LIBRARY OF CONGRESS 000003^=153 IS, lini mm mm — i -■i aSSffim mam 1H1 I mm m affiif nwuiniH HHiWBBHBaBBW BUcmnnnrB \J W~> \ * J /f not only to render more secure the fruit of the womb during a pregnancy, but to give passage to it in labor. The student ought always, in studying this part of his subject, to have at hand a good specimen of the female pelvis; but he should take notice, that, in the recent or living subject, these bony surfaces are invested with divers tis- 26 THE PELVIS LIGAMENTS RELATION TO PRESENTATION. sues, and sustain various organs -whose bulk and consistency give to the bony cavity an appearance and capabilities exceedingly different from those of the dried specimen. The lines that cross it in different directions, a b, c d, ef, ef, represent its diameters. The two small bones seen on the front of the pelvis, and which are respectively called the right and the left os pubis, are firmly and immovably united together by a fibro-cartilaginous ligament; and the triangular bone situated behind, and which is, in fact, a collection of consolidated vertebrae, is held in the strongest union to the side pieces or hip-bones, by means of a fibrous substance, called the auricular ligament, while the union is rendered vastly more solid and inde- structible by means of a quantity of ligament upon the exterior of the sacrum and hip-bones, as well as by other fibrous bands, called sacro-sciatic ligaments. All these ligaments are most economically adjusted, in order to avoid any encroachment upon the space required for the transmission of the child in parturition, to which end they are distributed either upon the external surface, or they are adjusted be- twixt articular surfaces, so as in no wise to diminish the capacity of the straits or the excavation. Meanwhile, the whole structure ac- quires, by means of them, the requisite strength and solidity; a strength that is, perhaps, greater than if they had consisted of a single bone. The obstetric pelvis has relation to the transmission of the child through the straits and excavation. A child at term is eighteen or twenty inches in length. It is obvious, then, that it must, while within the womb, be strongly flexed, the head being bent forwards upon the breast, the thighs flexed upon the belly, and the legs flexed upon the thighs, while the arms are pinioned against the sides in front of the thorax, in flexion. This state of universal flexion gives to the foetus the shape of an olive, Fig. 6. The olive-shaped mass is about twelve inches in its longitudinal, and four inches in its conjugate diameter; whence it is evident that, in a labor, one pole of the olive ought to present itself to the straits, which are large enough to give passage to a body only four inches in diameter. Can the student suppose that it is a matter of serious import to the woman, whether the cephalic or the pelvic pole be the presenting part? Not so, however, as to the foetus — to whom it is of immense importance that the cranial pole should be the first to descend. The cut exhibits the olive-Hke form in which the foetus lies packed while in the womb, and it ought to show that it is nearly indifferent THE PELVIS — SACRUM. 27 as to the mothers interests whether one or the other extremity of the foetus approaches the os uteri. In order to obtain very accu- Fi s- 6 - rate notions of the pelvis, all the portions of which it consists ought to be separated and stu- died, each in succession; to which end, I shall now proceed to enumerate them. They are eight pieces, whose names are as follows: — the sacrum; the coccyx; the right ilium; the left ilium ; the right ischium ; the left ischium ; the right pubis, and the left pubis. Thus, the student becomes master of the names of the eight pieces of which a pelvis is composed. As to its shape, the sacrum is a triangular pyramid. The inner face is larger than either of the two outer faces. It is concave, whereas their faces are convex. Hence, the pyramid is bent towards the excavation, and its concave face is what is called in midwifery the hollow of the sacrum. The sacrum has the following parts that are worthy of notice: — 1. The base. 2. The apex. 3 and 4. The two edges. 5 and 6. The two auricular facettes. 7. The sacral foramina. 8. The concavity or hollow. The base is of a triangular shape. At the base is to be seen the articular surface by which the bone, covered with its intervertebral cartilage, was united to the last lumbar vertebra. The anterior edge of that articular surface is the most salient point of the promontory of the sacrum; and there, also, is found the sacro-vertebral angle, so called, because the lumbar spine and the sacrum are joined together so as to make an obtuse angle at the place of junction. The words promontory, projection, and sacro- vertebral angle, are used as synonymous terms. The sacrum is fully four inches wide, measured from wing to wing, at its base. In descending, it becomes narrower down to its apex or point, upon which is an oblong or oval articular facette, by which it is united in the living subject to the os coccygis. 28 THE PELVIS — SACRUM. Fig. 7. Behind the edges of the sacrum, where the bone is broad, is seen upon either wing a smooth surface shaped like the human ear, whence it is called the auricular surface. There is a similar one on each hip bone or coxal bone, for the purpose of articulation. A strong fibro- cartilage, called from its form, the auricular cartilage, passes from the sacral to the coxal surface: it is about a sixteenth of an inch in thickness. It has no synovial cavity; and is so very strong that a considerable effort is required to separate the bones, even when held together by this ligament only. There are samples of labors in which this powerful bond of union has been broken by the violent efforts of the patient in thrusting the child through a pelvis too small for its passage. The adjoining figure of the sacrum represents its form very correctly, as seen in looking upon its front or hollow surface. It is about four inches long, and at the widest part, the breadth equals the length. This surface is the posterior wall of the excavation of the pelvis. There is observed a double row of holes or foramina for the transmission of nerves that come off from the brush-like extremity of the spinal cord. Four holes are to be counted in each row; occasionally a specimen is seen to contain five in each row. By filling these holes with putty, and pouring water upon the surface while holding the bone in a horizon- tal position, the cup will be found deep enough to hold an ounce of water, sometimes more, sometimes less, according as the hollow is deeper or shallower. Let not the Student disregard these foramina. He should observe the shallow grooves in the bone that lead to the holes, and reflect upon the comparative security thus given to their nervous cords, which, in most instances of labor, are by this means protected from injurious pressure by the head of the child or by any instruments used in midwifery. Pressure upon a nerve gives pain; violent pressure gives rise to intolerable agony, or it inflames or kills the nerve: let him, then, ponder on the possible consequences of pressure and contusion for the limbs that are supplied with nerve-force by means of these sacral bundles. THE PELVIS SACRAL FORAMINA. 29 While speaking of these internal sacral holes for the transmission of nerves, I may seize the occasion to insist that the compression of a nerve produces pain, and the pain is generally intense in the propor- tion of the violence done to the nerve — short of wholly destroying it. A child's head can scarcely get through the pelvis without com- pressing, more or less, some one of the nerves in range either on the right or left side of the sacrum. When the head rests upon one of these cords, the muscle or set of muscles innervated by it are thrown into spasm or cramp ; whence it is an ordinary occurrence to hear women. in labor complain of cramp in the thigh, the leg, &c, which ceases when the pressure is relaxed, and which returns again with the effort, until the head has passed down lower than the nerve — after which the cramp is nowhere felt. I think one of the most fearful sights of human agony that my eyes have ever witnessed, was that of a lady in North Sixth Street, Mrs. Th. S y, who, being in labor of her first child, and making rapid progress towards a delivery, began suddenly to scream, with the greatest violence, after uttering the words, "Oh, the cramp! the cramp! the cramp!" She was indescribably agitated, her counte- nance assumed the wildest expression, and all the persons in her chamber became much alarmed on account of the very extreme de- gree of anguish, or rather agony, which was depicted in her counte- nance and expressed by her shrieks. I had, for many years, been accustomed to the cries of puerperal women, to which I had become very indifferent, but this case deserved to be called terrible. The cramp affected the muscles of her right leg. I explained to her that the cramp was caused by the pressure of the child's head upon one of the right sacral nerves, and, though the appearance of the case was appalling, I exhorted her to bear down, hoping a few vigorous efforts would push the head lower than the point of pressure, and relieve her from the misery. I was disappointed; the cries ceased with the relaxation of the throe, only to return with every renewal of the con- traction. So intense was her distress, that she began soon to show signs of exhaustion of nerve-force, and I have now no doubt that she was in imminent danger of d^eath from the excess of pain. The labor was arrested, as to its progress, with every renewal of the labor pains ; and it appeared that her whole life-force and perception w r ere occupied with this sole agony. I was three-fourths of a mile from home ; and while her husband was gone for my forceps, for which I immediately sent him, she renewed her cries about every four minutes. I think she would have died in half an hour. Upon receiving the 30 THE PELVIS SACRAL FORAMINA. instrument, I speedily applied it and drew the head below the com- pressing point, and she bore the extraction without murmur, for the nerve was set at liberty as soon as I had drawn the head below it. For more than a fortnight after the labor there was a partial paralysis of the limb, following the pinch the nerve had suffered betwixt the foetal head and the bony pelvis. It did not wholly disappear for many days. Two years later, I encountered a similar scene in the same apartment. She seemed to dread nothing in the approaching labor but the "cramp!" and engaged me to be prepared with my forceps, which I unfortunately declined to do. When the head de- scended into the pelvis, she was seized with precisely the same kind and degree of pain; the forceps were brought to me from the same distance, and she was again as speedily relieved. In this labor, as in the former, a partial paralysis and numbness of the leg followed the parturition, and did not disappear until the month was out. In a third labor, during which I was confined to my house by sick- ness, she came under the care of my able colleague, Dr. R. M. Hus- ton, well known for his skill as an obstetrician. The same scene was renewed in this third case, and the Doctor felt obliged to relieve her by extracting the head with the forceps. I have attended her in a fourth labor in the year 1846, in which the position of the child was such as to avoid the pressure, and she gave birth to her infant without cramp, or any uncommon pain. I was in attendance upon a lady living in Turner's Lane, two and a half miles from my house. The labor had proceeded very towardly until the head got well down into the pelvis. I was in a lower par- lor conversing with her husband when we were both startled by the sudden, sharp screams of the patient from her chamber in the second story. We both hastened to the apartment, where I recognized a scene in all respects like those witnessed in the accouchement of Mrs. S y. After vainly exhorting my patient to bear down and push the child lower than the nerve, I engaged Mr. to wake his servant, for it was night, and send him on the fastest horse to the city for my forceps. Her agony was indescribable during the whole pe- riod of his absence. He had a ride of five miles — out and in. I got the instrument, and the child was delivered within two or three min- utes after it was placed in my hands. No evil consequences fol- lowed the pressure in this case. She had had several children, but in none of the labors had the nerve got so severe a pinch. Here, then, are four cases of forceps operations rendered indispensa- ble by pressure on the sacral nerves. I have seen no accounts of THE PELVIS COCCYX. 31 similar instances in the books. I have met with many hundred labors in which cramp was more or less violent; but these cases, above mentioned, were really frightful, and I have no doubt that both the distress and the danger were sufficient warrants for the instru- mental assistance. The movableness of the coccyx upon the sacrum is much relied upon as a means of amplifying the antero-posterior diameter of the lower strait of the pelvis. I do not think that the point of the coccyx usually recedes much during the transit of the foetal head in parturition. I here present a figure that represents the terminal or caudal ex- tremity of the spinal column of the natural size. It is called the os coccygis or cuckoo bone, in vulgar language the crupper bone. It consists of three pieces, altogether about an inch and a half long, that are separable in the young, but become anchylosed into one solid piece as advance is made in years. Two styloid processes ascend from the posterior lateral surfaces to rest upon the back part of the apex of the sacrum and prevent the point of the coccyx from being driven too far back- wards by the displacing pressure of the foetus in labor. The cornua, however, are not strong enough always to re- sist, and they occasionally break off with a loud sound. The sound may be heard at the distance of many feet from the woman in travail. In general, no very great inconvenience is produced by this fracture ; although there are met with a few instances in which a long-continued pain follows the accident. In young women, the articulation of the coccyx and sacrum is a movable one; anchylosis takes place in those who be°in to grow old, advancing beyond the youthful season of bloom and beauty. Hence, it is better that a woman should have her first children before this bony anchylosis takes place, inasmuch as when the sacrum and coccyx have become immovably joined together, the point of the little bone may arrest or distressingly retard the acts of child-birth. Most writers attribute to the coccyx a power to recede very con- siderably. My own observation has led me to regard this recession as less than it is generally admitted to be, and inspection confirms this doubt. The point cannot go very far backwards but at the ex- pense of a fracture of the cornua and of the lesser sacro-sciatic liga- ments which tie it firmly in a certain proximity to the tuberosities of the ischia. 32 THE PELVIS — SACROILIAC JUNCTION. Fk. 9. The manner in which the sacrum is joined to the coxalia or hips is worthy of attention. The two auricular facettes converge both down- wards and backwards, and are furnished with opposite bulbs and de- pressions, fitting into each other with the interposed fibro-cartilage before described. This double convergence of the surfaces has the effect of a dovetailing to prevent the sacrum from slipping down be- twixt the hips, when weighed down by the weight of the over-bur- dened body, or of being driven backwards by the resistance of the child in labor. The great groove or channel on the back part of the pelvis is almost filled up by means of ligament, so that there can be no stronger joint in the whole skeleton than the sacro-iliac joint. The cut is designed to show the sacro-vertebral angle, which is the point touched by the finger of the hand repre- sented in the figure, and the shape of the sacral curve; it represents an antero-posterior section of the bone through its middle. In it the base of the sacrum appears to project or advance over the excavation like a promontory. A chord line from the promontory to the point of the coccyx gives a sine of an inch, which is the greatest depth of the hollow. A badly shaped sacrum causes great diffi- culty in labor. Whether the curve be too shal- low or too deep, it is unfavorable ; the figure represents a desirable one. Having thus given an account of the os sacrum and os coccy- gis, our attention ne- cessarily turns to the hip-bones, called cox- al-bones, nameless- bones, or ossa inno- minata, which make up the sides and front part of the pelvis. Annexed is a cut that represents the right os innominatum or hip bone. The very name it bears affords suffi- cient evidence of the difficulty of describing Fig. 10. THE PELVIS — OS INNOMINATUM. 33 it in words ; I therefore request the reader to refer to the drawing, which affords a very correct notion of the form and arrangement of the several parts of which it consists. It is divided into three parts or pieces, that are named respectively the os pubis, os ischium, and os ilium. The pubis is on the left of the figure, the ischium at the lower part, and the ilium constitutes all the broad portion at the right and superior portion of the cut. If an os innominatum be taken from a subject under twelve or four- teen years of age, and macerated or boiled in water, it readily sepa- rates into three pieces; and the separation takes place because the pieces, in an under age, are not consolidated, or become one firm bone. The separation occurs in the acetabular region, where the several pieces are as yet not firmly united by ossific fusion ; a union that cannot become completed until the body has acquired a degree of development fitted to enable it to undergo the fatigue of gestation, which rarely occurs until the fifteenth year. A bone, taken from the os innominatum of a subject about twelve years old, serves to show the student the propriety of preserving for the adult skeleton the names of the three juvenile pieces ; for he will learn thereupon that it is very convenient to refer to them, in many cases, when we desire to direct the attention accurately to a certain point of the pelvis, of which we can then speak, as its ischial, pubic or iliac, portion. Fig. 11 is a representation of the appearances observable upon the exterior surface of the right os innominatum — 1 is the dorsum of the ilium; 2 is the acetabulum; 3, the venter, costa, or fossa ; 4, the anterior superior spinous process of the ilium; 5, the anterior inferior spinous pro- cess; 14, the tuberosity; 15, the ramus ischii ; 18, the descending ramus of the pubis ; 19, the symphysis pubis; while 20 is the thy- roid foramen, or obturator foramen. The anterior fifth of the acetabulum belongs to the Fig. 11. 34 THE PELVIS OS INNOMINATUM. pubis, the lower two-fifths to the ischium, and the upper and outer two-fifths to the os ilium. Upon the right inferior portion of the shaded drawing, Fig. 10, is seen a rough surface (7), shaped somewhat like a human ear — whence it is called the auricular surface. This rough disc is covered, in the recent subject, with a fibro-cartilage that seems to grow out of the bone, and is shaped exactly like the auricular surface; it is about one- sixteenth of an inch thick, as mentioned in describing the sacral auri- cular facette, into which it is inserted as strongly as it is into that of the innominatum. On the left extremity of the figure is another articular facette (17), that of the symphysis pubis. The inter-pubic ligament passes from this facette to its fellow on the left os pubis. The lower part of the picture (14), shows the rough tuberosity of the ischium, sciatic bone, or sitting bone, the point upon which the body rests when in a sitting posture. Just above and behind the tuber ischii is a sharp point, or spinous process (13), that is called the spine of the ischium. Between the lower end of the auricular facette of the ilium and the posterior extremity of the tuberosity of the ischium, is a deep incisura or notch (8), called the sacro-sciatic notch, because the incisura lies between the sacrum and the ischium. Inasmuch as the ilium also forms a part of the margin of this notch, it would be a better nomen- clature to call it the ilio-sacro-sciatic notch; which would express an anatomical truth fully. This notch is divided into the greater and lesser, and is converted, by means of the sacro-sciatic ligament, in the recent subject, into two large foramina or openings, through which pass certain nerves, vessels, and tendons of muscles. It would be improper, in this cursory examination of the os inno- minatum, to omit a reference to the smooth, or plane surface of the ischium, which is technically called the plane of the ischium. It is all that part of the inner surface of the bone that is bounded by the pubis and ilium above, by the sacro-sciatic notch behind, by the inner lip of the tuberosity below, and the posterior part of the obturator foramen in front. It is particularly denominated the inclined plane of the ischium, because the plane, in descending, approaches the plane of its fellow on the opposite side of the exca- vation. The Pubis. — The pubis is the smallest bone of the innominatum ; THE PELVIS OS INNOMINATUM. 35 it is the shear-hone — the bar-bone — the cross-bone — called, in Latin, os pubis, and also os pectinis; from pecten, a comb. As the pudenda is clothed with hair, the term pecten has been applied to that region, and the bone of the pubis has been called the os pectinis. Juvenal speaks of the pecten in Sat. vi. 370. Inguina traduntur medicis jam pectine nigro. The pubis is divided into the body, the symphysis, and the ramus. The body of the bone occupies about one-fifth of the structure com- posing the acetabulum, from whence it extends, the right one towards the left, forwards and downwards, and the left one, to the right, for- wards and downwards, until the two symmetrical bones meet in the anterior median line of the pelvis at a point called the symphysis pubis, where they are held in strong union by the inter-pubic liga- ment. The two symphyseal extremities of the bones are rough, as giving origin to the fibro-cartilage which unites them. From each symphyseal extremity there descends a thin flattish branch or process, called the ramus of the pubis, which is fused with the ascending ramus of the ischium, both of the left and the right side. The divaricating edges of these rami give the form of an arch, which is called the arch of the pubis. The body of the bone, as has been said, extends itself towards the symphyseal extremity — and that extremity sends down its ramus — so that there is left between the inferior edge of the body and the interior edges of the ramus of the pubis Flg * 12, and ischium, and the anterior edge of the plane of the ischium, a large va- cuity, which is the thyroid foramen be- fore mentioned. The pubis is often called, in English, the shear-bone, and the bar-bone. The figure gives an idea of the form of the pubis — as to its body, its symphysis, and its ramus — seen from behind looking forwards, or anteriorly. 36 THE PELVIS LIGAMENTS. Fig. 13. Let me again advise the student not to despise the strong English word, bar-bone, since its meaning is pregnant. This bone is really the bar on which turns the foetal head in its act of extension ; and the word bar-bone is, therefore, a very expressive one. The diagram (Fig. 12) may serve to show a symphysis pubis and sacrum cut through, and exhibiting half the carti- lage by which the pubis was joined to its fellow. This symphysis is half an inch thick from front to rear, and an inch and a half high from top to bot- tom. It is the bar which impedes the progress of the head in front, and which must go under the bar, to get into the world. In doing so, the head revolves beneath the bar- bone, as shown in the figure of the head marked in strong outline, and likewise in the successive positions it assumes (as indicated by the fine outlines), in revolving beneath the bar-bone. When the obstetrician takes the head by force of instruments from behind the bar to bring it into the world, he must do so by drawing it underneath the bar, as shown in the three figures. In the figure, Extension of the head is already begun, for the vertex has come a little way out of the strait. Symphyseal Ligaments. — The two symphyseal ends of the pubes are, as I said, united by a fibro-cartilage, passing interchangeably from one bone to the other. The lower edge of this ligament is called the triangular ligament. It serves both to strengthen the union and to depress the crown of the pubic arch, which arch is thus made rounder and lower, and softer. If the head were pressed immedi- ately against the bony structure, that structure, from its inelastic hard- ness, would contuse the soft parts of the woman or those of the child ; whereas the ligament is of the nature of a soft and elastic cushion. In dividing the symphysis, there is sometimes, not always, found in the centre of it a very small synovial sac. The ligaments of the pelvis are of very great importance. The firmness of the pelvis as an organ for transmitting the weight of the trunk to the lower extremities, and propagating their motion inversely to the trunk and limbs, is dependent upon the ligaments. I shall pre- sent the reader here with a view of them taken from a distinguished THE PELVIS — LIGAMENTS. 37 author, who, I hope, will not object to my exhibiting to the American student a copy of his beautiful drawing. I refer to Dr. Frederick Arnold, from whose Tabula Anatomicce, Fasciculus IV. Pars II. Continens Icones Articulorum et Ligamentorum, fol. Stuttgard, 1843, I have taken Fig. 13. In this figure the letter g is the sacrum ; s s s the posterior sacral foramina; h the os coccygis, j the right os innomi- natum, of which a portion has been removed, o the posterior superior spinous process of the ilium, b the greater sciatic notch, 10 the superior ilio-lumbar ligament; 11 inferior ilia-lumbar ligament; 12 superior sacro-iliac ligament; 13 the posterior superficial sacro-iliac ligament; 15 sacro-sciatic ligament; 16 the sacro-spinous ligament; 17 the sacro-tuberous ligament. Fig. 14. From a mere inspection of Dr. Arnold's figures it is evident that the chief ligamentous strength of the sacro-iliac junction depends, 1st, upon the powerful ligaments on the back part of the pelvis, out- side of the excavation ; and 2d, on the firm cohesion of the symphysis pubis by means of the strong inter-pubic ligament. The auricular or sacro-iliac cartilage is not represented, and yet it is so strong that I have been much foiled in endeavoring, before my class, to tear open the sacro-iliac joint by pulling asunder the ossa pubis after I had per- formed the section of the pubic ligaments: the origin or insertion of the auricular cartilage must be torn out from the bone before it will 38 THE PELVIS RELAXATION OF JOINTS. yield, for the fibres will not break. They can only be torn out by the roots. Opening of the Joints. — Many people among the mass of society suppose that in every labor, the joints become relaxed, in order to let the child pass through the bones ; and a good many ladies take a spoonful of oil of olives or palma christi, with a view to promote this desirable relaxation as they esteem it to be. I have known a young thing take the trouble, nightly, to anoint the mons veneris for a long period, with lily ointment, to soften the joint. It is understood, however, by the anatomist, that these joints do not become open and relaxed as a normal effect of gestation, of labor or of endermic or therapeutical measur&s, resorted to for that end. Yet they do, in some persons, relax, to their great injury or inconvenience. As to the symphysis pubis, I have on many occasions found it to be quite loosened, and admitting of motion. One of my patients, whom I have succored in many of her confinements, has greatly suffered from the relaxation of the symphysis pubis during the several last weeks of her pregnancies. The articulation becomes so loose as to make a very considerable cracking sound, when she would turn in bed, or walk; and she has been good enough, in order that I might verify the fact, to allow me to cause the motion by pressing with my hands on the opposite spinous processes of the iliac bones, by which means 1 could cause the two opposite pubes to approach or separate from each other, or ride up and down, passing each other in the di- rection of the length of the symphysis. When the patient in such a state of the interpubal ligament stands on the right foot, the right pubis rises upwards, while the left descends, and vice versa — so that the act of walking is not only attended with pain, but with tottering and uncertainty. The lady in question gives birth to children weighing ten and twelve pounds, but she has commonly recovered from the relaxation within about forty days after the birth of the child, and her pubic joint remains perfectly strong and efficient, until in an advanced stage of the next gestation, the pressure and the infiltration come to loosen and dispart the bones again. This lady has been fourteen times pregnant, and has given birth to twelve children at term. The joint did not give way until the sixth accouchement, which occurred Oct. 20th, 1833. The child weighed upwards of twelve pounds. The motion of the symphysis was very obvious, and very painful. She recovered from it, however, and did THE PELVIS PLANES. 39 not feel it again until near the close of a pregnancy, which was con- cluded on the 12th December, 1835, by the birth of a son. In about a month the articulation was again firm as ever. A daughter was born October 30th, 1837, which reproduced the relaxation. She soon got over this, and in the next pregnancy and confinement felt nothing of it. This labor was on the 2d of September, 1843. When the child was three months old, the relaxation took place, and was long trouble- some. She was again pregnant in 1845, but had no return of the incon- venience in the gestation or lying-in, which occurred January 20th, 1846. The joint gave way again soon after her last accouchement, Aug. 17, 1848 ; she discovered it on the 20th day of the month, and it is so movable, that a cracking sound is produced by turning in bed. Having now described with sufficient detail the several constituent bones of the pelvis, it is proper to take a view of the whole of that structure, which deserves to be regarded somewhat in the light of a great and important organ of parturition. 1 do not speak of it as of one of the items belonging to the domain of a special anatomy. The Whole Pelvis. — The female pelvis is divided into two por- tions, two cavities, two basins, or two pelves, one of which is the upper, and the other the lower; the greater, the lesser; the superior, the inferior ; the pelvis, the true pelvis or excavation, or cavity. The division betwixt the two portions is to be found at the linea ilio-pectinea, for the whole pelvic cavity is in a sense, worthy to be called, as it often indeed is called, a canal, a bony canal, the pelvic canal, in which is a narrows or straits, as the Dardanelles is a strait betwixt the Black and Mediterranean seas, parva componere magnis. The strait betwixt the upper and lower pelvis is called the superior strait; and it is a strait, because above it is the great, the larger basin, and below it is the smaller or lesser basin, w T hich, however, is a part where the pelvis is more spacious than it is at the strait itself. Plane of the Superior Strait. — The plane of the strait is an imaginary superficies, the anterior margin of which is at the sym- physis pubis, its posterior margin at the promontory, while the rest of its margin touches the inner lips of the linea ilio-pectinea. When the woman stands erect, or lies at length on the back, the plane of this strait dips at an angle of 50° to the axis of her body. Inclination of the Plane. — It must clearly appear that the plane of the superior strait dips at a variable angle in various positions of the trunk of the body; for if the subject be standing, it dips as above at 50°, but if the trunk be inclined forwards, the dip will be lessened ; 40 PLANES OF THE PELVIS. or if the trunk be inclined far backwards, it may be increased. Now this is an important item of obstetric knowledge, since upon it is founded our advice as to the decubitus of the patient, whom we may direct to extend her trunk or to flex it more or less, as we may desire to bring the plane of the superior strait into a position that may favor both the entrance of the presenting part into the strait, and its pas- sage through it. The figure is designed to show that the plane of the strait may give different angles with the spine, s * • according as the spine is brought more forward, or carried farther \ ! backwards over the opening. Thus e e e is a circle of which the diameter b f represents the inclination of the plane of the upper strait, equal to an angle of 135° f a, which is the ordi- nary altitude of the spinal co- lumn or axis of the trunk. If the patient lying upon her back should have her shoulders raised, so as to carry the spine forward to c, equal to 22.30°, the angle would be reduced to 112.30°. But if the shoulders should be still more elevated to d, the axis of the trunk would be at right angles to the plane of the strait bf- The same effect as to the incli- nation of the plane of the strait is produced in the patient, lying on her side, whenever she bends her head and trunk forwards; and, indeed, in labors, we see women constantly prompted by an instinctive sense of the utility of it, bending the trunk quite over the abdominal strait, to which, moreover, the old nurses and experienced crones urgently exhort them. A child's head, that in one inclination of the plane should be driven against the symphysis pubis, would with a lesser inclination of it plunge at once to the bottom of the pelvis. Justus Heinrich Wigand, the lamented author of the celebrated volume entitled Die Geburt des Menschen, was deeply impressed with the importance of a careful attention to the inclination of the plane, PLANES OF THE PELVIS. 41 Fig. 16. in Labors. He often made use of his knowledge of it as a foundation of his prognosis. I have copied these outline figures from the second edition of his work, by Froriep. They represent the female torso in profile. Each figure has marked upon it six lines, of which the two horizontal ones extend parallel to each other, from the promontory of the sacrum and the symphysis pubis respectively. In a well-formed pregnant female, the profile will resemble the outline figure, provided the child be not very large, nor the liquor of the amnios excessive in quantity. As in Fig. 16, the back bone will not be excessively curved. A line drawn hori- zontally forwards from the top of the sacrum will pass out at the navel, and equal angles will be formed by a line drawn from the top of the sacrum to the symphysis pubis, which indicates the inclination of the superior strait, and one drawn from the same point to the scrobiculus cordis. A line from the scrobiculus cordis to the symphysis pubis, will be perpendicular to the one first mentioned. Inspection of such a figure might well serve to establish a favorable prognosis ; since, cseteris paribus, any untoward circumstances would be very little to be expected with so perfect a form, proportion, and arrangement of parts. This, Fig. 17, is a copy of Wigand's figure 3d, in which he proposed to represent the pro- file of a pregnant woman of apparently perfect form, but the inclination of whose superior strait is excessive, as may be seen by ob- serving the line drawn from the top of the sacrum to the top of the symphysis pubis. In such a patient the plane of the strait looks almost backwards, and the indication of Con- duct would be to cause her to bend her body strongly forwards, flexing her thighs very much upon the pelvis. Such a direction alone might suffice to correct the excessive inclina- tion of the plane, whereas, if she should lie on the back with the shoulders low, and the limbs extended, the presenting part could Fig. 17. 42 PLANES OF TEE PELVIS. v fail to be driven upon the top of the ossa pubis. In this figure the back is mack more curved than in the former one. The horizontal line, from the base of the sacrum to the symphysis, rises far e the navel, and the upper triangle or that of the scrobicle is much smaller than that of the pubis. The line falling from the scrobicle to the pubis retires, whereas in the former figure it is perpendicular. In this figure the perpendicular line from the base of the sacrum is fai in advance of the upper dorsal vertebrae. The contemplation of these ingenious profiles of the admirable Ger- man cannot fail to increase the tact and knowledge of the student, to whom the study of them is warmly recommended. Here is Wigand's Fig. 4, in which is the profile of a woman with a pelvis so deformed as to imply a necessity for the operation of per- foration, on account of its vitiated conjugate diameter. The angle formed by the back part of the sacrum and spinal column is much too small. The bend is quite different from the gentle curve -::: in the first profile. F:s. IS. The scrobicle proj ects ve y much over the symphysis pubis, as by the line uniting them may be seen. T::e horizontal line from the base of the sacrum comes out just above the navel. The line from the scrobicle to the base of the sacrum, and that from the sacrum to the pubis are not equal — as in the first and more perfect figure. The chord line from the promontory to the coccyx retires, and the whole of it is in rear of the upper part of the spinal column. "Wigand's 5th figure represents a pregnant woman, the conjugate diameter of whose superior strait does not exceed one inch or one inch and a half; and which, according to most of the German ac- coucheurs, indicates a resort to the Caesarian operation. The belly is quite pendulous over the pudenda. The plane of the strait mak sharp angle with the horizontal line which comes out high above the umbilicus. The back is extremely hollow, ..sequence of the sinking of the sacral promontory down towards PLANES OF THE PELVIS. 43 Fig. 19. the pubis, and the line from the scrobiculus cordis to the ossa pubis retreats strongly in a backward direction, leaving the breast to hang far dver the pudenda in front. The curve of the sacrum is sharp, and the compensating curvature of the upper part of the vertebral column is highly characteristic of this malformed pelvis, and is an evil omen to the unfortunate woman. Such are some of Wigand's outline figures. I believe that the study of them will be very useful to the student. It takes many years of practice, and a great clinical experience and close observation like Wigand's, to enable one to become possessed at a glance, of the peculiarities of the case. He, however, was a Master in our art, a man who devoted his time to its improve- ment, and spent the last moments of his truly missionary life in laboring to complete the beautiful volume from which I have taken his drawings. It is a privilege and an honor to evoke such a man from his too early grave, in order that he, though dead, may yet speak in this distant land. Plane of the Inferior Strait. — The plane of the inferior strait is usually regarded as bounded by the inner lips of the two tubero- sities of the ischial bones, the rami of the ischia and Flg - 20 - pubis, the ischio-sacral ligaments, and the point of the coccyx. In this way we speak of the plane of the inferior strait as one plane only ; whereas, there are in fact , two such planes, an anterior and a posterior. This figure exhibits the contour of the outlet. The line c d represents the transverse diameter. The letters c ea ed show the anterior semi-cir- 44 DIAMETERS OF THE PELVIS. cumference, while c fbf d show the posterior semi-circumference of the outlet. Now from c d to a is an inclined plane, and from c d to b is another inclined plane. These planes intersect each otfeer at an angle of 140°, and they ought to be distinguished as the anterior and as the posterior inclined planes of the perineal strait. In midwifery it will be found that as the child descends, in order to escape from the womb, it first impinges upon the posterior inclined plane, which it depresses first, and then begins to depress the poste- rior edge of the anterior inclined plane. When it has succeeded in depressing the edges of the two planes, it escapes betwixt them, whereupon they resume their place like two valves, whose 'floating margins had been first violently separated, and then allowed to close again. Diameters of the Pelvis. — The diameters of the pelvis are cer- tain imaginary lines extending across the pelvic canal in different directions, but having reference, in the books, chiefly to the mensura- tion of the straits, or narrowest parts of the pelvis. For the superior strait there are assigned four diameters, which are, 1st, the antero-posterior ; 2d, the transverse; 3d, the right and 4th, the left oblique diameters. In the figure, a b is the antero-posterior diameter, which extends from the symphysis Fig- 21 - pubis to the promon- tory of the sacrum ; e f is the transverse, while g c and g c trace out the places of the right and left oblique diameters, as they pass diagonally from each sacro-iliac junction to each acetabulum. The lines a c and a c mea- sure the distance from the sacrum to the right and left acetabular regions of the pelvis. In the inferior strait, vid. Fig. 20, there are reckoned two diame- ters. 1st, the antero-posterior, and 2d, the transverse diameter. The knowledge of these diameters is of great importance in the scien- tific management of labors, on account of their relation and comparison DIAMETERS OF THE PELVIS. 45 to parts of the child, as presenting naturally, or as abnormally pre- sented, or placed. My measurements of the fetal head were reported to the meeting held at Philadelphia for celebrating the one-hundredth anniversary of the American Philosophical Society, on the 25th day of May, 1843. The mean magnitude of the child's head at term, according to the statements made in that paper, is greater than that stated in the books; for, of 300 heads measured with the calliper immediately after the birth of the child, there were forty heads whose smallest diameter was four inches or more than four inches in length; while only one head was less than three inches and a half, the usually supposed mean length of the transverse diameter. Now, the only interest we take in the measurement of the pelvis relates to a proportion between the pel- vis and the child that is transmitted through its canal ; but, if the child's head is 3.8 inches in its smallest diameter, the dried pelvis ought to be more than four inches, in order to allow for it a free transit. I measured ten pelves, among those in my collection, and the re- sults, as to the diameters of the upper and the lower straits, were as follows in the table which I subjoin : Superior Strait. Inferior Strait. No. of Pelves. Antero-Posterior. Transverse. Oblique. Antero-Posterior. Transverse. 1 4.2 6. 5.3 4. 4.3 2 4.4 5.5 5.5 3.6 4.4 3 3.9 4.8 4.7 2.7 4.2 4 3.5 5. 5. 2.9 4.3 5 4.2 5. 4.8 3.1 4.6 6 4.3 4.6 5.5 4.1 4.6 7 4.9 4.7 4.8 4.1 4.1 8 4.3 4.5 4.3 4.1 3.8 9 4.4 4.8 4.9 3.6 4.7 10 4.3 4.8 4.7 3.8 4.2 The mean in ten pelves is, for the superior strait — for the antero- posterior diameter, 4.2 ; for the transverse diameter, 5.1 ; and for the oblique diameter, 4.9. For the superior strait — the mean of the antero- posterior diameter, is 3.7 ; and for the transverse diameter, 4.3. I here present a tabular statement of the dimensions of the pelvis taken out of several authors, in order that the American student may easily collate opinions, and come to the conclusion, that these dimen- sions are not a fixed, but a variable quantity ; and that as one woman is taller or shorter than another, or has a larger foot, hand, nose, or chin than another, so she may have a pelvis adapted to her own spe- 46 AXIS OF PELVIS. cial proportions, or a pelvis of four inches to four and a half inches in its antero-posterior diameter. Sxtpeeioe Strait. Inferior Strait. Antero-posterior. Oblique. Transverse. Anlero posterior. Transverse. Smellie 4i - H 4i —5 Denmaa +4 + 5 +5 +4 Burns 4 5$ 5* 5 4* Ashwell 4 H 5 5 4 Churchill Baudelocque 4 \\ 5 4 4 Gardien 4 Ai 5 4 4 Velpeau 4 Ah 5 4 4 Boivin 4 4£ —5 4 4 Chailly 4 4^ 5 4 4 Cams 4 4£ 5 3*+** 4 Capuron 4 4^ 5 4i 4 Dewees 4-4 4-5 + 5 +4 —5 Axis of the Pelvis. — The inclination of the plane of the superior strait is so great, that the axis of that plane, if produced, in a down- ward direction, would fall upon the sacrum a short distance from the apex of the bone. The axis of the superior strait can never, therefore, represent the axis of the pelvis. The axis of the inferior strait, which is a line falling perpendicularly upon the so called plane of the inferior strait, midway from the pubis to the coccyx, could not represent the axis of the excavation. The antero-posterior diameter of the superior strait and that of the inferior strait approach each other at g * 22, an inclination which causes them to decussate at only a short distance in front of the pubis, as in the figure, in which a b represents the plane of the superior strait, and o i represents that of the inferior strait. If these lines should be produced in front, they would intersect at the distance of an inch or less at c. But the lines p c, q c, r c, s c, and t c, also repre- sent antero-posterior diame- ters of the pelvis, or planes of the pelvis, and each one of those planes has an axis, which is a line perpendicular to the centre of the said CARUS 7 S CURVE. 47 plane, so that the axis of the pelvis consists of the axis of the suc- cessive planes passed through in descending from the top to the bot- tom of the excavation. The line e f, and the line g k respectively represent the axis of the superior and that of the inferior strait. Carus's Curve. — A far preferable method of describing and under- standing the axis of the pelvis, is that proposed by Dr. Carl. Gustav. Cams, Prof, of Midwifery in the Medico-Chir. Acad, of Dresden. His views are stated in his Lehrbuch der Gyncskologie, etc., Part I p. 33, § 44. Professor Cams directs that one leg of a pair of compasses should be set in the middle of the posterior edge of the symphysis pubis of a bisected pelvis, as in the figure, which I have copied from his plate. The other leg of the compass being opened two and a quar- Fig. 23. ter inches, w r hich is half the antero-posterior diameter of the pelvis, a circle may be drawn downwards, commencing at the plane of the superior strait, and continued through gf, g e, and g a to the point of departure. This is Carus's circle, the curve of which represents, in the ex- cavation, the axis of the pelvis. This curve of Carus is the bent axis of the pelvis, and it is an imaginary curved line, in coincidence with which, the centre of the foetal encephalon moves as it passes from the upper pelvis through the excavation, the inferior strait, and the produced genital aperture, in the act of being born. If the head of the child in a labor, should continue to move, after its birth, in the same curve it moved in while within the pelvis, the head would come back to the point of departure at the centre of the plane of the supe- rior strait. Such is Carus's curve, or Carus's circle ; which is the bent axis of the pelvic canal, an important item of midwifery knowledge ; one with- out which a practitioner is incompetent scientifically to deliver a pla- centa, and far less to extract a child by turning, or to apply, and deliver with, the forceps, or the crotchet. I caution the student not to fail in understanding this point very perfectly. If he should make himself perfectly familiar with this curve of Carus, I see not how he 48 RECENT PELVIS. could make an}* mistake as to the appropriate direction of his efforts in any act of delivery, whether with the hand alone, or with instru- ments. The straits, diameters, planes, axes, and curves of the pelvis, are related, in an obstetrical view, to a certain form, magnitude, and po- sition of the presenting parts of the child, which, in its passage through the pelvis, performs certain movements that are spoken of as the mechanism of the labor, and which I shall proceed to explain after I shall have first spoken of the recent pelvis, and of the child in utero. The Recent Pelvis. — The figure, Fig. 24, represents a cross sec- tion of the recent pelvis. Fig- 24 - In it is seen the sacrum covered posteriorly with the integuments and muscles. The rectum lies in front of the ssfr cram, and a segment of the gut has been re- moved in making the cross section, because the intestine descends to the left of the median line of the sacral curve. In front of the rectum is the canal of the va- gina, upon the top of which is seen the womb whose fundus inclines forwards while the cervix looks in a direction backwards and d wards. The womb rests upon the vagina, which is kept extended by means of its connection to the rectum behind, and to the urethra and bladder of urine in front, and by no other powers. If the vagina should become shorter, the womb would be situated lower down in the pelvis; if the vagina should become longer, the womb would rise higher. The length of the vagina determines the height of the uterus, or its distance from the ostium vag-inse. □ In front of the vagina and womb, is the bladder of urine, with its canal of outlet, the urethra. The bladder lies behind the symphysis of the pubis, to which it is attached. The urethra comes out just under the bottom of the symphysis. RECENT PELVIS. 49 The bladder is covered, at its summit, with the peritoneal membrane, which descends a short distance on its posterior wall or bas-fond, and then turning upwards on the anterior face of the womb, passes over its top, and thence descends upon its posterior surface, from whence it continues downwards upon the back wall of the vagina. It descends one-third of the distance from the top to the bottom of the vagina, and then mounting upwards again upon the rectum, passes above the plane of the superior strait, to give a serous coat to the visceral contents of the belly. Let the student note the fact that the peritoneum does not descend more than half way from the top to the bottom of the front surface of this womb — and, therefore, that the front wall of the vagina has no relation whatever to the peritoneum ; whereas, the upper third of the posterior wall is clothed with a peritoneal coat. An instrument thrust through the upper part of the vagina, in a direction forwards, would wound the bladder; whereas, one forced through the upper part of the vagina, in a direction backwards, would pass into the peritoneal sac. This is the weakest part of the vagina, and, therefore, most liable to laceration or rupture in labors. It is the part most in danger from obstetric instruments. The sides of the vagina are related to the spaces included betwixt the peritoneal folds of the broad ligaments; and wounds and punc- tures, extending sideways or towards the ischial planes, would pass into the laminated and very loose cellular tela that exists in the inter- stices of the said ligaments. The pelvis contains also the levatores ani muscles, which descend like the converging rays of a fan, one on each side, and are so inserted as to lift the perineum, and consequently, all the movable contents of the pelvis, up towards the superior strait. The stronger the leva- tors, the deeper is the sulcus betwtet the nates ; and in general, the better sustained are the contents of the basin. In the young and vigorous the sulcus is deep; in the aged and feeble it descends lower and lower, so that, in very old and exhausted persons, the perineum becomes actually protuberant or convex. In the recent pelvis are numerous blood-vessels and nerves, supply- ing the contained organs, besides the large bundles of nerves that come out from the sacral foramina and soon leave the cavity, passing out through the ischiatic notches to form the great sciatic nerve. Here also are contained the ureters — while, overhanging the brim, are seen the psoas muscles, which seem to lessen the transverse di- ameter of the upper strait. Let the student be particular to note the 4 50 RECENT PELVIS. place and appearance of the psoas muscles, as they pass along the brim of the pelvis; and let him observe, that, when a woman who has recently been delivered, suffers from inflammation of the womb, she always experiences pain when she draws up the knees, because the overhanging bellies of the Flg - 25# psoas muscles, in contract- ing, to flex the thighs, press very painfully upon the globe of the uterus, which still juts up above the plane of the superior strait, filling up the whole of its trans- verse diameter. The figure may give some idea of the relation of parts in the recent pelvis, a is the aorta, and b the vena cava; c the internal iliac artery descending into the pelvic excavation ; d and f are the external iliac artery and vein ; f g the psoas muscles, h the rectum, i the womb, and k the bladder of urine. MECHANISM OF THE PELVIS. 51 CHAPTER II. MECHANISM OF THE PELVIS. OF THE MECHANISM OF LABOR, AS IT DE- PENDS UPON THE RELATIONS OF THE PELVIS AND THE FCETAL HEAD. Before I leave off speaking of the nature of the pelvis, I am to treat of what is usually called its mechanism, as dependent upon certain forms of the pelvis, and the relations of the child and its posi- tion to those forms. Fig. 26. Flexion, and Obliquity of the Head. — In head presentations, the occipito-mental diameter dips its occipital pole, and it generally assumes a direction that is oblique as to the plane of the superior strait, which it crosses diagonally. I say diagonally, for although it be true that a child may descend through the plane in a direct position, i. e. with its vertex, or its fore- head, to the pubis, such direct positions are rarely to be met with; and clinical experience shows that in the immense majority, the head sinks below the plane with the occipito-frontal dia- meter coincident with the oblique diameter of the upper strait, as in figure 26. The foetal head usu- ally descends through the plane of the abdom- inal strait in flexion, i. e. with the chin to the breast, and the vertex turned towards the left acetabulum, while the bregma, or upper part of the forehead, points towards the right sacro-iliac symphysis: vid. Fig. 26. The occipito-frontal diameter is probably nearly coincident with the plane 52 MECHANISM OF THE PELVIS. of the strait in the beginning of most labors, whence the occipito- mental diameter dips its occipital extremity beneath the plane. In proportion as the presenting part descends lower and lower, the dip of the occipital pole of the occipito-mental diameter increases. It must be so, since the occipitofrontal diameter could not descend horizontally into a pelvis too narrow for it. That diameter which, by my averages, is 4.10, could not without a dip, or see-saw, sink into the lower part of a pelvis whose transverse diameter, low down in the excavation, does not considerably exceed four inches. The deeper the head plunges into the cavity, the more strongly is the chin forced against the breast, or, in equivalent terms, the greater the flexion of the head. Rotation. — As the pains force the head lower and lower, the vertex is driven into strong contact with the plane smooth inner surface of the left ischium, which constitutes the left antero-lateral wall of the excavation. This plane of the ischium, which is inclined towards its opposite fellow, in both a forward and downward direction, repels the vertex that is pressed upon it, and the double inclination of the left plane serves to compel the vertex to slide downwards, forwards, and inwards, towards the pubal arch. It naturally turns towards the arch, because there is little to hinder its moving in that direction, save the soft parts, which offer a resistance whose force can by no means be compared with the resistance of the solid bony wall that repels or repercusses it. While little resistance is presented in the direction of the arch, or outlet, there is likewise very little to oppose the tendency of the face and forehead readily to slide into the hollow of the sacrum, that seems to gape to receive them. Under this view, there can be no doubt that the inclined plane of the ischium is the principal cause of the conversion of the oblique into the antero-posterior position, which the head acquires, when it reaches the lower part of the excavation. The inclined plane, therefore, is the chief cause of the rotation of the head. Thus, the head turns as it descends. It abandons the oblique atti- tude in which it engaged in the strait. Having reached the bottom, its occipito-frontal diameter coincides with the antero-posterior dia- meter of the pelvis, and the head is, therefore, found to be rotated. It was oblique, and in flexion. It has lost its obliquity, but still preserves its flexion at the bottom of the excavation; the vertex pressing against the posterior margin of the crown of the pubal arch. MECHANISM OF THE PELVIS. 53 The occipito-frontal diameter has turned one-eighth of a circle, from the acetabulum, to the symphysis pubis. This is rotation, a term much used in midwifery. Extension. — The rotation of the head being now completed, by the arrival of the vertex at the symphysis, and of the face in the hol- low of the sacrum, the head being still in flexion, the next, or third act of mechanism begins to be performed; I mean the extension of the head, or the departure of the chin from the breast. If the whole perineum could be cut away with a bistoury, I could suppose the child's head might come forth from the lower strait, without any extension, and with the chin still at the breast; but the pains now thrust the sagittal suture, in its whole length, indeed the entire crown of the head, against the elastic resisting perineum and posterior vaginal wall. The efforts, being often repeated, serve to push the perineum away from the crown of the pubal arch to let the vertex escape under it ; but, while the perineum is pushed off by this force, the same perineum jams the occipital bone of the child firmly against the crown of the arch ; so that, as the vertex emerges from the genital orifice, the os occipitis is pressed close to the symphysis, first at its lower edge, and next on its outer or front aspect. The cranium of the child is born as soon as the extension is complete, but not until then. Figure 27 exhibits the manner in which the vertex touches the inner surface of the crown of the arch when the rotation is complete. The Flg - 27 - faint lines show how it rolls out under the edge of the triangular ligament, and also how it rises upwards in front of the outer surface of the symphysis. Restitution. — As soon as the head is born, it begins to rotate back again, outside of the pelvis, to the same point or direction it had upon engaging within the pelvis. Its originally oblique posi- tion becomes restored, and this, which is the last act of mechanism, as to the head, is called the restitution Mechanism of the Shoulders' Delivery. — The cause of restitu- tion is to be sought for in the state or position of the shoulders. 54 MECHANISM OF THE PELVIS. When the vertex is at the left acetabulum, the right shoulder is at the right acetabulum, and the left one at the left sacro-iliac synchon- drosis. But the inclined plane of the right ischium repels the de- scending right shoulder, pushing or sliding it downwards, forwards, and to the left, until it comes to the symphysis pubis. The left shoulder meanwhile falls into the open chasm of the hollow of the sacrum that yawns to receive it freely. This rotation of the shoulders, or, in other words, rotation of the trunk of the body, causes the act of restitution of the head, which, being born, must turn coincidently with the rotation of the shoulders. Such is the act, or rather such is the succession of acts, commonly called the mechanism of the head in labor, in which the vertex pre- sents in the first position. I shall now recapitulate them as predicated of a vertex presentation in the first position. 1. Flexion.— The head becomes flexed; the chin going to the breast. It enters the pelvis obliquely, with the vertex to the left ace- tabulum. 2. Rotation takes place because of the repelling resistance of the plane of the left ischium, the lessened resistance under the arch, and the incurvation of the hollow of the sacrum. 3. Extension commences under the upward pressure of the peri- neum, and continues to increase until the child is born. 4. Restitution allow T s the vertex to seek its original oblique direc- tion, in which it goes back again towards the left acetabulum. In treating of labors, and the conduct of them, I shall have nume- rous occasions to refer to, and further to explain, the mechanism of the passage of the foetal head. Mechanism of the Pelvis, with Vertex in Second Position. — In this labor the vertex is to the right acetabulum. In saying that the vertex is to the right acetabulum, it is not intended to convey the idea that the posterior fontanel is always directed absolutely against the acetabular region. Experience will soon teach even a young practitioner, that the child retains in early stages of labor the ability to rotate its head right or left, and that it generally exercises this faculty very freely, spinning its head upon the cervical spine so as to turn the vertex sometimes quite close to the symphysis pubis, and then whirling it back to the top of the ischium, or even as far backwards as the ilio-sacral junction. As the cranium, however, plunges deeper and deeper into the excavation, it becomes so tightly MECHANISM OF THE PELVIS. 55 held that these rotatory motions cease, and it only moves in the direc- tion impressed upon it by the mechanics of the pelvis. The processes by which the vertex in a labor of the second posi- tion, as in figure 28, is brought forth, are the converse of those I have described as taking place in cases of first lg ' position. The flexion is followed by the ro- tation as the head sinks low into the cav- ity; the vertex being repelled towards the left by the inclined plane of the left is- chium. As soon as the pos- terior part of the sum- mit of the head reaches the perineum, the perineum, while it yields before the descending power, thrusts that body firmly upwards against the crown of the pubal arch, as in the first position. The extension or reversion of the head being completed by its expulsion, restitution takes place by carrying the vertex to the right acetabulum, outside, and the face is found to look to the left. The left shoulder turns to the right and forward to get under the arch, while the right shoulder goes to the sacrum, and so the shoulders are delivered ; sometimes the pubal shoulder is the first, and sometimes the sacral one is the first, to be expelled. Third Position. — The mechanism of the head, when the vertex presents in the third position, differs from the two just before de- scribed, only in the absence of the second act, the act of rotation. These third positions are very rarely observed ; and it is probable that w r hen they are met with, they depend upon a peculiar form of the superior strait. I have some pelves in which the antero-posterior diameter of the superior strait greatly exceeds the length of the transverse or oblique diameters. In such a pelvis it is obvious that the vertex would be more likely to present itself at the pubis, than at either acetabulum. In an ordinary conformation of the superior strait, a third position of the vertex presentation is extremely unlikely to occur, since long before the commencement of the labor, the prominence of the lumbar 56 MECHANISM OF THE PELVIS. vertebrae, and the overhanging promontory of the sacrum, would be almost sure to turn off the rounded forehead of the child into the right or left sacro-iliac region ; and this the more probably, inasmuch as the oblique being greater than the antero-posterior diameter, it affords an easy and inviting accommodation, as in the usual oblique mode of engagement. The three positions that have here been spoken of comprise the occipitoanterior positions of the vertex. They are those I have been accustomed to enumerate in the following order, viz., first, second, third, or, vertex left, vertex right, and vertex front positions. We have next to describe the fourth, fifth and sixth, or forehead left — forehead right — and forehead front positions of the vertex. Fig. 29. Fourth Position. — In the fourth position, the occipito-frontal diame- ter crosses the pelvis obliquely, as it does in the first position, with this difference, that its frontal extremity is at the left acetabulum, and its occipital pole at the right sacro-iliac junction. See figure 29. This is a true ver- tex presentation; and it must not be mis- taken for a presentation of the forehead. It is a true vertex presenta- tion, because the chin is close to the breast, and there is no departure ; on the contrary, the flexion is, perhaps, even stronger than in occipito- anterior positions. The mechanical form of the pelvis is so miraculously adapted to the wants of the economy in labor, that it has power, in a major part of these fourth positions, to rotate the vertex from the right sacro-iliac junction to the right acetabulum, and thence to the pubal arch; and that without any assistance given by the accoucheur. It is true that this favorable rotation sometimes requires the aid of the hand, or even of an instrument, as shall be described on the pro- per occasion. It also occasionally happens, that neither the hand alone, nor any instrument, can enable the surgeon to bring the vertex round to the front. In such case, it slides into the hollow of the sa- MECHANISM OF THE PELVIS. 57 Fig. 30. crum, and the labor is thenceforward rendered more painful and more difficult. When, in fourth positions, the vertex can rotate first to the acetabu- lum, and then to the arch, the labor is not seriously retarded, and the mechanism thenceforth is the same as has been already treated of and described; but when the posterior fontanel gets into the hollow of the sacrum, and will not suffer rotation, then the flexion becomes greater and greater as the fontanel slides down along the point of the sacrum, along the face of the coccyx, and down the mesial line of the perineum, until, having pushed off the perineum 4.10, the occipito- frontal diameter, the vertex slips over the fourchette, and immediately turns over back- wards, in strong extension, which allows the forehead, eyes, nose, mouth and chin successively to emerge from underneath the crown of the pubal arch, to complete the birth of the head. The annexed figure (30,) of a head in an occipito-posterior position, shows these truths clearly enough. This is the mechanism in all cases of birth in occipito-posterior positions, without rotation to the front; and the student will clearly understand that it must be so, since the length of the line from forehead to vertex is too great to permit it to be otherwise. Fifth Position. — The fifth position, as in figure 31, is that in which the vertex is to the left ilio- sacral Fig - 31 - space, and the fore- head to the right ace- tabulum. Here, as in the fourth position, the mechanical form of the pelvis tends to turn the vertex first towards the left ace- tabulum, and thence to the arch. Sixth Position. — The sixth position finds the vertex at the pro- 58 MECHANISM OF THE PELVIS. moratory of the sacrum. Madame Boivin met with only two such positions in 19,614 cases. I hare seen a greater number of sixth positions than were met with by that celebrated midwife, although the labors witnessed by her so greatly exceed in number all that I have seen. While the facts stated in her tables are to be relied upon for their historic accuracy, her statistical results cannot be admitted as the law of any practitioner's future experience. My own practice, for exam- ple, which has been a private practice, has shown me a far greater number of sixth positions than her vast clinical experience, in an im- mense Lying-in hospital, brought to her view. Madame Lachapelle saw no such case. A case of vertex labor in the sixth position occurred to me this day, of which I made the following note, in order that I might set it down here as a freshly remembered experience. Case.— July 8th, 1848, 10| A M. Mrs. E I , Pine street. This is the sixth child; a male, born fifteen minutes ago. The pains commenced moderately, at 4 P. M. yesterday, July 7th. Mrs. I. has been in pain at regular intervals all night. I arrived at quarter past nine, one hour since. The os uteri was nearly dilated; mem- branes unruptured. The anterior fontanel was touched through the membranes just behind the upper half of the symphysis pubis. By a strong pressure, I could conduct the index finger along the sagittal suture directly toward the sacrum, until I felt the triangular fontanel, leaving no doubt of the diagnosis. The left shoulder was at the right, and the right shoulder at the left ischium. The occiput was opposite to the top of the third segment of the sacrum; the flexion of the head was strong. Partly by pressing with my right index the right temple and zygoma towards the right; and partly by pulling with the same finger the right leg of the lambdoidal suture towards the left side of the pelvis and downwards, I converted this sixth into a fifth position. I now discharged the liquor amnii by rupturing the bag of waters. The next pain rotated the vertex to the left acetabulum, or first position, whence the vertex came forwards, and to the right, until it reached the arch, under which it began to extend, and was soon expelled. During the act of extension and expulsion of the head, and just before the whole head was completely born, an act of restitution com- menced. As soon as the head was free, the vertex went round again MECHANISM OF THE PELVIS. 