which we cannot fully be 
 aware of, delicate textures to violent compression ; we have to drag 
 the head through the whole length of the pelvic canal instead of merely 
 disengaging it from its proximal extremity ; and, finally, we have to 
 determine between the amount of actual obstruction and the degree of 
 justifiable force, with a nicety upon which success or failure will depend. 
 Is it, then, to be wondered at that the operation is looked upon with 
 apprehension as one beset with difficulties and dangers ? 
 
 While we freely admit that the objections with which delivery by 
 the long forceps is beset are in themselves sound, we must, at the same 
 time, express our conviction that they have been in some degree ex- 
 aggerated, and that to a greater extent by British than by Continental 
 and American obstetricians. We see no reason to doubt that, when 
 skilfully and warily employed, the best results will, in many instances, 
 follow from its use — the one essential element which, above all others, 
 
486 THE FORCEPS. [CHAP. 
 
 will contribute to success, being a careful selection of proper cases. It 
 is now very generally believed, by those who have had the greatest 
 experience, that a large proportion of the unfortunate results depend 
 upon improper instruments, and especially upon the use of such as are 
 deficient in power. The observations which, on this point, we have 
 already quoted from Dr. Barnes apply here with peculiar force. Power 
 and control are correlative factors towards the attainment of the result 
 which we desire, and if there is a deficiency in the former we can have 
 but little confidence in the issue of the case. 
 
 [The dread of the operation with the long forceps, spoken of by the 
 author, is one which is not shared by American obstetricians. No one 
 can doubt that if arrest occurs at the inferior strait or low down in the 
 cavity of the pelvis, the application of the forceps is less difficult than 
 when the progress of labor is checked with the head well up in the 
 cavity, or at the brim. But even under the latter circumstances, the 
 forceps are constantly used in this country, and many prefer them to 
 version, even when the head is movable. It should always be remem- 
 bered that when skilfully and properly used the instrument cannot 
 injure the mother. — P.] 
 
 As regards the mode of application, the long forceps differs in many 
 essential particulars from the other. Exceptional cases may no doubt 
 occur, in which the forceps is applied at the brim to effect delivery, 
 which is called for in consequence of inertia, haemorrhage, and the 
 like; but in such cases (in which we may assume the pelvis to be of 
 normal dimensions) the operation of turning will genei'ally be pre- 
 ferred. Delivery by the long forceps may practically be considered as 
 an operation in which the head is arrested by reason of contraction of 
 the pelvic brim. Our object, then, is, not to apply the blades in the 
 opposite oblique diameter of the pelvis to that occupied by the child's 
 head, so as to secure their adaptation to the sides of the cranium, but 
 rather to introduce them with special reference to the pelvic walls, so 
 as to be sure that each passes along the side of the pelvis, and is thus 
 opposite to the other in or near the transverse diameter of the brim. 
 When the head is still above the brim, it usually occupies, as we have 
 seen, a position which is more transverse than oblique, and the effect of 
 conjugate contraction at this part is to maintain that position even after 
 the head has actually engaged in the brim. Were we here to follow 
 the usual rule, and did we succeed in applying the blades in that way, 
 their grasp would be in the conjugate diameter, and in every effort we 
 would run the risk of subjecting the soft parts of the mother to inju- 
 rious pressure between the blades and the poles of the conjugate measure- 
 ment — the chief danger being posteriorly against the projecting sacral 
 promontory. Consequently, we must discard all preconceived ideas 
 and rules, and pass the blades in the direction in which there is most 
 room. 
 
 [The discussion of the vexed question, whether the forceps should be 
 applied in relation to the pelvis or the child's head, demands more than 
 the passing notice given it by the author. Most American authorities 
 teach that the forceps should be applied to the sides of the head if it is 
 possible to do so. Hodge, Elliot, and others, however, recognize the 
 
XXIX.] USE OF THE FORCEPS. 487 
 
 fact that this may be difficult or impossible when the head is transverse 
 at or below the superior strait. On account of the danger of wounding 
 the bladder and other delicate tissues, they advise that the blades be 
 applied obliquely, one over the brow and the other over the opposite 
 side of the occiput. Drs. Goodell, A. H. Smith, and Ell wood Wilson, 
 of Philadelphia, all assert that the blades should always be applied to 
 the sides of the child's head, no matter what may be its position in the 
 pelvis, nor at what stage in labor extraction is attempted. An equally 
 radical, but opposite opinion, has been assumed by the author, Barnes, 
 and others, in Great Britain, and by German obstetricians in general, 
 who assert that the position of the head should be practically disre- 
 garded and the forceps applied in relation to the pelvis. Among 
 American authors, these views have been adopted by Dr. C. C. P. 
 Clarke, of Oswego, N. Y., and they have been taught and practiced 
 in Philadelphia by Dr. W. F. Jenks and the editor for the past six or 
 seven years. 
 
 It will at once be seen that this is a very important question, not 
 only as regards the success which follows the use of the forceps, but 
 also as regards the convenience and comfort of the operator. It is 
 manifest that if the position of the child's head can be safely disregarded, 
 that the forceps are much more easily introduced. 
 
 In order to decide this question it will be necessary to study the 
 peculiarities of construction and action of the instruments employed, 
 as well as the mechanism of the birth of the head in delayed labor 
 from contraction of the pelvis. In describing the various varieties of 
 forceps used in this country, it will be remembered that they were 
 divided into two classes, those which are forcible compressors, and those 
 which are possessed of but slight compressing power. In the first class 
 are the instruments of Hodge, Robertson, Wallace, and Smith. These 
 are all constructed with the idea of developing this force to a consider- 
 able degree. Prof. Hodge, in his lectures and writings, strongly advo- 
 cated a resort to compression in order to diminish the size of the child's 
 head, so as to bring it through the contracted pelvic diameters. Now, 
 adopting the rule that the forceps should always be applied to the sides 
 of the head, it is the biparietal diameter which is shortened by this 
 pressure. It is an acknowledged fact, also, that in cases of contraction 
 of the brim, the head does not enter the pelvis with the biparietal in 
 one of the oblique diameters, but in the conjugate of the pelvis. Hodge, 
 Elliot, and others agree with Simpson, that it is dangerous to attempt 
 to apply the instrument to the sides of the head under these circum- 
 stances. Hodge also admits the fact that it is often very difficult to 
 effect this when the head is driven down into the pelvis intone of the 
 oblique diameters. He admits that the introduction of the blades is 
 more difficult under these circumstances than when the head is at the 
 superior strait. Dr. Ramsbotham, although an advocate for the appli- 
 cation of the forceps to the sides of the head, acknowledged, in 1862, 
 that he had " for many years been accustomed, however low the head 
 maybe, to introduce the blades within each ilium, because they usually 
 pass' up more easily in that direction." 
 
 It is therefore apparent that the highest authorities who advocate the 
 
488 THE FORCEPS. [CHAP. 
 
 cephalic application of the forceps, recognize that the rule is not uni- 
 versal in its application, and Ramsbotham may be said to have practi- 
 cally abandoned it. Those who favor the cephalic application assert 
 that unless the head is grasped in its biparietal diameter, compression 
 increases rather than diminishes the difficulty. It is to be remembered 
 that the advocates of this opinion use forceps which are powerful com- 
 pressors. The blades of Smith's, for example, are only two and a 
 quarter inches apart at the point where the space between them is widest. 
 
 The use of such instruments as these, the editor believes, is based 
 upon a false notion of the mechanism of labor in cases of contraction 
 which admit the use of the forceps. That compression will diminish 
 the diameters of the foetal head, no one can doubt, but if flexion is per- 
 fect, this does not result in flattening of the cranium between the resist- 
 ing portions of the pelvis which grasps it, so much as in elongation of 
 the head, increasing its fronto-mental diameter, a fact to which Barnes 
 has directed attention. Under these circumstances, traction made with 
 a properly constructed instrument, applied to the sides of the pelvis, 
 aids the moulding of the head by supplying the deficient portions of 
 the circle. Thus the elongation of the head is more rapidly effected, 
 and the duration of labor shortened. 
 
 If flexion is not entirely perfect, the head does not pass the brim of 
 a contracted as it does that of a normal pelvis. It is to be remembered 
 that the figure-of-eight pelvis is comparatively rare. In most cases the 
 deformity is due to an abnormal prominence of the sacral promontory. 
 The anterior margin of the pelvis preserving, as it does, its natural 
 rounded contour, would allow the head to pass if it did not meet with 
 resistance from the sharp point of the projecting promontory. The 
 result is, as Barnes has shown, that in labor under these circumstances, 
 " the promontory possesses a like importance at the brim or entry of 
 the pelvis to that which the symphysis pubis possesses at the outlet. 
 The promontory is a turning-point — a centre of revolution of the head, 
 just like the symphysis. The curve round the pubis, which Cams 
 described, has its counterpart in a curve round the promontory. In 
 ordinary labor, with a well-constructed pelvis, the head enters the 
 pelvis, and reaches nearly to the floor without deviating much from the 
 straight line which represents the axis of the brim. Thus it enters its 
 orbit, the circle of Cams, at once. 
 
 " But a projecting promontory, involving, as it does commonly, a 
 scooped-out sacrum below, disturbs this course. The promontory must 
 be doubled. I propose to call this curve the curve of the false jyromon- 
 tory." 
 
 If the degree of contraction is great, the rounding of the projecting 
 base of the sacrum may indent and even fracture the cranium. These 
 injuries generally occur just anterior to the ear, or in front of the bi- 
 parietal diameter, which is the one that is lessened by applying the 
 forceps to the sides of the head. 
 
 These facts point to the conclusion that the application of the instru- 
 ments in the manner generally recommended, instead of aiding, actually 
 interferes with the proper moulding of the head. If the pelvis is large 
 enough to allow the child to be born without injury, the application of 
 
XXIX.] 
 
 USB OF THE FORCEPS. 
 
 489 
 
 the blade behind the pubis can only interfere with adaptation and 
 descent, while the presence of its fellow on the side of the cranium next 
 to the sacrum prevents the head from doubling the promontory, by mak- 
 ing it "a centre of revolution/ 7 like that of the symphysis in the later 
 stages of labor. In place of the natural moulding, the head is violently 
 compressed and dragged through the inlet without any regard to the 
 measures which nature herself adopts to remedy the results of these 
 errors of conformation. Forceps are therefore to be applied in relation 
 to the pelvis and not to its contents. They are to be used as tractors, 
 not compressors. The instruments of Simpson, which are now begin- 
 
 FlG. 162. 
 
 C D, curve of abnormal promontory ; B A, Carus's curve. Modified from Barnes. 
 
 ning to be used in this country, have a space of three and one-quarter 
 inches between the fenestra*. Such an instrument is almost useless as 
 a compressor, but as a tractor it is efficient and powerful. In speaking 
 of this subject at the discussion at the Obstetrical Society of Philadel- 
 phia, in 1872, Dr. W. F. Jenks called attention to the fact that " the 
 great advantage which results from the use of an instrument intended 
 only to supplement a deficient vis a tergo, is that the mechanism of 
 labor can, and does in most cases, when the contraction is not too great, 
 proceed undisturbed, the head rotating anteriorly inside the blades. In 
 these cases, where this rotation does not take place, we only imitate 
 nature, for in cases of contracted pelvis, when the maternal efforts are 
 finally sufficient to effect delivery, we find that this rotation of the head 
 does not occur until late in the process of mechanism. 
 
 "The fact of rotation of the head occurring within the blades cannot 
 admit of any question. Any one who has used an instrument where 
 powerful compression is not excited, has had repeated opportunities of 
 verifying the fact. The testimony of Brown, Hohl, Scanzoni, Schroe- 
 der, and others is full and decisive on this point. That this rotation 
 does really take place, and that the operator is not deceived by having, 
 in fact, applied the instruments primarily on the sides of the head, is 
 
490 THE FORCEPS. [CHAP. 
 
 proved by the marks of the blades over the brow and behind the ear, 
 the marks showing the application of the instrument on the fronto- 
 mastoid diameter at the superior strait, where the want of relation be- 
 tween the head and pelvis was sufficient to cause the close adaptation 
 of the blades to the head, and their pressure into the soft tissues of the 
 scalp, while the position of the blades on the sides of the head in its 
 passage through the vulvar outlet leaves the fact of rotation beyond 
 doubt" 
 
 The great difficulty in these cases is when the head is driven down 
 between the projecting promontory and the brim. Every one knows 
 that it is often very difficult to seize it when it is free and movable at 
 the superior strait. These difficulties are so great that many competent 
 authorities practice version in preference to employing the forceps under 
 these circumstances. If the head, transverse at the superior strait, is 
 tightly compressed in the conjugate, it is much more troublesome to 
 apply the forceps to its sides than when it is free at the brim, just as 
 Hodge acknowledges that the blades are harder to get in place when 
 the un rotated head is wedged in the cavity, than it is when it is more 
 movable, but at the brim. Many assert that it is not possible to apply 
 the forceps to the side of the head when it is transverse and nipped 
 between the promontory and pubis. Indeed, this appears to be the 
 opinion of most authorities. We will not say that it is impossible to 
 do this, since accoucheurs of our acquaintance and of large experience 
 state that they have done it. We do not hesitate, however, to condemn 
 the practice as dangerous to the mother, without offering any additional 
 advantages to the child, since it interferes with the natural mechanism 
 of labor in contracted pelves. Dr. Jenks, in the discussion previously 
 alluded to, in speaking of the application of the forceps under these 
 circumstances, says that "in these cases the blades will grasp the head 
 in spite of any efforts to the contrary, in the oblique or fronto-mastoid 
 diameter ; in other words, they are applied to the sides of the pelvis, 
 for this term 'sides of the pelvis' must not, as is often the case, be 
 taken to represent mathematically the terminations of the transverse 
 diameter, but the space between the ilio-pectineal eminence and the 
 sacro-iliac synchondrosis. It would be well if the term 'sides of the 
 pelvis' should be abandoned, and the relation of the instrument to the 
 oblique diameter of the head substituted. The application of the in- 
 strument in these cases is not then a matter of election, but of neces- 
 sity."— P.] 
 
 The patient may here also lie on her left side ; and there is this 
 advantage in the double-curved forceps, that there is not the same 
 necessity for bringing the hips over the edge of the bed, as from the 
 nature of the pelvic curve the handle of the upper blade does not re- 
 quire to be nearly so much depressed. The rules given for the intro- 
 duction of the blades in these cases vary considerably. We prefer, as 
 in the case of the ordinary forceps, to pass the lower blade first. Some 
 operators, following the advice of Madame Lachapelle, will pass this 
 blade along the sacro-sciatic ligament ; but the most experienced of 
 modern authorities prefer to pass it over the perineum into the hollow 
 of the sacrum, a little to the left of the middle line. If the former 
 
XXIX.] 
 
 DELIVERY BY LONG FORCEPS, 
 
 491 
 
 method be practiced, the handle must be directed somewhat to the 
 right, although much less so than in the case of the straight forceps. 
 If, on the contrary, the operator should select, as we would recommend, 
 the second process, the blade may be directed, as is here shown, pretty 
 nearly in a horizontal position, into the hollow of the sacrum. That 
 the introduction of the double-curved forceps is a more complicated 
 proceeding than the operation previously described, no one will dispute; 
 and this indeed will appear from the description of this stage of the 
 process given by Dr. Barnes: u As the point of the blade," he says, 
 
 Fig. 163. 
 
 Introduction of long pelvic-curved forceps. 
 
 " must describe a double or compound curve — a segment of a helix — 
 in order to travel round the head-globe, and at the same time to ascend 
 forwards in the direction of Carus's curve so as to reach the brim of the 
 pelvis, the handle rises, goes backwards, and partly rotates on its axis. 
 The handle is now carried backwards and downwards to complete the 
 curve of the point around the head-globe, and into the left ilium. 
 Slight pressure upon the handle ought to suffice. This will impart 
 movement to the blade ; the right direction will be given by the rela- 
 tion of the sacrum and head." Dr. Barnes further illustrates this by 
 the following diagram (Fig. 164), which we have slightly modified. 
 
 The actual introduction of the blade is by no means so difficult, nor 
 is it a matter of such nicety as the above description would seem to 
 imply. The mere raising of the handle, after the blade has been so far 
 introduced, causes it to glide upwards, unless some obstacle should 
 exist to impede its progress. When thus adjusted to the side of the 
 head, the weight of the handle will tend to keep it in position, but 
 this will be more certainly effected by intrusting it to an assistant, who 
 should hold it back towards the periueum to facilitate the introduction 
 of the upper blade. As in the case of the other, this blade may also be 
 passed in the direction of the hollow of the sacrum, and is carried in 
 front of the lower blade, to the right of the middle line. The handle 
 
492 
 
 THE FORCEPS. 
 
 [CHAP, 
 
 being now depressed and carried backwards, its movement directs the 
 blade along the convexity of the child's head towards the right ilium ; 
 and, when the movement is complete, the handles should be in apposi- 
 tion and lock easily. Success in this will, however, depend upon the 
 extent and nature of the distortion ; but, if the lateral walls of the 
 pelvis are normal as regards their various planes, no great difficulty, 
 
 Fig. 164. 
 
 Diagram, showing various stages in the introduction of the long forceps (lower blade). 
 
 after a little practice, will be experienced in the introduction and 
 adjustment of the blades. The facility with which the lock is adjusted 
 may be looked upon, not only as evidence that the blades are in contact 
 with opposed surfaces of the head, but also that the case is one in which 
 we may hope for a favorable result. But if, on the contrary, we do 
 not succeed in introducing and locking the blades after one or two 
 attempts carefully conducted, we must abandon the case as one unsuita- 
 ble for the operation. 
 
 [In this country the forceps are generally applied with the woman 
 on her back. For this purpose she is to be brought to the side of the 
 bed, and if the head is high up in the cavity, or at the brim of the 
 pelvis, the buttocks must be well over the edge. The feet may rest on 
 
XXIX.] 
 
 DORSAL POSITION. 
 
 493 
 
 two chairs, or they may be supported by assistants. The position is 
 about that in which the patient is placed for the performance of the 
 operation of lithotomy. 
 
 It has been urged by those who apply the forceps with the woman 
 on her side, that changing her position unnecessarily disturbs the pa- 
 tient, and that the exertion which she has to make excites and alarms 
 her. These objections have but little force. On the other hand, it 
 may be urged that the accoucheur can appreciate the relations of the 
 head and pelvis more readily when the woman is in the dorsal position. 
 He can manipulate more easily both in introducing the blades ; and in 
 the last stage of the delivery of the head, when it is necessary to carry 
 the handles of the instrument well up towards the mother's abdomen. 
 
 The mode of introducing the blades when the woman occupies the 
 dorsal position does not differ in principle from the same manipulation 
 when the patient is on her side. It is to be remembered, however, 
 that in this country the long double-curved forceps are generally em- 
 ployed, no matter what may be the situation of the head. In order to 
 understand the movements which are necessary to effect the introduc- 
 tion of the instrument, the student should remember that the problem 
 is purely mechanical in its nature. He is called upon to grasp an oval 
 body in a curved canal with an instrument which has two curves, one 
 corresponding to the body to be seized, and the other to the passage in 
 
 Fig. 165. 
 
 Introduction of the first blade in the dorsal position. 
 
 which it lies. In consequence of this he has to- execute two move- 
 ments at the same time. Whatever may be the stage of labor at which 
 arrest occurs, the operator, having prepared his instrument, introduces 
 that blade of the forceps first which will be next the posterior commis- 
 sure of the vulva, when the two blades are applied and locked (Clarke). 
 It is always the blade which goes to the left side of the pelvis that oc- 
 cupies this position. It is to be lightly seized with the left hand, the 
 
494 
 
 THE FORCEPS. 
 
 [CHAP. 
 
 handle being elevated and carried to the right groin until the extremity 
 of the blade is parallel with the lips of the vulva. The fingers of the 
 right hand having been inserted into the vagina, the blade is now 
 passed along these as a guide by gently depressing the handle, and at 
 the same time carrying it inwards or towards the median line of the 
 mother. The instrument is therefore introduced by a compound move- 
 ment downwards and inwards, which leaves the lock projecting almost 
 directly upwards, or a little towards the left side. The blade may 
 now be supported by an assistant, or not, as may be necessary. The 
 opposite branch is now seized in the right hand, while the fingers of 
 the left are passed into the vagina to act as a guide. The handle is to 
 be elevated and carried towards the left groin, until the extremity of 
 
 Fig. 166. 
 
 Introduction of the second blade in the dorsal position. 
 
 the blade becomes parallel with the vulvar orifice, when the introduc- 
 tion commences. 
 
 The handle is now depressed, and at the same time carried towards 
 the right side, or the median line. This compound movement elevates 
 the blade in the pelvis, and at the same time carries it around the foetal 
 head, so that the handle of the right branch is brought parallel with 
 its fellow, and the articular surfaces are opposed to each other, and 
 locking is readily effected. 
 
 If the articulating surfaces of the lock are not directly opposed to 
 each other, the handles should be carried well back towards the peri- 
 neum, when the difficulty in locking is often overcome at once. 
 
 If this does not follow, it may be proper to pass the fingers of one 
 hand into the vagina, and by careful pressure upon one or the other 
 margin of the blade, as indicated, aided by gentle manipulations of the 
 handles, to so alter the position of the blades that locking can be 
 effected. If this is not accomplished without the exertion of much 
 force, the instrument should be removed and reapplied. 
 
XXIX.] LONG FORCEPS. 495 
 
 Many American obstetric authors and teachers who assert that the 
 forceps should always be applied to the sides of the child's head, give 
 special rules for the introduction of the instrument in each position of 
 the head. As in this work it is recommended that the blades be intro- 
 
 Fig. 167. 
 
 Instruments introduced and locked in the dorsal position. 
 
 duced in relation to the sides of the pelvis, the student is referred to 
 the writings of those who advocate opposite opinions for a description 
 of the various and complex manipulations by which the blades are 
 brought into relation with the sides of the head. — P.] 
 
 It is assumed by many writers that the blades, when introduced, 
 correspond to the antero-posterior diameter of the head. It is not so, 
 however. The head, indeed, very generally occupies the transverse 
 diameter of the pelvis, but the tendency of the blades is to adapt them- 
 selves to one or other oblique diameter, as has been showm by Simpson. 
 This has been conclusively established by examination of the head, 
 after delivery by this process, when it is found that one blade has 
 passed behind the ear, and the other has reached over the frontal bone 
 on the opposite side, and has been applied over or in the immediate 
 neighborhood of the orbit, as is shown in Fig. 168. 
 
 The forceps being thus applied, the next step in the process is an 
 attempt at extraction. Remembering the power which we possess in 
 so formidable an instrument as this, we must, in the first place, exer- 
 cise great caution in the matter of compression ; and this point is all 
 the more necessary as the handles will be found to gape more than is 
 usual, owing to the length of the cranial diameter which is between 
 the blades. Moderate compression is all that is necessary to maintain 
 the position of the forceps when well applied, for we know T that it is 
 not by manual compression only, but also by compression of the blades 
 by the walls of the natural passage, that their grasp is sustained. The 
 handles are to be seized by both hands and steady traction practiced, 
 the direction at first being somewhat backwards. As in the case of the 
 ordinary forceps, the traction must not be continuous, but in aid of 
 present, or in imitation of absent pains ; and, at the same time, we 
 
496 
 
 THE FORCEPS, 
 
 [CHAP. 
 
 combine with mere pulling effort a moderate degree of the swaying or 
 double-lever action, taking great care not to injure the perineum. 
 
 Fig. 168. 
 
 Long forceps applied. 
 
 The thorough control which the size of the handles gives us over the 
 instrument enables us to perceive with greater accuracy whether or not 
 the head can be dislodged by such efforts as we are justified in making. 
 This may be more exactly ascertained by passing the finger from time 
 to time in the direction of the head, when the descent of the occiput or 
 the rotation of the sagittal suture towards the conjugate diameter may 
 afford clear evidence that the head is making progress. As it descends, 
 the handles of the forceps will be observed to rotate, and in some cases 
 it may be possible to assist the rotation. When this stage has been 
 reached, it will be proper to carry the handles more forwards, and to 
 pull rather downwards than backwards, following the curved axis of 
 the pelvic cavity. Finally, the operator must carry the handles for- 
 wards and upwards in front of the symphysis; and, in order that this 
 may be effected with ease, the right thigh should be raised by the 
 nurse, or the patient may be laid on her back so as to permit the 
 handles to move upwards in the direction of the umbilicus. The 
 operator must, however, beware of moving the handles prematurely 
 in this direction, as he may thereby do mischief. And there is another 
 danger which he must specially avoid, viz., the ploughing up of the 
 perineum by the blade, which, in consequence of the rotation, is now 
 turned against it. This may, no doubt, be avoided by disarticulation 
 of the blades as the head approaches the outlet; but, as it is often 
 necessary to continue the traction to the last, extreme caution must at 
 this stage be observed. In nothing should we be more particular, than 
 in the slowness and deliberation with which we conduct the various 
 stages of this operation ; for, in all the details, the more closely we are 
 
XXIX.] APPLICATION TO FACE AND BREECH CASES. 497 
 
 enabled to imitate nature, the more likely is the operation to have a 
 successful result. 
 
 It may be necessary to apply the forceps in the treatment of pres- 
 entation of the face. So long as the chin is turned forwards, as it is 
 in what we have described as the third and fourth varieties, the case 
 is in all respects a normal one, and should be left to nature. But 
 inertia, and the other causes which call for the forceps in a cranial 
 position, may, in such a case, exist also, demanding instrumental 
 assistance. The application of the forceps is here in no respect more 
 difficult, nor more serious, than when the vault of the cranium is the 
 presenting part, the chin being regarded throughout as strictly anal- 
 ogous to the occiput in the mechanism and direction of its birth. The 
 rules, therefore, which have been laid down for the application of the 
 forceps in occipitoanterior positions of the vertex, may here be adopted, 
 mutatis mutandis, with equal propriety. It is very different when we 
 have to deal with a mento-posterior position of the face, which is by 
 far the most unfavorable of all possible presentations of the cephalic 
 extremity. Such is, as we have seen, the probable position of the 
 majority of face cases at the beginning of labor, rotation of the chin 
 forwards occurring as the head descends. 
 
 But the cases to which we refer are when this rotation fails, and 
 when the head descends into the cavity in its original position with 
 reference to the pelvis. Two methods of treatment have here been 
 suggested, and have apparently been practiced with success ; these 
 being application of extracting force over the occiput, so as to convert 
 it into an ordinary cranial position, and rotation by twisting the blades. 
 Smellie, Cazeaux, and others, have succeeded by the first method : but 
 that which seems most practicable, at least from a theoretical point of 
 view, is rotation, a manoeuvre which, for obvious reasons, can only be 
 practiced with the straight forceps. By the latter means, rectification 
 has in many instances been effected, so as to insure a favorable termi- 
 nation of the labor ; and it would be proper in every such case to make 
 the attempt; but, if we fail, and the symptoms indicate approaching 
 exhaustion, or are otherwise such as are held to imply a necessity for 
 speedy delivery, we may have no resource remaining but craniotomy. 
 If, in a deformed pelvis, the face presents at the brim, turning is better 
 than the long forceps in most cases ; and if the chin is backwards, there 
 can be no doubt about it. 
 
 In all cases of pelvic presentation, and in the last stage of delivery 
 by podalic version, we have the forceps ready, lest any difficulty should 
 arise in regard to the extraction of the head by the ordinary process. 
 The chin, in such cases, being almost always turned backwards towards 
 the perineum, the blades are passed in front of the sternum of the child 
 over the chin and sides of the head. The body of the child is then to 
 be carried upwards, towards the abdomen of the mother, by an assistant, 
 when, if the handles of the forceps are made to follow it in the same 
 direction, combining the movement with a moderate amount of traction, 
 the head will usually be extracted without difficulty. This is an opera- 
 tion in which delivery must often be effected with greater precipitancy 
 
 32 
 
498 
 
 THE FORCEPS. 
 
 [CHAP. 
 
 than usual — as, for example, when twitching of the limbs shows that 
 asphyxia is impending. There are other comparatively rare instances, 
 in which the operation is not effected with such ease. We may encounter 
 cases, for example, in which, the trunk being born, the face has not 
 rotated backwards. These are the instances in which Madame Lacha- 
 pelle advises us to rotate the face by the finger before extracting it ; 
 but, if this cannot easily be done, it will be better to adopt the plan 
 suggested by Velpeau, and endeavor to drag down the occiput beyond 
 the edge of the perineum, and deliver the head by a movement of ex- 
 tension, instead of, as is usual, by the ordinary one of flexion. There 
 are cases, also, in which the head, after turning or in breech presenta- 
 tion, is arrested at the brim in consequence of deformity, when it might 
 be possible to deliver by applying the forceps along the sides of the 
 pelvis ; and there are instances, rarer still, in which the head is sepa- 
 rated, and left behind in the cavity of the uterus, where we must attempt 
 extraction by the forceps, so adjusting the blades as to prevent the pos- 
 sibility of the occipito-mental diameter being thrown across the pelvis. 
 The difficulties which, under special circumstances, attend the intro- 
 duction of the forceps have given rise to innumerable modifications of 
 
 Fig. 109. 
 
 Fig. 170. 
 
 Ziegler's forceps. 
 
 Radford's forceps. 
 
 the instrument, none of them (with a few exceptions, such as the forceps 
 of Mondotte, in which the blades do not cross) affecting the general 
 principles upon which the instrument is constructed. To one or two 
 
XXIX.] VARIETIES. 499 
 
 only of the more important of these we may call attention. Dr. Ziegler, 
 of Edinburgh, has recommended a forceps of which the blades are 
 straight, but dissimilar. The fenestra of one blade is carried down to 
 the handle, and in introducing the instrument, the elongated fenestra 
 is slipped over the handle of the other blade, which has been previously 
 passed, and which serves, therefore, as a guide for the adjustment of 
 the other. What is described in the Obstetrical Society' 's Catalogue as 
 Mr. Philip Harper's forceps seems, both in principle and construction, 
 to be identical with Dr. Ziegler's. 
 
 Dr. Radford, again, has invented an instrument, of which the blades 
 are of unequal length, and in which there is a reversed position of the 
 lock. This ranks as a long straight forceps, and is designed by the 
 inventor for application to the head when it is arrested at the brim, 
 the long blade being passed over the face, and the short one over the 
 occiput. The opening formed by the curve in the shank of each blade 
 is for the purpose of passing a handkerchief through, and will enable 
 the practitioner, in addition to his hold of the handles, to use very 
 powerful and effective extracting force. To these we might add 
 numerous varieties, which exhibit infinite peculiarities, and which differ 
 from the familiar standards in the nature of the curves, pelvic or cranial, 
 the length of the fenestra?, the width of the blades, and the arrange- 
 ment of the shanks, handles, and locks. To describe even a tithe of 
 these would carry us beyond our prescribed limits, and would serve 
 no useful purpose. 
 
 In expressing a preference for the straight over the double-curved 
 forceps, in all ordinary cases, we must not be supposed dogmatically to 
 condemn the latter instrument in what are generally called short forceps 
 operations, or, indeed, in any other, save those in which we use the 
 forceps for the purpose of effecting rotation. The authority of those 
 who have pronounced more or less emphatically in its favor is of too 
 great weight to be overlooked. We are inclined, more particularly, 
 to admit the force of Simpson's observation, that it is well for the 
 operator to accustom himself to the use of one kind of instrument only, 
 as a strong argument in favor of the pelvic curve; but, on the other 
 hand, we entertain personally so strong a conviction that the straight 
 forceps, while it can effect, below the upper third of the pelvic cavity, 
 everything which the other can achieve, is essentially easier of applica- 
 tion by beginners, as it is, undoubtedly, simpler in construction than 
 its rival. When once its special difficulties are overcome, we cannot 
 doubt, however, that in hands familiar to its use, the double-curved 
 forceps fulfils all the indications of a safe and efficient extractor. 
 
 We would conclude this chapter with a single word of caution to the 
 young practitioner who has overcome the preliminary difficulties, and 
 w T ho has attained a certain amount of confidence and skill in the use of 
 the instrument. It is to beware lest this should lead him to a too fre- 
 quent and unnecessary application of it. Above all, let him remember, 
 that no mere question of time, or of his own convenience, can ever be a 
 sufficient warrant for operative interference. No operation is without 
 risk, and nothing, therefore, short of a conscientious conviction that he 
 
500 . THE VECTIS. [CHAP. 
 
 is about to act in the interests of the mother or the child, can ever 
 absolve him from the responsibility which attaches to him in virtue of 
 the position which he occupies. 
 
 CHAPTER XXX. 
 
 THE YECTIS ; FILLET ; BLUNT HOOK, ETC. ; DECAPITATION. 
 
 DISCOVERY OF THE VECTIS BY ROONHUYSEN — MODE OF USING THE VECTIS — CASKS 
 TO WHICH IT MAY BE APPLIED — THE FILLET; A CONTRIVANCE OF ANCIENT 
 ORIGIN ; APPLICABLE CHIEFLY TO BREECH CASES — THE BLUNT HOOK — THE 
 CROTCHET; PRECAUTIONS NECESSARY IN THE USE OF THE CROTCHET: THE 
 GUARDED CROTCHET — USE OF TWO CROTCHETS — DECAPITATION: VARIOUS IN- 
 STRUMENTS FOR: DESCRIPTION OF THE OPERATION: EXTRACTION OF THE 
 TRUNK : SUBSEQUENT EXTRACTION OF THE HEAD BY THE VARIOUS METHODS 
 OF THE FORCEPS, CROTCHET, OR CEPH ALOTRIBE. 
 
 About the same time that the discovery of the Chamberlens was 
 gradually brought to light and introduced into practice in this country, 
 the Vectis or Lever was being used for the delivery of women in Hol- 
 land by Roonhuysen. The frequent sacrifice of infant life — which was 
 rendered necessary in cases of difficult or obstructed labor — was no 
 doubt the cause which, in both cases, turned the attention of the in- 
 ventors to the subject, with the earnest desire to devise any means 
 whereby the crotchet and perforator might be superseded by some con- 
 trivance which would deliver the woman without destroying her child. 
 The discovery of Roonhuysen, although of much less importance than 
 that of Chamberlen, was an inestimable advantage in practice; and, by 
 the rude instrument contrived by the Dutch accoucheur, many success- 
 ful operations were performed by himself, his son, Ruysch, and some 
 others to whom the secret had been communicated. This original lever 
 was of the simplest possible construction, and consisted of a flat piece 
 of iron, bent at each end into a slight curve, and covered with soft 
 leather to protect the external parts. The secret of the lever was even- 
 tually purchased from those to whom it had been handed down after 
 Roonhuysen's death, by two Dutch physicians, Visscher and Van den 
 Poll, whose names are more worthy of being recorded than those of 
 the inventors, as they jointly paid the sum of 5000 livres in order that 
 they might impart to the world a secret which should never have been 
 withheld. As the knowledge spread, the simple contrivance of the 
 originators became altered and modified, until it resulted in the vectis 
 of the present day. 
 
 One is apt to suppose, that, as the Vectis is now seldom used, it has 
 been discarded as a worthless instrument. So far, however, from this 
 being the case, the vectis must always be looked upon as an extractor 
 of considerable power and efficiency, and the sole reason for the neg- 
 lect into which it has now fallen, is simply because it has been utterly 
 
XXX.] 
 
 THE VECTIS. 
 
 501 
 
 Fig. 171. 
 
 thrown into the shade by the forceps. There are, moreover, even in 
 the present day, practitioners of great experience who occasionally use 
 the vectis in certain cases in preference to the more familiar instrument. 
 The modern vectis has, in its general appearance, a certain resemblance 
 to a single blade of the short forceps, and like the latter, varies greatly 
 in its shape, handle, and fenestra ; but more particu- 
 larly in the curve which is given to it with a view to 
 efficient adaptation to the head of the child. The 
 variety which is here represented is one of the best 
 known of the numerous modifications of Roonhuysen's 
 lever. It is sometimes furnished with a hinge be- 
 tween the handle and the blade, — a principle which 
 has also been applied by some to the forceps, with the 
 view of facilitating the introduction of the upper 
 blade. Such an arrangement is, however, quite un- 
 necessary, if the woman is placed in the proper posi- 
 tion on her left side, and her hips are brought quite 
 over the edge of the bed, when it may be introduced 
 without difficulty with reference to any position of the 
 head, or any part of the circumference of the pelvic 
 wall. 
 
 If we had not at our command a safer and more 
 perfect agent in the forceps, there can be no doubt that 
 the vectis would be an instrument of every-day use 
 for the extraction of the child, whether employed as a 
 lever or a tractor. These two ideas have, manifestly, 
 been the guiding principles upon which suggestions as 
 to the modification of the instrument have been based ; 
 when the idea of leverage has predominated, the curve 
 has been slight ; whereas, when traction has been the 
 object, the curve has been greater, so as to secure, for 
 this purpose, a firmer hold of the head. No efficient action of the vectis 
 can, however, be produced, unless the principle of a simple lever is 
 more or less brought into play; for, even if we admit it as possible that 
 it may act as a tractor, it can obviously act only upon the end of a 
 cranial diameter, which latter becomes a lever, the fulcrum of which is 
 at the other pole of the diameter thus acted upon. But its efficient 
 action is scarcely compatible with this idea, as it will generally be 
 found necessary so to use it as to make the blade itself a lever, the ful- 
 crum of which must be found in some part of the pelvic wall. This, 
 in fact, is the great objection to the vectis, when we compare it with 
 the forceps, where the fulcrum of each blade is the lock. It may no 
 doubt be possible, in the case of the single lever, to protect the soft 
 parts by interposing a finger where the force is brought to bear upon 
 the fulcrum, and we may be sure that this is the manner in which 
 Roonhuysen and his followers operated ; but still, even under the most 
 favorable circumstances, the danger which arises from such a plan of 
 action must be viewed as considerable, and in direct proportion to the 
 mechanical force employed. 
 
 When the vectis is used with the view of facilitating delivery in 
 
 The vectis. 
 
502 THE VECTIS. [CHAP. 
 
 cases of cranial presentation, it is essential, in the first place, that the 
 position of the head be accurately ascertained ; and, further, that the 
 operation should be conducted with a perfect knowledge and apprecia- 
 tion of the laws upon which the natural phenomena of parturition de- 
 pend : the object being chiefly, therefore, to bring the occiput forwards 
 under the arch of the pubis. If we should thus succeed, by pulling 
 down the occiput, in increasing the occipitofrontal obliquity of the 
 head, it is clear that we are, at the same time, closely imitating the 
 process by which nature manages the descent of the head. This may, 
 if the uterus is acting efficiently, be all that is required ; and, in any 
 case, it advances matters a stage. But, in cases of unusual difficulty 
 or absolute inertia, little ultimate good will result if we stop short at 
 this stage of the operation, so that we can only act effectively by bring- 
 ing our force to bear against the two ends alternately of the occipito- 
 frontal diameter. So soon, therefore, as we have succeeded in causing 
 the occiput to advance, the vectis is to be withdrawn and adjusted to 
 the frontal pole; and by thus acting, now on the occiput and again on 
 the forehead, we may certainly and steadily cause the head to advance 
 in the direction of the outlet. A blade which is sharply curved will, 
 no doubt, take a firmer hold of the part to which it is applied, but 
 this advantage is probably more than counterbalanced by an increased 
 difficulty in its introduction. It is for this reason that a more gentle 
 or wider curve has been generally preferred, which, while permitting 
 of easier introduction, makes it more necessary that the blade itself 
 should be used as a lever; and, indeed, some have gone so far as to 
 say that no vectis can possibly be better than a single blade of the 
 straight forceps. 
 
 It would appear that the cases in which the modern accoucheur may 
 with advantage have recourse to the vectis, are those in which his 
 primary object is to act upon the occipitofrontal diameter of the head. 
 Should it seem, therefore, that all that is necessary is to insure the 
 descent of the occiput, it is possible that delivery may thus be effected 
 with even more safety than by the forceps, where the action bears upon 
 the poles of the transverse diameter. Contingencies may also arise, in 
 the course of many operations in midwifery, in which the operator 
 might avail himself of the vectis if it were at hand ; but it is probable 
 that in no instance is the vectis more applicable than when we wish to 
 correct malposition of the vertex. The natural process, by which 
 occipito-posterior positions of the vertex terminate by rotation, has 
 already been fully described ; and it has also been observed that an 
 essential condition to such rotation is the descent of the occiput, along 
 the posterior pelvic wall, while the forehead remains high in the direc- 
 tion of that cotyloid cavity to which it is turned. In proportion, there- 
 fore, as the forehead descends {fr onto- cotyloid position of West) along 
 the anterior wall, the more do we despair of natural rotation, and look 
 with apprehension to the probability of a tedious labor, or a birth with 
 the forehead to the pubis. Much may, as we have shown, be done by 
 the fingers of the operator directed against the frontal end of the occipito- 
 frontal diameter; and, indeed, while propulsive effort exists, nothing 
 is so likely as this to encourage descent of the occiput. But when this 
 
XXX.] 
 
 THE FILLET. 
 
 503 
 
 procedure fails, we have in the vectis a powerful auxiliary, which we 
 may pass over the occiput ; and, thus, by pulling the occiput down 
 and pressing the forehead up, we act simultaneously upon the two poles 
 of the long diameter, in restoring or maintaining that position of the 
 head in which alone nature effects rotation. We may even conceive it 
 possible, that, by a similar mode of procedure, we might convert by 
 this instrument a face presentation into one of the vertex, by producing 
 a rotation of the head on its transverse axis. We assume, then, that 
 with rare exceptions, the vectis, although a powerful instrument, is 
 completely superseded by the forceps; by which can be effected more 
 speedily and more safely, almost all that the vectis can accomplish. 
 
 The Fillet (laqueus) is probably the most ancient of all the instru- 
 ments used in obstetrics with the view of extracting a living child. In 
 its simplest form, it is nothing more than a loop or noose, which may 
 be variously adjusted so as to facilitate the delivery of the child. It 
 has been constructed, according to Ramsbotham, " of a strip of strong 
 cloth, silk, or leather, formed into, a running noose, and was sometimes 
 sewn up like an eel-skin, open at both ends, to admit the introduction 
 of a piece of whalebone, cane, or wire, throughout its entire length, by 
 which its application might be facilitated. It was intended to be in- 
 troduced over the head in whatever way was most easily accomplished ; 
 and, this done, the cane was to be withdrawn, the loop tightened, and 
 extraction was to be effected by main force." Such an instrument is, 
 in as far as cranial presentations are concerned, so manifestly inferior to 
 the forceps, that we can scarcely wonder that it has 
 so completely fallen into disuse as not even to be 
 mentioned in many of the best works on obstetrics. 
 Some modern authorities have, however, so far, ap- 
 proved of the principle upon which it is constructed, 
 as to direct their ingenuity to the manufacture of a 
 more perfect instrument, of which the " whalebone 
 fillet" here shown is the most familiar illustration. 
 Its length is about ten inches, the loop being seven 
 inches and a half, and its extreme width three inches 
 and a half. In its application, the loop is to be 
 passed over the occiput, and steady traction exer- 
 cised, when, if this is not sufficient, it may be 
 adjusted over the forehead or chin, thus alternating 
 the extracting force between the frontal and occipital 
 poles of the long diameter of the head, in a manner 
 somewhat similar to what is practiced in the case of 
 the vectis. 
 
 The fillet may still be usefully employed in the 
 management of breech presentations, when delivery 
 is arrested either by inertia or disproportion of the 
 parts. Some have, under such circumstances, in- 
 sisted that the forceps may be used ; but the expe- 
 rience of the great majority of practitioners has shown that we cannot 
 depend upon that instrument, which is essentially constructed for 
 application to the cranium. A most efficient means of extraction is, 
 
 Fig. 172. 
 
 Whalebone fillet. 
 
504 
 
 THE BLUNT HOOK, 
 
 [CHAP. 
 
 Fig. 173. 
 
 no doubt, afforded here by the blunt hook, but the objection to that 
 instrument, as has already been stated, is the injury which may, by its 
 use, be inflicted upon the groin and genital organs of the child. The 
 fillet may, however, be substituted, and employed both with safety and 
 efficiency. A simple loop or noose, as was the nature of the original 
 fillet, is, in such instances, to be passed over the flexure of the thighs, 
 by means of the fingers, an elastic catheter, or (as has been suggested) 
 the instrument which was designed by Belocq for plugging the poste- 
 rior nares. Nothing serves the purpose better than a simple skein of 
 worsted, one end of which is introduced in this way, and the other 
 extremity then passed through it so as to form a running noose. This 
 noose may, again, be adjusted so as to direct the extracting force in the 
 proper manner; and, as our object generally will be to pull down that 
 hip which is turned forwards in the pelvis, in advance of the other, 
 the noose should therefore be placed nearly over the anterior ischial 
 tuberosity. 
 
 The Blunt Hook, which is here shown, is also an instrument of 
 ancient date. It has been recommended in cases of obstructed breech 
 delivery ; but the danger of wounding the soft parts of the child w T hich 
 it entails, is now very properly held to be such a serious 
 objection to its use, that it has been entirely discarded 
 in cases where there remains a possibility of the child 
 being alive. In all cases in which the child is ascer- 
 tained to be dead, the blunt hook may be used without 
 hesitation ; and, in these cases, it is a powerful auxil- 
 iary to many of the more important operations of mid- 
 wifery. It is, however, less an instrument adapted to 
 any special operation, or operations, than one which 
 may be useful in a hundred different ways, while we 
 are attempting to extract the child in cases of unusual 
 difficulty. It acts most powerfully when hooked into 
 the flexure of a joint. In this way, as we have seen, 
 powerful extracting force may be brought to bear, 
 when the breech presents, by passing it over the groin; 
 and, in like manner, in cephalic presentations, the 
 shoulder may be made to advance by tractile effort of 
 a similar kind brought to bear upon the axilla. But 
 while these are, perhaps, the circumstances under which 
 the blunt hook is most frequently and usefully em- 
 ployed, it gives no idea of the real scope of the instru- 
 ment. This, indeed, embraces points in the detail of 
 many of the chief operations of midwifery ; and, in the 
 forcible extraction of the child, after the performance of 
 craniotomy or embryulcia, the hook is almost indispen- 
 sable. Its advantage, as compared with the crotchet, is that, as there 
 is no necessary laceration attendant upon its employment, it is not ab- 
 solutely unsuitable for the delivery of a living child ; and, besides, 
 that being blunt, there is not, should it chance to slip, the same risk 
 to the maternal parts. 
 
 The Crotchet was described by Hippocrates, more fully by iEtius, 
 
 The blunt hook. 
 
XXX.] 
 
 THE CROTCHET. 
 
 505 
 
 Fig. 174. 
 
 and is alluded to more or less distinctly by all the ancient writers on 
 midwifery. It is, like the instrument just described, a hook; but it 
 differs essentially in this, that it is always sharpened, so as to pierce 
 the tissues, and thus secure a better hold. In its nature, then, the 
 crotchet is an appliance which can never be used when we have any 
 hope, however remote, of saving the life of the child. The introduc- 
 tion and fixing of the instrument is a matter of little or no difficulty, 
 nor is it attended with any danger to speak of, as the sharpened por- 
 tion, being the point of the hook, is turned downwards. But, so soon 
 as the direction is reversed, and we attempt extraction, the crotchet 
 becomes, in careless and inexperienced hands, a highly dangerous im- 
 plement. In all cases, therefore, in which a sufficient hold can be had, 
 we will, as a matter of course, prefer the blunt hook ; but, 
 when it is necessary to act upon flat surfaces, the blunt 
 hook is worthless, and we are obliged to have recourse to 
 an instrument which may penetrate, and thus be fixed 
 upon any surface to which it is applied. The nature of 
 the crotchet renders, however, the maintenance of its grip 
 upon soft tissues extremely precarious, and any violent 
 effort at extraction can scarcely fail to cause extensive 
 laceration, which, in its turn, permits of the sudden de- 
 tachment of the instrument from the point at which it 
 has been fixed. Every practical accoucheur knows that 
 no confidence whatever can be placed in the instrument 
 as a tractor, unless we can fix it in some unyielding part 
 of the bony structures, upon which alone- we can safely 
 bring anything like efficient effort to bear. 
 
 But, even this is far from safe ; for, under the influence 
 of powerful effort, the crotchet may at any moment, even 
 when it is apparently well fixed, break suddenly from its 
 attachment. This is, in fact, the special danger of the 
 crotchet and the great objection to its use, as by such an 
 accident the maternal structures may, in a moment, be 
 seriously, or even fatally injured. It is on this account 
 that no sound practitioner will ever use the crotchet, with- 
 out taking great pains to guard against the result which 
 may possibly ensue ; and he therefore invariably uses the 
 finger of one hand as a guard to the crotchet, so that, if it should slip, 
 the maternal parts are efficiently protected. An instrument called the 
 " guarded" crotchet, in which a spoon-shaped blade is substituted for 
 the fingers, as a guard, is, as we shall find (see Fig. 183), occasionally 
 used at a certain stage of the operation of craniotomy. 
 
 While we thus admit the full force of the objections which exist to 
 the use of the crotchet, it must be confessed that, in cases of great diffi- 
 culty, it is a valuable, and almost indispensable aid. The point of 
 greatest importance is to secure for it a firm and unyielding attach- 
 ment, so that it is usual to try to fix it in the orbit or mouth, or else- 
 where in the same region, so as to maintain an efficient hold upon the 
 irregular bones of the face ; and, in those instances in which it is passed 
 within the cranium, or any of the other hollow cavities of the body, 
 
 The crotchet. 
 
506 DECAPITATION. [CHAP. 
 
 the same principle guides our action, so that we may find ourselves at 
 one time fixing it in the foramen magnum, and at another attaching it 
 to the spinal column, or the pelvic brim. 
 
 The nature of the crotchet is such that it can operate upon one point 
 only of the circumference of the head, or other presenting part. If we 
 act, therefore, in a cranial presentation, in this manner upon the orbit, 
 we run the risk of dragging down the forehead by a movement of the 
 head on its transverse axis, without securing any actual advantage, and 
 with the possibility, if the chin be backwards, of making matters worse. 
 xEtius, in one of the most interesting passages of his obstetric works, 
 recommends that we should operate by two crotchets, applied at the 
 sides of the pelvis, to opposite surfaces of the child's head, and then 
 pull downwards, in order that the traction may be equal, and in the 
 direction of the resultant of the two forces (ad neutr am partem dcclinans). 
 Had he but thought of the possibility of applying the same principle 
 to the delivery of the living child, he would almost inevitably have 
 discovered the forceps. But, as in the case of Hippocrates and the 
 olive, such speculations are perhaps more interesting than instructive. 
 The hint here given, as to the combined action of two crotchets, is not 
 to be despised, as there are certainly cases in practice in which the 
 principle indicated might usefully be adopted ; and this, in fact, was 
 recommended and practiced by Dr. Davis. In so far as cranial pres- 
 entations are concerned in which the forceps fails, or in which the use 
 of that instrument is contraindieated, no good can possibly result, 
 except under peculiar or exceptional circumstances, from the use of the 
 crotchet, until we have already diminished the head by perforation of 
 the cranium, and extraction of its contents. 
 
 Decapitation. — An instrument closely resembling, in shape and gen- 
 eral appearance, the blunt hook, but which is usually sharp within the 
 curve, has been used with success in the treatment of those difficult 
 cases of transverse presentation in which the ordinary methods of 
 treatment have failed. This operation simply consists in abridging 
 the long diameter of the child by a section made at the neck. It is 
 described by Celsus, and by many writers subsequently ; but, with the 
 exception of Davis, Ramsbotham, and, more recently, Barnes, the sub- 
 ject has not received that attention in this country which it seems ob- 
 viously to merit. It seems to us advisable, therefore, that we should 
 in this place describe the operation somewhat in detail. This mode of 
 procedure is chiefly applicable to those instances in which we have to 
 deal, either with a neglected case of shoulder presentation, where the 
 body of the child is partly impacted, or is so tightly embraced by the 
 uterus as to render turning impracticable; or with a case in which the 
 difficulty arises mainly from pelvic distortion, complicated with a trans- 
 verse position of the child. 
 
 The form of hook already described is that which is best known in 
 this country, and is commonly called Ramsbotham's hook; but a num- 
 ber of other instruments, more or less resembling this, as well as some 
 of a different construction, have been recommended. Among the latter 
 may be mentioned a contrivance which consists of a strong cord, which 
 is to be passed round the neck, and then, by a saw motion, is carried 
 
XXX.] REMOVAL OF THE HEAD. 507 
 
 to and fro by means of cross handles at its extremities, until the head 
 is severed. It is probable that a modification of the wire rope ecraseur 
 might be advantageously used for the same purpose, but the difficulty 
 in such cases would probably be the passing of the rope around the 
 neck. It w r ould appear that, with the ordinary instrument, a cutting 
 surface is by no means absolutely essential, as some have succeeded by 
 means of the ordinary blunt hook. The operation of decapitation by 
 Ramsbotham's hook or Braun's " decollator," is well described by Dr. 
 Barnes as consisting of three stages. The first stage is the application 
 of the decapitator and the bisection of the neck ; the second is the 
 extraction of the trunk ; the third, the extraction of the head. 
 
 The first point to be accurately ascertained is the position of the 
 body of the child, whether dorso-anterior or dorso-posterior. This 
 being determined, in the manner already described, by an observation 
 of the prolapsed hand, and the woman being placed in the ordinary 
 obstetric position, or on her back, the arm is to be firmly pulled down- 
 wards, so as to bring the neck, as far as is practicable, within the reach 
 of the operator, and is then to be intrusted to an assistant, whose duty 
 it is to maintain the position by steady and moderate traction. The 
 bladder — and, if it be necessary, the rectum — are now to be emptied 
 of their contents, and the hands and hook smeared with lard or oil. 
 The fingers of one hand — right or left, according to the position — are 
 then gradually insinuated in a direction corresponding to the anterior 
 surface of the child, so as to reach the front of the neck. With the 
 other hand the operator then introduces the hook, " laying flat," says 
 Barnes, "between the wall of the vagina and pelvis and the child's 
 back, until the beak has advanced far enough to be turned over the 
 neck. The beak w r ill be received, guided, and adjusted by the fingers 
 of the left (opposite) hand. The instrument being in situ, whilst 
 cutting or breaking through the neck, it is still desirable to keep up 
 traction on the prolapsed arm. In using Ramsbotham's hook, a saw- 
 ing motion must be executed, carefully regulating your action by aid 
 of the fingers applied to the beak. If Braun's decollator be used, the 
 movement employed is rotary, from right to left, and at the same time, 
 of course, tractile. The instrument crushes or breaks through the ver- 
 tebra?. When the vertebrae are cut through, some shreds of soft parts 
 may remain. These may be divided by scissors, or be left to be torn 
 in the second stage of the operation — the extraction of the trunk." 
 
 The delivery of the trunk and limbs of the child is now to be 
 effected, mainly by pulling upon the arm ; but, should the force requi- 
 site be considerable, it will be proper to pass the blunt hook into 
 the axilla of the opposite side, in order to economize the tractile force 
 on the depending arm. Care must, however, be taken not to use the 
 hook with too great force, as by causing the premature descent of the 
 upper shoulder we would throw the great diameter of the shoulders 
 across the pelvis, and thus, it may be, render the extraction of the 
 trunk a matter of increased difficulty. Generally speaking, no great 
 difficulty, in the absence of pelvic deformity, will be encountered in 
 this stage of the operation ; and steady traction will cause the shoulders, 
 trunk, and breech, successively to pass along the pelvic canal. The 
 
508 DECAPITATION. [CHAP. 
 
 head, if completely separated, will move to the side, and will be no 
 obstacle to the passage of the body. 
 
 The extraction of the head of the child, which constitutes the third 
 stage of the procedure, is by no means an easy operation, and is some- 
 times, in fact, the most difficult point of all. A good deal will depend 
 upon the condition of the uterus as regards contraction. During the 
 second stage, it will be the duty of an assistant to keep up steady 
 pressure upon the fundus of the uterus, and to follow it downwards 
 as the trunk is being gradually expelled, so as to encourage, as tar as 
 may be possible, efficient and symmetrical uterine contraction, under 
 the influence of which the head will be grasped, forced down in the 
 direction of the cavity, and maintained in a comparatively fixed position. 
 Another condition likely to exercise an important influence is the state 
 of the head itself, which, if decomposition has advanced, will be easily 
 compressible, the flat bones being so loosely connected with each other 
 as to admit of overlapping to a very unusual extent. Various methods 
 have been suggested and practiced for the extraction of the head from 
 the uterus. The instances in which it is expelled by the natural efforts 
 are few, and no confidence can, for obvious reasons, be placed in the 
 occurrence of such a result. In some cases, it has been successfully 
 removed, when compressible from putrefaction, by the fingers of the 
 operator ; but, in almost all ordinary cases, instrumental aid is re- 
 quired, when we have the forceps, the blunt hook, the crotchet, and 
 the cephalotribe to select from. 
 
 The great obstacle, in such cases, arises from the mobility of the 
 head, which rolls about within the cavity, and can sometimes only be 
 seized with difficulty. If, however, the head can be steadied and pressed 
 downwards by the assistant, whose hands are employed for this purpose 
 in the hypogastric region, the difficulty in question may be overcome. 
 If it be possible to fix the crotchet, or a small blunt hook, in the 
 foramen magnum or orbit, success may, in this way, with the aid of 
 the fingers, be quite practicable; but the risk of the crotchet slipping 
 is so considerable, that the more experienced modern operators have 
 pretty much discarded that instrument in favor of the others which 
 have been mentioned. The safest and most satisfactory operation, 
 when it is practicable, is that by the ordinary midwifery forceps. The 
 difficulty in this, as in the other operation, is to fix the head; for, as 
 soon as one blade is introduced, the head may escape to the upper part 
 of a relaxed uterus, or to either side, so as completely to elude the grasp 
 of the blades; but if we can succeed in seizing the head, either antero- 
 posteriorly or laterally, delivery will usually be completed without any 
 further obstruction. The only other point to which it is necessary to 
 pay particular attention, is the adjustment of the blades in such a 
 manner as may obviate the possible danger arising from jagged spicula, 
 which may project from the severed vertebra?, or from such splintering 
 elsewhere as may possibly have been the result of previous operative 
 efforts. 
 
 There are cases, however, in which much more serious difficulties 
 attend the extraction of the retained head. The worst examples of 
 this are instances in which there is pelvic deformity, and in which it 
 
. 
 
 XXX.] REMOVAL OF THE HEAD. 509 
 
 may be quite impossible for the ordinary diameters of the head to pass. 
 In these, and in the more diffieult of the cases unconnected with pelvic 
 distortion, it has been suggested that the perforator should be used. It 
 is to be feared, however, that, even in the hands of the most skilful, 
 great risk will attend the use of that instrument ; and, even if it were 
 not so, it must be admitted that the operation is one which we would 
 not, without great apprehension, intrust to the inexperienced. Hazard- 
 ous as the perforator always is, it is in this instance peculiarly so, owing 
 to the mobility of the head, in consequence of which it may rotate 
 suddenly and unexpectedly at the moment of perforation, and thus 
 direct the sharp point of the instrument against the uterine wall with 
 possible results too fearful to contemplate. If we are able, by means 
 of external manipulation, to fix the head against the brim, the per- 
 forator may be successfully employed against the occiput ; but, as mere 
 pushing force would most likely dislodge the head, it is proper to com- 
 bine boring with the more violent effort, which will, certainly, in econo- 
 mizing the latter, conduce to the safety of the operation generally. 
 After perforation, and evacuation of the contents of the cranium by a 
 process exactly similar to that which will be described under the head 
 of Craniotomy, the extraction of the head by the guarded crotchet, or 
 still better, by the craniotomy forceps, will be a matter of no great 
 difficulty ; but, in both cases, the greatest possible care should be taken, 
 as the head descends, to preserve the soft parts from laceration by the 
 splintered fragments of the bones. The Cephalotribe is an instrument 
 for which, in the management of such cases, we must express a very 
 decided preference, as being both safer and surer than either the per- 
 forator or the crotchet, and almost as simple as the forceps in its appli- 
 cation and management, as will be hereafter explained. And, after 
 discharging its special office of crushing the head, which is of such 
 importance in contraction of the brim, the cephalotribe may further be 
 employed as an extractor. The crushing process may be single or 
 double, but in either case the hold obtained by the blades of the instru- 
 ment gives a grasp of such power that extraction may then be an easy 
 matter. In this case, as in that of the forceps, the difficulty is in 
 steadying the head until the blades are passed and locked. 
 
 It is not only as a sequel to the operation of decapitation that extrac- 
 tion of the head has to be effected ; but it is also sometimes required 
 under other circumstances, such as its accidental separation after the 
 operation of turning. This is not likely to occur in experienced hands, 
 but the separation of the neck of a putrid child does not require much 
 force, and might happen to any one. Far less excusable are the cases 
 in which, in a breech presentation, or after turning, the head is arrested 
 at the brim, and such violence is used in attempts at extraction as to 
 result in tearing the trunk away from the head. In the absence of 
 evidence of the death of the child, it is scarcely to be conceived that 
 any one would use such violence as would of itself sacrifice the life of 
 the child. But, if the child be dead, the operator might imagine that 
 this is the safest and most natural method of delivery, and act accord- 
 ingly by employing an amount of force which, in the interests of the 
 mother, is quite unjustifiable, even should he succeed in his endeavor, 
 
510 TURNING. [CHAP. 
 
 seeing that he has, in the forceps and the perforator, agents by which 
 maternal risk is materially reduced. As an illustration of what igno- 
 rance and inanity may achieve under the seal of the profession, we may 
 here mention the details of a case of this kind, which was brought 
 under our notice many years ago. A young practitioner in a remote 
 country district having performed the operation of turning, experienced 
 such difficulty in getting the head through the brim that he called in 
 the aid of a friend of no greater experience than himself. Under the 
 influence of vigorous efforts thus reinforced, the body of the child was 
 brought into the world minus the h*ead. The removal of the retained 
 head was too much for the combined skill of the two operators, so that, 
 after repeated failure, they held a council ; and, after due and solemn 
 consultation, resolved to perform, and actually did perform — what? — 
 the most ingenious and speculative of our readers can scarcely conceive 
 it — the Ccesarian Section ! 
 
 CHAPTEE XXXI. 
 
 TURNING. 
 
 VARIOUS METHODS OF TURNING : TURNING AS PRACTICED BY THE ANCIENTS \ PO- 
 DALIC VERSION — CIRCUMSTANCES WHICH CALL FOR, AND CONDITIONS FAVOR- 
 ABLE TO THE OPERATION : THE OPERATION IN DETAIL : CHOICE OF HANDS : 
 INTRODUCTION OF THE HAND: PASSAGE OF THE OS: SEIZURE OF A FOOT OR 
 KNEE— CIRCUMSTANCES WHICH RENDER TURNING DIFFICULT : DIFFICULTY IN 
 SEIZING THE FOOT — CHILD TO BE TURNED FORWARDS — MANAGEMENT OF THE 
 CASE AFTER VERSION — PELVIC VERSION — CEPHALIC VERSION — TURNING IN 
 CONTRACTED PELVIS : DEGREE OF DISTORTION WHICH MAY ADMIT OF TURNING — 
 TURNING CONTRASTED WITH THE LONG FORCEPS, AND AS A SUBSTITUTE FOR 
 CRANIOTOMY — SPECIAL DIFFICULTIES — BIMANUAL OR BIPOLAR VERSION : PRO- 
 CESSES OF WIGAND, LEE, AND BRAXTON HICKS. 
 
 The operation of Turning, in its most extended sense, implies a 
 manoeuvre by which one of the poles of the long diameter of the child 
 is brought into the brim of the pelvis, the long diameter of the foetal 
 oval being thus made to correspond to the long diameter of the uterus. 
 Two varieties of turning may therefore be practiced: these are turning 
 by the head, or, as it is generally termed, Cephalic Version ; and turn- 
 ing by the feet, or Podalic Version. A special modification of the 
 latter, in which the breech, and not the feet, is brought down, has been 
 occasionally practiced, and separately described. 
 
 From the time of Hippocrates down to the middle of the sixteenth 
 century, Cephalic Version was almost exclusively practiced, the head 
 of the child being assumed to be the only natural presentation. This 
 assumption led to the frightful practice of turning by the head in all 
 presentations of the pelvic extremity. It is quite clear that both 
 
XXXI.] THE OPERATION. 511 
 
 Aristotle and Celsus held more correct views ; but the practice of Hip- 
 pocrates, nevertheless, held its ground until the period which we have 
 mentioned ; so that, up to that time, the modern operation of turning, 
 as practiced in the present day, was quite unknown. In 1561, Pierre 
 Franco, in. a work devoted chiefly to Surgery, suggested the mode of 
 turning by the feet, and this was subsequently adopted by Pare, Guille- 
 meau, Mauriceau, Baudelocque, and La Chapelle, to the complete ex- 
 clusion of the cephalic operation. The difficulties which, under certain 
 circumstances, surround the modern operation, seem, as late as the 
 end of last century, to have suggested doubts as to its propriety* in the 
 minds of Flamand, Osiander, and other distinguished accoucheurs of 
 that time, who therefore suggested that the practice of Hippocrates 
 should be resorted to in all but original presentations of the breech or 
 feet, to the exclusion, absolutely, of the new method. These views 
 found favor chiefly in Germany, but the podalic method made steady 
 progress, and came ultimately to be generally adopted. The con- 
 temptuous manner, however, in which cephalic version was passed over 
 or condemned by many of the most eminent writers of this period, led 
 for a time to the complete abandonment of this process; but, in the 
 present day, its value finds- general recognition in a certain class of 
 cases, — limited, no doubt, in point of numbers, as will be more particu- 
 larly shown in the sequel. 
 
 What is now, however, universally described as, par excellence, the 
 operation of Turning, is Podalic Version, which consists in bringing 
 down the feet when another part presents, and thus converting it into 
 a footling presentation. The circumstances which call for this opera- 
 tion embrace a large proportion of all cases in which a speedy delivery 
 is required, and especially those in which the necessity has arisen early 
 in the course of labor. Among the circumstances thus alluded to, may 
 be mentioned placenta previa, prolapse of the cord, sudden death of 
 the mother, certain cases of rupture of the uterus, and, in the opinion 
 of many, cases of moderate pelvic distortion, in which it has been pro- 
 posed as a substitute for the forceps, or the more formidable operation 
 of craniotomy. In transverse or shoulder presentations, again, it is the 
 invariable procedure ; and, in so far as this particular case is concerned, 
 it has already been described at some length. 
 
 It is of the first importance that the conditions favorable to the 
 operation should be correctly appreciated. As it is usually performed, 
 it is essential that the os and cervix should be sufficiently dilated to 
 permit of the passage of the hand ; but, as a moderate degree of dilata- 
 tion only is requisite for this, it follows that turning is available at a 
 stage of labor considerably earlier than we have seen to be necessary 
 for the safe employment of the forceps. Another favorable condition 
 applicable alike to all cases, is, that the membranes should be intact. 
 The reason of this is obvious ; for, so long as the liquor amnii remains, 
 the walls of the uterus are separated, in proportion to its quantity, 
 from the body of the child, the mobility of which is consequently 
 greater. Nothing, indeed, contributes so much to the ease with which 
 turning is effected as this; and, if the waters have escaped, and the 
 womb has thus been permitted to grasp the body of the child, the 
 
 , 
 
'512 TURNING. [CHAP. 
 
 operation is then found to stand in a very different category. The 
 condition of the os as regards dilatability is another most important 
 consideration, for a rigid or unyielding condition of this part of the 
 passage is justly looked upon as an unfavorable circumstance, and it is 
 therefore proper to wait, so long as the membranes remain unruptured, 
 until nature overcomes this resistance. 
 
 The Operation. — The condition of the bladder and rectum having 
 been attended to, the woman is, in the first instance, to be placed in 
 a convenient position. Some operators prefer that she should be on her 
 back, and others that she should be on her elbows and knees ; but 
 the English operator will generally choose the ordinary midwifery 
 position on the left side, the nates being brought to the edge of the 
 bed, so as to be within convenient reach. She should then be brought 
 under the influence of chloroform. This has the effect of facilitating, 
 both directly and indirectly, the passage of the hand, by overcoming 
 rigidity and spasmodic contraction, and obviating the embarrassment 
 which may arise from movements which are the result of apprehension 
 or pain. The uterus is to be supported by an assistant, or by the 
 other hand of the operator. By this means valuable assistance is 
 afforded, by movements which are made in concert so as to bring the 
 lower extremities of the child within reach. 
 
 The directions which are often given as to the hand which should be 
 employed are of little practical value. Indeed, it is impossible in some 
 cases, as in placenta prsevia, to recognize, before it has been passed 
 into the uterus, the conditions which are held to indicate the right 
 hand or the left. Most people can act much more efficiently with the 
 right than with the left hand, and there is no possible direction within 
 the pelvis in which the right may not be passed. The positions in 
 which there is most difficulty are those in which it may be necessary 
 to direct the hand, with the palm forwards, towards the left sacro-iliac 
 synchondrosis while the woman lies in the ordinary position on her left 
 side. In this case the hand must be pronated to the fullest extent; 
 and, if this movement of pronation is increased, as it may be by the 
 operator turning his back towards the patient, it will pass without dif- 
 ficulty. The left hand would undoubtedly serve the purpose better 
 here, if we could be sure of equally efficient action with it after the 
 introduction. But, if the operator is left-handed, he should use the 
 left hand in preference to the right; and, as our first object is to attain 
 the abdominal surface of the child, — which, in the great majority of all 
 positions, lies towards the back of the mother, — and as it must clearly 
 be easier to pass the left hand along the sacrum than the right, the left- 
 handed operator has a certain advantage. For the same reason, he 
 who is ambidextrous should use that hand which may best suit the po- 
 sition of the child ; but, if it should be impossible to ascertain the posi- 
 tion, he should select the left, as being more likely to conduct him to 
 the anterior surface of the child's body. 
 
 The operator should take off his coat, and bare his arm, so as to ob- 
 viate, as far as is practicable, any inconvenience which may arise from 
 pressure upon the muscles. The hand and arm are then to be liberally 
 smeared with lard, and the points of the fingers, which are brought 
 
XXXI.] THE OPERATION. 513 
 
 together like a cone,, are introduced within the vulva, and steadily 
 pushed upwards in the axis of the outlet. In the event of unusual 
 contraction at this stage, the obstacle will, to some extent, be overcome 
 by separating the fingers, so as to stretch the parts. No such difficulty, 
 however, usually exists, but a more important one is encountered as 
 the knuckles approach the orifice of the vagina. This is increased by 
 the action of the constrictor vaginae muscle, especially in those cases in 
 which chloroform has not been administered; but the resistance, by 
 the stretching action of the fingers, combined with moderate and un- 
 remitting pressure, will speedily be overcome, when the rest of the 
 hand will pass into the vagina, the muscles retracting upon it as it ad- 
 vances, and ultimately grasping the wrist. It is at this stage proper 
 to pause, which affords us an opportunity of more carefully examining 
 the presenting part, and it may be, of ascertaining the direction in 
 which the hand is to be passed, with greater certainty than can be 
 attained by the finger only. 
 
 The operator, bearing in mind the curve of the pelvic axis, now 
 alters the direction of his hand, so that its advance may coincide more 
 with the axis of the brim. His subsequent procedure will depend 
 chiefly upon the condition of the os. If it is well dilated, soft, and 
 distensible, the hand may be passed at once, and turning will probably 
 be effected with such ease as may astonish the. inexperienced. But, if 
 the os be comparatively undilated, or in any degree rigid, he must 
 proceed more warily, so as to avoid the slightest approach to violence, — 
 introducing first one, then two, and subsequently the remaining fingers, 
 in the most cautious manner possible. It is generally said that, to 
 warrant an attempt at turning, the os must be dilated to the extent of 
 a crown-piece. This is, of course, only intended as an approximation ; 
 and as much or more will depend on the dilatability, as upon the stage 
 of actual dilatation. 
 
 If the membranes are still unruptured, another object in avoiding 
 abruptness in manipulation is to preserve the membranes intact. With 
 this in view, therefore, we direct the fingers, so soon as they have passed 
 within the os, between the uterine wall and the external envelope of 
 the ovum ; and, the connection between those parts being lax, no great 
 difficulty is generally encountered in passing the hand upwards, with- 
 out rupturing the membranes, in the direction of the feet. 
 
 No part of this process is, however, to be attempted, without refer- 
 ence to the natural expulsive efforts. If the uterus is acting in the 
 usual manner by rhythmical contraction, we should choose the period 
 of relaxation for the advance of the hand ; but, so soon as the advent 
 of a pain is announced by contraction of the uterine walls, the hand 
 should be allowed to lie quite flat and inactive, with the palm towards 
 the child, until the period of relaxation marks the moment when our 
 efforts may be safely resumed. Any attempt at continuous effort is 
 wrong in principle, and is, we may be sure, apt to cause laceration, 
 and even rupture of the uterus. This rule is one which is not observed 
 in practice so strictly as it ought to be, and the wonder is, that accidents 
 are not more frequent than they actually are, in cases where force is 
 employed by the operator with no reference whatever to anything save 
 
 33 
 
514 
 
 TURNING. 
 
 [CHAP. 
 
 the resistance which he encounters. It will, however, as must be con- 
 fessed, often be found that the stereotyped direction to act during an 
 interval, and pause during a pain, cannot well be adopted, for the 
 simple reason that the contact of the hand excites the uterus to con- 
 tinuous, or at best remittent action, so that if we are to wait for absolute 
 inaction on the part of the uterus, we may abandon the effort altogether. 
 Such continuous or spasmodic action as this may be, as we have seen, 
 allayed by the administration of chloroform ; and, if it should persist, 
 we may still succeed, although it is necessary, in such instances, to act 
 with redoubled caution and deliberation. 
 
 As soon as the hand has reached so high in the uterus that the 
 inferior extremity of the child can either be felt, or may be assumed to 
 be on. the same level, the sac of the liquor amnii may be ruptured, and 
 the fingers passed in the direction of the foot or knee. The rupture 
 of the membranes is easily effected, by an effort of the fingers or the 
 action of the nails in the direction of the foetus, but with this the 
 mechanical advantage of the liquor amnii is not lost, as it is still 
 retained by the efficient plug formed by the arm which occupies the os 
 uteri. This renders the actual version an easy matter. The fingers of 
 the operator lay hold of a foot or a knee, which, in withdrawing his 
 hand, he brings with him, choosing, if he can, a moment of uterine rest 
 for the purpose,, and availing himself, if it be necessary, of the assistance 
 of the other hand, which is to be applied externally. As this is being 
 done, the original presentation retreats from the lower segment of the 
 uterus, so that the turning part of the operation is complete. 
 
 Much argument has been wast- 
 ed as to the propriety of bringing 
 down one leg or two. The sound 
 rule in practice is, that when we 
 succeed in securing one foot, we 
 should never pause to search for 
 the other ; as one is all that is 
 necessary, unless, perhaps, in 
 cases of pelvic deformity, which 
 we shall afterwards more par- 
 ticularly allude to. Nay, more 
 than this, the descent of one leg 
 has a positive advantage as com- 
 pared .with two, as thus, by in- 
 creasing the diameter of the 
 pelvis of the child, the parts are 
 more thoroughly dilated, so as 
 to admit of the ultimate passage, 
 rapidly, and with comparative 
 safety, of the head of the child. 
 And, as this is the stage at which 
 the life of the child is most fre- 
 quently compromised, it is as- 
 sumed, that by abridging its 
 duration, foetal life in the aggregate must, by this process, be saved. 
 
 Podalic version. 
 
XXXI.] PODALIC VERSION. 515 
 
 Still, when a very rapid delivery is desired, the operator knows that he 
 has a better and more efficient hold upon two limbs than he can have 
 upon one ; and he will, therefore, very naturally, bring down both 
 when they are within easy reach ; but, when the discovery and seizure 
 of the other limb involves extra effort or delay, not even in such a 
 case as this should he be otherwise than content with what he has 
 already achieved. 
 
 Constriction of the vaginal orifice, and incomplete dilatation of the 
 os, are, as we have seen, difficulties which are often encountered in 
 attempts at turning. Far more serious than those are the obstacles 
 which we meet with, when the conditions which we have indicated as 
 favorable to the operation do not exist. A case, for example, may be 
 brought under our notice for the first time at an advanced period of 
 labor, in which the os has been permitted to dilate, the membranes to 
 rupture, and the presenting part to descend in the pelvis before the 
 nature of the case has attracted particular attention, or the necessity for 
 turning has been recognized. The most familiar illustrations of this 
 are shoulder presentations, already described. In such cases, the liquor 
 amnii has, we shall suppose, long since escaped ; the uterine walls have 
 grasped the child in a firm embrace ; and the long-continued uterine 
 action has forced the shoulder down into the cavity of the pelvis. If 
 pelvic distortion should exist, impaction may have taken place; but, 
 independent of this, mere tonic uterine contraction may so wedge the 
 head as to render the case practically as bad as one of real impaction. 
 In such cases, the difficulties are often insurmountable, for the operator 
 cannot even pass his hand beyond the presenting part, and is obliged 
 to desist, or have recourse to some of the other operations of midwifery. 
 It is perfectly impossible to describe what experience alone can teach — 
 the amount of force which, in this, or any other stage of the operation, 
 we are warranted in employing. Anything even approaching to what 
 we would call violence, is not only improper, but ineffectual, so that 
 moderate and sustained effort, combined with an insinuating movement 
 of the fingers, should always be preferred, as being comparatively both 
 efficient and safe. If, for example, we were rudely and recklessly to 
 thrust the hand into the vagina without observing the precautions we 
 have detailed, we should, in all probability, inflict severe laceration on 
 the parts ; but if, on the contrary, we act with caution and discretion 
 in a case precisely similar, we effect our purpose with ease and safety. 
 The same principle obtains, and should never be lost sight of, in all the 
 subsequent stages. 
 
 Impaction implies resistance from the pelvic walls; but we have 
 obstacles of a not less insurmountable kind in the rigid condition of the 
 os or uterine walls, when, although success by violence may be possible, 
 it is only to be effected by what involves serious risk to the mother. 
 It is such considerations, therefore, based on general principles, which 
 should be our guide in practice, and deter or encourage us in an indi- 
 vidual case. It not unfrequently happens, as practice has taught every 
 experienced accoucheur, that these successive stages of difficulty have 
 been, one by one, surmounted, and yet, at the very moment when 
 success seemed just within our grasp, further progress was arrested. 
 
516 TURNING. [CHAP. 
 
 The tips of the fingers may even touch the knee or foot, and yet the 
 inch or so of further advance which is required can scarcely, by any 
 moderate effort, be achieved. This is a moment at which, in our 
 eagerness, we are apt to pass the line which separates prudence from 
 rashness. By a vigorous thrust of the arm, we may be confident that 
 we shall attain what we so much desire; and it is with difficulty only 
 that we can refrain from what alone seems wanting to complete success. 
 We must, however, with firmness, and what we may term self-denial, 
 resist this inclination, and wait a little until, perchance, we may wear 
 out the uterine resistance which constitutes the barrier to our progress. 
 
 It is here, however, most unfortunately, that the straining of the 
 fingers is apt, along with violent uterine contractions, to cause cramp 
 of the muscles of the hand, a condition which may absolutely paralyze 
 our efforts. By resting for a time, or stretching the fingers, the power 
 of the hand may return ; but it too often occurs that we find ourselves 
 quite powerless just at the moment when we have come to count upon 
 success crowning our efforts. Nothing will remain for us, in such a 
 case, but the withdrawal of the hand, to our great chagrin, and either 
 the introduction of the other, or the reintroduction of the same one 
 after it has had time to recover. What is particularly annoying, when 
 this is found to be necessary, is that the withdrawal of the hand from 
 the uterus permits of the escape of what liquor amnii remains, and, 
 consequently, of a still greater degree of uterine contraction upon the 
 body of the child. Even in such a case, however, we may ultimately 
 succeed by perseverance; and, when the hand has again been introduced, 
 our external manipulations may result in bringing the feet within reach. 
 But, with this measure of success, our difficulties may be far from being 
 at an end. 
 
 It sometimes happens that the hand is introduced, the foot seized 
 and brought down to the os, and yet complete version cannot be 
 effected. When the presence of the liquor amnii, or a relaxed condi- 
 tion of the uterine walls, permits of a certain degree of freedom of 
 motion, the presenting part will recede as the foot is pulled downwards 
 to the os. But, when the body of the child is firmly grasped by the 
 uterus, this is not the case, and some further manoeuvring, external or 
 internal, will be required to complete the operation. The mode of acting 
 externally through the abdominal w T alls has already been alluded to, and 
 will again be more particularly described. The internal manipulation 
 in these cases consists in pushing up the presenting part while we pull 
 down the foot. In other words, we act upon the two poles of the long 
 diameter of the foetus instead of one only. The vagina, however, being 
 already fully occupied by the hand of the operator, it will be impossible 
 for him to act upon the presenting part without letting go the hold 
 which he has of the foot ; but this is of all things what he least wishes 
 to do, as there is often great difficulty in securing it again. By a very 
 simple expedient he is able to effect all that he desires. A. running 
 noose of tape or worsted is to be passed over the forearm, and is then 
 pushed upwards over the hand and beyond the os calcis and instep of 
 the foot. When tightly drawn, this secures an admirable hold, and 
 the hand may be withdrawn, or at once brought to bear upon the head 
 
XXXI.] 
 
 TURNING BY THE NOOSE OR FILLET. 
 
 517 
 
 or presenting part, while the other hand pulls steadily upon the noose. 
 The same principle has been adopted, by Braun and other eminent 
 Continental practitioners, when difficulty arises in seizing the foot, and 
 various instruments have been devised by them with this purpose. 
 
 Fig. 176. 
 
 Turning by the noose or fillet. 
 
 One of these is described by Hyernaux of Brussels, under the name of 
 porte-lacs. When such combined action upon the two extremities of 
 the child fails, it may be impossible to effect delivery in this way ; so 
 that we may have to fall back upon the perforator or decollator, as the 
 case may be. Before finally abandoning the attempt to deliver by this 
 method, w r e must be sure that we have pulled down the foot in the 
 proper direction, so as to turn the child forwards. An error here is 
 not likely, as we would naturally pull the foot, when seized, directly 
 towards the os ; and if we have passed the hand along the abdominal 
 surface, we can scarcely go wrong; but it is quite possible that, by 
 omitting this precaution, and passing the hand over the dorsal surface, 
 we may not only find it vastly more difficult — if, indeed, it be possible 
 — to reach the foot, but we may discover, in addition, that when it is 
 reached and seized, turning is impracticable after all. 
 
 It is generally recommended by systematic writers, that we should 
 so manage the operation as to make sure that the abdomen of the child 
 is turned, after version, towards the spine of the mother, as is indicated 
 by the toes being directed towards the sacrum. This is, however, by 
 no means a matter of such importance as it might appear, for if, as 
 often happens, the toes should be pointed to the symphysis pubis, the 
 
518 TURNING. [CHAP. 
 
 trunk of the child will rotate as it descends, so as to bring the face 
 ultimately into the hollow of the sacrum, whatever the original posi- 
 tion may have been. But, when the natural rotation has not taken 
 place, it has been found necessary to assist the movement by manual 
 interference. The greatest caution must, in every case, be exercised, 
 to prevent, as much as may be possible, pressure upon the cord ; but, 
 in so far as this is concerned, what has already been said in regard to 
 presentations which are originally of the pelvic extremity, will serve 
 for our guidance in those cases in which the pelvic end of the fetal 
 oval is artificially, and for a particular purpose, brought down. One 
 advantage of effecting version, so as to bring the dorsal surface to the 
 front, will be to bring the cord naturally into the posterior part of the 
 pelvis from the first, by which we are enabled to place it in that situa- 
 tion in which it is least likely to be subjected to severe pressure. 
 
 When version is complete, we have converted the case, whatever it 
 may originally have been, into a presentation of the feet. It remains, 
 however, for consideration, whether w r e are to leave the case to nature, 
 or proceed to immediate delivery. It is almost always proper to pause, 
 at least for a time, until we see what nature is likely to do ; but, if the 
 symptoms are such as to call for prompt action, whether in the interests 
 of the mother or the child, we must act boldly, and without hesitation, 
 in effecting immediate delivery. It should be remembered, that so 
 long as the head of the child remains above the brim, the cord is not 
 likely to be subjected to any dangerous pressure, so that, while nothing 
 is lost by delay at this stage, something may be gained by pausing 
 until uterine energy is awakened. If the cord has prolapsed, or has 
 otherwise come within reach, at this or a subsequent stage, we will be 
 guided by the presence or absence of pulsation, and the other evidences 
 of vitality of the fetus, in determining whether to precipitate matters 
 or not. During the descent of the trunk, we must observe the usual 
 precautions, but at the last stage there must be no delay, and the for- 
 ceps and restoratives should be at hand, so that we may at once have 
 recourse to them should occasion arise, and that in the manner described 
 in the chapter on Pelvic Presentations. 
 
 The term Pelvic Version, as employed by English writers, implies 
 an operation in which the breech, and not the feet, is brought to the 
 os when another part originally presents. That this may, in rare 
 instances, be effected by dexterous management, does not admit of dis- 
 pute ; but, at the same time, such a course of procedure is so obviously 
 one of greater difficulty, as compared with podalic version, that we need 
 not wonder that the former operation, which, indeed, never attracted 
 much notice, has been all but entirely superseded by the latter. As 
 regards the ancient operation of Cephalic Version, it seems certain 
 that there are cases of transverse presentation in which we would be 
 justified in making an attempt at what is a less severe operation to the 
 mother, by pushing up the shoulder, and so manipulating as to cause 
 it to be replaced at the os by the head. Success could here only be 
 hoped for when the child is still movable within the uterus, and the 
 method most likely to be attended with success is what has been desig- 
 
XXXI.] PELVIC VERSION. 519 
 
 nated by Braxton Hicks and others, as the "bimanual" or "bipolar" 
 method, — to be afterwards described. 
 
 The application of the operation of ordinary or podalic version to 
 cases of pelvic contraction, is a mode of procedure which was practiced 
 long before the forceps was discovered. Nor did the discovery of that 
 important instrument throw the earlier operation entirely into the 
 shade; and, indeed, we find Denman, and other contemporary writers, 
 giving minute directions, a hundred years ago, as to the manner in 
 which the operation is, under such circumstances, to be effected. There 
 can be no doubt, however, that as operators became more skilled in 
 the use of the forceps, and the scope of that instrument became more 
 thoroughly understood, the number of cases of contracted pelvis in 
 which turning was practiced, was more and more diminished, until, at 
 last, the operation fell into complete disuse. In the present day, the 
 operation has been revived and strenuously advocated by Simpson; 
 and, although some experienced operators have condemned it, it is the 
 fact that many of the most distinguished living accoucheurs have 
 adopted his views and practice. Simpson maintained his position by 
 arguments and facts, — the former being characterized by the ingenuity 
 and ability which he possessed in such a high degree, and of which 
 his works afford no more striking illustration. 
 
 The fact that this operation involves a question of conservative mid- 
 wifery, is one which may alone suffice to secure for the subject earnest 
 and careful attention ; and this, indeed, it has received from almost all 
 recent writers. In cases in which the head is arrested by pelvic con- 
 traction at the brim, we have three possible modes of action between 
 which we must decide, — turning, forceps, or craniotomy. The two first 
 are conservative, the last destructive. The dangers and difficulties of 
 the long forceps are well known, and have been fully described; but 
 there are, probably, few operators who would not rather risk them than 
 wantonly destroy a living child, as we have too good reason to believe 
 has often been done. The case is quite different when the child is 
 dead ; for here we determine upon a plan of action which we under- 
 take solely in the interests of the mother, when craniotomy stands 
 before us under quite another aspect. The first point of importance, 
 then, is to determine whether or not the child is alive; and if, this 
 being established, we fail to deliver by the long forceps, or that instru- 
 ment is contraindicated, the question before us simply is : Shall we 
 turn, or perforate — attempt to save the child, or at once destroy it? 
 
 The reply to this question, involving as it does such weighty 
 responsibility, will depend upon a variety of circumstances, of which 
 the most important, perhaps, is the degree of pelvic distortion which 
 actually exists. It is impossible to fix the exact measurement of the 
 conjugate diameter which may be held to warrant an attempt at turn- 
 ing; and, even were it possible to determine this with fractional accu- 
 racy, our modes of practicing pelvimetry are so uncertain, that it is a 
 matter of the greatest difficulty, even to the most dexterous, to gauge a 
 pelvis during labor. Dr. Churchill fixes the limit at two inches and 
 six-eighths, and Dr. Barnes, — as we believe, with more justice, — at 
 
 . 
 
520 TURNING. [CHAP. 
 
 from three and a quarter to three and three-quarters inches ; so that we 
 may say, in round numbers, that when the conjugate diameter is less 
 than three inches, to attempt to turn would be to subject the woman to 
 needless risk, while we may be confident that nothing but failure could 
 attend our efforts. 
 
 But, seeing that this is a question where an eighth of an inch may 
 make all the difference between success and failure, and it is impossible 
 to ascertain the exact space with anything more than what is at best an 
 approach to accuracy, it follows, as a possible contingency, that we may 
 actually turn, and subsequently find that we have miscalculated either 
 the conjugate diameter or the size of the head, and that the latter will 
 not pass. Such a failure as this is not so serious a matter as might 
 at first sight appear; for if we have thus to resort ultimately to 
 craniotomy, that operation will be attended with very little more diffi- 
 culty and no greater risk than if we had begun by perforating the 
 vertex. The mother, no doubt, has been subjected to the risks of 
 turning in addition to those of craniotomy, but we are surely warranted 
 in incurring this additional risk in the hope, if successful, of saving the 
 child. 
 
 Let us now examine shortly the positive advantages which are 
 claimed by Simpson for the operation of turning in contracted pelvis. 
 The biparietal measurement of the head is, as he points out, greater 
 than the bimastoid ; and as, in turning, the latter enters the contracted 
 space first, he argues that, on obvious mechanical principles, the com- 
 pressibility of the head is increased by version ; and, as it is well known 
 that in some cases of this kind, when the child has been born alive, the 
 parietal bones have been found to be flattened, indented, or even frac- 
 tured, he concludes that turning under such circumstances is not only 
 a reasonable proposal, but an actual gain in facility of delivery and 
 safety to the child. He goes, however, too far, and attempts to prove 
 too much, when he maintains, as a corollary to this proposition, that 
 the effects of the uterine contraction, when it forces a presenting head 
 against a contracted brim, is to bulge outwards the biparietal poles, 
 and thus increase the mechanical difficulty with the progress of labor. 
 
 Simpson's theory has been contested by McClintock, E. Martin, and 
 others, upon the whole, we think, unsuccessfully ; while, in corrobora- 
 tion of his views, a considerable weight of practical evidence has 
 accumulated, of which the following from Barnes's lectures is a striking 
 illustration : " In the first place, let me state a fact which I have often 
 seen. A woman with a slight contracted pelvis, in labor with a normal 
 child presenting by the head, is delivered, after a tedious delay, spon- 
 taneously or with the help of forceps ; the head has undergone an 
 extreme amount of moulding, so as to be even seriously distorted. 
 The same woman in labor, again, is delivered breech first; the head 
 exhibits the model globular shape, having slipped through the brim 
 without appreciable obstruction. In the second place, I have, on 
 several occasions, been called to an obstructed labor in which the head 
 was resting on a brim contracted in the conjugate diameter. Of 
 had failed; the vis a tergo was insufficient. I have 
 
 
XXXI.] IN CONTRACTED PELVIS. 521 
 
 tried the long double-curved forceps, trying what a moderate compres- 
 sive power, aided by considerable and sustained traction, would do to 
 bring the head through, and have failed. I have then turned, and the 
 head coming base first, has been delivered easily. Upon this point I 
 cannot be mistaken/ 7 
 
 The operation of turning in contracted pelvis may thus present itself 
 to us under two distinct aspects, — as a substitute for the long forceps, 
 and as a substitute for craniotomy. As regards the former, the expe- 
 rience of many independent observers would seem to show that, on the 
 principle suggested by Simpson, turning may succeed when the forceps 
 will fail; that instrument being, therefore, applicable to those cases 
 only in which the contraction is moderate in degree. Owing to the 
 difficulty of ascertaining the exact dimensions of the head and pelvis, 
 a safe, and, we believe, a very general practice, is first to make a cau- 
 tious attempt with the long pelvic-curved forceps, and failing that, — 
 which, in skilful hands, is a safer operation to the mother, — to pro- 
 ceed at once to turn. Turning as a substitute for craniotomy, is a more 
 important point still — so important, indeed, in a conservative sense, 
 that it cannot fail to command the attention of every conscientious 
 practitioner. Impaction of the head, or difficulty of displacing it, so 
 as to admit of the passage of the hand, and a degree of pelvic contrac- 
 tion beyond the limit which we have stated, are the two principal 
 contraindications of the operation of turning. The death of the child 
 is not necessarily so, for craniotomy at the brim is by no means so safe 
 an operation but that it may fairly be balanced against turning, even 
 in the interests of the mother alone. 
 
 The operator must be prepared, in turning in a contracted pelvis, to 
 encounter special difficulties in individual cases, which it is impossible 
 fully to describe, or even to anticipate. Following the example of all 
 writers on the subject, we have alluded to the operation in reference 
 only to simple conjugate contraction at the brim, by far the most com- 
 mon of all the varieties of distortion. It requires no argument to show 
 that rules applicable to this alone must often fail. In the typical mal- 
 acosteon pelvis, we may find an actual increase in the conjugate 
 diameter, coupled with such deformity as may render craniotomy, or 
 possibly the Caesarian operation, the only practicable methods of deliv- 
 ery. In those cases in which there is a symmetrical distortion, it is of 
 importance that the large or occipital end of the head should, if possi- 
 ble, be thrown into the larger half of the pelvis. To effect this is, 
 however, a matter of very considerable difficulty ; and, we apprehend 
 that the rules laid down by E. Martin and others for effecting the ob- 
 ject cannot be held as being of much practical value. The accoucheur 
 must in no case lose sight of the infinite varieties of distortion to which 
 allusion has already been made, as these may at any time call for spe- 
 cial adaptations, to which thorough operative capacity and an intimate 
 knowledge of the subject can alone guide us. Another possible diffi- 
 culty we have known to occur in connection with twin pregnancy, in 
 which the operator, after introducing his hand, has seized the foot of 
 the wrong child. 
 
 . 
 
522 TURNING. [CHAP. 
 
 The operation to which alone we have hitherto alluded, is the ordi- 
 nary operation of turning, necessarily involving the introduction of the 
 whole hand within the cavity of the womb. There is, however, another 
 operation, or rather a modification of this operation, which may be 
 practiced with less risk to the mother, and even, as it would seem, 
 under circumstances which would render the ordinary procedure diffi- 
 cult, if not impossible. This is Bimanual or Bipolar Version, an 
 operation which is attracting, year by year, more and more of the 
 attention which it merits. Early in the present century, Wigand sug- 
 gested a method whereby the presentation of the child could be altered 
 without the slightest risk to the mother, by external manipulation 
 alone. His observation applied to transverse presentations only, and 
 his plan was, — having ascertained, by vaginal examination, the exact 
 
 Fig. 17' 
 
 Malacosteon pelvis. 
 
 position of the foetus, — so to press upon the child externally as to bring 
 to the os uteri that pole of its long diameter which was lowest in the 
 pelvis. In a word, he claimed to be able to practice both cephalic and 
 podalic version, without even introducing a finger into the vagina, 
 although he seems to have employed the inner hand to guide or receive 
 the head or breech into the os. The directions which he gives include 
 elaborate, but, we fear, impracticable instructions as to the manner in 
 which we should proceed — with the view of availing ourselves, to the 
 utmost, of gravitation — to place the patient, now on one side, and again 
 on the other, at various successive stages of the operation. It is quite 
 certain that Wigand never contemplated anything more than partial 
 version, so that his novel manoeuvre, which found considerable favor 
 in Germany, was never supposed to be applicable to cases of placenta 
 previa, nor to any other case in which the head was originally the 
 presenting part. 
 
 Dr. Robert Lee seems to have been the first to suggest a method of 
 turning, which is the opposite of that to which Wigand lent the weight 
 of his authority. In cases of incomplete dilatation of the os uteri, he 
 
L 
 
 XXXI.] BIPOLAR METHOD. 523 
 
 brought two fingers, which he passed into the uterus, to bear upon the 
 head, which he first of all attempted to displace; and, when he had 
 succeeded in this, he successively pushed aside those parts which came 
 opposite the os in the same direction as that in which the head had 
 disappeared, until, ultimately, the feet were made to present, or were 
 brought within reach of the finger, and so secured. We owe, however, 
 to Dr. Braxton Hicks the method of combined external and internal 
 version, which bids fair to supersede, in a great measure, the old 
 method, and for the expediency of which we can unhesitatingly, and 
 from personal experience, vouch. The conditions which have already 
 been mentioned as favorable to ordinary podalic version, are even more 
 essential to the successful performance of the bipolar method. Unless, 
 therefore, the child is movable with tolerable freedom within the uterus, 
 we can scarcely expect to succeed in effecting version by this, as we 
 should probably fail by the other method. But, until we have thor- 
 oughly tried the effect of chloroform in reducing rigidity and tonic 
 contraction of the uterine fibre, we should not too readily abandon the 
 chance which this operation may possibly afford us, and we may be 
 sure that if, at any stage, the conditions which are generally considered 
 to be favorable to the ordinary operation are manifested, we may hope 
 to succeed by this process. The operation of Braxton Hicks is, as will 
 be inferred, a combination of the methods of Wigand and Lee, in the 
 course of which, while the operator brings one hand to bear upon the 
 uterus through the abdominal walls, he simultaneously operates upon 
 the other end of the child by means of the finger, which he has intro- 
 duced into the vagina and through the os uteri, causing the one pole 
 to descend, as he encourages the other to recede. 
 
 In so far as transverse presentations are concerned, we are indebted 
 to Dr. Robert Lee for having first clearly pointed out that when the 
 child is situated quite transversely within the womb, its knee is gen- 
 erally within a finger length of the os uteri, and thus in some trans- 
 verse presentations, it is not very difficult to hook down the knee. 
 The child, however, as both he and Wigand have shown, does not 
 usually lie transversely, but rather obliquely in regard to the trans- 
 verse axis of the uterus, which removes the knee to some extent from 
 the immediate grasp of the finger, and brings at the same time the 
 operation of cephalic version somewhat more w T ithin the range of pos- 
 sibility. But, while we thus recognize, as we can scarcely fail to do, 
 the advantage of the bimanual method over either of those in which 
 one pole only is acted upon, the former admits, as will be seen, of a 
 far more extended application, such as was never sought to be accom- 
 plished, so far as we can see, either by Wigand or Lee. In cases of 
 placenta prsevia, therefore, or in cases of contraction of the brim of 
 not less than three inches in the conjugate diameter, the head being 
 the presenting part, it is quite possible, and in some instances by no 
 means difficult, to effect complete version by the bimanual method, 
 and thus avoid many of the risks of the ordinary operation. For the 
 details of this procedure we shall here quote the directions of Dr. 
 Braxton Hicks. 
 
 " I will now proceed to describe the mode by which I effect po- 
 
524 
 
 TURNING, 
 
 [CHAP. 
 
 dalic version. We will suppose a case where everything is natural ; 
 
 the os uteri dilated to admit 
 FlGl7S - one or two fingers, membranes 
 
 perfect, and the face towards the 
 right side. The patient may be 
 placed in the ordinary obstetric 
 position. Having lubricated my 
 left hand, I introduce it as far 
 into the vagina as is necessary, 
 in order to reach a finger's 
 length within the cervix. Some- 
 times it requires the whole 
 hand, sometimes three or four 
 fingers will be sufficient in the 
 vagina. Having clearly made 
 out the head and its direction, 
 whether to one side or other of 
 the os uteri, I place my right 
 hand on the abdomen of the 
 patient towards the fundus ; I 
 then endeavor to make out the 
 breech, which is seldom a diffi- 
 cult matter. The external 
 hand then presses gently but 
 firmly the breech to the right 
 side ; as it reeedes, so the hand 
 follows it either by gentle pal- 
 pation, or by a kind of, gliding 
 movement over the integuments, 
 while at the same time the 
 other hand pushes up the head 
 in the opposite direction, so as to raise it above the brim. It may be 
 mentioned that, when the head has descended a eonsiderable distance 
 into the pelvic cavity, or more than half way through the os uteri, it is 
 scarcely possible to lift it above the brim, especially if the uterus be 
 active. 
 
 " When the breech has arrived at about the transverse diameter of 
 the uterus, the head will have cleared the brim, and the shoulder will 
 be opposite the os. That is pushed on in like manner as the head, and 
 after a little further depression of the breech from the outside, the knee 
 touches the finger, and can be hooked down by it. It very frequently 
 happens, when the membranes are perfect, that, as soon as the shoulder 
 is felt, the breech and foot come to the os in a moment, in consequence 
 of the tendency of the uterus to bring the long axis of the child coin- 
 cident with that of its own. Should it, therefore, be difficult to hook 
 down the knee, depress the breech still more, and it will be almost 
 always the case that the foot will be at hand. 
 
 " It will, sometimes, render turning more easy if, as soon as the head 
 is above the brim, we pass the outside hand beneath it, and push it up 
 from the outside alternately with the depression of the breech. All this 
 
 Bimanual version: first stage. 
 
XXXI.] 
 
 BIPOLAR METHOD. 
 
 525 
 
 can generally be performed in a much less time than I have taken to 
 describe it, although in some it requires gentle, firm, and steady perse- 
 verance, with such a supply of patience as is always demanded in ob- 
 stetric operations. If the os will only admit one finger, and the foot 
 cannot be brought through in consequence, it can yet be retained at the 
 os by pressing it with that finger against the inner surface of the os; 
 the most convenient part being against the anterior part, because the 
 pubes will assist in supporting the pressure, while, at the same time, in 
 most persons, unless very stout, the band pressing externally above the 
 pubes is capable of assisting materially in retaining the leg in that posi- 
 tion, and securing the altered change, ready for us to take advantage of it, 
 should the case so require, as soon as the os dilates sufficiently ; and 
 the mere retention of the leg here is of considerable value, for, in cases 
 of turning, even when we cannot effect turning immediately after 
 having seized one of the limbs, yet the holding on to that part, and 
 thereby fixing it, ultimately produces such an improved relationship 
 between the uterus and its contents that the after operations succeed 
 more easily. Should the child face towards the left side, the only dif- 
 ference required in operating is, that the breech be pressed towards the 
 left side, and the head to the right." 
 
 Further on, in regard to Cephalic version, Dr. Hicks continues: 
 
 Fig. 17;). 
 
 Fig. L80. 
 
 Second stage 
 
 Third stage 
 
 "We will suppose, first of all, a case where the uterus is not active, the 
 liquor amnii not escaped, or only recently so, where the foetal head has 
 not passed the os. Introduce the left hand into the vagina as in po- 
 
 L 
 
526 EMBRYOTOMY. [CHAP. 
 
 dalic version ; place the right hand on the outside of the abdomen in 
 order to find the position of the fetus, and the direction of the head and 
 feet. Should the shoulder, for instance, present, then push it with one 
 or two fingers through the cervix in the direction of the feet. At the 
 same time, pressure by the outer hand should be exerted on the cephalic 
 end of the child. This will bring down the head close to the os ; then 
 let the head be received upon the tips of the inside fingers. The head 
 will play like a ball between the two hands ; it will be under their 
 command, and can be placed in almost any part at will. Let the head, 
 then, be planed over the os, taking care to rectify any tendency to face 
 presentation. It is as well, if the breech will not rise to the fundus 
 readily after the head is fairly in the os, to withdraw the hand from 
 the vagina, and with it press up the breech from the exterior. The 
 hand which is retaining gently the head from the outside should con- 
 tinue there for some little time, till the pains have insured the retention 
 of the child in its new position by the adaptation of the uterine walls 
 to its form." * 
 
 We shall make no apology to the reader for the length of this ex- 
 tract, and the prominence which we have thus given to the operation of 
 bipolar version, as we look upon it as one of the most important im- 
 provements in modern obstetrics, which is attracting an amount of 
 attention ever on the increase, and which is, if we mistake not, likely 
 ere long, to take the place of the more familiar procedure of ordinary 
 podalic version. 
 
 CHAPTEE XXXII. 
 
 EMBRYOTOMY. 
 
 CONDITIONS WHICH "WARRANT THE OPERATION — CRANIOTOMY: CONSISTS OF VARI- 
 OUS STAGES — PERFORATION : VARIETIES OF PERFORATORS : METHOD OF, AND 
 PRECAUTIONS TO BE OBSERVED IN PERFORATING — CRANIAL CONTENTS TO BE 
 BROKEN UP AND DISLODGED — TRACTION TO BE NOW EMPLOYED — USE OF THE 
 CROTCHET: WHERE TO FIX IT: DANGERS OF — THE GUARDED CROTCHET — THE 
 CRANIOTOMY FORCEPS — REMOVAL OF THE VAULT OF THE CRANIUM — PROTEC- 
 TION OF THE MATERNAL TISSUES — DAVIS'S OSTEOTOMIST — THE SCALP TO BE 
 PRESERVED — TURNING AFTER CRANIOTOMY — CANTING THE BASE, AFTER RE- 
 MOVAL OF THE FLAT BONES, AND BRINGING THE FACE DOWNWARDS — THE 
 CEPHALOTRIBE : FRENCH AND ENGLISH MODELS— CEPHALOTRIPSY THE FINAL 
 STAGE IN THE OPERATION OF CRANIOTOMY — DETAILS OF THE OPERATION — MAY 
 THE CEPHALOTRIBE BE USED AS A TRACTOR? — SUBSEQUENT EXTRACTION OF 
 THE TRUNK — CRANIOTOMY IN BREECH DELIVERY, AFTER THE PASSAGE OF THE 
 TRUNK — EMBRYULCIA: EVISCERATION OF THE FCETUS : APPLICABLE CHIEFLY 
 TO IMPACTED TRANSVERSE PRESENTATION — VAN HUEVEL'S FORCEPS SAW— DR. 
 BARNES'S PROCESS OF CRANIAL SECTION BY THE ECRASEUR. 
 
 Embryotomy is, in one sense, the most objectionable of all the 
 operations of Midwifery ; for, of all other possible modes of procedure 
 
 1 On Combined External and Internal Version: by J. Braxton Hicks, M.D., 
 F.R.S.,etc. London, 1864. 
 
XXXII.] 
 
 CONDITIONS REQUIRING CRANIOTOMY. 
 
 527 
 
 this is the one which most certainly involves destruction of the child. 
 ( )n this account, the accoucheur shrinks, with natural repugnance, from 
 an operation which necessarily implies mutilation of a dead, and must 
 destroy a living child. Such, however, is a view which we are apt to 
 carry to an extreme, and overlook, in so doing, the more important 
 Interests of the mother; while we forget that circumstances do arise, 
 when in full knowledge of the fact that the foetus lives, it may be the 
 duty of the accoucheur unhesitatingly to sacrifice the child, as this is 
 the only means by which he may reasonably expect to save the mother. 
 
 Our first and earnest, desire, of course, is to save, if it be possible, 
 the child as well as the mother; but, if it should became obvious that 
 all hope of a result so favorable must be abandoned, we may be sure 
 thai we are fully justified in giving up the child, if we recognize in this 
 the only mode of preserving the more important life. Nothing, of 
 course;, will justify this, short of an absolute; conviction that the vectis, 
 the forceps, and turning, arc; of no avail ; for then, and then only, are 
 we justified in laying aside the implements of conservative! midwifery, 
 and taking into our hands agents which are; destructive to the; child. 
 On the Continent generally, and especially in Roman Catholic countries, 
 where the religion s element corrjes more; prominently into play, foetal 
 Life is, it must be; confessed, more jealously guarded than with us. But, 
 while we 4 fully recognize the humane impulses which may thus sway a 
 purely scientific decision, it must be affirmed that, whenever it is cer- 
 tain that a living child cannot pass, nothing can be; more irrational 
 than to await the death of the child, before we act upon the conviction 
 thai it cannot live, — and thus allow the period to pass at which we may 
 confidently operate, in the expectation of preserving maternal at the 
 sacrifice of foetal existence. 
 
 However lightly, on tlu> other hand, we may view these considera- 
 tions, evidence of the death of the' e'hilel will always be held as of para- 
 mount importance, in all cases in which the operation of Embryotomy 
 may oiler itself for our consideration. Wheai this is clear all scruples 
 will vanish, as we have> the mother alone to consider; and, therefore, 
 wheai the 4 other modes of procedure are 4 impracticable, we' will proceed, 
 without hesitation, to the' performance of an operation which treats the; 
 de>ael foetus as a, mass of inert matter, to be removed at the least pos- 
 sible 1 risk to the> mother. 
 
 The conditions, then, which may be held as warranting the- operation 
 of Embryotomy are those in which the Forceps and Turning are of no 
 avail, and which, at the same time, preclude the passage of a living 
 child. In so far as contraction of the' conjugate diameter at the brim 
 is concerned, we have' already seen that, in the' e*ase' of a fully developed 
 child, we can scarcely ex peel a successful result from turning, when that 
 diameter is much less than three inches ; and this, therefore, we may 
 lake' as the' limit- within which the operation may be; demanded. Tu- 
 inors of any kind, — bony, malignant, or ovarian ; atresia of any portion 
 of (he ordinarily distensible canal ; impaction of the head, or extreme 
 contraction of the uterus, are illustrations of other causes which, inde- 
 pendently of ordinary pelvic distortion, may render delivery by embry- 
 otomy the' only method from which we can anticipate u favorable result. 
 
 L 
 
528 EMBRYOTOMY. [CHAP. 
 
 Although the history of former labors is, in such cases, to be admitted 
 as an important consideration, in determining our course of procedure, 
 the conclusions of many independent observers show very clearly that 
 this must not be allowed to take too prominent a position, as it not 
 unfrequently happens that women who have had an ordinary labor 
 before, under circumstances which are apparently similar, are, if not 
 relieved, subjected in subsequent labors to the greatest peril. This may 
 be due, according to Barnes, to progressive pelvic contraction, or, as 
 D'Outrepont holds, to progressive increase in the size of the children. 
 But, on the other hand, we may fall into the opposite error, if Dr. 
 Matthews Duncan's deductions are correct, — that after women have 
 attained the age of twenty-nine, the weight of their children falls, — 
 by supposing, that because craniotomy was found necessary on a former 
 occasion, it must necessarily be required in subsequent pregnancies 
 
 which have been allowed to go to the full time. Amon^ the rarer 
 
 . . . 
 
 conditions demanding craniotomy, are impacted mento-posterior posi- 
 tions of the face, cases of locked twins, in which one head can only be 
 released by perforating and reducing the bulk of the other, double- 
 headed monsters, and hydrocephalus. 
 
 There are, however, in addition to these, certain conditions of the 
 mother which may call for the operation. It has already been shown 
 that, in cases in which, from any cause, speedy delivery is required, 
 turning is to be preferred to the forceps, when the dilatation of the os 
 is not sufficient to admit of the safe use of that instrument: and to 
 this it may now be added, that an even less degree of dilatation of the 
 os will suffice for craniotomy than for turning, as all that is essential 
 is space for the introduction of two fingers and the extremity of the 
 perforator. In cases, therefore, of convulsions, great exhaustion, and 
 some instances of rupture of the uterus as already particularized, in 
 which the state of the os forbids both the forceps and turning, it may 
 be necessary for us to perforate. As a rule, how T ever, and excepting 
 the cases of rupture of the uterus alluded to, we should never operate 
 by craniotomy while there is a possibility of nature prevailing, until 
 we have given her a fair chance, and have waited to see what may be 
 effected by the ordinary process of moulding. 
 
 The condition of the parts, or the stage of labor at which the opera- 
 tion should be performed, is a matter of great importance, less perhaps 
 in regard to the mere facility with which it may be effected than with 
 reference to the safety of the woman. Although as has been observed, 
 a very moderate dilatation of the os is all that is essential, it affords 
 great comparative facility to the operator, and proportionate safety to 
 the mother, if the head is divested to a great extent of the covering 
 which, in the early stage of labor, it derives from the lower segment 
 of the uterus. It is of even greater importance that the head should 
 have descended, to some extent, into the pelvis, and be within easy 
 reach ; for the operation upon a head which is still above the brim will 
 be found, even under circumstances which are in other respects favor- 
 able, to be a very different operation from that in which it is arrested 
 within the cavity of the pelvis. There are conditions, however, which 
 may render a case manifestly impracticable, or which may admit of 
 
XXXII.] 
 
 PERFORATION. 
 
 529 
 
 doubt ; so that the peculiarities of individual cases must be our guide 
 as to whether anything is to be gained by delay, and, if so, to what 
 extent we are to maintain an expectant attitude. It is certain that we 
 have less choice here as to the period which we may choose for the 
 operation than obtains in regard to some of the other modes of proce- 
 dure which we have described. 
 
 The Operation. — Embryotomy almost always involves craniotomy, 
 so that the two terms are often used as synonyms. Craniotomy has 
 been often euphemistically described as " lessening the bulk of the 
 head." It consists of several stages, some of which may alone be re- 
 quired ; or it may be necessary, before effecting delivery, to go through 
 the whole of them, one after the other. We purpose, therefore, to ex- 
 plain these successive steps, as points in detail of one method of opera- 
 tive procedure, according to the degree of pelvic distortion, or other 
 circumstances which may constitute the special impediment, and in- 
 cluding the use of the omphalotribe. 
 
 The first step in all operations of craniotomy is Perforation, and for 
 this various instruments have been devised, which are termed per- 
 forators. The condition of the head, upon which its impact or resist- 
 ance depends, is, in the first place, to be overcome, in order to permit 
 of its collapse ; and it is with this object solely that we perforate, and 
 so act otherwise as to admit of the escape of the 
 contents of the cranium, so that the forces, natural fig. isi. 
 
 or artificial, may be brought to bear upon a part 
 which is now susceptible of a considerable diminu- 
 tion in its diameters. The form of instrument 
 which has by many Continental practitioners been 
 preferred, is one which, in the principle of its con- 
 struction, is almost identical with the ordinary 
 trephine; but what is preferred and invariably 
 used by English operators, is some modification of 
 the perforating scissors of Smellie. The instru- 
 ment here shown is that which was used by Simp- 
 son, and which generally bears his name. It con- 
 sists of two blades with shoulder-stops, the blades, 
 when in apposition, forming a triangle of which 
 the base is at the stops, with cutting edges, con- 
 verging to a point, which is the apex of the triangle. 
 The instrument is thus one which is to be used with 
 the greatest possible caution, lest injury should be 
 inflicted upon the soft parts of the mother. When 
 the blades are separated by pressing the handles 
 together, a powerful spring between the latter 
 causes them to close so soon as the grasp is relaxed. 
 [Mr. Holmes has also modified Smcllie's scissors by 
 bending the handles so that they cross each other, Simpson's perforator. 
 enabling the operator to open the blades with one 
 hand, as in Simpson's instrument. The late Professor Hodge used as a 
 perforator a pair of scissors having short blades, the longer of which, 
 
 34 
 
530 
 
 EMBRYOTOMY 
 
 [CHAP. 
 
 Fig. 182. 
 
 ! 
 
 measures an inch and a quarter, and the shorter, one inch. The blades 
 are very strong, and the longer one terminates in a triangular sharp 
 point, which is used as a perforator when the handles are closed. The 
 scissors may be employed to cut up the bones after perforation has been 
 effected. — P.] Its mode of application is as follows. The ordinary 
 preliminaries to the other operations of midwifery having been carefully 
 observed, the woman is to be placed, as usual, upon her left side. Two 
 fingers of the left hand are then introduced into the vagina, and brought 
 to bear upon the most depending portion of the vault of the cranium. 
 With the greatest possible caution, the blades are then to be passed 
 along the palmar aspect of these fingers, which serve as a guard to the 
 
 maternal parts, until it reaches the surface 
 of the cranium, through which it is thrust 
 by a combined pushing and boring move- 
 ment as far as the stops. While this is 
 being effected, particular attention should 
 be given, so that the force be applied at 
 right angles to the surface against which it 
 
 OCT O 
 
 impinges, otherwise the point is apt to glance 
 off, and may seriously wound the mother. 
 
 Some have advised that perforation should 
 be effected at the sutures or fontanclles ; but, 
 although this renders the operation some- 
 what easier, the disadvantage is that the 
 subsequent collapse of the head, by over- 
 lapping of the flat bones of which its vault 
 is composed, will necessarily obliterate the 
 aperture, and impede the escape of the cere- 
 bral tissue. It is, therefore, much better 
 that we should perforate the parietal bone 
 which presents; and, when this has been 
 done in the manner described, the handles 
 are pressed together and the blades separated. 
 This, by tearing asunder the parts, makes a 
 lacerated and irregular gap in the cranial 
 Avails ; but, in order to render the aperture 
 more patent, and thus facilitate the escape 
 of the contents, the handles are turned so as 
 to bring the blades half round, and another 
 similar incision is made at right angles to 
 the first. The perforator is then to be thrust 
 into the cavity of the cranium, and freely 
 moved about in all directions so as to break 
 up, as far as is possible, cerebrum, cere- 
 bellum, and membranes; and if the child is alive, it will be proper to 
 pass it in the direction of the medulla oblongata, so as to cause its 
 death, as cases have occurred in which, after perforation and escape of 
 the greater portion of the cerebrum, the child has been born alive. The 
 perforator is then to be removed with the same precaution as was ob- 
 
 Hodge's craniotomy scissors. 
 
XXXII.] PERFORATION. 531 
 
 served on its introduction. If the breaking up of the brain has not 
 been satisfactorily accomplished, this may be completed by the crotchet, 
 which, indeed, some operators prefer altogether for this purpose, with- 
 drawing the perforator so soon as the breach in the cranial walls has 
 been effected. 
 
 Complete disorganization of the textures within the cranium does 
 not necessarily imply their immediate expulsion, which can alone 
 insure collapse of the cranial vault. This, no doubt, has already been 
 in a great measure effected by the nature of the aperture which we 
 have made in the parietal, bone; but, unless uterine action is present, 
 and can act efficiently upon the cranium, the amount discharged, even 
 through a considerable gap, may be but trifling. In order, therefore, 
 to encourage compression, and the consequent diminution of the cranial 
 diameters, it has been suggested that we should extract the brain- 
 substance; and this may be effected without danger, and with more or 
 less of success, — which will be proportionate to the thoroughness with 
 which the cerebral disintegration has been effected, — by a scoop or 
 spoon, or by the injection within the cranium of a powerful stream of 
 water. So soon as a large portion of the cerebral contents has been 
 permitted to escape, the bones of the skull will collapse under the in- 
 fluence of very trifling compression. This, however, may completely 
 fail, whence arises the necessity of proceeding to another stage of the 
 operation. 
 
 If nature, after complete decerebration, fails to effect some advance 
 of the head, it will then be proper to attempt delivery by traction ex- 
 ercised upon any part of it where a secure hold may be maintained. 
 The ordinary crotchet, described in a former chapter (see Fig. 174), 
 is the instrument which was almost exclusively employed in ancient 
 times, and even in the present day is frequently resorted to. The idea 
 here is to fix the crotchet upon any part of the bones, and, if possible, 
 at the foramen magnum, or the sella turcica, where the best and most 
 effective grip may be had, with the least risk of slipping. The direc- 
 tions which are very generally given by the older writers for the employ- 
 ment of the crotchet after perforation, for the purpose of traction, seem 
 to point to fixing it upon some part of the inner surface of the parietal 
 bone, and, having thus secured a good hold, to drag steadily down- 
 wards. The great objection to the use of the crotchet in this way is 
 that it is always unsafe, and, in the hands of the inexperienced, emi- 
 nently so. No one uses the crotchet for this purpose, unless he has 
 j)reviously passed up the finger of one hand in order to protect the soft 
 parts from the possible effects of a sudden and unexpected detachment 
 of the instrument, which under other circumstances, would probably 
 inflict upon the mother severe, and possibly dangerous laceration. As 
 it is often difficult efficiently to protect the parts by means of the 
 finger, an instrument called the " guarded crotchet" has been devised. 
 It is variously constructed, but consists essentially of two blades, or 
 rather of a crotchet and a protecting blade. In that which is shown in 
 Fig. 183, the crotchet has three sharp teeth, and is furnished with the 
 ordinary forceps joint, by which it is articulated with the protecting 
 
 
532 
 
 EMBRYOTOMY. 
 
 [chap. 
 
 blade. The crotchet being introduced within the cranium, is fixed in 
 the ordinary manner, and the guard being then passed 
 fig^is3. j n f- ne llSLia l wa y outside of the scalp, the instrument is 
 locked, which, so long as this relative position is main- 
 tained, prevents all possibility of laceration by the sharp 
 part of the instrument. 
 
 The danger to the mother is, however, in point of fact, 
 less from the crotchet itself, than from the fracture and 
 sudden displacement of the bones to which it is attached. 
 Should the tractile force be trifling, the hold which the 
 crotchet gives us may be maintained ; but if, as is more 
 generally the case, we are obliged to use a considerable 
 degree of force, the crotchet often slips either from its 
 attachment, or by reason of fracture of the bone. It is 
 on this account that the guard of the crotchet cannot 
 alone be trusted to, and we must therefore pass up the 
 finger, which should be retained in apposition with the 
 head so long as our efforts may last, so that we may at 
 once perceive the earliest indication of slipping, and 
 adopt such precautions as may be necessary for the pro- 
 tection of the maternal structures. 
 
 The Craniotomy Forceps is, as now constructed, an 
 instrument which is greatly superior to the crotchet 
 Guarded crotchet, either single or guarded, and is applicable to almost all 
 cases in which the latter has been employed. When 
 perforation, with evacuation of the cerebral contents, has been com- 
 pleted, and it is found necessary to proceed to the further stages of the 
 operation, the blades of the craniotomy forceps are to be applied, one 
 within and the other without the cranium, that which is convex on 
 the outside being for application over the seal]). It will be observed 
 that one blade is fitted with sharp teeth corresponding to pits or 
 depressions upon the opposed surface of the other. When suitably 
 adjusted, therefore, all that the operator has to do is to press the 
 handles together with some force, which will insure a grasp upon the 
 wall of the cranium, over a more extended area, as well as more firmly, 
 than can, under any circumstances, be effected by the crotchet. The 
 handles being firmly bound together, traction must now be practiced in 
 the direction which may be proper to the actual position of the head. 
 If the bone gives way, the detached portions must be cautiously re- 
 moved, and a fresh hold obtained wherever the parts may seem most 
 likely to bear the strain ; but, when the resistance is great, it will soon 
 become evident that this method of extraction will fail, and we must 
 therefore pass to a more advanced stage still of the operation of crani- 
 otomy. 
 
 The process which, under such circumstances, is rendered necessary, 
 is the deliberate removal in detail of the flat bones, which require, for 
 this purpose, to be broken up into pieces of convenient size, in order 
 that the whole vault of the cranium may be thus removed, including, 
 in extreme cases, the occiput and the forehead. No part of the opera- 
 tion requires more caution than the removal of the fractured portions 
 
XXXII.] 
 
 CRANIOTOMY FORCEPS. 
 
 533 
 
 of the bones, which are often jagged and splintered, and always sharp 
 at the edges, so much so, sometimes, as to cut through the cuticle of 
 the fingers of the operator, which may afterwards be observed to be 
 scarred as if by the edge of a sharp knife. When a fragment of bone 
 becomes detached, in an attempt at extraction either by the crotchet or 
 craniotomy forceps, it is always better to remove it at once, and for 
 this purpose the finger will generally suffice. When our object is to 
 remove the whole cranial vault, the bones are, in the first place, to be 
 broken and separated from their attachments within the scalp — a part 
 of the operation which is best effected by means of the craniotomy for- 
 ceps. In this case, however, we introduce the blades somewhat differ- 
 ently, passing the outer blade between the scalp and the bone, so that 
 the latter is directly grasped. A smart wrench by the wrist is generally 
 all that is necessary to fracture the bone, when the severed portion 
 which remains between the blades may be removed by the aid of the 
 instrument. Much will, however, depend upon the shape of the fragment, 
 which is to be carefully ascertained by the finger acting in concert with 
 
 Fig. 184. 
 
 Fig. 185. 
 
 Craniotomy forceps. 
 
 Osteotomist. 
 
 the forceps. If it is very irregular in shape, it will, of course, be all 
 the more difficult to protect the soft parts of the mother from so many 
 cutting surfaces, and it may be necessary to divide it again before 
 attempting extraction. The mode of grasping the fragment must also 
 
534 EMBRYOTOMY. [CHAP. 
 
 be attended to, so as to bring elongated portions lengthwise, and in 
 many similar ways we may reduce risk by careful manipulation. Dr. 
 Davis was so impressed with the danger which attends the removal of 
 the fractured cranial bones that he devised an instrument, or rather a 
 series of instruments, which he termed Osteotomists, by which the bones 
 could be more safely removed. One of them is shown in Fig. 185. It 
 is of the nature of a powerful punch, by which successive minute por- 
 tions of the bones may be nipped off and removed in the grasp of the 
 blades, thus completely protecting the soft parts. Such an operation 
 was necessarily a very tedious one, and this is probably the reason why 
 the instrument was never much employed, and has latterly fallen into 
 complete disuse. We have, however, found it to be extremely useful 
 in cutting any spicule or sharp angular projections which may seem to 
 threaten laceration, and for this reason we look upon it as a most useful 
 aid to have at hand when we have to perform the operation of crani- 
 otomy. By dexterous management, however, we may generally suc- 
 ceed in safely removing much larger pieces of bone by the fingers than 
 can be effected by the osteotomist. 
 