59 to the sacrum, and the chin of the child rested with its under surface upon the front of the pudenda, the face looking upwards. This happened because the shoulders had not rotated at all, but plunged into the pelvis, the left one at the right, and the right one at the left ischium. With the next pain the left shoulder came to the arch, and the right one to the sacrum, and so they were delivered. The child was about seven pounds in weight. Here, then, was a clearly marked case of sixth position, notwith- standing which, the mechanical force of the pelvis and its strange adaptation to the form of the cranium, permitted me, with very slight assistance, to convert it into a fifth, and then into a first position. This rotation was fortunate for the mother; since, by effecting it, I prevented the necessity of a dilatation equal to the occipitofrontal circumference nearly, thus rendering necessary a dilatation equal merely to the bi-parietal circumference ; the former being nearly fif- teen inches, while the latter is not more than twelve inches. Face Presentation. — When the head presents in extension instead of coming down in flexion, we have presentation of the forehead, or of the face. If the extension be moderate, the forehead presents ; if it be very great, the face presents. When the face presents, it always comes down with the chin to one side, and the top of the forehead to Fig. 32. Fig. 33. the other side of the pelvis ; and it afterwards rotates the chin to the pubis or to the sacrum. In the case (Fig. 32), the chin is to the right ischium and the forehead to the left ischium. The natural movement 60 MECHANISM OF THE PELVIS. of the mechanism would gradually turn this chin to the front of the pelvis, and the top of the forehead to the sacrum, as in Fig. 33. In face presentations the chin must be born first; see Fig. 33. Here observe that, from the chin to the vertex is more than five inches, while there is no diameter five inches long to be found within the true pelvis. Hence if the mental extremity of the occipito-mental diameter descends into the cavity before the occipital extremity, it must escape first from the outlet in order to allow the occipital ex- tremity to escape last, and vice versa. There are many cases of face presentations that appear to afford remarkably easy deliveries, and to require no aid from the hand. In all those, however, where assistance is demanded, there is an important doctrine, one that should never be lost sight of in the Conduct of the cases. The doctrine is this — Bring the chin to the pubis. The figure may show that, if the chin be brought to the pubis, it will have to sink only an inch, or an inch and a quarter, in order to get below the level of the crown of the arch. As soon as it reaches that point, it ad- vances beneath the arch, and thus the mental extremity of the occipito- mental diameter begins to be born. When this first step is effected, the whole length of that diameter is soon expelled, or, in other words, the whole head is born ; its occipital extremity being the last point that emerges from the ostium vaginae. Should any one, in practice, reverse this doctrine, and bring the forehead to the pubis, he would do a great wrong; for as the chin must be born first, and the occiput last, the chin will have to slide down the whole length of the sacrum, five inches ; and over the ex- tended perineum two and a-half or three inches before it can escape: but, to do this, it will be required that the head and half the thorax of the child shall be jammed together within the excavation; for, from the chin of the child to the top of its sternum are not eight inches. Such a position is almost sure to demand an embryotomy operation for the delivery of the foetus. PRESENTING PARTS THE HEAD. 61 CHAPTER III, OF THE CHILD S HEAD AND OTHER PRESENTING PARTS. Fig. 34. The study of the form and dimensions of the child derives its im- portance from the relations of the foetus to the bony pelvis, through which it is destined to pass in the act of parturition. To know the form and magnitude of the head, as related to the pelvic canal, is of the highest importance; and, indeed, no man should be looked upon as a qualified practitioner who suffers himself to remain ignorant of every particular of the matter now referred to. The foetal cranium, divested of the bones of the face, closely resem- bles in form an ostrich's egg, upon the side of the lesser pole of which the facial bones are adjusted. In the figure of the foetal head which is annexed (Fig. 34), it is evident that if the bones of the face were removed, the re- mainder of the cranium would be oviform ; as I have on different occasions shown it to be, by removing those bones in presence of my class at the Medical College. In looking at the head from above down- wards, as in Fig. 35, page 62, the bones of the face are out of sight, and the cra- nium is evidently egg-shaped, the greater pole being at the occiput, while the lesser is at the forehead. The foetal head (Fig. 36) is copied with the camera from a cast of a foetal head, and gives a proper idea of the true form when covered with its integuments. The child perished in the labor, its head being too large to pass through the straits without the aid of the forceps. The longitudinal diameter of this oviform skull has, by most au- thors, been computed at four inches, and its conjugate at three inches and a half; both of which calculations are considerably under the mark of truth, as I have found by careful measurement. fh 63 PRESENTING PARTS — THE HEAD. The bones that enter into the composition of the skull, excepting the face pieces, are the os occipitis, the two ossa parietalia, the os frontis, the two ossa temporum, and the sphenoides. These are the bones that make up the principal bulk of the object, for the face bones do not add very considerably to the magnitude of the mass. The face bones are the maxilla inferior, the maxilla superior, the ossa malarum, ossa nasi, ossa palati, and the vomer. It seems hardly necessary to mention the ethmoides and the ossa unguis. In a neonatus, the process of ossification is not completed, and the edges of the cranial bones are not locked or dovetailed together by the serrse of the adult suture; whence it happens that the cranium is not a fixed magnitude or form, but is liable to change under the pressure of the parts through which it is driven by the great force of the labor- pains. A great advantage is found in this mobility of the cranial bones in certain instances, in which the pelvic circumference is too small, either absolutely or relatively; for, the child's head of four inches in its con- jugate diameter may become reduced or wire-drawn so as to pass through a superior strait of only three and a half inches, or even less ; and that without injury to the head, which, as soon as it has escaped from the pressure, begins to recover its normal form aeain. There are, on the other hand, to be met with certain specimens of the foetal cranium so solid and firm in their ossification as to yield not at all in labor, which is thus rendered both more painful and difficult. The young practitioner therefore should, in difficult cases, take com- fort from discovering by the touch that the foetal head is of a yielding nature, and hence not likely to resist too long the moulding or model- ing efforts of the throes, # THE HEAD. 63 Diameters of the Fcetal Head. — In the foetal head at term, of which there is a drawing on page 61, we are in the habit of imagin- ing certain lines called diameters, which are there represented, in Fig. 34. There is a line traced from the chin a, to the vertex or point of the head or occiput b, called by the English writers the oblique diameter, but which the French authors have induced us, of late, to denominate occipito-mental diameter, a phrase that explains itself. The next one is the line from d to e, called the occipitofrontal diame- ter, as indicating the distance from the occiput to the most salient point of the forehead. After this comes the perpendicular diameter, from c to h ; and lastly, in figure 35, page 62, the transverse or bi-parietal diameter, which passes from one parietal protuberance to the other, from a to b, and the temporal diameter, from c to d. As to these diameters, I have never deemed it expedient that the student should charge his memory with all of them ; yet he ought to know that the occipito-mental diameter is above five inches in length. He ought to know this, in order that he may also know that such a diameter cannot be see-sawed, or reversed, when the head has once fairly entered into the excavation, in which no space exists large enough to render such a change possible. If the extremity b descends first, it must escape first, or be returned above the superior strait ; and if the extremity a descend first, it must escape from the inferior strait first, or be returned above the linea ileo-pectinea, in order to be there see-sawed. The occipito-frontal diameter c a is four inches and ten-twelfths of an inch in length, — -a diameter too considerable to admit of its being see-sawed in the excavation, except under very extraordinary circum- stances, for there is, in general, not space sufficient for that end. I speak with very great confidence as to the above estimate, for I have carefully measured and recorded the size of three hundred crania of mature children that I received in the course of my obstetric prac- tice. The student will be in error if he adopts the common estimate of the authorities, which is too low at four inches. In a single series of one hundred and fifty heads, I found the occi- pito-frontal diameter in fifty-two of them to exceed 5 inches. In 11, it was SjMh; in 8, 5 T 2 2 ths; in 3, it was 5 T 3 2 ths; in 1, 5 T 4 2 ths; in 1, 5 T 6 2ths; in 2, S^ths; and in 1, 5i|ths. The sum of my occipito-frontal measurements was seven hundred and twenty-nine inches and seven-twelfths of an inch for one hundred and fifty crania. The mean was four inches ten-twelfths. The sum of the bi-parietal diameters of the said one hundred and fifty crania 64 THE HEAD. was five hundred and eighty-six inches and seven-twelfths — the mean, three inches and eleven -twelfths of an inch. The bi-parietal diameters exceeded four inches in sixty-eight of the children. In 19 it was 4.1 ; in 5 it was 4.2; in 6, 4.3; in 3, 4.4; in 1, 4.5; in only one case was less than 3.6, the usual estimate, and in that case it fell to 3.4. A paper containing statements of the above series, was read by me at the centennial celebration of the Amer. Phil. Society, on the 25th May, 1843, and was published in the "Proceedings," &c, Vol. III., p. 127. I measured one hundred and twenty-six occipito-mental diameters of neonati at term, of which the sum was six hundred and ninety- nine inches and five-tenths, so that the mean or average of the one hundred and twenty-six diameters was five inches and a half. I know no one who has measured so many, and I am sure that greater accu- racy is not to be attained by any person. Upon these grounds, therefore, I am to inform the student that the occipito-mental diameter of the foetus is five inches and a half, the occipitofrontal four inches ten-twelfths, and the bi-parietal three inches eleven-twelfths. The above statements ought to show that it is not a matter of small moment whether the head presents in labor by the vertex, the crown, or the forehead. Upon the presentation depends the circumference of the advancing body — if the vertex presents, we have a circumference equal to thrice the bi-parietal diameter, which would equal a circle of eleven inches and three-quarters in circumference. The oocipito-frontal diameter would give a circumference of upwards of fourteen inches, while the occipito-mental circumference would not be much under sixteen inches. Fontanels. — The bones of the head are divided from each other by the sutures. In fig. 35, page 62, showing a top view of the skull, may be seen the sagittal suture, a straight line which ex- tends from the middle, and sometimes from the base, of the os frontis backwards to the upper edge of the occipital bone, where it appears to dispart, branching into the two legs of the lambdoidal suture. In passing from the forehead backwards, this sagittal or arrow suture crosses the transverse or coronal suture, and at the place of crossing there is a large vacuity, as to bone, which is occupied, however, by the skin and strong membranes which constitute what is commonly called the mould of the head — technically, the anterior fontanel, the THE HEAD. 65 great fontanel, the frontal fontanel, or the bregma. It is of various size in. different specimens. When the ossification is precocious, it is small; in the contrary case it is large, and sometimes it is found to be very large. At the posterior terminus of the sagittal suture is found the poste- rior fontanel, often called the occipital fontanel. There is a very great difference between the anterior and the pos- terior fontanels. The former being quite large, quadrangular, and yielding to the pressure of the finger; the latter being so small that it can only be distinguished by the three suture lines that radiate from a common centre. Let the student carefully learn to make this dis- crimination, for if he should not do so, he will in practice find himself embarrassed in his diagnosis of the two fontanels. Too much care can hardly be bestowed upon the mastering of these two points; nor can one become too familiarly acquainted with the differences between them ; for, in trying to ascertain the precise position of any head-presentation, the accoucheur always seeks to place his index finger upon one or the other of these openings. It is clear that they must serve as points of departure in an exploration, — for if the index finger be in contact with the posterior fontanel, and the place that finger occupies in reference to any fixed point in the pelvis be well understood, the surgeon ought thence to deduce the very place of any and of every part of the cranium of the foetus. To know w T here the fontanel is, is to know where to conduct the hand, the forceps, the perforator, or the crotchet. It has been seen, in a preceding page, that the various positions assumed by the head w T hen it presents in labors, are enumerated, as first, second, &c, and that they are determined by reference to the points on the pelvis to W'hich the posterior fontanel is addressed. Presentations. — The student who shall have made himself master of the subject of the pelvic diameters is now enabled to appreciate the differences that arise in labors exhibiting unfavorable presentations or the head. He knows that the bi-parietal circumference of the head is not too great to admit of its ready transition through the excava- tion — and he as clearly understands that the occipitofrontal or the occipito-mental circumference w T ould prove too large for the canal. Therefore, in any case of delay or difficulty, he w 7 ould provide for effecting a coincidence of the bi-parietal circumference with the planes (of the excavation) through which it must necessarily pass. If the pelvis be four and a-half inches in its antero-posterior dia- 5 66 THE HEAD. meter at the superior strait, the occipital pole of the occipitofrontal diameter must dip so as to allow the vertex to descend, and thus be- come the presenting part. In fact, the foetus lies so packed up in the womb that it may be said to be in a state of universal flexion — the legs are bent upon the thighs, the thighs upon the trunk; the arms and forearms and the whole spinal column are in flexion — so that even the head is found to be flexed as a normal condition of the foetus in utero. The drawing exhibits very naturally the usual presentation and po- sition of a child at the beginning Fig. 37. of a labor. It represents the womb opened, with the foetus in w r hat is called a vertex presenta- tion in the first position; i. e., the posterior fontanel is turned to- wards the left acetabulum of the mother's pelvis, and the vertex, or occipital pole of the cranium, dips sufficiently to allow of its entering the pelvis through the plane of the superior strait. The drawing also shows how very much the spinal column is curved. It is manifest, that if pressure should be made upon the pelvic extremity of the co- lumn, in a direction from above downwards, it would be still more considerably bent — it would be an elastic resisting arch ; and the outward thrust of the cervical extre- mity of that arch would tend to flex the head, more and more, in pro- portion to the increasing violence of the thrusting effort, so that the lower the head descends, the more must the chin be pressed against the breast, and the more perfect the coincidence of the bi-parietal circumference with the planes of the excavation through which it happens to be passing. Unfortunately, the occipital extremity of the occipito-frontal diame- ter does not always dip, and the frontal extremity of it is sometimes found to be the dipping pole. In such an instance, the chin is said to depart from the breast, and we encounter a presentation of the crown of the head, the forehead, or even of the face, the head in the last named case becoming completely extended, instead of de- THE HEAD. 67 scending in flexion . But the account of these accidents must be deferred until we come to treat of those special presentations, which we hope to be able fully to explain and describe. The child at full term is about nineteen inches in length. Speci- mens are occasionally met with of children twenty-one inches high ; but they are rare. The average weight of a new-born child is somewhat about seven pounds — very many of them weigh eight pounds, and it is by no means a rare occurrence to find a child weighing nine, ten, eleven and twelve pounds at birth. I have never seen one yet that weighed fourteen pounds. The largest one I have weighed was thirteen pounds and a half avoirdu- pois. The mother soon afterwards perished with inflammation of the womb and bowels. To witness the birth of such a monster is appal- ling. I have heard of children of seventeen, and even of eighteen pounds weight at birth. Such relations always lead me to suppose that some mistake has occurred in weighing the infant. M. Velpeau justly remarks, that children of that weight are children of three months old, and that such magnitude is impossible at birth. My own clinical experience, which has been very abundant, has never enabled me to see a child of fourteen pounds weight at birth. The head of the child exceeds, in its smallest circumference, the cir- cumference of the thorax and shoulders, or the abdomen or the hips; wherever the head can pass, there will, therefore, be space for the transmission of the body. The length of the child, folded up in the womb in flexion, is about eleven inches from the summit of the head to the lower extremity of the pelvis, or buttocks. In about forty-nine out of fifty cases of pregnancy, the head is at the os uteri — in one out of fifty cases, the pelvis is at the os uteri, giving us the breech, feet, or knee presentation. When the head presents in labor, it is to be supposed that it has presented during the entire gestation, and vice versa. The vulgar notion that the child lies in the womb with its head to the fundus until labor is about to commence, and then turns his head downwards to the mouth of the organ, in order to escape head foremost, is erroneous — for the child is eleven inches long, and cannot turn it- self in a womb only seven or eight inches in conjugate diameter. If, in like manner, the breech presents in labor, we infer that it has pre- sented for many months antecedent to the commencement of the par- turient efforts. 68 PRESENTATIONS. Hippocrates said the child is packed up in shape like an olive in a narrow-necked flask — if one or the other pole of the olive presents itself to the aperture, it may escape ; otherwise, it must be broken, or the flask must be broken, in order to extract it. The same is true in midwifery. Either the cephalic or the pelvic pole of the foetal oval must descend, in order to its birth; and it is a matter of little moment which should be the pole, whether the cephalic or the pelvic, all other things being equal. Upon the whole, the head presentation is the most favorable for both mother and child, since nature provides that it shall occur in the ratio of forty-nine to fifty in frequency. Fig. 38. Two Presentations only — Cephalic and Pelvic. — Rigorously speaking, there are but two presentations in midwifery: one of the head — the other of the pelvis. As to the head presentation, it may deviate, and allow a shoulder to come to the os uteri ; but this is an accident of a cephalic presentation : an accident that has arisen from the impinging of the head upon the margin or brim of the pelvis, whence it has glanced upwards to the iliac fossa, permitting the shoulder to take its place. This is to be seen by inspecting the cut, in which the child's head, which originally pre- sented, has deviated, and gone above the plane of the superior strait, lodg- ing itself in the left iliac fossa, while the shoulder has come to the strait, and allowed the arm to prolapse. The cut may serve to show how the hand and arm have merely prolapsed ; making what is commonly denominat- ed an arm presentation — but is it not clear, the head having gone up, that the shoulder still really presents, and that the arm has merely fallen down, or prolapsed? From the above, it appears that we have — 1st. Cephalic presentations ; 2d. Cephalic presentations deviated, with descent of the shoulder; and, lastly, 3d. Cephalic presentations deviated, with descent of the shoulder, and prolapse of the arm. PRESENTATIONS AND POSITIONS. 69 Fig. 39. Here is a drawing representing a breach presentation, or presenta- tion of the pelvic extremity of the foetal oval. This is the second normal presentation of the child, the cepha- lic being the first. In this case, an accidental deviation might cause the buttock to glance upwards on the brim of the pelvis, to take its lodg- ment in the left iliac fossa. Such an accident would give rise to a footling labor, or to a presentation of the knees. A footling presentation, then, is only an accident happening in the course of a pelvic presentation — and the same may be said of the knee cases, which are very rarely met with. I recommend these views of presentations to the medical student, who, if he should adopt them, will find his notions of midwifery greatly simplified, and his memory not loaded with useless divisions and de- scriptions that serve only to embarrass him as a student and perplex him as a scholar or practitioner. These are the divisions I have proposed in my public Lectures ; and having found them convenient also at the bedside, 1 with confidence advise him to prefer them to the long catalogue of presentations in the books. Knowledge in its nature is simple, pure, not complex ; it owes its seeming complexity and abstruseness only to man. • If the student should ask me where I will place the presentation of the belly and the back of the foetus, I cannot reply, for I do not know whether they be derived from deviations of the pelvis or from deviation of the head. I am sure, however, that all such cases are accidents of the cephalic or of the pelvic presentation. The word presentation refers to the part of the foetus nearest the os uteri or excavation. Positions of a Presentation. — The word position refers to the relation between a certain part of the presentation, and a certain part of the pelvis. Thus in vertex presentations, the posterior fontanel may be in the fifth position, that is to say, the occiput of the child may be directed to the left sacro-iliac junction, and its forehead to the right acetabulum. 70 PRESENTATIONS AND POSITIONS. Care should be used to avoid confounding the terms presentation and position. There are six positions of the vertex presentation. 1st. Vertex to the left acetabulum. 2d. Vertex to the right acetabulum. 3d. Vertex to the symphysis pubis. 4th. Vertex to the right sacro-iliac junction. 5th. Vertex to the left sacro-iliac junction. 6th. Vertex to the promontory of the sacrum. There are four positions of the pelvic presentation. 1st. Sacrum to the left ischium. 2d. Sacrum to the right ischium. 3d. Sacrum to the pubic symphysis. 4th. Sacrum to the promontory. In the shoulder presentations there are four positions, two positions to each shoulder. Right shoulder presentation ; the head is in the left iliac fossa, the face looking backwards. Right shoulder presentation; the head is in the right iliac fossa, the face looking forwards. Left shoulder presentation, the head to the left looking forwards. Left shoulder presentation, the head to the right, looking back- wards. These being the principal presentations, with their several positions, I shall enter into full details of them when I come to treat of the special labors in which they require to be managed by the accoucheur. GENITALIA. 71 CHAPTER IV. THE ORGANS OF GENERATION. The organs of generation are divided into external and internal, the latter terra being applied to those that are contained within the cavity of the pelvis, and the former referring to those that appear upon the external surface of the pelvis. The external sexual organs, in the aggregate, are indicated by the word Pudenda; a word very happily selected as a reference to, rather than a direct denomination of, a part of the body which the sex, with- out exception even of any barbarous tribes, endeavor modestly to conceal from every eye. We are told that the first sinful indulgence of the human appetites was succeeded by the deepest consciousness of exposure, upon this subject, and the fig-leaf, which concealed the shame of the first woman, is a simple expression or emblem of female delicacy: the Venus de Medici is not less an expression of female modesty than of the utmost perfection of the female form : its modesty is the key to that inimitable, absolute and pervading beauty, which places it at the head of the ancient works of art, and renders the statue at once a truth in morals, and a profound homage to one of the best attributes of woman. Notwithstanding the aversion of females to every allusion to the pathological or obstetric affections of these organs, it is unavoidably incumbent on the practitioner to make himself acquainted with their anatomical structure, since they are the seats of diseases and acci- dents, and the agents of pathological and surgical processes, which the practitioner is often called upon to superintend ; and it would be the grossest injustice to the female patient, to assume the conduct of some of her sexual disorders, without a perfect preparation for the dis- charge of duties which, by their importance, necessarily take prece- dence of those considerations that, under other circumstances, it would be both wicked and disgusting to pretermit. Let the student of mid- wifery, therefore, experience no sentiment at variance with the mens 72 GENITALIA. sibi conscia recti, in turning his attention to this portion of our sub- ject. Pudenda. — The surface of the body which is found in front of, and just above the symphysis of the pubis, is raised so as to present the apr pearance of a protuberance, which, at the period of puberty, is covered abundantly with hair, and has received the denomination of Mons Veneris. The cutis, which covers this part, is supplied with numerous sebaceous follicles, and is ordinarily of a darker color than the general superficies. The size of the protuberance varies in different indivi- duals, being greatest in those who are fat, and partially disappearing in those who are much emaciated, while the projecting ossa pubis upon which the mons is constructed, serve, in all cases, to lift it upwards above the general level of the surrounding parts. The subcutaneous structure is largely supplied with an adipose deposit, contained in cells connected by so dense a tissue, that inflammations and abscesses occurring within it, are rendered remarkably painful, as is the case in all such affections occurring in unyielding textures. Vulva. — A little below the top of the pubic symphysis commences the genital fissure, which is most commonly designated by the term Vulva. Labia Pudendorum. — The parts which are separated by this fissure are called the Labia Pudendorum, or Labia Majora. They are composed of skin, which is disparted at the inferior portion of the Mons in order to admit of this construction, the division extending downw r ards to the lower extremity of the vulva, where it terminates in the inferior commis- sure of the vulva, at the anterior edge of the perineum. The labia, which consist, externally, of cutis in all respects similar to that of the Mons, and, like it, covered with hair, are lined, internally, with an epithelium, that serves to protect the mucous surface beneath. The basis of their structure is a rather loose cellular tela, supplied less abundantly than the part above with adipose cells, and therefore liable, under circum- stances of dropsical infiltration, of extravasation, or inflammation, to a great degree of swelling. The labia, since they serve as the outer limit of the vulva, are also liable to a great degree of elongation, or distension, during the transit of the child in parturition. This dis- tension is so great that it equals a circle of about ten or twelve inches in circumference. As the superior commissure of the vulva is found at least one inch above the bottom of the symphysis pubis, and the GENITALIA. 73 foetal head passes out between the top of the pubic arch and the infe- rior commissure of the vulva, the student will appreciate the very great extensibilhy of the labia majora; nor will he experience any surprise upon being informed that a great force is required to over- come their resistance ; that much time is often consumed for that end ; or that the labia are occasionally ruptured before they become sufficiently extended to admit of the escape of the head. I have seen several instances in which one labium was broken transversely during the transit of the head in a first labor. No evil consequences ensued in those instances, the wounds uniting by the first intention, or more slowly healing by the process of granulation. Labial Thrombus. — When the labia are put excessively upon the stretch, it occasionally happens that some of the ischiatic vessels, with which they are abundantly supplied internally, give way, and that a quantity of blood is soon poured out into the cellular tissue within. The extravasation may amount to only a teaspoonful, or may equal half a pound. Of course, in such a case, the labium must be greatly swollen, and of a dark color, causing very severe pain, or even sloughing of the part. The swelling is generally discovered soon after the conclusion of the labor, rarely before the labor is over. I have recited the circumstances of an interesting case of this labial thrombus, in my letters on Females and their Diseases, p. 65, to which I refer both for the case and for extended remarks upon the accident generally. When the occurrence of a rupture of vessels, pouring the blood into the texture of the labium, is discovered, it is proper at once to take certain precautions. The blood may be removed by making a free incision, to be practised upon the internal surface of the labium ; which indeed will be most easy to come at, because, in extensive swellings of this part, there is always eversion of the labium and not inversion, in consequence of the greater density of the cutis. The same thing is observed to happen in swellings of the lips, which seem to be then everted, as also in swellings of the eyelids, where some degree of ectropium is a common result of great distension. (Edema Labiorum. — Pregnant women are frequently afflicted with oedema of the lower extremities ; the swelling, in some examples, extending up along the thighs, when the watery infiltration causes a great distension of the labia soon after the fluid reaches them. I have seen a case in which, notwithstanding antecedently to the approach of 74 GENITALIA. abor, I punctured the labia repeatedly, so as to permit the serum freely to escape, the labia and perineum remained so swollen and hard, as to produce the highest degree of embarrassment during the parturient efforts. The student will perceive how greatly inconvenient it must be to have the whole perineum and labia pudendorum not only swelled, but hardened by the pack of the serum within their loose cellular mem- brane. Such a state is most particularly to be deprecated, when we have occasion to resort to a forceps operation. In a forceps operation, where the head is still inconveniently high in the pelvis, a thickened and rigid perineum is a deplorable obstacle. I have met with a case of the kind that wholly baffled all attempts to adjust the forceps — for the posterior commissure of the vulva could not be made to go far enough backwards to enable me to lock the joint of the instrument, and I was, at last, with the concurrent opinion of the late Professor Dewees, compelled to perform an embryulcia operation. I have met with numerous cases in which the perineum, as well as the labia, being thickened, the pressure of the descending child soon and easily dispersed the waters of the infiltration: nevertheless, I think that in all instances where the swelling is great, several punc- tures should be made with a lancet, towards the close of pregnancy, in order to permit the fluid to escape. A lesser degree of tumefaction does not demand so unpleasant a remedy, the water of the cellular tissue being readily pressed out by the advancing head, and dispersed into other portions of the cellular texture in the vicinity of the vulva. The punctures may be very safely made, and the operation gives no great pain. Labial Abscess. — The labia, occasionally, are the seats of ab- scesses that are excessively painful. They always point towards the inner surface. For the most part, they suppurate rapidly, and should be opened as soon as a deposit of pus can be ascertained to exist. Few instances will probably be found in which the medical attendant shall be able to discuss such inflammations, since their location deters the female from calling for his aid until intolerable pain or inconve- nience compels her to do so; and since, at such a stage, suppuration will, for the most part, be found inevitable. Whenever it is deemed practicable to effect a resolution of such inflammation, it ought to be attempted, for we know not what change of structure may take place, in consequence of abscesses in the labia. Whatever causes tend to affect the labia with permanent alterations of their form or density, are to be always carefully obvi- GENITALIA. 75 ated, since the part they perform in labor is highly important. A bleeding from the arm, followed by leeches to the part, and fomenta- tions with decoction of linseed, saturnine applications, &c, will be proper, upon the institution of an attempt to discuss an abscess in the labium. Cohesion of the Labia. — In young children it not unfrequently happens that the inner face of the labia pudendorum becomes irri- tated, which produces an adhesive inflammation, uniting the surfaces that are in mutual contact. The inevitable evacuation of the blad- der will, of course, always prevent a union of the whole extent of the labia. In all the instances of this kind that have fallen under my notice, I have found it sufficient to separate the cohering surfaces by forcing them apart with the fore and middle fingers of the left hand, while, with the end of a probe, drawn down directly upon the line of union, the adhe- sions are easily destroyed, and that without occasioning the least bleeding. The scalpel has never been required. In performing this operation in a good light, it will be seen that the union of the surfaces has taken place by the mutual interlocking of very delicate villi, much in the same way as the placenta and cotyledon of the sheep or cow are interlocked. The villi that are pulled apart in this process are ex- ceedingly delicate. I have been struck with this resemblance on seve- ral occasions. I have no doubt, however, that a case might occur, in which, by long neglect, the union should acquire so great a degree of solidity as to yield only to the knife. When the labia shall have been separated, in these instances of cohesion, they should be carefully kept from coming in contact by a pledget covered with cerate, as the adhesive tendency is renewed by the very violence which is required to obviate the consequences of a preceding irritation. M. Colombat, in his Treatise on the Diseases of Females, advises us to touch one, not both, of the recently separated surfaces, with a nitrate-of-silver-pencil in order to produce on that surface a state of vital action different from that existing on the uncauterized surface ; which he supposes must effectually obviate the tendency to cohesion. His idea is, that to adhere, both surfaces must possess the same adhe- sive temper. For my part, I have found it in all instances sufficient to direct the nurse to draw the point of the little finger, dipped in oil, strongly downwards, from the anterior to the posterior commissure. 76 GENITALIA. Such a process, daily repeated, effectually sets aside all possibility of re-establishing the cohesion of the labia. Differences of the Labia. — The appearance of the labia in vir- gins, is different from that observed in females who have borne chil- dren. In the latter, they present a somewhat shriveled or collapsed appearance, except in fat persons; and the inner surface, which in virgins is of a rose tint, becomes bluish or black in the aged, or those who have had children. The inferior commissure, also, is lower down in women who have borne children; whereas, in the virgin state, the lower commissure crosses the pubis almost as high up as the top of the triangular ligament. This is found to occur in most young females, examined early, in a first labor. The Nymphs. — The Nymphse are also called labia — labia minora, labia interna. They differ from the greater labia in that they consist of a duplicature of the mucous membrane, covered with a strong epi- thelial surface, and containing an erectile tissue ; whereas the greater labia have a basis of adipose texture possessing no erectile structure. In young persons, excepting neonati, the nymphse are wholly concealed within the genital fissure; but in those who are somewhat advanced in age, and who have borne children, one of them may be commonly ob- served to protrude beyond the vulva, a circumstance which depends not more upon a change of its proper structure, than upon the shrink- ing of the labia consequent upon advancing age and repeated par- turition, as has been already mentioned. The top of the nymphse is but little below the superior commissure of the vulva, and each nym- pha descends obliquely outwards, generally, terminating rather more than half way down the labium of each side. This arrangement gives it the appearance of a pointed arch. The color of the nymphse, in young persons, is a lively red ; they are thin, and their surface is not corrugated ; w T hereas, in women who have borne children, they assume a darker hue, and are sometimes observed to be very much thickened and corrugated, not unfrequently presenting a lobulated appearance. Haller informs us that hairs are occasionally found to grow upon them. They are supplied with a peculiar kind of sebaceous matter, which, in uncleanly individuals, accumulates in considerable quantities, giving rise to a disgusting fetor. It is useless to inquire into the motives for bestowing upon this or- gan a title which appertains to the Divinities that preside over foun- GENITALIA. 77 tains. It is at least certain that these bodies exercise no influence over the sources or direction of the urine. It is asserted that they subserve a very important end, to wit, the supply of an additional material for the distensions which these parts undergo in the last mo- ments of labor, thus diminishing the risk of rupture of the external parts of generation. I have, however, repeatedly ascertained, that at the instant of the extremest distension of the vulva, the nymphse are not effaced, but can be distinctly felt, like a firm ridge, little less ele- vated or marked than in the most entire repose of the organs. It is easy to verify this fact in any case of labor. There is high authority for the assertion that they are the subjects of erection under the excitements of the sexual passion, and possibly they may concur, therefore, in the production of the orgasm which seems essential to conception. It is proper to say, however, that the uses of the nymphse are unknown. They do not exist in any other species of mammalia. Notwithstanding that the fold of the nympha is not effaced or flat- tened out in labor, it sometimes happens, that, while contingently elongated by the extension of the labia, they suffer laceration. Like all other living tissues, they are obnoxious to inflammatory diseases, which are often extremely painful. The treatment of abscesses of these parts is conducted upon the same principles and indications as occur in those of the labia majora. In some cases of young children, the anterior edges of the nymphse become coherent from an adhesive inflammation developed in thern. If the cohesion extend far downwards, the two nymphae form a sort of curtain or flap in front of the urethra. This accident causes the urine, which cannot flow off pleno rivo, to dribble over the surface of the vulva and perineum, giving rise to painful excoriation. In a specimen mentioned by Colombat, the upper portions of the nymphse had not cohered, while the lower portion obstructed the urine and compelled it to rise upwards to escape beneath the clitoris. This gave rise to a urinary distress which was only relieved by the surgical separation of the cohering margins. M. Colombat cites several interesting cases of the kind. In those individuals in whom they protrude beyond the external surface of the vulva, excoriations of them are occasionally met with. Where such excoriations are rebellious under treatment, it is best to remove the protruding portion by the scalpel or scissors. This ope- ration may be safely resorted to, since it is a prevalent custom among many tribes of Arabs and Moors, and also the Coptic inhabitants of 78 GENITALIA. Egypt, to apply the rite of circumcision, or rather excision, to the young female. It cannot be needful, in a work so limited as this, to enter into in- vestigations concerning the so much talked of tablier des Hottentotes. For an ample account of the subject, I refer the curious student to Mr. Lawrence's Phys. and Zool. of Man, page 420, where a very considerable number of authorities may be found. M. Merat's remarks on the same subject may also be examined, sub voce, in the Die. des Sci. Med. An account of the Hottentot apron maybe found also in the Annals of the Museum, of Natural History. It was furnished by M. George Cuvier. There is no reason to suppose it is a case of hypertrophy. All travelers in Southern Africa now agree that it is an ethnographical characteristic of the Bushman women. The Clitoris. — The word clitoris, according to De Graaf, in his Treatise de Mul. Org. Gen. Inservientibus, p. 16, is derived from x%ntopi%eiv quod hanc partem lascive fricare ac contrectare significat. It is the organ of touch for the aphrodisiac sense. The tip of the clitoris juts out under the summit of the pointed arch formed by the union of the upper ends of the nymphae. The clitoris possesses very considerable analogy to the male penis : it consists of two corpora cavernosa possessing two crura, which, like the crura of the male penis, are attached to the ossa pubis ; and the analogy may be further prosecuted, by attending to the manner in which the deep crescentic fold of the upper part of the nymphse surrounds the apex of this organ. This fold is called the preputium clitoridis. The cli- toris differs from the male penis in that it possesses no corpus spon- giosum, and of course it can have no real glans, or urethral canal. It is erectile, and is endowed with the most intense erotic sensibility. The uses of the organ are probably to be sought in this peculiar endowment. Its asserted universal occurrence in the mammalia bespeaks its importance. I could never discover a clitoris in many females of the Didelphis Virginiana that I have dissected with a view to discover it. J. Miiller, at p. 1464 of his Physiology, has a paragraph on the sub- ject of the clitoris, in which he says, "that the clitoris of the mammal is of the same structure as the penis of the male embryo, both of them being formed upon the same principle of development. The embryo clitoris and the embryo penis at first resemble each other exactly, as to their external form. The corpus cavernosum is open or cleft, in GENITALIA. 79 both alike, so as to form an open canal. Both have muscles, ischio- cavernosi, and constrictores pudendi ; but, when the perineum closes, in the progress of development, in the male embryo, the latter muscles become acceleratores urinse. The clitoris becomes shorter, and the lips of its groove become converted into nymphse." Rudolph Wagner says, " that the generative organs are late in making their appearance, even later than the kidneys and supra-renal capsules. There is no trace of them at the end of the first month. The canalicular cleft of the penis is closed at the first month, and becomes the urethra. On the contrary, the edges of the cleft rise more and more, and become converted into nymphse in the female. " Here I may venture to remark that this law of development does not apply to the mammiferous quadrupeds, who are wholly destitute of nymphse. If the observations of the physiologist above named were correct, we should be at a loss to account for the failure of the analogy. ♦ The clitoris is the subject, in some individuals, of so great a degree of hypertrophia, that it comes to bear a marked resemblance to the male organ. Such affections, doubtless, are the causes of a prevalent vulgar belief in the existence of hermaphrodites. The cases of mo- noecious vegetables and of some annelides, as the earth-worm and other inferior creatures, may be cited as examples of the double sex in an individual constitution. The Indian corn, for example, fecundates by its male organ its own female germ. But, notwithstanding that monoecious plants, and some of the lower orders of the animal king- dom, contain within their bodies the organs of a double sex, we are not authorized to admit that a similar condition can occur in beings of a highly complex organization, where an entire individuality of the male and female is and must be indispensable. The prayer of Sal- macis, that her lover's body and her own might be united into a single one, although granted by the mythological divinities, leaves the sexual individuality both of Salmacis and Hermaphroditus unde- stroyed ; and so must it always be in nature. Wherever suspicions are entertained of the existence of an herma- phrodite, it will probably be found that an enlarged clitoris, or a bifid scrotum, presenting the appearance of labia pudendorum, has given rise to the suspicion. The Urethra and Vestibulum. — Just on a line with the top of the pubic arch, is a small bulbous projection, which encloses the orifice of the urethra : the triangular space included betwixt this bulb, the 80 GENITALIA. nymphse and clitoris, is called the vestibulum. It is important to understand its position, because it is always referred to in introduc- ing the catheter, which is very easily performed if one has a correct knowledge of this part, and very difficult of execution in the absence of such knowledge. The lower part of the vestibulum is divided ver- tically by a raised line or raphe, which can be readily felt with the point of the finger, and which leads directly to the orifice of the urethra, to which it should serve as a director in the operation above mentioned. The female Urethra is from an inch and a half to two inches in length. It turns upwards and backwards, directly under the triangular ligament of the pubis, at the base of the triangular space above called vestibulum. In introducing the catheter, the point of the tube should be directed perpendicularly to the surface of the vestibulum, and in- troduced within the orifice of the urethra, and then, by depressing the handle, the point will turn upwards behind the pubal bone towards the orifice of the bladder. Notwithstanding the female urethra is so short, it often happens that the bladder, when much distended with urine, and particularly during labor, is carried very high upwards, so that the urethra is much elongated. I have several times been obliged to introduce the catheter fully four inches, before it would enter the bladder of urine. The urethra is also very much elongated in some cases of retroversion of the womb. On account of the situation of the urethra, it is sometimes subjected to so severe a degree of pressure by the foetal head, that it sloughs before or after delivery, and gives rise to the distressing symptoms of urethro-vaginal fistula. It is also subject to contusion and laceration in some of the forceps or crotchet operations; accidents that cannot be too carefully guarded against by every humane or considerate practitioner, as entailing upon the patient the most distressing stilli- cidium of urine. The Hymen. — The Hymen is a fold of the mucous membrane of the genital surface, of the nature of a valvula connivens. It is a crescent, with the cornua directed forwards and upwards. It is situated just within the entrance of the vagina; and is ordinarily so thin and delicate as to yield to a slight force ; whence it is often found to be wanting in adult persons, having probably been ruptured during infancy or child- hood. Certainly there are many very young subjects met with in the anatomical rooms, in which no trace of it is to be discovered. The fold of mucous membrane of which it is composed, is broad in GENITALIA. 81 some, and very narrow in others. I am well convinced that I have, in many instances, met with the unruptured hymen during my ob- stetric practice. I may venture to assert, that whoever attends a great many women in first labors will have occasion to observe the ex- istence of a very narrow hymen in many such persons. I make this statement, not unaware that I may be charged with having mis- taken the fourchette for the organ in question. I think, however, that my opportunities in midwifery practice for acquiring experience have been sufficiently ample to warrant me against the commission of so gross an error. In some individuals, the hymen is not crescentic, but circular, with an opening in the centre, or in some other part of the plane ; and a few examples are met with in which the hymen is imperforate. I refer to page 94 of my Letters on Females and their Diseases, for a case in which the hymen formed a diaphragm in the vagina. Instances are also recorded of such firmness in the tissue, that incisions have been required in order to allow of the delivery of the foetus, which, by the resistance of the hymen, was prevented from being born. The foregoing should serve to convince the Student, that, as a test of virginity, this organ cannot be relied on, since it is often wholly wanting ; so slightly developed as to oppose no resistance in coitu, or even in labor ; and on some occasions, so strong as to require the aid of the surgeon for its destruction. The barbarous practices of some of the African nations, are worthy only of a barbarous people, and the distressing suspicions and doubts which sometimes are connected with vulgar errors on the subject of the hymen, ought, if possible, to be exploded. It appears to me to be the duty of the physician to speak in positive terms, and, when- ever suitable occasions offer, to reprobate so useless and often inju- rious a dogma. Fourchette — Fossa Navicularis. — A space that exists between the Fourchette, which is the inferior commissure of the labia, and the hymen, is called the Fossa Navicularis. The fourchette is a pretty firm fold of the tissues, serving to unite the lower extremities of the vulva. It is said to be generally ruptured in a first labor, which I do not think is true. It is doubtless often broken, and no evil conse- quences commonly ensue from the accident. The Perineum. — Although the term Perineum should in strictness 6 82 GENITALIA. apply to the whole of the space between the point of the coccyx and the lower end of the genital fissure, it is commonly, in midwifery, used in a more restricted sense, and indicates that space which exists between the lower end of the vulva and the anus. It is from an inch to an inch and a half in length. It is covered externally and below, with a dense but elastic skin. It is limited above, by the vagina, and posteriorly by the rectum; for, as the vagina and rectum are united by what is called the recto-vaginal septum, it is evident that the pyramidal space existing betwixt this septum, the fourchette and the anus, must constitute the perineum, using the word in its common acceptation. It is, in labors, very thick in some women, and feels extremely hard and resisting; in others it is very thin, soft, and easily dilated. Upon its rigidity or its extensibility depends the amount of time which will be required for its dilatation by the fetal head, or other presenting part. The student ought to pay great attention to the study of the peri- neum. Without a clear knowledge of its nature, and of its obstetric functions, he cannot comprehend certain phenomena in what is called the mechanism of labor. As I wish to avoid anticipating the subject, I shall only state, in this place, that to the resistance of the perineum is owing the extension of the head; and that this extension happens because, when the vertex comes just behind the crown of the pubal arch, in flexion, the energy of the pains is directed to the object of pushing off the perineum, in order to open the body for the birth. Now, while the crown of the head pushes the perineum away from the top of the arch, the perineum by its resistance thrusts the occipital bone of the foetus firmly against the arch, holds it there in close contact, and thereby compels the vertex, as it emerges, to rise upwards, along the genital fissure and the mons veneris. When the extension is com- plete, the child's head is born. See Fig. 13. I have already mentioned that the anterior edge of the perineum is, in many women, but little below the top of the pubic arch, and that the vulva is not opened until after the perineum has been some- what pushed outwards and distended. It does sometimes happen that more than one-half of the foetal head escapes from the lower strait, carrying out the perineum along with it, while the vulva is only opened enough to let the apex of the head emerge a very little. When distended in this way, the perineum is, perhaps, not thicker than the scalp, or even less so ; covers the head like a cap, and instead of being from an inch to an inch and a half long, measures between GENITALIA. 83 three and four inches. This great extension is sometimes kept up for a considerable length of time. The time necessary for the complete expansion of the perineum is very different in labors. I have waited six hours by the bedside after the head had begun to distend this part, and witnessed repeated efforts of the womb to overcome the resistance, the head being always forced back into the excavation by the elasticity of the perineum and the contraction of the levatores ani, until, at last, some long and powerful pain has forced it through the birth. It is highly import- ant, in making a prognosis, to have a very careful reference to the state of the perineum, as it alone often furnishes greater resistance, and consequent delay, than the os uteri, the straits and the vagina together. There are not a few cases in which it wholly refuses to dilate, and then, the child is forced downwards at the expense of the tissue, which bursts or is rent asunder, allowing of the immediate egress of the head. This laceration of the perineum generally takes place when the vulva is largely distended, the rupture commencing near the four- chette, and extending backwards as far as the anus, or even into the rectum. In other instances, the child has been expelled through a laceration of the perineum proper, not including the fourchette or any part of the vulva, the perforation being made betwixt the anus and vulva; the vagina is, of course, torn open. When such accidents happen without involving the bowel or its sphincter muscle, no very bad consequences are apt to ensue, the parts readily healing, by the continued and close contact of the sur- faces, with granulation. Should very hard and extensive cicatrices be formed in conse- quence of such lacerations, the vagina and perineum maybe rendered less fitted for the distensions of a subsequent labor, in which great care ought to be taken to obviate the repetition of so very untoward an accident. Lacerations do not always commence at the fourchette. I have already mentioned cases in which the lower third of the right labium was broken off, and an irregular lacerated wound extended from that point towards the perineum. The accident cannot be always avoided, even by the greatest care and skill. I have recently seen a case of laceration, in which the wound, commencing very near and within the inner third part of the left nympha, extended downwards and backwards, and then upwards in the vagina, in such a manner as to 84 THE VAGINA. have cut the tube nearly half off— a very singular case, and which must have been near allowing the head to come through the perineum. In all instances where the power that urges the child forth is very great, there is risk that the infant may be expelled before the perineum and vulva have sufficient time to dilate : they are, therefore, apt to be ruptured. Lacerations sometimes take place in forceps operations ; probably from want of patience in waiting for the dilatation of the parts, time not being allowed for the yielding of the textures. It is the invariable duty of the accoucheur to see that the parts shall have time to relax and dilate before the head is permitted to emerge ; an end which he can generally compass by supporting the perineum ; making pressure against it so far as he may dare, aiding it to jam the occi- pital region closely against the crown of the arch, and thus, while the head is kept from advancing, permitting the tissues to acquire the proper temper or disposition to yield. This, however, will be more apropos when we come to treat of the management of labor. The Vagina. — The Vagina is a membranous tube that connects the external with the internal organs of generation. Its length varies in different adult persons, being commonly longer in virgins than in women who have borne children recently, and especially in such as have given birth to a numerous offspring. It is also longer in preg- nant women about the fourth or fifth month, in consequence of the rising upwards of the gravid uterus, which then rests on the brim of the pelvis. A portion of its upper and posterior part is attached to the rectum by the recto-vaginal septum, and it is united to the urethra by the vesico-vaginal septum ; near its lower end it is provided with a sphincter muscle that serves to close it with more or less force. Occupying the middle of the pelvis, where the transverse diameter is more than four inches long, the sides of the vagina, when distended so as to receive the foetal head, may be carried laterally as far as the planes of the ischia. A great distending force is often required for this purpose, and the practitioner is detained for hours in order to obtain the requisite dilatation of the vagina. Such resistance depends upon the unyielding nature of its own proper tissue, and not upon any obstinate opposition from the surrounding textures : there is nothing betwixt it and the ischia, except the levatores muscles and a very loose cellular tela, comprehended betwixt the folds of the ligamenta lata. The lower end of the womb is attached to the upper extremity of the vagina. If the vagina becomes shortened and its two extremities THE VAGINA. 85 approach each other, the womb sinks lower down into the pelvis than its natural level. If the vagina be subsequently elongated by any means, the womb is carried upwards again. A prolapsion of the womb is essentially a shortening of the vagina, and the cure of such prolapsion is to be effected by restoring to this canal its proper lon- gitudinal dimension. A prolapsion of the womb is never a disease of the womb itself, but of the vagina and other parts that support the organ. It seems to me to be almost a work of supererogation to make this assertion — and yet I am led to do so because so much is said of the ligaments that suspend the womb. Let the student remember that there is a complete peritoneal cul- de-sac betwixt the rectum and the vagina. This is the cul-de-sac into which the fundus uteri falls in cases of total retroversion. It is clear then that here at least there is no suspensory ligament of the womb. The ligamenta lata do not suspend it — they merely stay it laterally, while the ligamenta rotunda serve to retain it in normal pro- pinquity to the pubis — or to keep it from oversetting backwards when a full bladder of urine tends to turn it over, or retrovert it. The anterior wall of the vagina, and parts of the womb itself, are con- nected with the bas-fond of the bladder. Such are the means of suspension of this organ within the pelvis. Is it not manifest that an elongated vagina carries the womb upwards, while a shortened or relaxed one lets it fall down, and that prolapsus is a fault of the vagina, which in procidentia becomes actually inverted, and comes quite forth from the genital fissure ? While in Bartholomew's Hospital at London in 1845, Mr. Edward Stanley showed me a case of procidentia uteri, in which the tissues of the vagina had become so enormously thickened — the womb, doubt- less, also much engorged — that that able surgeon in vain endeavored, for a long time in my presence, to return the mass into the cavity of the pelvis. The woman was in much pain. The accident had hap- pened several days before I saw the case. Mr. Lawrence was requested by Mr. Stanley to endeavor to replace the tumor — which he effected after considerable effort. Figure 40 represents very well the appearance of a case which I was invited to attend with Dr. Hains of this city. The woman was about seven and a half months gone with child. There pro- jected through the genitalia, a tumor as large as a man's arm and near five inches in length, covered with a dry epithelium. It was THE VAGINA. rugous as in the drawing. At the lower end or point was a deep pit. Upon thrusting the finger upwards to the metacarpus, in this cylindrical canal, the os uteri of the gravid womb was felt on a level with the rami of the pubis. I returned the whole mass within the pelvis, but it came down again. It consisted of a thickened and inverted vagina. It was thickened by infiltration. A pessary w T as adjusted, but the woman would not w T ear it. At full term she gave birth, in an easy labor, to a healthy child. At the beginning of the labor it was down. The labor pains had hardly set in, before the whole mass retired within the ostium vagina, as I was informed by Dr. Hains, who attended her in the confinement. The internal lining of the vagina is a mucous membrane, abundantly furnished with mucous follicles, whose secretions lubricate the parts in health, and particularly during labor, when their presence is of the greatest consequence. The parts, when deprived of it by frequent examinations, become dry and inflamed, which prevents their yielding to the distending forces, whereby the patient suffers protracted dis- tress that might be easily avoided by abstaining from the Touch, and thus preserving the humid and soft condition of the organ. Too fre- quent Touching not only removes the lubrication, but irritates the mucous membrane : it is greatly to be deprecated, as not only useless, but injurious as well as indelicate. A woman in labor should be examined as seldom as possible. There seems to be a dissidence in the opinions of authors relative to the structure of the vagina, particularly that of its tunica propria, which is either a real fibrous tissue, or a mere condensed laminated cellular membrane. It is surely not muscular beyond the possession of a muscular sphincter that closes its lower extremity, and possesses no other contractility than that which is called elastic, and which is common to the whole of the cellular structure. It closes speedily after the passage of a child, even one of a very large size. In some instances, where the child's head has lingered long in the vagina, an hour or more elapses before its calibre becomes much contracted. For some hours after the birth of a child, the introduction of the hand into the vagina may be effected with the use of very little force. The THE UTERUS. 87 vagina is subject to eversion, or to complete inversion, where there is procidentia or inversio uteri. Of course such accidents can never occur, nor can any tendency to them take place, without deranging both the bladder and rectum in consequence of their textural con- nection with this organ. The Womb. — The Uterus is attached to the upper end of the vagina. It is a pear-shaped body, compressed from front to rear, and varies in length, which may be from two and a half to three inches, being larger in women who have borne children than in those who have never been impregnated. It is divided into fundus, body, and neck ; the fundus being the uppermost, and the neck the lowermost part of the organ. The vagina is united to the womb in such a way as to permit its neck to project a short distance into that tube; in this regard also there is great variety, some women having almost half an inch of the cervix uteri hanging down in the vagina, while in others the connection seems to exist almost at the lower end of the cervix. See the engraving. The cut represents the womb b, and the vagina h, laid open, Fig. 41. in order to show the neck and mouth of the w T omb b project- ing into the upper end of the vagina. In it are also seen the round ligaments g g; the ova- ries e e; the ligament of the right ovary f, and the Fallopian tubes c c, with their fimbriated extremities d d. As the vagina is a curved canal, which proceeds back- wards from the vulva, and up- wards towards the rectum, it happens that the womb lies rather nearer to the sacrum than to the pubis. The womb is so situated that its long diameter is parallel to the axis of the superior strait, while the vagina is nearly parallel to that of the inferior strait ; hence, at their junction, they make an obtuse angle, any deviation from which implies a displacement of the womb. The breadth of the womb is about an inch and a half; its thickness about one inch. I subjoin a drawing that represents the internal or- gans divided transversely from top to bottom, and showing the front K8 THE UTERUS. or anterior half: a is the fundus or bottom of the womb, which is the Fig. 42. uppermost or highest portion of the organ, b is the triangular cavity, whose outlet is through the canal of the cervix (c), leading down to the orifice of the womb in the vagina, which orifice is called os tincse, or os uteri. At d d are seen the left and right Fallopian tubes laid open, to expose the narrow passage by which the ova are con- ducted from the ovaria f f. e e are the fimbriated extremities of the tubes, which are also called morsus Diaboli, or Devil's-bit. They are the infundibula which take up the ova as they spontaneously escape from the surfaces of the ovaries, which expel them once a month. The wing-like expansion on each side of the womb is a broad ligament, and the round ligament is seen through it and in front of it on either side of the uterus. Suppose half an inch of the cervix uteri to project into the upper part of the vagina; then, if the whole length be three inches, we shall have two and a half inches of the w T omb above the upper end of that canal. Such being the case, the w 7 omb w r ould fall over to the right or left side of the pelvis, were it not restrained or stayed by what are called its broad ligaments, which, passing from its sides towards the sides of the pelvis, keep it steady, or prevent it from assuming an oblique attitude; it would also fall backwards towards the sacrum, and sometimes become lodged or wedged under the promontory of that bone, were it not restrained from moving in that direction both by its round ligaments and by its connections with the bladder. It cannot fall forwards, for it is sustained by the bas-fond of the blad- der, which, by filling with urine, must, and does always push it backwards again. Structure and Powers of the Womb. — The substance of which the womb is composed has not been fully understood. In the unim- pregnated state, it is dense and gristly to the feel, and cuts very hard ; THE UTERUS. 89 the cut surface being of a faint pinkish hue,and of a fibrous appear- ance ; but those fibres are disposed without any apparent regularity or order. It is supplied with blood-vessels, absorbents and nerves, which are very small during the unirapregnated state; but the same vessels in the gravid womb acquire an enormous size, and are exceed- ingly numerous and tortuous, so that, in fact, the ovum, at full term, appears to be contained within a vast net-work, or rete vasculosum, united together by a quantity of muscular fibres. The womb, at the full term, is an exceedingly sanguine organ, being furnished with torrents of blood from the uterine and spermatic arteries, the former reaching it from below, and the latter from above, with free inoscula- tion of the several channels of circulation. As to the interior membrane, or mucous coat of the womb, it is unnecessary to speak here : the cut, exhibiting Mr. Coste's view, will explain the matter with sufficient clearness. Various attempts have been made to demonstrate the muscular fibres of the womb, and they have been divided into layers and planes and fasciculi for that purpose ; but the very fact of such difference of opinion is proof enough that the arrangement of them is not yet clearly known. If it were known and demonstrable, there would no longer exist any dissidence concerning it, since whatever is clearly demonstrable, ceases to be a subject of dispute or doubt. This much, at least, is well known; namely, that the contractile fibres of the womb are capable of acting partially, or so as to change the form of one part of the organ, while another part of it acts w T ith less intensity, or not at all. Thus, it occasionally happens that we find the uterus, after delivery, contracted in its middle, as if a string had been passed round it and drawn tightly, causing it to assume the shape of the hour-glass. This state is familiarly denominated an hour-glass con- traction. Again, we not unfrequently find the whole organ elongated, and almost of a farciminal form ; its fundus being raised high upwards, towards the epigastrium, while the body of it is narrow or slender like an intestine. I feel assured that I have sometimes found it, after de- livery, full nine or ten inches in length, and not more than four inches in transverse diameter, estimated by feeling it through the relaxed in- teguments of the abdomen. These circumstances prove that the ute- rine fibres which affect the conjugate diameter of the organ may act with force, while those which affect its longitudinal diameter are either in a state of repose, or of very slight action ; which leads us, as I think, to the inference, that the longitudinal and horizontal fibres are 90 THE UTERUS. Fig. 43. separate and independent organs or parts of the uterine structure. The annexed cut from M. Chailly's Midwifery, gives a view of the ar- rangement of muscular fibres which seem to converge upon the tubes and round ligaments. Let the student conceive of a separate non-coordi- nate action in these fascicles of mus- cles, and he will perceive that such action might greatly embarrass a la- bor in which the contraction ought to be consentaneous for the whole mus- cular apparatus of the organ. If this be a just view of the case, it will serve for the explanation of occurrences in labor that would otherwise embarrass us not a little; for example, we find the woman in travail sometimes suffering under the most intense pains, and making the greatest efforts without the smallest profit; and that, too, where we know certainly that the pelvis is of the amplest dimensions. What can be the cause that the child does not advance under such vigorous efforts? We find that the head is positively stationary notwithstanding the healthiest pelvic conforma- tion, a sufficient dilatation of the uterus, and violent labor pains. We are at once satisfied, and relieved of anxious doubts, when we reflect that the horizontal or transverse fibres are acting, and the longitudinal or perpendicular fibres are inert. There is a failure of co-ordination in the movements, and our duty will be clearly seen to consist in endeavors to restore the symmetry of contractile effort. As this circumstance generally results from some excess of a local or constitutional irritation, the former occasioned by tedious or violent labor, rheumatism, officious intermeddling, or the direct stimulation of ergotism ; and the latter by a too susceptible nervous system, re?- pletion, mental emotions, or vain efforts of labor long continued : it appears that, in the former case, we ought to resort to the tranquiliz- ing influences of laudanum clysters, cool air and drinks, and absti- nence from impertinent handlings ; whereas, in the latter, we may apply to the lancet, to a Dover's powder, to portions of morphia, or the black drop or opium, or the bath, after evacuations have been procured from the bowels by emollient and laxative injections; and that w T e ought to give orders for a full and free ventilation, and the use of suitable drinks. THE UTERUS. 91 But if it does sometimes happen that the movement of the hori- zontal fibres is inordinate, or in excess, it fortunately happens in the vast majority of cases that the powers of the longitudinal fibres are the greatest. The ovum being contained entirely within the uterus, it appears that it can only be expelled by the fundus approaching the os uteri ; or, in other words, by the shortening of the womb that results from the contraction of its longitudinal fibres. Let us remem- ber that the womb is attached to the upper end of the vagina, and that the ovum, in passing out from the uterus, must necessarily traverse that canal. It will then appear that the first contraction of the longi- tudinal fibres will tend to pull the circle of the os uteri open at the same time that the point of the ovum is insinuated into the enlarging orifice. This opening or dilatation of the orifice does not take place without resistance, which is chiefly perceptible, however, in the early stages ; for we find that while the fundus and body of the womb are vigorously condensed during a pain, the cervix also is strongly con- tracted, but less and less vigorously, as the dilatation becomes more considerable ; so that, indeed, it is not rare, at length, to perceive the whole circle of the cervix yield as if without opposition, to the greater power of the longitudinal fibres. The circle of. the os uteri is as it were pulled upwards, towards the fundus uteri, by the mus- cular expulsive powers ; so that it seems to be stripped over the lower segment of the ovum, over the head, or over whatsoever presenting part. I have known the whole dilatation to take place during a natural sleep. Some women require only a few pains to complete the dilatation, whereas others suffer hundreds of pains during several successive days, before the circular fibres are conquered by the protracted efforts of their antagonists. From thirty-five to fifty pains are probably felt by the average number of parturient women. If four hours be a mean of the dura- tion of labor, then the woman will be likely to have pains at the rate of one every ten minutes for the first hour — which would be six pains. She would probably have ten pains in the second hour, fif- teen in the third hour, and twenty pains in the fourth and last hour of the process — say, in all, fifty pains. While the generality of cases are thus favorable, there are multi- tudes of women who have not more than three or four; whereas some of them suffer from the repetition of two hundred contractions, and even a greater number than that. A considerable experience and trained habits of observation are 92 THE UTERUS. necessary to enable a practitioner to prognosticate the moment of de- livery, making up his judgment from the intensity of the pains of expulsion, as compared with those of opposition or retention. It is certain that no man, be his experience ever so great or his discrimi- nation ever so acute, can with absolute certainty calculate upon the moment when any given labor shall be brought to a conclusion, since no one can absolutely predict what shall be the exact degree of in- tensity of any muscular force, which, as it is a vital operation, so it is dependent on causes beyond our foreknowledge or perfect control. Young and inexperienced practitioners ought, therefore, to be very late in announcing their prognostic of the end of labor, as to time. I have remarked, that as the longitudinal fibres pull the os uteri open, the apex of the ovum is inserted into the opening : with each succeeding pain additional portions of the ovum pass into the os uteri, and through it, until at last, the fundus having approached very near the cervix, the whole of the ovum becomes excluded from the uterine cavity, after which the same longitudinal and horizontal fibres, meet- ing with no further considerable resistance, act in concert, and thereby reduce the womb down to -a very small size. It returns but slowly to the non-gravid condition. From fifteen to thirty days are required to effect this reduction. Let it be remembered that the womb is capable of contracting equally upon an ovum at term, and upon an abortion of three weeks, THE OVARIES. 93 CHAPTER V. THE OVARIES. The ovaries are organs for the preparation of ova, or eggs, which contain the germ of the offspring. In the mammals there are two ovaries, within each of which may be seen, with a good lens, from twelve to fifteen eggs, or yelks, in- closed within their proper capsules or ovisacs, which are commonly called Graafian follicles, or ovarian follicles. They were some time since denominated Graafian ova — because de Graaf imagined that these pellucid bullae w T ere the ova of the animals in which they were seen by him. Let the Student early make the discrimination between the follicle, the cell, or ovisac which contains the egg, and the minute egg itself, which is too small to be readily seen by the naked eye. The human ovary is about an inch in length, half an inch in depth, and more than a quarter of an inch through; in shape it is like a com- pressed olive. Each ovary is attached to the angle of the womb — one on the right, and the other on the left corner. It is connected with the uterus by a short foot-stalk of a fibrous structure, which is called the ligament of the ovary. The ovaries lie behind the Fallopian tubes, enclosed in a duplica- ture of the peritoneum, which adheres firmly to the proper covering or coat of the organ ; so that the ovary is invested by a serous mem- brane, as the liver, stomach or intestines are. Underneath the serous covering lies the strong white fibrous coat, or tunica albuginea, which is a closed sac containing the stroma, the peculiar tissue of the organ. There is thus no proper excretory- duct for this organ ; nevertheless, the Fallopian tube becomes, upon occasions, the vector of its product. The connection of the vector tube with the organ exists, in all probability, only during the moments of the sexual excitement, or orgasm. In the embryo, as late as to the sixth month, the end of the Fallopian tube is permanently attached 94 THE OVARIES. to the ovarium — before the seventh month the connection is broken. See Rosenmuller, Qucedam de Ovaritis Embryonum et Fcetuum Hu- manomniy p. 11. I have a specimen of foetus at the sixth month, in which the de- tachment has not taken place. The stroma of the ovary, with which the closed sac of the albu- ginea is filled, is a peculiar concrete, consisting, apparently, of a rather dense cellular tela, which is salmon-colored. Throughout the stroma are to be seen numerous delicate arterioles and venules, that are the distal branches of the spermatic artery, or, perhaps, more properly speaking, the ovaric artery. It is worthy of observation, that the blood of this circulation is brought from a great distance, since the ovaric artery arises on one side from the emulgent, and on the other from the aorta itself. As the ovaries, like the testicles in the male, are originally formed high up in the abdomen, near the kidneys, an economical purpose was answered by deriving their cir- culation from these sources. Whether there be any further and pe- culiar economical end to be attained by drawing this blood from such a distant point, remains unexplained. If the tunica albuginea of an ovary be divided with a scalpel, the stroma may be readily torn asunder by pulling the edges of the inci- sion apart with the fingers. The ovary of a mammal, when examined for the purpose, exhibits several watery vesicles, whose translucency renders them visible through the indusia or coats of the organ. By cutting the ovary open, and by carefully dissecting them out, these vesicles or bullae may be completely freed from all attachment, when they appear as globules filled with water, and of sizes varying from the bigness of a garden pea to that of a small bird-shot. In each ovary may be counted some fifteen of these vesicles. These Graafian vesicles — for so they are usually denominated — are also called Graafian follicles, Graafian cells, Graafian ova, and ovarian follicles. They are ovisacs. They are composed of a double mem- brane, one inside of the other. If a Graafian vesicle be punctured with a lancet, there spirts out, through the cut, a drop of water. This drop of water, when col- lected on a glass, or knife-blade, and placed under the microscope, is found to consist of a pellucid liquor, in which swim a great number of small grains. Among these grains there is a portion in which the grains are agglomerated in greater number, and in the midst of them, a yelk-ball is found. THE OVARIES. 95 Figure 44 represents this yelk-ball, bounded by a white, transpa- rent zone, which is called its zona pel- lucida. It is a perfect sphere, filled Fi s- 44 - with vitellary corpuscles, oil globules and puncta that swim in a transpa- rent liquor. The sphere or yelk-ball lies amidst the granules of the tunica granulosa before mentioned, as may be seen in the figure, taken from Rudolph Wagner's Prodromus. Outside of, or beyond the white zone, or zona pellucida, are the smaller gra- nules of the tunica granulosa, so that the ovum above represented is bounded by the transparent or white zone. These outside granules are the remains of the granular membrane that lines the inner concentric membrane of the Graafian follicle. Perhaps the physiologists go too far in calling it a membrane. — It consists of innumerable grains that settle themselves, touching each other, upon the inner wall of the vesicle, like the sediment in a vial. I do not deny that they deposit themselves thus under the forces of a vital affinity, and it is even probable that they do so — but whenever this vesicle is punctured, this so-called membrane be- comes decomposed, and floats out as grains along with the yelk-ball, great imiltitudes of them adhering to it. This granular membrane, or tunica granulosa, is thickest, in gene- ral, at that segment of the Graafian vesicle which is nearest the sur- face of the albuginea, and it forms a small heap — an acervulus or cumulus, which has been by Baer called the cumulus proligerus or discus proligerus. It is in the apex of this cumulus or cone that the egg is found, and it is chiefly among the debris of this acervulus that the microscope reveals the yelk, with its bright pellucid zone. Upon referring again to the above figure, the student will see, that in the yelk-ball, amidst its vitellary corpuscles, there is pictured a clear, transparent, oval vesicle, with a dark spot upon it. This is the germinal vesicle, and the dark spot is the germinal spot, or macula germinativa, which M. Coste calls the tache embryonaire. Such, in general terms, is the human ovary, which, I repeat, con- sists of a closed sac, filled with ovarian stroma, in which are deve- loped ova within capsules called Graafian follicles. These ova are true yelks about one-fifteenth of a line in diameter; in each unfecun- dated yelk is a germinal vesicle one-sixtieth of a Paris line in diame- 96 THE OVARIES. ter, and having upon its inner surface a germinal spot consisting of dark granules — the germinal spot being one-two-hundredth or one- three-hundredth of a line in diameter. I have many times observed the numerous granules, or dark puncta, that may be inspected by placing thin slices of ovary on the field of the microscope. There are immense numbers of these points, which are, by some, supposed to be nuclei, or cytoblasts — the inchoate ele- ments of ovarian ova. Such is the opinion of Martin Barry, who gives, in his papers, published in the London Phil. Trans., drawings of these appearances in the ova of various animals. If this notion be indeed founded in truth, then each ovary should be held to contain, not fifteen ova only, but the nuclei of hundreds of thousands of them. Perhaps, however, the microscopic view is not correct, and these points are acini of the gland, if it be a gland. Supposing them to be acini, and that an acinus may, by some physiological act, be cast off from its connection with the stroma that produced it, and carry away with it, like an inoculated bud or like a spore, or a pol- len grain, the metabolic and the plastic forces — by which to develop the ovarian ovule — still we have, in either case, the idea of a pro- ductiveness in creatures beyond imagination for vastness. The ovaries are abundantly supplied with nerves, derived (Longet, t. ii. 543) from three or four branches that come off from the renal plexus, and proceed, in company with the ovaric artery, to the place of distribution. They are called the ovaric plexus, and spend their terminal fibrils within the ovary, and in part, also, within the uterus, thus connecting the two organs in a common bond of sympathies. Regner de Graaf, of Delft, in Holland, where he died at the age of thirty-two years, on the 17th of August, 1673, published his work De Mulierum Organis Generationi Inservientibus in 1672, and gave, as I have said, his name to the ovarian vesicles, or ovi-capsules. They were by him considered to be ova, and were long, and even until lately, by many, regarded as ova, for no one, until recently, had acquired any correct notions of the ovum of the mammiferse. It is a title to immortality in the Republic of Letters, to have dis- covered the ovum of the mammal, and there has been a great conten- tion as to the priority in this claim. It appears to me that, although one person may have first seen the object, so many individuals have been concerned in establishing and explaining the natural history and physiology of the fact by laborious researches and patient efforts of rea- son, that no single person should be deemed entitled to all the credit; and THE OVARIES. 97 it is certain, that the world is too much indebted to divers persons on this account, not to divide the honors of the career among many claim- ants. I feel no inclination to enter the lists of this controversy in favor of any particular person, in which I have no other than a common interest of gratitude to the ingenious philosophers who have illumined my therapeutical path with floods of radiant light, freeing me from the errors and gropings of my blind predecessors, and enabling me clearly to perceive, and plainly understand, many mysteries of physiology and therapeutics that were utterly hid from their eyes. But the student of medicine ought to be somewhat acquainted with the literary history of the subject, lest he wander among authorities that have now ceased to have any claim to his obedience. Let him, therefore, understand that a meeting was held at Breslau, in Silesia, in the year 1825, in honor of the fiftieth year of the Doctorate of Professor Blumenbach. At that meeting was presented a volume under the following title: — Joan. Fried. Blumenbachio, etc. Sum- morum in Medicina honorum semis cecularia gratulatur ordo medicorum Vratislaventium, interprete Joanne Ev. Purkinje. P. P. 0. Sub- jects sunt symbolce ad ovi avium kistonam ante incubationem : cum duobus lithogr aphis. Vratislavice, Typis Universitatis. This volume was printed in September, 1825, and was not published, being de- signed only for private distribution. An edition of it was published for sale at Leipsic, in 1830, 4to., of which a copy is now before me. 1 look upon Professor Purkinje's book as the first in the series of the works of reform as to our knowledge of the ovaria. This is the work in which was first made known the existence of the germinal vesicle, commonly called the Purkinjean vesicle, of the bird's egg. Professor Purkinje had interested himself in the investigation of the cicatricula, or tread of the hen's egg. He was examining it in a vessel of water, in order to learn the nature of the cumulus that lies directly underneath the cicatricula, and of which Figure 45 is a Fig. 45. Fig. 46. representation. It has been very beautifully produced on wood by Mr. Gihon, from the original lithograph. 7 98 THE OVARIES. While, with a pair of dissecting needles, tearing the yelk asunder under water, and removing the broken-down masses with a pipette, he came upon a "most beautiful vesicle, " partly adhering to the margin of the pore in the apex of the cumulus, and partly detached from its bed therein. His own words are — "Haec dum lente ope perlustro, vesicula formosissima parte margini pori adherens, parte libera haud parum mirabundo mihi offertur." P. 2. Figure 47 ex- hibits this appearance. The cavity in which this Purkinjean, or germinal vesicle (the first that was ever seen), is contained, is Fi<* 47 . . represented by Purkinje as in the an- nexed cut, Fig. 47, also copied from his lithograph. It is a cross section of a portion of the yelk-ball and the cumulus, with its cavity, in the hol- low of which was found the Purkinjean vesicle. The transparent vesicle thus revealed, is almost as delicate in its structure as a soap- bubble. It can be found only in eggs that have not been fecundated, such as the pullet's egg, or yelks taken out of the ovary, in which, according to Von Baer, it exists, even in the very smallest yelks. The student now has a clear understanding as to the germinal or Purkinjean vesicle, discovered and made known in September, 1825. The next publication in the order of important discovery, w T as the De ovi Mammalium et Hominis Genesi. Epistolam ad Academiam Imperialem scientiarum Petropolitanam, dedit Carolus Ernestus A. Baer. Zoologies Prof. Publ. ord. Regiomontanus, cum Tabula Aenea. Lips. 1827, 4to. Such is the title of Von Baer's letter to the Imperial Academy of Sciences at St. Petersburg, on the subject of the ovum of the mam- miferous quadrupeds. In Von Baer's experiments, he, like Purkinje, never could find the vesicle in eggs already laid, but always detected it in even the small- est yelks of the egg bag. He supposes it to be the nucleus around which the matter of the yelk becomes subsequently aggregated. — This was the case also in the molluscs, in the lumbricus and in the leech. These researches led him to the discovery of the mammife- rous ovulum, in the following manner. Having observed a very minute ovulum in the Fallopian tube of the bitch, and feeling that such small ova could not consist of Graaf- ian vesicles, which are much larger, and that the liquor of the vesicle could not so soon acquire the firmness and solidity of the tubal speci- THE OVARIES. 99 men, he was led by curiosity, rather than by the hope of seeing with the naked eye, through the several coats of the Graafian vesicles, any ovula in the ovaries, to open a follicle with his scalpel, and placing the fluid that came forth upon the platine of his microscope : " Ob- stupui," says he, " profecto, cum ovulum ex tubis jam cognitum tarn clare viderem, ut ccecus vix negaret. Mirum sane et inexpectatum, rem tarn pertinacitur quaesitam, ad nauseam usque in quocunque compendio physiologico uti inextricabilem tractatam, tarn facillimo negotio ante oculos poni posse." P. 12. He informs us that this ovulum may, in some specimens of the ovary, be seen through the coats of the ovi-capsule. Everybody seems willing to concede to Von Baer the honor of this discovery, which was effected two years later than that of Purkinje, viz., in 1827. But, notwithstanding his good fortune as the disco- verer, he is not the true expositor of its nature, for he mistook the ovulum or yelk for the Purkinjean vesicle, and he says — " Demonstrabo enim mammalium ova vesiculis Purkinji reliquorum animalium com- parandas esse, quas in animalibus nonnullis, molluscis, acepalis v. c. et lumbricis ovorum evolutionem antecedere clare me vidisse puto" — that is to say, " he will show that the mammal ovum is to be com- pared with the Purkinjean vesicle in other animals, and that the evo- lution of it precedes that of the ova in certain molluscous creatures, as he' supposes to be verified by his observations." At p. 32, he argues the identity of the nature of the Graafian ova, and the ova of birds and spiders, which have a great quantity of vi- telline capsules and but little liquid, while the Graafian ova bear but few corpuscles and much albuminous fluid. " Besides, they resemble eggs in possessing a vesicle situated in a cumulus, and surrounded with a proligerous layer. Therefore, a Graafian vesicle, in view of the ovary, and in general, of the maternal constitution, is the true ovum of the mammal. 'Vesicula ergo Graafiana cum ad ovarium generatimque ad corpus maternum respiciamus, ovum sane est mam- malium.' ' Von Baer, notwithstanding the tyranny of the schools, al- most saw the real truth, for he remarks upon the fact, that the whole Graafian ovum cannot, as in birds, be transferred to the vector tube. " Hence in mammals," says he, " the inner vesicle (the true ovum) contains a richer vitellary matter, and as to the evolution of the foetus, it certainly proves itself to be a true ovum." In saying this, he was nearly free from the shackles of his scholastic prejudice. They were strong enough, however, to cause him to write of the ovulum, "Ovum fetale dici possit in ovo materno. Mammalia ergo habent ovum in ovo; aut si hac dicendi formula uti licet, ovum in secundapotentia." 100 THE OVARIES. The student, in reading the above, will candidly admit Von Baer's claims, though he will perceive how checked he was by the bonds of an old way of thinking. After all, the egg within an egg was, in his eyes, the true, separate, independent yelk-ball of the mammal. The ovum of the bitch is oV n t° iVh °f a Paris line in diameter, according to Von Baer. Now, notwithstanding M. Von Baer, as by the foregoing appears, is the discoverer of the mammal ovum, it is not doubted that Messrs. Prevost and Dumas had seen it in 1825 — the year in which Purkinje detected the germinal vesicle. They, on two occasions, turned out and saw the ovulum of the Graafian ovi-capsule in the rabbit. Yet, the glory is Von Baer's. As to the history of the Purkinjean vesicle in the mammal ovule , it appears now to be settled that the honor of its discovery belongs to Professor Coste of the College of France, though several Germans have attributed it also to Von Baer. M. Coste, in his Histoire Generate et Particuliere du Developpement des Corps Organises, says: " I was at first accused of having copied M. Baer; but, inasmuch as the opinions I had set forth were diametrically opposed to those of that great physiologist, the public early did justice to a reproach so unfounded, and the improper criticisms of Mr. Robert Froriep were promptly repelled by Bernhardt himself, in his inaugural thesis, Sym- bols ad Ovi Histonam, p. 25. This reproach having been set aside, an attempt was next made to bestow upon others the credit it was impossible to assign to M. Von Baer. It was pretended that the dis- covery was made at the same time, or nearly at the same time, by M. Coste in France, M. Bernhardt in Germany, and Mr. T. Wharton Jones in England. As to M. Bernhardt, it is enough for me to refer to that author's preface, in which he declares that his experiments were instituted for the purpose of ascertaining the correctness of my observations. Mr. Jones's publication is later by one year than mine ; a statement that might suffice for the present occasion, were it not that that physiologist has himself fully recognized my rights as to the priority of discovery, in his report on Ovology in the Brit, and For. Med. Review, No. 32, 1843, a paper in which he lays no claim to it himself, but attributes it to me." Thus far M. Coste, whose remark as to Bernhardt's preface is correct, as well as his citation of Mr. Jones's paper. Mr. T. Wharton Jones's words are as follows : — " By the discovery of the germinal vesicle, in the mammiferous THE OVARIES. 101 ovarian ovum, the complete analogy between the latter and the ova- rian ovum of the bird, &c, was established; and Baer's error regard- ing it dissipated. The correct view of the matter had been suspected by Purkinje, but he and Valentin had in vain searched for a germinal vesicle, and it was only on renewing their investigations, after the announcement that such a vesicle had been discovered in the rabbit's ovum by M. Coste, that they, Wagner and others, in Germany, were successful in finding it. M. Coste, therefore, as Bischoff observes, must, notwithstanding his very imperfect description and delineation of the germinal vesicle, be considered as its first discoverer." This, it appears to me, is enough to enable the student to see clearly the whole case, and I shall not further cite M. Coste, in his warm reclamations against M. Bischoff of Giessen. It is much to be regretted that, in the tranquil pursuits of letters and philosophy, there should arise occasions for reproach — the more, as so much honor always remains to be shared by the diligent mem- bers of the Republic. The world is very ready to acknowledge the services and merits of all those wise, learned, and good men, who, like Purkinje, Baer, Coste, Wagner, Jones, and BiscbofT, have in their publications endowed mankind with an impayable benefit. The discovery of the mammal ovum was rendered complete by the detection, in 1830, of the macula germinativa or germinal spot. It is diversely attributed to Professor Rudolph Wagner and Mr. T. Wharton Jones, and it may be esteemed a conceded point, that it was cotemporaneously observed, as it was cotemporaneously de- scribed, by those gentlemen in Germany and in England. The germinal spot is, by Wagner, in his Prodromus Histories Generationis Hominis atque Animalium, page 4, called primitive Keimschicht, and macules germinativce ; Professor Wagner, in a note, page 44, Part I., Elements of Physiology, says : — "I was myself the first to discover the germinal macula. I also described and figured the whole ovum in its successive stages with greater care and sequence than had yet been done." Wharton Jones says: "At one side of the germinal vesicle there is a small, round dark spot, discovered and described cotemporaneously by Rudolph Wagner and the author of this report." Brit, and For. Med. Review, 1843, p. 517. The germinal spot is from one-two-hundredth to one-three-hundredth of a Paris line in diameter. It consists of a collection of grains. — Wagner's words, Prodromus, p. 4, are: "If the germinal vesicle in man, and in the mammifers, be carefully examined with the micro- 102 THE OVARIES, scope, at four hundred or five hundred diameters, there will be seen, in one part of the vesicle, a dark, round spot." In this way he found it in mammals, birds, scaly amphibia, carti- laginous fishes, arachnoids, certain crustaceans, all molluscs, concha- ceans, echinoderms, medusans, and polyps. Upon a more minute examination, under still higher powers, there is seen a compressed orbicular stratum, of a lenticular shape, composed of minute mole- cules, closely agglutinated in form of an acervulus, &c. &c. This granulous germinal stratum appears to be the true living animal germ, existing antecedently to the act of impregnation. Hoc stratum granulosum germinativum, germen animale verum et vivum jam ante preegnationem praeformatum esse videtur. Having now laid before the student this account of the ovary, I shall annex a copy of Mr. Coste's magnified view of the ovarium from his grand atlas. In that superb plate the figure is ten inches in Fis. 48. its greatest diameter. Mr. Gihon has reduced it to this size. It was necessary to make it not more than four inches in diameter. Mr. Coste's intention was not merely to exhibit the shape of the ovary greatly magnified, but to show the internal structure of it, and the various progress of the ovarian ova in their ovi-capsules, during their THE OVARIES. 103 maturation, and the dehiscence and discharge of the follicles. It is the left ovarium that is represented. The expanded fimbria p, of the Fallopian tube p> is seen at the lower and right extremity of the draw- ing. Near this angle is seen a Graafian follicle v, the dehiscence or rupture of which has allowed a yelk, surrounded by its proligerous disc or cumulus, to escape. The opening has taken place through the tunica albuginea and the peritoneal coat, and the ovule marked ce, is still resting upon the exterior surface. Just above it is seen an- other less mature vesicle v, and a still smaller one above that — while farther to the left is a very small one. The line of incision passes near its lower angle across a pretty large and superficial follicle, one- half of which is seen through the coats of the ovary, and the other half quite uncovered by the dissection which has laid the organ open to view. To the right and upwards from this point is seen an emptied Graafian cell v, in which e is the outer surface of the whole cell. At v is the point of dehiscence, through which the egg escaped. This Graafian cell consisted of two coats or membranes, one contained w r ithin the other. The broken lacinise of the double ovisac are seen at the upper end near the margin of dehiscence, where they are marked g and i. These two coats are better represented in the fol- licle at the upper and left extremity of the cut — in which their floating and distinct membranes are seen at e and at i, whereas g indicates the granular deposits upon the inside of the follicle, which is called the tunica granulosa — or granular membrane. This granular mem- brane is so little tenacious, that upon puncturing and compressing a cell, it flows out with the water, and appears upon the microscope as a collection of innumerable grains, that are probably cytoblasts. Very near the superficial segment of this ovarian ovisac is seen the ovulum enclosed within its proligerous cumulus. In order that the student may here have a more complete idea of the ovary, I repeat the figure of the human egg, taken from Rudolph Wagner's Pro- Fi s- 49 - dromus Histor. Generationis, in which is seen the pellucid ring surrounding and enclosing a quantity of yelk corpuscles, among which, near the top, rests a trans- parent vesicle with a dark spot upon it. The pellucid ring is the zona pellucida of the egg, outside of which is a quantity of granular membrane that always comes out of the Graafian follicle sticking to the zone. It is necessary to remark that this 104 THE OVARIES. figure is greatly magnified, for a very strong sight is required to enable any one to see without a lens the egglet, whose diameter is but the twentieth of a Paris line. The grains inside of the pellucid zone are grains of yelk — or vitellary corpuscles. They are yelk, true yelk, like that of the bird's egg. The oval transparent vesicle within them is the germinal vesicle, and the dark spot upon that vesicle is the macula germinativa — tache embryonaire — or germinal spot. If the student will look upon the germinal spot as the nucleolus, the germinal vesicle as the nucleus, and the vitellary membrane as the cell, he will have an idea of a true independent cell, possessing the metabolic and plastic forces that can enable it to develop itself wherever the proper cytoblastema, or pabulum, is afforded to it for that purpose — i. e. in the ovary, the tube, the abdomen or the womb. The production within the ovary, of an ovum containing within it a germ possessing the power of evolution solely in the direction and dimensions of its own genus and species, is one of the most mysterious and wonderful works of God : one well fitted to overwhelm the mind with astonishment, and to make us feel amazed at the vastness and the indispensableness of those forces that are communicated by a Divine power to the simple and microscopic elements of the macula germinativa. Burdach, in his Physiology, t. i. 87, speaking of the tubular ovary, in which the materials of yelks are secreted in the cavity of the ovaries, in order to become ova, presumes this to be the mode in which ova are formed in all the insects, in most of the inferior crusta- ceans, in worms, and in certain mollusks. "Moreover, 5 ' says he, "there is not the least doubt that the substances of which the es^ is coin- posed, acquiring through the influence of the ovary their aptitude for a more elevated range of life, or already possessing it, tend partly also of themselves to take on a determinate form." Is it a new creature that is formed out of the macula germinativa: is a question that has often been asked; or is it a propagation and continuation of the old or parent substance? M. Huschke proposes that the ovary is an aciniferous organ, and that the germs of the off- spring are acini, which, under a physiological law, become decidu- ous, but carry away in their fall the vitality and accompanying forces that enable them to continue, after their separation, the career of Existence and Development. I do not feel myself competent to speak with authority upon this proposition: I shall only state, that very nu- merous and careful microscopic examinations of the ovarian stroma have not exhibited to me the evidences of the aciniferous nature of THE CORPUS LUTEUM. 105 that substance, wherefore I am the more inclined to adopt the opinion of the cytoblast character of the germ point. The Corpus Luteum. — Before I conclude my remarks upon the ovary, I ought to say something on the subject of the corpus luteum, a topic that has elicited an immense amount of discussion, and which still remains a vexata questio. Perhaps the principal interest that society has in the settlement of this question is one of a medico-legal nature; for although inquiries in this direction, of a medico-legal character, have not, so far as I am aware, led to any judicial deci- sions, I can conceive that important rights and interests might depend before a tribunal upon the views to be held as to the nature and inter- pretation of that singular product. The corpus luteum or yellow body is a peculiar substance found in the ovaries of animals that have lately passed through the rutting season, and in women that have lately been affected with their men- strua, or that have become pregnant. In some pregnant women the corpus luteum is either very small, or not readily discernible. In others lg " it attains a large size. In the cow, J0^^^\ the corpus luteum (vide Fig. 50) is /^^K()Y\m^k sometimes half as large as the ovary, iffy; ^wyMw^X Kill ( '//''•' ■ "?> n^™— ~^_ It has been regarded as a sure sign ^f|jjjV/'^^ ; ;:::V'',V. ■'■"'•XU^Mji^^-^ of fecundation. I regard it as a sign ^JlBlM ^ l) })Jljlil 0'^^ of a finished ovulation. On the 18th December, 1846, I made to the American Philosophi- cal Society a verbal communication, setting forth certain views I had entertained as to the vitellary nature of the corpus luteum ; and on the 15th January I read a memoir upon the subject, which was pub- lished in the Transactions, 1847, p. 131. In that communication I stated that, since the date of my first verbal memoir, I had carefully made researches both with my Chevallier's microscope and by other methods, as to the comparative appearances of vitellary matter taken from the egg, and matter procured from fresh corpora lutea. These renewed researches leave me very fully convinced that the yelk of eggs and the yellow matter found in a corpus luteum, are of the same apparent structure, form, color, odor, coagulability, and re- fractive power. Having placed a small quantity of yelk on the platine, and just before I had brought the object into the focus, I have been struck 106 THE CORPUS LUTEUM. with the appearance of the transmitted light; a bright-yellow, which fills the whole tube of the instrument. When I have, in like manner, placed a bit of fresh corpus luteum, of the cow or sheep, on the compressor, and have crushed it, by- turning the screw, I have found the tube filled with the same tinted light, before obtaining the focus. A portion of yelk placed beneath the objective, exhibits numerous granules, corpuscles containing a yellow fluid, and oil-globules, mixed with a quantity of punctiform bodies. Upon turning the screw of the compressor on a small lump of cor- pus luteum, carefully dissected out from its indusium, there is seen to escape from the crushed mass a quantity of granules, corpuscles filled with yellow fluid, oil-globules, and punctiform bodies swimming in a pellucid liquor. The appearances observed upon examining a portion of yelk and a portion of corpus luteum, are so similar that it would be difficult, I think, to discriminate between them, but for the exception, that along with the vitellary corpuscles and granules and globules of the yellow body, there will be found floes of laminated cellular tela, blood-discs, and other detritus of the organ, destroyed by the compressor. The transparent corpuscles transmit a yellow light, whether ob- served singly, or in clusters, or acervuli. The same is true of the corpuscles of the yelk. On crushing a bit of corpus luteum with the compressorium, there escapes much granular matter that accurately resembles the granules of the granular membrane, the proligerous disc or retinacula of the Graafian follicle. This is the case when great precaution has been used in procuring the bit from the outer superficies of the corpus lu- teum ; avoiding to take any portion that might have touched the inner superficies of the crypt left by the escape of the ovulum. The similarity in the appearance leads me to suppose an identity of nature and origin. I think no person accustomed to the use of the microscope could detect any difference between the molecules pressed out of a bit of corpus luteum, and those that escape from a crushed mammiferous ovule, or the yelk of an egg, excepting the debris or detritus before mentioned, which is plainly referable to the destructive power of the compressorium. I have so many times examined the mammiferous ovulum that I suppose myself quite competent to compare its contents with those of the corpus luteum, and with common yelk. THE CORPUS LUTEUM. 107 I hope I am entitled to say, that the coloring matter and the chief constituent bulk of a corpus luteum, is a true vitellary matter, deposited outside of the inner concentric spherule, or ovisac of the Graafian follicle. For the proof of the truth of this opinion I refer to the future ob- servations of the micrographers, who will be able to confirm or to confute my statement. There is not, so far as I know, any author who has taken this view of the constitution of the corpus luteum — though that substance has been the fruitful topic of elaborate research and hypothesis, owing to the interest connected with it both in a physiological and medico- legal relation. Previous to the year 1825, when John Evangelista Purkinje fortu- nately discovered the germinal vesicle of the unfecundated egg; and down to the year 1827, when Ch. Em. V. Baer detected the mammal ovum, whose germinal vesicle was detected by Coste; and the year 1830, when Rudolph Wagner ascertained the existence of the Keim- schicht, or macula germinativa, all notions and opinions on the mammal ovum may be set down as naught — since the opinions of the learned are now based on the discoveries just mentioned, which have led to a complete revolution in many most important constructions of physio- logical action, and therapeutical indication and treatment. It would be bootless, therefore, to ask what the writers of an earlier date than 1825 may have supposed upon the subject of the corpus luteum. Dr. Carpenter, John Miiller, Thomas Schwann, Henle, and Huschke have not hinted at the vitellary nature of the yellow body. Dr. Henle, in his Algemeine Anatomie, says, " So weiss mann namentlich, wie die Grafschen Blaschen, in folge der congestion welche den fruchtbaren beischlaf folgt, erst anschwellen und den platzen, wahrend sie zugleich von Blutt angefullt werden, welches sie almah- lig entfarbt, organisirt, und in eine narbensubstanz verwandelt, die zuleszt verschwindet." — P. 894. In this paragraph, Dr. Henle attributes the swelling and the burst- ing of the Graafian follicle to the congestion attending a fecundation. He says the ruptured cell is filled with blood, which colors it, becomes organized, converted into a scar-like substance, and then, at length, disappears. Dr. Huschke, in his Treatise on Splanchnology, elaborately details the opinions of authors on the corpus luteum ; but nowhere alludes to the vitellary nature of that body. 10S THE CORPUS LUTEUM. Dr. Gendrin, M. Maygrier, Dr. Robe:: Lee. Wharton Jones, M. Raciborski, Olivier D' Angers, M. Pouchet, make no mention of it — though they all enter into details, Dr. Montgomery, Dr. Swan, and, I think, Dr. P Prison, speak not of it. M. Flourens, and Iff. Velpeau, and Dr. Moreau, omit all allusion to the vitellary structure of the substance. Bernhardt, who was assisted in the construction of his Symbolxe ad ovi Mam. Hist, ante PrcEgnationem, by Dr. Valentin, in which ad- mired work is contained a complete deduction of the whole literature of the corpus luteum, alludes not to the idea. Von Baer's celebrated letter, De Ovi Mam. et Hominis Genesi, says of the corpus luteum. a: page 20, "Me judice, minime corpus novum est, sed stratum internum thecae majus evolutum" — which expresses. with sufficient clearness, the opinions set forth in the rest of his para- graph. Dr. Bischoff, of Heidelberg formerly, now of Giessen, in his Ent- wickelungsges chide der Saugthiere und des Menschen, says, at pasre 33 : " Wenn mann die erste entwickelune des gelben Korpers, unmittel- bar nach austritt des eies, bei Thieren beobachtet hat, so kann mann dariiber nicht in zweifel seyn, dass die bildung seiner masse von den innern flache des Graafschens Blaschens ausgeht. Da sie nun hier die aus zellen gebildete memJbrana granulosa befindet, da sir zuers: als gelber Korper erkennbarre masse gleichfalls aus zellen besteht, so ist es wohl gewiss, das von einer starkeren entwickeluns: dieser zeHen der membrana granulosa, die ich auch in der Periphaerie des eies noch nachweisen werde, die bildung des gelben Korpers ausgeht." From this passage, it seems that Dr. Bischoff is not far from dis- covering what I suppose myself to have discovered ; I mean the vitel- lary nature of the yellow body of the ovary. It appears needless to make any further citation in this place. I shall here offer the remark, that if the concave superficies of the ovisac, or inner concentric, is really charged with the office :f pro- ducing or excreting the vitellary matter of the ovulum, which musl be admitted, even if we allow to that body the metabolic and plastic cell- force, (for it must, at least, be the producer of the cytoblastem of the cell,) there is no very great difficulty in admitting that the convex or exterior superficies of the same membrane may exercise the same functions as a dominant of its elective affinities; which must be sup- posed of every vital excrete. THE CORPUS LUTEUM. 109 And such a supposition finds abundant support in the analogy of the organs ; as in the periosteal and medullary membranes of bones, for example ; which, under certain circumstances, are known to alter- nate their functional force ; the medullary membrane coming to be a depositor of phosphate of lime, instead of a remover ; and the periosteum a remover, instead of being a depositor of phosphate, which is its normal office. This mutation of powers, as to the mem- branes of bone, has so clearly been described by M. Flourens, in his admirable paper on the production of bone and teeth, in the Annates du Museum, that it needs no comment. But I am far from claiming this illustration for my view of the case, strong as I might deem it to be. It suffices better for me to know that vitellary matter is germinal matter, germinal cytoblastem ; and that the business of an ovary is to produce it ; and nothing else in nature can do it. As to the microscopic results at which I have arrived, I have no- thing more to do than tender them to the micrographers ; and I should feel most happy if these remarks, meeting the eyes of Dr. BischofF, or my kind friend, Dr. Pouchet, those gentlemen should deem them worthy of their attention, and confirmation or refutation. If they prove to be unfounded, I wish them to be confuted by better observers than I am. As to some other points of resemblance between yelk and corpus luteum, I have now to observe, that boiled corpus luteum becomes hardened, like yelk boiled hard. It is, in like manner, friable and granular, leaving a yellow stain on paper, like the stain from boiled yelk. Dr. Thomas Schwann found it evidently coagulated, granular, and friable, upon being boiled. In order to ascertain its odor, I threw a portion of corpus luteum on a live coal; — it gave out a strong odor of roasted eggs. Are the granules and corpuscles of the corpus luteum cytoblasts and cells ? I have not been able so clearly to make out their nuclei as to speak positively — I suppose them to be so. But Schwann, himself, who in one place seems to regard the nucleus as a sine qua non in cell-life, says, at page 204 of that most admirable and extraordinary volume the Microscopische Untersuchungen : "Die kernloser zellen, oder richtiger ausgedruckt, die zellen, in de- nen bisjetzt noch keine kerne beobachtet werden sind, kommen nur bei neideren pflanzen vor, und sind auch bei Thieren selten." Non- 110 THE CORPUS LUTEUM. nucleated cells, or, more correctly speaking, cells in which nuclei have not as yet been detected, are found in the lower vegetables, and are also rare in animals. And he cites, as examples of the non-nucleated cell, the young cells within the old cells of the chorda dorsalis, the cells of the yelk of the bird's egg, &c. &c. Be the non-nucleated vesicle a cell or not, it is very certain that the milk corpuscle, and, probably, the chyle corpuscle, are of that nature, — and no one can contemplate the amazing reproductive power of a cell or spore of the saccharomyces cerevisiae, without admitting for it all the properties of the cell-force. It is to the last degree reproduct- ive, as are also many of the filiform fungi, the muscardine, &c. The question at last is, whether I have made a discovery interest- ing to the physiologist, the practitioner, and the jurisconsult. If I am right in my opinions, it must be interesting. As a resume, I say that my views are based upon the fact that — 1. Equal masses of yelk and corpus luteum are equally yellow. 2. They alike fill the tube, before the focus is got, with a brilliant yellow light. 3. They alike consist of a pellucid fluid, in which float granules, corpuscles containing yellow fluid, oil-globules, and punctiform bodies. 4. These bodies, placed on the same platine, and diligently com- pared together, exhibit the same forms, size, tint, and refractive power. 5. Yelk, boiled hard, is granular and friable ; it is coagulated by heat. 6. Corpus luteum, boiled, becomes hard, granular, and friable — it is coagulated by heat. 7. Both substances, raw or boiled, stain paper alike of a yellow color. This experiment was repeated after Bernhardt, who says, " Cujus pigmentum aurantiacum (cor. lut.), admotis digitis adhseres- cebat."— P. 39. 8. There is this difference : — The crushed mass of corpus luteum contains patches of laminar cellular tela, detritus, and blood-discs, forced out by the compressorium; which cannot occur in the yelk, as that is contained within a vitellary membrane, in which its corpuscles are free ; whereas, in the corpus luteum, they are confined by the deli- cate cellular substance lying betwixt the concentric laminae of the Graafian follicle. 9. They refract alike. 10. Projected on a live coal, they alike give out the odor of roasted eggs. THE CORPUS LUTEUM. Ill While I, of course, derive this view from perceptions of my own senses only, I ought perhaps to take leave of it here, committing it to more capable observers, in order to know whether they perceive it as I do. But, while I suppose that farther observations may probably con- firm my views, I see no objection why I may not now offer some re- marks, in the way of a rationale, upon the point in question, the more particularly, as I hitherto have relied only upon my own observations. I therefore state, that all living beings are results of the operation of a reproductive or generative force. This is true both as to plants and animals; with the possible ex- ception of certain fissiparous and gemmiparous creatures, as well as of certain sporiferous fungi, and some creatures of a higher scale, as the nais proboscidea, &c. I say of these, that they constitute a possible exception to the law of reproduction by germs. I do not say they are exceptions. This reproductive force has the same relation to the conservation of the vegetable and animal genera, as the force of attraction has to the conservation of the brute masses of matter of the universe. For it is obvious that, but for this force, all the genera would die out in a single generation, and yet it is apparent that nothing is more permanent than the genera, which extend from age to age, touching the beginning, the whole course, and the end of time. All the existing genera are the same to-day as at the commencement of the present cosmic career, and are destined to be so until the next great cataclysm of the globe. M. Flourens, in his work on generation, makes use of the mot, the saying, un etre collectif, a collective being, in speaking of the immutable permanence of a genus. This fine saying leads the mind at once to a view of the importance of the law of genesis by which so great an end is attained. It would, perhaps, be superfluous to say that, but for the exercise of this force, all morals would be nullified, and blotted out of the great scheme of Providence ; for, should the genera fail or die out, the earth would become a desert; no flowers to bloom, no corn, nor wine, nor oil — no insect to sport in the sunbeam — no song of birds — no lowing of cattle — no voice of man to acknowledge, and praise, and give thanks to the Giver of every good and perfect gift. Thus the whole scheme of morals would cease and be terminated, leaving no witness here to the power of God, beyond the senseless play of the elective and gravitating attractions. Is it not clear, then, that the laws of this great conservative force 112 THE CORPUS LUTEUM. must be most important laws? Can such great forces have little or no concern with the regulation and co-ordination of the other life forces? I repeat, that for life they have the same importance as ap- pertains to the laws of attraction for the physical bodies of the globe. This force is the true development force, not only for the germ, but for the embryo, the fcetus, the child, the youth, and the man. He who shall know it truly, shall know the laws of life. It is not only a genetic, but a generic force. It determines the form and dimensions of the genera in an interminable succession of ages. No horrid passion, no wild lust, no insane desire can contravene the irreversible law of the distinction of the species and genera — "each after its own kind," — which, but for its provisions, would rush into chaotic confusion and mixture — whereas they are, in truth, trenchantly divided, and set apart, and for ever maintained, pure and unmixed. This force — this amazing force, is concentrated and summed up in a special animal or vegetable tissue. Nothing in animals, save a vitelliferous tissue, can yield or give out this force. It is the endow- ment of the ovarian stroma. It is the peculiar life-property of that concrete, and of nothing else. The stroma (Lager) of ovaries is a tissue developed and sustained by the combined agency of a spermatic or ovarian artery, and a sper- matic nerve. The spermatic nerves possess an intimate plexus and ganglionic relation to the spinal, the sympathetic, and the splanchnic systems of innervation — so that they are related, in fact, to all the organisms. Under the dominant indicative influence of the spermatic nerve, the ovaric artery, by its branches and termini, deposits the materials of the concrete of the stroma, with all its parts and mechanism. The general relation of the ovary to the whole of the innervations, while it enables it largely to influence them all, renders it liable to disturbance by their derangements. Its great influence is exhibited in pronouncing the single word sex, for the ovary is the sex of the woman, or the female. But if the ovary be her sex, then the whole peculiar physical, moral, and intellectual character of the female are derived from it, as their source and dominant — they are conformed to its wants, its powers, its offices — and often modified by its conditions. The materials of development for all the organs are derived from the blood, which may, without violent misapplication of the metaphor, be said to exist in a multilocular cyst, of which the cellulse are the different sanguiferous tubes and cavities of the vascular system. It is everywhere the same, and presents in each of the organs the same THE CORPUS LUTEUM. 113 liquor sanguinis, and discs — so that although all development is at the expense of the blood, yet there is an additional, esoteric nerve- force, to compel the elective attractions by which every living concrete is produced. The physiologist knows that this esoteric force is nerve-force — and he will not deny that, for the development of both a general and spe- cial anatomic structure, it must possess what I desire to characterize as a generic force, else all development would be in spherical forms, and of the same constituent elements. No power can so modify the generic force of the nerves and blood- vessels of the cephalic extremity of the inchoate embryotrophe as to protrude from it a pelvis or a foot. Nor could a leg be possibly deve- loped in the place of a prehensile limb. Even in the quadrumana the law holds good. A liver whose development depends on its nutritious artery and its nerves, could by no means be formed at the caudal or cephalic pole of a mammal. It must always have its central position. No exam- ples will be found of a lung placed below the diaphragm. Hence, I say, the law of generic development is a law applicable not to the creature only as a whole, but to each of its several constituent parts. The whole business of zoological classification depends upon this order. This law not only operates during the embryonal, the foetal and the puberic development, but is in force throughout the whole duration of life, perpetually repairing the organs, and maintaining their generic forms, against the waste and detritus of life, until the cessation of life. The membrana germinativa of the ovum, which is probably R. Wagner's macula, (Keimschicht,) is an elliptical or circular disc. Let me repeat what I just now said, that no power could determine the production of the pelvic at the cephalic, or the cephalic at its pel- vic segment ; nor a leg from the thoracic, or of an arm from the iliac region of the disc. Hence it is true to say, that such disc is endowed at different parts of it with a generic force, operative only in that one sole direction. I say generic, since the idea is applicable to all ani- mals whatever, and to all the parts of animals. My motive for making the foregoing remarks is, that they might serve as an induction or basis, as to the generic force of ovaries. An ovary is developed by an ovaric arterial trunk and its branches,, drawing the vital current from the aorta or the emulgent, and attended by the spermatic nerves, which I regard as reproductive nerves, and generic in their powers. 8 114 THE CORPUS LUTEUM. I say reproductive nerves, since their innervative force is devoted to the evolution of germs : no other nerve has such a mission : I say- germs — perhaps I ought to say cytoblastem. If Huschke's pretty idea, that each Graafian follicle is a cast-off acinus of the stroma, carrying away in its fall an endowment of vital force rendered complete by active fecundation, should prove to be well-founded, I see no escape from the attribution of this reproductive quality to the spermatic nerve. But, without discussing the question of the aciniferous nature of the stroma, the same attribution of the nerve-power is right, even under the hypothesis of an independent cell-life — for a reproductive cell could not exist but for the vitellary cytoblastem provided by the stroma, which is a vitelliferous tissue, and only that. Nothing else is so. The nature of the cytoblastem must determine the differences of cells. The cell of an oak germ is different from the cell of a cab- bage germ, nor have they the same cytoblastem. But the sole office of an ovary is to produce or prepare germs — it is germiferous; and it is so by its power to form vitellary matter. No other combination or arrangement of animal materials can produce yelk or vitellus. The complete germ is contained within a vitellary membrane — which is the boundary of the yelk. In the mammals this yelk is microscopic. In the ostrich and the cassowary it is a very large ball, as it is in some of the larger ophidians, as in the coluber boseformis, &c. The matured germ contained within a yelk is spontaneously and periodically extruded from the ovary, in order that it may be fairly exposed to the contact of the malefecundative element — which should be deemed impossible while it is buried within the recesses of the ovarium, covered by the double tunic of the follicle, and beneath both the fibrous and peritoneal indusium of the organ. To effect this extrusion, this spontaneous oviposit, the inner con- centric spherule of the follicle is compressed, by the deposition on its external convex surface, of yelk grains, corpuscles, oil-globules, punctiform bodies, and pellucid fluid — the beginnings of the corpus luteum — which gives to the concave surface of the cell an appearance of corrugations or convolutions like those of the brain, and which, as they daily increase by the continued deposit of yelk matter on the exterior, constantly reduce the size of the interior dimensions of the follicle, urging its contents towards the least resisting point of the surface of the ovary, until, at length, the porule being opened, by the THE CORPUS LUTEUM. 115 dehiscence of the coverings or capsule, the ovulum escapes into the fimbria, or falls with the peritoneal sac. After the escape of the ovulum, the yelk-producing force is not ex- hausted immediately, in all cases ; hence the growth of the corpus luteum continues for a time whose limit is not yet known. It is a periodical exacerbation of biotic force, that matures and bursts the Graafian cell. When the process of completing a germ and expelling it has been finished, the exacerbation ceases sooner or later, and a new periodical exacerbation of this strange life-force — or germ-producing force — is devoted to the maturation and spontaneous oviposit of another ovulum, and so on in succession, during the men- struating life of the woman; at every successive pairing season of birds; and at the annual rutting time of the more considerable mam- mals, and in all the migratory fishes at stated times. It surprises me to see that many able and distinguished writers still cling to the antiquated notions as to the ovaric fecundation, which M. Pouchet has shown to be an impossibility. It appears to me that my view of the vitellary composition of the corpus luteum, and the mechanical result of its accumulation in effecting the oviposit, ought to be received as satisfactory rationale of the germ-depositing func- tion. The fecundation of germs is a mystery which I deem beyond human cognition — and likely ever to remain so. The inquiry into the corpus luteum is far more feasible and practicable. No woman can menstruate but coincidently with, and in consequence of, the oviposit. Every oviposit is followed by a corpus luteum, which is larger or smaller, according to circumstances. Many women have scarce dis- cernible ones after conception — others have very large ones. The true and false corpora lutea differ only in magnitude — not in their essential nature. PART II. THE PHYSIOLOGY OF REPRODUCTION. CHAPTER VI. MENSTRUATION. Women are subject to a discharge of blood from the genitalia, which returns very regularly once a month. This monthly periodicity of the bleeding has given it, among many people and languages, the name of menses — menstrua, menstruation, catamenia, mois, monat- liche, menstruacion, mese, &c. Among us, it is called courses — periods, terms, monthlies, monthly sickness, unwell, times, and a variety of other names, hints, and allusions, that need not be summed up here. The discharge is not met with in children, in unmarriageable girls, nor in old women. It appertains to women only as long as they are capable of conceiving. They cease to be child-bearers when they cease to enjoy the power of menstruation. The first appearance of it is noticed among us at fifteen, but many are found to produce it at fourteen years, and some at thirteen and a-half years of age. In general women have ceased to menstruate after they have passed their forty-fifth year — yet there are vast num- bers who continue to be menstrual until they attain the age of fifty years. It is rare for a healthy woman to cease menstruating before she is forty years old ; some, however, cease at thirty-six. I said that the catamenial discharge is blood. It amounts to from four to six fluidounces of blood at each term. This is the rule — the exceptions are, that some women do not eliminate more than one or two ounces each time, and that others never lose less than ten or even sixteen ounces of blood. For the most part, as soon as the menses are perceived to begin to flow, the woman applies a T-bandage, consisting of a napkin, called the guard, folded like a cravat, which is pressed against the genitalia, while the ends are secured to a string or riband tied around the body above the hips; but I have seen some, not a few women, who assured me they had never used any other precaution than that of putting on a MENSTRUATION. 117 thicker petticoat for fear of the exposure of their state. Such persons can be very slightly hemorrhagic, since the want of a guard-napkin would be sure to expose their condition by stains of blood upon their feet or stockings. Many female patients have assured me they never use less than a dozen napkins upon each catamenial occasion — and fifteen, and even twenty such changes are not very rare in the history of healthy menstruations. An ounce to a napkin is not an excessive computation. Perhaps the student will acquire the justest idea of the ordinary quantity, by settling it in his mind, that four to six ounces is the most common rate for each normal menstruation. It seems to be a very indifferent matter for the health of women, whether they menstruate freely or not, provided each one is regulated by the habits, wants and normal forces of her own economy. Each female in menstruating obeys the law of her own special sys- tem, and not that of another woman's system; hence, if she habitually loses four ounces, and is well, no attempt ought to be made to aug- ment the amount of the discharge ; since her four ounces are what she requires, and not twelve ounces. On the other hand, one who has for years lost twelve ounces at each menstrual return, might be deemed sick, in case she should dispense four ounces and no more. Each catamenial period continues from three to five days ; so that the subject is not free from it more than from twenty-three to twenty- five days at a time ; and there are many examples to be met with in which the period of its duration is not less than seven or eight days for each menstruation. In the duration of the flow, as well as in the number of fluidounces discharged, each woman obeys a law of her own nature, and if that be fulfilled, her health is good, as to the duration. The young phy- sician should not, therefore, feel constrained to take in hand a case, because the number of menstruating days of his patient might be less than that of some other woman. Much disputation has attended the investigation of the menstrua. Some writers aver that the discharge is a secretion, and not an effu- sion or hemorrhage — some declaring it to come from the veins, and others from the arteries of the uterus. At present, these disputes ap- pear to be at an end. The valuable researches of Purkinje, Coste, Von Baer, Pouchet, Negrier, Bischoff, and others, have rendered it clear that the catamenial fluid is blood. Blood cannot be secreted. I am aware that the Student of Medicine, I mean the younger sort, will be apt to find himself, here, in a sea of doubts and perplexities 118 MENSTRUATION. arising from his respect for authors ; for he will have studied some of the older books, from which he will have derived notions difficult to eradicate from a young mind, in which they have taken deep root. Let him refer to the article on the ovaria, where he will find, that all that has been said upon the nature and causes of menstruation prior to the year 1825, is nonsense ; and that our real information began to acquire some philosophical certitude from the moment of the discovery of Purkinje's vesicle, which cast so bright a dawn upon the nature and laws of reproduction ; and that, by the labors of physi- ologists and naturalists since the said date, 1825, our dawn has grown to be a great shining light, under which things are clearly seen and understood, that were formerly wholly unknown or imperfectly com- prehended. In this department, then, let the student turn to the moderns. It will be proper for him, in a more advanced scholarship, to learn what our predecessors erroneously deemed of this matter. I repeat, then, that the menstrual fluid is blood ; but it is impure blood — it is impure only from the admixture of a quantity of mucus and epithelial scales. It is rich in blood-globules, and in serum ; and when it is abundant, hurrying itself from within the genital cavities, it is nearly pure blood. On the contrary, when it oozes slowly and tardily away, resting, perhaps, a long time in the cavity of the vagina, before the sphincter vaginae allows it to escape, it becomes slimy from the plen- tiful addition of mucus to it. This is especially the case in such as have a vaginal leucorrhcea, or in those who have the albuminous leu- corrhoea that is produced from the crypts and glandules of the canal of the neck of the womb. The beautiful engravings given to us by M. Pouchet in the Atlas of his Theorie Positive, are, doubtless, absolute faithful representa- tions of the microscopic view of the menstrual fluid. They ought to be conclusive in settling our opinions as to the nature of the genital discharge, not in women alone, but in various animals of the mam- miferous quadrupeds. It is not in every one of the older authors that erroneous notions are to be met with as to the quality of the menstrual discharge. To cite one distinguished example — Haller says: "Sanguis men- struus de sana, neque immunda foemina, rubore, calore, odoris ab- sentia, nihil ab alterius fceminae sanguine differt. Lentorem aliquem possit mucus admistus addidisse." — Physiologia, lib. 28, sect. 3. I may add here that Madame Boivin, whose knowledge of the MENSTRUATION. 119 whole topic is not inferior, perhaps, to that of any other writer, de- clares that it is blood like that from a vein. She says : — "La qualite du sang des menstrues, ne parait pas different de celui qui circule dans tout le systeme, lorsque la femme est saine, bien conforrnee, et qu'elle fait usage des moyens que la sante et la pro- prete exigent.'' — Mad. Boivin, Art. des Ace, 105. The few opportunities I have had of observing the appearances of the catamenial fluid, have been insufficient to enable me to come to positive conclusions: since healthy women admit of no such investiga- tion; and the morbid specimens, which are the only ones submitted to us, are not to be considered as samples of what flows naturally. Madame Boivin's account is, therefore, more worthy to be relied upon than that of any physician whatever. Madame B. can speak of the normal, and the medical man can only have access to the observation of an abnormal state or character of the discharge. The Student will pay greater respect to facts in making up his opinions than to any man's opinions. He is aware of the constitu- tion of healthy blood, whose analysis is in one thousand parts — Corpuscles ----- 127 Albumen 80 Fibrine 3 Water 790 1000 If such be the true results of analysis of the blood, and I take it that it is so, then let the Student compare it with the analysis of the fluid discharged by women in menstruation. M. Brierre de Boismont, in his work on menstruation, at p. 172, gives this analysis by Denis, of the menstrous fluid of a healthy per- son, aged twenty-seven years : Water 825.00 Globules 64.40 Albumen 48.30 Extractive matter - - - 1.10 Fatty " 3.90 Saline " 12.00 Mucous " - 45.30 1000.00 120 MENSTRUATION. Rindskopf (Simon's Chemistry of Man, 337), found the menstrual fluid to be acid, and composed of Water - 820.830 Solid residue - 179.170 Salts 10.150 In a second analysis, he found Water - 822.892 Albumen and hsemato- globulin 156.457 Extractive matter and salts 20.651 •anz Simon's Analysis was — Water - 785.000 Solid constituents - 215.000 Fat 2.580 Albumen 76.540 Hsemato-globulin 120.400 Extractive and salts 8.600 Dr. Letheby [London Lancet, May 2d, 1845), made an analysis of fluid detained by an imperforate hymen. It consisted of — Water 857.4 Solid constituents - 142.6 Fat 5.3 Albumen - 69.4 Globules ... 49.1 Hsematin - 2.9 Salts - 8.0 Extractive - - - 6.7 These analyses, I hope, may serve to convince the Student that the menstrual fluid is produced by effusion or extravasation, or hemor- rhage, and not by an act of secretion. There can be no analogy be- tween an act of secretion like that of the liver, kidney, or salivary gland, and a clear outflowing of pure blood of the capillary vessels, or other tubes that afford the outlets for such discharge. I repeat that there can be no blood secreted. The cause of menstruation is now, nearly on all hands, admitted to exist in the ovaries, and to be connected directly with the periodical evolution and discharge of the mature ovulum, a process denominated ovulation. When a woman's body, who has perished while menstruating, or MENSTRUATION. 121 soon after the performance of that act, is examined by the anatomist, he always finds upon the surface of one of the ovaries, a small bloody spot ; sometimes as large as the head of a very small pin, and some- times larger or smaller. If a delicate probe be pressed upon this bloody point it sinks into the ovary, the point descending into a cavity which contains a minute clot of blood. This cavity is the emptied Graafian vesicle, from which the ovulum has made its escape by pass- ing out through the bloody pore in the ovarium. The ovulum may be supposed to have fallen into the pelvis, where it is not to be seen, on account of its minuteness — being invisible to the naked eye. Its presence in the pelvis could not do any harm, if it were not fecun- dated. Perhaps, if it were fecundated, it might be discovered, by slitting up the Fallopian tube, in the canal of the tube, or it might be traced into the womb itself. The Student can readily find it in the cornu of the sheep's womb. The cut that I subjoin is a good representation of the appearances above mentioned, in the ovaries of a young female, who died eleven days after the commencement of her discharge. As she perished with a violent disease, it is possible that the healing or reparative processes may have been more tardy than they are in a healthy girl. Fig. 51. When the specimen was brought to me, I perceived the porule which had allowed the ovulum to escape, and I inserted a fine probe in it and down to the bottom of the -crypt* The edges of the pore being cleansed, the aperture, it was evident, had been opened by absorption to allow the contents to escape. The whole of the cir- cumjacent tissue was highly injected, as it is always found to be under such circumstances. With a scalpel I made an incision which split the pore, and sunk down to the bottom of the crypt, or emptied cell of de Graaf. In this crypt, I found a clot of blood, which filled it well. 1 i C MKHSJXMIFATIOir. Upon turning one of the flaps over, as in the figure, and after wip- LiiL" tie ine: sniaces tie an. :i: :: in irati:i :: ::: iiii.^ rieniraie ~as vis;:.;. I: ~:--5 :-:iv:ii.ri like tie ::i~"t in: is z: tie iraii: &l: tie seriate is a.i~ its s: ztmiitei. betaise tie iiieints: tnzeitrit ::at ::' tie Gmid: ttiiie is pressei in— a: is tt~ iris tie i:::: ;:' tie spienle. by tie n*"!,; ie: :si: tiat takes place bet— ix: i: aii tie : ate: : : ::. Tie i . : i 5 : i?.s eiiea-trei :: represei: tits appearaise :: :ie etn- ~:i\::i:is: ni hiiLziz- ie ias i:ie it — ei. -.---: i ;:;ii n: if t! T::ri tiat a~ til ei^Ti-iig ::iii repres-eit siti ieitate miii- tatitis ::' init is tie iie: ttities :: :ie : :pi e:-p ie:e ema-rer. T: :i:se ~i: nigit iesi:e :: see :iis appeaiaite as i: reaiy is. I rettnneii ai iis:e::i:i :: :ie :~a.:ies :: tie s:~. :: a :e:e:ei:e ::■ tie ex: lisite ftitrei eir:a~i:t:;s :: Ptitiet: raiit liariv :ie ines 1 : i / : £ : : i ni 7. :■: :ie Atias :: :ie T'.i: ■ Pterin Tie sane tiate, a: iiates 1 aia i\ ttitaiis verv J ist exrressitis :: tie raiaxte :: :ie rentes tipn tie si::i:e tt tie naiii:. :'::ia — irite tie :-iirS itaie tie : r esttee. I:, i "."iiii:e i::i^i.t iae.tb:ee veers siite. tie nteras aii —aria ::' = • :::: ienaie. — i; iiei siiieiiy — iiie neistriatii^;. Ii tiis spetinex I ietettei tie bitoiy p-ttxie Mi tie :ryp: beieati. iiiei — ii:. tie ttariina, Tie ta~ irv ::' tie ":iti ttxtaixe: bitoi :: tie nieises. Let the reader refer again to the cut, Fig. 51, -where he will End, ti: :i tie tin: :~iz~. tie nark t: ai ii:isi:i. I iti :iat iiti- sion upon the centre of a late cicatrix, which I supposed to be the s:a: ::' tie i i s t :: axteteieit neist:xni:i. Tie titatrix — is :::;..- plete, but upon cutting down through it, I came upon the cavity of the crypt, which still contained the remains of the old cloL This old clot had become, in a measure, granular and dryish. There were other cicatrices of still older menstruations ; and I doubt no£ that if the young woman had had during her life forty menstrua- tins, sir bai Lai ::rrv :i:atri:es t: tie vr:ni> ;; nptires :: tie Graafian cells, through which the ova had escaped. I do not mean to assert that an anatomist ought to be able to count, upon the oTaria of a subject, the number of menstruations, by count- ing the scars; for, many of the succeeding ruptures must take place through old scars, thus confounding or blending them together. Vv "i at I wish to express is, the opinion that a woman never does men- struate without rupturing a Graafian follicle and discharging an ovu- lum, and leaving a scar of the opened hila. tnai nav bieei ti:.i tie "■ :::_': as sie xaav bieei i:::i tie MENSTRUATION. 123 lungs, the Schneiderian membrane, or the stomach; but she does not menstruate except she also performs the offices of the periodical ovu- lation. From the foregoing it appears that the doctrine, as to the cause of menstruation, is as follows. 1. Up to the period of puberty, the ovaria do not contain any ma- ture or ripe ovules. 