 [The late Prof. Meigs having had great difficulty in delivering a 
 woman with a badly deformed pelvis, though he had at hand the 
 various craniotomy instruments, including those of Davis, devised a 
 much simpler forceps, one pair with straight, and the other with curved 
 blades. We have used these instruments in a number of cases, and 
 have found them very efficient in breaking up the cranium, though 
 they are not very useful as tractors. 
 
 The best of all craniotomy forceps is Simpson's cranioclast. The 
 length of the whole instrument is fourteen inches, and of the blades five 
 and a half inches. They are slightly curved. The larger of the two 
 blades is fenestrated with grooved sides. The shorter is solid, and 
 covered with transverse ridges which fit into the grooves in the opposite 
 blade. The two blades are joined by a pivot lock. 
 
 Braun has modified Simpson's instrument by increasing the length 
 of both handles and blades, as well as increasing the curvature of the 
 latter. Besides these changes he added a compressing apparatus to the 
 handles. 
 
 The blades are to be introduced separately, the fenestrated one on 
 the outside and the solid one on the inside of the perforated skull. The 
 cranioclast is a very efficient instrument, not only as a tractor, but 
 likewise to break up the vault of the cranium. — P.] 
 
 In removing the vault of the cranium, it is proper to preserve the 
 scalp. The object of this is to protect the maternal parts from injury. 
 It may happen, after a certain amount of progress has been made, and 
 a considerable portion of the vault removed, that the head collapses to 
 such an extent that the difficulty is got over, and extraction becomes 
 easy. In such a case the scalp is used as a covering for the bones 
 which remain, and as a protection from spiculse and sharp edges, which 
 might otherwise do mischief. 
 
 If, at any time in the process of removing the bones, or even earlier, 
 we are able to seize the forehead by the craniotomy forceps and pull it 
 down, this should always be done; but the difficulty in extreme con- 
 
XXXII.] 
 
 MEIGS S CRANIOTOMY FORCEPS. 
 
 535 
 
 traction is that the vault of the cranium is not yet sufficiently com- 
 pressible. It is mainly, therefore, with the object of ultimately bring- 
 ing down the forehead, which usually lies to the right side, that Ave 
 thus pick away the bones until there remains, when it is complete, 
 nothing but the scalp. 
 
 There is another method of procedure, not often resorted to, but 
 which, in some instances, is of undoubted efficiency after perforation. 
 This is the ordinary operation of Turning, which may sometimes be 
 
 Fig. 186. 
 
 Fig. 187. 
 
 Meigs's craniotomy forceps. 
 
 Braun's crauioclast. 
 
 effected without much difficulty when, by the perforator, we have 
 reduced the bulk of the child's head. To attempt this in cases of very 
 great distortion would, on many grounds, be improper ; but in more 
 moderate disproportion, it is sometimes an efficient and valuable 
 method of completing delivery. A striking instance of this kind, 
 which we saw with Drs. Lyon and Dick, was that of a woman in whom 
 it had been found necessary to perforate in consequence of very con- 
 siderable conjugate contraction. Traction with the craniotomy forceps 
 was found to be insufficient, and failed to dislodge the head of the 
 
536 EMBRYOTOMY. [CHAP. 
 
 child. A considerable portion of the bones was then removed, but, 
 before entirely removing them, and proceeding to the more advanced 
 stages of the operation, to be described immediately, an attempt was 
 made to turn, when, the foot being brought within reach, this was 
 effected without the slightest difficulty. In all such cases, it is of the 
 first importance that the scalp should cover the fractured bones, and 
 we should, therefore, be particularly careful that this should be insured 
 before we attempt to turn. 
 
 The flat bones being removed, the next question for consideration 
 which presents itself is one which, without a thorough knowledge of 
 the foetal and maternal parts, could not fail to give rise to much doubt 
 and apprehension. What remains behind of the head consists entirely 
 of the base of the cranium, a part which, even at this early age, is very 
 solid and unyielding, in order to afford protection to the vital struc- 
 tures which might otherwise be subjected to dangerous or fatal pressure. 
 The shape of the base of the skull is that of an irregular ovoid disk, the 
 long diameters of which are across the pelvis. It would seem, there- 
 fore, at first, as if no great advantage had been gained by the removal 
 of the flat bones; but a moment's consideration will show that a very 
 simple manoeuvre, and one which is generally easy of performance, will 
 suffice to place what remains of the head much more favorably. "I 
 have carefully," says Dr. Burns, " measured these parts, placed in dif- 
 ferent ways, and entirely agree with Dr. Hull, a practitioner of great 
 judgment and ability, that the smallest diameter offered, is that which 
 extends from the root of the nose to the chin. For, in my experiments, 
 after the frontal bones were completely removed, and the lower jaw 
 pressed back, or its symphysis divided so as to let its sides be pushed 
 away, this did not, in general, exceed an inch and a half. It is, therefore, 
 of great advantage to convert the case into a face presentation.' 7 The 
 practice thus recommended by Burns was at an earlier date upheld by 
 Dr. Osborn, who was the first clearly to show that, by canting the base 
 of the skull, so as to bring it edgewise into the brim, it was perfectly 
 possible to deliver a full-sized child through a conjugate diameter 
 measuring an inch and a half only. A very remarkable case, that of 
 Elizabeth Sherwood, was detailed by Dr. Osborn, and has been quoted 
 by many subsequent writers. This case, which is specially interesting 
 as bearing upon the question which we are now considering, may here 
 be advantageously detailed in a very abridged form. 
 
 The patient was so deformed, both in her spine and her lower extremities, " as never 
 to be able to stand erect for one minute without the assistance of a crutch under 
 each arm." At the age of twenty-seven she became with child, and was admitted 
 a patient into Store Street Hospital, where she was seen by W. Hunter, Denham, 
 and other eminent obstetricians of the day, who gave their sanction to the course of 
 procedure, which Osborn ultimately adopted with such remarkable success. Dr. 
 Osborn describes his first examination as follows: "Immediately upon the intro- 
 duction of the finger, I perceived a tumor, equal in size, and not very unlike in 
 feel, to a child's head. However, it was instantly discovered that this tumor was 
 formed by the basis of the sacrum and last lumbar vertebra, which, projecting into 
 the cavity at the brim, barely left room for one finger to pass between it and the 
 symphysis pubis, so that the space from bone to bone at that part could not exceed 
 three-quarters of an i?ich. ,} The operation which was determined upon (a decision 
 which gave rise afterwards to no little discussion) was to effect extraction by the 
 perforator and crotchet. "Even the first part of the operation, which in general is 
 
XXXII.] ELIZABETH SHERWOOD'S CASE. 537 
 
 sufficiently easy, was attended with considerable difficulty, and some danger. The 
 os uteri was but little dilated, and was awkwardly situated in the centre and most 
 contracted part of the brim of the pelvis. The child's head lay loose above the brim, 
 and scarcely within reach of the finger, nor was there any suture directly opposite 
 to the os uteri." The operation of perforation and decerebration was effected with- 
 out any unusual difficulty, and the patient was then left, as was the general practice 
 in those days, for six-and-thirty hours, in order to allow the uterus opportunity to 
 force the cranium downwards as far as possible within the reach of the crotchet, a 
 result which was counted upon to some extent, as the effect of putrefactive change. 
 
 " I determined," he continues, " to begin to make an attempt to extract the child. 
 I call it an attempt, for I was far from being satisfied in my own mind of the practica- 
 bility. My first endeavors were bent to draw the os uteri with my finger into the 
 widest part of the brim of the pelvis, and to dilate it as much as possible. But the 
 removal of the os uteri, and such dilatation of it as the bones admitted, were effected 
 without much trouble. I then introduced the crotchet through the perforation into 
 the head, and, by repeated efforts, made in the slowest and most cautious manner, 
 destroyed almost the whole of the parietal and frontal bones, or the whole upper 
 presenting part of the head, and as the bones became loose and detached, they were 
 extracted with a pair of strong forceps, to prevent, as much as possible, laceration 
 of the vagina in their passage through it. The great bulk of the head, formed by 
 the base of the skull, still, however, remained above the brim of the pelvis; and 
 from the manner in which it lay, it was impossible to enter without either diminish- 
 ing the volume, or changing the position: the former was the most obvious method, 
 for it was a continuation of the same process, and I trusted, would be equally easy 
 in execution. I was, however, grievous^ mistaken and disappointed, being re- 
 peatedly foiled in every endeavor to break the solid bones which form the basis of 
 the cranium, the instrument at first invariably slipping as often and as soon as it 
 was fixed, or, at least, before I could exert sufficient force to break the bone. At last, 
 however, by changing the position of the instrument, and applying the convex side 
 to the pubis, I fixed the point, I believe, into the great foramen, and by that means 
 became master of the most powerful purchase that the nature of the case admitted. 
 
 " Of this I availed myself to the utmost extent; slowly, gradually, but steadily 
 increasing my force till it arrived at that degree of violence which nothing could 
 justify but the extreme necessity of the case and the absolute inability, in repeated 
 trials, of succeeding by gentler means. But even this force was to no purpose, for 
 I could not perceive that I had made any impression on that solid bone, or that it 
 had been in the least advanced by all my exertions. I became fearful of renewing 
 the same force in the same way, and therefore abandoned altogether the first idea of 
 breaking the basis of the cranium, and determined to try the second by endeavoring 
 to change the position. I therefore again introduced the crotchet in the same 
 manner, and fixing it in the great foramen, got possession of my former purchase ; 
 then, introducing two fingers of the left hand, I endeavored with them to raise one 
 side of the forepart of the head, and turn it a little edgeways. Immediately and 
 easily succeeding in this attempt, the two great objects were at once accomplished ; 
 for the position was changed and the volume diminished. Continuing my exer- 
 tions with the crotchet, I soon perceived the head advance, and, examining again, 
 found a considerable portion of it had been brought into the pelvis. Every diffi- 
 culty was now removed, and, by a perseverance in the same means for a short time, 
 the remaining part of the head was brought down and out of the os externum." 
 
 We cannot wonder that the result in this case, and the satisfactory 
 recovery of the mother, should have been looked upon as a great 
 triumph of the crotchet as compared with the otherwise inevitable ex-, 
 pedient of the Caesarian Section. Of late years this question has been 
 more thoroughly investigated and illustrated. Dr. Braxton Hicks, in 
 a learned and elaborate paper, 1 describes very fully the mechanism of 
 the proceeding. What he recommends is to grapple the orbit and 
 draw it downwards by means of a small blunt hook. " The one 
 which I use," he says, " is of the following size : the diameter of the 
 iron rod from which it is made is about a quarter of an inch, of the 
 
 1 Obstetrical Transactions, vol. vi, 1865, p. 263. 
 
538 EMBRYOTOMY. [CHAP. 
 
 length of the ordinary blunt hook ; with handle also alike. The hook 
 is a half circle, about one inch in diameter, and is made hard, to pre- 
 vent its opening during traction ; the shaft is made of soft iron, and 
 can be bent by the hand into any form, being thus adaptable to any 
 situation. I may mention here that this hook is useful, in other cases, 
 in a variety of ways, where it is impossible to employ the unwieldy 
 blunt hook in general use." 
 
 Dr. Barnes, after removing the arch of the calvarinm, or the whole 
 of the bones if the distortion be extreme, prefers, for effecting the same 
 object, the craniotomy forceps. The instrument which he uses is of 
 considerable strength, and is provided with a screw at the ends of the 
 handles, which secures for it the ordinary advantages of the cephalo- 
 tribe, by crushing in the frontal bones, and has the further advantage 
 of securing an unyielding hold. " Then traction is made, carefully 
 backwards at first, in the course of the circle round the false promontory. 
 As the face descends it tends to turn chin forwards, and this turn may 
 be promoted by turning the handles of the instrument. It is not nec- 
 essary that the turn should take place, for the case differs entirely from 
 that of the normal head. There is no occiput to roll back upon the 
 spine between the shoulders. The head conies through flatwise like 
 a disk by its edge." 
 
 The above extracts, which represent the most modern and scientific 
 modes of practice, will suffice to show that where the pelvis measures 
 two inches, or even a little less, in the conjugate diameter, a fully de- 
 veloped child may yet possibly be extracted. It is obvious, however, — 
 the transverse diameter of the face being more considerable, — that, to 
 insure success, there must be a larger space, certainly not less than three 
 inches in the transverse diameter. "I go further," says Barnes, in 
 reference to this operation, " and declare that it is perfectly unjustifiable 
 to neglect this proceeding, and to cast the woman's life upon the slender 
 chance afforded by the Caesarian Section." 
 
 The Cephalotribe. — If the facts and arguments above cited are strictly 
 correct, the number of cases in which the cephalotribe is called for are 
 probably very limited in number. They are certainly much more so 
 than was at one time supposed. The earliest instrument designed for 
 crushing: the bones of the foetal skull seems to have been the Com- 
 pressor Forceps of Assolini, which was used by him to crush the base 
 of the skull and the face, early in the present century. The blades of 
 this instrument were not made to cross, so that when they were screwed 
 together, the fulcrum of each lever was the joint at the end of the han- 
 dles, where they were articulated. The only modern instrument re- 
 sembling this in principle is the cephalotribe of Lazarewitch of Char- 
 koff. What, with certain modifications, is known as the French 
 cephalotribe, was invented by the younger Baudelocque. It is, in 
 appearance, a most formidable instrument; the one in our possession 
 weighing no less than 4 lbs. 6J oz., and measuring across the blades 
 nearly two inches, in the widest part. It requires, therefore, no argu- 
 ment to show that such an apparatus is not applicable to a case like 
 -that of Elizabeth Sherwood. Various modifications have, in modern 
 times, been designed by Scanzoni, Braun, Simpson, and others, almost 
 
xxxn.] 
 
 THE CEPHALOTRIBE. 
 
 539 
 
 all of which are constructed with a moderate degree of pelvic curve. 
 They are all made lighter than the original instrument, as it has been 
 found that clumsiness may be, to some extent, avoided without any 
 material sacrifice of strength. The tendency of the English instru- 
 ments is to approach more in form to the ordinary midwifery forceps, 
 as is well shown in Simpson's cephalotribe, which is here represented. 
 
 Fig. 189. 
 
 Fig. 190. 
 
 Fig. 188. 
 
 Simpson's cephalotribe. 
 
 French cephalotribe. Dr. Matthews Duncan's cephalotribe. 
 
 As in the case of the forceps, there has existed in this country some 
 controversy as to whether the pelvic curve should or should not be 
 adapted to the cephalotribe, those who approve a£ the straight instru- 
 ment arguing with some force that the straight blades are easier of 
 application, and can alone be properly applied when we wish to rotate. 
 The fact that the head is at the brim seems to us, on the contrary, to 
 vindicate, on the same grounds which have been urged with reference 
 to the long forceps, that unless we are, as Pajot and some others advise, 
 absolutely to discard the instrument as an extractor, we must admit 
 that the principle of the pelvic curve must be conceded here also. The 
 objections which Dr. Kidd and others have urged against the pelvic 
 
540 EMBRYOTOMY. [CHAP. 
 
 curve have, however, so far prevailed that the English instruments are 
 all, without exception, made with a slighter curve than the French 
 ones. The French cephalotribes still retain, as we have said (and, we 
 may add also, the German modifications of Braun and Scanzoni), much 
 of the original formidable dimensions of the instrument. We might 
 have contented ourselves with the mere mention of this fact were it not 
 that of late years some able obstetricians have condemned the English 
 instrument, and insisted that we should do better to adhere more 
 closely to French models in the construction of cephalotribes. Dr. Mat- 
 thews Duncan, assisted by Professor Inglis of Aberdeen, and others, made 
 some very interesting experiments with a view of comparing the effects 
 of Simpson's cephalotribe and the more modern of the French instru- 
 ments. The experiments were performed on foetal crania, and on the 
 skulls of dogs, and certainly served very clearly to demonstrate that 
 the French cephalotribes have greater power. Are we, therefore, on 
 that account, to prefer them, to the exclusion of those with shorter 
 handles? 
 
 In reply to this question, Dr. Duncan expresses a decided preference 
 for the French cephalotribe, a modification of which he has devised, so 
 as to combine the lesser degree of pelvic curve which is characteristic 
 of English instruments, with certain other modifications which he con- 
 siders as offering some advantage. Dr. Duncan's cephalotribe is repre- 
 sented in Fig. 190. Drs. Barnes and Braxton Hicks are again warm 
 supporters of what we have termed the English cephalotribe, and while 
 they do not assert that the crushing force is equal to that of the French 
 instrument, they maintain that the power is attained in sufficient per- 
 fection for the object which we have in view, and that there is a gain 
 in the facility of handling, which may be held as sufficient to counter- 
 balance any trifling loss of power. 
 
 We have at present to consider the subject of Cephalotripsy as the 
 final stage of the operation of craniotomy in cases of great pelvic con- 
 traction. Perforation, decerebration, removal of the flat bones, and 
 canting edgewise of the base of the skull, have all, Ave shall suppose, 
 been successively tried, but to no purpose. Can anything further, we 
 ask ourselves, be done in this same direction? — a question which finds 
 its reply in the operation which we are now considering. The object 
 of the instrument is, as its name implies, to crush the unyielding base 
 into a pulp, and thus bring it through the contracted diameters. The 
 blades are introduced, in the same manner as those of the ordinary long 
 forceps, in the direction in which there is least resistance, which will 
 generally be the sides of the pelvis. They are passed high up, so as to 
 reach quite beyond the base, which it is our object to crush ; and, being 
 adjusted, the screw is then turned steadily and cautiously, while the 
 finger within the vagina takes note of what is being done, and is ready 
 to remove at once any spicule of bone which may crop up under the 
 influence of the crushing force. Whatever form of instrument we may 
 choose, it should be one which does not measure, when closed, more 
 than an inch and a half outside the widest part of the blades. This 
 admits, therefore, of such crushing as may enable the head to pass 
 through a diameter which may be contracted to that extent. If the 
 
XXXII.] THE CEPHALOTRIBE. 541 
 
 deformity is great, a second crushing may be necessary, and for this 
 purpose, the blades should be removed and reintroduced, so as to se- 
 cure a grasp which should be, as nearly as possible, at right angles to 
 the first. 
 
 It must not be supposed that it is only to cases in which the whole 
 of the flat bones have been already removed that the operation of 
 cephalotripsy is applicable. On the contrary, it may often be used 
 with advantage when only a portion of the vault has been got away. 
 This is generally sufficient to admit of the easy introduction of the 
 blades, so that, if unusual difficulty is experienced in extracting the 
 bones, and the head refuses to advance under steady traction, the 
 operation will have the double effect of crushing the base and per- 
 mitting the collapse of the skull, and complete escape of all its contents. 
 In this case, however, we should watch with special caution the effect 
 of the compression upon the cranium, otherwise the maternal parts 
 may, at any moment, be wounded by fragments of the tabular bones. 
 
 [The author ascribes powers to the cephalotribe which are hardly 
 warranted by the experience of others. The base of the skull is frac- 
 tured with great difficulty by this instrument. Von Weber experi- 
 mented on the heads of dead children, and found that though the base 
 may be broken, fractures are less common than simple bending of the 
 bones inward, or the turning of the base upon its axis. Hicks made 
 the same statement in 1870, and in a subsequent paper added that, 
 " the reduction ... of the base is a matter of great difficulty, and 
 requires great power in the instrument." Barnes believes that it may 
 be made to partly crush the base, and evidently takes what is a correct 
 view of the powers of the cephalotribe, — that it is useful rather to break 
 up the perforated cranium than to decompose the base. Hicks appre- 
 ciates the full extent of the powers of the instrument, when he asserts 
 that it is intended to crush the cranium so that the base may be turned 
 and brought through the contracted brim edgewise. — P.] 
 
 A subject, which has given rise to no little discussion, is whether or 
 not we should, after crushing, use the cephalotribe as a tractor. Pajot 
 condemns such a course, and recommends a procedure which he de- 
 scribes as " cephalotripsie repetee sans tractions" in which he leaves ex- 
 pulsion absolutely to nature. He also recommends, what, if feasible, 
 is certainly advantageous, — that we should rotate the head which has 
 been operated upon, so as to bring its crushed diameter in relation 
 with the contracted diameter of the pelvis. This condemnation of the 
 cephalotribe as a tractor, seems chiefly to be supported by those who, 
 in France or elsewhere, uphold the use of the bulky instruments which 
 are very obviously less suitable for such a purpose. What seems, there- 
 fore, to be the chief advantage of the lighter English instrument, is that 
 traction may by it be more safely performed. Indeed, it appears to us 
 in the highest degree irrational that we should forego all the advantages 
 of traction which spring from such a firm grasp of the head as the 
 cephalotribe gives. Caution, indeed, we can scarcely exaggerate ; but, 
 we can see no reason why, after efficient crushing, we should not pull 
 gently with the handles backwards, which we can, of course, do with 
 more safety, and at greater advantage, than if there was no pelvic 
 
542 EMBRYOTOMY. [CIIAP. 
 
 curve to the blades. Another disadvantage of removing the blades, 
 and leaving the further progress of the case to nature is said by Dr. 
 Barnes to consist in the resiliency of the foetal structures ; so that a 
 head flattened within the grasp of the cephalotribe so as to measure 
 not more than an inch and a half, may spring out on the removal of 
 the blades to more than two inches. 
 
 When the mutilated head at length glides through the chink which 
 has so obstinately barred its progress, the young operator may hastily 
 conclude that his operative difficulties are necessarily at an end. In 
 cases of minor disproportion, it will no doubt be so ; but, in extreme 
 distortion, the descent of the shoulders and trunk may be attended with 
 very considerable difficulty. If the remains of the head be still within 
 the grasp of the cephalotribe, it is proper to continue the tractile force 
 backwards, as far as may be practicable with a due regard to the in- 
 tegrity of the perineal structures. This is done with the view of disen- 
 gaging the anterior shoulder, or bringing it a little in advance, so that 
 the blunt hook may be fixed in the axilla to pull it through. It may 
 be necessary at this stage, when the blunt hook and crotchet fail to 
 effect delivery, that the cephalotribe should be again used, and the 
 trunk crushed prior to delivery ; a proceeding which, although rarely 
 necessary, is certainly preferable to the employment of such violence 
 as might otherwise endanger the tissues of the mother. 
 
 There are cases in which it is found necessary to lessen the bulk of 
 the head in breech presentations, or after turning, the head being 
 arrested after the trunk has been successfully disengaged from a con- 
 tracted pelvis. In this case, the conditions of the operation are in- 
 verted, but are not by any means, as a rule, more difficult. Perforation 
 may be effected behind the ear, and this situation should be selected 
 as the point at which we may most readily attain the cavity of the 
 cranium, and give exit to the brain-substance, so as to permit of the 
 collapse of the head. In this case, also, the cephalotribe may be em- 
 ployed with great advantage, by crushing the base of the skull, which 
 in this instance is in advance of the vault; and, if the measurements 
 are such as to have already admitted of turning, or of the descent of 
 the breech, we may be almost sure that the collapse of the head which 
 must now necessarily ensue, will amply suffice to permit of its passage 
 through the pelvis. 
 
 Embryulcia. — When some part of the child other than the head 
 presents, it may be necessary to use the perforator upon the trunk, 
 and endeavor to extract the child by the evacuation of the contents of 
 the thorax and abdomen. This is one of the methods, for example, 
 which have been practiced in cases of transverse presentation in which 
 turning is impracticable. There is no difficulty in such a case in making 
 a breach in the thoracic walls, below the axilla, of sufficient size to 
 admit of the removal of the lungs and heart, and, subsequently, by 
 perforation of the diaphragm, of the abdominal viscera — the most im- 
 portant of these being the liver, which, as is well known, is of great 
 size in the foetus. The breaking up of the organs prior to their removal 
 cannot be effected in the same bold manner as in craniotomy, as we 
 might easily perforate the trunk, and wound the walls of the uterus. 
 
XXXII.] EMBRYULCIA. 543 
 
 After thus reducing the bulk of the trunk, what should now be 
 attempted is an imitation of the natural processes of spontaneous evo- 
 lution, or spontaneous expulsion, which may be effected by forcibly 
 dragging down the breech, by the blunt hook or otherwise, after the 
 organs have been removed. This, however, is not always easy ; and 
 we have a vivid recollection of such a case, which we saw many years 
 ago, where turning had been found impracticable, and embryulcia had 
 been practiced to the extent of removing the whole of the abdominal 
 and thoracic organs. The crotchet and blunt hook were repeatedly 
 fixed upon the pelvis and lower vertebras, but without success, and the 
 woman ultimately died undelivered. Looking back upon this case 
 with the vividness with which memory recalls early experiences, we 
 feel assured that the treatment proper to it ought to have been decapi- 
 tation, and not evisceration. 
 
 The former operation lias been described in a previous chapter, and 
 should, we believe, be always taken into consideration when the 
 question of embryulcia in impacted transverse presentation crops up. 
 Evisceration is not, however, limited to cases of transverse presenta- 
 tion, but may be found necessary, and has often been practiced as a 
 sequel of craniotomy, when it may be requisite to diminish the bulk of 
 the trunk, on precisely the same principle as has guided us to perfora- 
 tion of the cranium at an earlier stage of the operation, where we 
 cannot succeed in delivering by the blunt hook, crotchet, or any other 
 instrument which we may employ purely for the purpose of traction. 
 It is probable, however, that under such circumstances, the process 
 previously detailed, in which the cephalotribe is the agent employed, 
 might be adopted with a better prospect of satisfactory results. 
 
 A very powerful instrument, but one rather complicated in its con- 
 struction, is that which was invented by Van Huevel, of Brussels, and 
 has subsequently been adopted by some eminent Continental prac- 
 titioners as a substitute for the crotchet, cephalotribe, and other instru- 
 ments, which we have described as essential to the performance of 
 craniotomy, under any circumstances which may involve greater diffi- 
 culty than usual. This instrument is known as Van HuevePs Forceps 
 Saw, and consists in the first place of forceps, of which the blades are 
 of unusual strength. On the inner aspect of the latter is a groove 
 extending from about one inch below the extremity to near the lock. 
 Within the groove, and protected by a band of steel, the chain saw is 
 introduced after the blades have been adjusted, and is then made to 
 cut from without inwards, or from the lock towards the tips of the 
 blades, until the head has been divided, — the chain being worked by 
 two small cross handles at its extremities, while its action, protected by 
 the blades of the forceps, may be looked upon as absolutely safe. 
 
 Dr. Barnes has lately suggested another operation, by which the wire 
 ecraseur may be used for the purpose of bisecting the head, or other- 
 wise operating upon the body of the foetus. This method of performing 
 Embryotomy was demonstrated by the inventor before the Obstetrical 
 Society, the instrument employed being the ecraseur of Braxton Hicks. 
 He recommends the employment, not of the wire rope suggested by 
 
544 EMBRYOTOMY. [CHAP. 
 
 Hicks, 1 but of a single loop of strong steel wire, which he manipulates, 
 so as to pass it through the cervix uteri and the chink of the pelvic 
 brim. The crotchet being passed into the hole made by the perforator, 
 and held by an assistant, so as to steady the head, the loop is guided 
 over the crotchet to the right side of the uterus, where the face lies. 
 u The compression being removed, the loop springs open to form its 
 original ring, which is guided over the anterior part of the head. The 
 screw is then tightened. Instantly the wire is buried in the scalp; 
 and here is manifested a singular advantage of this operation. The 
 whole force of the necessary manoeuvres is expended on the foetus. 
 In the ordinary modes of performing embryotomy, as by the crotchet 
 especially, and in a lesser degree by the craniotomy forceps and omphal- 
 otribe, the mother's soft parts are subjected to pressure and contusion. 
 The child's head, imperfectly reduced in bulk, is forcibly dragged down 
 upon the narrow pelvis, the intervening soft parts being liable to be 
 bruised, crushed, and even perforated. And this danger, obviously in- 
 creasing in proportion to the extent of the pelvic contraction, together 
 with the bulk of the instruments used, deprives the mother, in all cases 
 of extreme contraction, of the benefit of embryotomy, leaving her only 
 the terrible prospect of the Caesarian section. When the anterior or 
 posterior segment of the head is seized in the wire loop, a steady work- 
 ing of the screw cuts through the head in a few minutes. The loose 
 segment is then removed by the craniotomy forceps. In minor degrees 
 of contraction, the removal of one segment is enough to enable the rest 
 of the head to be extracted by the craniotomy forceps. But in the 
 class of extreme cases, in which this operation is especially useful, it is 
 desirable still further to reduce the head, by taking off another section. 
 This is best done by reapplving the loop over the occipital end of the 
 head." 
 
 A word may here be added as to the probable range of cases within 
 which the cephalotribe may be applied. Much will, of course, depend, 
 as has already been observed, upon the degree of contraction, not only 
 of the conjugate, but of the other diameters of the pelvis. In a discus- 
 sion on this subject, held at Berlin, the majority of the speakers thought 
 that a minimum of two inches in the conjugate diameter was necessary. 
 Crede, Pajot, Hicks, and Barnes have however encountered cases in 
 which the contraction ranged from one and three-quarters to one and 
 a half inches, and have yet been able successfully to accomplish the 
 operation. It is important that facts such as these should be borne in 
 mind when we have to consider the dernier ressort of operative mid- 
 wifery, — the Caesarian Section, — which will form the subject of the fol- 
 lowing chapter. 
 
 1 We have frequently employed this instrument for the removal of uterine polypi, 
 and in other similar operations, but have found that the wire ropes suggested by the 
 inventor are not to be depended upon, and are apt to snap under a powerful strain. 
 Thinking at first that this was due either to some imperfection of the instrument, or 
 to some fault in the annealing of the wire of which the rope was composed, we con- 
 sulted Dr. Hicks, who was so obliging as to order a complete instrument and ropes, 
 after his own model ; but the result was still far from satisfactory. From the expe- 
 rience we have since had of the single steel wire suggested by Dr. Barnes, we are 
 inclined to give to it a decided preference. 
 
XXXIII.] HYSTEROTOMY. 545 
 
 
 CHAPTER XXXIII. 
 
 HYSTEROTOMY AND ALLIED OPERATIONS. 
 
 HISTORY OF THE OPERATION OP HYSTEROTOMY — CASES IN WHICH IT IS JUSTIFIABLE : 
 MATERNAL MORTALITY: DIFFERENT RESULTS IN BRITISH AND CONTINENTAL 
 PRACTICE — CONDITIONS FAVORABLE TO SUCCESS — THE OPERATION ASD ITS 
 
 details: duties of the assistants: closure of THE WOUNDS — AFTER- 
 TREATMENT— CAUSES OF FATAL RESULT — EFFECT OF COLD IN PREVENTING 
 PERITONITIS — REPEATED SUCCESS OF THE OPERATION IN THE SAME CASES — 
 GASTROTOMY : CASES IN WHICH THE OPERATION IS REQUIRED — THE SO-CALLED 
 VAGINAL CAESARIAN SECTION — SYMPHYSIOTOMY: HISTORY AND NATURE OF 
 THIS OPERATION: OBJECTIONS TO IT — STOLTZ'S OPERATION OF PUBIOTOMY — 
 TABULAR STATEMENT SHOWING THE DEGREE OF CONJUGATE CONTRACTION AT 
 THE BRIM, WHICH MAY BE SUPPOSED TO INDICATE RESPECTIVELY THE OPERA- 
 TIONS OF THE LONG FORCEPS, TURNING, EMBRYOTOMY, AND THE CESARIAN 
 SECTION. 
 
 Hysterotomy, Laparo-Hysterotorny, or, as it is more familiarly 
 known, the Caesarian Section, is an operation whereby the foetus is 
 extracted through an opening which is made in the abdominal and 
 uterine walls. The propriety of such a procedure, in the case of the 
 sudden death of the mother, is, in the hope of extracting a living child, 
 so obviously a course to which no exception can be taken, that nothing 
 need be urged in justification of the operation in the abstract. 
 
 From the earliest period in the history of midwifery, it had been 
 occasionally practiced on women dying during labor; and the names 
 of Scipio Africanus, Manilius, Andrea Doria, and others, are recorded 
 as having been brought into the world under such circumstances, in 
 obedience to the law of Numa, which forbade the burial of a pregnant 
 woman in whom the operation had not been performed. About the 
 end of the sixteenth or the beginning of the seventeenth century, it 
 would appear that the operation had been performed in cases in which 
 the child had escaped into the cavity of the peritoneum ; but as this 
 proceeding is not, properly speaking, the Caesarian Section, these cases 
 are only to be regarded as instances of Laparotomy or Gastrotomy. It 
 is not precisely known at what epoch Hysterotomy was first performed 
 on the living woman ; for there is every reason to believe that the cases 
 published by Rousset in 1581 were to be referred chiefly to the pre- 
 ceding category. This work, celebrated in the history of the subject, 
 gave rise to the most extravagant expectations, and at one time the 
 operation was so recklessly performed by surgeons, that it was only by 
 the uncompromising attitude of Guillemeau and Ambroise Pare that it 
 fell into disfavor. It is of this period that Scipio Merunia spoke when 
 he talked, with pardonable exaggeration, of the operation being as 
 
 35 
 
546 HYSTEROTOMY. [CHAP. 
 
 common in France as bleeding in Italy. The opposition thus encoun- 
 tered in such influential quarters had well-nigh condemned the Caesarian 
 operation to oblivion ; but it was again revived, and gave rise to endless 
 and bitter discussion during the whole of the seventeenth, and, we may 
 add, the first half of the last century, without anything definite having 
 been elicited or determined upon, the profession being divided into two 
 parties, one of which condemned the operation in the most uncom- 
 promising way, while the other as warmly, and with even less of dis- 
 cretion, was enthusiastic in its support. It will be observed, therefore, 
 that the Caesarian Section, as now calmly looked upon in the light of 
 science, dates from quite modern times. 
 
 While it must be admitted that every step in advance which has been 
 established by conservative midwifery throws further into the shade the 
 sacrificial or more desperate operative resources of the art, there proba- 
 bly exist no practitioners in the present day who will not admit that 
 there are cases in which hysterotomy is justifiable on grounds which 
 will stand the test of the strictest scientific examination. Putting aside, 
 for the moment, the cases in which it may be practiced upon the dead, 
 it may be broadly asserted that the operation is called for on the living 
 in all cases in which the state of parts is such as to preclude the possi- 
 bility of delivery by embryotomy. In other words, we arc driven to 
 this last resource wherever we recognize the fact, that the foetus, how- 
 ever mutilated, cannot be extracted by the pelvic canal. 
 
 Considerable difference of opinion unfortunately exists as to the limit 
 of contraction which will warrant the performance of Hysterotomy. In 
 Germany it is very generally asserted that two and a half inches, in 
 the conjugate of the brim, is to be held as the limit in question; but 
 there are, in so far as we are aware, none in this country who indorse 
 this view. What has already been said in the preceding chapter affords 
 ample proof that Craniotomy may be successfully performed in con- 
 tractions of one inch and three-quarters; and the experience of some of 
 the most distinguished of modern operators seems to show that this 
 limit may be reduced to one inch and a half. We may say, then, con- 
 fidently, that when the conjugate diameter exceeds these limits, we are 
 in no case justified in at once deciding in favor of the Caesarian opera- 
 tion. We must once more, however, reiterate a former observation, and 
 call attention to the fact that the conjugate measurement is not alone to 
 betaken into account — as it is too much the fashion to do — seeing that 
 we may have irregular or angular distortion, in which the other diame- 
 ters are similarly or, it may be, chiefly distorted. And it is a point of 
 very great interest and importance that, of the whole number of re- 
 ported cases of hysterotomy, a large majority were due to osteomalacia, 
 in which, as we have seen, the typical distortion does not involve the 
 conjugate diameter at all. A much smaller number were cases of 
 rickets ; and, among the rarer conditions calling for the operation, may 
 be mentioned exostosis, fracture of the pelvis, spondylolisthesis, fibrous 
 or other tumors, and carcinoma of the os and cervix. What we wish, 
 therefore, more particularly to notice is that the conjugate measurement 
 cannot be accepted as the test of the necessity which may be assumed to 
 exist for the performance of this operation. 
 

 
 XXXIII.] HYSTEROTOMY. 547 
 
 The maternal mortality in this country has been so great — not less 
 than 85 per cent, of all recorded cases — that a very general idea prevails 
 that this is almost exclusively a child's operation. This is a double 
 error ; for, when we perform the operation, in a case where we know that 
 the child cannot be otherwise born, we give the mother the chance, small 
 though it be, of recovering from the effects of the operation, while 
 otherwise we must leave her to die; and, as regards the child, the re- 
 sults are far from being so favorable as to warrant us in looking upon 
 it as a child's operation, although it may, no doubt, fairly be inferred 
 that this is attributable in some degree to the fact that the operation is 
 often delayed too long. 
 
 If we turn for a moment from British to Continental statistics, it 
 must be admitted that the results are vastly more favorable in the 
 latter case. The reason of this is obvious, and has its origin directly 
 or indirectly in the greater regard for foetal life, which, on religious 
 grounds, causes hysterotomy to be looked upon with more favor than 
 embryotomy. Dubois says, for example, that when the brim is con- 
 tracted to two inches, and the child is living, we should choose the 
 former operation without hesitation. His authority, therefore, and that 
 of others of equal distinction, has necessarily led to the performance of 
 hysterotomy in a larger proportion of cases than has ever obtained in 
 this country. Moreover, the very anxiety to save the child leads to the 
 performance of the operation at a much earlier period of labor than is 
 practiced in this country ; and we cannot doubt that if is this which 
 brings about their successful results. [Dr. Robert P. Harris, of Phila- 
 delphia, has carefully investigated the history of the Caesarian operation 
 in the United States, and has published the results of his study in the 
 fourth volume of the American Journal of Obstetrics. Of 60 women 
 operated on in this country, 32 recovered and 28 died, a mortality of 
 46.66 per cent. Of the children, 27 were saved. Dr. Harris says 
 that " if we calculate the risks of gastro-hysterotomy in this country 
 from the cases operated on in cities and large towns, or by their sur- 
 geons in their immediate vicinity, giving them all the advantages that 
 skill and service can command, we find that sixty per cent, of the women 
 recovered." At the close of his second paper, he appends a tabular 
 statement of the results of seventeen operations " performed during 
 or at the close of the first day of labor." Of these women 73 J § per 
 cent, survived, while 86 f$ per cent, of the children were saved. It is, 
 therefore, not unreasonable to expect that in the future the results of 
 this operation will equal those of ovariotomy. — P.] It is, indeed, of vital 
 importance that the operation should not be delayed until symptoms of 
 exhaustion have set in, as has been too often the case in England, — 
 although we operate, primarily at least, in the interests of the mother, 
 and with a mere secondary consideration for the life of the child. It 
 is difficult to avoid the conclusion — in which we have the support of 
 Cazeaux — that the operation is rashly undertaken, by many of our Con- 
 tinental brethren, in cases where the proper operation is embryotomy. 
 This is one of many causes which should encourage us to give to the 
 subject of embryotomy our best and most earnest consideration, that we 
 may, by perfecting that operation, reduce more and more the necessity 
 
548 HYSTEROTOMY. [CHAP. 
 
 for having recourse to hysterotomy. If we admit the religious element 
 into the question, or other considerations, such as that suggested by 
 Denman — that we should gravely consider, whether, in the case of a 
 woman who, knowing that she cannot bear a living child, has allowed 
 herself to become pregnant, we should not act rather in the interests of 
 the child ; or, in other words, if we weigh the life of the child as of 
 equal importance in any case with that of the mother, we will speedily 
 become bewildered in the mazes of casuistry, and may be led to do 
 what is morally wrong. In a word, hysterotomy is no exception to 
 the general rule that we should act primarily in the interests of the 
 mother. 
 
 When the operation is called for by the death of the mother, either 
 before or during labor, there are no considerations which will encourage 
 a moment's hesitation or delay. During labor, it may be possible to 
 turn and deliver, or to extract by the forceps almost as rapidly as to 
 remove the child through the abdominal walls — and this proceeding 
 has the advantage of being less repugnant to the feelings of relatives 
 and friends ; but, if the os is not sufficiently dilated, or if labor has not 
 commenced, we have no choice in the matter, the only rule being to 
 extract the child without unnecessary delay. The period during which 
 the vitality of the child may be preserved is probably very limited. 
 Authentic cases are recorded in which the child has been removed alive 
 ten, fifteen, and even thirty minutes after the death of the mother ; but 
 we must treat as fables those instances of which we read, where it is 
 said to have been found alive ten, fifteen, or twenty-four hours after 
 the mother had ceased to live. In death before the seventh month, it 
 would be a manifest impropriety to operate ; but religious convictions 
 have caused this to be done in order that the child may have the 
 benefit of Christian baptism. 
 
 The Caesarian operation is, however, under certain circumstances, 
 imperatively demanded while the mother still lives. Let us see, there- 
 fore, what are the conditions upon which success will mainly depend. 
 The first, and perhaps the most important point, is the early recogni- 
 tion of the nature and extent of the obstruction. This will enable us 
 to prepare the woman, in some degree, for the great peril to which she 
 is about to be subjected, by careful attention to the bowels and so forth. 
 It is a matter of doubt, whether we should wait for the coming on of 
 labor, or induce it artificially. There are arguments in favor of both 
 modes of procedure, but perhaps the safest plan will be to wait until 
 nature gives evidence that she is about to call upon the uterus to assume 
 its physiological action, which will be an assistance to the operator at 
 certain stages ; and, besides, we are entitled to assume that, at the full 
 time, the healing process is more likely to be encouraged by the normal 
 physiological phenomena of involution. Under no circumstances should 
 we operate until the os has opened to some extent, so as to permit of 
 the discharges passing by the normal channel ; but, if it be thought 
 advisable to precipitate matters, this can always be done by some of 
 the ordinary modes of procedure for bringing on premature labor. 
 Winckel says that the most favorable period for the operation is the 
 end of the first stage ; and he recommends that we should not rupture 
 
XXXIII.] 
 
 THE OPERATION. 
 
 549 
 
 the membranes, as some have done, with the view of permitting the 
 escape of the liquor amnii. 
 
 The Operation. — The measures to be taken before commencing the 
 operation should be those which the most experienced of our ovarioto- 
 mists have found, of late years, to be conducive .to success. The 
 patient should be placed upon a high bed or table, in a good light, 
 with her shoulders a little elevated. The temperature of the room 
 should, if necessary, be artificially raised. There should be at hand 
 an abundant supply of hot and cold water, and a weak solution of 
 carbolic acid, with a sufficiency of towels and sponges. Several bis- 
 touries, with sharp and blunt points, artery forceps, ligatures of various 
 kinds (including antiseptic catgut), bandages, carbolized dressings, and 
 a long probang, will, with the usual minor instruments of an ordinary 
 pocket-case, be all that is necessary. The propriety of giving chloro- 
 form in this operation has been called in question, chiefly on account 
 of the disastrous effect which an attack of retching might have at a 
 
 Fig. 191. 
 
 Hysterotomy. 
 
 critical moment of the procedure ; but, if the stomach is empty before 
 this agent is administered, the risk is not likely to be great. The 
 operator, standing in front of the patient, and having ascertained that 
 the bladder is empty, must first examine the abdominal walls, in order 
 to ascertain, with precision, the position of the uterus with reference 
 to them. A final examination, per vaginam, should also be made, as 
 some cases of osteomalacia have been recorded in which the bones of 
 
550 HYSTEROTOMY. [CHAP. 
 
 an extremely distorted pelvis have yielded so much as to admit of the 
 passage of the hand. The primary incision is to be made in the middle 
 line, and should extend from a little below the umbilicus to about two 
 and a half inches above the pubic symphysis. Further than this it 
 would be imprudent to go in the latter direction, and, in the case of 
 extreme deformity or unusual shortness of stature rendering a larger 
 incision necessary than can be effected by this rule, the wound should 
 be commenced above, and a little to the left of the umbilicus. The 
 knife should be carried through the skin and subcutaneous cellular 
 tissue, and the various aponeurotic layers successively divided, until 
 the peritoneum is reached. Any bleeding vessels should be carefully 
 secured before going further. 
 
 The uterus having been previously adjusted, so as to bring its axis as 
 nearly as may be into parallelism with the abdominal incision, the 
 hands of two assistants are now to be placed above and below, with the 
 view of bringing the uterine and abdominal walls into close apposition, 
 and thus maintaining their relative positions until the operation has 
 been completed. The section of the peritoneum should be effected with 
 caution, not only with the view of protecting the subjacent uterine tissue, 
 but also to avert the possibility of wounding the bow r el, as cases have 
 been known in which convolutions of the small intestines were lodged 
 in front of the uterus. When the peritoneal cavity has been opened 
 in this manner, the operator should introduce, through the first minute 
 incision, a director, upon which he may cut ; or having made an aper- 
 ture sufficient to admit of the passage of the forefinger, that may be ad- 
 vantageously used as a director, along the palmar surface of which a 
 blunt-pointed bistoury may be passed. During the whole of this pro- 
 cess, the attention of the assistants should be sustained, so as to prevent 
 the possibility of protrusion of the bowels, while any discharge should 
 be assiduously removed by means of sponges wrung out of carbolic 
 solution. 
 
 The surface of the uterus being now brought into view, the next 
 stage of the operation consists in the section of its walls. It has been 
 said that the site of the placenta may be determined by auscultation, a 
 bulging of that portion of the uterine wall, and by certain other signs 
 to which it is unnecessary to refer ; but we do not believe that any of 
 these signs are such as may be depended upon, so that the exact situa- 
 tion of the placenta must remain, in some degree at least, doubtful. 
 The uterine incision is to be made in the middle line, so as to corre- 
 spond to that in the abdominal walls, and is to be carried cautiously 
 through the peritoneum and proper tissue of the organ, so as to avoid 
 the fundus and cervix ; the reason being that the section of the circular 
 fibres there situated would be extremely likely to cause a gaping of 
 the wound. As the knife approaches the inner surface of the uterus, 
 we must exercise some caution lest we injure the placenta, which may 
 be immediately subjacent ; and if it should chance that this structure 
 intervenes between us and the embryo, we must carefully make our 
 way to the edge of the placenta before attempting to extract the child. 
 
 If — as is usually considered a favorable condition at this stage — the 
 membranes are intact, the escape of the liquor amnii must be guarded 
 
XXXIII.] THE UTERINE INCISION. 551 
 
 against at the moment of perforation. For this purpose, the aperture in 
 the membranes should be made as minute as possible, and an assistant 
 specially detailed for this duty should carefully receive in sponges the 
 fluid as it escapes, so as to prevent its entrance into the cavity of the 
 peritoneum. An orifice of sufficient size being thereupon made, the 
 extraction of the child is to be effected with the least possible delay, 
 the feet being seized, and delivery promptly completed. While this is 
 being done, a certain amount of uterine contraction will usually occur, 
 which is an additional reason for speedy action on our part ; otherwise, 
 the breach in the uterine walls will become rapidly diminished in size. 
 It has not unfrequently happened that, when the body of the child has 
 been successfully extracted, the contraction has been so rapid as to cause 
 the neck to be so firmly grasped as to prevent the completion of the 
 operation, a state of matters in which it is better to enlarge the incision, 
 than to use force, by Avhich we can only succeed by tearing open the 
 wound. 
 
 If the placenta is not at once detached, the hand should be immedi- 
 ately introduced into the cavity, and the organ separated from its at- 
 tachments, and extracted as the hand is being withdrawn. The chief 
 risk of the operation at this stage is, of course, the haemorrhage which 
 necessarily occurs from the uterine sinuses which have been cut through, 
 as well as from the inner surface of that portion of the orgaji from 
 which the placenta has been separated. The former is the source from 
 which bleeding is chiefly to be looked for ; but experience has shown 
 that this risk is very much less than might have been anticipated, the 
 actual amount of discharge depending, in a great measure, on the effi- 
 ciency of the uterine contractions ; and it is certain that, fatal as the 
 operation is in its results, death rarely ensues from haemorrhage. The 
 greatest care on the part of the assistants is necessary, in order to pre- 
 vent the entrance of the blood and other discharges into the cavity of 
 the peritoneum, and the escape from it of the intestines. Perfect success 
 in this direction is, of course, impracticable; but we may be sure that 
 the less the quantity of such discharges that comes in contact with the 
 peritoneal membrane, the less likely is the dreaded peritonitis to be 
 severe or fatal in its character. The use of the carbolic solution, by 
 sponges and otherwise, will further reduce this risk. The escape of the 
 intestines may be prevented, and the approximation of the uterine and 
 abdominal walls efficiently maintained, by an expedient which was sug- 
 gested by Winckel. This consists in having the extremities of the 
 uterine wound hooked upwards by the finger, and thus brought into 
 contact with the walls of the abdomen, a manoeuvre which is peculiarly 
 applicable to cases in which the number of assistants is deficient. The 
 probang should finally be passed downwards through the os uteri to 
 the vagina, which insures for the discharges free egress by the normal 
 channel. 
 
 Delivery having been by these means effected, the mode of closure 
 and general management of the incisions, uterine and abdominal, is the 
 subject which next engages our attention. When the uterus has well 
 contracted, — a process which is materially hastened by pressure of the 
 organ, and even by the application of cold, — when all bleeding has 
 
552 HYSTEROTOMY. [CHAP. 
 
 ceased, and when the discharges have been wiped away as thoroughly 
 as possible, the edges of the wounds are to be brought into apposition. 
 It is a matter of dispute whether we should or should not stitch the 
 uterine wound. It is quite certain that this is not essential to success, 
 and it is doubtful, as may be inferred from the experience of Winckel, 
 whether or not it is in any way beneficial. Still, on ordinary surgical 
 principles, and recognizing the fact that, in a certain number of fatal 
 cases, the wound has been found gaping after death, we cannot wonder 
 that most operators seek in this way to promote union of the uterine 
 tissues. But for one circumstance, the most advantageous procedure 
 would be to bring the uterine and abdominal wounds into close apposi- 
 tion by the same suture ; but the circumstance in question is a most im- 
 portant one, and depends upon the contractility and natural involution 
 of the uterine tissue, which would probably involve forcible dragging 
 upon the wound. To effect closure of the uterine incision by means of 
 suture, while the risk referred to is at the same time avoided, has been, 
 therefore, the great object of many of those who have had occasion to 
 perform the operation. Mr. Spencer Wells, for example, in a case in 
 which he performed it with a successful result, passed an uninterrupted 
 silk suture, the end of which he brought through the vagina, and subse- 
 quently removed ; while Dr. Barnes suggests an ingenious but more 
 complicated method, by which the uterus is stitched and united to the 
 margin of the abdominal wound, while provision is, at the same time, 
 made for the contraction above referred to. 
 
 Whether or not the uterine wound is stitched, that in the abdominal 
 wall is, of course, to be carefully closed by suture. The material to 
 which a preference is usually given is fine silver wire, of which five or 
 six stitches are to be passed through the cutaneous and peritoneal 
 margins of the incision ; and after these have been carefully adjusted, 
 they are to be drawn tight and fastened in the usual way, additional 
 superficial sutures being, if necessary, added, so as to bring the whole 
 length of the superficial incision into accurate apposition. The carbol- 
 ized catgut ligatures suggested by Professor Lister may, with possible 
 advantage, be substituted for the silver wire. Prepared gauze or other 
 antiseptic dressings may now be applied, and are to be retained in their 
 position by strips of sticking-plaster and a carefully adjusted bandage. 
 
 A full opiate should now be administered either by enema or other 
 suppository, and perfect quiet and rest enjoined, the dressings being 
 undisturbed for five or six days. The sutures are to be removed about 
 the eighth day. The vagina may be washed out by injections of tepid 
 water with a little Condy's fluid, and the bladder emptied by means of 
 the catheter twice a day; and on the fourth or fifth day, the bowels 
 may be relieved by a simple enema. The diet throughout should be 
 of the lightest possible character, and every conceivable disturbing 
 element, bodily or mental, should be scrupulously avoided. 
 
 Reference has already been made to the operation of ovariotomy. It 
 must not, however, be supposed that we have any idea of tracing the 
 analogy which exists between the two operations. Hysterotomy, in- 
 deed, involves conditions which are manifestly far less favorable than 
 those which attend on an ordinary case of ovariotomy, and we need not 
 
XXXIII.] CAUSES OF FATAL RESULT. 553 
 
 wonder that the results are less successful. We cannot, however, avoid 
 the reflection, that not many years ago the latter operation was looked 
 upon as scarcely more promising in its results than that which we are 
 now considering; and, when we reflect further upon the wonderful 
 improvements which modern surgical skill has effected in the one 
 operation, we are surely justified in expressing a hope that the expe- 
 rience thus gained may be so made available as materially to reduce, 
 in the future, the fearful mortality which, in the past, has attended the 
 Caesarian Section. Upon nothing will the result be more likely to de- 
 pend than upon the period at which the operation is performed. If, 
 as has too generally been the case in this country, it is adopted only as 
 a last resource, when the vital powers are exhausted by lingering labor, 
 the expedient is, indeed, a desperate one. But if, on the contrary, the 
 necessity is recognized at a period sufficiently early to enable us to 
 select the time and the conditions which are most favorable, our prog- 
 nosis will admit of something more of hope. 
 
 The shock of the operation is often very great, and may prove fatal 
 at once, before the secondary effects of peritoneal inflammation have 
 manifested themselves. Haemorrhage is, as we have said, and as the 
 experience of Winckel has shown, by no means a prominent cause of 
 the fatal result; but it is otherwise with peritonitis, which may be 
 looked upon as almost inevitable when the woman survives the imme- 
 diate effects of the operation. This may come on within twenty-four 
 hours, and is indicated by the occurrence of rigor, severe abdominal 
 pain, with more or less tenderness on pressure, labored respiration, 
 flatulent distension of the bowels, and a rapid, wiry pulse. These 
 alarming symptoms may be combated by fomentations or poultices to 
 the abdomen, mild salines, and opium ; but, unfortunately, in the great 
 majority of cases, the symptoms will go on unchecked until, under 
 their influence, the patient succumbs. Metz, of Aix-la-Chapelle, in- 
 sists upon the importance of the sustained use of cold in averting peri- 
 toneal inflammation. The rash employment of this agent would, un- 
 doubtedly, as every one knows, rather tend, by reaction, to produce 
 inflammation than to repress it; but of this Metz was quite aware. 
 He recommends that, so soon as the woman has been put to bed after 
 the operation, compresses of cold water should be placed over the ab- 
 domen, and that, after a few hours, ice in a bladder should be sub- 
 stituted, while cold injections are thrown into the rectum, and the 
 patient is encouraged to swallow, from time to time, morsels of ice. 
 Under such treatment, he says, the patient is sensible of a feeling of 
 comfort to which she was previously a stranger, and this sensation may 
 be fully trusted to as a safe guide to the length of time, and the extent 
 to which this mode of treatment may be safely carried. So long, then, 
 as the woman remains comfortable, cold may be employed ; but the 
 moment she complains of chill or discomfort, the cold is at once to be 
 modified or withdrawn. Cazeaux seems to give a general support to 
 this mode of treatment, which has also been practiced by Kilian. Dr. 
 Metz asserts, that of thirteen cases treated on this principle one only 
 died, — a statement so glaringly absurd, that we can only suppose this 
 is one of the many pernicious instances of the reckless use of statistics 
 
554 HYSTEROTOMY. [CHAP. 
 
 with which, unfortunately, the literature of obstetrics is disfigured, and 
 which sometimes makes us incline to pass by with contempt sugges- 
 tions which may, nevertheless, have in them the germ of truth and 
 practical worth. 
 
 It sometimes happens, as a result of the healing process, that the 
 uterine and abdominal wounds become agglutinated, so as to produce 
 permanent adhesion at this place, without, as would appear, entailing 
 any serious inconvenience. This fact is made use of by those who 
 advocate the stitching together of the two wounds, and there has been 
 proved to exist, in some of those cases in which the Caesarian Section 
 has been repeatedly performed, an extent of adhesion which has ad- 
 mitted of the performance of the operation without opening the peri- 
 toneal cavity ; and it is obviously to this fact that the exceptional suc- 
 cess attendant on such operations is to be attributed. 
 
 [In 1870, Prof. T. G. Thomas, of New York, proposed to revive the 
 operation of Gastro-Elytrotomy as a substitute for the Caesarian Sec- 
 tion. As a preliminary to this operation, the os uteri is to be dilated 
 sufficiently to allow version to be performed. This being done, an 
 incision is made with a bistoury in the iliac fossa, the cut extending 
 from the spine of the pubis to the anterior superior spine of the ilium, 
 along the line of Poupart's ligament. The abdominal muscles being 
 divided, the peritoneum is to be separated from its attachments, until 
 the vagino-uterine junction is reached. A steel sound should now be 
 passed into the vagina, and the walls of that canal made tense, so that 
 they can be incised, the sound serving as a director. This done, the 
 os is pulled into the iliac fossa by a blunt hook, the fundus being tilted 
 in the opposite direction. By this means the operator is enabled to 
 pass his hand into the uterus, seize the feet, and extract the child 
 through the opening in the abdominal walls. Dr. Thomas has suc- 
 ceeded in extracting a living child in this manner in one instance on a 
 dying woman. Dr. Skene has since operated, but the merits of this 
 method of delivery in a narrow pelvis are not yet determined. The 
 immediate dangers are haemorrhage and shock, the more remote, cellu- 
 litis and septicaemia. How great the danger from haemorrhage may be, 
 experience alone can determine. — P.] 
 
 Gastrotomy , or Laparotomy, is an operation which has already been 
 alluded to as applicable to cases in which the child has escaped into 
 the abdominal cavity, either from a ruptured uterus, or in cases of 
 extra-uterine pregnancy. Some of the older cases which have been 
 recorded as Caesarian Section have clearly been of this nature, — the 
 operation being, as is obvious, only one stage of the more formidable 
 procedure which we have been considering. There may, possibly, be 
 cases, moreover, as has already been shown, in which, although the 
 cyst of an extra-uterine conception has not been ruptured, it is neces- 
 sary to perform this operation when the life of the mother is threatened 
 by pressure on important organs, and also under some other circum- 
 stances of a like nature. 
 
 The operation is simply the first stage of the Caesarian Section, and 
 it is to be conducted with precisely the same precautions ; but an aper- 
 ture must be left at the lower part of the external wound, to permit of 
 
XXXIII.] GASTROTOMY — SYMPHYSIOTOMY. 555 
 
 the escape of the discharges. It might naturally be inferred that an 
 operation which does not involve the uterine walls, would be attended 
 with much more favorable results. In practice, however, we shall 
 probably, when we take the whole circumstances into consideration, 
 look upon the one with as great apprehension as the other. The 
 operation of Gastrotomy has, in fact, certain special dangers in the 
 practice of midwifery, and is very different, in all respects, from the 
 ordinary operation for the removal of an ovarian cyst. The conditions 
 which attend rupture of the uterus, or of an extra-uterine cyst, have 
 already been detailed, when those accidents were under consideration. 
 In each case, the ovum, its appendages, and the liquor in which it floats, 
 all escape into the peritoneal cavity, along with a large quantity of 
 fluid and clotted blood, — a portion of which must necessarily be left 
 behind, — so that the chances of peritonitis are probably not less in the 
 one case than in the other. And, in the case of extra-uterine preg- 
 nancy, the peculiar anatomical conditions which are often involved 
 in the nature of the placental attachment, are of such a nature as to 
 render these cases specially hazardous. In fact, whatever statistics 
 may seem to prove, and Kilian and a few others may have said, we 
 must always look upon this operation as one of the last resources of 
 our art. 
 
 When the child is extracted by means of incision, practiced from 
 the vagina, the operation has by some been termed Vaginal Caesarian 
 Section, a phrase which is obviously improper. The circumstances 
 which may render necessary such an operation as this, are malignant 
 disease of the os and cervix, congenital occlusion of the os, or retrover- 
 sion of a gravid uterus. Similar operations, not involving the tissues 
 of the uterus, may be practiced in some rare instances of extra-uterine 
 pregnancy, in which the foetus may be reached in this way; but, in all 
 these cases, the operation is simple, and requires no special directions 
 other than to use bistouries and other instruments so guarded as to 
 incur no risk of wounding the surrounding tissues ; and, at the same 
 time, to cut with care, so as to avoid inflicting any injury upon the 
 child. 
 
 Symphysiotomy. — In 1768, Sigault, a young student of medicine, at 
 Paris, submitted to the Academie de Chirurgie, a proposition that 
 women might be delivered without very great risk, by means of an 
 operation which he thus named. The proposal was received with 
 ridicule, and the essayist was treated as a madman. Nothing daunted, 
 however, by this rebuff, the young Sigault stoutly maintained his posi- 
 tion for several years, but it was not until 1777 that he performed his 
 first operation in the presence, and with the assistance of the celebrated 
 Leroy, who, having espoused his cause, ultimately became a warm 
 advocate of the new procedure. Both mother and child were saved in 
 this case, and Sigault soon found himself famous and overwhelmed with 
 benefits, as the discoverer of a method which was to replace the hated 
 Csesarian Section, and, consequently, as a benefactor of his race. The 
 Academie de Medecine, as if to atone for the indignity which the sister 
 society had put upon him, received him with open arms, and actually 
 struck a medal in honor of the event. In France and Germany, the 
 
556 SYMPHYSIOTOMY. [CHAP. 
 
 profession was much divided on the subject, but in England it somehow 
 never gained a footing, nor would we even now have given any atten- 
 tion to the matter, were it not that, in all modern Continental works 
 on obstetrics, some degree of prominence is still given to the operation, 
 as one which might, under certain circumstances, be advantageously 
 performed. 
 
 The division of the pubic symphysis is, from a surgical point of view, 
 a matter so simple, that it is unnecessary to particularize the details. 
 It is proper, however, that in expressing as we now do the opinion that 
 the operation is one which must be unhesitatingly and absolutely re- 
 jected as irrational, some reason should be adduced for a view which 
 is so confidently expressed. To begin, then, symphysiotomy is to be 
 rejected as a mere chimerical idea, which had its origin in views as to 
 the movement of the pelvic bones during labor, than which nothing, 
 theoretically or practically, could be more incorrect. It was shown, in 
 an early chapter of this work, that the very trifling movement w T hich 
 nature permits during labor in the human pelvis is one in which the 
 symphysis pubis is the hinge. At the time when Sigault wrote, the 
 idea usually entertained was exactly the opposite — viz., that the hinge 
 w r as at the sacro-iliac synchondrosis, and that the pelvis gaped at the 
 symphysis ; and it could only, of course, have been with the object of 
 encouraging such a movement as this, that the operation could on 
 rational grounds be supported. Again, such an obstruction as might 
 seem to call either for Craniotomy, the Caesarian Section, or this new 
 operation, would, in a considerable majority of all cases, consist mainly 
 in contraction of the conjugate diameter of the brim ; but a moment's 
 reflection will serve to show that this operation is not one which is 
 likely to increase the diameter thus encroached upon, for, while it 
 certainly will augment the circumferential measurement of the pelvis, 
 and the transverse and oblique diameters, it leaves the conjugate com- 
 paratively untouched. And, if we turn to the results of the operation, 
 we will at once find that the boasted advantage has no existence, save 
 in the imagination of the inventor. Baudelocque says that, in forty- 
 one cases of the operation, fourteen women died, while only thirteen 
 children were born alive. The narrative of recorded cases shows that, 
 while the forces of nature may prevail after the operation, it will often 
 be found necessary to apply the forceps, or turn, after the original 
 operation has been completed. As regards ultimate results, Cazeaux 
 says, " In the most fortunate cases, the consolidation of the symphysis 
 is only complete after a lapse of three or four months. Women have 
 been seen in whom it had never taken place, and who, nevertheless, 
 have eventually been able to walk. There then forms, according to 
 Alphonse Leroy, a fibro-cellular tissue which, filling up the gap in the 
 symphysis, maintains the solidity of the articulation." 
 
 Various modifications of the operation have been suggested, including 
 one method which has received the support of Stoltz, of Strasburg, 
 and which he termed Pubiotomy. In this case the operation is per- 
 formed by a chain saw, which is introduced subcutaneously. A small 
 opening is first made to the right or left of the middle line over the 
 pelvic crest, and through this a strong needle, slightly curved, is intro- 
 
XXXIII.] PUBIOTOMY. 557 
 
 duced. This is passed behind the pubis, and brought out by the side 
 of the clitoris, and by it the chain saw, to which it has previously been 
 attached, is pulled through, and made to act upon the body of the pubis 
 from within outwards, until the bone has been divided. The operation 
 of symphysiotomy has been but once practiced, in so far as we are aware, 
 in this country ; and on the Continent, in the present day, it is so 
 seldom employed that the question may now be looked upon as forming 
 little more than an episode in the history of the operative midwifery of 
 the past. 
 
 It may be interesting at this place, by way of recapitulation — but 
 without any pretence of, or attempt at anything more than an approxi- 
 mation at accuracy — to set down, in a tabular form, the various con- 
 jugate measurements at the brim which, according to the best authori- 
 ties, may be supposed to indicate the necessity for the several operations 
 which we have now been considering. Burns, speaking of one of the 
 operations referred to, says, — and the observation will apply with equal 
 force to any of them, — " There is only one degree of disproportion, then, 
 betwixt the head and the pelvis which will admit of this ; but the 
 smallest deviation from it destroys the advantage of the operation. 
 Now, as this disproportion is so nice, we cannot in practice ascertain it; 
 for, although we could determine, within a hundredth part of an 
 inch, the capacity of the pelvis, yet we cannot determine the precise 
 dimensions of the head, and thus establish the relation of the two." 
 The student, we would again repeat, — at the risk of being accused of 
 unnecessary iteration, — must, above all things, beware of assuming 
 that conjugate contraction is his only guide, or one which is uniformly 
 to be relied upon. The following figures, therefore, have reference 
 only to cases of conjugate contraction, in which the other diameters are 
 either unaltered, or are, at least, not very greatly diminished. With 
 reference, more particularly, to the Caesarian Section, in which osteo- 
 malacia is the most frequent cause of deformity, it should be remem- 
 bered that, in that type of pelvis, the conjugate measurement, so far 
 from being a criterion of the deformity, is more likely to lead the 
 observer to conclusions which are quite erroneous. 
 
 With this explanation, then, the following may be given, as showing, 
 according to the most approved authorities, the degree of conjugate con- 
 traction at the brim, which may be supposed, under ordinary circum- 
 stances, to indicate the various operations which have been described : 
 
 Long forceps, 4 to 3£ inches. 
 
 Turning, 3£ to 2f " 
 
 Craniotomy, . . . . . . 3 to l| " 
 
 Caesarian Section, . . . . . 1£ and under. 
 
558 INDUCTION OF PREMATURE LABOR. [CHAP. 
 
 CHAPTER XXXIV. 
 
 INDUCTION OF PREMATURE LABOR. 
 
 HISTORY OF THE SUBJECT — NATURE AND SCOPE OF THE OPERATION — VIABILITY, 
 OR NON-VIABILITY OF THE CHILD — CONDITIONS WHICH JUSTIFY THE OPERA- 
 TION — VARIOUS METHODS OF PROVOKING UTERINE ACTTON : ERGOT: PUNCTUR- 
 ING THE MEMBRANES: SEPARATION OF THE MEMBRANES BY HAMILTON'S 
 METHOD: DILATATION OF THE CERVIX BY TENTS: INTRODUCTION OF AN 
 ELASTIC BOUGIE OR CATHETER INTO THE UTERUS: PLUGGING OR DISTENDING 
 THE VAGINA: THE METHOD OF KIWISCH BY THE VAGINAL DOUCHE : COHEN'S 
 METHOD BY INTRA-UTERINE INJECTIONS: DR BARNES'S PROCESS, CONSISTING 
 OF A "PROVOCATIVE" AND AN " ACCELERATIVE " STAGE: GALVANISM: 
 IRRITATION OF THE BREASTS — ANATOMICAL AND PHYSIOLOGICAL FITNESS OF 
 THE PARTS— CONSTITUTIONAL INFLUENCES. 
 
 It is with something of a sense of relief that we torn from a con- 
 sideration of the destructive operations of midwifery, to what is perhaps, 
 in the strictest and truest sense, the most conservative of all the re- 
 sources of our art. There is a fitness, moreover, in considering the 
 subject at this place, as it affords, within certain limits, a means by 
 which the necessity for the more serious operations may be avoided. 
 
 Of all methods of operative procedure which are applicable to the 
 practice of obstetrics, there is none which has given rise to such pro- 
 longed and often acrimonious discussion. Putting aside various ex- 
 pedients which were occasionally adopted both in ancient and modern 
 times to expedite delivery, there can be no doubt that the induction 
 of premature labor is an operation which we owe to the sound judg- 
 ment of the English school of midwifery, by the sheer force of which, 
 and the vigorous support it received from many influential quarters, 
 the operation was soon forced into notice. In 1556, a conference was 
 held in London, which was attended by the most eminent practitioners 
 of the day, at which this question was fully and exhaustively considered 
 in all its bearings, with the result of formally admitting it as a recognized 
 practice of the English School. 
 
 For reasons which have already been more than once adverted to, 
 the induction of premature labor was not likely to obtain a ready 
 assent on the Continent, where, on the contrary, it found opponents 
 who were so virulent in their hostility, that an operation, which is per- 
 haps above all others morally right as well as beneficent in its action, 
 was for many long years contemptuously rejected. The great force of 
 truth, however, ultimately prevailed, and the operation was performed 
 in Germany by Wenzel in 1804; but it was not till 1831 that Stoltz 
 of Strasburg led the way by performing the first operation in France — 
 not the least of the benefits which this distinguished obstetrician con- 
 
XXXIV.] CONDITIONS WHICH JUSTIFY THE OPERATION. 559 
 
 ferred upon that branch of science with which his name is still honora- 
 bly connected. From this moment, the success of the operation was 
 assured, even in the country where it had been longest resisted. Sen- 
 timental scruples in regard to foetal life, which had swayed the opinion 
 of many, were shown to be in this case quite irrational, and could be 
 supported by no argument, moral or religious ; the sophistry of which 
 could not easily be expressed. As time wore on, all doubt vanished, 
 and it may now be said that in the present day, the practice of the 
 Continent is as advanced as it is in England, and perhaps of late years 
 the operation has attracted even more attention than with us. The 
 only remnant of the original prejudice, which still exists in the minds 
 of some, is the opinion, occasionally entertained, that we should not 
 perform the operation repeatedly upon the same woman, on the prin- 
 ciple which has induced these persons to bring the interests of the child 
 into greater prominence in the case of a woman who has once been 
 delivered by craniotomy, and who ought, therefore, according to them, 
 to be exposed to the fearful danger of the Caesarian Section, in order 
 that the infant may be born alive. 
 
 The induction of Premature Labor, in its widest sense, is an opera- 
 tion varying greatly in its details, whereby the uterus is artificially 
 stimulated to expel its contents at any period prior to the completion 
 of the full term of utero-gestation. The merest glance at the subject 
 will therefore suffice to show that the operator must feel the sense of 
 responsibility more, the earlier the period of pregnancy at which the 
 presumed necessity for the operation may arise. At the sixth, and at 
 the ninth month, the operation will differ in no essential particular, and 
 may be attended with equally trifling risk to the mother. But, in the 
 one case, we sacrifice a child, by bringing it into the world before it is 
 viable ; while, in the other, we merely induce the premature expulsion 
 of an infant which there is every reason to suppose may survive; so 
 that, we must carefully draw a distinction between the induction of 
 abortion, and of premature labor in its more restricted sense. The 
 general opinion, which has found expression in the " Code Napoleon," 
 is, that the end of the sixth month is the period at which the foetus 
 may be considered viable ; but the experience of all accoucheurs extends 
 this till towards the end of the seventh month — before which time, in- 
 deed, w r e have but little hope that the child may be reared. It is clear, 
 therefore, that if the cause calling for the induction of premature labor 
 is of such a nature as to warrant us in deferring the operation until the 
 end of the seventh month has been reached, we should do so, avoiding, 
 at the same time, the risk of over-caution, which, by delaying too long, 
 may leave the mother exposed to the dangers from which it is our 
 primary object to save her. 
 
 The conditions under which we may be justified in performing the 
 operation vary considerably. When we operate before the middle of 
 the seventh month, we may look upon our procedure as one which we 
 undertake in the interests of the mother alone, without any reference 
 to the child, which is thus deliberately sacrificed. While it is true 
 that these are the cases in which a sense of responsibility is most likely 
 to weigh upon us, there are instances, undoubtedly, in which delay 
 
560 INDUCTION OF PREMATURE LABOR. [CHAP. 
 
 incurs a responsibility more serious still, in leaving the case to nature, 
 when the sole alternative of the Caesarian Section will almost surely 
 result in the sacrifice of the mother, and probably also of the child. 
 There is another class of cases, — which have been alluded to in a pre- 
 vious chapter, — in which we are sometimes, though very rarely, war- 
 ranted in inducing abortion. The most familiar example of this is 
 found in the excessive vomiting which occasionally attends pregnancy, 
 so as to bring women previously healthy to the very verge of dissolu- 
 tion. We have great difficulty in admitting this as a cause justifying 
 abortion, and most certainly no young practitioner should have recourse 
 to the operation, without very careful consideration, and, if possible, 
 the advice and assistance of those more experienced than himself. 
 For, if disaster does occur, — and we cannot doubt, from cases given by 
 Tyler Smith and others, that it occasionally does so, — from delay, we 
 cannot but fear that a too great familiarity, under such circumstances, 
 with an operation which is in itself simple enough, would result in a 
 wanton sacrifice of foetal life. Nature, as we have already shown, 
 almost invariably comes to the relief of such cases, so that the circum- 
 stances which might warrant the operation must be extremely rare. 
 
 There are instances, again, in which, at a more advanced period of 
 pregnancy, the operation is undertaken in the interests of the child. 
 There are few practitioners of much experience, who have not encoun- 
 tered cases in which women, often apparently robust, have been, on 
 successive occasions, delivered of stillborn children near the full time. 
 In such, we should not hesitate to bring on labor before the time at 
 which the death of the foetus was presumed to have occurred in former 
 pregnancies, fixing the period as near the natural termination of the 
 pregnancy as may be deemed prudent. The causes which give rise to 
 the death of the foetus, in these cases, are often obscure, and sometimes 
 can by no means be distinguished ; but in most instances there is, as we 
 may assume from what has actually been demonstrated, some diseased 
 condition, which interrupts the placental circulation, and thus causes 
 the death of the child. Any of the diseased conditions of the placenta 
 formerly enumerated, — such, for example, as fatty degeneration, — may 
 have this effect ; and it is, probably, when the disease is rapidly pro- 
 gressive, towards the end of pregnancy, that we are able, by premature 
 delivery, to avert its otherwise inevitable effect on the life of the child, 
 by placing the latter in circumstances in which, aerial respiration hav- 
 ing been established, it is independent of the placental circulation. 
 
 It is, as we have seen, a natural physiological accompaniment of 
 pregnancy, towards its termination, that the utero-placeutal tissues 
 loosen somewhat, preparatory to the occurrence of delivery; and, when 
 no actual disease of the placenta can be discovered, it has been sup- 
 posed that premature separation of the decidua may, either by rupture 
 of the vessels, or by interference with the circulation within them, 
 directly or indirectly destroy the foetus. In some cases, — of which we 
 have seen two examples, — it would seem as if the uterus, as in habitual 
 abortion independent of disease, had assumed a habit of throwing off 
 its contents at a certain time, before the conditions otherwise favorable 
 to live-birth were in operation ; and yet, when this so-called habit is 
 
XXXIV.] CONDITIONS WHICH JUSTIFY THE OPERATION. 561 
 
 once broken by the induction of premature labor at a somewhat earlier 
 period, the woman, in subsequent pregnancies, carries her children to 
 the full time. The operation may even be warranted in cases in which, 
 although the children may have previously been born alive, they have, 
 owing to the occurrence of some of the diseases referred to, been the 
 subjects of what has been termed, with some propriety, " intra-uterine 
 marasmus/' and have not long survived their birth. In cases of still- 
 birth, a very excellent rule which has been laid down for our guidance 
 in subsequent pregnancies is to examine with great care the placenta 
 and membranes. 
 
 The cases which are most frequent in their occurrence, and, at the 
 same time, most satisfactory in their results, are those in which we 
 operate with the double object of saving both mother and child from 
 great peril or almost certain death. Merriman has insisted, with great 
 justice, upon the caution which w T e should exercise, when the conditions 
 which seem to indicate the necessity for premature delivery occur in 
 primiparce. To a great extent, this warning is sound and judicious, 
 but we must avoid carrying the principle too far; for, if the circum- 
 stances are such as seem to preclude the possibility of the passage of a 
 mature foetus at the full term, we are equally justified, in primiparae, 
 as in other cases, in having recourse to an operation which thus obviates 
 inevitable risk. In pluripara?, much, and possibly everything, will 
 depend upon the history of former labors. If, for example, it has been 
 found necessary once or oftener, to relieve the woman in previous 
 labors by the operation of craniotomy, or even by turning or the long 
 forceps, with an invariably fatal result, the estimate which we may be 
 inclined to form of the probable danger is thus corroborated by expe- 
 rience ; but, where the indications are less certain, we must be firmly 
 convinced that the operation gives the best chance to the child as well 
 as to the mother, before we can hold ourselves as warranted in acting. 
 
 Inasmuch as the life of the infant will depend, in all cases, upon the 
 degree of development which has been attained prior to birth, it is of 
 the first importance that we should form a correct estimate of the period 
 beyond which we cannot safely go. As the necessity for this proceed- 
 ing, as well as for the more serious expedients of embryotomy and the 
 Caesarian Section, arises, in a very large proportion of cases, from con- 
 traction of the conjugate diameter of the brim, we should, in the first 
 place, endeavor to ascertain, with as much accuracy as may be attain- 
 able, the precise degree of the contraction. This may be done approxi- 
 mately by the methods of pelvimetry which have been already detailed. 
 It is obvious that such an amount of contraction as would call for the 
 Caesarian operation, will require measures for the relief of the woman 
 to be taken at an earlier period than when the diameters are such as to 
 point to embryotomy. In cases of conjugate contraction, as has already 
 been shown, the head lies pretty nearly in the transverse diameter, so 
 that it is the biparietal measurement which corresponds to the con- 
 tracted diameter of the brim. 
 
 While estimating, therefore, the degree of pelvic contraction, it is 
 proper that we, at the same time, bear in mind the probable measure- 
 ments of the biparietal diameter of the cranium at various epochs in 
 
562 INDUCTION OF PREMATURE LABOR. [CHAP. 
 
 the course of the last two or three months of pregnancy. Stoltz has 
 ventured to give measurements which, reduced to the standard of the 
 English inch, we may quote as probably approximating the actual con- 
 dition of the parts. Between the thirty-second and the thirty-third 
 week, the biparietal diameter is somewhere about two inches and three- 
 quarters ; from the thirty-fourth to the thirty-fifth, three inches ; and 
 from the thirty-sixth to the thirty-seventh, three inches and one-third. 
 If, therefore, we have to deal with a case in which the conjugate 
 diameter is two inches and a half, or under, we should operate not 
 later than the end of the seventh month, even making all allowance for 
 the greater compressibility of which the head, at this early period, is 
 susceptible. Conclusive proof of twin pregnancy may, as Cazeaux 
 has shown, modify our procedure in this particular, or might even 
 warrant us in abandoning the case to nature, if the contraction is not 
 excessive; and this for two reasons, — because twins are generally less 
 developed, and because their organization is seldom so perfect when 
 they are prematurely born as to enable them to maintain an indepen- 
 dent existence. 
 
 In cases of pelvic distortion where the conjugate falls under one inch 
 and three-quarters, the only possible alternative will, in most cases, be 
 the Caesarian Section. A case such as this necessitates abortion, for it 
 is only by operating in the course of the sixth month at latest, that we 
 can expect to save our patient, by the expulsion of the foetus before the 
 period of viability. At whatever period the operation may be resolved 
 upon, there is always a greater probability, which should not be lost 
 sight of, of obstruction from malposition of the foetus ; and the more 
 removed the case is from the natural term of gestation, the more likely 
 is this to occur, and to constitute a practical difficulty which may not 
 have been anticipated. It must not be supposed that pelvic contrac- 
 tions are the sole conditions, in addition to such as have previously 
 ibeen mentioned, which lead to the operation we are now considering. 
 We have already seen that, in certain cases of hemorrhage, w T hether 
 accidental or unavoidable, the only course of procedure that we can 
 adopt is one which, by inciting the uterus to premature contraction, 
 relieves the mother from the state of peril into which she has fallen, 
 and at the same time may be the means of preserving the child. 
 
 But, in addition to these, which clearly point to the operation, there 
 are many other instances which may fairly be admitted to stand in a 
 more doubtful category. When a woman, for example, is, towards the 
 end of pregnancy, affected by a serious disorder, which apparently 
 places her life in immediate jeopardy, it cannot fail to be a matter of 
 anxious consideration whether or not we are to reject the operative 
 means which we have at our command, which will generally save the 
 child, and may often save the mother. Here, as in all other cases, we 
 must place the interests of the mother before those of the child. It 
 will not be a safe rule in practice, although it may seem so in theory, 
 that we may operate to save the child, if we are persuaded that, by so 
 doing, we shall not augment the danger of the mother ; so that we 
 should, in such cases, operate only when we can convince ourselves that 
 
XXXIV.] CONDITIONS WHICH JUSTIFY THE OPERATION. 563 
 
 the procedure is also, in the main, one which affords the mother the 
 best chance of her life. 
 
 Cases of this kind, under a variety of forms, occasionally occur in 
 practice. In dropsical effusions into the great cavities, to such an ex- 
 tent as to interfere seriously- with the function of respiration, no pro- 
 found consideration is required to show that distension of the uterus is 
 an element or unit in the mechanical causes which place the woman's 
 life in peril ; and it is, at least, a reasonable assumption that, by sub- 
 tracting this unit from the sum-total of unfavorable conditions, we 
 give the mother an additional chance, while we withdraw the child 
 from the operation of causes which may materially imperil its exist- 
 ence. Certain cases of cardiac disease, or of aneurismal tumors, in 
 which the pressure of the gravid uterus seems likely to precipitate a 
 catastrophe which we may regard as ultimately inevitable, may, on 
 similar principles, be our warrant in inducing a premature expulsion 
 of the uterine contents ; but, in the course of practice, other exigencies 
 may offer themselves, in which, while the indications are less clear, we 
 may yet consider ourselves justified in bringing the pregnancy to an 
 abrupt termination. 
 
 Several years ago, we had an opportunity of seeing a case of this 
 kind in consultation with Dr. Dobbie, of Ayr. The patient was a lady 
 aged thirty, who had been for some years the subject of chronic asthma. 
 She was in the eighth month of her fourth pregnancy, laboring under 
 severe chronic bronchitis, of a cyanotic appearance, and with an ex- 
 tremely feeble and irregular pulse. All the ordinary means, applied 
 with much skill and discrimination, had failed to afford any relief, and 
 it was therefore resolved, in the apparently desperate circumstances of 
 the case, to have recourse to the induction of premature labor. Dr. 
 Dobbie kindly supplied me afterwards with the following details of the 
 issue of the case : " About eight o'clock on Friday evening I made a 
 vaginal examination, with a view to learn the exact position of things, 
 and, in doing so, I found the tissues all so lax and moist, and the 
 uterus reaching so low in the pelvis, — almost touching the perineum, — 
 that, without withdrawing my hand, I commenced dilating the os, 
 first with my forefinger, and then with the fore and middle fingers. 
 At the end of half an hour, and without any complaint of pain on the 
 patient's part, the os was fully the size of a crown, and I left it. Pains 
 had slightly commenced by this time, and they went on increasing, 
 but, throughout the labor, they were of a very moderate kind. At 
 10.45 p.m. labor was terminated by the birth of a living and healthy 
 female child. We did our best to support strength by stimulating 
 freely ; but without avail. She died at 5 A.M on Saturday." 
 
 This is a tolerably good illustration of the exceptional cases referred 
 to. The result, as regards the mother, was only what might have been 
 anticipated, had the symptoms detailed been observed unconnected 
 with the pregnant state ; and, if the case had been abandoned to the 
 operation of nature, we cannot doubt that the result would have been 
 a dead child as well as a dead mother. Furthermore, a retrospect of 
 the case does not now modify, in any degree, the opinion which we 
 entertained from the first, that the course resolved upon was — putting 
 
564 INDUCTION OF PREMATURE LABOR. [CHAP. 
 
 the child entirely out of consideration — that which gave the patient 
 the benefit of the last ray of hope which remained for her. It is im- 
 possible to detail all the conditions which may be supposed to justify 
 a similar course, but we may mention dropsy of the amnion, fibrous or 
 other tumors, albuminuria, convulsions, and mania, as among the cir- 
 cumstances which have, in the experience of able practitioners, been 
 found to call for the operation. 
 
 Hie Operation. — As usually practiced, the induction of premature 
 labor is a process in which operative aid plays an important, though a 
 quite subordinate part. The accouchement forcee of the older French 
 writers was a mode of procedure very different from this ; and, although 
 the opponents of the English scheme did not scruple so to designate it 
 in their bitter hostility, no analogy between the two can, in any sense, 
 be admitted. A^arious as are the methods which have been practiced 
 with a view to the expulsion of the foetus, these, with scarcely an ex- 
 ception, consist, in so far as operative procedure is concerned, of expe- 
 dients which are adopted with the view simply of inducing the uterus 
 to expel its contents. These provocative measures are, as we shall see, 
 very various ; but, so soon as uterine action has once been thoroughly 
 excited, the further progress of the case is usually left to nature. The 
 different modes of inducing uterine contraction, which are here referred 
 to, were divided by Stoltz into two classes. The first of these embraces 
 all methods which are supposed to act primarily upon the system, with 
 the object of producing, secondarily, the effect which we desire ; the 
 second comprehends all proceedings which may be adopted, with the 
 view of operating directly upon the ovum or uterus, and thus stimu- 
 lating, by reflex action, the latter to contract. 
 
 The operation of such means as may be referred to the first class is 
 too uncertain, and is, in fact, so little to be depended upon, that, in 
 modern times, they have been entirely abandoned, especially in cases 
 in which delay is to be avoided ; and there are, probably, no accouch- 
 eurs of the present clay who would waste time in maintaining an ex- 
 pectant attitude, in the hope that baths, bleeding, emetics, or even 
 purgatives, might possibly produce what they desire. The only agent 
 which, acting through the medium of the circulation, has still some 
 supporters, is the ergot of rye. That this drug acts, in a large number 
 of instances, upon the spinal cord, so as to influence the fibres of the 
 uterus, is a fact which no one can gainsay ; but, in cases of abortion, 
 and in all cases in which the uterus is in a state of quiescence, its action 
 is more variable, and less to be depended upon, than when it is em- 
 ployed during labor. While we reject it, therefore, as a provocative 
 agent, there seems no good reason why we may not use it in many 
 cases, — as we would in labor at the full time, — to expedite delivery, or 
 to sustain flagging uterine effort. 
 
 The other plan, — that of operating upon the ovum or uterus, so as 
 directly to excite the contraction of the latter, has entirely superseded 
 such of the more remote and indirect modes of procedure as have by 
 some been practiced. We propose to direct attention here to the more 
 important only of the numerous methods which have been devised 
 directly to effect contraction. 
 
XXXIV.J THE OPERATION. 565 
 
 1. The original mode of procedure, which received the support of 
 the London Congress above alluded to, consists in the Rupture of the 
 Membranes, by means of a quill sharpened at the point, or in any 
 other way which may be considered more safe, in order to permit of 
 the escape of the liquor amnii, and the partial collapse of the uterus. 
 This is a very certain and effectual method of inducing premature 
 labor, but it was soon found to be open to serious objections. In the 
 first place, it compromises very decidedly the chances of the child, by 
 allowing the uterine walls to come in contact with, and injuriously 
 press upon it, in its imperfectly developed condition, from the beginning 
 to the end of labor. And, secondly, it is far from being free from 
 danger, especially in cases of abortion, when, owing to the imperfect 
 dilatation of the cervix, the membranes are difficult to reach ; and many 
 cases have occurred of serious and even fatal results, from injuries 
 inflicted upon the cervical tissues in the course of those efforts, as has 
 often been the case in recorded examples of criminal abortion. On 
 these grounds, with the exception of certain cases of haemorrhage, in 
 which, for special reasons, it is preferred to other methods, its use is to 
 be condemned. 
 
 2. Separation of the Membranes by means of the finger or sound 
 introduced through the os uteri, was recommended and practiced by 
 Professor Hamilton, of Edinburgh; but it may fairly be assumed that 
 the result in such cases is due as much to the irritation and forcible 
 dilatation of the os and cervix, as to the partial separation of the mem- 
 branes, which is effected by sweeping the finger or sound round the 
 uterus, so as to cause their detachment. Still, as the integrity of the 
 membranes is in this way preserved, although, in many cases, it must 
 necessarily be imperilled, this may be looked upon as an improvement 
 upon the original process. 
 
 3. The Dilatation of the Os by tents has also been practiced with 
 considerable success, but in this case something more is attempted than 
 a mere excitement to contraction, in the forcible dilatation of the parts, 
 by which the natural process is in some degree aided. This latter in- 
 dication is, however, more thoroughly carried out in the method which 
 is now practiced by Dr. Barnes, as will afterwards be more particularly 
 explained. 
 
 4. The process which, in the opinion of most operators of the present 
 day, is to be preferred, as combining, in the highest degree, the quali- 
 ties of safety and efficiency, is the introduction within the uterus and 
 outside of the membranes, of an Elastic Catheter, which is passed with- 
 out a stylet for six or seven inches, and is allowed to remain in position. 
 The presence of this is resented by the uterus, and, sooner or later, the 
 organ is stimulated to contraction, as by any other foreign body. The 
 risk of injuring or separating the placenta, which some have urged as 
 an objection to this process, may practically be dismissed. With a 
 stylet, that might possibly occur ; but, when the catheter is introduced 
 properly, the resistance of the placental adhesion would, if encountered, 
 be sufficient to turn aside the flexible stem. 
 
 5. The introduction of Foreign Bodies into the Vagina has been 
 trusted to by some as a means of inducing premature labor. It has 
 
566 INDUCTION OF PREMATURE LABOR. [CHAP. 
 
 already been remarked, in discussing the treatment of the haemorrhage 
 of abortion, that the great objection to the use of the plug was the 
 danger, amounting almost to certainty, that the uterus would thereby 
 be excited to expel its contents. As our object in the one case is to 
 induce, what in the other we seek to avert, it may fairly be admitted 
 that distension of the vagina, by Braun's Colpeurynter, Gariel's air 
 pessary, or any other form of plug, is a safe method of provoking the 
 uterus to contract, although tardy and uncertain in its action. 
 
 6. The use of Vaginal or Uterine Injections was first suggested by 
 Continental practitioners ; and, as both of these methods have received 
 no inconsiderable amount of support in this country, it is proper that 
 we should give to them some particular consideration. The method of 
 Vaginal injection, which is known on the Continent as that of Kiwisch, 
 has, in this country, received the support of Tyler Smith, Churchill, 
 and other eminent accoucheurs. The process, as originally suggested, 
 consists in directing a continuous stream of warm water upon the os 
 uteri by means of a long tube, which is connected with a vessel placed 
 several feet above the level of the patient. Some operators, trusting 
 to the effect of the warmth of the injection, allow free egress of the 
 fluid from the vagina, while others use measures to prevent its escape, 
 with the view of effecting anatomical detachment of the membranes 
 from the uterine wall ; and Tyler Smith expresses a preference for the 
 alternate use of hot and cold water, as more certain to excite uterine 
 action. The injection is to be repeated once or twice a day, for ten 
 minutes or a quarter of an hour, when it seldom fails to bring on con- 
 traction after eight or ten applications, and sometimes after two or 
 three. Dr. Simpson substituted an ordinary Higginson's syringe, and 
 various modifications of the original apparatus have, from time to time, 
 been suggested. Simple and safe as this method may appear, later ex- 
 perience has shown that it is by no means free from risk, and cases 
 have been reported in which death had occurred ; so that, if it should 
 be employed, caution must in every case be exercised ; and we appre- 
 hend that it can only be adopted with perfect confidence, as regards the 
 safety of the patient, when nothing is done to prevent the free escape 
 of the fluid from the vagina. 
 
 The intra-uterine douche, which is generally known as Cohen's 
 method, was first recommended by Schweighauser in 1825. It was 
 originally introduced as an improvement upon Hamilton's process, as, 
 in its operation, it more thoroughly and effectually separates the mem- 
 branes from their uterine attachments. Abundant proof has been 
 afforded that this is an effective plan, but it remains for our considera- 
 tion whether or not it is to be admitted as a safe one. Dr. Barnes has 
 collected no less than ten cases in which a fatal result ensued from the 
 employment of the uterine douche, in some from shock, in others, as 
 has been assumed, from the passage of the injected fluid through the 
 Fallopian tubes into the abdominal cavity, and in others, as in a case 
 which he quotes from Ulrich, by the entrance of air into the circulation 
 through the uterine sinuses. In two cases mentioned by Simpson, the 
 cause of death was rupture of the uterus. " The occurrence/' he says, 
 " of the rupture was to be explained by the fact, that the uterus, being 
 
xxxiv.] barnes's method. 567 
 
 already fully distended, could not admit the few ounces of fluid with- 
 out being stretched and fissured to some extent ; and during labor 
 these slight fissures might easily be converted into fatal ruptures. In 
 one case, the patient died before labor was completed ; in the other, 
 in twelve hours after its termination." It has also been urged by the 
 same authority, that the placenta may be detached by injection ; and 
 that the position may possibly be altered, so as to change a cranial into 
 a transverse presentation. 
 
 While we cannot wonder that the methods above described have 
 received much support from influential quarters, we fear that such 
 results as have been reported must be taken as a sufficient warrant for 
 the absolute condemnation of the syringe as a means of inducing labor. 
 Some doubt may be admitted as to the original plan of Kiwisch ; but, 
 when this is combined with forcible distension of the vagina, by pre- 
 venting the escape of the injected fluid, which is tantamount to Cohen's 
 method, we feel that no evidence of mere efficiency, nor accumulation 
 of successful results, will warrant us in exposing a patient to such 
 danger, while, undoubtedly, safer means are at our command. Injec- 
 tions of carbonic acid gas, and of common air, within the cavity of the 
 uterus have also been practiced, but with such results as to deter any 
 one from such expedients in all time coming. 
 
 7. The most recent method of inducing premature labor, is that 
 which was suggested about ten years ago by Dr. Barnes, of dilatation 
 of the os and cervix by means of graduated fluid pressure. A similar 
 mode of procedure had previously been attempted by Dr. Keiller and 
 Mr. Jardine Murray ; but it is to Dr. Barnes that we certainly owe the 
 complete scheme of cervical dilatation, which is in the present day 
 gradually making its way into practice. The plan originally pro- 
 pounded by Dr. Barnes commenced by forcible dilatation of the os 
 uteri, and was one, therefore, to which the French opponents of the 
 general scheme would have applied their favorite term accouchement 
 forcee, with the full weight of the contemptuous epithet ; and to the 
 modified procedure which he now advocates the same term might still, 
 in a qualified sense, be applied. 
 
 His process now consists of two stages — provocative and accelerative. 
 For the first of these, and for reasons similar to those which have been 
 advanced in the preceding pages, he prefers the fourth of the methods 
 which we have described. Overnight he passes an elastic bougie six 
 or seven inches into the uterus, and coils up the remainder of the in- 
 strument in the vagina. Under favorable circumstances, some uterine 
 action will have been set up by the following morning ; and, if not, it 
 must still be left in situ for a time, until it is evident that the provoca- 
 tive action has been established. " Before rupturing the membranes," 
 he says, "adapt a binder to the abdomen, and let this be tightened, so 
 as to keep the head in close apposition to the cervix. This will often 
 prevent the cord from being washed down by the rush of liquor amnii. 
 Dilate the cervix by the medium or large bag, until it will admit three 
 or four fingers. Then rupture the membranes, and, before all the 
 liquor amnii has escaped, introduce the dilator again, and expand until 
 the uterus is open for the passage of the child. If the presentation is 
 
568 
 
 INDUCTION OF PREMATURE LABOR. 
 
 [chap. 
 
 Fig. 192. 
 
 natural, if there is room, and if there are pains, leave the rest to nature, 
 watching the progress of the labor. If these conditions are not present, 
 and one or other is very likely to be wanting — proceed with accelera- 
 tive methods — that is, to the forceps or turning ; or, in cases where the 
 passage of a live child is hopeless, to craniotomy. By pursuing this 
 method, we may predicate, with great accuracy, the term of the labor. 
 Twenty-four hours in all — counting from the insertion of the bougie — 
 should see the completion of the labor. The personal attendance of 
 the physician during two hours is generally enough. The mode of 
 proceeding must vary according to the conditions of the case." Writing 
 in 1862, he says, " It is just as feasible to make an appointment at any 
 distance from home to carry out at one sitting the induction of labor, 
 as it is to cut for the stone." 
 
 The fiddle-shaped bags referred to in the above extract are of the 
 form shown in the accompanying illustration. They are so constructed 
 as to be grasped in the middle or constricted part by the os and cervix, 
 which prevents them from slipping upw T ards 
 into the uterus, or downwards into the vagina. 
 Their introduction is effected by means of the 
 little cup-shaped pouch which is attached exter- 
 nally, into which the point of the uterine sound 
 may be adapted, and from which it may subse- 
 quently be withdrawn. Being first emptied of 
 air, and folded upon itself, the stop-cock at the 
 end of the tube being closed, it is passed in this 
 shape through the cervix. The nozzle of a 
 syringe, which has previously been filled with 
 water, is now adapted to the tube, through which 
 the fluid is cautiously injected. After moderate 
 dilatation of the bag, the stop-cock is again 
 closed, and the syringe removed, when the bag 
 will be found to be firmly fixed in its place. A 
 little practice, as w 7 e have learned by experience, 
 is necessary in the management of this instru- 
 ment, and especially of the stop-cock ; but a 
 close observation of the apparatus, and a few 
 test-experiments before its introduction, will ob- 
 viate any difficulty, and will at the same time serve to insure the effi- 
 ciency of the bag. The process of subsequent dilatation should be 
 gradual, and is effected by repeated injections, which, while increasing 
 the size of the bag, exercises a pressure or dilating force upon the cervix, 
 which is perfectly equable, and which is a pretty close imitation of the 
 manner in which nature effects dilatation by means of the sac of the 
 liquor amnii. It may be necessary to use successive bags, which pro- 
 gressively increase in size ; or, in the absence of a sufficient assortment, 
 two bags may be simultaneously introduced, and successively dilated, 
 until the requisite amount of distension is attained. The only objection 
 which occurs to us, as one which may possibly be urged against the use 
 of this contrivance, is the chance of the displacement of the presenting 
 part, by the expansion within the uterus of the fundus of the bag; but 
 
 Barnes's uterine dilators. 
 
XXXIV.] CONSTITUTIONAL INFLUENCES. 569 
 
 in so far as experience has gone, in the hands of the inventor, or of 
 those who have adopted his process, it does not appear that this objec- 
 tion has been experienced in actual practice. For our part, we have 
 repeatedly had occasion to use the apparatus, and, so far as a limited 
 experience may entitle us to form an opinion, we can, in every respect, 
 corroborate the assertions which have been made in its favor. 
 
 The methods of inducing premature labor which have been above 
 detailed do not, it need scarcely be said, embrace all that have been sug- 
 gested and practiced. At a very early period of the controversy, Gal- 
 vanism was looked upon by some as an agent from which important 
 results might be expected ; but, although this is a powerful and un- 
 doubted provocative to the uterine contraction in some cases, it is so 
 uncertain, that its use has now been abandoned — as has also been the 
 case with regard to many other expedients, from which at one time 
 brilliant results were looked for. Scanzoni has suggested an ingenious, 
 but rather fanciful method, depending upon the well-known sympathy 
 which exists between the mammae and the uterus. He has applied — 
 and in two cases, at least, with success — an apparatus of the nature of 
 an exhausting syringe, or sucking-pump, over the nipple for about two 
 hours, the irritation thus produced being propagated by sympathy to 
 the uterus. Most of the other methods suggested are either modifica- 
 tions of processes already described, or are not of sufficient importance 
 to require special consideration. 
 
 The condition of the ovum, the uterus, and the system generally, in 
 reference to this operation, are obviously points of no little importance. 
 The question of viability or non-viability of the foetus having been de- 
 termined by the period of pregnancy, the fitness, anatomically and 
 physiologically, of the maternal parts, and indirectly, that of the general 
 system of the mother, naturally attract attention. In deciding upon 
 the operation, we necessarily resolve upon a proceeding which, in a 
 manner, takes nature unawares. The condition of the cervix at various 
 periods of pregnancy, has been fully referred to in a previous chapter. 
 It is but natural, therefore, that we should anticipate difficulties, in 
 proportion to the extent to which the case is removed from the full 
 term of gestation. But, in practice, it is truly wonderful how nature 
 seems to adapt herself to the exigencies of the case ; for, not only do 
 the parts yield, to an extent upon which mere speculation would not 
 entitle us to rely, but the whole system seems to lend itself to our pur- 
 pose. The breasts enlarge and milk is secreted, after the seventh month 
 at least, and often earlier, for the sustenance of the infant, just as if 
 pregnancy had run an uninterrupted course. The dangers of parturi- 
 tion may be to some extent, but, in truth, are scarcely sensibly aug- 
 mented ; nor are certain after-effects of mature parturition — which have 
 yet to be detailed — much, if at all, more likely to accrue. 
 
 This brings to a conclusion what is generally termed Operative Mid- 
 wifery. The various modes of procedure which in this and previous 
 chapters have been described, do not, of course, include every skilful 
 tour de main which the experienced or ingenious practitioner will, under 
 special or peculiar circumstances, adopt. The object of the author has 
 
570 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 been rather to point to general principles, than to elaborate details 
 to which the increasing scientific accuracy of the art is daily giving 
 precision. 
 
 CHAPTER XXXV. 
 
 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 
 
 RIGIDITY OF THE OS: USE OF ANAESTHETICS AND OF BELLADONNA: FORCIBLE 
 DISTENSION: INCISION IF OS OCCLUDED — EFFECTS OF UTERINE DISPLACEMENT 
 — ABNORMAL CONDITIONS OF THE VULVA AND OF THE VAGINA : RIGIDITY : 
 PERSISTENT HYMEN : CICATRICES FROM SLOUGHING : TREATMENT OF THESE 
 CONDITIONS — VAGINAL THROMBUS — UTERINE POLYPUS; MANAGEMENT OF, 
 WHERE IT OBSTRUCTS LABOR — OVARIAN TUMORS — FECAL ACCUMULATION IN 
 THE RECTUM .* RECTOCELE — DISTENSION OF THE BLADDER: CYSTOCELE — STONE 
 IN THE BLADDER AN OCCASIONAL IMPEDIMENT — HERNLI — OTHER TUMORS 
 WHICH MAY IMPEDE LABOR — MALIGNANT DISEASE OF THE CANAL. 
 
 In treating of the management of natural labor, various obstructions, 
 arising from the condition of the soft parts, were necessarily alluded to. 
 The form under which obstruction of this kind most frequently presents- 
 itself is that of Rigidity, either of the os uteri or of the perineal struc- 
 tures. Generally speaking, this is an occurrence which exists quite 
 independently of any diseased condition of the parts, and is, in fact, a 
 purely functional lesion, yielding, as all experience has shown, to time ; 
 or to bloodletting, tartar emetic, chloroform, and the warm bath. 
 Such obstructions as this may exist in every conceivable degree, from 
 that which causes but a trifling delay, to the more obstinate forms 
 which only yield after long-continued, and possibly exhausting labor. 
 But, in addition to these, there are yet other cases in which the ob- 
 struction of the os is of a more serious nature, depending either upon 
 peculiarity of structure or actual disease ; and it is in cases such as 
 these, as was before mentioned, that the force of the uterine contraction 
 has been so great as, in some rare instances, to separate the os and 
 cervix, in the form of a ring, from the rest of the uterus ; or, in some 
 more common way, to produce rupture of the organ. 
 
 There are some cases in which there seems to be actual occlusion of 
 the os, such as is sometimes observed in the unimpregnated uterus. 
 Impregnation in the case of an absolutely occluded os is as impossible 
 as that the normal function of menstruation should be carried on ; and 
 therefore, we assume, in such cases, that the closure must have taken 
 place subsequently to the entrance of the seminal fluid. It is, of course, 
 possible, that the os may remain open to a very limited extent, and yet 
 the state of the tissues render distension impossible, so as practically to 
 constitute an impediment as insurmountable as actual occlusion would 
 be. In cases of anteversion of the gravid uterus, which is associated 
 
XXXV.] OCCLUSION OF THE OS. 571 
 
 with pendulous abdomen, one result of the displacement is that the os 
 uteri is tilted upwards and backwards beyond the reach of the finger, a 
 condition which might readily enough be mistaken for occlusion, unless 
 the observer should take the precaution to introduce the hand within 
 the vagina, so as to explore thoroughly that part of it which is towards 
 the hollow of the sacrum. Injuries, the result of former labors, the 
 indiscriminate use of cauterants, and some other similar causes, may 
 give rise to a species of callous rigidity, which is scarcely to be over- 
 come by any means short of actual incision ; and in the worst cases of 
 all, in which the tissues are the seat of induration from cancerous 
 disease, the barrier may be so impassable as to render necessary the 
 desperate expedient of the Caesarian Section. 
 
 In bygone times, the treatment of rigid os consisted in the free use 
 of the lancet, the administration of tartar emetic, and the employment 
 of the warm bath. That these agents have the effect, in most cases, of 
 overcoming simple rigidity is certain ; but, in the present day, anaes- 
 thetics are always preferred as being safer, simpler, and equally reliable. 
 Chloroform is usually preferred ; but recent observations would seem 
 to indicate that the effect produced by chloral hydrate is even more 
 marked. [Under certain circumstances the preparations of opium are 
 among the most useful remedies that can be administered for the relief 
 of rigidity of the os. This remedy is particularly useful in weak 
 women with irritability of the nervous system and deficient muscular 
 force. Such persons often have ineffective pains for a long time, the os 
 uteri being scarcely affected by them. A dose of morphia, or any other 
 preparation of opium, large enough to secure two or three hours' sleep, 
 will often be followed by rapid relaxation of the os. Indeed, w r e have 
 seen a rigid os, which had remained unchanged for hours, become relaxed 
 and undergo complete dilatation during a couple of hours' sleep induced 
 by a large dose of morphia. — P.] Belladonna, in the form of injection, 
 is much extolled by the French accoucheurs ; but this is an expedient 
 which is to be resorted to with caution, as faintness, headache, vertigo, 
 and the other constitutional effects of the drug, are apt unexpectedly to 
 be induced. The cases, according to Cazeaux, in which belladonna is 
 most likely to do good, are those in which there is not rigidity, but 
 spasmodic contraction of the fibres of the neck, an active and not a 
 passive force. Although the os may, in ordinary cases, with scarcely 
 an exception, be readily detected by the finger, it would appear that 
 there are instances in which, although it has been impossible to feel it, 
 its presence has been revealed to the eye by the speculum. This at 
 least is an assertion which has been made by some whose opinions must 
 always command respect; but it appears to us that the difficulty of 
 using the speculum in labor, and the impossibility of recognizing the 
 os when it is high in the hollow of the sacrum, must render this mode 
 of investigation a very unsatisfactory one. The treatment of labor 
 obstructed in this way may come to be a matter involving considerable 
 perplexity. If the os, or the situation where surrounding induration 
 marks the point at which it has become occluded, can be discovered, 
 mechanical means, such as sponge-tents, and the like, must be used for 
 its dilatation ; but when no aperture whatever can be distinguished, 
 
572 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 even when uterine action has been in operation for some time so as to 
 bear upon the inferior segment of the uterus, no course remains for us 
 but to incise the organ at its most dependent part, and thus avoid the 
 danger with which the woman is threatened. 
 
 The necessity for such an operation being once recognized, no advan- 
 tage, but the contrary, will ensue from delay. Beyond a certain degree 
 of uterine effort, all that is essential is the presence of such pains as 
 may secure the passage of the head so soon as a channel is opened up 
 for it. The effect of delay, indeed, in such a case, would be to incur 
 the danger of rupture of the uterus, and to allow the period to pass at 
 which the patient is best able to bear the continued strain entailed by 
 the ordinary phenomena of propulsive labor. In so far as the opera- 
 tion is concerned, the incision should be made from before backwards, 
 by a blunt-pointed bistoury, or by a series of incisions radiating from 
 the real or imagined site of the occluded os. Great care should, of 
 course, be taken not to wound the rectum or bladder ; and the reason 
 why the antero-posterior direction is preferred is, that the uterine 
 arteries may with certainty be avoided. The incision should be made 
 to a limited extent only, for, the breach being once effected, and uterine 
 effort being present, the head will, partly by stretching and partly by 
 tearing, open a passage for itself as it is forced onwards. A number 
 of morbid conditions of the os and cervix have occasionally been ob- 
 served to cause serious obstruction to labor. Of these the most impor- 
 tant is, of course, cancer; but there are oases in which induration and 
 hypertrophy of the whole cervix, or it may be of the anterior lip only, 
 has constituted an impediment scarcely less formidable. In some 
 instances, it would appear that the cause of obstruction may be an 
 hypertrophied and elongated condition of the cervix, as in a case 
 reported by Mr. Roper, in the Obstetrical Observations for 1866. The 
 treatment proper to such a condition would be dilatation by means of 
 sponge-tents, or by air or water bags. Abscess and thrombus of the 
 lips of the os have also been encountered as rare impediments to the 
 passage of the child. 
 
 The more important displacements of the gravid uterus have already 
 been spoken of; and, from the observations then made, the influence 
 which such malpositions may exercise upon the course of pregnancy 
 may be in a great measure inferred. The effect of displacement for- 
 wards — anteversion or anterior obliquity — of the uterus must necessa- 
 rily be to throw the os backwards; and, at the same time, the axis of 
 propulsive action deviates from that which is normal in proportion to 
 the extent of the displacement. If, along with this, there is any con- 
 traction of the pelvic brim, the result of the misdirected force may be 
 that the head does not become engaged in the cavity, and that the 
 anterior and inferior part of the uterus is exposed to injurious pressure. 
 This condition of matters — which is recognized by a combined abdomi- 
 nal and vaginal exploration — may best be remedied by raising the 
 depressed fundus, and maintaining it in that position by a bandage. 
 In this way, the axis of the uterus is brought more into coincidence 
 with that of the brim, a result which may be still further insured by a 
 supine position. 
 
XXXV.] EFFECTS OF UTERINE DISPLACEMENTS. 573 
 
 Posterior and lateral obliquities have also been noted as impediments 
 to delivery, but to these unnecessary prominence is given by most Con- 
 tinental authorities. In the former case, the os will probably be dis- 
 cerned in front, behind the symphysis; and, in lateral obliquities, the 
 os will be directed to the side opposite to that to which the fundus 
 is inclined. Although practical difficulty from these obliquities is rare, 
 it may happen that the head remains above the brim, while the shoul- 
 der which is lowest in the uterus, slipping down, becomes the present- 
 ing part. 
 
 An abnormal condition of the vulva and vagina, congenital or other- 
 wise, may sometimes cause serious obstruction to the course of labor. 
 Union of the labia and nymphge may exist to a greater or less extent ; 
 and, as the smallest possible vaginal orifice is all that is essential to 
 impregnation, an obstacle of this kind, whether congenital or the result 
 of cicatricial union and contraction, may require the aid of art. The 
 persistence of the hymen is another condition of a similar kind, which 
 has sometimes been observed to such an extent as to constitute an im- 
 passable barrier. An extreme rigidity of the external parts has been 
 noticed, chiefly in the case of women who become pregnant for the first 
 time, either at an advanced age or very young. This rigidity of the 
 perineum will generally yield to the vigorous pressure of efficient labor 
 pains ; but it sometimes happens that the resistance is obstinate, and 
 requires assistance. In' all these cases, incision should not be practiced 
 until the head has descended to the perineum, and then only to such 
 an extent as may be absolutely necessary, remembering always that a 
 trifling incision thus made will be extended as the head advances. 
 
 Our anxiety, in such circumstances, would be chiefly directed to the 
 perineum, a laceration in which may, as we have seen, prove a very 
 serious matter, by running back into the rectum. In order to avert 
 such a catastrophe, therefore, we should make the incision, not in the 
 middle line, but on either side, so as to direct the tear laterally and 
 not posteriorly ; and, even when such lacerations may have a formida- 
 ble appearance at the moment of birth, they will rapidly contract, and 
 a few days afterwards will be no longer visible. If the obstacle depends 
 — whether in the vagina or at the orifice — upon contraction which is 
 the result of disease or previous laceration, the difficulties of the case 
 may be very great. Not unfrequently the cicatrices are formed of 
 strong ligamentous bands, which prevent the distension of the vagina, 
 and may even pass across from one side of the canal to the other as 
 imperfect septa. It has been recommended, when this is recognized 
 early, that gradual dilatation should be attempted by means of tents or 
 bougies. In the minor cases, the stricture will ultimately yield before 
 the pressure which, during labor, is brought to bear upon it from 
 within ; but, in the worst cases, operative interference will be required. 
 It has been found that free incision of such vaginal cicatrices is apt to 
 be followed by serious haemorrhage. What, therefore, is a much safer 
 plan is to act in the same manner as we have recommended in incisions 
 practiced at other portions of the parturient canal. A number of su- 
 perficial incisions, or scarifications, parallel to the axis of the vagina, 
 will, when the head descends, yield, and admit of tearing, which should 
 
574 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 be effected to such an extent only as may be necessary for its passage. 
 Such tearing is, of course, free from the ordinary risks of haemorrhage ; 
 but a moderate amount of bleeding is, perhaps, rather to be desiderated 
 than otherwise, as it will tend to promote relaxation of the parts. The 
 division of bands or septa may be conducted upon the same principle; 
 and it has been recommended that we should partially divide them 
 cautiously during the pain, even allowing the knife to be forced by the 
 pain against the obstruction. If it does not speedily yield, the finger 
 may be used freely to encourage the tearing asunder of these structures, 
 using the knife as little as may be practicable. In this way the diffi- 
 culty will gradually be overcome, and the descending head will make 
 its way, or may even be assisted by the forceps. 
 
 The vagina may be very small, or contracted congenitally at some 
 part of its length, or in its whole extent, — the canal, although sufficient 
 for the purposes of impregnation or menstruation, being utterly inade- 
 quate for the function of parturition. Should such a condition as this 
 call for operative procedure, it will be necessary to give relief to the 
 constriction by cautiously combining tearing with incision, as in the cases 
 of contraction from adhesion, adopting such means as may be best 
 suited to protect the adjoining hollow viscera from injury. 
 
 Again, the soft parts may be the seat of diseased conditions, giving 
 rise to Tumors of any portion of the canal, which may prove mechanical 
 impediments to labor. GEdema of the vulva has already been men- 
 tioned as an occasional result of pregnancy, and it would appear that 
 sometimes this exists to such a degree as to constitute a mechanical 
 obstruction. Thrombus of the vagina — which is observed both during 
 gestation and after delivery — occasionally, by its unusual development, 
 bars the passage of the head, and at the same time presses injuriously 
 upon the bladder and the rectum. These tumors, depending as they 
 do upon the rupture of bloodvessels, usually make their appearance 
 suddenly — a diagnostic feature which is of considerable importance. 
 Sometimes the blood infiltrates the cellular tissue, and at other times it 
 is accumulated within cavities which it forms for itself; and, in the 
 latter case, a certain degree of modified fluctuation will probably be 
 observed, while the pain by which the original tumefaction has been 
 accompanied, and the bluish color which the tumor exhibits externally, 
 will generally suffice to indicate, with precision, the nature of the case. 
 
 The prognosis of vaginal thrombus, whether occurring during preg- 
 nancy, labor, or at a more advanced period, is very serious. " Of 
 sixty-two cases," says M. Deneux, " which have come to my knowl- 
 edge, the mother has succumbed in twenty-two ; and, with the excep- 
 tion of a single case, the children in those twenty-two cases were lost." 
 In cases which prove fatal, the loss of blood seems to be the immediate 
 cause of death; but in those instances in which the primary risk is 
 avoided, gangrene or suppuration may ultimately be the cause which 
 leads to the fatal result. We have at present nothing to do with the 
 treatment of thrombus occurring during pregnancy or after labor ; but 
 in those cases in which it constitutes an actual obstacle to delivery, 
 nothing is open to us beyond free incision, which may be made in the 
 most dependent portion of the tumor, and of such size as its dimen- 
 
XXXV.] 
 
 UTERINE POLYPUS. 
 
 575 
 
 sions may seem to render necessary. The immediate effects of gan- 
 grene and suppuration, and their probable results, will, of course, in 
 such a case excite, and with good cause, the serious apprehension of the 
 accoucheur. Among the other tumors which may be encountered 
 during labor, we may mention, in addition to those which have already 
 been detailed, phlegmonous enlargements, cysts, syphilitic vegetations, 
 and such tumors as have been figured by Martin in his Atlas, as due 
 to hypertrophy or degeneration of the nymphae and preputium clitori- 
 dis, — all of which must be managed on ordinary surgical principles. 
 
 Polypoid tumors, springing from the uterus, may sometimes con- 
 stitute very serious obstacles to delivery, as is here shown. The mere 
 existence of a tumor of this character is not, however, to be accepted 
 
 Fig. 193. 
 
 Uterine polypus as an obstacle to delivery. 
 
 as evidence of a condition which absolutely prohibits the passage of 
 the child, as much will depend upon the mobility as well as the com- 
 pressibility of the tumor. In a case published by Dr. Beatty, to 
 which Dr. Churchill refers, " the tumor was so large and apparently 
 so fixed, that Caesarian Section was anticipated ; nevertheless, at the 
 time of labor, it was elevated sufficiently to allow of the birth of the 
 child without any assistance." In some cases of polypi with a narrow 
 pedicle, the effect of continued pressure and extensive effort has been 
 to detach the growth, and expel it in advance of the child. The man- 
 agement of such cases will depend, in a great measure, upon the con- 
 ditions already mentioned. If, for example, it is movable, and the 
 head has not yet descended into the pelvis, so as to render such a result 
 impossible of attainment, we should try, as has in some instances been 
 
576 
 
 OBSTRUCTIONS TO LABOR. 
 
 [CHAP. 
 
 done with success, to push the tumor upwards during the interval 
 between the pains, and retain it in its elevated position until the head 
 takes precedence of it in its descent. Should this, however, fail, the 
 nature of the tumor being undoubted, the proper treatment will be to 
 remove it, which may be effected with the least possible risk by means 
 of the wire ecraseur. 
 
 In some cases of ovarian disease, the tumor, instead of developing 
 upwards, as is usual, in the direction of the abdominal cavity, falls 
 downwards into the pouch of Douglas, between the rectum on the one 
 hand, and the uterus and vagina on the other. Such a condition will, 
 no doubt, as a rule, give rise to abortion or premature labor ; but, as 
 the system is often slow to respond to such influences, it may happen 
 that pregnancy, under these circumstances, goes on to the full term. 
 In such a case as this, the obstacle, mechanically speaking, is much the 
 
 Fig. 194. 
 
 Ovarian tumor obstructing deliver) 
 
 same in the case of the uterine polypus just alluded to, as is shown in 
 the accompanying figure. The anatomical relations of a tumor such as 
 this are widely different from the other case, as it is to be reached, not 
 within the vulvo-uterine canal, but by perforation of the peritoneum 
 either from that side or from the rectum. Such tumors vary considera- 
 bly both in size and form, and the first point, therefore, upon which it 
 is necessary to decide is, whether or not it is of such a nature as to con- 
 stitute an impossibility, or merely a difficulty, in the passage of the 
 foetus. This will depend in a great measure upon the structure of the 
 tumor. Such growths are, as is well known, most frequently cystic in 
 their nature, and, consequently, admit of a considerable amount of flat- 
 tening, which would also be encouraged by the elasticity of their walls. 
 The benefit of this mechanical advantage may, however, be lost by the 
 
XXXV.] OVARIAN TUMORS. 577 
 
 nature of the pressure which is exercised by the advancing head ; for, 
 if the higher part be firmly pressed, as is quite possible, between the 
 head or other presenting part and the pelvic brim, so as to bring the 
 walls of the cyst into complete apposition, the lower portion may bulk 
 still more prominently during a pain, and be rendered at that moment 
 harder and more resistant. We should not, in such a case, confine our- 
 selves to vaginal exploration, but endeavor, by the introduction of one 
 or more fingers into the rectum, to ascertain the nature of the case, 
 with such precision as may be possible under the circumstances. 
 
 The treatment applicable to these cases must obviously depend upon 
 the information to be derived from such examination as may be practi- 
 cable. If the volume, seat, and nature of the tumor seem to encourage 
 the belief that the forces of nature may prevail, we should do nothing 
 further than to make sure, by securing an empty condition of the blad- 
 der and rectum, that no extraneous influence exists, which may further 
 complicate the acknowledged difficulties of the case. If, however, a 
 purely expectant treatment should not result in the progress which we 
 desire, it will be proper to attempt to push the tumor beyond the upper 
 boundary of the pelvis; but, if it should show a tendency to fall back, 
 which will generally happen during the interval between the pains, we 
 must attempt to retain it in such a position as may enable us to apply 
 the forceps or to introduce the hand for the purpose of version, in which 
 latter case the arm of the operator in the vagina will prevent the tumor 
 from again descending towards the floor of the pelvis. 
 
 In cases in which the descent of the head, or the existence of adhe- 
 sions, renders any displacement of the tumor impossible, it is even of 
 greater importance that we should recognize, what is not always an 
 easy matter, whether or not it is cystic. If so, and we leave it to na- 
 ture, the result will probably be either rupture and escape of its con- 
 tents into the cavity of the peritoneum, or a violent inflammatory action, 
 the result of pressure. The puncture of such cysts from the vagina, as 
 advised by Merriman, has been practiced with perfect success, and is 
 obviously the only method of treatment which is open to us. To ob- 
 viate the possibility of an error in diagnosis, an exploratory trocar 
 should, in the first instance, be passed into the tumor, and when its na- 
 ture is thus conclusively demonstrated, a larger trocar and canula may 
 be employed, and the contents as thoroughly as possible evacuated. 
 Complete success can, under such circumstances, only be counted upon 
 when the cyst is unilocular ; but when it is a multilocular cyst, or the 
 contents are unusually thick, it has been found necessary, in order to 
 lessen the tumor, to incise from the vagina, a mode of procedure which, 
 although dangerous, is probably less so than the doubtful results of the 
 accidents which we have indicated as likely to supervene. Some have 
 proposed puncture by the rectum ; but, as the dangers of this operation 
 are greater than the other, it ought to be rejected, unless, perhaps, 
 under very peculiar circumstances. 
 
 When the tumor is solid, the difficulties of the case are greatly in- 
 creased. In such a case, it being impossible to push it back, we have 
 to balance the chances of embryotomy or the Caesarian Section against 
 an operation which has for its object the separation and removal of the 
 
 37 
 
 L 
 
578 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 growth. Merriman recommends that, if we can convince ourselves of 
 the absence of serious adhesions, we should proceed by the method of 
 extirpation ; but, putting aside the difficulty of determining this point 
 before the operation has actually been commenced, we fear that this 
 procedure can seldom be justifiable. If the tumor be of such a size as 
 to leave an available gap of an inch and a half or two inches in the 
 pelvis, the operation of craniotomy would, we think, with the im- 
 proved appliances now at our command, afford a much better prospect 
 of success ; and, even when this hope is denied us, the Caesarian opera- 
 tion, if performed early, would give the patient a better chance than 
 removal of the tumor, and might at least have the effect of saving the 
 child. The result of all these operations has, however, been extremely 
 unfavorable. 
 
 An accumulation of hardened faeces in the rectum has occasionally 
 proved a very serious obstacle to labor. Such a condition can, of 
 course, only happen where there has been great carelessness, and ne- 
 glect of the function, so as to permit the lodgment of such a mass 
 within the rectum as may actually bar the advance of the head. The 
 treatment obviously indicated in such a case, is the relief of the bowels 
 by means of emollient enemata ; but, should these fail, owing to the 
 size or extreme induration of the mass, it may be necessary to scoop out, 
 or otherwise remove the contents of the rectum, and in one way or 
 other the tumor will usually be dissipated without difficulty. The only 
 other affections of the rectum which may be supposed to impede de- 
 livery are scirrhus, which has seldom been observed of such a size as 
 to form a serious obstacle, and rectocele, in which the lower part of the 
 gut protrudes into the vagina. 
 