2. At the completion of the puberic age, ovula are matured within the Graafian cells, and the woman continues to mature or ripen them as long as she continues susceptible of impregnation; that is to say, from the attainment of complete puberty, which is generally in the fifteenth year of her age, in this country, until the age of forty-five, or change of life. 3. The ova contained within the Graafian follicles are matured periodically — in women, once a month ; in other animals, at stated intervals; in the larger animals, once a year; or even with still longer intervals, as in the elephant, and creatures that carry the young in the womb more than an entire year. I need only advert to the universality of the law of periodicity as to the evolution or maturation of germs; and I do not find myself called upon to explain why there should be, in the economy of Provi- dence, a law of periodicity for the great purposes of reproduction. It suffices to perceive that it could not have been otherwise, without introducing the greatest disorders among the living creatures under the dominion of that same all-wise Providence. In the vegetable, as in the animal kingdom of Nature, we clearly perceive, on every hand, the wide-spread reign of this law; for we see the forests annually repeating the sexual act upon which their genera depend for a perpetual renewal. The grasses, and flowers, and fruit trees, raise this great annual hymn to show the continued will, power, and beneficence of God ; and the whole of the insect tribes, the worms, the fishes, birds, and mammals, are under a perfect obedience to the same great force. The influence of domesticity has, by Fred. Cuvier, been shown to have a power not dissimilar from the power of civilization, to modify, in some degree, the operation of the reproductive forces. Under this modifying force, we find certain of our domestic quadrupeds and birds to have lessened the duration of their reproductive intervals, but such instances ought not to change our convictions as to the universality, or of the necessity, of this strange periodicity. The modifying power of protection, of abundant and more nutritious food, of habit, &c, 124 MENSTRUATION'. might well be supposed to add a greater vigor to the physical opera- tions of our domestic creatures. There is no denying such influence for those portions of the Human race in which the arts of civiliza- tion, under the protection of wise and beneficent codes of law, permit the human form and forces to acquire their highest perfection. As I have, in my Letters to the Class, treated, at considerable length, upon the evidences of the universality of the reproductive periodicity, I shall not repeat those details in this place, but beg leave to refer the student to Letter XXVIIL, p. 364. I take it for granted, then, that the ovarium has power to mature one Graafian follicle at a time, during which process, the upper seg- ment of the spherule rapidly rises above the surface of the ovary, becomes extremely thin, and finally opens by a delicate pore, through which the ovulum, or little yelk containing the ripened germ, escapes into the pelvis, or is carried down to the womb, after being ingurgi- tated by the infundibulum of the Fallopian tube. 4. During the whole menstrual life of women, extending from the fifteenth to the forty-fifth year of their age, the stroma of the ova- ries, which contains, perhaps, myriads of germ points, r 4 is ripening- many Graafian follicles, and if those that are situated at considerable depths beneath the surface should be examined, we might find our- selves at a loss to know which, of a number of them, would be the first to be fully ripened. As to those that have risen near to the surface, there might be less hesitation to point out the ripest one. They all grow, perhaps, pari passu, during the greater part of the inter-menstrual period, for we discover no signs of extraordinary activity in their evolution, except as the woman approaches the time for being taken unwell. As that time approaches, she exhibits the constitutional and local signs of increased sanguine determination to the organs within the pelvis. She has lum- bar, and sacral, and sur-pubal pain, and fullness or tension, with heat or warmth and weight, all of which symptoms are relieved and car- ried away with the torrent of the menstrual hemorrhage, which is the bloody and external visible sign of the extraordinary vascular and nervous excitement of the internal genitalia. Which of the genitalia ? Is it the uterus, or the ovary, that is the focus of this sanguine tour- billon*! In all ovaries containing mature follicles, whether of woman, or of quadrupeds, that I have examined, I have noticed the undeni- able evidences of increased vascular activity, as seen in the nume- rous arterioles and venules, as well as capillary tubes, in the imme- MENSTRUATION. 125 diate vicinity of the developing follicle. See the wood cut Fig. 48, page 102, copied from Prof. Coste's atlas. These circumstances lead me to the conviction, that the ripening ovulum, in the last days of its progress to perfection, is hurried through its processes by a violent, almost explosive, augmentation of the phy- siological forces resident in the stroma. Such augmentation of biotic activity can come only through the nerves and blood-vessels of the part. But, seeing the potent, nay, the dominant influence upon the whole life-force, of the ovaria, whose stroma is the essence, in physics, of the female sexual nature, what wonder have we when we perceive that influence extending itself to the whole reproductive apparatus, and even to the whole moral and physical being ? Is it not vigorous enough to excite the affluxionor molimen of the monthly hemorrhage? It is the periodical intensity of the ovaric force that, exciting the so- matic energies in general, occasions the phenomena of menstruation. 5. During the last days of the developing of the ovarian ovulum, the vascular circulation and the nervous intensity of the organ are greatly augmented — a state which passes beyond the boundaries of the stroma itself, and being propagated to the uterus and vagina, renders them the seats of a sanguine affluxion and engorgement. Under such circumstances, the uterus increases in weight; it ac- quires a redder hue, is more sensitive, and sinks somewhat lower in the pelvis. From such engorgement and affluxion it is delivered by means of the mensual hemorrhage, which escapes from the vessels on the inner aspect of the womb, falls into the vagina, and thence flows upon the outer surface of the external genitals ; and it is called menses, catamenia, show, &c. &c. It is pure blood, mixed with uterine, tubal, and vaginal mucus, and epithelium. Such is the doctrine of menstruation, a doctrine that resolves itself into one of local plethora or hypersemia, which liberates the physi- cian and the philosopher from the bonds of every ancient prejudice on the subject, and shines upon his therapeutical and chirurgical path with a light so strong and clear, that he need no longer stumble and grope amongst a chaos of vulgar, yet time-honored, opinions and methods. It is difficult for me to imagine that any reasonable person could, after reading the foregoing statement of the doctrine, entertain any the least doubt of its sufficiency or its truth. It has been established by the labors and good fortune of Coste, Negrier, Gendrin, Lee, Jones, Raciborski — and more than all, byPou- chet of Rouen. I am far, however, from withholding the expression 126 MENSTRUATION. of my admiration for the indispensable researches of Purkinje, Von Baer, Wagner, Thomas Schwann and BischofF. It is the doctrine, not of the humble author of this volume, but of the celebrated and honored men whose names I have above recited. The former doctrines of menstruation give us no clear indications of a therapeutical treatment of the disorders so frequently connected with that periodical act. It was foolishness to assign as a cause of the menstrual periodicity an influence of the moon, since observation and experience showed to all inquirers that there is no coincidence of the act with any particular phase of the moon, some women being always to be found just beginning, just concluding, or midway be- tween the periods of monthly evacuation. The doctrine of a general plethora, peculiar to the sex, and required of them as a means to the end of reproductiveness, was easily confuted by the always obvious facts of persons menstruating regularly even when very much reduced by sickness or other causes of oligsemia. The true doctrine was that of a local plethora, or, in other words, a state of periodical hyperemia of the reproductive organs; and now that doctrine is not only established, but it is made plain to the under- standing, for the periodical paroxysm of stromatic force, that hurriedly concludes the ripening of the most perfect ova, establishes the affluxion which fills the capillaries of the reproductive organs, and engorges them, or renders them hyperaBmic to the point of compelling the monthly hemorrhage by which the hyperemia is removed, leaving behind it no trace of indisposition. This admirable exposition, for which we are so greatly indebted to its discoverers, preserves us from the most serious errors in our prac- tice ; while it reveals to us a vast deal of information as to the state and wants of women in whom the catamenia have become disordered, or in whom they have never appeared. Heretofore, physicians have looked to the bloody sign alone as the act; hereafter they will be likely to look upon the maturation and discharge of the ovarian ovule as the physiological act of menstrua- tion, and upon the sanguineous effusion only as the sign that the physiological act has been or is being performed. True menstruation is the regular periodical evolution and expulsion of an ovule; it is ovulation. This act may suffice to cause the wo- man to bleed mensually, or it may prove insufficient to that end. It is, for the most part, a matter of indifference whether it does or does not cause the mensual hemorrhage; the essential thing is to mature and deposit the ovule. MENSTRUATION. 127 There are many circumstances of the menstruating girl or woman that are able to prevent her from bleeding, notwithstanding she enjoys all the other faculties of a perfect health. As to the woman. A married woman who conceives in the womb does not necessarily upon that account cease to mature and deposit her germs. On the contrary, she retains a strong tendency to men- struate up to an advanced period of gestation. Yet, she does not, as a very general rule, discharge the mensual fluid. But, there are many examples of women who do actually retain, in the early months of pregnancy, the power to pour out from the vessels of the womb the usual product of menstruation; an act that leads them to abortion. Probably a woman has a much greater liability to abort at the time of her mensual crises than at any other time; which can only depend upon the occurrence of the catamenial effort under the periodical in- tenseness of the germiferous force. The same is true of the woman who gives suck. A woman with a nursling at the breast does not, in general, men- struate until the child is seven months old ; and thousands of women do not menstruate until they have weaned the child. Yet these wo- men are liable to become pregnant; indeed, there are many who do become pregnant again and again before they have weaned, and be- fore they have had the return. Such facts are proofs of the continu- ance of the germ production in the ovary as well as of the ovulation. As to the young girl. A young female who has been brought up at home, in the country, is rarely sent to a boarding-school to finish her education without soon finding herself the subject of a catamenial derangement. She may have been perfectly regular at home ; but, soon after she takes her place upon the school form, and devotes many hours to study, the menses are apt to be suspended, and to remain suspended until she leaves the school and ceases to consume her nerve-force in those mental or intellectual operations that require for their effectuation all the biotic force she is capable of evolving. The consumption of this force leaves her destitute both of the power and the necessity to discharge the menstrual blood ; not depriving her, however, of the force required to fulfil the true physiological office, the ripening, to wit, and the discharging of her monthly ovulum from the stroma. Her ovulation goes on regularly and she is well, though not visibly menstruous. I have found many young women thus affect- ed ; but, the health being in all other regards perfect, I have not ven- tured to interfere, beyond the interference of recommending a lessened intensity of mental labor, a more abundant and exciting diet, and a 128 MENSTRUATION. proportional amount of daily exercise in the free air. Such amenor- rheas cease as soon as the girl leaves school. The pregnant and the suckling woman do not menstruate because the life-force is fully occupied otherwise — they fulfil the germiferous law — in the same way — the studious and sedentary school girl does not menstruate visibly, because her nervous mass is already pre- occupied. She performs, however, the physiological act of the ovi- ponte — or ovulation. Let the woman miscarry — or wean — and she will soon perceive the visible sanguine sign of her ovi-ponte. Let the over-tasked school girl cease to call upon her nervous mass for impossible sup- plies of biotic force, and her menses will speedily return and be regular in time and in sum ; for her nervous energy is no longer mis- directed and improperly consumed, in studies beyond its supply. It is time to say a few words upon the catamenia as connected with the computation of the commencement of pregnancy. I presume that a woman can not be fecundated except it be coin- cidently with the ovi-ponte. As a rule, then, a woman is liable to become pregnant only at and about the periods of her monthly sickness, and in computing the commencement of pregnancy we shall commit few errors if we begin the count at the day following that on which the flow ceased. Two hundred and eighty days should be allowed as the usual duration of a gestation. One who is regular ought to see every twenty-eighth day. If she sees for three days only, then she ought to be twenty-five days with- out seeing. In what portion of these twenty-five days is it that she is liable to impregnation ? Dr. Pouchet says that the liability extends to twelve days after the drying up of the discharge, and not beyond that time. It is, perhaps, rash to say so; and yet it seems improbable that the ovule should retain its vitality without fecundation, so long as twelve days after its escape from the follicular pore. The Jewish law commands the woman to abstain from the hus- band's bed until she have become clean. She is unclean eight days after the disparition of the last drop. Several Jewish females, having numerous children, have informed me that they have reli- giously observed this law in all their marriage. If these women spoke truly, they give incontrovertible evidence that the fallen ovule retains its fitness for impregnation, not only during the eight days subsequent to the drying up of the courses, but even longer, since we MENSTRUATION. 129 know not precisely at what period of the mensual act the ovule departs from the cell. In the case mentioned on page 122, of the young girl whose womb and ovaria were given to me by Dr. J. Wal- lace, the patient died while menstruating — and the uterus still con- tained a certain quantity of the menses. Yet here the crypt was open and the ovule had escaped. It might be fecundated as soon as the menses should disappear. I repeat that we do not, as yet, know at what period of the men- sual act the vesicle bursts. The above example proved to me that the rupture took place in the young girl before the drying up of the discharge. So that, in the case of the Jewish women, if the same rule holds, we perceive that the ovule may be discharged, and yet retain its vitality without fecundation for eight days, and for more than eight days. In July, 1848, a young girl destroyed herself by taking arsenic, just before the expected return of the menses. Dr. Wistar, of this city, who examined the body, informs me that in one of the ovaries was a blood-red spot the size of a lentil. There was no absolute rup- ture of the crypt as yet, nor any blood in the uterine cavity. After the foregoing, I am clearly not called upon to say at what precise period after the courses, a woman cannot possibly conceive. I have no doubt there is such a period. Time, and opportunity to observe, can alone settle this point. The celebrated case of the birth of Louis XIV., and the advice of the court physician relative thereto, ought not to be cited, since they have none of the charac- teristics of rigorous truth. It shows, however, the old date of opinions on this point. I am for the present very willing to believe, with M. Pouchet, that a woman shall not conceive later than the twelfth day. There are questions connected with this topic that ought not to be lost sight of by the diligent student, who desires to prepare himself upon all the points of a professional duty. For example — Some women are to be met with who never menstruate, and who yet preserve a most perfect physical and mental health. Among these exceptional creatures, those are to be found in whom the ovaria or the uterus has not been developed. Dr. Renauldin, on the 28th of Feb. 1826, reported to the Royal Academy of Medicine, the case of a woman who died at the age of fifty-two years. She had never had any appearance of menstruation. The breasts were not developed. She had only a cervix uteri, which was of the size of a 9 1 30 MENSTRUATION . writing quill — no womb-proper — and the ovaries were scarcely de- veloped. Such a woman could not menstruate for the double failure of uterus and ovary. There could be no sexual passion — indeed, such a crea- ture was scarcely sexual. When Percival Pott, the illustrious surgeon, removed the ovaria of his patient under an operation for hernia — he took away with them the power of menstruation. There are numerous examples of females who did never menstruate, owing to the absence of the ovaries. As to the cases of absence of the womb, they are less rare than the former, and they ought not to be lost sight of by the inquirer, lest he permit his ignorance to lead people into a grievous unhappiness. A woman ought not to be married who has never menstruated, until it shall have been clearly ascertained that she is not amenorrhoeal from faulty development. I have seen two pretty women who were suffered to marry before it was ascertained that they had no wombs. Any attempts that were made in either of these cases, to bring on menstruation, are well fitted to cast ridicule upon the physicians. A physician should never be other than cautious in all his dealings with cases of absent or suspended menstruation. I state the following instance, in order to show the evil effects of a want of medical cau- tiousness. Mrs. Blank, aged twenty-two and a half years, was married to her present husband more than two years ago. She is of a middling stature and a fair complexion, and presents all the exterior appear- ances of a person in perfect health. She is not fat, but has a certain embonpoint, a good tournure, and a very feminine and most agreeable expression of countenance. She is, indeed, a handsome woman. She has never menstruated, nor has she suffered pain, or any severe attack of any disease. Seeing that she did not menstruate at the pro- per period, medical advice was sought and followed in the treatment of the case. The treatment was unsuccessful, and she was married with the expectation of her friends that the union would be followed by an eruption of the catamenia. The mammae were, at the period of the marriage, well developed, and the pudenda was amply supplied with hair; indeed, all the phenomena of a perfect development of the sexual system were present except the menstrual office. The husband found, however, that some unknown cause acted as MENSTRUATION. 131 an impediment to the congress, and after more than two years of con- cealment, he consulted me on the subject. An opportunity being allowed to me for a full investigation in pre- sence of the mother, I found the external organs perfectly formed, the mons large, the labia and the nymphse as w T ell as the clitoris, perfect, and the os magnum of a natural appearance, but the vagina was a mere cul-de-sac, not more than two inches and probably less than that in length. Upon pressing the point of the finger strongly against the bottom of the cul-de-sac, it seemed to have no connection with any part above it. I requested the lady to lie on her back; and introducing the index finger of the right hand as far as possible into the rectum, I explored with it the excavation of the pelvis, in order to discover any tumor or organ that might be contained within the cavity; but as all the tissues were ductile and very yielding, I began to suspect that there might be no womb at all in the case. Therefore, laying the fingers of the left hand upon the lowest part of the hypogaster, and pressing them firmly towards the finger that was used in exploring the internal parts, I found that they could be brought so near to each other as to make it perfectly clear that there was no womb in the case, or I must have felt it, so near was the approximation of the finger of the right to those of the left hand. Having by the most careful exploration in this manner discovered the unfortunate state of the young lady, I felt obliged, in a conscien- tious discharge of duty, to tell her the whole truth, which I did in the best way I could ; and yet, as may be readily supposed, the know- ledge of her situation was accompanied with all the manifestations of that violent distress and agitation which might naturally flow from such unhappy circumstances. The aphrodisiac sense in this lady is very strong, which might well be the case where the ovaria are fully developed, even though the uterus had never been evolved in her constitution. I was deeply impressed myself with the melancholy fate of two estimable persons, who would never have placed themselves in so unhappy a condition, if by a proper exploration of the parts before marriage, the real state of things could have been discovered. The case also seems to show how improper it is to permit the rites of mar- riage to be solemnized for persons who do not possess all the attri- butes properly belonging to the sexes. I do not contend that every case of failure to menstruate at the proper season is indicative of the necessity for exploration by the touch ; but I think no case of extra- 132 MENSTRUATION. ordinary protraction of an emansio mensium, and especially where any question of courtship or marriage is likely to arise, should be al- lowed to go on without the acquirement, by the medical adviser, of a true and perfect knowledge of the facts as to the organization of the parts. In the early part of the present year, 1848, I met with another ex- ample of similar want of development in a comely young person who had been married some three months before. A shallow vaginal cul- de-sac at the bottom of well developed external genitalia, mammary glands of full size, warm aphrodisiac temperament, and abundant hair, showed that all the sexual physical attributes were present, save only as to the absence of the uterus — no trace of which could be detected by Dr. Pancoast, Professor of Anatomy, by Dr. Jewell, of Philadelphia, or by my own careful exploration. No doubts were left upon our minds of the complete failure of uterine development. The persons interested in this unfortunate situation, though less sensitive than those mentioned above, were rendered unhappy by so grave a mis-alliance — probably the last consequences it maybe greatly to be deplored. How important, then, is it that medical attendants, the only persons who can be competent, should be always ready and watchful as to the points of duty. Not only on account of the risk of fatal mistakes of the kind above mentioned, should we be ever attentive to the duty of making accu- rate diagnosis, but there are a great many other shoals and quick- sands in the track of the young practitioner who fills his sails with the prosperous and flattering winds of his earliest successes. He would find himself under obedience to a good rule, who should firmly resolve not to pronounce an opinion, as to the catamenial dis- order, until he has taken measures to form a solid and inexpugnable judgment on the case submitted to his inquiry. The consultations relative to this class of diseases are very nume- rous for a medical man engaged in business. Well, let it be a rule to suspect of pregnancy every married woman who complains of amenorrhoea. This, though so obviously proper, is a rule often lost sight of by the medical practitioner, whence it happens that we en- counter, now and then, the ridiculous circumstance of protracted and vain attempts to bring on menstruation in married women, who at length prove to be pregnant. I have met with many such instances. Let every married woman who does not menstruate be, therefore, treated as if reasons exist for supposing her to be gravid. If, by the lapse of time or by the occurrence of circumstances, a solid convic- MENSTRUATION. 133 tion can be attained that the patient is not gravid, she may be suffi- ciently early subjected to a treatment conformable to her wants. In like manner, in young unmarried women failing to menstruate, yet exhibiting no other evidence of disordered health, there is time enough to consider what may be requisite in the treatment. The more especially, if we may believe that, which I consider undeni- able, namely, such a woman, healthy, vigorous, and in all respects enjoying the complacency that can only exist in those that be well, does really perform her physiological act of menstruation — to wit, in the regular deposit of her germiferous ova; or that pregnancy pre- vents the exercise of menstruation. It will, perhaps, appear to be almost a rudeness to make this asser- tion, and I should not venture to make it in this place, but under a sense of the duty I owe the young student, which calls upon me to put him early upon his guard. I have so often been nearly deceived in instances of this kind, that I am convinced that nothing but a con- stant cautiousness has saved me from making the grossest mistakes. Many have been the occasions of my being consulted for catamenial obstruction, with a design to entrap me into the administration of drugs that might remove the difficulty by procuring abortion, but like all those who will resolve to adopt the rule which I suggested above, I have hitherto escaped so distressing an error of commission. Should a female, presenting all the appearances of brilliant health, complain of such obstruction, I should be sure to come to one of the conclu- sions indicated in the paragraph — viz. : either the ovarian stroma is active and regular in the performance of its mensual physiological act, or a gravid state prevents the sign of the act from becoming manifest. 134 AMENORRHEA. CHAPTER VII. AMENORRHEA. If a girl reaches her fifteenth or sixteenth year, and falls into dis- ordered health, her catamenia not making their appearance, she is commonly presumed to be laboring under amenorrhoea, to which is attributed the vicious state of her constitution, and which it is sup- posed must be removed, in order to admit of a more perfect play of the powers of the economy. Those who have never had the menstrua are said to be laboring under emansio mensium, or retention of the menses; while those who have already been regulated, but are now deprived of it, are said to be affected with suppressio mensium, or amenorrhoea. There are many causes that may suffice to prevent a young person from menstruating w T hen she attains the usual age for it, besides that general torpor or slowness of development of which I have already spoken. Thus there may be a total absence of the uterus ; or the uterus may possess a faulty conformation, as I have already men- tioned. The canal of the cervix may be imperforate. The ovaria may be wanting. The vagina may be imperfectly developed, or of monstrous form. The entrance to it may be closed by adhesive inflammation, or by an imperforate hymen, or non-development. If the non-appearance, at due time, of the menses should depend upon a general deficiency of the vital forces, it would be easy to verify the cause, by carefully observing and comparing the play of the great functions ; and upon their being found to be free from any special disorder, the inference would be strong in favor of a mode of treatment calculated to excite and invigorate the whole system; or the prudent physician might advise that no treatment should be adopted, but rather that confidence ought to be placed in the powers of nature, which, in proper time, can overcome disorders of this particular class. But in all cases of emansio mensium, it is of the last importance for the medical adviser to reflect carefully upon the circumstances of the patient before instituting any plan or method of cure. AMENORRHEA. 135 Is it not notorious among the profession that the medical treatment of amenorrhea is eminently empirical, unsatisfactory, and unsuc- cessful? It must be admitted, that the subject is, in a practical view, a very difficult and embarrassing one; nevertheless, I feel much per- suaded, that a more considerate and a more rational attention devoted to the cases which fall under our notice, would enable us more fre- quently to administer relief, without being obliged to resort, as we are now, often to every one of the menagoga in succession, and in vain. A blister applied to the thorax often cures a pleurisy, upon the principle that "pars dolens trahit," or the principle of counter-irrita- tion. It is equally true, that any considerable external or internal fixed irritation may prevent or counteract the natural tendency of the system to produce catamenia. A wet stocking, a draught of cold and damp air, produces in the skin a certain condition which frequently serves to prevent or arrest the menstrual offices ; a fortiori, therefore, some latent disorder of an important viscus or organ, would scarcely fail to interrupt, or in some measure trouble, this delicate depurative act. Hence, instead of opening the great volume of the Materia Medica, and searching under the head of Menagoga for some specific means of removing the difficulty, let the medical man carefully study the state of the patient's health, endeavoring by repeated inquiries to learn the rate of the several great functions, and that of numerous minor ones, in order, in their excess or deficiency, to find a cause of the amenorrhea, which he will then be able to treat with the reason- able methods that a perfect understanding of the case will suggest to him. It is not to be supposed that if a woman's constitution can be brought into healthful play in all other regards, she will be vicious or disordered in this instance, of menstruation. I grant that sudden arrests or stoppages may take place from slight and perhaps local causes ; but I speak now of the instances of rebellious obstructions. I wish to impress the idea, not that a woman is unhealthy because she fails to menstruate, but rather, that she fails to menstruate be- cause she is unhealthy. Let us suppose a case. A young woman has her feet wet the day preceding that on which she should be regular. She has a rigor, succeeded by fever, intense headache, vomiting, pain in the loins and hypogastria, &c, all which phenomena are results of the violent re- action of the system upon the morbific impression of cold and damp- ness. The symptoms frequently appear before the time of the flow, and they continue with more or less severity until the show takes 136 AMENORRHEA. place, when they are immediately relieved; or, as is often observed, they are first relieved by a venesection or purge, after which the show makes its appearance; or they may wholly prevent the menses from coming down, and be the first instance of a long series of failures. It appears to me to be quite clear that in a major part of such cases as I have supposed, a sound philosophy leads us to endeavor to sub- due the constitutional disturbance by the proper means for that end, so that the patient may recover in order to menstruate, and not that she may menstruate in order to recover. The treatment of acute cases by venesection, purgatives, warm baths, camphor, opium, &c. &c, shows conclusively that the physi- cians appreciate the real principles of such practice, and it is therefore the more surprising that they are many times, in chronic cases, ob- served to abandon reason, and follow the most empirical, crude and indigest notions of treatment. Of all the great functions, none, I am persuaded, is so intimately related to the menstrual affections as that of the circulation. Let its condition be fully investigated and understood: is there an improper momentum of the blood directed upon other organs ? is it excessive without particular determinations? is the movement of the blood en- feebled ? does the patient, by exercise or labor, compel the circula- tion in the capillaries of the muscles to be sufficiently active and free, to obviate the tendency which is thus acquired to the central or visceral congestions and engorgements so ordinary in the sedentary and lazy ? Inquiries should always be made concerning the state of the hepatic functions. Is there a torpid or obstructed portal circulation ? Can the whole venous circulation of the chylopoietic viscera, destined at last to pass through the portal vein, be vitiated without in some mea- sure affecting that of the genitalia ? If the bile is acrid, or weak, or deficient, will it not cause disorders of the alimentary canal, that must retard or hinder the natural tendency of the vital movements in the womb and ovaria ? In such circumstances, attempts made to restore the health by forcing medicines, for of such are most of the class menagoga, will rather serve to fix and rivet the irritation, than to re- move it ; at least, they are generally fruitless. If she be menaced with consumption, for example, the woman early loses the catamenia, and a pressing demand is made upon the medical attendant for its restoration; but rash attempts to effect its return by means of emme- nagogues, are quite as apt to bring on hsemoptoe, as the more natural discharge which is the object of so great a solicitude. The skin has an intimate relation, by sympathy, to the whole of AMENORRHEA. • 137 the mucous system, whether respiratory, digestive, or genito-urinary. It cannot be, therefore, too carefully looked to. In amenorrhoea it is, for the most part, dry, pale, and not sufficiently elastic. In extreme cases it becomes so much altered, so opake, harsh and disagreeable, as to attract the attention very particularly. Its chlorotic color gives to bad cases of amenorrhoea the title of green sickness, or chlorosis: such a state must be inseparable from an engorged and obstructed condition of the viscera, which, whenever they are oppressed and crushed under the masses of blood imposed upon them, can never cease to be the centres of movement for the sanguine as well as nerv- ous systems, and thus appropriate the tendencies of fluxion that ought to exist towards the uterus. If we recall the blood to its legitimate channels, by restoring to the skin its proper energies, in removing the visceral obstructions or torpor, the amenorrhoea ceases, and the rate of all the functions becomes equalized. Moderate bleeding, local or general; purgatives; an emetic; frictions with the flesh brush, or with salt, or dry mustard; the warm bath; a blister judiciously timed; the wearing of flannel next to the skin; exercise on horse- back ; walking, as a regular duty ; dancing, and various gymnastic amusements — all these may be safely looked to as means of relief, far more to be depended upon than the empirical administration of drugs, whose modus operandi is, in general, but darkly suspected, and never fully understood. The removal of corsets and all tight bandages or dresses, and the rigorous prescription of flannels, stockings, shoes, shawls, &c, must not be deemed unworthy of the physician's attention, any more than the dietetic regulations, which should always correspond to the wants of the case for the time being. Among the causes of disordered menstruation, we ought not to lose sight of the disturbing nature of those deviations by which the womb is, so to speak, dislocated and tortured. Both anteversion and retro- version, as well as various degrees of prolapsion, bring upon the ute- rus states of disordered action well calculated to interfere with the normal play of its functions as to menstruation. After having subdued or mitigated the local disorders, and the con- stitutional disturbance arising from them, if the sanguine apparatus of the womb still fails to act properly, in yielding the catamenial dis- charge, the time is arrived for resorting to the emmenagogue articles. It is a general complaint, that we have, as yet, no good emmena- gogues ; and that the uncertainty in regard to their operation, is as great as to that of the diuretics. It would seem, indeed, that the mate- 138 AMENORRHEA. ria medica includes no article that exercises an immediate or specific action upon the womb, if we except the secale cornutum ; and even of its powers much question is still made, notwithstanding a great deal of experience already had of its employment. Among the articles of the materia medica, those are most to be relied upon, as emmenagogues, which exert an indirect influence on the womb by sympathy with the bladder or rectum : such are cantha- rides and aloes, by the administration of either of which, we have it always in our power to produce a very considerable excitement in the pelvic viscera. The action of the womb upon the rectum and bladder is well known to be very decided: tenesmus, dysuria, and other graver affections accompany and make manifest some of the uterine diseases. So, too, when the bladder is highly irritated by cantharides, or the rectum by drastics, the uterus partakes of the excitation or in- creased vital action. In fact, it is found that aloetics and cantharides are among the most successful of the emmenagogues. I am convinced that these articles are ordinarily administered without sufficient bold- ness, and that they ought to be freely employed whenever they are indicated. The operation of these medicines upon the womb may be greatly promoted by the occasional employment of the hip-bath, the pedilu- vium with infusion of mustard, and full draughts of infusion of some aromatic herb, especially the pulegium. The tincture of black helle- bore, in doses of a teaspoonful, has often been in my hands followed by a restoration of the menstrua. The dose should be repeated every six or eight hours, being followed by the use of an aromatic infusion. The volatile tincture of guaiacum ; the decoctions of seneca, of madder, of serpentaria ; the tinctures of castor, of aloes and myrrh, and the chalybeate preparations, are all justly chargeable with the great un- certainty as to their operations of which Dr. Cullen so loudly com- plains. They undoubtedly do succeed now and then, when happily timed, and furnish, at least, an armamentarium medicum, from which the enlightened and judicious practitioner can select the means of combating the principal disorder, after he shall have first mastered the constitutional disturbances, which, in general, offer the most con- siderable portion of the resistance he has to contend with. It is very true that a case of amenorrhoea may depend upon a faulty life-force in the womb itself, which, from a sluggish condition of its circulation, depending upon some feebleness of its system of nerves, shall fail to perceive and obey the influences that should legitimately act upon it, in coincidence with the periodical exacerbation of the AMENORRHEA. 139 ovarian life-force. In such an instance, whatever might seem to quicken the activity of the life of the child-bearing organ itself, might serve as a positive emmenagogue. On the other hand, as the uterus is eminently fibrous, it is the fre- quent seat of rheumatic disease, which, occupying it wholly, may have power to prevent it from performing the act of the menstrual elimination. Certainly, rheumatism is among the commonest of the disorders of the womb, and when it acquires a chronical character, it scarcely fails to carry disorder into the periodical offices of the organ. Again, the uterus is subject to engorgement, which is not uncom- monly connected with some deviation of its place or attitude. Such deviations are scarcely consistent with a healthful power of the womb, whose nervous and circulatory operations suffer in consequence, — especially in the instances in which the cervix uteri becomes bent, as is frequently the case. In all these forms, the medical treatment should be preceded by a surgical method — as the uterus would not be likely to recover its health until the organ should have been re- lieved of its false place or attitude. In my opinion, though the causes now enumerated are not rarely to be regarded as lying at the foundation of amenorrhceal affections, the major part of the examples are dependent upon a cessation of the force by which ovarian vesicles are evolved and matured. Patients suffering with chronical maladies, attended with protracted amenor- rhcea, exhibit, in the ovarian stroma, no vestiges of the Graafian vesi- cles. I lately examined the ovaria of a girl who died after some eighteen months of severe chronical ailments, during which she did not menstruate. Those ailments had no connection at all with any state of the reproductive organs, yet upon carefully examining the ovarian stroma of both the ovaries, it was found to be a compact, whitish stroma, very similar to that which we observe in women long past the change of life. No trace of the ovarian vesicle existed in either of them. It is clear from this dissection that the lady could not possibly have menstruated, if the doctrine be true — and further, that, in case her health could have been restored as to her chronic malady, many days, weeks or months must have elapsed, before the ovarian stroma could have developed the vesicles, matured and discharged them, so as to give rise to the sanguineous sign of the mensual act. It is apposite, further, to ask, in this place, what powers are possessed by the mena- goga, capable of speedily restoring the discharge, in such cases of amenorrhcea. 140 AMENORRHEA. This subject brings me to the consideration of certain articles as therapeutical agents in the disorders now in question, and I shall pre- sent, as concisely as possible, the opinions I have long entertained, and elsewhere expressed. The human female does not menstruate until full puberty. The woman ceases to menstruate at forty-five years of age. She men- struates during thirty years of her life. She required fifteen years of development to acquire the power, and she survives the exhaustion of it some twenty years, less or more. She possessed the same anato- mical character both before her puberty and after the change of life that she had during the highest vigor of the menstrual forces. In- deed, it is not rare to meet with persons who, being robust during childhood and in approaching to puberty, lose their strength and vi- gor of health as soon as they become regular and bear children, in order to acquire strong health again, upon the completion of the change of life. What is it that a female acquires at puberty, and what is it that she loses at the change of life ? which, while she possessed it, enabled her to menstruate with precise regularity, or perform all the functions relative to the mensual forces? The anatomist can discern nothing beyond certain differences in the ovaries. It appears to me that she has acquired a peculiar surplus of biotic force — a complement of the somatic powers, designed, like the com- plementary powers of plants, to enable them to effect the great object of extension and conservation of genera — a force not required in the ordinary occurrences of a mortal life ; and, therefore, vouchsafed to them only as special and extraordinary powers adapted to the attain- ment of a special and extraordinary end. Such powers could only be intermittent and paroxysmal — they could be periodical — and in nature we find them not only paroxysmal, but very exactly periodical, in all the classes, and, indeed, in all the departments of organic existences. In his Physio-Philosophy, Oken says — " The blood is the fluid body; and the body is the fixed and rigid blood." These are the words of Prof. Oken, who, in using them, has but reiterated the sayings of his predecessors. The saying is a true one. And if so, then it follows that the body depends essen- tially for its constitution on the blood. If the blood be perfect, the body is likely to be so, and vice versa. The ordinary status of the body depending upon the crasis of the blood, how indispensable is a proper crasis of it to the execution of those paroxysmal, intermittent, AMENORRHEA. 141 periodical special acts, whose nature and sources we are con- sidering. But the blood, out of which the whole body is made and main- tained in its status sanitatis ! Whence comes this blood, this genera- tion of the body ? I have neither purpose nor time to enter at length into an examina- tion of the principles of the hsematosis. Such an essay requires not a few pages, but a volume ; but without entering at large on the sub- ject, I may, in hopes of explaining myself, state a few particulars for that end. 1. The blood is daily renewed by means of the alible matter digested, in the stomach and bowels, and absorbed by the lacteal ab- sorbents, by which it is transferred to the blood-vessels. 2. The whole of the blood is contained in the heart, the arteries, the capillaries, the erectile tissue, and the veins. 3. The only tissue that the blood touches is the endangium, which is the lining or interior membrane of all blood-vessels. In the vis- cera — in all the organs, indeed — it is probable that the ultimate ramuscle of a vessel consists solely of endangium, the stronger coats being unnecessary in the last distributions. The endangium, to use the idea of Prof. Burdach, separates the blood from the body, as the scarf-skin separates the body from the external world. The endan- gium is the delimitory membrane of the blood. The blood perishes, or changes very soon, almost immediately after it escapes from within the endangia. It is converted — bio-trophically, or it is coagulated, or it becomes dissolved, or it ceases to be blood upon leaving the cavity of the endangium. 4. Notwithstanding the chyle — particularly chyle taken from the upper end of the thoracic duct — contains vesicles or globules, or cor- puscles, that are of a reddish hue, and that are the results of the earliest morphological powers of the hsematosis, it is not proper to regard these corpuscles as blood. 5. Soon after the chyle is poured into the cavity of the endangium, and becomes exposed to the influences of the oxygen in the lungs, it acquires the character of perfect blood. 6. It is not to the oxygen alone that it is indebted for this farther morphological development. 7. Contact with the endangium is essential to that development, since the blood loses its physical character as soon as it ceases from that contact. The endangium contains the force that makes the blood. This proposition, which I put forth in my 142 AMENORRHEA. Letters to the Class, has been denied. I reiterate it here — and I ask what violence is done to probability in this doctrine, — seeing it is universally admitted that the power of a cell — a far more simple and elementary body — is so great that it can, out of the alible cytoblastem in which it exists, produce by its metabolic and plastic energy, car- tilage, ligament, skin, muscle, accisiferous viscera, nerve, and, indeed, all the solids of the body ? If the to wtufiauxov xat to it-kwtixov really appertain to the simple tissues of cells, may we not concede a higher power to the elementary structure, which we call endangium ? The cell-power is a power of pressure and contact, not a power of perco- lation or endosmose or exosmose merely. 8. The endangium is the blood-membrane. When it is healthy, the blood is so — when it is diseased, the blood becomes diseased. The health of the endangium is as essential to a normal haematosis as that of the gastro-intestinal mucous membrane is to the health of the digestive forces. In diseases of the endocardium, the functions of the heart are modified, but, the endocardium is the endangic membrane of the heart. Similar affections of the endangium ranging throughout extensive portions of the sanguiferous system, derange the blood-ves- sels and the blood. 9. Simple diminution of the life-force in the endangium, produces the idiopathic forms of ansemia, in which the solid constituents of the blood become lessened in quantity, w T hile the aqueous constituent in- creases in quantity. 10. One thousand grains of healthy blood ought to contain seven hundred and ninety grains of water. In anaemia a thousand grains may contain eight hundred and fifty grains of water — or even more. Such a state of the blood is anaemia. 11. Plethora is a contrary state, one in which the watery propor- tion is lessened, and the solid constituents augmented. 12. The endangium is the regulator of these proportions — when its powers are either lessened or exaggerated, the crasis is changed. 13. The nervous mass, acted on by oxygen, gives out the nerve- force, the biotic force, the life-force. It does not extricate or give out that force under any other exciter or influence. 14. The arterial blood conveys oxygen, which it imparts to the nervous mass. Perfect blood conveys the due amount of oxygen to develop a perfect innervative force. Imperfect blood cannot convey a due amount of oxygen — whence the innervations produced by it are inevitably imperfect. 15. The health, activity and power of all the organs, are but the AMENORRHEA. 143 exact expression of their innervation. Under circumstances of imper- fect blood in the endangium, their health, activity and power become deranged. In these fifteen propositions, I have set forth the opinions I have long held as to the influence of states of the endangium upon the health. I am, perhaps, imprudent to put them forth in this manner, and without the support of many facts and many arguments that I deem confirmatory of them. I prefer, however, to submit them to the reader in all their nakedness, rather than not to present them for his examination. I hope that in any event, they may serve me to elucidate the rationale I am about to state as to the amenorrhceal affections which are still under consideration. I have said that the reproductive is a complementary force, and that menstruation is a sign of the active state of that force. The blood of an anaemical girl is incapable of developing her innerv- ative force in sufficient amount for the regular operation of the ordi- nary functions. She will, therefore, scarcely produce nervous force sufficient to execute both the special and the complemental offices of her life. The amenorrhceal girl is generally anaemical. To cure her anaemia is to re-establish her dominion over both the special and the comple- mental, powers and offices of the system. No attempt should be made to bring on menstruation in order to the cure of the anaemia — but, mutatis mutandis, the anaemia should be cured in order that her blood, fully and thoroughly oxygeniferous, may enable her nervous mass to extricate the biotic force in some, equal to the demands of the general, as well as the special or comple- mental, wants of the economy. The curative indications for such ends consist in the use of drugs, frictions, baths, exercise, dress, diet, and medicines — as well as the psychiatric recommendations that may be apposite for the cases. Drugs. — Aperients are, for the most part, indispensable, and they may well consist of a basis of aloes, or other resinous cathartics, in combination with rhubarb or extract of colocynth — and upon occa- sions, of mercury. The celebrated Hooper's pill, which is familiarly known by every mother in the land, is composed chiefly of aloes. The Dinner-pill, or Lady Webster's pill, is also aperient on account of the aloes combined with it. In some of the samples of amenorrhoea, which, while they depend mainly upon a want of vigor in the blood, may derive a part of their 144 AMENORRHEA. rebelliousness from unhealthy states of the circulation and innervations of the pelvic viscera, a useful resource is to be found in the compound powder of Jalap. Doses, consisting of twenty grains of Jalap, forty grains of cream of tartar, and six drops of oil of anise-seed, may be given every alternate morning with considerable advantage. I have sometimes directed my patients to procure half a dozen packages, each containing such a dose, and to use one of them every other day, until the whole of them should be taken. When an idea is entertained that the hepatic secretions are im- paired, under a vicious state of the putal circulation, a very proper alterative will be obtained in the exhibition of six grains of blue-pill, fifteen grains of extract of taraxacum, and ten grains of soda, sus- pended with a dram of gum Arabic, or an ounce of distilled mint or cinnamon-water. Such a dose should be followed by an aperient dose of magnesia, oil, senna, or salts. Tonics. — The most available tonic is iron. Iron appears to possess a peculiar power to modify the rate of the hsematosis. Certainly, one might in vain endeavor to remove certain cases of ansemia by the aid of quinine, the various vegetable tonics, and the mineral tonics, with the same rapidity and certainty as with the ferruginous medicines. I believe that common experience teaches the truth of the above proposition. I know not what is the rationale of the almost specific power of the martial preparations in anaemical disorders, and I am unwilling to enter upon the question, whether the iron enters into direct combination with the blood, to render it more powerful and more noble by its union with it — or whether it acts as a direct tonic for the solids of the economy, thus empowering her to exert a greater energy of potentialization upon the cell-life of the blood-corpuscles. I am not capable of settling this question, and I suppose no other man is able to do so — nor is it vitally important that it should be settled. But I deem that nothing is better or more clearly established, as a therapeutical maxim, in my mind, than this, namely, that an ansemical girl, who labors under no other malady, is cured of her ansemia in about sixteen days, by the proper use of iron. There are a great many martial preparations. Vallet's mass, which is the same article as the pil. ferri carb. of the U. S. Pharmacopoeia, is a very serviceable article, and the purple precipitated carbonate of iron is also an article of great power, but not unapt to prove irritating to the stomach, especially in the extrava- gant doses commonly allowed — as a teaspoonful twice or thrice a-day. AMENORRHEA. 145 The pills of Dr. Blaud, of Caux, have also acquired a great celebrity for their emmenagogue power. They consist of carbonate of iron, combined with sulphate of potash. The muriatic tincture of iron has likewise been much employed — as has also the combination of iodine with iron. Now, in the exhibition of ferruginous medicines, it is understood that the iron is the therapeutical agent on which reliance is placed — and there seems to me little advantage in exhibiting it in combination with any particular acid, since it is to be supposed that such com- binations are immediately dissolved and new relations established with the metallic base, in the stomach. Hence, I in theory greatly prefer to administer the article in its metallic form, and thanks to the ingenuity of Messrs. Quevenne and Miquelard, of La Pitie hospital, at Paris, we are favored with an impalpable powder of iron, that is prompt to enter into chemical union with the acids of the digestive canal. This beautiful agent, which is produced by passing a current of hydrogen over peroxide of iron heated to redness in a porcelain tube, is a microscopic powder of iron — since the hydrogen, having united with the oxygen of the peroxide to form water, has left the iron pure and uncombined. It is prepared at Paris, by M. Quesnesville, the successor of Messrs. Pelletier and Caventou, and sold by the import- ers and apothecaries in this country. My own custom is, to exhibit it in the form of pills weighing two grains, and I habitually direct the patient to take one of the pills very soon after each daily meal: if swallowed while the stomach is engaged in the act of digestion, it does not occasion any sensation ; and it is present and in readiness for any salifying acid that happens to result during the chymification of the food. It is both inodorous and tasteless, and may be used without danger during an indefinite series of days, or weeks, or months. No doubt rests upon my mind that it is the most powerful, safest and least disagreeable tonic drug that the therapeutist can pre- scribe for the amenorrhceas depending upon a principle of anaemia — the most ordinary principle of those maladies. I ought to add, that my attention was attracted to it by M. Raciborski's work sur la Ponte Periodique, and that it is to him I am first indebted for the practical advantages I have received from this medicine. In addition to the doses of iron used as above, it is necessary for the patient to observe certain rules as to the action of the bowels, which cannot be expected under the imperfect and irregular extrica- 10 146 AMT.XO&RHCEA. 'i:n :f hictic force of the anaemical girl to be exact and orderly as for persons in health. Medicines, of which the basis is aloes, are particularly adapted to such cases. The elixir proprietatis ; the pill of aloes and rhubarb; the pill called Lady Webster's or English dinner pill ; the tinctura sacra, and a variety of such formulas, afford the opportunity Foi select- ing such preparations as may seem best suited to the existing indi- cations. Acescent food is the cause of much digestive distress. The aces- cent vegetables and fruits ought, therefore, to be eschewed, and, indeed, a considerable proportion of the food should be taken from the animal kingdom. Brown meats and game are preferable. A roast chicken, or roast beef or mutton, is preferable to other kinds of market provision, and it is, when practicable, useful to cause the patient to take a portion of meat at breakfast and tea, as well as at dinner. Hot drinks, as coffee, tea, and chocolate, or cocoa, are debilitating to the already feeble powers of the stomach. When such articles ought not to be allowed, the patient can take claret and water, with meat and bread, and butter and eggs, for the breakfast, often with signal advantage. But the wine should be pure and unadulterated with brandy, which is so commonly added to every cask of claret sent I ] the I nited States for sale. Good Bordeaux wine, non-f relate, that not brandied, makes an admirable substitute for boiling tea, coffee, and chocolate, which, though they may not sensibly injure persons in str::.g health, are yet surely unsuitable to the feeble and attenu- ited female. There is no health without exercise and light. The patient should much in the open air, exposed to solar light, when not too intense. See sh: :i:l r-inf:rce t'ne rowers of the circulation by means of exer- r. The best exercise is active, not passive exercise. But I dare not devote these pages to an extended discussion oi this subject. I e in my seventh and twenty-seventh •• Letters to the Class," pretty :.-.-:.:'.-■ :~i my views on the topic, and refer the Student to those Letters. PREGNANCY. 147 CHAPTER VIII PREGNANCY. Pregnancy.— The subject of pregnancy is one that is worthy of the most careful study by those who intend to devote themselves to the pursuits of Obstetricy, and indeed, it merits the attention of all per- sons desirous to become acquainted with those miraculous powers and actions of the living body, that result in forming and perfecting a human being, the crowning work of the Deity, who thus ordains man to come forth from the darkness of non-entity, to shine upon the stage of the world, and there act his part for immortality. There have appeared a great many speculations and theories upon the subject of Generation: yet it is true that, however ingenious or inventive their authors, or however eloquent or argumentative in urging the adoption of their peculiar views, there still remains a terra incognita of Embryogeny, which human sagacity, perseverance and toil have never been able to explore ; and which seems purposely set beyond the reach of the utmost stretch of human wisdom or learning. It must ever, w^e should think, remain impossible for man to com- prehend the secret mysteries of those proximate causes, by the force of which, a non-existent, or formless being is drawn forth of the dark stream of time, and launched out on the boundless ocean of eternity; made partaker of a prospective immortality ; charged with the burden of responsibilities to God and his fellow creatures ; and bound by nu- merous liens to the physical world, of which he has also become a part by the very fact of his entrance into a moral state. Such a sub- ject, nevertheless, cannot fail to prove interesting to the Medical Student, whether he approaches it in view of its physiological con- nections, or whether he wishes to investigate it as a psychological inquiry of the utmost importance in any system of moral philosophy. What subject indeed could be more replete with interest, than one which pretends or seeks to explain all the changes that are experienced by the embryo, from its first discoverable estate as a drop of pellucid 148 PREGNANCY. lymph, up to the time when it comes forth into the world endowed with all the powers that are appropriate to a healthy, full grown foetus at term! Such a study involves a comparison of its organs with those of the adult animal, and a complete history of their development and growth ; and it ought also to comprise an account of the accidents and diseases to which it is exposed or liable, with a full detail of all the peculiarities of the ovum and its several parts, and a comparison of them with the similar parts in various animals. The subject com- prises, therefore, a vast field of physiology, which might be profitably explored by the curious Student ; but the limits of this work are too confined to admit of it being treated of at length on this occasion. If, as has been eloquently said, the springing up of a blade of grass from the bosom of the earth is calculated to fill the mind with wonder and amazement, what far more vivid impressions of the miracles of power are likely to be made upon those who contemplate the unfold- ing of those organs and faculties, by means of which man learns not only to know and acknowledge his Maker, but to render himself, as it were, a still more fitting image of Him, by the cultivation of the faculties that have justly given him the title of the lord of creation! In addition to the interest as a merely philosophical study with which our subject is clothed, it appears to me indispensable that the Medical Student should make himself acquainted with it, as taught in the present era, and that he should aim to obtain a thorough know- ledge of the subject, a knowledge supposed to fit him for the con- duct of cases in midwifery. But, let him consider whether, in aiming at this so called practical knowledge, he is not also called upon to make himself master of all those scholarly acquisitions which alone can shed a light of revelation upon the dark and doubt- ful questions that in his practice he must not only solve, but instantly solve. To know that a pregnant woman has a child in the womb, and to learn by rote something of the presentations, positions, and manoeuvres relative to the midwifery operation, is but a vulgar know- ledge, common to old women and to physicians who confine them- selves to the study of text-books and the unrecorded and misunder- stood experience of their own clinical operations. The Student ought to study the subject not merely as a midwifery qualification, but as an Obstetric Science, the possession of which places him in the fore front of his professional rank. Pregnancy is the development of an embryo or foetus in the womb. An account of pregnancy comprises a relation of all the changes PREGNANCY. 149 that take place in the reproductive organs, and in the whole economy of the female, from conception to the end of the puerperal state, as well as a history of the development of the foetus. It is proper, however, for convenience sake, to separate the account of pregnancy and embryogeny from that of parturition, which in itself presents a great and imposing subject of study. Inasmuch as there are, besides natural or healthful pregnancies, cases to be met with of morbid or preternatural pregnancies, the latter merit a proper share of consideration. Hence, we ought to inquire not only into the physiological, but into the pathological con- ditions that are brought about by pregnancy, and learn the seat, nature, causes, signs and cure of many troublesome disorders and dangerous accidents that overtake the gravid woman. Fecundation. — In order that a woman may become pregnant, it is necessary that a germ, matured in one of the ovaries, should be ex- pelled from its Graafian follicle, and then fecundated by the encounter of it with the male sexual element, the sperm or seed. I have already shown that the germ is contained within an ovum or egg ; which the woman, like all other reproductive animals, matures and spontaneously discharges at regular periods. I shall by no means pretend to show what is the nature of the mu- tual influences of the seed and the ovum, or which it is of the two that in this generative encounter furnishes the nucleole of the new entity about to start on the career of development. These are mysteries beyond human ken, and likely ever so to remain. It is in the mean time unquestionable that the concurrence of two different systems of genital organs is indispensable ; that one of them must be female, ovaric, or germiferous, and the other male, yielding spermzoons and a fluid of peculiar properties. Neither the female nor the male is endowed with the independent power of reproduction. It is usually admitted that the female yields the germ, and the male a material which, upon some combination or contact with the germ, imparts to it the power to grow or augment in a certain ratio, and only in given and rigorously predetermined forms. Without desiring to call in question this opinion as to the germife- rous nature of the female, an opinion which I cannot but adopt, I may avail myself of the occasion to advert to the opinion set forth by M. Schleiden, that the developing matter of the embryo plant — its primal soli d — is contributed by the male organ of the vegetable. Mr. S. shows that the pollen tube is a series of cells propagated from 150 PREGNANCY. the pollen grain — that the pollen tube shoots its terminal cell into the ovary of the plant, and that cell, making use of the cytoblastema, the medium in which it is now placed, begins the career of the new vegetable, plant, or tree. In this view, the terminal cell of the pollen tube is the germ, and the anther which yields the pollen grain is a female, not a male organ. For that which produces the germ is female. But, even if M. Schleiden is correct in his views, the dogma is not overthrown — na- turalists have merely mistaken the sexual characters of plants, calling those female that are truly male, and vice versa. At the present day, it is not doubted that the woman produces the germ by the force of her ovarian stroma ; yet it is not long ago that it was contended that a zoosperm, or spermatic animalcule conveyed to the surface of the ovary, and entering in at a pore, finds a nidus or matrix for its early morphological operations, being thus the start- ing point of the embryogenic processes. Little doubt exists as to the cell-nature of the ovulum of the mam- mals — and there is some reason to believe in the cell-nature of the spermzoon. If they be equally cells, which hath the pre-eminence, or which is the true germ? and where is the philosopher that can, with absolute assurance, declare which of these cells is the primal solid in the generic or fecundative processes ? I freely acknowledge my own ignorance of the essential nature of fecundation. Fecundation is not conception — a woman may have within her organs a fecundated ovulum, without having conceived. Conception. — A fecundated ovulum entering into the womb through the Fallopian tube, and falling without delay into the vagina, may be destroyed or lost before conception can take place. It may be washed away in a torrent of blood, or carried off amidst a quantity of mucus. An ovum may suffer the encounter with the male element even in the infundibulum or fimbria of the tube, and falling out into the cavity of the pelvis or belly, be wholly lost from not making its attachment to the serous surface on which it has fallen. Conception is the fixation of a fecundated ovum upon the living surface of the mother ; it is the formation of an attachment to or union with the womb, the tube, &c, of the mother. This is conception, viz., the fixation of a fecundated ovum. If a conception take place in the womb, it is pregnancy — if out of the womb, it is PREGNANCY. 151 extra-uterine pregnancy — in the Fallopian tube, tubal pregnancy — in the ovarium, ovaric pregnancy — in the pelvis or belly, abdominal or ventral pregnancy — if it occur in the substance of the wall of the womb, it is called interstitial pregnancy. Commencement of pregnancy. — Pregnancy ordinarily begins soon after the disappearance of a periodical effusion of the menstrua. Several days, probably, always elapse betwixt the act of fecunda- tion and that of conception. The ovum, in the mean time, under the power of endosmose is augmenting in volume and undergoing import- ant changes in the arrangement and mixt of its constituent ele- ments ; changes that are requisite to fit it for the higher act of forming its attachment to the mother. It is not precisely known how many days ordinarily elapse between the end of the process of ovulation and fecundation, and that of con- ception. M. Velpeau seems to entertain doubts as to the four ova he describes at page 25 of his Embryologie, and which were from eight to twelve days old. It is not known how long they had been in the womb before their expulsion. Probably, Sir Everard Home's speci- men, described in the Lond. Phil. Trans., was a human embryo of seven days. The facts seem to concur in proving that shortly after the act of fecundation the conception takes place ; but it is probable that the time is various. As menstruation coincides with the periodical act of ovulation, and as the sexual embrace is attended with the orgasm whether gravidity follows it or not, there is great reason to suspect that the coitus of the sexes is frequently followed by fecundation of ova that are subse- quently lost by effluxion, and it is to the last degree improbable that every fecundated ovum shall be able to effect its mesenteric attach- ment or fixation. Fecundation and conception can take place only after the dehiscence and discharge of the Graafian follicle, whose ovulum, without the aphrodisiac orgasm, must necessarily be lost. It is not known how long after the close of a menstruation, the ovum continues fit for and liable to fecundation. Our researches, which clearly prove that an ovum is discharged with each menstrual period, have not revealed to us the date of the dehiscence and discharge. I am confident that the nearer to the close of the menstrua, the more probable is the fecundative result of a congress of the sexes. I have one uterus, taken from a woman who died while menstruating, in which the dehiscence of the follicle and the escape of the ovum were 152 PREGNANCY. complete ; so that, in this instance I may venture to suppose that a fecundation would be more probable, the sooner the encounter of the elements after the close of the menstrua. Perhaps some women go through the whole menstrual hemorrhage before the discharge of the ovum from the ovarian ovisac. If. Pouchet thinks, that the egg retains its susceptibility to the male excitant ibr at least twelve days ; ftei the ovulation. It is quite certain that it does retain its susceptibility for eight days; for, certain Jewish women, who remain under obedience to their law, neve: admit of the embrace until eight days have passed since the show of their uncleanness has disappeared. Other Jews construe the command as forbidding any intercourse until eight days after the first manifestation of the effusion. To this effect I have been repeatedly informed by Jewish females, who had no ostensible motives to mislead me ; so that, I find a great religious sect to prove that fecundation of the ovulum is possible eight days at least subsequent to the drying up of the catamenia, which is probably more than eight days after the escape of the ovarian yelk, since I have never observed the uterus of one dying soon after the catame- nia in which the empty bloody crypt of the egglet was not visible. Amidst the doubt and uncertainty that rest upon the subject, it must be regarded as scarcely possible to set a fixed term. Hippo- crates and Galen, and most medical men, as well as most women, since them, believe that the sooner the sexual congress follows the men- struation, the more liable is the woman to conceive. It was, if this notion be true, a singular policy of the Jewish legislator, that pro- nounced such deadly reprobation upon all violators oi the law of women's cleanness; and it seems to me a subject of surprise that the daughters of Abraham should, to this day, obey a custom calcu- lated to obviate the greatest possible productiveness of their nation. The number of the Jews at the date of the expatriation under the reign of Vespasian and Titus, was about 5,000,000 souls. There is reason to think that it has remained nearly stationary since the over- turns : f their city by Titos. If ever the curious law of cleanness of women be abrogated as to the Jewish wives, would the augmented chances of fecundation cause the sons of Abraham to become as the stars of the firmament, and the sands on the sea shore for number? Is it the operation of this ancient law that has kept the population of the Jewish people down, through so many centuries, to one even tenor of about 5,000,000 souls: I presume that in the present state of our knowledge, there is no one who can inform us at what period of the menstrual hyperemia, PREGNANCY. 1 53 the dehiscence of the Graafian capsule usually takes place. I repeat that I have not met with any specimen of ovary taken from an indi- vidual dying during or soon after the monthly flow, in which the ova- rian capsule was not already ruptured, and the egg escaped. The uterus and ovaries of a young woman who died suddenly, while men- struating, pleno rivo, is in my collection. The bloody pore and empty crypt showed that the ovulum, in that case, had escaped early in the menstruation. It is probable that the ovulation may in some women shortly pre- cede, while in the majority it absolutely coincides, in point of time, with the first appearances of the hemorrhage. As to the impression still entertained by some reputable authors, that the discharge of the ovule depends upon the aphrodisiac orgasm, it is too unreasonable an hypothesis; too unreasonable, I say, because, the dehiscence being the effect of absorptive power, and not of a lacerative or vulnerative force, it is idle to attribute to a momentary orgasm, which perhaps has no direct influence on the ovaries, a result that requires many days of the slow operation of the absorbents of the ovarium. The regularity of the ovulative paroxysm is as great in the virgin as in the married woman ; and is equally regular, moreover, in the vegetable as in the animal kingdom. It is much to be desired that careful observations, made as to the state of the ovaries in persons dying just before, pending, or soon after, the close of the monthly flow, should be laid before the profession in order that more accurate notions may be had upon the subject. As to the precise place at which the encounter of the sexual ele- ments takes place, we do know that it may, and sometimes does, occur in the Fallopian tube; and we have certain proof of it in all the cases of tubal pregnancy, which are but too numerous in the records of Medicine. Possibly it may likewise occur within the womb itself; and it may be hereafter ascertained that the instances of placenta prsevia are the results of a late fecundation, which admits of the fixation of the product upon the os uteri internum. The examples of ventral or abdominal pregnancy ought not to be taken as proof of an encounter of the male and female elements within the peritoneal sac. It is more reasonable to suppose that the encounter having taken place in the fimbria, the fecundated ovule, after falling out of the grasp of the infundibulum, has made its mesenteric attach- ment to some point of the peritoneum upon which it has rested. As to ovarian pregnancies, I cannot deem them possible, except under the following circumstances. Both Bischoffand Martin Barry 154 PREGNANCY. have found the zoosperm upon the surface of the ovary in animals killed immediately post coitum: this is sufficient proof that the prolific semen had been transported by the tube or cornu to the fimbria, whose grasp of the ovarium had deposited the zoosperms upon the ovarian indusium. If we suppose this transfer to be effected at the moment of the appearance, in the opened hila, of a mature ovule, it is clear .the generative encounter would here take place, and the act of fecundation become complete. Upon some change of posture of the woman the further escape of the fecundated ovule might be prevented, the pore being stopped by the pressure of a fold of broad ligament, a loop of intestine, or other obstructing cause ; and thus the fecundated germ, imprisoned within its cell, might commence its career of development, making the ancient follicle, which produced it, become its matrix or succedaneous womb, up to the time at which it must inevitably burst. I am compelled to adopt this hypothesis; for I can by no means con- ceive that fecundation of a germ contained within an unopened Graafian follicle can possibly take place, as I fully adopt and truly believe Mr. Pouchet's doctrine as to the spontaneous discharge of the ovulum pre- viously to the fecundation. I cannot believe that the male seed enters into the ovisac, through not the peritoneum only, but through the albuginea and the concentric coats of the ovisac. Fig. 52. Decidua. — When pregnancy takes place, the womb is provided with a lining or coat, called the decidua or caduca. This caduca has been represented as a membrane, which is excreted by the uterus, as a means of securing the product of the conception, and affords to it a nidus in which to imbibe the earliest elements or pabulum of its growth. For a long time past it has been generally supposed that the womb, coincidently with the fecundative era, throws out a viscous excretion from its inner walls, so as to line or plaster the whole surface with the viscid matter. The cut is designed to show the manner in which this occurs. The dark, thick outlines repre- sent the womb already somewhat expanded by the growing ovum, a is the canal of the neck of the womb, b is the orifice of the left Fallopian tube, whose fellow is seen at the opposite angle, c is the decidua or caduca excreted by the inner surface of the PREGNANCY. 155 womb, covering it as with a soft inductus. d is the vacant cavity of the uterus, e the same decidua or caduca, pushed off from the sur- face by the globe of the ovum g, which, as it increases in size, thrusts the decidua, or reflects it, as in the outlines from e to e. It is this part to which the name of decidua reflexa, or caduca reflexa, has been given, f indicates the chorion or outer membrane of the ovum. It often happens that women miscarry in the early stages of their pregnancy; and where the event occurs in the most favorable man- ner, the entire product of the gestation is thrust out in an unbroken or perfect state. When this occurs, we find, upon examination, an oviform or pyriform body, upon the upper segment of which is seen a mass of tufted chorion, while the remainder consists of a dense and rather solid fleshy mass, which is the original or true decidua, called decidua vera. By careful manipulation it is possible to extract from the upper part of this mass the complete and perfect ovum, consisting of the chorion with its remaining tufts, inside of which chorion is the amnion, the water of the amnios, and the embryo. A good notion of the appearance of the whole decidua, after the ex- traction of the ovum, may be got by ex- amining Fig. 53, which is pear-shaped. Fi s- 53 - The pit or depression at the upper end, out of which the ovum was taken, is the reflected decidua. It is clear that if the ovum should continue to grow, and to reflect the decidua, or carry it before it, the decidua reflexa would at last come in contact with the decidua vera, be pressed against it, and that they would weld or solder together, so that, at length, it would be impossible to sepa- rate, or even distinguish them' from each other. The cavity of the decidua vera, which was a closed sac, was, ac- cording to Breschet, filled originally with a fluid. Breschet gave to this liquor the denomination of hydro-perione. Of course such hydro- perione must be absorbed in the process of reflection, and ultimate fusion of the decidua reflexa and vera. We shall find, further on, other opinions on this subject. Such are the Hunterian views of the decidua. Other explanations /:'■ ::' "_. i . _ " lit- . tt ... ; -- : ;- ztzSzZmL. — _.::. z-:-.. rei ~ ::: ; :: nifrrsiif . . . i t ; : ' : ; . : : . " i . .- . - : : :n . : :=•■: :i t -. i . : . t : . : t : : lining in the interior of tbe womb, contending that the corpus nan- ::?_- .nniiiTes — ::i:i ::: :■= 1.1:1. 21: :il: "if :i:.f: — i_ :f :if :':ii:. :: "if rresr-:: 117. :: -f-7 -i T rXisTfi:-: :: i ~i:ii> :-:.:> :; s:-zit sir. is :it ?~i-rr£c:zl ris?-r :: :it iif: iirie.; ::zlz :rrn Ii I- 1 . C : i 1 e ' s A:". : rfiresfiriiz mr—it-i -It" ::' nii Tfxri:!. 11: :n:ir "ifn. ::.7 whiek ex h i bits Ac appearances seen in a piece cnt fiom flne snb- 5:11:7 :: 1:7 — :~:. :i ~ i::i if 'i: ::::: '::::: ~7ii::ii7 1" ; T - giet much thu :::z: :.r iesirr :: "-..: :::::•:::.:: -is::; : :.- :-rfi '-r::::zs::-'.::. :: — .::_• :it 1.- mixe:. ~i::i rtiiz- seists a piece cut from the uterus. Tie rlri: uni i::i:i ::' :if :.:- * 1: 7 : r : : 7 s 7 1 " 5 m 7 i:::ii sm 1:1:7 :.:' :i7 111::: ::'::: Fis ■:. -1.17 1: 1: - ±7 LTT-fLT- : 7 . r: - : - 1 7 7l. 11 1.7 i" . : : _. 7 111 ::' "iris :_: :£ :j ±6 s-i::. 1:1 seer 1: :"lf iift I::::. 11-7 1:1 ::^ : : : ::' V \ -_ Das* da Corps organ^ the folk ~ :.:: ::. :::t; inn: :: i: 111 :■: ?.::::i:i ::' 1 1:1: z-:i nil itiji :: :it: irrisiri 17 n:::if. ~i:" i~::: ::.f Crr11f.11 -75:;. 75 ::' i: :~i:.7i :i :izii itiiri.T zi::f i-Tii:ri :in :it ::i, j body of the womb, phlagosed, and of ; PREGNANCY. 157 ance, in obedience to the laws of a pre-established harmony, is modi- fied as it is in the maramifers, during the season of the rut, and pre- pared for the reception of the ovule, whose spontaneous maturation is about to occasion its fall. "While, indeed, the ovarian capsule that is about to burst becomes the seat of this rapid evolution, the vascular apparatus of the womb is developed and injected in an extraordinary manner; that of the mucous membrane especially, forms at the surface of the membrane beneath the delicate layer of epithelium with which it is invested, an elegant network with irregularly lozenge-shaped meshes, each of which incloses the orifice of one of the innumerable glandular tubes of which it almost wholly consists. This vascular reticulation is so decided and so rich, that in certain subjects it communicates to the inner surface of the womb a more or less violaceous hue. In all probability it is through these delicate ramuscles of which the net- work consists, that the menstrual blood oozes. In cases where a pregnancy has become somewhat advanced, and the ovum, lodged upon the mucous surface, has affected it so as to cause it to assume all the characteristic features of the caduca, these ramuscles become so greatly developed, that many of them attain the size of a quill- barrel. A definite opinion may now be obtained of their real nature, and we may feel convinced that the major portion of this sub- stance belongs to the venous system ; — so that the mensual hemor- rhage which they yield, is evidently, in chief, derived from the reser- voir of the black blood." ****** "These glandular tubes, one end of which is related to the mus- cular layer, while the other opens upon the free surface of the mucous membrane, are in number so considerable, that their orifices give the appearance of a strainer to the surface. Their presence in the tissue of the membrane increases its thickness to such a degree that in many subjects, it forms plica?, or elevated convolutions, that are soft, com- pressed, and so jammed together, as to leave no void space in the cavity of the womb. These convolutions, when the ovum descends from the tube, seize it and retain it by their contact or pressure. Upon inspecting the extraordinary thickness of this membrane, one might be led to suppose it the seat of a true pathological hypertrophy, or other alteration, were it not that repeated experience, corroborated by the examination of the parts, in women dying of accidents at the commencement of pregnancy, afford us the undeniable proofs of its being a normal condition of things." 158 PREGNANCY. M. Coste's engravings give very beautiful illustrations of the asser- tions of the above paragraph, and I have the pleasure to bear witness to the fidelity of at least one of his pictures, of which he presented me with an engraved and colored copy while I was in Paris in 1845. Not only was that engraving a most faithful copy of the water-color drawing, but M. Coste had the kindness to show me the anatomical specimen from which the drawing was made. It is impossible for the art to give a more perfect representation of an object. In the course of the researches that I made in the years 1847-8, upon the reproduction of the Opossum, I had occasion to examine the uteri of many of those animals both in the gravid and non-gravid Fig. 55. state. I present to the reader an outline drawing of the uro-genital apparatus of that singular animal, which is a monotreme. In this figure a is the urinary bladder ; bb, the first wombs ; cc, the second- ary wombs; dd, the ovaria; e, the uro-genital sinus along the surface of which (e) laid the rectum. The sinus uro-genitalis and the rec- tum united in a cloaca or monotrematous sac, which, as in the birds, gave outlet to the products of digestion, urination, and conception. PREGNANCY. 159 I examined this animal on the 3d of April, 1847, and found seven marsupial embryons in the pouch, which, from their size, I have rea- son to suppose must have come into the marsupium about the 10th of March, as they compare with my specimens of the 7th of March. This figure represents the bladder, wombs, and sinus, inflated by the blowpipe. The wombs bb, when the animal is in rut, become twice or nearly thrice as large as they are in the figure; and the in- creased magnitude depends solely upon the development of the tubuli, of which M. Coste speaks in the above quotation. The cavity is very minute — bean-shaped, and filled with an apparently slimy matter. In an opossum examined last winter, there being present Drs. I. Wallace and E. Wallace, the aorta was injected with size colored with vermilion. Much of the injection was found to be effused into the small bean-shaped cavity of the wombs bb — but there were a great multitude of straight tubuli standing vertically as to the paries of the womb, that were filled with the red injection, presenting the ap- pearance of waving, or straight red lines, passing from the inner super- ficies of the substance of the womb down through the soft deciduous matter to the inner delimitation of it. The cut, Fig. 56, gives a pretty correct view of the appear- ances presented upon cut- ting one of the wombs open in its longitudinal diameter. The lenticular-shaped ca- vity is seen in it as well as the converging tubuli. It gives also a good idea of the thickness of the uterine walls, compared with the accidentally developed interior membrane. On the exterior of the womb is seen the ovary, with part of its cornu, or Fallopian tube. I think no one who has examined M. Coste's engraving of the gravid womb, opened, can fail to be struck with the immense comparative development of the uterine tubuli during the rut of the opossum. It is among the apparent slimes of this texture, that the Rev. Dr. Bach- man, of Charleston, S. C, found the young embryons moving — as ex- pressed in his paper to the Philad. Acad, of Natural Sciences, 1848. I in vain searched for such free embryos in the numerous speci- mens of Didelphis in rut that I examined with the Drs. Wallace. We discovered none. Having sent specimens of these wombs to Professor Owen this Fig. 56. 160 PREGNANCY. spring, I ought, perhaps, to wait for his superior judgment upon the subject ; but I venture, in the mean time, to call attention to the simi- larity of the tubular appearance in those wombs, to that discovered in the human uterus by M. Coste, and of which I have already presented the copy of an engraved specimen on page 156, taken from that ad- mirable physiologist. I leave it to the Student now to judge for himself, as to the nature of the deciduous coat of the womb ; and to decide betwixt the Hun- terian explanation of it, already given, and the new doctrine, of which he has here the sufficient elements, for the purpose of making up his opinion. The ovum, after reaching the uterine cavity, grows rapidly. At first, it must be supposed to augment in consequence of an act of en- dosmose, which conveys to its interior, the cytoblastema that it finds in the mucous fluids amidst which it exists. Gradually developing its substance by means of changes in the vitellary mass that attends it, and also, probably, by means of a pabulum it finds in the mucus, by which it is surrounded, it soon commences the acts of evolution of its parts. This process is effected by sending forth to all its parts, by means of the ventricles of the heart, the sanguine materials which it creates in order that it may be so converted. As the foundations of the tissues are being built up in these histo- logical deposits, the nervous mass is everywhere deposited among them, and is in fact their essential element This nervous mass, in the form of nervous fibrils and cords, like all the rest of the solids, is derived from the blood — for nothing is truer than Oken's assertion, that " The blood is the fluid body, and the body the fixed and rigid blood," so that the whole of the developments of the embryo and foetus are the results of organic deposits, henceforth derived from its blood alone. The embryo requires an engine for the circulation of its blood. Hence the features of the heart become so early disclosed — the path of the aorta is laid out by the blood itself; and the omphalo-mesenteric vessels are traced in order that the functions of the umbilical vesicle may not fail. The aorta divides as it grows longer, into two branches, which are not two primitive iliacs, but two umbilical arteries, designed to send the blood of the embryo to circulate near the mother's blood, and to take from it the quantity of oxygen requisite for its aeration, and a certain plasma which it brings back to the body of the embryo. These two PREGNANCY. 161 umbilical arteries give off branches which become, at length, suffi- ciently large to be demonstrated as the external iliacs, the femorals, the popliteals, &c, for the vessels of the limb are productions from the umbilicals which, at last, assume their permanent character as iliacs, femorals, popliteals, &c. The blood of the embryo, by the extension of its umbilical vessels, comes at last to circulate among the cellular mass that is developed on the outer surface of the chorion, amidst which it receives its supplies of oxygen and also its alible elements. As the embryo is now enclosed within its amnion, chorion, decidua reflexa, and decidua uterina, it cannot be considered, of itself, to have any contact with the maternal surfaces — nor has it any connection w T ith the mother, save by its blood alone, which it sends forth, pro- jecting it, so to speak, far beyond the limits of its own body, in the distal tufts of the branches of its umbilical vessels, to spread it upon the living wall of its mother's tissues, there to receive its endowment of oxygen. The only part of the child that touches the mother is the blood of the child. The embryonal blood having traversed the capillary system of the placental tufts, returns by the channel of the umbilical veins. All the umbilical venules, in their inchoate state, have, probably, the power of taking up, by endosmose or absorption, some species of plasma or cytoblastema, from the maternal surfaces. They convey this, together with the aerated blood of the umbilical capillaries, into the single tube of the umbilical vein, which delivers it back to the child, by pouring it partly into the hepatic porta, and partly into the inferior cava by way of the ductus venosus. In speaking of the absorptive power on the placental venules, I do not wish to be considered as asserting a power of absorption like that of the lacteal and lymphatic apparatus. I mention the fact — and I do not wish to state that the act is done by any other than the en- dosmose power; for I do not venture to suppose the existence of regu- lar absorbent vessels in the mass of the placenta, where no efforts have yet succeeded in making them manifest. Professor Liebig's Researches on the motion of the Juices in the animal body, may be one's sufficient warrant to believe that the placenta can take up from the maternal tissues an amount of organic material adequate to the development of the uterine embryo and foetus. While the embryo is growing, the amnios continues to fill with larger and still larger quantities of water, the placenta increases in 11 162 PREGNANCY. size, and the womb, which affords the nidus for the tender young, aug- ments pari passu, with the ovum and its contents. The womb yields to the antagonistic force of the expanding ovum, It undergoes a compulsory development. The womb always resists this expanding power; it makes daily and perhaps hourly efforts to cast forth the burden from its cavity. But, the ovum commences its career of development in the cavity of the womb, which is composed of the wall of the fundus and cor- pus uteri. The long cylindrical cervix is not, at first, interested in the strug- gle or contest between the expanding ovum and the resisting cavity. It stands as the guardian of the fruit of the conception. The cervix uteri is the seat of what the ancients called the facultas retentrix, and it continues superior in force to the facultas expultrix until the close of pregnancy, when being abolished, the facultas expultrix acquires sole dominion, and labor commences. If at any time, during the course of a pregnancy, the retentive power of the cervix should fail, the expulsive power of the fundus and corpus uteri immediately begins to expel the ovum. Many of the abortions that we meet with are caused by the weak- ness of the womb — that is to say, by the weakness of the cervix uteri, which gradually yields to the antagonizing contraction of the body and fundus, and allows the ovum to come forth and be lost. The physician makes use of this principle in the treatment of cases in which the indication is plain to bring on premature labor. If he di- lates the canal of the cervix with his finger, or with a sponge tent, he takes away the facultas retentrix, and the ovum comes off. While the uterus is thus the reluctant agent of the forces of the ovum, it gradually increases in volume and weight, as well as in the cubic content of its cavity. After labor, it weighs a pound and a half: in the non-gravid state, it weighs two ounces and a half. It follows, therefore, that in the course of a gestation, a vast increment of its mass takes place, and that this whole sum consists in living organic molecules or living solids, that are deposited within its limits and be- come constituents of them. Under what power is it that so great a mutation is effected? There is no other mode to explain it, than by reference to the aug- mented intenseness of the action of its nervous mass, compelling the organotrophic operations at the expense of the blood brought into it by the uterine and spermatic vessels ; for Oken says, truly, that the blood is the fluid body, and the body the fixed and rigid blood. PREGNANCY. 163 I shall not endeavor to give the rationale of the influence exercised upon this nervous mass by the growing ovum. Perhaps John Hunter would ascribe it to the stimulus of distension. Suffice it for me to say, that at any time in the course of the whole career, that career may be instantly arrested, and brought to a close, by destroying or with- drawing the ovum, or by taking away the retentive power of the cer- vix uteri ; for, to discharge the waters of the amnios by puncture, to dilate the canal of the cervix with a sponge-tent, or to energize im- moderately the facultas expultrix of the fundus and corpus uteri by means of ergot, is to arrest and bring to a close the whole operations of the reproductive processes. But as the womb grows larger, its arteries and veins become elon- gated — their coats become more considerable in size and weight. The nerves are enlarged, or, at least, they are extended, or produced. The absorbents, in like manner, are augmented, and more than all, the great masses of muscular tissue existing in the virgin womb in potentid, rather than in reality, acquire a visible and palpable magni- tude and force. As the womb expands, driven outwards in every dimension from its centre, its walls do not diminish in thickness, although they be- come softer and more succulent. Torrents of blood circulate in the tortuous branches of the uterine arteries, and soak along in the im- mense sinuses and veins, some of which are large enough freely to admit a finger in their cavities. In the development of the veins in the gravid womb, the fibrous coats of them do not appear to undergo much change or addition. It is the lining membrane, the endangium, that is chiefly increased, pari passu, with the augmentation of the calibre of the vessels, so that in examining the gravid womb, one sees rather great holes and channels lined with a smooth endangium, running among the tissue, than real veins. In this respect there is nothing peculiar to the womb, since it has been long known that the veins within a viscus consist only of the endangium, as must indeed have been the case in the earliest stages of development even of the aorta itself, for the blood makes its own channel. It makes therefore its endangium first, and the more tough, fibrous, and elastic parts of the tubes afterwards. From the foregoing, it appears that the augmentation in weight, volume, and capacity of the gravid womb, is a compulsory process under an antagonistic force applied and sustained by the developing ovum. The ovum may be compared to a powerful acephalocyst that attaches itself by means of its placental mass, serving as its absorp- 164 PREGNANCY. tive organ, to the living wall of the womb, which it compels to yield in every dimension for its growing wants of accommodation. The womb increases in weight as the pregnancy proceeds. The means of its suspension in the cavity of the pelvis are always the same in the gravid as in the early non-gravid state. It is to be expected, then, that as the uterus becomes heavier, it shall sink somewhat lower down, and that the woman shall, if she be a susceptible creature, perceive some symptoms like those of a falling of the womb. Although the womb is growing larger, the lower part of the abdo- men does not become larger. On the contrary, the early sinking downwards of the womb causes the hypogastrium, in some cases, to be less protuberant than before the conception, and hence the French proverb, " A ventre plat Enfant il y a." These signs of falling of the womb in women who are married, should be ever by the physician held in suspicion, until he has full reason to believe that they are not results of an early pregnancy, and there is frequently no little embarrassment for him in coming to a positive conclusion. Even the vaginal taxis cannot, in all instances, give him an assured ground of opinion, since the engorgement of the uterus, so frequently coincident with its prolapsions, are with dif- ficulty to be distinguished from the augmented volume of the same organ arising from gravidity. The reproductive organs have a direct connection with the cerebro- spinal and the ganglionic system of innervations. There is, therefore, no part nor parcel of the economy, into relation with which it cannot, under certain states of health, be brought. They are among the most powerful disturbers of the complacency of the organisms. They con- stitute an imperium in imperio, whose behests are not to be dis- obeyed. These organs can disturb the brain — the respiration — the digestion — the circulation — the secretions — the nutrition. When the womb has become the seat of an advancing gestation, and feels the impulse of development, the complacency of the other innervations is discomposed. The stomach is one of the organs ear- liest to be called into consentaneous distress. The sympathy of the stomach is, in general, independent of any marked change of the tem- perature, and of the rate of the arterial pulse. It is expressed by anorexia — by nausea, and oft-times by vomiting. Probably the sali- vation, which is also a common symptom in pregnancy, is one of the PREGNANCY. 165 same category of disturbances — as is also the sore-mouth of pregnant and suckling women. Multitudes of women suffer from nausea only in the morning hours, the sympathy being interrupted by the business, the preoccupation, and the fatigues of the day, to return again on the following morning and follow the same course. In others, the nausea is perpetual — and attended with the most obstinate vomiting. A young woman, under my care, vomited very soon after the con- ception. She vomited every day, and many times daily during the whole course of her pregnancy. When her labor came on, which was a fierce one, her disposition to vomit was greatly aggravated with every renewal of the contractions. To such a height did this symp- tom rise that I found it seriously to contravene the intent and purpose of the labor pains. It is not a good practice, in general, to rupture the membranes of a primipara ; but in this instance I concluded, that if the ovum could be allowed to discharge the waters, the condensa- tion of the womb that would follow might put an end to the vomit- ing. I thrust my index finger through the distended bag of waters at the next pain. From that moment the nine-months' vomiting ceased and returned no more. The labor, no longer delayed and contravened by the troublesome vomiting, hastened to a favorable conclusion. When the student, having finished his early studies, shall have ad- vanced to the higher grade of the scholar and counselor, he will meet with numerous occasions to feel astonished at the perverseness of the nausea and vomiting of pregnancy, as well as the enormous discharges of saliva protracted through weeks and months of distress. I attended a lady in Spruce street, a few years since, who, during nearly three consecutive months, appeared to vomit up every particle of her ingesta. It was her own opinion, coincided in by her friends and attendants, that the total amount of all her food and drinks re- turned very soon after they were swallowed. Although she felt much weakened, I could not perceive that, under this process, she lost her flesh, and in the end, she gave birth to a healthy daughter. It is apparent that she must have been nourished during this time — but the manner, and the quantity, have remained ever since a mystery that I cannot explain. I cite this as one case only out of a great number that have occurred in my practice. In my Letters on Females and their Diseases, p. 483, is the account of a case of vomiting from pregnancy, which brought the woman's life into great peril. I made the first note of her case in my case- book, Sept. 18th, 1842. She had then been vomiting since the first 166 PREGNANCY. days of April. She assured rue she had rc-mited more than thirty times daily, and her mother, a prudent, sensible woman, said that she had vomited more than sixty times a-day. This vomiting ceased upon the use of large quantities of champagne. Upon some impru- dences in exercise and diet, the vomiting returned, and continued until the child was born. She was frightfully reduced — to such a degree, indeed, that at the eighth month I was nearly decided to bring on premature labor. Certain motives having dissuaded me from that step, she finally was delivered and recovered her health. Now, such a case of vomiting ought not, by the Student, to be regarded as a case of sympathetic disturbance of the stomach merely. It is true that the earliest manifestations of the gastric disorder are attributable to sympathy with the womb ; but when the malady has attained so fearful a height, it becomes itself the primary disorder, and cannot be correctly explained but as an actual inflammation of the stomach and duodenum, with grave derangements of the circu- lation and secretions of the liver itself. This woman discharged im- mense quantities of brown, ropy mucus, often charged with red blood. The epithelium of the stomach and duodenum was unques- tionably in many places removed, leaving the corpus mucosum bare, or raw. If I had fulfilled my design to bring on a premature labor, I should not thereby, perhaps, have cured the gastro- enteritis; but by removing another and considerable cause of constitutional disturbance, her con- stitution would have been earlier left at liberty to recall the gastro- duodenal and hepatic tissues to their wonted rates of vital activity. The woman did, in fact, recover after the birth of her child. If the digestive organs are susceptible of such great deviations of their activity as those I have above mentioned, they will, a fortiori, be liable to slighter manifestations of derangement; as by acidity, eruc- tations, flatulency, and irregular action of the bowels, either as cos- tive or as the subjects of diarrhoea. Many of these troubles vanish while the woman takes exercise in her carriage or on foot; because, as before said, the powers of the constitution, when devoted to the purposes supposed in every case of active employment, are not liable to be checked and diverted by a patible consent of the stomach with the womb. Hence such women should be advised to walk or ride, or to busy themselves with their affairs, and avoid a sedentary and slothful life. The acidity and eructations, and the diarrhoea or costiveness of pregnancy may be obviated by the use of alkalies, whether soda or PREGNANCY. 167 potash, magnesia, lime, or ammonia. Some vigor maybe communi- cated to the gastric innervations by means of champagne; or by brandy and water, rum and water, or by certain of the bitter spirit- uous tinctures, combined with aperients. I readily cured a case of this sort, in the spring of 1848, in a person who had suffered great distress from vomiting, cardialgia, flatulency, and constipation. She had a mixture composed of sweet tincture of rhubarb tw T o ounces, and tincture of gentian one ounce. A dessert- spoonful of this medicine, taken once a day, dissipated all the symp- toms. Two drops of tincture of aconite, in a tablespoonful of water, may be given for the dose, in certain of the cases, with marked relief. Many of those examples that consist of nausea and vomiting during the early part of the day, but which cease after the meridian hour, may be set aside by the following method : — Let a cup of coffee, with a toast, be brought to the bed-side at the earliest morning hour. The patient should be called from her sleep to take this preliminary breakfast, without rising from bed. As soon as it is taken let her lie down to sleep again, if possible. It appears useless to offer a rationale of this method. I am very confident, however, that, in a considerable number of persons, it will be found to put a sudden stop to the vomiting, as well as to the nausea. Certainly, many of my patients have been speedily, as well as permanently cured by it, and that in very distressing instances of the nausea. Inasmuch as the gravidity of the womb enables it to disturb the alimentary organs in the manner above mentioned, it might reason- ably be inferred that the rest of the nervous mass is also liable to interruption of its regular action, from similar causes. In regard to the temper and disposition of the woman, considerable modifications are sometimes observable. Those who are by nature amiable and gentle, become peevish, and fretted by trifles — full of false alarms and idle fears; while persons naturally ill-tempered, become charitable, and kind, and courageous. Strange desires, longings, wishes for extraordinary, unprocurable, or disgusting kinds of aliment, are said to arise in pregnant women; but in a long clinical practice I have never met with any examples of the sort ; which leads me to infer that these longings are more frequent in the books than in the practice of our art. Quickening. — The child acquires a power of slight muscular mo- tion at an early stage of pregnancy; but, as it is defended by the 168 PREGNANCY. decidua and the membranes, and floats in an abundant liquor amnii, the first feeble motions of its body or limbs cannot make themselves felt, through so many coverings, by the living tissue of the womb. In general, the embryo attains the age of four months and a half be- fore it becomes sufficiently large and strong to make itself felt by the mother when thrusting with its feet or hands, or when suddenly re- dressing its body from its usually flexed position. When the child hath first acquired this power to make its motion felt by the mother, it is said to be quick with life, or to have quick- ened, and the event is called the quickening. The lawyers have looked upon a child quick with life, as worthy of the protection of the laws ; for it is felony, maliciously, and with evil intent, to kill a child that is quick with life in the womb, but not felony to kill one that is not quick with life. It appears to me that there is here a distinction without a difference; for the child of six weeks or of two months is as essentially quick with life as one of five or seven, or even of nine months. It is to be hoped that this barba- rous and ignorant distinction, a remnant of early legislation, may be done away with by our modern legislatures, and that the wretches who for hire lend our art to the detestable baseness teneros avellere foetus, may be liable to condign punishment for the crime, committed at whatever stage of the gestation. It was formerly proposed to explain this occurrence of quicken- ing by supposing that the womb just at that time, having grown too large to remain in the cavity of the pelvis, suddenly escapes from it into the free abdomen above, and that the suddenness of its rise and intrusion is the cause of the first sensation. But I conceive that no one now adopts such an opinion. X As the ovum grows larger day by day, so doth the womb continue to expand, adding molecule to molecule, weight to weight, and mass to mass. The lower belly becomes visibly protuberant, and the swelling is one fashioned upon the pear-shaped womb that lies beneath and pushes the belly outwards. The Student should remember that other bodies besides the womb may cause the abdomen to enlarge — ■ but that no object save the uterus itself can give to the hypogaster its peculiar gravid shape. The form of the hypogastric tumor dependent on the state of gravidity, furnishes to the physician a very useful means of diagnosis, which ought not to be neglected in some of the difficult cases ; cases in which it is a matter of extreme consequence to individuals that no mistake should be made as to the real nature of the symptoms. PREGNANCY. 169 The navel is, in the non-gravid woman, a deep depression or dim- ple. This depression is caused by the contraction or shortening of the remainders of the two umbilical arteries and veins, which, after the birth, draw the skin inwards and downwards to make the pit of the navel. In the gravid woman, when the six months are past, the navel rises to the general level of the skin — and, as the womb grows larger in its progress, the umbilicus protrudes, because the ligamen- tous remainders of the umbilical vessels, wdiich are deployed with the rest of the teguments, can no longer draw it inwards. A pouting of the navel is, therefore, one of the consequences and signs of a preg- nancy of six and more than six months advanced. Other tumors also make the navel to pout. Sometimes it happens that the gravid womb fills up by its bulk the cavity of the pelvis so much as to produce cramps in the legs, by pressing too firmly upon and obstructing the sacral and obturator nerves. There is no remedy but patience and time. When the womb has got fairly up into the cavity of the abdomen, it lies in front of the convolutions of the intestines ; even the transverse colon lies rather behind the upper part of the fundus; so that, when, in a gravid subject, the abdomen is laid open, nothing is to be seen but the uterus in front. The edge of the right lobe of the liver, or a segment of the greater curvature of the stomach, the omentum, and colon lie upon the top towards the reverse of the fundus uteri. In this situation it is impossible for the bowels to receive, in the same manner and degree the stimulating and natural succussions of the abdominal muscles that they receive under ordinary circum- stances. Those succussions are constant provocatives to a healthful activity of the peristaltic force, and are essential thereto. The failure of them tends to render the peristaltic motion languid or torpid, and therefore costiveness is a very ordinary state in advanced pregnancy. Let the Student reflect upon the evil effects of such torpor, in over- loading the alimentary tube with the undischarged residuum of the digestion, by which the tension of the abdomen is increased, and the mesenteric and hepatic circulations and innervations brought into disorder, which ought to be corrected by the proper remedies. As the womb approaches nearer to its term of gestation, the reten- tive faculty grows gradually less, from the deploying of the upper part of the cervix, which becomes a part of the general cavity for the accommodation of the ovum. The expulsive faculty makes frequent efforts to overcome the antagonism of the cervix. These efforts, which doubtless lend a chief aid in the act of deploying the cervix 170 PREGNANCY. uteri, are to be detected in the alternate hardening and softening of the globe of the uterus under the hand placed upon the abdomen. If the hand be placed upon the abdomen, it may be that the impression will first be received of a great softness and pliability of the textures; but, upon keeping the palm in situ, the tumor begins to grow harder and harder until a very condensed condition of the organ is produced by this tonic contraction of its muscular tissue. These contractions are not productive of the least pain or any dis- agreeable sensation, save a feeling which women designate as a " drawing" sensation. One feels surprised, sometimes, upon observ- ing the very positive force of these contractions, to hear the woman say that they produce no pain in the back or hypogastrium. These contractions are repeated very often during many weeks. The effect of them is to reduce the cylindrical neck of the womb to the shape of a cone — or rather to the form of the lesser pole of an egg, and to make the os tincse acquire a circular instead of its usual oblong or oval form, and to render it a dimple or a pit in the apex of the now oviform uterus. When this dimple has become completely de- veloped by the resolution of the cylindrical into the conoid al cervix, labor is ready to begin, and the next repetition of the contraction might justly be accounted as the first pain of the labor, for the labor pain is nothing else than contractions of the organ in which the ex- pulsive faculty tends to overcome the retentive faculty, and thus free the uterus of its contents, by thrusting them forth into the vagina, and thence into the world. The uterus rising upwards in the cavity of the belly finally attains the length of full twelve inches. I measured the gravid uterus at term, in an individual who died suddenly before the onset of labor, during the present month of June, 1848. It was twelve inches long, and eight inches in transverse diameter. The broad ligaments rise, of course, as the womb rises ; and the ligamenta rotunda, which, ex- tending from the internal abdominal rings to the angles of the uterus, ought not, in a normal state, to be more than two and a half to three inches in length, by the mounting upwards of the uterus towards the scrobiculus cordis, at last acquire a length of five or six inches at least, serving to stay or steady the womb as it goes up, and on occa- sions, tending to render it oblique to the right or left, in proportion as the right or left ligamentum rotundum is the readiest, or the most re- luctant to yield, as the womb rises and compels it to accompany the ascent. I call the attention of the Student to this condition of these liga- PREGNANCY. 171 ments, now, in order that he may in this connection clearly under- stand that if the round ligaments should not diminish their own longi- tude pari passu with the lessening of that of the womb after labor, and if they should continue elongated, or weak and relaxed, after the womb has returned nearly to its non-gravid dimensions, then the womb, having no support to prevent it from falling backwards, will be liable to dip its fundus below the promontorium, and be overset backwards, or retroverted. Whenever this accident, happens, it is attributable to a fault of the round ligaments, and to nothing else; since, with round ligaments two and a half inches in length, the fun- dus could not possibly retreat far enough from the symphysis pubis to admit of the state of retroversion. Let the Student early learn that one of the common accidents of the lying-in state is this very accident, the non-contraction of the ligamenta rotunda — and let him carefully estimate the effects, as to obstruction, pain, bearing down, and gene- ral disturbance of the health, likely to arise from the accident in ques- tion. While he is ignorant of these simple facts in pathology, he will permit his patients to suffer needlessly ; but, well informed on this point, he will surely obviate by his precautions much sore dis- tress. The accident is by no means an uncommon one, after abortion at the third or fourth month. In such instances, when the woman is found to complain of pain in the back, and within the pelvis, with urinary and rectal tenesmus, and be confined to the bed, instead of readily recovering, as she might be expected to do, after a few days, let the Student look to it, that he make a full exploration for the estab- lishment of a sound diagnosis. It is proper that I should now recur to the consideration of the development of the foetus, and explain its nature as a part of the doctrines appertaining to the subject of pregnancy. In doing so, I cannot avoid speaking of the appendages of the foetus, for the secun- dines, though attached to the new being, and perhaps strictly to be considered a part of it, are yet in a degree to be regarded as an ex- trinsical and accidental, or transitory apparatus. When the Graafian follicle, in completing the acts of ovulation, bursts, and discharges its yelk into the infundibulum of the Fallopian tube, the ovulum falls off free and unconnected with any part of the maternal tissues. It is no more connected with the living parent that produced it, than is the bud that is carried by the gardener a dozen miles from its original stock to be inoculated into another tree ; yet, like it, it is a living, independent and vigorous being. The ovulum passes along the canal of the Fallopian tube, aug- 172 PREGNANCY. menting as it goes. The vector tube discharges it into the cavity of the womb, where the greater portion of its orb is enveloped in the deciduous mass, leaving a segment only of its superficial spongy mass to seek a perfect contact, and establish a union with the living wall of the maternal tissues. At first it remains unattached, but in process of time it becomes fixed to some point of the surface, the outer face of its tufted chorion attaching itself to the inner surface of the uterus. This fixation constitutes what is called conception. Probably the spongioles or tufts of the chorion extend themselves, like the roots of a plant in the soil, into the softish deciduous mass that the womb has prepared for the purpose. It is only that segment of the orb of the ovum that looks directly towards the uterine wall which it touches, that preserves the tufts of the chorion which rise everywhere in equal abundance from the whole ball. The rest of the chorion covered by the decidua reflexa soon loses its tufts, and becomes smooth and polished like a serous membrane, save here and there a few remaining tufts or spongioles that may be detected, in cases of abortion, as late as the fifth month ; as in a sample in my collection, and as was the case in Win, Hunter's specimen described in his table x, fig. 4. The nature of the connection thus formed is the subject of great differences of opinion, that have not been settled by the authority of John Hunter, who first proposed a rational explanation of this difficult point, in his article on the placenta, which may be consulted in his volume of papers on the Animal Economy. According to Mr. Hunter, the placenta is a symmetrical organ, consisting of two parts, one derived from the womb, and the other from the child. Seller, in his work Die Gebatirmutter, und das Ei des Me?ischen, stoutly denies that the placenta belongs to the mother, and Velpeau,in his Ovologie ou Embryologie humaine^. 65, says: "Et j'ose affirmer avec plus d'assurance que jamais que le placenta humain est entierement foetal." I declare, with greater confidence than ever, that the human placenta is entirely foetal. While the celebrated Velpeau thus resolutely rejects the Hunterian doctrine that there is a uterine portion of the placenta, other very eminent persons equally insist that an important portion of the mass is actually derived from the womb ; and that whenever it is extruded by the contractions of the organ, not only is the foetal portion expelled, but the whole of the uterine portion, being detached at the same time, comes off with the foetal half; from which, indeed, there is afterwards PREGNANCY. 173 no possibility of separating it, nor even of distinguishing them, the one from the other. I here venture to remark, that this is not pretended to take place in any other animal; certainly not in the ruminants, in whom the ute- rine cotyledons and placentules separate completely from each other, the womb keeping its own organ, and the embryo carrying its portion away with it when expelled. I may here ask whether it is probable that so great a difference does really exist in the warm-blooded, respir- ing mammals, of which man is one species? Prof. Owen, of London, is one of the distinguished, eminent natu- ralists who contend that the placenta is constituted of materials, part of which belong to the mother and part to the ovum. Mr. Owen says that, after having carefully compared the Hunterian preparations with the results of his own examinations of the gravid uterus at full period, "I now believe they all fully bear out Mr. Hunter's general view, viz., that the maternal blood is diffused, by means of the tortuous arte- ries, into the spongy cellular substance of the placenta, where it bathes the capillaries of the foetal circulation, and is returned by the oblique decidual adventitious sinuses and channels into the orifices of the ute- rine veins." Vide note in Hunter on the Animal Economy, p. 102. M. Flourens, Professor of Comparative Physiology at the Jardin des Plantes, says, in his Cours sur la Generation, p. 130, that the umbi- lical vessels of the mammifers, which everywhere pierce the chorion, in order to come at the internal surface of the womb, are called pla- centas. The placenta is an inherent characteristic of viviparous pro- duction. It cannot, therefore, exist in the oviparae. Mr. F. divides the mammals into two great classes, one of which comprises man, the rodentia, and the carnivora; while in the other class are arranged the pachydermata, the solipedes, and the ruminantia. In the first class, he contends, there is a vascular inosculation of the mother's vessels with those of the ovum, whereas no trace of such vascular union can be detected in the second. I have cited this distinguished physiologist in order to show his opinion ; but I am far from advising the Student to adopt it upon his authority. His assertion that the placenta is a characteristic of vivipa- rous production, is denied by high authority; and notwithstanding I am prompted to agree with him, I admit that the most careful research has never enabled me to discover the least trace of a placenta in the early marsupial embryon, as I have stated in my paper on the Didel- phis, in Amer. Phil. Trans. Mr. Owen's assertion in regard to these differences in the classes, 174 PREGNANCY. is as follows: — "Thus the placental intercommunication between the foetus and mother, in the human subject and quadrumana, is carried on by the contact of the foetal capillaries with maternal extravasated blood; while in the ruminants, the mare and the sow, it takes place by the apposition of capillaries to capillaries, and the two parts of the placenta, viz., foetal and maternal, can be separated. In the ferae and rodentia there appears to be an intermediate structure." Loc. cit. Let the Student, while pondering upon these propositions of Masters in our science, observe that, though the separation of the placenta in child-birth is essentially hemorrhagic, and not so in the parturition of the quadrupeds, which might lead to inferences in favor of a different plan of union, yet organs of such vital importance in the economy of the genera are not likely to be modeled upon plans absolutely differ- ent in creatures so nearly allied in their great types. In all the mammifers there is one type for the brain and nerves, one for the respiration, one for the circulation, one for the absorption, secretion, reproduction, &c, and there should, a fortiori, be but one for the great and indispensable branchio-absorptive apparatus of the foetus. Fabricius ab Aquapendente says the chorion or the umbilical vessels dispersed throughout the chorion, may be applied in two dif- ferent ways, of which one is by the mutual inosculation of the terminal branches of the umbilical vessels with the uterine veins; and the other is by the termini of the umbilical vessels plunging into the fleshy substance, like roots into a soil. Fabricius, Opera Omnia, fob p. 42; Lips., 1687. I might devote many of these pages to a relation of the various con- jectures and explanations contained in the Medical Library upon the subject of the utero-placental connection. The discussion between Eschricht and Weber — the elaborate researches of Breschet, of Vel- peau, Flourens, Coste, BischofT, &c. &c, might afford abundant ma- terials of citation ; but as I wish to give my own views as to a common property in the Republic of Letters, I prefer that the Student or Scholar should refer to those writers at first hand, and meanwhile to express my own sentiments upon the points under consideration. No one, I should suppose, can, for a moment, doubt that the pla- centa is the agent of nutritive absorption, at the same time that it affords to the embryo the sole means of its oxygenation ; nor, that oxygen is as essential as the alible material to its existence and growth. In order to the effectuation of these two prime objects, there must be contact of tissues belonging to the independent foetus, with those PREGNANCY. 175 of the parent; and as the foetus itself is completely separated from the mother by its interposed chorion, amnion, decidua, and waters, it must develop an apparatus, by means of which to project its blood far beyond the limits of its own body into a system of placental capil- laries. It is to be supposed that, in these capillaries, the blood gives off carbon and receives oxygen, either after the manner of lungs, or branchise; and, at the same time, drinks in, by endosmose or by real absorption, the fluid materials, out of which to maintain and augment its own crasis and sum. In this apparatus for projecting the blood of the foetus beyond its real limits, and bringing it back again augmented and oxygenated, the aorta, as I have already said, divides into two umbilical vessels, which, running outwards along the cord, subdivide at its extremity into myriads of arterioles and capillaries, which, constituting numerous tufts or branches connected together by a loose cellular tissue, is called the placenta. These capillary tufts, wherever they may be attached, are placentas. In the human placenta, and in those of certain quadrupeds, all these placental tufts are united into a single disc, cake, or placenta, as in the adjoining fig. 57, which shows the uterine surface, where the lobules of the placenta are seen divided by the lines of the septa. These lobules are very numerous; and if, instead of being assembled in one disc, they were disseminated over various parts of the womb, the analogy to the ruminant organ would be greater. Fig. 58 ex- Fiff. 57. Fig. 58. hibits the foetal surface of the placenta. The umbilical cord contain- ing its two arteries and its vein, is seen reaching the placenta at its centre, and dividing its vessels into numerous branches, which radiate towards the circumference. In other animals, as the ruminants, the 176 PREGNANCY. tufts are separated from each other and distributed to different parts of the chorion, so as to make a great number of placentas. In certain other genera, the tufts consist of zones, surrounding the oval ovum, or they are scattered everywhere like a paste over the entire super- ficies of the ovum. I have counted one hundred and twenty placentas upon the chorion of a cow. Now, it happens that, when, in a quadruped, these variously formed placentas are detached in the act of parturition and expelled from the womb, no blood follows the detachment — nor do we ever hear of the uterine hemorrhages in the mammifers that so frequently in the wo- man render labors alarming and dangerous. Yet, the foetus of the larger quadrupeds is evolved and completely nourished by an appa- ratus which, to be capable of supplying it w T ith alible matter and oxy- gen, might be deemed to require at least as absolute a union of the uterus and placenta as is contended for by Hunter and his advocates, as to the human organ. It is said that the fcetus of the whale is up- wards of twenty feet in length at term. To develop so enormous a product, one might well suppose a union as close as that in the human embryo, which is only eighteen inches long, and of the weight of seven pounds. It is not pretended, however, that the parturition of the mysticetus is hemorrhagic; nor that there is a deciduous coat of the womb that is converted into what Hunter calls a maternal placenta. To develop an embryo is, therefore, a possible power, independent of a vascular union or a maternal placenta. Those, therefore, who contend for the truth of the Hunterian explanation, do so on the ground of a supposed fact, and not on one of a necessity. But, as the largest mammal foetuses do not require it, it would appear to be reasonable, at least, not to adopt the theory in man, except upon anatomical conviction. The placentules of Fig. 59. ■M0WL. the ruminants consist of very large villi which interlock with similar villi, or rather, digita- tions that rise up from the cotyledons on the inner aspect of the womb. I add here in fig. 59, a view of them in which the placentule is seen drawn out of the cotyledon. PREGNANCY. 177 Let the Student procure from the butcher's shambles, the gravid uterus of a sheep or cow, and carefully separate, one by one, the one hundred and twenty placentas from their one hundred and twenty uterine cotyledons, and let him judge whether or no there is, or ever could be any vascular union between them, and whether the womb furnishes any portion of the placental mass that is throw T n off in par- turition. If he repeats the same experiment as to the sow, the rat, the rabbit, the bitch, and the mare, he will be surprised afterwards to contemplate the drawings and representations, in the books, of the microscopic appearances discovered in the human placenta. The engravings, for example, in Breschet's w>ork, will seem to represent rather the imagination of the artist than the truth of nature ; and I may make the same remark as to Ritgen's beautiful picture in his Beitrage, and to Dr. William Hunter's nineteenth plate. To possess a gravid womb at term, and to enjoy an opportunity to examine it carefully, is to be what Noortwyck calls rarissimum hocce spolium mactus. Even in London, Professor Owen appears to have w T aited long before obtaining such a privilege. I have enjoyed but few such opportunities during a long course of business in a great city. Those I have had were as carefully im- proved as my means would admit; and as I must confide in myown, rather than in other men's senses, I find it impossible, under my own observations, to adopt the views of the Hunters, and I prefer the opin- ions of Seiler and of Velpeau. One ought not lightly to dissent from such authorities, nor is it without a sentiment of profound respect for the Hunters, that I claim the privilege to see with my ow 7 n eyes, in a matter so authoritatively determined by those great benefactors of Medicine. In w T hat is called Deliverance, the whole placenta comes off from the womb. As a general rule, it is separated from its sessile position on the vault of the fundus, by the same pain that chases the buttock of the child into the vagina, and is completely extruded from the genital fissure in about ten minutes. Sometimes it is expelled within twenty minutes after the ■/ommencemeni of a labor. I have removed a vast number of placentas without staining the hand w T ith blood, or perceiving a drop upon the mass itself. The placenta comes off with equal readiness at the third, fifth, or the ninth month, showing that no other action of the womb is required for its expulsion than that of its muscular tissue, and that all times* and stages are indifferent as to the facility. I find that, in dissecting the gravid womb at full term, the slightest 12 178 PREGNANCY. traction suffices to remove the placenta from the surface where it had ever before enjoyed an undisturbed attachment ; and that, too, very soon after death. I am convinced that the connection may be broken up even by puffs of air from the blow-pipe; and that it is not more adherent than is the peel of a perfectly ripe orange to the fruit. Can it be that the womb may exfoliate its half of the placenta with such amazing facility, and that, too, in all the stages of pregnancies. Do these facts consist with the idea that arteries pass from the womb into the placenta? Are other arteries broken so easily? I have already mentioned, at page 170, the case of a lady who died here in June, 1848. In that necroscopy, in presence of Dr. Yardley and Dr. Wallace, I detached the whole of the placenta from the womb, after the careful injection made of the aorta by Dr. Wallace, an ex- pert anatomist, who had secured the external iliacs before throwing the injection into the trunk. Neither I, nor those gentlemen, upon the most minute and careful search, aided by good lenses, could verify the existence of even a single vessel passing from the womb to the placenta. Much of the injection was effused into the cellular meshes of the placenta. It was an infiltration of the material, and not an injection, in the anatomical sense of the term. We arose from the dissection, equally and unanimously convinced that we had not seen a single vessel broken off, or pulled out, in the slow, gentle, and most careful divulsion of the two utero-placental surfaces. This examination was made within less than twenty-four hours after the demise of the lady. During the epidemic of cholera here, I examined a womb within a very few hours after the death of the woman, in company with the late Dr. J. Hopkinson, then prosector at the University of Pennsylvania. He, though an able anatomist, was unable, as I was, to detect anything broken, save mucous tractus, though the light and the glasses were good, and the most scrupulous care was used, without precipitation or rudeness in the operation. A similar opportunity was enjoyed, a few years since, at the Penn- sylvania Hospital, in a womb gravid with twins. Here, also, I de- tected nothing but mucous tractus. Another very fine specimen, at the seventh month, was afforded to me by Professor Pancoast at the Jefferson College. In this case, many medical students observed the divulsion of the surfaces without detecting any vessels. These are the opinions I adopt — but when so many explanations abound, who is he that can feel perfectly assured of the soundness of PREGNANCY. 179 his own ? There is perhaps a strong argument against these opinions which I conceive it a duty to state ; for that which I desire is, the truth. The argument may be presented as follows: The lining membrane of both veins and arteries, w T hich Bichat calls membrane commune, and which by Burdach is denominated endan- gium, is the true blood-vessel, the fibrous and elastic coats being mere additamenta and fortifications of the genuine blood-vessel. In the depths or interior of the viscera, the endangium is applied directly to the gangue of the viscus, which gives to venous sinuses the appearance of mere cells or cavities, particularly in the womb, where they are in some instances as large as a finger. It is a faculty of blood in motion, to make a channel or vessel for itself, which vessel is found to be lined with endangium. As the womb expands in pregnancy, the orifices of vessels upon its inner wall become more and more capacious, and possibly the endangium of some of these orifices may be extended, forced, driven, or deeply impressed among the delicate spongioles and tufts of the chorion, giving rise to the appearance of vascular cylinders plunging into the placenta, or passing from it to the womb, and thus uniting the two surfaces, uterine and placental. To examine Wm. Noortwyck's, Hunter's, Lee's and Ritgen's plates, is to perceive that the number of these communications, if they really exist, (and I have never been able to detect them,) cannot, from their fewness, be supposed to exert any conformable influence upon the great branchio-absorptive operations of the mammal placenta. Hence, I con- clude, that where such endangial tubes have been detected passing across the surfaces, their existence has been accidental, and that they do not exist as a normal indispensable part of the machinery of the organs. I repeat, that if arteries and veins were naturally existent in this place, the divulsion of the surfaces in labor, or artificially, would require a force far exceeding that wdiich is usually required to effect their separation. As to the idea that the blood of the uterus is freely poured into the cellular meshes of the placenta, (an act of absolute extravasation,) and that the placental capillaries acquire their oxygen and plasma from being bathed with that effusion — I can by no means adopt it, seeing it is contrary to all analogy in any conspectus of the circulation. Blastoderm. — The child continues in the womb during nine months, or two hundred and eighty days, according to the common computation or reckoning. This is the length of time required for the 180 PREGNANCY. evolution of all its parts, which may be supposed to have existed in potentid in the ovarian germ. At the commencement it was a mere membrane or blasto-derm, so called from jSxaero? a germ, and s?^a skin, commonly called germinal membrane. This is what, in the hen's egg, is called the cicatricula or the tread, and is supposed to be divisible into three layers or strata, of which the inferior, or that which looks inward towards the centre of the yelk, is the mucous layer, the outer one the serous layer, and the middle or interposed one the vascular layer. The mucous layer is deemed to be the basis of the digestive tube, the serous layer is held to give origin to the skin and muscles, &c, and the vascular layer is devoted to the development of the heart and circulatory apparatus. Such is the doctrine inculcated by some of the writers on Embryo- geny. We have seen that the mammal ovum is microscopic, and that the vitellary ball is thrust forth from the ovi capsule, seized upon by the Fallopian tube, and, as is supposed, deposited in the course of about eight days, in the cavity of the womb. By the time it reaches the womb it has acquired considerable additional volume, and very shortly aferwards is found to be a visible and palpable mass, already covered with its villi of the chorion, as in Velpeau's figure 1, repre- senting an ovum of eight or twelve days, in his first plate. Microscopy has not hitherto revealed a double coated capsule of the vitellary granules and corpuscles, but certainly only a few days elapse after the fecundation, before we may discover that the vitellary mem- brane, now become chorion, contains within it another vesicle or membrane called the amnion, in which is enclosed the embryo, with the waters and the cord. The heart of the embryo is early developed first as a straight pul- sating cylinder or artery which is afterwards bent, and finally con- verted by its morphological laws into the complex organ of the warm- blooded circulation. This heart drives the blood into the embryonal sarcode, wherein the blood makes its own channels, which, as they be- come complete, are blood-vessels. As the blood advances, the sub- stance is converted histologically, and becomes tissue, for "the blood is the fluid body? and the body the fixed and rigid blood," to reiterate the fine saying of Oken. Thus the blood creates the organs. Allantots. — Among other organs it creates the allantois. This is a small vesicle or bladder which rises from the pelvic extremity of the embryo, and springing forwards from the still open belly, proceeds be- PREGNANCY. 