 On the opposite side of the vaginal canal, the condition of the blad- 
 der may exercise an obvious influence on the progress of the case. The 
 importance, not only in obstetrical operations, but in ordinary practice, 
 of attending to that viscus, so as to protect it from the effects of dis- 
 tension, is a point, as has already been repeatedly mentioned, of the 
 highest importance, *as neglect of this not only endangers the bladder 
 itself, but also may form an obstruction to labor. Cystocele, as an im- 
 pediment, consists in the protrusion of the neck and lower part of the 
 bladder in the direction of the vagina, forming a tumor of such size as 
 to prevent the passage of the head. The idea usually entertained of 
 this seems to have been that it is due, in a great measure, if not en- 
 tirely, to neglect of the usual precautions for insuring the evacuation 
 of the bladder; but we are at one with Dr. Tyler Smith in supposing 
 that this, although a possible cause, is certainly not the usual one. 
 Prolapse of the bladder is by no means an uncommon, and is some- 
 times a very troublesome affection, in women who have borne large 
 families; and, when a woman in whom this occurs becomes pregnant, 
 we may be pretty sure that unless special care be taken at the time of 
 delivery, difficulties are extremely likely to arise. The impediment 
 will best be obviated by the opportune use of the catheter; and if the 
 cystocele already exists as an obstruction, care must be taken to pass 
 the catheter backwards into the tumor, or to raise and press upon the 
 latter so as to insure its evacuation. Caution must be exercised in the 
 
XXXV.] STONE TN THE BLADDER. 579 
 
 diagnosis of this affection, for it has happened that the fluctuating sac 
 has been mistaken for the membranes, and perforated with the view of 
 giving exit to the liquor amnii, the assumed cause of the obstruction. 
 It has also been mistaken and punctured, in a case reported by Merri- 
 man, for a hydrocephalic presentation. 
 
 An interesting illustrative case, in which the tumor was of consider- 
 able size, is narrated by Madame Lachapelle. " The first thing," she 
 writes, " that attracted attention was a pediculated tumor, about the 
 size of an egg, which, projecting a little from the vulva, seemed to be 
 attached to the anterior and right wall of the vagina, about its middle 
 part. The pedicle was about an inch and a half in thickness, and the 
 tumor contained a fluid which could be completely pressed out of it 
 through the pedicle, when we were able to feel an aperture with thick- 
 ened borders, which appeared to me to communicate with the bladder. 
 In reference to the position of the woman, it was found that the tumor 
 increased in size in the erect posture; it often disappeared after mic- 
 turition, and was always retracted under the influence of a cold bath. 
 The uterine contraction increased the volume of this hernia, and the 
 head, in its descent, pushed it in advance, and stretched it strongly. I 
 reduced it after having emptied the bladder, and I recommended the 
 pupils to support it with two fingers during each uterine contraction. 
 The head soon cleared the passage, and itself retained the hernia, and 
 the labor terminated happily." 
 
 A urinary calculus may, of course, coexist with the pregnant state, 
 but will usually produce no effect, mechanical or otherwise, upon the 
 progress of gestation. In rare instances, however, it has been found 
 that the stone has been so placed as to be imprisoned in the lower 
 segment of the bladder by the pressure of the head of the child against 
 the pubis. The advance of the head still further tends to confirm this 
 position, and, ultimately, the stone, encroaching, as it does, upon the 
 calibre of the pelvic canal, constitutes a serious impediment to delivery. 
 The diagnosis is not always easy, but if the tumor behind the pubis is 
 hard, circumscribed, and evidently situated beyond the pelvis; if it is 
 fixed during contraction, and movable during the relaxation of the 
 uterus, the symptoms are sufficiently significant to indicate the use of 
 a sound, which will at once disclose the nature of the case. The cir- 
 cumstance in which a calculus is most likely to be an obstacle to labor, 
 is when it is complicated with vaginal cystocele — an anatomical con- 
 dition of the parts obviously favoring the descent of the stone by gravity. 
 Smellie gives among his cases that of the wife of a coal porter, who, 
 having long suffered from the symptoms of stone, became pregnant. 
 She was attended during labor by a midwife, who recognized the pres- 
 ence of a hard body in advance of the head, but, her resources being 
 limited, she was content to wait and watch the progress of events. 
 Ultimately, a hard and rounded substance of considerable size was 
 extracted from the vagina, which, on examination, was found to be a 
 calculus of large size. The removal of the obstacle admitted of the 
 immediate passage of the child; but the incontinence of urine, which 
 remained, was, undoubtedly, due to vesico-vaginal fistula — an accident 
 then considered irremediable. 
 
580 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 The treatment of all such cases will consist — if the period has not 
 already passed when this may be effected — in attempting to push the 
 stone upwards into that part of the bladder which is above the brim, 
 and, if necessary, retaining it there during the intervals between the 
 pains, until the head shall descend, so as to prevent its slipping down 
 again. If the head has already made some advance in its passage 
 through the pelvis, it may still be possible to push up the stone by 
 operating during the interval between the pains, if only we can displace 
 the head a little so as to admit of its passage upwards. But, if the 
 calculus is so placed that it is impossible to dislodge it from its position, 
 the case may become a very serious one, as the only remaining resource 
 will then be the removal of the body which prevents the accomplish- 
 ment of the function of parturition. The safest mode of procedure, as 
 to its immediate results, would, under such circumstances, probably be 
 the dilatation of the urethra and the extraction of the stone. Such an 
 operation is, however, open to two objections. In the first place, it 
 can only be safely performed slowly, a condition which obviously does 
 not suit the exigencies of the case; and, again, it leaves most unsatis- 
 factory results in a long continuance of incontinence of urine. It is 
 probable, therefore, that the most judicious course would be, when the 
 obstacle seems such as to preclude the possibility of safe delivery by 
 the forceps or turning, to perform the operation of vaginal lithotomy, 
 cutting down upon the stone through the neck of the bladder, and 
 removing it in the usual way. The operation of lithotrity has also 
 been suggested ; but, in so far as we arc aware, it has never been 
 practiced. 
 
 Certain rare forms of hernia may coexist with pregnancy, and may 
 even form impediments to the termination of labor. It is, it must be 
 confessed, very unlikely that such tumors should, in any considerable 
 degree, oppose the passage of the child ; but there undoubtedly exists 
 the more indirect, but not less serious danger, which arises from com- 
 pression or strangulation of a hernial tumor, wherever situate. Such 
 hernise have been observed in the posterior part of the pelvis, the 
 bowel, or omentum, or both, having descended, in the first instance, 
 into the cul-de-sac of the peritoneum which lies between the vagina 
 and the rectum, making its way downwards in the same direction, until 
 it may ultimately protrude at the perineum, and form a perineal hernia ; 
 while, if it bulges into the vagina, it is a vaginal hernia. The protru- 
 sion may also take place from a different quarter, the bowel passing 
 along the canal of Nuck, and ultimately forming a tumor in the labium 
 of either side, which is anatomically analogous to scrotal hernia in the 
 male. The diagnosis of these tumors will seldom cause much per- 
 plexity, if the case is one of ordinary enterocele; but, if it be con- 
 stituted by the omentum alone, the absence of gurgling on reduction, 
 and of other characteristic signs, may invest the case with considerable 
 obscurity. The treatment in all cases is the same, — to practice the 
 taxis, and maintain the displaced viscus in its proper situation while 
 labor is in progress, with the object, as we have said, partly of pre- 
 venting the possibility of mechanical obstruction, but mainly with the 
 view of protecting the displaced parts from injurious pressure. 
 
XXXV.] VARIOUS TUMORS. 581 
 
 The various tumors which have been described do not, it need 
 scarcely be said, embrace all the possible varieties of abnormal growth, 
 which may be encountered as impediments to the progress of labor. 
 Fibrous, fatty, or encysted growths may spring from any portion of the 
 cellular tissue of the pelvis. The direction which these most frequently 
 take, is that of the recto-vaginal pouch ; but they have also been ob- 
 served in the sides of the canal, and even between the uterus and the 
 bladder. To distinguish such abnormal structures from those which 
 have their origin in the tissues of the various organs which are situated 
 in the pelvis will always be a matter of difficulty, sometimes of impos- 
 sibility. Everything will depend upon the mobility and compressibility 
 of such tumors, and the result, in many cases, will simply be an in- 
 creased difficulty in the passage of the child, the forces of nature ulti- 
 mately overcoming the obstacle. 
 
 But, in some cases, the volume and immobility of the tumor may be 
 such as to preclude the possibility of any such favorable result; and, 
 in that case, we may be forced to adopt such surgical means as may 
 with the least risk get rid of the difficulty. If it is a cyst, it will be 
 proper, therefore, to evacuate its contents ; and, if solid, its size, shape, 
 and the nature of its connection, by adhesion or otherwise, must serve 
 as our guides to such operative measures as, on general principles, the 
 nature of the case seems to demand. Excision of such tumors is, of 
 course, under these circumstances, an operation which is attended with 
 peculiar risk: it has been practiced by an incision through the vaginal 
 walls; and, in some other cases, with success, by a more extensive 
 incision involving the thickness of the perineum. The w T orst cases are 
 those in which the size of the tumor, its immobility, and the great 
 extent of its adhesions, render such operations impracticable ; and, in 
 these nothing will be left to us beyond the more desperate resources of 
 operative midwifery. 
 
 Frequent reference has been made to malignant tumors as obstacles 
 to delivery. The nature of this fearful class of diseases is such that 
 the impediment may have its origin in the bones, ligaments, uterus, 
 bladder, rectum, or any conceivable part or structure of the pelvic con- 
 tents. Moreover, from a tumor of trifling size, it may attain dimen- 
 sions which are only limited by the capacity of the pelvic canal; and 
 the tendency of all malignant growths to invade contiguous textures 
 frequently places the case in a category peculiar to itself, inasmuch as 
 it is impossible to isolate it either for the purpose of removal or dis- 
 lodgment. In the ordinary or scirrhous form, the stony hardness of 
 the tumor, which is absolutely incapable of distension, the infiltration 
 and infection of surrounding tissues, the binding together of the parts, 
 the presence of ulceration, and the existence of marked cachexia, will 
 generally render diagnosis a matter of no difficulty. 
 
 In the initiatory stage of the disease, the diagnosis will naturally be 
 more obscure, and in cauliflower excrescence, and the rarer fungoid 
 forms of malignant disease, the symptoms are very different from those 
 above indicated, but are still sufficiently characteristic to enable us to 
 form a definite opinion as to the nature of the case. From what has 
 been said, it will be obvious that no surgical rules can be laid down 
 
582 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 for the management of cases such as these, whether the tissue primarily 
 invaded be the labia, the uterus, or any other portion of the canal. 
 The nature of the case, and the extent of the obstruction can alone be 
 our guides. Malignant atresia has repeatedly been overcome by 
 incision of the diseased structures, with success as regards delivery of 
 the child ; but, in those cases in which the disease is extensive, it will 
 only remain for us to decide between the forceps and the other more 
 serious operations. 
 
 CHAPTEE XXXVI. 
 
 OBSTKUCTIOK DEPENDING OJS" THE STATE OF THE OVUM. 
 
 HYDROCEPHALUS : DIAGNOSIS OF : MANAGEMENT OF SUCH CASES — SPINA BIFIDA — 
 OBSTRUCTION FROM ASCITES, HYDROTHORAX, AND DISTENSION OF THE BLAD- 
 DER — GASEOUS DISTENSION FROM PUTREFACTION — TUMORS SPRINGING FROM 
 THE FCETUS — ANCHYLOSIS OF THE JOINTS, AND INTRA-UTERINE FRACTURE — 
 PREMATURE CLOSURE OF THE SUTURES — UNUSUAL DEVELOPMENT OF THE 
 FC3TUS — SPECIAL DIFFICULTIES IN PLURAL PREGNANCY: LOCKED TWINS — 
 MONSTERS WHICH IMPEDE DELIVERY: THE SIAMESE TWINS, AND OTHER SIMI- 
 LAR CASES — SHORTNESS OF THE UMBILICAL CORD AS AN OBSTACLE — DORSAL DIS- 
 PLACEMENT OF THE ARM — THICKNESS AND PERSISTENCE OF THE MEMBRANES. 
 
 It not unfrequently happens that, although the maternal parts are, 
 in every respect, normal, and the position everything that may be de- 
 sired, the relative proportions which should exist between the ovum 
 and the canal are disturbed by an abnormal condition of the former. 
 The peculiarities in structure which give rise to mechanical obstruction 
 of this nature, consist, mainly, of an increase in size, whether of the 
 whole foetus or of some of its parts, arising, in one class of cases, from 
 faults of development, and in another, from the effects of intra-uterine 
 disease. The peculiarities alluded to may affect either the foetus itself 
 or some of the other parts of the ovum : no reference is here made to 
 malposition of the foetus, a subject which has already received full 
 consideration. 
 
 The diseases of the child from which such unfortunate conditions 
 spring, are those in which some one of its parts becomes the seat of such 
 an increase in size as to constitute an impediment, more or less serious, 
 to the progress of labor. Of these the more important are hydroceph- 
 alus, fluid distension of the great cavities of the trunk, and tumors 
 of various kinds springing from its external surface. Hydrocephalus 
 is, of all such affections, not only, as might be expected, the most im- 
 portant from a mechanical point of view, but is so also in point of fre- 
 quency. One form of this affection, or rather one which has been by 
 many writers, erroneously described as such, is an effusion of fluid be- 
 neath the scalp or pericranium, and consequently, exterior to the cranial 
 

 XXXVI.] HYDROCEPHALUS. 583 
 
 cavity. Examples of this, which has been termed external hydro- 
 cephalus, are very rare, and have usually been found to be associated 
 with a general condition of infiltration affecting the whole of the ex- 
 ternal tissues of the foetus. It is a condition which usually involves 
 the life of the foetus, so that any serious impediment from a child which 
 is in all probability putrid need scarcely be anticipated. 
 
 The internal variety, or what is known as true Hydrocephalus, is a 
 much more serious as well as a more frequent occurrence, and may 
 exist to such an extent as absolutely to preclude the possibility of de- 
 livery by the unaided efforts of nature. In this case, the fluid which 
 is effused within the cranial cavity, varies greatly in quantity. In those 
 instances in which the quantity is small, the difficulties of parturition 
 may not be materially augmented, as the compressibility of the head 
 is, in consequence of the nature of its contents, relatively increased — a 
 condition which obviously tends to facilitate its passage, and compen- 
 sates for the actual increase of bulk. Owing to this, indeed, and asso- 
 ciated probably with ample pelvic diameters, very large heads have 
 been known to pass naturally. In some cases, the head, in consequence 
 of the quantity of fluid which is poured out by the morbid process, at- 
 tains enormous dimensions. When the disease is slow in its progress, 
 the flat bones become developed to a very unusual extent, but when 
 more rapid, the deposit of bone does not keep pace with the distension 
 of the head, and the latter, under such circumstances, may present itself 
 under the form rather of a bag of fluid than of an ordinary cranial pres- 
 entation. The rule certainly is that the process of ossification fails to 
 overtake that of fluid distension, and a marked characteristic, therefore, 
 of hydrocephalic heads is that the sutures and fontanelles are more 
 apart than usual. 
 
 When the size of the head is considerable, and the symptoms conse- 
 quently well marked, the recognition of hydrocephalus is generally 
 easy enough. The presenting part, which in these cases is arrested 
 above the brim, is found to be less resistant, and less convex than usual. 
 The sutures and fontanelles are, however, to be distinctly felt ; and, if 
 we can feel that the former are agape, and the latter of larger size than 
 usual, with more or less of a feeling of fluctuation, there will be little 
 room for doubt. The existence of a large posterior fontanel le is par- 
 ticularly characteristic ; and, if the hand can be fully introduced, the 
 great size of the head will be recognized. 
 
 This applies, of course, to those cases only in which the cranium pre- 
 sents at the brim. It often happens, however, in such instances, that 
 the same reasons which, under ordinary or normal circumstances, cause 
 the head to adapt itself to the smaller end of the ovoid cavity of the 
 uterus, operate by so determining the presentation, that what is here 
 the larger extremity of the foetal oval lies in the fundus of the uterus, 
 the pelvic extremity being downwards. The conditions being thus ab- 
 sent upon which alone our diagnosis can depend, no suspicion is enter- 
 tained as to the nature of the case ; and it is only when, after the head and 
 trunk have passed the brim, and the head is there arrested, that suspi- 
 cion is awakened, and the existence of hydrocephalus possibly recog- 
 nized. For, in such cases, it is by no means an easy matter to make 
 
584 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 sure of this as it is only a limited portion of the occiput which can be 
 reached with the finger j but, if we find the pelvis of average dimen- 
 sions, and arc able to recognize a large head with its hones loosely 
 articulated, and a trunk and limbs somewhat loss in size (ban usual, we 
 shall probably take these (acts as sufficient collectively to warrant a 
 confident decision. Another symptom which, when the bead presents, 
 has been insisted upon by Blot, is that while the bead is absolutely 
 arrested at the brim, the whole body of the foetus is higher relatively to 
 the abdominal walls; and, therefore, the pulsations of. the fcetal heart 
 may bo recognized as high as, or even higher (ban, the level of the 
 umbilicus. 
 
 The nature of the obstruction depends not merely upon the quantity 
 of fluid effused within the cranium, but also upon the development of 
 the flat bones, and the degree of compression of which the head is sus- 
 ceptible. These conditions may, however, with truth be regarded as 
 subsidiary t<> another, arising from the manner in which the head 
 descends and becomes engaged in the pelvis. A mere bag of water, 
 (and the head is sometimes reduced mechanically to this condition) 
 may, so long as it remains unruptured, be an impediment as insur- 
 mountable above the brim as an absolutely solid mass would be. But, 
 if the eon format ion of the parts, and ot her conditions, should permit of 
 the engagement of such a tumor, so that its lateral walls are efficiently 
 compressed by the pelvic canal, matters are so completely altered, that 
 an elongated oval, containing an equal bulk of fluid, may pass through 
 the passage, while one which is spheroidal, or, with reference to the 
 aperture of the brim, transversely ovoid, cannot even enter. It is, no 
 doubt, on this principle that those cases have occurred, of which we 
 read, where a child has been born alive, with a head measuring, in its 
 circumference, twenty-two or twenty-four inches, whereas (he normal 
 Standard is, on an average, about thirteen inches and a half. 
 
 While recognizing these facts, however, (he operator must beware of 
 trusting to such a result, unless lie finds that die pelvis is ample, and 
 the cephalic tumor is pointing downwards, thus giving indications of 
 moulding itself to the pelvic canal. There are, perhaps, few contin* 
 gencies in the practice; of midwifery in which a careful and early 
 diagnosis is of greater importance than here; for, however revolting 
 the operation of craniotomy may be to a well-regulated mind, the more 
 fearful risk of delay must be; from the first, admitted into our calcula- 
 tion. In seventy cases collected by Dr. Thomas Keith, rupture of the 
 uterus occurred in so large a proportion as sixteen ; while, in every one 
 of the five cases recorded by Dr. Robert Lee, in his Clinioal Mid' 
 wifery, the mother was lost either from rupture of the uterus, or 
 inflammation of the organ, facts which — independently of many others. 
 corroborating the conclusion — point significantly to the danger (hat, in 
 such eases, attends delay. 
 
 The indications of treatment are, from one point of view, sufficiently 
 obvious; but our action will, in no small measure, be swayed by the 
 presence or absence of symptoms indicating the vitality of the child. 
 If the child is dead, we do not require to wait for absolute certainty of 
 diagnosis. Evidence of serious obstruction is all that, in such a case, 
 
XXXVI.] HYDROCEPHALUS. 585 
 
 we would think necessary to warrant us in perforating and giving vent 
 to the fluid which is pent up within the cranium. But, when the child 
 still lives, the responsibility which attaches to the operation is greatly 
 increased, and- the error which, in such cases, is most likely to be com- 
 mitted is that the operator may wait until the mother has become 
 exhausted or the child has died ; whereas, he ought to have sooner 
 recognized the fact that the passage of a living or viable child was 
 impossible, and have acted upon the principles which we have already 
 laid down as applicable generally to cases of destructive or sacrificial 
 midwifery. The immediate effect of craniotomy, in hydrocephalus, 
 generally is to reduce the bulk of the head, by the escape of a large 
 amount of fluid, to an extent much greater than obtains when perfora- 
 tion is practiced under other circumstances. It may happen, as in some 
 recorded cases, that the operation, as well as the diagnosis, may be com- 
 plicated by the coexistence of what has been described as " external," 
 along with internal hydrocephalus, when it may be necessary to evac- 
 uate the external accumulation of fluid before piercing the cranium. 
 To such an extent does the distension sometimes occur that several 
 pints of fluid have been removed by simple perforation, when collapse 
 of the cranium takes place, so as to permit of the expulsion of the head 
 under the influence of the natural efforts. 
 
 It has happened that, after perforation, and evacuation of the serum 
 contained within the cranium, the child has been born alive; so that, 
 although the chances of a child surviving under such circumstanses 
 may be considered as extremely small, it has been urged by Cazeaux 
 and others that the operation should be so performed as, if possible, to 
 to prevent laceration of the cerebral structures, and the inevitable 
 sacrifice of the child which must thus ensue. It has been suggested, 
 therefore, that, on this account, the ordinary perforating apparatus 
 should be rejected, and a simple puncture effected, by means of a 
 trocar or guarded bistoury, sufficient to penetrate the membranes 
 through a fontanelle or suture, and nothing more. From what has 
 already been said, it will be apparent that, in the minor cases, any 
 mode of procedure which may promote lateral compression of the head 
 may, with possible advantage, be adopted in preference to craniotomy. 
 With this in view, therefore, it is usual and proper to attempt delivery, 
 in the first instance, by means of the forceps, when the compressing 
 power of that instrument may be employed to a somewhat greater 
 extent than is usual ; but, if this fails, and the circumstances of the case 
 are otherwise such as to preclude the hope of expulsion by the unaided 
 efforts of nature, the more serious operation should be practiced without 
 delay. 
 
 If the difficulty should arise in a presentation of the pelvic extrem- 
 ity, — which occurs, according to Scanzoni, in one in five of all cases of 
 hydrocephalus, — the operation is one which cannot be performed with 
 the same facility. Various modes of procedure have been suggested as 
 applicable to such instances. It has been found possible, for example, 
 to reach the cranial cavity through the mouth, by piercing the base of 
 the skull through the vault of the palate ; and, in other cases, it has 
 been successfully practiced through the orbit ; but what, in such cases, 
 
586 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 we would recommend, in preference to either of these methods, would 
 be direct perforation behind the ear, should it be possible to reach that 
 part of the cranium for the purpose. 
 
 It has sometimes happened that the tumors which are connected 
 with osseous deficiency of the cranium or vertebral column, and which 
 are known to the surgeon as Crania Bifida, or Spina Bifida, have at- 
 tained such dimensions as to prove an obstacle to delivery; in which 
 case it may be necessary to perforate the tumor and evacuate the fluid 
 which it contains. Effusions into the other great serous cavities of the 
 body, although less frequent in their occurrence than hydrocephalus, 
 render delivery equally impossible. In Ascites, the development of 
 the abdomen is sometimes enormous, and is revealed by the fluctuation 
 as well as by the size. The only affection of a similar kind with which 
 we might possibly confound it, is distension of the bladder, which, 
 when the urethra is impermeable, may give rise to a tumor of great 
 size, which may require tapping equally with the peritoneal effusion. 
 The description of such a case was communicated by M. Depaul to the 
 Aeademie de Medecine ; and this, it may here be observed, is, along 
 with other similar cases, one of the most important points of evidence 
 upon which physiologists rely in supposing that the urine of the foetus 
 is naturally evacuated into the amnionic cavity. 
 
 When the peritoneum of the child is distended with fluid, so as to 
 prevent its passage, that cavity must be pierced by a trocar, and the 
 fluid which it contains drained away by the canula. Hydrothorax is 
 still less frequent in its occurrence. It is indicated by an enlargement 
 of the thoracic region and intercostal bulging, and may require punc- 
 tures to be practiced between the ribs, with precisely the same object 
 as in the other case. In all these cases, the operation of perforation 
 should be so performed as to avoid injuring the internal organs ; for 
 not only would this entail unnecessary mutilation, but might defeat our 
 object, by preventing the escape of the fluid. The development within 
 the body, as a result of putrefaction, of enormous quantities of gas, is a 
 fact familiar to the medical jurist, and one which may take place within 
 the womb as well as under other circumstances. In some rare in- 
 stances, it has occurred that, in consequence of this, severe laceration 
 has been inflicted, with a fatal result ; and, in other cases, labor has 
 been terminated in consequence of a rupture giving issue to the pent- 
 up gas. No hesitation should, in such a case, deter the operator, as 
 the evidence of the child's death will be otherwise complete, and he is 
 bound to act so as to protect the mother from risk. 
 
 Tumors of various kinds may spring from the surface of the foetus, 
 or be developed in connection with some of the internal organs, and 
 may, by attaining unusual size, render labor impossible of natural 
 termination. Tumors have, for example, been observed, which had 
 their origin in the liver or the kidneys, enlarging the trunk to an 
 enormous extent, so as absolutely to prevent its passage, and render 
 indispensable the operation of embryulcia, in the course of which it 
 has been found necessary to break up the tumor, and remove it piece- 
 meal before we can complete the delivery. Another rare condition of 
 the foetus, which may be a very serious obstacle, is anchylosis of the 
 
XXXVI.] PLURAL PREGNANCY. 587 
 
 articulations, and the same may be said of those cases in which there has 
 been intra-uterine fracture as the result of violence, the limbs having 
 united at an angle. It is difficult to say what, under such circumstances, 
 should be done, if the condition has been recognized before birth ; but, 
 in so far as anchylosis is concerned, we may assume that the joints will 
 probably be united while the limbs are flexed upon the body in the usual 
 attitude of the foetus, and that the conditions are therefore not altogether 
 unfavorable to the natural termination of labor. A more serious impedi- 
 ment has been in some instances found to arise from premature closure 
 of the sutures and fontanelles. This, in a perfectly normal condition 
 of the parts otherwise, may give rise to great delay, if not impaction, 
 by its being impossible for the head to adapt itself in any way to the 
 shape of the passage; and, as Dr. Tyler Smith has observed, the dan- 
 gers of such a condition are not limited to the mechanical hindrance to 
 delivery, but may be looked upon as an extremely probable, if not 
 certain cause of idiocy, by preventing the development of the brain. 
 
 The child sometimes, even when not retained within the uterus 
 beyond the ordinary period of gestation, attains a size so greatly in 
 excess of the ordinary standard, as to cause a very difficult or danger- 
 ous labor. If we take, as has already been stated in round numbers, 
 the average weight of the fully developed foetus as seven pounds and a 
 quarter, we are not astonished when we find in practice, that when it 
 approaches twelve pounds the labor is, unless the maternal parts are 
 of unusual capacity, a slow and painful one. But, when it reaches 
 fourteen, fifteen, or nearly eighteen pounds (as in one well-known and 
 authentic case already cited) it is difficult to conceive how by any pos- 
 sibility such a child could pass. If, however, we look closely at chil- 
 dren which are much above the average, it will be observed that the 
 increase in weight is to a great extent due to the development of fat 
 beneath the skin, so that it is the trunk and limbs, rather than the 
 cranium, which are increased in size, and it is on this account that we 
 find the powers of nature sufficient for the expulsion of the child. If 
 the increase of bulk has been the result of a protracted sojourn of the 
 foetus in the womb, the case will probably be more serious in its nature ; 
 and, certainly, in all such, we may be sure that the maternal as well 
 as the foetal mortality will be increased relatively to the size of the 
 child. Statistics, indeed, tell us that this is the case, even as regards 
 the comparatively trifling difference which exists between the male and 
 female cranium. It is, however, very rare that, in the absence of pelvic 
 deformity, cases of unusual foetal development may not be delivered 
 by the forceps or turning, which we may term the minor operations of 
 midwifery. 
 
 The occurrence of Plural Pregnancy may in various ways give rise 
 to difficulty, and even to serious obstruction. In the case of multiple 
 pregnancy, the products of conception may be disposed in almost any 
 manner compatible with the limits and mechanical conditions of the 
 uterus ; but it does not appear that any great difficulty has been met 
 with, in these instances, unless one or more of the children has been 
 in a faulty position. The same remark applies to twin pregnancy. In 
 the latter, the two children are most frequently observed to occupy 
 
588 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 each a side of the womb, with the cephalic extremities downwards, and 
 one head somewhat in advance of the other. In a very considerable 
 number, the head of one child and the breech of the other present; 
 while, in rarer instances, the feet of both may be downwards, or one 
 or both may lie transversely in the womb. 
 
 In plural pregnancy the uterus, no doubt, acts at a certain mechanical 
 disadvantage, inasmuch as its propulsive force is communicated to the 
 foetus which is lowest in the uterus — not directly, as in single preg- 
 nancy, but indirectly through the bodies of the others. But, as has 
 been well observed, this disadvantage is usually compensated for by 
 the comparatively smaller size of the children. The cases where delay 
 is most likely to occur are those in which the breech of the first child 
 is the presenting part ; and, as this descends, the difficulties, as in 
 ordinary cases, will be greatly increased by any unusual resistance at 
 the outlet. And then, after the passage of the breech, the descent and 
 birth of the head — a matter of difficulty, as we have seen, even in pres- 
 entations of the breech in single pregnancy — is here so much more so 
 that, unless the accoucheur was at hand to afford the assistance of his 
 art, that child, at least, would be almost certainly sacrificed. 
 
 As has already been observed in an early chapter, when the subject 
 of plural pregnancy was under discussion, there is very often a period 
 of considerable delay after the birth of the first child. This is probably 
 due, in many instances at least, to uterine exhaustion ; and the pause 
 which then ensues is a perfectly natural condition, which we should 
 rather encourage, as it enables nature to recruit her exhausted forces, 
 and thus bring them into renewed activity when the period arises for 
 the expulsion of the remaining contents of the uterus. The recommen- 
 dations, therefore, which are given by some authorities as to the cir- 
 cumstances which warrant, in such cases, operative interference, should 
 be received with great caution, and only acted upon when the condi- 
 tions are such as to indicate beyond the possibility of doubt that it is 
 proper to aid or precipitate labor in any way. 
 
 But the most serious mechanical difficulty which may arise in the 
 course of labor in plural pregnancy, is what has been described in the 
 case of twin pregnancy as "locked twins." When the membranes are, 
 as has previously been shown (see Figs. 91 and 92). so arranged that 
 each child lies in its own complete sac, the expulsive forces act, even 
 under such mechanical disadvantages, so as to expel one child first, and 
 to leave the other still enveloped in its own amnion. The first birth 
 thus takes place without any particular difficulty. But, if they are 
 inclosed in one amnionic cavity, the parts of the two may fall into such 
 a position as to make delivery a matter of the greatest possible diffi- 
 culty. The most common form of locking is when the first child pre- 
 sents by the breech, and passes downwards up to a certain point without 
 impediment ; but when serious obstruction occurs, and we are thus led 
 to make a more particular examination, it is discovered that the descent 
 of the head is obstructed by the presence in the pelvic cavity of the 
 head of the second child, which has caused the chins to be so hitched 
 together that the completion of the first birth is rendered a matter of 
 impossibility, unless the twins are small or the pelvis large. If, under 
 
XXXVI.] LOCKED TWINS. 589 
 
 such circumstances, we pull upon the body of the partially born child, 
 we only make matters worse by locking them more firmly together. 
 In some cases, when the condition of the parts is such as to admit of 
 it, it may be possible, by pressing back the heads in the direction of 
 the uterus, to unlock them, and thus to permit of their descent singly. 
 But, if this endeavor should fail, it will become evident that the only 
 way to disengage them is to break up the compound wedge and so 
 admit of the passage of one or other of the children. 
 
 This may be effected in two ways, as has been well demonstrated by 
 Dr. Barnes; either by decapitating the first child, which we have the 
 least chance of saving owing to the pressure which is being exercised 
 on its umbilical cord, or by perforating the head of the second child, 
 so as to admit of the passage of the first. In the first case, the body 
 which occupies the vagina will at once pass, and its head receding will 
 admit of delivery of the second child by the forceps; and in the second, 
 which is only justifiable when we have reason to believe that the other 
 child is dead, we allow the perforated head to be flattened to such an 
 extent as to admit of the passage of the head of the first, through the 
 diameters which the operation has succeeded in reducing. This latter 
 plan has the obvious advantage over the former that the difficulty of 
 extracting the severed head is thereby avoided. 
 
 There is another form of locking, in which both of the twins present — 
 as is most frequently the case — by the head. The first head passes in 
 this case without difficulty into the pelvis, but the head of the second, 
 descending along with the trunk of the first, prevents further progress 
 by presenting the bulk of a head and a thorax simultaneously at the 
 brim. The mechanical management of such a case as this may be a 
 matter of even greater difficulty than the former. Perforation of the 
 head which is within reach can obviously do no good, so that it is only 
 by guiding the perforator upwards to the second head, and reducing 
 its bulk in the usual way, that the operation may be, with any hope of 
 success, adopted. In such cases, as has been shown by the experience 
 of Dr. Graham Weir and others, it may be possible by dexterous 
 manipulation to obviate the serious difficulties which exist. It has 
 been found practicable in this way to extract by the forceps the child 
 which originally presented while the head of the other was pushed 
 aside by an assistant. External manipulation has also succeeded in 
 skilful hands in forcing onwards the head which was situated highest 
 in the pelvis, and thus causing it to take precedence of that which 
 originally presented. All cases of locked twins are, however, serious 
 complications, and are therefore with justice looked upon as among 
 those dangers against which the operator should be prepared. 
 
 The first or second child may present in a preternatural manner, — 
 by the shoulder, for example, as has before been explained — and in 
 such a case, we have to beware of the mistake, which has been com- 
 mitted, of seizing the wrong foot or feet when the hand is introduced 
 for the purpose of turning ; or it may happen, as in a case narrated by 
 Madame Lachapelle, that when turning has been successfully effected, 
 and the breech extracted, locking by the chins is the perplexing result. 
 It is to be borne in mind that, in plural pregnancy, there is a greater 
 
590 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 risk of haemorrhage, owing to the extent of surface to which the pla- 
 centa is attached. And, in cases in which there is an inosculation of 
 the cords, there is, at an earlier stage, another special risk, if we leave 
 the placental portion of the severed cord untied. 
 
 Various forms of Monstrosity give rise to difficulty in the course of 
 labor, and in extreme cases it is only possible to complete delivery by 
 embryotomy or the Csesarian Section. We have here, of course, 
 nothing to do with such departments of teratology as are illustrated by 
 acephalic or anencephalic monsters; and still less with those which are 
 anopic or cyclopic, as such conditions present no mechanical obstacle 
 whatever. The many different forms of ectopy present, as a rule, little 
 or no difficulty; but in the more complete form, as in a case figured by 
 Vrolik, the whole of the thoracic and abdominal viscera are external to 
 the child, and may impede its passage. It has been observed, in another 
 form of monstrosity, that the liver projecting through the unclosed um- 
 bilicus (Exomphalos) has, by its augmented size, caused a serious impedi- 
 ment, which might well be expected to bar the progress of ordinary labor. 
 
 The forms of monstrosity which are, from the point of view of me- 
 chanical obstruction, the most serious, are those in which the two chil- 
 dren in a twin pregnancy become fused together to a greater or less 
 extent, the union or fusion being anatomically symmetrical. Infinite 
 as the varieties of such cases are, this rule is never violated, and is 
 indeed the only possible method of which the laws which regulate 
 development can admit. Thus, we have union of sacrum to sacrum, 
 occiput to occiput, or abdomen to abdomen ; but never sacrum to 
 occiput, or abdomen to sacrum. There may be one perfect trunk with 
 two heads, as shown in the annexed cut, which closely resembles a 
 case of this kind, which we had an opportunity of seeing with Dr. 
 George Mather ; but the union may be even higher than the cervical 
 vertebra?, when we have more or less fusion of the crania. In such 
 a case as the one here represented, in which the size of the various 
 parts was rather more than is usual at the full time, a mere glance will 
 suffice to show, not only that labor must necessarily be impeded, but 
 that it is scarcely possible, in a normal condition of the parts as regards 
 size, that a natural termination should take place. 
 
 In a case which has been described by Meigs, one head descended 
 first and was delivered. It then became fixed under the subpubic 
 angle, and the ultimate process of delivery was precisely similar to what 
 takes place in the spontaneous expulsion of a transverse presentation, 
 the trunk, breech, lower limbs, and, lastly, the second head, passing 
 through the external parts. In the case to which reference was made 
 above, delivery was accomplished with the greatest possible difficulty. 
 It was a primiparous case, and the breech was the presenting part, 
 everything going on well until the heads entered the pelvis, when com- 
 plete arrest took place. The crotchet failed completely, and as Dr. 
 Mather thought that the head was too high to use the perforator with 
 safety, he attempted, by means of steady traction, to bring it more 
 w T ithin reach, when, to his astonishment, two heads descended, situated 
 obliquely with reference to each other, in the pelvis, so that the one 
 was a little in advance of the other. In this way, and after long- 
 
XXXVI.] 
 
 MONSTROSITY. 
 
 591 
 
 protracted efforts, the heads, which were quite the average size, passed. 
 The pelvis was, as might have been expected, a capacious one; but even 
 this does not make the case less interesting. The mode of delivery 
 described by Meigs is generally supposed to be the only possible way 
 in which such a child can be born without perforation or decapitation ; 
 but the case above given, which is extremely rare, if not unique, shows 
 that if the other be the rule, it has at least, like many other rules, 
 exceptions. 
 
 In that class of cases in which there is one head and a double condi- 
 tion of the lower parts of the body (Janiceps), the difficulty is not likely 
 to be so great, as it is much more conceivable that two pelves could be 
 sufficiently pressed together during their descent as to admit of their 
 
 Fig. 195. 
 
 Fig. 196. 
 
 Double-headed monster. 
 
 Double monster. 
 
 simultaneous passage through the pelvis of the mother. The monster 
 here shown, from one which was described by Dr. J. G. Walter, has 
 three legs and four arms. Complete fusion of the pelves was found on 
 examination after death to have occurred, and there was also union of 
 the ensiform cartilages. On first sight it may appear that delivery, in 
 such a case, would be even more difficult than of the ordinary two- 
 headed monster; but a little consideration will show that the possibility 
 of one head at a time passing along the pelvis, gets rid of the greatest 
 difficulty which attaches to this variety. The probability of a trans- 
 verse presentation in such a case is, however, very strong ; and this, of 
 course, would be a most unfortunate circumstance, as turning and 
 bringing down the feet would inevitably bring the heads together, and 
 thus make matters worse than ever. 
 
592 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 It has occasionally happened that twins, more or less completely 
 united or fused together, have been born alive, and have even attained 
 maturity. In the most familiar instance of this kind — that of the well- 
 known Siamese twins — there was a mere band of union; but it is indeed 
 difficult, in regard to this and other similar cases, to conceive even the 
 possibility of birth, unless after mutilation or putrefaction ; in fact, we 
 can only suppose, in reference to such, that the maternal pelvis has 
 been of unusual capacity, that labor has occurred prematurely, or that 
 both of these conditions have been combined. Another comparatively 
 rare form of monstrosity has been mentioned under "Twin Pregnancy" 
 as monstrosity by inclusion; and, in this case, the tumor of the perineum, 
 which contains the foetus in fostu, may be a serious obstacle. It will 
 readily be understood — and the more so as they are of extremely rare 
 occurrence — that such cases may cause great perplexity to the accoucheur, 
 and, whether the diagnosis is accurately formed or not, cannot fail to 
 be a very serious barrier to delivery. So various, however, are the 
 forms under which monstrosities present themselves, that it is impos- 
 sible to lay down any general rules which might serve for the guidance 
 of the practitioner. In a considerable number of cases, it has been 
 found necessary to decapitate, eviscerate, and otherwise mutilate one or 
 both of the united twins or repeated parts before it has been possible to 
 relieve the woman of the contents of her womb. Care must, it need 
 scarcely be added, betaken, not only to insure correctness of diagnosis, 
 but also not to operate rashly, for there can be no doubt that we are 
 morally bound to consider the life of monsters as scrupulously as that 
 of the fetus in normal pregnancy. 
 
 Shortness of the umbilical cord is generally mentioned in systematic 
 works as a possible mechanical hindrance to delivery. It is certain, how- 
 ever, that such an occurrence is extremely rare. We do not mean to 
 assert that the cord is not occasionally short, but merely that this effect 
 of shortness is not one which is likely often to take place. Cases do 
 occasionally occur, in which the actual length of the funis does not ex- 
 ceed two or three inches, a condition which, if the placenta is normally 
 situated, must imply delay in delivery, rupture of the cord, premature 
 separation of the placenta, or inversion of the uterus. Some have 
 denied that any impediment whatever is in this way likely to arise; 
 but the evidence which has been advanced in favor of the contrary view 
 seems pretty clearly to show that in cases of protracted labor, which 
 have only terminated after rupture of the cord, the probable cause of 
 the delay must have been the extreme shortness of the link which 
 bound the foetus to its utero-placental attachment. 
 
 What is certainly of more frequent occurrence than actual shortness 
 of the cord is — what has mechanically precisely the same effect — coil- 
 ing of the cord round the child. In such cases, there is usually not 
 only no shortening of the cord, but an undue-length of it, which is the 
 original cause of the coiling which takes place round the neck more fre- 
 quently than round any other part of the foetus. This artificial short- 
 ening is, we believe, of more frequent occurrence than is usually sup- 
 posed ; and every practitioner knows that few things are more common 
 in practice than to find one, two, or more coils of the funis round the 
 
XXXVI.] DORSAL DISPLACEMENT OF ARM. 593 
 
 neck of the child. The exact stage of delivery at which arrestment 
 from this cause is most likely to occur, depends upon the length, or the 
 length exclusive of coils, of the cord ; but, as a rule, it would appear 
 that it is seldom that much inconvenience is complained of until the 
 stage of expulsion approaches, when, for the first time, the cord is put 
 upon the stretch, and pain is, probably, to some extent complained of 
 in the region of the uterus. It has been stated, as a symptom during 
 labor of shortness of the cord, that if the placenta is attached at its 
 usual site, a depression of the fundus occurs at every pain, the rounded 
 form being restored in the interval. That such an occurrence may take 
 place, it would be impossible to deny ; but it seems to us pretty clear 
 that this is one of the instances, of which illustrations are too frequent 
 in medical literature, wdiere what we may call a theoretical symptom 
 is set down as a real or practical one. 
 
 It has frequently been observed, when the cord was coiled round the 
 neck of the child, that progress was for the first time arrested during 
 or after the birth of the head. This has probably to some extent, led 
 to the routine practice of disengaging the coils as soon as their presence 
 is detected — although the main cause undoubtedly is a dread of suffo- 
 cation of the child by pressure on the respiratory passages. It has in 
 some instances been found necessary, when the cause of the obstruction 
 was evident, to cut the cord, a course of procedure which must recom- 
 mend itself to the operator when the nature of the case is obvious. 
 Caution should of course be exercised to prevent haemorrhage from the 
 cut vessels, by placing a ligature speedily on the umbilical side of the 
 section ; but it has been pointed out that a slight discharge is rather 
 favorable in its effect than otherwise when asphyxia is threatened, a 
 condition which may very probably be found to exist, along with the 
 semi-apoplectic condition depending upon interruption to the circula- 
 tion in the great vessels of the neck. In breech presentation, or after 
 the performance of podalic version, the cord sometimes is found sur- 
 rounding the trunk or entangled among the limbs, wdience it will be 
 proper to disengage it if possible, and, if this cannot be effected, to cut 
 it, rather than run the risk of obstruction in what, for the child at least, 
 is always a critical labor. After such cases, it is proper to introduce 
 the hand into the vagina to ascertain that there is no inversion of the 
 uterus, unless the. state of the organ as observed through the abdomi- 
 nal walls, is in all respects satisfactory. 
 
 A rare and curious cause of obstructed labor has been shown by Sir 
 James Simpson to arise from dorsal displacement of the arm. This 
 may occur either in pelvic or cephalic presentations. In the former 
 case, which is more frequent, it is probably due, as Barnes shows, to 
 an improper and imprudent dragging upon the limbs, the tendency of 
 which is, as has formerly been shown, to allow the arm to pass up 
 alongside of the head. If one or other arm should, in this process, get 
 behind the head — as is still more likely to occur in unskilful turning — 
 it is not difficult to understand how the arm may get behind the neck 
 and beneath the occiput, and thus constitute an impediment of a very 
 serious character, the limb being so placed that its reposition is a matter 
 of no inconsiderable difficulty. The arm will, in such cases, generally 
 
 38 
 
594 OBSTRUCTIONS TO LABOR. [CHAP. 
 
 lie against the symphysis pubis, and it will therefore only be practi- 
 cable to dislodge it, if we can succeed in pushing the parts upwards, so as 
 to leave sufficient room, between the occiput and the upper part of the 
 symphysis, to admit of such manipulation as may effect our object. In 
 Simpson's case, the presentation was one of the head, in which the arm 
 had in some peculiar way which it is difficult to understand got on to 
 the nape of the neck, and was thrown transversely across the pelvis. 
 The course suggested by him for the management of such cases is to 
 bring the arm clown by the side of the head, as its complete reposition 
 above the brim would probably be impossible, and allow labor to go on 
 in this way, the presentation now being an ordinary head and arm case ; 
 but we are impressed with the idea that the mode of procedure adopted 
 by Dr. Jardine Murray in similar circumstances, which simply con- 
 sisted in turning, meets much more fully the difficulties of the case. 
 
 There is but one other condition arising from the state of the ovum 
 to which we think it necessary here to refer. This is unusual thick- 
 ness and resistance of the membranes, which, sometimes, while things 
 are otherwise going on favorably under efficient uterine contraction, 
 absolutely stops the progress of the labor. It is needless to recapitu- 
 late what has already been said as to the management of the mem- 
 branes ; the only important point being that, before we decide on rup- 
 turing them, which will at once bring the difficulty to an end, we 
 should be sure that the proper function of the membranes has been 
 effected in producing dilatation of the os. No danger will accrue to 
 the child, so long as the presence of the liquor amnii protects it from 
 injurious pressure. 
 
 CHAPTEK XXXVII. 
 
 UTERINE INERTIA AND PRECIPITATE LABOR. 
 
 IRREGULARITIES IN THE PROGRESS OF LABOR: OFTEN DUE TO INTESTINAL DE- 
 RANGEMENT — INERTIA : INFLUENCE OF TEMPERAMENT, CLIMATE, AGE, EMO- 
 TION, EXCESSIVE DISTENSION, PREMATURE RUPTURE OF THE MEMBRANES, ETC. 
 — INFLUENCE OF IRREGULAR UTERINE ACTION : UTERINE TETANUS — WIGAND'S 
 CLASSIFICATION: DIFFERENT GRADES AND VARIETIES OF INERTIA — TREAT- 
 MENT OF INERTIA: IF FROM OVER-DISTENSION OR DISPLACEMENT OF THE 
 UTERUS : IF FROM INTESTINAL DERANGEMENT — VARIOUS MODES OF EXCITING 
 REFLEX UTERINE ENERGY — STIMULANTS AS A RULE TO BE AVOIDED — USE OF 
 THE FORCEPS IN INERTIA — ERGOT: ITS NATURAL HISTORY, AND PHYSIOLOGI- 
 CAL EFFECTS : RULES FOR ITS USE IN MIDWIFERY — OTHER OXYTOXIC AGENTS — 
 PRECIPITATE LABOR: CAUSES OBSCURE: APPARENT CONNECTION WITH MEN- 
 STRUAL EXCITEMENT — LABOR MAY BE PRECIPITATE FROM DEFICIENT RESIST- 
 ANCE — DANGER OF RUPTURE AND LACERATION OF THE UTERUS — TENDENCY 
 TO POST-PARTUM HEMORRHAGE — TREATMENT: EMPTY BOWELS: OPIUM: 
 SOURCES OF REFLEX IRRITATION TO BE CAREFULLY AVOIDED. 
 
 In no two cases of labor is the course of the process precisely similar, 
 although the vast majority are from first to last perfectly normal. 
 
XXXVII.] UTERINE INERTIA. 595 
 
 Nothing is more familiar to the accoucheur than the sudden and un- 
 locked for changes which occur in the course of an ordinary case. In 
 one instance, the tardy and inefficient progress which has characterized 
 it during many tedious hours gives place, without any very obvious 
 reasons, to efficient and even violent action, which brings the act to a 
 precipitate termination ; while, in another, the safe and steady progress 
 which has led us confidently to anticipate a speedy issue of the case, is 
 provokingly interrupted by a failure of expulsive power — and that, too, 
 not unfrequently, when the second stage of labor is nearly at an end. 
 Such occurrences as these are generally of no great importance, and 
 resolve themselves most frequently into a trial of patience, or a mo- 
 ment of hurry and excitement ; but cases do now and again occur, in 
 which a failure of action, or violence of propulsive force, demands 
 prompt and energetic treatment. 
 
 It* has very frequently been observed that, in these matters, much 
 depends upon the temperament and constitution of the mother ; so 
 that, in members of the same family, in persons of similar temperament 
 or constitutional power, and to some extent in those of similar social 
 position, there will often be observed a certain resemblance in the char- 
 acter and progress of the labor. In some cases, in which the balance 
 between pow T er and resistance is in any way disturbed, it would almost 
 appear as if nature availed herself of some special compensating condi- 
 tion which the exigencies of the case had called into play. The woman, 
 for example, whose health has been impaired by chronic disease,, or in 
 whom the constitutional vigor and tone are naturally feeble, has as a 
 rule comparatively weak uterine action, and alw T ays deficient voluntary 
 force ; but yet the labor runs a normal course, for the want of tone in 
 nerve and fibre favors relaxation of the parts, and thus, proportionately 
 and in a compensatory manner, diminishes the resistance. In women, 
 moreover, of this temperament, the anatomical peculiarities of the sex 
 are generally well marked, and the ample and shallow pelvis thus 
 offers a comparatively trifling resistance to the passage of the child. 
 If, however, we contrast with this, the tall, vigorous and muscular 
 woman, we find that in the latter there is a very general tendency to 
 the male type of pelvis, involving a tardy passage of the child through 
 the pelvic canal. May we not infer that it is in some degree in com- 
 pensation for this that she is furnished with muscles so powerful, and 
 constitutional vigor so marked, to enable her to overcome the greater 
 resistance which in a feebler frame would constitute an insurmountable 
 barrier. 
 
 There are many morbid conditions which exercise an influence more 
 or less marked on the progress of parturition, to which we have had 
 occasion more particularly to refer. We may here mention one cause, 
 in regard to which no doubt can possibly be entertained, as leading 
 both to tardy and precipitate action on the part of the expelling powers. 
 This is the condition of the intestinal canal, any irritation of which 
 may not only excite powerful reflex contraction, but may cause irregu- 
 lar uterine action, and in other cases may arrest it altogether ; this being 
 one of many reasons wdiy tardy and precipitate labors are ahvays con- 
 sidered together. An attentive observation, from a physiological point 
 
596 UTERINE INERTIA. [CHAP. 
 
 of view, of the phenomena which accompany parturition, and more 
 particularly of the nervi-motor action of the uterus, will suffice clearly 
 to show that there are many different ways whereby the forces upon 
 which the act of birth depends may be disturbed or thrown out of gear, 
 with the result, in one class of cases, of a labor which is too rapid to 
 be safe, and, in another, of an arrest in the process which may prove a 
 source of danger to the mother as well as to the child. It is, indeed, 
 upon a correct appreciation of the physiological phenomena referred to 
 that a sound and judicious treatment can alone be based. 
 
 Inert Labor. — It will be inferred from what has just been said that, 
 in some constitutions, there is a natural tendency to tedious labor by 
 reason of a deficiency in the expelling power. Within certain reason- 
 able limits, this calls for no treatment, and is attended with no risk • 
 but when these limits are exceeded, the case is to be considered as 
 abnormal. Besides general debility, from whatever cause arising, there 
 are other conditions which have been observed to increase the liability 
 to inefficient uterine and expulsive action. Thus, climate and season 
 exercise an influence which, although far from uniform, is sometimes 
 obvious, the relaxing effect of a high temperature, in those instances, 
 enfeebling the nervous and muscular tone ; and it has even been stated 
 that the result of long residence in the tropics has a permanently ener- 
 vating effect, which may be manifested subsequently in temperate lati- 
 tudes. Another cause is sometimes found to exist in the age of the 
 woman, and in cases of precocious pregnancy this is occasionally very 
 distinct. In women, again, who become pregnant for the first time in 
 advanced life, it is well known that labor, as a rule, is tardy ; and, 
 although the idea usually entertained is that this is due mainly to in- 
 creased anatomical resistance, there can be no doubt that, in a certain 
 proportion of cases, it depends upon deficient force. 
 
 In those who have borne many children in rapid succession, the 
 action of the uterus is often found to become enfeebled towards the 
 close of the childbearing epoch, probably because the organ has not 
 had sufficient time for rest, and for the gradual development of those 
 structural changes which succeed delivery, during and after the period 
 of involution. The influence of emotional causes, although marked, is 
 generally temporary ; as is often seen on the arrival of the accoucheur, 
 when it arises from fear. Any sudden alarm, startling intelligence, or 
 anything which may give rise to sudden emotion, may produce precisely 
 the same effect; and, although, as a rule, the uterus in such cases will, 
 after an uncertain interval, resume its function, it occasionally happens 
 that the pause is so long, or occurs at such a critical period in the labor, 
 that it is necessary to have recourse to art to expedite or complete the 
 delivery. The various displacements of the uterus, which act by alter- 
 ing the axis of expulsion, are often considered under this head; but 
 that which is a purely mechanical cause of delay, has already been 
 referred to in a previous chapter. What is here implied by inert labor, 
 has reference, almost exclusively, to a faulty condition of the expulsive 
 forces, in which they are abnormally feeble and inefficient; and this 
 feebleness of contraction may either exist throughout the whole period 
 of labor, or may come on, more or less abruptly, in the course of a case 
 

 XXXVII.] CAUSES. 597 
 
 which had, up to that time, progressed in a manner leaving nothing to 
 be desired. 
 
 The Causes upon which a failure of uterine action depends embrace, 
 in addition to those above mentioned, certain conditions of the parts, 
 more or less strictly morbid. To these attention must be given, as it 
 is manifest that a mere routine treatment, adopted without an intelli- 
 gent reference to the circumstances of the case, must necessarily often 
 fail of its object, and may sometimes only tend to make matters worse. 
 Excessive distension of the uterus, by thinning the walls or the organ 
 beyond ordinary limits, is one of the conditions to which we refer. The 
 effect of dropsy of the amnion, for example, may in this way interfere 
 with the due action of the organ ; and, in such a case, less good will 
 be derived from the exhibition of agents which excite the uterus to 
 contract than from rupturing the membranes, and thus allowing the 
 uterine wall to come into contact with the surface of the child, when it 
 will in all probability be roused to active energy. 
 
 The death of the child was believed by Baudelocque to weaken ma- 
 terially the uterine contractions ; but Dubois asserts, and modern 
 accoucheurs generally agree with him, that when the woman is in good 
 health, the death of the child exercises no influence whatever, in the 
 way of enfeebling uterine action, and that if it sometimes happens that 
 labor goes on more slowly when the child has ceased to live, this is 
 to be accounted for by the fact that the death of the child is probably 
 the result of some disease of which the mother has been the subject, 
 and that, consequently, her forces have been already weakened. The 
 premature rupture of the membranes, and consequent discharge of the 
 waters, very generally causes a tardy labor, but this operates chiefly in 
 the first stage, and is mainly due to want of the mechanical dilating 
 power of the bag of membranes. Inefficient uterine action has often 
 been observed to be associated with undoubted morbid conditions of 
 the organ. Among these may be mentioned, rheumatism, gout, and 
 neuralgia ; and, in addition, congestion and inflammation of the uterus. 
 In so far as congestion and inflammation are concerned, while their 
 occasional existence cannot be disputed, there can, we imagine, be little 
 doubt that the older writers greatly exaggerated their importance and 
 frequency, as an excuse for the never-failing remedy of the lancet. A 
 morbid condition, however, of the uterine fibre, depending upon some 
 form of uterine inflammation, is a possible, and we would venture to 
 say a probable, cause of some of the most complete cases of uterine 
 inertia. 
 
 A distended bladder or rectum may, in addition to the mechanical 
 impediment which it constitutes, act injuriously in arresting uterine 
 action ; and it has been observed, in those cases in which pressure on 
 the sacral nerves causes cramps in the lower limbs, and the excessive 
 agony to which these give rise, that the effect on the uterus is to weaken 
 and not to increase its action. Several cases of this kind are cited by 
 Meigs. 
 
 Another effect which is occasionally produced is irregular action, in 
 which the whole of the organ is not symmetrically contracted. Irregu- 
 lar contractions, as we have already seen, give rise to retention of the 
 
598 UTERINE INERTIA. [CHAP. 
 
 placenta, hour-glass contraction, and inversion of the uterus ; and, in 
 like manner, they necessarily occasion pains, which are inefficient, in- 
 asmuch as they do not act upon the whole circumference of the ovum. 
 In such cases, the pains are more irregular in their occurrence, and the 
 suffering, which is severe, is referred at one time to one part of the 
 uterus, and again to another. Sometimes, the hand placed over the 
 abdomen can detect inequality on the surface of the contracting organ, 
 showing w 7 hat parts are in action and what parts are paralyzed. Under 
 the influence of contractions such as these, labor makes little or no 
 progress, the bag of membranes does not project in the usual way 
 during a pain ; or, if the second stage has been reached, the presenting 
 part of the child makes no advance. The woman now becomes ex- 
 hausted, the pulse frequent, and the case may assume a grave aspect. 
 It is to the more serious forms of this that the name of " uterine teta- 
 nus " has been given. 
 
 Inefficient uterine action being thus found to depend upon such a 
 variety of causes, it is not to be wondered at that attempts have been 
 made to classify the cases. Wigand proposed to divide all into three 
 groups. In the first, the womb contracts, not only quite regularly, but 
 even to such an extent that the child is bent forwards at each pain, 
 and the labor has in general an otherwise normal course ; but this 
 course is very tedious, and the pains are interrupted by too long inter- 
 vals. This he calls Inertia Uteri. In the second grade, which he de- 
 scribes as Adynamia or Atonia Uteri, the uterus also contracts in a 
 manner which is, so far, quite regular ; but the contraction is incom- 
 plete, of short duration, and inefficient, and lasts longer at the fundus 
 than in the lower segment of the organ. In the third grade, all pain 
 in the uterus has ceased, so that, beyond a certain feeble tension, no 
 trace of contraction is 'to be observed : this condition Wigand describes 
 as Lassitudo, Exhaustio, or Paralysis Uteri. Scanzoni proposes that we 
 should draw a distinction only between "primary" and "secondary" 
 inefficient action, including, under the first term, all cases in which, 
 from first to last, the womb lacks sufficient energy to complete the 
 labor without assistance; and, under the second, those cases in which 
 the contractions were originally sufficient, but have failed in the course 
 of labor, so that, in the end, all the symptoms of primary inertia are 
 manifested. 
 
 We doubt much whether any such system of classification is of value, 
 either as a guide to practice or in elucidating the subject; and we there- 
 fore prefer, as embracing all cases of failure of uterine action, the 
 simple term Inertia, which is generally used in this sense by English 
 writers. Obviously, however, this may exist in any grade, from mere 
 feebleness of contraction to absolute paralysis of the uterus. It is 
 proper, in considering this subject, not to overlook the possibility of 
 failure in the auxiliary expulsive forces; for it must be obvious that, in 
 the course of the second stage, anything which may prevent the effi- 
 cient action of the expiratory muscles must of necessity interfere, more 
 or less, with the act of parturition. Acute or chronic pulmonary dis- 
 ease, therefore, as well as cardiac or hepatic disorders, and the ascites 
 which often accompanies them, may, with other abnormal conditions, 
 
XXXVII.] TREATMENT. 599 
 
 so interfere with the dynamical phenomena of parturition as very seri- 
 ously to obstruct the progress of labor. 
 
 Treatment. — A careful consideration of the circumstances above men- 
 tioned, as applicable to individual instances, will always be our best 
 guide to the treatment of those cases in which there is a failure of the 
 vis a tergo. An error in the axis of expulsion, which is usually de- 
 pendent on anteversion of the gravid uterus, and therefore does not 
 strictly fall under our notice here, may be managed without difficulty, 
 under ordinary circumstances, by postural treatment or by the abdomi- 
 nal bandage, so as to bring the axis of the uterus, as nearly as may be 
 possible, into coincidence with that of the pelvic brim. Over-disten- 
 sion of the uterine cavity, by reason of dropsy of the amnion, plural 
 pregnancy, or any other cause, should, if symptoms of inertia develop 
 themselves, be treated by rupture of the membranes, — and that for 
 reasons which have already been stated. 
 
 Although, perhaps, rheumatism of the uterus has been somewhat 
 exaggerated, as regards its importance as a cause of retarded labor, the 
 symptoms should always be taken into consideration, as they are such 
 as may divert our attention from the inefficiency of the labor. These 
 symptoms have been well described by the younger Naegele. " Rheu- 
 matism of the uterus," he says, " is recognized by the following signs. 
 During labor, and often before it, the uterus is unusually sensitive to con- 
 tact, both from without and from within. The pains are feeble, short, 
 infrequent, and unusually painful, and, in fact, excite as much pain at 
 their commencement as normal pains do at the height of the contrac- 
 tion. During the interval between the contractions, the pain does not 
 cease. The woman complains of heat, great thirst, and uneasiness ; 
 the pulse is rapid, small, and hard. In the course of labor, the suffer- 
 ing from the pains increases, in proportion as their efficiency dimin- 
 ishes. In favorable cases, the pains cease for a time, the patient falls 
 asleep, after which regular pains soon recur, and continue until the 
 completion of the labor; but when the case is mistaken or unskilfully 
 treated, the labor becomes extremely protracted, debility and cramp 
 come on, and rheumatism passes into metritis." 
 
 In a large proportion of cases, as we have seen, the cause of the 
 failure of uterine action is to be found in the condition of the alimen- 
 tary canal ; and, on that account, one of the first points that we should 
 attend to in all cases, is the condition of the primce vice; and, in like 
 manner, and for similar reasons, it is advisable to ascertain the condi- 
 tion of the bladder, which sometimes exercises a scarcely less important 
 influence on the progress of the case. The effect of relieving a dis- 
 tended or irritated viscus is often so striking, that a very common and 
 frequently efficient mode of treatment, in cases of uterine inertia, is to 
 throw an enema of a stimulating character into the rectum ; and, in 
 fact, so susceptible is the uterus, even in these cases, to reflex irritation, 
 that a simple enema of warm water will often suffice to awaken its dor- 
 mant energy. 
 
 The action of the organ may also be roused by other expedients of a 
 still more simple character. A warm diluent drink is often found to 
 have an effect as marked as an enema, and when the strength has be- 
 
600 UTERINE INERTIA. [CHAP. 
 
 come in any way exhausted, it will be proper to substitute for this, 
 strong soup, or even some form of stimulant. The accoucheur can 
 scarcely, however, be too cautious in sanctioning the use of stimulants 
 in labor. Among the lower classes in Scotland, — where whisky is the 
 panacea for all evil, — it will often be impossible to prevent its employ- 
 ment ; but the universal opinion of all who have witnessed the indis- 
 criminate administration of stimulants in labor is that the effect, as a 
 rule, is to retard and not to advance the period of delivery. The reflex 
 activity of the uterus is often aroused by digital examinations, which 
 seem to excite the nerves of the cervex, or those which are distributed, 
 in some abundance, to the tissues of the perineum. Free examination 
 of those parts, therefore, which, under ordinary circumstances, is to be 
 condemned, may here be practiced without hesitation, should the uterus 
 show any symptoms of response, a result which will be further en- 
 couraged by firm pressure over the surface of the abdomen. 
 
 The position of the woman often exercises, at all stages of labor, a 
 very decided effect on the vigor and efficiency of the pains ; and, in a 
 woman in whom there is an evident tendency, on the part of the 
 uterus, to flag in its efforts, the erect posture, by permitting the child 
 to gravitate towards the lower segment, has generally a most beneficial 
 effect ; so that it is often proper in these cases to cause the woman to 
 walk about the room, even at an advanced stage of labor, in the hope 
 that this result may ensue. An abdominal bandage, properly applied, 
 will frequently be found to contribute much both to the comfort of the 
 woman and the efficiency of the pains, on account of the pressure which 
 is thus exercised upon the uterine walls, the stimulus which is afforded 
 to the muscular fibres, and the increased efficiency with which the 
 abdominal muscles are enabled to act; and in the same manner, no 
 inconsiderable assistance may be afforded by firm pressure exercised, 
 during a pain, by the palms of the hands placed over the abdomen. 
 The effect, indeed, of pressure of this kind is often very striking, so 
 much so that of late years general attention has been directed to this 
 method of treatment as a substitute for the ordinary oxytoxics. When 
 a tendency to inertia exists, something will usually be effected by care- 
 fully watching the course of labor, encouraging the woman to husband 
 her efforts in the first stage, and urging her to make full use, during 
 the second stage, of the expiratory muscles, by closing the glottis, fixing 
 the limbs, and abstaining from crying during the presence of pain. 
 
 In a certain number of cases, however, the uterus sinks into a state 
 of complete inertia; or the pains become so feeble that it is evident 
 that labor cannot be completed by the unaided powers of nature. This 
 condition is one which is often attended with no inconsiderable amount 
 of risk both to mother and child. If the failure should occur in the 
 early stage of labor, before dilatation of the os has been effected, or the 
 head has descended into the pelvis, we may place more confidence in 
 nature, and may wait for a reasonable time in the expectation that more 
 efficient action will be set up; or we may employ the more simple means, 
 which have been detailed, with the view of stimulating the uterine 
 fibres to contract. When the os is fully dilated, or even, as we have 
 seen, at an earlier stage, when we have reason to believe that there is 
 
XXXVII.] ERGOT. 601 
 
 dropsy of the amnion, rupture of the membranes is a perfectly proper 
 and justifiable procedure, and will often be followed, after a brief inter- 
 val, by vigorous contraction. Should this fail, or should the inertia 
 have become developed in the course of the second stage, we have then 
 to choose between the forceps, or some other mode of operative delivery, 
 and the oxytoxic agents, of which the ergot of rye is by far the most 
 important. 
 
 When the head is low, and the conditions otherwise are such as to 
 render the operation both easy and safe, the forceps should, in most 
 instances, be preferred ; and, in all cases in which the circumstances are 
 such as to call for a speedy delivery, we should have recourse to this 
 operation, or to turning. But, when the head is high in the pelvis, 
 and there is no obvious necessity for rapid delivery, we may resort to 
 some of the agents referred to. 
 
 Ergot, which is, as we have said, the most important of the class of 
 drugs to which we refer, is to the accoucheur an agent so important 
 and so powerful, that we may here interpolate a brief account of it, 
 and of the rules which should guide us in its employment in the exi- 
 gencies of ordinary practice. "The Ergot, or Spur," says Christison, 
 " seems to affect occasionally all the Graminacese, more rarely the Cy- 
 peracese, and sometimes even the Palms. No plant, however, presents 
 it so frequently, or of such size, as common rye, — the Secale Cereale. 
 It is generally thought to arise under the influence of undue moisture; 
 and although this condition seems not to be absolutely essential, it is 
 never produced with such certainty as in wet seasons, and in districts 
 where the soil is damp, rain frequent, and the atmosphere still and 
 misty, especially at the time the grain is coming into flower. In these 
 circumstances, it is produced, according to some, by punctures made by 
 insects in the glumes, while the substance of the seed is pulpy; others 
 conceive that it is caused by the spawn, or sporidia, of a peculiar species 
 of fungus." The Ergot of Rye is an irregularly cylindrical body, 
 averaging about an inch in length, and slightly curved, like the spur 
 of a cock, — hence the name "Spurred Rye." It has a very powerful 
 toxic action, and gives rise, when taken in large quantity, or for a con- 
 siderable time, to two classes of symptoms, — convulsive and gangrenous. 
 It produces, as has been demonstrated by Dr. Brown-Sequard, an in- 
 fluence on the vaso-motor nerves, and thus causes contraction of the 
 vessels of the spinal cord, on which account it is frequently used in 
 congestive and inflammatory affections of that structure. There can 
 be no doubt that it is through that channel that its specific action on 
 the uterus is produced ; and it unquestionably is the most certain in its 
 action of all the agents hitherto discovered in promoting the contraction 
 of the muscular fibres. 
 
 Its action may always be counted upon with more certainty when 
 the uterus is fully developed ; so that in abortion, it cannot be depended 
 upon as likely to promote the expulsion of the ovum, with anything 
 approaching to the certainty with which, towards the end of pregnancy, 
 the uterus responds to its action. Still, although thus comparatively 
 inefficient, there are no circumstances under which its action on the 
 uterus may not be manifested ; so that w r e not only find it sometimes 
 
602 UTERINE INERTIA. [CHAP. 
 
 to act with unexpected vigor in the expulsion of an early embryo, but 
 even in the un impregnated organ in the treatment of menorrhagia ; and 
 it has occurred to us more than once to be able to demonstrate the 
 uterine nature of a doubtful abdominal tumor by the contractions pro- 
 duced in it by the action of several doses of ergot. It is, however, 
 when labor has actually commenced that the action of ergot is most 
 marked; but there can be no doubt that, under other circumstances, it 
 operates, although with less certainty, in inducing abortion or prema- 
 ture labor, or otherwise initiating uterine action. 
 
 The physiological effects of the drug are, of course, of great interest 
 to the accoucheur. We may here pass over, as foreign to our subject, 
 its more important toxic effects ; but we may note that it has frequently 
 been observed to produce nausea and vomiting, which, of course, may 
 absolutely prevent the possibility of its action. In such cases, it has 
 been given in the form of enema with perfect success. The usual effect 
 on the circulation is a diminution both in the frequency and fulness of 
 the pulse, sometimes accompanied with faintness and pallor. In some 
 instances, symptoms of cerebral disorder manifest themselves in the 
 form of weight and pain in the head, giddiness, delirium, dilatation of 
 the pupil, and stupor; but these symptoms commonly follow the uterine 
 contractions, and are usually observed in those cases in which an un- 
 necessarily large quantity of the drug has been administered. That 
 such symptoms may be manifested is enough to show that ergot is 
 always to be used with some caution. 
 
 Its action on the uterus, with which we have more particularly to do, 
 is generally observed in from ten to fifteen minutes after the medicine 
 has been taken, and is indicated by an increase in the violence and 
 duration of the pains. When the full effect of the drug has been pro- 
 duced, the pains are quite different from those of normal labor, inas- 
 much as they are absolutely continuous, or are, at least, without any 
 proper interval, although there may be irregular periods of remission. 
 Tli is uninterrupted contraction of the uterine tissue necessarily involves 
 a certain interference with the utero-placental circulation, over and 
 above what occurs in the rhythmical contraction of ordinary labor; and 
 it must be admitted that the absence of the natural periods of uterine 
 rest may, if long-continued, place the life of the child in peculiar 
 jeopardy. This, however, has, we believe, been greatly exaggerated. 
 " The ergot," says Dr. Hosack, " has been called, in some of the books, 
 from its effects in hastening labor, the pulvis adpartum; as it regards 
 the child, it may, with almost equal truth, be denominated the pulvis 
 ad mortem: for I believe its operation, when sufficient to expel the 
 child, in cases where nature is alone unequal to the task, is to produce 
 so violent a contraction of the womb, and consequent convolution and 
 compression of the uterine vessels, as very much to impede, if not 
 totally to interrupt, the circulation between the mother and child." 
 This assertion has been satisfactorily refuted by Chapman, Dewces, 
 and others; but still we are inclined to think there is some grain of 
 truth in it — at least in those cases in which labor is protracted in spite 
 of strong and unceasing pains. Dr. F. H. Ramsbotham supposed that 
 the toxic action of the drug might be extended from the mother to the 
 

 XXXVII.] ERGOT. 603 
 
 foetus, and the figures which he gives would seem to go some way to 
 prove his assertion. Of 36 cases in which he induced premature labor 
 by puncturing the membranes, 21 children were born alive; while in 
 26 cases in which labor was induced by ergot alone, 12 children only 
 were born alive. Apart from the fact that such statistics are open to 
 many fallacies, we repeat our conviction that the danger of ergot to the 
 child has been greatly exaggerated ; and we believe that the unsatis- 
 factory results which have been reported have been mainly due to the 
 rash administration of the drug, without any reference to the conditions 
 upon which alone we can rely for a satisfactory result. 
 
 The violence of the contractions produced by ergot is such that we 
 are never safe in administering it, unless we are convinced that the 
 anatomical conditions are such as to admit of the passage of the child 
 without extreme or unusual resistance. To give ergot, therefore, in a 
 case of shoulder presentation or of deformed pelvis, when the os is 
 undilated, or when the soft parts generally are rigid, dry, and undilat- 
 able, is manifestly wrong; and, in the first two cases, would amount 
 to malapraxis in the worst form. As regards the condition of the os, 
 the rule is as stated, but is not so absolute. If it were so, it would 
 debar us from making use of ergot in the induction of premature labor, 
 where its action initiates the commencement of the first stage. Nor, 
 as regards ordinary cases, are we to admit that we must always wait 
 until the os has become dilated ; for there are instances in which a 
 dilatable state of the os, with a properly lubricated condition of the 
 passages, would be quite sufficient warrant, in the absence of all action, 
 for the administration of ergot. If labor should become arrested before 
 the os has opened to some extent, there can be no question of medicinal 
 treatment, as there is no risk either to mother or child in the arrest of 
 a labor which has as yet barely begun. When the head is low in the 
 pelvis, the forceps, as already remarked, will usually be preferred ; and, 
 if any delay should arise after the exhibition of ergot, the head being 
 well in the pelvis, it may be proper to complete the delivery by instru- 
 mental aid. Indeed, we believe that the number of cases in which the 
 two may with propriety be combined is larger than is generally believed. 
 The objection to the forceps, in the case of an absolutely inert uterus, 
 is that we may empty the organ, which then, contracting imperfectly, 
 admits of alarming or fatal haemorrhage; but if we combine the two, 
 the one force will not only aid the other, but the ergot will insure safety 
 after delivery by maintaining the womb in a proper state of tonic con- 
 traction. If the contractions are violent, speedy delivery is always to 
 be desired, as a considerable number of cases of rupture of the uterus 
 are on record from the use of ergot alone. 
 
 The mode in which ergot is usually administered is in the form of 
 infusion. Two drachms of fresh ergot coarsely crushed may be in- 
 fused for twenty minutes in six ounces of boiling water; one-fourth of 
 the infusion to be given at intervals often or fifteen minutes until dis- 
 tinct uterine action is manifested. If, with the second or third dose, 
 the desired effect is already produced, it is wrong to proceed further, 
 for the result of more than is necessary will only be to increase the 
 tetanic character of the contractions and the risk both to mother and 
 
604 UTERINE INERTIA. [CHAP. 
 
 child. If the quantity above mentioned has been given in four doses 
 without any response on the part of the uterus, it will be needless, and 
 indeed improper, to pursue the treatment further ; and cases do, not 
 unfrequently, occur, in which the drug seems to be absolutely inert. 
 The infusion should always be freshly made ; but the great objection to 
 it is that one cannot be sure of the quality of the ergot, more especially 
 if it has been kept for any time, when it is apt to become mouldy, or 
 to be entirely destroyed by an acarus, which feeds upon it and leaves 
 the grain as a mere shell. All these difficulties are got rid of by the 
 use of the Liquid Extract or the Tincture of the British Pharmacopoeia, 
 either of which may be given in doses of twenty or thirty minims for 
 three or four times and at the same intervals as the infusion. Schacht's 
 " Liquor Secalis " also contains the active principle of the drug, and 
 may be given in drachm doses ; but the liquid extract is the prepara- 
 tion which we can with the greatest confidence recommend, as we have 
 had more experience in its use. 
 
 Ergot w T as used by women for hurrying labor long before it was 
 known to the profession ; and the same remark may be made of Borax, 
 which was used by the ancients, and has been employed quite recently 
 in Germany by some in preference to ergot, being supposed to be free 
 from the objections which attach to ergot as a toxic agent. Cinnamon 
 and Strychnia have also been employed, as well as numerous other 
 drugs; and a very thorough trial has been made of galvanism, which, 
 although it has an undoubted effect upon the uterine fibre, is certainly 
 less to be depended on than ergot, and has therefore fallen entirely into 
 disuse. 
 
 It has often been stated that the various agents of this class should 
 not be made use of in the case of primiparse ; but to the judicious prac- 
 titioner such a rule is quite unnecesary, as he will not fail to take into 
 consideration the greater resistance which naturally obtains in the case 
 of a first labor. There is, in fact, if he does not lose sight of the special 
 conditions referred to, no reason why he should not avail himself of the 
 action of the oxytoxic agents in priiniparaB as well as in pluriparse. 
 For the guidance of the inexperienced practitioner, we will add one 
 caution only, — that he should not be too eager in his endeavors to bring 
 a case to a speedy termination ; for it often happens that a sudden cessa- 
 tion of the uterine efforts is merely an indication that the organ is col- 
 lecting itself for more vigorous action and a final effort. 
 
 Precipitate Labor. — Although of less frequent occurrence than failure 
 of the expulsive force, the accidents which may accrue in labors which 
 are too rapid are scarcely less serious. In the great majority of all such 
 cases, there is some peculiarity of constitution or temperament. It has, 
 indeed, not unfrequently been observed in the same patient in succes- 
 sive pregnancies, and even in different members of the same family. 
 It would also appear to be occasionally connected with a morbid irrita- 
 bility of the generative system which may have been previously mani- 
 fested in undue excitement at the menstrual periods. In some extreme 
 instances, the action, from the very commencement of labor, is so severe 
 that the patient is compelled to bear down from the first. The appear- 
 ance and expression of the countenance, and the state of the pulse, de- 
 
XXXVII.] PRECIPITATE LABOR. 605 
 
 note a condition of excitement and suffering which is quite abnormal ; 
 and, in such instances, we may with some reason dread the occurrence of 
 uterine rupture at a stage when we are comparatively powerless to avert 
 it. The pains are almost continuous ; and, if the parts are relaxed, the 
 child may be forced through the passage with a rapidity which is 
 almost appalling. In such instances, indeed, when the woman is taken 
 unawares, the child may be born while she is yet in the erect posture, 
 and dashed upon the floor. 
 
 Although, as we have seen, the usual effect of premature rupture of 
 the membranes is to retard labor, the contact of the uterine walls with 
 the surface of the child has occasionally the effect of rousing the organ 
 to action of the most violent and uncontrollable kind, although the 
 parts may as yet be but imperfectly prepared for the stage of expulsion. 
 Emotional causes of various kinds may also have a similar effect in pro- 
 ducing contractions, of such energy as to bring the labor to a termina- 
 tion with unexpected rapidity. In some cases, the operation of these 
 causes is obviously beneficial, and the mere threat of operative inter- 
 ference, or the production of the forceps, will sometimes have the effect 
 of rousing the flagging energy of the expulsive forces, and bringing 
 matters to a termination before operative measures have been resorted 
 to. Scarlatina and other acute febrile disorders have in some instances 
 a precisely similar effect. 
 
 In another class of cases, the rapidity of the labor seems to be due 
 less to the violence of the pains than to the deficiency of the resistance 
 to the passage of the child through the parturient canal. In the case 
 of a pelvis of unusual size, this may take place, even although the 
 pains are in no way beyond the average; and, of course, if such an 
 anatomical condition as this is combined with violent uterine action, 
 the rapidity of the delivery may be such that only a few minutes in- 
 tervene between the preliminary pains and the termination of labor. 
 If the head is smaller or more yielding than usual, or the soft parts 
 more than ordinarily dilatable, these conditions will also contribute to 
 a similar result. 
 
 The dangers attendant upon precipitate labor are various. The ex- 
 treme violence of the contraction may cause rupture of the uterus ; or, 
 the rapid passage of the child may cause laceration of the cervix, va- 
 gina, or perineum, and the more remote dangers to which these acci- 
 dents give rise. In other cases, the uncontrollable violence of the ex- 
 pulsive action of the voluntary muscles (which in such a case become 
 virtually involuntary) may force the air into the cellular tissue, and 
 cause emphysema of the face and neck. The sudden emptying of the 
 uterus may be followed by a period of complete relaxation, so that all 
 such cases are known to be peculiarly liable to post-partum haemor- 
 rhage. Rupture of the membranes only makes matters worse, and the 
 direct pressure to which, in such cases, the child is subjected, exposes it 
 also to no inconsiderable risk. 
 
 Another danger to the child arises from the risk of delivery taking 
 place when the woman is in the erect posture, when it may be seriously 
 injured by being dashed upon the floor. The rupture of the cord, 
 which would probably occur under such circumstances, is not, as some 
 
606 PRECIPITATE LABOR. • [CHAP. 
 
 have supposed, an important source of danger, seeing that the fact of 
 laceration of the vessels, which must take place, is an effectual barrier 
 to haemorrhage. It has been observed, in cases in which the resistance 
 was much less than the expulsive force, that the uterus, in its undilated 
 condition, has been forced down upon the perineum, and has even pro- 
 truded externally before the os had sufficiently yielded to permit of the 
 passage of the child. 
 
 The treatment of precipitate labor consists in adopting such measures 
 as are available for moderating the violence of the uterine action. As 
 a considerable number of cases are associated with some intestinal de- 
 rangement, it is proper, in the first instance, to wash out the bowels by 
 a simple injection of tepid water, the soothing effect of which will 
 sometimes become at once apparent. But if, as is more likely, the tur- 
 bulence of the uterine action still continues, nothing is so likely to pro- 
 duce a decided effect as opium, given in the form of a suppository of 
 one of the salts of morphia. This is better than the exhibition of any 
 of the preparations of the drug by the mouth, more especially if there 
 is a tendency to irritability of the stomach. The other sedatives have 
 a similar, although less certain, effect; and, in many cases, the result of 
 chloroform inhalation is wonderfully to moderate the uterine action. 
 
 A knowledge of the physiology of the expulsive forces will instinc- 
 tively guide us to such management of the case as may obviate, as far 
 as possible, any voluntary action. Everything, therefore, which the 
 woman might seize, or anything against which she could press her feet, 
 should be carefully removed, while the action of the pain should be 
 watched, and the woman encouraged to cry out lustily rather than to 
 fix the glottis. Such modes of treatment as we have shown to be use- 
 ful in inertia, should here be scrupulously avoided, and a directly con- 
 trary plan adopted. We should carefully avoid, therefore, digital ex- 
 aminations, beyond what may be considered absolutely necessary, and 
 protect the patient from all sources of mental emotion or physical ex- 
 citement, and from any other cause which experience has proved to ex- 
 ercise a decided influence upon the uterine fibre. On no account should 
 the woman be allowed to assume or maintain the erect posture, which 
 is well known to act as a fresh incentive to uterine action, by allowing 
 the child to gravitate downwards and press against the os and cervix. 
 Although, theoretically, we might naturally suppose that the ordinary 
 abdominal bandage would rather encourage than abate uterine action, 
 it has been found that it sometimes has a soothing effect, adding to 
 the comfort of the patient, and in some degree relieving her suffering. 
 Should this expedient be tried, it will be well so to adjust the bandage 
 as to support the womb by pressure applied chiefly between the lum- 
 bar and hypogastric regions. When procidentia is threatened, it may 
 be necessary to support the uterus by means of a bandage applied ex- 
 ternally, and so adjusted as to press against the vulva. When the lower 
 segment actually protrudes, a hole should be made in the bandage so 
 as to aid the longitudinal fibres of the uterus in mechanically overcom- 
 ing the resistance of the circular fibres and tissues of the os. In this 
 way Naegele has operated successfully, allowing the child to be born 
 actually through the aperture in the supporting bandage. 
 
XXXVIII.] THE PUERPERAL STATE. 607 
 
 In cases of violent and precipitate labor, the fearful exertion to 
 which the patient is impelled may culminate in an epileptic seizure, or 
 even in apoplexy. In some cases the suffering is so great and so con- 
 tinuous, and the woman is worked up into such a state of frenzied ex- 
 citement that, at the moment of delivery, she is actually unconscious of 
 what she does. It is in consideration of this that the Continental codes 
 look with leniency upon child murder perpetrated under such circum- 
 stances ; and, probably, even in our own country, if such facts were 
 substantiated, the law would take a similarly lenient view, although it 
 is not set forth in the statute-book. Another question in medical juris- 
 prudence, and which may have an important bearing in cases of sus- 
 pected infanticide, is the likelihood of the mere rapidity of the birth 
 being the cause of death of the child, as cases are recorded in which 
 children have been born while the woman was in the erect posture, or 
 even when she was at stool. It would appear, also, that sometimes, 
 owing possibly to the great cerebral excitement, there is a greater 
 tendency to the occurrence of puerperal mania, in women in whom 
 the symptoms during labor have been of the nature of those above 
 described. 
 
 CHAPTEE XXXVIII. 
 
 THE PUERPERAL STATE : LACTATION. 
 
 management oe the puerperal state — the lochia: nature and source of 
 — after-pains: treatment of— the lacteal secretion: milk fever: 
 colostrum — the child to ee put to the breast at fixed intervals — 
 agalactia — galactorrhea : two varieties of — management of lacta- 
 tion — effects of over-feeding — duration of lactation — effects of 
 menstruation and pregnancy upon lactation — disorders of lactation 
 — inflammation and abscess of the mamma: effects of: treatment — 
 excoriation and fissure of the nipples : prevention of : treatment of. 
 
 The management of labor, up to the stage when the accoucheur is 
 able to leave his patient after her delivery, has already been described 
 in a previous chapter. We now propose, however, to consider, some- 
 what more in detail, the treatment of the woman during the puerperal 
 state, — while she is under the influence of conditions which, although 
 strictly physiological, may very readily become morbid. The condi- 
 tion of the woman during the period immediately succeeding the ter- 
 mination of labor is one of delightful calm and repose, which offers a 
 remarkable contrast to the excitement and frenzy of the concluding 
 stage of the process. The falling of the pulse shows the subsidence of 
 a turbulent circulation, and is due, in some degree, to a modified shock. 
 When labor has been easy, and of moderate duration, there are no 
 
608 THE PUERPERAL STATE. [CHAP. 
 
 symptoms of shock ; but in other cases, and in proportion to the vio- 
 lence and duration of the process, the patient shows symptoms, more 
 or less distinct, of debility, and the shock to the nervous system mani- 
 fests itself further by intolerance of light and sound and other symp- 
 toms of temporary exhaustion. Perfect quiet, and, above all things, 
 refreshing sleep, will speedily rouse the woman from the condition into 
 which she has fallen ; and so important, indeed, is the latter point, that 
 many experienced practitioners were in the habit of giving an opiate, 
 as a matter of routine, shortly after delivery. In ordinary cases, how- 
 ever, opium is unnecessary ; but, whenever there is shock and marked 
 exhaustion, a moderate dose of the Liq. Opii Sedativus may frequently 
 be given with advantage. 
 
 The old method of treatment by starvation during the first few days, 
 — when the diet was confined to tea, water-gruel, or arrowroot — finds 
 few, if any, supporters at the present time. Nothing, indeed, could be 
 more irrational than such treatment, or more likely to retard recovery 
 and discourage the lacteal secretion ; so that it will be quite proper, 
 after the first day at least, in the great majority of instances in which 
 the patient has had some sleep, to give chicken-soup, or beef tea, in 
 addition to the dry toast, gruel, arrowroot, and sago, which are properly 
 given at this stage, as being substances easy of digestion. 
 
 In the course of his subsequent visits, the accoucheur should see that 
 the bandage is properly managed, and tightened from day to day; and 
 it is well, by firm and equable pressure, exercised over the hypogastric 
 region — which has often the effect of dislodging clots — to be assured 
 of the satisfactory state of the uterus as regards contraction. One of 
 the first points to which he addresses his inquiries is with reference to 
 the function of the bladder, which is sometimes resumed with difficulty. 
 Laving with warm water w T ill usually be all that is required to excite 
 the bladder to contraction ; but, in some cases in which the labor has 
 been difficult, the viscus is actually paralyzed, so as to require the use 
 of the catheter, which may have to be repeated for several days. 
 
 If the bowels have been freely moved, as they should always be, 
 shortly before delivery, we need pay no attention whatever to that 
 function until forty-eight hours have elapsed. Torpor of the bowels is, 
 after labor, an almost invariable condition, which is probably due, as 
 Dr. Tyler Smith says, to " the exhaustion induced by labor in all the 
 organs under the influence of the spinal cord. 7 ' Under the ordinary 
 conditions of the puerperal state, it is, therefore, necessary to give some 
 laxative medicine — of which class of remedies castor oil is undoubtedly 
 the best. Other laxatives may, no doubt, act with equal efficiency ; 
 but, as a rule, and especially in the form of pill, they are not to be 
 depended upon. It is somewhat remarkable that, sluggish as the 
 bowels are, they respond very readily to the action of laxatives, even 
 in the case of those who are habitually costive. It will therefore rarely 
 be found necessary to prescribe more than a dessertspoonful of castor 
 oil, which may be given with lemon-juice early in the morning. On 
 several occasions we have seen an ordinary dose of half an ounce 
 followed by such violent action as to require opiates to restrain the 
 purging. 
 

 XXXVIII.] TREATMENT AFTER DELIVERY. 609 
 
 [The teaching of the author in regard to the use of purgatives is in 
 accordance with that of most systematic writers on obstetrics. Pro- 
 fessor Fordyce Barker, of New York, however, in his work on Puer- 
 peral Diseases, strongly condemns the administration of castor oil to 
 lying-in women, especially such as are predisposed to haemorrhoids. 
 When the editor began the practice of medicine, it was the rule to give 
 a dose of oil on the third day after confinement. Any departure from 
 this time-honored custom was the subject of severe criticism, upon the 
 part of both the patient and her nurse. The action of the castor oil 
 was frequently attended with violent straining and hypercatharsis, 
 which sometimes resulted in an attack of the piles, which the woman 
 bore with a martyr-like resignation, because she was led to believe that 
 it would ward off some indefinite trouble, which it was feared would 
 follow if the medicine was not taken. 
 
 These facts led the writer to abandon the use of castor oil among his 
 puerperal patients, and instead of looking upon it as " the best" laxa- 
 tive medicine that can be employed under these circumstances, he 
 believes it to be one of the worst, on account of the uncertainty of its 
 action. 
 
 In many cases there is no necessity to administer a purgative on the 
 third day, and we can fully confirm Professor Barker's statement, that 
 many women need no laxative at all, as the bowels often act spon- 
 taneously between the second and fourth day after delivery. If they 
 do not they can be stimulated by an enema, a small dose of rhubarb, 
 or two or more of Lady Webster's dinner pills. — P.] 
 
 The Lochia. — While the placenta, during the third stage of labor, is 
 being separated and expelled, a considerable amount of haemorrhage 
 naturally takes place, and, after the completion of the process, blood 
 continues to ooze from the ruptured and partially closed vessels on the 
 inner surface of the womb. Efficient and rhythmical contraction of 
 the uterus prevents the flow from becoming so profuse as to be dan- 
 gerous ; but still, a certain amount of discharge goes on for a time; 
 and, indeed, it is well known that the maintenance of this discharge, 
 for a certain time after delivery, is, to some extent, a guarantee of the 
 favorable progress of the case, while, on the other hand, its premature 
 arrestment is an almost invariable accompaniment of the more serious 
 puerperal disorders, and is therefore always looked upon with more or 
 less of apprehension. In order to understand the true nature of the 
 lochial discharge, it is necessary to consider for a moment the anatomical 
 condition of the parts from whence it springs. 
 
 That part of the uterus from which the placenta has been separated 
 was compared by Harvey to the stump of a limb after amputation ; 
 but, although the simile has been frequently repeated, physiologists are 
 well aware that it is only to a limited extent correct. The vessels, no 
 doubt, are torn across in the course of the separation of the placenta, 
 but, with this exception, there is no real breach of tissue, as nature has 
 for many weeks been preparing for the process of separation. At birth, 
 the inter-utero-placental tissue divides into two layers, as was formerly 
 explained, one of these remaining adherent to the uterine wall, along 
 with portions of the decidua serotina. If the womb be examined 
 
610 THE PUERPERAL STATE. [CHAP. 
 
 shortly after delivery, that part of it to which the placenta was attached 
 will be observed to be thicker than the other portions, and projecting 
 somewhat into the cavity of the uterus. Upon this surface, which is 
 rugged and unequal, small clots, projecting from the orifices of the 
 closed vessels, and so contributing to their efficient closure, are ob- 
 served, along with shreds of membrane; and, over the whole inner 
 surface of the cavity of the organ, remains of the decidua vera or of 
 the subjacent textures from which it has been stripped are clearly to be 
 made out. The discharge, then, which constitutes the lochia is, in the 
 first instance, composed of almost pure blood. After this, it is still 
 sanguineous, but has been found by M. Robin to contain an unusually 
 large proportion of white corpuscles. As the discharge changes in char- 
 acter, the proportion of white corpuscles becomes higher and higher, 
 and these are believed by the same authority to have their origin 
 directly in the inner surface of the uterus. After the second day, the 
 white corpuscles increase in number, while the red globules diminish. 
 The discharge gradually assumes a reddish-gray, and then a greenish 
 or yellowish hue, at which period there are scarcely any red corpuscles 
 to be found. The white corpuscles are, however, the predominating 
 element, and some of them may now be observed to have become 
 voluminous and full of fatty granules, having in fact assumed the char- 
 acters which have gained for them the name of "granular globules. " 
 Along with these elements will be found fragmentary traces of the 
 decidua, and also pavement epithelium from the mucous membrane 
 of the vagina. 
 
 The lochial discharge has a peculiar odor, sometimes offensive in 
 character, but at no time, if it follows a normal course, is there a puru- 
 lent discharge, nor is the process in any way analogous to the suppura- 
 tion which accompanies the reparative process of a healing stump. 
 While the remains of the decidua are thus being separated, the small 
 clots which plug the vessels, or are adherent to the surface, undergo a 
 process of disintegration, and are separated along with the other con- 
 stituents of the lochia. The new mucous membrane, which, according 
 to Robin, begins to form beneath the decidua as early as the fourth 
 month, is distinct about the ninth day, when the columnar epithelial 
 cells begin to be developed. The surface then becomes smooth, and 
 the discharge becomes colorless and finallv ceases, these changes going 
 on pari passu with the process of fatty degeneration of the muscular 
 fibres which has been previously described. 
 
 Care should be taken by the nurse to promote, while avoiding un- 
 necessary interference, the lochial discharge. A strict regard to clean- 
 liness is the most important indication. The external parts are, with 
 this view, to be sponged lightly with tepid water, and the napkins 
 changed as often as may be necessary ; and, if the foe tor is unusually 
 great, or if the- part have been lacerated, it is well to wash out the 
 vagina daily by a warm water injection containing a small quantity of 
 carbolic acid. The discharge is also promoted by the acts of defecation 
 and micturition, and by any change of posture; and it is a good prac- 
 tice, after the second day, if nothing should occur to contraindicate 
 such a procedure, to encourage the woman to make water on her knees, 
 
XXXVIII.] THE LOCHIA. 611 
 
 which permits of the escape of any portion of the fluid which may have 
 become accumulated in the cavity of the vagina. 
 
 After-Bains are the natural accompaniments of the contractions which 
 usually take place after labor, having for their object the expulsion of 
 any clots that may be contained within the cavity of the uterus, and 
 probably the expulsion of the clots which seal the vascular orifices. 
 These after-pains are trifling or altogether absent in primiparse, but are 
 almost always present, in a greater or less degree, in women who have 
 previously borne children. Up to a certain point, they have a decidedly 
 salutary effect, and contribute to the favorable progress of the case; 
 but it not unfrequently happens, particularly in women who have had 
 many children, that they are so severe as to cause much suffering and 
 no little constitutional disturbance. Anything, in these cases, which 
 tends to engender reflex uterine contraction will be pretty sure to ag- 
 gravate the symptoms, so that vaginal examinations and irritation of 
 the rectum and bladder should, as far as possible, be avoided or recti- 
 fied. One of the most familiar causes of after-pains, so common as to 
 have given rise to an aphorism among nurses, is the application of the 
 child to the breast; and the accoucheur should generally avail himself 
 of this well-known fact to insure thorough and efficient uterine con- 
 traction. And we may here repeat what was stated on a previous 
 occasion, that nothing, perhaps, tends so much to insure that the after- 
 pains shall be moderate in degree, as firm pressure on the fundus, and 
 careful attention to the contraction of the uterus during and after the 
 expulsion of the placenta. 
 
 The after-pains usually commence soon after labor, and in bad cases 
 they last for three or four days. In other cases, again, they are at first 
 moderate, and, after some time, come on with great violence. If there 
 be any suspicion of retained coagula, it will be proper to pass the finger 
 into the vagina, and remove any clots which may be within reach. 
 Should no such cause be discernible, and the pains still persist, the 
 application of a warm poultice over the hypogaster, or a soothing injec- 
 tion into the vagina, will often suffice to allay the suffering, if not to 
 cause perfect relief. In France, an ointment containing belladonna 
 has been extensively used, and no doubt may be productive of benefit, 
 but the objections to the general use of this drug have already been 
 stated. In some instances, the pains are distinctly neuralgic, or are 
 associated with a rheumatic condition of the uterus ; and in these, as 
 well as in all other cases in which the sufferings of the woman go beyond 
 a certain point, and especially when they prevent sleep, opium may be 
 given without hesitation, either by the mouth or by enema. It is well, 
 however, before giving opium in any form, to be sure that there is no 
 irritation of the bowel, from overdistension or any other cause, as it 
 will be proper to relieve that condition before having recourse to seda- 
 tives. Dr. Tyler Smith found benefit occasionally to result from the 
 application of an anodyne embrocation to the breasts. It must be 
 clearly understood that after-pains, although due, in their usual form, 
 to a physiological action, are, when severe, not to be neglected; for,, 
 not only may the want of sleep and constitutional irritation lead to> 
 unpleasant results, but the case, if abandoned to nature, may even pass 
 
612 THE LACTEAL SECRETION. [CHAP. 
 
 into inflammatory disease, which, at this particular epoch, is, as we 
 shall see, peculiarly disastrous in its effects. 
 
 [Professor Barker [Puerperal Diseases, p. 8) describes a variety of 
 neuralgic after-pains which is met with occasionally. In these cases 
 the abdomen is neither tender nor distended, but the uterus, though 
 normal in size, is tender on pressure. There is no febrile reaction. 
 This condition does not yield to opiates, but is promptly relieved by five 
 to ten grains of quinia, given night and morning. At the same time, 
 Dr. Barker recommends that a liniment, composed of chloroform §j 
 and compound soap linament §vj, should be applied to the abdomen on 
 flannel.— P.] 
 
 The Lacteal Secretion. — The enlargement of the breasts, which is so 
 characteristic a sign of pregnancy, is usually accompanied, not only 
 with increased development of the mammary glands, but also, during 
 the last few months of gestation, with a secretion of more or less milk. 
 The quantity is, however, small, and although it may, in some cases, 
 be pressed out in jets from the nipple, there is no accumulation of the 
 fluid in the ampulla? of the galactoferous ducts. In most women, no 
 marked alteration takes place until about the third day, when the secre- 
 tion of the milk — properly so-called — commences. At this time, there 
 often is what has been described as a rush of milk to the breasts. The 
 glands become considerably enlarged and greatly more vascular, and 
 the pulse very commonly rises a little, when the mother may complain 
 of headache. A febrile condition has indeed been described by the 
 older writers as a normal accompaniment of the establishment of the 
 secretion, but the constitutional symptoms to which the local determi- 
 nation of blood at this time gives rise can scarcely with propriety be 
 described as a fever. This is true, at least, in regard to all ordinary 
 cases ; but it is by no means an unusual occurrence for the patient to 
 be attacked with a rigor, which is generally slight, followed by heat of 
 skin, rapid pulse and headache — symptoms which are relieved by free 
 perspiration and a copious secretion of milk. 
 
 This is what is commonly known as Milk Fever, and is identical 
 with what is otherwise described as ephemera or weid. Whatever the 
 degree of fever may be, the state of the breasts requires prompt atten- 
 tion. One of the advantages of putting the child early to the breast is 
 that it draws out the nipple, which may be small or flat ; and what is 
 now very likely to occur, should this have been omitted, is a projection 
 of the areola, which participates in the tumefaction of the rest of the 
 gland, so that the nipple falls in as it were on a level with the skin, 
 when it becomes a matter of some difficulty for the child to seize it. 
 Putting the child to the breast is the natural and almost instinctive 
 method which the woman adopts for the relief of the painful distension 
 which she experiences, but as the child at first drinks but sparingly, it 
 may be necessary for the nurse to relieve the gland by the use of the 
 breast-pump or otherwise, aided by gentle frictions with olive or cam- 
 phorated oil. These may be directed more especially to such portions 
 of the gland as may show a tendency to induration or knotting, due in 
 the first instance to local accumulations of milk, and subsequently, if 
 neglected, to inflammation of the surrounding tissues, which may pro- 
 
XXXVIII.] LACTATION. 613 
 
 eeed to abscess. It is always of importance to keep the breasts cool at 
 this stage, and it may even be necessary to keep down the temperature 
 by evaporating lotions when there is reason to apprehend the more 
 violent action which is apt to culminate in abscess. No small amount 
 of suffering arises in some instances from the weight of the inflamed 
 gland,, which gives rise to dragging and aggravation of all the symp- 
 toms. This condition can fortunately be greatly relieved by the simple 
 expedient of suspending the breast by means of a handkerchief slung 
 round the neck. 
 
 It is a very usual thing for nurses to put the child frequently to the 
 breast, with the view of relieving such symptoms as are here described. 
 This, however, should always be done with caution, and in view of the 
 whole circumstances of the case. For, it must be remembered that this 
 effect of the contact of the child is not only to empty the breasts but 
 also to stimulate them to increased secretion, and if this latter effect — 
 as it well may be — is in excess of the former, the treatment is obviously 
 injudicious, and is likely either to precipitate the direct effects of in- 
 flammation, or to induce an excessive secretion of milk, which in most 
 women has a serious effect upon the general health. Besides, the too 
 frequent contact of the child is apt to cause certain painful affections of 
 the nipple, to which we shall afterwards advert, and is by no means 
 free from risk to the child itself. 
 
 The Colostrum, or milk first secreted, is somewhat irritant, and thus 
 has a satisfactory effect in removing, by its laxative action, what re- 
 mains of meconium in the bowels, and in preparing the mucous mem- 
 brane of the alimentary canal for its functions of assimilation and excre- 
 tion ; but the too frequent ingestion of this, or even of perfectly 
 developed milk, is apt to keep up a continuous digestive action in the 
 stomach, and give that viscus no time to rest; and even when the child 
 sucks vigorously, the repeated overdistension of the stomach only 
 results in rejection again and again of what has been swallowed. The 
 mother ought, if possible, on each occasion, to put the child to both 
 breasts, as the emptying of one, and leaving the other in a state of com- 
 plete distension, as is sometimes done, is not likely to contribute much 
 to her comfort. It % is always better partly to empty both breasts than 
 wholly to empty one. 
 
 It is, therefore, of great importance that the mother should be warned 
 from the first not to put the child too frequently to the breast. If 
 the child sleeps by her side, this is the ready method of cure for rest- 
 lessness and screaming fits, and the child is often allowed to fall asleep 
 with the nipple in its mouth; but, if it once contracts this habit, it may 
 become impossible for it to be put to sleep in any other position, while 
 it drinks at intervals without the consciousness of the mother. This, of 
 course, an experienced nurse will never permit, but it is a matter of 
 greater difficulty to determine what is sufficient nourishment for an in- 
 fant, and at what intervals it should be given. This would perhaps fall 
 more properly to be considered in the following chapter, but as it in- 
 volves the interests of the mother as well as those of the child, we may 
 here observe that it is of much importance to accustom the child from the 
 first to drink at regular intervals. These, to begin with, may be every two 
 
614 LACTATION. [CHAP. 
 
 hours, or if the child be premature or feeble, and on that account able 
 only to take a small quantity of nourishment at a time, it will be 
 necessary to put it to the breast at shorter intervals. But the object of 
 the mother should always be to increase the interval until, after the 
 second or third week, the infant becomes accustomed to take its natural 
 nourishment every three or even four hours. This enables the mother 
 to have her natural rest, and allows of the steady and satisfactory filling 
 of the breasts against the stated periods. 
 
 It often happens, in women, too, who have an abundant supply of 
 milk, that much disappointment results from the frequent escape, and 
 consequent waste of the secretion. A certain amount of overflow, just 
 at the commencement, when the breasts are tumid and distended, is so 
 far beneficial ; but when this goes on, — independent, it may be, of the 
 amount of the secretion — it comes to be a serious matter, and may give 
 rise to no little perplexity and annoyance. The milk which thus runs 
 from the breasts may keep the woman in a constant state of moisture 
 and discomfort, and although it is possible to collect the fluid dis- 
 charged in small vessels which are used for the purpose, and even to 
 give it to the child by a spoon, this is always an unfortunate occur- 
 rence. It is certain that, by careful attention to the period at which 
 the child should be put to the breast, on the one hand guarding against 
 overdistension, and on the other avoiding frequent and irregular ap- 
 plications of the child, much may be done to prevent this loss. In 
 some cases, when the glands reach a certain stage of distension, the 
 woman is conscious of a feeling of momentary discomfort, and then of 
 involuntary contraction, immediately after which the greater part of 
 the accumulated secretion is expelled, not unfrequently in jets. In 
 other instances, this spasmodic contraction is excited by the contact of 
 the child, when both breasts are simultaneously the seat of contraction, 
 so that while the infant is half choked with the milk of one breast, 
 that of the other is expelled in jets as before. In another class of cases, 
 the application of the child is attended with acute pain in the breast 
 of a neuralgic character, sometimes, indeed, so severe as to cause the 
 woman to cease nursing. Emollient and sedative applications, such as 
 belladonna, have been employed with the view of soothing this painful 
 affection; but in some cases it defies both these and internal remedies, 
 and ultimately compels the woman to yield. 
 
 Every conceivable shade of difference is found to exist between dif- 
 ferent women, even of the same constitution and temperament, in the 
 quantity of the lacteal secretion, and also in regard to its quality. In 
 one case, we find a delicate, fragile woman, who may even be the sub- 
 ject of constitutional disease, and who is, nevertheless, overburdened 
 with milk ; while, in the next which comes under our notice, a young, 
 robust, and vigorous woman, who has never had an hour's illness, fails 
 completely in so far as the lacteal function is concerned. We do not, 
 of course, mean to imply that these are common cases, but they are 
 certainly not such as would cause the experienced practitioner a mo- 
 ment's astonishment. The commencement of lactation may, in like 
 manner, be ushered in with all the usual symptoms, and be at first 
 abundant only to fail in a few days ; while, in another, the secretion is 
 
XXXVIII.] GALACTORRHEA. 615 
 
 ultimately satisfactorily established after a period of doubt and diffi- 
 culty. Although, therefore, we know that strong and healthy women 
 are more likely to prove good nurses, we can never be certain, until a 
 week, or even longer, has passed, how the case, in this respect, is likely 
 to turn out. There is no doubt that, although there are other condi- 
 tions which influence the secretion of the milk, the state of the uterus, 
 and the natural sequence of events of which it is the seat, exercise an 
 important influence, owing to the well-known sympathy which sub- 
 sists between the organs. 
 
 In the condition which has been termed Agalactia, the secretion is 
 either altogether arrested, or is manifestly insufficient in quantity for 
 the nourishment of the infant. Among the most frequent causes which 
 lead to this condition are acute diseases, more especially if they imme- 
 diately succeed the period of delivery. It is, in fact, one of the most 
 common symptoms of those febrile diseases which sometimes supervene 
 on the puerperal state, to the alarm of the attendants, and not seldom 
 with the most disastrous results ; and the failure of the secretion is 
 always looked upon as of more serious import, if it is accompanied by 
 the premature cessation of the lochia. But, independent of any other 
 marked or serious symptom, there is sometimes a simple failure of the 
 discharge, where it is difficult or impossible to recognize the cause. 
 
 We are not, however, to suppose that such failure is conclusive evi- 
 dence of permanent incapacity, on the part of the woman, to discharge 
 this natural function. If due to a febrile condition of moderate dura- 
 tion, the discharge will often reappear with the abatement of the pyrex- 
 ial symptoms ; so that, by feeding the infant artificially for a time, we 
 may wait until we see whether or not the function will be re-established. 
 This will be furthered by the application of warm fomentations to the 
 breasts, and of late years the leaves of the castor-oil plant have been 
 extensively used as a local application, with the view of increasing or 
 exciting the secretion. For this purpose the leaves are to be boiled in 
 a small quantity of water, and are to be applied along with the water 
 in which they have been infused, in the form of a fomentation. 
 
 The quantity of the lacteal secretion is, under no circumstances, to 
 be accepted as a criterion of its quality. The eye enables us, in some 
 measure, to judge of the abundance of the corpuscular elements upon 
 w T hich the nutritive value of the secretion mainly depends. This may, 
 however, be more accurately ascertained by means of a lactometer, or 
 by the use of the microscope ; but it is to be remembered that the 
 richest milk is by no means that which is necessarily best suited for the 
 child. 
 
 Galactorrhea , or a too abundant secretion of milk, has been described 
 under two forms, involving very different conditions and management. 
 In the one, the quantity alone is abnormal, the nutritive value of the 
 secretion being unaffected, so that our object in treatment would natu- 
 rally be to guard against such an unnecessary drain upon the mother, 
 as might be expected ultimately to compromise her general health. 
 In this variety, the effect produced upon the child may be perfectly 
 satisfactory, the only inconvenience, in many cases, being from the 
 rapidity and abundance of the flow from the reservoirs within the gland, 
 
616 LACTATION. [CHAP. 
 
 so that the mouth of the child fills much more rapidly than it can 
 swallow, to its great and obvious discomfort. The treatment of such 
 a case should consist mainly, if not entirely, in regulation of the diet, 
 watching narrowly the while what effect is being produced upon the 
 health of the mother, and adopting such means as may seem necessary 
 for its rectification, by the partial arrestment of the discharge, or other- 
 wise. 
 
 In the other variety of galactorrhea, the conditions are widely dif- 
 ferent. Here, too, there is abnormal abundance ; but, in addition, we ' 
 find that the increase in bulk depends mainly or entirely upon an 
 augmentation of the watery part of the fluid. Not only is this a state 
 of matters extremely unfavorable to the infant, but it is often observed 
 to exercise an unsatisfactory influence upon the mother. Indeed, in 
 extreme cases, so serious and so obvious are the effects thus produced, 
 that the expression " Mammary Diabetes" has been suggested by the 
 rapid emaciation which occasionally supervenes. Along with great 
 feebleness, there unfortunately exists sometimes, in these cases, com- 
 plete loss of appetite, so that it is almost impossible to combat the 
 symptoms by what we might judge to be appropriate diet. When the 
 anorexia is less marked, the digestive functions may be disturbed, — 
 gastric and intestinal disorders being of frequent occurrence, taking the 
 form, it may be, either of vomiting with heartburn and pyrosis, or of 
 obstinate diarrhoea with flatulent distension and tenesmus. In those 
 cases, ordinary remedies may prove of little avail, and after a few weeks 
 of struggle it will become evident that no alternative remains except 
 to wean the child, and take such other measures as may permanently 
 arrest the secretion. This affection is believed to be particularly dan- 
 gerous to those who have any phthisical tendency. 
 
 From what has been said, it will be sufficiently obvious that the 
 Management of Lactation must not unfrequently be a prominent part 
 of the duties of the accoucheur. Nothing, in this respect, is more 
 important than that the diet of a nursing woman should be, in quantity 
 and quality, such as is most likely to conduce to the health of the 
 child, as well as to her own. In the case of a perfectly healthy woman, 
 but little attention to regimen is required, — nothing further being 
 necessary, in such instances, than that the woman should avoid any 
 imprudence in diet, while in other respects she need make no change 
 in her ordinary habits. The pregnant state, however, and the subse- 
 quent exhaustion which attends the process of parturition, very generally 
 leave the woman in a condition which manifestly requires generous 
 treatment, in order that the health may be re-established, while pro- 
 vision is made for the special drain on the system which the function 
 of lactation involves. Among the higher classes, where luxurious 
 habits tend to the diminution of constitutional vigor, and among the 
 inhabitants of towns, the necessity for such treatment is much more 
 prominently marked than in country districts, where a life of physical 
 exertion, spent, to a great extent, in the open air, implies hygienic con- 
 ditions which are the very opposite of those which we observe in the 
 other case. In ordinary practice, however, the necessity for a liberal 
 dietary is so universally recognized that there is a danger of falling 
 
XXXVIII.] MANAGEMENT OF LACTATION. 617 
 
 into a routine practice in this respect, the result of which will, un- 
 doubtedly, in some cases, be the reverse of beneficial. 
 
 As the result of some experience and close observation, we are con- 
 vinced that indiscriminate overfeeding and stimulation of nursing 
 women is a more frequent cause of the disorders of early infancy than 
 is usually supposed. Nurses and mothers can readily understand how 
 a thin and watery milk should fail to nourish the child, but it is by no 
 means so easy to convince them that a specimen rich in nutritious ele- 
 ments may possibly be, from its very richness, the cause why an infant 
 does not thrive. We have again and again seen cases of obstinate 
 diarrhoea, with or without vomiting and other symptoms of gastro- 
 intestinal derangement, which could only be attributed to this cause. 
 Drugs are of no avail : the appearance of the mother may be such as to 
 prevent even a suspicion of any fault on her side, and yet strict inquiry 
 as to what she eats and drinks often points clearly to the simple and 
 only proper treatment. It is to the use of stimulants that the attention 
 should in these cases be more particularly directed ; for we often find 
 that women are encouraged, without any reference whatever to their 
 general health, or the state of the milk, to take considerable quantities 
 of ale or stout, or of the stronger wines. Diminishing the quantity of 
 these stimulants, and in some cases absolutely forbidding their use, will 
 certainly, in many instances, be followed by a marked and immediate 
 amelioration in the symptoms. But, even when stimulants are not ad- 
 mitted into the dietary, the cause may still be discovered in the habitual 
 use of food which is too stimulating in its character, or which is taken 
 in too great quantity. 
 
 An interesting series of observations, bearing directly on this sub- 
 ject, have been deduced from analyses conducted by M. Peligot, with 
 the view of ascertaining the nutritive value of the lacteal secretion at 
 various epochs. From these analyses it would appear that the longer 
 the milk remains in the breast, the thinner and more aqueous does it 
 become. It has been clearly established, further, that the milk which 
 first flows from a distended breast — this being the portion soonest se- 
 creted — is comparatively watery, and that the quality of the milk be- 
 comes richer as the gland is progressively emptied. Hence a very 
 obvious indication of treatment. When, for example, the child seems 
 to be suffering from too rich milk, and there is reason to suppose that 
 it is put too frequently to the breast, before the gland has time to fill, it 
 may suffice to extend the period between the repasts, which, by giving 
 the gland time to fill, also insures that the child obtains a less rich 
 milk, and one more suited to its digestive capabilities. And we be- 
 lieve that the same facts may possibly be turned to account in the treat- 
 ment of the opposite class of cases, where the secretion is too watery, 
 and yet abundant, by partially emptying the breast before the child is 
 put to it, so that, the more watery portion of the milk being removed, 
 the child obtains the more nutritious residue. 
 
 The duration of lactation varies very considerably. It may cease 
 quite unexpectedly, a few weeks, or even days, after the secretion has 
 been established, or it may last for years. Between these two extremes 
 the range is obviously great ; but, as a rule, in cases in which the 
 
618 LACTATION. [CHAP. 
 
 whole circumstances are perfectly normal, the average duration may 
 be set down as from twelve to fifteen months. This is, of course, sup- 
 posing that the woman goes on nursing, and that nothing is done with 
 the view of interrupting the function. The influence which is pro- 
 duced upon lactation by the menstrual function, is a subject in regard 
 to which very vague ideas are sometimes entertained. As a rule, a 
 woman does not menstruate while she continues to nurse, so that no 
 disturbing influence from this source normally exists. In a very con- 
 siderable number of instances, however, she menstruates after five or 
 six months ; and, in a small proportion of cases, the menstrual function 
 is regularly discharged during the whole period that she gives suck. 
 Much discussion has taken place as to the influence which the consti- 
 tutional disturbance inseparable from the menstrual molimen exercises 
 on the process of lactation ; and the question is often put to the medi- 
 cal attendant, whether the appearance of the catamenia is a sufficient 
 reason for ceasing to nurse. It is beyond doubt that, in a large num- 
 ber (probably the majority) of cases in which menstruation occurs dur- 
 ing lactation, no perceptible effect is produced upon the child. It is 
 equally true, however, that marked disturbance of the one function 
 attends the premature establishment of the other, as is evidenced by 
 the most delicate of all tests, — disturbance of the functions of the child, 
 which in some cases is very marked, and recurs at successive menstrual 
 epochs. We must not, therefore, in replying to the question stated 
 above, rashly assume, either that menstruation forbids nursing, or that 
 it is to be disregarded. The truth lies between the two, and the solu- 
 tion of the question is to be found in a careful observation of the effects 
 which are produced on the mother and child, upon which alone a defi- 
 nite opinion can be formed. 
 
 It sometimes happens that a woman becomes pregnant while she is 
 still nursing, although the rule is that, during lactation, the generative 
 functions are in abeyance, in so for, at least, as ovulation is concerned. 
 In the exceptional instances referred to, it is not too much to suppose 
 that, the whole generative force being diverted into a new channel, the 
 nursing power must necessarily diminish ; and that this is actually the 
 case, is the experience of all who have watched these phenomena most 
 closely. During the first weeks of such a pregnancy, the lactation 
 may be but little disturbed, although there is good reason to believe 
 that a failure in the amount of the milk, or an alteration in its quality, 
 precedes, not unfrequently, the period at which the woman becomes 
 conscious of her state. On the whole, we do not hesitate to assert that 
 the existence of pregnancy is a clear indication that the woman should 
 cease to nurse. 
 
 The important function of lactation is liable to certain disorders, or 
 disturbing influences, the management of which comes necessarily un- 
 der the duties of the medical attendant. The most familiar of these is, 
 undoubtedly, Inflammation of the Mamma ; and, when we consider 
 the sudden determination of blood, and consequent turgescence of the 
 gland, our feeling may be one of astonishment, not that it often in- 
 flames, but rather that it, as a rule, escapes inflammation. From 
 whatever cause it may spring, the condition of the gland during the 
 
XXXVIII.] MAMMARY ABSCESS. 619 
 
 puerperal state must manifestly be such as to favor the extension of 
 inflammatory action which has arisen within the structure. Exposure 
 to cold, the irritation of sore nipples, and constitutional disturbance of 
 various kinds, are a few, among; many, causes leading to local inflam- 
 mation, which almost invariably attacks, in the first instance, the 
 tubular structure of the gland. But a mere local affection of an exter- 
 nal organ of limited extent, would probably be looked upon with little 
 alarm, were it not for the fact that there here exists a peculiar liability 
 to the formation of pus, resulting only too frequently in the formation 
 of Mammary Abscess. 
 
 It is said that women of a weakly, delicate, or scrofulous constitution 
 are peculiarly liable to mammary abscess ; but, whether this be the case 
 or not, there are many cases in which, in women of perfect health and 
 vigorous constitution, this troublesome affection quite unexpectedly 
 manifests itself. There is, certainly, a great tendency to its reappear- 
 ance in those who have suffered on a former occasion ; but, beyond this, 
 there is no marked predisposition upon which we can rely. The in- 
 flammation which precedes the formation of abscess is, if it be at all 
 severe, ushered in by rigors, which are often of considerable severity. 
 This is immediately followed by fever, and very shortly by lancinating 
 pain in the breast, which is increased on pressure. The site of the pain, 
 usually circumscribed, is further indicated by the presence of swelling 
 and hardness, which, in favorable cases, become gradually resolved as 
 the inflammation subsides, without the formation of pus. 
 
 But, when abscess forms, the progress of the case is widely different. 
 The inflammatory action, commencing, as we have seen, in the glan- 
 dular structure, extends to the cellular tissue. The tumor, hard before, 
 becomes less circumscribed and softer, although no less painful. The 
 general symptoms are unabated; and, as the swelling still further 
 increases, the cutaneous surface becomes hot and red, and ultimately 
 cedematous, and glazed or shining. The latter symptoms indicate the 
 formation of pus, the presence of which is still more clearly manifested 
 by the feeling of fluctuation, which becomes more and more distinct as 
 the cavity enlarges, and the pus approaches the surface. With the 
 formation of matter, there may be a renewal of the rigors, and there is 
 generally painful throbbing and exacerbation of the fever. Finally, 
 the cutaneous tissues yield, and the abscess bursts, discharging its con- 
 tents, to the great relief of the patient. Unfortunately, however, her 
 troubles do not always cease here; for, under the influence of a pro- 
 tracted drain on the system, she may be reduced to a condition of 
 deplorable weakness, which may be aggravated by obstinate gastric or 
 intestinal derangement, or by profuse night-sweats. The cases which 
 are, in the first instance, the most severe are not necessarily those which 
 ultimately produce the most serious effect upon the patient. It is true 
 that the symptoms are, at first, in proportion to the violence of the 
 inflammation and the extent of the abscess. But, on the other hand, 
 the violence of the attack is often, under such circumstances, apparently 
 expended ; and, unless the discharge is abnormally protracted, the 
 gland may gradually resume its healthy condition and normal function, 
 w T hile the constitutional symptoms rapidly disappear. 
 
620 LACTATION. [CHAP. 
 
 In another class of cases, the symptoms at the outset are compara- 
 tively moderate, and the abscess correspondingly small. When the 
 latter discharges itself, or is relieved by operation, the cavity contracts, 
 and we imagine that the case is at an end. But, ere long, the former 
 symptoms reappear, a second abscess forms, runs its course, and dis- 
 charges its contents as before ; and, in some cases, a succession of such 
 local inflammations, individually of limited extent, may produce, col- 
 lectively, such effects as more seriously to influence the health than a 
 case which may at first have excited more apprehension in our minds. 
 In those cases of repeated small abscesses, there is often extensive in- 
 duration, which may affect the whole, or the greater part of the gland, 
 especially that part of it immediately surrounding the nipple. 
 
 [For purposes of study, inflammation of the mammary gland may be 
 divided into three varieties ; that affecting the areolar tissue of the 
 organ ; that involving the tissues between the breast and the chest- wall 
 (subglandular inflammation) ; and lastly, that affecting the glandular 
 tissue proper. The first and second varieties do not differ in their 
 nature from simple phlegmonous inflammations in other parts of the 
 body, but the subglandular form is attended with some special symp- 
 toms, owing to the deep seat of the inflammation, and to the fact that 
 the pus when it forms is bound down by the thick tense mammary 
 gland on one side, and the unyielding chest-wall on the other. The 
 result is that the woman suffers extreme pain, and sometimes grave 
 constitutional disturbance. The pus when formed approaches the 
 surface slowly, and if the abscess is not opened the matter often finds 
 egress by several orifices, which result in long fistulous tracts, which heal 
 slowly, and which may result in profound exhaustion from the com- 
 bined influence of the discharge and the irritation which they produce. 
 
 The glandular form of mastitis is often attended with considerable 
 constitutional disturbance. There is more febrile reaction than when 
 the inflammation involves the subcutaneous connective tissue alone, 
 while the pain is often severe. A number of abscesses sometimes form 
 in succession in different portions of the gland. The swelling may 
 become indolent, the induration continuing for weeks, and even months, 
 almost unchanged. We have seen four months elapse before suppura- 
 tion occurred, the woman in the meantime being troubled by the weight, 
 tenderness, and lancinating pains in the diseased breast. During this 
 period there is always a hope that the formation of pus can be pre- 
 vented. — P.] 
 
 The result of severe inflammation of the mamma, whether the abscess 
 be single or multiple, usually is to destroy the nursing function of the 
 gland. It is not that the secerning function of the gland is necessarily, 
 or even generally, arrested ; but rather that the application of the child 
 is attended with such pain and irritation, that it is at once impossible 
 and undesirable. If the matter has been allowed to make its way to 
 the surface, it often happens that a certain amount of sloughing occurs 
 of the tissues surrounding, and immediately subjacent to, the orifice. 
 By the same process, the continuity of the galactoferous tubes is also 
 occasionally destroyed, and, as a consequence, a lacteal fistula is estab- 
 lished. The continued secretion of milk in the unaffected portions of 
 
XXXVIII.] TREATMENT OF MAMMARY ABSCESS. 621 
 
 the gland is sometimes a serious obstacle, in this and other ways, to the 
 satisfactory issue of the case ; so that it is proper, in many instances, 
 by friction or the external application of belladonna, to do what we can 
 to arrest permanently the function of the mamma on the affected side. 
 It sometimes happens that, by sympathy or otherwise, the other gland 
 becomes similarly affected by inflammation and abscess, which, of 
 course, makes the case a much more serious one. 
 