181 twixt the outer chorion and the inner amnion, to enlarge and to attach itself to the chorion, carrying with it the blood-vessels which create it, and which are umbilical arteries which it applies by their distal extremes to the inner aspect of the chorion. This chorion they pierce, and goto seek an attachment, as placental tufts, to the inner wall of the womb. This bladder is the allantois. When the belly of the embryo becomes closed in, this bladder becomes strictured at the navel and in the trac- tus of the umbilical cord. The narrow strictured part of the vesicle is now a long cylindrical tube. The part retained within the now closed abdomen is the bladder of urine; the long cylindrical part is the ura- chus, and the outer expanded, or, to speak correctly, uncompressed and unstrictured portion is the allantois. The urine secreted in the kidney passes by ureters into the bladder of urine, and in the early stages of uterine life flows through the urachus into the bag of the allantois. Thus the allantois maybe said to be a bladder or vesicle, upon which the umbilical arteries climb towards the wall of the womb to attach themselves there. The word allantois should, according to Kraus, in his Lexicon, be allantodes. Its Latin equivalent is farcimen, of which the English translation is sausage, or gut-pudding. The ear- liest description of it was given by Galen, who evidently took it from the investigation of the ovum of the ruminants, in whose horned womb the allantois is a remarkable and most obvious organ which lines the interior of the whole chorion, and passes through or pierces its two ends to go to fill up the cornu as far as possible. No more correct description can be found of it than in M. Flourens' Cours sur la Generation. By many its existence in the human ovum is wholly denied; yet it. is asserted that in very early stages of foetal existence, injections into the urinary bladder of the embryo can pass along a urachus in the cord and go to be effused betwixt the amnion and the chorion : certainly it is by no means demonstrable in any advanced state of human pregnancy, as the Student will experience whenever he shall have an opportunity to dissect the aborted ovum, or inquire into the appearances of the secundines thrown off in an easy natural labor. Umbilical Vesicle. — The human yelk, as I said, is a microscopic globule filled with vitellary corpuscles. When the blastoderm has partly undergone the morphological change that converts it into the earliest rudimental embryon, part of the yelk corpuscles still remain unappropriated; and, as they are still contained in their original vitel- line membrane, they constitute a small but visible ball called the urn- 182 PREGNANCY. bilical vesicle. This vesicle opens into the intestinum ileum of the embryo by means of a long pipe or tube called the omphalo-mesenteric duct or vitelline duct. Velpeau says that the yelk matter contained in the umbilical vesicle can be pressed along the tube and through it squeezed into the gut. It is supposed to furnish a pabulum to the early embryo, but is lost after the fourth month ; for, by that time the amnion has grown so considerably as to fill up completely the cavity of the chorion; wherefore the umbilical vesicle being squeezed flat betwixt the amnion and chorion, finally disappears, becoming of no functional value when the child has completely established its branchio-absorptive connection with the parent. Omphalo-Mesenteric Vessels and Cord. — In perfect ova, aborted at the period of two months, or a little later, the Student will rea- dily distinguish the umbilical vesicle shining through the chorion and lying betwixt it and the delicate amniotic membrane. I add here a figure that may serve to explain its arrangement. Let a be a portion of the abdomen of the embryo, and c c the navel or umbilical ring; b b the navel string or cord laid open; d the umbi- lical vein bringing back the blood from the placenta and passing Fig, 60. L-^j '- Dr. Henry Bond, an eminent practitioner of this city, has proposed a placenta forceps for the delivery of the secundines in abortion, of which Fig. 69 is a representation. Fig. 69. Dr. Bond's instrument is ten inches in length, and so rounded that it is difficult to conceive of an operator awkward enough to pinch with it any of the parts of the mother. An inspection of the drawing suf- fices, without further explanation, to give an idea of its usefulness. While I lay before the Student these instruments for the extraction of the dead ovum, I ought to warn him against too facile a disposition as to the employment of them, and to assure him they will often disap- point his expectations, and sometimes where they do succeed, lead to evil consequences as to the mother. The ovum, in abortions, inhabits the body and fundus uteri. The cervix stands guardian as the facultas retentrix over the deposite, and reluctlantly yields it a passage. In doing so the conical neck of the womb must become a cylindrical canal, into which the fundus and corpus uteri thrust their intolerable burden. When this cylindrical canal hath received into its calibre a small ovum, or the remains of one, it has, of itself, little or no power of expulsion, but merely grasps the ovum and holds it fast. It holds it sometimes for many days. I have found it to hold the ovum in this manner for many consecutive days, because the very os uteri would not let it escape, refusing to yield, chiefly perhaps because no dilating pressure was applied. In the long run it yields, the os tincse becomes wide open, and then, a bearing down effort, a fit of coughing — or 216 PREGNANCY. — ABORTION. — TAMPON. straining at stool or urine drives it forth into the vagina. Now, until the canal has become truly cylindrical, Dr. Bond's forceps and Dr. Dewees' hook are not to be employed without much care and gentle- ness. For the most part it is better to wait until all is prepared and then remove the object with the index finger. In those cases in which a proper attempt to extract the debris of the ovum has failed, those who like the support of high authority may console themselves by referring to Puzos, who at page 193 says that " eette terminaison est bien moins effrayante; mais elle est bien plus longue; jai vu de ces fontes durer six semaines a deux mois; et pendant tout le temps, ou les vuidanges sont si foetides, jai vu ces fernmes tourmentees de fievres irregulieres de degouts et d'inquiet- udes." He thinks these cases ought to be left to nature. If, upon making examination in abortions, the state of the cervix is found to be unfavorable to the speedy expulsion of the offending cause, and the hemorrhage be not too threatening, recourse may be had to the application of napkins, wrung out of cold vinegar and water, to the hypogastrium and pudenda; to the administration of dilute aromatic sulphuric acid ; to the acetate of lead, with opium ; or to the preparations of secale cornutum — as the powder, in doses of five to ten grains re- peated pro re nata, or its vinous tincture, of which a teaspoonful may be given every half hour, or at intervals of one or more hours, accord- ingly as the events of the case seem to demand. A powder consisting of five grains of alum and one grain of nutmeg may be given as a hemostatic every half hour or hour. The lancet may be resorted to, to aid, both in diminishing the hemorrhagic nisus, and in favoring the dilatation of the cervix, to which nothing contributes more powerfully than venesection. This, however, should be used with great good Tampon. — But above all the means of nutting an end to troublesome hemorrhage, I ought to applaud the tampon, or plug. This tampon may be composed of a sponge; or, what is far better, of pieces of cotton or linen cloth or patent lint, torn into squares of from two to three inches, which may be pressed into the vagina, one at a time, until that entire canal is filled and distended with them. They should be kept there by a napkin, worn as for the menstrua, or by pressure with the hand of a nurse, a napkin being interposed, until the flow is effectually checked, at least. The tampon may be allowed to remain in situ from six to twelve, or even to twenty-four hours in winter; and when re- moved, it is generally followed by the ovum, or its remains, which PREGNANCY. ABORTION. — TAMPON. 217 are frequently found attached by a coagulum to the upper part of the tampon. Should any dysury be caused by its presence, the bladder may be readily relieved by the catheter while the woman preserves a horizontal posture, which should never give place to a vertical one, until all probability of a return of the hemorrhage has disappeared. I do not understand how a woman can be permitted to die with hemorrhage, in an abortion, while materials for a tampon are at hand, since the discharge may always be effectually controlled by it. The remedy gives no pain, if properly used; and, so far as my experience of its employment bears me out, it never causes any considerable in- convenience; while, I may add, it always succeeds. A good many cases of abortion, in the early stage, as from the sixth week to the tenth week, have fallen under my notice, in which the uterus was unable to expel the remains of the ovum, and in which I could not extract it. The female, in such instances, save one, has always recovered without the ovum having been visibly discharged ; but there always was an excretion, continued for many days, of offen- sive dark-colored grumes and sanies, which I accounted for by sup- posing that the substances in the uterus had macerated and come off in a state of semi-solution, as in the instances above cited from Puzos. I think that there is no danger in leaving such occurrences in the hands of nature ; and that it is better to do so than reiterate attempts to extract by force, that have perhaps already proved quite vain ; especially, considering that there is as great danger of exciting inflammation by those attempts, as could be anticipated from the gra- dual maceration of the ovum. I am not disposed to deny that the presence of a putrefying substance, even of a small size, in the womb, is capable of developing violent inflammation and fever; but it has not happened so with me, and I have given the same opinion to some medical friends, by whom I have been consulted, without the least cause to regret having given such advice. Let me be clearly understood, however, to recommend that the last remainders of the ovum should be brought off, where it is practicable by means of any reasonable efforts to do so. I shall not omit the present opportunity for repeating, w T ith regard to the tampon, that it is not a proper remedy for those cases in which any hope is yet entertained of saving the pregnancy. Let us suppose an instance in which the placental attachment has taken place at the fundus uteri; that a partial detachment of the pla- centa has happened, and that the blood, having forced its way in a narrow stream, or rivulet, betwixt the womb and the outer surface 218 PREGNANCY. — ABORTION. TAMPON. of the ovum, has at length made its appearance at the pudendum. Nothing is more common than to see such cases of show suppressed by venesection, recumbency, an opiate, some doses of elixir of vitriol, or cold lemonade. Should any practitioner, anxious to promote the formation of a coagulum, and thereby stop the effusion of blood and save the pregnancy, have instant recourse to the tampon, what would be the consequence? The blood, instead of escaping externally, would be forced back on the ovum, while the newly effused portions of it, instead of flowing by the route already formed, would continue to dissect off or separate the ovum more and more, until the whole of it should be detached, and at last come off, enveloped in the centre of a compressed clot. To use the tampon, therefore, is to ensure the abortion ; hence it is only a remedy for the hemorrhage of abortion, and not a remedy for miscarriage, which it not only cannot prevent, but actually ensures, or renders certain. The blood which continues to flow into the womb, after the vagina has been closed by the tam- pon, may be compared to a river dammed across its channel, and whose waters, in consequence, overflow their banks, drowning the adjacent country. With regard to the tampon, I have further to add, that its employ- ment in advanced stages of pregnancy, although allowable in certain instances, demands very great discrimination, inasmuch as it is capa- ble of converting an open into a concealed hemorrhage, as we shall have occasion more fully to remark when we come to the considera- tion of uterine hemorrhage, in labor. It may, under the proper indica- tions, be with safety employed up to the close of the fifth month of gestation ; since the womb, until that period, is incapable of admitting sufficient quantity of blood to give any well grounded fears of a fatal concealed hemorrhage. But at a later stage, the capacity of the ute- rus is so much increased that the tampon, if employed at all, ought only to be used while the practitioner himself carefully observes its effects, remaining at hand to remove it in case the uterine cavity should become distended and filled either with fluid or coagulated blood to a threatening amount. I was told, not long since, of an instance in which a gentleman, treating a case of hemorrhage, after delivery, was pressingly called for to visit another woman in labor, and as he felt compelled to go, he tamponed the vagina with his hand- kerchief, by which means he effectually suppressed the apparent he- morrhage, but, upon returning shortly afterwards, he found the patient dead ; the womb having filled with blood, instead of that fluid having escaped at the vulva — just such a conclusion to the affair as ought to PREGNANCY. PROLAPSUS. 219 have been expected from the use of the tampon under such circum- stances. It has on several occasions happened to me to see the tampon inju- diciously employed in this way. Two of the persons were nearly ex- piring when I arrived and immediately removed them, and one other for whom it had been applied early in a flooding labor, without pla- cental inplantation, was expiring when I reached the house — a dread- ful case of mala praxis to which I shall recur in a future page. Prolapsus. — It is commonly thought that women who suffer under repeated abortions, are quite as much if not more subject to a conse- quent prolapsus uteri than those who are confined at full term. The natural tendency of labor is to produce a prolapsion of the womb, and that tendency must be much greater where the vagina has been much distended and pressed out of its ordinary form, than where the vagina has not been so affected. This might lead one to deny that abortions are as likely to bring on a state of prolapsus as labors at term. But those women who miscarry are, for the most part, not sick any longer than during the actual miscarriage. They generally get up, most imprudently, the next day, or in some instances even on the same day. The solid and weighty substance of the uterus now bears down the vagina, to whose upper extremity the organ is attached ; and the vagina, weakened and relaxed by the discharges of the miscarriage, and ofttimes after abortion, affected with vaginitis, makes less resist- ance than is common, so that tire womb takes permanently a much lower level in the pelvis than it ought to have. All the difficulties and embarrassments likely to accrue from this vicious situation of the womb, might be obviated by a little patience and prudence in the beginning. The woman should be warned in clear intelligible language that too early a getting up exposes her to the risk of suffering from a falling or bearing down of the womb, which may ruin her health and thereby render her unhappy for life. Unfortunately, she feels too well to believe that our words are other than useless and needless vaticinations, and so she is not willing to maintain a recumbent posture more than one or two days. It should be considered that while a woman, lying-in, is in a physi- ological state, one laboring under miscarriage is in an opposite con- dition — that she is sick, and often needs care not less sedulous than the other one requires. The womb is in fault, as to the miscarriage in some of the cases, and any man conversant with the events of our obstetric practice knows that the organ is occasionally left inflamed, or 220 PREGNANCY. RETROVERSION. hyperaemic, and irritable to the last degree. In these instances the organ is situated much as it is when affected with hypertrophy. Long continued uterine tenesmus, sanguine affluxion, enfeebling discharges and persistent pain, might well be expected to result in a descent or prolapsus, scarcely to be avoided by those who suffer frequent distress- ing abortions, and especially by those who pay not the least regard to the common sense dictates of the medical man. Retroversion. — In proportion as pregnancy advances, the womb increases in longitudinal diameter; so that if it should from any cause happen to be turned over backwards, the top of the fundus uteri would lodge in the hollow of the sacrum, while the os tinea? would be pressed upon the symphysis of the pubes, or above it. The fact of such a dis- placement being occasionally met with cannot be doubted, and the inconveniences and dangers arising from it are too numerous to admit of my passing over it here without a few remarks. Considering that the antero-posterior diameter of the pelvic exca- vation is equal to four and a half inches, it is reasonable to suppose that the unimpregnated womb cannot readily be caught under the projection of the sacrum, even if it be liable to be thrown backwards under that promontory. Yet the unimpregnated uterus is liable to be turned over, or retroverted, and retained in that false position, until the reposition of it be effected by a skilful hand. The womb is about three inches long; but as the vagina is attached by the recto-vaginal septum to the gut behind, it appears that if the fundus uteri should be caught, in retroversion, below the promontory of the sacrum, it might readily remain there, until, as above said, it should be reposited by the hand of the attendant. There is no reason to doubt that the uterus is frequently turned over backwards, but not retained; for the urinary bladder, when very full of water, extends backwards and downwards, pushing the top of the womb along with it. If this hap- pen to a woman about two and a half or three months gone with child, she will scarcely fail to have a serious retroversio uteri. There are persons who bring on these uterine deviations by a bad habit of retaining the urine until the bladder becomes over-full. Such, at least, is the opinion I have formed from inquiries addressed to the patients themselves. Some women, from a fastidious delicacy, or from circumstances of the society in which they pass their hours, fail to yield to the ordinary solicitations of nature as to the discharge of the urinary bladder, and allow that organ to become so distended that it equals the bulk of a PREGNANCY. — RETROVERSION. 221 pint or even a quart measure, before they take notice of it. So great a bulk as this occupying the space behind the lower portions of the abdominal muscles and betwixt them and the sacrum, cannot but put upon the stretch both of the ligamenta rotunda, wdiich is equivalent to the effect of thrusting the fundus uteri down upon, and even below the promontory of the sacrum. Can there be any doubt that such a habit, persisted in for years, would result in the state of retroversio uteri ? I saw this day, July 12, 1848, a young lady of 22 years of age, who has been married now ten months. She presented all the exter- nal characteristics of fine health. She has never conceived. She has a constant pelvic distress, and has suffered for eight years with the most distressing dysmenorrhcea, informing me that she has never had her catamenia without very violent pain. The menstrua are abundant and regular. She uses a dozen napkins at each period, and some- times more than a dozen. There is severe pain in coitu, which can- not be perfectly effected. I found the os tincse half an inch behind and below the crown of the pubal arch — and the fundus uteri occupied the recto-vaginal cul-de- sac. Upon causing her to turn over upon the face I readily reposited the womb — but it came down again upon the least motion. Now this person had never had any considerable illness nor met with any acci- dent. When I pressed the index finger firmly on the lips of the os tineas or on the cervix she felt acute pain, and said the pain was the same in kind as that of her dysmenorrhcea. Her habit has always been to retain the urine long, so that sixteen or twenty ounces fre- quently collect before she discharges it. Can there be any doubt this habit is the cause of the retroversion? There is no other discovera- ble cause. Suppose the fundus of a gravid uterus to be caught and detained under the promontory, as just above mentioned, and that the child proceed in its growth, carrying with it the w T omb in wdiieh it is en- closed; the consequences must be a complete impaction of the womb into the excavation — a total prevention of the flow of urine, by pres- sure on the urethra — a stoppage of the canal of the rectum — severe pressure upon the internal sacral foramina, with their nerves ; and un- less by timely measures obviated, the certain and miserable death of the patient. In the case examined by Dr. Hunter, so completely im- pacted, or jammed w T as the womb into the cavity of the pelvis, that after the death of the patient it was found impracticable to get the 222 PREGNANCY. RETROVERSION. uterus up out of the excavation, until the pubis was cut through with a saw, in order to admit of the enlargement of the brim of the pelvis. It is difficult to conceive of a situation more frightful than that of a patient under such circumstances. The case, with the fine illustra- tive engraving, is contained in Hunter's Tables of the gravid womb. As to the retroversions that follow pregnancy, I conceive that they are the after-labor results of non-contracting ligamenta rotunda. When the womb has attained its full size, at term, the round liga- ments have become much elongated, rising high up in the abdomen to their points of origin near those of the Fallopian tubes. If now the uterus, in a labor of some four hours, condenses itself, and in some fifteen days afterwards nearly recovers its non-gravid volume and weight, it does not necessarily happen that the round ligaments shall be equally active in their own reduction to their usual state. But, if they continue flaccid, relaxed, and elongated, nothing is left to hold the womb in proper propinquity to the symphysis pubis — it falls over against the promontory, is pushed beneath it by the distending blad- der, and held in such dislocation by the mechanical form of the curve and the promontorium. My experience teaches me that most of the instances of retroversion are attributable to a distended bladder, whether after parturition or no. The modest delicacy of women often compels them to resist the most urgent desire to pass off the urine. A female riding in a carriage, or placed in such a situation that she cannot withdraw from the company without being suspected of a desire to rains will allow the bladder to fill almost to bursting; and if she be preg- nant about three months, she will scarcely fail to have retroversion of the womb. When at last she obtains an opportunity to evacuate the bladder, she finds she has a partial or total suppression of urine. The usual recourse is had to spirits of nitre, to water-melon seed or parsley root tea, and, perhaps, a dose of castor oil may be resorted to; but as relief can only come by some mechanical remedy, the medical man is at length, and reluctantly, sent for. Case. — A few years ago I was called to a young woman who had been a short time married. She arrived in town by one of the pub- lic conveyances from the eastward. She had a constant and irrepress- ible desire to urinate, and could only succeed in getting off a few drops at a time. She told me she was pregnant; had just arrived from a journey, and that she was suffering the most acute distress from irrepressible inclination to urinate. As the disorder had come PREGNANCY. RETROVERSION. 223 on suddenly and in a state of high health, I at once told her she had a retroversion, the nature of which I explained to her, and she submitted to the necessary investigation ; upon which I found her womb turned over, and upon repositing it she was immediately cured. I suppose that, in traveling, her bladder, for want of an opportunity to empty it, had become very much distended; that its bas-fond had pressed upon the anterior superior face of the womb more and more as it became more and more distended, until the fundus uteri, jammed under the promontory of the sacrum, could not get out again, without the aid of a physician. — Vide my Letters to the Class, sub voce. One of my critics condemns the rapdity of my diagnosis in the case. I respectfully refer him to the passages in which I explained, that by using the method of exclusion in the analysis, I could not possibly arrive at any other opinion. To see a healthy-looking woman seized with complete retention of urine, without having been before the subject of any urinary ail- ment, is always warrant enough for us to suspect a retroversion of the womb, especially if the patient be at the time pregnant, and not ad- vanced beyond the fourth month. The symptoms of which such patients complain are either a total retention, a stillicidium, or a great dysury; with pains about the region of the pubis and sacrum, constant tenesmus, or bearing down, and a sense of obstruction or stoppage in the rectum. No case like this ought to be suffered to pass without making an examination pervaginam. For this purpose let the patient lie on her back, near the right side of the bed; the feet drawn up near to the breech ; the head and shoulders raised with pillows. The physician should stand by the bed-side, and with his left hand placed upon the hypogastrium, ascertain if the bladder be much distended: it will sometimes be felt almost as high up as the umbilicus. The fore finger of the right hand may next be carried into the vagina, in order to seek for the os tincse, which is to be found behind the symphysis pubis, or even thrust over and above it: the vagina seems to be ob- structed by a hard body, which is the bas-fond of the womb, whose fundus is turned down into the hollow of the sacrum, and jammed into the cul-de-sac, composed of the reflexion of the peritoneum, which lines the upper posterior half of the vagina and the front of the rectum. Having thus verified the existence of a retroversion, the next steps required to be taken are those that are demanded for the repositing the womb. Among the most pressing indications of cure, is the re- 224 PREGNANCY. RETROVERSION. lief of the suppression of urine, which in general is easily fulfilled by the introduction of the catheter, which should be a male catheter, composed of the French elastic material. A long one is the best, because the womb, in changing its own position, carries up the neck of the bladder, and thus elongates the urethra so very considerably, that it will be found convenient to use a long instrument for the eva- cuation of the water. Inasmuch as the most ordinary cause of retroversions is a distended bladder, it has been thought that the removal of this distension is the sufficient remedy, it being supposed that the uterus might recover its attitude as soon as the pressure which overset it should be taken off. Indeed, there are cases in which the restoration takes place soon after the bladder becomes emptied. I have related in my " Letters on Females, &c," cases of retroversion cured by the catheter alone, and one, from an English authority, in which a most dangerous case of retroversion in pregnancy, which could not be cured by the hand, gave way to the use of the catheter, left for a longtime in the bladder, by which means that organ was completely hindered from filling up, and obstructing the efforts of the fundus to rise upwards to its natural situation. It has well been contended that for retroversion of the gravid womb, a sound discretion indicates the propriety of leaving the case in nature's care, after this preliminary measure has been accom- plished, lest by any rude or too persevering attempts to replace the uterus, the ovum might suffer so much injury as to bring on an abor- tion. I admit that I am not prepared to decide as to the necessity for such great prudence, since I have only on one occasion put it to the test. On that occasion I drew off the urine two successive days, the accumulation being very great; and then finding that the mal-po- sition was not rectified, I was compelled to replace the womb with my hand: no inconvenience whatever followed the operation, although the patient was near four months complete, gone with child. In a subsequent pregnancy, the same person suffered a retroversion of the womb, nearly at the same period ; and when I was called to see her, I immediately proceeded to restore it to the proper attitude. In this case also the pregnancy was not in the least interrupted. Having succeeded in drawing off the water, the patient, if neces- sary, should have a copious enema, in order to unload the rectum, which, if replete with faecal matters, might offer considerable obsta- cles to the success of our attempt. In the next place we ought to endeavor to raise the fundus, the patient lying on her left side, by pressing the bas-fond of the w T omb, which can be felt through the PREGNANCY. RETROVERSION. 225 hinder surface of the vagina, upwards, with the fingers, so as to lift the whole mass in a direction parallel with the axis of the brim. The cervix uteri is tied to the more anterior parts of the pelvis by the vagina and the vesico-vaginal septum, so that if we carry the mass considerably upwards, it must be by tilting the fundus in that direction. Attempts of this kind will not always succeed. Where they fail, a finger may be passed into the rectum, the fore finger of the left hand, if the woman is on her left side, and of the right hand if she be upon her back. Before the finger has passed very far, it meets with the fundus uteri, which presses upon the canal of the intestine ; in this situation we have far more power to move the womb than when the effort is made only from the vagina. Pushing gently and steadily upwards, we find the mass gradually to recede, until at length the fun- dus, liberated from its restraint, suddenly emerges, with a sort of jerk, from under the promontory, from which instant the woman is cured. I have sometimes failed of success, until I placed the patient in a more favorable attitude; one in which she could not bear down, and thus oppose the success of my measures. I have directed that she should turn on her face ; then draw her knees up under her until the thighs were in a vertical position, giving to the pelvis the highest pos- sible elevation: the face was to be placed on the bed without pillows, and the point of the thorax was also to be touching the bed. Lying in this posture, the power of mere gravitation might suffice, in time, to unhitch the fundus uteri from beneath the promontory ; since all tenes- mus and bearing down are thus arrested. After waiting a short space, until the effects of the position were secured, I have pushed up the fundus very easily by acting either through the vagina or the rectum. A woman who has just recovered from a retroversion, ought to lie in bed two or three days, and should not, for a few days, be left more than six or eight hours without evacuating the bladder, spontaneously or by the catheter, lest that organ, filling again, should unhappily a second time depress the fundus, and thus cause us to lose all our trouble for want of a moderate precaution. The gravid womb, doubtless, becomes, in four months and a half, too large to admit of the occurrence of retroversion : but the accident may occur at any period short of it ; it may take place not only in the non-gravid, but in the virgin uterus. Case. — On the 22d of February, 1828, 1 was called to visit Elizabeth B., aged about twenty years. She had complained for several months past of dragging pain in the left side of the abdomen, with a sense of 15 226 PREGNANCY. — RETROVERSION. weight and great uneasiness within the pelvis. She has menstruated regularly. For the last three weeks she has been persecuted with con- stantly repeated and painful desire to go on the stool; with symptoms of strangury, or dysury, amounting often to stillicidium urinae. After a careful inquiry into the history of her case, I informed her of the nature of my diagnosis ; and she at length agreed to permit an examination by the Touch, as I assured her that I had no means of relief for her, if there were really a retroversion, short of the Touch. In this painful necessity she submitted, with a laudable unwillingness, to the opera- tion, and it was with no little difficulty that I at length carried the finger beyond a remarkably strong hymen into the vagina. The os uteri was found near the symphysis of the pubis, and the fundus was discovered overturned into the peritoneal cul-de-sac. After a long perseverance in endeavoring to raise the fundus, I was compelled to attempt it with the forefinger of the left hand passed into the rectum, by which method I pushed the uterus up ; whereupon she immediately declared that she was fully relieved of the sense of weight and pain that had so long been tormenting her. She continued well from that moment. I consider this a case of considerable interest, inasmuch as it further proves the possibility of a long-continued retroversion of the womb in the non-gravid and virgin state of that organ. There are some persons to be met with, in whom retroversion takes place so readily, that the least exertion of strength brings it on. Tn a single individual I am sure that I have been called on to restore it to its position twelve or fifteen different times. So great, in that case, is the tendency of the womb to turn over, that it has several times occurred, notwithstanding the presence in the vagina of a very large globe pessary, and I do never regard her as exempt from the proba- bility of an attack except when in a state of pregnancy. I presume that in her case there is not only a great relaxation of the vagina and its connecting media, the recto and vesico-vaginal septa, but there must also be supposed to exist a condition of the ligamenta rotunda, which has allowed them to become elongated to such an extent that the least pressure on the anterior face of the womb pushes it back- wards and downwards. No one, I think, could suppose a case of retroversion, without at the same time implying the round ligaments, which pass from the angles of the organ out of the abdominal canal, and abdominal rings, to be lengthened — and even stretched. A per- manent elongation or laxity of those ligaments would add a great facility to the disposition to oversetting of the organ. As there is reason to believe that there is a character of muscu- PREGNANCY. RETROVERSION. 227 larity attached to the round ligaments, proceeding as they do from, and being composed of, the same tissues as the womb, we may indulge, in any case, the hope, that time, if not drugs and medicines, will bring them back to their natural tension and length, so as to obviate the evil propensity to the retroverted state of the uterus. The accident of retroversion may be considered serious or danger- ous just in proportion as it occurs at a more advanced period of preg- nancy ; for, according as the pregnancy is of an older date, is the necessity greater for a speedy reposition of the organ. I have, I think, pointed out sufficiently at length, the dangers to be apprehended from a retroversion continued until the whole mass becomes so impacted into the excavation, as to render its extrication, without abortion, im- possible. As I have met, hitherto, with no example in which it was impossible to replace the gravid organ, I do not feel it incumbent upon me, at this time, to do more than refer to the severer methods of extri- cating the woman : which are, first, the artificial rupture of the amni- otic sac, which, by allowing the water to escape, reduces the size of the womb so much as to enable the operator to succeed in restoring it to its proper position; or lastly, the puncture of the womb itself, when it is found impossible to pass a bougie into the os uteri. The Student ought early to become aware that some of these retro- versions are rendered incurable by the formation of adhesive deposits that tie the fundus uteri close down to the back part of the pelvis; and that as these adhesive bands cannot be approached with the bis- toury nor otherwise broken up, the womb is liable to remain in a state of permanent retroversion. M. Amussat mentions two such cases in his Essay on retroversion, and I have met with two, one of which only was verified by the necroscopy. I shall publish one case as drawn up by Dr. Yardley, and illustrate it by a cut copied from a drawing by Mr. Mcllvaine, who had the specimen before him; and which constitutes one of the most interesting preparations in the Mu- seum of the College. The following is the history of the case, as drawn up by Dr. Yardley himself, who allows me to publish it here. Case. — "Mrs. N became my patient in the spring of 1840. I visited her on account of a diarrhoea which had continued for some time, and which was attended with distressing pain in the left side. "A regulated diet, saline frictions of the skin, which was cold and dry, together with small doses of mass, hydrargyri, opium, and ipecacuanha, soon cured the diarrhoea; but, as the pain in the side and other symptoms of disease still continued, I was induced to 228 PREGNANCY (TUBAL). — ■RETROVERSION. investigate the case more fully. I then learned that since her mar- riage, about three years previously, she had had two attacks of uterine hemorrhage, which were pronounced by her physician to be abortions ; though nothing like an ovum had ever been detected, and he had never examined the state of the uterus. "The first attack came on on New Year's day, 1838, after taking a very long walk; and, though the hemorrhage was not profuse, it was attended by such excruciating pain in the side, on being moved, that it was necessary to bring her bed into the parlor, where she remained several weeks. The hemorrhage and pain gradually subsided, and by the 1st of June, she appeared to have regained her usual health. "The second attack took place April 12th, 1839, and came on suddenly when making some unusual exertion while engaged at her toilet. The pain was so severe as to cause fainting, and was attended by vomiting, diarrhoea, retention of urine, tenesmus, severe bearing- down efforts, and slight uterine hemorrhage. These symptoms were mitigated by general treatment, without resorting to the catheter, or making a vaginal examination. She was confined to her chamber nearly three months under this attack, and was still suffering from its effects when I was consulted in her case. Her menses were irregu- lar ; her bowels frequently disordered ; she was unable to take her accustomed exercise, on account of a bearing-down pain and distress in the pelvic region, which was increased by exertion of any kind. Her husband informed me that since her last attack she had always suffered severely from sexual intercourse. "I considered these symptoms sufficiently indicative of disease or displacement of the uterus to call for an examination of the state of the parts. I found the uterus low in the pelvis, hot and swollen, and so sensitive as to preclude further exploration. Rest in a recumbent position ; bleeding; cupping over the sacrum ; and general antiphlo- gistic treatment, in ten days, produced so much relief that the patient declared herself better than she had been for more than a year. I then made a second examination, and found the engorgement, heat and tenderness much diminished ; but there was considerable pro- lapsus, and the uterus and vagina were morbidly sensible. " I was desirous that the patient should remain longer in the re- cumbent position, but the weather being warm, and confinement very irksome, I introduced a gilt-ring pessary, and sent her into the country. " Mrs. N returned about the middle of September. She in- formed me, that for three weeks after the introduction of the pessary, PREGNANCY (TUBAL). RETROVERSION. 229 she felt unusually well ; she was able to stand and walk without suf- fering, and the distress in the pelvic region was much mitigated ; — but about that time, when using considerable exertion, she felt the instru- ment move, and it continued to trouble her until it came away. After the displacement of the instrument, her old symptoms returned, though for a time she was better than before its introduction. "After keeping the patient quiet a few days, I made another exami- nation ; — all morbid sensibility of the parts had now subsided, so as to admit of a full exploration, and, for the first time, I detected in the hollow of the sacrum, a round, hard body, with a deep indentation between it and the lower part of the neck of the uterus. " It was difficult to decide whether this was a tumor, or the fundus of the uterus bent down in that position ; but after a careful examina- tion, I was disposed to regard it as the latter, though it was much lower and more prominent than I should have expected from the situation of the os tincse, which was not more anterior than is usual in simple prolapsus of an equal degree. "After pressing up the uterus as far as I could, I introduced a gilt- globe pessary under the fundus, hoping it would gradually restore the organ to its proper position, and that if it came away, the patient could replace it herself, which was important, as those repeated examina- tions were very disagreeable to her. " The globe pessary was retained but a short time, and as it caused considerable pain and uneasiness during its retention, the patient was unwilling to have it again introduced. " At the suggestion of Professor Horner, of the University of Penn- sylvania, I next placed the patient on her knees in the bed, with her head and shoulders as low as possible, and introduced an instrument into the rectum under the fundus of the uterus, and by that means, assisted by its own gravitation, endeavored to dislodge it from its posi- tion. In this manner I succeeded in pressing the uterus up much higher than before, and after again introducing a ring pessary I re- quested the patient to remain quiet for a few days. This ring kept its position two weeks, and was productive of much relief, but it then came away, and the unpleasant symptoms returned. " This process of pressing up the uterus and introducing a pessary, was repeated several times; and it was found that a ring pessary was the only kind that was of any advantage, for while a ring retained its proper position, the patient was comparatively comfortable. This relief, from the use of a ring pessary, appears remarkable, when, after death, it was discovered in what manner the uterus was bound down 230 PREGNANCY (TUBALJ. — RETROVERSION. to the rectum; there is, however, no doubt of the fact, and it may be explained by supposing that the anterior wall of the rectum was pressed forward and upward, or the adhesions stretched. " The difficulty of retaining the ring in its proper position, however, seemed to increase ; rings of silver gilt, glass rings, ivory rings, rings of hard wood, such as ebony and lignum vitse, and rings of gum- elastic were all tried, but the gilt rings were found much the best. " Discouraged by my want of success in the treatment of the case, I sought further counsel, and Professor Hodge of the University of Pennsylvania saw her with me, July 10th, 1841. On examination, he readily detected a retroflection ; a displacement of the uterus with which he was familiar, and which he calls a retort uterus from the fact that the uterus is bent on itself in the form of a retort. "He proposed the introduction and persevering use of a pessary of a peculiar form, which he has successfully used in many cases of the kind; I had an instrument made after his pattern, and introduced it; but it was not of the proper size, and caused considerable discomfort, which the patient attributed to the form of the instrument, and to my regret, was unwilling to have another one of the kind used. "During the following five years, she pretty much abandoned medi- cal treatment, except that, whenever her sufferings became unusually severe, she applied to me, when by pressing up the uterus and intro- ducing a ring, she would be much relieved for a time. Several other physicians were consulted in the case, but nothing important or novel was suggested. OS " Her symptoms gradually grew worse, and in July, 1847, 1 visited her, and found her confined principally to her bed; she appeared slightly emaciated; her brilliant color was gone, and she suffered severely from sickness of the stomach. She informed me that after passing her monthly period about three weeks, she had had a slight show, which had returned every few days for the last two weeks ; mak- ing about nine weeks from her last regular monthly period. On making an examination, I found the uterus occupying the same position it had heretofore done, and somewhat larger than before, but apparently not larger than an ordinary unimpregnated adult uterus. "I declined adopting any active treatment without assistance, and suggested Professor Meigs, of the Jefferson Medical College, who saw with me on the 17th of July. Dr. Meigs was sanguine, after exam- ining the state of the parts, that the uterus could be restored to its proper position, notwithstanding the length of time it had been dis- placed. PREGNANCY (TUBAL). — RETROVERSION. 231 "He came next day prepared with an instrument to press up the fundus of the uterus, and with some small gum-elastic bottles, of the kind recommended by Hervez de Chegoin, in the hope that by gra- dual pressure in this manner we might succeed in restoring the organ to its proper position. " The patient complained of much pain when the doctor attempted to press up the uterus, though but moderate force was used. I filled the bottles with curled hair, which I found to answer admirably on account of its elasticity, and introduced one of them carefully be- tween the perineum and the fundus of the uterus. It gave no pain, and was retained without inconvenience, and appeared as though it would fulfil the indication. "I kept her in her bed a few days, after which she rode out occa- sionally, and once walked several squares. " On the evening of the 5th of August, after using much more ex- ertion than she had done for several months, the ball was forced away, and she was attacked with severe bearing-down efforts, so that it was a considerable time before she could be removed to her chamber. After she had been carried to her bed, I made an examination, and found the uterus at the os externum, and the bearing-down pains so severe as to threaten its expulsion from the vagina. " After administering an anodyne enema, and in some measure tranquilizing her system, I succeeded in pressing the uterus up to its former position, and introduced the gum-elastic ball at her own re- quest, as she said she felt safer and more comfortable while it was in situ. " The patient was unable to leave her chamber, and seldom her bed from this time ; and she often passed whole days and nights in the most awkward positions because the least motion increased the pain beyond endurance. Her stomach became so irritable that it was sel- dom anything would be retained in it even for a single hour. She became weak for want of nourishment. The most excruciating neu- ralgic pains pervaded every part of her abdomen, so as to preclude the possibility of any examination either externally or per vaginam ; and to increase the difficulty of diagnosis, she became tympanitic. " The w T ise women of the neighborhood said she was in the family way ; but of this we were not satisfied ; and Dr. Meigs, who placed considerable reliance on the appearance of the nipple, examined her breasts carefully, and there was not the slightest change of the areola. "An anodyne enema was administered every evening, but her nights were generally sleepless, and she gradually grew worse till the 19th 232 PREGNANCY ( TUB AL).— RETROVERSION. of August, when I was obliged to leave the city for a few days. My friend Dr. Jewell attended her for me, and has furnished me with the following notes of the case:" "My first visit to Mrs. N. was made on Thursday, August 19th, at the request of my friend Dr. Yardley, who was to be absent from the city for several days. " Her condition, when I saw her, was anemic ; countenance thin, pale and sallow, expressive of long-continued and wasting disease; pulse sharp and frequent; abdomen tympanitic and exceedingly tender to the touch ; tongue clean and moist ; stomach so exceedingly irritable as to reject all nourishment and medicine, craving only ice, which, however grateful for a moment, afforded no relief. All her suffering was directed to a most excruciating pain in the left iliac region, ac- companied with extreme gastric distress, which symptoms had been in existence and increasingly so, for several days. "Fomentations of brandy and spices were applied to the abdomen, and various anti-emetics and sedatives were ineffectually tried for the vomiting. " In the afternoon, the symptoms being more aggravated, twenty- five leeches were applied over the stomach, and an enema of forty drops of laudanum in a gill of warm flaxseed tea thrown into the rectum. In the course of the night the gum elastic ball pessary, which had been introduced by Dr. Yardley, for the retroversion of the womb, came away during an effort to vomit, and was not replaced. " Friday 20th. Found her very weak and exhausted, with some slight relief from pain and vomiting ; expressed herself to be easier, but dreaded the return of the severe suffering she had experienced the day before. Was troubled with flatulency and slight oppression at the prsecordia. Directed the effervescing draught, with thin arrow root, in small quantities, and to be frequently repeated. The fomenta- tions to be continued as yesterday. " In the afternoon was sent for in haste — that Mrs. had convul- sions. On my arrival at her bedside, I found her in a collapsed con- dition, insensible, extremities cold, pulse and breathing scarcely per- ceptible, and her whole appearance completely blanched. By the persevering help of stimulants and artificial heat she gradually re- vived. "I learned from the family, that previous to her insensibility, she had complained of an agonizing pain in her left side, and an increase of sickness at the stomach, and in a few moments after went into con- vulsions. PREGNANCY (TUBAL). RETROVERSION. 233 " So forcibly was I struck with her bloodless condition at this time, I remarked to her husband, that she had all the appearance of one who had lost a great amount of blood from flooding. " Being comfortably restored, before I left I ordered her brandy and water ; ice in small and repeated doses, with essence of beef; and to repeat the enema of laudanum and flaxseed tea if the pain returned, together with the following prescription in doses of twenty drops every hour: B. — Solut. sulph. morph. £i ; HofT. anod. liq. 3ij. "During the three following days, the vomiting continued with very little abatement. Every attempt to administer nourishment or medi- cine was indomitably resisted by the stomach, with the exception of the brandy and the morphine solution. On each successive day an anodyne injection was given, to subdue the attacks of pain in the left side. Her pulse in the mean time was feeble and frequent, her coun- tenance blanched, and her whole condition so much exhausted as to afford but slight hope of her recovery. On Tuesday, 24th, however, there was an apparent amendment in her case; her pulse began to react, she was able to retain a little nourishment, the vomiting had in a great degree subsided, and her expression was, "I feel comfortable." Her bowels not having been open for several days, I ordered her a turpentine enema, to which they responded readily, though not freely. " Wednesday, Aug. 25th. Had passed an easy night, but without much sleep ; upon the whole she had improved, was cheerful, had taken a cup of tea and had eaten some calf 's-foot jelly ; the tenseness and tenderness of the abdomen had subsided. I could make consid- erable pressure without causing either pain or sickness, and for the first time I was able to detect a tumor in the left iliac region, upon which spot, however, she could not allow pressure without acute pain. "I felt quite encouraged with her appearance and the improvement in her symptoms, as did also her friends. Feeble hope was given that she might be restored. She asked for a peach, w 7 hich was allowed her, and I left her in good spirits. " It was near 3J o'clock, P. M., when I was summoned by a hasty messenger, that Mrs. was dying. On approaching her bedside, which was surrounded by weeping friends, I found her lifeless. "I learned that she continued as well and as cheerful as when I left her in the morning, up to 3 o'clock, when she was suddenly attacked with violent pain, followed by a convulsion, which in a few minutes ended in death." 234 PREGNANCY (TUBAL -RETROVERSION. Having inserted the foregoing account of Mrs. N 's case, by Drs. Yardley and Jewell, it only remains for me now to say, that the necroscopic examination of the body of this unfortunate lady was made by Dr. Ellerslie Wallace, in presence of Dr. Jewell and the author of this article, on Friday, August 27, 1847. Upon exposing the contents of the abdomen by a crucial dissection, and looking downwards into the excavation of the pelvis, there was discovered a great quantity of coagulated blood and serum, which being removed, the uterus was observed to extend across the pelvis from front to rear, Fig. 70. PREGNANCY (TUBAL). RETROVERSION. 235 lying horizontal in the excavation, and covered by the left Fallopian tube, which was turned over from left to right quite across the pelvis coincidently with the transverse diameter. The tube was enor- mously enlarged, having been converted into a sac which contained a foetus of near three months, developed in a tubarian gestation. The uterus being measured, was a little more than four inches long, and at the broadest part three and three-fourth inches wide. The child-bearing Fallopian tube could be lifted up from where it laid upon the front surface of the womb — no inflammatory attach- ment having as yet been formed to bind them together. Upon lifting the tube-sac off the uterus, and then attempting to raise the fundus uteri out of its retroverted position, it was not possible to succeed, in consequence of the adhesive bands and bridles that bound it to the lower part of the sacrum. When these adhesions had been divided by the scalpel, Dr. Wallace could lift the fundus out of its bed, and reposit the womb. This I had been unable to effect during Mrs. N 's lifetime, either with the hand or with Hervez de Chegoin's caoutchouc pessary. I was not surprised to find the fundus glued in this manner to the lower part of the sacrum, for I had, in June, an- nounced to Dr. Yardley my belief that it was adherent — an opinion founded upon the firm resistance of the tumor to all my attempts to reposit it. I may remark here, that I believe the womb might have beemgot out of its false and adherent position by means of the caout- chouc pessary, by slow and cautious proceeding, had not the tubal pregnancy unhappily supervened. I suppose that the adhesions might have been gradually broken or absorbed under the elevating power of M. Hervez's method. The rupture of the tube had occurred near its outer end, which from its being turned over and laid upon the prostrate womb, was found nearer the right than the left ischium. Through the edges of laceration in the tube-sac, one of the feet of the embryon was pro- truding. The uterus and its appendages were removed with consent of the friends. Upon laying the uterus open, it was found to be filled with a decidu- ous mass and with bloody slime. The cavity was somewhat enlarged, but the paries of the uterus w T as very thick, like that of a uterus con- tracted after delivery. The tube was now laid over to the left, its natural position, and opened; whereupon it disclosed the embryon, as in the figure, which was taken by Mr. M'llvaine ad vivum. The de- ciduous membrane is seen in the cavity of the uterus, its edges being laid over on the cut surfaces. 236 EXTRA-UTERINE PREGNANCY. I regard the case as an interesting one, from its showing the presence of its decidua in utero in a tubal pregnancy, and more especially, as presenting an example of adherent retroversion ; and, perhaps not less so, as exhibiting tubal pregnancy in a woman with adherent retroversio uteri. Extra- Uterine Pregnancy. — I have met with three cases of extra-uterine pregnancy in the tube, all of which proved fatal about the third month, and I should expect the death of the patient to take place at or before the third month in any case, since it is improbable that the tube can ever furnish the material for a matrix longer than during some ninety days, at which time the tube-sac must become so much thinned and extenuated by its expansion as to burst. The rup- ture of the tube will be attended with fatal hemorrhage because, being the seat of gestation, it has become highly vascular, in order to the carrying on of the gestation within its walls. I do not believe that a tubal pregnancy will ever be suspected until it has burst and begun to bleed. One of these cases I have just related, as drawn up by Dr. Yardley, under the head of retroversion. If a woman should experience the signs of pregnancy, as to change of the aureole, as to nausea, pica and malaccia, as to growth of the breasts, extraordinary sensation within the pelvis, &c, and thereupon, when having attained to the middle of the second or to the third month, be seized with horrible pain inthe hypogastrium and pelvis, turn pale, lose the pulse and faint — I should suspect the rupture of a tube- sac of extra-uterine pregnancy. It is true that the above symptoms might be expressions of affections of the ureter, or perhaps of the bowel; but, in case they should continue and increase, with signs of concealed hemorrhage, so as to leave no doubt of imminent death, I think the diagnosis could not be other than a ruptured tube-sac of gestation. Such a diagnosis w r ould not lead to any hopeful therapeutic or chi- rurgical intervention, for nothing is to be done in these melancholy cases beyond the adoption of mere palliative measures. No man would be mad enough, under such diagnostic, to perform a gastrotomy operation. Case. — I had some years ago, a young woman under my care who supposed herself to be pregnant some two or three months. One morn- ing she took the broom to sweep her chamber-carpet, when suddenly she felt agonizing pain in the left iliac and pelvic region, which TUBAL PREGNANCY. 237 extended through the belly. She fainted and became mortal pale and pulseless; the agony was terrible. I supposed she had ruptured the sac of a tubal pregnancy. She expired in the course of a few hours, with all the symptoms of hemorrhage in the abdomen. I could not obtain permission to examine the body. Case. — I saw another case which I shall relate in this place as follows : Mrs. , aged thirty-two, a healthy woman, mother of four children, was in excellent health on Sunday, October 7th. At six o'clock in the morning, she was singing and playing with her chil- dren. At seven o'clock, her husband, who was sick up stairs, heard her ascending the stair-case and groaning heavily ; when she entered his room, she appeared alarmingly ill. A physician, Dr. , was sent for, and found her with a pulse one hundred and forty ; in violent pain, extending from the top of the thorax on the right side, quite down to the iliac region. He attended her all day, applied a blister to the right side of the belly, gave a cathartic, &c. She passed a dreadful night, but was easier at eight o'clock next morning ; the pulse then one hundred and twenty. He left her for a short time, but found her worse on returning to the house. I was sent for, and arrived at half past two o'clock. She appeared to be dying at the time of my arrival. As she had vomited very much, and had a most excessive tympany, with violent pain in the whole belly, she got an enema, which brought off a great deal of stercoraceous matter, with- out sensible relief. In half an hour she said, " Raise me up — my breath is leaving me." I raised her a little on the pillows, and she swooned and died. Twenty hours after death, I opened the abdo- men and found it filled with about thirty ounces of blood, and bloody serum. The whole pelvis was filled with coagula, and a great quantity of blood was among the bowels. This blood came from a ruptured left Fallopian tube, which con- tained a foetus of six or seven weeks. The ovarium was somewhat enlarged. The womb had a deciduous lining, and the canal of the cervix was filled with a claret-colored mucus or lymph. The womb was larger than a non-gravid womb, though not a great deal larger. I have not had under my care any cases of ventral or abdominal pregnancy, though I have had opportunities to witness the examina- tion of bodies of persons perishing from this dreadful accident. I shall merely express some doubt that I feel as to the propriety of any gas- 238 SIGNS OF PREGNANCY. trotomy operations in such cases, save mere incisions for the escape of the contents of the suppurating sac and the remains of the foetus. I refer the Student to the records, for samples of life not only con- tinued long after the complete development of the abdominal foetus, but of good health enjoyed notwithstanding. The late distinguished incumbent of the chair of Midwifery in the University of Pennsylva- nia, published an account of a lady who carried out a normal preg- nancy, notwithstanding she had in the abdomen an extra-uterine foetus which she carried many years. Signs of Pregnancy. — I have been, on several different occasions, both vexed and amused upon observing how prone are some medi- cal practitioners to overlook the signs of pregnancy even in married women, their patients. One gentleman, of great experience, tapped a woman for ascites — but his trocar went into the gravid womb and penetrated the shoulder of the foetus. She fell into labor and recovered of the accident; the child had the mark of the trocar on his shoulder. Many instances of the strangest oversight have occurred within my range of observation ; instances in which the size of the belly, the married state of the pa- tient, and the obvious evidences of gestation as well as its probability, ought not to have been overlooked, nor mistaken for diseases requir- ing troublesome, disgusting, or dangerous therapeutical prescription. The safest rule would be to suppose every married woman of the proper age, with suspension of the catamenia while not giving suck, as pregnant, and to treat her as gravid until convinced of the contrary. Let the Student imagine for a moment, how very disagreeable must be the reflections that follow the clearing up of so egregious an error as that of administering powerful emmenagogues to married women, who, nevertheless, would not miscarry ; or who, now and then, are found to miscarry under such a diagnosis. The signs by which a woman knows herself to be pregnant are, the cessation of her regular menses, and the subsequent enlargement of the abdomen, the movements of the foetus, certain constitutional or local disturbances or disorders, and modifications of the mammae. A married woman, who has been well regulated, suspects that she has conceived, if she fails to menstruate at the proper term; but this cannot be considered as conclusive evidence of conception, since so many and such various causes are found to obstruct and avert the regular course of the menstrual function. A second failure, espe- cially if it be not accompanied with any signs of depraved health, SIGNS OF PREGNANCY. 239 renders the suspicion still more valid ; while after a third and fourth omission, the change of form, and at last the perceptible motion of the embryo put all doubt to flight. I may say, however, with great con- fidence, that the audible or visible movements of the foetus afford the only true and infallible signs of the existence of pregnancy. There are many accidental or correlative signs which establish probability of the existence of pregnancy: among which I may men- tion, nausea and vomiting; a gradual increase or development of the maramse; a change of the areola of the breast, which becomes more protuberant or elevated, and acquires a dark brown hue, which is much relied upon, especially in first pregnancies. The nausea is mostly found to occur in the morning, and is attended in some indi- viduals with a distressing heartburn, and a salivation or spitting of saliva. Some people are affected with gravel, or dysury, from the extension of irritation to the neck of the bladder, or from pressure of the enlarging womb upon the posterior surface of that organ. An irritable state of the temper indicates it in some women, which is at- tributable to the general malaise that must attend the gastric embar- rassments which the early stages of pregnancy are so commonly found to produce. Toothache, earache, styes on the eyelids, morph on the skin, a dark aureole around the eyes, and strange unaccountable longings or appetites, are also signs of pregnancy, rather to be noted after pregnancy is fully ascertained, than to be depended upon as sure evidences of its existence. By means of the Touch, pregnancy may be pretty surely ascertained, before quickening has taken place, but not surely. By the Touch we can readily learn that the womb is enlarged, altered in form, and contains something; but I do not see how any physician can absolutely aver what that something is, unless he can perceive a spontaneous motion in it; so that even the ballottement, or tilting the embryo upon the point of the finger, does not furnish, to my mind, any sure evi- dence that the tilted body is an embryo. I adhere, therefore, to the opinion I have already expressed, that we have no certain signs of pregnancy except those derived from the visible, palpable, or audible motions of the child. Auscultation, either by means of the stethoscope or the direct application of the ear to the abdomen of the woman, enables us to perceive two very distinct sounds, one of which is the beating of the heart, and the other is that which has been called the placental souffle, bruit de souffle, or bellows-like sound ; the latter being occa- sionally attended with a sound like the cooing of a dove. Whenever 240 SIGNS OF PREGNANCY. we can distinctly hear the beating of the foetal heart, so as even to count the number of its pulsations, all doubt must be at an end. The placental sound, or the souffle, is a very distinct sound, which has been supposed to indicate not only the presence of a foetus, but also that it continues to live, the rushing or blowing sound being said to always cease as soon as the foetus expires : it is said to be, in some way not yet sufficiently understood, connected with the movement of the blood in the placenta, and to cease, of course, with the cessation of that movement, which is itself dependent on the systole of the foetal heart. Upon a more, scrupulous inquiry as to the value of the bruit de souffle, in the diagnosis of pregnancy, it has been found that the ear- lier opinions of it were erroneous, and I believe that there are few w T ell-informed physicians to be now met with who give it even the smallest portion of their confidence in the unfacile discriminations that they are sometimes charged to make. It is not to be doubted that the sound is produced by the rush of blood in vessels, and in my opinion, sustained by very long practice in obstetric auscultation, it depends upon the motion of blood in the iliacs and hypogastrics. I have cer- tainly heard the same sound after delivery as before the child was born ; and I have heard it, as dependent upon pressure by tumors within the abdomen. Hence I have not the least confidence in it as an object in obstetric auscultation. The sounds of the foetal heart need never be mistaken. They can be detected at the fourth month, when the opportunity is good. M. Depaul has heard them much earlier. To look for them earlier than the fourth month is, however, in general, merely to lose one's time and find a mortification. It is perhaps, on some accounts, of less consequence to be able to ascertain the existence of pregnancy in the married than in the un- married woman. The lapse of twenty weeks, and sometimes of six- teen weeks, makes it surely known ; and the married woman, who has no motive to keep it a profound and important secret, readily imparts a knowledge of her situation, or her suspicions relative thereto, to the physician, or her friends. Not so with the unmarried female, whose reputation depends upon the concealment of her misfortune, or her crime. I have frequently been very sorely embarrassed by uncer- tainty as to the condition of a patient whose ruddy cheeks and embon- point seemed quite incompatible with a suppression of the catamenia, and whose complaints of aches and pains might possibly be merely assumed as a means of deceiving the medical adviser. Physicians are frequently applied to by the unfortunate or guilty for relief from PREGNANCY AUSCULTATION. 241 "obstructions," when the applicant has only a design to obtain some powerful deobstruent or emmenagogue, which may serve to procure an abortion, that she knows no honest or respectable medical practi- tioner could be induced to procure, for any pecuniary reward what- ever. I hold it, therefore, to be a duty, in all cases, or ranks, to compare the complaints of amenorrhea with the appearance of the patient, and if some evident malady does not accompany the supposed suppression, to withhold all medical aid, until time or necessity dis- close the indications that are to be fulfilled. In physic, nothing should be taken for granted. It is too much to expect that a female, who has it at heart to conceal her pregnancy, will confess it to a medical man. Experience teaches us the very contrary. Case. — I was requested some time since by a lady to visit a favorite servant, whose situation excited her apprehension, as she had failed to menstruate for the antecedent seven months, and was already consider- ably swollen with something like dropsy. Being directed to the young person's apartment, I found her in bed, covered up to the throat with bed-clothes, but the face that peeped out from above them actually shone with ruddy health, or agitation, or both. The pulse was natural, the tongue clean, the respiration normal, and the entire physiognomical expression as healthful as possible. She informed me that she had a stoppage of the courses for the last seven months, and felt very bad, and was now alarmed at a swelling of the stomach, which had in- creased greatly of late. Suspecting that she had an important secret, I asked some questions about pains in the stomach, and upon per- mission obtained, placed my hand on the abdomen, being almost cer- tain that I should feel the motions of a foetus; but, however long I held my hand on the abdomen, no movement of the child could be felt; so that, although I was certain she was pregnant, I was as yet unprepared to tell her so. I at length got permission to apply the ear against the side of the abdomen, and distinctly heard the placental souffle, and afterwards the stroke of the foetal heart. Upon this assur- ance I told her she was pregnant. " If I am," she replied, "I wish God may strike me dead!" and continued, with much temper and even passion, to declare that I maligned her and slandered her. I was obliged to leave her without the least assent, on her part, to my diagnosis, although she knew perfectly well that I spoke only a truth with which she had been long acquainted. She went out of town, and was confined in the country with a fine boy. Many examples of similar perverseness, in denying pregnancy, the signs of which were perfectly plain to me, and ought to have been obvious to the most 16 242 PREGNANCY AUSCULTATION. careless observer, have fallen under my notice; so that I deem it a solemn duty, previously to the exhibition of emmenagogue medicines, to ascertain that some signs of disordered health are present, in order that I may not commit the unpardonable fault of provoking an abor- tion, instead of removing a morbid obstruction of the catamenia. Let me warn the young beginner here, to take special care, in his diagnosis, that he shall first know the woman to be pregnant before he dare venture to say so. How could a gentleman commit a more unpardonable, or more insulting error ? I might here abstain from any further enumeration of the signs of pregnancy ; for I am accustomed myself to decline giving an opinion in any case, until I am sure that I cannot be mistaken, which I never can be when I hear the foetal heart, clearly and distinctly repeating its beats in the womb. Quickening is not a sign to be depended on; for the woman may perceive it, when the physician cannot. Her convincement is not an equivalent for his own convincement. Even the sensible motions felt upon palpation of the abdomen may deceive both the woman and the doctor. Multitudes of such deceptive cases are met with in a long career of practice. I have seen a woman who had the sensible motions of a child in her belly, though she had given birth to a foetus at full term only six weeks before, and several physicians who exam- ined her declared the motions to be caused by a child. Yet her cervix uteri was an inch long in the vagina, and the abdomen so soft as to enable one to push his hand down so far as to feel the spinal column. Many of my patients have engaged their monthly nurses and called me in, who, when I arrived, were found to be troubled with tympanitis only. Tenues in auras evadit. — See certain cases in my Letters to the Class, under the article Tympanitis. The toothache, the ephelis, the hordeolum, nausea, salivation, pica, pouting of the navel, and even milk in the breasts, are merely inferen- tial signs, and are by no means to be depended on. I repeat that I can rely only on the heart's motion heard in auscultation, and that sign cannot be detected until the fourth month. This is the rule ; the exceptions, few in number, are those in which it has been found in the pregnant woman as early as three months and ten days. Depaul, Traite Theorique et Pratique a 1 ' Auscultation Medicate, p. 248, gives us the following relation. Case. — " Madame T , who has already borne several children, had her courses on the 10th to 15th April. From the 17th to the 20th of same month, she co- habited with her husband ; he then left Paris on a journey of a fort- PREGNANCY AUSCULTATION. 243 night. Upon his return early in May, he found his lady confined to bed with the early symptoms of a typhoid fever, which in a few days became perfectly well marked, and continued twenty-four or twenty-five days. Her convalescence required a lapse of time nearly as long; and no sexual relation occurred until after her recovery. Nevertheless, upon the first of August following, as her courses had not reappeared, I was requested to see her with a view to determine whether this retention, which was very naturally attributed to the severe disease she had lately suffered, might require the employ- ment of certain remedies for its cure. I confess, that I was at first inclined to give up the idea of a pregnancy, begun antecedent to the commencement of the typhoid fever. I was little inclined to suppose its existence, computing it from the new sexual relations succeeding her convalescence; but the examination per vaginam, enabling me to detect a notable development of the volume of the uterus, I fell back upon the first opinion, of the propriety of which I became fully convinced, when, after having applied the stethoscope at various times upon the inferior region of the abdomen, I discovered the double pulsations, which were repeated 140 times a minute, while the pulse of the mother was only seventy-six. I could not hear the souffle uterin. Her confinement occurred in the following January." M. Depaul, if the above case is to be relied on, heard the double sounds 100 days, or three months and ten days after the fecundation had taken place. The pregnancy continued 174 days after the audi- tion of these foetal sounds by Dr. Depaul. Probably few such early detections will be made by all the readers of this paragraph. Inasmuch as I have spoken at length on the signs of pregnancy in my "Letters," I shall beg to refer the Student for further informa- tion, to that volume sub voce. PAET III. THE THERAPEUTICS AND SURGERY OF MIDWIFERY. CHAPTER IX LABOR. In coming now to this third division of our subject, or Midwifery proper, the Student ought to be informed that the practice of this art is one requiring not only a large amount of obstetrical or scientific information, but also a great deal of prudence and delicacy, as well as knowledge of the world; without which he will scarcely attain to any considerable eminence or happiness in the practice of it. From the foregoing imperfect statement of the anatomy and physiology of mid- wifery, subjects which, to be well described, would require several volumes rather than a few short chapters in this one, it will have been seen, that a great variety of considerations must precede the study of Midwifery proper; and that these considerations relate not only to the structure and functions of the living body, but also to every step in the development of that body, from the earliest dawn of its existence, up to the complete maturity of its powers and faculties. Such studies as these are in the highest range of philosophical con- templations. While they belong, perhaps strictly, to the dominion of Natural History, they can never be disconnected from a pure Meta- physics, since the laws of life and those of mind are one and the same. Again, so delicate and difficult, in point of conduct and conversation, are the duties of the accoucheur, that there is nothing short of abso- lute good sense and tact can carry a man without reproach or mis- fortune through a long career of this business. There have not been wanting very good writers to show that the whole of this study and practice ought to be confined to persons of the tender sex; asserting that the relations of the sexes ought not to war- rant those familiarities that are inseparable from the practice, by men, LABOR. 245 of the Art of Midwifery ; and, in the world, at the present day, though it is admitted that the Surgeon accoucheur is an indispensable person in society, he is by many looked upon with a sort of doubt and dis- trust, on account of the very peculiar nature of his pursuits. It ought to be evident to the intelligent and ingenuous Student, that some fit preparation of the mind to the discipline of this Art is required as an introduction to the exercise of it; since, to go at once from the College, and without reflection, into the very questionable position in which he is about to be placed, shows, to say the least, a great want of prudence and forethought. Many clever men have made shipwreck of their hopes by the want of a little reflection as to the course they should pursue ; or by early abandoning themselves to professional habits, which, without the least intention on their part, have gradually assumed a tone of familiarity, which has been construed into impertinence, or downright insult. In my opinion, no woman can be placed in a sanatary condition compelling her to appeal to the aid of the accoucheur, without some sense of a mortified delicacy. If this be true, it is quite clear that the only reparation for, or the only means of obviating this unpleasing impression, consists in the exhibition to herwards, of the most pro- found respect and sympathy, proffered with a sincere conviction of the painful nature of her position, as well as the indispensable pro- priety and necessity of submission to it. A female possessed of ordinary sensibility will be less affected by the sacrifice of feeling she is thus compelled to make, if she be treated as an object of respectful consideration, than if approached with a light and indifferent address ; and while she finds her own pride less wounded, will be both more confiding in the wisdom of her physician, and grateful for his counsel or service, as well as respectful to and considerate of his calling and profession. The occurrences that befall in the course of an accoucheur's pro- fessional life, are many times of a nature to require at his hands secrecy, and good faith ; for he cannot but become the depository of many informations, in which are involved the reputation and even honor of persons, and the safety of most important interests. Let the Student, then, before he goes any farther, make his mind firm in the resolution to guard with good faith those secrets with which he may become acquainted as physician, or Surgeon-accoucheur. He ought beforehand to consider the meaning of the term professional secrets, and know that they are confidences made to his station as physician, and not to himself as a person ; for, of the vast number of 246 LABOR. those which may be hereafter communicated to him, or discovered by him, not a tithe or a hundredth part of them would ever be his, but for his professional standing. If a man, therefore, is dishonored who reveals a secret communicated by a friend, how far more base is he who takes advantage of his professional standing to make public circum- stances that have been entrusted, so to speak, not to himself alone, but to the sacred character of the latrist. It is not in regard to grave and serious matters only, that he is called upon to be silent, prudently abstaining from acquiring for him- self and his brethren, the unenviable character of the babbler — even the most inconsiderable circumstances as to the sick, are confidences that ought not to be disappointed and betrayed. This is a just and true remark, and it is a rule that ought to be followed in all circum- stances and ages. The great Caliph Al-Mamun, as we are informed by Abul-Pharajius, in his History of the Dynasties, was a friend of science, and he exhibited his patronage, by fostering many learned men, among whom were some of our own profession. Among other of his medical favorites, was John Ocularius, whose duty it was to visit the Commander of the Faithful everyday, and that in his most private apartment, alone. The caliph gave him great honor, and allowed him a monthly sti- pend of one thousand gold sequins for his services. Upon one occasion, as the physician came out of his master's apart- ment, in passing through an ante-room, he was asked by one of the servants, " What is the caliph doing?" " He is sleeping," was the reply. But unhappily, this reply was communicated to the successor of Mahomet, whereupon the culprit was sent for, and brought before the chief of Islam. " What!" said he to the offender, "have I em- ployed you as my physician, and admitted you to my intimacy, in order that you should report to my servants as to my private occu- pations? Go out of my house." The poor medico, in telling this story, to account for his fall, added that the caliph never afterwards would admit him into his presence ; which was but the just punishment of a professional indiscretion. Let the Student reflect upon the punishment deserved by those who babble the concerns of families or individuals. John Ocularius was turned out of the court of Al-Mamun for merely saying that his master was asleep ! But, in addition to the quality of discreetness above insisted upon, the Student should firmly resolve to merit the appellation of Scholar — LABOR. 247 a title far more honorable than that of mere knight, or nobleman, or minister of state. It is to the Scholar that the world is indebted for its preservation from its own violence and vices. It is to the Scholar that it is in- debted for good laws, for science, and for all the arts. The Scholar is the promoter of virtue, and decency, and good conduct, both by his precept and his example ; for it is to him that mankind turn their eyes to see what is wisdom, and virtue, and true liberty. All those who are not, by education, brought out of the bondage of ignorance, are slaves indeed ; slaves of lust, of superstition, and ignorance. Hence it is evident that the Scholar is the only real nobleman, and his no- bility becomes more and more exalted in the ratio of his elevation in virtue and knowledge, towards the fountain and source of all know- ledge and virtue. The Student ought not to rest satisfied with the bare intention to make himself equal, in skill and dexterity, to the common midwives of the country. He ought to be resolved to become fully acquainted with the dynamics of the generation-sphere ; by the irregular ope- ration of which, as Wigand says, the power of the uterus in labors is so often baffled, and its energies misdirected. If he studies well the therapeutics of midwifery, and practises them well, there will be no occasion to twit him with the reproach so commonly cast on the accoucheur, that when he is called in, " one or the other, mother or child, goes to the grave," to use the words of Wigand, which I can- not but quote in this place. " Gibt es keine gegend, keine stadt mehr, wo das Publikum es nicht anders w T eiss und gewohnt ist als dass, w T o ein accoucheur sein hand anlegt, wenigstens eins von beiden, das Kind oder die Mutter, darauf gehen miisse ? Kennen, wir jetzt keine Geburtshelfer mehr, die, wo sic hinzugerufen werden, keine andere Indication zu machen im Stande sind, als augenblick- lich mit Zange oder Faust, iiber den unschuldigen Uterus herzu- fallen, und ihn, wie einem Dieb und Spitzbuben der das Kind gestohlen hat, zu mishandeln?" " Are there not any districts or cities to be found, in which the public generally suppose that where a physician is called in, one of the two, mother or child, must be sacrificed ? — and are there no accoucheurs at the present day, who, being called to a case of labor, can discover no other indication of treatment than that of instantly, with hands, or with tongs, falling upon the innocent womb, to abuse and maltreat it as a thief, or robber that has stolen the child?" These words of Wigand are strong words ; let them sink deep into 248 LABOR. the heart of the Student, for they are from the lips of as true and noble a Scholar as has in any age graced the annals of Medicine. Let the Student now enter upon his pursuit with a resolution to add something to the value of the art he is about to practice during his future life ; let him leave to the brethren, and to the world, some fruit or fruits of his observation, his reflections, or his experience. He is about to enter upon a life singularly arduous and toilsome, involving sudden and most painful responsibilities to individuals, and to society at large. He is doomed to sacrifice himself for his station. There are no vacations or holydays for him; and night itself is turned into day; for his occu- pations cease not with the setting sun ; his task is never done. More labors occur at night than during the day ; a circumstance that adds greatly to the onerous and distressing duties of the Accoucheur. M. Quetelet, of Brussels, in his treatise Sur V Homme et le Deve- loppement de ses Facultes, &c, t. i. p. 108, says that, being led by curiosity to inquire whether there is any connection between the hours of the day and the number of births, he employed in his calcu- lations certain results communicated to him by Dr. Guiette, who was then attached to the Maternity Hospital St. Pierre, at Brussels. They were collected during eleven years, from 1811 to the end of 1822. M. Quetelet communicated them to M. Villerme, who found them per- fectly analogous to results obtained at the Hospital de la Maternite, at Paris. In making out his tables, M. Quetelet adds a column showing the number of the still-born children, and a third column indicating the results obtained by M. Guiette in 1827 and 1828. Hours. Births, Still-born, Births, 1811-1822. 1811-1822. 1827, 1323. After midnight 798 53 145 Before noon 614 51 119 After noon 574 59 119 Before midnight 694 55 148 Total 2680 218 531 " These results show that births are more numerous at night than during the day; the ratio for the eleven years from 1811 to 1822, is 1492 to 1188, or 1.26 to I ; and for the two years' results of Dr. Gui- ette, 1827, 1828, the ratio is 293 to 238, or 1.23 to 1 : hence, there are born at night almost exactly five children for four born during the day." LABOR. 249 Dr. Buck, of Hamburg, came to nearly similar results. M. Que- telet sets up the following table of them : — Births. Winter. Spring. Summer. Autumn. Mean. After midnight 325 320 291 312 312 Before noon 270 252 256 216 249 Afternoon 190 136 189 235 183 Before midnight 215 292 264 247 256 These figures give the ratio of 1.31 to 1 for the night and the day. Particular observation shows, that at about the hours of noon, and midnight, the births are least numerous. Notwithstanding the ratio of night to day births is as above stated, it will happen, that of those referred to as day births, a very large number will require the counsel of the physician during the night. It is true, therefore, that his task is a severe one. With these remarks, I now proceed to treat of Mid- wifery, which is the art of assisting women in labor. Labor is the process by which the contents of the gravid womb are expelled; and the word is highly expressive of the fatiguing, violent, and painful struggles and efforts of the woman to overcome the obstacles to her deliverance from the uterine burden. Labor should commence, as we have already seen, at or about the two hun- dred and eightieth day from the last appearance of the menses, or the one hundred and fortieth day after quickening; and it may, in general, be expected to terminate without any artificial power or assist- ance, after a few hours of travail — the time being greater or less, according to the amount of the power employed, or the resistance to be overcome. The average duration of labor has been stated at four hours: I should think it greater. There are many examples of women in labor w T ho are completely delivered in ten minutes from the first perception of the signs of parturition: very numerous cases occur in which labor is protracted during twenty-four hours; while some of the patients are occupied three, four, and even five days, with continuous efforts to bring the child into the world. I have wit- nessed one labor of nine days' duration, and many of from three to five days. The essential element of labor is the contraction of the muscular fibres of the womb, the end or object of which is the evacuation of the uterine cavity, so that, the whole of its contents being ejected, it may return again to the non-gravid state, when it will measure from two and a half to three inches in length, about an inch and a half in width, and half an inch or three quarters of an inch in thickness; the 250 LABOR. organ being, before the commencement of contraction, about twelve inches long by seven or eight inches in transverse diameter. As the os uteri is closed during pregnancy, it follows that the expulsion of the contents of the organ cannot take place until the orifice becomes sufficiently opened to permit the child to pass out; and. that there is also required for the purpose a sufficient dilatation of the vagina, and of the vulva ; in all which parts a greater or less de- gree of resistance or obstacle is found; which, taken in connection with the resistance afforded by the bony structures and the perineum, are generally the causes of a delay of several hours in the birth of the child, even where it presents itself most favorably to the openings through which it is destined to effect its exit. In a vast majority of cases, the powers of the womb alone are insuffi- cient to effect the delivery of the child ; and its birth is considerably aided by the efforts of the abdominal muscles, and the diaphragm, which are not only capable of making a direct expulsive effort, but, by presenting a point (Pappui for the contracting womb, can assist it, more efficiently to exert its own peculiar forces. The abdominal muscles and the diaphragm, acting alone, can push the point of the womb down low into the excavation, and hold or fix it there, while the fundus and body of the organ are propelling the ovum against the obstacles that stand in the way of its escape. Hence, although the essential element of labor consists in the uterine contractions, there are collateral dynamic elements of the process that greatly avail in its completion, and that ought always to be well understood, in order that they may be either called into action, or restrained, as the obstetrician may please to direct. Perhaps the best idea of the dilating pains of labor is, that the presenting part of the child is pressed against the circle of the os uteri, which, by the contraction of the body and fundus, is drawn upwards over it, so as to strip the womb up over its head, its body and its legs, until the whole is expelled from the os uteri. Cause of Labor. — The cause of labor, or, I should rather say, the cause of the onset of labor, is not well understood; although it is quite probable that it is to be found only in the inability of the womb, in any given case, to bear further distension. Labor begins from a necessity of the uterine constitution, and not from any ascertained degree of development of the child, which, whether large or small, is most likely to be born two hundred and eighty days after the last catamenial period of the mother; but may not be born until three hundred, or even more days have elapsed. The size of the child LABOR. 251 is not found to bear a proportion to the excess of the duration of the pregnancy. It does, in fact, frequently occur, that the womb begins its contractile effort long before the expiration of the two hundred and eighty days; or, on the other hand, it fails to commence its contraction for several days after the two hundred and eighty have elapsed; but, whenever it does begin, it is because it will admit of no further or longer-continued distension. The theory by which Baudelocque endeavors to account for it, and which I have already explained, is, that there is a contest or antagonization betwixt the fibres of the cervix and those of the fun- dus and body of the womb ; that, in the early months of pregnancy, the fibres of the body and fundus yield to, while those of the cervix resist the distending force, until about the seventh month, at which time they also begin to yield, and continue to yield until the end of the ninth month. These fibres of the cervix may be regarded as the seats of the retentive, while those of the fundus and body are the seats of the expulsive faculty or power. At the ninth month they are ba- lanced, or antagonize each other exactly. At length, the development of the womb going on, those of the fundus become the more powerful, and those of the cervix and os uteri are developed, and finally so com- pletely opened as to allow the ovum to escape. This explanation is, perhaps, as good as any that could be offered; but, although human sagacity or reason may remain ever incompetent to the task of unfold- ing the secret forces on which the commencement of labor, or rather the completion of the utero-gestation, depends, it is perhaps not unwor- thy of remark, that, in the development of the gravid uterus and its contents, we behold a wonderful adaptation of parts to the purposes they are destined to fulfil ; since the growth of the child would, if continued indefinitely, make its delivery impossible, and therefore the Author of nature has, by a simple law, provided against such a fatal contingency; the womb, by that law, refusing to yield any further than is sufficient to allow the child to acquire a certain degree of magnitude and vigor, essential for its respiratory life, but not too considerable to prevent its birth from taking place ; and this perhaps is, after all, a sufficient solution of the problem. Subsidence of the Womb. — The term of utero-gestation and the commencement of labor may be supposed to be fixed, and rendered necessary in part, also, by the great distension of the abdominal muscles, and intolerable pressure upon and displacement of the parts contained within the abdomen. I know not what influence on the 252 LABOR. production or excitement of labor may be exercised by the altered state of the abdominal muscles themselves; but it is, perhaps, not too much to infer that they do at length exert some considerable share of influence, by their constant or tonic contractile operation, in aiding the fundus and body to overcome the retentive effort of the os uteri, any yielding or relaxation of which tends to invite or provoke the contractile effort of the fundus. We see, at least, that, in the last days of pregnancy, the womb settles down with its apex in the Exca- vation, and the woman seems much smaller than she was before this sinking downwards of the uterine globe was perceived. Now, it may be asked what can cause this settling or sinking downwards of the womb, if it be not either the action of the abdominal muscles and dia- phragm, which have pushed it downwards, or the contraction of the womb itself? It is probable that both of these influences are, some- times, concerned in the matter; and at other times only one of them, and either of them ; for it happens that when the womb is much sunken, it in one case feels very hard and firm, as if its fibres were in a state of contraction or condensation ; whereas in another case it is soft and flaccid, notwithstanding it may be very much depressed into the excavation; no sign of actual labor being present in either ex- ample. The sinking downwards of the womb takes place, in some per- sons, several days before the first pains are felt. In such cases it must generally be regarded as wholly passive in the matter; it is forced down by the muscles, and not by any intrinsic action or power of its own. This is called the subsidence of the womb before labor comes on, and it is a sign of the approach of that crisis which monthly nurses and experienced women are acquainted with — and which it is proper that the Student should also be able to appreciate. Labor Pains. — The contractions of the womb take place at inter- vals, which are longer at the beginning, and shorter as the labor ad- vances. They last from fifteen to thirty or forty seconds, and, on many occasions, even longer. The intervals, at first, are from twenty to thirty minutes ; but as the irritation becomes more intense, the pains are repeated every five, three, and two minutes, and even every minute ; increasing in violence and duration until the organ is freed from its load. As to the duration and number of the pains, I said a little while ago that the average duration of a labor has been stated to be four hours. If this computation is a correct one, then it may be said that in the first hour the woman shall have a pain every twelve minutes, which LABOR. 253 would give five pains for the first hour. If she should in the second hour have a pain every six minutes, she would have ten pains in the second hour : pains every five minutes of the third hour would amount to twelve pains ; and if she should be affected with them every three minutes during the fourth and last hour, she would suffer the pains twenty times in that period. So that twenty, twelve, ten, and five pains would make up the sum of forty-seven pains for the labor. The whole duration of the whole of the labor pains, supposing each one to last only twenty seconds, under this computation would be about fifteen minutes ; so that, in a labor of four hours the woman would be fifteen minutes under labor-throes, and three hours and three quarters without them. It is to be understood, however, that much pain and distress may be present, notwithstanding the womb is not actually contracting. This calculation refers, therefore, only to the state a woman is in when under the influence of a labor pain, and not to the other causes of distress, from pressure, distension, and the disparting of the textures in the pelvis. The pain felt in labor is owing to the sensibility of the resisting, and not to that of the expelling organs. Thus the sharp, agonizing, and dispiriting pains of the commencement of the process, which are called grinders, or grinding pains, are surely caused by the stretching of the parts that compose the cervix and os uteri and upper end of the vagina. They are rarely felt in the fundus and body of the organ ; and nineteen out of twenty women, if asked where the pain is, will reply that it is at the lower part of the abdomen, and in the back — indicating, with their hands, a situation corresponding to the brim of the pelvis, and not higher than that — a point opposite to the plane of the os uteri. When the pains of dilatation are completed, and the foetal presenta- tion begins to press open the whole vagina, the pain will, of course, be felt there, and is finally referred to the lower end of the rectum, and the sacral region generally. The last pains, which push out the peri- neum and put the labia on the stretch, will of course be felt in those parts chiefly. The painful sensation, under these circumstances, is represented as absolutely indescribable, and comparable to no other pain. The effect of the pain on the bladder and rectum might easily be foreseen ; but, even where they fail to excite the sympathetic action of those parts, the descent of the foetal head, which sometimes fills up the pelvic canal, as a cylinder is filled by its piston, must cause the 254 LABOR. evacuation of the entire contents of the lower rectum and bladder of urine. The effects produced by the pains and efforts of labor upon the constitution are very striking. The mind, in the beginning, is anx- ious, irritable, fearful, and full of the most gloomy anticipations; but as the process goes on, and the expulsive efforts become more and more violent, it acquires courage and firmness and the most dogged resolution. The patient seems like one who has a task set for her, which she is resolved to execute as rapidly as possible ; and she there- fore bears the great pains of expulsion far more submissively, or rather courageously, than the small or dilating pains. The actions of the woman indicate pretty clearly, to the practised eye, the state of advancement of the process. Antecedently to the exit of the head from the os uteri, or its deep insertion into that circle, the voluntary efforts of the patient are confined to a violent grasping of things with her hands. She generally seizes the hand of a bystander, and squeezes it violently, or endeavors to twist or wring it, not pull it. Such an action always indicates a grinder, or a pain of dilatation ; but when an expulsive effort takes place, she not only grasps with all her force, but she pulls at anything in her reach; so that an experienced accoucheur generally can decide, upon entering the chamber during a pain, that the dilatation is or is not completed, by observing whether the patient merely squeezes or presses the hands of her assistants, or, on the other hand, whether she pulls them with great violence. This low position or situation of the presentation at length institutes a tenesmus, or bearing-down sensation, which is a desire to press with all the forces of the abdominal muscles, whatever exists within the pelvis, beyond the limits of the body. Tenesmus, is, in the beginning, controllable by the will, but when it has become exaggerated by the presence of the presenting part in the ostium vagina?, it does happen that no exhortation or fear is capable of inducing the woman to refrain from making the effort, in certain cases. Sometimes, however, the patient may be aroused from the all-absorbing tenesmic sense, and made to heed the urgent appeals of the surgeon to desist from efforts that endanger her. The urine and stool are generally expelled pretty soon after the commencement of the tenesmic pains of labor. But in some patients, the first signs of labor coincide with a disposi- tion to go on the close stool. In addition to the signs derived from the woman's voluntary actions, the practitioner can frequently decide upon the degree of forwardness LABOR. 255 of the labor, by attending to the nature of his patient's expressions and moans, and her respiration. In the early stages of labor during the dilating pains, she either gives out her breath freely, with voice, or merely holds it, making use of no straining or bearing-down effort ; and even if she be here requested to strain or bear down, as at stool, she will resist, or cannot obey, the injunction. Women cannot bear down, at the very beginning of labor. Bearing-down means an effort to expel by contracting the muscles of the belly; but when the womb is full, its fundus at the scro- bicle, and its os at the plane of the strait, the recti muscles can- not expel, they can only hold or compress it. The same is true of the oblique and transversalis muscles. When, however, the fundus has descended low in the abdomen, having foilowed the os uteri which has by this time been pressed down to the bottom of the excava- tion, then the abdominal muscles can exert a vast expulsive energy. So that, when the os uteri is nearly or quite opened, and the expulsive pains alone operate, the woman not only holds her breath, but she makes use of the muscles of respiration to fix the thorax firmly, and then, in the most forcible manner, contracts the muscles of the abdo- men upon the womb. If she be now enjoined to desist from bearing down, she often fails to obey the injunction, because the tenesmus of labor, like that of dysentery, is irrepressible. The muscles that she employs in bearing down, after she has fixed the diaphragm and other muscles belonging to respiration, are the rectus abdominis, the external and internal obliqui, and the transversalis. Is it not clear, that while the fundus uteri is high up in the abdomen, the violent contraction of these muscles would have little effect in forcing the uterus downwards, but would rather compress the womb against the back part of the abdomen; while ; on the other hand, when the uterine globe has sunk low down in the belly, the operation of these abdominal muscles, as agents of expulsion, must become very great and cogent ? I have ever found it useless to urge a woman to bear down upon a grinding pain, and always feel it incumbent upon me to cause the nurses and by- standers to desist from exhorting the patient to bear down, in the early stages of labor ; an exhortation which they very kindly, but very un- timely, never fail to make. Such voluntary efforts cannot be benefi- cial in their influence on the labor, but they may become pernicious, in certain circumstances, where they not only tend to disorder the sanguine circulation, but very much and very early help to exhaust the strength. 256 LABOR. I have placed here a cut, Fig. 71, which shows the state to which the cervix uteri must arrive before the full efficacy of the true expulsive, or bearing- down pains can become manifest. This is a cross section of the pelvis, with the womb and a part of the already dilated vagina. It seems that the cervix uteri has become almost cylindrical, from being a cone, as it was before labor began. The bag of waters is seen bulging out from the fully dilated orifice. The waters are nearly ready to give way — and, in fact, there are many la- bors in which, as soon as the crevasse in the membranes takes place, the child's head rushes rapidly through the orifice and descends to the very bottom of the excavation, or is even expelled by the same single pain. Constitutional Effects of the Pains. — Even leaving out of the question the exciting effects of the pangs and agonies of travail, we should naturally expect that the muscular exertions of the parturient subject would, as in violent exercise, greatly accelerate the circulation of the blood, and augment its momentum ; and we accordingly find the pulse grows more and more elevated as the efforts become greater and greater; the heart beats with increased violence, and the pulsations amount to one hundred and upwards in the minute ; even one hundred and twenty beats are not uncommon. The respiration becomes hurried in proportion, and of course the heat of the body tends to be developed pari passu with the augmentation of the circulation and respiration; so that fever would soon become intense, were it not that the most pro- fuse diaphoresis, chiefly from the upper part of the body and head, comes on to prevent the occurrence of what would, otherwise, become a dangerous fever, and in a few instances does become so. I have already taken occasion to remark upon this excited state of the vascu- lar system, that it is not to be deprecated except in those instances in which it goes beyond the just bounds. It is, however, always worthy of close observation, in order that its tendency to excess may be checked, by a free use of cooling drinks; by ventilation ; by lighten- ing the bed-clothes; by making the patient comfortable in her bed — removing wet sheets and heated pillows ; by an enema, or purge ; and lastly and chiefly, by the use of the lancet. The state of the mind is also worthy of a large share of the Accouch- LABOR. 257 eur's regard. The most cheering and satisfactory assurances that the state of the labor will admit of, should be given, with a due observance of the truth. A woman will be more comforted and composed by being made certain that she shall be delivered in six hours, than by a promise which she does not fully believe, that half an hour more shall put a period to her anguish. No promises should be made, that may not be implicitly relied upon by the physician himself, as well as by the patient. One of the golden verses of Pythagoras says, sfiov ogxov — Keep thy troth. Outward Signs of Labor. — The signs of labor are those which we obtain from simply observing the woman's manner, and from hearing her own account of her symptoms ; or they are such as we obtain from the Touch, or examination per vaginam. For the most part the state- ment of the patient herself, or that of her monthly nurse, is taken as our sufficient early evidence, and we wait for a certain degree of manifest progress before we address ourselves in a more particular manner to establish the absolute diagnosis, which cannot be very certainly done without the Touch. Still, there may be observed the subsidence of the abdominal swelling, owing to the sinking of the apex of the uterus into the exca- vation, and in some measure, to an increase of tonicity in the whole organ. In most of the cases, the new vital intensity, set on foot, manifests itself by augmented moisture of the genitalia, and especially by a viscous mucus, that not a little resembles the white of eggs, which, moreover, is frequently stained with a little blood coming from the disrupted capillaries about the cervix uteri. This tenacious mucus is not yielded by the vagina, but always and only by the cervix. An increased tendency of the bladder of urine to expel its contents, also marks the beginnings of labors; and the rectum is favorably affected when the pelvic excitement prompts it to dejection of its contents. Nausea and vomiting are frequently met with in the lying-in room, as symptoms of commencing labor ; though it is true they mostly present themselves when the os uteri is about one-third dilated. Violent and protracted tremors of the body and limbs, with clatter- ing of the teeth, as in ague, are very generally observed, but they are unaccompanied with any chill or sense of coldness. Finally, pain in the back and hypogastrium, lasting about twenty seconds, attended with hardening of the uterine globe, and recurring 17 258 LABOR. at regular even intervals, is a sign much to be relied upon, though the vaginal taxis gives us the safest assurance by revealing the state of the os uteri. In general, we are accustomed to note, by a watch, the length of the intervals betwixt the pains, and to form an opinion of their intens- ity, by the gestures or moans, or other complaint of the woman. If the patient have reached her full term, we are free to announce from these points of diagnosis, that labor is begun; and if, upon making examination per vaginam, we find the os uteri dilated ever so little, and the membranes rendered tense during the pains, we may be quite sure that the parturient process has commenced. The application also of the hand to the abdomen discovers during each pain a hardness and rigidity of the uterine globe that give place to a flaccid and yielding softness during the absence of the pain. Such are signs of the true pains of labor. Touching or Examination. — If the patient's assent can be obtained, after the proper reasons for asking the privilege of making an exami- nation per vaginam have been laid before her, we should have two principal objects in view, while performing that operation: one of these is, to note the presentation, and the other, the position. There are other observations to be made at the same opportunity, such as the degree of softness or relaxation of the parts — their moisture or dryness — the state of the rectum, and the sensibility of the parts. Upon obtaining the patient's consent to the examination, she should be requested to lie on the bed upon her left side, with her hips near the foot of the bed, and the knees drawn upwards towards the abdo- men, a small pillow having been previously placed betwixt the knees. Except upon occasions of the greatest emergency, a third person should always be present, and the physician ought to refuse to perform the operation of Touching, except in the pre- sence of a third person, who ought to be some elderly indivi- dual, acting as the nurse for the occasion. Let the attendant provide a napkin, and a small quantity of poma- tum, lard, or other unctuous substance, and a basin of water for the hands. When a smart pain comes on, the left hand of the practitioner being pressed against the sacrum of the patient, outside of the bed- clothes, the fore-finger of the right hand, properly anointed with the lard, should be introduced into the vagina, nearest to, and pressing slowly upon its posterior commissure, taking care not to bruise or irri- tate the patient by any rough or hasty proceedings. If the point of the LABOR. 259 finger be now carried along its posterior wall, towards the upper extre- mity of the vagina, the os uteri is felt, and its degree of dilatation ascer- tained. When the finger comes to the os uteri, if the pain still continues, let the greatest care be taken not to rupture the chorion or bag of waters, as it is called, especially in a first labor. These membranes are extremely tense during the pain, which forces them down through the opening of the womb, forming the segment of a sphere, of greater or less size, according to the greater or less degree of the dilatation : if they should be too rudely touched while in a state of tension, they might burst, and permit the liquor amnii to escape; an unfavorable event in the early stage of labor, which it both retards and renders more painful. There is no need for pressing against the bag of waters during the pain, because, by waiting until the pain subsides, the bag becomes relaxed, and can then be pushed back again w T ithin the mouth of the womb, so as to enable the finger to touch the head. For the most part, we only ascertain, in such an examination, the pre- sentation, and being satisfied with that, we wait until a great dilata- tion, or the discharge of the waters, allows us to discover the p o s i t i o n . During the operation of Touching, we also endeavor to learn the con- dition of the orifice of the womb, as to whether it is rigid, unyielding, or soft and dilatable ; whether it be thick and dry, or thin and moist, with an abundant discharge of glairy phlegm. We also ascertain if the os uteri is in a favorable position, that is, in the middle of the pelvis, w r here it ought to be; or on one side; or high up behind, to- wards the sacrum ; and we rectify its position, if need be, by changing the situation of the mother to her back, or to either side, according as we may judge most fitting to bring the mouth of the womb into its proper place. Thus, suppose the mouth of the womb inclined alto- gether to the right side of the pelvis, the patient being on her left side; let her turn on to her back, or quite over to her right side, and the axis of the womb will be brought more nearly to the middle line or axis of the pelvic canal. We are, also, in this operation, to form an opinion as to the probable resistance to be made by the vagina, perineum, and labia, so as to make up our prognosis, which it is best, however, to keep as a secret not to be divulged for the present. At length, the pains having opened the os uteri to the greatest ex- tent, (as in Fig. 71,) and driven down the bag or bladder of waters almost to the orifice, the membranes burst, and the fluid of the ovum escapes with a gush. As soon as practicable after the escape of the liquor amnii, the Touching should be repeated, and now there is little 260 LABOR. difficulty in determining the position of the head, though it may often be ascertained through the unruptured membranes. In general, that side of the pelvis in which the head can be felt at the lowest level, is the one to which the vertex points — for the vertex already dips, in order to enter the bony canal. But if, upon feeling the scalp with a finger firmly pressed upon it, a suture is discovered, which, upon being traced, is found to meet with two other sutures, and no more, that point of meeting will be the posterior fontanel or vertex; and it will be in the first position if it be near the left aceta- bulum ; in the second position if it be found near the right acetabu- lum, and in the third position if it be directly behind the symphysis of the pubis. But if, instead of three sutures, there be four, with a large membranous or soft space betwixt their points of union, it will be the anterior fontanel; and if it be near the left acetabulum, the head will be in the fourth position; in the fifth if it be to the right aceta- bulum, and in the sixth if it be near the pubis. False Pains. — There are a sort of pains that afflict some women towards the end of pregnancy, which, however severe and unbear- able they may be, are nevertheless very justly denominated false pains, to be discriminated only by Touching. I have many times been kept out of my house all night in order to be near a patient supposed to be in labor; and having been refused the privilege of making the examination until morning, after so tardy an admission of my request, I have found an os uteri perfectly closed, and a still tubulated or cylindrical cervix: so that I have been obliged to announce not only that the patient was not in labor, but that she had not yet reached the full term of pregnancy by ten days or a fortnight. It is exceedingly vexatious thus to be baffled by the unreasonable backwardness of the patient to submit to an operation which she knows to be necessary and inevitable; but we shall, in all early stages of labor, except those where the water comes off at the very commencement, be liable to such disappointment and deception, until we verify our other inferences by the infallible test of Touching. The similarity of these false pains to the true pains of labor is very great; there is even to be felt the hardening of the abdomen: .but, if carefully appreciated, it will be found that the rigidity is occasioned by a contraction, not of the womb itself, but of the muscles of the belly, that are so constricted upon the uterine tumor as to make even the womb appear to be contracted ; whereas it is actually only compressed. LABOR. 261 False pains, then, are essentially involuntary contractions of the abdo- minal muscles. They are, probably, of the nature of tenesmus, and are caused either by the ventral irritation produced by the distended womb, or else by intestinal irritation from sordes, flatus, acidity, rheu- matism, and other causes that would also suffice, in the non-gravid state, to bring on spasms of the abdominal muscles. The difference between those of the non-gravid and those of the gravid state is, that in the former they are paroxysmal, but in the latter they are regularly periodical; which latter character they acquire from some law of the uterine innervation that I am unable to explain. False pains are, likewise, common symptoms of rheumatism of the womb. This rheumatic disorder is far more common than has gene- rally been supposed ; and, when misunderstood, is the fruitful source of anxiety and doubt to the practitioner, besides of insufferable dis- tress which it occasions for the patient herself. Wigand, Geburt des Menschen, band. i. p. 82, says that although rheumatismus uteri is sometimes connected with rheumatic pains of other parts of the body, yet, for the most part, only the womb and organs of generation suffer on such occasions. The causes, he thinks, are to be found in the hyperaesthetic state of the gravid womb, its exposure to cold from its projecting condition, and carelessness as to Jress during pregnancy. The characteristic signs of the disorder in labors, consist, according :o Wigand, in a general painful sensibility of the womb to the touch, vvhich is attended with contractions of the organ that are painful alike at the beginning, middle, and end of the labor-pain. The pain of a contraction in the rheumatic womb differs thus from that of a healthy uterus. In the latter, a normal pain gives no distress during the first half of the contraction (Wehen Cyklus), for the pain of a labor-pain does not commence until the mass of the organ begins to exert its superior power by thrusting the presentation into the dilating cervix uteri and vagina. I have met with several instances of rheumatic gravid womb, where the woman was tormented with false pains for many days previous to the real attack of labor. In one delicate female, pregnant with her first child, there was daily pain in the womb for a month before the child was born ; and these pains had so far the external character- istics of labor, that the most experienced practitioner might be de- ceived by them, until he should clear up the diagnosis by the Touch. The Touch alone could convince him that the os uteri was not in the least concerned in the matter; the tubule or cylinder of the vaginal 262 LABOR. cervix remaining as complete!}' undeployed as in the most perfect repose of the gestation. In all such instances, the globe of the womb is sore to the touch, and only the slight occasional condensations that occur in all wombs towards the close of pregnancy could be looked to as the sources of the patient's distress. It may well be conceived that a rheumatic uterus could not but be painful whenever its parts should be disturbed by the normal contractions of its muscular tissue. In certain examples of rheumatism of the uterus, I have found the patient with a sore belly, often finding herself in apparent labor and as often disappointed ; yet disclosing to the Touch a partially dilated os uteri for many days, yea, even for a whole month, before the veri- table attack of labor came on. Let the Student remember that when he shall be hereafter sum- moned again and again, to a false alarm, as it is called, for the same patient, he will probably have to treat a rheumatismus uteri. Let him bleed such patient; let him keep her in bed, covered rather too warmly than not enough so with bed-clothes ; let him give her some doses of Dover's powder, or anodyne enemata, at night; let her abdomen be bathed two or three times a day with equal parts of warm oil and laudanum, and let him see to it, that she entertain a soluble state of the bowels by means of gentle aperients, of which a pure pre- cipitated sulphur, with calcined magnesia, is the most to be desired. Case. — I advise the Student early to come to the resolution of being cautious in giving his diagnosis and prognosis of these doubtful cases of labor. I know that there belongs to professional men a disposition to pronounce at once. This, perhaps, arises from a false pride, which prompts them to seem to know all things at a glance, or by mere intuition. If the young beginner, being called to a supposed case of labor, should witness a very regular recurrence of pains in the belly, and should also place his hand on the abdomen of the woman during one of these pains, he might find it very hard, and be led to pro- nounce, "Yes, it is her labor." Let him never pronounce, let him never give an opinion until he knows upon what it is founded. For example, I was called in the month of July, 1841, to a lady having very regular pains, which she said were like those she had experienced in her two former labors. During one of these I held my hand on the abdomen, which became hard, and evidently so because the womb was contracting strongly. " How far are you advanced, madam, in your pregnancy?" " Seven months and one week, sir!" "In that case I ought, before making any prescription, to learn absolutely LABOR. 263 whether the womb is opening or not; for if it be opening, then your labor is begun, and must proceed ; if not, then you ought to have some remedy to prevent it from beginning, lest your child should be born prematurely, and thereby lost, from its non-viability." Effectively, I found the os uteri open so much that I could introduce two fingers and touch the chorion, which was tense. The cervix yet retained a quarter of an inch of its tubular form. I said, "You are in premature labor; but, as there is not the least degree of vascular excitement, and no pain except this that you complain of, I shall give orders to send you a potion of laudanum, in hopes of arresting the case here." She went out to her full time, up to which date I was repeatedly called to give assistance in her supposed attacks of labor. But, when the labor came on in earnest, the relaxation of the cervix w T as already so great that she delivered herself in a very few minutes. I am sur- prised, when I reflect upon it, that the retentive power of the cervix and os uteri should have enabled her so long to keep the ovum within the womb. This was doubtless a specimen of disordered innervation of the womb, arising from a rheumatic principle acting on the mass of that organ. She had just come ashore from an East India ship, from Madras. Such cases as the above occur repeatedly in course of a consider- able practice. I have seen a patient with the os uteri as large as a dollar and with strong pains, cease to suffer, sit up, walk about, and even go out for days in succession, before the labor was resumed and terminated. The regular manner in which labor pains recur has long been the subject of curious speculation. I have not found any writer whose explanation of this periodicity satisfies me, and shall not repeat here for my reader the mere hypotheses which I reject myself. It is enough to state that the contractions increase in frequency and power in proportion as the uterus grows small, or approaches more nearly to the moment of excluding its gravid contents — a most singular phe- nomenon, which, of itself, is almost sufficient to refute all the existing hypotheses as to the anatomical arrangement and composition of the muscular texture of the organ. The observation, however, is per- fectly true. In the contraction of the muscles of locomotion or relaxa- tion we find that the greatest power of the organ is excited at a point midway between elongation and the greatest condensation. Thus the biceps acts with the greatest force w T hen the arm is bent to a right angle, and not when it has drawn the hand up to touch the clavicle, nor when the arm is fully extended; but in the case of the uterine 264 LABOR. fibres, if we adopt the common theories, we must admit that the nearer the extremities of the muscular fibres are brought to each other, the stronger do they act. In the case of the uterine fibres, whatever be the cause of the first contractions, or whatever be that of the periodical return of them, both the forces, periodical and dynamic, seem to acquire strength by exertion. The weakest pains are those which are met with in women who have the womb enormously dis- tended with water, or with twins; the uterus, in such cases, seeming to be distended beyond the just limit, and to lose thereby its tonic or contractile force; a case similar to that which is observed in an over- distended bladder, w T hich, as is well known, refuses to act upon its contents; so that, even with the catheter introduced, it is sometimes necessary for the physician to aid the bladder by pressing his hand strongly upon the hypogastrium. The indisposition to energetic movement in a womb too greatly distended by an excessive quantity of liquor amnii, or by double preg- nancy, may for the most part be obviated by early rupturing the ovum, and allowing the waters to run off; but we cannot, even by this prac- tice, always remove a certain atony or apathy of the womb, which em- barrasses the labor very much ; nor prevent a troublesome hemorrhage after delivery, the consequence of that atony. The womb, like the bladder, when once over-strained by distension, is exceedingly prone to relax and fill, so as to become over distended again, because it is inert — atonic. In a labor pain, it does not happen that the whole muscular appara- tus of the womb enters into contraction at the same moment of time. The fundus may be the first to begin the contractile movement, or the muscular mass of the cervix may take the initiative in the action, which, extending slowly over the whole muscular tissue, engages it at length in one uniform and equable effort at condensation of the whole womb. The observation of this fact is due to the celebrated Wigand, already quoted, one of the most careful and intelligent investigators of the phenomena of parturition who has existed in any age or country. Since my attention was called to it, in his beautiful work, Die Ge~ hurt des Menschen, I have many times noticed, that the earliest evi- dences of movement, upon the recommencement of the pain in labor, was a gentle drawing together, constriction or contraction of the mouth of the womb. This motion I have discovered by the Touch, before the woman herself was made conscious of it; and I have said: "Now the pain is come," to which she replied in the negative, but soon cor- LABOR. 265 reeled her speech; for, as I have said, when the contraction begins in the cervix, it overspreads or extends to the whole organ. The fundus, in other instances, is the first to exhibit manifestations of contractility. In this case, if the indicator finger be held in con- tact with the circle of the os uteri, so as, at the same time, to touch the bag of waters or head of the foetus, it will be found that the bag grows more tense and begins to descend ; or the head moves down- wards, being urged on by the contraction of the fundus, before the circle of the os is felt at all to harden or constringe itself. In a labor pain, the whole womb contracts. Let not the Student, then, imbibe the false notion that the cervix relaxes while the fundus and body contract. It is true that he will find, in a labor pain, that the contraction of the fundus commonly lasts longer than that of the cervix, and that the cervix becomes more dilated towards the latter half than in the first half of a pain, agreeably to Wigand's observation, ante. If a pain continues twenty seconds, and the woman is to be exhorted to bear down her pain, she ought not to begin to bear down, during the first ten seconds, but she should exert herself to improve the last ten seconds. The advantage of doing so has appeared to me very great, in numerous labors that I have superintended. In the matter of labor pains, it is worthy of remark that the tenor of them is uncertain, and the action often capricious. For example, the cervix may give way regularly and progressively to a certain point, where its dilatable disposition ceases, for a time. It is wrong to prog- nosticate of a matter so uncertain. A man founding his prognosis upon the uniform progress of the dilatation in a labor, may announce that the end is nigh — when the dilatability is only nigh to a certain point, where it is destined to stop for many hours. Near the end, when, by the contractions of the fundus and corpus uteri, the child's head has been forced partially into the vagina or quite through the os uteri, the tenesmus, or straining with the auxiliary or abdominal muscles, begins, and, as I have already mentioned, the whole womb, with its contents, is now pushed downwards. Under these circumstances, the circle of the os uteri first descends very low in the excavation, and its anterior lip may be felt, stretched behind and across the pubic arch, a little below its crown. There is no labor in which the anterior segment of the circle of the os uteri does not descend lower than the crown of the pubal arch in front; but as soon as the mouth of the womb is fully opened, and the head completely lodged in the vagina, the lips of the womb ascend, probably, quite to the top of the pelvis in front, and as high as the projection of the sacrum be- 266 LABOR. hind — the os uteri encircling the throat of the foetus with a gentle or moderate contraction. At this stage of the labor, the fundus uteri approaches much nearer the os uteri — nearer by at least four inches, or four and a half, perhaps. When the head escapes from the vulva, the thorax of the child takes its place in the vagina, and at last, as the thorax emerges, the abdomen and lower extremities succeed it in that place, so that soon, nothing remains in the womb but the placenta and membranes, with a few ounces of blood and water. The fundus is now not more than five inches from the os uteri, instead of twelve inches, as it was at the beginning of labor. The womb is strongly contracted in the last expulsive throe ; and if the placenta were not detached even earlier than this, it could scarcely retain its connection with the uterine sur- face, now that its superficies is so greatly reduced in size. In fact, we do find, in a large majority of cases, that the placenta is pushed wholly or in part into the vagina, by the same pain that forced the abdo- men and breech of the child to take that situation ; or if it be not thrust quite out of the womb, it lies loose and detached within the cavity of that organ, and ready to be expelled upon the slightest renewal of contraction, or even by the voluntary expulsive effort of the abdominal or auxiliary muscles. Instances do occur, of a morbid adhesion of the placenta to the womb, in which it is not detached even for some time after the birth of the child ; and I think I have noticed that where the attachment exists at the anterior part of the cavity, it is least apt to be thrown ofFby the same pains that expel the child. The con- stringing movement at the fundus is greater than at the front or back of the womb ; hence, a placenta attached to the fundus is more likely to come off well, than one seated on another part of the cavity. Extrusion of the Placenta. — The separation of the placenta is commonly followed by an effusion of blood. This effusion is incon- siderable in proportion as the action that condenses the uterine tissue is more energetic and stable. It is supposed that nearly all, if not all, the blood that comes off, flows from what was the placental surface of the womb. Now, as the placenta is from fifteen to twenty inches in circumference, it will occupy a space equal to such a superficies, on the w T omb, before labor begins; but when the womb has contracted so as to be no bigger than two fists, the placental surface of it must at last, come to be not more than one and a half or two inches in diameter, so that the effusion from its vessels is greatly checked, and, in very tonic uteri, wholly suppressed for a time. If in any case the tonicity LABOR. 267 ceases to exist, then the womb expands again more or less, and blood begins to flow. The womb becomes condensed by the muscular con- traction, for the muscular fibres are disseminated everywhere in the substance of the organ; but, inasmuch as there is a great deal of arte- rial, capillary, venous, absorbent, and cellular matter that serves to make up the sum of the uterine mass, these materials, which are not contractile, serve as an elastic resistance to the muscularity, and thus cause the organ to spring open again as soon as the muscles relax, or lose their tonicity. It is desirable, therefore, after delivery, to have a well contracted and tonic womb. The Child. — During the whole of this process of parturition, the child is quite passive : if alive, its body possesses a certain degree of firmness and solidity (wanting in the dead foetus) that enables the womb to force it downwards, and cause it to dilate the parts it is destined to pass through. It does not assist itself; as indeed it could not do, with its thighs and arms flexed upon the body, and the legs crossed perhaps upon the epigastrium, and pinioned by the coats of the womb, which press it together into a compact and passive mass. If the child be dead, and especially if it have been long dead, its tissues are less firm and resisting; its articulations are all loosened, and even the cranial sutures become relaxed; so that when the contractions of the womb act upon the foetus to expel it, the whole mass of it yields, to a certain extent, and is squeezed together by the pains. Under such circumstances, the parts to be dilated are opened much more slowly; for a portion of the power is expended or lost in pressing the soft and yielding mass of the child into some degree of solidity before it can be efficaciously impelled against the organs to be riven open. A child long dead, in a first labor, is often, therefore, a cause of trou- ble. It might almost be true to say, that in this sense, a living child helps itself in the labor, while a dead one does not. Outward Thrust of the Spinal Arch of the Child. — At the beginning of labor, the womb acts only upon the ovum en masse: compressing the membranes and their contents. The lower part of the chorion is pressed like a bag into the os tincse, and protrudes through it, and is often burst and the waters discharged, before the fundus of the womb comes to press firmly on the child's breech and push it downwards. But whenever the fundus uteri does begin to compel the child downwards, it can only do so by acting on the pelvic extremity of the spinal column. The cephalic or cervical extremity 268 LABOR. of this column, of course resists the force, and the spine becomes more arched. It is as if one end of a bow were set up on the floor, and the hand resting on the upper end should press it directly down- wards in order to bend the bow. The outward thrust of the arch is in this case so great that the ends of the bow strive to retreat to the parallel of the centre of the piece. In the same manner the cervical end of the spinal arch, attached as it is to the condyles of the occipital bone, will naturally thrust backwards and thus raise the vertex and depress the chin; or I should rather say (as the head is downwards), it will depress the vertex and raise the chin, forcing it towards the infant's breast ; while the vertex, which is the occipital extremity of the occipito-mental diameter, descends, as the presenting part. This happens the more readily, as the child's head lies over the pelvic opening, which, so to speak, yawns to receive it. This bending of the neck, or carrying of the chin to the breast, is a most important act in the mechanism of a labor; it is called the flexion of the head; and when it takes place in due degree, it enables the head to descend into the pelvis with very little obstruction; for the other change, called the rotation of the head, does not take place well if this first step fails. The head of a child at term passes very easily into and through a well-formed pelvis, provided it present certain of its diameters only to the canal. Now the diameter extending from the child's chin to its vertex is 5.5 in many children; but the outlet of the pelvis is nowhere more than four and a half inches, at most. Of course, the child could not be born should it present such a diameter. Again, the diameter extending from the vertex to the space between the eyebrows, is fully 4.5, and often more than that; but from one ischial tuberosity to the other is but four inches, so that were this cephalic diameter of 4.5, to be parallel with this bis-ischiatic diameter of four inches, the head would stop ; it could not descend any farther. The vertical diameter of the head is, however, only 3.75, which is smaller than any one of the pelvic diameters ; so that no great ob- struction can, in any natural labor, be offered by the bones, provided the chin be, early in the process, borne strongly against the breast, so as to make the vertex descend, and cause a considerable dip of the horizontal diameter of the foetal cranium. Positions. — The promontory of the sacrum juts into the superior strait in such a manner as to turn any rounded body off, either to its right or left side, and accordingly, it rarely happens that either the forehead or the vertex can pass down immediately in front of the pro- LABOR. 269 montory ; but, as there is a concavity on each side of it, the vertex, or the forehead, passes down in this concavity, which gives to the head an oblique direction, as to the opening, or plane of the superior strait. The cut shows how the intrusion of the promontorium into the outline of the superior strait, may serve as a guide to the forehead, com- Ig " ' pelling it to rest in the right, or in the left sacro-iliac space, as the case may be. The forehead, in a majority of \ mSSsxV ' I instances, goes to the right of the promontory, or in front of the right sacro-iliac symphysis, while the ver- tex descends below the brim, oppo- site to the left acetabulum ; not at a fixed point, but either nearer the front of the pelvis, or more posteriorly, as the case may be. Indeed, the child generally is found to bore with its head, so as to turn the vertex now forwards and now backwards, until at last it becomes fixed in one position, by getting under the arch of the pubis. So common is it to observe the child to descend with the vertex opposite to the left acetabulum, that that is taken or counted as the first posi- tion of a vertex presentation; and Baudelocque, whose authority on this subject is much followed in the United States, enumerates a second, third, fourth, fifth and sixth position, the enumeration or order being founded on the supposed relative frequency of the several sorts, as they are met with in practice. Thus the most frequent, according to Baudelocque, is the first posi- tion, in which the vertex is directed to the left acetabulum, and the forehead to the right sacro-iliac symphysis. Next in order is the second position, in which the vertex is to the right acetabulum, and the forehead to the left sacro-iliac symphysis. The third position is that in w T hich the vertex is behind the pubis and the forehead in front of the promontory. The fourth position is that where we find the vertex at the right sacro-iliac symphysis and the forehead towards the left acetabulum. The fifth position is that in which the vertex is at the left sacro-iliac symphysis, and the forehead towards the right acetabulum. And lastly, the sixth position, wherein the vertex is at the promon- tory and the forehead at the symphysis pubis. It is doubtless extremely convenient and proper to reduce all the possible modes of vertex presentations to a small, yet sufficiently comprehensive classification : but the reader, and especially the young 270 LABOR. Student, should remember that all these classifications are human inventions. They are the proposita or the dogmata of different men ; and, in fact, it is possible for any presentable part of the head to pre- sent itself at any part of the brim. If he should, however, find any difficulty in remembering the order or application of these several positions, let him make use of such an arrangement as the following, which I place before him in this connection, rather than refer him back to an antecedent page. Beginning with the vertex at the left acetabulum, let him say, ver- tex left, then proceeding to the second position, in which the vertex is at the right acetabulum, let him say vertex right, and so on for the whole of the six positions as follows: Vertex left, vertex right, vertex front. Forehead left, forehead right, forehead front. If the vertex be at the left acetabulum, the forehead is of course at the right sacro-iliac symphysis; if it be at the right acetabulum, the forehead is at the left sacro-iliac junction, and vice versa; for all these six positions are vertex positions. So, if it be forehead left, the ver- tex is at the right sacro-iliac joint. If the forehead be to the right, the vertex is near the left sacro-iliac symphysis ; if the forehead be front, the vertex is towards the promontory. Hence I repeat, vertex left, vertex right, vertex front; forehead left, forehead right, forehead front. The first three are occipito-anterior positions, and the last three are occipito-posterior positions. I have ever found this enumeration the easiest one to remember, and as a real nomenclature of the positions, I prefer it to all others, and recommend it to the Student of Medicine. Madame Boivin, in her Memorial sur VArt des Accouchemens, gives us a table showing the relative frequency of these positions. In her practice, in 20,517 births, there were 19,584 vertex pre- sentations, of which there were of the 1st position, 15,693 2d u 3,682 3d a 6 4th a 109 5th a 92 6th a 2 Madame Lachapelle's practice in 22,243 births, showed that there were 20,698 vertex presentations, of which there were of the LABOR. 271 1st position, 15,809 2d " 4,659 4th " 164 5th " 66 That distinguished Obstetrician, Dr. C. F. Nsegele, Professor of Midwifery at Heidelberg, asserts, that while the most ordinary position of the vertex presentation is that in which it is found nearest the left acetabulum, the one next in frequency is the fourth, or forehead left position, and he calls it therefore, the second, in his enumeration. Dr. Nsegele makes this enumeration of first and second positions at page 114 of his Lehrbuch der Geburtshiilfe, fyc, and at sect. 264, p. 120, gives his views as to the very ordinary occurrence of fourth positions ; and at sect. 267, p. 122 — declares that, ceteris paribus, the forehead left positions are as favorable for the mother and child also, as the first or vertex — left positions, the vertex rotating spontaneously from the right sacro-iliac junction to the right acetabulum, and then to the pubal arch. In a conversation I had with this venerable and most honored pro- fessor at Heidelberg, in 1845, he gave me convincing proofs of the correctness of his opinions of this circumstance. Indeed, I kept a register of presentations a few years since, upon learning, through a publication of Dr. N.'s Mechanism of Labor, made by Dr. Edward Rigby, now of London, that the common view as to the greater frequency of the vertex right position, was erroneous. I am fully convinced, by my registry, and by the course of my clinical ex- perience ever since, that Prof. N. is quite correct in his statements, and I venture to assure the Medical Student, that while he shall surely meet with vertex left positions more frequently than any others, he shall as surely find the forehead-left positions next in point of fre- quency. This is a comfortable doctrine ; for, the tyro, who has studied in the books the so-called mechanism of the head in the pelvis, is very likely to be startled at the first case of forehead left presentation he shall meet with; but if he now learns that it is a natural position, and the one second in point of frequency, he will not suffer himself to be dis- turbed by the occurrence; particularly if he remembers Dr. Nsegele's assurances, as above expressed. Dr. N.'s words are: "Die geburten bei der zweiten shadellage gehen, unter ubrigens ganz gleichen um- standen, durchaus ohne grossere Schwierigkeit als die bei der ersten, vor sich, und es hat nicht den allermindesten Einfluss auf die Mutter 272 LABOR. oder das Kind, ob der Kopf sie in der ersten oder in der zweiten Sha- dellage zur Geburt stellt." Dr. Edward Rigby, of London, who was Prof. Nsegele's pupil at Heidelberg, translated, some years since, as I stated, a small volume of his worthy teacher's, on the mechanism of labor. At p. 36, Dr. X. informs us, that, according to his observations during many years, made with the greatest possible care and attention, the fourth position, that in which the occiput is near the right sacro-iliac symphysis, is, after the first, far the most frequent in occurrence of all the head presentations; whereas, he thinks the second position of the vertex occurs very rarely. Out of one hundred labors where the head presented, there were twenty-nine cases of the fourth position ; and out of another series of thirty-six labors there were twenty-two of the first, and eleven of the fourth position. The result of his inquiries shows that the fourth is to the first position in frequency, as one is to two and a half. I am glad to be able to confirm Dr. N.'s statement so far as to say, that I am of opinion, from my own experience and observation, that the fourth position is far more frequently met with, in my own prac- tice, than any other except the first. The reader has already seen in the table, that in Madame Boivin's records the relative frequency was 15,693 of the first, 3,682 of the second, and only 109 of the fourth. I am sure that the statistical review will not be borne out by the experience of the reader of our Midwifery Library. Prof. Simpson agrees with Dr. N.'s views. Mechanism. — Let the head enter the pelvis obliquely, the vertex being in the first, or vertex left position — it is not to be understood that the dip of the horizontal diameter of the head will carry the posterior fontanel into the centre of the pelvic canal: on the contrary, such a dip would be too great — and the vertex, or posterior fontanel, glides down along the ischium, repelled by that bone, and directed by its inclined plane inwards and forwards ; so that it describes a spiral line in its descent, and the vertex, which on entering the upper strait was directed to the left, is, without any change of posture of the child's body, turned near a quarter or a sixth of a circle, to bring it under the arch of the pubis, beneath which it extends itself again after recovering from its first flexion, so as to allow the crown of the head, the forehead, the face, and last of all the chin, to roll out, in succession, from the floor of the vagina and edge of the perineum. These three mutations are the most important in the mechanism of labor: first, the flexion; second, the rotation; and third, the extension LABOR. 