 The treatment of inflammation of the mamma is thus, it need scarcely 
 be observed, a matter of the highest importance. The initiatory phenom- 
 ena of inflammation are to be combated by a careful management of 
 the secretion, which should not be permitted to accumulate within the 
 gland. This is, however, a matter of considerable difficulty ; for, while 
 the application of the child, or the breast-pump, is often productive of 
 irritation, rubbing of the breasts, which is the other alternative, is apt 
 to increase it also. Cold or evaporating lotions are not to be depended 
 upon ; so that we are often obliged at once to have recourse to leeches, 
 fomentations, and poultices, just as we would in the case of the inflam- 
 mation of any other gland. 
 
 Should all our endeavors fail — as, unfortunately, they often will do 
 — to arrest the inflammation, the earliest indications of the formation of 
 pus are to be earnestly looked for. So soon as fluctuation can be de- 
 tected, however faintly, the case may, we believe, often be cut short by 
 early puncture, by means of an exploratory trocar or needle, which, 
 by giving vent even to a few drops of pus, relieves tension, and often, 
 apparently, arrests the course of the disease. Where fluctuation is 
 already distinct, and near the surface, free incision should be practiced, 
 on ordinary surgical principles, in the most depending part, so as to 
 give immediate egress to the pus which has formed, making the open- 
 ing — in order to avoid the lacteal tubes — in a direction radiating from 
 the nipple. Both before and after the operation, great comfort is afforded 
 to the woman by suspending the breast, by means of a handkerchief 
 tied round the neck. In the case of a large abscess, the contraction of 
 the cavity may be promoted by the application, externally, of broad 
 strips of sticking-plaster, so adjusted as to contract the cavity within 
 which the matter lies. In other respects, the affection is to be treated 
 as an ordinary surgical lesion, while the general health must of course 
 be carefully attended to. Whenever much trouble is encountered in 
 the treatment of mammary abscess, we should not delay in ordering the 
 removal of the child from the breast. 
 
 [The treatment of mammary inflammation and abscess is a subject of 
 great practical importance, and one about which the young practitioner 
 cannot be too thoroughly informed. It is unfortunately one in regard 
 to which the directions of text-books are too often vague and indefinite. 
 
 For a number of years the editor, in his clinical lectures at the Phila- 
 delphia Hospital, has taught the large classes of students who have 
 honored him with their presence, to give personal attention to the con- 
 dition of the breasts in every parturient woman under their care. Many 
 nurses appear to think it their especial function to attend to these organs, 
 and the writer has frequently known them to resent any interrogations 
 of the accoucheur in regard to the breasts, as an unwarrantable inter- 
 
622 LACTATION. [CHAP. 
 
 ference with their duties, while the young physician is too apt to accept 
 their statements,. and to be restrained from making a personal examina- 
 tion of the glands from motives of delicacy. As a consequence of this 
 we have several times known mammary abscess to be discovered by the 
 medical attendant too late to be aborted, or the conditions which give 
 rise to it to escape his notice until too late to prevent these distressing 
 results. We cannot therefore lay down a better practical rule for the 
 guidance of the young obstetrician, than to make himself personally 
 acquainted with the state of the breasts of his puerperal patient each 
 day until the danger of mastitis is past. If the nurse is trusted, and 
 information is received secondhand, he will surely have to regret his 
 negligence sooner or later. 
 
 The treatment of inflammation of the breast varies with the condi- 
 tion of the patient and the stage of the disease. It may sometimes be 
 aborted if treatment is commenced during the first twenty-four hours 
 after the commencement of the disease. If the patient is vigorous, 
 with high febrile reaction, and a full, strong pulse, we would not hesi- 
 tate to administer a fever mixture containing ipecacuanha or even tar- 
 tarized antimony. This may be safely given on the fourth or fifth day 
 after confinement. The dose should be large enough to produce nausea, 
 and diaphoresis, which will be followed by relief of pain, fall of tem- 
 perature, and a diminution in the force and frequency of the pulse. 
 At the same time the woman should take a saline cathartic. The gen- 
 eral treatment of the subglandular variety does not differ materially 
 from that of inflammation of the areolar tissue of the organ itself. 
 
 In that form of inflammation in which the subcutaneous areolar tissue 
 is involved, the local treatment is very important. The patient will 
 sometimes be relieved by the application of leeches, but more frequently 
 the local use of iodine and astringent solutions will be found to be suf- 
 ficient. In order to be useful in aborting mammary inflammation, 
 iodine must be applied early, before the end of the first twenty-four 
 hours. Our own practice is to put it on freely, and then to cover the 
 breast with cloths wet in a strong solution of acetate of lead and opium. 
 If the patient is debilitated and weak, as is too often the case, depress- 
 ing febrifuges are, of course, contraindicated. In these women a com- 
 bination of neutral mixture and sweet spirits of nitre may be given 
 with quinia in doses as large as the patient will bear, as recommended 
 by Prof. Barker. Mr. Skey prefers dessertspoonful doses of Hux- 
 ham's tincture, but the alcohol in this preparation sometimes disagrees 
 with the stomach. In both strong and debilitated patients narcotics 
 may be demanded to relieve pain and procure sleep. 
 
 There are two questions in relation to the treatment of this stage of 
 the disease which demand a passing notice. Most nurses and even a 
 number of physicians imagine that benefit will be derived from rubbing 
 the breast under these circumstances. It is supposed that this favors 
 the discharge of the milk. We know of no more irrational treatment, 
 and it cannot be too strongly condemned. If an abscess was forming 
 in the cellular tissue of the arm, thigh, or any other part of the body, 
 any intelligent physician or surgeon would at once prescribe rest. In 
 
XXXVIII.] TREATMENT OF MAMMARY ABSCESS. 623 
 
 inflammation of the connective tissue of the breast, however, rubbing 
 is sometimes advised as though the diseases of this organ were governed 
 by laws different from those which control other parts of the body. 
 
 The second matter is the supposed influence of the milk. There can 
 be no doubt that the accumulation of this secretion in the glands leads 
 to irritation and pain. When this is the case they should be emptied 
 by sucking, performed either by the nurse or a puppy. If a breast- 
 pump is employed it should be done with great care. We have known 
 this instrument to cause an abscess many times, while we have very 
 rarely known it prevent one. Dr. McClintock, of Dublin, believes 
 that bad consequences rarely follow the accumulation of milk in the 
 breasts, and no inconsiderable experience has led the editor to conclude 
 that there is much truth in this opinion. The profession is not even 
 now freed from the erroneous pathological views of Puzos and his fol- 
 lowers, in which the retention of the milk played a prominent part. 
 The mammary gland, it seems, has been supposed to be an exception 
 to all secreting organs in the body in the tact that retention of its 
 secretion is followed by inflammation. This is not the case with the 
 kidneys, liver, or salivary glands. It is true, however, that the breasts 
 differ from these organs, because their secretion is not constant, because 
 they are called into functional activity more or less suddenly, and in a 
 manner that predisposes the organs to irritation and inflammation. 
 While, therefore, we wish to ascribe all due importance to the retention 
 of the milk, and acknowledge that it may produce uneasiness and dis- 
 comfort for the woman, we must protest against this being assigned a 
 high place amongst the causes of mastitis, as well as against the alleged 
 necessity of repeated and thoroughly emptying the organs in inflam- 
 mation of the areolar tissue of the gland and that which is between it 
 and the chest-walls. 
 
 The treatment of the first stage of glandular inflammation of the 
 breast is to be conducted upon the same general principles which 
 govern the management of the other varieties. In this form gentle 
 frictions are sometimes useful during the early stages by dislodging 
 the thickened secretion of the gland. The hand should be covered 
 with sweet oil or a solution of camphor in sweet oil, and the breast 
 rubbed from the circumference towards the nipple. Prof. Barker says 
 that he has found local applications of belladonna useful in this form 
 of the disease. We have repeatedly used the extract applied to the 
 breast on a cloth, but have never felt willing to conclude that much 
 benefit results from its use. It certainly relieves pain, but it is doubt- 
 ful whether it exerts much influence in diminishing the lacteal secretion. 
 Dr. McClintock believes that it does not, and in cases in which he 
 applied the cere-cloth to one breast and belladonna to the other in the 
 same woman, the results on the two sides did not differ materially. 
 
 If the measures just described do not arrest the progress of the in- 
 flammation, it is the duty of the medical attendant to favor sup- 
 puration by all the means at his command. It is important now to 
 decide at what time the abscess should be opened. Most authors 
 advise the early use of the lancet. The editor followed this advice for 
 a number of years after commencing practice. He was often mortified 
 
624 LACTATION. [CHAP. 
 
 and disappointed to find that after the discharge of the pus the process 
 of repair did not go on at all rapidly. After having read Dr. McClin- 
 tock's Clinical Memoirs on Diseases of Women, he concluded to try 
 the plan of opening the abscess late, which that author recommends. 
 The result of this practice has been in the highest degree satisfactory, 
 and has led him to conclude that the popular idea that an abscess 
 should " be ripe" before it is opened, is not entirely without foundation. 
 The writer's practice is to watch the disease carefully during the sup- 
 purative stage to prevent burrowing of the pus, but not to interfere 
 unless this occurs, until the pus has approached the surface and the 
 abscess is almost ready to open spontaneously. 
 
 It may be said by some, that under these circumstances it is not 
 necessary to use the bistoury at all. Clinical experience has disproved 
 this. If left to open itself, sloughing of the skin and subcutaneous 
 tissue may occur, leading to so much destruction of tissue that the 
 recovery of the patient may be considerably delayed. The incised 
 wound made by the knife preserves these tissues, while the evacuation 
 of the abscess is followed by contraction of its cavity and rapid recovery 
 of the patient. 
 
 Subglandular abscesses are often exceptions to the rule that punctures 
 should be made late. The pus in these is bound down between the 
 large, tense gland in front, and the unyielding chest-walls behind. 
 As a result, the patient suffers great pain, and yet it may be impossible 
 to demonstrate the presence of pus by fluctuation. Under these cir- 
 cumstances the breast should be seized and pulled forwards, when a 
 fine trocar or an aspirating needle may be inserted between the gland 
 and the thoracic wall in order to determine whether suppuration has or 
 has not occurred. If it has, an incision should be made beneath the 
 most dependent part of the gland. 
 
 If cure does not follow the discharge of the pus, the pressure by ad- 
 hesive strips, as recommended by the author, should be tried. 
 
 During this stage of the disease the strength of the woman should 
 be sustained by the use of good food and tonics. 
 
 In certain cases, and especially in the subglandular variety, long 
 fistulous tracts may follow an abscess. It is sometimes very difficult 
 to heal these. To lay open the sinus it is necessary to cut through the 
 whole thickness of the mammary gland, a procedure which is too serious 
 to adopt. In a case of this kind, in which several fistulous sinuses 
 followed an abscess between the gland and the chest-wall, we succeeded 
 in effecting a cure by repeated injections of a solution of carbolic acid 
 through a small trocar. In another instance a small piece of a stick of 
 nitrate of silver was carried to the bottom of the sinus and left there. 
 A cure followed. Many other remedies had been tried and had failed. 
 Injections of iodine and of the sulphates of zinc and copper have been 
 recommended under the same circumstances. Such sinuses can gen- 
 erally be readily cured if treated on ordinary surgical principles. — P.] 
 
 Excoriation and Fissure of the Nipple are affections so common, and 
 withal so troublesome and painful, that their treatment should be a 
 matter of interest to every careful and judicious practitioner. Although 
 in themselves they are comparatively of little moment, they are of 
 
XXXVIII.] TREATMENT OF MAMMARY ABSCESS. 625 
 
 peculiar importance as causes of the more serious affections which we 
 have just been considering. Much may, undoubtedly be done in the 
 way of prevention. Women, among the higher classes especially, should 
 be instructed to lave the nipple, for many weeks before delivery, with 
 some mild astringent or stimulant lotion, such as a weak solution of 
 tannin in rose-water, or any dilute spirit. Yv T hen, however, excoriation 
 has already taken place, the nurse should be instructed to apply some 
 very gentle astringent at first — nothing being better than a strong infu- 
 sion of tea. Failing this, the applications above recommended for pre- 
 vention may be tried, or other similar medicaments, — of which there is 
 an endless variety, — may be adopted. Care must, however, be taken 
 to avoid such substances as may be prejudicial to the child, — such as 
 acetate of lead ; and in all cases the application should be washed off 
 very gently before the infant is put to the breast. In the more obsti- 
 nate cases, the following will be found an admirable substitute: 
 
 R. Acid. Tannici, .... gr. iij. 
 
 Glycerin., ..... ( ^ss. 
 
 Unguent. Cetacei, ad . . • £h 
 Sig. To be used as directed. 
 
 Fissures or chaps are even more troublesome than excoriation ; for, 
 although they may at first be but trifling, every application of the child 
 tends to tear them open, and undo the healing process of the interval. 
 The above, or any similar ointment, will here also be found of great 
 use, the best method of application being to introduce it into the chap 
 by means of scraped lint. Should the margin of the fissure become 
 callous, it may be necessary to apply freely the solid nitrate of silver. 
 The nipple-guard, or shield, is, in all cases, useful in protecting the 
 affected parts from the pressure of the dress ; and, when much pain is 
 experienced in the act of suckling, the artificial nipple should be em- 
 ployed, which will protect the parts from the violence to which they 
 are often subjected by the vigorous sucking of a healthy child. In 
 some obstinate cases, the irritation is such that it may ultimately be 
 found necessary to remove the child permanently from the breast, and 
 to obtain the services of a hired nurse. 
 
 [Erosion, or fissure of the nipple, can sometimes be cured by the use 
 of a solution of nitrate of silver, varying from ninety to one hundred 
 and eighty grains to the ounce. The eroded or fissured surface should 
 be carefully cleaned and the solution applied with a camel's hair brush. 
 I am in the habit, if possible, of exposing the nipple to the direct rays 
 of the sun, after the application, until the surface becomes black. The 
 nitrate thus used forms a firm covering for the diseased surface. When 
 it separates the physician will often have the satisfaction of finding his 
 patient well. This method of treatment is applicable to fissures, 
 erosions, and to ulcers, providing the last do not involve the orifices 
 of the milk-ducts. If this is the case, the woman will have to quit 
 nursing. — P.] 
 
 40 
 
626 THE NEWLY BORN CHILD. [CHAP, 
 
 CHAPTEK XXXIX. 
 
 THE NEWLY BORN CHILD. 
 
 MANAGEMENT OE THE COED— CLOTHING— CLEANLINESS — LIGHT AND AIR — COLOS- 
 TRUM : IMPROPER USE OF LAXATIVES — THE MOTHER TO NURSE IE POSSIBLE — 
 SELECTION OE HIRED NURSES : THEIR DIET AND REGIMEN — CAUSES OF DIFFI- 
 CULTY IN SUCKING — CONGENITAL MALFORMATIONS — THE EXCRETORY FUNC- 
 TIONS — DIARRHCEA : SIMPLE OR " CATARRHAL," AND INFLAMMATORY OR "DYS- 
 ENTERIC" varieties: treatment of each — constipation: management 
 
 OF— ICTERUS NEONATORUM — THRUSH — ARTIFICIAL FEEDING: SUBSTITUTES 
 FOR BREAST-MILK : COW'S MILK, DILUTED AND SWEETENED: NURSING-BOT- 
 TLES: NURSE TO BE PROCURED IF CHILD DOES NOT THRIVE: OTHER ARTICLES 
 OF DIET: LIEBIG'S FOOD FOR INFANTS — WEANING — DENTITION. 
 
 The subject of this chapter has reference to certain points relative 
 to the management of the infant after its birth, and the treatment of 
 some of the more common ailments which are apt to attack it during 
 the first weeks or months of its existence. 
 
 So soon as the nurse has, after the termination of labor, attended to 
 those matters of detail which are essential to the comfort and safety of 
 the mother, her attention is naturally turned to the child, which is 
 then to be washed and dressed. The first point to be looked to after 
 it has been thoroughly cleansed by soap and warm water, is the stump 
 of the cord, which undergoes a process of putrefaction, and, ultimately, 
 in the course of a few days, separates at the cutaneous margin of the 
 umbilicus. The decomposition of the tissues of the cord takes the form 
 rather of withering than of moist putrefaction ; but, before it drops off, 
 there is generally more or less of the odor characteristic of the process 
 which is going on. To obviate this, it has long been the practice to 
 wrap the cord in cotton or linen, passing the stump, in the first in- 
 stance, through a hole which has been burnt in the cloth, so as to secure 
 the antiseptic action of the charred margin. This, of course, is not es- 
 sential, but is, undoubtedly, favorable to cleanliness ; and the dressing 
 may be renewed at proper intervals, to be determined by the amount 
 of moisture which makes its appearance, and which will depend, in a 
 great measure, on the thickness of the cord. It occasionally happens, 
 after the stump has dropped off, that the navel remains gaping and 
 raw, sometimes with ulceration, and even sloughing of the margins, a 
 condition which is always serious and sometimes fatal. For some time 
 after the separation is complete, there remains a tendency, more or less 
 marked, to the formation of umbilical hernia. This is particularly 
 noticeable in the case of children who are subject to screaming fits, and 
 to the straining which accompanies them; and is in all cases to be 
 guarded against by the application over the umbilicus of a soft pad, 
 

 XXXIX.] CLOTHING. 627 
 
 formed by several folds of linen, which is retained in position by a 
 broad bandage of flannel with which the abdomen of the child is 
 swathed. By increase in the thickness or otherwise, the pad may be 
 so modified, in cases in which protrusion is threatened, as to retain the 
 bowel within the abdominal cavity. 
 
 [Dr. William Goodell prevents many of the accidents which may 
 arise during the separation of the cord by the following modification of 
 Dr. A. F. A. King's method of managing that organ. When the 
 child is ready for removal, Dr. G. cuts the cord at the usual place, 
 and then seizes it between the thumb and forefinger of the left hand, 
 close to the umbilicus. Holding it firmly in this position, he then 
 proceeds to "strip" it with the thumb and index finger of the right 
 hand. 
 
 By this means all of the blood and much of the gelatine of Wharton 
 is removed. If there are accumulations of the latter in projections of 
 the funis, these lobules are to be nicked with the scissors, and their con- 
 tents squeezed out. The pressure near the umbilicus should now be 
 temporarily suspended, when the internal portions of the vessels col- 
 lapse. The part is now subjected to a second stripping, after which, 
 haemorrhage having ceased, it is tied in the usual manner. It is now 
 left entirely free without any dressing whatever. The result is that it 
 separates without any bad smell whatever, falling off " like a ripe fruit, 
 without leaving a raw stump." 
 
 Dr. Goodell states that since he has adopted this method of treating 
 the cord in the Preston Retreat, the astringent lotions, which he for- 
 merly had frequent occasion to use, are never called for ; " but that 
 since adopting this new method, out of more than two hundred infants 
 not a single one had had a pouting, angry-looking, or purulent um- 
 bilicus; nor had any one suffered from fungoid vegetations or umbilical 
 hernia."— P.] 
 
 The clothing of the child is in some measure to be regulated with 
 reference to season and climate. In all cases, however, it is to be re- 
 membered that birth almost necessarily involves a sudden and consid- 
 erable diminution of temperature. Any failure, therefore, in the vigor 
 of the circulation, such as may be anticipated in premature delivery, is 
 very likely to be attended with a corresponding diminution in the 
 temperature of the body, which not imfrequently involves great and 
 sudden risk to the life of the child. The maintenance, therefore, at 
 first, of an equable temperature is of the highest importance, and is 
 universally recognized. On these grounds, flannel — which, as a bad 
 conductor of heat, tends materially to sustain a steady temperature — 
 is, to a great extent, employed in the clothing of infants. It has also 
 the advantage of absorbing the discharges to some extent, and thus 
 preventing any irritation which may arise from their prolonged contact 
 with the cutaneous surface. While the infant is thus wrapped in its 
 swaddling-clothes, care should be taken so to arrange them as to admit 
 of free movement of the limbs from the first. It was at one time sup- 
 posed that the head of the child should be protected as carefully as its 
 trunk ; but the general practice now is rather to keep the head cool, so 
 that, in this country at least, it is the exception rather than the rule, 
 
628 THE NEWLY BORN CHILD. [CHAP. 
 
 to put even a light cap on the head of a child. Important as the 
 maintenance of an equable temperature is in all cases, it is much more 
 so when the infant is brought prematurely into the world, — when it is 
 necessary, in order to maintain the circulation, to swathe the limbs in 
 cotton-wool, at least during the first few weeks after birth. In all 
 cases, for the first few months, the heat of the trunk and lower limbs 
 is further insured by the use of long clothes. 
 
 Strict cleanliness is essential to the well-being of the infant; and in 
 nothing is the difference between a good and careless nurse more clearly 
 evidenced than by the management of the napkins, and the protection of 
 the parts from the contact of urinary and fecal discharges. Neglect 
 here frequently gives rise to troublesome excoriation of the nates, or in 
 the flexure of the groins; and nothing, perhaps, is of more importance 
 than that the child should be kept dry as well as clean. The use of 
 the warm bath is universal; but, as regards the frequency with which 
 it is to be employed, some degree of discretion may be exercised in indi- 
 vidual cases. Many nurses, after the first few days, undress and bathe 
 the infant, if perfectly healthy, night and morning, and apparently 
 with benefit as well as with safety. Caution should, however, in this 
 respect, always be enjoined, as, in some instances, too frequent bathing 
 seems to produce an exhausting effect ; and, in the case of feeble or sick 
 children, it may only be possible to insure cleanliness by rapid spong- 
 ing, while the bath is either avoided altogether, or repeated only at 
 intervals of two or three days. During the first six weeks, the child 
 should not be permitted to remain in the bath for more than two or 
 three minutes. 
 
 Light and air are as essential to the growth of a child as to that of a 
 plant. At first, however, caution is, even in these respects, necessary. 
 A dim and subdued light is thus more suitable, until the organs of 
 vision become, in some degree, accustomed to the new stimulus; and, 
 in like manner, until the new function of respiration, and the mainten- 
 ance of temperature, are efficiently and vigorously discharged, we must 
 take care, in our anxiety for pure air, not to expose the infant to vicis- 
 situdes of temperature. In the warm weather of summer, it may be 
 taken out somewhat earlier, although, as a rule, it is better not to carry 
 the child out of doors before the end of the second week; but, when 
 this stage has been reached, nothing, perhaps, is of greater importance, 
 or has a greater effect on the health and development of the infant, than 
 its daily exposure in the open air, clothed according to the requirements 
 of the season. 
 
 During the weeks which immediately succeed its birth, the infant 
 passes the greater portion of its time, by day as well as by night, in 
 sleep; but in this respect there is great variety, even with healthy 
 children. For example, it often happens that they sleep quietly and 
 almost continuously during the day, awakening only at intervals to go 
 to the breast, while at night they are wakeful and restless. This, after 
 a time, is often rectified by the management of an intelligent nurse, who, 
 by keeping the child awake during a part of the day, or it may be by 
 bathing it at night instead of the morning, succeeds in breaking the 
 habit, to the great relief and comfort of the mother, who otherwise has 
 
XXXIX.] SELECTION OF NURSES. 629 
 
 her rest broken and her nursing powers impaired. Sleep is certainly 
 encouraged, and often very markedly so, by the daily exposure to the 
 open air. 
 
 The child should, for various reasons — some of which have been pre- 
 viously mentioned — be put early to the breast. The laxative action of 
 the Colostrum generally produces the discharge from the bowels of the 
 dark-colored meconium which is lodged there. It is too much the 
 habit of nurses to dose the infant w T ith castor oil, under the idea that 
 it is necessary in order to set up the execretory function of the bowels. 
 This practice is no less deleterious in its results than it is irrational in 
 theory; and, in point of fact, there is no more fruitful cause of subse- 
 quent gastric irritation and intestinal derangement. The accoucheur 
 should therefore put his absolute veto on any such treatment without 
 his sanction, at least during the period while he remains in attendance. 
 It is no doubt more frequently necessary when the child is being nour- 
 ished with substitutes for breast-milk, but in the great majority of cases, 
 it is, to say the least, perfectly unnecessary. Another very general 
 practice is, during the first two days, before the secretion of milk has 
 been thoroughly established, to feed the child with sugar and water. 
 The effect of this, too, is often the reverse of beneficial, as this syrup is 
 not only unsuitable to the nourishment of a newly born child, but it is 
 also apt to derange the functions and to give rise to ulterior ailments, 
 which may be the cause both of trouble and anxiety. A mixture of 
 cow's milk and water, with a very small proportion of sugar, — or, better 
 still, of sugar of milk, — is a more eligible substitute ; but so soon as the 
 milk becomes abundant, all such methods should be abandoned for the 
 natural secretion of the mother's breast. 
 
 Every mother should be encouraged to nurse her own offspring, un- 
 less under certain exceptional conditions which have been referred to in 
 the preceding chapter. For not only is this to her advantage ultimately, 
 by preventing too frequent pregnancies, but it is to the advantage of the 
 child, by furnishing it with what nature has specially provided for its 
 support. What has already been said with reference to the function of 
 lactation, is sufficient clearly to show how important is the management 
 of that function, in its bearing upon the child, no less than upon the 
 mother. Care should be taken from the beginning to put the child to 
 the breast at something like fixed intervals, gradually extending the 
 periods from two to four hours, as has already been explained. This, 
 by allowing the breasts to fill, and permitting the mother satisfactory 
 and continuous sleep, goes some way to maintain the quality of the 
 milk; while, as regards the child, it gives the digestive and assimila- 
 tive functions time to rest. There is certainly no more fertile cause of 
 the minor digestive derangements, than the habits which prevail among 
 the ignorant, of constantly putting the infant to the breast, as the ready 
 method of cure for restlessness or screaming fits. 
 
 Various circumstances, — sometimes occurring quite unexpectedly, — 
 may render it impossible that the mother can nurse her infant. When 
 this is the case, the medical attendant should always recommend that 
 the services of a hired nurse be at once obtained ; and, if this recom- 
 mendation be acted upon, the duty of selecting a nurse devolves natu- 
 
frSO THE NEWLY BORN CHILD. [CHAP. 
 
 rally upon him. This is a matter of no small importance. From 
 what has been said in the preceding chapter as to the nutritive value 
 of the milk in different cases, it will be obvious that some caution must 
 be exercised, and especially that we should not too hurriedly infer, 
 either from the abundance or the apparent richness of the milk, that 
 the woman is to be looked upon with confidence, as necessarily a good 
 nurse. There are certain other matters in regard to which it is our 
 duty to inquire. We thus look narrowly, and as a matter of course, 
 to the general health, circumstances, and age of the applicant ; a per- 
 fectly healthy young woman, from a country district, and between the 
 ages of eighteen and twenty-eight, being generally preferred. With 
 reference to general health, some have attached considerable importance 
 to the state of the teeth, as affording a reliable indication ; and, al- 
 though this has certainly been exaggerated, there can be no doubt that 
 the early loss of the teeth, and especially of the front teeth, by decay, 
 is so far an unfavorable symptom. It is obviously our duty to deter- 
 mine, in so far as this may be possible, whether she is the subject of 
 any disease which may be transmissible to the child. Any evidence, 
 should it but amount to a suspicion, of serious organic disease, and es- 
 pecially of a phthisical tendency, may be held to warrant rejection. 
 Unfortunately, the circumstances are such, in many cases, as to admit 
 of, at least, the possibility of a syphilitic taint, and this is, therefore, 
 a point in regard to which we should very specially be on our guard. 
 To glance at the throat, the skin, the glands of the neck, and the hair, 
 are, on this account, matters almost of routine in such investigations. 
 We should also examine the breasts, — not only with regard to their 
 secretion, but as to the state of the nipple; and the presence of severe 
 excoriations, and still more of fissures at the base of the nipple, are to 
 be held as unfavorable conditions. And this for various reasons, — 
 one of the most important of which is the fact, that we can have no 
 confidence that she will prove a zealous and attentive nurse, if any 
 application of the infant to the breast is attended with discomfort or 
 suffering. If we have a choice in the matter, we should also select a 
 nurse whose condition, as regards the age of the milk, may be as nearly 
 as possible that of the mother, and if any change is permitted, it is 
 better that she should have been confined a little later than before her. 
 It is always a matter of importance to be able to see the child of the 
 nurse; and its condition may often be held to indicate the nutritive 
 value of the milk. There are, of course, other matters, which have 
 reference to the character and disposition of the woman, or to the fact 
 of her having had previous experience in the rearing of children, 
 which may be held as being of no small importance ; but these are, 
 perhaps, questions which do not so immediately come under the cogni- 
 zance of the medical attendant. 
 
 The diet and regimen of hired nurses is a matter to which some 
 prominence should be given. It is, indeed, of greater importance in 
 this case than in that of the mother, that no overfeeding or other 
 similar imprudence should be permitted. The simple rule in all such 
 cases should be that the woman is supplied with plain and easily di- 
 gested food, which, in point of quantity, should be ample, but, at the 
 
XXXIX.] CONGENITAL MALFORMATIONS. 631 
 
 same time, not more than is requisite for the maintenance of perfect 
 health. If, with the view of contributing to the health and vigor of 
 the child, the nurse is plied, as is often the case, with strong soups, 
 gruel, and stimulating articles of diet, at short intervals during the 
 day, the result is likely to be exactly the reverse of what is anticipated, 
 and the child suffers from overrichness of the milk, while the nurse 
 becomes rapidly fattened. No rule can be laid down, however, as to 
 the diet suitable for nurses, beyond this, — that a large proportion of 
 their food should consist in the simple and possibly frugal fare to 
 which they have been accustomed. In this way the danger to which 
 we have referred may always be avoided, but everything will, of course, 
 depend upon the habits of the country or district from which the nurse 
 has been procured. In the rural districts of Scotland, for example, 
 oatmeal, in the form of porridge, and generally eaten with buttermilk, 
 is one of the most important items in the daily food of the masses, 
 and is well known to be admirably adapted for women who are nurs- 
 ing, although it was some years ago stated in a report presented to 
 Parliament on the dietary of the English prisons that the food referred 
 to was " similar to what is used in England for the fattening of pigs." 
 The habits of the English peasantry and of the lower classes in all 
 large towns will require to be taken into consideration in the regula- 
 tion of the diet. With us, beer and other malt liquors are seldom 
 used, and are, therefore, quite unnecessary ; indeed it may be said that 
 if a woman cannot nurse without stimulants, her assistance may be 
 dispensed with. But, in England, where the daily use of beer is all 
 but universal, this, to which the woman has become accustomed, should 
 always be given, as probably essential to the maintenance of her phys- 
 ical condition. 
 
 The infant, if healthy, instinctively seizes the nipple from the first 
 and sucks vigorously, and indeed has often been seen to suck the finger 
 of the accoucheur before the trunk was born. It is not, however, always 
 so. The difficulty arises, in many cases, from a peculiarity in the con- 
 formation of the nipple, which may either be unusually small, or — 
 what is more common — has been carelessly allowed to be pressed in by 
 the dress during pregnancy. This may generally be got over by having 
 the nipple drawn out by the nurse or by a strong child, by the breast- 
 pump, or by a soda-water bottle used like a cupping-glass, care being 
 taken not to permit the parts to relapse into their former condition. 
 With care and proper management on the part of the nurse, this diffi- 
 culty is seldom a serious one. The child may, in other cases, especially 
 when born prematurely, be unable by weakness to take the breast, a 
 condition which is highly unsatisfactory. The woman, in these cases, 
 should milk her breast into the mouth of the child, when it will gen- 
 erally swallow the milk as it flows; or she may drain it off by the 
 pump, and feed the infant by a spoon ; but the objection to this is that 
 it is a bad plan to use a spoon if it can be avoided, for the child thus 
 becomes accustomed to the spoon, and still further loses the instinct for 
 the nipple. An idea extensively prevails among the lower classes that 
 when a child has difficulty in sucking, or refuses the breast, it is 
 " tongue-tied," but this is an obvious error. It, no doubt, does happen, 
 
632 THE NEWLY BORN CHILD. [CHAP. 
 
 although very rarely, that the fnenum of the tongue is too short, or 
 attached too far forward, but in ordinary practice, it will probably not 
 occur oftener than once in a lifetime that the accoucheur is obliged to 
 divide the frsenum for this variety of congenital malformation. 
 
 It is the duty of the accoucheur to examine the child after its birth, 
 and to inquire on his subsequent visits as to the various functions, in 
 order that congenital malformations may not be overlooked. It may 
 thus become evident either immediately or shortly after birth that the 
 child is affected with some peculiarity which must be remedied in order 
 to save its life. Such malformations as harelip fall more properly iuto 
 the domain of surgery, but in the case of an imperforate condition of 
 the anus or urethra, the general practitioner must be prepared to act 
 promptly. In the former, an operation is necessary by incision in the 
 direction of the rectum, or it may even be necessary in extreme cases to 
 form an artificial anus. Imperforate urethra, again, is rare, probably 
 for the reason which is pointed out by Burns, that " generally the canal 
 opens, in supposed cases of imperfo ration, about midway between the 
 scrotum and glans penis;" and the result of experience seems to be that 
 perforation of the glans seldom succeeds, so that it would probably be 
 better to cut down upon the urethra than attempt to find its extremity. 
 It may be necessary, even where there is no closure, to pass a probe or 
 a very small elastic catheter into the bladder, in consequence of retention. 
 
 We are often told, a considerable time after delivery, that the child 
 has not made water. On such information, however, we must never 
 act, unless there is some evidence of distension of the bladder. The 
 urine is often voided in the bath, and thus escapes the notice of the 
 nurse; and if retained for a longer period than usual the application of 
 cold water over the hypogaster, or a teaspoonful of cold water given by 
 the mouth, will generally have the effect of causing contraction of the 
 viscus. Nor is a tardy action of the bowels to be held as necessarily in- 
 dicating the administration of laxatives; for, in this as in the other 
 case, nature generally will, if left to herself, bring the function into per- 
 fect order without any extraneous assistance. We must, in like manner, 
 be cautious in the administration of such drugs as are usually employed 
 in the treatment of diarrhoea. Be it remembered, in the first place, that 
 there is, in healthy children, the greatest possible difference in the 
 manner in which the bowels discharge their functions. In one, the 
 frequency and the character of the evacuations may seem to amount to 
 diarrhoea, and in another the dejections are habitually costive; but so 
 long as the infant remains in perfect health, drugs of all kinds are to 
 be scrupulously withheld. In many cases, we may suceeed in produc- 
 ing the effect which we desire through the mother, but we can scarcely 
 be too cautious in any attempt to act directly upon the child. 
 
 Diarrhoea, although of more frequent occurrence during the process 
 of dentition, may happen at any period subsequent to the birth of the 
 child. A strict attention to the directions which have been given above 
 will suffice, as we have reason to believe, in most cases, to avert many 
 special conditions which are apt to lead to this troublesome affection ; 
 but even under circumstances the most favorable, the diarrhoea of infants 
 is only too familiar from its frequent occurrence. The ordinary " simple " 
 
XXXIX.] DIARRHCEA. 633 
 
 or catarrhal variety of diarrhoea, which is the most frequent, is also the 
 least serious; but, in the case of the newly born child, the enormous 
 quantity which is sometimes poured out may reduce the strength of a 
 puny infant so rapidly, as to place it in a most critical condition in the 
 course of a few hours, without any evidence whatever of inflammatory 
 action. If the action of the bowels is accompanied with obstinate 
 vomiting, the case may be looked upon as much more alarming in its 
 nature; but simple, uncomplicated diarrhoea is seldom dangerous, unless 
 it passes into the more serious variety. The appearance of the discharge, 
 as seen on the napkins, varies greatly, from a watery and almost color- 
 less fluid to a slimy matter, which may be frothy or bright-yellow like 
 the yolk of an egg, and in other cases green, mixed with fragments of 
 curdled milk, and possibly streaked with blood. A much more alarm- 
 ing variety is where the diarrhoea takes the "inflammatory" or "dysen- 
 teric" form, when it is generally attended with corresponding gastric 
 disturbance, with a marked increase in the temperature and in the fre- 
 quency of the pulse. Between the extremes, the varieties in individual 
 cases are endless, and, consequently, the treatment which may be held 
 as applicable in each must vary in a corresponding degree. 
 
 Unless on an emergency arising from the violence of the symptoms, 
 we should always, in very young children, try the milder measures first. 
 A teaspoon ful of lime-water given with a little boiled cow's milk, or 
 with the milk of the mother, has often a marked and immediate effect. 
 The number of cases which may be traced to imprudence in the dietary 
 of the mother or the nurse is, we believe, much greater than is generally 
 supposed ; and we would, therefore, recommend that this should always 
 be inquired into, and, if necessary, modified without delay. Should 
 the presence of blood in the stools, an appearance of tenesmus, and 
 general inflammatory symptoms, indicate the existence of the more 
 serious form, nothing has a better effect, if it can be retained, than 
 castor oil with a single drop of laudanum. Among other available 
 astringents are the tinctures of catechu or kino, which may be admin- 
 istered in the usual way with chalk mixture, to which may be added, 
 in the event of flatulence being a concomitant symptom, a proper pro- 
 portion of peppermint or pennyroyal water. The young practitioner 
 cannot be too cautious in the use of opium in any of its forms ; for, 
 although he may thus succeed in checking the discharge, the benefit 
 which results is often temporary in its character, and, indeed, the 
 symptoms would sometimes seem to come on after opium worse than 
 before. The bright-green appearance of the evacuations, to which 
 reference has already been made, is not to be looked upon as necessarily 
 a very unfavorable condition ; and one object in mentioning the fact at 
 this place is that this condition seems somewhat too frequently to be 
 admitted as a reason for the administration of powerful drugs. When, 
 at a somewhat more advanced age, the child is being fed, an alteration 
 in its diet and a recurrence to the simpler nourishment of the early 
 months will often suffice to arrest the symptoms. 
 
 In the case of habitual Constipation, a favorite remedy is manna 
 given with milk. Nothing is easier, of course, than to move the 
 bowels, either by this, by castor oil, or by any other laxative ; but it 
 
634 THE NEWLY BORN CHILD. [CHAP. 
 
 will generally be found that if we begin with laxatives, they must be 
 continued. On this account, many nurses prefer to use an injection of 
 soap — or to pass into the rectum a small piece of soap, which is cut so 
 as to admit of its easy introduction. We cannot doubt, however, that 
 a large proportion of such cases are unnecessarily treated, and would 
 do quite well if left alone. 
 
 It is only possible for us very briefly to notice a few of the more 
 common ailments which affect the infant shortly after its birth. The 
 vulgar nomenclature of these disorders has unfortunately shrouded the 
 subject with an obscurity, which the limited knowledge of most mid- 
 wives rather tends to deepen. Such terms as " hives " and " gum" are 
 familiar in the mouths of experienced matrons of the lower class ; but, 
 unfortunately, indicate nothing — or, rather, so many different things, 
 that the words have lost any scientific signification which they may 
 have had. One of the most common of the affections alluded to is 
 what is known as Icterus Neonatorum. It was at one time generally 
 supposed that this very common affection indicated some serious patho- 
 logical condition, the liver as well as its function being believed to be 
 implicated. The chief symptom of this familiar affection is a tinging, 
 more or less marked, of the skin, which becomes of a yellow color. 
 In immature or feeble children, this gradually deepens, and distinctly 
 affects the conjunctiva; while the colorless condition of the evacuations 
 points still more clearly to the analogy which subsists between this and 
 ordinary jaundice. Although it may be too much to suppose, as some 
 have done, that this is a " perfectly natural state, in which the skin 
 and other secreting organs are called on for a few days to assist in dis- 
 posing of the bile, until the demand for it to minister to the digestive 
 function becomes equal to its abundant supply," we may, in the case 
 of a child otherwise healthy, look upon the phenomenon in question 
 without the slightest apprehension. If excessive, it is usual to give a 
 grain of Hydrarg. c. Greta, followed by a small dose of castor oil ; but 
 even this is rarely necessary, as the discoloration generally passes off 
 spontaneously, and almost as rapidly as it came on. 
 
 We may here briefly advert to one other of the affections of infancy, 
 which is generally, although not invariably, associated with impaired 
 nutrition. This is familiarly known under the name of Thrush. If 
 we look into the mouths of children who are the subjects of this affec- 
 tion, we observe on the surface of the mucous membrane of the tongue, 
 lips, and cheeks, a number of small, circular, white spots, which appear 
 at the first glance as if minute portions of curdled milk had adhered to 
 the surfaces in question. A more careful examination shows either 
 that they cannot be detached, or, if so, that the subjacent surface pre- 
 sents an eroded appearance. Microscopic researches, as to the nature 
 of this affection, have proved that it is due to the presence of a crypto- 
 gamic vegetation, which is, more or less obviously, associated w 7 ith 
 derangement of the digestive functions. It has been conclusively 
 demonstrated that this may be transplanted from one mucous surface 
 to another • and we have seen more than one case in which a trouble- 
 some affection of the nipples, and of the contiguous cutaneous surface, 
 had apparently been directly produced by it. The treatment will con- 
 
XXXIX.] , SUBSTITUTES FOR BREAST-MILK. 635 
 
 sist in such measures as may remedy the digestive ailment upon which 
 it is presumed to depend ; and, at the same time, the local affection is 
 to be treated by the application of a solution of twenty grains of borax 
 in an ounce of water, which may be replaced in the more obdurate 
 cases by a solution of nitrate of silver, of four grains to the ounce of 
 distilled water. 
 
 [The most efficient remedy which we have ever employed for the 
 relief of this common affection, is a saturated solution of the sulphite 
 of soda, which may be applied to the mucous membrane of the mouth 
 by means of a soft rag, several times a day. At the same time the 
 child should be allowed to swallow one or two grains of the drug in 
 solution. The good results of this method of treatment manifest them- 
 selves in a short time. — P.] 
 
 In cases in which the parents are not in circumstances to afford the 
 services of a wet-nurse, and in other instances in which there is an un- 
 conquerable repugnance to the employment of a hired nurse, it may be 
 necessary, from the first, to rear the child by the use of certain substi- 
 tutes for breast-milk — its natural food. Our primary object must, 
 therefore, be to provide such nourishment for the infantas may, chemi- 
 cally and otherwise, most nearly resemble that which nature provides. 
 Ass's or goat's milk probably approach in their composition nearest 
 to the secretion of the mammary gland in the human female, and, if 
 obtainable, may on that account be preferred. The objection to the 
 milk of the cow is, that it is so much richer in the corpuscular element 
 that, if given undiluted to a young infant, it rarely fails to engender 
 some form of gastro-intestinal disorder. This, however, is, in the vast 
 majority of cases, the best substitute which is within reach; and, as the 
 fundamental objection to its employment is its richness, experience has 
 shown that simple dilution with water furnishes a material by which 
 hundreds of thousands of infants are, without difficulty, reared in this 
 country. Still, even under circumstances the most favorable, it is 
 obvious that the best substitutes for breast-milk are open to objection; 
 and we are, therefore, not astonished to find the infants, thus artificially 
 reared, are more liable to disease, and more likely to succumb to it. 
 On this account alone, were there no other argument in favor of it, it is 
 the duty of the accoucheur to insist, as far as he can, upon all children 
 being reared at the breast ; and, in the case of children born prema- 
 turely, he should absolutely refuse his sanction to any proposal other- 
 wise to nourish it. 
 
 The amount of water to be added to cow's milk will, of course, depend 
 upon its quality. If rich and pure, an equal bulk, or even more, of 
 water may be added, but it is, in towns at least, rarely necessary to add 
 more than a third of water, in order to reduce an average specimen to 
 the extent which is requisite. Such a mixture as this is, as compared 
 with human milk, deficient in the saccharine element, and it is on that 
 account usual to sweeten it with the ordinary sugar of commerce; but 
 what should always be preferred, when it is within reach, is the sugar 
 of milk, which is now prepared in considerable quantities for this pur- 
 pose from the whey of cow's milk. The mixture should always be 
 given w r arm, about blood heat, to which temperature, therefore, it must 
 be artificially raised. A great variety of nursing-bottles has been de- 
 
636 THE NEWLY BORN CHILD. [CHAP. 
 
 vised, most of them being simple as well as ingenious in construction, 
 with the object of enabling the child to suck from an artificial nipple 
 at the extremity of the apparatus. [One of the simplest possible con- 
 struction should always be selected. This cannot be insisted upon too 
 strongly. All devices intended to save nurses should be studiously 
 avoided, owing to the difficulty in keeping them clean. A plain bottle 
 with an ordinary artificial nipple is the only nursing apparatus that 
 should be allowed. — P.] In a word, our whole object is — when a child 
 has to be reared artificially — to assimilate all the conditions as nearly as 
 possible to those which exist when the natural source is available. The 
 success of bottle-feeding depends very greatly upon the care and expe- 
 rience of the mother or nurse, and upon nothing does the ultimate result 
 hinge more than upon strict attention to cleanliness. It is well known 
 that it is more difficult thus to rear a child in summer than in winter, 
 from the rapidity with which, in the former case, the temperature acts 
 upon the milk. It is also well known that, when the apparatus is not 
 kept scrupulously clean, small particles of curd are apt to accumulate 
 within it or the tube, and these again, if swallowed by the infant, are 
 more than likely to excite gastric or intestinal disturbance; but these 
 difficulties are fortunately in a large majority of cases completely over- 
 come, and the infants, if originally vigorous and mature, are often 
 pictures of health. 
 
 So long as, under such alimentation, the functions of digestion and 
 assimilation are perfectly discharged, we may well be content with the 
 condition of the child; but when — as occurs in a certain proportion of 
 cases — the child pines and is not thriving, the digestion is impaired, or 
 obstinate diarrhoea supervenes, we must, without delay, adopt means for 
 its relief. It is usual, when at all practicable, to obtain the milk for an 
 infant from one cow, and what, in the condition alluded to, has often 
 been found sufficient is simply to change the cow, as, under other cir- 
 cumstances, we might do with the nurse. Bat, when this and other 
 simple remedial measures fail in producing an effect, and the infant con- 
 tinues to droop, we should lose no time in urging that a nurse be 
 obtained at once. In many cases this is delayed until the condition of 
 the child becomes critical, and the assistance of the nurse, when event- 
 ually obtained, is too late to rally the little sufferer from the condition 
 into which it has fallen; and, in fact, this question often devolves a 
 serious responsibility upon the medical attendant, who is certainly 
 blameworthy if he fail to interpose his authority before it is too late. 
 
 The period at which other articles of food are to be permitted to the 
 child, is another question in regard to which we are often expected to 
 express an opinion. Much will no doubt depend upon the health of 
 the mother, and the abundance or otherwise of the lacteal secretion, but 
 Ave have great reason to believe that the tendency is considerably to 
 anticipate the period at which a variety of diet may safely be permitted. 
 We think we are justified in concluding that, for the first three months, 
 milk, and milk alone, is the best as well as the most natural food for 
 the child ; but, in this as in most other respects, the safest and most 
 reliable indication is to be found in the condition of the child itself. 
 So long, indeed, as its appearance and development, the manner in 
 which its functions are discharged, and the extent to which it enjoys 
 
xxxix.] liebig's food for infants. 637 
 
 refreshing and quiet sleep, indicate perfect health, too much caution 
 cannot be exercised in sanctioning any change, unless indeed the in- 
 terests of the mother should render it imperative. 
 
 Of the many substances which have been employed as substitutes 
 for, or supplementary to, milk in the alimentation of infants, nothing 
 has, perhaps, of late years, attracted more attention than the Food for 
 Infants which was devised as the result of much original research by 
 Baron Liebig. 1 Boiled bread and milk, arrowroot, corn flour, and a 
 host of simple and easily digested substances are extensively employed, 
 the articles selected depending more upon the fancy or prejudice of the 
 nurse than on any marked superiority of one over another. Nothing, 
 we are assured, is better than rusks, if they can be obtained of good 
 quality ; and if well made they require no boiling, but are to be cov- 
 ered for a minute or two with boiling water, which is then poured off, 
 and milk or cream, with a very little sugar, added before it is broken 
 up. When the child grows older, a little carefully made chicken soup 
 or beef tea may be given twice a week ; and, by thus adopting each 
 change of diet with caution, it may be gradually altered so as to suit 
 the increasing requirements of a higher stage of development. 
 
 Weaning. — The separation of the child from the mother involves 
 something of a crisis in its existence, and is generally, as might be ex- 
 pected, attended with more or less constitutional disturbance. The 
 condition of the mother must necessarily, as has already been shown, 
 point clearly in many cases to the conclusion that the infant should, in 
 her interest, be at once withdrawn. But, when circumstances are in 
 all respects favorable, it has in every instance to be determined what 
 is the proper period for weaning — what time, in the interests of both, 
 is to be selected for the severance of that physiological tie which binds 
 
 1 This may be obtained in any quantity, carefully prepared by ^ninent chemists, 
 but as its price puts it beyond the reach of the humbler classes, we are induced to 
 borrow some sentences from a little pamphlet published on this subject by a lady, 
 whose main object was to bring the food within the reach of all. " The ingredients 
 required," she writes, " are the following; 
 
 Malt, ^ oz. 
 
 Second Flour, J oz. 
 
 Skimmed Milk, . . . . . . 6 oz. 
 
 Water, 1 oz. 
 
 Bicarbonate of Potash, 1\ grains. 
 
 "I may mention here that, after picking out other seeds which are often found 
 among malt, and which may be injurious, the malt should be crushed in a mortar or 
 ground in a coffee-mill. Mix all the ingredients together, and put them in a pan 
 thoroughly clean, boil for six or eight minutes, stirring all the time; remove from 
 the fire, strain through an ordinary sieve or piece of muslin, and give to the child 
 through a feeding-bottle. See that the holes in the nipple of the tube are large 
 enough to admit of the food passing through them, and that it be not given too 
 warm. The above quantity daily will be found sufficient for an infant for the first 
 few days; but very soon it will have to be increased to two or three cupfuls, and 
 more. For a newborn child who has to be fed entirely on this food, it should be 
 made at first half milk and half water. Use skimmed milk ; new milk is too 
 strong. If properly made, the food should be quite sweet, and taste as though 
 sugar had been put into it; but sugar must on no account be used. The quantity 
 required for twenty-four hours may be made at once, and heated for use as required. 
 Malt can be had at the bakers', who use it for making bread, it is dry and slightly 
 crushed, and should be ground fine before using ; this can be done in an ordinary 
 coffee-mill." 
 
638 THE NEWLY BORN CHILD. [CHAP. 
 
 together the mother and her offspring. It is very unusual to wait until 
 the occurrence of pregnancy or the condition otherwise of the mother, 
 show clearly that she is no longer able to supply proper nutriment to 
 the child. Were we even to look at the case without any reference 
 whatever to the maintenance of her health, a very little reflection 
 should suffice to show that nursing beyond a certain average period is 
 little likely to maintain the health or well-being of the infant; but, as 
 in this matter, the interests of the mother are in a sense inseparable 
 from those of the child, it is sometimes a question involving both care 
 and discrimination absolutely to fix the time for weaning. 
 
 It has frequently been asserted that the natural period for separating 
 the child from the mother is on the completion of the process of denti- 
 tion ; and it may, perhaps, be admitted that, theoretically, the idea is 
 not destitute of validity. Every one knows, however, that, although 
 it may be possible to nurse for two years — the period at which the first 
 dentition is usually completed — the amount of milk secreted ceases 
 long before that to be sufficient for the nourishment of the child. 
 Indeed, the cases are exceptional in which a woman is able to suckle 
 her child, without assistance in the way of extra aliment, for a longer 
 period than ten months ; and a large proportion of mothers and nurses 
 require supplementary aid much sooner than this. In cases, therefore, 
 of protracted lactation, the breast-milk is generally an insignificant 
 portion of the total nourishment which is given to the child ; and we 
 can scarcely doubt that, under such circumstances, weaning might have 
 long before been effected, in the interest of the infant, as well as in that 
 of the mother. For while, on the one hand, a deteriorated lacteal se- 
 cretion can scarcely fail to exercise a pernicious influence on the child ; 
 so, on the other hand, a long-continued drain on the system is seldom 
 without its effect on the health of the nurse. 
 
 With a healthy and vigorous nurse, it is better that the child should 
 have nothing but what she can afford it for the first six or seven months ; 
 ami, certainly, the practice of feeding the infant during the night, so 
 as to avoid trouble and disturbance to the mother, which has become 
 too common of late, is one to which — save under exceptional circum- 
 stances — we should give no countenance. A partial failure in the 
 quantity or quality of the milk may, no doubt, occur at a period very 
 much earlier than that to which we refer; so that it may be absolutely 
 necessary, even at the second or third month, partially to feed, while 
 nursing is simultaneously going on. It is, in all cases, advisable to 
 accustom the infant to other food before the breast-milk is withdrawn ; 
 otherwise, the process of weaning is much more troublesome, and is 
 more likely to be productive of unsatisfactory results. When this is 
 done, and when the proper time arrives, the quantity of milk should 
 be gradually and steadily diminished, and the proportion of other 
 nutriment correspondingly increased, until the latter alone remains. 
 Seldom, however, is this effectual without more or less of trouble, 
 arising from the restlessness which the deprivation of the milk excites 
 in the child ; but, if the weaning process has not been too abrupt, the 
 screaming fits and other evidence of discomfort will not last beyond a 
 couple of days. And, as regards the mother, any discomfort which 
 
XXXIX.] DENTITION. 639 
 
 she may experience may be easily kept within moderate bounds by 
 saline laxatives, abstinence from fluids, and the application of bella- 
 donna or cooling lotions to the breast, until the gland ceases to discharge 
 its function. 
 
 The general health of the child is the point which, above all others, 
 is of importance in its bearing on the period to be selected for weaning. 
 It is proper, therefore, to await the subsidence of any febrile attack, or 
 even of an ordinary catarrh, or some other trifling ailment, before 
 weaning the child ; and it is, we may say, the universal practice to 
 regulate the process, in some measure, by the progress of dentition, 
 which is, as we shall see presently, almost invariably marked by stages, 
 these being separated by intervals, during which such constitutional 
 disturbance as may attend the eruption of the teeth completely disap- 
 pears. It is well, therefore, to select the latter periods as those at 
 which constitutional irritation is less likely to be engendered. There 
 is, as we may well suppose, the greatest difference in the ease with 
 which children are weaned — the deprivation causing, in one case, 
 scarcely a gesture indicating uneasiness or discomfort, and, in another, 
 a degree of fretfulness, and even of constitutional disturbance, which 
 seems quite out of proportion to the cause. This depends, no doubt, 
 upon the temperament, or possibly, upon constitutional causes ; but 
 there is every reason to believe that the idea, which has so long obtained, 
 in regard to the bearing which the progress of dentition should have on 
 the question of weaning, is well founded, and ought, in all cases, to be 
 admitted, as affording indications of no small importance. But to 
 attempt to fix absolutely the period of weaning, as applicable to all 
 cases, is as absurd in theory as it would be found to be unsatisfactory 
 in practice, were it for no other reason than the well-known irregularity 
 which attends dentition. In the case of a perfectly healthy infant, and 
 an average result in the eruption of the teeth, we may, however, assume 
 that ten months is a proper period for weaning, as at this time there is 
 usually a pause in the process of dentition, subsequent to the appear- 
 ance of the eight incisors. 
 
 Dentition. — Among the many reasons which indicate the necessity 
 for a careful alimentation of the child during the early months of its 
 existence, there is perhaps none of greater importance than that the 
 system may be prepared for the contingencies which so often attend the 
 eruption of the teeth. From imperceptible constitutional disturbance, 
 to derangement of all the functions, and convulsions at the cutting of 
 every tooth — which may be held as indicating the extremes — cases 
 offer themselves presenting every conceivable variety of symptom in- 
 termediate between the two. There are few more perfect illustrations 
 of the delicate sympathy which exists between functional disturbance 
 and distal irritation, than are afforded by watching the progress of the 
 first dentition. As a rule, indeed, the symptoms are merely those of 
 local irritation ; but in a large proportion of all cases, the sympathy 
 referred to is evidenced by more or less of gastro-intestinal derange- 
 ment, while, in a considerable number of instances, a reflex irritation 
 is manifested in symptoms which indicate, more or less clearly, a 
 disturbance of the nervous centres. 
 
640 THE NEWLY BORN CHILD. [CHAP. 
 
 Although, as a general rule, the development of the milk teeth within 
 the jaw involves neither local nor constitutional disturbance, and it is 
 only as they are about to penetrate the gum that the symptoms to 
 which we have alluded first manifest themselves, the influence of the 
 process is sometimes exhibited a considerable time before the teeth 
 upon which the phenomena depend make their appearance. So long 
 as no tumefaction, or other morbid condition of the gum, is observable, 
 our treatment can only be expectant, or, at least, directed to the func- 
 tions which are disturbed ; but this is clearly one of the conditions to 
 which we have already referred as indicating the necessity of caution 
 in the matter of weaning — for there can be little doubt that, in such 
 cases, a change, and especially a sudden change, in the nature of the 
 food, is very likely to be followed by an aggravation in the general 
 symptoms. Such a state of matters is, in fact, sufficient warrant for 
 protracting the period of nursing until more favorable conditions 
 manifest themselves, which w r ill generally be the case on the eruption 
 of the first teeth. 
 
 Although the process is subject to many irregularities, the teeth gen- 
 erally make their appearance in a certain order, as is represented in the 
 following formula, where the figures indicate the month at which, in 
 mature and healthy children, we may expect the various teeth, the den- 
 tition usually commencing with the incisors of the lower jaw : 
 
 Molars. Canine. 
 
 Incisors. 
 
 Canine. 
 
 Molars. 
 
 24—12 
 
 18 
 
 9—7—7—9 
 
 18 
 
 12—24 
 
 From this it appears that the milk teeth — which are twenty in num- 
 ber — come through the gums in the following order. It is, of course, 
 understood that an infant may be born with teeth, or may not have a 
 tooth until several months later than is indicated by the formula, and 
 in either case without -a single special symptom. On an average, then, 
 the central incisors make their appearance in the course of the seventh 
 month, and are followed, about the ninth, by the lateral incisors. After 
 this, which is the time generally selected for weaning the child, there is 
 a pause of something like three months. At the end of these three 
 months, the first molars come to the surface; and, at intervals of six 
 months, the canines and second molars respectively, — so that the denti- 
 tion is usually completed about the end of the second year. If the 
 delicacy of the child on the one hand, or premature or irregular erup- 
 tion of the groups of the teeth on the other, should disturb our calcula- 
 tions, it may be necessary to modify the ordinary routine procedure; 
 and, in any case, the symptoms of irritation, local or general, to which 
 reference has been made, and which indicate the approaching eruption 
 of a tooth or group of teeth, should be held as warranting us in post- 
 poning the period for weaning. 
 
 A very limited experience in the treatment of the diseases of infancy is 
 sufficient to show that the eruption of the deciduous teeth is intimately 
 connected with many of the most important of these. It has, on this 
 account, been admitted from time immemorial that the management of 
 
XXXIX.] DENTITION. 641 
 
 children during teething, is a point which often involves both responsi- 
 bility and anxiety. It is, however, a matter which can admit of no 
 doubt that a knowledge of this familiar fact leads in no small number 
 of cases to illogical inferences and slovenly practice. Nothing can well 
 be imagined more irrational than to suppose that all the ailments which 
 may affect the child during the period of dentition, depend upon local 
 irritation, due to the impending eruption of the teeth ; and it is scarcely 
 less absurd to conclude that all irritation is to be relieved by the pro- 
 miscuous use of the gum lancet. On the latter point, West well ob- 
 serves that — "such a proceeding is nothing better than a piece of bar- 
 barous empiricism, which causes the infant much pain, and is useless or 
 mischievous in a dozen instances, for one in which it affords relief." 
 
 So long as the process of teething is going on quite naturally, or is 
 only accompanied with restlessness or slight fever, the less we interfere 
 the better. The progress of the tooth towards the surface is necessarily 
 slow, but the manner in which the tissues of the gum which cover it are 
 gradually attenuated, so as to admit of its final emergence, form no ex- 
 ception to the generally admirable manner in which nature discharges 
 her manifold functions in the animal economy. And yet it is too much 
 the fashion in many quarters to have recourse to the lancet, in a very 
 large proportion of cases, its use being supposed to be indicated by any, 
 even the most trivial, of the ailments of dentition. In certain cases it 
 is admitted that the lancet is the proper and only treatment; but, the 
 more carefully we watch the natural process, the more cautious do we 
 become in resolving upon lancing the gums of an infant. The condi- 
 tions which may be admitted as warranting the operation are mainly 
 these: 1st. When the child is suffering, and the tooth is so nearly 
 through that we are sure that cutting down upon it will at once relieve 
 the tension, and permit of the passage of the tooth. 2d. When the 
 gums are swollen, hot, and tender, and obviously more vascular than 
 usual, but in this case we operate, not with the view of bringing the 
 tooth through, but to give relief to local symptoms, upon which con- 
 stitutional disturbance may be supposed to depend; and 3d. The 
 occurrence of convulsions during one of the periods of active dentition 
 is generally, and with perfect propriety, looked upon as justifying us in 
 using the lancet, even although the state of the gum may not seem to 
 warrant the operation. This we do, less from a conviction that the 
 procedure is likely to be efficacious, than in the hope that it may prove 
 so. When a tumid state of the gum is associated with aphthae, or with 
 that severe variety of inflammation of the gum to which in infants the 
 name of Odontitis has been given, the use of the lancet, far from being 
 beneficial, only makes matters worse. And where, in the case of tense 
 and swollen gums, it is employed, not for the purposes of scarification 
 but in the expectation of bringing the tooth through, there is some 
 reason to fear — and, indeed, this is a point which is very generally be- 
 lieved — that an incision of this kind results in a cicatrix, ultimately 
 rendering the passage of the tooth through the gum more difficult than 
 if we had left it untouched. 
 
 The mode of cutting the gum varies according to the nature of the 
 tooth over which we are operating. In the case of the incisors, the in- 
 
 41 
 
64:2 PHLEGMASIA DOLENS. [CHAP. 
 
 cision should be longitudinal, and directly along the cutting edge of 
 the tooth. As regards the molars, again, it is usual to make a crucial 
 incision. While we are inclined to think that the idea of a cicatrix in 
 the gum proving a serious obstacle has been in some degree exaggerated, 
 we think that it is well to avoid, if this be practicable, the possibility of 
 any such result. This may be done in a very simple way by so operating, 
 when we cut or scarify the gums with the mere object of depletion, as 
 to avoid that portion of the surface through which the tooth must ulti- 
 mately pass. We have generally found that scarification practiced, not 
 over the alveolar ridge, but near the base of that portion of the gum 
 which is chiefly affected, has a perfectly satisfactory effect, and besides 
 this will also be found in most cases to be attended with a more consid- 
 erable flow of blood than when we proceed in the usual way. It often 
 happens that the effect of scarification of the gnms, although marked, 
 is but temporary, and, on that account, it is frequently necessary to 
 repeat the operation again and again, to subdue symptoms which are 
 exceedingly apt to recur. 
 
 In the treatment of Odontitis, the lancet should be scrupulously 
 avoided, as there is here a tendency to the formation of troublesome 
 ulceration at the site of any incision or scarification which may be prac- 
 ticed. Our attention should, in such cases, be directed to the state of 
 the digestive functions ; and, by a careful regulation of the diet and 
 otherwise, — while the local affection is to be met by the application to 
 the affected surface of a solution of borax, with or without the chlorate 
 of potash, — the symptoms will generally in some degree be controlled. 
 The latter drug may also be given internally, in the manner suggested 
 by Dr. Hunt, in doses of two grains every four hours. 
 
 CHAPTER XL. 
 
 PHLEGMASIA DOLENS. 
 
 the puerperal state in its relation to disease — phlegmasia dolens : 
 nomenclature — causes : after labor and when unconnected with 
 delivery — symptoms: premonitory signs: pain: white swelling: 
 tension: heat: constitutional symptoms: the limb pits on pressure 
 during convalescence: loss of power in the limb — morbid anatomy: 
 character of the effused fluid: plugging of the veins: state of 
 the lymphatics — pathology: milk-leg: angeioleucitis : crural phle- 
 bitis : experiments of m'kenzie and h. lee: views of tilbury fox: 
 review of the pathology of the subject — treatment: is bloodlet- 
 ting justifiable? blisters: bandaging: is contagion possible? gen- 
 eral treatment to be directed as a rule to a condition of debility : 
 tonic regimen : antiseptic remedies — causes of protracted convales- 
 CENCE. 
 
 Passing now to the consideration of what are essentially diseases 
 of the puerperal state, we observe that, apart from such affections 
 
XL.] PHLEGMASIA DOLENS. 643 
 
 as are assumed to belong to the condition referred to, there is ample 
 evidence of a peculiar constitutional sensitiveness, one effect of which 
 is to increase the gravity of symptoms arising from what, under other 
 circumstances, we would call quite ordinary diseases. There is, in fact, 
 no disease to which a recently delivered woman is not as liable as 
 others ; but in her case there is this special danger, that what we would 
 call but a trivial ailment may, in consequence of the special conditions 
 under which she is placed, be attended with symptoms of serious and 
 alarming import. An ordinary catarrh, for example, may so disturb 
 that repose of the functions, which seems to be a prominent character- 
 istic of the puerperal state, that an amount of constitutional disturb- 
 ance is produced out of all proportion to the essential nature of the 
 disorder. A state which is naturally one of calm quiescence is changed 
 to a condition in which a turbulent circulation, arrested secretions, and 
 violent fever, give no small cause for anxiety ; and it is on this ac- 
 count that we so carefully guard against the occurrence of such influ- 
 ences as may change the case at once from a favorable into an unfavor- 
 able category. All ordinary diseases, then, which are accompanied with 
 what are called febrile symptoms, are looked upon with considerable 
 apprehension, as they are apt to be accompanied, in the special cases in 
 question, with a train of supernumerary symptoms which are held as 
 characteristic of the puerperal state. 
 
 It is, perhaps, in a sense, not too much to assume, that what are 
 called the diseases of the puerperal state are merely more marked illus- 
 trations of the condition to which we refer. The peritonitis, the 
 metritis, the mania of a puerperal patient, are thus nothing more than 
 familiar diseases modified by special conditions, one of which is what 
 we have ventured to call, for lack of a better name, a peculiar consti- 
 tutional sensitiveness. We are amply warranted, however, as the 
 sequel will show, in considering each of these affections with reference 
 to the period succeeding delivery ; and we shall find that, not only are 
 the symptoms modified, but they are so to such an extent as to require, 
 in many cases, a treatment quite different from that which is supposed 
 to be applicable to the disease in its ordinary form. 
 
 Phlegmasia Dolens, or Phlegmasia Alba Dolens — the disorder which 
 forms the subject of this chapter — forms no exception to the rule just 
 stated. It is, indeed, more strictly a disease of the puerperal state 
 than many of the affections which we shall have to consider, inasmuch 
 as it is seldom observed save as associated with recent delivery. That 
 the puerperal state is not, however, essential to its manifestation is 
 universally admitted, as it has sometimes been met with in women 
 who have never been pregnant, and even in persons of the opposite 
 sex. Few diseases have had a greater variety of designations applied 
 to it than this : anasarca serosa, phlegmasia lactea, oedema lacteum, white 
 leg, and crural phlebitis, being but a few of the many appellations under 
 which it has been described, a study of which, indeed, is not unin- 
 structive, as it almost gives an epitome of the various pathological 
 theories which have been successively advanced to account for the 
 somewhat peculiar phenomena of the disease. Excluding the very few 
 cases in which it, or a precisely similar condition, has been observed to 
 
6±4 PHLEGMASIA DOLENS. [CHAP. 
 
 attack the arm, phlegmasia clolens consists in a white painful swelling 
 of the leg. Although, as we have said, it is not necessarily associated 
 with the puerperal state, it is almost always observed in women who 
 have been recently confined, the period of its occurrence varying from 
 the fifth to the thirtieth day, and, in very exceptional cases, at an earlier 
 or later date than the extremes mentioned. It is more common in 
 pluriparae than in primiparse, and is more likely to occur in women 
 who are of a feeble and delicate constitution than in those who are 
 robust. In a very considerable number of cases, it has followed the 
 various accidents and complications of delivery, and has even been 
 noticed to occur more frequently after removal of a retained placenta. 
 All English writers on the subject agree in asserting that it usually 
 attacks the left in preference to the right leg, which Mr. White of 
 Manchester seemed to think was due to the fact of women in this 
 country habitually lying on the left side during labor; while Dr. 
 Ramsbothani supposed that it "may possibly, in some inexplicable 
 manner, be dependent on the different distribution of the right and left 
 spermatic vein — the right terminating direct in the vena cava, the left 
 in the renal." 
 
 In no class of cases has it been so frequently observed as in women 
 whose strength has been reduced to a low ebb by haemorrhage either 
 during or after labor; and this, no doubt, accounts for the observation 
 made by Merriman that it is relatively of common occurrence after 
 placenta praevia. Women who have once suffered from phlegmasia 
 dolens are by no means so liable to it in subsequent pregnancies as we 
 might perhaps be disposed to anticipate; and it has generally been 
 observed that when it does so recur the subsequent attacks are much 
 less violent. Mr. White says that he never knew it happen to a woman 
 more than once ; but this does not tally with the experience of most 
 modern practitioners. One very troublesome and annoying peculiarity 
 of this affection, is the tendency, exhibited unfortunately in a consider- 
 able proportion of cases, which the disease has, after having partially 
 run its course in one leg, to be transferred to the other, and there pass 
 through the same tedious stages, still further reducing the strength of 
 the woman, and postponing the period of her convalescence — it may be 
 by several months. 
 
 It may be interesting here to mention the circumstances under which 
 phlegmasia dolens has been observed when unconnected with recent 
 delivery. Puzos and, since his time, many modern writers have re- 
 corded cases in which all the usual phenomena have been manifested 
 in the course of pregnancy. In a more considerable number of in- 
 stances, it has been observed as occurring after abortion, particularly 
 ill; cases in which the placenta or any other portion of the ovum has 
 been left behind. It has also been found to occur after the removal of 
 polypi, the enucleation of fibrous tumors, and the operation of lithot- 
 omy. In another class of cases, to adopt the classification of Dr. 
 Tilbury Fox, it may be met with as part of a general disease. Under 
 this head he includes those instances in which it has been developed as 
 one of the distressing phenomena of puerperal fever ; and, occasionally, 
 in cases of ordinary continued fever, a similar complication has been 
 
XL.] SYMPTOMS. 645 
 
 found to arise. With this variety are ranged three cases in which it 
 was observed to coexist with dysentery, erysipelas, phthisis, and what 
 Dr. Humphry described as a " preternatural coagulability of the fibrin 
 of the blood." A considerable number of instances have been recorded 
 in which the disease has been associated with malignant growths, not 
 in the pelvic region merely, which we could more readily understand, 
 but as affecting distant organs, such as the stomach or the mammary 
 gland. In a third class of cases, still observing the classification of 
 Dr. Fox, phlegmasia dolens is met with as complicating other local dis- 
 eases ; and under this head are ranged, and all on sufficient authority, 
 examples of iliac abscess, suppressed menstruation, haemorrhoids, 
 hepatic disease, and dislocation of the shoulder. These exceptional 
 cases have, as we shall find, an obvious and important bearing on the 
 hitherto obscure pathology of the affection. 
 
 Symptoms. — As in most other diseases, the violence and typical dis- 
 tinctness of the symptoms of phlegmasia dolens vary considerably; and 
 in some cases they are so feebly marked, that we have difficulty in 
 determining whether the case should be classified under this head or 
 should be considered as a simple case of oedema. In an ordinary case, 
 the symptoms may either come on suddenly, when they are often ush- 
 ered in by a rigor of some severity, or they may manifest themselves 
 more insidiously, when certain premonitory signs are frequently noticed. 
 These are, generally, — in the puerperal variety, to which we shall in 
 future exclusively refer, — a feeling of weight and discomfort in the 
 hypogaster, extending round the brim of the pelvis, which is soon re- 
 placed by actual pain, accompanied with more or less of constitutional 
 disturbance. The pain is commonly referred more particularly to the 
 inguinal region on the side which is about to become the seat of the 
 disorder. We have more than once noticed that pain is complained of 
 in the region of the hip-joint; but as this is not mentioned by other 
 writers on the subject, we infer that the occurrence is exceptional. Dr. 
 Denman describes, as a premonitory symptom, that "before the appear- 
 ance of any swelling or sense of pain in the limb about to be affected, 
 women become very irritable, with a sense of great weakness, and 
 grievously oppressed in their spirits, without any apparently sufficient 
 reason; complaining only of transient pains in the region of the uterus, 
 and from these the approach of the disease has frequently been fore- 
 told." The pain commencing, as has been described, in the inguinal or 
 pelvic region, extends downwards, and as the various districts of the 
 thigh and leg become successively invaded by it, the swelling of the 
 limb steadily advances in the same direction, until, at the height of 
 the disease, the whole limb presents the white, glazed, and sometimes 
 enormously swollen condition which is so eminently characteristic. This 
 is further accompanied by a complete loss of power, the patient being 
 quite unable to move the limb, or indeed to change her position in bed 
 without assistance. The tissues are tense and elastic, but although they 
 yield before the finger, they do not pit on pressure after the swelling 
 has assumed its characteristic appearance. The temperature of the limb 
 is usually increased. 
 
 Notwithstanding the great swelling of the limb, the veins can gen- 
 
646 PHLEGMASIA BOLENS. [CHAP. 
 
 erally be distinctly felt, hard and rolling under the ringer like a thick 
 cord. This is more particularly the case in regard to the femoral vein, 
 which may often be traced from the groin downwards, although the 
 pressure gives rise to considerable pain. The swelling in some cases 
 extends to the hip and vulva. The glands of the groin participate in 
 the irritation, and sometimes become affected with well-marked inflam- 
 matory action, although they very rarely suppurate. The action obvi- 
 ously extends to the lymphatics, and sometimes the only appearance 
 which varies the surface of the white limb is a faint red streak here and 
 there, indicating the situation of the affected vessels. A similar appear- 
 ance, which in this case is more diffused, has also been observed over 
 the course of the venous trunks. It was first remarked by Dr. Stokes, — 
 an observation which has been corroborated by Dr. Churchill, — that 
 the amount of the swelling is no proof of the severity of the disease; 
 but that, on the contrary, "the severity of the constitutional symptoms 
 is often inversely as the swelling of the limb." 
 
 In a certain number of eases, the symptoms run a somewhat different 
 course. Obviously, in the instances referred to, the disease does not 
 originate in the pelvis, and is ushered in by no such preliminary pelvic 
 symptoms as have been described above. "Sometimes," says Burns, 
 "there is no uneasiness in the belly, and the first symptom is sudden 
 pain in the calf of the leg. Within twenty-four hours after the pain is 
 felt, the limb swells and becomes tense; it is hot but not red — it is 
 rather pale, and somewhat shining." It is a matter of considerable 
 importance that the peculiarities of this variety, which is by no means 
 uncommon, should be borne in mind; for otherwise the idea of "crural 
 phlebitis," which is very commonly supposed to express the pathology 
 of the disease, might altogether divert our attention from symptoms 
 which are nevertheless identical in all important particulars with those 
 which are truly characteristic of phlegmasia dolens, the only difference 
 being that in the cases which we are here considering, the disease 
 begins below and thence extends upwards. 
 
 The constitutional symptoms are just such as one might anticipate 
 from a local affection of such importance. The lochia! and lacteal 
 secretions are either arrested or modified, and in the case of the former, 
 the discharge sometimes becomes offensive. The degree of the fever is 
 indicated by the frequency of the pulse, which is seldom under 120. 
 The complete loss of appetite, the furred tongue, and the state of the 
 evacuations, all show how much the gastro-intestinal functions are 
 disturbed. The patient is restless, sleepless, and complains much of 
 thirst. 
 
 After a time, which varies much in different cases, all the symptoms 
 undergo an improvement. The fall of the pulse, and the subsidence 
 generally of the constitutional symptoms, are accompanied both by 
 relief of pain and a diminution in the swelling of the leg. A remark- 
 able change now takes place in the character of the swelling, as it is no 
 longer elastic and resistant, but pits on pressure like ordinary oedema ; 
 and this change is sometimes observable before there is any very marked 
 difference in the size of the leg. The loss of power in the limb, most 
 marked in cases where the swelling has commenced at the groin, is often 
 
XL.] PATHOLOGY. 647 
 
 very persistent, and is one of the last symptoms to yield. We may 
 expect, therefore, occasionally to meet with cases in which, in the 
 absence of all evidence of constitutional disturbance and apparently of 
 local change, this paralyzed condition of the leg remains for months 
 and even for years. In some cases of exceptionally long continuance 
 of immobility, there remains a permanently thickened condition of the 
 tissues, which may somewhat increase the circumference of the limb. 
 In most cases, the ordinary sensibility of the leg is affected for a con- 
 siderable time, and the patients often complain of what Dr. Churchill 
 graphically describes as a wooden feel, which may persist in a degree 
 for a long period. A varicose condition of the veins has been sometimes 
 observed after phlegmasia dolens, which has been supposed by some to 
 be due to a special morbid condition. 
 
 But, while the great majority of cases thus end in resolution, and 
 ultimately in satisfactory although possibly tardy convalescence, it is 
 not always so. For, in a few, suppuration occurs, in the limb itself, 
 in the inguinal glands, or within the pelvis, in which latter case it may 
 be difficult to say which is the primary and which the secondary dis- 
 order. As the result of such suppuration, and, in some very rare 
 instances, of gangrene, the exhaustion is so great that the patient suc- 
 cumbs; but so uncommon is such an event that the opportunities which 
 have been afforded for the examination of the white leg after death are 
 extremely rare. Let us see, however, what are the facts which morbid 
 anatomy has disclosed. 
 
 "On opening the limb/' says Churchill, "it is found to be distended 
 with serum, effused into the cellular membrane." This assertion is no 
 doubt correct, but it is incomplete, and, being so, is apt to lead to an 
 erroneous assumption. The words quoted will serve equally well for 
 the description of what is observed when we cut into a part distended 
 by ordinary oedema ; but the symptoms already detailed show one thing 
 at least very clearly, that phlegmasia dolens is something essentially 
 different from oedema. It has been found, moreover, that the fluid 
 which exudes in the latter condition is watery in its nature; but care- 
 fully observed facts have shown that the limb, and especially the fibro- 
 cellular and cutaneous tissues, are distended in phlegmasia dolens, with 
 a peculiar serosity which is more or less coagulable. Again, thrombus 
 or plugging of the venous trunks of the limb, usually in the neigh- 
 borhood of the groin, has been so constantly observed that it may be 
 assumed as a phenomenon essential to the disease. This may exist 
 with or without inflammation of the coats of the vessels. And, fur- 
 ther, the great majority of observers have noted that the lymphatics are 
 also affected, their main trunks and more important glands often yield- 
 ing evidence of inflammatory action, which in the latter situation has 
 occasionally, gone on to suppuration. 
 
 Pathology. — The symptoms, morbid appearances, and even the va- 
 rieties in nomenclature, all strongly point to one conclusion, — that the 
 pathology of this disease has given rise to many differences of opinion, 
 is in itself peculiar and perplexing, and remains, even at the present 
 time, still somewhat obscure. It was at one time generally believed 
 that the "white leg" was due to the presence of milk in the limb, and 
 
648 PHLEGMASIA DOLENS. [CHAP. 
 
 the idea was so far favored by the fact, that in most cases the lacteal 
 secretion disappears. It is, however, somewhat surprising to find 
 Puzos and Levret giving their countenance to an idea so absurd ; for, 
 although pathology in their days was still in its infancy, their assump- 
 tion was far less advanced than the views of Mauriceau, who held, at 
 a period seventy years earlier, an opinion which, indeed, comes pretty 
 near some quite modern doctrines, when he describes the accident as 
 one " which often succeeds pain in the ischiadic region, and is caused 
 by a reflux — which takes place on those parts — of the humors which 
 ought to be evacuated by the lochia." The believers in this theory of 
 a metastasis of the milk recommended that the child should be kept 
 constantly to the breast. 
 
 Towards the end of the last century, the subject attracted consider- 
 able attention in this country. Mr. White, of Manchester, then ad- 
 vanced the theory that the disease depended on obstruction, or on some 
 other morbid condition, of the lymphatic vessels and glands of the 
 affected part; and subsequent writers suggested rupture of the lym- 
 phatic vessels, or an inflammatory condition of the same parts, as the 
 morbid lesion to which the familiar phenomena of the disease were, 
 at least primarily, to be attributed. The opinion adopted by Dr. Hull 
 was, that phlegmasia dolens consists "in an inflammation of the mus- 
 cles, cellular membrane, and inferior surface of the cutis, extending, in 
 some cases, perhaps, to the large bloodvessels, nerves, lymphatics, and 
 glands." This, which was sarcastically called by Davis "Dr. Hull's 
 capacious theory," indicates a belief that the disease is due to inflamma- 
 tory action, but it otherwise throws no light upon the subject. Up to 
 this time, no suspicion seems to have been entertained as to the part 
 which the veins take in the production of the symptoms. The priority 
 of publication on this subject is due to M. Bouillard, who, about the 
 end of 1822, related several cases and dissections, — which were shortly 
 afterwards published in the Archives Generates, — in which the crural 
 vein was obliterated, and in regard to which he expressed a belief that 
 the peculiar symptoms of this disease were due to obstruction of the 
 venous trunks. Several years before this, the attention of Dr. Davis 
 had been particularly attracted to this subject, in consequence of the 
 death of a patient of his from phlegmasia dolens, but his essay was 
 not published till some months after the date of M. Bouillard's com- 
 munication. 
 
 In the case in question, a very careful dissection was made by Dr. 
 Davis, assisted by Mr. Lawrence, in the course of which it was demon- 
 strated that " the femoral veins, from the ham upwards, the external 
 iliac, and the common iliac vein as far as the junction of the latter with 
 the corresponding trunk of the right side, were distended, and firmly 
 plugged with what appeared a coagulum of blood. The femoral por- 
 tion of the vein, slightly thickened in its coats, and of a deep-red color, 
 was filled with a firm bloody coagulum, adhering to the sides of the 
 tube. The trunk of the profunda was distended in the same way as 
 that of the femoral vein ; but the saphena and its branches were empty 
 and healthy." Ultimately, Dr. Davis advanced the theory that phleg- 
 
XL.] PATHOLOGY. 649 
 
 masia dolens is essentially Crural Phlebitis, and under this name, as a 
 synonym, the affection is still described by most English writers. 
 
 Although for a time the authority of Dr. Davis, supported by the 
 corroborative testimony of Dr. Robert Lee and others, seems to have 
 checked further inquiry, and to have resulted in a general belief, that 
 what had been for so long a physiological problem was at last solved, 
 many of the best pathologists were still dissatisfied with the phlebitic 
 theory, and we believe with good reason. Virchow was one of the first to 
 point out — what has since received ample corroboration — that, in phleg- 
 masia dolens, inflammatory changes in the vessels may be altogether 
 absent. In other words, thrombus is not necessarily preceded, although 
 it may be followed, by inflammation of the coats of the vein where the 
 obstruction has taken place. In this country, Dr. McKenzie took a 
 prominent part in opposition to the views which were generally admit- 
 ted. In the course of a very painstaking investigation of the subject, 
 conducted, to a great extent, in the form of experiments on the lower 
 animals, the inferences which he ultimately drew from his labors were 
 as follows : 1. That inflammation of neither the iliac nor femoral veins 
 would account for, or give rise to, phlegmasia dolens ; 2. That the ex- 
 tensive obstruction of the veins met with in this disease is not producible 
 by merely local causes, such as injury or inflammation of these vessels ; 
 3. That irritation of the lining membrane of the veins, independ- 
 ently of such local injury or inflammation, will only give rise to ob- 
 struction of these vessels, to an extent commensurate with that of the 
 irritation which may have been excited within them ; 4. That exten- 
 sive irritation of the lining membrane of veins, giving rise to obstruc- 
 tion and all the phenomena of phlebitis, may be excited by the 
 presence of various unhealthy matters in the blood circulating with this 
 fluid, and determined upon particular portions of the venous system ; 
 5. That the origin of the disease is therefore to be sought for rather in 
 a vitiation of the circulating fluid than in any local injury, imflamma- 
 tion, or disease of the veins. 
 
 Mr. H. Lee also performed a series of experiments conducted on a 
 somewhat similar principle. His observations were meant to show, 
 and, in point of fact, did clearly show, that it is by no means an easy 
 matter to excite inflammatory action in the lining membrane of veins, 
 even although irritant or septic substances be introduced into the veins 
 and brought directly into contact with their lining membrane. These 
 results are in perfect harmony with those which, quite independently, 
 were obtained by Dr. McKenzie. Experiments were also devised by 
 the latter with the view of determining the effect of irritation on the 
 external coats of the vessels; and, although he injured and irritated 
 their coats in various ways so as to excite localized inflammatory 
 action, he found that such inflammation showed little tendency to 
 spread, and that the lining membrane remained free from any effect 
 arising from the irritation applied to the external parts of the vessel. 
 Dr. McKenzie quite admits that coagulation of the blood contained in 
 a vein is one of the phenomena of true phlebitis ; but he insists, and, 
 we think, proves, that changes in the blood, due to septic action, may 
 produce a thrombus with equal certainty. The effect of an admixture 
 
650 PHLEGMASIA DOLENS. [CHAP. 
 
 of pus in precipitating the fibrin is clearly demonstrated in the follow- 
 ing experiment, which is one of those performed by Mr. H. Lee : 
 "Some blood was drawn from a healthy horse, and poured into three 
 vessels capable of containing three ounces each. The blood in the 
 first vessel was allowed to remain as a standard of comparison. To 
 that in the second vessel was added some viscid matter from an indolent 
 tumor in the horse's neck ; to that in the third, some pus from a 
 chronic abscess. The contents of the third vessel (blood and pus) 
 began to coagulate in three minutes ; the mass was firm in four. In 
 eight minutes the contents of the first and second vessels had become 
 firm." 
 
 Dr. Tilbury Fox, in two very able papers communicated to the 
 Obstetrical Society of London in 1861, and published in their Trans- 
 actions for that year, enters very fully into the subject, and strongly 
 opposes the view that phlebitis is an essential phenomena of phlegmasia 
 dolens. His leading idea is, that the cause of the peculiar phenomenon 
 of white leg "is an impediment to the return of blood and lymph from 
 the affected part •" and he goes on further to observe, "that the causes 
 of such impediment may be, so far as regards the vessels, extrinsic and 
 intrinsic" The extrinsic causes comprise all cases of pressure on the 
 vessels from tumors, abscess, etc. The intrinsic causes again are all 
 assumed to produce coagulation, and the more important of these are: 
 1. Phlebitis, septic or non-septic; 2. Introduction of morbid matter 
 into the vein, producing simple thrombus, but not phlebitis; 3. Pre- 
 ternatural coagulability of the fibrin of the blood, as assumed, and, in 
 a manner, proved by Drs. Humphry and Graily Hewitt. While not 
 denying the possibility of crural phlebitis being associated with, or 
 even preceding the phenomena of phlegmasia dolens, Dr. Fox argues 
 with much force and ability in favor of the conclusion that a septic 
 action proceeding from the denuded inner surface of the uterus is the 
 most probable cause of the disease. With reference to this he writes 
 as follows : 
 
 " It can in no wise be denied that the parturient woman is a subject 
 apt for the occurrence of thrombus ; there is hyperinosis, the uterus 
 offers a denuded stop, its veins are thin, osmosis is easy, the lymphatic 
 act and circulation are active in removing the disintegrating uterus in 
 conjunction with the veins, etc. These constitute an analogous con- 
 dition to that stage in which phlegmasia dolens is wont to occur else- 
 where — I mean the ulcerative stage and kind of disease, e.g., dysentery, 
 cancer, phthisis — so much so that we should not expect it to occur when 
 wound is absent, except from extrinsic pressure. This close relation 
 of wound in the one case — phlegmasia dolens — and the absence of it 
 in the other — oedema — is a contrasting difference in the pathology of 
 the two states ; in other words, where wound is, the lymphatics are 
 involved. Now for the culminating point, — the cause of the rapid 
 absorption. I have been particularly struck, in the cases that have 
 come under my notice from the outset, by the occurrence of notable 
 haemorrhage, or profuse discharge of other kind ; and I find, from 
 close inquiry, that the reminiscence of the practice of others, well able 
 and qualified to give an estimation of the point, affords the like result. 
 
XL.] PATHOLOGY. . 651 
 
 I have been desirous for some time to ascertain if there be any relation 
 between the two phenomena, — discharge and phlegmasia dolens. My 
 belief is, that the cases which cannot be accounted for by the existence 
 of phlebitis, or pressure, are due to simple coagulation, the result of 
 tolerably rapid absorption of morbid fluid ; this excess of absorption, 
 over and above what is natural, being induced by the occurrence of 
 notable sudden discharge — the latter being the culminating point in 
 the causation. We do find present facility for rapid absorption, wound, 
 and morbid fluid, in the cases in which phlegmasia dolens, of the type 
 under discussion, occurs. Of course, this is at issue with Dr. Humphry, 
 who, in his recent pamphlet, says that there certainly seems no reason 
 to attribute the affection to an introduction of pus, or other morbid 
 fluid, into the circulation/' 1 
 
 Dr. Fox sums up his conclusions, with reference to the disease under 
 consideration, as follows : " Prop. I. In phlegmasia dolens both veins 
 and lymphatics are obstructed. Prop. II. The obstruction may be due 
 simply to extrinsic pressure. Prop. III. Or to inflammatory changes 
 in the coats of the vessels, leading to coagulation. (This depends upon 
 virus action.) Except during epidemics of puerperal fever, this is not 
 so common as supposed. Prop. IV. It is pretty well admitted that 
 rapid ingress of abnormal fluid, suddenly, and in large amount, will 
 cause instantaneous coagulation of the blood ; and it is also admitted 
 that large drains from the system are followed by rapid and compen- 
 sating absorption. There is good reason for believing that these con- 
 ditions are fulfilled, in a perfect and ample degree, in conjunction with 
 the presence of wound — facilitating absorption — in a great many cases 
 prior to the occurrence of phlegmasia dolens, and that the latter is 
 frequently thus evolved. Prop. V. These different modes of evolution 
 may be more or less conjoined." 
 
 On a review of the whole subject, and setting aside such of the older 
 theories as are clearly incompatible with the possibilities of modern 
 pathology, we cannot but admit that phlegmasia dolens is still a matter 
 in regard to which we have much to learn. That obstruction of the 
 venous trunks, from whatever cause arising, is essential, we do not 
 question ; but it is clear that this will not account for the phenomena 
 which we observe, since the symptom which, above all ethers, is held 
 to be indicative of an obstruction to the venous return — oedema, to 
 wit — is, during the active stage of the disease, absent. Nor do we 
 believe that the simple theory of phlebitis can be accepted as a solu- 
 tion of the problem, in so far, at least, as this may be considered the 
 proximate cause of the disease. No one can dispute that phlebitis 
 causes coagulation of the blood contained in the affected vein. In those 
 cases of phlegmasia dolens in which the affection has been associated 
 with the more serious varieties of puerperal fever, clear evidence of 
 inflammation of the coats of the veins has been observed ; and the 
 theory referred to has received still further corroboration from the 
 observation of Dr. Robert Lee, who traced such venous inflammation 
 
 1 u Transactions of the Obstetrical Society of London." 1861. 
 
652 PHLEGMASIA D0LENS. [CHAP. 
 
 to its most probable source, in the uterine branches of the hypogastric 
 vein. 
 
 But, on the other hand, it has been satisfactorily demonstrated, both 
 by Dr. McKenzie and by Mr. H. Lee, that the veins, and especially 
 their lining membrane, are singularly averse to taking on inflammatory 
 action ; and it has also been shown, with almost equal certainty, that 
 the deeper color of the membrane referred to is not a necessary indica- 
 tion of inflammation, but is due rather to the action of the coloring 
 matter and the contact of the clot. But, were we even to admit that 
 phlebitis is an essential part of the disease now under discussion, there 
 is no sufficient evidence that the one condition depends upon the other. 
 If we study the description given by surgical pathologists of the affec- 
 tion known as "fibrinous phlebitis," with which alone phlegmasia do- 
 lens can fairly be compared, we find that, among the more important of 
 the symptoms which are detailed, swelling of the limb below the affected 
 part and oedema of the surrounding cellular tissues are among those 
 which are most prominently put forward. In no single case, so far as 
 we know, since M. Breschet first demonstrated and named the affection, 
 has phlebitis been described as involving, in the case of a limb, the 
 white, elastic, painful, and benumbed condition which is so diagnostic 
 of the other disease. We do not hesitate, therefore, to reject the term 
 "crural phlebitis" as synonymous with phlegmasia dolens. 
 
 While giving every weight to the authority of such names as Denman, 
 Caspar, and Dewees, we confess that the theory with which their names 
 are associated is even less satisfactory than the other, for were we to 
 admit that angeioleucitis may account for the appearance and character 
 of the swelling, this affords no explanation whatever of the fact that the 
 veins are plugged with clots. We may indeed be perfectly sure that to 
 them the fact last mentioned was unknown; for had it been brought 
 under their knowledge it could scarcely have failed to prove to them 
 that, even if, as Denman said, "the glands and lymphatics of the limb 
 were evidently the parts first and primarily affected," there was some- 
 thing more than this necessary to account for the phenomena ordinarily 
 observed in these cases. What has already been explained in reference 
 to the symptoms of the disease, and the attendant morbid conditions, 
 certainly proves that, in some cases at least, the vessels and glands 
 of the lymphatic system are involved; but probably no one will now 
 attempt to maintain that an inflammation of these structures will, if 
 uncomplicated, account for the w 7 hite leg of the puerperal state. 
 
 On the whole evidence, we are of opinion that the first crude theory 
 of Maurieeau points significantly in the direction to which we may most 
 confidently look for a solution of the difficulties which beset the subject. 
 We do not of course mean that his quaint idea of a "reflux of humors" 
 from the womb upon the limb was, in the sense which he attached to 
 the expresssion, a pathological speculation w r hich modern experience 
 could justify; but rather that, in thus pointing out a possible connec- 
 tion between a local lesion and a septic action, starting as in other 
 analogous cases from the wound, he indicated, in a striking manner, the 
 direction in which we should seek for a solution of the problem. There 
 is abundant evidence to prove that septic agents of various kinds may 
 
XL.] PATHOLOGY. 653 
 
 cause coagulation of the blood. The experiments of Mr. H. Lee, 
 already alluded to, showed that pus produced this effect. Dr. McKenzie 
 ligatured the left femoral vein of a dog and injected half an ounce of a 
 solution containing lactic acid. The animal died in half an hour, and 
 on examination it was found that "the iliac veins on the left side from 
 the femoral up to the cava, and a considerable extent of the cava, were 
 obstructed by what appeared to be a firm coagulum; and on opening 
 these vessels this was found to be closely adherent to their lining mem- 
 brane." An exceedingly interesting case bearing on the same point is 
 given by Dr. Tilbury Fox, of a lad, aged twelve years, who, being 
 bitten in the thumb by an adder, presented next day "a perfect and 
 complete specimen of phlegmasia dolens" in the affected limb, so that 
 we may assume that coagulation had been at least one of the results of 
 the poison which was introduced in the manner described. 
 
 On the whole, therefore, we think that the preponderance of evidence 
 is in favor of the idea that, in most cases of phlegmasia dolens, there 
 is a precipitation of the fibrin by the action of some septic agent which 
 has made its way into the blood, or has been developed in that medium. 
 In this sense, Virchow's theory " that the first pathological condition is 
 the formation of a clot in the vein," may be accepted as highly probable. 
 Certainly this is more likely than that true phlebitis is essentially the 
 proximate cause, although no one can dispute either that phlebitis may 
 cause coagulation, or that inflammation of the vein-tissues may accom- 
 pany the other and more essential phenomena of phlegmasia dolens. 
 It may obviously, and with perfect propriety, be urged against this 
 theory that a septic action having its origin in a wound cannot apply to 
 those cases in which the symptoms of undoubted phlegmasia dolens 
 manifest themselves unconnected with the pregnant state. But we 
 cannot see that this must necessarily be admitted as a serious difficulty ; 
 for, if the proximate cause of the disease is assumed to be a septic action 
 proceeding in a great majority of cases from the recently denuded uterine 
 surface, it is surely not too much to assume that, in exceptional cases, 
 the septic action which leads to coagulation may proceed from intrinsic 
 causes, or even from poison introduced in some other way from without, 
 as in Dr. Tilbury Fox's case above alluded to. 
 
 It is, however, impossible to avoid the conclusion that a septic action 
 and the resulting coagulation cannot satisfactorily account for all the 
 phenomena of the disease. All that is necessarily involved in such a 
 hypothesis is mechanical obstruction in a venous trunk, from which we 
 could only anticipate oedema as a direct result. To the development, 
 therefore, of the white elastic swelling something more is required ; and 
 this forces upon our notice the inquiry as to what are the auxiliary or 
 supplementaiy conditions referred to. 
 
 No modern writer on the subject ventures to advocate the theory, 
 which at one time had the support of the most distinguished obstetri- 
 cians of the age, that the seat of the disease is essentially in the absorbent 
 or lymphatic system. The facts demonstrated with reference to the 
 veins preclude such a belief. But it by no means follows that the 
 absorbent system takes no share in the development of the symptoms 
 alluded to. The red streaks occasionally observed over the course of 
 
654 PHLEGMASIA DOLENS. [CHAP. 
 
 the larger lymphatic vessels, and the exceptional occurrence of inflam- 
 mation and suppuration in the glands, prove quite clearly that they 
 may be involved. But there are other considerations which seem to 
 indicate something more than this, and that an affection of the lym- 
 phatics is an essential, although, probably, a secondary part of a typical 
 case of phlegmasia dolens. If we assume, as some of the most dis- 
 tinguished of modern pathologists have done, that the lymphatic system 
 affords the channel through which the fibrin is introduced into the 
 blood, we can readily understand why an obstruction in the vessels of 
 that system, whether inflammatory in its nature or purely mechanical, 
 may cause many of the essential phenomena of the disease. Plugging 
 of a venous trunk could but cause oedema ; but venous obstruction, 
 plus an impediment to the circulation in the lymphatic system, may 
 very readily be assumed to cause symptoms very like those which we 
 have already described. " If there be any relation," says Dr. Fox, 
 '■ between the lymphatic fibrin and the cellular tissue, it is easy to 
 understand how obliteration of the lymphatics may give rise to the 
 peculiar character of phlegmasia dolens, on account of the retention of 
 the fibrinous material in the tissues — the cellular especially, which is 
 so rich in lymphatics. . . . The cellular tissue itself seems to be hyper- 
 trophied, the lymph also gelatinizing in its interstices." 
 
 The marked loss of power in the affected limb, out of all proportion 
 to the mere amount of swelling, and which is, as we have seen, fre- 
 quently of long continuance, seems, at one time, to have led to the idea 
 that the nerves were primarily involved ; and M. Duges has certainly 
 shown that, in some cases at least, inflammation of the nerves and of 
 their sheath occurs. It seems to us, however, that serious lesion of the 
 nervous trunks is, even from a purely theoretical point of view, by no 
 means necessary to the temporary paralysis so characteristic of the dis- 
 ease. All, in fact, that is necessary to the arrestment of the nervine 
 functions is pressure; and, in the condition to which the parts are 
 reduced in the rapid development of a tense swelling, we may be sure 
 that the nerves can scarcely escape such pressure as may produce the 
 effect to which we refer. 
 
 The confusion which has so long prevailed in regard to the pathology 
 of phlegmasia dolens seems to have been due, in a considerable degree, 
 to the obstinacy w T ith which pathological theories were pinned to affec- 
 tions of the individual tissues or textures. No such theory can, as it 
 seems to us, satisfactorily account for what, in these cases, we observe. 
 It is, no doubt, of great interest to determine, if we can, what part or 
 parts of the animal economy are primarily involved ; but we may be 
 quite sure that, if we take up any exclusive theory, as to the disease 
 being one of a single fluid or a single texture, we may pass into a field 
 of speculation which is little likely to lead us to the truth. Doubtful 
 though many points in regard to its pathology may be, we have no 
 difficulty in refusing to admit of Crural Phlebitis, or Angeioleucitis, as 
 terms which represent the true nature of phlegmasia dolens. Either 
 of these conditions may, no doubt, exist; but if it be so, they are 
 secondary rather than essential. Thrombus, or obstruction otherwise 
 to the venous return is apparently essential ; and, in so far as the 
 
XL.] TREATMENT. 655 
 
 absorbents are concerned, it is possible that Dr. Tilbury Fox is correct 
 in assuming that a similar obstruction is produced in them. But, as 
 regards the latter, no plugging of lymphatic trunks has ever, in so far 
 as we are aware, been demonstrated. Nor do we believe that it has 
 been established that the disease is inflammatory in its origin, nor even 
 that the inflammatory process is, at any stage, an essential pathological 
 condition. On the contrary, we think that we perceive in the narrative 
 of post-mortem appearances in fatal cases, another, and a very obvious 
 source of error. That morbid appearances indicating inflammatory 
 action have been frequently observed after death, we can well believe ; 
 but we must bear in mind that fatal cases are rare, and that, in ordinary 
 cases, even when severe, there is rarely evidence, during life, of any 
 such action. We demur, therefore, to the conclusion, that in the morbid 
 phenomena of exceptionally severe cases, we have a demonstration of 
 the essential features of what we have called an ordinary or typical 
 case. Inflammation, in fact, we take to be, whether it is observable in 
 the veins, the absorbents, or the contiguous tissues, an exceptional and 
 essentially a secondary occurrence. 
 
 Treatment. — The fact that phlegmasia dolens follows in so large a 
 proportion of cases upon a condition of debility and exhaustion, usu- 
 ally produced by haemorrhage, shows pretty clearly that the case is 
 not one for an antiphlogistic regimen. This may be conceded even by 
 those who believe most implicitly in the inflammatory nature of the dis- 
 ease; and the opinion must necessarily gain strength if we assume that 
 a septic action proceeding from or associated with constitutional ex- 
 haustion, is an essential part of the disease. A belief in the inflamma- 
 tory theory has not unnaturally led to a very general impression that 
 bloodletting should usually be adopted. Few persons in the present 
 day would probably think of general bloodletting, but it is commonly 
 taught that leeches should be applied over the course of the affected 
 vein ; and, indeed, the rules for treatment which are laid down by many 
 writers on the subject are such as to convey the impression that leeches 
 are applicable to all cases. Such an idea is, of course, at variance with 
 the view which we have expressed as to the nature of the disease, and 
 cannot, certainly, be admitted as a safe guide to judicious treatment. 
 The cases, in fact, to which the application of leeches is advisable are 
 those only in which there is evidence of a local inflammatory action, 
 which may very readily be induced under such circumstances, either in 
 the lymphatics or in some other of the tissues of the limb. But even a 
 clear indication of true inflammation does not necessarily warrant de- 
 pletion, for we must first — and this is the most important point of all 
 — be sure that the aifection has not sprung from debilitating causes, for 
 if it be so, to bleed is simply to encourage exhaustion, and to facilitate 
 the absorption of septic materials. Bloodletting, then, we believe to 
 be applicable to that comparatively rare class of cases only, in which 
 inflammation exists in the absence of constitutional exhaustion. 
 
 Considerable benefit appears to have been derived in many instances 
 from the application of blisters to the leg. Some have gone so far as 
 to say that in the treatment of this disease, blisters are to be regarded 
 as specifics, but this is evidently a pardonable exaggeration. They may 
 
656 PHLEGMASIA DOLENS. [CHAP. 
 
 be applied, as we believe, with a reasonable prospect of success, in cases 
 where there is inflammation, and where the general condition of the 
 patient prevents us from having recourse to bloodletting, and there is 
 certainly one effect upon which we may count with some confidence, — 
 that being a cessation, or at least an alleviation, of the pain which is so 
 characteristic a feature of the more severe examples of the disease. 
 Otherwise, the only effect which is likely to be derived from this method 
 of treatment differs in no respect from that which, under similar con- 
 ditions, we anticipate from the action of counter-irritation of any kind. 
 Probably Dr. Churchill is quite correct when he says that, although his 
 own experience is decidedly in favor of the utility of blisters, " in many 
 cases turpentine fomentations will answer equally well." 
 
 Bandages, if judiciously employed, are extremely useful in the cure 
 of phlegmasia dolens. To the early stage, while the swelling is rapidly 
 being doveloped, Arm bandaging is for obvious reasons inapplicable, 
 and might very possibly be attended with further arrest of the circu- 
 lation, and sloughing similar to what has occasionally occurred from 
 careless or unskilful bandaging in surgical practice. What is at this 
 period safer and more judicious is to swathe the limb in fomentations, 
 which, if the pain be severe, may be sprinkled with laudanum. On 
 the subsidence of the more acute symptoms, bandaging may always be 
 resorted to, at first with flannel and subsequently with an ordinary 
 roller bandage. What may be safely held as indicating the period at 
 which bandaging is proper, is when the limb pits on pressure, this pit- 
 ting being probably impossible until the permeability at least of the 
 lymphatic trunks has been restored. 
 
 Certain facts which have been observed with reference to the prog- 
 ress of these cases have suggested a suspicion that, in its more severe 
 varieties, or, it may be under exceptional circumstances, the affection 
 may be propagated by contagion. That it may be so, when associated 
 with the more serious phenomena of puerperal fever, we can readily 
 believe; but we do not think that there is any evidence which would 
 lead us to suppose that an ordinary case is thus communicable. The 
 assertion has, however, been made upon high authority, and it will 
 thus be well, even should the precaution be deemed superfluous, to take 
 such means as may render any propagation of the disorder in this man- 
 ner as little likely to occur as may be possible. 
 
 From what has already been said, it may be inferred that the consti- 
 tutional treatment applicable to phlegmasia dolens is to be adopted far 
 more frequently to a state of general debility than to a sthenic condi- 
 tion requiring antiphlogistic remedies. We speak, of course, of such 
 cases as present the features of an ordinary puerperal case ; but we do 
 not mean to deny that exceptional treatment may be absolutely requi- 
 site to the proper management of particular cases, where marked local 
 inflammation and accompanying fever of the sthenic type may call for 
 prompt and energetic action. The state of the bowels must be care- 
 fully attended to, and, although it will rarely be advisable to give 
 strong purgatives, it is almost always necessary to regulate the dis- 
 charges by gentle laxatives or enemata, and to maintain them other- 
 wise in a healthy condition. Should the lochia become in any degree 
 
XL.] TREATMENT. 657 
 
 offensive, simple tepid injections may be thrown into the vagina once 
 or twice a day in the usual way. From a very early period of the case, 
 the diet must be generous, and it will often be deemed expedient to 
 give beef tea or stronger soups, and even wine from the first. During 
 the period of convalescence, a similar method of treatment must be 
 persevered in. 
 
 A tonic regimen being thus clearly indicated, it is often found neces- 
 sary to administer iron, quinine, and other tonics. Dr. McKenzie, with 
 the view of neutralizing any septic materials which may exist in the 
 blood, recommends the administration, either of hydrochloric acid, or 
 of the sesquicarbonate of ammonia in full, concentrated, and frequently 
 repeated doses. He directs that " an ounce of hydrochloric acid should 
 be taken daily in a quart of barley or plain water, sweetened with 
 syrup of ginger, and flavored with lemon-peel." 
 
 It is by no means a rare occurrence that, in cases of this affection, 
 quite unconnected with pelvic abscess or any other secondary affection, 
 convalescence is extremely protracted. This, no doubt, depends chiefly, 
 and in many cases entirely, on the effect which has been produced upon 
 the nerves, resulting, in extreme cases, in actual paralysis of the limb. 
 To the treatment of this condition, stimulating frictions are suitable, 
 and it has also been recommended that, at this stage, a succession of 
 small blisters be applied over the limb at various parts. Nothing is 
 better, in such cases, than tepid sea-bathing, and especially the salt- 
 water douche, followed by friction of the parts. There is good reason 
 to believe that, in some instances of slow recovery, this is due to the 
 permanent plugging of the venous trunks, or possibly to their oblitera- 
 tion as the result of inflammatory action. In this case, as after deliga- 
 tion of arterial trunks, it may be some time before an efficient collateral 
 circulation is established, and the functions of the parts are thus but 
 feebly discharged. It is much more probable, however, that changes 
 take place in the clot, which ultimately result in the restoration, partial 
 or complete, of the circulation within the vessel. " The blood," says 
 Murphy, " has the power of separating from itself a fibro-albuminous 
 element without the intervention of any membrane, and independently 
 of any inflamed surface. Through this medium, the coagulum be- 
 comes adherent to the sides of the vein (as in the old aneurismal sac); 
 and if it be attached to the whole circumference, the inner portions 
 become softened and broken down. A complete cylinder of fibrin 
 may in this way be formed in the interior of a vein, through which 
 (when the fluid portions of the coagulum are removed) the blood will 
 circulate." We need scarcely wonder, then, that the results of treat- 
 ment are often unsatisfactory, and convalescence proportionally tardy. 
 
 42 
 
658 PUERPERAL INSANITY. [CIIAP. 
 
 CHAPTEE XLL 
 
 PUEKPEEAL INSANITY. 
 
 NOMENCLATURE — NORMAL EFFECT OF PREGNANCY ON THE MIND — INSANITY ASSO- 
 CIATED WITH PREGNANCY, LABOR, OR LACTATION — TRUE PUERPERAL INSAN- 
 ITY : PATHOLOGICAL THEORIES: CONNECTION OF PUERPERAL INSANITY WITH 
 ALBUMINURIA — PUERPERAL MANIA: TO BE DISTINGUISHED FROM PHRENITIS: 
 IS ESSENTIALLY A DISEASE OF EXHAUSTION — SYMPTOMS : SIGNIFICANCE OF A 
 RAPID PULSE: VIOLENCE: DELUSiONS — PROGNOSIS — PUERPERAL MELANCHO- 
 LIA : DISTINGUISHING CHARACTERISTICS : PROBABLE TERMINATIONS — TREAT- 
 MENT : PREVENTION : BLOODLETTING TO BE AVOIDED : MANAGEMENT OF THE 
 DIGESTIVE FUNCTIONS: EMETICS: VASCULAR SEDATIVES: NERVOUS SEDA- 
 TIVES: OPIUM, HYOSCYAMUS, CHLORAL, ETC. : DIET AND REGIMEN : SECLUSION 
 AND RESTRAINT : TREATMENT DURING CONVALESCENCE : TENDENCY TO RE- 
 CURRENCE AFTER SUBSEQUENT LABORS. 
 
 The term Puerperal Insanity is here chosen in preference to the 
 more familiar designation of Puerperal Mania, for the obvious, and, we 
 think, very sufficient reason, that the forms under which mental aber- 
 ration may occur, in the puerperal state, are various, and the propor- 
 tion of cases in which the symptoms are of such a nature as to fall 
 under the category of Mania, is by no means so overwhelming as to jus- 
 tify the exclusive use of that name. 
 
 It requires no very close observation of pregnancy and the puerperal 
 state, to discover that the mental as well as the bodily functions are, 
 in a very considerable proportion of all cases, disturbed. The psycho- 
 logical phenomena to which we here refer, are far from being symp- 
 tomatic of mental unsoundness, or what we may call insanity, but are 
 indicative merely of the presence and operation of some disturbing influ- 
 ence, dependent, doubtless, upon the condition in which the woman is 
 placed. For example, it is by no means an uncommon thing — as we 
 had occasion to notice in connection with the Signs of Pregnancy — for 
 the temper of the woman to be changed for the worse during the course 
 of a pregnancy. She becomes fretful, capricious, and, in many inde- 
 scribable ways, different in disposition from what had hitherto been 
 her individual characteristics. Further, the emotional faculties are less 
 under control, when the causeless tears or laughter indicate an hys- 
 terical disposition ; and, in other cases, the organs of special sense, and 
 especially those of taste and smell, are strangely perverted, in a man- 
 ner which every practitioner has had opportunities of witnessing. We 
 may, therefore, venture to assume that this psychological sensitiveness 
 can scarcely fail, when it exists, in some degree to predispose to a more 
 serious disturbance of the mental faculties. 
 
 Mental alienation, associated with the highest function of the gener- 
 
XLI.] CAUSES. 659 
 
 ative organs, occurs under a variety of circumstances. It may thus 
 manifest itself during pregnancy, in the course of labor, during the 
 puerperal state, or while the woman is nursing. The insanity of preg- 
 nancy is developed, in the majority of cases, between the third and the 
 seventh month. It is generally characterized by melancholia, or by 
 moral perversion ; and the result of treatment is, as compared with the 
 other varieties, very satisfactory. What was described by Montgomery 
 as the mania of labor, is rather a frenzy or temporary delirium, — the 
 result, probably, of the agony which the woman suffers, or of temporary 
 disturbance of the cerebral circulation. "It is not," he says, " accom- 
 panied nor followed by any other unpleasant or suspicious symptom ; 
 it occurs, perhaps, after the patient has been talking cheerfully, and, 
 having lasted a few minutes, disappears, leaving her perfectly clear and 
 collected, and. returns no more, even though the subsequent part of the 
 labor should be slower and more painful. In every instance which 
 came under my observation, the patients were conscious that they had 
 been wandering, and occasionally apologized for anything wrong they 
 might have said, although they were not aware of what the exact na- 
 ture of their observations might have been." The insanity of lactation 
 has been observed, in a very large proportion of cases, after the sixth 
 month of nursing, — a fact which, along with the accompanying symp- 
 toms, points clearly to the conclusion that the disease is the result of 
 debility, proceeding from an injudicious prolongation of the period of 
 nursing. It is more frequent in women over thirty years of age, and 
 in those who have previously borne children, but especially so in those 
 who have become repeatedly pregnant at short intervals. In this va- 
 riety also, the insanity more generally assumes the melancholic than the 
 maniacal type. 
 
 The subject of true puerperal insanity is, however, that with which 
 we have here more particularly to deal. This distressing affection is 
 by no means of rare occurrence. According to Esquirol, about one- 
 twelfth of the women admitted to the Salpetriere afforded clear exam- 
 ples of this variety, while among the more opulent classes the propor- 
 tion was even higher, — nearly one-seventh. But even this, we may 
 be sure, gives us no idea of the much greater frequency of the disease, 
 which we may well assume when we reflect that these are merely hos- 
 pital statistics, and cannot, therefore, embrace the large number of cases 
 w r hich occur in private practice, and which are, from first to last, 
 treated at home, or under private supervision. The statistics of the 
 subject further teach us, that primiparse are more liable than pluriparas, 
 and that the class of cases in which susceptibility to puerperal insan- 
 ity is most marked, are those in which women between the ages of 
 thirty and forty a^e confined for the first time. In a considerable 
 number, — it is said, indeed, in about half of all cases encountered in 
 practice, — hereditary predisposition has been noted ; and it would fur- 
 ther appear, that complicated and exhausting labors are much more 
 frequently followed by insanity than those in which the course of labor 
 has been normal. It was first pointed out by Esquirol, and the ob- 
 servation has been confirmed by others, that unmarried women, who 
 feel deeply the degradation of their position, are much more susceptible 
 
660 PUERPERAL INSANITY. [CHAP. 
 
 than others. These, then, in addition to the functional susceptibility 
 which is so characteristic of the puerperal state, may be confidently 
 admitted as predisposing causes. But, as regards exciting causes, and 
 the pathology of the disease, there is little upon which we can rely. 
 Cold, imprudence in diet, sudden mental shock, disordered bowels, and 
 a number of other similar conditions, have been generally assumed as 
 causes of puerperal insanity ; but most of them, as it appears to us, on 
 insufficient evidence. 
 
 From a pathological point of view, the etiology of the subject is even 
 more obscure. We may readily obtain, by observation, abundant evi- 
 dence of the sympathy which subsists between the uterus and the 
 cerebrum, and we need, therefore, scarcely wonder that attempts have 
 occasionally been made to connect the mental disturbance with uterine 
 lesion. But, although we may admit that a certain number of authentic 
 cases have been advanced on undoubted authority, and were we even 
 to concede that metritis may apparently be the proximate cause of 
 insanity in some instances, it is abundantly evident that, in the great 
 majority of cases, no such cause exists. Other instances — to which 
 the same observation may apply — have been recorded, in which there 
 was an apparent connection between the mental disorders to which we 
 refer, and ovarian or peritoneal inflammation. Some writers — among 
 whom we may mention Burns and Davis — were of opinion that the 
 disease was of inflammatory origin, and described it as a modification 
 of phrenitis ; but modern experience thoroughly corroborates the view 
 which was taken by Gooch, "that the disease is not one of congestion 
 or inflammation, but one of excitement without power," — an opinion 
 which derives most ample confirmation from the narrative which he 
 gives, in his admirable thesis on this subject, of eleven cases in which 
 there could at no time have been any inflammation of the structures 
 within the cranium. Dr. Ferrier supposed that the loss of reason, in 
 most cases, was mainly due to some interference with the establishment 
 of the function of lactation. On this subject he remarks : " I am in- 
 clined to consider puerperal mania as a kind of conversion. During 
 gestation, and after delivery, when the milk begins to flow, the balance 
 of the circulation is so greatly disturbed, as to be liable to much dis- 
 order, from the application of an exciting cause. If, therefore, cold 
 affecting the head, violent noises, want of sleep, or uneasy thoughts, 
 distress a puerperal patient before the determination of blood to the 
 breasts is regularly made, the impetus may be converted to the head, 
 and produce either hysteria or insanity, according to its force, or the 
 exciting cause." Such a theory seems, however, in the present state 
 of our knowledge, to have little to recommend it. 
 
 One of the most interesting of modern speculations, with regard to 
 the pathology of puerperal insanity, had its origin in a suggestion 
 which was made by Simpson, that there might be an essential connec- 
 tion between that disorder, and disease of the kidney, or at least the 
 presence of albumen in the urine. That the disease may thus or in 
 some other way have a toxsemic origin is, of course, perfectly possible ; 
 and the theory has further a peculiar interest in connection with puer- 
 peral eclampsia, in which albuminuria is a phenomenon familiar to 
 
XLT.] ALBUMINURIA. 661 
 
 modern pathologists. Simpson's original suggestions on this subject, 
 which were published in 1857, depended upon the observation of four 
 consecutive cases, in all of which he found albumen present in the urine. 
 His subsequent experience, with ample corroborative evidence from 
 other sources, can leave little doubt in the mind that his first idea was 
 correct, and that between the two conditions there probably exists an 
 essential though inexplicable bond of association. It would appear 
 that the presence of albumen is only indicated by the usual tests for a 
 short time after the attack commences, and is, therefore, less persistent 
 than in the case of convulsions. "The fire of disease goes on burning/' 
 says Simpson, " in these cases of insanity, after the lighted match is 
 merely applied, and the strange morbid clockwork runs on, as it were, 
 after the key that wound it up is withdrawn. I have seen all traces of 
 albuminuria in puerperal insanity disappear from the urine within fifty 
 hours from the access of the malady. The general rapidity of its dis- 
 appearance is, perhaps, the principal, or, indeed, the only reason why 
 this complication has escaped the notice of those physicians among us 
 who devote themselves with such ardor and zeal to the treatment of 
 insanity in our public asylums." 
 
 Sir J. Simpson, while making no pretence of solving what all admit 
 to be a pathological riddle, seems to think that the cause of this disease 
 may hereafter be discovered by the pathological chemist to consist in 
 certain changes in the renal secretion, involving, secondarily, chemical 
 changes in the blood itself. One well-known effect, which is apt to 
 follow the appearance of albumen in the urine, is a diminution in the 
 quantity of urea excreted. But, as Frerichs has shown, the mere 
 presence of an excess of urea in the blood does not necessarily involve 
 a septic action on the nervous system ; and the same able observer holds 
 that the decomposition of urea, resulting in the formation of carbonate 
 of ammonia, affords a satisfactory explanation of the intoxicating or 
 poisonous effect which is produced through the blood upon the nervous 
 centres in the case of puerperal eclampsia. And it is, perhaps, not too 
 much to assume that this theory, if correct in the case of convulsions, 
 may equally apply to the phenomena of puerperal insanity. Sir J. 
 Simpson suggests further, in support of this theory, that the state of 
 the blood is favorable to the occurrence of such decomposition as may 
 be necessary to the formation either of the carbonate of ammonia, or 
 of some other organic toxicological agent, possibly of an alhcdoidal 
 character. " In the blood of the puerperal female," he writes, — 
 "greatly modified as it is in the normal states of pregnancy and de- 
 livery, and containing as it does after parturition the effete elements of 
 the involving or disintegrating uterus, and the materials for the new 
 lacteal secretion — ferments and agents may possibly exist which are 
 more apt to develop special morbid poisons out of the retained renal 
 excretions, than happens in other states of the system. But, I repeat, 
 the whole subject is yet quite dark and conjectural, and will remain so 
 till pathological chemistry is able to cast some light upon it." 
 
 Dr. Donkin, of Newcastle, contributed a very excellent paper on this 
 subject. 1 Recognizing the fact that puerperal insanity may present 
 
 1 Edinburgh Medical Journal, May, 1863. 
 
662 PUERPERAL INSANITY. [CHAP. 
 
 itself under a variety of forms, he deduces from the history of recorded 
 eases, facts which appear to him to warrant the conclusion "that the 
 acute dangerous class of cases are examples of ursemic blood-poisoning, 
 of which the mania, rapid pulse, and other constitutional symptoms are 
 merely the phenomena ; and that the affection, therefore, ought to be 
 termed ursemic or renal puerperal mania, in contradistinction to the 
 other form of the disease." Although most persons, familiar with 
 the subject, will probably consider that Dr. Don kin goes too far in 
 thus treating the matter as a fact conclusively demonstrated, his paper 
 is replete with interest, and will well repay the trouble of perusing it. 
 
 Dr. Fordyce Barker, in his recent work, asserts that in a large 
 number of cases of puerperal insanity which have come under his 
 observation, he has found albumen associated with so small a propor- 
 tion, that he finds himself compelled to regard it, when present, as 
 simply a coincidence and not a cause. It is his firm conviction that 
 the mental emotions constitute the exciting cause infinitely more fre- 
 quently than all other causes combined, and he adduces very interesting 
 statistical facts in support of his theory. 1 
 
 The form of puerperal insanity which is of most frequent occurrence 
 is that in which the symptoms are commonly manifested within a 
 fortnight after delivery, and present with greater or less distinctness 
 the characteristic features of acute mania. It is to this alone — the 
 paraphrosyne puerperarum of Sauvages — that the designation " Puer- 
 peral Mania" can with perfect propriety be attached. Of fifty -seven 
 cases noticed by Burrows, thirty-five were maniacal, sixteen melan- 
 cholic, and eight alternating; and, although the relative proportion of 
 cases has varied according to the experience of various writers, all agree 
 that the maniacal cases are greatly in excess of the others. This is, 
 no doubt, the class of cases, the observation of which by the earlier 
 writers on the subject gave rise to the idea that the violence of the 
 symptoms was due to inflammation. It were absurd to deny that 
 phrenitis is possible in lying-in women as in others ; but no one now 
 questions the accuracy of the statement made by Gooch, "that furious 
 delirium from inflammation of the brain is a rare disease in childbed." 
 What seems to have given, for a time, apparent confirmation to the 
 inflammatory theory was the fact that, in fatal cases of puerperal 
 mania, the brain was found congested. The experiments of Dr. Kelly 
 upon the lower animals, and a host of pathological facts which have 
 been put on record since his day, have conclusively proved to demon- 
 stration, what is familiar to every modern pathologist — that death from 
 haemorrhage and other exhausting causes, produces in the brain that 
 very appearance of increased vascularity which, as we assume, was 
 accepted by Burns, Davis, and others, as evidence of inflammatory 
 action. 
 
 Although, therefore, we admit phrenitis to be classed as a possible 
 complication of the puerperal state, there is little likelihood of our 
 diagnosis being obscured by such an occurrence. The very early period 
 of its accession after delivery, and the manifestation of headache, suffu- 
 
 1 The Puerperal Diseases, by Fordyce Barker, M.D., New York, 1874. 
 

 XLI.] SYMPTOMS. 663 
 
 sion of the eyes, and other local symptoms referable to the head, would 
 doubtless indicate the nature of the disease to the judicious practitioner. 
 But not only do we discard the idea of inflammation as pathognomonic 
 of puerperal mania, but we embrace without hesitation a directly op- 
 posite view, that it is essentially a disease of exhaustion. This is so 
 far indicated by the fact already mentioned, that puerperal insanity 
 in both its forms is more common after exhausting and operative 
 cases, than when the progress of labor has been normal. It is further 
 strongly corroborated by the details of treatment, in which we are not 
 astonished to find that patients fainted after the abstraction of a few 
 ounces of blood ; and by the experience of the most reliable modern 
 authorities. 
 
 The symptoms of puerperal mania do not differ in any very essential 
 particular from those which are exhibited by patients who are the sub- 
 jects of the same disease unconnected with the puerperal state. Still, 
 there are peculiarities which are of sufficient importance to warrant a 
 special description of the features of what we may call a typical case. 
 The observer of psychological phenomena does not require to be told that 
 there are great, and even perplexing, differences in individual instances. 
 In cases in which an attack on former occasions, hereditary tendency, or 
 any other cause, may particularly direct our attention to the patient; 
 or when the observer has had much special experience in the treatment 
 of insanity; a certain, restless, anxious manner, with more or less irri- 
 tability, will sometimes presage the coming storm, and certainly one of 
 the worst possible of premonitory symptoms is obstinate insomnia, or 
 unrefreshing rest broken by frightful dreams. We borrow from Dr. 
 Ramsbotham the following graphic description of this, and the subse- 
 quent stages of the disease : 
 
 "In mania there is almost always, at the very commencement, a 
 troubled, agitated, and hurried manner,' a restless eye, an unnaturally 
 anxious, suspicious, and impleading expression of face; sometimes it is 
 pallid, at others more flushed than usual ; — an unaccustomed irritability 
 of temper, and impatience of control or contradiction; a vacillation of 
 purpose, or loss of memory ; sometimes a rapid succession of contradic- 
 tory orders are issued, or a paroxysm of excessive anger is excited about 
 the merest trifle. Occasionally, one of the first indications will be a 
 sullen obstinacy, or listlessness and stubborn silence. The patient lies 
 on her back, and can by no means be persuaded to reply to the questions 
 of her attendants, or she will repeat them, as an echo, until, all at once, 
 without any apparent cause, she will break out into a torrent of language 
 more or less incoherent, and her words will follow each other with 
 surprising rapidity. These symptoms will sometimes show themselves 
 rather suddenly, on the patient's awakening from a disturbed and un- 
 refreshing sleep, or they may supervene more slowly when she has been 
 harassed with watchfulness for three or four previous nights in succes- 
 sion, or perhaps ever since her delivery. She will very likely then be- 
 come impressed with the idea that some evil has befallen her husband, 
 or, what is still more usual, her child ; that it is dead or stolen ; and if 
 it be brought to her, nothing can persuade her it is her own ; she sup- 
 poses it to belong to somebody else : or she will fancy that her husband 
 
664 PUERPERAL INSANITY. [CHAP. 
 
 is unfaithful to her bed, .or that he and those about her have conspired 
 to poison her. Those persons who are naturally the objects of her 
 deepest and most devout affection, are regarded by her with jealousy, 
 suspicion, and hatred. This is particularly remarkable with regard to 
 her newly born infant; and I have known many instances where 
 attempts have been made to destroy it, when it has been incautiously 
 left within her power. Sometimes, though rarely, may be observed a 
 great anxiety regarding the termination of her own case, or a firm con- 
 viction that she is speedily about to die. I have observed upon occa- 
 sions a constant movement of the lips, while the mouth was shut ; or 
 the patient is incessantly rubbing the inside of her lips with her fingers, 
 or thrusting them far back into her mouth ; and if questions are asked, 
 and particularly if she be desired to put out her tongue, she will often 
 compress the lips forcibly together, as if with an obstinate determina- 
 tion of resistance. One peculiarity attending some cases of puerperal 
 mania is the immorality and obscenity of the expressions uttered; they 
 are often such, indeed, as to excite our astonishment, that women in a 
 respectable station of society could ever have become acquainted with 
 such language." 
 
 We have no reliable information as to the number of cases which 
 prove fatal, but there is no doubt that one of the most important symp- 
 toms as indicating the probability of a fatal result is extreme rapidity 
 of the pulse. "Mania," said William Hunter, "is not an uncommon 
 appearance in the course of the month, but of that species from which 
 they generally recover ; when out of their senses, attended with fever 
 like paraphrenitis, they will in all probability die." Gooch corrobo- 
 rates generally this assertion, and narrates in illustration a very inter- 
 esting case : " One evening, several years ago, a surgeon called upon 
 me, wishing me to return with him many miles into the country, to see 
 his wife, who had become maniacal a few days after her delivery. I 
 was at that time attending a lady in her first labor whom I could not 
 leave, but I offered to go with him if he would wait till the labor was 
 over. It was going on wearily, there was no prospects of its being over 
 before morning, and as he was anxious to return home, he took an- 
 other physician whom I recommended. Before leaving me, however, 
 he said he should like to talk with me about the case. I took down a 
 volume of Dr. William Hunter's manuscript lectures and showed him 
 this passage (quoted above). He said he was sorry to read it, for that 
 his wife's pulse was very rapid. About a week afterwards, I heard that 
 she was dead." It would appear, however, as if the views of Hunter 
 and Gooch had found too literal an interpretation in many modern 
 treatises, for it would almost seem to be the deliberate opinion of some 
 that a rapid pulse meant death and a slow one recovery. The pulse is 
 probably the most certain indication which we have ; but it is not to be 
 relied upon solely, to the exclusion of others. Extreme rapidity in the 
 beats is in this, as in all the other more serious disorders of the puer- 
 peral state, a symptom of grave import ; but too much has been made 
 of it; and for our part, we are quite convinced that there are many 
 cases in which the pulse rises above 120, and remains at that rate for 
 days in succession, and yet convalescence is ultimately quite satisfactory. 
 
XLI.] SYMPTOMS. 665 
 
 When the pulse suddenly rises at the commencement of the attack, the 
 symptom is undoubtedly more alarming. 
 
 In the worst cases, the milk and lochia are entirely suppressed ; but 
 this is not usually the case, although both functions are more or less 
 interfered with, the nutritive value of the milk, at least, being generally 
 deteriorated. There is obstinate insomnia, which often defies the calm- 
 ing influence of the strongest drugs. The digestive functions become 
 impaired in a marked degree, the tongue being furred, and the odor 
 of the breath not unfrequently offensive. The urine is scanty and high- 
 colored, and the alvine evacuations are offensive — there being some- 
 times diarrhoea, but more frequently constipation. The cases in which 
 the patient is extremely violent are exceptional ; but it is often im- 
 possible, or at least a matter of great difficulty, to induce her to remain 
 silent or at rest. She insists on rising to discharge some imaginary 
 neglected household duty, and her delusions may turn into all kinds of 
 odd channels. She in many instances refuses food, and it may, on this 
 account, even be necessary to use force in order that such nutriment as 
 is essential to maintain life may be introduced into the stomach. The 
 delusion, in one very obstinate case of this nature which came under our 
 observation, was, that putrefaction was going on internally, and that 
 food only tended to supply material for the morbific process ; and in 
 other cases it has been noticed, that, although the patient obstinately 
 refused food when urged to take it, she would, if she could obtain it 
 furtively, take it greedily and voraciously. Again, a prominent char- 
 acteristic of these cases, which adds greatly to the responsibility of 
 their management, is the undoubted tendency to suicide, which may 
 show itself in many ways, although hidden with all the craft and cun- 
 ning of insanity. 
 
 It has been remarked as a feature characteristic of puerperal mania, 
 that, occasionally, the woman, although her mind is pervaded by delu- 
 sions, has a strange underlying conciousness that her thoughts and 
 actions are under the influence of some mysterious power. It has been 
 stated, that seldom or never is this consciousness of a delusion mani- 
 fested in other forms of insanity. Gooch states that the symptoms, in 
 some cases observed by him, closely resemble those of delirium tremens, 
 and he has also seen symptoms, of the nature of catalepsy, which were 
 associated with distinct puerperal mania. If we may accept as prob- 
 able the theory to which allusion has already been made, — that albu- 
 minuria, in mania as well as in eclampsia, points to the proximate 
 cause, — we cannot be astonished to find that clinical experience in some 
 measure seems to indicate a connection between them. We even find, 
 that by some the expression " epileptic puerperal mania" has been em- 
 ployed as indicating the occasional coincidence of the phenomena of 
 eclampsia with those of mental aberration. In some instances the 
 mania has been preceded by convulsions, while in others the mental 
 phenomena have been the, first to develop themselves. 
 
 The Prognosis of these cases involves, as will readily be understood, 
 questions of deep interest in individual instances. As regards the risk 
 to life, it is, as we have attempted to show, an error to suppose that a 
 rapid pulse is necessarily the forerunner of death. But there is another 
 
QSQ PUERPERAL INSANITY. [CHAP. 
 
 error, which at one time led to a contrary belief. This finds expression 
 in a remark which Dr. Gooch attributes to Dr. Baillie, who, when con- 
 sulted about a case, remarked " that the question was not whether she 
 was to get well, but when she was to get well." To this Gooch adds 
 dryly, "the patient died a week after this prognosis." The fact is, 
 that death from puerperal insanity does now and again occur, and more 
 frequently from the maniacal than from the melancholic form. Dr. 
 Churchill says that he should himself lay great stress, in forming a 
 prognosis, upon the presence or absence of uterine complication; and 
 the observation, coming from such a source, merits careful attention. 
 
 The question of prognosis involves not only the danger to life, but 
 the prospect of speedy restoration to reason. In this respect, in so far 
 as mania is concerned, we may look forward with considerable confi- 
 dence, especially in the absence of hereditary predisposition, to an early 
 recovery. " Within three weeks," says Dr. J. B. Tuke, 1 " or more fre- 
 quently earlier, the mania gradually subsides, and is replaced by a state 
 of dementia, generally accompanied by delusions, which almost invari- 
 ably assume the form of mistaken identity. These gradually disappear, 
 leaving a haziness of apprehension, and a state suggesting the idea of 
 waking from a dream. The patient can now, generally, be induced to 
 work, and otherwise employ herself. From that moment you may 
 look with almost certainty to ultimate recovery." There are cases, 
 however — chiefly those of hereditary taint — in which the delusions be- 
 come confirmed, and in which, although the general health may have 
 been quite restored, the mental aberration is persistent. Dementia, of 
 a more serious nature than that mentioned by Tuke, gradually takes 
 the place of mania, and hopeless chronic insanity is the result. 
 
 Although in the insanity of pregnancy the majority of cases are of 
 the melancholic type, it is otherwise with true puerperal insanity; 
 where melancholia, although by no means rare, is, as compared with 
 mania, comparatively unfrequent. Few cases which, from the first, 
 come under this category, present characteristic symptoms earlier than 
 the sixteenth day, and a large proportion of cases come on considerably 
 later than this. All at first may go on to our perfect satisfaction : the 
 patient has been able to leave her bed at the usual time ; her appetite 
 is good ; she sleeps well, and is able to nurse her child ; it is assumed 
 on all hands that convalescence has been satisfactorily established. 
 Perhaps a month after the birth of the child, a change comes over the 
 mother, which, to her attendants, is quite inexplicable. The pride 
 and interest in a firstborn child gradually fades away, and a cloud of 
 sadness, utterly without cause, slowly spreads itself over the aspect 
 and demeanor of the mother. Causes, which are either imaginary, or, 
 if real, are of the most trivial character, give rise to fits of silent weep- 
 ing, during which the patient is not demonstrative, and rather avoids 
 than seeks sympathy. The gloom deepens as the curtain falls. No 
 longer does the cry of the infant awaken a tender sympathy in her 
 heart; on the contrary, she maintains a moody silence, and not only 
 never inquires for her infant, but seems to look upon it with actual 
 
 1 Edinburgh Medical Journal, May, 1865. 
 
XLI.] MELANCHOLIA. 667 
 
 aversion. Delusions — all of the melancholic type — if they have not 
 already manifested themselves, now become apparent. She believes 
 that in marrying she has violated some important moral obligation. 
 While she heaps all sorts of accusations on her own head, she compara- 
 tively rarely complains of others. Too frequently the religious element 
 enters into her morbid ponderings, and she fancies herself lost, and her 
 soul beyond all hope of salvation. 
 
 And not by day only, but by night, do these gloomy impressions 
 weigh upon her mind, so that sleeplessness is an early and most trouble- 
 some symptom, resisting often all the ordinary methods of alleviation. 
 The appetite fails, or becomes capricious ; or she may absolutely refuse 
 to take any nourishment, except upon earnest solicitation, or even the 
 employment of force. As the lochial discharge has most likely ceased 
 before the symptoms of insanity make their appearance, no reference 
 need be made to that; but, as regards the lacteal secretion, it will 
 generally be observed that, even in robust women, who previously had 
 an abundance of milk, it is rapidly arrested, and the breasts become 
 flaccid. The bowels are sometimes tolerably regular, but, as a rule, 
 are constipated, and the dejections foetid. The urine is high in color 
 and scanty, unless there is an hysterical element in the case, when there 
 may be a great flow of a low specific gravity. The pulse may be 
 accelerated, but is seldom so continuously. In some instances, symp- 
 toms of moral insanity are prominent. In cases in which there has 
 been — even long previously — a tendency to intemperate habits, these 
 may reappear, in the earlier stage, in the form of aggravated dipso- 
 mania, in which the morbid craving for stimulants may assert itself in 
 the most intense form ; and the patient will, if unable to procure ordi- 
 nary stimulants, greedily consume eau-de-Cologne, spirits of sal vola- 
 tile, valerian, or spirits of lavender, should such be left within her 
 reach. And, in like manner, the pica of pregnancy may appear in an 
 exaggerated form, when she will eat soap, or even more disgusting 
 substances which may be at her command. 
 
 The progress and ultimate issue of such a case are matters which give 
 cause for deep apprehension. It is not a fatal result that we dread so 
 much as permanent insanity. The observation of Gooch on this point 
 merits the dignity of an aphorism, when he says that "mania is more 
 dangerous to life, melancholia to reason." When the two varieties — 
 mania and melancholia — are considered together, it has been said that 
 the period of convalescence ranges from a few days to two years ; but, 
 if we take the trouble to analyze the cases, and separate the one class 
 from the other, it will become quite obvious that the examples of pro- 
 tracted convalescence are, almost invariably, those in which melancholy 
 has been the prevailing type. And, in like manner, if we avail our- 
 selves of such statistical observations as may seem most reliable, it is 
 equally clear that the melancholic cases afford by far the greater num- 
 ber of those instances in which reason has permanently succumbed. In 
 so far as we can gather from the observations of those who have given 
 most attention to the subject, it would seem that the existence of albu- 
 men in the urine has no such marked association with puerperal melan- 
 
668 PUERPERAL INSANITY. [CHAP. 
 
 cholia as it has with mania of the same class ; but this is a point in 
 regard to which more extended clinical study is still required. 
 
 Treatment. — From every aspect of the case, the treatment of puer- 
 peral insanity is a subject of surpassing clinical interest, and One which 
 deserves, we venture to assume, more attention than has, in some sys- 
 tematic works, been accorded to it. This is particularly the case as 
 regards prevention; for we can scarcely doubt that, when the symp- 
 toms are such as to indicate disturbance of the cerebral functions, much 
 may be done, in the way of warding off an attack, by a judicious em- 
 ployment of the remedies to be hereafter mentioned. This remark 
 applies chiefly to cases where there is a marked hereditary taint, or 
 where the patient has been insane at previous confinements. An illus- 
 tration of the latter came recently under the notice of the writer. 
 
 A delicate lady, who had married very young, became insane (mani- 
 acal) about ten days after her first, and nine days after her second con- 
 finement, and on the latter occasion the convalescence had been ex- 
 tremely protracted, and the danger to life at one time great. Much 
 anxiety was naturally felt by herself and her friends on the approach 
 of a third confinement, particularly as, towards the end of the ninth 
 month, she became hysterical, sleepless, and melancholy, as on the 
 former occasions. A very remarkable feature in the case was the ten- 
 dency to dreams of a disturbing kind, which not only rendered such 
 sleep as she obtained un refreshing, but made her actually dread falling 
 asleep. The state of the tongue and dejections indicated considerable 
 derangement of the digestive functions. As the period of expected 
 delivery approached, the symptoms became still more marked; but 
 they seemed to be, in some degree, under the control of the remedies 
 which were adopted, — the most effectual being hydrate of chloral for 
 the nervous symptoms, and colocynth with hyoscyamus for the bowels. 
 Labor passed over quite favorably and in every respect satisfactorily, 
 the patient being, however, as might have been anticipated, very feeble 
 and exhausted after its completion. After delivery, very strict pre- 
 cautions were observed to maintain perfect quietness, and freedom from 
 any possible worry or annoyance. A certain amount of sleep was ob- 
 tained by chloral : opium made matters worse. The child was not put 
 to the breast, and the lacteal secretion was easily kept under. It was, 
 in this case, a matter of intense interest to watch the struggle for reason ; 
 for, although at no time did she exhibit symptoms of insanity, there 
 was not the slightest doubt that she was on the verge of it ; but, hap- 
 pily, after a fortnight had elapsed, she rapidly improved, her appetite 
 increased, and she enjoyed natural and refreshing sleep ; until ere many 
 more days had passed, she was pronounced convalescent. It is too 
 much to expect that this narrative proves that an impending attack of 
 mania was warded off; but the impression is, nevertheless, fixed on 
 the minds of those who watched the case, that constant and anxious 
 supervision, and above all, skilful and judicious nursing, saved the 
 patient from a recurrence of her former malady. 
 
 The cases, however, in which preventive treatment can be expected 
 to be of much avail, are probably of very rare occurrence ; and there, 
 no doubt, is a danger — against which we would caution the inexperi- 
 
XLI.] TREATMENT. 669 
 
 encecl — of looking with apprehension upon what our fears may magnify 
 into premonitory symptoms, and thus adopting, on insufficient grounds, 
 methods of treatment, upon the successful results of which we com- 
 placently congratulate ourselves. 
 
 The symptoms which accompany a violent attack of puerperal mania 
 — when there is rapid pulse, heat of head, and great cerebral disturb- 
 ance — are such as very readily to explain how, for so long a period, 
 the lancet was employed as a measure of the veriest routine. Apart 
 from the theory of phrenitis, the very violence of the symptoms seemed 
 to demand prompt and free bloodletting. The change which public 
 and professional opinion has undergone during the last forty years is, 
 however, such that we scarcely think it necessary to recommend caution 
 in regard to this once familiar remedial measure. Were it otherwise, 
 we might point to many facts which conclusively prove that puerperal 
 mania is essentially a disease of debility ; and that, if the heat of head, 
 and other local symptoms, should seem to suggest the application of 
 leeches to the temples, even this practice must be adopted with the 
 greatest possible caution ; for cases have undoubtedly occurred, in 
 which a very moderate loss of blood has precipitated a fatal result. In 
 cases of actual phrenitis, bloodletting is, of course, in some form or 
 other, urgently demanded ; but no real difficulty should prevent the 
 discrimination of these very rare cases from the ordinary varieties of 
 puerperal mania. 
 
 The gastro-intestinal disturbance, which is so invariable an accom- 
 paniment of the case, requires, from the first, careful attention, and 
 generally prompt treatment. If the bowels, therefore, are overloaded, 
 a purgative should at once be administered ; and, although we must not 
 expect an immediate cure, as in one of Gooch's cases, we may look for 
 some relief in the symptoms, and especially of the irritability and rest- 
 lessness so characteristic of the disease. But it will not suffice simply 
 to see that the bowels are thoroughly cleared of their contents, which 
 are often highly offensive ; for, be the case long or short in its duration, 
 the judicious regulation of the bowels is one of the most important 
 indications of treatment. For this purpose, aloetic purgatives are 
 appropriate, from their derivative action. It would appear that, in 
 some cases, signal benefit has been derived from the administration of 
 emetics. " If the powers of the constitution are not low, and the gas- 
 tric symptoms are very marked — namely, a foul tongue, an offensive 
 breath, and a yellow eye — an emetic, not of antimony, but ipecacuanha, 
 may be given." So wrote Gooch, and most modern writers have re- 
 peated his recommendation of emetics, at least as an exceptional method 
 of treatment. Care must be taken, of course, not to administer those 
 depressing agents when the face is pale, the skin cold, and the pulse 
 quick and weak ; and, indeed, the more prominently we keep before 
 us the leading fact, that puerperal insanity is a disease of debility, the 
 less likely will we be to have recourse to antiphlogistic remedies. 
 
 Although bloodletting is, for reasons already fully explained, contra- 
 indicated, there is often observable such a degree of vascular excite- 
 ment, that we may naturally inquire whether this cannot be allayed by 
 some safer measures. The application of cold to the head, or what is 
 
670 PUERPERAL INSANITY. [CHAP. 
 
 even better, laving the forehead and temples with warm water — after 
 which there is a refreshing feeling of coolness — may produce the de- 
 sired effect. In other cases, we may administer any of the vascular seda- 
 tives, of which none, probably, will be more likely to effect the pur- 
 pose we require than tartar emetic, in such doses as may be necessary 
 to produc a depressing effect — taking great care, for obvious reasons, 
 not to push it too far. One or two drops of the tincture of aconite, or 
 of the tincture of veratrum viride, have been recommended by Simp- 
 son for the same purpose. 
 
 Undoubtedly, the most important remedies to which we have to refer 
 are the class of nervous sedatives. At the head of the list stands opium 
 — the sheet-anchor, as it has been called, of the alienist physician. It 
 is to be observed, however, that there exists a considerable diversity of 
 opinion as to the propriety of administering opium in the puerperal 
 varieties of insanity. It is quite certain that in some cases it proves of 
 no avail, while in others the result is the reverse of beneficial. Simpson, 
 who admits this, says, " Whatever may be the way in which you give 
 the drug, remember always, as the general rule to guide you in its ad- 
 ministration to such patients, that it must be given in very large doses. 
 If you expect to have any good effect from it, you must give, in gen- 
 eral, not less than two or three grains of solid opium, or an equivalent 
 dose of some of the cognate preparations." If unusual difficulty is 
 encountered in the administration of the drug in the ordinary way by 
 the mouth, the same authority recommends the introduction into the 
 rectum of a suppository containing one or two grains of morphia ; and 
 he mentions an interesting case in which that was followed by a sleep 
 of sixteen hours, from which the patient awakened quite free of ma- 
 niacal symptoms. Dr. Tuke observes that the exhibition of opium, as 
 well as of the other narcotics, is not beneficial when the leading symp- 
 tom is acute mania; and it is w T ell that we should bear this observation 
 in mind as coming from one of much experience in the treatment of all 
 forms of insanity. In some instances, chloroform has been employed 
 with much benefit, the patient being brought fully under the effect of 
 the anaesthetic, a little more being given from time to time as she seems 
 about to awake. Hyoscyamus, in combination with ether or ammo- 
 nia, and Indian hemp, have also been employed with the same, object. 
 Camphor was Gooch's favorite remedy, but it is not now so frequently 
 employed as at one time it was. The hydrate of chloral is another 
 remedy which has of late, to some extent, superseded opium in the 
 treatment of insanity, as in many other disorders ; and experience 
 seems to show, that in this drug Ave have a most important addition to 
 the materia medica of the class of diseases in question. The use of the 
 warm bath should not be forgotten in an enumeration of sedative 
 agents, and there can be no doubt, that by it a beneficial effect is pro- 
 duced even when drugs have failed. Let us always remember that the 
 primary objects which we have in view, in the exhibition of this class 
 of remedies, is to procure sleep. If we succeed in our object, the pa- 
 tient may at once recover ; but, unfortunately, as a rule, she relapses, 
 on awaking, into the violence and delusions of her unhappy state. 
 
 As regards diet, unless deterred by special circumstances, such as 
 
XLI.] SECLUSION. 671 
 
 gastric or intestinal derangement, we should at once permit the use of 
 soups in moderation, along with other substances of easy digestion 
 which may suggest themselves. In many cases, a small quantity of 
 wine may be added, about two ounces, perhaps in the first instance, to 
 be increased as the necessities of the case may seem to require. As the 
 case goes on, it will generally be proper to give more generous diet, 
 and to be more liberal, it may be, in the use of stimulants ; for we may 
 be perfectly sure, that, as this was a disease of debility from the first, 
 an improved physical condition is an essential concomitant of recovery. 
 
 The general management and control of the patient involves the im- 
 portant points of seclusion and restraint. Our aim, in this respect, is, 
 above all, to guard the woman from whatever may prove a source of 
 excitement. The experience of every one clearly proves, that to permit 
 of free association with relatives and friends is, in the highest degree, 
 injudicious. Such interviews give rise to excited appeals as to being 
 relieved from the irksomeness of restraint, and generally awaken in the 
 mind painful impressions, which leave the patient for a time in a worse 
 mental condition than before. In most cases, therefore, in which the 
 symptoms show unusual obstinacy, it is well to separate the patient 
 from her friends and to leave her entirely to the management of those 
 who have special experience in the treatment of the insane. This should, 
 if possible, be done in her own house, for we confess to a great reluc- 
 tance to send persons suffering under this comparatively curable variety 
 of insanity to be immured in a lunatic asylum, to associate, probably, 
 with persons whose minds are also deranged. We do not deny the ad- 
 vantage of a system of constant and intelligent supervision, but if this 
 can be equally well secured at home, it is always well to avoid the 
 stigma which attaches to confinement in an asylum, and which many 
 women, after their recovery, will feel most acutely. As reason is grad- 
 ually being restored, too great caution can scarcely be exercised in per- 
 mitting her to renew her intercourse with her friends ; and, if it should 
 seem that interviews with them still excite her, the period of seclusion 
 must be extended. There are cases, however, in which the visit of a 
 relative or friend has the best possible effect, in diverting the mind 
 from its morbid condition into channels which are more healthy, by 
 reason of the association of ideas which recall the past. It is at this 
 stage that change of air and scene is more particularly beneficial. Dur- 
 ing the whole course of treatment, the patient should not be left for a 
 moment alone, and, as a prominent characteristic in such cases is suicidal 
 impulse, it is always proper to see that nothing be left within her reach 
 which might render self-injury possible. 
 
 The treatment of melancholia differs in some respects from what has 
 been prescribed as proper to the maniacal variety. There will, for 
 example, in cases which manifest this type of insanity, be no necessity 
 for the use of any of the vascular sedatives, as the circulation is little, 
 if at all disturbed. From the first, therefore, we should adopt a more 
 nutritious regimen than in the other and more frequent cases; but, 
 unfortunately, we must look forward to a long illness and lingering 
 convalescence, and in some unhappy instances, to the symptoms gradu- 
 ally being merged in those of hopeless dementia. It will more frequently 
 
672 PUERPERAL ECLAMPSIA. [CHAP. 
 
 be found necessary, in the melancholic cases, to remove the patient from 
 home, and even to place her in strict confinement. 
 
 The question of the recurrent nature of the disease is the only other 
 point upon which we need touch ; and it is one in regard to which 
 authors do not seem to be agreed. Gooch thinks that it is unusual; 
 but a careful observation of such meagre statistical facts as are at our 
 command seems to point strongly to the conclusion, that there is a 
 decided tendency to the recurrence of the disease in the subsequent 
 pregnancies of women who have previously been the subjects of puer- 
 peral insanity. It is in cases in which there is hereditary taint that 
 this is most distinct, but the tendency in all cases is sufficiently marked 
 to warrant us in taking every precaution to avoid the other exciting or 
 predisposing causes of the disease. Tuke's cases were recurrent in the 
 proportion of fifteen out of seventy-five. 
 
 CHAPTER XLIL 
 
 PUEEPERAL ECLAMPSIA. 
 
 DEFINITION — CONNECTION BETWEEN ECLAMPSIA AND ACUTE BRIGHT'S DISEASE — 
 ECLAMPSIA FROM OTHER MORBID CONDITIONS — EFFECTS OF PREGNANCY ON 
 THE SYSTEM — PERIOD OF EXPLOSION — SYMPTOMS: PREMONITORY SIGNS; 
 OiDEMA, ALBUMINURIA, CEPHALALGIA, ETC. — PHENOMENA OF THE FIT: 
 PERIOD OF TONIC AND CLONIC CONVULSIONS, AND OF COMA — PATHOLOGY: 
 ALBUMINURIA: DECOMPOSITION OF UREA, AND FORMATION IN THE BLOOD 
 OF CARBONATE OF AMMONIA: EFFECTS OF PRESSURE ON THE RENAL VEINS: 
 DETECTION OF ALBUMEN IN THE URINE — MORBID ANATOMY — EFFECT OF 
 LABOR PAINS — MATERNAL AND FCETAL MORTALITY — PROGNOSIS : IN ECLAMPSIA 
 GRAVIDARUM, PARTURENTIUM, ET PUERPERARUM — TREATMENT: PROPHY- 
 LAXIS: USE OF ACIDS: PURGATIVES AND DIURETICS: INDUCTION OF PREMA- 
 TURE LABOR: TREATMENT DURING THE FIT: BLOODLETTING; CHLOROFORM; 
 CHLORAL : OBSTETRICAL TREATMENT AT VARIOUS STAGES OF LABOR; ACCELE- 
 RATION ; RUPTURE OF THE MEMBRANES ; USE OF THE FORCEPS. 
 
 Under the designation of Puerperal Eclampsia are included, not 
 only such instances of the malady in question as are manifested during 
 the puerperal period, but all cases, without exception, which are observed 
 in the course of pregnancy, during labor, or after delivery. It was for 
 this reason that we deferred any notice of Eclampsia as a complication 
 of gestation or delivery, until, having the whole subject before us in 
 its broadest aspect, we should be in a position to review the highly 
 interesting speculations to which modern pathology has of late so 
 largely contributed. 
 
 It is scarcely necessary to remark that the affection which we are 
 now about to consider does not include all cases, without exception, in 
 which symptoms of the convulsive or epileptiform type manifest them- 
 

 XLII.] ECLAMPSIA. 673 
 
 selves during pregnancy or childbed. It is, for example, a disorder 
 distinct from, although, in its more conspicuous phenomena, closely 
 analogous to epilepsy. But, so great is the preponderance of cases in 
 which the symptoms of true puerperal eclampsia exist, that we think 
 we are perfectly justified in agreeing with those who look upon a certain 
 train of symptoms and pathological facts as essential, or nearly so, to 
 the disease in question. " Eclampsia puerperalis," says Braun, "is an 
 acute affection of the motor function of the nervous system, charac- 
 terized by loss of consciousness and of sensibility, by tonic and clonic 
 spasms, and occurs only as an accessory phenomenon of another disease, 
 generally of Bright's disease in an acute form, which, under certain 
 circumstances, spreading its toxaemic effects on the nutrition of the 
 brain and the whole nervous system, produces those fearful accidents. 
 The toxaemia (or blood-poisoning) in eclampsia gravidarum, parturen- 
 tium et puerperarum, is commonly produced by uraemia; i. e., by a 
 change of urea which is retained in the blood, or by retention of the 
 excrementitious constituents of the urine. . . . Under the common 
 appellation of ' Eclampsia 7 several pathological processes have hitherto 
 been comprehended, which do not even present an identical series of 
 symptoms, and which have only this in common, that there exist tonic, 
 and specially clonic spasms, along with loss of sensibility." 
 
 The exceptional varieties of eclampsia, to which the author here 
 refers, are cases in which the origin is to be discovered in defective 
 purification of the blood, arising from quite different causes — such as 
 imperfect elimination of carbonic acid through the lungs, the retention 
 of bile in the blood (cholcemia), or the operation within that fluid of 
 certain other septic agents — the nature of which is little understood — 
 such as are developed occasionally in the course of typhus, or some 
 other continued fever. Epilepsy, when it occurs, is to be distinguished 
 partly by the symptoms of the attack, but more particularly, if not con- 
 clusively, by the absence of albumen in the urine, both before and after 
 the attack. Cases have been met with, in which the cause was pre- 
 sumed to reside in an altered condition of the blood, as regards the 
 proportion of its various normal ingredients — such as hyperinosis, 
 leukaemia, or hyclraemia. One of the symptoms which immediately 
 precede dissolution, in cases of haemorrhage, is a convulsive seizure, 
 presenting most of the features of eclampsia, and supposed by most 
 authorities to be due to anaemia. Finally, and putting aside the cases 
 in which convulsions are due to some diseased condition or functional 
 disturbance of the nervous centres, there are other instances, in which 
 an irritation of the peripheral nerves gives rise, by a reflex action, to 
 similar symptoms, which are often associated with other hysterical 
 manifestations, and are therefore called, with some propriety, hysterical 
 convulsions. With rare exceptions, then, arising from these or similar 
 causes, puerperal eclampsia may be looked upon as essentially connected 
 with uraemic poisoning, which, again, is associated with, or dependent 
 upon, an albuminous condition of the urine. 
 
 Before entering upon the consideration of the symptoms and pathology 
 of this alarming disorder, it may be well to look closely, were it but 
 for a moment, upon some of the conditions essential to the pregnant 
 
 43 
 
67-4 PUERPERAL ECLAMPSIA. [CHAP. 
 
 state. The constitutional sensitiveness, to which we have already 
 more than once referred as eminently characteristic of pregnancy, can 
 scarcely fail to display itself in its relation to the nervous system and 
 its all-pervading influence. Dr. Barnes has quite recently 1 argued, 
 with much force and great ingenuity, in favor of a theory which he 
 advances, that nature provides, against the period of parturition, a 
 special supply of nerve-force; that this is associated with an increased 
 irritability of the nervous centres; and that it implies a corresponding 
 organic development of the spinal cord. This involves, we apprehend, 
 pretty much the same idea as that which we have expressed, although 
 it is couched in more precise and more philosophic terms. What more 
 likely, may we not infer, than that the force of the nervous system thus 
 surcharged may, by derangement of excited signals, be reflected upon 
 the wrong track, and thus cause convulsive action in unlooked-for 
 quarters, and frequently disaster as the result? But, besides this, we 
 cannot but regard the altered condition of the blood in pregnant 
 women, as, in some degree, predisposing to a morbid condition, one of 
 the essential factors of which is an abnormal state of the blood itself. 
 These changes, as formerly mentioned, consist in an increase of water 
 and of fibrin, a diminution in the quantity of albumen, and a reduc- 
 tion in the proportion of the red, with a relative increase in the white 
 corpuscles. 
 
 There is another point of great interest, to which Barnes directs 
 attention in his lectures above alluded to, — that all generative acts 
 manifest an emotional and a convulsive element. "It further deserves 
 to be noted here, that emotion takes a large part in every act or process 
 ^f the generative function. In short, emotional affectability is the 
 measure of convulsive liability. Another proposition I would state is 
 the correlative of the preceding one. It may not be quite so obvious 
 dn its truth, but I think I shall be able to show that it is equally con- 
 stant. It is this : An energy which may be compared with, if not 
 identical in nature with, convulsion, is an essential element in the 
 leading acts of the generative function. I have known instances of an 
 epileptic fit being repeatedly induced by the sexual act. I have heard 
 of several other like cases. Voisin mentions one. La Motte knew a 
 woman who, not pregnant, always vomited sold actione coitus." 
 
 The period at which eclampsia most frequently develops itself, is 
 generally stated to be during the course of labor. As, however, it is 
 also noticed for the first time during the last weeks of pregnancy in a 
 large number of cases, and as labor is often an immediate result of a 
 convulsive seizure, it cannot be an easy matter to determine what is its 
 relative frequency with regard to the three periods of pregnancy, labor, 
 and childbed. According to Braun and Wieger, more than half of all 
 cases occur during labor, but, for the reason above stated, this may well 
 be admitted as doubtful ; and, for our part, we are inclined to agree 
 with the conclusions of the writer of the able article on this subject in 
 the Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, that 
 
 1 See his Lumleian Lectures on the Convulsive Diseases of Women Lancet, 
 April, 1873. 
 
XLII.] ' SYMPTOMS. 675 
 
 the relative frequency of the three epochs is correctly expressed in the 
 following order, — pregnancy, labor, after delivery. Statistics are not 
 much to be relied upon, but it may be noticed that an average of Eng- 
 lish and Continental practice seems to yield about 1 case of eclampsia 
 in 350 labors. 
 
 Symptoms. — Although the convulsive seizure sometimes comes on 
 quite unexpectedly, there are probably few cases in which premonitory 
 symptoms of some kind or other might not have heen detected. One 
 of the most important of the premonitory symptoms is oedema, which, 
 indeed, is of common occurrence, especially in the ankles, feet, and 
 labia majora. This oedema is generally developed some weeks before 
 the appearance of the first fit, and it is occasionally, although somewhat 
 rarely, to be observed in the upper part of the body and in the face. 
 Should this symptom be manifest, the suspicion of the attendant will, 
 almost as a matter of course, be excited, with the result of an immediate 
 examination of the urine, which will be found to yield a large quantity 
 of albumen by the ordinary tests of heat and nitric acid. The micro- 
 scope, in most of these cases, reveals the presence in the fluid of hyaline 
 tube-casts, with or without blood-corpuscles ; or it may indicate, by 
 appearances familiar to the pathologist, the presence of more advanced 
 and serious renal disorder. 
 
 In a considerable number of instances, no oedematous indication 
 attracts attention, even although undoubted albuminuria exists; but, 
 when this more conspicuous and familiar symptom is absent, there are 
 other premonitory symptoms, which in some cases are of high impor- 
 tance, and, in all, demand careful attention. According to Chaussier, 
 there are three symptoms which, as premonitory indications, deserve 
 special attention : these are cephalalgia, derangements of vision, and 
 epigastric pain. The headache — which is the most frequent of all — is 
 extremely acute, and is usually complained of in the frontal region. 
 At first it is intermittent, but subsequently, and especially when the fit 
 is near at hand, the pain often becomes continuous. When the sense 
 of sight is any way disturbed, this is justly looked upon as an indica- 
 tion of grave import. There is, at first, either cloudiness or dimness 
 of vision, or that peculiar indistinctness which gives one the idea of 
 looking through the highly rarefied atmosphere over a furnace — familiar 
 to those who are the subjects of trifling biliary derangements. In other 
 examples, objects seem to exhibit peculiar colors, and the vision becomes 
 gradually more impaired, although in some instances the affection is 
 intermittent. Very often the loss of sight does not come on till imme- 
 diately before the fit, and cases have probably been witnessed by most 
 practitioners of experience, in which a patient, either during labor or 
 before it, complains of sudden and complete loss of vision, and in a few 
 minutes, or it may be seconds, is overwhelmed with the most violent 
 eclamptic seizure. The third of the premonitory symptoms of Chaus- 
 sier, epigastric pain, is of less frequent occurrence than the other two. 
 The suffering is described as being extremely severe, lasting often for 
 hours ; and when it is of unusual severity, it is said to be an almost 
 certain precursor of a convulsive attack. In no inconsiderable propor- 
 
676 PUERPERAL ECLAMPSIA. [CHAP. 
 
 tion of all cases of the affection, no albumen is to be detected, and this 
 is a fact which must be carefully borne in mind. 
 
 The convulsive seizure characteristic of true puerperal eclampsia 
 varies so little, save in intensity and duration, that to have witnessed 
 and carefully observed even a single attack will suffice to make one 
 familiar with its main diagnostic; features. The following description 
 of the fit is in a great measure borrowed from the essay already alluded 
 to. Probably, after some of the precursory symptoms already described, 
 the patient seems deeply absorbed and preoccupied ; then her gaze be- 
 comes fixed for a few seconds, and the fit commences immediately by 
 rapid contractions of the muscles of the face, of the 1 eyelids, and of the 
 eyeballs, which seem to roll in their sockets. These twitching move- 
 ments, which give to the countenance a most painful expression, pres- 
 ently give place to tonic contractions of the same muscles, and of the 
 neck. The mouth is first twisted towards the left, and the face is slowly 
 turned towards the shoulder of the same side. The upturned eyeballs 
 show, through the half-closed eyelids, the inferior segment of the scler- 
 otic. After being slowly turned to the left, the face, by a movement in 
 the contrary direction, turns towards the right shoulder. From the 
 head, the convulsive phenomena rapidly extend to the other parts of the 
 body. The extensors of the trunk, thrown into violent contraction, 
 tend to bend the spinal column backwards (opisthotonos). The trunk 
 becomes perfectly rigid. The legs are equally so and generally extended. 
 The hands close with force, the thumb being bent inwards upon the 
 palm, and grasped by the other fingers. Occasionally, the predominant 
 action of the flexor muscles has the effect of fixing the different seg- 
 ments of the superior extremities in a semiflexed position, so that the 
 arm sometimes takes the attitude which is given to it to protect the head 
 from a menaced blow. Finally, the diaphragm and the respiratory 
 muscles become involved. Respiration is suspended ; the face becomes 
 livid; and the tongue, if projecting from the mouth at the commence- 
 ment of the fit, is seized and lacerated by the spasmodic closure of the 
 jaws, and the blood, which escapes from the wound thus produced, 
 tinges the saliva which flows from the lips. The muscles of the larynx, 
 and possibly those of the throat, being strongly convulsed, close these 
 orifices. Consequently, the air, compressed by the convulsive constric- 
 tion of the thorax, can only escape with great difficulty, and produces 
 a peculiar intercepted hissing expiration. There is observed, at the 
 same time, a complete loss of consciousness and of all sensation. The 
 patient neither sees nor hears; and if we pinch or burn the skin, she 
 makes no attempt to withdraw from an irritation of which she does 
 not seem to have the slightest perception. 
 
 Clonic convulsions, affecting the whole muscular system, soon succeed 
 the tonic variety. Jerking movements of the head, trunk, and limbs, 
 take the place of the general rigidity of the preceding period. Fright- 
 ful contortions of the countenance are the result of irregular movements 
 of the mouth, eyelids, and eyeballs. Respiration, which up to this 
 point is almost completely suspended, becomes gradually re-established. 
 The expiratory act is interrupted and stertorous ; a frothy, and often 
 bloody foam is forced from between the lips. The movements of the 
 
XLII.] PATHOLOGY. 677 
 
 trunk and limbs consist of twitcliings, so trifling in extent as merely to 
 move the body without displacing it, so that there is not the same 
 necessity for restraint as in some other convulsive diseases. The pulse, 
 if strong and full at the commencement of the fit, is rapidly accelerated 
 under the influence of the muscular and respiratory disturbance, and 
 becomes extremely feeble towards the height of the paroxysm. It 
 sometimes happens that the contents of the bladder and rectum are 
 voided during the fit, either by paralysis of the sphincter, as some have 
 supposed, or by convulsive action of the diaphragm or the muscles which 
 form the abdominal walls. 
 
 As the fit passes off, all these symptoms progressively decline. The 
 balance of the respiratory and circulatory functions is restored ; the color 
 of the surface becomes natural; the movements of trunk and limbs be- 
 come feebler and less frequent, and finally cease. In a word, the con- 
 vulsive manifestations of eclampsia may be divided into two distinct 
 periods. The first, which is characterized by tonic convulsions, seldom 
 lasts more than twenty or thirty seconds : the second period, that of 
 clonic convulsions, lasts much longer — from one to five minutes, or even 
 more. The gradual restoration of the respiratory function during this 
 second period, prevents any special danger to life ; and it is, therefore, 
 during the first, or tonic period only, that there is immediate risk. 
 After the fit has entirely ceased, the patient remains in a comatose con- 
 dition, the depth and duration of which is in proportion to the intensity 
 of the paroxysm, so that the patient may regain consciousness in a few 
 minutes, or after the lapse of many hours. A dull languor, or a con- 
 fused feeling, with headache, is then very generally complained of, and 
 it may thus be some time before the patient completely recovers. This 
 is, of course, supposing that she has but one attack, or that a consider- 
 able interval occurs between them. In extreme cases, the tonic phe- 
 nomena are such in intensity and duration that the patient's life is at 
 once sacrificed ; and, in those cases in which the fits succeed each other 
 with great rapidity, the patient has, as it were, no time to regain her 
 consciousness, and she remains in a condition of complete coma, which 
 is only disturbed by the recurrence of the dreaded paroxysms, and 
 which persists until the case terminates either in recovery or death. 
 
 Pathology. — In considering the morbid conditions, and the laws 
 which regulate the abnormal muscular action of puerperal eclampsia, we 
 shall confine our 'observations almost exclusively to the true or ursemic 
 variety, so admirably described by Braun. We have already admitted 
 that chohemia, and the many varieties of toxaemia, may give rise to 
 symptoms which are apparently identical with those of ursemic eclamp- 
 sia. In like manner, epileptic patients may, during labor, or at any 
 subsequent stage, be attacked with convulsive seizures, which the pre- 
 vious history of the case, the occurrence of the "aura," and the ab- 
 sence of albuminuria, will enable us, without difficulty, to discrimi- 
 nate. Hysteria, too, may simulate many of the symptoms which have 
 been detailed, but in this case also, the absence of albumen, — with a 
 history of " globus," " clavus," or abundant urine, and an imperfect 
 insensibility during the fits, — should prevent us from falling into 
 serious error. But to enter upon the comparative pathology of all 
 
678 PUERPERAL ECLAMPSIA. [CHAP. 
 
 these affections would lead us far beyond bounds, and we must there- 
 fore content ourselves, by stating, as concisely as possible, what has 
 been established or conjectured in regard to the ordinary or uraamic 
 variety. 
 
 That albuminuria and puerperal eclampsia are mutually dependent 
 upon each other, or, at least, are of simultaneous occurrence in the vast 
 majority of all cases, is an assertion not likely, in these days, to be se- 
 riously controverted. But it is by no means agreed, as to the albumen 
 and the paroxysm, which is the cause and which the effect. Accord- 
 ing to Braun, and those who support his views, the albumen appears 
 in the urine as the result of that inflammatory affection of the kidney 
 commonly known as Bright's disease. As a result of this, the blood 
 is poisoned with excrementitial elements of the urine, and especially 
 with urea. The experiments and researches of Frerichs, alluded to in 
 the previous chapter, have conclusively shown that the presence of 
 urea in the blood, even in considerable quantity, does not give rise to 
 eclampsia; and the conclusion which he has reached is, that the active 
 poison is the carbonate of ammonia, produced, as he assumes, by the 
 decomposition of the urea, which must, therefore, be acted upon by 
 some particular ferment, the nature of which has yet to be discovered 
 by the pathological chemist. Frerichs does not admit the essentially 
 inflammatory nature of the disease; at least he appears to do so only 
 to a limited extent, when he assumes, in explanation of the formation 
 of the hyaline tube-casts, that the inflammatory theory can only hold 
 good in so far as the exudation of blood-plasma is connected with a 
 paralytic dilatation of the capillaries. Braun, however, broadly main- 
 tains that the disease is of inflammatory origin, and that the nature 
 of the morbid process is identical with that of Bright's disease. 
 
 The other theory to which we have referred is that held by those 
 who, while admitting the existence of albumen in the urine as an es- 
 sential phenomenon, assert that this is the effect of eclampsia, and not 
 its cause, — which is, by them, supposed to be the result of some blood 
 disease, or of some blood poison, hitherto unknown to science. And 
 certainly the fact that, in so many instances, the convulsions precede 
 the abuminuria lends some confirmation to this view. 
 
 We think that Braun is too absolute in his assertion that Bright's 
 disease is the cause of puerperal eclampsia. He does not, indeed, deny 
 the existence of the ansemic and other varieties already named, but he 
 gives the latter so little prominence that one is apt to conclude from 
 his description, — what, probably, he never intended, — that their im- 
 portance is so little that they scarcely merit notice. No one, obviously, 
 can take a clear and comprehensive view of the pathology of puerperal 
 eclampsia, who does not freely admit that there are cases in which no 
 ursemic poisoning exists. There is, however, we think, no impropriety, 
 in the present state of our knowledge, in employing the term "true" 
 as synonymous with " ursemic," in the nomenclature of puerperal 
 eclampsia. But there is another point, in regard to which Braun seems 
 to have carried his theory too far, or, at least, in regard to which he has 
 failed to prove his case, — viz., that all cases of albuminuria are neces- 
 sarily examples of true Bright's disease. Frerichs's idea on this point 
 
XLII.] PATHOLOGY. 679 
 
 seems much more likely to be correct, for, if we do not misunderstand 
 him, he appears to say that, although fibrinous exudation and albumi- 
 nous urine indicate, undoubtedly, the first stage of Bright's disease, 
 and in that case have an inflammatory origin, it by no means follows 
 that the same symptoms cannot, by any possibility, proceed from other 
 than inflammatory causes. 
 
 When the uremic theory was advanced, it was assumed as possible 
 that, in a large proportion of cases, albuminuria and the consequent 
 succession of pathological changes w T ere due to pressure on the renal 
 veins. This has been, to a certain extent, experimentally proved ; and, 
 indeed, it seems to afford the only satisfactory explanation of the rapid 
 disappearance of all symptoms of renal disturbance upon the delivery 
 of the woman; an issue which we could not look for with equal confi- 
 dence in any other case, unconnected with pregnancy, in which an ex- 
 amination of the urine gave the same chemical and microscopical results. 
 We do not for a moment mean it to be inferred that pressure on the 
 renal veins can account for all cases. On the contrary, it is well known 
 that the symptoms may, although very exceptionally, be developed, 
 either early in the pregnancy, or after delivery, when such pressure as 
 is implied is obviously impossible. But we do think that the subse- 
 quent history of cases of puerperal eclampsia affords some ground for 
 the supposition that the theory is worthy of more attention than Braun 
 and Lever seem to have accorded to it. If, on the other hand, the dis- 
 sections of Frankenhauser are to be held as demonstrating a direct con- 
 nection with the nerves of the uterus, we must admit it as possible — 
 as was indeed long before conjectured by Tyler Smith — that the nervous 
 system and not the vascular system may after all be the starting-point 
 of puerperal eclampsia. 
 
 The presence of albumen in the urine is shown very clearly by the 
 ordinary tests, of which the cold nitric acid test is one of the most deli- 
 cate. By this method, a small portion of urine is placed in a test-tube, 
 which, being held at an angle, while strong acid is slowly poured down 
 the side, allows the acid to flow to the bottom. If albumen be present, 
 and the experiment carefully performed, the contents of the tube then 
 show three zones, — the upper, clear urine ; the lower, clear acid ; and 
 the intermediate zone, where the two fluids have mingled, an opaque layer 
 of coagulated albumen. It is unnecessary to detail the various falla- 
 cies which are to be guarded against in testing for albumen, as these are 
 now familiar to every clinical student. The observer should not forget 
 that albumen is sometimes present intermittently, and that, therefore, 
 a negative result by the tests is not conclusive evidence of a satisfactory 
 discharge of the renal functions. The cylindrical tube-casts are most 
 easily distinguished, according to Braun, if we examine the fresh urine, 
 about an hour after it has been drawn off by the catheter, withdrawing, 
 by means of a pipette, a few drops of the fluid from the bottom of the 
 vessel. These casts are, however, it should be remembered, necessarily 
 absent in alkaline urine, as they are dissolved in the carbonate of am- 
 monia, which is the product of decomposition of the urea. Very elabo- 
 rate descriptions are given by Frerichs of the different varieties of tube- 
 casts, but such observations belong more strictly to the pathology of a 
 
680 PUERPERAL ECLAMPSIA. [CHAP. 
 
 renal disease, than to the explanation of a puerperal disorder. We 
 would direct attention here, further, to two important practical points 
 to which Braun gives a prominent position; first, "The quantity of 
 albumen has generally an intimate relation to the extent, intensity, and 
 duration of acute Bright's disease, but not so constantly to the violence 
 of the eclampsia;'' and, again, "The more acute the Bright's disease, 
 the darker is the urine, and the more numerous, generally are the 
 blood-corpuscles." 
 
 Morbid anatomy throws no very new nor clear light upon the sub- 
 ject. In fatal cases, which are necessarily the most severe, we would 
 naturally expect to find evidence, more or less distinct, of Bright's dis- 
 ease, in one or other of its stages or forms; but this cannot fairly be 
 held as indicating with equal certainty, the pathology of those cases in 
 which we venture to assume that the cause consists more in mechanical 
 obstruction or peripheral irritation than in pathological lesion, and in 
 which, presumably, a fatal result would be less likely to ensue. Proba- 
 bly the result depends, then, in a great measure, upon the extent to 
 which the structure of the kidney has become involved ; and if, in fatal 
 cases, the hypersemic or exudative stage has rarely been observed, we 
 may be sure that it is because these cases usually recover. If, on the 
 other hand, the terminal stage, or stage of atrophy, has been reached, 
 we cannot wonder that such irremediable disorganization should culmi- 
 nate in a fatal result, with or without convulsions. Besides the morbid 
 appearances which are characteristic of lesion of the kidneys, the only 
 observations of importance which have been made are, that the lungs 
 are constantly ©edematous and sometimes emphysematous — the result, 
 as is assumed, of the straining of the fits. The spleen is almost always 
 enlarged, but this should not be mentioned as characteristic of the dis- 
 ease in question, as it is well known that enlargement of this organ 
 is very usual, if not invariable, during pregnancy and the puerperal 
 state, associated, probably, with some compensatory changes in the 
 circulation. 
 
 Some have supposed that uterine contractions have an important 
 share in the etiology of eclampsia. That the disease may be mani- 
 fested during pregnancy and after delivery shows clearly enough that 
 this is not an essential condition, even although we may admit it as a 
 possible cause. But, in truth, uterine action is much more likely to be 
 the effect than the cause of eclampsia; for, if there be any truth in the 
 theory — to which some prominence has been given in previous chap- 
 ters of this work — that deficient aeration of the blood is a cause of ute- 
 rine action, prematurely or at the full term, we can have no difficulty 
 in admitting that this condition exists, during the paroxysm of eclamp- 
 sia, in a high degree. "By exciting pains," says Braun, "and increas- 
 ing their strength, fits cannot be produced at will, nor even aggravated. 
 For w T e have made the observation that, under a high degree of reflex 
 sensibility, convulsions cannot be induced at will, at definite periods, 
 by violent irritation of the uterus." We do not doubt this assertion, 
 that fits cannot be produced at will; but there are many cases on record 
 of fits being produced, under such a degree of reflex sensibility as is 
 here referred to, by attempts to introduce the hand into the uterus, 
 
XLII.] EFFECT OF LABOR PAINS. 681 
 
 during labor, for the purpose of turning, or after labor, with the view 
 of removing the placenta ; or, it may be, from emotional or other ex- 
 ceptional causes. This may, no doubt, be assumed to be attributable 
 to uterine sensitiveness ; but we are inclined to agree, for anatomical 
 reasons, with Dr. Tyler Smith, that the irritation in such cases is more 
 likely to spring from the vagina or the cervix uteri than from the 
 nerves which are distributed to the body and fundus of the womb. On 
 the whole, however, we must conclude that there is a very subordinate 
 relation between uterine pains and ursemic eclampsia. 
 
 The maternal and foetal mortality arising from this disease are sub- 
 jects of great and obvious interest, since about thirty per cent, of 
 mothers have hitherto succumbed to its effects, direct or indirect. A 
 mortality so large as this must necessarily awaken in the mind an 
 earnest desire for methods of treatment more effectual than any now at 
 our command, and there can be little doubt, that, if the death-rate 
 from this cause is in the future to be materially reduced, it must be by 
 a careful and earnest investigation of pathological theories, and an ob- 
 servation, dictated by the same spirit, of clinical facts. The life of the 
 foetus is certainly to be looked upon, in every case of puerperal eclamp- 
 sia, as in considerable danger. This fact being admitted, it is by no 
 means agreed as to what is the cause upon which it depends. The 
 stoppage of the circulation in the maternal vessels of the placenta, as 
 suggested by Kiwisch, can hardly account for this; for, were it so, the 
 danger would cease with the fit, whereas, the infant dies in about a half 
 of all the cases, and almost always when the symptoms are severe and 
 come on in rapid succession. There is good reason to believe that the 
 actual cause of death in such cases is an extension of the toxic influ- 
 ence from the blood of the mother to that of the child. On this point 
 Braun observes, — " If, after numerous ursemic convulsive fits, the child 
 is born alive, a large quantity of urea is found in the blood taken from 
 the umbilical cord ; but if it is born dead, we can, immediately after 
 the birth, demonstrate the presence of carbonate of ammonia in the 
 foetal blood." 
 
 It has been said that, next to rupture of the uterus, eclampsia is the 
 most disastrous affection which it is possible for us to encounter in the 
 practice of obstetrics. There are certain questions of prognosis, there- 
 fore, in regard to which much anxious speculation must necessarily 
 arise. The points, as already remarked, which chiefly call for anxiety, 
 are an abundance of albumen (when the urine solidifies on boiling), 
 violent fits with short intervals, and profound coma : the converse of 
 these gives good hope of recovery. The dangers, however, of eclamp- 
 sia depend, in no slight degree, upon the condition of the woman, and 
 especially the period as regards pregnancy, labor, or childbed, at which 
 the sv mptoms first manifest themselves. When eclampsia occurs during 
 pregnancy, it is almost always during the last three months that the 
 first attack takes place, the viability of the child being in most cases 
 undoubted. It rarely happens in these cases — and then only when the 
 symptoms are moderate — that pregnancy is permitted to go on to its 
 natural term ; and this alone, irrespective of toxsemic action, is apt to 
 compromise the life of the child. In one-fourth of the cases, according 
 
682 PUERPERAL ECLAMPSIA. [CHAP. 
 
 to Braun, the albuminuria, or rather the ursemic or ammoniacal intox- 
 ication of the blood/ is sufficient, without the occurrence of eclamp- 
 sia, to induce premature labor; but, if the convulsive disorder should 
 be developed, the chances of mature gestation and the life of the child 
 are still further reduced. 
 
 When rhythmical uterine contractions, and other symptoms, have 
 indicated the commencement of labor before the manifestation of the 
 convulsive phenomena, the effect which is produced upon that process 
 is necessarily watched with much anxiety. In a certain number of 
 cases, the obvious result is an acceleration in the progress of the labor, 
 w T hen delivery is sometimes completed with great rapidity. " The 
 process of labor," says Baudelocque, " in these cases, seems even more 
 rapid then in others, as the child has often been found between the legs 
 of the mother, although, an instant before, no disposition to delivery 
 had been remarked." Inasmuch as no facts have hitherto been re- 
 corded which prove that the muscular system of organic life partici- 
 pates in the turbulent action of the muscles of animal life, it seems 
 likely that the rapid expulsion in these instances is due rather to defi- 
 cient resistance in the latter than to abnormal force of the former. It 
 is quite possible, however, that the pains may, by a reflex action upon 
 the nervous centres — surcharged, as Barnes supposes, by an excess of 
 nervous force — excite the expulsive efforts to such an extent as to 
 induce this result. But this is widely different, as will be observed, 
 from a morbid supernumerary force arising from convulsive action. 
 The result of delivery in effecting a diminution in the frequency and 
 violence of the paroxysms is universally acknowledged, and is recog- 
 nized in practice by the rule which is admitted to be of universal ap- 
 plication, — to assist delivery as soon as the condition of the parts indi- 
 cates that that stage has been reached when the passage of the child may 
 be safely effected. 
 
 It is a matter of dispute whether the eclampsia which develops itself 
 for the first time after delivery, is, or is not, more dangerous than the 
 other forms. Theoretically, one would think so, seeing that, uterine 
 excitation and pressure on the renal veins being no longer in operation, 
 the occurrence, under such circumstances, might be held as indicating 
 a more grave constitutional affection. But Pajot, Blot, and others, 
 have strongly deprecated this assumption, and have stated as the result 
 of their experience, that in these cases, the issue is on the whole more 
 satisfactory. In those instances in which fits have come on before 
 delivery, the completion of labor, although it usually produces a marked 
 amelioration of the symptoms, by no means places the woman out of 
 danger. It has been observed by Blot that, putting aside the danger 
 of repeated attacks of eclampsia, there is in such cases a special tendency 
 to post-partum haemorrhage ; and others have noticed that there remains 
 a proclivity to the various inflammatory affections to which a parturient 
 woman is liable, such as uterine phlebitis, peritonitis, pelvic cellulitis, 
 and the like, the occurrence of which is obviously favored by the de- 
 
 1 Hammond and others have denied that the urea in the blood decomposes into 
 carbonate of ammonia. 
 
XLTI.] TREATMENT. 683 
 
 rangemcnts of the circulatory system which repeated attacks of eclampsia 
 necessarily engender. 
 
 Treatment. — The earliest stage at which the question of treatment 
 may offer itself for our consideration, is when the symptoms during 
 pregnancy are such as to cause serious apprehension of an impending 
 explosion. The most important of these are albuminuria, tube-casts in 
 the urine, and oedema. Although a complete cure of albuminuria is 
 very rarely obtained during pregnancy, something may, no doubt, be 
 done in the way of moderating the disease, and preventing its passing 
 into its higher and more incurable grades. It is, at least, possible, by 
 the administration of ferruginous tonics and by a liberal diet, as recom- 
 mended by Cazeaux, to ameliorate a watery or otherwise deteriorated 
 condition of the blood, and a good general effect is often produced by 
 the use of tepid and vapor baths. In order to prevent decomposition 
 of the urea in the blood, or to neutralize the carbonate of ammonia 
 already formed, it was suggested by Frerichs that tartaric acid, benzoic 
 acid, or lemon-juice should be regularly given, a recommendation which, 
 although it has not yet received the assent of some eminent physicians, 
 must be looked upon with interest as the necessary corollary to that 
 author's proposition as to the pathogenesis of the disease. In every 
 case, the function of the bowels should be carefully regulated, but 
 purgation as a prophylactic measure, although strongly recommended 
 by some, must be resorted to with caution, as there is a risk of thereby 
 reducing the strength, which is already enfeebled. The quantity and 
 microscopic conditions of the urine afford the best indications as to the 
 necessity which exists for the use of diuretics. Braun recommends 
 that, when exudation has taken place into the Malpighian capsules and 
 the tubuli of Bellini and Fcrrein, the cylindrical clots must be removed 
 from them, and the formation of new ones prevented. If the current 
 of fluid proceeding from the vascular knot of the Malpighian bodies 
 into the Malpighian capsules be strong, then the copious use of diluents 
 is sometimes alone sufficient to wash away the cylindrical clots, and 
 recovery ensues. But, if the secretion of urine be very scanty, and 
 ursemic intoxication threatens to come on, then the force of the current 
 proceeding from the Malpighian bodies must be increased, and the 
 cylindrical clots removed, for which purpose the acids (above men- 
 tioned), and the mineral waters of Selters and Vichy arc best adapted. 
 According to the example of Frerichs, pills of tannin and extract of 
 aloes may be used for restoring the normal tone. 
 
 It has been proposed, with the view of obviating eclampsia and its 
 dangers, that premature labor should be induced. Tarnier recommends 
 that this should be done before the symptoms become urgent ; but we 
 think that Braun's view is decidedly more judicious, when he insists 
 that labor should only be provoked when the symptoms are such that 
 the life of the woman is in danger. When the child is already dead, 
 Ave are, of course, more justified in having recourse to this measure. 
 When labor comes on without eclampsia, it has been recommended by 
 Chailly that chloroform be employed, with the view of warding off the 
 attack. 
 
 In the treatment of eclampsia, in which the explosion has already 
 
684 PUERPERAL ECLAMPSIA. [CHAP. 
 
 taken place, our mode of procedure must necessarily differ, according 
 to the period — pregnancy, labor, or childbed — at which the fits develop 
 themselves. But, as regards the treatment during the paroxysm, the 
 indications are the same in all cases, and consist mainly in doing what 
 we can so to act upon the nervous system as to moderate central irrita- 
 bility, and reduce peripheral or reflex excitability to a minimum. It 
 is but a few years since all cases of eclampsia, with the exception of 
 the ansemic and hysterical varieties, were treated upon one and the 
 same principle — that being free general bloodletting. The facts, how- 
 ever, which modern pathology has disclosed have completely altered 
 the plan of treatment. Perhaps, in some quarters, the rejection of the 
 lancet has been too absolute. Indeed, we incline strongly to this belief; 
 for there are cases, in which the constitution and temperament of the 
 woman, and the violence of the attack, along with evidence of vascular 
 tension of the brain, quite warrant us in supposing that venesection 
 would afford the best chance of recovery. Still, it must be confessed 
 that indiscriminate bleeding was a monstrous error, and that it would 
 be better to do nothing at all than to bleed without selection of cases. 
 Those who, in the present state of professional opinion, shrink most 
 from the idea of the lancet, may at least, in suitable cases, apply 
 leeches freely to the temples. 
 
 A remarkable effect is produced, in many cases of puerperal eclampsia, 
 by the administration of chloroform, ether, and other anaesthetic agents; 
 an effect which, in some instances, quite surpasses our expectations. 
 The approach of a repeated paroxysm, or symptoms such as make us 
 dread the commencement of a first seizure, are a sufficient warrant to 
 adopt this method of treatment. Respiration being much impeded, as 
 we have seen, during the fit, it is proper at that time to withhold the 
 chloroform, so as not in any way to interfere with the function of 
 respiration while the aeration of the blood is already so seriously in- 
 terrupted. Anaesthesia, however, often has the effect of holding in 
 subjection the premonitory symptoms, and so long as this result is 
 undoubted, we may keep up the effect until the patient falls asleep, or 
 the approach of stertor shows that the action of the drug can be safely 
 pushed no further. When chloroform — which is the agent usually 
 employed — fails to avert convulsions, it has very generally the effect 
 of modifying them ; and we may infer that, by its action on the muscles 
 of the mouth, throat, and larynx, the danger of suffocation, during the 
 period of tonic spasm, is materially diminished. And there can be 
 no doubt, as Barker observes, that chloroform alone has considerably 
 diminished the rate of mortality in these painful eases. 
 
 The hydrate of chloral is another anaesthetic agent, which has of late 
 been strongly recommended. The sedative and narcotic effects of this 
 drug are well known, but it is not so generally understood that when 
 it is pushed further, it produces an anaesthetic effect, under the influence 
 of which a woman may be delivered without experiencing the slightest 
 suffering. We can, without hesitation, corroborate much of what has 
 been advanced of late in regard to the marvellous effects of this drug 
 in the treatment of convulsive diseases. When given in what we may 
 call ordinary sedative doses — not more than thirty grains — its effect is 
 
XLII.] ANAESTHETICS. 685 
 
 safe, and in most cases efficacious ; but, should we think of giving larger 
 and repeated doses, we must bear in mind, that very alarming symp- 
 toms are occasionally produced, and that death has even been the result 
 of what we might consider quite an ordinary dose. A number of cases 
 have been of late recorded in proof of the efficacy of chloral in eclampsia. 
 We extract the following from the Gazette des Hopitaux of Feb. 22, 
 1873 : " A woman of twenty-one, pregnant for the first time, who had 
 suffered for fifteen days from oedema of the lower limbs and of the 
 eyelids, from headache, somnolence, great weakness, and frequent calls 
 to urinate, was admitted to the hospital of La Charity, under the care 
 of M. Bourdon. On her admission, a large quantity of albumen was 
 discovered in the urine. Three days passed without any appreciable 
 change in her condition ; but, on the fourth day, a violent attack of 
 eclampsia took place, which lasted for ten minutes. During the period 
 of resolution, an enema containing four grammes (a little more than 
 one drachm) of hydrate of chloral was administered, after which the 
 patient almost immediately fell asleep. At the visit on the following 
 morning labor had not commenced. Foreseeing the probability of a 
 renewed attack, M. Bourdon had two injections prepared, each con- 
 taining four grammes of chloral. The first was administered at ten 
 o'clock in the morning, just as labor had commenced. The second 
 was given two hours afterwards. At three o'clock the labor terminated, 
 without the woman having experienced the slightest pain. On the 
 evening of the birth, a second eclamptic attack took place. A draught 
 containing four grammes of chloral was at once administered ; she had 
 a quiet night, and no fresh attack took place ; the oedema rapidly dis- 
 appeared, and the patient left the hospital fifteen days afterwards." 
 
 The effects of chloral are further illustrated in a remarkable thesis 
 by M. Charpentier, 1 in which he contrasts the effects of the various 
 remedial agents which, up to this time, have been employed in the 
 treatment of eclampsia. He, more particularly, compares the effect 
 of treatment by the old method of bleeding, and the modern plan of 
 anaesthesia, with the following striking result, which we quote, how- 
 ever, with the reservation applicable to obstetrical statistics in general : 
 
 Mortality in cases treated by bleeding, . . .35 percent. 
 " " " anaesthetics, . .11 " 
 
 We must carefully avoid, moreover, the danger of adopting any par- 
 ticular method of treatment to the exclusion of others. If we admit 
 that throbbing carotids, and marked suffusion of the eyes and face after 
 the subsidence of the fits, are exceptional symptoms, warranting blood- 
 letting, we may, in like manner, concede that ice to the head may, in 
 similar cases, be beneficial. Dashing the face and surface with cold 
 water during the fit, as recommended by some, is always to be avoided; 
 for it is quite obvious that an excitation of this kind is likely to be 
 followed by reflex convulsive phenomena. Sponging with warm water, 
 or tepid vinegar and water, has been found useful; and opium, in some 
 form or other, has often been freely administered, both by the mouth 
 
 1 De l'influence de divers traitements sur les acces eclamptiques. Paris, 1873. 
 
686 PUERPERAL ECLAMPSIA. [CHAP. 
 
 and by enema, in eases in which the other methods of treatment have 
 not operated with sufficient rapidity. 
 
 What may be called the obstetrical treatment of eclampsia involves a 
 more particular reference to the stage at which the seizure occurs. The 
 cases in which we would be justified in inducing premature labor are 
 very exceptional; for it must be remembered that the usual effect 
 of eclampsia is to bring on labor, so that we need not Interfere in the 
 process. Still, there certainly are eases where the gravity of the symp- 
 toms may call for prompt and decisive action. 
 
 In eclampsia occurring during labor, our mode of procedure must, 
 of necessity, be regulated entirely by the stage of the process which has 
 been reached. There are, however, two preliminary points which it is 
 necessary to have in view throughout: 1st, that on account of the 
 extreme irritability of the nervous centres, we should avoid, as far as 
 possible, all sources of reflex irritation, and, above all, any unnecessary 
 manipulation or digital examination; and, 2d, that although we recog- 
 nize the importance of speedy delivery, we must be extremely careful, 
 in adopting operative means for accelerating the process, to choose, if 
 it be practicable, those only which are least likely to excite increased 
 muscular action, whether of the voluntary or involuntary muscles. If 
 the os is still closed and rigid, Ave content ourselves with cold applica- 
 tions to the head, and at the same time, by means of chloroform or 
 chloral, attempt to allay the nervous irritability, while we await the 
 result of the natural process of cervical dilatation. If we wish to bring 
 on labor, the safest method of provocation is to introduce an clastic 
 catheter, in the manner described in a previous chapter. 
 
 When the os is already partially dilated and dilatable, the treatment 
 which is now recommended by almost all the best authorities, is to 
 rupture the membranes, and, after thus permitting the escape of the 
 waters, narrowly to observe the subsequent stages of the process. For- 
 cible dilatation of the os (accouchement forcie) is a method of procedure 
 which can scarcely he admitted as warrantable under any circumstances, 
 and the same observation applies to the incision of the soft parts after 
 the method recommended by Baudelocque. When the os is dilated, 
 and the stage, consequently, has arrived at which the forceps may 
 easily be applied, we hold the blades in readiness for immediate use ; 
 but, even here, if the parts are anatomically in a favorable condition, 
 it is better to leave the case for a time to nature 1 . When the head has 
 passed downwards in the pelvis, and is pressing on the perineum, we 
 need have little hesitation in using the instrument, should tin; condi- 
 tion seem urgent, or the labor begin to flag. The operations of tinning, 
 or of craniotomy, should never be entertained, unless in the presence of 
 malpresentation or pelvic disproportion, when the rules applicable to 
 these complications must be observed. Ai'ivv delivery, if is advisable 
 that the removal of the placenta should not be long delayed, and (he 
 accoucheur should pay particular attention to the contraction of the 
 uterus and the removal of clots. 
 
 Should the convulsions persist after delivery, or should they then 
 come on for the first time, full doses of opium or chloral, the adminis- 
 tration of chloroform, cold to the head, perfect rest and quiet, and the 
 
XLIII.] PUERPERAL FEVER. 687 
 
 emptying of the bowels, if necessary, by a simple enema, are the main 
 points to be attended to. It is very unlikely that at this stage bleeding 
 would be held to be advisable, but it is possible that some benefit might 
 be derived from ligature of the limbs, by which a large quantity of 
 blood — thirty ounces, according to Vogel — may be temporarily with- 
 drawn from the circulation; but this is a process in regard to which 
 we must learn more before we can be confident as to its results. When 
 the convulsions present the eharacter of hysteria, or are of the so-called 
 anaemic variety, the treatment must, of course, be modified, in the one 
 case, by the addition of the familiar antispasmodic remedies, and, in the 
 other, by the administration of stimulants, with, subsequently, generous 
 diet and tonic restoratives. 
 
 CHAPTEE XLIII. 
 
 PUERPERAL FEVER AND ALLIED AFFECTIONS. 
 
 PERPLKXING NATURE OF THE SUBJECT— PUERPERAL FEVER: DOES A SPECIFIC 
 PI ERPKRAL POISON REALLY EXIST ? — SHOULD THE TERM " PUERPERAL FEVER " 
 BE RETAINED? — METRIA — PHYSIOLOGICAL PECULIARITIES OF THE PUERPERAL 
 STATE— PUERPERAL SEPTICEMIA — MODE OF SEPTIC POISONING— CON N ECTION 
 WITH CERTAIN ZYMOTIC INFLUENCES: ERYSIPELAS, SMALL-POX, SCARLET 
 FEVER, ETC—CONNECTION WITH POST-PARTUM INFLAMMATIONS— PUERPERAL 
 PERITONITIS; MAY EXIST INDEPENDENTLY OF PUERPERAL FEVER: SYMPTOMS 
 OF AN ORDINARY ATTACK ; OF TH E MORE SEVERE FORM — FALSE PERITONITIS — 
 PUERPERAL METRITIS ; OK LESS FREQUENT OCCURRENCE : SYMPTOMS — UTERINE 
 PHLEBITIS: SYMPTOMS AT FIRST OBSCURE: SECONDARY ABSCESSES IN THE 
 LATER STAGE: TISSUES CHIEFLY INVOLVED — VAGINITIS; STHENIC AND AS- 
 THENIC — INFLAMMATION OF THE UTERINE LYMPHATICS. 
 
 There is, perhaps, in the whole range of obstetrics, no subject 
 which the writer and teacher approaches with so profound a convic- 
 tion of difficulties to be encountered, as that group of affections of the 
 puerperal perio'd to which the term Puerperal Fever has, witli a some- 
 what loose signification, been given. Beyond what he has learned 
 from personal experience, he naturally turns to the literature of the 
 subject, in the expectation that, by an analysis of the opinions expressed 
 by the best authorities, he may succeed in formulating an intelligible 
 nosological classification, reliable pathological data, and clear views of 
 treatment. A very short experience will suffice to dissipate this delu- 
 sion, so that he will soon recognize the difficulties of his position. It 
 must be confessed, however, that the general tendency of the most 
 recent contributions to this department of our literature has been to 
 clear away many of the prejudices and errors of the past. That per- 
 plexities still remain is matter which can cause us no surprise, and we 
 
688 PUERPERAL FEVER. [CHAP. 
 
 may be well content if we can recognize in the views of the present day 
 theories which are more intelligible, more consistent with personal ex- 
 perience, and which point significantly to a solution of many problems 
 which have vexed successive generations of able writers and expe- 
 rienced practitioners. 
 
 When we employ the term "puerperal fever" in the singular num- 
 ber, the expression may be held to imply a belief in the existence of a 
 specific fever which runs a definite course to a crisis, after a period of 
 latency, and is due to what we call a specific poison, in the same sense 
 as we have a typhous, an enteric, and a variolous poison. This puer- 
 peral poison was commonly assumed to be developed only in the puer- 
 peral state, and communicable only from one puerperal woman to 
 another. The first question to be determined then is — does any such 
 specific poison exist? or, in cognate terms — does any such disease occur 
 as specific puerperal fever? 
 
 To these questions we do not hesitate to give a negative reply ; and 
 indeed we confess to the existence of an impression that the term " puer- 
 peral fever" might be discarded, to the ultimate advantage of all con- 
 cerned. The expression " post-partum fevers" has been suggested, and 
 is in some ways to be preferred ; but, in the present and still unsettled 
 state of the subject, it would, we believe, be dangerous to abolish old 
 familiar landmarks, and on that account, we are content to retain it, 
 employing it, as it were, under protest, and in a guarded or limited 
 sense. One might have less hesitation in retaining the name, had it 
 anything even approaching to a definite signification, but the fact that 
 ideas the most conflicting have been, and are entertained on this sub- 
 ject, is the chief reason of the perplexity and obscurity in which the 
 whole subject is involved. 
 
 If proof of this were desired, all that is necessary is to read the ac- 
 counts given of various epidemics, and of the experience of those whose 
 high reputation and recognized power of observation are the most per- 
 fect guarantee of their good faith. Each depicts a febrile disease of the 
 puerperal period ; but the symptoms, far from harmonizing, present 
 the most startling contrasts. Are we then painfully to collate such 
 facts, and by describing a multiplicity of varieties, draw attention to 
 points of contrast more than to features of resemblance ? Or, again, 
 we find one author asserting that, under the most heroic use of the 
 lancet, almost all his cases recovered ; a second has observed that, when 
 bloodletting was practiced, almost every case died ; while a third 
 describes, under the name of puerperal fever, an affection so trifling 
 that it was usually checked by a single close of Dover's powder. Are 
 these cases really of the same nature, — we ask in excusable bewilder- 
 ment, — or are they the same in name only? It were easy to multiply 
 questions of this kind, which meet us on every hand, as we follow the 
 narratives of recorded facts; but enough has been advanced to show 
 with sufficient clearness the perplexing nature of the subject which we 
 have now reached. 
 
 The more carefully one examines the whole matter, more especially 
 if with a desire to secure a comprehensive grasp of the subject, the more 
 apparent does it become that it is necessary to group together, under 
 
XLIII.] IS IT SPECIFIC? 689 
 
 one head or generic designation, the greater number of the inflamma- 
 tory and febrile affections of the puerperal state. It was this feeling, 
 we presume, which led to the adoption by the Registrar-General of the 
 term " Metria/' under which head that functionary ranges all cases of 
 death from the acute affections of the puerperal state. After due con- 
 sideration, however, we have grouped all these affections together under 
 the title which has been adopted for this chapter, so that the inflam- 
 matory affections of the puerperal state may be considered along with 
 the so-called puerperal fever. Not that it is doubted that peritonitis 
 and metritis may exist as simple inflammations, but because it is uni- 
 versally admitted that these affections are among the most frequent 
 concomitants of the more fatal cases of the childbed fevers, evidence, 
 indeed, of the existence of the former having been found by M. Tonnelle 
 in no less than 193 out of 222 dissections. While, therefore, we shall 
 consider these inflammatory affections apart, we desire not to lose sight 
 of their important affinities, both pathological and practical. It was 
 no doubt a consideration of these facts which led some of the most 
 eminent American practitioners, and the French school generally, to 
 adopt the conclusion that puerperal fever is primarily a local inflam- 
 mation. They differed much as to their ideas in regard to the tissues 
 actually involved, the greater number, perhaps, maintaining that phle- 
 bitis in some form was the initiatory inflammatory phenomenon ; and 
 some have gone so far as to imply their disbelief in the possibility of 
 the local inflammations existing apart from what they call true puer- 
 peral fever. 
 
 But, in rejecting the theory, long held in common with many others, 
 that there exists a specific puerperal poison, we are bound to state, as 
 clearly as the difficulty of dealing with a still obscure subject will 
 permit, what views we propose to substitute for those discarded. 
 Nothing, we think, is clearer than that writers have, under the head 
 of puerperal fever, described a number of quite different affections ; 
 and if we attempt arbitrarily to state what of these are, and what are 
 not the true fever, we will only contribute to the chaotic confusion in 
 which the whole subject is involved. But, if we take a bolder and 
 more comprehensive grasp of the subject, and admit that the symptoms 
 which we call puerperal fever may arise from a number of different 
 poisons or causes, and that the apparently specific character of the dis- 
 ease is due, not. to anything specific in the cause, but to the peculiar 
 physiological condition under which a puerperal woman lies, then we 
 shall see some ray of light through the clouds. And, although, from 
 this point of view, we cannot expect that all our difficulties shall dis- 
 appear, we shall find that the prospect brightens, and we look, for the 
 first time with confidence, to a period when the mists shall still further 
 be cleared away, and enlightened pathological views may point the w T ay 
 to more successful treatment, and a saving of human life. 
 
 Of all the modes in which fever may be generated in a puerperal 
 woman, that by means of septic absorption, for which her condition at 
 the moment offers peculiar facilities, is, we now believe, decidedly the 
 most frequent, although it is only of late years that it has come promi- 
 nently into notice. Some go so far as to say that to these cases alone 
 
 44 
 
690 PUERPERAL FEVER. [CHAP. 
 
 should the term puerperal fever be given. "Under the term puerperal 
 fever," says Schroeder, "we plaee all such diseases of puerperal women 
 as are caused by the absorption of septic matter, that is, organic sub- 
 stances in the process of decomposition." If Ave could accept this view 
 without reserve, the whole subject would become simplicity itself; but 
 until certain facts connected with the germ theory of disease, and the 
 presence and diffusion of bacteria in septic matter are cleared up, it 
 would be premature to close the question. Matthews Duncan, who 
 agrees with Schroeder, prefers the term of puerperal pyaemia ; but 
 whether the word employed be septicaemia, pyaemia, or ichorrhaemia, 
 the essential points are — a wound capable of absorbing, and a poison 
 which is there absorbed. 
 
 The idea of septic absorption by the surface from which the placenta 
 has been removed is no new one. The theory of the present day is not, 
 however, founded upon a mere surgical speculation, but has its basis in 
 a series of brilliant investigations, including the demonstration of phle- 
 bitis and lymphangitis, of thrombosis and embolism by Virchow, and 
 the well-known researches of Lister in regard to the action of septic 
 poisons generally, and the influence produced by the development of 
 bacteria. It is now known that poison introduced in this way does 
 not generally act at the site of the placenta, but through the slight 
 lacerations which occur in the tissues of the cervix, or through wounds 
 which are the result of tearing of the fourchette, or fissures in any part 
 of the vulvo-vaginal canal. 
 
 The septic material may be introduced by the finger, by infected 
 sponges or dressings, possibly through the atmosphere; and, in a 
 limited number of cases, where unhealthy action has taken place in the 
 wounds, absorption takes place of decomposing maternal parts by the 
 surrounding living tissues. But, while we believe that this affords by 
 far the most satisfactory solution of the question in regard to most 
 cases, it seems to us equally clear that a fever, apparently identical in 
 its symptoms and course, may arise from other poisons and other causes. 
 Erysipelas is one of the most apparent of these, so much so, indeed, that 
 they who believe in the existence of a specific poison have even sur- 
 mised that the two poisons were identical, a conclusion which is not 
 altogether inconsistent with the septicaemic theory. 
 
 It is manifest that women, during the puerperal period, may be so 
 circumstanced as to come within the range of the poison of any of the 
 specific eruptive fevers. The result of the contagious influence is fever. 
 Take the most familiar illustration, scarlatina; and, we ask — Is this 
 fever scarlatina pure and simple; or is it what we call puerperal fever, 
 modified more or less by the action of the specific poison? That this 
 is at the present moment a point of special significance, is clearly indi- 
 cated by the interesting debate which, while these pages are passing 
 through the press, continues to occupy the attention of the Obstetrical 
 Society. The manner in which this discussion has been conducted, by 
 encouraging expressions of opinion from practical men, quite as much 
 as by inviting theoretical speculations, seems to warrant the belief that 
 this newly awakened interest will not be barren of results. In regard' 
 to the question which we have proposed, the balance of opinion was in 
 
XLIII.] SEPTICEMIA. 691 
 
 favor of the view to which we adhere, — that although the poison of 
 scarlatina may produce in puerperal women scarlatina and nothing 
 more, this is not the rule, but a rare exception. What we are apt to 
 overlook in discussing this whole subject, is the peculiar condition of 
 the woman, no less in the condition of her blood, than in the newly 
 organized function of lactation and uterine involution. Need we won- 
 der then, that, when a woman so placed is attacked with scarlatina, these 
 facts should derange the action of a special poison, and give to the dis- 
 ease which is engendered more or less of the features of what — still 
 under protest — we call puerperal fever. It matters little in practice 
 whether we say that it is modified scarlatina, or modified puerperal fever, 
 so long as we recognize the affinity which subsists between the two. 
 
 In precisely the same manner the other eruptive fevers may induce 
 an affection which, whether it retains more or less of the specific char- 
 acteristics of the disease from which it has been engendered, usually 
 gives clear evidence of the puerperal type of febrile disease. Variola 
 and typhus may thus take their course, but the puerperal state fearfully 
 augments the risk ; and we have lately seen an extremely painful case 
 in which a case of undoubted enteric fever, occurring in the puerperal 
 period, passed into a condition which it was impossible to distinguish 
 from the more familiar septicemic variety. 
 
 There is another class of cases in which the earliest symptoms are 
 clearly inflammatory. In these, the symptoms and course of the malady 
 present, as a rule, points of contrast with puerperal fever which are very 
 striking. Be it well understood that we do not speak now of inflam- 
 mations which arise in the course of the more common variety of the 
 fever. These we may, without hesitation, refer to the adjacent septic 
 action. But when the patient, by exposure to cold or imprudence of 
 any sort, becomes affected with an inflammation which attacks the tis- 
 sues of the peritoneum, the womb, or the neighboring structures, the 
 inflammation, thus or otherwise engendered, sometimes runs to a fatal 
 result, giving rise the while to symptoms which, if not identical with, 
 it would be injudicious to separate from those of puerperal fever. 
 
 An adherence to the term " puerperal fever," or the limiting of that 
 designation to any particular class of post-partum disorders, may then 
 be considered as points of deep interest, but, comparatively, of little 
 practical importance. This we shall endeavor, in the sequel, to prove. 
 The importance of precision in nomenclature is a point which can scarcely 
 be overestimated, but in the present divided state of opinion it is ob- 
 viously unattainable, however much to be desiderated. Precision, as 
 we now stand, means dogmatism ; and although it is much easier to be 
 dogmatic than to be judicial, the only attitude which is justified by the 
 science of the present day is one which, while it permits us to express 
 our individual opinion and experience, debars us from pinning our faith 
 to any theory of which subsequent research may demonstrate the error. 
 Should the day arrive when all are willing to read " puerperal septicae- 
 mia," for " puerperal fever," we shall willingly give in our adhesion, 
 but in the meantime we prefer to term it a puerperal fever. 
 
 Under the designation of " allied affections," it is well that we should 
 consider at this place those local inflammatory affections, which although 
 
692 PUERPERAL FEVER. [CHAP. 
 
 in their simple form not entitled to rank as fevers, are, as we have said, 
 apt to run into a peculiar and fatal febrile condition. In their simple 
 form, or early state, we prefer to call them "post-partum inflammations." 
 
 [We would have been glad if the author had been bold enough to 
 have abandoned the term "puerperal fever" entirely. This would 
 certainly be more in accordance with the tendency of modern thought, 
 though such a course is strongly opposed by many high authorities, 
 among whom Prof. Fordyce Barker, of New York, occupies a promi- 
 nent position. This gentleman, in the recent discussion on this subject 
 before the Obstetrical Society of London, has thus tersely stated the 
 question at issue : " The gist of the matter, stripped of its superfluous 
 and obscuring elements, lies in the inquiry whether there be a disease 
 which attacks puerperal women, and only puerperal women." We 
 believe that the careful study of the diseases of childbed women which 
 have long been described under the name of puerperal fever, will decide 
 this question in the negative. The truth can only be reached by study- 
 ing this subject in its broadest sense. Conclusions cannot be justly 
 drawn from the study of a single series of cases, or from observations 
 made during any one period of an outbreak of one of these diseases. 
 All of the phenomena of the various puerperal disorders of this class 
 must be separately investigated, and their value carefully estimated 
 before' correct conclusions can be reached. The great source of diffi- 
 culty appears to be the fact that affections of the most diverse nature 
 may lead to the production of the same symptoms, and that these have 
 their origin in the same causes. This expression is used advisedly, 
 and its meaning will become apparent in the sequel. 
 
 That the author is correct in his view that precision is unattainable 
 in the present state of our knowledge cannot be denied. Any classifi- 
 cation of these diseases made at the present time must be open to 
 criticism and subject to important modification with the increase of our 
 information upon these subjects. But differences in nomenclature have 
 long impeded the march of our knowledge of the puerperal diseases, 
 and at the risk of his " precision " being styled "dogmatism," the editor 
 ventures to suggest the following classification of the affections usually 
 described under the name of puerperal fever. We believe that they 
 may be divided into three classes : 
 
 I. Local inflammatory diseases : 
 
 a. Metritis. 
 
 b. Pelvic cellulitis. 
 
 c. Pelvic peritonitis. 
 
 d. General peritonitis. 
 
 II. Septic diseases : 
 
 a. Pysemia and septicaemia. 
 
 b. Diphtheria of wounds. 
 
 o. Erysipelas of the genitals and internal organs. 
 
 III. Idiopathic fevers in the puerperal female. 1 
 
 1 This classification is a slight modification of that published by the editor in a 
 paper entitled a " Description of a form of Puerperal Fever which occurred at tho 
 
XLIII.] SEPTICAEMIA. 693 
 
 In the first of these classes vaginitis, which is described by the 
 author, might have been included. Phlebitis and angeioleucitis are 
 not mentioned, because, although we have met with these many times, 
 we have never known them to be primary in their origin. In all cases 
 in which they have come under our notice, they have been the result of 
 septic or purulent infection. 
 
 Metritis appears to be rare as a primary disease. In a large majority 
 of cases it results from the absorption of some morbific matter which 
 produces one of the septic diseases which are usually described as 
 " puerperal fever." 
 
 The great difficulty which has prevented the classification of the 
 various affections which have been described under this one name is 
 that all of them may be attended with, or produce the symptoms of 
 purulent or septic infection. 
 
 Any one of the first class, though at its commencement a simple 
 inflammatory disease, may produce pyaemia or septicaemia. This has 
 led to their being confounded with the latter diseases when primary 
 in their origin. One of the most common effects of septic or purulent 
 infection in the puerperal woman is peritonitis, but under these cir- 
 cumstances the serous inflammation is of a different nature, has a 
 different origin, and runs a totally different course from that form of 
 general peritonitis which sometimes follows labor, and which apparently 
 results from exposure or the extension of a traumatic inflammation. 
 The latter is a sthenic, the former an asthenic disease. The latter 
 always begins in the hypogastric region and extends upwards. The 
 former being due to the altered condition of the blood as well as to 
 extension of inflammation from continuity of tissue may begin in that 
 part of the peritoneum which is most remote from the uterus and its 
 appendages. We have a number of times seen the evidences of inflam- 
 mation confined to the peritoneum covering the diaphragm, liver, 
 spleen, and stomach, in these cases. Bloodletting promptly destroys 
 the victims of pyaemic peritonitis. It as certainly saves life in sthenic 
 inflammation of that membrane if resorted to during the first few hours 
 after the commencement of the disease. 
 
 But acute general peritonitis, however high the reaction may be in 
 the first instance, may be followed by exhaustion of the vital powers, 
 when the products of inflammation or suppuration may be absorbed, 
 and contaminating the blood, lead to septicaemia or pyaemia, which is 
 generally described as " puerperal fever." 
 
 Precisely the same remarks apply to pelvic cellulitis and pelvic 
 peritonitis. Either may be a primary disease, or it may be secondary, 
 the result of the absorption of some animal poison. In the first case 
 they begin as local inflammations, and are to be treated as such. They 
 may end in resolution or suppuration, and under the latter circum- 
 stances result in purulent absorption and the production of pyaemia, 
 which has led to their being denominated " puerperal fever." 
 
 One great source of difficulty in the study of these diseases has arisen 
 
 Philadelphia Hospital, characterized by diphtheritic deposits on wounds of the geni- 
 tal passages, and other peculiar phenomena." American Journal of the Medical 
 Sciences, January, 1875, p. 46. 
 
694 PUERPERAL FEVER. [CHAP. 
 
 from the belief which has been entertained by some of the best obstet- 
 rical authorities who have ever lived, that the poisons of the idiopathic 
 fevers are convertible into that of a distinct disease peculiar to the 
 lying-in woman, and which was called "puerperal fever." This ques- 
 tion demands a careful examination. The editor has had opportunities 
 to observe a large number of cases of puerperal diseases during the past 
 ten years. He has also seen a number of women who were attacked 
 with one of the essential fevers during the puerperal period. He has 
 never made any observations which would lead to the conclusion that 
 the poison which produces scarlet, relapsing, or typhus fevers, or any 
 other diseases of their class is convertible into a materies morbi, which 
 Avhen taken into the system of a puerperal woman is capable of produc- 
 ing a disease peculiar to the puerperal female, and which is capable of 
 being indefinitely propagated by contagion or inoculation among other 
 lying-in women. It is to be remembered that allusion is here made 
 to a specific disease peculiar to the puerperal period, one which does 
 not occur under any other circumstances. This is important, for it 
 cannot for one moment be denied that under these circumstances a 
 disease is generated which is entirely different from the essential fever 
 in which it originated and which is capable of being transmitted from 
 one puerperal woman to another, through the atmosphere and on the 
 hands or clothing of the accoucheur. 
 
 Notwithstanding what has been said, there is reason to believe that 
 the poisons of scarlet fever, variola, and other diseases of their class 
 produce primarily the same effects upon the puerperal woman that they 
 do upon her non-puerperal sister. Under the former circumstances, 
 however, the course of the disease is modified by the puerperal state. 
 Women who have been recently delivered are peculiarly susceptible to 
 the influence of purulent and septic absorption. This fact is so gen- 
 erally admitted that it does not need demonstration. In this state the 
 pelvic tissues, the vagina, cervix uteri, and pelvic areolar tissue are 
 more or less injured and bruised as the result of labor. Under ordi- 
 nary circumstances the puerperal period is passed, and these parts are 
 restored to their normal condition without giving rise to any abnormal 
 symptoms. If the woman is attacked by typhus, scarlet, or typhoid 
 fever, the case is totally different. The vitality of these tissues is im- 
 paired by the injuries sustained during labor, while their nutrition is 
 now interfered with by the blood changes induced by the zymotic dis- 
 ease which has attacked the woman. The result is that these bruised 
 tissues undergo inflammation, the absorption of the products of which 
 still further impairs the condition of the blood, and leads to the pro- 
 duction of pyaemia or septicaemia. The symptoms of local inflamma- 
 tory action and purulent or septic contamination of the blood may be 
 -so severe as to entirely overshadow the original disease and the one 
 which induced them. Pyaemia or septicaemia thus produced does not 
 differ in its nature from the same affections in non-puerperal females 
 and in males. 
 
 Erysipelas contracted under the same circumstances runs a somewhat 
 modified course. It is terribly fatal when it attacks the wounded geni- 
 tal organs of a newly delivered woman. It produces death directly, 
 
XLIII.] PERITONITIS. 695 
 
 or the fatal termination may be due to pyaemia or septicaemia in which 
 the erysipelas may result. — P.] 
 
 Peritonitis — Puerperal Peritonitis. — This, as one of the most frequent 
 inflammatory sequelae of delivery and the most familiar accompaniment 
 of puerperal fever, is the affection which naturally is the first to attract 
 our attention. Inflammation of the peritoneum may, as we have said, 
 exist and run its course without any manifestation of symptoms indi- 
 cating the operation of a morbid poison ; in other words, puerperal 
 peritonitis may exist as an affection distinct from puerperal fever. In 
 some cases it affects a small portion only of the membrane in the pelvic 
 region ; when it may give rise to a more chronic affection (Pelvi-peri- 
 tonitis), which will fall to be considered in a subsequent chapter. 
 
 An ordinary attack of peritonitis almost always comes on within a 
 week of the period of delivery. The patient is seized with a rigor, of 
 greater or less severity, followed by heat of skin, acceleration of the 
 pulse, and other febrile symptoms. At the same time, she complains 
 of pain in one spot — usually in the pelvic region — whence, if violent in 
 degree and unchecked, it may pass over the whole of the abdomen. 
 Imprudence during the period of convalescence may no doubt lead to 
 the development of simple peritonitis, but this is less frequently the 
 case than we might have anticipated. The sooner after labor the 
 symptoms are manifested, the more serious is our prognosis as to the 
 issue of the case; and, in a large proportion of cases, if not checked by 
 appropriate treatment, it is apt to run rapidly to a fatal termination. 
 That portion of the abdomen which is the seat of the inflammation has 
 often been observed to be swollen and tumid. The pulse is quick, 
 wiry, and incompressible, and rises in frequency as the inflammation 
 extends; the tongue is not usually much altered in the early stage. 
 Nausea and vomiting are of frequent occurrence as the disease pro- 
 gresses, and the swelling and tumefaction of the belly become more 
 marked. The bowels are obstinately costive, and, in the more advanced 
 stages, the patient lies on her back with her knees drawn up. 
 
 To this, if the symptoms are unchecked, succeeds a second stage, 
 which it is sometimes impossible to distinguish from one of the more 
 familiar forms of puerperal fever. There is now a decided change in 
 the character of the symptoms. The pulse, although it loses nothing 
 of its rapidity, and may even become more rapid, changes in character 
 from the inflammatory to the asthenic type. There is a marked altera- 
 tion in the countenance, a pitiful appearance of ghastly distress. The 
 belly swells still further and becomes tense, with great aggravation 
 of the suffering, so that the patient can now no longer bear even the 
 pressure of the bedclothes. If the lochial discharge has not been pre- 
 viously arrested, it now becomes fetid, and the breasts become flaccid. 
 The tongue is dry and often furred, and the unhappy patient suffers 
 from excessive thirst. The violence of the vomiting in some degree 
 subsides, but the patient is now attacked with diarrhoea, which is often 
 violent and uncontrollable. The extremities become cold ; the surface 
 of the body is bedewed with a clammy .perspiration ; and low mutter- 
 ing delirium sets in. With these symptoms, or even at an earlier 
 period, there is a remission or cessation of the pain, which sometimes 
 
696 PUERPERAL FEVER. [CHAP. 
 
 gives rise to fallacious hopes in: the mind of the patient and her friends. 
 Hiccough, picking of the bedclothes, and delirium are the immediate 
 precursors of death. Occasionally, a rapid metastasis of the inflam- 
 mation takes place, even after an abatement of the symptoms has led 
 us to hope that the danger had passed. The inflammatory process may 
 thus blaze out afresh and with equal violence — in the pleura, for ex- 
 ample — and we have known a second metastasis take place, first to one 
 pleura, and subsequently to the other. 
 
 When a case goes on to this more advanced stage, it is difficult to 
 say, with any approach to certainty, whether it is to be regarded as, 
 from the first, an example of puerperal fever. Whether it be so or not 
 seems a matter of very secondary importance, if, in the end, the symp- 
 toms of the two are identical. Nor is it of any great moment to deter- 
 mine where the one variety ends and the other begins. If we admit 
 the fact, that the puerperal poison may be generated from various 
 sources, may we not assume it as probable — to say the least — that it 
 may be developed in the course of an inflammatory disorder, which is 
 so frequently its accompaniment? 
 
 When peritonitis occurs as a complication of puerperal fever, which 
 constitutes one of the worst forms of the latter, the symptoms are, from 
 their earliest development, of a violent, if not of a malignant type. 
 The pulse is, from the first, extremely rapid and thready, about 140 in 
 the minute, and destitute of any force. Instead of there being con- 
 stipation — which is the prevailing characteristic of simple peritonitis — 
 diarrhoea sets in early, and the case, thus passing over, as it were, the 
 initiatory stages of the disorder, plunges the patient at once into a state 
 from which recovery may seem to be all but hopeless. The form is of 
 a low type from the first, and the abdominal tumefaction commences at 
 an earlier stage. It has also been remarked, that in this variety the 
 pain begins in the region of the diaphragm, and radiates from that 
 point, instead of from the pelvic region, over the whole peritoneal sur- 
 face — and that with much greater rapidity than in the other form. It 
 would appear, also, that in the more serious form, there is a remarkable 
 difference in the exudative effects of the inflammatory action. In 
 ordinary peritonitis, adhesive lymph is poured out, as an attempt at 
 reparation on the part of nature, barring the further progress of the 
 malady by gluing the parts together. But, in the more serious and 
 fatal form, which has most likely its origin in contagion, the lymph is 
 not adhesive, the inflammation is not circumscribed, and both Hulme 
 and Leake found that, in these cases, the peritoneum is softened to 
 such an extent that it actually seems gangrenous. 
 
 False Peritonitis — Acute Tympanites. — We place these affections to- 
 gether, not from any idea of their identity, but because they are con- 
 ditions which may seriously embarrass the practitioner who may not be 
 aware of the possibility of their occurrence, or, what is worse, may lead 
 him, through a false diagnosis, to adopt methods of treatment which 
 are the reverse of beneficial. The term, False Peritonitis, implies ab- 
 dominal pain which is not inflammatory in its origin. It is, in all 
 probability, due, either to intestinal irritation, or to some neuralgic 
 affection of the abdominal walls in consequence of over-distension. 
 
XLIII.] METRITIS. 697 
 
 The severity of the pain, the acceleration of the pulse, and the other 
 constitutional symptoms to which it gives rise, may lead, very possibly, 
 to a hasty conclusion that true peritonitis is the disease with which we 
 have to deal. It would seem, however, from the description given by 
 Dr. Fergusson of a malady which came constantly under his notice in 
 the year 1827 and the early part of 1828, and to which he gave the same 
 name, that this comparatively trivial affection may possess something 
 of an epidemic character, although it may be relieved by the simplest 
 remedies. The treatment which has been found most efficacious is the 
 administration of a full opiate. 
 
 The name, Acute Tympanites, was given by Dr. Ramsbotham to an 
 affection which he himself had frequently observed, which he believed 
 to be a variety of the intestinal irritation of Marshall Hall, and which 
 is particularly interesting in this respect, that it very closely resembles 
 ordinary puerperal peritonitis; so closely, indeed, that, to judge from 
 the description given by Dr. Ramsbotham of the symptoms, it must 
 be a matter of no small difficulty to distinguish the two affections. 
 We are inclined to think, however, that he has given too much promi- 
 nence to this affection as an independent puerperal disorder. 
 
 Puerperal Metritis. — This is an affection which, uncomplicated, is of 
 much less frequent occurrence than peritonitis. Hysteritis, or Metritis, 
 under the ordinary childbed conditions, involves the idea of an acute 
 inflammation, attacking tissues which are the seat of a very peculiar 
 process of involution, a part of the physiological phenomena of gesta- 
 tion. In a chronic form, it is by no means of unfrequent occurrence; 
 but, under such circumstances, the result is not usually fatal. In the 
 acute form, however, it has been observed to be very fatal, and to ter- 
 minate, as in the case of peritonitis, with all the horrors, apparently, 
 of puerperal fever. In the mode of access, it does not differ materially 
 in its symptoms from peritonitis. The pain, however, is in this case 
 referred more particularly to the hypogastric region, where the uterus 
 may be distinguished of larger size, and sometimes harder, than is 
 usual at the period. On a digital examination by the vagina, the na- 
 ture of the cause is further revealed, by the heat and tenderness of the 
 os uteri. This has been more frequently observed as a consequence of 
 severe or protracted labor than the peritoneal variety ; and, in those 
 cases in which a fatal result has ensued, extensive disorganization of 
 the uterine tissues has been remarked. 
 
 That an inflammatory affection, having its seat in the tissue proper 
 of the uterus, may occur in childbed, we cannot dispute. But it may 
 well be doubted whether many of the cases which have been referred 
 to this category ought not rather to have been classed under a different 
 head, — Uterine Phlebitis. To no one do we owe more, as regards the 
 elucidation of this subject, and a painstaking investigation of the 
 principal phenomena upon which it depends, than to Dr. Robert Lee. 
 Opinions are, however, on this matter, far from harmonious. It is easy 
 to conceive that, when the structure of the uterus is the seat of inflam- 
 matory action, it can be no simple matter to determine, during life, 
 what share the various tissues of the organ take in the morbid phenomena 
 upon which the symptoms depend. If the evidence is not altogether 
 
698 PUERPERAL FEVER. [CHAP. 
 
 clear, many facts combine to show that there are, in a considerable 
 number of cases of puerperal fever, indications of great significance, 
 which it is difficult to explain on any other hypothesis. The earlier 
 symptoms may, indeed, admit of a different interpretation. At first 
 there is more or less of rigor, followed by pyrexia, and accompanied 
 with pain in the hypogastric region, generally referred more particu- 
 larly to the iliac or ischiadic region of one side. The condition of the 
 lochial and mammary secretions varies, although the general tendency 
 is to the arrestment of both. These symptoms are usually developed 
 within three or four days after delivery, and diarrhoea — and not, as in 
 the case of peritonitis, constipation — is a prominent feature in the case. 
 A tympanitic condition of the abdomen is almost uniformly observed, 
 but the general tenderness, and other symptoms of peritonitis, are, for 
 the most part, absent. The pulse is generally over 120, and sometimes 
 reaches 150, and is soft and compressible from the first. Should reso- 
 lution take place at this stage, it would, we believe, be impossible to 
 say whether it has been a case of metritis, of phlebitis, of circumscribed 
 peritonitis, or of any of these combined. 
 
 If the case goes on, however, — and, sometimes in the worst form, 
 very shortly after the seizure, — a new class of symptoms is developed, 
 which alone can be held as pathognomonic of phlebitis, and of the 
 blood poisoning, which has probably been the result of traumatic sep- 
 ticaemia. The patient now complains of pain in various parts of the 
 body, — most frequently in the neighborhood of the joints. In these 
 situations, swellings and erysipelatous blushes appear, indicating the 
 formation of secondary abscesses; or the abscesses may form internally 
 either in the neighborhood of the uterus, or in distant organs, — such as 
 the lungs, liver, or kidneys, — and occasionally they are imbedded 
 deeply in the substance of the muscles. In some cases, the eye, and 
 more commonly the left eye, has been the seat of violent destructive 
 inflammation. Such formations of pus, if neither violent nor exten- 
 sive, may, in some fortunate instances, be looked upon as critical, and 
 in that sense favorable ; but, unfortunately, experience points to a con- 
 trary result. In the worst cases, which have been observed in various 
 epidemics, the tendency of the inflammatory process to attack the joints 
 has been uniformly well marked, and the fearfully rapid nature of the 
 action, the enormous quantity of pus which is formed, and the destruc- 
 tion of the articular cartilages, have only too frequently been demon- 
 strated in post-mortem examinations. 
 
 Puerperal phlebitis may extend to the proper tissue of the uterus, 
 and also to the peritoneum, — in which latter case the symptoms of 
 peritoneal inflammation are superadded to those which more vaguelv 
 indicate inflammation of the uterine veins. It would appear that, in a 
 certain number of fatal cases, the action is confined to the uterus, — a 
 result which may easily be explained by supposing that death had taken 
 place before the toxaemia had time to produce its distal effects, in the 
 production of abscess, etc. 
 
 Vaginitis. — A protracted labor, in which the presenting part of the 
 child has been allowed to remain too long in the same situation, may 
 give rise, by pressure, to very severe inflammation, and even to slough- 
 
XLIII.] VAGINITIS. 699 
 
 ing of the walls of the vagina. In so far as the latter form is concerned, 
 its results have already been incidentally referred to, and consist mainly 
 of vesico-vaginal fistula, and of contraction of the vagina, or the forma- 
 tion of septa or bands, which ultimately constitute serious impediments 
 to the progress of labor. There is, moreover, too much reason to be- 
 lieve that the injudicious or unskilful use of instruments is a fruitful 
 cause of this complication, and, indeed, rash operative procedure of any 
 kind is not unlikely to produce it, by the actual mechanical violence 
 which is thus inflicted. Inflammation of these tissues, however, even 
 when it does not proceed to gangrene, may prove a very serious com- 
 plication, and, by the constitutional irritation which it engenders, may 
 give rise to serious apprehension. The risk, in such a case, is not only 
 from the effects of local lesion, leading to septic action and puerperal 
 fever, but from the danger which exists of the fire which is thus kindled 
 spreading, and, by involving the uterus, the peritoneum, etc., giving 
 rise to the panic of a general conflagration. It may, with reason, be 
 objected, that an inflammatory affection of this kind should not be in- 
 cluded under the generic designation of puerperal fever; but, while 
 we admit the force of the observation, we recognize between it and the 
 other inflammations, as between those and puerperal fever, such intimate 
 pathological affinities, that we have no hesitation in placing them in 
 juxtaposition. Inflammation of the vagina is accompanied with much 
 swelling and tumefaction of the neighboring parts, and with an alter- 
 ation in the nature of the discharge, which gives rise to more or less of 
 foetor. The orifice of the urethra is involved, so that there is extreme 
 difficulty or impossibility of micturition, and the condition of the vulva 
 is such as to give rise to great annoyance, — these symptoms, taken 
 together, affording a ready means of diagnosis. 
 
 An affection, scarcely less important than this, although it has less 
 direct connection with the subject of puerperal fever, is inflammation of 
 the vagina, of an asthenic type, similar to what occasionally occurs in 
 the course of typhus or other fevers. In this case, the whole vagina 
 without any obvious local cause, is quickly involved in inflammation of 
 the type alluded to, which defies all treatment, local or general, and 
 rapidly passes into gangrene. The result of such violent and rapid 
 action has been to involve the recto-vaginal septum in almost its whole 
 extent, and to cause such a degree of vesico-vaginal intercommunica- 
 tion as to defy even the improved remedial appliances of modern sur- 
 gery. And, even when the destructive process has not involved those 
 viscera, we have seen such implication of the perineal tissues, and con- 
 sequent contraction, as to leave a bare exit for the menstrual flux. 
 
 This is, of course, supposing that the patient survives. Unfortu- 
 nately, however, when the inflammation assumes this type, recovery can 
 scarcely be looked for, and the patient succumbs, either from the action 
 of the morbid poison, from an extension inwards of the inflammation, 
 or more frequently still, from these two causes combined. The ex- 
 tremely rapid and feeble pulse, with cold extremities, and the offensive 
 lochial discharge, indicate the type of the case; and soon the clammy 
 surface, the anxious countenance, with hiccough, subsultus, and delirium, 
 show only too clearly that the end is at hand. 
 
700 PUERPERAL FEVER. [CHAP. 
 
 Another variety of puerperal inflammation is that form of the process, 
 in which it has its seat in the Uterine Lymphatics. This was first 
 described in France by M. Dance, and has since that time attracted the 
 attention, both in this country and abroad, of most systematic writers. 
 The presence of pus within the vessels of the lymphatic system has 
 been repeatedly demonstrated; but, in so far as the symptoms are con- 
 cerned, it would seem to be impossible to distinguish the affection from 
 some others which have been described, and especially from uterine 
 phlebitis. But, besides this, it is extremely improbable that, in the 
 condition of the uterus at the puerperal period, angeioleucitis should be 
 present without involving, more or less, the other tissues. And, perhaps, 
 the converse may equally hold good, — that inflammation originating in 
 other tissues may very readily pass to the lymphatic system. Although 
 attempts have been made to show that the worst results of puerperal 
 fever spring from inflammation of the lymphatics, Virchow has proved 
 that lymphatic thrombosis is a favorable symptom in so far as it bars 
 the transport of infected material. 
 
 The various affections above detailed by no means embrace all the 
 complications which may exist along with puerperal fever, whether in 
 the relation to it of cause or of effect. And if we were to attempt an 
 analysis of what may be called anomalous cases, we would but compli- 
 cate still further a subject which we are specially anxious to put in as 
 simple a light as possible. Some have placed phlegmasia dolens in 
 this category, and in the cases in which that affection has been observed 
 along with puerperal fever, it may well be supposed that both are the 
 result of the same poison. It is quite obvious, however, that puerperal 
 fever cannot be considered as a result of phlegmasia dolens ; otherwise, 
 the latter affection would be looked upon with much apprehension, 
 instead of involving, as it does, a favorable prognosis. The general 
 state of the system in childbed, to which we have already so frequently 
 referred, is singularly favorable to an extension of inflammatory action 
 which has already been commenced. It need scarcely, therefore, cost 
 us a moment of surprise, when we find the local inflammations of the 
 puerperal state blazing out with a violence which defies extinction, and 
 rapidly assuming the asthenic or adynamic features, which are held to 
 be characteristic of the most fatal form of puerperal fever. 
 
XLIV.] CONTAGION. 701 
 
 CHAPTER XLIV. 
 
 PUERPERAL FEVER, ETC.— (Continued.) 
 
 QUESTION OF CONTAGION — SEPTICEMIC INFECTION — OTHER SPECIFIC POISONS — ARE 
 INFLAMMATORY CASES CONTAGIOUS? HISTORY OF EPIDEMICS — SYMPTOMS OF 
 PUERPERAL FEVER — MORBID ANATOMY : MALIGNANT AND OTHER VARIETIES 
 CONTRASTED : LESIONS OF OTHER ORGANS : PATHOLOGICAL APPEARANCES NO 
 INDICATION OF THE VIRULENCE OF THE ATTACK — EVIDENCE OF A CHANGE OF 
 TYPE IN PUERPERAL FEVERS — TREATMENT: ALL VARIETIES TO BE TREATED 
 AS IF CONTAGIOUS: RECORDED RESULTS OF BLOODLETTING AND PURGING: 
 GOOCH'S TREATMENT: CONNECTION OF METASTATIC INFLAMMATION WITH 
 THROMBUS AND EMBOLISM: UTERINE PHLEBITIS: PURULENT FORMATIONS: 
 EFFECT OF EMETICS : CALOMEL AND OPIUM ; TURPENTINE ; BLISTERS AND 
 EXTERNAL APPLICATIONS; TONIC AND STIMULANT TREATMENT; TAPPING 
 THE PERITONEUM : PROPHYLACTIC TREATMENT : CLEANLINESS : USE OF AN- 
 TISEPTICS. 
 
 Before going further in our attempt to describe the symptoms and 
 treatment of the fevers of the puerperal state, it is proper that the sub- 
 ject of contagion should receive that careful attention which its impor- 
 tant practical bearing demands. For purposes of convenience, we may 
 divide the question of contagion into two parts — 1st, Is puerperal fever 
 contagious? — and, 2d, Are the "allied affections" contagious, and, if 
 so, to what extent ? Some confusion may here arise as to the meaning 
 of the word Contagion. " By a contagious disease," says Schroeder, 
 " is meant one in which a specific poison is produced within a diseased 
 organism, and which, transferred to other individuals, always produces 
 the same specific disease, such as measles, scarlatina, small-pox, syphilis, 
 etc." It will at once be noticed that if we concede that puerperal fever 
 is not due to a specific poison, and at the same time admit the accuracy 
 of Schroeder's definition of the word, we necessarily come to the con- 
 clusion that puerperal fever is not a contagious disease. Such hair- 
 splitting in regard to the meaning of words tends more frequently to 
 confusion than to precision, and preferring, as we do, the word " con- 
 tagious" to "communicable," we employ the former in its broader and 
 more colloquial signification. 
 
 In reply, then, to the first part of the question, we hesitate not for a 
 moment to say that puerperal fever is contagious. According to Barker, 
 there have been described, since 1740, upwards of two hundred epidemics 
 of puerperal fever, and it would perhaps be sufficient, in most minds, 
 to establish the truth of our proposition, carefully to peruse the details 
 of one or two of these outbreaks, when the facts will be seen to be utterly 
 irreconcilable with any other theory. Many observations, in themselves 
 conclusive, are on record. " Two medical men," says Dr. Tyler Smith, 
 
702 PUERPERAL FEVER. [CHAP. 
 
 " brothers and partners, attended, in the space of five months, twenty 
 cases of midwifery. Of these fourteen were affected with puerperal 
 fever — a fatal result ensuing in eight cases. The only other known 
 death from puerperal fever, in the same town, within the period named, 
 occurred in the case of a patient attended by a medical man who had 
 assisted at the post-mortem of one of these puerperal patients. After 
 this disastrous period, the two brothers relinquished all their midwifery 
 engagements for one month, in which time five of their cases were 
 attended by other practitioners, and no instance of fever occurred in 
 the course of that month. They then returned, and several fatal cases 
 again happened. . . . Dr. B-oberton, of Manchester, relates, per- 
 haps, one of the most cogent instances of contagion and fatality on 
 record. In the space of one calendar month, a certain midwife attended 
 twenty cases belonging to a lying-in charity : of these, sixteen had puer- 
 peral fever, and all died. The other midwives of the same charity, 
 working in the same district, attended, in the same time, 380 cases, 
 none of whom were affected with puerperal fever. In another large 
 town, containing many thousands of inhabitants, and numerous medi- 
 cal men, fifty-three cases of puerperal fever occurred. Of these, no 
 less than forty happened in the practice of one medical man and his 
 assistant." 
 
 If these facts do not suffice to establish beyond all question the doc- 
 trine of contagion, we would refer the reader to the works of Gooch, 
 Routh, and Semelweiss, for evidence which appears to us to be un- 
 answerable. Those who oppose the contagious view, attempt to account 
 for such facts as have been quoted, by exaggerating the importance of 
 epidemic influences. That epidemic and atmospheric influences bear 
 upon the question we do not dispute, but that these will enable us to 
 account for such cases as have been mentioned we cannot for a moment 
 believe. The well-known occurrence of sporadic cases has also been 
 urged against the doctrine of contagion. It is, however, so easy to 
 account for such cases, by the septicemic theory, that we may pass this 
 subject by without further comment. There are other influences which 
 may well be assumed to have some share in the manifestation of the 
 disease, such as the general health, temperament and constitutional 
 vigor of the patient, and the circumstances under which she is confined. 
 It has been repeatedly noticed that depressing mental emotions exercise 
 a very marked effect, so that women who have been seduced are more 
 prone to the disease than others. " Several of the worst cases I have 
 seen," observes Dr. Churchill, "are mainly attributed to this cause." 
 
 The doctrine of contagion is, in regard to septicemic puerperal fever, 
 now all but universally received ; but in regard to the other varieties, 
 and the allied inflammatory affections, the question presents itself for 
 solution under conditions of greater difficulty. We have already ex- 
 pressed our opinion that, although scarlatina may run its course in a 
 woman who has been recently delivered, without the development of 
 any marked symptoms beyond those of the specific fever, such cases 
 very frequently pass into a condition which is identical with puerperal 
 fever. But, beyond this, we are convinced that from the contagion 
 thus developed, puerperal fever may be again and again reproduced ; 
 
XLIV.] CONTAGION. 703 
 
 and, if we are right in this, the same remark will apply to the other 
 specific fevers. 
 
 One or two examples, illustrative of the manner in which a disease 
 apparently identical with puerperal fever is generated by different 
 poisons, may here be adduced. A patient was admitted by some over- 
 sight, into the wards of the Dublin Lying-in Hospital, while laboring 
 under typhus fever; but the error having been discovered, she was 
 removed in a few hours. In the beds on the right hand and the left 
 of this woman were two lying-in women ; both were attacked with 
 puerperal fever, and both died. " In another case," says Dr. Tyler 
 Smith, "a medical man was in constant attendance upon a patient 
 suffering from gangrenous erysipelas, and, between the 8th of January 
 and the 22d of March, attended the labors often women ; all had puer- 
 peral fever, and eight of the patients died. This was in a town of 
 moderate size, and no other patients in the place were known to have 
 had puerperal fever. A remarkable instance, to the same effect, is 
 related by Dr. Ingleby. Two practitioners attended a post-mortem 
 where the patient died from this disease. The first was summoned, in 
 one direction, to a midwifery patient, who w T as attacked with puerperal 
 fever ; the other attended two cases in succession, both of whom w 7 ere 
 seized with the same disease." The enormous mortality which at one 
 time prevailed in the Lying-in Hospital of Vienna, gave rise to the 
 belief that the disease was propagated by means of poison communicated 
 by students who had recently been engaged in dissection, and the ob- 
 servations of Dr. Semelweiss strongly corroborate the supposition. It 
 seems to us, however, that this has been considerably exaggerated as a 
 means of generation of the poison, as the evidence upon which the 
 assumption rests is derived mainly, though not entirely, from lying-in 
 hospitals. Medical students are proverbially careless in these matters, 
 unless they are under strict supervision ; but it is somewhat strange 
 that observation, extended over many years of the practice of a large 
 lying-in charity, where the women are delivered by students and mid- 
 wives exclusively at their own homes, has failed, in our own experi- 
 ence, and in that of others, in recognizing any such marked septic 
 influence as Semelweiss would have us anticipate. That the cadaveric 
 poison has, undoubtedly, caused puerperal fever, is, however, quite 
 enough to demand from every one the strictest precautions which can 
 be devised, in order to avert so dreadful a calamity. 
 
 In regard to the cases which may be supposed to be of inflammatory 
 origin, the case is different. A simple inflammation is not communi- 
 cable ; but when a case, at first simple, runs a rapid course, and ends 
 fatally with the symptoms, let us suppose, of peritonitis and metritis 
 combined, he would be a bold man who would venture to assert that 
 there was no danger. We have never seen any reason to doubt that 
 such a disease is communicable, and we have never been able to dis- 
 cover any essential difference between it and the other varieties. We 
 can scarcely imagine a more important practical point, than to be able 
 to distinguish between what are, and what are not, communicable dis- 
 eases of this class. But, unfortunately, practical points have rather 
 been lost sight of in recent theoretical discussions, and for our part 
 
704 PUERPERAL FEVER. [CHAP. 
 
 we would decline at present to give any opinion. For the practitioner 
 the only safe rule is to look upon all such cases with suspicion, and to 
 adopt the most stringent and careful precautions in every serious inflam- 
 matory case, lest he should become the means of carrying death to his 
 patients. 
 
 Puerperal fevers have been met with under different forms, and as 
 we might anticipate, the intensity or concentration of the poison is 
 attended with a corresponding virulence in the symptoms. But, be- 
 sides that, it would seem that in particular outbreaks of the disease, 
 the cases resemble each other in manifesting certain complications, 
 chiefly inflammatory. But instead of attempting to classify the differ- 
 ent forms by talking of Malignant Fever, Hidrotid Fever, and the 
 like, we prefer to make the attempt to treat the whole matter in a more 
 comprehensive and simple manner. The older writers describe this 
 affection as " childbed fever." The term " puerperal fever" dates from 
 the beginning of last century. 
 
 About 1746 a dreadful epidemic of puerperal fever appeared in Paris, 
 a very accurate and full description of which was given by Malouin. 1 
 The mortality was so frightful, that at the Hotel Dieu scarcely a single 
 patient recovered. "The disease usually commenced with diarrhoea; 
 the uterus became dry, hard, and painful : it was swollen, and the 
 lochial discharge was irregular. The women then experienced pain in 
 the bowels, particularly in the situation of the broad ligaments; the 
 abdomen was tense; and to these symptoms was added headache, and 
 sometimes cough. On the third or fourth day after delivery, the 
 mammae became flaccid. On opening the bodies, curdled milk (sie) 
 was found on the surface of the intestines, and a milky, serous fluid in 
 the peritoneum. A similar fluid was found in the thorax of certain 
 women ; and when the lungs were divided, they discharged a milky 
 or putrid lymph." 
 
 During the latter half of the eighteenth century, violent epidemics 
 appear to have occurred in most of the principal towns of Europe, and 
 of these the history and details have, in many instances, been preserved. 
 The lying-in hospitals of Vienna, Paris, Lyons, and London, were all in 
 turn attacked, with results, as regards maternal mortality, too dreadful 
 to contemplate. In the great hospital at Vienna, for example, the death- 
 rate has reached as high as one in six of all the women admitted. It 
 would appear, further, that the disease, when once established in a 
 locality, showed a tendency to return ; and, with regard to Paris, 
 Tenon observes, that " it has come to prevail more and more, and to 
 be, as it were, naturalized." We must not suppose, however, that the 
 mortality from this cause was only observable in the statistics of lying- 
 in hospitals, for the disease spread by contagion as well as by epidemic 
 influences, through all classes of society ; and there can, we presume, 
 be little doubt that the mortality was enormously increased by the ob- 
 stinate incredulity of those who refused to admit that the disease was 
 contagious. Still, it has always been upon lying-in hospitals that the 
 great weight of mortality has fallen ; and, although improvements in 
 
 1 Meraoires de l'Academie des Sciences. 1746. 
 
XLIV.] EPIDEMICS. 705 
 
 construction, and the greater attention which is now paid to ventilation, 
 cleanliness, and disinfection, have greatly reduced the hospital death- 
 rate, there is no doubt that much yet requires to be accomplished before 
 perfection is attained, or even approached. 
 
 The statistics of the Loudon, Dublin, Edinburgh, and Aberdeen 
 hospitals all show that, wherever observed, the disease was a very 
 fatal one; but if we examine into the details given of previous epidem- 
 ics, we cannot fail to be struck with the fact that there has been a great 
 variety in their nature. When we find a history of an epidemic in 
 which the mortality has been comparatively trifling, and bloodletting 
 has obviously been attended with a beneficial result, we may well doubt 
 whether this should be called puerperal fever. But, putting aside for 
 the moment such doubtful epidemics, we find that when the asthenic 
 type of the disease is perfectly marked from the outset, the local lesions 
 vary at different times; and we thus observe that in some epidemics 
 the peritoneum is chiefly involved, while in others the affection of the 
 joints, and other distant parts, may be held to indicate the presence of 
 uterine phlebitis as the special characteristic of the prevailing epidemic. 
 Another fact which stands out very prominently in the history of epi- 
 demics, is the marked variation in the intensity of the disease, or the 
 virulence of the poison, so that in one case we have a low percentage of 
 deaths, while in another the patients are, as it were, struck dead by a 
 fever which runs its course in a few hours. 
 
 It is a fact, beyond all question, that the disease we are now consid- 
 ering attains its maximum of intensity in hospital epidemics. It 
 usually originates in the course of the second, third, or fourth day, 
 although sometimes later, and cases have been recorded in which it has 
 come on before delivery. It is sometimes ushered in by a rigor, but 
 this is far from being invariable; and, indeed, it may be remarked that 
 the violence of the rigor is in this case much less marked than, in some 
 instances, where the impending disorder is comparatively trivial. The 
 patient is conscious, from the first, of a feeling of great depression, 
 which is often accompanied with headache and uneasiness at the pre- 
 cordial region. There has often been observed, even thus early, a 
 haggard, anxious expression of countenance, as if she were in dread of 
 an impending calamity. The pulse is feeble, or at least compressible, 
 and is seldom less than 130, rising in many cases to 150 and upwards. 
 Extreme rapidity is a very bad sign, especially if associated with a 
 high temperature. There may sometimes be a rigor and a hot stage, 
 quickly followed by free perspiration, which, supposing it to be criti- 
 cal, we may look upon as a favorable augury ; but, as the case goes on, 
 we soon observe that the discharge from the skin brings no relief to the 
 symptoms : it continues profuse to the end, and a peculiar odor has 
 sometimes been observed. Those instances in which the perspiration 
 constitutes a peculiar feature of the case are not common, but were con- 
 sidered of sufficient importance by Blundell to warrant him in describ- 
 ing a distinct variety of puerperal fever, which he, from the leading 
 symptom, called "Hidrosis," or " Hidrotid Fever." 
 
 Generally speaking, however, the skin is hot and dry, although to- 
 wards the termination of a fatal case it becomes cold, damp, and 
 
 45 
 
706 PUERPERAL FEVER. [CHAP. 
 
 clammy. The effect produced on the milk and lochia is variable ; and 
 there are even cases in which these discharges are more than usually 
 abundant. Vomiting is by no means an uncommon symptom ; but it 
 does not generally come on very early, and the matter ejected is some- 
 times dark in color, like coffee-grounds, and occasionally very offen- 
 sive. Diarrhoea is, as we have already seen, an almost invariable 
 symptom in the later stages of those inflammatory affections which pass 
 into puerperal fever; but, in cases of the ordinary type, diarrhoea often 
 comes on at a much earlier stage, when the offensive nature of the 
 evacuations often indicates still further the extent to which the digest- 
 ive functions ato involved. The tongue presents at first no distinctive 
 character, but, as the case rapidly advances, the deep fur — white or 
 brownish, moist or dry — is a further index of the extent to which the 
 normal functions are disturbed. Marked delirium is not usual, but 
 there is often observed an excited condition in which the patient ex- 
 hibits a peculiar tendency to loquacity, amounting, it may be, to slight 
 delirium in awakening from sleep. 
 
 In a very large proportion of cases, the peritoneum or uterus, or 
 both, are involved. Thus, one of the earliest symptoms, after the dis- 
 ease has been thoroughly established, is abdominal pain, which either 
 originates in the hypogastric region, or, more exceptionally, in the 
 epigastrium. The pain is excessively acute, so that the patient will 
 frequently complain of the weight of the bed-clothes; and it is soon 
 accompanied with more or less swelling, or tumefaction, — the enlarge- 
 ment being due, in the first instance, to flatulent distension, and, sub- 
 sequently, to fluid effusion, which is poured into the cavity of the ab- 
 domen. In some cases, the pain is associated with enlargement of the 
 uterus, which may be recognized through the abdominal walls. This 
 has sometimes given rise to the idea, when the general symptoms were 
 not carefully observed, that the pain was due to those irregular con- 
 tractions of the organ which are commonly known as after-pains, and, 
 under this impression, valuable time has been lost. 
 
 As the abdominal distension increases, which often happens 'with 
 extreme rapidity, the sufferings of the patient are proportionally aug- 
 mented. She now lies on her back, breathing rapidly, sometimes with 
 her knees drawn np, and exhibiting on her countenance that appear- 
 ance of ghastly distress which is so painful to witness. The surface 
 and extremities become cold ; the mechanical impediments to perfect 
 respiration give something of lividity to the countenance; and the 
 symptoms, becoming otherwise more grave, indicate that the period 
 has been reached when hope may be well-nigh abandoned. At this 
 period, the abdominal pain, tenderness, and tension often diminish ; 
 and, but for the ominous pulse and countenance, we might fancy that 
 the patient was better. The diarrhoea continues, the stools being 
 passed in bed ; vomiting occurs, without any retching, of a dark or 
 greenish matter; and the patient may now breathe with greater ease. 
 The pulse is undiminished in frequency, but it is otherwise changed 
 for the worse, as is indicated by its thready or imperceptible character. 
 The intellect generally remains clear to the end ; but in some cases low 
 
XLIV.] MORBID ANATOMY. 707 
 
 muttering delirium, subsultus tendinum, and other similar symptoms, 
 come on before death ensues. 
 
 Such symptoms are, as will be observed, almost identical with those 
 which have been described as characteristic of the fatal inflammatory 
 affections previously mentioned. If we attempt to follow the descrip- 
 tion and classification of various authors, we find that the varieties and 
 divisions of puerperal fever are infinite, and are, were we disposed still 
 further to classify, susceptible of more elaborate subdivisions still. For 
 our present purpose, however, it may suffice to observe, that although 
 we believe the symptoms above detailed to be among the more impor- 
 tant of those which arise in the course of an ordinary septicemic case, 
 other varieties may exhibit themselves, in the experience of any man, 
 which may differ in important particulars. But we recognize in this 
 admission no reason for more elaborate classification of a subject which 
 has already been classified out of all shape, and which, plastic as it is, 
 it is difficult to mould into a simple, comprehensive, and comprehen- 
 sible form. 
 
 Morbid Anatomy. — The various forms under which puerperal fever 
 may manifest itself involves, almost necessarily, a corresponding variety 
 in the appearances produced in the different tissues which may be im- 
 plicated. In the case of the post-partum inflammatory affections which, 
 after a somewhat longer course, apparently pass into puerperal fever, 
 and thence to a fatal result, the appearances of an ordinary local inflam- 
 mation are, as we might confidently anticipate, more distinctly revealed. 
 In peritonitis, for example, the more closely the case resembles, in its 
 symptoms and progress, the purely local disease, the more closely do 
 the morbid appearances correspond. When the septic infection is con- 
 centrated or malignant, as in hospital epidemics, the fatal result ensues 
 with such rapidity that there are really no marked post-mortem appear- 
 ances. In ordinary cases, however, the lesions are conspicuous. In 
 many cases there may be observed in the vulva, vagina, or cervix, or 
 at the site of the placenta, an ulcerative action at the margin of the 
 existing wound. This is called the " puerperal ulcer," and the neigh- 
 boring parts will be found to have participated more or less in the 
 unhealthy action. Inflammation, softening, and even sloughing or 
 gangrene of the mucous membrane of the womb, is often noted, the 
 extent of the changes corresponding in some degree to the virulence of 
 the morbid action. The pelvic connective tissue is very generally the 
 seat of a diffuse inflammatory oedema, to the development of which the 
 relaxed condition of the parts gives mechanical encouragement. The 
 inflammatory process has also been traced to the lymphatics, the veins, 
 and the parenchyma of the uterus, and in a large proportion of the 
 fatal cases the inflammation will be found to have spread to the peri- 
 toneum and from that again by mere continuity of tissue to structures 
 more remote. 
 
 In some cases there is found clear pathological evidence of inflam- 
 matory action in distant organs which cannot have been transmitted 
 thither by continuity. These appearances will generally be found to 
 have reference to symptoms manifested during life, and constitute what 
 is usually called metastasis. A new interest has been given to this 
 
708 PUERPERAL FEVER. [CHAP. 
 
 subject by the discoveries of Virchow and his followers in regard to 
 thrombus and embolism, and we can have little hesitation in admitting 
 the possibility of a fragment of an infected and disintegrated thrombus 
 being conveyed by the circulation to a point in the arterial system, 
 where, being arrested, it becomes a fresh centre for violent inflamma- 
 tion. Billroth and Waldeyer refer all circumscribed metastatic inflam- 
 mation to embolism, but in the present state of our knowledge this is 
 certainly going too far, although we may admit that this theory gives 
 us by far the most satisfactory explanation of the phenomena of metas- 
 tatic inflammation in these cases, and more particularly of the formation 
 of purulent deposits in distant organs. 
 
 In regard to these distant abscesses, it may here be remarked that 
 they have most frequently been found associated with the malignant 
 or epidemic variety of the disease, of which we have many descriptions, 
 chiefly from hospital experience. On this point, Boivin and Duges 
 observe that "pus is sometimes found even in the substance of the 
 womb, and generally nearer to its exterior than its interior surface. 
 Thus, pus collects into distinct abscesses, from one to five inches in 
 diameter, — sometimes into a simple or multilocular deposit, with a 
 greenish or viscous appearance ; at other times it is infiltrated into the 
 fleshy fibres, imparting to them a reddish-yellow color, perceptible 
 through the peritoneum. In this latter case, tumors form — which are 
 sometimes hard and projecting — upon the fundus uteri; at other times, 
 they are flattened, soft, and broad. These latter come further down 
 towards the lateral regions, and often form a continuation, together 
 with purulent infiltration between the laminae of the broad ligaments, 
 with the cellular tissue of the pelvis and the substance of the ovarian 
 ligaments." This has reference to certain secondary purulent forma- 
 tions which we shall have occasion to notice in our next chapter. There 
 is here also, as in the peritoneal form when rapidly fatal, a tendency to 
 turbid effusion into the serous cavities. 
 
 The most interesting, however, of all the points upon which patho- 
 logical anatomy may be expected to throw light, are those which are con- 
 nected with uterine phlebitis, an affection which has, as we have seen, 
 been supposed by eminent modern writers on the subject to bear the 
 most intimate relation to true puerperal fever. The primary and es- 
 sential morbid change in this variety is inferred from the condition 
 in which the ovarian and uterine veins and their branches within the 
 uterus have been found. We do not doubt that here, as in phlegmasia 
 dolens, erroneous inferences have been drawn from a mere discoloration 
 of the lining membrane of the vein, associated with the presence of a 
 clot; but many of the appearances which have frequently been observed 
 and described, are so unequivocal, that the existence of true phlebitis 
 must be conceded. Of this nature are thickening, contraction, and ab- 
 sorption of the tissues of the vein, and the presence of lymph and pus 
 as obvious products of local inflammatory action. Certainly in some 
 cases, and probably in many, this inflammation of the veins is asso- 
 ciated with softening of the muscular tissue, or some other sign equally 
 significant of metritis. 
 
 In the less severe cases, it will probably be found that the inflam- 
 
XLIV.] MORBID ANATOMY. 709 
 
 matory process has not extended further than the veins of the uterus 
 itself, or the veins which directly communicate with it; but, in some 
 instances, evidence of inflammation is said to have been traced as high 
 as the renal veins, or even the vena cava itself, although there is reason 
 to believe that, in these latter examples, the mere presence of pus in the 
 vein has sometimes been admitted as evidence of inflammation of its 
 structure. 
 
 The presence of pus within the veins, in the region of the uterus, is 
 to be accounted for chiefly by the changes which take place in the blood- 
 clot, which is the more immediate result of phlebitis. Coagulation is, 
 as we have seen, equally the result of pysemic action ; but we are here 
 considering it as the effect of, or, at all events, as associated with, true 
 inflammation of the veins. From the disintegration and decomposition 
 of the blood-clot, pus is evolved, and becomes the cause of some of the 
 more characteristic of the morbid appearances of uterine phlebitis. 
 The circulating medium is poisoned with pus, the result of which may 
 be immediate septic coagulation ; or, the poison being carried, by de- 
 tached portions of the thrombus or otherwise, to distant localities, it 
 there produces the secondary phenomena which are disclosed after death. 
 In a large proportion of these cases, swellings are observed in the neigh- 
 borhood of the joints, which, on being freely incised, give exit to pus. 
 In the worst cases, pus is found within the joint itself, and the liga- 
 ments and cartilaginous surfaces afford proof of a rapidly destructive 
 inflammation. If the eye has been affected, evidence will there be found 
 of inflammation, of equal violence, although limited in extent. Abscess 
 may also be found in the muscles or cellular tissue of the limbs; and, 
 in other cases, what has been supposed to be an abscess, has turned out 
 on examination, to be an effusion of sero-sanguineous fluid. The brain 
 is rarely affected; but, within the cavity of the chest, clear evidence 
 has often been observed of that metastasis of inflammation, to which 
 allusion has already been made, sometimes within the lungs, — which 
 have been found condensed, of a dull-red color, and infiltrated with 
 purulent matter, — while, at other times, the violence of the disease 
 seems to have expended itself mainly on the pleura. The heart is often 
 enlarged and softened; and, within the pericardium, lymph and serum 
 may, with the usual alterations in the membrane itself, afford conclu- 
 sive proof that inflammation has been present here also. The various 
 portions of the intestinal canal, from the stomach to the rectum, have, 
 in exceptional instances, been found to have been severely affected, 
 usually by a simple extension of the inflammatory process from the 
 contiguous position of the peritoneum. Ulceration and perforation of 
 the stomach have been noted in some of those cases. The spleen and 
 liver have also been found to be extensively disorganized, and their 
 tissues the seat of single or multiple abscesses. In the greater number 
 of the cases which were examined by Dr. Hulrne, he found the omentum 
 inflamed, and frequently black and gangrenous. In no small propor- 
 tion of fatal cases, the kidneys have been found to present evidence of 
 similar disorganization, obviously the result of violent inflammation : 
 generally speaking, one kidney only is affected. 
 
 In the malignant variety of the fever, the following indications in 
 
710 PUERPERAL FEVER. [CHAP. 
 
 addition to those which have been already detailed, are mentioned by 
 Dr. Copeland, in his Dictionary of Practical Medicine. In several 
 cases, in which bloodletting had been practiced, he observed, that "on 
 every occasion I was struck by the peculiar faint odor, and very dark 
 hue of the blood; by the very soft state of the clot when the blood did 
 separate into crassamentum and serum; by the appearance which occa- 
 sionally presented itself, of a mass exactly resembling, in color and 
 consistence, a common jelly, the coloring matter covering the bottom of 
 the vessel in the form of a precipitate ; and by, in some instances, a 
 separation only of serum, the large, loose, gelatinous crassamentum con- 
 sisting chiefly of this jelly-like matter, the lowest stratum of which con- 
 tained the black or dark-brown precipitate of coloring matter. These 
 appearances of the blood were presented in several cases in the hospital, 
 in 1823 and three or four subsequent years, in which cases blood had 
 been taken before I saw the patients. It may here be remarked, that 
 I have seen many cases of this form of the disease, in which leeches 
 had been applied to the abdomen ; but in nearly all, and especially in 
 those which occurred in the hospital, the blood which flowed from the 
 bites did not coagulate; and great difficulty, almost amounting to an 
 impossibility, of arresting the bleeding from them was generally ob- 
 served, owing both to the state of this fluid, and to the impaired vital 
 cohesion of the tissues, characterizing the advanced stage of the malig- 
 nant form of this domestic pestilence." This condition of the blood, 
 which has frequently been remarked, points very significantly to the 
 operation of some powerful morbid poison. In the cases which prove 
 most rapidly fatal, nothing may, indeed, be revealed on examination, 
 beyond this peculiar condition of the blood, and, it may be, a little 
 turbid serum in the peritoneum and the other serous cavities. 
 
 The pathological appearances, then, are no reliable indication of the 
 virulence of the attack, as has also been frequently observed in the case 
 of other febrile diseases which prove rapidly fatal. Generally speaking, 
 however, in very severe cases, the extent of the local lesions is commen- 
 surate with the severity of the attack ; and, although we may meet 
 with cases ultimately fatal, in which the metro-peritoneal symptoms 
 are moderate in degree, a careful examination will usually disclose irre- 
 fragable evidence of violent local inflammation. While, therefore, the 
 appearances are often such as to indicate a degree of malignancy and 
 rapid action, which can only be explained on the hypothesis of puer- 
 peral fever, we are aware of no mode of disclosure by which morbid 
 anatomy can reveal to us, with even an approach to certainty, how we 
 may distinguish between the various types of the disease. The post- 
 mortem appearances in the sporadic variety are certainly much less for- 
 midable than in the epidemic form ; and, indeed, it is evident that the 
 description both of symptoms and of morbid appearances, which we 
 read in many admirable works, is founded almost entirely upon an 
 experience of hospital epidemics ; whereas it should be clearly under- 
 stood that the disease in sporadic cases, or even when communicated 
 by contagion in private practice, is, as a rule, much less disastrous in 
 its results than the once dreadful, and still formidable scourge of lying- 
 in hospitals. 
 
XLIV.] TREATMENT. 711 
 
 Another point which we have already alluded to, in reference to the 
 symptoms, is also borne out by a careful analysis of recorded morbid 
 phenomena. This is the tendency in the disease to change its type or 
 form, as evidenced by the tissues which, in successive epidemics, or 
 even at short intervals during the same epidemic visitation, are mainly 
 affected. It were easy to multiply illustrations of this, but we shall, 
 in the meantime, content ourselves with the following example from the 
 experience of M. Tonnelle, whose name has already been mentioned in 
 connection with the subject. "Softening of the uterus," he states, 
 " after showing itself frequently in the first half of the year 1822, and 
 particularly about January, disappeared entirely in the months of July 
 and August, which were characterized, in a remarkable manner, by the 
 frequency of inflammation of the veins. Afterwards, it began to rage 
 anew with great violence in September and October, and again disap- 
 peared in the last two months, during which term the mortality was 
 inconsiderable." 
 
 Treatment. — The treatment of puerperal fever varies according to the 
 class to which each case belongs. If, however, we take what is at once 
 the most simple and comprehensive view of this part of our subject, we 
 shall find that the symptoms and morbid appearances seem to reveal the 
 fact that we have a single disease to treat, — whatever we may choose to 
 call it, — and that our treatment will only be modified by the stage of 
 the disease, the nature of the symptoms, and the character of the com- 
 plications which may arise. Nothing can well be imagined more ab- 
 surd, and nothing, in fact, has been more disastrous in its results, than 
 to manage all cases of puerperal fever upon one and the same principle. 
 One feature, indeed, is common to all cases, and consists in the conta- 
 gious nature of the disease. This is the leading idea, which, more than 
 anything else, we would again impress upon the student with all the 
 emphasis at our command. Whether the case be one of peritonitis, 
 metritis, or malignant puerperal fever, the risk of contagion must 
 always be borne in mind ; and although we must admit that the danger 
 is much less in, for example, simple peritonitis, we can never be sure 
 that it is absent, and therefore we should treat every case, without ex- 
 ception, as if its contagious nature were already demonstrated. 
 
 A further reference to the history of various epidemics shows, with 
 remarkable clearness, that methods of treatment which have been found 
 useful at one time have proved the reverse of beneficial at another. 
 Dr. Gordon, who, in 1789, when the disease appeared in Aberdeen, 
 saw a large number of cases, wrote, several years afterwards, a most 
 excellent treatise on the subject, in which he drew attention, with much 
 force of argument and illustration, to a new and successful method of 
 practice, by means of the bold and early use of the lancet, — taking 
 twenty or twenty-four ounces at once, and, if necessary, ten more soon 
 afterwards. "When I took away," he says, "only ten or twelve 
 ounces of blood from my patient, she always died; but when I had the 
 courage to take away twenty or twenty-four ounces at one bleeding, in 
 the beginning of the disease (i. e., within six or eight hours after the 
 attack) the patient never failed to recover. After the bleeding, it was my 
 practice to bring on a diarrhoea, which, when excited, I found necessary 
 
712 PUERPERAL FEVER. [CHAP. 
 
 to continue through the whole course of the disease, till it was entirely 
 conquered." Nothing, we would say, were we reading of a new and 
 unknown disease, can be more simple than this ; nothing more clear 
 than the indications of practice. In an epidemic which occurred in 
 Leeds early in the present century, the treatment of Dr. Gordon was 
 energetically adopted by Mr. Hey ; and although, prior to this, every 
 case that had come within his knowledge died, no sooner did he purge 
 his patients and bleed them early, to the extent of thirty, forty, and 
 even fifty ounces, than they recovered, in the proportion of thirty cases 
 out of thirty-three. Such facts, which were further corroborated by 
 Armstrong, Mackintosh, and others, were held to be so significant, that 
 for many years the treatment of epidemic and contagious puerperal 
 diseases was, simply, heroic bloodletting. 
 
 About 1829, a remarkable essay was published by Gooch on what 
 he terms " The Peritoneal Fevers of Lying-in Women," which effectu- 
 ally staggered the belief of those who had clung most persistently to 
 the bold measure of Gordon. It would seem that, before this, doubt, 
 founded upon unsuccessful results in treatment, had sprung up in the 
 minds of many ; but, till Gooch wrote, no one had had the courage to 
 controvert ideas so generally entertained. One of the first points to 
 which he calls his readers' attention, and which he states with great 
 force is the marked distinction which subsists between various epidemics, 
 and the result of their treatment at the hands of different observers, 
 who imagined that they were all treating the same disease. He makes 
 it quite obvious that the disease of which William Hunter says, " of 
 those attacked by this disease, treat them in what manner you will, at 
 least three out of four will die," cannot be, in all respects, the same as 
 Dr. Butter treated in Derbyshire, "with ten grains of rhubarb and ten 
 grains of cordial confection every day," without a single fatal result. 
 Nor can it be possible that the fatal scourge of the London and Paris 
 hospitals can be the same as that observed by Richter of Gottingen, of 
 which he observes, " I have often seen the childbed fever, and always 
 treated it successfully." Gooch began his practice with a decided 
 prejudice in favor of bloodletting, and his results seem to have been 
 so far satisfactory, when he saw the patients early ; but when several 
 days had been allowed to elapse, the issue was almost uniformly fatal. 
 As his experience increased, he fully recognized the fact, that a blind 
 and slavish adherence to the lancet sometimes inflicted irreparable injury 
 upon the patient. 
 
 In 1823, Dr. Copeland was appointed consulting physician to Queen 
 Charlotte's Hospital, and the result of his experience is given by Dr. 
 Fergusson. " The disease was malignant, and often ran its fatal course 
 in twenty-four hours from the first appearance of the symptoms. . . . 
 The treatment ultimately adopted by Dr. Copeland for this malady was 
 boldly stimulant. Immediately upon the appearance of the symptoms, 
 a bolus containing from eight to sixteen grains of camphor, from ten to 
 twenty grains of calomel, and from one to three of opium was given, 
 and repeated in four, five, or six hours. The dose of camphor was 
 very rarely less, and but seldom above that named, and the interval 
 between the two doses sometimes only three hours, but never longer 
 
XLIV.] TREATMENT. 713 
 
 than six hours. The dose of opium in the second and subsequent 
 boluses was regulated according to the effect of the first. Soon after 
 the second bolus was administered, about half an ounce of spirits of 
 turpentine and an equal quantity of castor oil was given, on the surface 
 of some aromatic water; and if these did not operate fully on the bowels 
 within three hours, the same medicines in double and treble quantity 
 were administered in enemata. The bolus just mentioned was still 
 continued at the same intervals, or after five or six hours from the 
 exhibition of the second or preceding one. Very soon afterwards, and 
 generally subsequent to the administration of the turpentine draught 
 and enema, a large piece of flannel folded several times, and sufficient 
 thus to cover the whole abdomen, was directed to be wrung as dry as 
 possible out of very hot water, to be instantly freely sprinkled with 
 spirits of turpentine, and applied over the abdomen, to be closely 
 covered by wash leather or a dry cloth, and to be kept thus applied for 
 some time, or renewed until erubescence of the surface of the abdomen 
 was produced. The success of the above treatment in the malignant 
 form I found to be almost complete, for scarcely a case terminated fatally 
 in which it was early resorted to." 
 
 It is quite clear that the stimulating treatment detailed in the above 
 extract, and which was attended with results so satisfactory, must have 
 been directed against a fever of a different type from that which was 
 encountered by Gordon and Hey. The more, indeed, do we study the 
 history of puerperal fever, the more prominently does the fact stand 
 out that the type of the disease has varied much during the last hundred 
 years; and that while, in one epidemic, the sthenic or inflammatory 
 nature of the symptoms has been such as to warrant the boldest anti- 
 phlogistic treatment, in another, the asthenic type has prevailed from 
 the first, when stimulant treatment has alone been attended with suc- 
 cess. We shall not here enter upon the question, whether or not there 
 has been, as some have alleged, a. general change in the type of all 
 diseases from the sthenic to the asthenic form ; but, admitting the force 
 of many facts which have been advanced in support of this assertion, 
 we confess to having entertained all along a strong impression that the 
 idea has led to an all but invariable discontinuance of general blood- 
 letting as a feature of modern practice, which is an exaggeration, and, 
 as such, to some extent, an error. It is quite clear, however, that 
 during the last forty years the type of puerperal fever has been usually, 
 although not invariably, asthenic or adynamic. 
 
 All this leads directly to the practical conclusion that, although the 
 nature of the treatment to be adopted should depend upon the type 
 under which the disorder presents itself, and also upon the stage at 
 which the case is brought under the notice of the physician, that type 
 is, in the experience of all modern practitioners, mainly asthenic. There 
 is no single plan of treatment applicable alike to all cases. Indiscrim- 
 inate bloodletting is sure to lead to disaster, and invariable stimulation 
 is not free from risk. It is the first duty, therefore, of the judicious 
 practitioner to determine the nature of the individual case, and the 
 special treatment proper to it. The cases to which bloodletting is most 
 applicable are undoubtedly those in which the earliest symptoms indi- 
 
714: PUERPERAL FEVER. [CHAP. 
 
 cate acute inflammation of the peritoneum, of the uterus, or, more 
 probably still, of both. When a patient, therefore, of robust constitu- 
 tion, complains, after a rigor, of acute hypogastric pain, which is ac- 
 companied by a rapid, incompressible pulse, throbbing temples, and 
 suffused countenance, we should not hesitate to apply from ten to twenty 
 leeches over the surface of the abdomen. Few persons nowadays 
 would be bold enongh to bleed from the arm, but it by no means fol- 
 lows that there are no cases in which this would not be the more judi- 
 cious treatment. If the thing is to be done at all, it must be done 
 boldly; and, above all, it must be done early, for, if the patient has 
 passed the acute stage, to bleed her is probably to hasten her doom. It 
 is to be remembered, however, that cases do occur in which the symp- 
 toms are such as to baffle even the most experienced observer ; and in 
 such instances it has been suggested that the bleeding should be more 
 tentative in its nature, the effect of the flow being carefully noted, and 
 only continued if the pulse and other indications show that it is being 
 well borne. 
 
 It does not, in the least, matter what names we give to those acute 
 affections upon which bloodletting has been found to produce so de- 
 cidedly beneficial an effect. For all practical purposes, it is sufficient 
 carefully to distinguish between them and the purely septic cases, in 
 which bloodletting is inadvisable, unless inflammation should arise as 
 a complication, and at an early stage. A rapid compressible pulse, 
 distended abdomen, diarrhoea, and the characteristic appearance in the 
 countenance of ghastly distress, are among the more important of the 
 signs which indicate that depletion must not be ventured upon. 
 
 The same simple rule must be our guide as to the administration of 
 purgatives. Free purgation is generally proper, in the cases to which 
 venesection is applicable; and it is well known that, in peritonitis, 
 constipation is an almost invariable symptom. Our object is to elimi- 
 nate the septic material through the channel of the alimentary canal. 
 The extent to which purgation is to be be carried, and the class of med- 
 icine to be selected, must be determined, in each case, according to the 
 judgment of the medical attendant; but it may be well for him to re- 
 member that, in some fatal cases, the morbid appearances have been 
 such as to suggest the probability of an irritant action from violent 
 drastics having had some share in the result. It is better, therefore, 
 when the bowels do not respond to a sufficient dose, rather to supple- 
 ment that by an enema, than to run the risk of further irritation. In 
 the later stages of the ordinary disease or in the malignant variety, 
 strong purgatives are contraindicated, not only because diarrhoea is a 
 common symptom towards the end, but because there is no hope of a 
 beneficial derivative action from the bowels. To such a case, the milder- 
 laxatives, or enemata containing turpentine, are appropriate. 
 
 [The disease to which the author evidently alludes, in speaking of 
 bloodletting, is peritonitis, to which the term puerperal may be appro- 
 priately prefixed. We have seen a number of cases of this affection, and 
 have resorted to bloodletting occasionally for its relief. We know of no 
 remedy the use of which is followed by more brilliant results, but to be 
 of any service it must be employed at the outset of the disease, certainly 
 
XLIV.] TREATMENT. 715 
 
 within the first twenty-four hours after its commencement. The patient 
 should be bled when sitting up in bed, and the flow should not be 
 checked till syncope is about to occur. To be useful, venesection must 
 be employed boldly. We have seen it terminate the disease at once. 
 
 There are few American practitioners, however, who follow either 
 general or local depletion by the use of purgatives. These are very 
 universally condemned in this country as dangerous remedies in this 
 disease. They excite peristaltic action of the bowels, and increase 
 rather than relieve the irritation and inflammation. 
 
 The depletion should be followed by the use of veratrum viride and 
 opium. Of the former enough should be given to keep the pulse 
 thoroughly under control. It should be kept at 75 or 80 per minute. 
 Opium relieves pain, quiets emotional disturbance, allays nervous irri- 
 tability, and arrests the peristaltic movements of the bowels. It has 
 to be given boldly and in large quantities, because in this disease there 
 is a remarkable tolerance of its effects. Professor Alonzo Clark, with 
 whom this plan of treatment originated, says that a woman " who was 
 unaccustomed to the use of opium in health, and who was not intem- 
 perate, took the first twenty -six hours, of opium and sulphate of mor- 
 phia, a quantity equivalent to 106 grains of opium ; in the second 
 twenty-four hours she took 472 grains ; on the third day, 236 grains ; on 
 the fourth day, 120 grains; on the fifth day, 54 grains; on the sixth 
 day, 22 grains ; and on the seventh, 8 grains/' It is therefore apparent 
 that we are to be guided by the effect produced rather than by the 
 quantity of medicine administered. My own rule is to give enough 
 of some fluid preparation of opium to bring the respirations down to 
 12 per minute. The probabilities are that they will fall to 10 or even 
 to 8, which need occasion no alarm if the medicine has been carefully 
 given. To produce this impression it is safe to commence with doses 
 of one-third or one-half of a grain of morphia in solution, given every 
 hour, and continued umtil the desired effect is produced. If it fails in 
 this, the dose must be increased until the woman is semi-narcotized. 
 The effect must be produced, no matter what quantity of opium is 
 needed to do it. If vomiting interferes with the administration of the 
 remedy by the stomach, it may be given by hypodermic injection. 
 
 The opiate often has to be continued for many days. The tolerance 
 of the patient is the best guide to follow in deciding when to diminish 
 the quantity or to stop its use. As the disease improves, the tolerance 
 diminishes. Patients are often injured by stopping the opium too soon. 
 This fact cannot be too strongly impressed upon the mind of the young 
 practitioner. 
 
 The local treatment of peritonitis is important. Turpentine stupes 
 applied to the abdomen, and kept on as long as the patient will bear 
 them, are useful as counterirritants, while, as Prof. Barker says, 
 enough of the remedy is probably absorbed to produce some constitu- 
 tional effect. This is shown in the restoration of the suspended lochial 
 discharge, the diminution of the tympany, and the stimulation of the 
 patient. When the turpentine is removed, the abdomen should be 
 covered with soft cloths, wet with warm water, to which laudanum may 
 or may not be added, according to circumstances. The whole should be 
 
716 PUERPERAL FEVER. [CHAP. 
 
 surrounded with oiled silk. We have seen blisters applied in the early 
 stage of the disease, but at this time they are not only useless, but are 
 actually injurious. During the second stage, after the acute symptoms 
 have disappeared, a blister is useful in the treatment of the inflammatory 
 indurations which result from the disease. Under these circumstances 
 it not only subdues the remaining inflammation, but it materially as- 
 sists in effecting the resolution and absorption of the inflammatory 
 formations in the peritoneal cavity. 
 
 If the symptoms of purulent infection should supervene, in conse- 
 quence of an attack of general peritonitis, the patient must be treated 
 as in other cases of pyaemia. — P.] 
 
 In the worst forms of the disease, and especially in hospital epi- 
 demics, the power of medicine and the skill of the practitioner are 
 alike set at defiance ; but, however desperate the symptoms, and ap- 
 parently hopeless the prognosis, we must persevere so long as life lasts. 
 Between simple puerperal peritonitis and the malignant fever — which 
 is as deadly as the plague — infinite varieties may be observed ; but 
 the management of all will be more successful if we proceed upon gen- 
 eral principles, rather than minute and special distinctions. We shall, 
 therefore, content ourselves by mentioning, in addition to the means 
 already detailed, the various remedies which have been found useful by 
 the most experienced and able of those who have written on the subject. 
 
 M. Doulcet, in the course of a severe epidemic at the Hotel Dieu, 
 thought of using emetics at an early stage of the disease, and the 
 results, as detailed by him, were eminently satisfactory. Subsequent 
 expe3*ience, however, has not realized, in the hands of others, the hopes 
 which M. Doulcet's statements seemed to encourage. The emetic em- 
 ployed was ipecacuanha, and it was repeated daily until the symptoms 
 were subdued — a potion being administered in the interval, composed 
 of oil of almonds, syrup of marshmallow, and Kermes' mineral. At 
 one time, calomel was given very freely in those cases, and, on the 
 whole, as it would appear, with benefit. On this point Gooch observes, 
 "I have never given it systematically in a number of cases, but what 
 experience I have is in its favor. In the Westminster Lying-in Hos- 
 pital, where ten or twenty grains of calomel used to be given every 
 day, with purgatives, the gums sometimes were affected, and these 
 patients invariably recovered." The fact of all those recovering where 
 the gums were affected may, however, be otherwise explained, on the 
 supposition that if they live long enough for mercury to produce its 
 constitutional effect, the urgent danger of the case has necessarily, in 
 some measure, passed. It will generally be found advantageous to 
 combine opium with the mercury, but, in this respect, much will depend 
 upon the stage which the disease has reached. Spirits of turpentine 
 has been very highly recommended in the treatment of puerperal 
 fever, but the effects produced by its internal administration seem to 
 have been somewhat exaggerated. Flatulent distension of the bowels 
 is, however, so frequent a complication, that we would naturally antici- 
 pate some benefit from this drug, although, perhaps, it would be more 
 correctly described as a palliative. In point of fact, there is nothing 
 of the nature of a specific remedy which we are warranted in recom- 
 
XLIV.] TREATMENT. 717 
 
 mending with any confidence, but it is proper that attention should be 
 called to the sulphites and sulphurous acid, both of which have been 
 strongly supported by some recent German writers ; and it is well to 
 remember that, if the sulphites are freely employed, a purgative action, 
 which we are desirous on other grounds of producing, will be induced. 
 The cold water treatment, which has so undoubted an effect in reducing 
 temperature, has received the support of Schroeder, but it is more 
 than doubtful whether we would be justified in anticipating from this 
 any more reliable effects than from the specific remedies hitherto 
 suggested. 
 
 Blisters to the abdomen have been thoroughly tried, but without any 
 very satisfactory results. Among modern authorities, Dr. Churchill 
 seems, however, to retain some belief in their efficacy, and says that, 
 from the cases he has seen, he is "inclined to think blistering useful, 
 and it affords an opportunity of applying mercurial ointment to a 
 highly absorbent surface." Iodine has also been suggested, but the 
 external applications which find most favor are either warm poultices 
 or turpentine fomentations. 
 
 The asthenic character which has been so generally observed in the 
 more recent epidemics has led many, whose experience has been con- 
 fined to cases of this type, to discard all treatment in favor of a stimu- 
 lant and tonic regimen from the first. Dr. John Clarke gave bark in 
 powder and decoction, with opium and wine. M. Beau found great 
 benefit in the use of quinine in doses of fifteen to thirty grains in the 
 day. Certainly, the results of free stimulation have been such as to 
 warrant us in persevering, while life lingers, in the use of this, which 
 is perhaps the most valuable class of remedies at our command. 
 
 It has lately been proved by Mr. Spencer Wells that, in ovariotomy, 
 benefit is derived by boldly tapping and withdrawing large quantities 
 of turbid serum, in cases in which extreme effusion had come on in 
 connection with other symptoms of septicaemia. It remains to be 
 determined by the experience of the future, whether, by puncture from 
 the vagina or in the abdominal walls, the withdrawal of similar effusions 
 may, in puerperal fever, be attended with equally favorable results. 
 
 The topical treatment of the most probable centres of septic infection 
 must never be lost sight of. It is to be feared that the dread which 
 attaches to this disease renders practitioners sometimes culpably timid 
 in regard to the manipulation of the genital organs, and so duties are 
 left absolutely to the nurse, which ought at least to have our careful 
 supervision. If, in any case, foetor or any other abnormal symptom 
 should arise in connection with the discharges, antiseptic injections are 
 indicated ; and, if necessary, carbolic dressings should be applied to the 
 lacerations, and even weak solutions of carbolic acid injected into the 
 uterus. This, with the strictest attention to cleanliness, will go far to 
 check or modify the progress of the disease. 
 
 The question of prophylactic treatment, which naturally suggests 
 itself here, is second in importance to no point relative to our subject. 
 The rules of lying-in institutions are generally framed with the view 
 of prohibiting students who are engaged in the dissecting-room from 
 the practice of midwifery, or, at least, point to the strictest precautions 
 
718 PUERPERAL FEVER. [CHAP. 
 
 being observed. The danger, however, is much greater from those who 
 are engaged as dressers in hospitals where there is erysipelas or hospital 
 gangrene. Improved ventilation has proved in hospitals an invaluable 
 check on the ravages of the epidemic disease ; and there is good reason 
 to believe that in some instances neglect of proper drainage has led to 
 an aggravation of the type. The case of the General Lying-in Hos- 
 pital, which was built on the marshy land by the Thames, affords an 
 illustration of this, as after proper drainage the mortality in that insti- 
 tution diminished in the most remarkable manner. Where there is 
 the slightest reason to suspect the possibility of any zymotic influence, 
 chlorine, Condy's fluid, or carbolic acid, should be freely employed, as 
 there cannot be the slightest doubt that these agents tend to neutralize 
 this or any other morbid poison. Large lying-in hospitals, as at present 
 constructed, must be unhesitatingly condemned ; for great as are the 
 educational advantages attached to such institutions, the cost in human 
 life is too fearful to contemplate. The smaller establishments are more 
 easily managed, and of late years show a rate of mortality which is, as 
 compared with former experience, highly satisfactory. Still, much in 
 this particular direction requires to be done before hospitals are freed 
 from this one special danger, and it is more than probable, as we con- 
 ceive, that this may ultimately be achieved by the cottage hospital plan, 
 the great objection to which is, unfortunately, especially in large towns, 
 its cost. 
 
 It is impossible to exaggerate the importance, in its bearing upon 
 prophylaxis, of the strictest attention to cleanliness on the part of the 
 practitioner, who in an ordinary case should wash his hands not only 
 after but before each examination. Such a precaution would no doubt 
 be scrupulously observed had he just come from a case of scarlatina or 
 erysipelas, or from a post-mortem examination ; but, the more com- 
 pletely the doctrine of septic infection is established, the more clearly 
 does it appear that the great majority of cases of puerperal fever are 
 preventible, and, if so, we may be sure that to act, in every case, as if 
 we had special reasons to fear that we might propagate the disease, is 
 the surest Avay to reduce the risks to a minimum. For ordinary prac- 
 tice, thorough cleansing with hot water and soap will suffice, and the 
 nail-brush should also be used, as below and at the root of the nails are 
 the situations in which septic matters are most likely to be retained. 
 The precautions necessary, where we have any special cause for alarm, 
 consist in a still stricter attention to cleansing the hands, and here, in 
 addition to soap and water, Condy's fluid or carbolic acid should be 
 employed. We must not, however, lose sight of the fact that the finger 
 of the accoucheur is not the only possible conductor of the poison. 
 Unless the nurse directly imports the poison, the fact of her attention 
 being confined to one case at a time renders her less likely to infect a 
 patient than a general practitioner who, in the course of a single day, 
 supposing his obstetric practice to be quite free from fever, may have 
 visited several cases of scarlatina, dressed a wounded limb affected with 
 phlegmonous erysipelas, and performed a post-mortem examination. 
 But, on the other hand, the nurse in the course of her special duties 
 comes directly in contact with the discharges, so that there is no point 
 
XLV.] DIPHTHERIA OF PUERPERAL WOUNDS. 719 
 
 of greater importance in the education of these women than the necessity 
 of inculcating strict cleanliness in their own persons as well as in that 
 of their patient. A weak solution of carbolic acid may be habitually 
 employed. Again, the poison may very readily be conveyed by the 
 dress, so that it should be changed where we have previously been in 
 attendance upon a suspicious case. And, in like manner, the linen, 
 napkins, and so forth, are possible vehicles of conveyance ; but this, 
 for obvious reasons, is more likely to take place in hospital, than in 
 private practice. 
 
 It has frequently happened that no cleansing, or disinfection, or 
 change of dress, has had any effect in checking a series of fatal cases in 
 the practice of the same person, so that no alternative remains but to 
 withdraw absolutely from practice for six weeks or more. Does this 
 not show that there are other modes of communication ? If we are 
 right in supposing that transmission, even of a septic poison, is possible 
 through the medium of the atmosphere, may we not assume that, in 
 cases of great virulence or concentration of the poison, the system of 
 the accoucheur may become impregnated with the poison, and that, 
 although harmless to him, it may again be given off by the lungs or by 
 the skin. It is true that disease germs have never been seen or traced 
 through the air ; but practice founded on this belief has, in the hands 
 of Lister and his pupils, been attended with brilliant resul s. It is too 
 much to hope that one day, by a process of antiseptic delivery, the 
 fearful danger of this poison may, even in hospital practice, be reduced 
 within narrow bounds, to the benefit of humanity, and the lasting credit 
 of modern science. 
 
 [CHAPTEE XLV. 
 
 DIPHTHEKIA OF PUERPEKAL WOUNDS. 
 
 PREVALENCE DURING THE PAST FIVE YEARS — SYMPTOMS I THOSE WHICH PRECEDE 
 THE OUTBREAK: THE DIGESTIVE SYSTEM: PAIN AND ABDOMINAL TENDER- 
 NESS : PULSE AND RESPIRATION : TEMPERATURE : COUNTENANCE I MENTAL 
 CONDITION: LOCAL SYMPTOxMS — FALSE MEMBRANE ON WOUNDS — JOINT COM- 
 PLICATIONS — DIAGNOSIS AND PROGNOSIS — PATHOLOGICAL ANATOMY — NATURE 
 
 — CAUSES — treatment: quinia : opium: local remedies: cauterization 
 
 OE DIPHTHERITIC "WOUNDS: VAGINAL AND INTRA- UTERINE INJECTIONS: 
 PROPHYLAXIS. 
 
 This is a disease of the puerperal state which is not alluded to by 
 the author. The first American writer who described it, so far as we 
 are aware, was Professor Fordyce Barker, who directed the attention 
 of the Obstetric Section of the New York Academy of Medicine to the 
 subject, in 1860 and 1861. Speigelberg and Schroeder also allude to 
 the presence of false membrane on genital wounds in some cases. Pro- 
 fessor Edward Martin, of Berlin, believes that diphtheritic deposits on 
 
720 ' DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 
 
 wounded surfaces of the genital organs, " is the only essential element 
 of puerperal fever." This affection has recently acquired a new interest 
 and importance in this country. Since the early part of the year 1870, 
 the editor has seen many cases of the disease. During the past five 
 years it has prevailed more or less extensively throughout various parts 
 of the country, and in the hospitals of some of our large cities. Between 
 February 7th, 1870, and July 1st, 1874, about one hundred cases of 
 this disease occurred in the obstetrical wards of the Philadelphia Hos- 
 pital, of which, twenty-five per cent, were fatal. We have already 
 published a history of the outbreak in the American Journal of the 
 Medical Sciences for January, 1875, from which this account of the 
 disease is condensed. 
 
 Symptoms. — The disease may set in suddenly or be preceded by 
 certain premonitory symptoms. Among the latter are pelvic pain and 
 uneasiness, usually supposed to be after-pains by the patient. This 
 pain is at times associated with swelling and relaxation of the uterus, 
 and a peculiar sunken, pale countenance, which continues throughout 
 the disease. The last is a most important symptom when it occurs. 
 Indeed we believe it to be the most significant of the phenomena which 
 are likely to be noticed before the outbreak of the disease. Pelvic 
 pain, tenderness, and enlargement of the uterus may be due to other 
 and temporary causes, but this change of the countenance, which will 
 be more fully described in the appropriate place, indicates that a potent 
 poison has already entered the blood, and commenced its destructive 
 work. The symptom is withal very characteristic, and more than once 
 it has been the first thing which has excited our alarm on entering the 
 chambers of our patients, or the wards of the hospital. These symp- 
 toms may exist for twelve or eighteen hours before the disease fairly 
 explodes. 
 
 If these premonitory symptoms are absent, the disease sets in suddenly 
 at the end of the first or during the second, but rarely later than the 
 third day after delivery. It may commence with a well-marked chill 
 or a rigor. The latter is the more common, though even this is some- 
 times absent. The woman rarely has a severe chill. Succeeding this 
 cold stage is a hot one, in which the febrile reaction is high. In the 
 early stages the skin is hot and dry. Later, after two, three, or four 
 days, it becomes moist, the perspiration appearing at irregular intervals. 
 The heat of the skin during the first few days is very great. Calor 
 mordax may be as marked as it is in scarlet, typhus, or relapsing fevers. 
 Later, a marked elevation of temperature is not revealed by the touch. 
 
 The digestive system is always more or less disturbed. In the early 
 stages the tongue is covered with a white or yellowish-white fur. This 
 sometimes disappears quickly, and in flakes, leaving the organ red, 
 smooth, and dry, in the centre. In some cases the margins are red 
 and clean, with a clean triangular space at the tip. During the last 
 stages of the disease the tongue may become dry, and covered with 
 sordes. This is nearly always its condition in fatal cases. The appe- 
 tite is almost always destroyed, though many women suffering from 
 this disease will take all the food which is offered to them. Vomiting 
 is a frequent though not a constant symptom. The ejected matters are 
 
XLV.J SYMPTOMS. 721 
 
 often of a bright-green color. The bowels are generally constipated. 
 Diarrhoea is rare, except in fatal cases. The abdomen is distended 
 with gas. The degree of distension is sometimes extreme, especially 
 when death is about to occur, when it may materially impede respira- 
 tion. The abdomen is generally tender. This tenderness usually 
 begins in one or both iliac fossae, and extends upwards till nearly all 
 the abdominal surface is involved. 
 
 The patient rarely complains of much pain in the abdominal and 
 pelvic cavities. When asked to take a deep breath, she usually mani- 
 fests more or less uneasiness. The severity of the pain and the degree 
 of tenderness bear no proportion whatever to the extent and intensity 
 of the inflammation of the peritoneum. The most extensive and severe 
 peritonitis may exist, and yet the patient manifest little or no uneasiness 
 when the abdomen is firmly and even rudely manipulated. This has 
 been repeatedly observed in fatal cases, in which the post-mortem 
 examination revealed the existence of the most severe and extensive 
 inflammation of the peritoneum. In other cases the pain may be severe, 
 and the abdomen exquisitely sensitive to pressure. These symptoms 
 are rare, however. It is very seldom that complaint is made of the 
 weight of the bed-clothes, and the decubitus is nearly always on the 
 back with the limbs fully extended. 
 
 The pulse during the first twenty-four hours is full and round, but 
 rather compressible. It is never small, hard, and corded, as it is in 
 acute sthenic non-septic peritonitis. It quickly runs up to 120, 130, 
 or 140 per minute, and we have seen it as high as 170 on the third 
 day after confinement. In a few days it becomes very frequent, Aveak, ■ 
 and compressible, as in all typhoid diseases. Throbbing of the carotid 
 and the other large arteries which are superficial in their position,, is a 
 frequent symptom. 
 
 The respirations are frequent, and the patients usually complain of 
 pain in the abdomen and pelvis upon taking a full inspiration. In 
 fatal cases, as death approaches, breathing is often greatly interfered 
 with, and rendered singultiform by the extreme tympany. In the 
 majority of the cases the disease runs its course without any pulmonary 
 complication, but acute pleurisy and pneumonia are not rare, and may 
 set in at any time after the third or fourth day of the disease. The 
 pleurisy is generally bilateral. It is often latent, and hence the con- 
 dition of the lungs should always be carefully watched in this disease. 
 In rare cases the symptoms of pleuritic inflammation may completely 
 mask those of the peritonitis. 
 
 The temperature ascends abruptly at the outset of this disease, and 
 reaches 104° or 105° Fahr. in a few hours. This sudden elevation is fol- 
 lowed in one or two days by a decline in which the body heat approaches 
 more or less nearly to the normal standard, but does not reach it. This 
 decline occurs in both favorable and fatal cases. It does not afford the 
 slightest ground for a favorable prognosis. In fatal cases there may 
 be a regular and apparently a favorable decline of temperature for one, 
 two, or three days before death. Unless this diminution of the body 
 heat is associated with corresponding favorable changes in the pulse, 
 respirations, and appearance of the patient, it indicates that the disease 
 
 46 
 
722 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 
 
 will rapidly run on to a fatal issue. In favorable cases one of the first 
 indications of the approach of convalescence is an increase in the morn- 
 ing remission, which continues to become more marked from day to 
 day. The diagrammatic representation of the variations of the tem- 
 perature consequently sometimes has the appearance of that produced 
 by a quotidian intermittent fever. After these diurnal variations have 
 become marked, when they vary from 3° to 6° Fahr., there is some- 
 times a tendency for the morning temperature to fall below the nor- 
 mal standard. We have seen it as low as 95° Fahr. This decline is 
 attended with profound collapse. The only discharge which accom- 
 panies it is a profuse perspiration. Sudden fall of temperature and 
 collapse are exceptional rather than constant phenomena of the disease. 
 In all cases in which we observed them the patients recovered. When 
 convalescence is retarded by suppuration in the abdominal or pelvic 
 cavities, the normal temperature may not be regained until the ninth 
 or tenth week of the disease. Under these circumstances the ther- 
 mometer furnishes the most reliable indications of the danger of the 
 patient, which has not passed until the temperature has regained the 
 normal standard. 
 
 The expression of the countenance is peculiar and characteristic. As 
 the changes in the physiognomy of the patient frequently precede the 
 constitutional symptoms, they are of considerable diagnostic value. 
 Either before or after the initial chill, the features assume a shrunken 
 appearance, the eyes, which are surrounded by livid, dark-colored 
 areola?, recede in their sockets ; the nose becomes pale, pinched, and 
 sharp ; the lips are thin, and the skin of the face has somewhat the 
 color and appearance of parchment. As the patient is nearly always 
 cheerful and happy, her smiles under these circumstances give her a 
 weird, ghastly expression of countenance, which cannot be readily foj*- 
 >gotten. 
 
 More or less delirium occurs in fatal cases before death. It is of the 
 low muttering variety that is met with in other typhoid diseases. Vio- 
 lent maniacal delirium may occur at the outset, but this is rare. The 
 mental condition which is characteristic of the affection, is an utter in- 
 ability on the part of the patient to appreciate her condition. She does 
 not believe herself to be ill, but at each visit receives her medical attend- 
 ant with a smile, and the confident assurance that she is perfectly well. 
 If she recovers she appears to be unaware that she has been seriously 
 ill. If the issue is fatal, death steals on her, and the woman makes no 
 sign that she knows the solemn change is at hand. This mental con- 
 dition is one of the saddest and strangest we have ever witnessed. 
 
 The symptoms connected with the genital organs are of the highest 
 importance. The appearance of a yellowish ash-colored diphtheritic 
 false membrane upon wounds of the perineum, fourchette, vagina, 
 and cervix is the characteristic local phenomenon of the disease. The 
 slightest injury of any one of these parts during labor is followed by 
 the formation of this membrane upon its surface. It never makes 
 its appearance upon uninjured tissues in the first instance, though it 
 may spread to these during the progress of the disease. It may line 
 the whole vaginal canal and interior of the uterus, and we have found 
 
XLV.] DIAGNOSIS — PROGNOSIS. 723 
 
 it on an inflamed surface of the mucous membrane of the descending 
 colon. This diphtheritic formation varies from a mere film to a thick, 
 tough, tenacious false membrane. The parts upon which it appears 
 sometimes ulcerate rapidly, as though the membrane had an erosive 
 or dissolving action on the tissues. In from two to ten days the diph- 
 theritic formation separates, leaving an ulcer which heals slowly by 
 granulations if the disease is not fatal. 
 
 Diphtheritic deposit may make its appearance on wounds of the 
 genital organs before the initial chill or rigor occurs, but in these cases 
 it is associated with shrinking of the features, pallor of the face, pelvic 
 pain, and swelling of the uterus. 
 
 The false membrane which has been described is, without doubt, 
 diphtheritic in its nature. Prof. Lusk, who witnessed an outbreak of 
 this disease at Bellevue Hospital, in New York, says that Dr. Steurer, 
 who was one of his internes during the epidemic, has recently studied 
 the microscopical appearances of this membrane in connection with 
 Prof. Yon Recklinghausen, of Strasburg. Dr. Steurer says, "We 
 found it a true diphtheria. Micrococci were found beneath the deposit 
 and scattered throughout the tissues of the uterus, whence they were 
 taken up by the sinuses, and conveyed into the circulatory system. 
 They may be found in the muscular structure of the vulva, and always 
 occur in colonies. They are sometimes found in the bloodvessels of 
 the kidney, distending whole glomeruli." 
 
 The lochia may be diminished or entirely suppressed. When per- 
 sistent they may be more or less offensive. The uterus becomes en- 
 larged. This appears to be due to swelling rather than relaxation. 
 The enlargement may be so great that it is difficult to believe that the 
 organ is empty. This symptom appears with the pelvic pain, and may 
 precede the chill or rigor. 
 
 Inflammation of the joints must be noted among the local symptoms. 
 This may come on any time from the third to the twelfth day. Any 
 of the joints may be affected. The process is identical in its nature 
 with that which occurs in surgical pyaemia. 
 
 The most important results of the disease are inflammatory indura- 
 tions and purulent accumulations in the pelvic and abdominal cavities. 
 These are detected after the acute symptoms have disappeared, by com- 
 bined vaginal and abdominal examination. The abscesses may open 
 into the vagina, bowel, or through the abdominal wall, and they some- 
 times give exit to enormous accumulations of pus. 
 
 Diagnosis. — This is not difficult. The presence of a diphtheritic 
 false membrane on an injured surface of the genital tract sets all doubts 
 at rest. 
 
 Prognosis. — This should be guarded. The establishment of marked 
 morning remissions of temperature is a favorable sign. Fall of tem- 
 perature without corresponding favorable changes in the pulse, respira- 
 tions, and appearance of the patient, presages death. Obstinate diar- 
 rhoea is an unfavorable symptom. 
 
 Pathological Anatomy. — If death occurs during the early stages of 
 the disease, injured surfaces and adjoining parts of the genital organs 
 are found covered with the diphtheritic false membrane which has 
 
724 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 
 
 been described in connection with the symptoms of the disease. If 
 life is prolonged for several days, the false membrane may have sepa- 
 rated, leaving unhealthy, dark-colored, sloughing ulcers. Starting 
 from these lesions of the fourchette, vagina, or cervix, and having its 
 origin in them, is a pathological change of the highest importance. 
 This is inflammation of the connective tissue. Beginning at the 
 wound, it extends upwards till it involves the whole of the pelvic and 
 much of the subperitoneal connective tissue, which becomes infil- 
 trated with a gelatinous substance, which may be transparent or stained 
 with the coloring matters of the blood. Mingled with this substance 
 are cell-elements, which have their origin in differentiation of the con- 
 nective-tissue corpuscles and the migrated white blood-corpuscles. 
 
 At those points in the pelvis where the cell-elements are produced 
 rapidly and profusely, there is perceptible swelling, which formed the 
 pelvic tumors discoverable during life by vaginal examination. These 
 inflammatory indurations are most frequent in the broad ligaments, at 
 the sides of the pelvis, in contact with the bones, and low down upon 
 either side of the cervix uteri. In size they may vary from mere 
 points to masses as large as an orange. The appearances presented by 
 a section of these inflammatory swellings vary with the duration of the 
 disease before death. In the early stages they have a somewhat irreg- 
 ular nodular outline, and are more or less firm to the touch. The cut 
 surface in the first stage is red, with yellowish points, such as are found 
 in other phlegmonous inflammations, scattered here and there. When 
 the disease has progressed farther, and suppuration has occurred,, the 
 swellings are converted into abscesses. 
 
 In a number of cases inflammation of the connective tissue extends 
 outwardly from the pelvis, and involves the anterior surface of the 
 thigh. This may lead to obstruction of the veins and lymphatic ves- 
 sels by thrombi, and the production of phlegmasia dolens. 
 
 The inflammation and swelling of the connective tissue of the pelvis 
 likewise frequently lead to thrombosis and occlusion of the veins and 
 lymphatic vessels of the part. These often appear as prominent lesions 
 at the autopsy, and consequently undue importance is liable to be at- 
 tached to them in this, as has been done in other puerperal diseases. 
 Virchow has directed attention to the fact that thrombosis of the lym- 
 phatics is a conservative and not a destructive change. 
 
 The uterus is nearly always large and flabby. Its interior may be 
 covered with diphtheritic false membrane. There is generally more or 
 less endometritis, while the walls of the organ are thickened from swell- 
 ing and inflammation. 
 
 The peritoneal covering of the Fallopian tubes is generally intensely 
 inflamed when peritonitis complicates the case. The mucous mem- 
 brane is injected and covered with bloody mucus. The fimbriated 
 extremity may be occluded, after which the products of inflammation 
 may accumulate in its cavity in considerable quantities. 
 
 The ovaries are much less likely than the tubes to escape the effects 
 of the disease. Their anatomical position is such that inflammatory 
 action readily extends to them from the connective tissue of the broad 
 ligament. The result is that they may be almost entirely destroyed by 
 
XL V.] NATURE. 725 
 
 inflammation and suppuration, even when the Fallopian tubes are but 
 slightly affected by disease. 
 
 The other lesions of this disease are those of septic affections in gen- 
 eral, so that it is not necessary to occupy additional space in their de- 
 scription. The peritoneum, pleura, and pericardium may be extensively 
 inflamed, and one or more joints may be completely disorganized, but 
 these changes, though they may overshadow and obscure other anatomi- 
 cal alterations, are not an essential part of the disease. The character- 
 istic anatomical alterations of this affection are the formation of a diph- 
 theritic false membrane upon wounded surfaces, and inflammation of 
 the pelvic and subperitoneal connective tissue. 
 
 Nature. — This disease is closely allied to pysemia. The two resemble 
 each other in their liability to joint complications, the formation of 
 thrombi, to alterations of temperature, and in other symptoms. It 
 differs from pysemia and septicaemia, however, in the constant presence 
 of diphtheritic deposit on wounded surfaces. It is probably analogous 
 or identical with the " diphtheria of wounds/' or hospital gangrene, 
 described by Billroth (Surgical Pathology, p. 308). 
 
 It is possibly due to the absorption of a septic poison by an injured sur- 
 face, but there is some reason for believing that it may be parasitic in its 
 origin. In order for the poison to enter the system, some channel must 
 be opened for its admission. Unfortunately every woman is more or less 
 injured during labor. It is admitted by the highest authorities that 
 septic matter, when it enters the system by an injured surface, produces 
 two effects, high febrile reaction and inflammation of the tissues with 
 which it comes in contact, whether it reaches them directly or- through 
 the medium of the blood. If these opinions are correct, the pathologi- 
 cal appearances become perfectly intelligible. The process is at first 
 entirely local. The materies morbi of the disease produces inflammation 
 of the surface injured during labor. This is followed by the produc- 
 tion of a false membrane, which is as important a feature of the dis- 
 ease as the ash-colored leathery formation is in the throat in diphtheria. 
 
 If the inflammation stopped here it would be well for the patient, 
 but from this point it extends in various directions, affecting the con- 
 nective tissue, and through this involving other structures, the veins, 
 lymphatics, ovaries, and peritoneum. At the same time the morbific 
 matter to which the diphtheritic changes in the wound owed their 
 origin is being reproduced in large quantities in the inflamed areas. It 
 enters the blood, producing high febrile reaction and inflammation in 
 organs which are remote from the locality in which the process had its 
 origin. 
 
 Peritonitis has always been assigned a prominent place in the dis- 
 cussion of the pathological appearances of " puerperal fever." In 
 "diphtheria of wounds" and all the class of diseases to which it be- 
 longs there is every reason to believe that it occupies a subordinate 
 position. Though the inflammation may be so intense and extensive 
 as to overshadow all other anatomical alterations, it is but an effect of 
 the disease, and not the disease itself. In the affection which is being 
 described, and in pyaemia and septicaemia, when the poison of the dis- 
 ease has accumulated to a certain extent in the circulating fluid, it may 
 
726 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 
 
 produce inflammation of any tissue with which it comes in contact. The 
 serous membranes are peculiarly susceptible to its influence, and hence 
 peritonitis, pleuritis, and pericarditis are common effects of the entrance 
 of septic matter into the system. 
 
 That peritonitis is not always due to the extension of inflammation 
 from the pelvic connective tissue upwards is proved by the fact that 
 the inferior portion of the membrane may escape, while that part of it 
 which lines the upper portion of the abdominal cavity may have un- 
 dergone the most severe changes. The editor has seen the peritoneum 
 of the pelvis and lower part of the cavity of the belly almost unaltered, 
 while the spleen, liver, and stomach were literally buried in lymph. 
 
 While the pleurisy of this disease may be due to extension of inflam- 
 mation upwards through the diaphragm, this is not its universal origin. 
 The fact that it may occur when the peritoneum of the upper part of 
 the cavity remains healthy proves this, while the fact that the disease 
 is bilateral is an indication of its constitutional origin. 
 
 The opinion that diphtheria of puerperal wounds is at first a local 
 disease, appears to be sustained by the clinical history of the affection, 
 as well as by its pathological appearances. The local symptoms, the 
 diphtheritic membrane, evidences of pelvic inflammation, and swelling 
 of the uterus precede the symptoms of constitutional reaction several 
 hours. Even the appearance of the countenance may be materially and 
 characteristically altered before the occurrence of the initial chill and 
 the fever which follow it. The effects of the poison which has entered 
 the blood can be distinctly traced in the local inflammation of the in- 
 jured surfaces and the connective tissue of the pelvis before it has had 
 time to produce constitutional reaction, or before the amount of septic or 
 parasitic matter in the circulating fluid is sufficient to give rise to fever. 
 
 Causes. — For the production of this disease it is necessary for the puer- 
 peral woman to be brought in contact with virus of the disease, and that 
 she should present an injured surface capable of absorbing it. There is 
 reason to believe that the poisons of pyaemia, septicaemia, and diphtheria 
 of wounds do not enter the system by the skin, lungs, and intestinal 
 canal, but find their way into the blood by a wound, which must be either 
 fresh or have had the granulations on its surface destroyed if they pre- 
 viously existed. Billroth has shown that a healthy granulating surface 
 will not absorb septic matter. These expressions indicate the impor- 
 tance of traumatism in the production of the disease. 
 
 The disease may be autogenetic or heterogenetic in its origin. In 
 the second class of cases, the poison may be derived from the atmosphere, 
 or the woman may be inoculated with it by her accoucheur, or nurse, 
 or by the use of soiled clothing, sponges, or towels. While it is impossi- 
 ble not to recognize the fact that this affection is inoculable or manu- 
 ally contagious as syphilis and vaccine diseases are, we know of no 
 facts which prove that it is contagious, in the widest sense in which that 
 term is used. A large experience has apparently shown that it is not 
 reproduced as variola, typhus and relapsing fevers are. The whole 
 difference may be summed up by saying that the channels by which 
 the disease germs enter the system, are not the same in the two classes of 
 cases. It is a demonstrated fact that the seeds of variola may gain access 
 
XLV.] TREATMENT. 727 
 
 to the circulation by more than one avenue. It is probable that the 
 same is true of typhus fever and other diseases of its class. The poisons 
 of syphilis and vaccine disease can only be transmitted by a wound. 
 Clinical observations appear to warrant the conclusion that the same is 
 true of the poison of this disease. 
 
 Diphtheria of wounds is not a disease peculiar to hospitals. We have 
 recently met with it in a number of patients whose means enabled them 
 to command every comfort, and under circumstances in which every 
 possible source of contagion was removed. We have seen it make its 
 appearance in a remote rural district, hundreds of miles from any large 
 city, and where it could not possibly have been due to contagion. The 
 accoucheur, in this case, had been in ill-health for some time and had 
 not seen a case of septic disease or attended a woman in labor for more 
 than six months. It cannot be denied, however, that the wards of a 
 hospital in which this disease makes its appearance, may become con- 
 taminated and unfit to be occupied by puerperal patients. In this, 
 the disorder does not differ from pyaemia, septicaemia, and hospital 
 gangrene in surgical wards. 
 
 Treatment. — There is no internal remedy which is a specific for this 
 disease. Immediately after the initial symptoms make their appearance, 
 the patient may be given simple fever mixtures of sweet spirits of nitre, 
 and the solution of acetate of ammonia, and neutral mixture. Veratrum 
 viride cannot be resorted to. The disease is asthenic in its type and 
 veratrum does not reduce the frequency of the pulse of debility. 
 
 Quinia is recommended by many authorities in the treatment of dis- 
 eases of this class. From ten to twenty-five grains should be pre- 
 scribed daily, in two doses, one in the morning and the other in the 
 evening. This method of giving the remedy appears to be followed by 
 better results than the administration of small doses at short intervals. 
 Large doses of this drug are sometimes followed by a- temporary fall 
 of temperature, but it is difficult to decide whether this is due to the 
 medicine or not. The comparison of the records of the temperature 
 of a number of cases in which quinia was given, with those of others 
 who did not take it, shows that it is unsafe at present to attribute to 
 quinia any power to reduce the heat of the body in this disease. 
 
 As peritonitis is one of the most common results of the absorption of 
 the virus of this disease, the treatment must be largely directed to the 
 relief of the symptoms of this complication. For this purpose, opium, 
 or some of its preparations, is the most valuable remedy. It should be 
 given as in acute peritonitis, until pain is relieved, and the patient is 
 made comfortable. In bad cases this does not occur until the woman 
 is semi-narcotized. The quantity administered should be limited only 
 by the effect produced. It is sometimes necessary to give a grain, or 
 even much more of morphia in solution, at short intervals. In these 
 cases, the improvement that follows the bold use of narcotics is some- 
 times very surprising. 
 
 The use of the sulphites and hyposulphites has not been followed 
 by any good results in our hands. Large doses of the tincture of the 
 chloride of iron seemed to irritate the stomach. Carbolic acid likewise 
 disordered the stomach, and appearred to produce diarrhoea. 
 
728 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 
 
 The nourishment of the patient is a point of the highest importance. 
 Good food should be given from the outset, and stimulants should be 
 administered if required. 
 
 Purgatives are injurious, except when specially indicated. Local 
 depletion by leeches is dangerous, not only because it produces depres- 
 sion, but because it may be difficult -to arrest the hemorrhage from the 
 bites. 
 
 Local Treatment. — Turpentine stupes should be applied to the abdo- 
 men as soon as the woman begins to complain of pain. These may be 
 followed by warm applications covered with oiled silk. 
 
 The most important question in connection with the local treatment 
 concerns the management of the diphtheritic ulcers. This will have 
 to be decided by future experience. Local applications are rarely called 
 for to prevent sloughing. If of use it is to prevent the absorption of 
 septic matter, and the growth of micrococci at first, and afterwards to 
 aid the process of repair. The wounds are often very difficult to detect 
 if situated high up in the vagina or on the cervix uteri, and it is very 
 questionable whether the physician is justified in introducing a specu- 
 lum, to seek for them when the tissues about the vulva and perineum 
 are found to be healthy on inspection. 
 
 We have employed local applications of carbolic acid and Monsel's 
 solution under these circumstances, but have never felt satisfied that 
 they were beneficial. Speaking of this matter, Professor Lusk says, 
 " In my own experience, prompt cauterization with strong carbolic 
 acid or the application of Churchill's tincture to the diphtheritic mem- 
 brane, was often followed by a surprising amelioration of the symptoms, 
 which had assumed an alarming character." In the latter portion of 
 the same interesting and highly important paper, Dr. Lusk adds that 
 after the wards at Bellevue Hospital had become thoroughly poisoned 
 by the "miasm" of this disease, "cauterization of the local lesions 
 ceased to possess any marked efficacy." 1 This probably explains why 
 the writer obtained no benefit from their use. He did not employ either 
 carbolic acid or the solution of the subsulphate of iron, at the outbreak 
 of the disease, as he did not at the time appreciate the importance of 
 the appearance of false membrane upon wounded surfaces. After the 
 disease had become firmly fixed in the wards of the Philadelphia Hos- 
 pital, their use certainly produced little if any amelioration of the 
 symptoms. 
 
 Dr. Lusk's experience would appear to warrant the inference that 
 we may hope for much benefit from these remedies in sporadic cases, 
 occurring in hospitals and in private practice. 
 
 Injections, both vaginal and intra-uterine, have been recommended in 
 diseases of this class. Offensive lochia would appear to be a positive 
 indication for their use, but we have not derived that benefit which we 
 anticipated from their use. It is important to remove any decompos- 
 ing matter from the vagina, yet it must be remembered that when the 
 disease commences at the fourchette and low down in the posterior wall 
 
 1 The Genesis of an Epidemic of Puerperal Fever. Amer. Journ. of Obstet., 
 November, 1875. 
 
XLV.] PROPHYLAXIS. 729 
 
 of the vagina, the tube of the syringe may carry the virus to the lesions 
 of the cervix, and thus set up a new focus, through which the contami- 
 nation of the blood may be increased. Reasoning and clinical expe- 
 rience have therefore led us to employ vaginal injections somewhat 
 charily in this disease, but they ought not to be absolutely condemned. 
 An offensive and copious vaginal discharge indicates their use. 
 
 Intra-uterine injections are more dangerous than vaginal, and, in the 
 cases in which we have used them, they have done harm with few ex- 
 ceptions. They often produce pain, and their use may be followed by 
 an increase of fever and abdominal uneasiness. 
 
 Though there is still uncertainty about the usefulness of caustics 
 applied to the genital wounds, and of intra-uterine injections, the 
 medical attendant is not without resources. The diphtheritic ulcers 
 need careful treatment. They heal slowly at best. They are to be 
 managed on general principles. A stimulating local treatment is gen- 
 erally required. Cleanliness cannot be too carefully observed, and in 
 a hospital every patient should have her own basin, towels, and sponges. 
 In place of the last, however, it is better to use oakum or some other 
 substance that can be thrown away after it has been soiled. 
 
 Prophylaxis. — The means by which inoculation may be prevented 
 need not be alluded to here. During labor it is important to make as 
 few vaginal examinations as is consistent with the safety of the patient. 
 The placenta should be delivered by Credos method. 
 
 Whether cauterization of such wounds as may be visible immediately 
 after delivery will prevent the disease, has not been determined by 
 clinical experience. The measure is certainly worth a trial. Nitrate 
 of silver, nitric acid, or bromine, might be used. 
 
 We know of no drugs which have any influence in preventing the 
 disease. Large doses of quinia, tincture of the chloride of iron, and 
 various other medicines were tried in the Philadelphia Hospital without 
 avail. The only s'ure prophylactic is to remove the woman from an 
 infected atmosphere before labor sets in. — P.] 
 
730 PELVI-PERITONITIS. [CHAP. 
 
 CHAPTER XLVL 
 
 PELYI-PERITONITIS : SUDDEN DEATH IN PUERPERAL 
 PERIOD: ANAESTHESIA. 
 
 PELVI-PERITONITIS — INFLAMMATION OF THE UTERINE APPENDAGES — " FULNESS," 
 "HARDNESS," AND " TUMOR " — PELVIC CELLULITIS: ANATOMY OF THE 
 PELVIC CELLULAR TISSUE — BERNUTZ ON PELVI-PERITONITIS — DIAGNOSIS OF 
 PELVIC CELLULITIS AND PELVI-PERITONITIS — ENGORGEMENT OF THE UTERUS 
 — DETECTION OF PUS: FLUCTUATION — TREATMENT: ALLEVIATION OF PAIN: 
 APPLICATION OF LEECHES, POULTICES, FOMENTATIONS, ETC. : METHODS OF 
 PROMOTING ABSORPTION; MERCURY; IODINE; COUNTER-IRRITATION: THE 
 OPERATIVE TREATMENT OF ABSCESS — PERI-UTERINE HEMATOCELE — SUDDEN 
 DEATH IN PUERPERAL PERIOD : EMBOLISM OF PULMONARY ARTERY — ARTERIAL 
 EMBOLISM — ENTRANCE OF AIR INTO VEINS — ANAESTHESIA: VARIOUS ANES- 
 THETIC AGENTS : EFFECTS OF CHLOROFORM ON THE BLOOD AND ON THE PROG- 
 RESS OF LABOR : DISADVANTAGES OF CHLOROFORM : MODERN PRACTICE. 
 
 In addition to the diseases which have been grouped together in the 
 two preceding chapters, under the common designation of puerperal 
 fever, there are other affections, chronic for the most part in their nature, 
 which require some notice at our hands. These are by no means nec- 
 essarily associated with the puerperal state, although about a half of all 
 cases have their origin in inflammatory processes which arise, more or 
 less distinctly, from the condition under which women remain for a 
 certain period after delivery. The connection between the disorders 
 which we are about to describe and puerperal fever is, in some cases, 
 direct and unmistakable; but, in the great majority of instances, the 
 disease, although inflammatory in its nature, has no such intimate rela- 
 tion to puerperal fever as to admit of its being placed in the same cate- 
 gory. For these and other reasons, it is thought better to consider the 
 group of affections to which we have referred as separate from, although 
 associated with, those previously described. 
 
 In most systematic works, even by those w r hose merit is universally 
 recognized, these affections are dismissed with a brief notice, and under 
 a great variety of names. The first difficulty, therefore, which we en- 
 counter, is in the matter of nomenclature — Pelvi- peritonitis, pelvic cellu- 
 litis, subperitoneal inflammation, peri-uterine phlegmon, perimetritis, 
 parametritis, and inflammation of the uterine appendages, are only a few 
 of the many designations under which this group of affections have 
 been described. They may be most usefully considered together, for 
 purposes of analysis and such description as is here possible. A very 
 brief preliminary definition of the various terms above employed is, 
 however, essential. 
 
XLVI.] PELVIC CELLULITIS. 731 
 
 What was originally described by M. ~Nonat as peri-uterine phlegmon, 
 is better known to English readers under the more familiar designation 
 of pelvic cellulitis, with which we may assume it to be almost synony- 
 mous. The idea involved is an inflammatory affection, tending to the 
 formation of abscess, which has its seat in the cellular tissue between the 
 uterus and peritoneum, or in some other part of the same tissue within 
 the pelvis. Both expressions are unfortunate, and involve a funda- 
 mental error. Subperitoneal inflammation is another synonym equally 
 objectionable. That inflammation of the uterine appendages is very com- 
 monly associated with the class of affections which we shall describe is 
 universally admitted ; but if used as a comprehensive designation, as 
 Churchill has employed it, it may be supposed — and if so, very erro- 
 neously — to be confined to these tissues. 
 
 Dr. Matthews Duncan, who has treated the subject in his well-known 
 work at considerable length, and with his usual ability, adopts the 
 words parametritis and perimetritis, borrowing the idea of this nomen- 
 clature, as he tells us, from Virchow, who, taking example from the 
 heart and other organs, proposes to use peri to signify inflammation of 
 serous membrane, and para to imply inflammation of cellular or con- 
 nective tissue. "Perimetritis, then," he adds, "will strictly imply in- 
 flammation of the uterine peritoneum. Parametritis will imply inflam- 
 mation of the cellular tissue in connection with the uterus. Similar 
 terms may be found for the Fallopian tubes, perisalpingitis and para- 
 salpingitis, and likewise for the ovaries. But I shall seldom have occa- 
 sion to resort to them. In the present imperfect state of our diagnostic 
 resources, it would be mere pedantry to do so frequently. There are 
 only a few cases in which we can assert, during life at least, that the 
 pelvic peritonitis is parasalpingitis, or perioophoritis, or that the pelvic 
 cellulitis is parametritis, parasalpingitis, or paraoophoritis. To hide 
 our ignorance on this point, it would be convenient if we had a rough 
 word expressing the internal genital organs, to which to prefix the ad- 
 verbs 'peri' and 'para/ But we have not such a word, and I shall 
 therefore, in accordance with old custom, give the uterus the prece- 
 dence, and use terms compounded of it, as perimetritis, parametritis, 
 etc., without always implying, by such use, a meaning exclusively and 
 properly uterine, but implicating also the tubes and ovaries. I shall, 
 indeed, use the words perimetric inflammation and perimetritis, parametric 
 inflammation and parametritis, with a still wider meaning, implying in- 
 flammations which directly owe their origin to disease or injury of the 
 uterus, tubes, or ovaries. For example, a lumbar abscess, or an iliac 
 abscess, may be perimetric or parametric in origin, although lumbar or 
 iliac in mere situation." 
 
 Pelvi-peritonitis, again, is the name to which a preference is given by 
 Bernutz, and which is used by him in a sense precisely similar to that 
 which Dr. Duncan has attached to his term " Perimetritis." There is 
 very little in a mere name after all ; but if we were to select the one 
 which is least likely to lead to misapprehension, we would be inclined 
 to select pelvi-peritonitis, as indicating a limited peritoneal inflamma- 
 tion, involving that portion of the membrane which invests the uterus, 
 or other generative organs, and often causing adhesive matting together 
 
732 PELVI-PERITONITIS. [CHAP. 
 
 of various parts, and the formation of tumors, which may be discovered 
 both from the brim of the pelvis and from the vagina. 
 
 If we read in most standard works, an account of what is usually 
 called Pelvic Cellulitis, it would seem at first as if the subject were 
 exhausted, and placed on a basis which nothing could shake. All 
 tumors, abscesses, and inflammations in the pelvic region were regarded 
 in the light of this simple pathology, that an inflammation in the sub- 
 peritoneal cellular tissue represented the proximate cause of the disease 
 in almost every case. No one, however, who carefully observes such 
 facts as may come practically under his observation, or who even takes 
 the trouble to analyze the obstetrical and gynceco logical records of the 
 last few years, can fail to come to the conclusion that, so far from the 
 subject being finally disposed of, it would be more correct to say that 
 it is still in its infancy. And the more vigorously did he pursue his 
 investigation, the more clear would it become that there lies here a field 
 of study which is of deep interest, and of much promise. 
 
 From the results which have been disclosed by post-mortem examina- 
 tions, it is certain that the uterine appendages are not unfrequently the 
 seat of inflammation, varying in degree and in extent ; the action, in 
 some instances, being confined to the peritoneal coat, and in others 
 extending more deeply, so as to involve the entire thickness of the 
 Fallopian tube on the side affected. If the ovary is the seat of the 
 disease, the result may, in like manner, be displayed, either on the 
 surface of the organ, or, — should the action have reached more deeply, 
 or have originated there, — the stroma may be found extensively dis- 
 organized, and occupied with abscesses varying in size. Such serious 
 disorganization may at any time result from an extension of the 
 destructive inflammation so characteristic of puerperal peritonitis ; but, 
 in the cases now under consideration, the symptoms are generally more 
 chronic from the first, and are often looked upon, in reference to other 
 coexisting phenomena, as merely secondary. It can be no easy matter, 
 therefore, to determine where the disease has had its origin. The 
 symptoms of inflammation of the uterine appendages are almost always 
 very obscure. When the pain is circumscribed by limited peritoneal 
 inflammation-, its site in the iliac fossa, or lateral region of the hypo- 
 gaster, may be held to indicate a probability that the structures in 
 question are affected ; but there are no reliable means for determining 
 whether the morbid action is limited to the peritoneum and subjacent 
 tissue, or extends further, so as to involve the deepseated structures of 
 the tube or ovary. 
 
 The diagnosis of these affections depends, in a great measure, upon 
 the results of abdominal palpation and vaginal examination; and, from 
 the many fallacies which may spring in the course of such an investiga- 
 tion, it may be added, that upon the special experience of the examiner 
 the accuracy of any opinion which may be formed will greatly depend. 
 Dr. Matthews Duncan directs attention, at considerable length, and 
 with much propriety, to the loose manner in which the expressions, 
 "fulness," "hardness," and "tumor," are employed in the narratives 
 which we read of such cases ; and it is quite clear, although the words 
 themselves are sufficiently explicit and significant, that much confusion 
 
XLVI.] DIAGNOSIS. 733 
 
 arises from this source, especially, perhaps, in confounding tumor with 
 mere hardness. The same remark applies to any investigation which 
 may be made from the vagina ; and it is, in every case, of the highest 
 importance that we should determine if any connection exists between 
 an enlargement observable from above and one which is made out 
 from below. In the case of a solid tumor, free from serious adhesions, 
 this is very readily recognized by such method of investigation — the 
 impulse communicated from one direction being readily transmitted to 
 the other. If it be a cyst or abscess, fluctuation is thus sometimes dis- 
 tinguished, without any difficulty, between the two hands, which are 
 simultaneously employed in the examination. But, in the case of 
 mere diffused fulness, or hardness, or a tumor which is bound down 
 by adhesions, the difficulty of diagnosis is increased, to an extent which 
 is only fully recognized by those who have devoted most attention to 
 such matters. 
 
 Pelvic cellulitis, peri-uterine phlegmon, or parametritis, — and accept- 
 ing those expressions as synonymous, — indicates, as already stated, an 
 inflammation of the subperitoneal cellular tissue, possibly radiating 
 thence, and always involving a tendency to the formation of abscess. 
 Until within a comparatively recent period, every mysterious tumor 
 or enlargement following delivery, was, without much hesitation, 
 referred to this category. Recent investigation seems, however, to 
 assign to it a much less important position. To no one is modern 
 science more indebted, in reference to this subject, than to M. Ber- 
 nutz ; but there can be little doubt that that experienced and able ob- 
 server undertook to prove too much, when he thrust aside pelvic cel- 
 lulitis, — merely admitting the possibility of its existence, — to make room 
 for his own idea of pelvi-peritonitis. It is a dangerous thing to prove 
 too much, inasmuch as anything approaching to exaggeration is apt to 
 attach discredit, even to investigations which are otherwise of the high- 
 est importance. But, freed from this blemish, no impartial critic can 
 deny that M. Bernutz has rendered to this particular department of 
 science the most eminent service, in boldly exposing the fallacies which 
 attach to the familiar idea of pelvic cellulitis. 
 
 " The slightest dissection," says the writer referred to, " shows that 
 the cellular tissue subjacent to the peritoneum is so thin and scanty 
 that it is impossible to separate the serous from the uterine tissue ; and 
 that, consequently, it cannot be the seat of swellings, which, according 
 M. Nonat's observations, attain, in the space of a few hours, to the size 
 of a hen's egg. The only other possible position for the so-called 
 ante- and retro-uterine phlegmons is the small band of cellular tissue 
 situate at the junction of the neck with the body of the uterus, and 
 this we can hardly credit, unless it be proved by an undoubted post- 
 mortem examination, which has never yet been adduced. In the ab- 
 sence, then, of direct proof, I may be allowed to doubt the existence of 
 this affection as described by M. Nonat. I have for four years asked 
 for proof of this proposition ; and, as no one has yet been able to give 
 it, I shall assert that the swellings we are now considering, are certainly 
 not formed by the inflammation of the thin ring of cellular tissue which 
 encircles the upper portion of the neck of the uterus. In the excep- 
 
734 PELVI-PERITONITIS. [CHAP. 
 
 tional cases, where this tissue is involved in the inflammation of the 
 surrounding parts, it but very slightly augments the peri-uterine swell- 
 ing, and this only when there exists also pelvi-peritonitis." It is not 
 here denied, as will be observed, that inflammation of the subperitoneal 
 cellular tissue occurs ; it is merely pointed out that anatomical research 
 strongly discredits the idea that inflammation is likely to be propagated 
 directly from the uterus to the cellular tissue. It would appear that 
 the only situation at which the cellular tissue subjacent to the perito- 
 neum has any appreciable thickness, is where it joins the broad liga- 
 ments, — a situation at which all authorities admit of the probability of 
 pelvic cellulitis; and even Bernutz himself confesses that phlegmons 
 of the broad ligaments are justly so called ; but he points out, at the 
 same time, as an inference from various elaborate dissections, by MM. 
 Jarjavay and Lefort, that the disposition of the various aponeurotic 
 lamellae almost necessarily directs such purulent formations as may 
 ensue towards the abdominal walls, or else to the deep iliac fossa. 
 
 Aran and Bernutz make a broad but unfortunate distinction between 
 iliac abscesses and those which are now under consideration. The 
 history of an ordinary iliac abscess is no doubt very different; but, if 
 we are to admit that the subperitoneal tissue and the internal genital 
 organs are the site of inflammation, it is surely no great stretch of the 
 imagination to believe that an abscess which is the result of this may 
 make its way into the iliac fossa, so that, while originating within the 
 true pelvis, the bulk of the resulting tumor is actually abdominal 
 rather than pelvic. 
 
 What we owe chiefly to Bernutz, is the clear demonstration of the 
 fact, that a large proportion of so-called cases of pelvic cellulitis are 
 not so at all, but that the symptoms are due to circumscribed inflam- 
 mation of the pelvic peritoneum. This pelvi-peritonitis is, as we have 
 said, identical with the perimetritis of Matthews Duncan. " I con- 
 clude," says Bernutz, " that inflammation of the pelvic serous mem- 
 brane is always symptomatic, and that it is generally symptomatic of 
 inflammation of the ovaries or Fallopian tubes. Thus great interest 
 attaches to the study of this affection ; and it is very important thor- 
 oughly to understand the symptoms, in order to describe satisfactorily 
 the uterine, and more especially the tubo-ovarian diseases which occa- 
 sion it." By pelvi-peritonitis, then, we understand an affection which 
 is essentially a secondary or symptomatic one, — the inflammation origi- 
 nating, according to Bernutz, in the uterus, tubes, or ovaries, and ex- 
 tending thence to their peritoneal investment. It is difficult to under- 
 stand how the disease can spread in this manner without involving the 
 intermediate cellular tissue, but the difficulty is very simply solved by 
 Bernutz, by the denial that any such tissue exists over the uterus, ex- 
 cept at the site already alluded to between the layers of the broad liga- 
 ment. That this is the case we very much doubt, and, although it 
 may be extremely thin, all analogy would lead us confidently to expect 
 that a trace at least of cellular tissue must there be discoverable. That 
 the peritoneal affection in these cases is secondary to inflammation of 
 the subjacent organs is a fact which, in regard at least to the majority 
 of cases, he has succeeded in establishing ; but we do not think that 
 
XLVI.] TUMORS. 735 
 
 he is warranted in assuming that pelvi-peritonitis can be produced in 
 no other way. In some cases, the result has been the formation of 
 cysts in the peritoneum, which are circumscribed by the inflammatory 
 process, and may contain a purulent or muco-purulent fluid. In 
 others, the tumor — the nature of which during life it had been impos- 
 sible to determine — was discovered, on post-mortem examination, to 
 consist of a mass of viscera matted together by adhesions, usually in- 
 volving the tube and ovary with contiguous portions of the bowels. 
 The diagnosis of this latter class of tumors is particularly difficult, as 
 the structure of the mass is such as to render almost useless the valu- 
 able information which we obtain in other cases from fluctuation and 
 percussion. Another point of importance, in reference to such cases, is 
 the possibility of a mechanical obstruction to the function of that part 
 of the bowel which is involved. 
 
 In a case seen with Mr. Moore, this appeared to us to be the cause 
 of the severity and alarming nature of the symptoms. The patient 
 had been confined about a month previously, and being out for her 
 first drive, she imprudently got out of the carriage, and sat for a short 
 time on a bench in an exposed part of the park. On her return home 
 she felt unwell. The following day acute pain was complained of in 
 the left side above the groin, and the symptoms generally went on 
 increasing in severity, while a tumor became developed in the region 
 referred to. This tumor was irregular in shape and indistinct in out- 
 line, but, being exquisitely tender, it was difficult to make a satisfactory 
 examination of it, further than that it was manifestly connected with a 
 corresponding fulness which was easily recognized from the vagina. 
 It was with the greatest difficulty that the action of the bowels w r as 
 maintained ; the tympanitic distension was enormous ; and for some 
 days the occurrence of obstinate vomiting prevented the administration 
 of any remedies, or almost of any food by the mouth. Considerable 
 benefit was derived from the use of suppositories containing tar, but 
 it was on several occasions found necessary to give egress to the pent-up 
 flatus by the use of O'Byrne's tube. Ultimately, after a long and 
 anxious illness, this lady recovered, and the tumor disappeared. 
 
 We have here to do only with those cases of pelvi-peritonitis w 7 hich 
 are associated with the puerperal state, which constitute, indeed, nearly 
 a half of all cases from whatever cause arising. The disease, of course, 
 originates, in almost all of this class of cases, in the uterus, and the 
 affection is therefore one of metro-peritonitis ; and this portion of the 
 peritoneum is the more likely to be the seat of the lesion, the sooner 
 the symptoms are developed after delivery. If after a longer interval, 
 the chance of its being inflammation of the appendages is proportion- 
 ally greater. 
 
 In attempting to form a diagnosis between pelvi-peritonitis and 
 pelvic cellulitis, the following are among the more important points 
 which it is proper to bear in mind. In the former the affection is 
 usually, though not invariably, limited to the true pelvis, and may be 
 distinctly recognized from the vagina; in the latter, the true phlegmon, 
 originating in the cellular tissue, cannot be reached from the vagina, 
 but, tending to spread towards the iliac region, can usually be made 
 
736 PELVI-PERITONITIS. [CHAP. 
 
 out by hypogastric palpation at an early stage of the case. The ten- 
 dency to the formation of abscess and discharge of pus is greater in 
 cellulitis than in peritonitis, so that the symptoms indicating the for- 
 mation of pus may come to be of some importance in doubtful cases. 
 If it be correct to assume that pelvic cellulitis, when it follows labor, 
 generally originates in the broad ligaments, we can have no difficulty 
 in understanding how tumors, originating in pelvi-peritonitis, and thus 
 being intimately connected with the uterus, are not only more within' 
 the reach of the finger, but are frequently found to produce very marked 
 displacement of the uterus in proportion to the size of the swelling. 
 In the more chronic variety, the diagnosis of pelvi-peritonitis may 
 involve doubts as to the nature of the tumor which is recognized from 
 the vagina. The difficulty is supposed to be greatest in the case of the 
 affection which lias been termed " engorgement of the uterus," in which 
 the tissue proper of the uterus is increased in volume; but the regu- 
 larity in these cases, in the outline of the tumor, its mobility, its firm 
 consistency, and the transmission downwards of movements communi- 
 cated to it from above, will probably serve to enable us to form a 
 pretty confident opinion. Uterine displacements of various kinds and 
 fibrous tumors may also be mistaken, and erroneously supposed to be 
 tumors, the result of pelvi-peritonitis. 
 
 The formation of an abscess is probably the result which, in puer- 
 peral cases, we look to with the greatest apprehension. It is only of 
 late that it has been fully recognized that pus may accumulate in the 
 form of abscess, not only in the cellular tissue but also within the 
 peritoneum. This, indeed, forms a most important practical analogy 
 between pelvi-peritonitis and the familiar pelvic cellulitis of most 
 writers. The majority of all pelvic abscesses, occurring at the period 
 of which we speak, are probably due to the latter affection ; but some 
 of our most able gynaecologists hold a contrary opinion, and believe that 
 intra-peritoneal purulent collections form the majority of grave abscesses 
 in this situation. Supposing it to be admitted that the idea generally 
 entertained as to the origination of pelvic cellulitis within the folds of 
 the broad ligament is w r ell founded, an interesting subject of investiga- 
 tion is thus suggested. Nor can we wonder that numerous dissections 
 have been made, and experiments by injection or inflation of the cellu- 
 lar tissue performed, with the view of determining what direction an 
 abscess in this particular situation is likely to take. The question is, 
 however, far from solved, and we certainly find abscesses taking quite 
 unexpected directions. " The most frequent extension of parametric 
 abscesses," writes Matthews Duncan, " is either upwards, or into the 
 iliac fossa on either side. But they may go much further. They may 
 extend along the rectum to the perineum. They may extend to the 
 kidneys. They may, in assuming these directions, attack only cellular 
 tissue, or, in addition, may lead to destruction of muscles, as of the 
 psoas and iliacus. I have dissected such abscesses in the puerperal 
 state, and in connection with non-puerperal disease, extending from 
 the kidney to the uterus." 
 
 One of the most important practical points connected with these ab- 
 scesses, whether they be parametric or perimetric, is the method to be 
 
XL VI.] TREATMENT. 737 
 
 employed for the detection of pus. Every clinical student is taught that 
 fluctuation is the most reliable sign of the presence of fluid within a 
 cavity which it fills, and is instructed how to apply the test, the manip- 
 ulation being somewhat varied according as the accumulation is large 
 as in ascites, or small as in an ordinary superficial abscess. In this 
 strict sense, however, fluctuation is very rarely available in the diag- 
 nosis of pelvic abscess, for the obvious reason that while we require, to 
 produce real fluctuation and at the same time to appreciate it, two 
 hands, — as a rule, in the investigation of these tumors, one hand, or it 
 may be one finger only, is available. The circumstances under which 
 actual fluctuation is then discoverable are to be found in those cases 
 only in which the tumor has reached above the pelvic brim in the direc- 
 tion of the iliac fossa or elsewhere, or when it is possible to produce the 
 wave of fluctuation between the fingers and the vagina, and the other 
 hand applied to the abdominal wall. The presence of fluid may, how T - 
 ever, often be recognized quite easily by the finger in the vagina; but 
 there are many cases in which to be certain requires a high degree of 
 the tactus eruditus. " This is, however," as Dr. Duncan observes, 
 " not feeling fluctuation. It is merely the educated finger picking up 
 such sensations as enable the mind to perceive a collection of fluid in 
 a cyst or bag. The finger cannot both produce fluctuation and feel the 
 shock of the wave." 
 
 Treatment. — The management of pelvic cellulitis and pelvi-peritonitis 
 depends, in the first place, and very obviously, upon the nature of the 
 case. It will depend, moreover, upon whether the symptoms are acute 
 or chronic ; whether the disease is progressive or stationary • and 
 whether there is already evidence of the formation of an abscess. It is 
 quite clear, therefore, that on many points, the ordinary principles of 
 surgical treatment must be our guide; but, in so far as the treatment to 
 be pursued is identical with what a moderate acquaintance with clinical 
 surgery would indicate, we shall not follow the subject. There are, 
 however, many special practical considerations, most of which experi- 
 ence alone can teach ; but to one or two of these we may here briefly 
 advert. Of the symptoms which call for prompt treatment, none is of 
 more importance than local pain. If the seat of the pain reaches above 
 the brim, nothing is more grateful to the feelings of the patient than 
 the application to that region of poultices and fomentations, which may 
 be sprinkled with laudanum, or otherwise modified to suit the exigen- 
 cies of the case. When the tumor is more truly pelvic, and can only 
 be felt from the vagina, the vaginal douche sometimes gives temporary 
 relief, and in other instances medicated pessaries, such as were recom- 
 mended by Sir James Simpson, may be employed. Bernutz strongly 
 advocated the internal use of conium, and it may even be necessary to 
 use some of the preparations of opium. 
 
 The sufferings of the patient are sometimes greatly aggravated by the 
 pressure which the tumor exercises on neighboring viscera, especially 
 the bladder and the rectum, when the functions of these parts may be 
 seriously interfered with. The exact nature of this class of symptoms 
 will entirely depend upon the anatomical relations which the tumor 
 bears to contiguous parts. When the pressure is forwards, in the direc- 
 
 47 
 
733 PELVI-PERITONITIS. [CHAP. 
 
 tion of the pubic symphysis, the suffering from pressure upon the neck 
 of the bladder is sometimes excruciating, and as one result of this may 
 be constant calls to micturate, which is often effected with difficulty, 
 the pain which is thus produced may be intense. In some instances, 
 the bladder can only be emptied by the regular use of the catheter. 
 When the pressure takes the other direction, the suffering is not so 
 severe, but there is almost always more or less pain in the back. In 
 some cases, there is obvious mechanical interference with the function 
 of the bowels, the difficulty in the act of defecation, and the flattened 
 condition of the faeces, showing clearly the nature of the case. In other 
 instances, there is apt to be obstruction of a more serious nature, as in 
 pelvi-peritonitis involving the bowel, when the patient suffers much, 
 both from obstruction and from flatulent distension. In every such case, 
 the action of the bowels should be scrupulously watched, and, on the 
 slightest sign of obstruction, immediate means must be taken to prevent 
 the possibility of serious results, by the combined action of laxatives 
 and enemata. A simple injection of soap and water, with or without 
 turpentine, may, in such cases, be given every night, — a mode of prac- 
 tice which will, in many instances, contribute to the comfort of the 
 patient. 
 
 The treatment, generally, of a case will divide itself into the arrest 
 of inflammation, the promotion of absorption, and the discharge of pus 
 when abscess has actually formed. It is with the view of fulfilling the 
 first of these indications that bloodletting, in such cases, is usually 
 recommended. Few persons will, probably, think of general blood- 
 letting. It is, at least, difficult to conceive a case in which the circum- 
 stances would warrant such a measure. It is otherwise, however, as 
 regards leeching, from which, in some instances, very marked and de- 
 cided benefit may be anticipated. Leeches may be applied to the 
 groins, the perineum, or the uterus ; but, although blood drawn from 
 any of these situations may be productive of excellent results, it is ob- 
 vious that the direct abstraction of blood from the uterus, — more espe- 
 cially if that organ is involved, primarily or secondarily, in the morbid 
 action, — is the procedure from which we may anticipate the most 
 marked effect. But, if the nature of the case be such that it is impos- 
 sible to introduce the speculum, the leeches may be applied to the 
 vulva, taking care that they do not bite too high ; for it has happened 
 that very troublesome bleeding has been the result of the application 
 of leeches to the vagina, from the difficulty of reaching and controlling 
 the bleeding point. " I believe/ 7 says Bernutz, "that four leeches ap- 
 plied to the cervix are as good as three times that number applied 
 externally ; for, not only is it nearest to the seat of inflammation, but 
 the relief to all the genital organs is greater. I do not think even 
 scarification can be compared with leeches, in point of utility; the 
 amount of blood drawn off is, comparatively speaking, quite insignifi- 
 cant ; and there is the possibility of serious consequences resulting." 
 
 It is never necessary to apply more than three leeches at a time to 
 the os and cervix, for if the quantity of blood which is withdrawn 
 should not be deemed sufficient, the flow may be encouraged by a 
 warm hip-bath, by means of which the quantity may often be regulated 
 
XLVI.] TREATMENT. 739 
 
 at will. As a rule, it is not advisable to aim at the abstraction of a 
 large quantity of blood, as a very moderate discharge is all that is 
 necessary thoroughly to deplete an organ of the size of the womb; but, 
 besides this, there is danger of interfering with the menstrual function, 
 should we push depletion too far, — more especially if the period be 
 at hand. In the actual application of the leeches, some nicety of ma- 
 nipulation is sometimes required, to prevent them from crawling round 
 the edge of the speculum, when they will probably fix upon the vagina, 
 or even pass out by the vulva ; and, as it has happened that disagreea- 
 ble symptoms have resulted from the leech making its way into the 
 uterus, it is recommended, in pluripara?, or in any case where the aper- 
 ture is large, to put a small plug of wool in the gaping os. It is to 
 the acute stage, mainly, of the cases of pelvi-peritonitis, in which the 
 uterus or its appendages are assumed to be the original seat of the dis- 
 order, that leeching is applicable ; but there are, undoubtedly, cases of 
 cellulitis in which congestion of the womb exists as a complication, 
 where the treatment is precisely similar. And, at any stage of the 
 more chronic forms, an exacerbation of the symptoms may present such 
 features as clearly to call for local depletion. In the present state of 
 our knowledge, it will not do to pause in these cases until our diag- 
 nosis is complete. The indications which point to bloodletting as the 
 proper remedy at the time being clear, it is a very secondary matter to 
 determine whether the peritoneum or the cellular tissue is the part 
 involved. 
 
 Poultices, fomentations, hip-baths, and the vaginal douche, are ex- 
 tremely valuable agents in these as in other affections, in controlling 
 inflammatory action, and, as has already been observed, in alleviating 
 pain. But the fact is, that there is no stage of the disease at which 
 this class of remedies may not be found beneficial. They should be 
 employed continuously in the acute stage ; and in the case of an abscess 
 which threatens to point externally, the application of poultices may also 
 be diligently carried out. In cases where the result of the inflamma- 
 tory action has been the formation of a tumor, or more diffused hard- 
 ness, it comes to be a question whether nothing can be done with the 
 view of promoting absorption. At one time, when the professional 
 belief in mercury was unbounded, the drug would naturally have sug- 
 gested itself as an essential part of the treatment, either in the acute 
 stage, in that of which we are now speaking, or in both. It must be 
 confessed, however, that comparatively little faith is now placed in 
 mercury as a remedial agent. Many reject it absolutely, in this and 
 other diseases ; but in so passing from the abuse to the absolute neglect 
 of the drug, we think that the modern physician, as in the case of gen- 
 eral bloodletting, has gone too far. We should certainly recommend 
 that the patient may have the chance which such a remedy affords her ; 
 but, if there be anything to contraindicate the use of mercury, it may 
 be abandoned with less regret than if we had more faith in its action. 
 The most suitable preparation is the perchloride, which may be admin- 
 istered in doses of ygth of a grain, and should never be carried beyond 
 the stage at which the gums, etc., indicate, faintly, commencing 
 mercurialization. 
 
740 PELVI-PERITONITIS. [CHAP. 
 
 Iodine is another remedy of the same class, which many will employ 
 w T ith less hesitation, either in the form of iodide of potassium internally, 
 or, it may be, by the external application of the tincture or ointment. 
 The latter may be applied when the tumor is hard and chronic, and 
 can easily be recognized through the abdominal walls ; or they may be 
 employed in similar circumstances through the vagina, a method of 
 treatment which has been found beneficial in many of the uterine dis- 
 orders familiar to the gynaecologist. Blistering has been strongly advo- 
 cated by some after the acute stage is past, and no one will deny that 
 experience would encourage us to look to this mode of treatment for 
 satisfactory results; but we confess to a preference for the external 
 application of iodine, by which irritation may be maintained for a long 
 period, its action being, of course, kept within moderate bounds so as 
 not to irritate too much. 
 
 In cases in which pelvic abscess has formed, and the ordinary signs 
 reveal that pus is present in considerable quantity, it comes to be an 
 important practical point whether we are to operate by incision or leave 
 the case absolutely to nature. In so far as can be gathered from the 
 experience of modern practice, abscesses, wherever existing, are now 
 much less frequently opened than was the ordinary practice of a quarter 
 of a century ago. But, whatever be the case as regards ordinary surgi- 
 cal practice, it is certain that, in the management of pelvic abscesses, 
 particular care and discrimination is necessary. Caution is more im- 
 peratively demanded when the tumors show a tendency to point in the 
 groin or elsewhere above the pelvis; but it must at the same time be 
 remembered that, while the danger of premature operation is admitted, 
 the greater danger of rupture of the sac and escape of its contents into 
 the peritoneal cavity must not be overlooked. Some have said that 
 such an abscess should be opened when it threatens to burst into the peri- 
 toneum ; but in what this threatening consists, or how we are to rec- 
 ognize the danger, is what no one has attempted to show. If the 
 abscess is acute in its history and progress, it is better to leave the 
 operation to nature ; but, if it is mature and chronic, and shows no 
 tendency to point externally, it comes to be a very delicate matter to 
 determine whether we shall operate or not. If we dread its opening 
 into the peritoneum, we must at the same time bear in mind what the 
 experience of West, Bernutz, Aran, and others has clearly shown, — 
 that, even if we open an abscess, this does not prevent its subsequent 
 perforation into the peritoneal cavity. If the symptoms of hectic fever 
 manifest themselves, or if the tumor gives rise to great suffering, the 
 idea of operation will naturally receive encouragement; but, in the 
 absence of these conditions, it is always better to wait. Pelvic abscesses 
 may point at various situations externally, which are well known to 
 the surgeon, or they may only be reached through the vagina, or even 
 by the rectum; but, in any case, when the operation is resolved upon, 
 the opening should be free, so as to admit of a thorough evacuation of 
 the cyst. " Old pelvic abscesses," Dr. Duncan observes, "demand 
 even boldness in operating. ... I have repeatedly operated in cases 
 where I knew the abscesses were several years old ; and in such cases 
 
XLVI.] TREATMENT. 741 
 
 sometimes more than once ; and I have never had reason to doubt the 
 propriety of the treatment/' 
 
 There is another class of pelvic tumors, the nature of which was 
 recognized by Ruysch in 1691, but which has received very little atten- 
 tion except at the hands of quite modern gynaecologists. These are the 
 sanguineous tumors — the result not unfrequently of menstrual accumu- 
 lation outside of the uterus — to which the name of Peri-uterine Hema- 
 tocele has been given. This question is too complicated to enter upon 
 here, and, indeed, there is only one section of it — the intra-pelvic hemor- 
 rhage occurring in extra-uterine pregnancies — which comes strictly 
 within the scope of our subject. These tumors are merely mentioned 
 at this place, as they might possibly give rise to difficulties in the diag- 
 nosis of the affection which we have just been considering. 
 
 Sudden death in the puerperal state is a subject which of late has 
 attracted considerable attention, more particularly since the phenomena 
 of thrombus and embolism have been more thoroughly understood, as 
 these are undoubtedly the cause of death in a large number of the fatal 
 cases. 
 
 In the course of puerperal fever, as has already been stated, what we 
 may call septic embolism is by no means of un frequent occurrence. 
 Among other localities, the detached clot may lodge in the pulmonary 
 artery and its branches. If a small branch only is occluded, the symp- 
 toms are correspondingly slight, but if the main trunk, or a large branch 
 is blocked, death may either be immediate, or may occur after an in- 
 terval, during which the leading symptoms are precordial oppression, 
 dyspncea, cyanosis, and a low temperature. But it is not only in the 
 course of a case of septicaemia that this may happen. The highly 
 fibrinated condition of the blood, natural to the normal condition of 
 the woman at this period, may be still further increased as the result 
 of exhausting haemorrhage, a condition manifestly favorable to the for- 
 mation of thrombus, and the subsequent accident of embolism. But 
 even in a case in which no single symptom has occurred to disturb the 
 approach of convalescence, embolism may occur quite unexpectedly. 
 If not immediately fatal, there is good reason to believe that, under the 
 favorable circumstances of absorption, disintegration of the clot, or 
 the establishment of collateral circulation, recovery is by no means 
 impossible. 
 
 Cerebral embolism is also an occasional cause of sudden death in the 
 puerperal woman. Several interesting cases of this are recorded in Dr. 
 Fordyce Barker's recent work, from which it would appear that the 
 left middle cerebral artery is the most frequent site of the lesion, so 
 that, as Dr. Barker observes, we might expect aphasia to be a leading 
 symptom. The difficulty in such a case would be to distinguish between 
 apoplexy and embolism. 
 
 The entrance of air into the veins is well known as a cause of sudden 
 death. There is no doubt that the provisions of nature after delivery 
 are not such as to favor the ingress of air to the uterine veins ; but it 
 has been demonstrated that under a certain degree of pressure it is pos- 
 sible, and it is believed by some to be a rare cause of sudden collapse. 
 
742 PELVI-PERITONITIS. [CHAP. 
 
 Twenty years ago, no one could presume to write a treatise on Mid- 
 wifery without an elaborate disquisition on the subject of Anaesthesia. 
 The then recent discovery of chloroform and of the anaesthetic power 
 of sulphuric ether was an era in the history of surgery ; and we cannot 
 wonder that the obstetrician should have claimed for his art the immu- 
 nity from pain and the other advantages of which his surgical brethren 
 were so gratefully availing themselves. We look back to this period 
 (circa 1848), and turn over the pages of the pamphlets which mark the 
 bitterness of the controversy which was then being waged, with a feel- 
 ing partly of amusement and partly of humiliation. The theological 
 tone which was prevalent in some quarters is the most extraordinary 
 feature in the whole affair ; but how sensible and able men could write 
 such trash, and argue gravely against the iniquity which was being 
 perpetrated in relieving women from the effects of the Divine curse 
 "in do! ore paries" will ever remain an inscrutable psychological phe- 
 nomenon. 
 
 There are many agents which have been classed as anaesthetics, and 
 there no doubt are many more. At present, ether and chloroform are 
 the only two which are habitually employed ; and to these we may 
 perhaps add chloral, as it is now pretty well known that a patient, 
 thoroughly under the influence of this drug, may go through the whole 
 stages of labor without any sensation of pain or any consciousness of 
 the process which is going on. Ether and chloroform, however, the 
 one in America and the other in this country, are, from the evanescent 
 nature of their effects, preferred to those agents whose operation is 
 more permanent, and after which disagreeable results are more likely 
 to accrue. At first, partly from the impulse and surpassing interest 
 given to the subject by its eminent discoverer, chloroform was used 
 somewhat indiscriminately in cases of labor which were in all respects 
 normal ; but subsequent experience has shown that such wholesale use 
 of anaesthetic agents cannot be supported, either by argument or by 
 practical experience. 
 
 The result of numerous experiments has proved that chloroform, 
 which is sparingly soluble in the blood, travels through the circulation 
 in considerable quantity, in an uncombined state. It having a strong 
 affinity for oxygen, the ordinary chemical changes which normally 
 take place in the blood, are thereby materially interfered with, and Dr. 
 Snow has shown that, in consequence of this, the quantity of carbonic 
 acid evolved from the lungs is materially diminished. Such an effect, 
 if of short duration, will probably produce no very serious result upon 
 the economy; but should the action be unduly protracted — which is 
 necessary, if we wish absolutely to annihilate pain in labor — we can 
 well imagine that the ultimate results may be in some way or other 
 unsatisfactory. It has frequently been observed and many have noted 
 it as a remarkable fact, that the effect of chloroform does not seem in 
 any way to arrest or even to modify the expulsive efforts ; but, if we 
 bear in mind what has been said in regard to the reflex action produced 
 by an excess of carbonic acid in the blood, the experiments of Dr. Snow 
 afford a ready explanation of this, which was at one time supposed to 
 be a phenomenon, unique in itself, and of great interest. 
 
XLVI.] ANESTHESIA. 743 
 
 The effect of chloroform on the nervous system is, however, the point 
 in regard to which, in the practice of midwifery, the greatest amount 
 of interest attaches. In the view which we take of the subject, by far 
 the most important point is that a moderate dose of chloroform may 
 annul, or at least deaden sensation, without disturbing the power of 
 motion or consciousness. This enables us to alleviate the sufferings of 
 our patient by a trifling dose, and without bringing her fully under 
 the influence of this powerful agent. The interference, therefore, with 
 the chemical changes which are constantly going on in the blood is 
 proportionally diminished. The further we push the administration 
 of chloroform, or of the other anaesthetics, the more thoroughly is the 
 cerebro-spinal or reflex function influenced, until at last the motor fibres 
 of the respiratory nerves are affected, and stertor indicates that the 
 Ultima Thule of safety has been reached. 
 
 The disadvantages of chloroform in the practice of obstetrics are, in 
 the first place, the tendency to vomiting, which is so apt to be produced 
 in the course of its administration. For obvious reasons, however, the 
 stomach rarely contains much food at the period of delivery, and this 
 is no doubt the reason why vomiting is, in midwifery practice, com- 
 paratively rare. Still, it does occur; and more than that, it occasion- 
 ally persists for a considerable time, to the manifest disturbance of the 
 patient during the post-partum period. Partly on this account, and 
 partly, it may be, in consequence of the effect which is produced on the 
 nervous centres, it has been pretty clearly established that the indis- 
 criminate use of chloroform, or other anaesthetics, predisposes to haemor- 
 rhage after delivery. Another objection which has been stated is 
 perhaps of less importance, — that in operations, the annihilation of 
 sensation removes what was before a reliable safeguard, as, for example, 
 when the blades of the forceps are applied, the patient is no longer 
 conscious of the pain caused by including a portion of the vaginal 
 mucous membrane in the lock — the suffering produced by which would 
 previously have caused her to cry out. 
 
 The question of anaesthetics seems to us to stand thus. In eclampsia, 
 in some cases of mania, and in all cases of operative midwifery, it is, 
 without exaggeration, invaluable. In ordinary cases, it is always to be 
 used with caution ; but if employed in small quantities on a handker- 
 chief on the approach of each pain, towards the termination of the 
 second stage, it can never do harm. It thus allays pain and assuages 
 nervous irritability ; and, in the hand of the skilful practitioner, it is a 
 power for good and never for evil. 
 
APPENDIX. 
 
 THE BIPARIETAL OBLIQUITY OF NAEGELE. 
 
 Foe reasons which have already been stated, but chiefly with the 
 view of avoiding controversial matters in the text, I have thought it 
 better to express; in the form of an appendix, the reasons which have 
 led me to reject the theory of biparietal obliquity as an element in the 
 mechanism of parturition. The 1 following observations, with some 
 modifications, are mainly taken from my work on the Mechanism of 
 Parturition, published in 1864. Tin 1 error of Naegele is certainly not 
 so commonly taught as it was once, and many distinguished teachers and 
 writers have completely abandoned it; but the fact of its still being a 
 matter of common belief, together with the respect which is due 4 to any 
 doctrine having the stamp of authority of the distinguished Professor 
 of Heidelberg, makes it both necessary and fitting to analyze the sub- 
 ject with some care. But, as some doubt has occasionally arisen in re- 
 gard to the exact nature of NaegelcV views, it will be proper first to 
 make sure what his opinions were, before proceeding to refute them. 
 
 In his celebrated essay, originally published in Meckel's Archiv, 
 'Naegele describes, in addition to the pelvic and occipito-frontal ob- 
 liquities, a third obliquity, the biparietal. He maintained, that, in re- 
 gard to its transverse measurement, the head entered the brim obliquely, 
 "so that the greatest breadth of the skull (from one tuber par let ale to 
 the other), as also the breadth of its base, never in its passage, under 
 ordinary circumstances, coincides with the diameter of the brim." On 
 this point he says also, in describing the first position : 
 
 " The head has not at the brim a direct but a perfectly oblique position, so that 
 the point which lies lowest or deepest is neither the vertex nor the sagittal suture, 
 but the right parietal bone. The sagittal suture is nearer to the promontory of the 
 sacrum than to the pubis, and divides the OS uteri, which is directed backwards 
 
 and generally somewhat to the left, into two very unequal parts The higher 
 
 the head is, the more does its long diameter approach the transverse of the brim, 
 and the more oblique is its position, on account or which the right ear can generally 
 be felt without difficulty behind the pubis, which would not bo the case if the 
 head had a perpendicular direction." 
 
 These extracts leave no room for doubt that his meaning was really 
 a lateral flexion of the head, an approximation of the ear to the corre- 
 sponding shoulder. He also describes, but in terms which, being some- 
 what vague, have led to some misapprehension, that there is a bi- 
 parietal obliquity at the outlet; but in this he is, as has been observed 
 in the chapter on the " Mechanism of Parturition/' quite correct. The 
 
746 
 
 APPENDIX. 
 
 following observations, it is proper here to explain, have reference to 
 the first cranial position. 
 
 Biparietal Obliquity. — It will be understood that, in considering the 
 second kind of obliquity — that, to wit, by means of which the head 
 being rotated on its occipito- frontal axis brings the left ear, in the po- 
 sition which we are considering, towards the left shoulder — I must, in 
 pursuance of my plan, view the head in reference to the axis of the 
 brim alone. The presenting point of the cranium I shall consider 
 throughout, until the head reaches the floor of the cavity, as that 
 through which the axis of the brim passes, its situation being altered 
 only by a variation in the different kinds of obliquity. 
 
 Most modern writers, including the many eminent obstetricians of 
 our time, agree in adopting Naegele's view with reference to this ob- 
 liquity. It is, therefore, with much diffidence and hesitation that I here 
 submit a contrary opinion, although I have only convinced myself of its 
 truth after a careful and laborious study of the progress of labor. I am 
 persuaded that, in a pelvis of ordinary dimensions, the usual course of 
 labor is for the head to enter directly in the axis of the brim, with the 
 sagittal suture equidistant from pubis and sacrum. The accompanying 
 illustrations show this more plainly, and in both the observer will re- 
 member that he is looking upwards and forwards, the axis of vision 
 
 Fig. 197. 
 
 Fig. 198. 
 
 In Figs. 197 and 198, the floor of the pelvis has heen removed by a section, including the greater 
 part of the walls of the cavity. In Fig. 197, the head is represented as descending directly in the axis 
 of the brim. The dotted circle shows the effect on the apparent position of the os uteri of a slight 
 displacement to the side. In Fig. 198, the head is represented as descending in the position described 
 by Naegele. 
 
 corresponding to that of the brim. The direct position, as here shown, 
 is in most respects the same as that which was taught by the leading 
 obstetricians who immediately preceded Naegele. He, however, dis- 
 
APPENDIX. 
 
 747 
 
 covered and first announced the incontrovertible fact which is set forth 
 in the following words : 
 
 "The finger which is introduced in the central or middle line of the pelvic cavity, 
 and brought in contact with the head, will touch the right parietal bone in the 
 vicinity of the tuber At the brim, the head does not assume a perpendicu- 
 lar, but perfectly oblique position (kerne gerade, sondern eine ganz schiefe Stellung), 
 so that the part which is situated lowest or deepest is neither the vertex nor the 
 sagittal suture, but the right parietal bone." 
 
 I repeat that the fact thus stated in general terms is incontestable, 
 inasmuch as it obviously refers to the axis of the cavity ; but Naegele 
 goes beyond this, and pushes his conclusions much further than the 
 facts of the case warrant, when he says that the sagittal suture is nearer 
 the promontory of the sacrum than the symphysis pubis, and that the 
 biparietal measurement can never during labor coincide with the plane 
 of the pelvic entrance. I may mention here that, although I began 
 my study of the subject with a firm conviction that Naegele was right 
 in this particular, I have been step by step driven to the conclusion 
 
 Fig. 199. 
 
 Fig. 199 shows the great amount of lateral obliquity (qua the horizon) of the head advancing in the 
 axis of the brim, the centre of the sagittal suture being, although much nearer the sacrum, exactly 
 midway between the promontory of that bone and the symphysis pubis. It shows also how during 
 the whole of this stage of labor, the right tuber parietale may be described, in general terms, as the 
 part which first meets the finger, or as lowest in the pelvis, advancing as it does in the direction of 
 the dotted line parallel to the axis of the brim. If the head were in the transverse position, the sink- 
 ing of the tuber parietale would be still more decided, but in that case it would be slightly to the left 
 of the middle line. 
 
 a B, the plane of the brim meeting the horizon at an angle of 60° at a. 
 
 c r>, the axis of the brim passing through the centre of the sagittal suture and the coccyx, and 
 meeting the horizon at r> at an angle of 30°. 
 
 that he is perfectly wrong. It is perhaps unnecessary to say that the 
 view which I take of the position of the head at the brim is, albeit 
 somewhat heterodox, far from original. Nor is the doctrine without 
 powerful supporters, as this is the view entertained and clearly ex- 
 pressed by Velpeau and Cazeaux in France, and more recently in this 
 
748 APPENDIX. 
 
 country by Dr. Matthews Duncan ; and several other observers, among 
 whom I may mention Drs. West and Paterson, 1 have arrived indepen- 
 dently at the same conclusion, which they have expressed in a more 
 cursory but not less decided manner. M. Cazeaux expresses it as 
 follows : 
 
 " Avant la rupture de la poche des eaux, la tete du foetus est legerement flechie 
 sur le devant de la poitrine, et les rapports des diametres de la tete avec les diame- 
 tres du detroit superieur sont les suivants ; le diametre occipitofrontal est parallele 
 au diametre oblique gauche du detroit superieur ; le diametre biparietal est parallele 
 au diametre oblique droit; la circonference occipito-frontal de la tete est parallele 
 au pourtourdu detroit superieur; Paxe de ce detroit superieur passe par le diametre 
 trachelo-bregmatique." 
 
 The arguments of Naegele on this point are stated, as indeed all his 
 views are, with great clearness and precision, and are, I admit, appar- 
 ently conclusive and convincing. But I do not despair of being able 
 to show that he has been led into error, if my readers will only deign 
 to put aside for a time a preconceived opinion, and study the subject in 
 nature. I may fail in any argumentative attempt to show that Naegele 
 was wrong, or I may be met with reasoning more subtle than my own ; 
 but I would only ask that, as my arguments are founded upon practi- 
 cal research, those who would refute them should test the matter fairly; 
 a task which will involve some labor, but which is within the power 
 of every practitioner in midwifery. 
 
 In admitting the general accuracy of most of Naegele's descriptions, 
 I assume that the fundamental error from which, more than any other, 
 his mistake arose, was ignorance, at the time he wrote his essay, on the 
 subject of the great obliquity of the brim in respect to the horizon. 
 There must, I think, have been remaining in his mind some remnant 
 of the old idea of the horizontal brim ; for it must be remembered that 
 his attention was not directed to the subject of the relation which the 
 pelvis bears to the trunk and limbs, until some years after the date of 
 the publication of his paper on the mechanism of parturition. If the 
 brim were indeed parallel to the horizon, or nearly so, the fact of the 
 finger meeting the parietal bone in the vicinity of its tuber would be 
 clear and irrefragable evidence of the so-called lateral or biparietal 
 obliquity of the head. But if we do not allow ourselves to lose sight of 
 the fact that the brim is inclined at an angle of 60°, and that the vertex 
 or presenting part passes downwards and backwards so obliquely as to 
 meet the horizon at an angle of 30° — even admitting that the right 
 parietal bone in the vicinity of its tuber is the lowest part in the pelvis 
 — I cannot see how this is to be accepted as evidence of anything else 
 than that the head is advancing directly in the axis of the brim, but 
 very obliquely with regard to the cavity, and still more so with refer- 
 ence to the horizon, as is shown in Fig. 197. 
 
 If to this great and admitted obliquity we superadd that which, 
 according to Naegele, separates the sagittal suture from the axis of the 
 brim, so as to bring the middle part of the suture opposite the fourth 
 division of the sacrum; "whether," says the younger Naegele, "the 
 
 1 Glasgow Medical Journal, October, 1862. 
 
APPENDIX. 749 
 
 head stands deeper or shallower," we must first believe that the trachelo- 
 bregmatic measurement is as nearly as possible parallel to the horizon. 
 
 The first difficulty which shook my conviction in the accuracy of 
 Naegele's statement was here encountered. Granting for the moment 
 that his description is correct, let any one take a foetal skull and place 
 it in the dried pelvis in such a position that the vertex is approaching 
 its floor, with the sagittal suture directed as above described, when he 
 will find — and there is, I think, no avoiding this conclusion — that the 
 ear could in all circumstances be felt with the greatest ease ; and yet we 
 all know that it is almost always a matter of considerable difficulty to 
 reach the ear at this stage, even more so indeed than when the head is 
 situated higher. This difficulty has not by any means been overlooked 
 by Naegele ; but having adopted one fundamental error, he makes this 
 the standard by which he gauges deviations from his theory, and thus 
 is inevitably led further astray. He explains it thus : " The higher 
 the head is, the more oblique is its direction, for which reason the ear 
 can generally be felt behind the pubis without difficulty, which would 
 not be the case if the head had a straight direction." 
 
 I admit that on the first blush this argument has a significance, 
 which it does not, however, maintain on closer examination. In the 
 first place, he commits himself to the opinion that this alleged obliquity 
 has no reference to the resistance which the head experiences from the 
 pelvis, inasmuch as it is greater before this resistance can have come 
 into play. He then goes on to assume that the fact of the ear being 
 left behind the pubis at an early stage of labor, is a proof of this 
 obliquity. With reference to this point, I would remark that he -seems 
 to me, throughout his whole essay, to put too much weight on the 
 facility with which the ear may be felt at the beginning of labor. That 
 it may in many cases be so felt is an undoubted fact ; but as far as my 
 experience goes, I have in the great majority of cases found it no such 
 easy matter to reach the ear, in any stage of labor, as Naegele would 
 have us believe. When I can so reach it, it only proves to me, what 
 Naegele himself admits, that the head approaches the transverse diameter 
 more than usual. For it must be remembered that the upper part of 
 the pubic symphysis is within easy reach of the outlet, and that, on 
 account of the inclination of the brim, when the ear moves to the side 
 it moves at the same time upwards along the ilio-pectineal line, and 
 consequently further from the finger. This then is a mere assertion of 
 Naegele's; his proofs are in no degree incompatible with the idea of a 
 direct entrance of the head. I am quite willing to admit that in some 
 extreme cases in which the ear is felt with Unusual ease, as well as on 
 other rare occasions, there may be some exceptional obliquity ; but I 
 am perfectly convinced that this is the exception, and the direct entrance 
 the general rule. But there are other arguments familiau to every 
 obstetrician which must be met, and, if possible, refuted. 
 
 " The sagittal suture," says Naegele, " divides the os uteri, which 
 projects backwards and generally somewhat to the left, across into two 
 very unequal segments." Mark how ingeniously he argues from a 
 preconceived opinion, and trims his facts to suit his theory. We may 
 allow the alleged inequality of the segments in the meantime to pass ; 
 
750 APPENDIX. 
 
 but as this is quite insufficient to account for the amount of obliquity 
 which he describes, he maintains that the os is displaced in the very 
 directions which suit his argument — viz., backwards and to the left. 
 For it will be observed, on a reference to Fig. 197, that the eifect of a 
 slight displacement to the left is, in the direct position at the brim, to 
 throw the small segment forwards, and it will be understood at a glance 
 that the further effect of a displacement backwards would be to leave 
 the sagittal suture concealed by the anterior lip of the os; whereas, by 
 bending the head towards the left shoulder, his theory restores the rel- 
 ative positions of os and suture. This is the flimsiest of all his argu- 
 ments, inasmuch as it is purely theoretical, and depends entirely for its 
 accuracy on the correctness of his original statement in regard to the 
 obliquity. The difficulties in determining the relations of the os during 
 labor are very great; but taking, as I do, the fact of the sagittal suture 
 crossing the os at the beginning of labor as evidence of the direct entrance 
 of the head, I see no reason to doubt that the centre of the os corre- 
 sponds pretty nearly to the axis of the brim. I even doubt the general 
 accuracy of the assertion that the smaller segment is behind, and I have 
 certainly, at an early stage of labor, found it to vary considerably in 
 this respect. Dr. Paterson, who, although admitting this fact, is never- 
 theless convinced that the head enters the brim directly, attempts to 
 account for it by supposing that the os is displaced forwards ; but I 
 rather think that he has no more proof to offer of this statement than 
 JNaegele had of his, or than I might have if I chose to assert that the 
 os was always displaced to the right merely because this would suit my 
 purpose. 
 
 The statement which accompanies the above, to the effect that the 
 sagittal suture is much nearer to the promontory of the sacrum than to 
 the pubis, is equally erroneous. But, with reference to this, a certain 
 misapprehension is apt to occur, if we use, instead of the words of 
 Naegele, the expression, " nearer the sacrum," which some modern 
 writers employ. For, as a natural consequence of the head advancing 
 m the axis of the brim, the suture is beyond all doubt near the sacrum; 
 but it is as certainly no nearer to the promontory oftlie sacrum. I think 
 there is no one who has a correct idea of the relation which the pelvis 
 bears to the vertebral column, and who will introduce his whole hand 
 with a view to determine the position of the head at the brim, who can 
 fail to arrive at the same conclusion as that which I have attained. 
 For my part, I have left no means untried by which this might be 
 tested. On introducing an instrument which is well known to surgeons 
 as Professor Buchanan's rectangular staff for lithotomy, I have been 
 able to place the angle on the second bone of the coccyx, inclining the 
 short limb until it coincided, as nearly as I could guess, with the axis 
 of the bnim, when it never failed to guide me, if properly placed, to 
 the sagittal suture, or some point very near it, on either side. I have 
 even attempted a crucial experiment by measuring, by means of a 
 flexible scale, the distance from the sagittal suture to the promontory 
 of the sacrum on the one hand, and the pubis on the other; and 
 although, for obvious reasons, the results were not so accurate as to 
 
APPENDIX. 751 
 
 warrant of themselves any definite conclusion, they certainly tended to 
 confirm my belief. 
 
 But the greatest difficulty of all, and the fact which, more than 
 anything else, seems to confirm Naegele's theory, is the situation in 
 which the tumor called the caput succedaneum forms, in those cases in 
 which the waters have escaped, and the head is exposed at an early 
 period of labor to the pressure of a rigid and undilatable os. On this 
 point I have to acknowledge my obligation to Dr. Matthews Duncan, 
 whose researches on the evidence afforded by the situation of the swell- 
 ing, as described by Naegele, solved my only remaining doubt on the 
 subject. Every accoucheur has had frequent opportunities of confirm- 
 ing the accuracy of the following statement of Naegele's, and w r hich 
 apparently affords striking corroborative proof of the accuracy of his 
 assertions : 
 
 " In certain circumstances, a swelling of the cranial integuments forms after the 
 os has begun to dilate, which in the further progress of labor, when the os changes 
 its situation and direction, and the head its position against it, disappears again by 
 degrees; nevertheless, as dilatation proceeds, it may still be felt for some time, 
 although much softer. This swelling (in that position of the head which we are 
 talking of) is situated upon the right parietal bone, close to its upper edge, and 
 equidistant from both angles. Sometimes a small piece extends over the suture to 
 the left parietal bone ; its circumference depends upon the degree of dilatation which 
 the os uteri has attained." 
 
 Now this situation of the swelling may indicate one of three things : 
 the os may either be inclined forwards; or it may be subjected to greater 
 pressure at certain points of its circumference; or, again, the head may 
 be placed obliquely. Of these, with the proof which I elsewhere have 
 of the direct entrance of the head, I consider the last as the most im- 
 probable of the three. It must always be remembered that, to account 
 for the degree of obliquity described by Naegele, we must adopt in 
 addition his theory that the os is displaced backwards and to the left ; 
 but nevertheless we must endeavor to account for the fact that the bulk 
 of the swelling at least is to be found at the right parietal bone. I 
 have already alluded to the theory advanced by Dr. Paterson, that the 
 os is inclined forwards, which would, if correct, afford a most satisfac- 
 tory explanation of the phenomena as detailed above. Proof of its 
 accuracy is, however, wanting ; and indeed the difficulties which an 
 examination offers are such that we cannot hope for a strict demonstra- 
 tion of the fact, even if true, unless we were to argue from the assumed 
 fact that the entrance of the head was direct, and thus adopt the very 
 error in reasoning which has led Naegele astray. 
 
 The theory by which Dr. Matthews Duncan attempts to account for 
 this, demands a separate consideration. This able writer is of opinion, 
 that it is a mistake to suppose that the thickest or most prominent part 
 of the swelling corresponds to the centre of the area upon which it has 
 been formed, but that this is to be found in the direction in which the 
 least resistance is offered to its formation. Applying this argument to 
 the formation of the swelling in this stage, he says : 
 
 " The caput succedaneum of the first stage of labor is often formed after the head 
 has passed the brim of the pelvis, and is lodged in the upper half of the cavity of 
 the bony pelvis. Were we to be cautious and exact in reasoning, all such swellings 
 
752 APPENDIX. 
 
 should be excluded from the argument, for evident reasons. It is only those formed 
 at the plane of the brim, or very near it, that can, under any circumstances, afford 
 assistance in settling this question : under the actual deficiencies of exact data, we . 
 must be content with stating principles. Now it is evident that the direction of the 
 caput succedaneum of the first stage will be that of least resistance — that is, the 
 direction of the axis of the undilated vagina; in other words, the caput will be 
 thickest when the head is least supported, and may, in other parts with the centre 
 of the os uteri, be so inconsiderable as not to attract notice. Further, and for the 
 same reason, the centre of the caput succedaneum, or the centre of the os uteri, will 
 not correspond with the thickest portion of the swelling, but in this case be behind 
 it, or near the left parietal bone. The oblique direction downwards and forwards 
 of the vagina will lead the caput in that direction, and the support given by the 
 posterior wall of the vagina to the posterior half of the space inclosed in the circle 
 of the os uteri will cause thickness of the swelling over the right, and comparative 
 thinness over the left parietal bone, and displacement of the thickest portion of it 
 forward in the pelvis, that is, in the direction of the right parietal and away from 
 the left parietal bone." 
 
 This theory is extremely ingenious and affords to me the only ex- 
 planation of the facts described by Naegele, which gives a rational and 
 satisfactory solution of the problem, in conformity with the phenomena 
 which I myself have observed. For its absolute accuracy I cannot 
 vouch ; but I cannot help thinking that it is in the main correct, or at 
 least that it points out the direction in which we are to search for truth. 
 
 My last argument is one which, while of itself it goes for nothing, is 
 at least admissible as corroborative proof, and is drawn from a consid- 
 eration of the cm bono f No such argument would for a moment stand 
 against a single observed fact, and we have too many instances of this 
 in the history of the subject to permit us to tread otherwise than warily 
 on such dangerous ground. But after all we may surely ask what is 
 the use of this alleged obliquity ? It is not only said to take place 
 before the head is actually engaged in the brim, but, according to 
 Naegele, is more marked then, and cannot therefore be due to any 
 resistance from the hard parts of the pelvis. But, even if it did not 
 occur till the head experienced the resistance of the brim itself, it is 
 difficult to conceive what mechanical advantage would result therefrom, 
 as there is ample room and to spare in any well-formed pelvis for the 
 biparietal measurement of a full-sized foetal cranium. In the case of the 
 long diameter of the head, we are able, without any difficulty, to assign 
 a cause for the obliquity which causes the occiput to pass in advance of 
 the forehead, but in this case I cannot imagine a single theory which 
 will bear examination for a moment. I can understand how it may 
 exceptionally occur, being rendered necessary by a deformed pelvis, a 
 distended rectum, or some other cause; but I am perfectly convinced 
 that the rule in the vast majority of cases is, that the head enters the 
 pelvis directly , in — or nearly in — the axis of the pelvic brim. 
 
INDEX. 
 
 Abdomen, appearance of, in pregnancy, 156 
 
 flattening of, in pregnancy, 156 
 Abdominal pain, in pregnancy, 243 
 
 pregnancy. 196 
 
 tumors, diagnosis of, from pregnancy, 157 
 Abortion, causes of, 369 
 
 comparative frequency of, 368, 385 
 
 definition of term, 367 
 
 different periods of, 368 
 
 distinction between threatened and inev- 
 itable, 376 
 
 distinguished from delayed menstruation, 
 374 
 
 expulsion of placenta in, 377 
 
 management of haemorrhage in, 382 
 
 management of placenta in, 383 
 
 retention of the ovum in, 377 
 
 retention of placenta in, 376 
 
 symptoms of, at various periods, 373 
 
 tendency to repeated, 373 
 
 treatment of, 379 
 
 treatment after, 385 
 
 treatment of inevitable, 382 
 
 treatment, preventive, in T 379« 
 
 treatment of threatened, 379. 381 
 
 use of placental forceps in, 384 
 Accidental haemorrhage, 387, 401 
 
 dangers of, 403 
 
 causes of, 388, 401 
 
 evacuation of liquor amnii in, 403 
 
 Goodell on, 402 
 
 induction of premature labor in, 562 
 
 operation of turning in, 403 
 
 site of placenta in, 401 
 
 symptoms of, 388, 389, 401, 402 
 
 treatment of, 403 
 
 use of Barnes's bags in, 403 
 
 use of styptics after delivery in. 403 
 Accoucheur, armamentarium of, 270 
 
 duties of, in labor, 270 
 After-pains, 61 1 
 
 treatment of, 611 
 Agalactia, 615 
 
 causes of, 615 
 
 treatment of, 615 
 Ala vespertilionis, 64 
 Albuminuria, in pregnancy, 233 
 
 connection of, with puerperal eclampsia, 
 673, 675, 677 
 
 connection of, with puerperal insanity, 
 660. 668 
 
 detection of, in urine, 679 
 
 effect of, in inducing premature labor, 
 682 
 
 morbid anatomy in, connected with puer- 
 peral eclampsia, 678 
 
 on renal veins as 
 
 Albuminuria, pressure 
 cause of, 679 
 symptoms of, 235 
 treatment of, 236, 683 
 Allantois, formation of, 105 
 Amnion, dropsy of, 236, 240, 597, 599, 601 
 dropsy of, as a cause of uterine inertia, 
 
 597, 599, 600 
 formation of, 104 
 Anaesthesia, in midwifery, 742 
 in eclampsia. 684, 743 
 in mania, 670, 743 
 use of chloral, 670, 684 
 use of chloroform. 670. 684, 742 
 use of ether, 742 
 Angeioleucitis, connection of, with puerperal 
 
 fever, 700 
 Anorexia, in pregnancy, 223 
 Anteflexion, of uterus in pregnancy, 245 
 Anteversion, of uterus in pregnancy, 245 
 Anus, examination by, in pregnancy, 165 
 Aorta, compression of, in post-partum haemor- 
 rhage, 412 
 Appendix, 745 
 Area germinativa, 103 
 Areola, 154 
 
 changes in, during pregnancy, 154 
 umbilical, 156 
 Arm, displacement of, in breech presenta- 
 tions. 338 
 dorsal displacement of, obstructing labor, 
 
 593 
 examination of, in transverse presenta- 
 tions, 343, 345 
 prolapse of, in transverse pres 
 
 351 
 presentations, see Transverse 
 tions. 
 Articulations, anchylosis of, foetal, 
 ing labor, 586 
 inflammation of pelvic, 243 
 mobility of. during labor, 31, 36, 242 
 Ascites, in foetus, obstructing labor, 586 
 in pregnancy, treatment of, 234, 239 
 Asphyxia, indications of, in breech presenta- 
 tions, 339 
 Astringents, use of, in post-partum haemor- 
 rhage, 413 
 Auscultation of foetal heart, 16S 
 of foetal heart in twins, 170 
 
 'Batllottement, 167 
 
 Bandages, abdominal, application of, 283, 
 
 411, 599, 608 
 Belladonna, use of, in rigidity of os, 570 
 
 entations, 
 Presenta- 
 obstruct- 
 
 48 
 
754 
 
 INDEX. 
 
 Bimanual version, 350, 522 
 
 conditions favorable to, 523 
 method of Braxton Hicks, 523 
 
 Binder, use of, in America, 283 
 
 Biparietal obliquity, in cranial presentations, 
 288, 292, 297, 298. See Appendix. 
 
 Bladder, calculus in, obstructing labor, 579 
 catarrh of, in pregnancy, 233 
 distension of, obstructing labor. 578 
 distension of, as a cause of uterine iner- 
 tia, 597 
 distension of foetal, obstructing labor, 586 
 prolapse of, obstructing labor, 578 
 
 Blastodermic vesicle, formation of, 103 
 
 Blood, condition of, in pregnancy, 225 
 
 Blunt hook, 504 
 
 use of, in breech presentations, 337 
 use of. in decapitation, 505 
 
 Breech presentations, 324 
 
 arms passing up alongside head in, 338 
 
 artificial delivery of head in, 340 
 
 birth of head in, 331 
 
 birth of shoulders in, 330 
 
 compression of umbilical cord in, 336, 339 
 
 craniotomy in, 542 
 
 critical periods in, 336, 339 
 
 diagnosis of, 326 
 
 dorso-anterior positions in, 326 
 
 dorsT-posterior positions in, 326 
 
 dragging on lower iimbs in, to be avoided, 
 
 338 
 first position in, 327 
 second position in. 330 
 third position in, 332 
 fourth position in, 333 
 hydrocephalus, with, 583 
 indications of asphyxia of child in, 339 
 management of, 336 
 mechanism of labor in, 325, 327 
 movement of restitution in, 328 
 movement of rotation in, 327, 332, 333 
 nature of assistance to be rendered in, 
 
 335 
 natural termination of, 328 
 occipito-posterior termination of, 332 
 operative interference in, 335 
 special risks of, 329, 332, 335 
 use of the forceps in. 337, 341, 497 
 use of vectis, fillet, or blunt hook in, 337, 
 503 
 
 Brow presentations; 323 
 
 Bulbi vestibuli, 49 
 
 Cadaveric poison, connection of, with puer- 
 peral fever, 703, 718 
 Caesarian section, see Hysterotomy. 
 Caput succedaneum, 264 
 
 in cranial presentations, 264, 295 
 
 in face presentations, 317 
 Caruncula? myrtiformes, 50 
 Catheter, mode of introducing female, 49 
 Cephalotribe, use of the, in craniotomy, 538, 
 544 
 
 use of the, in decapitation, 509 
 Childbed fever, see Puerperal Fever. 
 Chloral, use of, in midwifery, 670, 684, 742 
 
 in puerperal eclampsia, 685 
 
 in puerperal mania, 67u 
 Chloroform, use of, in midwifery, 606, 670, 
 684, 742 
 
 disadvantages of, in midwifery, 742 
 
 Chloroform, effect of, on blood, 743 
 effect of. on nervous system, 743 
 in precipitate labor, 606 
 in puerperal eclampsia, 684, 743 
 in puerperal mania, 670, 743 
 Chlorosis, in pregnancy, 225 
 Chorion, formation of, 106 
 Cicatrices, obstructing labor, 573 
 Circulation, disorders of, in pregnancy, 225 
 
 in foetus, 137 
 Clitoris, 49 
 
 hypertrophy of, 55 
 Coccyx, 35 
 
 Columnas rugarum, 51 
 
 Compound or complicated presentations, 352 
 Conception, 97 
 
 in plural pregnancy, 191 
 Constipation, in newly born child, 633 
 
 in pregnancy, 224 
 Convulsions, see Puerperal Eclampsia. 
 Corpus luteum , differences between unimpreg- 
 nated and impregnated, 83 
 formation of, 80 
 Cough, in pregnancy, 225 
 Cramps, in labor, 275 
 
 Crania bifida, as an obstruction to labor, 586 
 Cranium, foetal, diameters of, 134 
 fontanelles of, 134 
 sutures of, 133 
 vertex of, defined, 136 
 Cranial planes, engagement of, at the brim, 
 
 291 
 Cranial presentations, 289 
 
 analogy between face and, 317, 319, 323 
 biparietal obliquity in, 288, 292, 296, 
 
 297. See Appendix, 
 bregmato-cotyloid, and fronto-cotyloid 
 
 positions of, 306 
 caput succedaneum in, 264, 295 
 cause "of rotation of cranium in, 294, 301 
 classification of, 290 
 comparative frequency of the four, 31 1 
 complicated with other presentations, 352 
 engagement of cranial planes at brim in, 
 
 291 
 examination of fontanelles and sutures 
 
 in, 292, 300, 303, 308 
 first position in, 291 
 second position in, 299 
 third position in, 302 
 fourth position in, 307 
 head at the brim in, 291 
 head at the outlet in, 298 
 mechanism of labor in, 289, 303 
 moulding of head in, 289. 308 
 movement of restitution in, 298,300 
 movement of rotation in, 295, 300, 304, 
 
 307 
 occipito-anterior positions in. 291 
 occipito-posterior positions in, 291, 303 
 occipitofrontal obliquity in, 291 
 occipito posterior positions in, artificial 
 
 rectification of, 31 1 
 occipito-posterior positions in, fronto- 
 
 anterior termination of, 306 
 occipito-posterior positions, mechanism 
 
 of labor in, 303 
 occipito-posterior positions in, natural 
 
 termination of, 304 
 occipito-posterior positions, terminating 
 
 in face presentations, 308 
 other possible positions in, 311 
 
INDEX. 
 
 755 
 
 Cranial presentations, pelvic obliquity in, 297 
 
 resume of. 302 
 
 tabular comparison of face and, 324 
 
 theories as to causation of, 128 
 Cranioclast, Braun's, 534 
 
 Simpson's, 534 
 Craniotomy, 526 
 
 canting the base of the skull in, 536 
 
 conditions favorable to, 528 
 
 conditions warranting, 527 
 
 contrasted with turning, 519, 521 
 
 cranial section by ecraseur in, 543 
 
 extraction of the trunk in, 542 
 
 in breech presentation. 542 
 
 in puerperal eclampsia, 686 
 
 operation of turning after, 535 
 
 perforation in, 529 
 
 question of, in deformities of the pelvis, 
 460 
 
 stages of, 529 
 
 use of the cephalotribe in, 538, 544 
 
 use of the craniotomy forceps in, 533 
 
 use of the crotchet in, 531 
 
 use of the osteotomist in, 534 
 
 Van Huevel's forceps saw in, 543 
 Craniotomy forceps, Meigs's, 534 
 
 use of the, in craniotomy, 538 
 
 use of the, in decapitation, 509 
 Craniotomy scissors. Hodge's, 529 
 Crede's method of delivering the placenta, 
 
 282 
 Crotchet, 504 
 
 history of the, 505 
 
 objections to use of the, 505 
 
 the guarded, 505, 531 
 
 uses of the. 505 
 
 use of the, in craniotomy, 531 
 
 use of the, in decapitation, 509 
 
 use of double, 506 
 Crowning, stage of, in labor, 265 
 Crural phlebitis, see Phlegmasia Dolens. 
 Cystocele, obstructing labor, 577 
 
 Decapitation, 506, 543 
 
 extraction of head in, 508 
 
 extraction of trunk in, 507 
 
 instruments used in, 506 
 
 mode of operating in, 508 
 
 stages of operation in, 507 
 
 use of the forceps in, 508 
 Decidua, formation of, 108 
 
 reflexa, 110 
 
 serotina. 110 
 
 vera, 1 10 
 
 in extra-uterine pregnancy, 197 
 Deformities of pelvis, 442 
 
 eequabiliter, justo-major and -minor, 450 
 
 at the brim, 444 
 
 at the outlet, 448 
 
 Caesarian section in, 460 
 
 causes of, 443 
 
 classification of, 443 
 
 effects of, 450 
 
 effect of muscular action, in causing, 450 
 
 exaggerated sacral curvature, 448 
 
 flattening of the sacrum in, 448 
 
 funnel-shaped pelvis, 448 
 
 induction of premature labor in, 458, 560 
 
 infantile type of pelvis, 449 
 
 in malacosteon, 443, 446 
 
 in rachitis, 443 
 
 Deformities of pelvis, in the cavity, 447 
 
 masculine type of pelvis, 449 
 
 obliquely distorted pelvis, 447 
 
 osteo-sarcoma, causing, 451 
 
 spondylolisthesis, 450 
 
 symptoms of, 452 
 
 the result of disease or injury, 443 
 
 treatment in, 457 
 
 turning or craniotomy in, 459 
 
 use of the forceps in, 458 
 
 use of pelvimeters in, 453 
 Dentition, 639 
 
 disorders of, 641 
 
 management of children during, 641 
 
 odontitis in, 641 
 
 order of eruption of teeth in, 640 
 
 practice of lancing the gums in, 641 
 
 process of, a guide to proper period for 
 weaning, 637, 640 
 
 reflex effects of. on system, 639 
 
 symptoms of, 639 
 
 treatment after, 639 
 Diarrhoea, in pregnancy, 224 
 
 inflammatory or dysenteric, in newly 
 born child, 633 
 
 simple or catarrhal, in newly born child, 
 633 
 Digestion, disorders of, in pregnancy, 220 
 Digital examination, 158, 164 
 
 in labor, 270, 274, 600, 606 
 
 reflex effect of, as a cause of rupture of 
 uterus, 434 
 Diphtheria of puerperal wounds, see Puerperal 
 
 Wounds. 
 Displacements of uterus, 59, 67, 244, 251 
 
 as a cause of uterine inertia, 596, 598 
 
 obstructing labor, 572 
 Dropsy, general, in pregnancy. 235 
 
 of amnion, 236,240, 597, 599, 601 
 Dysmenorrhoea, membranous, 200 
 Dyspnoea, in pregnancy, 224 
 
 Ecraseur, use of, in craniotomy, 543 
 Ectopy, obstructing labor, 590 
 Embryo, definition of term, 120 
 
 demonstration of structures of, 108 
 
 formation of, 101 
 Embryo cell, formation of, 101 
 Embryotomy, 526 
 
 conditions warranting, 519, 527 
 Embryulcia, 542 
 Enteric fever, connection of, with puerperal 
 
 fever, 691 
 Ephemera or weid, 612 
 Ergot, 601 
 
 character of contractions caused by, 602 
 
 dangers in use of, 603 
 
 improper use of, a cause of rupture of 
 uterus, 433 
 
 in induction of labor, 564, 602 
 
 mode of administering, 603 
 
 natural history of, 601 
 
 physiological effects of, 602 
 
 rules for use of, in midwifery. 603 
 
 use of, in distinguishing uterine tumors, 
 602 
 
 use of, in post-partum haemorrhage, 411, 
 412 
 
 use of, in uterine inertia, 600 
 Ether, use of, in midwifery, 742 
 Erysipelas, connection of, with puerperal 
 fever, 690, 703 
 
756 
 
 INDEX. 
 
 Examination, vaginal, 158, 164, 270, 274, 600. 
 
 606 
 Excoriation of nipple, 624 
 Excretions, disorders of, in pregnancy, 233 
 Exomphalos, obstructing labor, 590 
 External organs of generation, 48 
 Extra-uterine pregnancy, 194 
 
 causes of, 196 
 
 development of membranes in, 197 
 
 development of ovum in, 194, 196, 198 
 
 sympathy of uterus in, 198 
 
 symptoms of, 199 
 
 symptoms of rupture of sac in, 201 
 
 terminations of, 20 L 
 
 treatment of, 203 
 
 varieties of, 195 
 
 Face presentations, 315 
 
 analogy between cranial and, 315, 319, 
 323 
 
 caput succedaneum in, 316, 317 
 
 causes of, 315 
 
 classification of, 316 
 
 diagnosis of, 316 
 
 distinction between obstetrical and ana- 
 tomical face in, 315 
 
 first position in, 317 
 
 second position in, 318 
 
 third position in, 317 
 
 fourth position in, 316 
 
 mechanism of labor in, 316 
 
 mento-antei ior positions in 316, 317 
 
 mento-posterior positions in, 316,317 
 
 inento-posterior positions, artificial recti- 
 fication of. 321, 322 
 
 mento-posterior positions, natural termi- 
 nation of, 320 
 
 movement of restitution in, 317 
 
 movement of rotation in, 317, 318 
 
 operative interference in, 322 
 
 tabular comparison of cranial and, 324 
 
 termination of occipito-posterior cranial 
 positions in, 307 
 
 use of the straight forceps in, 497 
 Fallopian tubes, 65 
 Fecundation, sue Conception. 
 Feeding, artificial, of newly born child, 635 
 Fillet, cases suitable for use of the, 503 
 
 history of, 503 
 
 mode of using, 504 
 
 in breech presentations, 338," 503 
 
 in turning, 616 
 Fissure of nipple, 624 
 Foetus, altitude of, in uterus, 128 
 
 characteristics of monthly stages in de- 
 velopment of, 125 
 
 circulation in, 137 
 
 definition of term, 120 
 
 dimensions of mature, 127 
 
 diseases of, 215 
 
 diseases of. obstructing labor, 582 
 
 fracture of bones of, 216 
 
 functions of, 136 
 
 length and weight of, at birth, 127 
 
 movements of, observed by mother and 
 accoucheur, 165, 166 
 
 nutrition in, 141 
 
 pulsation of, in pregnancy, 168 
 
 pulsation of, in twin pregnancy, 170 
 
 respiration in, 139 
 
 secretions in, 142 
 
 Foetus, signs of death of, 352 
 
 spontaneous intra-uterine amputation of, 
 216 
 
 unusual development of, obstructing 
 labor, 582 
 Foetal heart, auscultation of, 168 
 
 auscultation of, in twin pregnancy, 169 
 Fontanelles of foetal cranium, 134 
 
 examination of, in labor, 292, 293, 300, 
 303, 307 
 
 premature closure of, obstructing labor, 
 587 
 Foot presentations, diagnosis of, 334 
 
 diagnosis of foot from hand in, 335 
 Fossa navicularis, 49 
 Fourchette, laceration of, 266, 279 
 Fractures, causing deformities of pelvis, 452 
 
 intra-uterine, 216, 587 
 Frenulum pudendi, 49 
 Forceps, 460 
 
 application of the, 474. 476 
 in dorsal position, 493 
 Jenks on, 489 
 to sides of pelvis, 486 
 
 Chamber Jen's, 461 
 
 circumstances requiring the use of the, 
 472 
 
 conditions essential to application of, 474 
 
 craniotomy, 533 
 
 Davis's. 466 
 
 Elliot's, 469 
 
 French, 462 
 
 Harper's. 499 
 
 history of, 460 
 
 Hodge's, 466 
 
 the long, 483 
 
 long, application of. 486 
 
 long, cases suitable for, 483, 485 
 
 long, contrasted with turning, 519, 521 
 
 long, mode of applying, 490 
 
 long, modes of extraction by, 495 
 
 long, necessity of double curve in, 483 
 
 modes of action of the, 480 
 
 mode of applying the, 480 
 
 mode of extraction by the, 480 
 
 modifications of the, 498 
 
 placental, 384 
 
 question of single verstis double curved, 
 463, 464, 483, 499 
 
 Radford's, 499 
 
 Robertson's, 469 
 
 Smith's, 469 
 
 Simpson's, 471 
 
 the short, 46^ 
 
 short, cases suitable for, 463, 472 
 
 the straight, 464, 465 
 
 straight, reasons for preferring, 465 
 
 straight, use of, in face presentations, 497 
 
 use of, in breech presentations, 337, 341, 
 497 
 
 use of in decapitation, 509 
 
 use of, in deformities of pelvis, 458 
 
 use of, in funis presentations, 366 
 
 use of, in occipito-posterior cranial posi- 
 tions, 482 
 
 use of, in placenta prsevia, 396 
 
 use of, in puerperal eclampsia, 686 
 
 use of, in uterine inertia, 601. 603 
 
 use of long and short, relative dangers 
 of, 485 
 
 Wallace's, 468 
 
 Ziegler's, 498 
 
INDEX. 
 
 757 
 
 Funis, see Umbilical Cord. 
 Funis presentations, 355 
 
 causes of, 356 
 
 diagnosis of, 359 
 
 postural method of treatment in, 364 
 
 turning in, 366 
 
 relation of, to other presentations, 356 
 
 reposition by fingers and otherwise. 363 
 
 rupture of membranes in, to be avoided, 
 361 
 
 special risks of, 359 
 
 treatment in, 360 
 
 use of forceps in, 366 
 Funic souffle, 170 
 
 Galactorrhoea, 615 
 
 treatment of, 616 
 
 varieties of, 616 
 Galvanism, use of, in induction of premature 
 labor, 569 
 
 use of, in post-partum haemorrhage, 362 
 
 use of, in uterine inertia, 412 
 Gastrodynia, in pregnancy, 224 
 Gastro-elytrotomy, 554 
 Gastrotomy, 554 
 
 cases requiring, 555 
 
 in extra-uterine pregnancy, 204 
 
 question of, in rupture of uterus, 439. 
 440 
 
 special dangers of, in midwifery, 555 
 Gelatin of Wharton, 112 
 Germinal spot, 78 
 
 vesicle, 78 
 
 function of, 99 
 Glands, mammary, 55 
 
 vulvo-vaginal, 53 
 Goodell on accidental haemorrhage, 402 
 Graafian vesicle, structure of, 76 
 Gravid uterus, 144 
 
 changes in os and cervix of, 159 
 
 displacements of, 244 
 
 involution of muscular fibres of. 146 
 
 muscular fibres of, 144 
 
 muscular layers of, 145 
 
 progressive development, and anatomi- 
 cal relations of, 147 
 Gums, practice of lancing the, in dentition, 
 641 
 
 Haemorrhage, accidental, see Accidental 
 
 Haemorrhage. 
 Haemorrhage, after delivery, preceding ex- 
 pulsion of placenta, 404 
 distinction between accidental and un- 
 avoidable, 387, 398, 401 
 in abortion, 374. 376 
 management of, in abortion, 382 
 true post-partum, see Post-partum Haem- 
 orrhage, 
 unavoidable, see Placenta Praevia. 
 Hand, examination of, in transverse presenta- 
 tions, 343, 345 
 diagnosis of, from foot, 334 
 Hernial tumors, obstructing labor, 580 
 Hidrosis, 704, 705 
 Hydatidiform moles, 209 
 pathology of, 210 
 symptoms of, 211 
 terminations of, 212 
 treatment of, 213 
 
 Hydrocephalus, foetal, 582 
 diagnosis of, 582 
 
 external and internal varieties, 583 
 maternal mortality in, 584 
 pelvic presentations with, 584, 585 
 treatment in, 584 
 
 Hydrorrhoea, 241 
 
 Hydrothorax, foetal, obstructing labor, 586 
 
 Hymen, 50 
 
 imperforate, 55 
 persistent, in labor, 573 
 
 Hysterotomy, 545 
 
 amount of contraction warranting, 546 
 cases in which it is justifiable, 547 
 causes of fatal result in, 553 
 closure of the wound in, 551 
 conditions favorable to success in, 548 
 details of the operation, 549 
 in deformities of the pelvis, 461 
 history of, 545 
 
 maternal mortality in, 547, 548 
 removal of the placenta in, 551 
 treatment after, 552 
 
 Ichorrhsemia, 690 
 Icterus neonatorum, 634 
 
 Impaction in labor, distinction between " ar- 
 rest "' and, 457 
 Induction of premature labor, 558 
 Barnes's process, 567 
 conditions justifying, 559 
 details of operation, 564 
 dilatation of the os by tents, 565 
 history of, 558 
 in accidental or unavoidable hasinor- 
 
 rhage, 562 
 in excessive vomiting of pregnaney, 222, 
 
 560 
 in habitual death of foetus near full time, 
 
 560 
 introduction of elastic catheter in, 565 
 in impaired general health of mother, 562 
 methods of, 565 
 nature and scope of, 559 
 in pelvic contraction, 458, 560 
 plugging or distending the vagina in, 565 
 rupture of the membranes in. 565 
 separation of the membranes in, 565 
 to obviate puerperal eclampsia, 683 
 use of ergot in, 564 
 use of galvanism in, 569 
 vaginal or uterine injections in, 566 
 viability of child in. 559 
 Inert labor, see Uterine Inertia. 
 Insanity, see Puerperal Insanity. 
 Intellectual faculties, aberrations of, in preg- 
 nancy, 243 
 Intestinal derangements, influence of on 
 
 labor, 595, 601, 606 
 Intestines, prolapse of, in rupture of uterus, 
 
 438 
 Inversion of uterus, 418 
 
 as a cause of post-partum haemorrhage, 
 
 407 
 causes of, 420 
 chronic cases of, 425, 426 
 diagnosis of, 422 
 distinctions between, and polypus, 408, 
 
 424 
 distinctions between, and simple pro- 
 lapsus, 424 
 
758 
 
 INDEX. 
 
 Inversion of uterus, dragging on cord as a 
 
 cause of, 420 
 in unimpregnated state, 420 
 irregular contraction of uterus as a cause 
 
 of, 421 
 management of adherent placenta in, 425 
 mechanism of the displacement in, 422 
 paralysis of the fundus, as a cause of, 421 
 removal by ecraseur in, 429 
 successive stages of, 419 
 sustained elastic pressure in, 427 
 symptoms of, 423 
 Thomas's operation for the reduction of, 
 
 429 
 treatment in, 425 
 treatment in chronic cases of, 427 
 uterine inertia as a cause of, 421, 427 
 
 Knee presentations, diagnosis of, 334 
 Kiestein, 152 
 
 Labia majora, 49 
 Labia minora, 49 
 
 hypertrophy of, 54, 575 
 Labor, 252 
 
 action of voluntary muscles in. 256, 264, 
 273 
 
 caput succedaneum in, 264 
 
 causes of, 252 
 
 cramps in thighs during, 275 
 
 crowning, stage of, in, 256 
 
 digital examination in, 270, 271, 274, 
 600, &06 
 
 duties of accoucheur in, 268 
 
 effect of emotional causes on, 254 
 
 first stage of, 257 
 
 first stage, duration of, 263 
 
 first stage, management of, 273 
 
 first stage, rigor on termination of. 262 
 
 first stage, termination of, 262 
 
 functions of liquor amnii in. 261 
 
 inert, see Uterine Inertia. 
 
 influence of intestinal derangements on, 
 595, 599. 606 
 
 insanity of, see Puerperal Insanity. 
 
 irregularities in the progress of, 594 
 
 management of, 26S 
 
 mechanism of, 284 
 
 mechanism of dilatation of os and cervix 
 in, 261 
 
 mobility of articulations during, 30, 35, 
 242 
 
 natural lubrication of vagina in, 260 
 
 obstructions to, $?e Obstructions to Labor. 
 
 oedema of anterior lip of os in, 264, 275 
 
 pains of, 258, 262, 264, 266 
 
 perineum, dilatation of, 265 
 
 perineum, laceration of, in, 266, 279 
 
 perineum, rigidity of, in, 279 
 
 perineum, support of, in, 277 
 
 peristaltic action of uterus in, 256 
 
 persistent hymen in, 573 
 
 precipitate, fee Precipitate Labor. 
 
 preliminary arrangements in, 269 
 
 preparation of bed for, 274 
 
 preparatory stage of, 257 
 
 reflex function of spinal cord in, 255 
 
 retention of urine in, 275 
 
 rigidity of os in, 264, 276, 571 
 
 rupture of membranes in, 262, 276 
 
 second stage of, 265 
 
 second stage, management of, 274 
 
 Labor, second stage, termination of 266 
 
 "show' 1 on termination of first stage, 
 262 
 
 stages of, 257 
 
 third stage of, 266 
 
 third stage, management of, 281 
 
 use of stethoscope in, 276 
 Labor pains, 258 
 
 character of, in first stage, 262 
 
 character of, in second st;ige, 264 
 
 character of, in third stage, 266 
 
 difference between true and false. 260 
 
 effect of, on maternal pulse, 259 
 
 effect of, on uterine souffle, 259 
 
 false treatment of, 269 
 Lactation, 612 
 
 agalactia, 615 
 
 disorders of, 618 
 
 duration of, 617 
 
 galactorrhcea, 615 
 
 influence of menstruation on, 618 
 
 influence of pregnancy on, 618 
 
 insanity of, see Puerperal Insanity. 
 
 management of, 616 
 
 milk too rich, 617 
 
 milk too watery, 617 
 
 pain in mammae during, 614 
 
 prejudicial effects of overfeeding in, 614 
 Laparotomy, see. Gastrotomy. 
 Leucorrhcea, 238 
 Ligaments of ovaries, 65 
 
 of pelvis, 39 
 
 of uterus, broad, 63 
 
 of uterus, posterior, 66 
 
 of uterus, round, 64 
 
 vesico-uterine, 65 
 Ligature of limbs, in puerperal eclampsia, 
 
 687 
 Liquor amnii, 108 
 
 evacuation of, in accidental hamorrhage, 
 403 
 
 evacuation of, in placenta praevia, 393 
 
 functions of, in labor, 261 
 
 management of, see Membranes. 
 Lochia, 609 
 
 management of the, 610 
 
 nature and source of the, 609 
 
 Malacosteon, 443, 445 
 
 contrasted with rachitis, 444 
 Mammae, application of child to, at fixed in- 
 tervals, 613, 629 
 
 changes in, during pregnancy, 153 
 
 early application of child to, 283, 411, 
 612, 613, 629 
 
 inflammation and abscess of, 619 
 
 management of, after delivery, 612 
 
 pain in, during nursing, 614 
 
 secretion of milk in, 154, 612 
 Mammary abscess, varieties of, 620 
 
 treatment of. 621 
 Mammary glands, 55 
 Mania, see Puerperal Insanity. 
 Meatus urinarius. 49 
 
 Mechanism, of dilatation of os and cervix in 
 labor. 260 
 
 of expulsion of placenta, 267 
 
 of labor, 284 
 
 of labor in breech presentations, 325, 327 
 
 of labor in cranial presentations, 290, 303 
 
 of labor in face presentations, 315 
 
INDEX, 
 
 759 
 
 Melancholia, see Puerperal Insanity. 
 Membranes, artificial rupture of, in labor, 276 
 
 artificial separation of, in induction of 
 labor, 565 
 
 development of, in extra-uterine preg- 
 nancy, 197 
 
 disposition of, in twin pregnancy, 191 
 
 management of, in funis presentations, 
 361 
 
 management of, in puerperal eclampsia, 
 686 
 
 management of, in transverse presenta- 
 tions, 343 
 
 premature rupture of, as a cause of pre- 
 cipitate labor, 605 
 
 premature rupture of, as a cause of uter- 
 ine inertia, 597 
 
 rupture of, in induction of labor, 565 
 
 separation of, in induction of labor, 565 
 
 spontaneous rupture of, in labor, 261 
 
 unusual thickness and resistance of, ob- 
 structing labor, 594 
 Menstruation, 87 
 
 analogy between "rut" and, 88 
 
 amount of discharge during, 9t 
 
 cause of, 97 
 
 character of discharge in, 92 
 
 conditions influencing age at which first 
 occurrence of, 89 
 
 delayed, distinguished from abortion, 374 
 
 duration of, 9 I 
 
 duration of epoch of, 96 
 
 influence of lactation on, 618 
 
 irregularities in, 96 
 
 phenomena attending first occurrence of 
 88 
 
 source of discharge in, 92 
 
 suppression of, in pregnancy, 151 
 Metria, 689 
 
 Metritis, see Puerperal Metritis. 
 Midwifery, defined, 33 
 
 history of, 17 
 Milk, escape of, from mammse, 614 
 
 estimation of quality of, 615 617 
 
 period for permitting other food than. 636 
 
 secretion of, see Lactation. 
 
 substitutes for breast-, 635. 637 
 
 treatment when too rich or watery, 617 
 Milk fever, 612 
 Miscarriage, see Abortion. 
 Missed labor, 215 
 Moles, 206 
 
 false, 206 
 
 fleshy, 208 
 
 hydatidiform, see Hydatidiform Moles. 
 
 true. 207 
 Mons veneris, 4S 
 Monstrosities, 218, 590 
 
 acephalic, 590 
 
 anencephalic, 590 
 
 ectopy, 590 
 
 exomphalos. 590 
 
 fusion of twins, 590 
 
 by inclusion, 192, 592 
 
 obstructing labor, 590 
 
 the Siamese twins, 592 
 Moral faculties, aberrations of, in pregnancy, 
 
 243 
 Morbus coxarius causing deformities of pel- 
 vis. 452 
 Morning sickness, of pregnancy, 152, 218, 
 369, 560 
 
 Nervous system, disorders of, in pregnancy, 
 
 243 
 Newly born child, 626 
 
 administration of laxatives to the, 629, 
 
 632 
 application of, to mammae at fixed inter- 
 vals. 613. 629 
 artificial feeding of the, 635 
 cleanliness of, 626, 628 
 clothing of, 627 
 
 congenital malformations of, 632 
 desirability of mother nursing, 629 
 diet and regimen of hired nurses of, 630 
 difficulties of. in sucking, 631 
 early application of, to mammoe, 283, 41 1, 
 
 612, 613, 629 
 food of, before mammary seeretion estab- 
 lished, 629 
 habitual constipation in, 633 
 harelip in, 632 
 
 imperforate anus or urethra, in the, 632 
 inflammatory or dysenteric diarrhoea, in 
 
 the, 633 
 management of the, 626 
 management of the bowels in the, 629, 632 
 management of the cord in the, 626 
 management of restlessness in the, 628 
 necessity of air and light to the, 628 
 nurse to be procured if artificial feeding 
 
 fail, 636 
 period for permitting ether food than 
 
 milk, 636 
 premature must be reared at the breast, 
 
 635 
 retention of urine in the, 632 
 selection of hired nurses for the, 630 
 simple or catarrhal diarrhoea in the, 633 
 thrush in the, 634 
 Nipple, changes in, during pregnancy, 154 
 
 excoriation and fissure of, 624 
 Nursing, application of child to mammse at 
 
 fixed intervals. 613, 629 
 artificial feeding of the child, 635 
 desirability of rearing child at breast, 
 
 629, 635 
 early application of ehild to mammas, 
 
 283. 411,612, 613, 629 
 food of child before mammary secretion 
 
 established. 629 
 Liebig*s food for infants, 637 
 nursing-bottles. 636 
 premature child must be reared at breast, 
 
 635 
 substitutes for breast-milk, 635 
 Nymphoe, see Labia Minora. 
 
 Obstructions to labor, 570 
 
 abnormal conditions of vulva and vagina, 
 
 573 
 anchylosis of foetal articulations, 586 
 ascites of foetus, 586 
 cicatrices from sloughing, 573 
 coiling of cord round child, 593 
 omnia bifida and spina bifida, 586 
 eystocele, 578 
 distension of bladder, 578 
 distension of foetal bladder, 586 
 dorsal displacement of the arm, 593 
 ectopy, 590 
 
 effects of uterine displacement, 572 
 exomphalos, 590 
 
760 
 
 INDEX. 
 
 Obstructions to labor, fecal accumulation in 
 rectum, 578 
 fibrous, fatty, or encysted growths, 581 
 gaseous distension from putrefaction, 586 
 hernial tumors, 580 
 hydrocephalus of foetus, 582 
 hydrothorax of foetus, 586 
 hymen, persistent, 573 
 hypertrophy of anterior lip and cervix, 
 
 275, 572 
 hypertrophy of nymphse and preputium 
 
 clitoridis, 575 
 intra-uterine fracture, 216, 587 
 locked twins, 588 
 
 malignant disease of the canal, 581 
 monstrosities, 590 
 occlusion of os, 571 
 ovarian tumors, 576 
 plural pregnancy, 588 
 polypoid tumors of uterus, 575 
 premature closure of sutures and fonta- 
 
 nelles, 587 
 prolapse of the bladder, 578 
 rigidity of the os, 264, 276, 570 
 rigidity of the perineum, 279, 573 
 scirrhus of rectum and rectocele, 577 
 shortness of cord, 592 
 spasmodic contraction of the cervix, 571 
 tumors, renal, hepatic, etc., 586 
 unusual development of foetus, 581 
 unusual thickness and resistance of the 
 
 membranes, 594 
 urinary calculus, 579 
 vaginal thrombus, 574 
 Occipitoanterior cranial positions, mechan- 
 ism of labor in, 290 
 Occipito-frontal obliquity, in cranial presen- 
 tations, 291 
 Occipito-posterior cranial positions, artificial 
 rectification of, 309 
 bregmato-cotyloid termination in. 303 
 fronto-cotyloid termination in, 306 
 mechanism of labor in, 290, 303 
 natural termination in, 304, 306 
 terminations of in face presentation, 307 
 Occlusion of os uteri, obstructing labor, 570 
 Odontitis, 642 
 
 Omphalomesenteric vessels, 105 
 Organs of generation, external, 48 
 
 internal, 58 
 Os uteri, abscess and thrombus of lips of, in 
 labor, 572 
 changes in cervix and during pregnancy, 
 
 159 
 condition and appearance of unimpreg- 
 
 nated, 61 
 detection of, by speculum, 571 
 hypertrophy of anterior lip of, in labor, 
 
 275, 572 
 mechanism of dilatation of in labor, 261 
 mode of applying leeches to cervix and, 
 
 738 
 occlusion of, in labor, 570 
 oedema of anterior lip of, in labor, 264, 
 
 275 
 relation of, to pelvic walls in pregnancy, 
 162 
 Osteomalacia, see Malacosteon. 
 Osteosarcoma, causing deformities of pelvis, i 
 
 451 
 Osteotomist, use of the, in craniotomy, 534 
 Ovaries, anatomy of, 75 
 
 Ovaries, ligaments of, 65 
 Ovarian pregnancy, 195 
 
 Ovarian tumors, diagnosis of, from pregnancy, 
 158 
 
 obstructing labor, 576 
 Ovulation, phenomena of, 79 
 Ovum, anatomy of, 77 
 
 contact of, with spermatozoa, 100 
 
 development of, 101 
 
 development of, in extra-uterine preg- 
 nancy, 194, 197 
 
 hEemorrhagic discharges from, 205, 207 
 
 premature expulsion of, 367 
 Oxytoxics, use of, in uterine inertia, 601 
 
 Pain, abdominal, in pregnancy, 243 
 of labor, see Labor Pains, 
 mammary, during nursing, 614 
 uterine, in pregnancy, 243 
 Parametritis, 720 
 Parovarium, 65 
 Parturient canal, axis of, 42 
 Parturition, cause of comparative difficulty in 
 human species, 27 
 forces which effect, 254 
 in the primates, 27 
 in the various races, 27 
 mechanism of, 284 
 post-mortem, 254 
 Pelvic cellulitis, 720 
 
 abscess in, treatment of, 740 
 
 anatomy of pelvic cellular tissue with 
 
 regard to, 733 
 diagnosis between pelviperitonitis and, 
 
 735 
 mode of detecting pus in, 737 
 treatment in, 737 
 Pelvic measurements, 45 
 
 conjugate, warranting the different op- 
 erations, 557 
 Pelvic presentations, see Breech Presenta- 
 tions, 
 comparative frequency of, 327 
 special risks of, 329, 332, 335 
 Pelvimetry, instrumental and manual, 452 
 Pelvi-peritonitis, 695, 730 
 
 abscess in, treatment of, 740 
 
 Bernutz on, 733 
 
 counter-irritation in, 740 
 
 diagnosis between pelvic cellulitis and, 
 
 735 
 leeching in, 738 
 mode of detecting pus in, 737 
 mode of diagnosis in, 732 
 treatment of, 737 
 use of iodine in, 740 
 use of mercury in, 739 
 Pelvis, 33 
 
 sequabiliter justo-raajor and -minor, 450 
 
 angles of, 41, 46 
 
 axis of the true, 42 
 
 bones of, 34 
 
 brim of, 43 
 
 cavity of, 43 
 
 comparative anatomy of, 23 
 
 deformities of, see Deformities of Pelvis. 
 
 development of, 46 
 
 diameters of, 43, 45 
 
 difference between male and female, 37 
 
 floor of, 48 
 
 funnel-shaped, 448 
 
INDEX. 
 
 761 
 
 Pelvis, human, a curved canal, 29 
 
 inclination of, 41 
 
 infantile type of, 450 
 
 inflammation of articulations of, 242 
 
 ligaments and articulations of, 89 
 
 inalacosteon, 445 
 
 masculine type of, 449 
 
 mobilitv of articulations of, during labor, 
 30, 36, 242 
 
 obliquely distorted, 447 
 
 outlet of, 44 
 
 rachitic, 445 
 
 soft structures connected with, 47 
 
 true and false, 3(3 
 Perforator, use of, in craniotomy, 529 
 
 use of in decapitation, 510 
 Perimetritis, 720, 784 
 Perineum, 49 
 
 dilatation of in labor, 205 
 
 laceration oi\ 266, 280 
 
 management of in labor, 277, 279 578 
 
 treatment in threatened laceration of, 279 
 
 treatment of rigidity of, in labor, 279, 578 
 Peritonitis, see Puerperal Peritonitis. 
 Peri-uterine hematocele, 741 
 Peri-uterine phlegmon, see Pelvic Cellulitis. 
 Phlebitis, see Puerperal Phlebitis. 
 
 crural, see Phlegmasia Dolens. 
 Phlegmasia dolens, 642 
 
 after-effects of, 646 
 
 antiseptic remedies in, 657 
 
 causes of, 643 
 
 causes of protracted convalescence in, 657 
 
 causes of, unconnected with recent de- 
 livery, 644, 652 
 
 characteristic appearance of swelling in, 
 646 
 
 connection of with hemorrhagic cases, 
 044 
 
 connection of with puerperal fever, 700 
 
 efficacy of blistering in, 055 
 
 morbid anatomy of, 047 
 
 most common in left leg. 044 
 
 most common in pluriparse, 044 
 
 nomenclature of, 643 
 
 pathology of, 04 7, 051 
 
 premonitory signs of, 645 
 
 question of bloodletting in, 655 
 
 question of contagiousness, 650 
 
 symptoms of, 645 
 
 tendency of, to attack other leg, 644 
 
 terminations of, 047 
 
 treatment of, 055 
 
 use of bandages in, 656 
 
 usual time of occurrence of, 644 
 Phosphatio diathesis, in pregnancy, 38 
 Phrenitis, to he distinguished from puerperal 
 
 mania-, 862 
 Placenta, 113 
 
 abnormalities of, 405 
 
 adherent, extraction of, 281 
 
 adherent, management of, in inversion of 
 uterus, 425 
 
 anatomy of, 1 13 
 
 apoplexy of, 213, 371 
 
 artificial extraction of, in placenta pre- 
 via, 396 
 
 artificial separation of, in placenta prce- 
 via, 899 
 
 atrophy of, 214 
 
 calcareous degeneration of, 214 
 
 causes and treatment of retained, 404 
 
 Placenta, causes of true adhesion of, 405 
 Credc"s method of delivering, 282 
 diseases of, 213, 370 
 diseases of, causing abortion, 870 
 disposition of, in twin pregnancy, 192 
 dropsy of, 214 
 expulsion of, 266 
 expulsion of, in abortion, 8 77 
 extraction of, 2S1 
 
 extraction of, in rupture of uterus, 439 
 fatty degeneration of, 213 
 functions of, 1 16 
 hypertrophy of, 214 
 inflammation of, 214 
 management of, in abortion. 2S8 
 mechanism in expulsion of, 207 
 removal of, in hysterotomy, 55 I 
 results of disease in, 214, 870 
 retention of, 281, 404 
 retention of, in abortion, 377 
 site of, in accidental haemorrhage, 402 
 spontaneous expulsion of, in placenta 
 pnvvia. 890, 890 
 
 Placenta previa, 8S7 
 
 artificial extraction of placenta in, 890 
 artificial separation of placenta in, 898 
 causes of, 8SS 
 
 evacuation of liquor amnii in, 398 
 idea of ancients as to nature of, 8S0 
 natural terminations of complete and 
 
 partial, 890, 897 
 operation of turning in, 392, 894 
 proclivity to recurrence of, 891 
 spontaneous expulsion of placenta in, 390, 
 
 43(1 
 symptoms and signs of, 388 
 treatment of, 'A\^ 1 
 treatment, resume of, 400 
 use of Barnes's bags in, :Wi\ 400 
 use of forceps in, 396 
 use of styptics after delivery in, 403 
 use of vaginal plug or tampon in, 392, 
 
 895 
 varieties of complete and partial, 387 
 
 Placental forceps, use of, 384 
 
 Placental presentation, see Placenta Previa. 
 
 Plethora in pregnancy, 228 
 
 Plural pregnancy, 190 
 
 as an obstruction to labor, 587 
 
 duration of, 194 
 
 mode of impregnation in, 191 
 
 Polypus, fibroid, of uterus, distinctions be- 
 tween, and inversion, 407, 423 
 obstructing labor, 575 
 
 Positions, classification of, 290 
 
 Post-part urn hemorrhage, 404, 406 
 astringents in, 4 13 
 causes of, 400 
 
 compression of aorta in, 413 
 effects of rest and position in, 115 
 fibroid tumors of uterus as a cause of, 407 
 inversion of uterus as a cause of, 407 
 manual pressure on uterus in, 41 I 
 passage of hand into uterus in, III 
 plugging in, 41 2 
 reflex effect of cold in, 4 1 1 
 symptoms of, 408 
 tendency to reaction in, 416 
 
 transfusion in, see Transfusion. 
 treatment in, 410 
 use of ergot in, 411, 413 
 use of galvanism in, 412 
 
 l'i 
 
762 
 
 INDEX. 
 
 Post-partum haemorrhage, use of Gariel's air 
 pessary in, 412 
 
 use of stimulants and opium in, 415 
 
 use of styptics in, 413 
 
 uterine inertia as a cause of, 405, 406 
 Post-partum inflammations, connection of, 
 
 with puerperal fever, 691, 707 
 Precipitate labor, 604 
 
 causes of, 605 
 
 dangers of, 605 
 
 from deficiency of resistance, 605 
 
 influence of premature rupture of mem- 
 branes on, 605 
 
 influence of temperament on, 604 
 
 treatment in, 606 
 
 use of opium and chloroform in, 606 
 Pregnancy, 144 
 
 abdominal, 196 
 
 abdominal pain in, 243 
 
 albuminuria in, see Albuminuria. 
 
 anteflexion and anteversion of uterus in, 
 245 
 
 appearance of abdomen during, 156 
 
 ascites in, 234, 239 
 
 ballottement in, 167 
 
 cases of protracted, 178 
 
 catarrh of bladder in, 233 
 
 changes in mammae during, 153 
 
 changes in os and cervix during, 159 
 
 changes of umbilicus in, 156 
 
 changes in urine during, 152 
 
 chlorosis in, 225 
 
 color of vagina in, 54, 158 
 
 constipation in, 224 
 
 diarrhoea in, 224 
 
 differential diagnosis of abdominal tumors 
 from, 157 
 
 digestive disorders in, 151, 218, 369, 560 
 
 digital examination in, 158, 164 
 
 discoloration of skin in, 156 
 
 diseases of, 218 
 
 disorders of circulatory system in, 225 
 
 disorders of locomotion in, 242 
 
 disorders of nervous system in, 243 
 
 disorders of respiration in, 224 
 
 disorders of secretion and exeretion in, 
 232 
 
 duration of, 176 
 
 duration of, in cows and mares, 177 
 
 effects of, on the system, 674 
 
 examination per ami in in, 165 
 
 extra-uterine, see Extra- Uterine Preg- 
 nancy. 
 
 flattening of abdomen in, 157 
 
 fcetal pulsation in, 168 
 
 funic souffle in, 170 
 
 influence of lactation on, 618 
 
 insanity of. 659 
 
 mode of calculating duration of, 183 
 
 morning sickness of, 152, 218, 221, 369, 
 560 
 
 normal effect of, on the mind, 658 
 
 ovarian, 195 
 
 plethora in, 228 
 
 plural, see Plural Pregnancy. 
 
 quickening in, 165 
 
 salivation in, 152, 232 
 
 signs of, 149 
 
 signs of certain, 175 
 
 suppression of the cataraenia in, 151 
 
 table showing signs of, at various epochs, 
 175 
 
 Pregnancy, treatment in digestive disorders 
 of, 220. 560 
 
 tubal, 195 
 
 uterine pain in, 243 
 
 uterine souffle in, 171 
 
 vaginal examination in, 54, 158, 159,162 
 
 vaginal pulse in, 159 
 Premature labor, 385 
 
 causes of, 386 
 
 definition of term, 367 
 
 effect of albuminuria in causing, 682 
 
 induction of, see Induction of Premature 
 Labor. 
 
 influence of emotional causes on, 605 
 
 symptoms of, 386 
 
 treatment of, 386 
 Presentation, compound or complicated, 352 
 
 definition of term, 285, 289, 294 
 
 of the arm or shoulder, see Transverse 
 Presentations. 
 
 of the breech, see Breech Presentations. 
 
 of the brow, 322 
 
 of the face, see Face Presentations. 
 
 of the foot, 334 
 
 of the knee, 334 
 
 of the pelvis, see Pelvic Presentations. 
 
 natural and faulty, 289 
 
 of the vertex, see Cranial Presentations. 
 
 relative frequency of various presenta- 
 tions, 289 
 Prolapse of uterus, distinctions between in- 
 version and, 424 
 
 in pregnancy, 244 
 Pubiotoray, 556 
 Puerperal angeioleucitis, 700 
 Puerperal eclampsia, 672 
 
 Barnes's theory of causation of, 674 
 
 connection of., with acute Bright's dis- 
 ease, 673, 675, 677 
 
 definition of, 672 
 
 detection of albumen in urine in, 679 
 
 distinction of from other forms of eclamp- 
 sia, 672, 677 
 
 duration of tonic and clonic convulsions, 
 and of coma in, 676 
 
 formation of carbonate of ammonia in 
 blood in, 678 
 
 ligature of limbs in, 687 
 
 maternal and fcetal mortality in, 681 
 
 morbid anatomy of, 680 
 
 mortality of treatment by bleeding and 
 anaesthetics in, 685 
 
 pathology of, 677 
 
 premonitory symptoms and signs of, 675 
 
 pressure on renal veins as a cause of albu- 
 minuria in, 679 
 
 question of bloodletting in, 684, 685 
 
 question of induction of labor to obviate, 
 683 
 
 reflex sensibility in the causation of, 680 
 
 rupture of the membranes in, 686 
 
 symptoms of, 675 
 
 theories as to connection between, and 
 albuminuria, 678 
 
 treatment after delivery in, 686 
 
 treatment of during fit, and in different 
 epochs, 684 
 
 treatment, obstetrical, in, 686 
 
 treatment, prophylactic, in, 683 
 
 turning or craniotomy in, 686 
 
 use of anaesthetic agents in, 684, 685, 743 
 
 use of the forceps in, 686 
 
INDEX. 
 
 763 
 
 Puerperal eclampsia, uterine contractions as 
 a cause of, 680 
 fever, 687 
 
 affections allied to, 691, 703 
 causes of, 688, 700 
 circumstances favoring propagation of, 
 
 689, 701 
 
 classification of diseases usually called, 
 
 692 
 condition of blood in malignant form of, 
 
 709 
 connection of, with angeioleucitis, 699 
 connection of, with cadaveric poison, 703, 
 
 717 
 connection of, with enteric fever, 691 
 connection of, with erysipelas, 690, 703 
 connection of, with metritis, 697 
 connection of, with peculiarities of puer- 
 peral state, 690, 700 
 connection of, with peritonitis, 695, 707 
 connection of, with phlegmasia dolens, 
 
 700 
 connection of, with post-partum inflam- 
 mations, 692, 707 
 connection of with puerperal vaginitis, 
 
 699 
 connection of, with scarlatina, 691 
 connection of, with septic absorption, 
 
 690, 702, 707 
 
 connection of, with typhus fever, 691, 703 
 
 connection of, with uterine phlebitis, 697, 
 708 
 
 connection of, with variola, 691 
 
 different forms of, 704, 707 
 
 history of epidemics of, 704 
 
 morbid anatomy of, 707 
 
 nomenclature and classification of, 688, 
 691 
 
 question of contagiousness of, 701, 711, 
 717 
 
 question of specific nature of, 688 
 
 question of tapping in, 717 
 
 reasons for retaining term of, 691 
 
 symptoms of, 705 
 
 treatment of, 711 
 
 treatment by bloodletting in, 711, 713 
 
 treatment by emetics in, 716 
 
 treatment, prophylactic, in, 711, 717 
 
 treatment by purgatives in, 712, 714 
 
 treatment by stimulants and tonics in, 
 712, 717 
 
 treatment, topical, in, 718 
 
 use of antiseptics in, 718 
 
 use of blisters in, 717 
 
 use of calomel in, 716 
 
 use of cold baths in, 717 
 
 use of iodine in, 717 
 
 use of the sulphites in, 716 
 
 use of turpentine in, 716 
 
 variations in type of, 704, 705, 711, 712, 
 713 
 Puerperal peritonitis, acute, sthenic, 714 
 
 treatment of, 714 
 Puerperal phlebitis, 698 
 
 connection of, with puerperal fever, 698 
 
 morbid anatomy of, contrasted with pu- 
 erperal fever, 707 
 Puerperal insanity, 737 
 
 causes of, 659 
 
 connection of, with albuminuria, 660, 668 
 
 during labor, 659 
 
 during lactation. 659 
 
 Puerperal insanity, during pregnancy, 659 
 
 hereditary predisposition in, 659 
 
 influence of age on, 659 
 
 most frequent in primiparae, 659 
 
 nomenclature of, 658 
 
 normal effect of pregnancy on the mind, 
 658 
 
 pathological theories of, 660 
 
 prognosis of, 665, 667 
 
 recurrence of attacks of, 672 
 
 relative frequency of, 659 
 
 seclusion and restraint in, 671 
 
 suicidal impulse in, 671 
 
 treatment of, 668 
 
 true, 659 
 Puerperal mania, 662 
 
 essentially a disease of exhaustion. 662 
 
 phrenitis to be distinguished from, 662 
 
 prognosis of. 665, 667 
 
 significance of a rapid pulse in, 664 
 
 symptoms of, 663 
 
 treatment of, 668 
 
 treatment of, preventive, 668 
 Puerperal melancholia, 666 
 
 prognosis of, 667 
 
 symptoms of, 666 
 
 treatment of, 671 
 Puerperal metritis, 697 
 
 morbid anatomy of, contrasted with pu- 
 erperal fever, 707 
 Puerperal peritonitis, 695 
 
 connection of, with acute tympanites, 696 
 
 connection of, with puerperal fever, 695, 
 696 
 
 distinction between, and acute tympan- 
 ites, 696 
 
 false, 696 
 
 morbid anatomy of, contrasted with pu- 
 erperal fever. 707 
 
 symptoms of ordinary, 695 
 
 symptoms of severe, 695 
 Puerperal pyaemia, 690, 693 
 Puerperal state, connection of, with puer- 
 peral fever, 690, 700 
 
 management of the, 283, 607 
 
 relation of the, to disease, 643 
 
 sudden death in, 741 
 Puerperal vaginitis, connection of, with pu- 
 erperal fever, 698 
 Puerperal wounds, diphtheria of, 719 
 
 causes of. 726 
 
 diagnosis of, 723 
 
 nature of, 725 
 
 pathological anatomy of, 723 
 
 peritonitis in, 725 
 
 prognosis of, 723 
 
 prophylaxis of, 729 
 
 symptoms of, 720 
 
 treatment of, 727 
 Pyrosis, in pregnancy, 224 
 
 Quickening, 165, 185 
 
 Rachitis, 443 
 
 contrasted with malacosteon, 445 
 Rectocele, obstructing labor, 578 
 Repercussion, see Ballottement. 
 Respiration, disorders of, in pregnancy, 224 
 Restitution, movement of, in cranial presen- 
 tations, 298 
 
764 
 
 INDEX. 
 
 Retroflexion of uterus in pregnancy, 246 
 Retroversion of uterus in pregnancy, 246 
 Rigidity of os uteri, 264, 276, 570 
 
 causes of, 570 
 
 from diseases, 570 
 
 functional, 570 
 
 occlusion of os in, 570 
 
 treatment of, from disease, 571 
 
 treatment of simple or functional, 571 
 Rigidity of perineum, 279, 573 
 
 treatment in, 573 
 Rigor in labor, 262 
 
 Rotation, movement of, in breech presenta- 
 tions, 327, 332, 333 
 
 movement of, in cranial presentations, 
 293, 300 
 
 movement of, in face presentations, 316, 
 317 
 Rupture of sac in extra-uterine pregnancy, 201 
 Rupture of uterine ligaments, 437 
 Rupture of uterus, 430 
 
 atrophy of uterus as a cause of, 434 
 
 causes of, 433 
 
 during pregnancy, 430 
 
 extraction of child in, 438 
 
 extraction of placenta in, 439 
 
 improper use of ergot as a cause of, 433 
 
 premonitory symptoms of. 435 
 
 prolapse of intestine in. 439 
 
 question of gastrotomy in, 440 
 
 question of turning in, 440 
 
 reflex effect of digital examination as a 
 cause of, 434 
 
 relation of, to duration of labor, 433 
 
 relative frequency of, in primiparse, 432 
 
 rigidity of os as a cause of, 435 
 
 signs of, 435 
 
 sites of laceration in, 432 
 
 treatment during pregnancy, 441 
 
 treatment in, 437 
 
 varieties of, 431 
 Rupture of vagina, 436 
 Rut, analogy between, and menstruation, 88 
 
 Sacrum, 34 
 
 exaggerated curvature of, 448 
 
 flattening of the sacrum, 448 
 Salivation, in pregnancy, 152, 232 
 Scarlatina, connection of, with puerperal 
 
 fever, 690 
 Scirrhus of rectum, obstructing labor, 578 
 Scybalae, as a cause of uterine inertia, 597 
 
 obstructing labor, 578 
 Secretions, disorders of, in pregnancy, 232 
 Semen, composition of, 98 
 Senses, special, affections of, in pregnancy, 
 
 243 
 Septic absorption, connection of, with puer- 
 peral fever, 690, 703, 707 
 Septicaemia, 690 
 
 Shoulder presentations, see Transverse Pres- 
 entations. 
 
 comparative frequency of, 342 
 Show, in labor, 262 
 
 Skin, discoloration of, in pregnancy, 156 
 Souffle, funic, 170 
 
 uterine, 171 
 Spermatozoa, contact of ovum with, 100 
 
 development of, 98 
 
 duration of life of, 179 
 Spinal cord, reflex function of, in labor, 255 
 
 Spondylolisthesis, 450 
 
 Spina bifida, as an obstruction to labor, 586 
 Spontaneous evolution, in transverse pres- 
 entations, 346, 353 
 Spontaneous expulsion, in transverse pres- 
 entations, 347 
 Stethoscope, use of, in labor. 276 
 Stimulants, use of, in labor, 599 
 Strychnia, use of, in uterine inertia, 604 
 Styptics, use of, in post-partum haemorrhage, 
 
 413 
 Sucking, difficulties of the newly born child 
 
 in, 631 
 Sudden death in puerperal state, 741 
 Superfecundation, 185 
 Superfoetation, 185, 188, 200 
 relation of, to twins, 185 
 Suspended animation, treatment of, 280 
 Sutures, of foetal cranium, 133 
 
 examination of, in labor, 292, 300, 303, 
 
 307 
 premature closure of, obstructing la- 
 bor, 587 
 Symphysiotomy, 555 
 
 history and nature of, 555 
 results of, 556 
 
 Teething, see Dentition. 
 Thrombus, of lips of os uteri, 572 
 
 of the vagina, 230, 574 
 Thrush, in the newly born child, 634 
 
 treatment of, 635 
 Tumors, foetal, obstructing labor, 586 
 
 maternal, obstructing labor, 575, 581 
 Transfusion, 416 
 
 ''immediate" and "mediate" processes 
 of, 417 
 Transverse presentations, 341 
 
 causes of, 342 
 
 cephalic version in, 350 
 
 combined version in, 350 
 
 comparative frequency of, 342 
 
 diagnosis of positions in, 343 
 
 dorso-anterior and dorso-posterior posi- 
 tions in, 344 
 
 examination of arm in, 343, 345 
 
 methods of operative interference in, 349 
 
 podalic version in, 350 
 
 premature rupture of membranes in, to 
 be avoided, 343 
 
 probable course of, in unaided cases, 345 
 
 prolapse of arm in, 351 
 
 signs of, before and during labor, 342 
 
 spontaneous expulsion in, 347 
 
 spontaneous evolution in, 346, 352 
 
 treatment of, 349 
 Triplets, 194 
 Tubal pregnancy, 195 
 Turning, 510 
 
 bipolar version, 350, 522 
 
 cephalic version, 518 
 
 choice of hands in, 512 
 
 circumstances rendering operation of, 
 difficult, 513 
 
 conditions requiring, and favorable to, 
 511 
 
 contrasted with craniotomy, 519, 521 
 
 contrasted with the use of the long for 
 ceps, 519, 521 
 
 history of, 510 
 
 in accidental hsemorrhage, 403 
 
INDEX. 
 
 765 
 
 Turning, in deformities of pelvis, 458, 459 
 
 in funis presentations, 366 
 
 in placenta praevia, 392, 394 
 
 in puerperal eclampsia, 686 
 
 in rupture of uterus, 440 
 
 management of the case after, 518 
 
 measurements admitting of, 519 
 
 method of Robert Lee, 522, 523 
 
 method of Wigand, 522 
 
 mode of operating in, 512 
 
 operation of. after craniotomy, 535 
 
 pelvic version, 518 
 
 podalic version, 511 
 
 position of the child after, 517 
 
 question of bringing down one leg or two 
 in, 514 
 
 question of, in contracted pelvis, 519 
 
 question of, in funis presentations, 366 
 
 special difficulties of, in deformities of 
 pelvis, 521 
 
 use of the noose or fillet in, 517 
 
 various methods of, 511 
 Twins, fusion of, 590 
 
 locked, obstructing labor. 588 
 
 the Siamese, 592 
 Twin pregnancy, diagnosis of, 193 
 
 disposition of membranes and placenta 
 in, 191 
 
 relation of, to superfcetation, 191, 193 
 
 varieties of, 190, 191 
 Tympanites, acute, distinctions between and 
 puerperal peritonitis. 696 
 
 symptoms of, 697 
 Typhus fever, connection of, with puerperal 
 fever, 691, 703 
 
 Umbilical cord, anatomy of, 111 
 
 coiling of, round foetus obstructing labor, 
 592 
 
 compression of, in breech presentations, 
 336, 339 
 
 diseases of, 215, 371 
 
 diseases of. causing abortion, 371 
 
 dragging on, a cause of inversion of 
 uterus, 420 
 
 knots on, 112, 365 
 
 ligature of, 281 
 
 ligature of, in twin pregnancy. 281 
 
 management of the, after birth, 626 
 
 presentation of the, see Funis Presenta- 
 tions. 
 
 shortness of, obstructing labor, 592 
 
 vessels of, 106 
 Umbilical vesicle, 104 
 Umbilicus, changes of, in pregnancy, 156 
 Unavoidable haemorrhage, see Placenta Pre- 
 via. 
 Unimpregnated uterus, 58 
 
 anatomy of, 58 
 
 axis of, 59 
 
 condition and appearance of os in, 61 
 
 difference between, and impregnated, 62, 
 83 
 
 displacements of, 67 
 
 ligaments of, 62 
 Uracbus, 105 
 Urethra, 50 
 Urine, changes in, during pregnancy, 152 
 
 detection of albuminuria by examination 
 of, 679 
 
 retention of, after delivery, 609 
 
 Urine, retention of, in labor, 275 
 
 retention of, in newly born child, 632 
 
 Urinary calculus, obstructing labor, 579 
 
 Uterine appendages, inflammation of, 730 
 
 Uterine inertia, 594 
 
 as a cause of inversion of uterus, 420, 427 
 as a cause of post-partum hasmorrhage, 
 
 405, 406 
 causes of, 595 
 
 distended bladder or rectum in, 597 
 influence of age and frequent pregnancy 
 
 on, 596 
 influence of climate and season, 596 
 influence of emotional causes, 596 
 influence of excessive uterine distension, 
 
 597, 599, 600 
 influence of irregular uterine action, 597 
 influence of temperament, 596 
 influence of uterine displacements, 596, 
 
 598 
 morbid conditions of the uterus in, 597, 
 
 599 
 treatment in. 599 
 use of ergot in, 601 
 use of the forceps in, 601, 603 
 use of galvanism in, 412 
 Wigand's and Scanzoni's classifications 
 of, 598 
 
 Uterine lymphatics, inflammation of, asso- 
 ciated with puerperal fever, 700 
 
 Uterine pain in pregnancy, 243 
 
 Uterine phlebitis, see, Puerperal Phlebitis. 
 
 Uterine souffle, 171 
 
 effect of labor pains on, 258 
 
 Uterine tumors, diagnosis of, from pregnancy, 
 157 
 use of ergot in distinguishing, 602 
 
 Uterus, 58 
 
 abnormal development of, 73 
 
 atrophy of, as a cause of rupture of, 434 
 
 attitude of foetus in, 128 
 
 bloodvessels of, 71 
 
 case of impregnation in double, 189 
 
 difference between unimpregnated and 
 
 impregnated. 61, 83 
 displacements of, 59, 67, 244. 251 
 displacements of, as a cause of inertia, 
 
 596, 598 
 
 displacements of, obstructing labor, 571 
 fibrinous and haetnorrhagic casts of, 207 
 fibroid tumors of, causing post-partum 
 
 haemorrhage, 407 
 gravid, see Gravid Uterus, 
 inversion of, see Inversion of Uterus, 
 irregular action of, causing inertia, 598 
 ligaments of, 63, 66 
 lymphatics and nerves of, 72 
 malformations of, 73 
 morbid conditions of, causing inertia, 
 
 597. 598 
 
 nervi-motor functions of, in labor, 254 
 peristaltic action of, in labor, 256 
 rupture of, see Rupture, 
 spontaneous expulsion of, 437 
 sympathy of, in extra-uterine pregnancy, 
 
 198 
 tumors of, obstructing labor, 575 
 unimpregnated, see Unimpregnated Ute^ 
 
 rus. 
 
 Vagina, 51 
 
766 
 
 INDEX. 
 
 Vagina, abnormal conditions of, obstructing 
 labor, 573 
 change in color of, during pregnancy, 54, 
 
 158 
 double, 55 
 examination by, in pregnancy, 54, 158, 
 
 159, 162 
 laceration of. 436 
 
 natural lubrication of, in labor, 260 
 plugging of, in abortion, 382 
 plugging of, in placenta prjsvia, 392, 395 
 plugging of, in post-partum haemorrhage, 
 
 412 
 the so-called Caesarian section through, 
 
 555 
 thrombus of, 230, 574 
 Vaginal pulse, in pregnancy, 159 
 Vaginismus, 55 
 Vaginitis, granulosa, 238 
 
 puerperalis, 698 
 Varicose veins, in pregnancy, 230 
 Variola, connection of, with puerperal fever, 
 
 691 
 Vectis, 500 
 
 cases suitable for, 502 
 history of, 500 
 
 Vectis, mode of using, 501 
 
 objections to use of, 501 
 
 use of, in breech presentations, 337 
 Version, cephalic, 350 
 
 combined, see Bimanual Version. 
 
 podalic, 350, 511 
 Vertex, definition of term, 136 
 Vestibule, 49 
 Vitriform body, 108 
 Voluntary muscles, action of, in labor, 256, 
 
 264, 273 
 Vomiting, in pregnancy, 152, 220, 369 
 
 question of induction of labor in, 222, 560 
 
 treatment of, 220, 223, 560 
 Vulvo-vaginal follicles, sebaceous and mucip- 
 arous, 53 
 Vulvo-vaginal glands, 53 
 
 Weaning, dentition a guide to proper period 
 
 of, 637 
 Weid or ephemera, 612 
 
 Zona pellucida, 77 
 
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 these periodicals are regarded by the profession promises to render the enterprise a 
 permanent one, and it is with especial pleasure that he acknowledges the valuable 
 assistance spontaneously rendered by so many of the old subscribers to the "Jour- 
 nal." who have kindly made known among their friends the advantages thus offered, 
 and have induced them to subscribe. Relying upon a continuance of these friendly 
 exertions, he hopes to be able to maintain the unexampled rates at which these works 
 
 (For "The Obstetrical Journal," see p. 22.) 
 
2 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 
 
 are now offered, and to succeed in his endeavor te place upon the table of every 
 reading practitioner in the United States the equivalent of three large octavo volumes, 
 at the comparatively trifling cost of Six Dollars per annum. 
 
 These periodicals are universally known for their high professional standing in their 
 several spheres. 
 
 I. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
 
 Edited by ISAAC HAYS, M.D. 7 
 
 is published Quarterly, on the first of January, April, July, and October. Each num- 
 ber contains nearly three hundred large octavo pages, appropriately illustrated wher- 
 ever necessary. It has now been issued regularly for over fifty years, during nearly 
 the whole of which time it has been under the control of the present editor. Through- 
 out this long period, it has maintained its position in the highest rank of medical 
 periodicals both at home and abroad, and has received the cordial support of the en- 
 tire profession in this country. Among its Collaborators will be found a large number 
 of the most distinguished names of the profession in every section of the United 
 States, rendering the department devoted to 
 
 ORIGINAL COMMUNICATIONS 
 
 full of varied and important matter, of great interest to a'll practitioners. Thus, during 
 1874, articles have appeared in its pages from nearly one hundred gentlemen of the 
 highest standing in the profession throughout the United States* 
 
 Following this is the "Review Department," containing extended and impartial 
 reviews of all important new works, together with numerous elaborate " Analytical 
 and Bibliographical Notices" of nearly all the medical publications of the day. 
 
 This is followed by the "Quarterly Summary of Improvements and Discoveries 
 in the Medical Sciences," classified and arranged under different heads, presenting 
 a very complete digest of all that is new and interesting to the physician, abroad as 
 well as at home. 
 
 Thus, during the year 1875, the "Journal" furnished to its subscribers 98 Orig- 
 inal Communications, 95 Reviews and Bibliographical Notices, and 283 articles in 
 the Quarterly Summaries, making a total of about Five Hundred articles emanating 
 from the best professional minds in America and Europe. 
 
 That the efforts thus made to maintain the high reputation of the "Journal" are 
 successful, is shown by the position accorded to it in both America and Europe as a 
 national exponent of medical progress : — 
 
 America continues to take a great place in this 
 class of journals (quarterlies), at the bead of which 
 the great work of Dr. Hays, the American Journal 
 of the Medical Sciences, still holds its ground, as our 
 quotations have often proved. — Dublin Med, Press 
 and Circular, Jan. 31, 1872. 
 
 Of English periodicals the Lancet, and of American 
 the Am. Journal of the Medical Sciences, are to be 
 regarded as necessities to the reading practitioner. — 
 N. Y. Medical Gazette, Ja a. 7, 1871. 
 
 The American Journal of the Medical Sciences 
 yields to none in the amount of original and bor- 
 
 And that it was specifically included in the award of a medal of merit to the Pub- 
 lisher in the Yienna Exhibition in 1873. 
 
 The subscription price of the " American Journal of the Medical Sciences" has 
 never been raised during its long career. It is still Five Dollars per annum ; and 
 when paid for in advance, the subscriber receives in addition the "Medical News and 
 Library," making in all about 1500 large octavo pages per annum, free of postage. 
 
 II. 
 
 THE MEDICAL NEWS AND LIBRARY 
 
 is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 
 annum. Its "News Department" presents the current information of the day, with 
 Clinical Lectures and Hospital Gleanings ; while the " Library Department" is de- 
 voted to publishing standard works on the various branches of medical science, paged 
 
 * Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted 
 by the Editor are paid for by the Publisher. 
 
 rowed matter it contains, and has established for 
 itself a reputation in every country where medicine 
 is cultivated as a science. — Brit: and For. Med.-Chi- 
 rurg. Review, April, 1S71. 
 
 This, if not the best, is one of the best-conducted 
 medical quarterlies in the English language, and the 
 present number is not by any means inferior to its 
 predecessors. — London Lancet, Aug. 23, 1873. 
 
 Almost the only one that circulates everywhere, 
 all over the Union and in Europe. — London Medical 
 Times, Sept. 5, 1S68. 
 
Henry 0. Lea ? s Publications— (Am. Journ. Med. Sciences). 3 
 
 separately, so that they can be removed and bound on completion. In this manner 
 subscribers have received, without expense, such works as " Watson's Practice," 
 " Todd and Bowman's Physiology," " West on Children," " Malgaigne's Sur- 
 gery," &c. &c. W T ith Jan. 1875, was commenced the publication of Dr. William 
 Stokes's new work on Fever (see p. 14), which will be completed during 1876. 
 
 As stated above, the subscription price of the " Medical News and Library" is 
 One Dollar per annum in advance; and it is furnished without charge to all advance 
 paying subscribers to the "American Journal of the Medical Sciences." 
 
 III. 
 
 THE MONTHLY ABSTRACT OF MEDICAL SCIENCE. 
 
 The "Monthly Abstract" is issued on the first of every month, each number con- 
 taining forty-eight large octavo pages, thus furnishing in the course of the year about 
 six hundred pages. The aim of the Abstract will be to present a careful condensa- 
 tion of all that is new and important in the medical journalism of the world, and all 
 the prominent professional periodicals of both hemispheres will be at the disposal 
 of the Editors. To show the manner in which this plan has been carried out, a con- 
 densed summary of the contents of the numbers from January to June, 1875, will be 
 found subjoined. It will thus be seen that during the last six months it has contained — 
 
 Twenty-tJiree Articles on Anatomy and Physiology. 
 
 Thirty-three " " Materia Medica and Tlierapeutics, 
 
 Ninety -siac 6( t( Medicine. 
 
 Ninety-two " ** Surgery. 
 
 Sixty-one " " Midwifery and Gynaecology. 
 
 Eleven, " (( Medical Jurisprudence and Toxicology 
 
 Three * ( * ( Hygiene— 
 
 making in all Three Hundred and Nineteen articles in six months, or at the rate of 
 more than Six Hundred articles per annum. 
 
 The subscription to the " Monthly Abstract," free of postage, is Two Dollars 
 and a Half a year, in advance. 
 
 As stated above, however, it will be supplied in conjunction with the "American 
 Journal of the Medical Sciences" and the "Medical News and Library," making 
 in all about Twenty-one Hundred pages per annum, the whole free of postage, for 
 Six Dollars a year, in advance. 
 
 The first volume of the " Monthly Abstract," from July to December, 1874, can 
 be had by those who desire to have complete sets, if early application be made, for 
 $1 50, forming a handsome octavo volume of 300 pages, cloth. 
 
 In this effort to bring so large an amount of practical information within the reach 
 of every member of the profession, the publisher confidently anticipates the friendly 
 aid of ail who are interested in the dissemination of sound medical literature. He 
 trusts, especially, that the subscribers to the "American Medical Journal" will call 
 the attention of their acquaintances to the advantages thus offered, and that he will 
 be sustained in the endeavor to permanently establish medical periodical literature 
 on a footing of cheapness never heretofore attempted. 
 
 PBEMIUM POK HEW SUBSORIBEKS TO THE " JQUMAL," 
 
 Any gentleman who will remit the amount for two subscriptions for 1876, one of 
 which must be for a new subscriber, will receive as a premium, free by mail, a copy of 
 "Flint's Essays on Conservative Medicine" (for advertisement of which see p. 15), 
 or of "Sturges's Clinical Medicine" (see p. 14), or of the new edition of "Swayne's 
 Obstetric Aphorisms" (see p. 24), or of "Tanner's Clinical Manual" (see p. 5), 
 or of "Chambers's Restorative Medicine" (see p. 16), or of "West on Nervous 
 Disorders of Children" (see page 21). 
 
 %* Gentlemen desiring to avail themselves of the advantages thus offered will do 
 well to forward their subscriptions at an early day, in order to insure the receipt of 
 complete sets for the year 1876, as the constant increase in the subscription list 
 almost always exhausts the quantity printed shortly after publication. 
 
 lUP The safest mode of remittance is by bank check or postal money order, drawn 
 to the order of the undersigned. Where these are not accessible, remittances for the 
 "Journal" may be made at the risk of the publisher, by forwarding in registered 
 letters. Address, 
 
 HENRY C. LEA, 
 
 Nos. 706 and 708 Sansom St., Philadelphia, Pa. 
 
Henry C. Lea's Publications-— (Dictionaries). 
 
 jyUNGLISON {ROBLEY), M.D., 
 
 Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 
 
 MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
 taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
 Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
 Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formulas for 
 Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology of 
 the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
 English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
 ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
 some roval octavo volume of over 1100 pages. Cloth, $8 50; leather, raised bands, $7 50, 
 {Just Issued.) 
 
 The object of the author from the outset has not been to make the work a mere lexicon or 
 dictionary of terms, but to afford, under each, a condensed view of its various medical relatione, 
 and thus to render the work an epitome of the existing condition of medical science. Starting 
 with this view, the immense demand which has existed for the work has enabled him, in repeated 
 revisions, to augment its completeness and usefulness, until at length it has attained the positioB 
 of a recognized and standard authority wherever the language is spoken. 
 
 Special pains have been taken in the preparation of the present edition to maintain this en- 
 viable reputation. During the ten years which have elapsed since the last revision, the additions 
 to the nomenclature of the medical sciences have beengreaterthanperha.ps in any similar period 
 of the past, and up to the time of his death the author labored assiduously to incorporate every- 
 thing requiring the attention of the student or practitioner. Since then, the editor has been 
 equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
 vious revision. Especial attention has been bestowed on the accentuation, which will be found 
 marked on every word. The typographical arrangement has been much improved, rendering 
 reference much more easy, and every care has been taken with the mechanical execution. The 
 work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
 the additions have been incorporated with an increase of but little over a hundred pages, and 
 the volume now contains the matter of at least four ordinary octavos. 
 
 "VVe are glad to see a new edition of this invaluable 
 work, and to find that it has been so thoroughly revised, 
 and so greatly improved. The dictionary, in its pre- 
 
 A book well known to our renders, and of which 
 every American ought to be proud. When the learned 
 author of the work passed away, probably all of us 
 feared lest the book should not maintain its place 
 in the advancing science whose terms it defines. For- 
 tunately, Dr. Richard J. Dunglison, having assisted his 
 father in the revision of several editions of the work, 
 and having been, therefore, trained in the methods and 
 imbued with the spirit of the book, has been able to 
 edit it, not in the patchwork manner so dear to the 
 heart of book editors, so repulsive to the taste of intel- 
 ligent book readers, but to edit it as a work of the kind 
 should be edited — to carry it on steadily, without jar 
 or interruption, along the grooves of thought it has 
 travelled during its lifetime. To show the magnitude 
 of the task which Dr. Dunglison has assumed and car- 
 ried through, it is only necessary to state that more 
 than six thousand new subjects have been added in the 
 present edition. "Without occupying more space with the 
 theme, we congratulate the editor on the successful 
 completion of his labors, and hope he may reap the well- 
 earned reward of profit and honor. — Plnla. Med. Times, 
 Jan. 3, 1874. 
 
 About the first book purchased by the medical stu- 
 dent is the Medical Dictionary. The lexicon explana- 
 tory of technical terms is simply a sine qua non. In a 
 science so extensive, and with such collaterals as medi- 
 cine, it is as much a necessity also to the practising 
 physician. To meet the wants of students and most 
 physicians, the dictionary must be condensed while 
 comprehensive, and practical while perspicacious. It 
 was because Dunglison's met these indications that it 
 became at once the dictionary of general use wherever 
 medicine was studied in the English language. In no 
 former revision have the alterations and additions been 
 so great. More than six thousand new subjects and terms 
 have been added. The chief terms have been set in black 
 letter, while the derivatives follow in small caps; an 
 arrangement which greatly facilitates reference. We 
 may safely confirm the hope ventured by the editor 
 " that the work, which possesses for him a filial as well 
 as an individual interest, will be found worthy a con- 
 tinuance of the position so long accorded to it as a 
 standard authority." — Cincinnati Clinic, Jan. 10, 1874. 
 
 sent form, is a medical library in itself, and one off 
 which every physician should be possessed. — iV. Y. Med. 
 Journal, Feb. 1874. 
 
 With a history of forty years of unexampled success 
 and universal indorsement by the medical profession of 
 the western continent, it would be presumption in any 
 living medical American to essay its review. No re- 
 viewer, however able, can add to its fame; no captious 
 critic, however caustic, can remove a single stone from 
 its firm and enduring foundation. It is destined, as a 
 colossal monument, to perpetuate the solid and richly 
 deserved fame of Itobley Dunglison to coming genera- 
 tions. The large additions made to the vocabulary, we 
 think, will be welcomed by the profession as supplying 
 the want of a lexicon fully up with the march of sci- 
 ence, which has been increasingly felt for some years 
 past. The accentuation of terms is very complete, and, 
 as far as we have been able to examine it, very excel- 
 lent. We hope it may be the means of securing greater 
 uniformity of pronunciation among medical men. — At- 
 lanta Med. and Surg. Journ., Feb. 1874. 
 
 It would be mere waste of words in us to express 
 out admiration of a work which is so universally 
 and deservedly appreciated. The most admirable 
 work of its kind in the English language. — Glasgow 
 Medical Journal, January, 1866. 
 
 A work to which there is no equal in the English 
 language. — Edinburgh Medical Journal. 
 
 Few works of the class exhibit a grander monument 
 of patient research and of scientific lore. The extent 
 jf the sale of this lexicon is sufficient to testify to its 
 usefulness, and to the great service conferred by Dr. 
 Robley Dunglison on the profession, and indeed on 
 jthers, by its issue. — London Lancet, May 13, 1865. 
 
 It has the rare merit that it certainly has no rival 
 in the English language for accuracy and extent of 
 references. — London Medical Gazette. 
 
 TIOBLYN {RICHARD I).), M.D. 
 
 A DICTIONARY OF THE TERMS USED IN MEDICINE AND 
 
 THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
 M.D., Editor of the "American Journal of the Medical Sciences." In one large royaJ 
 12mo. volume of over 500 double-columned pages; cloth, $1 50 ; leather, $2 00. 
 It is the best book of definitions we have, and ought always to be upon the student's table.— Southern 
 Med and Surg. Journal. 
 
Henry C. Lea's Publications — (Manuals). 
 
 R 
 
 OZ) WELL {G.F.), F.R.A.S., frc. 
 A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
 
 istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
 Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
 History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
 many illustrations : cloth, $5. 
 
 nTFILL {JOHN), M.D 
 
 and 
 
 C[31ITH {FRANCIS G.), M.D., 
 
 Prof, of the Institutes of Medicine in the Univ. of Penna 
 
 AN ANALYTICAL COMPENDIUM OF THE VARIOUS 
 
 BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
 new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
 volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly "bound in 
 leather, with raised bands, $4 75. 
 
 The Compend ot'Drs. Neilland Smith is incompara- 
 bly the most valuable work of its class ever published 
 in this country. Attempts have been made in various 
 quarters to squeeze Anatomy, Physiology, Surgery, 
 the Practice of Medicine, Obstetrics, Materia Medica, 
 and Chemistry into a single manual ; but the opera- 
 tion has signally failed in the hands of all up to the 
 advent of " Neill and Smith's' ' volume, which is quite 
 a miracle of success. The outlines of the whole are 
 admirably drawn and illustrated, and the authors 
 are eminently entitled to the grateful consideration 
 
 »f the student of every class. — N. 0. Med. and Sura. 
 Tournal. 
 
 There are but few students or practitioners of me- 
 iicine unacquainted with the former editions of this 
 ma,ssuming though highly instructive work. The 
 yhole science of medicine appears to have been sifted, 
 is the gold-bearing sands of El Dorado, and the pre- 
 cioas facts treasured up in this little volume. A com- 
 plete portable library so condensed that the student 
 may make it his constant pocket companion. — West- 
 cm Lancet. 
 
 H 
 
 ART8H0RNE {HENRY), M. D., 
 
 Professor of Hygiene in the University of Pennsylvania. 
 
 A CONSPECTUS OF THE MEDICAL SCIENCES; containing 
 
 Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
 Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one lar»e 
 royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
 wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) 
 
 aud the clear and instructive illustrations in some 
 parts of the work.— American Journ. of Pharmacy, 
 Philadelphia, July, 1874. 
 
 The volume will be found useful, not only to stu- 
 dents, but to many others who may desire to refresh 
 their memories with the smallest possible expendi- 
 ture of time.— N. Y. Med. Journal, Sept. 1874. 
 
 The student will find this the most convenient and 
 useful, book of the kind on which he can lay his 
 hand. — Pacific Med. and Surg. Journ., Aug. 1S74. 
 
 The work before us has already successfully assert- 
 ed its claim to the confidence aud favor of the profes- 
 sion ; it but remains for us to say that in the present 
 edition the whole work has been fully overhauled 
 and brought up to the present status of the science. — 
 Atlanta Med. and Surg. Journal, Sept. 1874. 
 
 The work is intended as an aid to the medical stu- 
 dent, and as such appears to admirably fulfil its ob- 
 j ect by its excellent arrangement, the full compilation 
 f facts, the perspicuity and terseness of language, 
 
 T UDLOW {J.L.), M.D. 
 ^A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 
 
 Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
 Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
 and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
 12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. 
 The arrangement of this volume in the form of question and answer renders it especially suit- 
 able for the office examination of students, and for those preparing for graduation. 
 
 fTANNER {THOMAS HAWKES), M.B.,8fc. 
 
 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
 
 NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
 
 Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
 
 &c. In one neat volume small 1 2mo. , of about 375 pages, cloth, $1 50. 
 
 *^* By reference to the " Prospectus of Journal" on page 3, it will be seen that this work is 
 
 offered as a premium for procuring new subscribers to the "American Journal of the Medical 
 
 Sciences." 
 
 The objections commonly, and justly, urged again.-st 
 the general run of "compends," "conspectuses," and 
 other aids to indolence, are not applicable to this little 
 volume, which contains in concise phrase just those 
 practical details that are of most use in daily diag- 
 nosis, but which the young practitioner finds it diffi- 
 cult to carry always in his memory without some 
 quickly accessible means of reference. Altogether, 
 the book is one which we can heartily commend to 
 those who have not opportunity for extensive read- 
 ing, or who, having read much, still wish an occa- 
 sional pracu« o1 reminder.— N. ¥. Med. Gazette, Nr.y. 
 10, 1870. 
 
 Taken as a whole, it is the most compact vade me- 
 cum for the use of the advanced student and junior 
 practitioner with which we are acquainted. — Boston 
 Med. and Surg. Journal, Sept. 22, 1870. 
 
 It contains so much that is valuable, presented in 
 so attractive a form, that it can hardly be spared 
 even in the presence of more full and complete works. 
 Its convenient size makes it a valuable companion 
 to the country practitioner, and if constantly car- 
 ried by him, would often render him good service, 
 and relieve many a doubt and perplexity.— Leaven- 
 worth Med. Herald, July, 1870. 
 
Henry 0. Lea's Publications— (Anatomy), 
 
 Q.RAY (HENRY), F.R.S., 
 
 Lecturer on Anatomy at St. George's Hospital, London. 
 
 ANATOMY, DESCRIPTIVE AND SURGICAL. The DrawiDgs by 
 
 H. V. Caeter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- 
 tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
 and improved London edition. In one magnificent imperial octavo volume, of nearly 900 
 pages, with 465 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- 
 ther, raised bands, $7 00. (Just Issued.) 
 The author has endeavored in this work to cover a more extended range of subjects than is cus- 
 tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
 also the application of those details in the practice of medicine and surgery, thus rendering it both 
 a guide for the learner, and an admirable work of reference for the active practitioner. The en • 
 gravings form a special feature in the work, many of them being the size of nature, nearly ali 
 original, and having the names of the various parts printed on the body of the cut, in place of 
 figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
 which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
 refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
 the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
 a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
 essential use to all physicians who receive students in their offices, relieving both preceptor and 
 pupil of much labor in laying the groundwork of a thorough medical education. 
 
 Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
 price, rendering it one of the cheapest works now before the profession. 
 
 The illustrations are beautifully executed, and ren- 
 der this work an indispensable adjunct to the library 
 of the surgeon. This remark applies with great force 
 to those surgeons practising at a distance from our 
 large cities, as the opportunity of refreshing their 
 memory by actual dissection is not always attain- 
 able.— Canada Med. JovJrnal, Aug. 1870. 
 
 The work is too well known and appreciated by the 
 profession to need any comment. No medical man 
 can afford to be without it, if its only merit were to 
 serve as a reminder of that which so soon becomes 
 forgotten, when not called into frequent use, viz., the 
 relations and names of the complex organism of the 
 human body. The present edition is much improved. 
 —California Med. Gazette, July, 1870. 
 
 Gray's Anatomy has been so long the standard of 
 perfection With every student of anatomy, that we 
 need do no more than call attention to the improve- 
 ment in the present edition.— Detroit Review of Med. 
 and Pharm., Aug. 1870. 
 
 From time to time, as successive editions have ap- 
 peared, we have had much pleasure in expressing 
 the general judgment of the wonderful excellence of 
 Gray's Anatomy. — Cincinnati Lancet, July, 1870. 
 
 Altogether, it is unquestionably the most complete 
 and serviceable text-book in anatomy that has ever 
 been presented to the student, and forms a striking 
 contrast to the dry and perplexing volumes on the 
 same subject through which their predecessors strug- 
 gled in days gone by. — N. ¥. Med. Record, Jane 15, 
 1870. 
 
 To commend Gray's Anatomy to the medical pro- 
 fession is almost as much a work of supererogation 
 as it would be to give a favorable notice of the Bible 
 in the religious press*. To say that it is the most 
 complete and conveniently arranged text-book of its 
 kind, is to repeat what each generation of students 
 has learned as a tradition of the elders, and verified 
 by personal experience. — N Y. Med. Gazette, Dec. 
 17, 1870. 
 
 S 
 
 MITH [HENRY H.), M.D., and JJORNER ( WILLIAM E.), M.I)., 
 
 Prof, of Surgery in the Univ. of Penna. , &e. Late Prof, of Anatomy in the Univ. ofPenna., Ac. 
 
 AN ANATOMICAL ATLAS, illustrative of the Structure of the 
 
 Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
 
 fifty beautiful figures. $4 50. 
 The plan of this Atlas, which renders it so pecu- 1 the kind that has yot appeared ; and we must add, 
 liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up," 
 tistical execution, have been already pointed out. We j is so creditable to the country as to be flattering to 
 must congratulate the student upon the completion our national pride.— American MedicalJournal. 
 of this Atlas, as it is the most convenient work of I 
 
 UHARPEY 1 WIT juIAM), M.D., and Q UAIN [JONES fr RICHARD). 
 HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 
 
 Leidy, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two 
 large octavo volumes, of about 1300 pages, with 511 illustrations; cloth, $6 00. 
 The very low price of this standard work, and its completeness in all departments of the subject, 
 should command for it a place in the library of all anatomical students. 
 
 fJODGES [RICHARD M.), M.D., 
 
 Late Demonstrator of Anatomy in the Medical Department of Harvard University. 
 
 PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 
 
 one neat royal 12mo. volume, half-bound, $2 00. 
 The object of this work is to present to the anatomical student a clear and concise description 
 of that which he is expected to observe in an ordinary couise of dissections. The author has 
 endeavored to omit unnecessary details, and to present the subject in the form which many years' 
 experience has shown hfci to be the most convenient and intelligible to the student. In the 
 revision of the present edition, he has sedulously labored to render the volume more worthy of 
 the favor with which it has heretofore been received. 
 
 HORNER'S SPECIAL ANATOMY AND HISTOLOGY. I In 2 vols. 8vo., of over 1000 pages, with more thao 
 Eighth edition, extensively revised and modified. I 300 wood-cuts; cloth, $6 00. 
 
Henry C. Lea ? s Publications— {Anatomy). 
 
 TffllLSON {ERASMUS), F.R.S. 
 
 A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 
 
 by W. H. G-obbecht, M. D., Professor of General and Surgical Anatomy in the Medical Col- 
 lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. la 
 one large and handsome octavo volume, of over 600 large pages; cloth, $4 00; leather, 
 $5 00. 
 Hie publisher trusts that the well-earned reputation of this long-established favorite will be 
 more than maintained by the present edition. Besides a very thorough revision by the author, it 
 has been most carefully examined by the editor, and the efforts of both have been directed to in- 
 troducing everything which increased experience in its use has suggested as desirable to render it 
 a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
 tomy. The amount of additions which it has thus received may be estimated from the fact thai 
 fcho present edition contains over one-fourth more matter than the last, rendering a smaller type 
 and an enlarged page requisite to keep the volume within a convenient size. The author has not 
 only thus added largely to the work, but he has also made alterations throughout, wherever there 
 appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
 most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
 has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
 the number of illustrations, of which there are about one hundred and fifty more in this edition 
 than in the last, thus bringing distinctly before the eye of the student everything of interest or 
 importance. 
 
 TIE ATE [CHRISTOPHER), F. R. C. S., 
 
 •*■-*■ Teacher of Operative Surgery in University College, London. 
 
 PRACTICAL ANATOMY: A Manual of Dissections. From the 
 
 Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
 
 M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
 
 In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth, $6 50 ; 
 
 leather, $4 00. {Lately Published.) 
 Dr. Keen, the American editor of this work, in his 
 preface, says: "In presenting this American edition 
 of 'Heath's Practical Anatomy,' 1 feel that I have 
 been instrumental in supplying a want long felt for 
 a real dissector's manual," and this assertion of its 
 editor we deem is fully justified, after an examina- 
 tion of its contents, for it is really an excellent work. 
 Indeed, we do not hesitate to say, the best of its class 
 with which we are acquainted ; resembling Wilson 
 In terse and clear description, excelling most of the 
 eo-called practical anatomical dissectors in the scope 
 of the subject and practical selected matter. . . . 
 In reading this work, one is forcibly impressed with 
 the great pains the author takes to impress the sub- 
 j ect upon the mind of the student. He is full of rare 
 and pleasing little devices to aid memory in main- 
 
 taining its hold upon the slippery slopes of anatomy. 
 — St. Louis Med. and Surg. Journal, Mar. 10, 1871. 
 
 It appears to us cartain that, as a guide in dissec- 
 tion, and as a work containing facts ot anatomy in 
 brief and easily understood form, this manual is 
 complete. This work contains, also, very perfect 
 illustrations of parts which can thus be more easily 
 rnderstood and studied; in this respect it compares 
 favorably with works of much greater pretension. 
 Such manuals of anatomy are always ravorite works 
 with medical students. We would earnestly recom- 
 mend this one to their attention; it has excellences 
 which make it valuable as a guide in dissecting, as 
 well as in studying anatomy. — Buffalo MedAcal and 
 SurgicalJour rial, Jan. 1871. 
 
 BELLAMY [E.) , F.R. C.S. 
 
 THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- 
 
 Book for Students preparing for their Pass Examination. With engravings on wood. In 
 ona handsome royal 12mo. volume. Cloth, $2 25. {Just Issued.) 
 
 We welcome Mr. Bellamy's work, as a contribu- 
 tion to the study of regional anatomy, of equal value 
 to the student and the surgeon. It is written m a 
 clear and concise style, and its practical suggestions 
 add largely to the interest attaching to its technical 
 details — Chicago Med. Examiner, March 1, 1874. 
 
 We cordially congratulate Mr. Bellamy upon hav- 
 ing produced it. — Med. Times and Qaz. 
 
 We cannot too highly recommend it.— Student's 
 ■Journal. 
 
 Mr. Bellamy has spared no pains to produce a real- 
 ly reliable student's guide to surgical anatomy — one 
 which all candidates for surgical degrees may cm- 
 suit with advantage, and which posseses much ori- 
 ginal matter — Med. Press and Circular. 
 
 M: 
 
 ACLISE [JOSEPH). 
 
 SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one 
 
 volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best 
 style and beautifully colored, containing 190 figures, many of them the size of life; together 
 with copious explanatory letter-press. Strongly and handsomely bound* in cloth. Price 
 $14 00. 
 
 ,$ions have hitherto, we think, been given. While 
 he operator is shown every vessel and nerve where 
 <in operation is contemplated, the exact anatomist is 
 refreshed by those clear and distinct dissection,.-, 
 which every one must appreciate who has a particle 
 of enthusiasm. The English medical press has quite 
 exhausted the words of praise, in recommending this 
 admirable treatise. — Boston Med. and Surg. Journ. 
 
 We know of no work on surgical anatomy which 
 «an compete with it. — Lancet. 
 
 The work of Maclise on surgical anatomy is of the 
 highest value. In some respects it is the best publi- 
 cation of its kind we have seen, and is worthy of a 
 place in the library of any medical man, while the 
 student could scarcely make a better investment than 
 this. — The Western Journal of Medicine and Surgery. 
 
 No such lithographic illustrations of surgical re- 
 
 H 
 
 ARTSHORNE [HENRY], M.D., 
 
 Professor of Hygiene, etc , in the Univ. ofPenna. 
 
 HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- 
 tion, revised. In one royal 12mo. volume, with 220 wood-cuts ; cloth, $1 75. {Just Issued.^ 
 
8 
 
 Henry C. Lea's Publications — (Physiology). 
 
 MARSHALL {JOHN), F. R. S., 
 
 '*£*- Professor of Surgery in University College, London, &c. 
 
 OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. 
 
 With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- 
 cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large 
 and handsome octavo volume, of 1026 pages, cloth, $6 50 ; leather, raised bands, $7 50. 
 
 tive, with which we are acquainted. To speak oi 
 this work in the terms ordinarily used on snch occa- 
 sions would not be agreeable to ourselves, and would 
 fail to do j ustice to its author. To write such a book 
 requires a varied and wide range of knowledge, con- 
 siderable power of analysis, correct judgment, skill 
 in arrangement, and conscientious spirit. — London 
 Lancet, Feb. 22, 1868. 
 
 There arefew, if any, more accomplished anatomists 
 and physiologists than the distinguished professor of 
 surgery at University College ; and he has long en- 
 joyed the highest reputation as a teacher of physiol- 
 ogy, possessing remarkable powers of clear exposition 
 and graphic illustration. We have rarely the plea- 
 sure of being able to recommend a text-book so unre- 
 servedly as this.— British Med. Journal, Jar . 25, 1868. 
 
 In fact, in every respect, Mr. Marshall has present- 
 ed us with a most complete, reliable, and scientific 
 work, and we feel that it is worthy our warmest 
 commendation.— St. Louis Med. Reporter, Jan. 1869. 
 
 We doubt if there is in the English language any 
 compend of physiology more useful to the student 
 than this work. — St. Louis Med. and Surg. Journal, 
 Jan. 1869. 
 
 It quite fulfils, in our opinion, the author's design 
 of making it truly educational in its character — which 
 Is, perhaps, the highest commendation that can be 
 asked. — Am. Journ. Med. Sciences, Jan. 1869. 
 
 We may now congratulate him on having com- 
 pleted the latest as well as the best summary of mod- 
 ern physiological science, both human and compara- 
 
 flARP ENTER [WILLIAM B.), M.D., F.R.S., 
 
 *-^ Examiner in Physiology and Comparative Anatomy in the University of London. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 
 cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A ne~w 
 American from the last and revised London edition. With nearly three hundred illustrations. 
 Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of 
 Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo 
 volume, of about 900 large pages, handsomely printed; cloth, $5 50 ; leather, raised bands, 
 $6 50. 
 
 We doubt not it is destined to retain a strong hold 
 on public favor, and remain the favorite text-book in 
 our colleges. — Virginia Medical Journal. 
 
 With Dr. Smith, we confidently believe "that the 
 present will more than sustain the enviable reputa- 
 tion already attained by former editions, of being 
 one of the fullest and most complete treatises on the 
 subject in the English language." We know of none 
 from the pages of which a satisfactory knowledge of 
 the physiology of the human organism can be as well 
 obtained, none better adapted for the use of such as 
 take up the study of physiology in its reference to 
 the institutes and practice of medicine. — Am. Jour. 
 Med. Sciences. 
 
 The above is the title of what is emphatically tht 
 great work on physiology ; and we are conscious that 
 it would be a useless effort to attempt to add any- 
 thing to the reputation of this invaluable work, and 
 can only say to all with whom our opinion has any 
 influence, that it is our authority. — Atlanta Med. 
 Journal. 
 
 DI THE SAME AUTHOR. 
 
 PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- 
 
 can, from the Fourth and Revised London Edition. In one large and handsome octavo 
 volume, with over three hundred beautiful illustrations Pp.752. Cloth, $5 00. 
 As a complete and condensed treatise on its extended and important subject, this work becomea 
 a necessity to students of natural science, while the very low price at which it is offered places it 
 within the reach of all. 
 
 JTIRKES ( WILLIAM SENHOUSE), M.D. 
 
 A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, 
 
 M.D., F.R.C.S. A new American from the eigbth and improved London edition. With 
 about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
 ume. Cloth, $3 25; leather, $3 75. {Lately Issued.) 
 Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, 
 presenting within a narrow compass all that is important for the student. The rapidity with 
 which successive editions have followed each other in England has enabled the editor to keep it 
 thoroughly on a level with the changes and new discoveries made in the science, and the eighth 
 edition, of which the present is a reprint, has appeared so recently that it may be regarded as 
 the latest accessible exposition of the subject. 
 
 On the whole, there is very little in the book 
 which either the student or practitioner willnotfind 
 of practical value and consistent with our present 
 knowledge of this rapidly changing science ; and we 
 have no hesitation in expressing our opinion that 
 this eighth edition is one of the best handbooks on 
 physiology which we have in our language. — N. Y. 
 Med. Record, April 15, 1873. 
 
 This volume might well be used to replace many 
 of the physiological text-books in use in this coun- 
 try. It represents more accurately than the works 
 of Dalton or Flint, the present state of our knowl- 
 edge of most physiological questions, while it is 
 much less bulky and far more readable than the lar- 
 
 ger text-books of Carpenter or Marshall. The book 
 is admirably adapted to be placed in the hands of 
 students. — Boston Med. and Surg. Journ., April 10, 
 1873. 
 
 In its enlarged form it is, in our opinion, still the 
 best book on physiology, most useful to the student. 
 —Phila. Med. Times, Aug. 30, 1873. 
 
 This is undoubtedly the best work for students of 
 physiology extant. — Cincinnati Med. News, Sept. '73. 
 
 It more nearly represents the present condition of 
 physiology than any other text-book on the subject. — 
 Detroit Rev. of Med. Pharm., Nov. 1873. 
 
Henry C. Lea's Publications— (Physiology). 9 
 
 f)ALTON {J. C), M.D., 
 
 -*"- , Professor of Physiology in the College of Physicians and Surgeons, ITew York, &c. 
 
 A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 
 
 of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
 with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
 ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. (Now Ready.) 
 
 From the Preface to the Sixth Edition. 
 
 In the present edition of this book, while every part has received a careful revision, the ori- 
 ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
 new material. Although the whole field of physiology has been cultivated, of late years, with 
 unusual industry and success, perhaps the most important advances have been made in the two 
 departments of Physiological Chemistry and the Nervous System. The number and classification 
 of the proximate principles, more especially, and their relation to each other in the process of 
 nutrition, have become, in many respects, better understood than formerly ; though it is evident 
 that this fundamental part of physiology is to receive, in the future, modifications and additions 
 of the most valuable kind. 
 
 The additions and alterations in the text, requisite to present concisely the growth of positive 
 physiological knowledge, have resulted in spite of the author's earnest efforts at condensation, 
 in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- 
 pographical arrangement has accommodated these additions without undue enlargement in the 
 bulk of the volume. 
 
 The new chemical notation and nomenclature are introduced into the present edition, as hav 
 ing now so generally taken the place of the old, that no confusion need result from the change. 
 The centigrade system of measurements for length, volume, and weight, is also adopted, these 
 measurements being at present almost universally employed in original physiological investiga- 
 tions and their published accounts. Temperatures are given in degrees of the centigrade scale, 
 usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. 
 New York, September, 1875. 
 
 A few notices of the previous edition are subjoined. 
 The fifth edition of this truly valuable work on 
 Human Physiology comes to us with many valuable 
 Improvements ana additions. As a text-book of 
 
 physiology the work of Prof. Dalton has long been 
 well known as one of the best which could be placed 
 in the hands of student or practitioner. Prof. Dalton 
 has, in the several editions of his work heretofore 
 published, labored to keep step with the advancement 
 In science, and the last edition shows by its improve- 
 ments on former ones that he is determined to main- 
 tain the high standard of his work. We predict for 
 the present edition increased favor, though this work 
 has long been the favorite standard. — Buffalo Med. 
 and Surg. Journal, April, 1872. 
 
 An extended notice of a work so generally and fa- 
 vorably known as this is unnecessary. It is justly 
 regarded as one of the most valuable text-books on 
 the subject in the English language. — St. Louis Med. 
 Archives, May, 1872. 
 
 We know no treatise in physiology so clear, com- 
 plete, well assimilated, and perfectly digested, as 
 Balton's. He never writes cloudily or dubiously, or 
 
 in mere quotation. He assimilates all his material, | ical Record, April, 1872, 
 and from it constructs a homogeneous, transparent 
 
 argument, which is always honest and well informed, 
 and hides neither truth, ignorance, nor doubt, so far 
 as either belongs to the subject in hand. — Brit. Med. 
 Journal, March 23, 1672. 
 
 Dr. Dalton's treatise is well known, and by many 
 highly esteemed in this country. It is, indeed, a good 
 elementary treatise on the subject it professes to 
 teach, and may safely be put into the hands of Eng- 
 lish students. It has one great merit — it is clear, and, 
 on the whole, admirably illustrated. The part we 
 have always esteemed most highly is that relating 
 to Embryology. The diagrams given of the various 
 stages of development give a clearer view of the sub- 
 ject than do those in general use in this country ; and 
 the text may be said to be, upon the whole, equally 
 clear. — London Med. Times and Gazette, March 23, 
 1872. 
 
 Professor Dalton is regarded justly as the authority 
 in this country on physiological subjects, and the 
 fifth edition of his valuable work fully justifies tha 
 exalted opinion the medical world has of his labors. 
 This last edition is greatly enlarged.— Virginia Clin- 
 
 D 
 
 UNGLISON {ROBLEY), M.D., 
 
 Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 
 
 HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 
 
 extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
 large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 
 
 JEH31ANN{C. O.). 
 
 PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
 
 tion by George E Bay, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of 
 Chemistry in the Medical Department of the University of Pennsylvania, with illustrations 
 selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
 plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
 hundred illustrations, cloth, $8 00. 
 
 ry 7 THE SAME A UTEOR. 
 
 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 
 
 German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory 
 Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- 
 vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, 
 cloth, $2 25. 
 
10 
 
 Henry C. Lea's Publications — (Chemistry), 
 
 ATTFIELD {JOHN), Ph.D., 
 
 Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c. 
 
 CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL 5 
 
 including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
 of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revised 
 by the author. In one handsome royal I2mo. volume ; cloth, $2 75 ; leather, $3 25. 
 (Lately Issued.) 
 
 engaged in medicine and pharmacy, and we heartily 
 commend it to our readers. — Canada Lancet, Oct. 
 1871. 
 
 No other American publication with which we are 
 acquainted covers the same ground , or does it so well. 
 In addition to an admirable expose" of the facts and 
 principles of general elementary chemistry, the au- 
 thor has presented us with a condensed mass of prac- 
 tical matter, just such as the medical student and 
 practitioner needs. — Cincinnati Lancet, Mar. 1874. 
 
 We commend the work hearlily as one of the best 
 text-books extant for the medical student. — Detroit 
 Rev. of Med. and Pharm., Feb. 1872. 
 
 The best work of the kind in the English language. 
 — N. Y. Psychological Journal, Jan. 1S72. 
 
 The work is constructed with direct reference to 
 the wants of medical and pharmaceutical students ; 
 and, although an English work, the points of differ- 
 ence between the British and United States Pharma- 
 copoeias are indicated, making it as useful here as in 
 England. Altogether, the book is one we can heart- 
 ily recommend to practitioners as well as students. 
 —N. T. Med. Journal, Dec. 1871. 
 
 It differs from other text-books in the following 
 
 "When the original English edition of this work was 
 published, we had occasion to express our high ap- 
 preciation of its worth, and also to review, in con- 
 siderable detail, the main features of the book. As 
 the arrangement of subjects, and the main part of 
 the text of the present edition are similar to the for- 
 mer publication, it will be needless for us to go over 
 the ground a second time ; we may, however, call at- 
 tention to a marked advantage possessed by the Ame- 
 rican work— we allude to the introduction of the 
 chemistry of the preparations of the United States 
 Pharmacopoeia, as well as that relating to the British 
 authority. — Canadian Pharmaceutical Journal, 
 Nov. 1S71. 
 
 Chemistry has borne the name of being a hard sub- 
 ject to master by the student of medicine, and 
 chiefly because so much of it consists of compoundn 
 onlv of interest to the scientific chemist ; in this work 
 
 particulars : first, in the exclusion of matter relating such portions are modified or altogether left out, and 
 to compounds which, at present, are only of interest J in the arrangement of the subject-matter of the work, 
 to the scientific chemist; secondly, in containing the practical utility is sought after, and we think fully 
 chemistry of every substance recognized officially or attained. We commend it for its clearness and order 
 in general, as a remedial agent. It will be found a to both teacher and pupil.— Oregon Med. and Surff. 
 most valuable book for pupils, assistants, and others Reporter, Oct. 1871. 
 
 F 
 
 OWNES {GEORGE), Ph.D. 
 A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 
 
 Practical. With one hundred and ninety-seven illustrations. A new American, from the 
 tenth and revised London edition. Edited by Robert Bridges, M. D. In one large 
 royal 12mo. volume, of about 850 pp., cloth, $2*75 ; leather, $3 25. (Lately Iss?ted.) 
 
 This work is so well known that it seems almost 
 superfluous for us to speak about it. It has been a 
 favorite text-book with medical students for years, 
 and its popularity has in no respect diminished. 
 Whenever we have been consulted by medical stu- 
 dents, as has frequently occurred, what treatise on 
 chemistry they should procure, we have always re- 
 commended Fownes', for we regarded it as the best. 
 There is no work that combines so many excellen- 
 
 ■>ther work that has greater claims on the physician, 
 pharmaceutist, or student, than this. We cheerfully 
 recommend it as the best text-book on elementary 
 chemistry, and bespeak for it the careful attention 
 of students of pharmacy. — Chicago Pharmacist, Aug, 
 1869. 
 
 Here is a new edition which has been long watched 
 for by eager teachers of chemistry. In its new garb, 
 
 ces. It is of convenient size, not prolix, of plain and under the editorship of Sir. Watts, it has resumed 
 perspicoous diction, contains all the most recent its old place as the most successful of text-books.— 
 
 discoveries, and is of moderate price 
 Med. Repertory, Aug. 1869. 
 
 -Cincinnati I Indian Medical Gazette, Jau. 1, 1869 
 
 It will continue, as heretofore, to hold the first rani 
 Large additions have been made, especially in the is a text-book for students of medicine. — Chicago 
 department of organic chemistry, and we know of no Y?d. Examiner, Aug. 1S69. 
 
 
 
 DLING ( WILLIAM), 
 
 Lecturer on Chemistry at St. Bartholomew's Hospital, &c. 
 
 A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use 
 
 of Medical Students. With Illustrations. From the Fourth and Bevised London Edition. 
 In one neat royal 12mo. volume, cloth, $2. 
 
 flALLOWAY {ROBERT), F.G.S., 
 
 *^" Prof, of Applied Chemistry in the Royal College of Science for Ireland, <ftc. 
 
 A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lob- 
 
 don Edition. In one neat royal 12mo. volume, with illustrations; cloth, $2 50. (Just 
 Issued.) 
 
 The success which has carried this work through repeated editions in England, and it3 adoption 
 as a text-book in several of the leading institutions in this country, show that the author has suc- 
 ceeded in the endeavor to produce a sound praotieal manual and book of reference for the che- 
 mical student. 
 
 Prof Galloway's books are deservedly in high i We regard this volume as a valuable addition to 
 esteem, and this American reprint of the fifth edition \ the chemical text-books, and as particularly calca- 
 (1869) of his Manual of Qualitative Analysis, will be I lated to instruct the student in analytical researches 
 acceptable to many American students to whom the \ of the inorganic compounds, the important vegetable 
 English edition is not accessible. — Am, Jour, of Set- I acids, and of compounds and various secretions asd 
 ince and Arts, Sept. 1872. excretions of animal origin, —Am. Jo-am. of Pharm,., 
 
 I Sapt, 1S72. 
 
Henry C. Lea's Publications— {Chemistry). 
 
 11 
 
 'jDLOXAM {G. L.), 
 
 •*-* Professor of Chemistry in King's College, London. 
 
 CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 
 
 don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- 
 tions. Cloth, $4 00; leather, $5 00. (Lately Issued.) 
 It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- 
 sive for those studying the science as a branch of general education, and one which a student 
 may use with advantage in pursuing his chemical studies atone of the colleges or medical schools. 
 The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders 
 the work especially useful to those who are being educated for employment in manufacture. 
 
 We have in this work a complete and most excel- 
 lent text-book for the use of schools, and can heart- 
 ily recommend it as such. — Boston Med. and Surg. 
 Journ., May 23, 1874. 
 
 Of all the numerous works upon elementary chem- 
 istry that have been published within the last few 
 years, we can point to none that, in fulness, accuracy, 
 and simplicity, can surpass this; while, in the num- 
 ber and detailed descriptions of experiments, as also 
 in the profuseness of its illustrations, we believe it 
 stands above any similar work published in this coun- 
 try The statements made are clear and con- 
 cise, and every step proved by an abundance of ex- 
 periments, which excite our admiration as much by 
 their simplicity as by their direct conclusiveness. — 
 Chicago Med. Examiner, Nov. 15, 1873. 
 
 It is seldom that in the same compass so complete 
 and interesting a compendium of the leading facts of 
 chemistry is offered.— Druggists' Circular, Nov. '73. 
 The above is the title of a work which we can most 
 conscientiously recommend to students of chemistry. 
 It is as easy as a work on chemistry could be made, 
 at the same time that it presents a full account of that 
 science as it now stands. We have spoken of the 
 work as admirably adapted to the wants of students ; 
 it is quite as well suited to the requirements of prac- 
 titioners who wish to review their chemistry, or have 
 occasion to refresh their memories on any point re- 
 lating to it. In a word, it is a book to be read by all 
 who wish to know what is the chemistry of the pre- 
 sent day. — American Practitioner, Nov. 1873. 
 
 Among the various works upon general chemistry 
 issued, we know of none that will supply the average 
 wants of the student or teacher better than this. — 
 Indiana Journ. of Med., Nov. 1873. 
 
 We cordially welcome this American reprint of a 
 work which has already won for itself so substantial 
 a reputation in England. Professor Bloxam has con- 
 densed into a wonderfully small compass all the im- 
 portant principles and facts of chemical science. 
 Thoroughly imbued with an enthusiastic love for the 
 science he expounds, he has stripped it of all need- 
 less technicalities, and rounded out its hard outlines 
 by a fulness of illustration that cannot fail to attract 
 and delight the student. The details of illustrative 
 
 experiment have been worked up with especial care, 
 and many of the experiments described are both new 
 and striking. — Detroit Rev. of Med. and Pharm., 
 Nov. 1873. 
 
 One of the best text-books of chemistry yet pub- 
 lished. — Chicago Med. Journ., Nov. 1873. 
 
 This is an excellent work, well adapted for the be- 
 ginner and the advanced student of chemistry. — Am. 
 Journ. of Pharm., Nov. 1873. 
 
 Probably the most valuable, and at the same time 
 practical, text-book on general chemistry extant in 
 our language. — Kansas City Med. Journ., Dec. 1873. 
 
 Prof. Bloxam possesses pre-eminently the inestima- 
 ble gift of perspicuity. It is a pleasure to read his 
 books, for he is capable of makiug very plain what 
 other authors frequently have left very obscure. — 
 Va. Clinical Record, Nov. 1S73. 
 
 It would be difficult for a practical chemist and 
 teacher to find any material fault with this most ad- 
 mirable treatise. The author has given us almost a 
 cyclopedia within the limits of aconrenient volume, 
 and has done so without penning the useless para- 
 graphs too commonly making up a great part of the 
 bulk of many cumbrous works. The progressive sci- 
 entist is not disappointed when he looks for the record 
 of new and valuable processes and discoveries, while 
 the cautious conservative does not find its pages mo- 
 nopolized by uncertain theories and speculations. A 
 peculiar point of excellence is the crystallized form of 
 expression in which great truths are expressed in 
 very short paragraphs. One is surprised at the brief 
 space allotted to an- important topic, and yet, after 
 reading it, he feels that little, if any more, should 
 have been said. Altogether, it is seldom you see a 
 text-book so nearly faultless.— Cincinnati Lancet 
 Nov. 1873. 
 
 Professor Bloxam has given us a most excellent 
 and useful practical treatise. His 666 pages are 
 crowded with facts aud experiments, nearly all well 
 chosen, and many quite new, even to scientific men. 
 . . . It is astonishing how much information he often 
 conveys in a few paragraphs. We might quote fifty 
 instances of this. — Chemical News. 
 
 WOHLER AND FITTIG. 
 
 ¥V OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 
 ditions from the Eighth German Edition. By Ira Remsen, M.D., Ph.D., Professor of 
 Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo. 
 of 550 pp., cloth, $3. 
 As the numerous editions of the original attest, this work is the leading text-book and standard 
 authority throughout Germany on its important and intricate subject — a position won for it by 
 the clearness and conciseness which are its distinguishing characteristics. The translation has 
 been executed with the approbation of Profs. Wbhler and Fittig, and numerous additions and 
 alterations have been introduced, so as to render it in every respect on a level with the most 
 advanced condition of the science. 
 
 J£0 WMAN {JOHN E.) ,M.D. 
 
 PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 
 
 by C.^L. Bloxam, Professor of Practical Chemistry in King's College, London. Sixth 
 American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
 pp. 351, with numerous illustrations, cloth, $2 25. 
 J£Y THE SAME AUTHOR. (Lately Issued.) 
 
 INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 
 
 ANALYSIS. Sixth American, from the sixth and revised London edition. With numei- 
 oas illustrations. In one neat vol., royal 12mo., cloth, $2 25. 
 
 KH" APP'S TECHNOLOGY ; or Chemistry Applied to 
 the Arts, and to Manufactures. With American 
 fcdditioas, by Prof. Wastes. S. Johkson. In two 
 
 very handsome octavo vol an?.es, with 500 wood 
 engravings, oloth, $8 00 
 
12 Henry 0. Lba ? s Publications— (Mat. Med. and Therapeutics). 
 pARRISH {EDWARD), 
 
 Late Professor of Materia Medica. in the Philadelphia College of Pharmacy . 
 
 A TREATISE ON PHARMACY. Designed as a Text-Book for the 
 
 Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
 Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In on® 
 handsome octavo volume of 977 pages, with 280 illustrations; cloth, %b 50; leather, $6 50. 
 {Lately Issued.) 
 The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au- 
 thor, have postponed the preparation of this new edition beyond the period expected. The notes 
 and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegand, 
 who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- 
 ence which have been introduced during he last ten years. It is therefore hoped that the new 
 edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard 
 text-book and work of reference for all engaged in the preparation and dispensing of medicines. 
 
 Of Dr. Parrish's great work on pharmacy it only- 
 remains to be said that the editor has accomplished 
 his work so well as to maintain, in this fourth edi- 
 tion, the high standard of excellence which it had 
 attained in previous editions, under the editorship of 
 its accomplished author. This has not been accom- 
 plished without much labor, and many additions and 
 improvements, involving changes in the arrangement 
 of the several parts of the work, and the addition of 
 much new matter. With the modificatious thus ef- 
 fected it constitutes, as now presented, a compendium 
 of the science and art indispensable to the pharma- 
 cist, and of the utmost value to every practitioner 
 of medicine desirous of familiarizing himself with 
 the pharmaceutical preparation of the articles which 
 he prescribes for his patients. — Chicago Med. Journ., 
 July, 1S74. 
 
 The work is eminently practical, and has the rare 
 merit of being readable and interesting, while it pre- 
 serves a stricily scientific character. The whole work 
 reflects the greatest credit on author, editor, and pub- 
 lisher It will convey some idea of the liberality which 
 has been bestowed upon its production when we men- 
 tion that there are no less than 2S0 carefully executed 
 illustrations. In conclusion, we heartily recommend 
 the work, not only to pharmacists, but also to the 
 multitude of medical practitioners who are obliged 
 to compound their own medicines. It will ever hold 
 
 an honored place on our own bookshelves. — Dublin 
 Med. Press and Circular, Aug. 12, 1874. 
 
 We expressed our opinion of a former edition in 
 terms of unqualified praise, and we are in no mood 
 to detract from that opinion in reference to the pre- 
 sent edition, the preparation of which has fallen into 
 competent hands. It is a book with which no pharma- 
 cist can dispense, and from which no physician can 
 fail to derive much information of value to him in 
 practice. — Pacific Med. and Surg. Journ., June, '74. 
 
 With these few remarks we heartily commend the 
 work, and have no doubt that it will maintain its 
 old reputation as a text-book for the student, and a 
 work of reference for the more experienced physi- 
 cian and pharmacist . — Chicago Med. Examiner, 
 June 15, 1874. 
 
 Perhaps one, if not the most important book upon 
 pharmacy which has appeared in the English lan- 
 guage has emanated from the transatlantic press. 
 " Parrish 's Pharmacy" is a well-known work on this 
 side of the water, and the fact shows us that a really 
 useful work never becomes merely local in its fame. 
 Thanks to the judicious editing of Mr. Wiegand, the 
 posthumous edition of "Parrish" has been saved to 
 the public with all the mature experience of its au- 
 thor, and perhaps none the worse for a dash of new 
 blood. — Land. Pharm. Journal, Oct. 17, 1874. 
 
 OTILLE {ALFRED), M.D., 
 
 *3 Professor of Theory and Practice of Medicine in the University of Penno.. 
 
 THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise 
 
 on the Action and Uses of Medicinal Agents, including their Description and Historj. 
 
 Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 
 
 pages. Cloth, $10; leather, $12. {Just Iss?ied.) 
 The care bestowed by the author on the revision of this edition has kept the work out of the 
 market for nearly two years, and has increased its size about two hundred and fifty pages. Not- 
 withstanding this enlargement, the price has been kept at the former very moderate rate. 
 
 It is unnecessary to do much more than to an- 
 nounce the appearance of the fourth edition of this 
 well known and excellent work. — Brit, and For. 
 Med.-Chir. Review, Oct. 1875. 
 
 For all who desire a complete work on therapeutics 
 and materia medica for reference, in cases involving 
 medico-legal questions, as well as for information 
 concerning remedial agents, Dr. Stille's is '■'■par ex- j 
 cellence" the work. The work being out of print, by 
 the exhaustion of former editions, the author has laid I 
 
 the profession under renewed obligations, by the 
 careful revision, important additions, and timely re- 
 issuing a work not exactly supplemented by any 
 other in the English language, if in any language. 
 The mechanical execution handsomely sustains the 
 well-known skill and good taste of the publisher. — 
 St. Louis Med. and Surg.- Journal, Dec. 1874. 
 
 The prominent feature of Dr. Stille s great work 
 is sound good sense. It is learned, but its learning 
 is of inferior value compared with the discriminating 
 judgment which is shown by its author in the dis- 
 cussion of his subjects, and which renders it a trust- 
 worthy guide in the sick-room. — Am. Practitioner, 
 Jan. 1875. 
 
 From the publication of the first edition " Stille's 
 Therapeutics" has been one of the classics; its ab- 
 sence from our libraries would create a vacuum 
 which could be filled by no other work in the lan- 
 
 guage, and its presence supplies, in the two volumes ' 1874. 
 
 of the present edition, a whole cyclopaedia of thera- 
 peutics. — Chicago Medical Journal, T?el). 1875. 
 
 The magnificent work of Professor Stifle is known 
 wherever the English language is read, and the art 
 of medicine cultivated ; known so well that no enco- 
 mium of ours could brighten its fame, and no unfa- 
 vorable criticism could tarnish its reputation.— Phil- 
 adelphia Med. Times, Dec. 12, 1S74, 
 
 The rapid exhaustion of three editions and the uni- 
 versal favor with which the work has been received 
 by the medical profession, are sufficient proof of its 
 excellence as a repertory of practical and useful in- 
 formation for the physician. The edition before us 
 fully sustains this verdict, as the work has been care- 
 fully revised and in some portions rewritten, bring- 
 ing it up to the present time by the admission of 
 chloral and croton-chloral, nitrite of amyl, bichlo- 
 ride of methylene, methylic ether, lithium com- 
 pounds, gelseminum, and other remedies. — Am. 
 Journ. of Pharmacy, Feb. 1875. 
 
 We can hardly admit that it has a rival in the 
 multitude of its citations and the fulness of its re- 
 search into clinical histories, and we must assign it 
 a place in the physician's library; not, indeed, as 
 fully representing the present state of knowledge in 
 pharmacodynamics, but as by far the most complete 
 treatise upon the clinical and practical side of the 
 question. — Boston Mtd. and. Surg. Journal, Kov.5» 
 
Henry C. Lea's Publications— {Mat. Med. and Therapeutics). 13 
 
 Q.RIFFITH (ROBERT E.), M.D. 
 
 A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
 ing and Administering Officinal and other Medicines. The whole adapted to Physician? and 
 Pharmaceutists. Third edition, thoroughly revised, with numerous additions, tn John M. 
 Maisgh, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 
 and handsome octavo volume of about 800 pages, cloth, $4 50 ; leather, $5 50. (Just Issited ) 
 
 This work has long been known for the vast amount of information which it presents in a con- 
 densed form, arranged for easy reference. The new edition has received the most careful revi- 
 sion at the competent hands of Professor Maisch, who has brought the whole up to the standard of 
 fche most recent authorities. More than eighty new headings of remedies have been introduced, 
 the entire work has been thoroughly remodelled, and whatever has seemed to be obsolete has been 
 omitted. As a comparative view of the United States, the British, the German, and the French 
 Pharmacopoeias, together with an immense amount of unofficinal formulas, it affords to the prac- 
 titioner and pharmaceutist an aid in their daily avocations not to be found elsewhere, while three 
 indexes, one of "Diseases and their Remedies," one of Pharmaceutical Names, and a General 
 Index, afford an easy key to the alphabetical arrangement adopted in the text. 
 
 The young practitioner will find the work invalu- j 
 % eligible modes of administering i 
 Am. Joury,. of Pkarm., Feb. 1874. 
 
 Our copy of Griffith's Formulary, after long use, 1 
 first in the dispensing shop, and afterwards in our J 
 medical practice, had gradually fallen behind in the I 
 onward march of materia medica, pharmacy, and 
 therapeutics, until we had ceased to consult it as a I 
 daily book of reference. So completely has Prof. 
 Maisch reformed, remodelled, and rejuvenated it in 
 the new edition, we shall gladly welcome it back fco 
 ourtable again beside Dunglison, Webster, and Wood 
 & Backe. The publisher could not have been more 
 fortunate in the selection of an editor. Prof. Maisch 
 is eminently the. man for the woi-k, and he has done 
 it thoroughly and ably. To enumerate the altera- 
 tions, amendments, and additions would be an end- 
 Less task; everywhere we are greeted with the evi- 
 dences of his labor. Following the Formulary, is an 
 addendum of useful Recipes, Dietetic Preparations, 
 List of Incompp.tibles, Posological table, table of 
 Pharmaceutical Names, Officinal Preparations and 
 Directions, Poisons, Antidotes, and Treatment, and 
 copious indices, which afford ready access to all parts 
 of the work. We unhesitatingly commend the book 
 as being the best of its kind, within our knowledge. 
 — Atlanta Med. and Stcrg. Journ,^ Feb. 1874, 
 
 able in suggest 
 many remedies. 
 
 To the druggist a good formulary is simply indis- 
 pensable, and perhaps no formulary has been mire 
 extensively used than the well-known work before 
 us. Many physiciaus have to officiate, also, as drug- 
 gists This is true especially of the country physi- 
 cian, and a work which shall teach him the means 
 by which to administer or combine his remedies in 
 the most efficacious and pleasant manner, will al- 
 ways hold its place upon his shelf. A formulary of 
 this kind is of benefit also to the city physician in 
 largest practice.— Cincinnati llinic, Feb. 21, 187-t. 
 
 The Formulary has already proved itself accepta- 
 ble to the medical profession, and we do not hesitate 
 to say that the third edition is much improved, and 
 of greater practical value, in consequence of the care- 
 ful revision of Prof Maisch.— Chicago* Med. Exam- 
 iner, March 15, 1874. 
 
 A more complete formulary than it is in its pres- 
 ent form the pharmacist or physician could hardly 
 desire. To the first some such work is indispensa- 
 ble, and it is hardly less essential to the practitioner 
 who compounds his own medicines. Much of what 
 is coutained in the introduction ought to be com- 
 mitted to memory by every student of medicine. 
 As a help to physieians it will be found invaluable, 
 and doubtless will make its way into libraries not 
 already supplied with a standard work of the kind. 
 — The American Practitioner, Louisville, July, '7-L 
 
 fJLLIS {BENJAMIN), M.D. 
 
 THE MEDICAL FORMULARY: being a Collection of Prescriptions 
 
 derived from the writings and practice of many of the most eminent physicians of America 
 and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
 whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
 tion, carefully revised and much improved by Albert H. Smith, M. 2X la one volume 8v@. 
 of 376 pages, cloth, $3 00. 
 
 13EREIRA [JONATHAN), M.D., F.R.S. and L.S. 
 X MATERIA MEDICA AND THERAPEUTICS; being an Abridg- 
 
 ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with 
 the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
 Druggists, Medical and Pharmaceutical Students, <fec. By F. J. Farrk, M.D., Senior 
 Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia ; 
 assisted by Robert Bbktlev, M.R.C.S., Professor of Materia Medica and Botany to the 
 Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S. , Chemical 
 Operator to the Society of Apothecaries. With numerous additions and references to the 
 United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
 University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
 printed pages, with 236 illustrations, cloth, $7 00; leather, raised bands, $8 00. 
 
 D HNGLISON'S NEW REMEDIES, WITH FORMULA 
 FOR THEIR PREPARATION AND ADMINISTRA- 
 TION. Seventh edition, with extensive additions. 
 One vol. 8vo., pp. 770; cloth. $4 00. 
 
 WHAT TO GBSERVE AT THE BEDSIDE AND AFTEE 
 Death is Medical Cases. Published under the 
 authority of the London Society for Medical Obser- 
 ration. From the second London edition. 1 vol. 
 royal 12mo,, cloth. $1 00. 
 
 I '•HRIoTISON'S DISPENSATORY. With copious ad 
 -H.ir.TiB, and 213 large wood-GnKra^nsrs By R 
 Eglesfeld Griffith, M.D. One vol. 8vo., pp. 1000 
 
 i cloth. $4 00. 
 
 j CARPENTER'S PRIZE ESSAY ON THE USE OF 
 Alcoholic Liquors in Health and Disease. New 
 edition, with a Preface by D. F. Condie, M.D., and 
 explanations of scientific words. In one neat 12mo. 
 
 1 volume, pp. 178, cloth. 60 cents. 
 
14 
 
 Henry C. Lea's Publications— (Pathology, &c). 
 
 J>RUNTON (T. LAUDER), 31. D., 
 
 -&-* Lecturer on Materia Medica and Therapeutics at St. Bartholorntw's Hospital, &c. 
 
 A MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 
 
 INCLUDING THE PHARMACY, THE PHYSIOLOGICAL ACTION, AND THE THE- 
 RAPEUTICAL USES OF DRUGS. In one neat octavo volume. {Preparing.) 
 
 JPENW1CK {SAMUEL), M.D,, 
 
 ■*- Assistant Physician to the London Hospital. 
 
 THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 
 
 Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
 In one very handsome volume, royal 12mo., cloth, $2 25. (Jnst Iss7ied.) 
 
 Of the many guide-books on medical diagnosis, 
 claimed to be written for the special instruction of 
 students, this is the best. The author is evidently a 
 well-read and accomplished physician, and he knows 
 how to * each practical medicine. The charm of sim- 
 plicity is not the least interestiugfeatnrein the man- 
 ner in which Dr. Fenwick conveys instruction. There 
 are few books of this size on practical medicine that 
 contain so much and convey it so well as the volume 
 before us. It is a book we can sincerely recommend 
 to the student for direct instruction, and to the prac- 
 titioner as a ready and useful aid to his memory.— 
 Am. Journ. of Syphilography, Jan. 1874. 
 
 It covers the ground of medical diagnosis in a con- 
 
 cise, practical manner, well calculated to assist the 
 student in forming a correct, thorough, and system- 
 atic method oi f examination and diagnosis of disease. 
 The illustrations are numerous, and finely executed. 
 Those illustrative of the microscopic appearance of 
 morbid tissue, &c, are especially clear and distinct. 
 — Chicago Med. Examiner, Nov. 2673. 
 
 So far superior to any offered to students that the 
 colleges of this country should recommend it to their 
 respective classes. — y. O. Med. and Surg. Journ., 
 March, 1874. 
 
 This little book ought to be in the possession ol 
 every medical student. — Boston Medical and Surg. 
 Journ., Jan. 15, 1S74. 
 
 o 
 
 RE EN (T. HENRY), M.D., 
 
 Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School. 
 
 PATHOLOGY AND MORBID ANATOMY. With numerous Illus- 
 trations on Wood. In one very handsome octavo volume of over 250 pages, cloth, $2 50. 
 {Lately Published.) 
 
 thology and morbid anatomy. The author shows that 
 he has been not only a student of the teachings of his 
 confreres in this branch of science, but a practical 
 and conscientious laborer in the post-mortem cham- 
 ber. The work will provea useful one to the great 
 mass of students and practitioners whose time for de- 
 votion to this class of studies is limited.— Am. Journ. 
 of Syphilography, April, 3872. 
 
 We have been very much pleased by our perusal of 
 this little volume. It is the only one of the kind with 
 which we are acquainted, and practitioners as well 
 as students will find it a very useful guide ; for the 
 information is up to the day, well and compactly ar- 
 ranged, without being at all scanty.— London Lmn- 
 eet, Oct. 7, 1871. 
 
 It embodies in a comparatively small space a clear 
 statement of the present state of our knowledge of pa- 
 
 GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 
 Translated, with Notes and Additions, by Joseph 
 Leidy, M. D. In one volume, very large imperial 
 quarto, with 320 copper-plate figures, plain and 
 colored, cloth. $4 00. 
 
 LA ROCHE ON YELLOW FEVER, considered in its 
 Historical, Pathological, Etiological, and Therapeu- 
 tical Relations. In two large and handsome octavi 
 volumes of nearly 1500 pages, cloth. $7 00. 
 
 HOLLAND'S MEDICAL NOTES AND REFLEC- 
 TIONS. 1 vol. 8vo., pp. 500, cloth. $3 60. 
 
 LAYCOCK'S LECTURES ON THE PRINCIPLES 
 and Methods of Medical Observation and Re- 
 search. For the use of advanced students and 
 j unior practitioners. In one 'very ueat royal 12mc . 
 volume, cloth. $1 00. 
 
 BARLOW'S MANUAL OF THE PRACTICE OF 
 MEDICINE. With Additions by D. F. Cosdib, 
 M D. 1 vol. 8vo., pp. 600, cloth. $2 50. 
 
 TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 
 Diseases. In one neat octavo volume, of 320 pagea, 
 cloth. $2 60. 
 
 S 
 
 TURGES {OGTAVIUS), M.D. Cantab., 
 
 Fellow of the Royal College of Physicians, &-c. <fre. 
 
 AN INTRODUCTION TO THE STUDY OP CLINICAL MED- 
 ICINE. Being a Guide to the Investigation of Disease, for the Use of Students. Id one 
 handsome 12mo. volume, cloth, $1 25. {Litely Issued.) 
 
 T)AYIS [NATHAN S.), 
 
 -U Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 
 
 CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES ; 
 
 being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
 pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
 handsome royal 12mo. volume. Cloth, $1 75. {Lately Issued.) 
 
 VTOKES (WILLIAM), M.D., D.C.L., F.R.S., 
 
 *-J Regius Professor of Physic in the Univ. of I>xiblin, See. 
 
 LECTURES ON FEVER, delivered in the Theatre of the Meath Hos- 
 pital and County of Dublin Infirmary. Edited by John William Moore, M.D , Assistant 
 Physician to the Cork Street Fever Hospital. In one neat octavo volume. {Preparing.) 
 #*^ To appear in the •' Medical News and Library" for 1875. 
 
Henry C. Lea's Publications— {Practice of Medicine). 
 
 15 
 
 IjfLINT {AUSTIN), M.D., 
 
 «». Professor of the Principles and Practice of Medicine in Belleuue Med. College, N. Y. 
 
 A TREATISE ON THE PRINCIPLES AND PRACTICE OF 
 
 MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 
 
 edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 
 
 pages ; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. {Just Issued.) 
 
 By common consent of the English and American medical press, this work has been assigned 
 
 6o the highest position as a complete and compendious text-book on the most advanced condition 
 
 of medical science. At the very moderate price at which it is offered it will be found one of the 
 
 cheapest volumes now before the profession. A few notices of previous editions are subjoined. 
 
 Western Journal of 
 
 Admirable and unequalled 
 Medicine, Nov. 1869. 
 
 Dr. Flint's work, though, claiming no higher title 
 than that of a text-book, is really more. He is a man 
 of large clinical experience, and his book is full of 
 «uch masterly descriptions of disease as can only be 
 
 excellently printed and bound — and we encounter 
 that luxury of America, the ready-cut pages, which 
 the Yankees are 'cute enough- to insist upon — nor are 
 these by any means trifles ; but the contents of the 
 book are astonishing. Not only is it wonderful that 
 any one man can have grasped in his mind the whole 
 
 drawn by a man intimately acquainted with their j scope of medicine with that vigor which Dr. Flint 
 various forms. It is not so long since we had the j 3hows, but the condensed yet clear way in which 
 pleasure of reviewing his first edition, and we recog- j tn i g is done is a perfect literary triumph. Dr. Flint 
 aize a great improvement, especially in the general 1 * s pre-eminently one of the strong men, whose right 
 part of the work. It is a work which we can cordially ] to do this kind of thing is well admitted ; and we say 
 recommend to our readers as fully abreast of the sci- j no more than the truth when we affirm that he is 
 sa.ce of the day. — Edinburgh Med. Journal, Oct. '69. j very nearly the only living man that could do it with 
 
 One of the best works of the kind for the practi- i such results as the volume before vs.— The London 
 fcioner, and the most convenient of ail for the student. Practitioner, March, 1869 
 «~Am. Journ. Med. Sciences, Jan. 1869. 
 
 This work, which stands pre-eminently as the ad- 
 vance standard of medical science up to the present 
 &ime in the practice of medicine, has for its author 
 one who is well and widely known as one of the 
 leading practitioners of this continent. In fact, it is 
 seldom that any work is ever issued from the press 
 more deserving of universal recommendation. — Bo- 
 minion Med. Journal, May, 1869. 
 
 The third edition of this most excellent book scarce- 
 ly needs any commendation from us. The volume, 
 &s it stands now, is really a marvel : first of all, it is 
 
 This is in some respects the best text-book of medi- 
 cine in our language, and it is highly appreciated on 
 the other side of the Atlantic, inasmuch as the first 
 8dition was exhausted in a few months. The second 
 sdition was little more than a reprint, but the present 
 has, as the author says, been thoroughly revised. 
 Much valuable matter has been added, and by mak- 
 ing the type smaller, the bulk of the volume is not 
 much increased. The weak point in many American 
 works is pathology, but Dr. Flint has taken peculiar 
 pains on this point, greatly to the value of the book, 
 —London Med. Times and Gazette, Feb. 6, 1869. 
 
 £>F THE SAME AUTHOR. 
 
 ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 
 
 TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. {Just Issued.') 
 
 CONTENTS. 
 I. Conservative Medicine.- II. Conservative Medicine as applied to Therapeutics. III. Con- 
 servative Medicine as applied to Hygiene. IV. Medicine in the Past, the Present, and the Fu- 
 ture. V. Alimentation in Disease. VI. Tolerance of Disease. VII. On the Agency of the 
 Mind in EtiolGgy, Prophylaxis, and Therapeutics. VIII. Divine design as exemplified in th© 
 Natural History of Disease. 
 
 TXTATSON {THOMAS), M. D., frc. 
 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF 
 
 PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
 vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
 ations, by Henry Hartshgrne, M.D., Professor of Hygiene in the University of Pennsylv- 
 nia. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Published.) 
 
 rare combination of great scientific attainments com- 
 bined with wonderful forensic eloquence has exerted 
 
 It is a subject for congratulation and for thankful- 
 ness that Sir Thomas Watson, during a period of com- 
 parative leisure, after a long, laborious, and most 
 honorable professional career, while retaining full 
 possession of his high mental faculties, should have 
 employed the opportunity to submit his Lectures to 
 a more thorough revision than was possible during 
 the earlier and busier period of his life. Carefully 
 passing in review some of the most intricate and im- 
 portant pathological and practical questions, there- 
 suits of his clear insight and his calm judgment are 
 now recorded for the benefit of mankind, in language 
 which, for precision, vigor, aud classical elegance, has 
 rarely been equalled, and never surpassed The re- 
 vision has evidently been caost earefully done, and 
 the results appear in almost every page. — Brit. Med. 
 Journ., Oct. 14, 1871. • 
 
 The lectures are so well known and so justly 
 appreciated, that it is scarcely necessary to do 
 more than call attention to the special advantages 
 of the last over previous editions. The author's 
 
 extraordinary influence over the last two generations 
 of physicians. His clinical descriptions of most dis- 
 eases have never been equalled ; and on this score 
 at least his work will live long in the future. The 
 work will be sought by all who appreciate a great 
 book. — Araer. Journ. of Syphilography, July, 1872. 
 We are exceedingly gratified at the reception of 
 this new edition of Watson, pre-eminently the prince 
 of English authors, on "Practice." We, who read 
 the first edition shall never forget the great pleasure 
 and profit we derived from its graphic delineations 
 of disease, its vigorous style and splendid English. 
 Maturity of years, extensive observation, profound 
 research, and. yet continuous enthusiasm, have com- 
 bined to give us in this latest edition a model of pro- 
 fessional excellence in teaching with rare beauty in 
 the mode of communication. But this classic needs 
 no eulogium of ours.— Chicago Med. Journ., July, 
 1872. 
 
 ryUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
 ^THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising 
 
 Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, 
 Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal 
 octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, 
 $15; cloth, $1.1. 
 
16 
 
 Hbney C. Lea's Publications — (Practice of Medicine), 
 
 ffARTSHORNE {HENRY), M.D., 
 
 ■"■J. Professor of Hygiene in the University of Pennsylvania. 
 
 ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MED1- 
 
 CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- 
 proved. With about one hundred illustrations. In one handsome royal 32nio. volame, 
 of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Just Issued.) 
 The thorough manner in which the author has labored to fully represent in this favorite hand- 
 book the most advanced condition of practical medicine is shown by the fact that the pregent 
 edition contains more thnn 250 additions, representing the investigations of 172 authors not re- 
 ferred to in previous editions. Notwithstanding an enlargement of the page, the size has been 
 increased by sixty pages. A number of illustrations have been introduced which it is hoped 
 will facilitate the comprehension of details by the reader, and no effort has been spared to make 
 the volume worthy a continuance of the very great favor with which it has hitherto been received. 
 
 The work is brought fully up with all the recent 
 advances in medicine, is admirably condensed, and 
 yet sufficiently explicit for all the purposes intended, 
 thus making it by far the best work of its character 
 ever published.— Cincinnati Clinic, Oct. 24, 1874. 
 
 We have already had occasion to notice the previ- 
 ous editionsof thiswork. It is excellent of its kind. 
 The author has given a very careful revision, in view 
 of the rapid progress of medical seience.— N. Y. Med. 
 Journ., Nov. 1874. 
 
 Without doubt the best book of the kind published 
 in the English language. — St. Louis Med. and Surg, 
 Journ., Nov. 1874. 
 
 As a handbook, which clearly sets forth the essen- 
 tials Of the PRINCIPLES AND PRACTICE OP MEDICINE, W8 
 
 do not know of its equal.— Va. Med. Monthly. 
 
 As a brief, condensed, but comprehensive hand- 
 book, it cannot be improved upon. — Chicago Med. 
 Examiner, Nov. 35, 1874. 
 
 pAVY{F. W.),M.D.,F.R.S. t 
 
 ■M- Senior Asst. Physician to and Lecturer on Physiology, at €her/s Hospital, &n. 
 
 A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- 
 
 ders and their Treatment. From the second London edition. In one handsome volum*, 
 small octavo, cloth, $2 00. 
 jyY THE SAME AUTHOR. (Just /«*««?.) 
 
 A TREATISE ON FOOD AND DIETETICS, PHYSIOLOGI- 
 CALLY AND THERAPEUTICALLY CONSIDERED. In one handsome octavo volume 
 of nearly 600 pages, cloth, $4 75. 
 
 SUMMARY OF CONTENTS. 
 
 Introductory Remarks on the Dynamic Relations of Food — On the Origination of Food — The 
 Constituent Relations of Food — Alimentary Principles, their Classification, Chemical Relati ons. 
 Digestion, Assimilation, and Physiological Use3 — Nitrogenous Alimentary Principles — Non- Ni- 
 trogenous Alimentary Principles — The Carbo-Hydrates — The Inorganic Alimentary Principles — 
 Alimentary Substances — Animal Alimentary Substances — Vegetable Alimentary Substances — 
 Beverages — Condiments — The Preservation of Food — Principles of Dietetics — Practical Dietetics 
 — Diet of Infants — Diet for Training — Therapeutic Dietetics — Dietetic Preparations for the Inva- 
 lid — Hospital Dietaries. 
 
 ftHAMBERS {T. K.), M.D., ~~~ 
 
 ^J Consulting Physician to St. Mary's Hospital, London, &e. 
 
 A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- 
 
 NESS. In one handsome octavo volume. Cloth, $2 75. (Now Ready.) 
 
 convey his meaning in the fewest possible words, he 
 is certainly unexcelled and rarely equalled by any 
 writer ia the English language. It is altogether a 
 work of rare excellence, and should, as it doubtless* 
 will, speedily find a place on the table of ©very phy- 
 sician. — TheN. Y. Sanitarian, June, 1S75. 
 
 Thiswork is a substantial addition to our standard 
 works, and not only should the neat little volume 
 find a place in tbe most restricted libraries, bat its 
 contents ought to be read, marked, learned, and in- 
 wardly digested by each practitioner, mntil they 
 have become woven into the web of the ordinary 
 ©very-day thought of all medical men who traly love 
 their profession. — Land. Praiiitioner, June, 183&. 
 
 In compiling this small but comprehensive manual 
 Dr. Chambers has laid the profession under a debt 
 of gratitude to him. Rewrites on the subject like 
 one who has given his mind to it, and therefore is 
 entitled to speak with authority. As a pioneer, Dr. 
 Chambers deserves much credit ; he has opened up a 
 new field of which others will no doubt avail them- 
 selves. Taken altogether, this work is one which 
 gives, in an agreeable form, much valuable informa- 
 tion on a most important subject, and ought to have 
 a large sale both in the profession and out of it. — 
 London Med. Record, May 19, 1875. ' 
 
 In thorough mastery of the subjects uponwhieb. he 
 writes, and in the happy command of language to 
 
 J>Y THE SAME AUTHOR. (Lately Published.) 
 
 RESTORATIVE MEDICINE. An Harveian Annual Oration. 
 
 Two Sequels. In one very handsome volume, small 12mo., cloth, $1 00. 
 
 With 
 
 -nRINTON {WILLIAM), M.D., F.R.S. 
 ^LECTURES ON THE DISEASES OF THE STOMACH; with an 
 
 Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
 tion. With illustrations on wood In one handsome octavo volume of about 300 pages 
 
 oloth, $3 25. „____ 
 
 POX { WILSON), M.D., 
 
 -*■ Holme Prof, of Clinical Med., University Coll., London. 
 
 THE DISEASES OF THE STOMACH: Being the Third Edition of 
 
 the "Diagnosis and Treatment of the Varieties of Dyspepsia " Revised and Enlarged. 
 With illustrations. In one handsome octaYo yoUime 3 cloth s $2 00, (Just Issued*) 
 
Henry C. Lea's Publications. 
 
 17 
 
 J^LINT [AUSTIN), M.D., 
 
 -*■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 
 
 A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 
 
 AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
 edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 
 
 Dr. Flint chose a difficult subject for his researches, 
 and has shown remarkable powers of observation 
 and reflection, as well as great industry, in his treat- 
 ment of it. His book must be considered the fullest 
 and clearest practical treatise on those subjects, and 
 should be in the hands of all practitioners and stu- 
 dents. It is a credit to American medical literature. 
 — Amer. Journ. of the Med. Sciences, July, 1860. 
 
 We question the fact of any recent American author 
 In our profession being more extensively known, or 
 more deservedly esteemed in this country than Dr. 
 Flint. We willingly acknowledge his success, more 
 particularly in the volume on diseases of the heart, 
 in making an extended personal clinical study avail- 
 
 able for purposes of illustration, in connection with 
 cases which have been reported by other trustworthy 
 observers. — Brit, and For. Med.-Chirttrg. Review. 
 
 In regard to the merits of the work, we have no 
 hesitation in pronouncing it full, accurate, and judi- 
 cious. Considering the present state of science, such 
 a work was much needed. It should be in the hands 
 of every practitioner. — Chicago Med. Journ. 
 
 With more than pleasure do we hail the advent of 
 this work, for it fills a wide gap on the list of text- 
 books for our schools, and is, for the practitioner, the 
 most valuable practical work of its kind. — N. 0. Med. 
 News. 
 
 f>¥ THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
 TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
 RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
 of 595 pages, cloth, $4 50. 
 
 Dr. Flint's treatise is one of the most trustworthy 
 guides which we can consult. The style is clear and 
 distinct, and is also concise, being free from that tend- 
 ency to over-refinement and unnecessary minuteness 
 which characterizes many works on the same sub- 
 ject.— Dublin Medical Press, Feb. 6, 1867. 
 
 The chapter on Phthisis is replete with interest ; 
 and his remarks on the diagnosis, especially in the 
 early stages, are remarkable for their acumen and 
 great practical value. Dr. Flint's style is ciear and 
 elegant, and the tone of freshness and originality 
 
 which pervades his whole work lend an additional 
 force to its thoroughly practical character, which 
 cannot fail to obtain for it a place as a standard work 
 on diseases of the respiratory system. — London 
 Lancet, Jan. 19, 1867. 
 
 This is an admirable book. Excellent in detail and 
 execution, nothing better could be desh-ed by the 
 practitioner. Dr. Flint enriches his subject with 
 much solid and not a little original observation.— 
 Ranking 1 s Abstract, Jan. 1867. 
 
 JDT THE SAME AUTHOR. (Ju«t Ready.) 
 
 PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
 ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
 MENT, AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
 Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
 College, New York. In one handsome octavo volume 
 
 This volume, containing the results of the author's extended observation and experience on a 
 subject of prime importance, cannot but have a claim upon the attention of every practitioner. 
 
 JPULLER [HENRY WILLIAM), M. D., 
 
 -*■ P7iysicia?i to St. George 1 s Hospital, London. 
 
 ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 
 
 Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
 English edition. In one handsome octavo volume of about 500 pages, cloth, $3 50. 
 
 WILLIAMS [G. J. B.), M.D., 
 
 Senior Consulting Physician to the Hospital for Consumption, Brompton, and 
 
 'WILLIAMS [CHARLES T.), M.D., 
 
 Physician to the Hospital for Consumption. 
 
 
 PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- 
 ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat 
 octavo volume of about 350 pages, cloth, $2 50. (Lately Published.) 
 
 He can still speak from a more enormous experi- 
 ence, and a closer study of the morbid processes in- 
 volved iu tuberculosis, than most living men. He 
 owed it to himself, and to the importance of the sub- 
 ject, to embody his views in a separate work, and 
 we are glad that he has accomplished this duty. 
 
 After all, the grand teaching which Dr Williams has 
 for the profession is to be found in his therapeutical 
 chapters, and in the history of individual cases ex- 
 tended, by din t of care, over ten, twenty, thirty, and 
 aven forty years. — London Lancet, Oct. 21, 1871. 
 
 LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, 
 
 of 500 pages . Price $3 00. 
 SMITH ON CONSUMPTION ; ITS EARLY AND RE 
 
 MEDIABLE STAGES. 1 vol. 8vo., pp. 254. $2 26. 
 
 WALSHE ON THE DISEASES OF THE HEART AND 
 GREAT VESSELS. Third American edition. In 
 1 vol. 8vo., 420 pp., cloth. $3 00. 
 
18 
 
 Henry C. Lea's Publications — {Practice of Medicine). 
 
 ROBERTS ( WILLIAM), M. D., 
 
 •*•*' Lecturer on Medicine in the Manchester School of Medicine, &c. 
 
 A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 
 
 EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
 ond American, from the Second Revised and Enlarged London Edition. In one large 
 and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately 
 Published.) 
 The author has subjected this work to a very thorough revision, and has sought to embody in 
 it the results of the latest experience and investigations. Although every effort has been made 
 to keep it within the limits of its former size, it has been enlarged by a hundred pages, many 
 new wood-cuts have been introduced, and also a colored plate representing the appearance of the 
 different varieties of urine, while the price has been retained at the former very moderate rate. 
 
 diseases we have examined. It is peculiarly adapted 
 
 The plan, it will thus be seen, is very complete, 
 and the manner in which it has been carried out is 
 in the highest degree satisfactory. The characters 
 of the different deposits are very well described, and 
 the microscopic appearances they present are illus- 
 trated by numerous well executed- engravings. It 
 only remains to us to strongly recommend to our 
 readers Dr. Roberts's work, as containing au admira- 
 ble resume of the present state of knowledge of uri- 
 nary diseases, and as a safe and reliable guide to the 
 clinical observer. — Edin. Med. Jour. 
 
 The most complete and practical treatise upon renal 
 
 to the wants of the majority of American practition- 
 ers from its clearness and simple announcement of the 
 facts in relation to diagnosis and treatment of urinary 
 disorders, and contains in condensed form the investi- 
 gations of Beuce Jones, Bird, Beale, Hassall. Prout, 
 and a host of other well-known writers upon this sub- 
 ject. The characters of urine, physiological and pa- 
 thological, as indicated to the naked eye as well as by 
 microscopical and chemical investigations, are con- 
 cisely represented both by description and by well 
 executed engravings. — Cincinnati Journ. of Med. 
 
 jyASHAM ( W. R.), M. D., 
 
 ■*-* Senior Physician to the Westminster Hospital, &c. 
 
 RENAL DISEASES : a Clinical Guide to their Diagnosis and Treatment. 
 
 With illustrations. In one neat royal 12mo. volume of 304 pages, cloth, $2 00. 
 
 details of larger books here acquire a new interest 
 from the author's arrangement. This part of the 
 book is full of good work. — Brit, and For. Medico- 
 Ihirurgical Review, July, 1870. 
 
 The chapters on diagnosis and treatment are very 
 good, and the student and young practitioner will 
 find them full of valuable practical hints. The third 
 part, on the urine, is excellent, and we cordially 
 recommend its perusal. The author has arranged 
 his matter in a somewhat novel, and, we think, use- 
 ful form. Here everything can be easily found, and, 
 what is more important, easily read, for all the dry 
 
 The easy descriptions and compact modes of state- 
 ment render the book pleasingand convenient. — Am. 
 Journ. Med. Sciences, July, 1870. 
 
 INCOLN (D. F.). 31. D., 
 
 Physician to the Department of Nervous Diseases, Boston Dispensary. 
 
 ELECTRO THERAPEUTICS; 4 Concise Manual of Medical Electri- 
 city. In one very neat royal 12mo. volume, cloth, with illustrations, $1 50. (Just Issued.) 
 
 The work is convenient in size, its descriptions of 
 methods and appliances are sufficiently complete for 
 the general practitioner, and the chapters on Electro- 
 physiology and diagnosis are well written and read- 
 able. For those who wish a handy-book of directions 
 for the employment of galvanism in medicine, this 
 will serve as a very good and reliable guide. — New 
 Remedies, Oct. 1874. 
 
 It is a well written work, and calculated to meet 
 the demands of the busy practitioner. It contains 
 the latest researches in this important branch of med- 
 icine. — Peninsular Journ. of Med., Oct. 1S74. 
 
 Eminently practical in character. It will amply 
 repay any one for a careful perusal. — Leavenworth 
 Med. Herald, Oct. 1874. 
 
 This little book is, considering its size, one of the 
 very best of the English treatises on its subject that 
 has come to our notice, possessing, among others, the 
 rare merit of dealing avowedly and actually with 
 principles, mainly, rather than with practical details, 
 thereby supplying a real waut, instead -of helping 
 merely to flood the literary market. Dr. Lincoln's 
 style is usually remarkably clear, and the whole 
 book is readable and interesting. — Boston Med. and 
 Surg. Journ., July 23, 1874. 
 
 We have here in a small compass a great deal of 
 valuable information upon the subject of Medical 
 Electricity. — Canada Med. and Surg. Journ.. Nov. 
 1874. 
 
 L 
 
 EE [HENRY), 
 
 Prof, of Surgery at the Royal College of Surgeons of England, etc. 
 
 LECTURES ON SYPHILIS AND ON SOME FORMS OP LOCAL 
 
 DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one 
 
 handsome octavo volume : cloth; $2 25. (Now Ready.) 
 CONTENTS. 
 
 Lectures I., II., III. General. — IV. Treatment of Syphilis — V. Treatment of Particular 
 and Modified Syphilitic Affections — VI. Second Stage of Lues Venerea; Treatment — VII. Lo- 
 cal Suppurating Venereal Sore; Syphilization ; Lymphatic Absorption ; Physiological Absorp- 
 tion ; Twofold Inoculation — VIII. Urethral Discharges : different kinds ; Treatment; Conclu- 
 sions of Hunter and Ricord — IX. Prostatic Discharges — X. Lymphatic Absorption continued ; 
 Local Affections ; Warts and Excrescences. 
 
 DIPHTHERIA ; its Nature and Treat -nent, with an 
 account of the History of its Prevalence in vari- 
 ous Countries. By D. D. Slade, M.D. Second and 
 revised edition. In one neat royal 12mo. volume, 
 cloth, $1 25. 
 
 LECTURES ON THE STUDY OF FEVER. By A. 
 Hudson, M.D., M.R.I.A., Physician to the Meath 
 Hospital. In one vol. 8vo., cloth, $2 50. 
 
 A TREATISE ON FEVER. By Robert D. Lyons, 
 K C C. In one octavo volume of 362 pages, cloth, 
 $2 25. 
 
 CLINICAL OBSERVATIONS ON FUNCTIONAL 
 NERVOUS DISORDERS ByO. Hanofield Jones, 
 M.D., Physician to St. Mary's Hospital, &c. Sec- 
 ond American Edition. In one handsome octavo 
 volume of 348 pages, cloth, $3 25. 
 
Henry C. Lea's Publications— ( Venereal Diseases, etc.). 
 
 19 
 
 T>UMSTEAD {FREEMAN J.), M.D., 
 
 J~* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 
 
 THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
 
 EASES. Including the results of recent investigations upon the subject. Third edition, 
 
 revised and enlarged, with illustrations. In one large and handsome octavo volume of 
 
 over 700 pages, cloth, $5 00 ; leather, $6 00. 
 
 In preparing this standard work again for the press, the author has subjected it to a very 
 
 thorough revision. Many portions have been rewritten, and much new matter added, in order to 
 
 bring it completely on a level with the most advanced condition of syphilograpby, but by careful 
 
 compression of the text of previous editions, the work has been increased by only sixty-four pages. 
 
 The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a 
 
 complete and trustworthy guide for the practitioner. 
 
 It is the most complete book with which we are ac- 
 quainted in the language. The latest views of the 
 best authorities are put forward, and the information 
 Is well arranged — a great point for the student, and 
 still more for the practitioner. The subjects of vis- 
 ceral syphilis, syphilitic affections of the eyes, and 
 the treatment of syphiiis by repeated inoculations, are 
 very fully discussed. — London Lancet, Jan. 7, 1871. 
 
 Dr. Bumstead's work is already so universally 
 known as the best treatise in the English language on 
 venereal diseases, that it may seem almost superflu- 
 ous to say more of it than that a new edition has been 
 Issued. But the author's industry has rendered this 
 new edition virtually a new work, and so merits as 
 
 (1ULLERIER (A.), and 
 
 ^•S Surgeon to the Hdpital du Midi. 
 
 much special commendation as if its predecessors had 
 not been published. As a thoroughly practical book 
 on a class of diseases which form a large share of 
 nearly every physician's practice, the volume before 
 us is bv far the best of which we have knowledge. — 
 N. Y. Medical Gazette, Jan. 28, 1871. 
 
 It is rare in the history of medicine to find any one 
 book which contains all that a practitioner needs to 
 know; while the possessor of "Bumstead on Vene- 
 real" has no occasion to look outside of its covers for 
 anything practical connected with the diagnosis, his- 
 tory, or treatment of these affections. — N. Y. Medical 
 Journal, March, 1871. 
 
 J?UMSTEAD [FREEMAN J.), 
 
 -*-* Professor of Venerea I Diseases in the College of 
 Physicians and Surgeons, N. Y. 
 
 AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 
 
 Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
 with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
 life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 
 per part. 
 Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
 lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
 tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
 A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
 
 We wish for once that our province was not restrict- 
 ed to methods of treatment, that we might say some- 
 thing of the exquisite colored plates in this volume. 
 —London Practitioner, May, 1869. 
 
 As a whole, it teaches all that can be taught by 
 means of plates and print. — London Lancet, March 
 13, 1869. 
 
 Superior to anything of the kind ever before issued 
 on this continent.— Canada Med. Journal, March, '69. 
 
 The practitioner who desires to understand this 
 branch of medicine thoroughly should obtain this, 
 the most complete and best work ever published.— 
 Dominion Med. Journal, May, 1869. 
 
 This is a work of master hands on both sides. M. 
 Cullerier is scarcely second to, we think we may truly 
 say is a peer of the illustrious and venerable Ricord, 
 while in this country we do not hesitate to say that 
 Dr. Bumstead, as an authority, is without a rival. 
 Assuring our readers that these illustrations tell the 
 whole history of venereal disease, from its inception 
 to its end, we do not know a single medical work, 
 
 which for its kind is more necessary for them to have. 
 —California Med. Gazette, March, 1869. 
 
 The most splendidly illustrated work in the lan- 
 guage, and in our opinion far more useful than the 
 French original. — Am. Journ. Med. Sciences, Jan. '69. 
 
 The fifth and concluding number of this magnificent 
 work has reached us, and we have no hesitation in 
 saying that its illustrations surpass those of previous 
 numbers. — Boston Med. and Surg. Journal, Jan. 14, 
 1869. 
 
 Other writers besides M. Cullerier have given us a 
 good account of the diseases of which he treats, but 
 no one has furnished us with such a complete series 
 of illustrations of the venereal diseases. There is, 
 however, an additional interest and value possessed 
 by the volume before us ; for it is an American reprint 
 and translation of M. Cullerier's work, with inci- 
 dental remarks by one of the most eminent American 
 syphilographers, Mr. Bumstead. — Brit, and For. 
 Medico-Chir. Review, July, 1869. 
 
 IF 
 
 LL {BERKELEY), 
 
 Surgeon to the Lock Hospital, London. 
 
 ON SYPHILIS AND LOCAL 
 
 one handsome octavo volume ; cloth, $3 
 
 Bringing, as it does, the entire literature of the dis- 
 ease down to the present day, and giving with great 
 ability the results of modern research, it is in every 
 respect a most desirable work, and one which should 
 find a place in the library of every surgeon. — Cali- 
 fornia Med. Gazette, June, 1869. 
 
 Considering the scope of the book and the careful 
 attention to the manifold aspects and details of its 
 subject, it is wonderfully concise. All these qualities 
 render it an especially valuable book to the beginner, 
 
 CONTAGIOUS DISORDERS. In 
 
 25. 
 
 to whom we would most earnestly recommend its 
 study ; while it is no less useful to the practitioner.— 
 St. Louis Med. and Surg. Journal, May, 1869. 
 
 The most convenient and ready book of reference 
 we have met with.— N. Y. Med. Record, May 1, 1869. 
 
 Most admirably arranged for both student and prac- 
 titioner, no other work on the subject equals it ; it is 
 more simple, more easily studied. — Buffalo Med. and 
 Surg. Journal, March, 1869. 
 
 yEISSL (#.), M.D. 
 
 A COMPLETE TREATISE ON VENEREAL DISEASES. Trans- 
 lated from the Second Enlarged German Edition, by Frederic It. Sturgis, M.D In one 
 octavo volume, with illustrations. (Preparing.) 
 
§0 
 
 Henry C. Lea's Publications— (Diseases of the Skin). 
 
 VITILSON {ERASMUS), F.R.S. 
 
 ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 
 
 enth American, from the sixth and enlarged English edition. In one large octavo volume 
 of over 800 pages, $5. 
 
 A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
 EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- 
 teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin } 
 and embracing accurate representations of about one hundred varieties of disease, most of 
 them the size of nature. Price, in extra cloth, $5 50. 
 the Text and Plates, bound in one handsome volume. Cloth, $10. 
 
 and acceptable help. Mr. Wilson has long been held 
 as high authority in this department of medicine, and 
 his book on diseases of the skin has long been re- 
 garded as one of the best text-books extant on the 
 subject. The present edition is carefully prepared, 
 and brought up in its revision to the present time. In 
 ohis edition we have also included the beautiful series 
 of plates illustrative of the text, and in the last edi- 
 tion published separately. There are twenty of these 
 plates, nearly all of them colored to nature, and ex- 
 hibiting with great fidelity the various groups of 
 diseases. — Cincinnati Lancet. 
 
 Also 
 
 No one treating skin diseases should be without 
 a copy of this standard work. — Canada Lancet. 
 
 We can safely recommend it to the profession at 
 the best work on the subject now in existence ir 
 the English language.— Medical Times and Gazette 
 
 Mr. Wilson's volume is an excellent digest of the 
 actual amount of knowledge of cutaneous diseases : 
 it includes almost every fact or opinion of importance 
 connected with the anatomy and pathology of the 
 skin. — British and Foreign Medical Review. 
 
 Such a work as the one before us is a most capital 
 
 j^F THE SAME AUTHOR. 
 
 THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 
 
 eases of the skin. In one very handsome royal 12mo. volume. $3 50. 
 
 fflELIGAN [J. MOORE), M.D., M.R.I. A. 
 
 A PRACTICAL TREATISE ON DISEASES 
 
 OF 
 
 Fifth American, from the second and enlarged Dublin edition by T. 
 In one neat royal 12mo. volume of 462 pages, cloth, $2 25. 
 
 THE SKIN, 
 
 W. Belcher, M.B. 
 
 their value justly estimated; in a word, the work is 
 fully up to the times, and is thoroughly stocked with 
 most valuable information. — New York Med. Record, 
 Jan. 15, 1867. 
 The most convenient manual of diseases of the 
 
 Chicago 
 
 Fully equal to all the requirements of students and 
 young practitioners. — Dublin Med. Press. 
 
 Of the remainder of the work we have nothing be- 
 yond unqualified commendation to offer. It is so far 
 the most complete one of its size that has appeared, 
 
 and for the student there can be none which can com- skin that can be procured by the student, 
 pare with it in practical value. All the late disco- Med. Journal, Dec. 1866. 
 veries in Dermatology have been duly noticed, and 1 
 £ Y THE SAME AUTHOR. 
 
 ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 
 
 volume, with exquisitely colored plates, <tc, presenting about one hundred varieties of 
 disease. Cloth, $5 50. 
 
 The diagnosis of eruptive disease, however, under 
 all circumstances, is very difficult. Nevertheless, 
 Dr. Neligan has certainly, "as far as possible," given 
 a faithful and accurate representation of this class of 
 diseases, and there can be no doubt that these plates 
 will be of great use to the student and practitioner in 
 di'awing a diagnosis as to the class, order, and species 
 to which the particular case may belong. While 
 looking over the "Atlas" we have been induced to 
 examine also the "Practical Treatise," and we are 
 
 inclined to consider it a very superior work, com- 
 bining accurate verbal description with sound views 
 of the pathology and treatment of eruptive disease*. 
 — Glasgow Med. Journal. 
 
 A compend which will very much aid the practi- 
 tioner in this difficult branch of diagnosis. Taken 
 with the beautiful plates of the Atlas, which are re- 
 markable for their accuracy and beauty of coloring, 
 it constitutes a very valuable addition to the library 
 of a practical man. — Buffalo Med. Journal. 
 
 ZJILLIER [THOMAS), M.D., 
 
 ■**•-*■ Physician to the Skin Department of University College Hospital, &c 
 
 HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 
 
 Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. 
 
 Cloth, $2 25. 
 We can conscientiously recommend it to the stu- 
 dent; the style is clear and pleasant to read, the 
 matter is good, and the descriptions of disease, with 
 the modes of treatment recommended, are frequently 
 Illustrated with well-recorded cases. — London Med. 
 Times and Gazette. April 1, 1865. 
 
 It is a concise, plain, practical treatise on the vari- 
 ous diseases of the skin ; just such a work, indeed, 
 as was much needed, both by medical students and 
 practitioners. — Chicago Medical Examiner, May, 
 1865. 
 
 ANDERSON [McCALL), M.D., 
 
 •£*- Physician to the Dispensary for Skin Diseases, Glasgow, &c. 
 
 ON THE TREATMENT OF DISEASES OF THE SKIN. With an 
 
 Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. {Lately Published.) 
 
 GUERSANT'S SURGICAL DISEASES OF INFANTS I DEWEES ON THE PHYSICAL AND MEDICAL 
 AND CHILDREN. Translated by R. J. DtTXGM- TREATMEN'" 'W!H T T.ORlStf El<w„ n th edition. 
 son, M.D. 1 vol. 8vo. Cloth, $2 50. | 1 v©i. Svo. of 548 pages. Cloth, $2 80. 
 
Henry C. Lea's Publications-— (Diseases of Children). 31 
 
 &MITH {J. LE WIS), M. D., 
 
 A-' Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. 
 
 A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 
 
 CHILDREN. Third Edition, revised and enlarged. In one handsome octave volume. 
 (Preparing.) 
 
 From the Preface to the Second Edition. 
 
 In presenting to the profession the second edition of his work, the author gratefully acknow- 
 ledges the favorable reception accorded to the first. He has endeavored to merit a continuance 
 of this approbation by rendering the volume much more complete than before. Nearly twenty 
 additional diseases have been treated of, among which may be named Diseases Incidental to 
 Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, 
 and the various forms of Paralysis. Many new formulae, which experience has shown to be 
 useful, have been introduced, portions of the text of a less practical nature have been con- 
 densed, and other portions, especially those relating to pathological histology, have .been 
 rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid 
 an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of 
 the page, the number of pages has been enlarged by more than one hundred. 
 
 227 West 49th Street, New York, April, 1872. 
 
 The work will be found to contain nearly one-third more matter than the previous edition, and 
 it is confidently presented as in every respect worthy to be received as the standard American 
 text-book on the subject. 
 
 Eminently practical as well as judicious in its 
 teachings. — Cincinnati Lancet and Ohs., July, 1872. 
 
 A standard work that leaves little to be desired. — 
 Indiana Journal of Medicine, July, 1872. 
 
 We know of no book on tbis subject that we can 
 more cordially recommend to the medical student 
 and thepractitioner.— Cincinnati Clinic, June 29, '72. 
 
 We regard it as superior to auy other single work 
 on the diseases of iufancy and childhood. — Detroit 
 Rev. of Med. and Pharmacy, Aug. 1872. 
 
 We confess to increased enthusiasm in recommend- 
 ing this second edition. — St Louis Med. and Surg. 
 Journal, Aug. 1S72. 
 
 fJONDIE {D. FRANCIS), 31. D. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 
 
 Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
 printed pages, cloth, $5 25 ; leather, $6 25. 
 The present edition, which is the sixth, is fully up 
 to the times in the discussion of all those points in the 
 pathology and treatment of infantile diseases which 
 
 kave been brought forward by the Germau and French 
 
 teachers. As a whole, however, the work is the best 
 American one that we have, and in its special adapta- 
 tion to American practitioners it certainly has no 
 equal. — New York Med. Record, March 2, 1868. 
 
 WEST {CHARLES), M.D., 
 
 * " Physician to the Hospital for Sick Children, &c. 
 
 LECTURES ON THE DISEASES OF INFANCY AND CHILD- 
 HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
 and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. (Just Issued.) 
 The continued demand for this work on both sides of the Atlantic, and its translation into Ger- 
 man, French, Italian, Danish', Dutch, and Russian, show that it fills satisfactorily a want exten- 
 sively feU by the profession. There is probably no man living who can speak with the authority 
 derived from a more extended experience than Dr. West, and his work now presents the results of 
 nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
 cases which have passed under his care. In the preparation of the present edition he has' omitted 
 much that appeared of minor importance, in order to find room for the introduction of additional 
 matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 
 
 Of all the English writers on the diseases of chil- I living authorities in the difficult department of medl- 
 dren, there is no one so entirely satisfactory to us as | cal science in which he is most widely known.— • 
 £»r. West. For years we have held his opinion as I Boston Med. and Surg. Journal. 
 judicial, and have regarded Mm as one of the highest | 
 
 £>Y THE SAME AUTHOR. (Lately Issued ) 
 
 ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
 
 HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- 
 don, in March, 1871. In one volume, small 12mo., cloth, $1 00. 
 
 jgMITH (EUSTACE), M. D^~ 
 
 Physician to the Northwest London Free Dispensary for Sick Children. 
 
 A PRACTICAL TREATISE ON THE WASTING DISEASES OF 
 
 INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
 English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) 
 
 scribed as a practical handbook of the common dis- 
 eases of children, so numerous are the affections con- 
 sidered either collaterally or directly. We are 
 acquainted with no safer guide to the treatment of 
 children's diseases, and few works give the insight 
 into the physiological and other peculiarities of chil- 
 dren that Dr. Smith's book does.— Brit. Med. Journ., 
 
 This is in every way an admirable book. The 
 modest title which the author has chosen for it scarce- 
 ly conveys an adequate idea of the manybubjects 
 upon which it treats. Wasting is so constant an at- 
 tendant upon the maladies of childhood, that a trea- 
 tise upon the wasting diseases of children must neces 
 uarily embrace the consideration of many affections 
 of which it is a symptom ; and this is excellently well 
 doae by Dr. Smith. The book might fairly be de- 
 
 April 8, 1871. 
 
22 
 
 Henry C. Lea's Publications — (Diseases of Women). 
 
 rJWE OBSTETRICAL JOURNAL. {Free of pontage/or 187G.) 
 
 THE OBSTETRICAL JOURNAL of Qreat Britain and Ireland; 
 
 Including Midwikeky, and the Diseases of Women and Infants. With sin American 
 Supplement, edited by J. V. InGHAM, M.D. A monthly of about 80 ootnvo. pages, 
 very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
 cents each. 
 
 Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- 
 ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
 Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- 
 rial, Historical, Forensic, and Miscellaneous j Selections from Journals; Correspondence, &o. 
 Collecting together the vast amount of material daily accumulating in this important and ra- 
 pidly improving department of medical science, the value of the information which it pre- 
 sents to the subscriber may be estimated from the character of the gentlemen who have already 
 promised (heir support, including such names as those of Drs. ATTHILL, ROBERT Baunks, IIknry 
 Bennkt, Thomas CHAMBERS, FLEETWOOD CHURCHILL, MATTHEWS DtTNOAN, Ouaii.y IIhwitt, 
 
 Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Ttlbr Smith, Ddward J. 
 
 Tilt, Spencer Wells, &c. Ac. ; in short, the representative men of British Obstetrics and Gynae- 
 cology. 
 
 In order to render the Obstetrical Journal fully adoquate to the wants of the American 
 profession, each number contains a Supplement devoted to the advances made in Obstetrics and 
 Gynecology on this side of the Atlantic. This portion of the Journal is under the editorial 
 charge of Dr. J. V. Ingham, to whom editorial communications, exohanges, books for re- 
 view, Ac, may be addressed, to the care of the publisher. 
 
 *#* Complete sets from the beginning can no longer be furnished, but subscriptions can com- 
 mence with January, 1875, or with Vol. II., April, 1871. 
 
 rpHOMAS {T.GAILLARD),M.D. t 
 
 Prqfe880r of Obstetrics, &c, in the. College of Physicians and Surgeons, N. Y., &c, 
 
 A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 
 
 edition, enlarged and thoroughly revised. In one large and handsome ootavo volume of 
 
 800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 
 
 The author has taken advantage of the Opportunity a Horded by the call for another edition of 
 
 this work to render it worthy a continuance of the very remarkable favor with which it has been 
 
 received. Every portion has been subjected to a conscientious revision, and no labor has been 
 
 spared to make it a complete treatise on the most advanced condition of its important subject. 
 
 Am. Jouru. of obstetrics, 
 
 A work winch has reached a fourth edition, and 
 that, t oo, Id the short Bpaoe offlve years has achieved 
 a reputation which places it almost beyond the 
 reach of criticism, and the favorable opinions which 
 we have already expressed of the former editions 
 seem to require that we should <li> little more than 
 announce this new issue. Wo cannot refrain from 
 saying that, as a practical work, this is seoond to 
 none in the English, or, indeed, in any other Lan- 
 guage. Tim arrangement of I be contents, the admi- 
 rably clear manner in which the Subject of the dif- 
 ferential diagnosis of several of tim diseases is 
 bandied, leave nothing to he desired by the praoti- 
 tiouer who wants a thoroughly clinical work, one 
 to which he can refer in difficult oases of doubtful 
 diagnosis with the certainty of gaining light and 
 Instruction Dr. Thomas is a man with a very clear 
 bead and decided views, and there seems to be no- 
 thing which he so niurli dislikes as hazy notions of 
 
 diagnosis and blind routine and unreasonable thera- 
 peutics. The student who will thoroughly study 
 this i) ink and test its principles by clinical observa- 
 tion, will certainly not be guilty of these faults.— 
 London Lancet, Feb. 13, 1875. 
 
 The latest edition of this well-known text-book 
 retains the essential characters which rendered the 
 earliost so deservedly popular It is still pre-emi- 
 nently a practical manual, intended to convey fco 
 students in a clear and forcible manner a sufficiently 
 complete outline of gynaecology. In a word, we 
 should s.i v that anyone who intended tO make a 
 
 special study of gynaecology could hardly do better 
 than to begin with a minute perusal of this hook, and 
 that any one who intended to keep gynaecology sub- 
 ordinate to general practice, should hardly fail to 
 have it on hand for future reference. — N. Y. Med. 
 Journ , Jan. 1875. 
 
 Reluctantly we are obliged to close this unsatis- 
 factory notice of so excellent a work, and in conclu- 
 sion would remark that, as a teacher of gynecology, 
 both didactic and clinical, Prof. Thomas has cer- 
 tainly taken the lead far ahead of his confreres, 
 and as an author he certaiuly has met with unusual 
 
 and merited suocess.- 
 Nov. 1874. 
 
 This volume of l'rof. Thomas in its revised form 
 
 is classical without being pedantic, full In the details 
 
 Of anatomy and pathology, without ponderous 
 
 translation of pages of German literature, describes 
 distinctly the details and difficulties of each opera 
 tion, without wearying and useless tninatlao, and is 
 
 in all respects a, work worthy Of confidence, justify- 
 ing the high regard In which Its distinguished au- 
 thor is held by the profession. — Am. Supplement, 
 
 Obstet. Journ., Oct. 1874. 
 
 Professor Thomas fairly took the Profession of the 
 
 Dnlted BtateS by storm when his hook first m;vde Its 
 appearance early in IS68. Its reception was simply 
 enthusiastic, notwithstanding a low adverse criti- 
 cisms from our transatlantic brethren, the tirst large 
 edition was rapidly exhausted, and in six mouths a 
 second one was issued, and in two years a third one 
 
 was announced and published, and wears now pro- 
 mised the fourth. The popularity of this work was 
 not ephemeral, and its success w<\^ unprecedented In 
 the aunalsof American medical literature. Six years 
 is a long period in medical scientific research, hut 
 Thomas's work on " Diseases of Women" is still the 
 leading native production of the United States. This 
 order, the matter, the absence of theoretical disputa- 
 
 tlveness, the fairness of statement, and the el 
 of diction, preserved throughout the entire i 
 
 the book, indicate that Professor Thomas did not 
 overestimate his powers when ho conceived th 
 and executed the work of producing a new treatise 
 upon diseases of women. — PROP. I'ali.kn, in Louis- 
 ville Med. Journal, Sept. 1874. 
 
 Upon looking the work over, we think we can ea- 
 sily BOS why it Should be popular. It is ideal - and 
 simple in style, and, in the host sense of the word, 
 practical. The arrangement In also natural, and is 
 especially full In the therapeutical department i d all 
 our reading of such works as this we know of none 
 other in any language that has made a more favor- 
 able impression on on mind. — OhicaffO Journ. of 
 Nervous and Mental J)is6'xses, Jan 1875. 
 
Henry C. Lea's Publications — (Diseases of Women). 
 
 23 
 
 ffODGE (HUGH L.), M.D., 
 
 J 2 Emeritus Professor of Obstetrics, Ac, in the University of Pennsylvania. 
 
 ON DISEASES PECULIAR TO WOMEN; including Displacements 
 
 of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
 one beautifully printed octavo volume of 531 pages, cloth, $4 50. 
 
 From Prof. W. H. Byford, of the Rtish Medical 
 College, Chicago. 
 
 The book bears the impress of a master hand, and 
 must, as its predecessor, prove acceptable to the pro- 
 fession. In diseases of women Dr. Hodge has estab- 
 lished a school of treatment that has become world- 
 wide in fame. 
 
 Professor Hodge's work is truly an original one 
 from beginning to end, consequently no one can pe- 
 ruse its pages without learning something new. The 
 book, which is by no means a large one, is divided into 
 two grand sections, so to speak : first, that treating of 
 the nervous sympathies of the uterus, and, secondly, 
 
 that which speaks of the mechanical treatment of dis- 
 placements of that organ. He is disposed, as a non- 
 believer in the frequency of inflammations of the 
 uterus, to take strong ground against many of the 
 highest authorities in this branch of medicine, and 
 the arguments which he offers in support of his posi- 
 tion are, to say the least, well put. Numerous wood- 
 cuts adorn this portion of the woi'k, and add incalcu- 
 lably to the proper appreciation of the variously 
 shaped instruments referred to by our author. As a 
 contribution to the study of women's diseases, it is of 
 great value, and is abundantly able to stand on its 
 own merits.— N. Y. Medical Record, Sept. 15, 1868. 
 
 W: 
 
 EST (CHARLES), M.D. 
 
 LECTURES ON THE DISEASES OF WOMEN. Third American, 
 
 from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
 $3 75 ; leather, $4 75. 
 
 seeking truth, and one that will convince the student 
 
 As a writer, Dr. West stands, in our opinion, se- 
 cond only to Watson, the "Macaulay of Medicine ;" 
 he possesses that happy faculty of clothing instruc- 
 tion in easy garments ; combining pleasure with 
 profit, he leads his pupils, in spite of the ancient pro- 
 verb, along a royal road to learning. His work is one 
 which will not satisfy the extreme on either side, but 
 It is one that will please the great majority who are 
 
 that he has committed himself to a candid, safe, and 
 valuable guide. —N. A. Med.-Chirurg Review. 
 
 We have to say of it, briefly and decidedly, that it 
 is the best work on the subject in any langunge, and 
 that it stamps Dr. West as the facile, princeps of 
 British obstetric authors.— Edinburgh Med. Journal. 
 
 J?ARNES [ROBERT), M.D., F.R. G.P., 
 
 •*~* Obstetric Physician to St. Thomas's Hospital, Ac 
 
 A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
 CAL DISEASES OF WOMEN. In one handsome octavo volume of about 800 pages, with 
 169 illustrations. Cloth, $5 00 ; leather, $6 00. (Just Issued.) 
 The very complete scope of this volume and the manner in which it has been filled out, may 
 be seen by the subjoined Summary of Contents. 
 
 Introduction. Chapter I. Ovaries; Corpus Luteum. II. Fallopian Tubes. III. Shape of 
 Uterine Cavity. IV. Structure of Uterus. V. The Vagina. VI. Examinations and Diagnosis. 
 VII. Significance of Leucorrhoea. VIII. Discharges of Air. IX. Watery Discharges. X. Puru- 
 lent Discharges. XI. Hemorrhagic Discharges, XII. Significance of Pain. XIII. Significance 
 of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diagnosis and Treatment. 
 XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor- 
 ders. XVIII. Amenorrhea. XIX. Amenorrhoea (continued). XX. Dysmenorrhoea. XXI. 
 Ovarian Dysmenorrhoea, &c. XXII. Inflammatory Dysmenorrhoea. XXIII. Irregularities of 
 Change of Life. XXIV. Relations between Menstruation and Diseases. XXV. Disorders of Old 
 Age. XXVI. Ovary, Absence and Hernia of. XXVII. Ovary, Hemorrhage, &c, of. XXVIII. 
 Ovary, Tubercle, Cancer, &c, of. XXIX. Ovarian Cystic Tumors. XXX. Dermoid Cysts of 
 Ovary. XXXI. Ovarian Tumors, Prognosis of. XXXII. Diagnosis of Ovarian Tumors. XXXIII. 
 Ovarian Cysts, Treatment of. XXXIV. Fallopian Tubes, Diseases of. XXXV. Broad Liga- 
 ments, Diseases of. XXXVI. Extra-uterine Gestation. XXXVII. Special Pathology of Ute 
 rus. XXXVIII General Uterine Pathology. XXXIX. Alterations of Blood Supply. XL. 
 Metritis, Endometritis, <fcc. XLI. Pelvic Cellulitis and Peritonitis, &c. XLII. Hematocele, &o 
 XLIII. Displacements of Uterus. XLIV. Displacements (continued). XLV. Retroversion and 
 Retroflexion. XLVI. Inversion. XLVII. Uterine Tumors. XLVIII. Polypus Uteri. XLIX. 
 Polypus Uteri (continued). L. Cancer. LI. Diseases of Vagina. LII. Diseases of the Vulva. 
 
 mas, and Peaslee, as if these eminent men were his 
 countrymen and colleagues, and gives thorn a credit 
 which must be gratifying to every American physi- 
 cian.— Am. Journ. Med. Set, April, 1874. 
 
 Embodying the long experience and personal obser- 
 vation of one of the greatest of living teachers in dis- 
 eases of women, it seems pervaded by the presence 
 of the author, who speaks directly to the reader, and 
 Bpeaks, too, as one having authority, And yet, not- 
 withstanding this distinct personality, there is noth- 
 ing narrow as to time, place, or individuals, in the 
 views presented, and in the instructions given; Dr. 
 Barnes has been an attentive student, not only of Eu- 
 ropean, but also of Americau literature, pertaining to 
 diseases of females, and enriched^his own experience 
 by treasures thence gathered ; he seems as familiar, 
 for example, with the writings of Sims, Emmet, Tho- 
 
 Throughout the whole book it is impossible not to 
 feel that theauthor has spontaneously, conscientious- 
 ly, and fearlessly performed his task. He goes direct 
 to the point, and does not loiter on the way to gossip 
 or quarrel with other authors. Dr. Barnes's book 
 will be eagerly read all over the world, and will 
 everywhere be admired for its comprehensiveness, 
 honesty of purpose, and ability. — The Obstet. Journ. 
 of Great Britain and Ireland, March, 1874. 
 
 DEWEES'S TREATISE ON THE DISEASES OF FE 
 MALES. With illustrations. Eleventh Edition, 
 with the Author's last improvements and correc 
 tions. In one octavo volume of 536 pages, with 
 plates, cloth. $3 00. 
 
 CHURCHILL ON THE PUERPERAL FEVER AND 
 OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
 8vo., pp. 450, cloth. $2 50. 
 
 ASHWELL'S PRACTICAL TREATISE ON THE DIS- 
 EASES PECULIAR TO WOMEN. Third American, 
 from the Third and revised London edition. 1 vol. 
 8vo., pp. 528, cloth. $3 50. 
 
 MEIGS ON THE NATURE, SIGNS, AND TREAT- 
 MENT OF CHILDBED FEVER. 1 vol. 8vo., pp. 
 365, cloth. $2 00. 
 
24 
 
 Henry C. Lea's Publications— {Midwifery). 
 
 H 
 
 ODGE {HUGH L.), M.D., 
 
 Emeritus Professor of Midwifery, &c, in the University of Pennsylvania, &e. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
 
 trated with large lithographic plates containing one hundred and fifty-nine figures from 
 original photographs, and with numerous wood-cuts. In one large and beautifully printed 
 quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 
 
 The work of Dr. Hodge is something more than a 
 •Imple presentation of his particular views in the de- 
 partment of Obstetrics; it is something more than an 
 ordinary treatise on midwifery ; it is, in fact, a cyclo- 
 paedia of midwifery. He has aimed to embody in a 
 single volume the whole science and art of Obstetrics. 
 An elaborate text is combined with accurate and va- 
 ried pictorial illustrations, so that no fact or principle 
 Is left unstated or unexplained. — Am. Med. Times, 
 Sept. 3, 1864. 
 
 We should like to analyze the remainder of this 
 excellent work, but already has this review extended 
 beyond our limited space. We cannot conclude this 
 notice without referring to the excellent finish of the 
 work. In typography it is not to be excelled ; the 
 paper is superior to what is usually afforded by our 
 American cousins, quite equal to the best of English 
 books. The engravings and lithographs are most 
 beautifully executed. The work recommends itself 
 for its originality, and is in every way a most valu- 
 able addition to those on the subject of obstetrics. — 
 Canada Med. Journal, Oct. 1861 
 
 It is very large, profusely and elegantly illustrated, 
 and is fitted to take its place near the works of great 
 
 obstetricians. Of the American works on the subject! — Glasgow Med. Journal, Oct. 1S64. 
 It is decidedly the best. — Edinb. Med. Jour., Dec. '64.1 
 
 %*% Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
 on receipt of six cents in postage stamps. 
 
 WANNER (THOMAS H), M. D. 
 ON THE SIGNS AND DISEASES OF PREGNANCY. First American 
 
 from the Second and Enlarged English Edition. With four colored plates and illustrations 
 on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
 The very thorough revision the work has undergone 
 has added greatly to its practical value, and increased 
 
 We have examined Professor Hodge's work with 
 great satisfaction ; every topic is elaborated most 
 fully. The views of the author are comprehensive, 
 and concisely stated. The rules of practice are judi- 
 cious, and will enable the practitioner to meet every 
 emergency of obstetric complication with confidence. 
 — Chicago Med. Journal, Aug. 1864. 
 
 More time than we have had at our disposal since 
 we received the great work of Dr. Hodge is necessary 
 to do it justice. It is undoubtedly by far the most 
 original, complete, and carefully composed treatise 
 on the principles and practice of Obstetrics which has 
 ever been issued from the American press. — Pacific 
 Med. and Surg. Journal, July, 1864. 
 
 We have read Dr. Hodge's book with great plea- 
 sure, and have much satisfaction in expressing our 
 commendation of it as a whole. It is certainly highly 
 instructive, and in the main, we believe, correct. The 
 great attention which the author has devoted to the 
 mechanism of parturition, taken along with the con- 
 clusions at which he has arrived, point, we think, 
 conclusively to the fact that, in Britain at least, thg 
 loctrines of Naegele have been too blindly received. 
 
 materially its efficiency as a guide to the student and 
 to the young practitioner. — Am. Journ. Med. Sci., 
 April, 1868. 
 
 With the immense variety of subjects treated of 
 and the ground which they are made to cover, the im- 
 possibility of giving an extended review of this truly 
 remarkable work must be apparent. We have not a 
 single fault to find with it, and most heartily com- 
 mend it to the careful study of every physician who 
 would not only always be sure of his diagnosis of 
 
 pregnancy, but always ready to treat all the nume- 
 rous ailments that are, unfortunately for the civilized 
 women of to-day, so commonly associated with the 
 function.— N. T. Med. Record, March 16, 1S68. 
 
 We recommend obstetrical students, young and 
 old, to have this volume in their collections. It con- 
 tains not only a fair statement of the signs, symptoms, 
 and diseases of pregnancy, but comprises in addition 
 much interesting relative matter that is not to be 
 found in any other work that we can name. — Edin- 
 burgh Med Journal, Jan. 1868. 
 
 S WAYNE {JOSEPH GRIFFITHS), M. D., 
 
 *-s Physician- Accoucheur to the British General Hospital, &c. 
 
 OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
 MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
 London Edition with Additions by E. R. Hcjtchins, M. D. With Illustrations. In one 
 neat 12mo volume Cloth. $1 25 {Lately Issued.) 
 #^* See p. 3 of this Catalogue for the terms on which this work is offered as a premium to 
 subscribers to the "American Journal of the Medical Sciences." 
 
 It is really a capital little compendium of the sub- i answers the purpose. It is not only valuable for 
 ject, and we recommend young practitioners to buy it youug beginners, but no one who is not a proficient 
 and carry it with them when called to attend cases of in the art of obstetrics should be without it, because 
 labor. They can while away the otherwise tedious it condenses all that is necessary to know for ordi- 
 
 hours of waiting, and thoroughly fix in their memo- 
 ries the most important practical suggestions it con- 
 tains. The American editor has materially added by 
 his notes and the concluding chapters to the com- 
 pleteness and general value of the book. — Chicago 
 Med. Journal, Feb. 1870. 
 
 The manual before us containsin exceedingly small 
 compass — small enough to carry in the pocket — about 
 all there is of obstetrics, condensed into a nutshell of 
 Aphorisms. The illustrations are well selected, and 
 serve as excellent reminders of the conduct of labor — 
 regular and difficult. — Cincinnati Lancet, April, '70. 
 
 'Hiis is a mostadmirablalit tie work, and completely 
 
 nary midwifery practice. We commend the book 
 most favorably. — St. Louis Med. and Surg. Journal, 
 Sept. 10, 1870. 
 
 A studied perusal of this little book has satisfied 
 us of its eminently practical value. The object of the 
 work, the author says, in his preface, is to give the 
 student a few brief and practical directions respect- 
 ing the management of ordinary cases of labor ; and 
 also to poiut out to him in extraordinary cases whea 
 and how he may act upon his own responsibility, and 
 when he ought to send for assistance. — N. ¥. Medical 
 Journal, May. 18^0 
 
 w 
 
 INCKEL (F.), 
 
 Professor and Director of the Gynaecological Clinic in the University of Rostock. 
 
 A COMPLETE TREATISE ON THE PATHOLOurF AND TREAT- 
 MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of 
 the author, from the Second German Edition, by James Read Chadwick, M D. In one 
 ootavo volume. (Preparing.) 
 
Hen&y C. Lea's Publications — {Midwifery), 
 
 25 
 
 T EISHMAN {WILLIAM), M.D., 
 
 
 Regius Professor of Midwifery in the University of Glasgow, &c. 
 
 SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 
 
 PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
 and Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to the 
 Philadelphia Hospital, &c. In one large and very handsome octavo volume of over 700 
 pages, with about two hundred illustrations. {Preparing.) 
 
 This is one of a most complete and exhaustive cha- 
 racter. We have gone carefully through it, and there 
 is no subject in Obstetrics which has not been con- 
 sidered well and fully. The result is a work, not 
 only admirable as a text-book, but valuable as a work 
 of reference to the practitioner in the various emer- 
 gencies of obstetric practice. Take it all in all, we 
 have no hesitation in saying that it is in our judgment 
 the best English work on the subject. — London Lan- 
 cet, Aug. 23, 1873. 
 
 The work of Leishman gives an excellent view of 
 modern midwifery, and evinces its author's extensive 
 acquaintance with British and foreign literature ; and 
 not only acquaintance with it, but wholesome diges- 
 tion and sound judgment of it. He has, withal, a 
 manly, free style, and can state a difficult and compli- 
 cated matter with remarkable clearness and brevity. 
 —Edin. Med. Journ., Sept. 1873. 
 
 The author has succeeded in presenting to the pro- 
 fession an admirable treatise, especially in its practi- 
 cal aspects ; one which is, in general, clearly written, 
 and sound in doctrine, and one which cannot fail to 
 add to his already high reputation. In concluding 
 our examination of this work, we cannot avoid again 
 eaying that Dr. Leishman has fully accomplished 
 that difficult task of presenting a good text-book upon 
 obstetrics. We know none better for the use of the stu- 
 dent or junior practitioner. — Am. Practitioner, Mar. 
 1874. 
 
 It proposes to offer to practitioners and students 
 
 "A Complete System of the Midwifery of the Present 
 Day," and well redeems the promise. In all that 
 relates to the subject of labor, the teaching is admi- 
 rably clear, concise, and practical, representing not 
 alone British practice, but the contributions of Con- 
 tinental and American schools. — N. Y. Med. Record, 
 March 2, 1874. 
 
 The work of Dr. Leishman is, in many respects, 
 not only the best treatise on midwifery that we have 
 seen, but one of the best treatises on any medical sub- 
 ject that has been published of late years. — Land. 
 Practitioner, Feb. 1874. 
 
 It was written to supply a desideratum, and we will 
 be much surprised if it does not fulfil the purpose of 
 its author. Taking it as a whole, we know of no 
 work on obstetrics by an English author in which the 
 student and the practitioner will find the information 
 so clear and so completely abi east of the present state 
 of our knowledge on the subject.— Glasgow Med. 
 Journ., Aug. 1873. 
 
 Dr. Leishman's System of Midwifery, which has 
 only just been published, will go far to supply the 
 want which has so long been felt, of a really good 
 modern English text-book. Although large, as is in- 
 evitable in a work on so extensive a subject, it is so 
 well and clearly written, that it is never wearisome 
 to read. Dr. Leishman's work may be confidently 
 recommended as an admirable text-book, and is sure 
 to be largely used. — Lond. Med. Record, Sept. 1873. 
 
 JDAMSBOTHAM {FRANCIS H.), M.D. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
 
 CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
 edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
 Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one large 
 and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
 bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
 all nearly 200 large and beautiful figures. $7 00. 
 
 We will only add that the student will learn from 
 tt all he need to know, and the practitioner will find 
 it, as a book of reference, surpassed by none other. — 
 Stethoscope. 
 
 The character and merits of Dr. Ramsbotham's 
 work are so well known and thoroughly established, 
 that comment is unnecessary and praise superlluous. 
 The illustrations, which are numerous and accurate, 
 are executed in the highest style of art. We cannot 
 too highly recommend the work to our readers. — St. 
 Louis Med. and Surg. Journal. 
 
 To the physician's library it is indispensable, while 
 to the student, as a text-book, from which to extract 
 the material for laying the foundation of an ed ucation 
 on obstetrical science, it has no superior. — Ohio Med. 
 and Surg. Journal. 
 
 When we call to mind the toil we underwent in 
 acquiring a knowledge of this subject, we cannot but 
 envy the student of the present day the aid which 
 this work will afford him. — Am. Jour, of the Med. 
 Sciences. 
 
 QRURCHTLL {FLEETWOOD), M.D., M.R.I. A. 
 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 
 
 American from the fourth revised and enlarged London edition. With notes and additions 
 by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- 
 dren,'' &c. With one hundred and ninety-four illustrations. In one very handsome octavo 
 volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. 
 
 T>ARRY [JOHN &), M.D., 
 
 Obstetrician to the Philadelphia Hospital, Vice-Prest. of the Ob&tet. Society of Philadelphia 
 
 EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 
 
 DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
 (Preparing.) 
 
 MONTGOMERY'S EXPOSITION OP THE SIGNS 
 AND SYMPTOMS OF PREGNANCY. With two 
 exquisite colored plates, and numerous wood cuts. 
 In 1 vol. 8vo., of nearly 600 pp., cloth. $3 75. 
 
 BIGBY'S SYSTEM OF MIDWIFERY. With Notes 
 and Additional Illustrations. Second American, 
 edition. One volume octavo, cloth, 422 pages. 
 $2 60. 
 
26 
 
 Henry C. Lea's Publications— (Surgery). 
 
 6 1ROSS {SAMUEL J).), M.D., 
 Professor of Surgery in the Jefferson Medical College of Philadelphia. 
 
 A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 
 
 and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
 carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
 umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) 
 The continued favor, shown by the exhaustion of successive large editions of this great work, 
 proves that it has successfully supplied a want felt by American practitioners and students. In the 
 present revision no pains have been spared by the author to bring it in every respect fully up to 
 the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
 nearly one-fourth, notwithstanding which the price has been kept at its former very moderate 
 rate. By the -use of a close, though very legible type, an unusually large amount of matter is 
 condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
 This, combined with the most careful mechanical execution, and its very durable binding, renders 
 it one of the cheapest works accessible to the profession. Every subject properly belonging to the 
 domain of surgery is treated in detail, so that the student who possesses this work may be said to 
 have in it a surgical library. A few notices of the previous edition are subjoined : — 
 
 It must long remain the most comprehensive work 
 on this important part of medicine. — Boston Medical 
 and Surgical Journal, March 23, 1865. 
 
 We have compared it with most of our standard 
 works, sach as those of Erichsen, Miller, Fergusson, 
 Syme, and others, and we must, in justice to our 
 author, award it the pre-eminence. As a work, com- 
 plete in almost every detail, no matter how minute 
 or trifling, and embracing every subject known in 
 the principles and practice of surgery, we believe it 
 stands without a rival. Dr. Gross, in his preface, re- 
 marks "my aim has been to embrace the whole do- 
 main of surgery, and to allot to every subject its 
 legitimate claim to notice;" and, we assure our 
 readers, he has kept his word. It is a work which 
 we can most confidently recommend to our brethren, 
 for its utility is becoming the more evident the longer 
 it is upon the shelves of our library.— Canada Med. 
 Journal, September, 1865. 
 
 The first two editions of Professor Gross' System of 
 Surgery are so well known to the profession, and so 
 highly prized, that it would be idle for us to speak in 
 praise of this work.— Chicago Medical Journal, 
 September, 1865. 
 
 We gladly indorse the favorable recommendation 
 of the work, both as regards matter and style, which 
 we made when noticing its first appearance.— British 
 and Foreign Medico- Chirurgical Review, Oct. 1865. 
 
 The most complete work that has yet issued from 
 the press on the science and practice of surgery. — 
 London Lancet. 
 
 This system of surgery is, we predict, destined to 
 take a commanding position in our surgical litera- 
 ture, and be the crowning glory of the author's well 
 earned fame. As an authority on general surgical 
 subjects, this work is long to occupy a pre-eminent 
 place, not only at home, but abroad. We have no 
 
 1DY THE SAME AUTHOR. 
 
 PRACTICAL TREATISE ON 
 
 hesitation in pronouncing it without a rival in our 
 language, and equal to the best systems of surgery in 
 any language. — N. Y. Med. Journal. 
 
 Not only by far the best text-book on the subject, 
 as a whole, within the reach of American students, 
 but one which will be much more than ever likely 
 to be resorted to and regarded as a high authority 
 abroad. — Am. Journal Med. Sciences, Jan. 1865. 
 
 The work contains everything, minor and major, 
 operative and diagnostic, including mensuration and 
 examination, venereal diseases, and uterine manipu- 
 lations and operations. It is a complete Thesaurus 
 of modern surgery, where the student and practi- 
 tioner shall not seek in vain for what they desire.— 
 San Francisco Med. Press, Jan. 1865. 
 
 Open it where we may, we find sound practical in- 
 formation conveyed in plain language. This book i« 
 no mere provincial or even national system of sur- 
 gery, but a work which, while very largely indebted 
 to the past, has a strong claim on the gratitude of the 
 future of surgical science. — Edinburgh Med. Journal, 
 Jan. 1865. 
 
 A glance at the work is sufficient to show that the 
 author and publisher have spared no labor in making 
 it the most complete "System of Surgery" ever pub- 
 lished in any country. — St. Louis Med. and Surg. 
 Journal, April, 1865. 
 
 A system of surgery which we think unrivalled in 
 our language, and which will indelibly associate his 
 name with surgical science. And what, in our opin- 
 ion, enhances the value of the work is that, while the 
 practising surgeon will find all that he requires in it, 
 it is at the same time one of the most valuable trea- 
 tises which can be put into the hands of the student 
 seeking to know the principles and practice of this 
 branch of the profession which he designs subse- 
 quently to follow.— The Brit. Am.Journ., Montreal. 
 
 A 
 
 AIR-PASSAGES. In 1 vol. 8vo. 
 
 FOREIGN BODIES IN THE 
 
 with illustrations, pp. 468, cloth, $2 75. 
 
 SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. 
 
 cloth, of over 650 pages ; with about 100 wood-cuts. 
 
 $3 25. 
 COOPER'S LECTURES ON THE PRINCIPLES AND 
 
 Practice of Surgery. In 1 vol. 8vo. cloth, 750 p. $2. 
 
 GIBSON'S INSTITUTES AND PRACTICE OF 8US- 
 gert. Eighth edition, improved and altered. With 
 thirty-four plates. In two handsome octavo vol- 
 umes, about 1000 pp. , leather, raised bandt . $6 60. 
 
 M 
 
 1LLER [JAMES), 
 
 Late Professor of Surgery in the University of Edinburgh, &c. 
 
 PRINCIPLES OE SURGERY. Fourth American, from the third and 
 
 revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
 two hundred and forty illustrations on wood, cloth, $3 75. 
 
 UY THE SAME AUTHOR. 
 
 THE PRACTICE OF SURGERY. Fourth American, from the last 
 
 Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
 sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, cloth, 
 $3 75. 
 
 QARGENT [F. W.), M.D. 
 ° ON BANDAGING AND OTHER OPERATIONS OF MINOR 
 
 SURGERY. New edition, with an additional chapter on Military Surgery. One handsome 
 royal 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Cloth, $1 76. 
 
Henry C. Lea's Publications — (Surgery). 
 
 2? 
 
 ASEHURST {JOHN, Jr.), M.D., 
 
 Surgeon to the Episcopal Hospital, Philadelphia. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. In one 
 
 very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 
 
 cloth, $6 50; leather, raised bands, $7 50. (Lately Published.) 
 The object of the author has been to present, within as condensed a compass as possible, a 
 Complete treatise on Surgery in all its branches, suitable both as a text-book for the student and 
 a work of reference for the practitioner. So much has of late years been done for the advance- 
 ment of Surgical Art and Science, that there seemed to be a want of a work which should present 
 the latest aspects of every subject, and which, by its American character, should render accessible 
 to the profession at large the experience of the practitioners of both hemispheres. This has been 
 the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- 
 torily. 
 
 Its author has evidently tested the writings and 
 experiences of the past and present in the crucible 
 of a careful, analytic, and honorable mind, and faith- 
 fully endeavored to bring his work up to the level of 
 the highest standard of practical surgery. He is 
 frank and definite, and gives us opinions, and gene- 
 rally sound ones, instead of a mere resume of the 
 opinions of others. He is conservative, but not hide- 
 bound by authority. His style is clear, elegant, and 
 scholarly. The wcrk is anadmirable tex-tbook, and 
 a useful book of reference It is a credit to American 
 professional literature, and one of the first ripe fruits 
 of the soil fertilized by the blood of our late unhappy 
 war.— N. Y. Med. Record, Feb. 1, 1872. 
 
 Indeed, the work as a whole must be regarded as 
 an excellent and concise exponent of modern sur- 
 gery, and as such it will be found a valuable text- 
 book for the student, and a useful book of reference 
 for the general practitioner. — N. Y. Med. Journal, 
 Feb. 1S72. 
 
 It gives us great pleasure to call the attention of the 
 profession to this excellent work. Our knowledge of 
 its talented and accomplished author led us to expect 
 from him a very valuable treatise upon subjects to 
 which he has repeatedly given evidence of having pro- 
 fitably devoted much time and labor, and we are in no 
 way disappointed.— Phila. Med. Times, Feb. 1, 1872. 
 
 H 
 
 OLMES {TIMOTHY), M.D., 
 
 Surgeon to St. George's Hospital, London 
 
 SURGERY, ITS PRINCIPLES 
 
 some octavo volume of about 800 pages. 
 
 AND PRACTICE. 
 
 with over 400 illustrations. 
 
 In one hand- 
 
 ( Nearly Ready.) 
 
 DIRRIE ( WILLIAM), F. R. S. E., 
 
 Professor of Surgery in the University of Aberdeen. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 
 
 John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
 Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 316 
 illustrations, cloth, $3 75. 
 
 JJAMILTON {FRANK H.), M.D., 
 
 Professor of Fractures and Dislocations, &c, in Bellevue Hosp. Med. College, New York. 
 
 A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
 
 TIONS. Fifth edition, revised and improved. In one large and handsome octavo volume 
 of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75. (Nearly Ready. \ 
 This work is well known, abroad as well as at home, as the highest authority on its important 
 subject — an authority recognized in the courts as well as in the schools and in practice — and 
 again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
 gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
 author has thus had the opportunity of making have enabled him to give the most careful consid- 
 eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
 to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever 
 of value has been added in this department since the issue of the fourth edition. It will there- 
 fore be found considerably improved in matter, while the most careful attention has been paid 
 to the typographical execution, and the volume is presented to the profession in the confident 
 hope that it will more than maintain its very distinguished reputation. 
 A few notices of the previous edition are subjoined : — 
 
 Prof. Hamilton has aworld-wide reputation as the 
 author of a Treatise on Fractures and Dislocations, 
 which it is safe to say has no equal in the English 
 language. — Buffalo Med. and Surg. Journ., Nov. 
 1872. 
 
 The best work on the subject now published. — Am. 
 Journ. of Med. Sci., Jan. 1S73. 
 
 It is undoubtedly the best on those subjects in the 
 English language — Nashville Med. and Surg. 
 Journ., Dec. 1872. 
 
 It is not, of course, our intention to review, in ex- 
 tenso, Hamilton on "Fractures and Dislocations." 
 Eleven years ago 6uch review might not have been 
 out of place ; to-day the work is an authority, so well, 
 so generally, and so favorably known, that it only 
 remains for the reviewer to say that a new edition is 
 Just out, and it is better than either of its predeces- 
 sors.— Cincinnati Clinic, Oct. 1-1, 1871. 
 
 Undoubtedly the best work on Fractures and Dis* 
 locations in the English language. — Cincinnati Med. 
 Repertory, Oct. 1871. 
 
 We have once more before us Dr. Hamilton's admi- 
 rable treatise, which we have always considered the 
 most complete and reliable work on the subject. As 
 a whole, the work is without an equal in the litera- 
 ture of the profession. — Boston Med. and Surg. 
 Journ., Oct. 12, 1871. 
 
 It is unnecessary at this time to commend the book, 
 except to such as are beginners in the study of this 
 particular branch of surgery. Every practical sur- 
 geon in this country and abroad knows of it as a most 
 trustworthy guide, and one which they, in common 
 with us, would unqualifiedly recommend as the high- 
 est authority in any language.' — N. Y. Med. Record, 
 Oct. 16, 1871. 
 
28 
 
 Henry C. Lea's Publications — (Surgery). 
 
 PRICHSHN {JOHN EX 
 •*~ j ' Professor of Surgery in University College, London, etc 
 
 THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 
 
 gioal Injuries, Diseases, and Operations. Revised by the author from the Sixth and 
 enlarged English Edition. Illustrated by over .seven hundred engravings on wood. In 
 two large and beautiful OOtavo Volumes of over 1700 pages, cloth, $0 00 ; leather, $1 1 00. 
 (Lately Issued.) f 
 
 Author's "Preface to the N/u> American Edition. 
 
 u The favorable recent. ion with which the ' Science and Art of Surgery' has been honored by the 
 Surgic&l Profession in the United States Of America has been not, only a source of deep gratifica- 
 tion and of just pride to me, but has laid the foundation of many professional friendships that 
 are amongst the agreeable and valued recollections of my life. 
 
 "I h ;ivc endeavored to make the present edition of this work more deserving than its predecessor! 
 of the favor that has been accorded to them. In oonsequenoe of delays that have unavoidably 
 
 occurred in the publication of the Sixth British Edition, lime has been afforded to me to add to fh'iH 
 
 one several paragraphs which 1 trust, will bo found to Increase the practical value of the work." 
 London, Oct. 1872. 
 On no former edition of this work has the author bestowed more pains to render it, a complete and 
 satisfactory exposition of British Surgery in its modern aspeots. Every portion has been sedu- 
 lously revised, :ind a large number ol new illustrations have been Introduced. I Q addition to the 
 materia] thus added to the English edition, the author has furnished for the American edition such 
 materia] as has aooumulated since the passage of the sheets through the press in London, so that 
 
 the work as now presented to the American profession, oontains his latest views and experience. 
 The increase in the size of the work has seemed to render necessary its division Into two vol- 
 umes. Great care has keen exercised in its typographical execution, and it is confidently pre- 
 sented as in every respect worthy to maintain the high reputation which has rendered it a stand* 
 
 ard authority on this depart. menl of medical science. 
 
 These are only a few of the points Id winch the 
 present edition of Mr. Erichsen's work surpasses its 
 
 predecessors. Throughout there is evidence Of ft 
 
 laborious ca.ro a.ini Bolicltude in seizing the passing 
 knowledge of the day, which reflects the greatest 
 credit on the author, and muoh enhances the value 
 
 of his work. We oan only ad mire the industry which 
 has enabled Mr. Eriohsen thus to succeed, amid the 
 distractions of active practice, In producing emphatic* 
 
 al I y Tin', hook of reference and study for British prao- 
 tltioners of surgery, London Lancet, Oct. 26, 1872 
 
 Considerable changes have been made In this edi- 
 tion, and nearly a. hundred 06W i 1 1 usl rai ions h.i ve 
 I n 'on added. It is d i Hie u 1 1 in a small com pass lo point 
 OUt I ho a Mora lion, and addition-, ; t'oi , a.s the author 
 
 states In his preface, they are not confined to anyone 
 
 portion, but are distributed generally through the 
 
 Subjects Of Which the WOl'k treats. Certainly one of 
 
 the most valuable seotions of the hook seems to us to 
 be that which treats of the disease* of the arteries 
 and the operative proceedings » inch i hey nee, 
 in few text-books Is ho much carefully arranged Ln< 
 formation collected. — London Med, Times ana Qa&., 
 oet. 26, 1872. 
 
 The entire work, complete, as the great English 
 treatise on Burgei \ of our own tune, is, we oan asHure 
 our readers, equally well adapted for the moat junior 
 
 student, and, a; a, I k of reference, for the advanced 
 
 practitioner — Dublin Quarterly ■lour mil. 
 
 jHRUITT {ROBERT), 
 THE PRINCIPLES 
 
 All that the surgical student or pra 
 
 desire. — Dublin. Quarterly Journal. 
 It 1h a most admirable hook. We do not know 
 
 when WO have examined one with more pleasure. — 
 
 Boston Med. and Surg. Journal. 
 
 M.R.C.S.,Src. 
 AND PRACTICE OF MODERN SURGERY. 
 
 A new and revised American, from the eighth enlarged and improved London edition. Illus- 
 trated with four hundred and thirty -tWO WOOd engravings. In one very handsome octavo 
 volume, of nearly 700 large and closely printed pages, cloth, $'l 00 j leather, $5 00. 
 
 practice of surgery are treated, and 80 clearly and 
 
 perspicuously, as to elnoldate every lmportai plo. 
 
 We nave examined the hook most, thoroughly, and 
 
 thai this SUCCesa is well merited, liis hooli, 
 
 ir, possesses the Inestimable advant 
 ia ring the Bubjeots perfect iy well arranged and olas< 
 
 lifted, I of being written In a style at on 
 
 uccinot,— Am, Journal of Med, Sciences. 
 
 in Mr. Druitt's book, though containing only some 
 
 eeven hundred pages, both the principles and the 
 
 A 
 
 SI J TON (T. J.). 
 
 ON THE DISEASES, INJURIES, ANT) M AEFOK ,M ATIONH OF 
 TIIM RECTUM A.ND ANUS; with remarks on Habitual Constipation. Second A morioan, 
 from the fourth and enlarged London edition. With handsome illustrations. In one very 
 
 beautifully printed octavo volume of ahoul 800 pages, cloth, $.'1 25. 
 
 jyiQELO W [EENR Y ./.), M. />., 
 
 LJf Professor of Surgery tn the Massachusetts Med, < 1 <>iU'ge.. 
 
 ON THE MECHANISM OF DISLOCATION 
 
 AND FRACTURE 
 
 OF THE HIP. With the Reduction Of the Dislocation by the Flexion Method. With 
 numerous original illustrations. In one very handsome octavo volume. Cloth, $2 50. 
 
 T A WSON [GEORGE), F. R. C.S., Engl, 
 
 J-J Assistant Surgeon to tin- Royal London Ophthalmic Hospital, Moor fields, &o. 
 
 INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 
 
 diate and Remote Effects. With about one hundred illustrations. In one very hand- 
 some octavo volume, cloth, %'A 50 
 It is an admirable practical book la the highest nnd best khuha of t.br pbrano. — London Medical Times 
 and f/azttte. May IB, 1867. 
 
Henry C. Lea's Publications-— (iSWgery). 
 
 29 
 
 T>RYANT {THOMAS), F.R.C.S., 
 
 &-* Surgeon to Guy's Hospital. 
 
 THE PRACTICE OF SURGERY. With over Five Hundred En- 
 
 gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, 
 cloth, $6 25 ; leather, raised bands, $7 25. (Lately Published.) 
 
 and fairly, yet it is no mere compilation. The book 
 combines much of the merit of the manual with the 
 merit of the monograph. One may recogui 
 
 Again, the author gives us his own practice, his 
 own beliefs, and illustrates by his own cases, or those 
 treated in Guy's Hospital. This feature adds joint 
 emphasis, and a solidity to his statements that inspire 
 confidence. One feels himself almost by the side of 
 the surgeon, seeing his work and hearing his living 
 words. The views, etc., of other surgeons are con- 
 sidered calmly and fairly, but Mr. Bryant'.s are 
 adopted. Thus the work is not a compilation of 
 other writings; it is not an encyclopedia, but the 
 plain statements, on practical points, of a man who 
 has lived and breathed and had his being in the 
 richest surgical experience. The whole profession 
 owe a debt of gratitude to Mr. Bryant, for his work 
 in their behalf We are confident that the American 
 profession will give substantial testimonial of their 
 feelings towards both author and publisher, by 
 speedily exhausting this edition. We cordially aud 
 heartily commend it to our friends, and think that 
 no live surgeon can afford to be without it. — Detroit 
 Review of Med. and Pharmacy, August, 1873. 
 
 As a manual of the practice of surgery for the use 
 of the student, we do not hesitate to pronounce Mr. 
 Bryant's book a first-rate work. Mr. Bryant has a 
 good deal of the dogmatic energy which goes with 
 the clear, pronounced opinions of a man whose re- 
 flections and experience have moulded a character 
 not wanting in firmness aud decision. At the same 
 time he teaches with the enthusiasm of one who has 
 faith in his teaching; he speaks as one having au- 
 thority, and herein lies the charm aud excellence of 
 his work. He states the opinions of others freely 
 
 almost every chapter of the ninety-four of which the 
 work is made up the acuteness of a surgeon who has 
 seen much, and observed closely, and who gives forth 
 the results of actual experience. In conclusion we 
 repeat what we stated at first, that Mr. Bryant's book 
 is one which we can conscientiously recommend both 
 to practitioners and students as an admirable work. 
 — Dublin Journ. of Med. Science, August, 1873. 
 
 Mr. Bryant has long been known to the reading 
 portion of the profession as an able, clear, and graphic 
 writer upon surgical subjects. The volume before 
 us is one eminently upon the practice of surgery and 
 not one which treats at length on surgical pathology, 
 though the views that are entertained upon tnis sub- 
 ject are sufficiently interspersed through the work 
 for all practical purposes. As a text-book we cheer- 
 fully recommend it, feeling convinced that, from the 
 subject-matter, and the concise and true way Mr. 
 Bryant deals with his subject, it will prove a for- 
 midable rival among the numerous surgical text- 
 books which are offered to the student. — N. Y. Med. 
 Record, June, 1873. 
 
 This is, as the preface states, an entirely new book, 
 and contains in a moderately condensed form all the 
 surgical information necessary to a general practi- 
 tioner. It is written in a spirit consistent with the 
 present improved standard of medical and surgical 
 science. — American Journal of Obstetrics, August, 
 1S73. 
 
 w 
 
 ELLS [J. SOELBERG), 
 
 Professor of Ophthalmology in King's College Hospital, Sec. 
 
 A TREATISE ON DISEASES OF THE EYE. Second American, 
 
 from the Third and Revised London Edition, with additions; illustrated with numerous 
 engravings on wood, and six colored plates. Together with selections from the Test-types 
 of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 
 pages; cloth, $5 00; leather, $6 00. {Lately Published.) 
 
 The continued demand for this work, both in England and this country, is sufficient evidence 
 that the author has succeeded in his effort to supply within a reasonable compass a full practical 
 digest of ophthalmology in its most modern aspects, while the call for repeated editions has en- 
 abled him in his revisions to maintain its position abreast of the most recent investigations and 
 improvements. In again reprinting it, every effort has been made to adapt it thoroughly to the 
 wants of the American practitioner. Such additions as seemed desirable have been introduced 
 by the editor, Dr. I. Minis Hays, and the number of illustrations has been largely increased. The 
 importance of test-types as an aid to diagnosis is so universally acknowledged at the present day 
 that it seemed essential to the completeness of the work that they should be added, and as the 
 author recommends the use of those both of Jaeger and of Snellen for different purposes, selec- 
 tions have been made from each, so that the practitioner may have at command all the assist- 
 ance necessary. Although enlarged by one hundred pages, it has been retained at the former 
 very moderate price, rendering it one of the cheapest volumes before the profession. 
 
 A few notices of the previous edition are subjoined. 
 
 On examining it carefully, one is not at all sur- i lucid and flowing, therein differing materially from 
 prised that it should meet with universal favor. It some of tlie translations of Continental writers on this 
 is, in fact, a comprehensive and thoroughly practical subject that are in the market. Special pains are 
 treatise on diseases of the eye, setting forth theprac- taken to explain, at length, those subjects which are 
 
 tice of the leading oculists of Europe and America, 
 aud giving the author's own opinions and preferences, 
 which are quite decided and worthy of high consid- 
 eration. The third English edition, from which this 
 is taken, having been revised by the author, com- 
 prises a notice of all the more recent advauces made 
 in ophthalmic bciehee. The style of the writer is 
 
 particularly difficult of comprehension to the begin- 
 ner, as the use of the ophthalmoscope, the interpre- 
 tation of its images, etc. The book is profusely and 
 ably illustrated, and at the end are to be fouud 16 
 excellent colored ophthalmoscopic figures, which are 
 copies of some of the plates of Liebreich's admirable 
 atlas.— Kansas City Med. Journ., June, 1874. 
 
 ' A URENCE {JOHN Z.), F. R. G. S., 
 
 Editor of the Ophthalmic Review, &c. 
 
 A HANDY-BOOK OF OPHTHALMIC* SURGERY, for the use of 
 
 Practitioners. Second Edition, revised and enlarged. With numerous illustration 
 one very handsome octavo volume, cloth, $2 75. 
 
 In 
 
 For those, however, who must assume the care of 
 diseases and injuries of the eye, and who are too 
 much pressed for time to study the classic works on 
 the subject, or those recently published by Stellwag, 
 Wells, Bader, and others, Mr. Laurence will prove a 
 safe and trustworthy guide. He has described in this 
 
 edition those novelties which have secured the confi- 
 dence of the profession since the appearance of his 
 last. The volume has been considerably enlarged 
 and improved by the revision and additions of its 
 author, expressly for the American edition.— Am. 
 I Journ. Med. Sciences, Jan. 1870. 
 
30 Henry C. Lea's Publications. — (Surgery, &c). 
 
 rpHOMPSON(SIR HENRY), 
 
 ■* Surgeon and Professor of Clinical Surgery to University College Hospital. 
 
 LECTURES OjST DISEASES OF THE URINARY ORGANS. With 
 
 illustrations on wood. Second American from the Third English Edition. In one neat 
 
 octavo volume. Cloth, $2 25. (Just issued.) 
 My aim has been to produce in the smallest possible compass an epitome of practical knowl- 
 edge concerning the nature and treatment of the diseases which form the subject of the work ; 
 and I venture to believe that my intention has been more fully realized in this volume than in 
 either of its predecessors. — Author's Preface. 
 
 JDT THE SAME AUTHOR. 
 
 ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 
 
 THE URETHKA AND URINARY FISTULA. With plates and wood-cuts. From the 
 third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
 (Lately Published.) 
 
 T)Y THE SAME AUTHOR. (Just Issued.) 
 
 THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY 
 
 AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 
 355 pages, with thirteen plates, plain and colored, and illustrations on wood. Cloth, $3 75. 
 
 /TAYLOR {ALFRED S.), M.D., 
 
 •*■ Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital 
 
 MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 
 
 by John J. Reese, M.D., Prcf. of Med. Jurisp. in the Univ. of Penn. In one large 
 octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Just Issued.) 
 
 In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- 
 dence" the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of 
 consulting the sheets of the new edition of the author's larger work, " The Principles and Prac- 
 tice of Medical Jurisprudence," which is now ready for publication in London. This has enabled 
 him to introduce the author's latest views upon the topics discussed, which are believed to bring 
 the work fully up to the present time. 
 
 The notes of the former editor, Dr. Hartshorne, as also the numerous valuable references to 
 American practice and decisions by his successor, Mr. Penrose, have been retained, with but few 
 slight exceptions ; they will be found inclosed in brackets, distinguished by the letters (H.) and 
 (P.). The additions made by the present editor, from the material at his command, amount to 
 about one hundred pages; and his own notes are designated by the letter (R.). 
 
 Several subjects, not treated of in the former edition, have been noticed in the present one, 
 and the work, it is hoped, will be found to merit a continuance of the confidence which it has so 
 long enjoyed as a standard authority. 
 
 j$Y THE SAME AUTHOR. (Now Ready.) 
 
 THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 
 DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 
 volumes, cloth, $10 00; leather, $12 00. 
 
 This great work is now recognized in England as the fullest and most authoritative treatise on 
 every department of its important subject. In laying it, in its improved form, before the Ameri- 
 can profession, the publisher trusts that it will assume the same position in this country. 
 
 TftY THE SAME AUTHOR. New Edition— Now Ready. 
 
 POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 
 
 MEDICINE. Third American, from the Third and Revised English Edition. In one 
 large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. 
 This work, which has been so long recognized as a leading authority on its important subject, 
 has received a very thorough revision at the hands of the author, and may be regarded as a 
 new book rather than as a mere revision. He has sought to bring it on all points to a level 
 with the advanced science of the day; many portions have been rewritten, much that was of 
 minor importance has been omitted, and every effort made to condense a complete view of the 
 subject within the limits of a single volume. Dr. Taylor's position as an expert has brought 
 him into connection with nearly all important cases in England for many years. He thus speaks 
 with an authority that few other living men possess, while his intimate acquaintance with the 
 literature of toxicology on both sides of the Atlantic, renders his work equally adapted as a 
 text-book in this country as in Great Britain. 
 
 • 
 CONTENTS. 
 
 Poisons.— Absorption and Elimination— Detection— Action— Influence of Habit— Classifica- 
 tion of Poisons— Evidence of Poisoning— Diseases resembling Poisoning— Inspection of the Dead 
 Body— Objects of Chemical Analysis— Moral and Circumstantial Evidence in Poisoning, Ac. <fcc. 
 
 Irritant Poisons.— Mineral Irritants— Acid Poisons— Alkaline Poisons— Non-Metallic Irri- 
 tants—Metallic Irritants— Vegetable Irritants— Animal Irritants. 
 
 Neurotic Poisons.— Cerebral or Narcotic Poisons— Spinal Poisons— Cerebro-Spinal Poisons— 
 Cerebro-Cardiac Poisons. 
 
Henry 0. Lea's Publications — {Psychological Medicine, &c). 31 
 
 qiUKE {DANIEL HACK), M.D., 
 
 J- Joint author of " The Manual of Psychological Medicine," &e. 
 
 ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 
 
 THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
 Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Just Issued.) 
 The object of the author in this work has been to show not only the effect of the mind in caus- 
 ing and intensifying disease, but also its curative influence, and the use which may be made of 
 the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- 
 ject have long been familiar to the profession, but no attempt has hitherto been made to collect 
 and systematize them so as to render them available to the practitioner, by establishing the seve- 
 ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate 
 medicine the means which have been employed so successfully in many systems of quackery, the 
 author has produced a work of the highest freshness and interest as well as of permanent value. 
 
 T>LANDFORD {G. FIELDING), M. D., F. R. G P., 
 
 JL* Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 
 
 INSANITY AND ITS TREATMENT: Lectures on the Treatment, 
 
 Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
 United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
 handsome octavo volume of 471 pages; cloth, $3 25. 
 This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- 
 tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of 
 more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- 
 formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment 
 be called upon to take action in relation to patients. 
 
 It satisfies a want which mast have been sorely 
 felt by the busy general practitioners of this country. 
 It takes the form of a manual of clinical description 
 of the various forms of insanity, with a description 
 of the mode of examining persons suspected of in- 
 sanity. We call particular attention to this feature 
 of the book, as giving it a unique value to the gene- 
 ral practitioner. If we pass from theoretical conside- 
 rations to descriptions of the varieties of insanity as 
 
 actually seen in practice and the appropriate treat- 
 ment for them, we find in Dr. Blandford's work a 
 considerable advance over previous writings on the 
 subject. His pictures of the various forms of mental 
 disease are so clear and good that no reader can fail 
 to be struck with their superiority to those given in 
 ordinary manuals in the English language or (so far 
 as our own reading extends; in any other. — London 
 Practitioner, Feb. 1871. 
 
 w- 
 
 INSLOW {FORBES), M.D., D.G.L., frc. 
 
 ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS 
 
 OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
 phylaxis. Second American, from the third and revised English edition. In one handsome 
 octavo volume of nearly 600 pages, cloth, $4 25. 
 
 EA {HENRY C). 
 
 'SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 
 
 LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, 
 Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; cloth, $2 75. 
 (Lately Published.) 
 
 We know of no single work which contains, in so 
 •mall a compass, so much illustrative of the strangest 
 operations of the human mind. Foot-notes give the 
 authority for each statement, showing vast research 
 and wonderful industry. We advise our confreres 
 to read this book and ponder its teachings. — Chicago 
 Med. Journal, Aug. 1870. 
 
 As a work of curious inquiry on certain outlying 
 points of obsolete law, "Superstition and Force" is 
 one of the most remarkable books we have met with. 
 — London Athenaeum, Nov. 3, 1866. 
 
 He has thrown a great deal of ligh t upon what must 
 be regarded as one of the most instructive as well as 
 
 interesting phases of human society and progress. . . 
 The fulness and breadth with which he has carried 
 out his comparative survey of this repulsive field of 
 history [Torture], are such as to preclude our doing 
 justice to the work within our present limits. Bat 
 here, as throughout the volume, there will be found 
 a wealth of illustration and a critical grasp of the 
 philosophical import of facts which will render Mr. 
 Lea's labors of sterling value to the historical stu- 
 dent.— London Saturday Review, Oct. 8, 1870. 
 
 As a book of ready reference on the subject, it is of 
 the highest value. — Westminster Review, Oct. 1867. 
 
 TOY THE SAME AUTHOR. (Lately Published.) 
 
 STUDIES IN CHURCH HISTORY 
 
 PORAL POWER— BENEFIT OF CLERGY 
 12mo. volume of 516 pp. cloth, $2 75. 
 The story was never told more calmly or with 
 greater learning or wiser thought. We doubt, indeed, 
 if any other study of this field can be compared with 
 this for clearness, accuracy, and power. — Chicago 
 Examiner, Dec. 1870. 
 
 THE RISE OF THE TEM- 
 
 EXCOMMUNICATION. In one large royal 
 
 Mr. Lea's latest work, ' ' Studies in Church History," 
 fully sustains the promise of the first. It deals with 
 three subjects — the Temporal Power, Benefit of 
 Clergy, and Excommunication, the record of which 
 has a peculiar importance for the English student, and 
 is*a chapter on Ancient Law likely to be regarded as 
 final. We can hardly pass from our mention of such 
 works as these — with which that on "Sacerdotal 
 Celibacy" should be included — without noting the 
 
 literary phenomenon that the head of one of the first 
 American houses is also the writer of some of its most 
 original books. — London Athenceum, Jan. 7, 1S71. 
 
 Mr. Lea has done great honor to himself and this 
 country by the admirable works he has written on 
 ecclesiologicaland cognate subjects. We have already 
 had occasion to commend his "Superstition and 
 Force" and his "History of Sacerdotal Celibacy." 
 The present volume is fully as admirable in its me- 
 thod of dealing with topics and in the thoroughness — 
 a quality so frequently lacking in American authors — 
 with which they are investigated. — N. Y. Journal of 
 Psychol. Medicine, July, 1870. 
 
32 
 
 Henry C. Lea's Publications. 
 
 INDEX TO CATALOGUE 
 
 American Journal of the Medical Sciences 
 Abstract, Half-Yearly, of tbe Med Sciences 
 Anatomical Atlas, by Smitb and Horner 
 Anderson on Diseases of the Skin 
 Ashton on the Rectum and Anus . 
 Attfield's Chemistry .... 
 Ashwell on Diseases of Females . 
 Ashhurst's Surgery .... 
 
 Barnes on Diseases of Women 
 Bellamy's Surgical Anatomy 
 Bryant's Practical Surgery . 
 Bloxam's Chemistry • 
 Blandford on Insanity .... 
 Basham on Renal Diseases . 
 Brinton on the Stomach 
 Bigelow on the Hip 
 Barlow's Practice of Medicine 
 Bowman's (John E.) Practical Chemistry 
 Bowman's (John E.) Medical Chemistry 
 Brunton's Materia Medica 
 Bumstead on Venereal .... 
 Bumstead and Cullerier's Atlas of Venereal 
 Carpenter's Human Physiology . 
 Carpenter's Comparative Physiology . 
 Carpenter on tbe Use and Abuse of Alcohol 
 Chambers on Diet and Regimen 
 Chambers's Restorative Medicine 
 Christison and Griffith's Dispensatory 
 Churchill's System of Midwifery . 
 Churchill on Puerperal Fever 
 Condie on Diseases of Children . 
 Cooper's (B. B.) Lectures on Surgery . 
 Cullerier's Atlas of Venereal Diseases 
 Cyclopedia of Practical Medicine . 
 Dalton's Human Physiology . 
 Davis' Clinical Lectures 
 Dewees on Diseases of Females . 
 Dewees on Diseases of Children . 
 Druitt's Modern Surgery 
 Dunglison's Medical Dictionary . 
 Dunglison's Human Physiology . 
 Dunglison on New Remedies 
 Ellis's Medical Formulary, by Smith . 
 Erichsen's System of Surgery 
 Fenwick's Diagnosis .... 
 Flint on Respiratory Organs . 
 
 Flint on the Heart 
 
 Flint's Practice of Medicine . 
 
 Flint's Essays 
 
 Flint on Phthisis . 
 
 Fownes's Elementary Chemistry . 
 
 Fox on Diseases of the Stomach . 
 
 Fulleron the Lungs, &c. 
 
 Green's Pathology and Morbid Anatomy 
 
 Gibson's Surgery 
 
 G luge's Pathological Histology, by Leidy 
 Galloway's Qualitative Analysis . 
 
 Gray's Anatomy 
 
 Griffith's (R. E.) Universal Formulary 
 Gross on Foreign Bodies in Air-Passages 
 Gross's Principles and Practice of Surgery 
 Guersant on Surgical Diseases ol Children 
 Hamilton on Dislocations and Fractures 
 Hartshorne's Essentials of Medicine . 
 Hartshorne's Conspectus of the Medical Scie 
 Hartshorne's Anatomy and Physiology 
 Heath's Practical Anatomy . 
 Hoblyn's Medical Dictionary 
 
 Hodge on Women 
 
 Hodge's Obstetrics 
 
 Hodges' Practical Dissections 
 Holland's Medical Notes and Reflections 
 
 Holmes's Surgery 
 
 Horner's Anatomy and Histology 
 Hudson on Fevers .... 
 
 Hill on Venereal Diseases 
 Hillier's Handbook of Skin Diseases 
 Jones (C. Handfleld) on Nervous Disorders 
 
 PAGE 
 . 1 
 
 3 
 
 6 
 
 20 
 28 
 in 
 2:s 
 
 27 
 28 
 7 
 29 
 U 
 3] 
 18 
 16 
 28 
 14 
 II 
 i I 
 14 
 19 
 19 
 
 Kirkes' Physiology .... 
 
 Knapp's Chemical Technology 
 
 Lea's Superstition and Force 
 
 Lea"8 Studiesin Church History . 
 
 Lee on Syphilis ..... 
 
 Lincoln on Electro-Therapeutics . 
 
 Leishinan's Midwifery .... 
 
 La Roche on Yellow Fever . 
 
 La Roche on Pneumonia, &c. 
 
 Laurence and Moon's Ophthalmic Surgery 
 
 Lawson on the Eye .... 
 
 Laycock on Medical Observation . 
 
 Lehmann's Physiological Chemistry, 2 vols 
 
 Lehmann's Chemical Physiology . 
 
 Ludlow's Manual of Examinations 
 
 Lyons on Fever .... 
 
 Maclise's Surgical Anatomy . 
 
 Marshall's Physiology . 
 
 Medical News and Library . 
 
 Meigs on Puerperal Fever 
 
 Miller's Practice of Surgery . 
 
 Miller's Principles of Surgery 
 
 Montgomery on Pregnancy . 
 
 Neill andJSmith's Compendium of Med. Science . 
 
 Neligan's Atlas of Diseases of the Skin 
 
 Neligan on Diseases of the Skin . 
 
 Obstetrical Journal . 
 
 Odling's Practical Chemistry 
 
 Parry on Extra-Uterine Pregnancy 
 
 Pavy on Digestion 
 I Pavy on Food 
 
 Parrish's Practical Pharmacy 
 
 Pirrie's System of Surgery . 
 
 Pereira's Mat. Medica and Therapeutics, abridged 
 
 Quain and Sharpey's Anatomy, by Leidy 
 
 Roberts on Urinary Diseases . 
 
 Ramsbotham on Parturition . 
 
 Rigby's Midwifery 
 
 Rodwell's Dictionary of Science . 
 
 Swayne's Obstetric Aphorisms 
 
 Sargent's Minor Surgery 
 
 Sharpey and Quain's Anatomy, by Leidy 
 
 Skey's Operative Surgery 
 
 Slade on Diphtheria .... 
 
 Smith (J. L.) on Children 
 
 Smith (H. H.) and Horner's Anatomical Atlas 
 Smith (Edward) on Consumption . 
 
 Smith on Wasting Diseases in Children 
 
 Stille's Therapeutics .... 
 
 Sturges on Clinical Medicine 
 
 Stokes on Fever ..... 
 
 Tauuer's Manual of Clinical Medicine . 
 
 Tanner on Pregnancy 
 
 Taylor's Medical Jurisprudence 
 
 Taylor's Principles and Practice of Med J 
 
 Taylor on Poisons . 
 
 Tuke on the Influence of the Mind 
 
 Thomas on Diseases of Females . 
 
 Thompson on Urinary Organs 
 
 Thompson on Stricture . 
 
 Thompson on the Prostate 
 
 Todd on Acute Diseases . 
 
 Walshe on the Heart 
 
 Watson's Practice of Physic 
 
 Wells on the Eye . 
 
 West on Diseases of Females 
 
 Weston Diseases of Children 
 
 West on Nervous Disorders of Children 
 
 What to Observe in Medical Cases 
 
 Williams on Consumption 
 
 Wilson's Human Anatomy . 
 
 Wilson on Diseases of the Skin 
 
 Wilson's Plates on Diseases of the Skin 
 
 Wilson's Handbook of Cutaneous Medicine 
 
 Winslow on Brain and Mind 
 
 Wohler's Organic Chemistry 
 
 Winckel on Childbed 
 
 Zeissl on Venereal . 
 
 isp 
 
 For "The Obstetrical Journal," Five Dollars a year, see p. 22. 
 
OCT -0 ISM