273 of the head. The regular succession of these several states is neces- sary to an easy natural labor; and the principal business of the medi- cal attendant, in such labors, is to see to it that they occur in due order and time. I am reminded here of the necessity there is to warn the Student to stop a moment, and consider what is really the presenting part in a first or vertex-left position. He should reflect that the fontanel, which is directed towards the left acetabulum, is a good ways off from the ostium vaginae towards the left — and that in fact, the part that he Touches in his Examination is the right parietal bone, whose parietal protuberance meets the point of the finger introduced for the exploration or diagnosis. To reach the vertex, therefore, he must carry the palp of the finger upwards and outwards, and backwards towards the left acetabular region, where it will come in contact with the triangular or occipital fontanel. In second positions or vertex- right positions it is the left parietal boss that presents and so on as to the rest of the positions. The vertex, therefore, is not truly the pre- senting point, in vertex labors. As to any person's being able to explain the mechanism of the pelvis, or its operation in parturition, without the aid of the subject, either recent or dried, I hold it to be an impossibility. Let the stu- dent, therefore, who wishes to comprehend this matter, which involves probably the most important information that he will have occasion for in obstetric practice — let him take a dried pelvis and a foetal cranium, each w T ell and naturally proportioned to the other — let him plunge the cranium into the excavation, holding it in the first position, but without flexion ; he will find that it cannot descend very far, on account of the rapid approach of the inclined planes of the ischia below. But if he now turns the vertex somewhat downwards, or brings the chin upwards, it will descend a little farther. As he presses it downwards, the inclined plane of the left ischium tends to repel and deflect it towards the pubic arch, in which direction no great bony resistance is offered. If it glance upon the obturator membrane, and indent it, the resiliency of that tissue is sufficent to repel it still more, and still more to deflect it towards the front ; in fact, it easily takes a pivot or rotatory movement, which is greatly enhanced or pro- moted by the structure of the back and lateral parts of the pelvic excavation, which are so inclined as to likewise repel and deflect the forehead, backwards, and cause it to fall into the hollow of the sac- rum. Let this experiment be tried both with the dip or flexion, and without it, and it will be seen that in the first case the rotation is 18 274 LABOR. almost spontaneous, and in the last very difficult, if not impossible, without powerful extrinsic aid. The rotation being completed, the vertex is found jutting forth under the arch of the pubis : it emerges more and more completely until the occiput, or the upper part of the nucha becomes pressed against the crown of the arch, when the further progress of this part ceases — it becomes a fixed point, or it is an axis, on which the head, as before said, turns or rolls out from the orifice of the vagina, at the close of which evolution the extension of the head is complete. After the head is born, the face turns again to the side of the pelvis, towards which it was directed at the beginning of labor, or before the rotation began; and that is called its act of restitution. If the vertex was left, when within the pelvis, it seeks the left when driven out of the excavation. While the head is undergoing these mutations, the shoulders of the child are entering the basin. In the first position, the vertex is to the left acetabulum, and the right shoulder to the right acetabulum, while the left one is to the left sacro-iliac junction. As the shoulders descend, the right one rotates towards the arch of the pubis, and the other falls backwards into the hollow of the sacrum ; the thorax is now plunged deep into the excavation, where its farther progress is arrested by the floor of the pelvis. A renewal of the uterine effort forces the left shoulder to glide off from the apex of the sacrum and coccyx, and displace the perineum, which it thrusts backwards, out of its way, until the shoulder is born. The edge of the perineum is now retired so far backwards as to allow the right shoulder to disengage itself from under the crown of the pubic arch; and the body of the child is immediately afterwards expelled with great violence, occasioned by the irresistible tenesmus the woman experiences in this stage ; and which compels her to bear down with her whole energy. Sometimes the shoulder nearest the pubis is first expelled; generally, the other is the first to be born. A repose of eight or ten minutes follows the birth of the child, and a slight pain, or a voluntary bearing down, expels the placenta and membranes, as before said. The almost supernatural exertions and struggles of the woman, as well as the painful sensations she experiences, and the novel impres- sions made upon her nervous system by the successive stages and occurrences of parturition, have brought about a violent excitement of the nervous and circulatory systems of the economy; the former of which is resolved by cries of joy, by tears, and by the delightful sense LABOR. 275 of security, of triumph, and finished toil, and by that gushing tender- ness which a mother feels for her new-born and helpless progeny. The latter rapidly abates, under the greater or less abundant effusion of blood, and the abstraction of the stimulus of exertion, pain and dismay. The flood of perspiration gradually subsides, and a short sleep, the best restorative, soon permits the patient to feel "comfortable," a phrase peculiarly adapted to the case of a puerperal woman. A review of the whole of the phenomena, both physiological and psychological, that are evolved during the progress of a case of labor, presents perhaps the most perfect example of the state of hysteria that can be anywhere observed. I shall not devote these pages to a comparison of them with those of an hysterical paroxysm, but merely refer the reader to his clinical observation, whether past or future, for a confirmation of this view of the case. Indeed, the whole matter of a labor is ipso facto, a matter depending merely on a status or modality of the womb, and its influences, and sympathies. It therefore is a pure specimen of the local action and constitutional influence displayed by the child- bearing organs, and the whole of what Wigand calls the generation- sphere. The lochia, for such is the denomination of the bloody discharge that follows, flow in such abundance as to require five or ten nap- kins to imbibe the blood effused during the first twenty-four hours; after which they decrease in quantity, and grow pale, until by the tenth or fifteenth day, many women have none but a whitish discharge, which also ceases between the twentieth and thirtieth day. On the day after delivery, the globe of the uterus appears to be larger than it was immediately after the discharge of the placenta. It can generally be felt, in the hypogastrium, during from six to ten days ; after which it retreats into the recesses of the pelvis, diminishing daily in size, until, by the end of the month, it is nearly as small as before it was gravid. Such is the history of Labor, in general terms, which, though it may perhaps afford a pretty good coup d'ceil of the phenomena by which it is characterized, is not sufficiently in detail for the purposes of this work; on which account I shall proceed to treat of other par- ticulars in the ensuing pages. In general as soon as the signs of respiratory life are fully estab- lished in the child, it is severed by the attendant, who divides the navel string after having secured it with one or with two ligatures, and puts an end, by this severance, to all connection with its mother. As to the child, it comes, in a good labor, healthy and vigorous 276 LABOR. into the world. The loud sounds of its vagitus, its cries, pervade the apartment and carry consolation and even transport to the bosom of the fatigued, exhausted, and terrified parent. "Ah, mio corazon! Mio carissimo, querido corazon," said a Spanish lady, from the midst of her pangs, as soon as the head of her offspring became free, and before the shoulders were born — for she heard its vagitus uterinus — - and her heart went forth with passionate expressions of love, to greet it even before it was completely ushered into the world. As a physician, who has passed a life among those who were in pain, in peril, and in fear of imminent death, I must have been witness to many scenes of human emotion — but of all the expressions of love, made manifest in voice and in speech, that I have ever wit- nessed, the most intense, the most rapturous and holy, have been the thoughts that breathed and words that burned as they vehemently issued from the lips of a young mother, whose body had just escaped from the fell sufferings of those who, in sorrow travail in child-birth, according to the primal woe pronounced against her sex. The child being born, it remains that the secundines, consisting of the placenta and membranes, shall be expelled from the uterine cavity. The same kind of power that was used to force the child into the world is required for the delivery of the after-birth. I believe that the after-birth comes off in about ten minutes. There are many labors in which the placenta is chased out of the womb into the vagina by the same pain that pushes the child forth. But, in general, this is not the case, the placenta being only loosened and detached, in whole or in part, and left lying crushed up into a sort of ball by the contraction of the womb upon it. After a repose of some ten minutes, it may be, and it is an indif- ferent matter, twenty minutes, the contractile power of the uterus is again in activity. This excites the tenesmus, as before, and the woman, bearing down, coincidently with the uterine contraction, pushes forth the after-birth, generally accompanied with coagula, and a quantity of fluid blood. The pregnancy is thus brought to its close. Lochia. — After the expulsion of the entire product of the concep- tion, the patulous orifices of vessels, left exposed by the separation of the placenta, freely discharge several ounces of blood. This dis- charge is called lochia. As the cavity of the womb is not obliterated by the conclusion of the labor, it must happen that the blood effused within its capacity shall coagulate, and that the patient shall dis- charge from time to time a utero-morphous-clot, as large as an egg, LABOR. 277 or as large, sometimes, as a man's fist. As the organ grows smaller and smaller, these coagula become less and less; the flow assuming more and more the appearance of the menstrua. In the course of a fortnight in some, of a month, in others, the last traces of uterine ex- cretion dependent on the late pregnancy have disappeared, and the woman is restored to the Jewish estate of cleanness. The lawgiver of that ancient race pronounced that a woman could not be clean until the fortieth day. But our Christian women gene- rally deem a month sufficient for the whole process of the uterine pur- gation. As to the lochia, let the Student learn that when the milk begins to be abundantly secreted, which is on the third day, or about seventy- two hours after the close of the labor, the mammary molimen serves to check the determination to the womb ; and consequently to lessen the amount of the lochia — which, however, becomes again abundant on the fifth day. Can it be that the opened orifices of the uterine ves- sels, from which the lochia are discharged, shall return to their nor- mal, non-gravid condition, without the intervention of a state fit to be called phlebitis? Such is the proposition of an able French writer. Having now given a plain account of what happens in an ordinary labor, I shall in the next page proceed to give directions for the Conduct of a Labor. I cannot, in doing so, avoid some iteration, nor shall I apologize further for so doing, since, without repetitions, I cannot possibly maintain the even tenor of the story, for, though Ob- stetrics is a Science, it is made up of a vast number of unconnected items. 278 CONDUCT OF A LABOR. CHAPTER X. CONDUCT OF A LABOR. The conduct of a labor comprises the whole management of a parturient patient, from the first begining of her pains, until the com- plete exclusion of the secundines ; and it ought also to include all that is done for the security of the mother and the child, during the period immediately ensuing the birth. As labors are extremely various in their characters, as to duration, pain, facility or difficulty, the title at the head of this chapter is a comprehensive one, and fruitful of topics which, if properly handled, could not fail to prove interesting and instructive to whatsoever reader might desire, under such a head, to seek for useful, and indeed I might say, indispensable information. The conduct of a labor might refer to any, and so to all possible events in Midwifery; for Midwifery, after all, is but the conduc t of labors. Any person meriting the name of obstetrician may be supposed competent to the conduct of a natural labor, where the series of phenomena proceeds with rapidity, and in a perfectly natural order of succession and duration, provided he will remember the oft repeated adage, "a meddlesome midwifery is bad;" and be therefore willing to abstain from impertinent interferences. A kindly Provi- dence has so ordered this painful office of parturition,, that the ac- coucheur, in most cases, hath really little to do except to receive and protect the child, and attend to the delivery of the after-birth ; extending his care to the disposal of both the mother and her offspring for the first few hours after the termination of the labor. To show w T hat the proportional number of unassisted or natural labors is, to those that require the aid of science or skill, I may state that out of twenty thousand five hundred and seventy children born at the Hospital de la Maternite, for the time under the care of Madame Boivin, only three hundred and thirty-four required to be assisted; leaving twenty thousand one hundred and eighty-three children that CONDUCT OF A LABOR. 279 came into the world by the natural powers dedicated to the office of parturition. An idea of the time required for the completion of the process of child-birth, may be gained from the following table taken from Dr. Churchill's Theory and Practice of Midwifery, 1846. o "3 • QJ CO m ro ■<# Authors. ►2 ■ rt 3 a o 3 o 3 O 3 O > 3 So E so 08 CO s ° o H Hf' a a a <1 Dr. Merriman 500 206 398 442 450 Dr. Collins 15,850 13,012 15,084 15,346 15,586 264 Dr. Maunsell . 839 347 647 734 793 36 Dr. Beatty . . 1182 577 958 1114 69 Dr. Churchill . 1285 366 760 , 1119 166 Dr. Granville . 640 • • 515 above 12 hours 104 Upon referring to Dr. Collins' work, p. 22, it will be seen that of the 15,850 cases observed, 7,050, nearly one-half, were delivered in two hours, and that 11,257 were delivered in four hours of labor, which is nearly three-fourths for the first four hours. Cautions. — Although it will appear from the foregoing statements that women generally are found capable of helping themselves, yet every labor is not a natural one, nor is every natural one an easy one ; and, where the deviation from the normal character of the phenomena is at all considerable, much reflection and prudence are required in order to prevent a natural labor from becoming laborious, difficult, or actually preternatural. Were it so, that all the cases of parturition should end favorably, and pass easily through their several stages, there would, certainly, be no occasion for medical interference, and we might lay down our vocation and take up a less disagreeable one. But the facts happen not so : hence, when a labor is protracted through many successive hours of apparently fruitless distress, the sufferer loudly claims that something should be done for her relief, which compels the medical attendant to employ such arguments and exhortations as may serve to reassure and compose her, or else adopt some real or pretended measures for relief, or for accelerating the birth. In the " Woman's Booke" the venerable Rainald says: "Also the Mydwyfe muste enstruct and comfort the partie, not onlye refresh- ing her with good meete and drinke, but alsoe with sweete wordes, gevying her goode hope of a speedefull deliveraunce, encouraging and enstomakyngher to pacience and tolleraunce, byddyingher to holde in breath so muche as she may, also strekyng genttily with her handes 280 CONDUCT OF A LABOR. her belly above the Navell, for that helpeth to depresse the byrth downewarde." Fol. XL That practitioner confers a real benefit on his patient, who thus, by kindness, by a proper degree of candor, or the evident possession of confidence in his own knowledge or skill, either convinces the patient that the time is not at hand for intervention, or that, when the time shall arrive, all the needful judgment and dexterity will be employed for her security. A woman may utterly fail of all her courage and firmness, and so, by falling into a despairing or fretful humor, greatly retard and embarrass the parturient processes, to that extent, indeed, as to render some manual operation necessary, merely be- cause she has lost faith and trust in her attendant; which irritates her mind so as to act most disastrously on the physical functions : whereas, she shall recover a great, and indeed a sufficient degree of power, immediately upon the appearance of some other person, either celebrated for his professional abilities, or exhibiting in countenance and manner, the evidences of confidence in himself and in the re- sources of his Art. This observation, which is of the greatest truth and importance, is to be found in that admirable volume, the London Practice of Midwifery, which is supposed to present a summary of the lectures of Dr. Clarke of London. The young practitioner, who sometimes permits his own disappointment to affect in any degree, his remarks or his gestures, exerts a very injurious influence upon his patient. He ought under all circumstances to retain a perfect com- mand over his feelings; and, above all, to be in full possession of the most accurate theoretic knowledge at least, of the processes about to be perfected, and of the measures that are indicated in their several stages, whether they occur in the natural order and manner, or whether anything arise to interfere with or obstruct them. Such a practitioner will rarely lose the confidence of his patient, no matter how severe or protracted her sufferings may be. He will support her spirits and hopes with his steady and confident assurances of relief in due time, and thus prevent the mischief that ensues where the mind, distracted with pain, fatigue and dismal fears, carries disorder into all the func- tions of the body. Nothing conduces more commonly to the production of the very uncomfortable state of things now alluded to, than the making of rash promises or prognostics. No one can know be- forehand when a labor shall be terminated. If the first stages proceed ever so favorably, the latter may give the greatest possible trouble ; and any failure of a prognostic cannot but diminish the woman's reliance upon the ability of her attendant. No good CONDUCT OF A LABOR. 281 practitioner makes them. Let the student of Midwifery, therefore, early resolve to avoid all the difficulties which arise from such great imprudence. It is true that the adept practitioner can sometimes make shrewd guesses as to the hour of deliverance — but he who sometimes gains a small credit for his success will find that he is a loser, in the main, upon the prognostications he may have made. Some very good grounds of prognosis he may take upon the fashion or form of the woman's body, as I have shown from Wigand at page 41 of this volume. He ought to learn something of her stature and shape — and it is proper for him to inquire as to any obliquity, any over distension, any deviation that may exist — and this he can do without offending the delicacy of the patient, who will rarely refuse to rise from her seat and stand up before him, that he may know if all is right as far as can be deemed by external palpation. If she be lying on the back, it is not at all difficult even to make but the diagnosis of the presentation, either by feeling the orbi- cular head at the fundus or cervix, or by auscultation of the abdomen. If he should find the foetal heart nearer to the fundus than to the cer- vix, he will know that the case is one in which the pelvic extremity presents. I have repeatedly ascertained, by touching the belly, during the absence of the pains, that I was to treat a breech case — and have made all my arrangements accordingly. Cautions as to the Circulation. — Few women go through labor without a very great acceleration of the pulse, and increase of its force and volume. This excitement is sometimes attended with the development of nervous symptoms, to such a degree as to require measures for its diminution. When carried to a certain extent, an increased activity of the circulation is very advantageous. It develops in the nervous system, both cerebral and ganglionic, a vast increase of energy, which is acknowledged and responded to by every part of the constitution, particularly the circulatory system ; and it serves to hasten the arrival of the happy moment of release, by augmenting the expulsive energies of the womb; to the vigorous and regular contrac- tions of which, a somewhat elevated state of the vital forces seems requisite in almost all cases. It should not be interfered with, then, except under peculiar circumstances : as, for instance, where it occa- sions headache, mental excitement verging towards delirium, or tremors, and irregular action of the muscles, carried to an unsafe extent. The excess of excitement ou^ht to be removed in such cases, in order to prevent it from passing into debility and exhaus- 282 CONDUCT OF A LABOR. tion, the constant results of a great excess of it; and more especially, to obviate the danger of convulsions, apoplexy, and other accidents to which the female constitution is obnoxious under violent excitements or efforts. I have in a great many instances observed, that the pains have fallen, or become irregular and spasmodic, in consequence of this constitutional irritation, and that they have recovered their vigor and regularity by removing the excess of bed-clothes, bathing the hands, face and throat with cool water, and by the exhibition of cooling drinks, together with free ventilation of the apartment. Great comfort and even renewal of strength, hope and courage, commonly follow a change in the outward circumstances of the patient, as to her bed and other things relative to her labor. Thus a woman who may have been lying for seven or eight hours upon the same spot, comes at last to sink into a sort of pit made by the weight of her hips. The continued escape of fluids, as urine, liquor amnii, blood and serum, which are all heated by the heat of her own body, is frequently found to wet her up as far as the shoulder blades ; and she remains pinioned as it were to the spot, aching in every limb, and imploring death, which she really expects. Such a person should, as a mere office of humanity, be taken up, cleansed from head to foot, and replaced upon a bed made up with clean bed-clothes. In cases where these simple cares would not suffice, I have scarcely failed to re-estab- lish the regular course of events by taking blood from the arm. Notwithstanding that most women have a very greatly increased fre- quency and force of the pulse, during the more active stages of labor, it is not universally the case ; some females passing through the whole process without any change whatever in the rate of the circulation. Cases. — The following case was under my care on the 9th of Feb- ruary, 1828. Mrs. B., aged twenty-five years, in labor with her first child, was attacked with the pains at seven o'clock A. 2\I., and was delivered at twelve o'clock of a healthy female infant. The whole amount of blood discharged at the separation of the ovum did not exceed three ounces. The pulse was very slow throughout the labor, not exceeding sixty-five pulsations per minute, even during the most violent expulsive pains. Some time after the complete expulsion of the secundines, the os uteri was two inches in diameter, and as hard and smooth as a ring of ivory. November 3, 1840, I attended Mrs. W. C. L., aged twenty-two years, in labor with her first child. The pulse during the whole process never rose above seventy-two, and soon after the birth of the child fell down to sixty-five beats per CONDUCT OF A LABOR. 283 minute. The labor commenced at two o'clock A. M., and terminated at five o'clock P. M. The pains, even the great ones, were but a few minutes apart, so that I have rarely witnessed a more tedious one, notwithstanding many have fallen under my notice which were much more protracted. I could cite many cases from my practice in which the pulse was quite unaffected throughout the whole process of parturition. Professor Dewees has been justly celebrated for the boldness and good judgment with which he has resorted to venesection, in some cases of labor. The quantity drawn by him, in instances which he has reported, although, doubtless, fully demanded by the exigencies at the time, and justified by the results, may, nevertheless, have induced some persons of lesser powers of discrimination, unnecessarily to resort to a similar mode and extent of depletion; hence, it is not uncommon to hear of very large bleedings, of thirty or forty ounces at a time, during labor. I must aver, that I think such very large abstractions of blood not often necessary, and would, therefore, take this opportunity to warn the reader to discriminate carefully, in making up his judgment concerning the quantity to be drawn in each particular case. For example, where the woman has become too much excited as to her circulation, in the manner above pointed out, I have no idea that it is necessary to draw away a great quantity of blood : let him not bleed, then, until, to use a very common phrase, the pulse is soft. He does not want a soft pulse. In labor, or at least in the violent stages of labor, the pulse ought to be full, vigorous, and somewhat accelerated. If he bleeds till the pulse becomes soft, he will substitute for a state of excitement and excessive power, one of debility and lowness, quite as much to be deprecated. The purpose of venesection, in the instances I at present propose, is to take off the strain of the blood-vessels — to mitigate the general stimulation which ensues upon too rapid a revolution of the blood. I therefore think that it is better, for the most part, to limit our bleed- ings, for these general purposes, to something under, rather than beyond sixteen ounces. But on the other hand, where symptoms, strongly threatening, of apoplexy, convulsions, pulmonary hemorrhage, inflammation, &c, make their appearance, the lancet should be used in the most fearless manner. The same is true of those cases where a great relaxation of the tone of the tissues is required for some special and pressing object, such as the relaxation of a strictured vagina, or a very rigid uterus, the removal of a violent congestive or inflamma- tory accumulation of blood in the brain. 5 &c. &c. 284 CONDUCT OF A LABOB. Actus. — It is difficult to conceive of an individual who, when un- der high excitement, whether from fever or other causes, doth not experience a considerable diminution of that excitement, upon the operation of an aperient or cathartic medicine. The facility and promptitude with which the alvine discharge can be effected by means of enemata, renders a resort to them of very common occurrence: and, in fact, where only a slight reduction of excitement is wanted, they answer the end proposed very fully ; yet a dose of some neutral salt, of magnesia, or castor oil, may be bene- ficially administered, in instances where there is a promise of suffi- cient time for the alvine operation to take place before the delivery of the child. Aperient doses are the more evidently indicated, in labor, because it cannot be doubted that the constitutional disorder brought on by the pain and fatigue of labor, must, in some measure, extend to the digestive organs : nothing is more common than to meet wi:h parturient patients who vomit very much ; while water-brash, heart- burn, and sour eructations are also exceedingly common, and often quite distressing. As to the exhibition of purgative medicines to women in labor, it ought to be understood that in the selection of the article, care should be taken to provide one not likely to operate with violence ; which would be very objectionable, both as to the trouble it might give during the parturient process, and to the inconvenience experienced by alvine operations occurring soon after the birth of the child. For my own part, I prefer, in general, that a patient should not have a dejec- tion until the third day. Still I very commonly advise the exhibition of a dose of castor oil, in cases where I have to fear a long and reluctant dilatation of the cervix. I administer the drug in such cases, because I stem to have observed that the operation of it tends to subduct the power of the cervix and os uteri, or that it relaxes the sphinctorian force of the retentive fibres of the uterus, as it does that of the sphinc- ter-ani muscles. It excites also the expulsive faculty of the womb, as it does that of the colon and rectum, and abdominal muscles. Case. — This day, September 2d. 1848, I found an os uteri not big- ger than a swan quill, though the waters had gone off full fourteen hours, and the woman had had sharp pains for eight hours. I gave her a tablespoonful of oil, and in three hours the child's head had passed through the dilated os into the vagina. The foregoing remarks tend to show not only that medicines of an aperient kind are frequently indicated in obstinate and protracted CONDUCT OF A LABOR. 285 labors, but they also show that great care is required as to the exhi- bition of food to such patients. Some food is wanted, particularly for those whose pains are of the lingering kind, and allow the process to remain unfinished for many hours. For the most part, tea, bread, or gruel, sago, &c, are found to suit the patient best. The best drinks are gum-water, toast-water, lemonade, cold water, and such articles as these ; the object here being to sustain the system, by means of nutriment, while under severe effort, at the same time that we care- fully avoid calling that effort in the direction of the digestive organs by overtasking them. The whole powers of the economy should, therefore, be husbanded and preserved, as much as possible, in their normal condition, in order that they may be directed and determined towards the womb and its auxiliary organs. In the case of a very slow labor, which should be unattended with constitutional symptoms, or any evidences of gastric disorder, a light broth, or even some small portions of very digestible meat, might, upon due reflection, be allowed to the patient. Decubitus. — The attitude of the patient exercises, in many circum- stances, a notable influence on the progress of labor. It is the almost universal custom, in this country and in England, to direct the woman to lie upon her left side, with the knees drawn up ; a posture which is highly convenient to the practitioner, and productive of the least possible exposure of the woman's person. But where the labor proceeds slowly, the heat and the pressure occasioned by lying still, under such circum- stances, become highly injurious. The woman ought, therefore, to be directed to turn on her back, or even on to the opposite side, or to rise and sit in an easy chair, from time to time. I do not recommend that she should be too much urged upon this point ; but I remark, that the influence of custom is so great, that a proposition to turn on the back is not unfrequently received here, with something like astonishment and aversion by the by-standers, who seem to regard that attitude as, at the least, one of indelicacy. Hence, it is proper to assign reasons for the request. In cases where the retardation arises from an improper direction of the expulsive forces, it is of the highest importance to direct the patient as to her attitude. For example, if a lateral segment of the os uteri can be felt towards the middle of the pelvis, and the other one is either out of reach of the finger, or very high up on the side of the ischium, it will be found that the fundus uteri is directed to one side of the abdomen, giving more or less obliquity to the long axis of the 286 CONDUCT OF A LABOR. womb, and of course an oblique line of direction to its forces, which are decomposed, or partially nullified thereby. Case. — On Sunday, November 30th, 1828, I was sent for to visit Mrs. C, whom I found lying upon her right side. The pains seemed so expulsive, that when I arrived, I expected to receive the child immediately, for she bore down like one in the last throes of labor. I requested her to turn upon the left side, informing her that that posi- tion was the most convenient for me. She did so. The pains now became inefficient, and partook, in appearance, of the character of the grinding pains. I found that the uterus had obliqued far down to the left side, as soon as she turned over, which interfered with the due exercise of its power. She was again placed on the right side, which brought the womb into its proper line of direction, and the labor ended, after three or four pains. The same consequences follow from an anterior obliquity of the axis of the uterus ; but, in this case, the ante- rior segment, or lip of the womb, seems to hold the head as in a sling or pouch; the anterior edge of the orifice being stretched across the head, quite towards the middle of the pelvis ; whereas the posterior edge of the circle either cannot be felt at all, or is felt high up towards the promontory of the sacrum. It is evident, that in such a state of things, a good deal of power must be lost in pushing away the ante- rior part of the cervix, which should be preserved, or more usefully employed in other efforts. "We are advised, in order to remove the difficulty, to draw the os uteri forwards towards the symphysis, and retain it there by the fingers; but there are in many cases, a rudeness and violence in this plan, which will be easily understood by such as shall make the attempt, and who, moreover, will often find that they cannot retain it in the desirable place, without giving pain, and exerting so much force as to expose the os uteri to contusion or rupture. If the woman lies on her back, the fundus uteri will retire towards the spine, bringing its axis into the proper range ; and of course the plane of the os uteri will take its proper station: a child will, in some instances, be delivered much sooner if this precaution be taken, than if it be omitted. ^Yhen we meet with patients who allow themselves to be violently agitated by the pains of labor, so as to require actually to be held, at a period when the perineum is in danger of rupture (and women are now and then so distressed as to lose all command of themselves), the best attitude is the one on the back, with the kness drawn up : in this position they are kept much stiller and quieter than when on the CONDUCT OF A LABOR. 287 side. I had a woman under my care in November, 1833, who was so violent that two or three women could not keep her still: when I caused her to assume the dorsal position, she became passive enough. To assist the Flexion and Rotation. — I have spoken, in another place, of the dip of the occipito-frontal diameter of the foetal head. The nearer to the middle of the excavation we find the posterior fontanel, the greater is the dip. In the conduct of labors, we may exert a most beneficial influence, by paying due attention to the dip of the occipito- frontal diameter, which ought to bring the posterior fontanel down towards the axis of the excavation; not down to the axis, indeed, but yet, not too far off from it. The vertex must always, at first, be towards one of the lateral pelvic walls. But where the posterior fontanel is found quite up towards the side of the pelvis, and the anterior fontanel is at the same time within reach of the finger, we may feel assured that the dip has not taken place, and the retardation of the labor may safely be attributed to that cause. Could we, under such circum- stances, get the vertex down, or more towards the centre of the pelvis, the pains would be more successful. Now, as the edges of the parietal bones over-ride the edge of the occipital bone, they form a ledge, which gives a good purchase for two fingers, which, when applied upon that ledge, are generally enabled to draw the vertex downwards to the required position. Whenever this operation is to be attempted, it should be tried during the absence of the pains; and when the vertex is once pulled downwards, it ought to be retained in its place until a new pain comes on, and thus enables the operator to secure whatever advantage he has gained. Should the head be placed, by this gentle method, in the desired attitude, it is as easy to conceive, as it is in- deed common to witness, the increased facilities it affords for the delivery. In this case it is useful sometimes to make the womb take an oblique position in the belly. For example, suppose the vertex to be to the left, and to be unable to dip : it is clear that if the woman should lie upon her left side, and if the fundus of the womb should be thrust down towards the left side, the vertex would have less difficulty in descending. I have always found it much easier to pull the vertex down than to push the forehead up ; because, the finger, acting upon the ledge above described, does in reality act upon the longer end of the lever, of which the atlas represents the fulcrum; whereas, in an attempt to push up the forehead, so situated, the lever we use is very short — its 288 CONDUCT OF A LABOR. I real extremity would be the chin; but we cannot reach that part. Moreover, when we attempt any strong force, the bones of the os frontis are so yielding, that they are readily indented, and we are obliged to desist for fear of contusing the brain ; the fingers, in fact, being applied near the upper edge of the os frontis, where the ossifi- cation is as yet very incomplete. The same objection does not hold as regards the posterior edges of the parietalia and os occipitis, which are very firm before birth. The labor may be retarded by the failure of the head to undergo rotation. It is sometimes very difficult, at the bedside, to learn wherefore the head does not rotate, in a patient, who, in another labor, meets with no such difficulty. I am aware that it frequently arises from failure of the dip above spoken of; but I wish now to speak of a case in which the head has sunk very low, where the dip is good, but yet the rotation fails : I have on many occasions, after much doubt and anxiety upon the subject, found that it could be fully accounted for, by referring to the grasp of the cervix uteri, which actually bound and held the head so firmly, that it was unable to execute its pivot motion. The remedy, in such cases, is patience ; for as soon as all resistance of the cervix is over, in consequence of the fatigue of the parts, or the acquisition of a perfect dilatability, the pains will push the head down, and the inclined planes of the pelvis will cause it to execute its spiral or rotatory movement in the most rapid manner. In all the cases where the rotation fails for want of the requisite dip, or approach of the chin to the breast, let that want be supplied by pulling down the vertex as directed. It must be admitted that such gentle measures will not succeed always, but we have, then, the powerful resource of the whole hand, which may be introduced into the vagina, and sometimes within the cervix; and which, taking the head in its palm and fingers can place the vertex wherever it may be desirable to fix it. It should be remembered, however, that a vectis is, very rarely, but yet imperatively, demanded for the management of such a case. To correct Obliquity. — The obliquity of the womb, which, by vitiating the direction in which its forces act, may greatly retard the progress of a labor, may also be a cause of failure both of the dip and the rotation of the head. Suppose the breech of the child to lie very low down in the right flank of the patient ; if the vertex be to the left side of the pelvis, the dip will be very difficult to effect, and the rota- tion must in consequence fail. The remedy is to correct the obliquity CONDUCT OF LABOR. VAGINAL VESICOCELE. 289 by changing the position of the woman. It is easy to conceive, that if the vertex remain directed still to the left, and the breech could be now thrown far down to the left, the dip would be very much facili- tated. I have on many occasions reaped the benefit of attending to this point. Labors are rendered slow, painful, and even ineffectual, by vaginal vesicocele. The bladder of urine in these instances, instead of main- taining its place in front of the womb, appears to fall down below the top of the symphysis of the pubis, making a soft, elastic, and painful tumor there. Sometimes the depressed bladder is directed to one side of the pelvis, as in the following instance. Case.— Mrs. B.'s labor.— September 8th, 1848, 12 M. In labor since yesterday morning. Expected her confinement last month, about 15th to 20th. She recovered from her last menstrua November 10th, 1847, and has not seen since that date. If we adopt Prof. Naegele's method of calculation, and go back to October 10th, September 10th, and August 10th, which is three months, and then add to August 10th seven days, we should look for the accouchement on the 17th August. In fact, on that day she had a considerable show, — which was repeated for many days, inducing her to keep her chamber, which she has not since left. Her pains are frequent and attended with violent tenesmus or bearing down. By the Touch I find the os uteri very high and scarcely to be reached ; open to the size of a ten cent piece, very thick and hard: the head presents ; the membranes unruptured. Having made this diagnosis and given some directions as to the conduct and prescribed for the tenesmic distress, I saw her again in the evening, about seven o'clock. The pains, it was said, had been repeated every few minutes ; and upon coming into the apartment, one would suppose the child was pressing the perineum violently, so loud was the sound of her respiratory effort in bearing down. She had passed the urine very often; the bowels had been moved by an enema. I immediately examined, expecting to find the child's head under the arch, but was surprised to discover that it had not advanced at all since mid-day. The os uteri might be as much as an inch in diameter and not more. Upon introducing the finger to the os uteri it appeared to encounter a sort of cushion-like tumor occu- pying the right half of the Excavation. On the left side of the Exca- vation there was nothing abnormal — the finger could be pressed to the left as far as the ischial plane. Upon discovering the tumor in ques- 19 290 CONDUCT OF LABOR. — VAGINAL VESICOCELE. tion, my first impression was that it was a case of pelvic enterocele like that in Dr. Bicknell's patient; but farther exploration showed that it was not in the recto-vaginal peritoneal cul-de-sac — which cleared up the diagnosis on that point. I asked again as to the urination — which had been frequent and free. I introduced a catheter into the urethra — but when it had advanced about two inches it stopped, nor did any urine escape. I expected to carry the point of the catheter downward and backwards into the tumor, which I now presumed could be nothing else than a cystocele, consisting of the bladder of urine which had been crushed under the womb and obstructed so as to be unable to discharge the whole of its contents. Finding I could not cause the catheter to advance without using imprudent violence, I withdrew it. The patient laid on the back with the knees drawn up. Introducing three fingers of the right hand far into the pelvis, when the pain was off, I pressed the palps of the fingers upon the inferior surface of the mass, and lifted it upwards towards the plane of the superior strait. Just as I had raised it partially up, there came on a violent tenesmic effort — and the urine rushed from the orifice of the urethra in jets so violent as to surprise me. In the course of three or four such jets, the whole of the urine in the bladder was expelled ; the tumor disappeared, and within forty minutes, the whole of the remaining dilatation of the cervix was completed and the child born. As soon as the bladder was emptied, the singular, extraordinary tenesmic efforts returned no more — but the phenomena of expulsive action were thenceforth perfectly natural and customary. The patient, when I came into her apartment, was found to be in a state of extraordinary excitement, representing her sufferings as intole- rable, her face redly flushed and heated, and the pulse rapid and irritable. This case seems to me worthy of record. First as presenting an example of the bladder crushed beneath the uterus. Second, as exhibiting the method of making diagnosis of such a case. Third, as showing how it may be successfully treated. And fourth, as proving that pains and distresses that contravene the co-ordinate action of the uterus in labor, being removed, the conformable play of its forces may be expected to take place. In this very case, even the dilatation of the cervix was held in suspense until I relieved the bladder; whereupon, the co-ordinate operations of the womb being no longer contravened, they effected the delivery in forty minutes. September 18. The patient is sitting up to-day. She has no CONDUCT OF LABOR. THE CERVIX AND OS. 291 urinary distress, and has not had any complaint since the birth of the child, save a feeling of soreness and aching in the pelvis which lasted only a few days. Management of the Cervix and Os Uteri. — The head has sunk low into the Excavation ; the fontanel is in the proper position, neither too near to, nor too far from the symphysis : but it advances not at all ; pain after pain passes over, with great suffering to the mother, and yet with no sensible advance to the head. What can occasion the retardation ? The finger passes up behind the symphysis to the supe- rior strait, and moves along the linea ileo-pectinea a considerable dis- tance, showing conclusively that no disproportion exists between the head and the bony canal it is destined to traverse. All uneasiness of mind on the practitioner's part will cease as soon as he discovers that the cervix uteri, which he had thought to be sufficiently dilated to offer no farther considerable opposition, has ceased for a time to yield, and takes hold of the head during every pain, in such a manner as to prevent the parietal protuberances from escaping into the vagina. The proper remedy here, also, is patience; a small venesection; a large draught of some warm relaxing fluid ; the fortunate occurrence of nausea; a careful adjustment of the axis of the uterus, and of that of the pelvis ; or perhaps a few very powerful exertions of the auxil- iary muscles in bearing down, to which the woman can be exhorted. I have often, after allowing myself to get into a fret relative to the slow progress of affairs, found all my uneasiness dissipated by a more careful examination ; thus, as above, clearly ascertaining that no other than soft obstruction existed; whereas, from too careless an examin- ation, I had been erroneously led to believe that the os uteri had mounted up over the parietal protuberances of the foetal head, and that some unknown cause of retardation existed. Effects of a bad Sacrum. — The hollow of the sacrum is the es- sential cause of the specific properties of the excavation. Those pro- perties will be present in perfection, where the sacrum is perfectly well formed and adjusted: but the sacrum may be either too little curved or too much so. I have specimens of both kinds of deviation. Inas- much as the rotation of the head requires, for its regular and easy per- formance, a good curve in the sacrum, it is striking, that a very straight sacrum must offer considerable impediments to that important act. Hence, a sacrum with too little curve will protract the period of delivery; and in fact, a case might arise, and such a one has arisen, 292 CONDUCT OF LABOR. LONG SYMPHYSIS. -where no rotation at all could take place, but where the delivery, at last, must occur without this important act in the mechanism of labor — the vertex coming out under the tuber ischii : a case requiring the very extremest degree of flexion of the head. Let the Student reflect a moment, and he will perceive what process must be substi- tuted for the rotation. The occipito-bregmatic diameter is but three and a half inches, but the tubera ischii are four inches apart ; hence, where the rotation fails, there must occur a greater dip, causing the occipital fontanel to take a position nearly in the centre of the pelvic canal, by which the relations of size between the head and pelvis are restored, and the occipital bone is enabled to pass out under the ischium, and the parietal protuberance under the pubal arch. Such a great degree of dip may be much promoted by the help of the fingers, as before stated, but it will take time. It is not very difficult when the head is of a medium size. On the other hand, if the sacrum be too much curved, its apex will jut forwards towards the pubis, so as to form a sort of shelf, on which the head lies ; the expulsive forces being, for a long time, vainly ex- pended in impelling the head down upon this shelf or ledge. The gradual compression of the cranium, however, at length moulds it into the requisite form, and allows it to slide off the ledge, and the delivery takes place. It is to be understood, that the very aggravated degrees of this vicious conformation involve the necessity of direct interference with some one of the various instruments employed in obstetric operations. Influence of a badly shaped Pubis. — When the pubal arch is not low, but retains the character of early life or of the male pelvis, it happens that great retardation takes place; because the act of exten- sion of the head cannot happen in due time. Such a narrow arched pelvis compels the head to continue its descent much longer than one where the arch is broad and low. It has as bad an effect as, and in- deed it is equivalent to, a long symphysis pubis ; for in the ordinary conformation, as soon as the occipital bone can come to apply itself to the arch, the vertex begins to rise ; extension of the head taking place, and the perineum requiring no inordinate degree of protrusion. But imagine a pubic symphysis of two and a half inches, instead of one of an inch and a half, and it is plain that the perineum must go farther down before the head can escape under the arch. Case. — A patient with a very narrow arch had been under my care CONDUCT OF LABOR. — THE PERINEUM. 293 in two of her labors, in which, the natural pains being insufficient, I was compelled to augment them by the ergotic stimulation. By vio- lent efforts of the womb and abdominal muscles, she gave birth in both cases to living children. I need not say, in self-defence, that I waited as long as I deemed it prudent to do so, but my confidence in her strength was vain in each instance. In 1841, I delivered her for the third time; but was obliged to use the forceps. The Perineum. — The resistance of the perineum and vulva are so great, in many women, as seriously to retard the delivery. I have waited six hours by the bedside, after the vertex has begun to jut out between the labia, the patient all the while suffering severe labor pains, which vainly tended to expel the head. In such cases there is nothing to be done but wait patiently, after having placed the woman's con- stitution in its proper attitude by means of venesection ; by every psychiatic resource of exhortation, assurance, encouragement, and honest promise of relief; by the least fatiguing posture of the body ; by the application of mucilaginous fomentations to the genital region; by the exhibition of relaxing drinks, and by the warm bath. I con- sider that we have no right to apply a force, additional to one that nature furnishes, and which it is evident must be effective if left to itself. Under such perverse resistance of the soft parts, time is re- quired to enable them to acquire a yielding temper. To force the head through them by the ergot or the forceps, would be to incur the hazard of shocking lacerations of the external organs of generation, or even of the womb itself, which it is rashness, in the highest degree, to stimulate and lash into fury, in cases where the uterine contractions are already very powerful, and where they would soon effect the de- livery, were it not that the external parts are unprepared to admit of it. The true principle of practice here is, to diminish the resistance, and not to increase the power, already perhaps excessive, and therein dangerous. Let me be fully understood as referring, in the above remarks, only to cases where the energies of the uterus are great and manifest, but yet unequal to the task of overcoming the resistance rapidly, and where they evidently will overcome it in a reasonable time. In other circumstances, as where the resistance is powerful and the pains poor and weak, let the just proportion be established, by means of the ergot, a glass of wine or the forceps, between the power, and the resistance it is destined to vanquish. Three years ago, I attended a young woman in labor with her first child. The process was most painfnl and tedious. The head was fully six hours 294 CONDUCT OF LABOR. — THE PERINEUM. pressing upon the perineum and external parts, under violent uterine contractions. The child was at length born, but was dead. As this was a result which I very much feared, I was extremely desirous of applying the forceps. Would it have been justifiable to use them in a case when the contractions were so strong as to lead me to apprehend that the perineum would give way under every natural pain? I think not. It is perhaps impossible to find expressions fitted justly to set forth the tormenting doubts and anxieties of the accoucheur in cases like this; cases where he feels that he has power to terminate the suffer- ings of his patient, but dares not violate the injunctions of his con- science, which tells him he may not yet intervene. When, at last, the head begins to emerge, it does so by pushing away the perineum before it, which continues to cover the cranium like a tight cap. It should be remembered that the direction of the forces is parallel to the axis of the superior strait ; but it is equally true that the direction of the movement is not in the same line, at this stage ; the head is repelled by the curved line of the sacrum ; it is driven against the sacrum, but, coincidently, w T ith Carus's curve, vide Fig. 23, page 47, glides off from its curved surface towards the outlet; from which, if unrestrained by the perineum, it would escape without much extension. It has happened that the head has passed directly through the perineum, perforating it as if a six pound ball had passed through it, without injuring the commissure of the vulva, or the sphincter muscle of the anus; and there is supposed, always, to exist some danger of its tearing the anterior edge of the perineum, at least, when that point is unsupported. Hence the general care of writers to direct that the perineum be supported. From the foregoing remarks, the Student will be enabled to appre- ciate the value of this injunction concerning support to the perineum, and to know how it ought to be executed. He knows that a towel should extend from the lower part of the sacrum up towards the top of the vulva, and be pressed against the parts in such a manner as to protract or continue the inclined plane of the sacrum, whereby exten- sion of the head will be enforced, and no danger occur of its being too strongly propelled against the now thin tissues, which might be lacerated were the head not to follow the curved line of its movements. The degree of pressure made by the hand must be proportioned to the exigencies of the particular case. It should be always sufficiently great to cause the head to undergo extension, at least; and, where the tissues yield with difficulty, so as to furnish grounds to fear their CONDUCT OF LABOR. THE CORD THE SHOULDERS. 295 laceration, the further advance of the head may be safely counteracted, for a time, by firm pressure, which should be continued until the soft parts acquire a proper dilatability. The young practitioner, and the Student, should be warned against falling into a habit of beginning too early to support the perineum. If the part should be too early pressed upon with a napkin, it might become heated, and thus lose its disposition to dilate: and it is assuredly not necessary to sustain it, or support it, until so great a degree of extension has taken place as to put it in some danger of being lacerated. Cord round the Neck. — The head is born : perhaps the cord is turned once, or even more than once around the child's neck, which it encircles so closely as to strangulate it. Let the loop be loosened, by pulling the yielding end of the cord, sufflcently to enable it to be cast off over the head. This cannot always be done : if so, in any case, let the child pass through it by slipping it down, along its body, over the shoulders. If it seems impossible to slip the cord over the head or shoulders either, it should be let alone : and in a great majority of cases it will not prevent the birth from taking place, after the occurrence of which, the cord can be cast off. Should the child seem to be detained by the tightness of the cord, as does rarely hap- pen, or in danger from the compression of its jugular vessels, the funis may be cut with the scissors, and tied after the delivery. Under such a necessity as this, a due respect for one's own reputation should induce him to explain, to the by-standers, the reasons which rendered so considerable a departure from the ordinary practice indispensable. I have known an accoucheur's capability called harshly in question upon this very point of practice. I never felt it necessary to do it but once. The Shoulders. — If the shoulders should not rotate, so as to bring one of them under the arch, that motion may be given by one or two fingers, introduced, and made to act upon the shoulder nearest the pubis, so as to draw it into its proper place. If difficulty occur, and the shoulder does not advance, press the child back against the edge of the perineum, and that will often afford room for the advance of the shoulder, which had been thrust over the top of the brim of the pelvis by the resiliency of the edge of the perineum which is pressed against the posterior part of the child's neck, whereby it pushes the opposite side of the neck against the pubis. I have sometimes 296 CONDUCT OF LABOR. THE CHILD. caused the shoulders to descend immediately, by merely pressing the perineum downwards and backwards ; the child, whose shoulder was jammed up above the top of the symphysis pubis, slipping down behind the symphysis, as soon as the cause that pushed it forwards (namely, the pressure of the perineum) was withdrawn. Sometimes the shoulder nearest the sacrum, and at others that nearest the pubis, escapes first. The student will, in practice, readily perceive which one he ought to assist; he will at times be compelled to try one, and then the other, being uncertain which is likely to emerge first. It is considered bad practice to drag out the body, except in very particular circumstances — the womb and abdominal muscles are sufficiently powerful for that object ; and if it be permitted to come away slowly, we shall have a more complete contraction of the womb, and a more ready detachment and extrusion of the placenta. Therefore, it is better to leave the expulsion of the body to nature, merely removing any cause of delay, that may obviate its descent and escape. "Where the delay is great, and the child becomes very black in the face, and the respiration is either not established or in an unpromising condition, we are fully warranted to expedite the delivery by making use of one or more fingers, fixed as a blunt crotchet in the axillae. How to treat the Child. — As soon as the child is born, lay it on its back, out of the reach of the waters, which sometimes stand in a deep puddle by the breech of the mother — the child ought never to be exposed to the danger of suffocation. If it breathes regularly, it is well ; if not, blow suddenly into its face, and drop some cold spirit on to the region of the diaphragm. These and a few smart frictions are, in general, all that are demanded. Take care that the infant be not too rudely or suddenly handled. It ought not to be agitated by any violent or hasty motions. In many of the instances, life is already nearly extinct, and so, the child can no more endure to be rudely handled or shaken than can a fainting girl. It is enough to see and know that the child lives. That its heart is beating and its diaphragm moving — for these are the two great motives of life. If the diaphragm moves it pours the oxygen upon the blood — but, oxygeniferous blood sent forward to the brain by the contracting heart excites the biotic force in the neurine. That force is life made manifest in motion. The cord should not be cut until the pulsations have ceased near its placental extremity: it would be vain to wait for its cessation near the child's body, as doubtless blood is thrown into the arteries long even CONDUCT OF LABOR. THE PLACENTA. 297 after the ligature is applied ; in fact, children do sometimes bleed at the cord hours after they have been dressed, if the cord have been imperfectly secured. There is no need to tie the cord twice, unless there be twins; w T hich can always be ascertained by feeling for the uterine tumor. Tie only one ligature, and that at the distance of an inch or two from the belly, and cut the navel string, holding the cord tightly betwixt the finger and thumb. If it be not held, it will spurt the blood sometimes to a good distance, and soil the bed, or even the practitioner's clothes. Conceal the cut end of the placental portion of the cord in the napkin with which the perineum has been defended, in order that. its blood may not fly over the bed; and then, give the child to the nurse. There is danger of dropping the infant if it be not properly taken hold of. It should be seized with the left hand, by one or both ancles ; the back of its neck ought to rest in the arch formed by the thumb and forefinger of the accoucheur's right hand, while its back lies in his palm, and the points of the remaining three fingers are under its right axilla. If held in this manner, it can by no means fall to the ground. I have seen a child taken hold of under the arms by both hands, and lifted up in a manner I thought quite inse- cure, considering that it is slippery with the waters or blood from which it had just been taken up. Placenta. — In most cases the placenta comes away in eight or ten minutes — Dr. Hunter thought in twenty minutes. The care required in regard to the placenta is considerable ; for no one can say, of any labor, that it will end well, until the after-birth is completely dis- charged, and for at least an hour after that consummation. The French call the delivery of the placenta, emphatically, deliverance, delivery. We ought always to ascertain, after having given away the child, what is the state of the womb. To that end, place a hand on the hypogastrium, and if a hard tumor be felt there, the womb is contracted ; if the womb is either not to be felt at all, or is very soft and yielding, or very large, a few T gentle frictions on the abdomen will cause it to contract ; and now if a finger be passed up to the os uteri, the after-birth will be felt either in it, or just above it; if in it, let the woman bear down immediately, wmile the cord is tightened, by pulling moderately at it. The mass will descend slowly into the vagina, either edgewise or not ; if not edgewise, one edge may be hooked down w 7 ith the finger, and a few efforts of bearing down will expel it from the vulva. It should be received in the left hand, and turned or twisted round several times by the right hand, in order that 298 CONDUCT OF LABOR. RETAINED PLACENTA. the membranes may be gathered into a string or rope, so that, when they are drawn out, none of them need be left adhering to the ute- rine surface, where, by detaining portions of blood, they might give occasion to putrefaction, with offensive and injurious discharges. A complete, clean delivery ought always to be effected, if possible. If the woman finds, the next day, that portions of membrane are hang- ing out of the vulva, she becomes alarmed, or at least thinks her medical man careless or ignorant. Notwithstanding that the pla- centa may be carefully rolled, as above directed, we sometimes find that where the membranes have been very much broken by the child, or where they are extremely delicate, the cord we have formed by twisting them, is breaking, so that a considerable remnant of them is about to be left in the uterus, which we cannot get possession of, without passing up the hand at least into the vagina. My custom, when I find the membranes breaking, is to cease pulling until I have wrapped them in a small rag, which enables me to twist, them still more, and thus draw them entirely away. Now they are so slippery that they cannot be twisted with the fingers, but when a dry rag is wrapped round them, we can twine them, and pull them as much as we may think needful. Retained Placenta. — It unhappily does not always befall that the placenta comes away soon ; we may wait half an hour or an hour, for the expulsion of the after-birth, and yet upon examination, repeated from time to time, discover that it has not come within reach of the finger. Frictions upon the abdomen are known powerfully to excite the peristaltic fibres of the alimentary canal ; but their effects upon the womb are far more decided: it maybe said, that when made upon the hypogastrium, they generally compel the womb to recom- mence its contraction — some wombs are so excitable that a touch brings on the after-pains; they ought, therefore, to be instituted. The consent of parts, also, causes the womb to act sometimes, as soon as the woman makes a strong bearing down effort, to which she should be urgently prompted, if needful. When a contraction has been procured by frictions, or in any other way, it may be rendered permanent by pressure; therefore, let an assistant be properly taught to apply the palm of the hand over the uterine globe, and not take it off, until told to do so. Such assistant, however, ought to be one worthy of the trust; an ignorant one might, by pressing at an incon- venient moment, indent the soft and relaxed fundus uteri, and thus cause the beginning of an inversion of the organ. I have no doubt CONDUCT OF LABOR. — HOURGLASS. 299 that some of the cases recited in the books were brought about in this way. In all those patients who habitually flood in labor, this precaution ought to be observed. When the hand is removed, a bandage should be ready to occupy its place. If the os uteri be very much closed, it is probable that the placenta will require a long time to come away ; and I know no objection to a patient wait- ing for the spontaneous movement of the organ, where no hemor- rhage, or other unusual appearance is observed. Some writers have been disposed to assign a fixed period, up to which the accoucheur ought to wait, before he resorts to compulsory measures for the delivery. But there can be, or ought to be, no fixed rule on the subject, except this one rule, namely, the placenta must be got away, as there is no security while it is left. I have never gone away from a patient leav- ing the placenta undelivered. I think I have never waited for its spontaneous extrusion more than an hour and a half, for I have always supposed that if it would not take place in one hour, there was little prospect of its taking place in twenty-four hours. I cheerfully admit, however, that cases may and do occur, in which a longer delay might be advisable. I have not met with such cases. I wish to be under- stood as speaking, in this place, of the placenta retained in utero, and not of cases where it is partly expelled into the vagina; for, when in the vagina, I think there can be no necessity for waiting at all; it ought to be removed at once. Ruysch, the celebrated Dutch anato- mist, zealously inculcated the doctrine, that, as the expulsion of the placenta is a natural office, it ought not to be interfered with, except upon the occurrence of symptoms making such intervention indis- pensable; and his authority having been deemed unquestionable, was yielded to by several physicians of eminence, who nevertheless found, after losing not a few patients from hemorrhage, inflammation, &c, the consequence of retained placenta — that experience is the best teacher ; and they therefore reverted to the custom of securing the expulsion of the secundines by artificial measures, wherever the powers of nature were incompetent to that function. Hourglass Contractions. — As to placenta retained by what is called hourglass contractions, I am very confident in the assertion that it is always an adherent one. Where the connection of the placenta to the uterine surface has, by force of some certain inflammatory action, become preternaturally firm, the substance of the placenta acts as an internal antagonist to the contraction of that part of the uterus on which it sits. In fact, the placenta may be said to splint the womb, 300 CONDUCT OF LABOR. — HOURGLASS. and keep its superficies extended. Now, when all the rest of the womb, except the placento-uterine region of it, is left without antago- nism, it contracts as usual, but the antagonized portion remains ex- tended, splinted by the after-birth, so as to be incapable of contract- ing like the rest, which, of course, by their contraction, shut the pla- centa up in a cell, a cavity, which is the upper cavity of the before- mentioned hourglass. I have never seen an hourglass contraction without adherence of the after-birth, and I take it for granted, that as soon as an hourglass contraction is discovered, there is discovered along with it the indication to deliver, there being no reasonable hope that a spontaneous delivery will take place. I freely, therefore, advise the reader to deliver at once in all cases where the existence of an hourglass contraction can be clearly made out. This operation maybe performed so as to give no great pain; it requires to be always attended with explanation of the necessity, and assurances of great carefulness and tenderness in the performance of it. Half the hand should be insinuated into the ostium vaginae first, as far as the thumb, which being next buried in the palm, permits us to get the whole hand into the pelvis. From thence, either the whole hand, or half the hand, or sometimes the index finger alone, may be made to enter the cavity of the Womb, to detach and seize upon the placenta, which, when fairly severedr of its unnatural connection to the uterine wall, may be removed by the hand, or left to be expelled by the contractility of the organ. It is a very safe and proper con- duct, however, to bring it away in withdrawing the hand, so as to let the uterus contract as much as possible. A placenta will weigh from a pound to a pound and a half. Let the Student reflect that such a mass, if within the uterine cavity, must distend it considerably ; and if he cannot touch it by passing the finger up to the os tincse, the fundus of the womb must, of course, be high up within the abdomen. Therefore, in any case of retained placenta, he will find the fundus perhaps fully as high up as the navel. It will require, then, in order to get it, that the hand should be introduced: the finger cannot reach far enough. From the dilated state of the vulva and vagina, after delivery, no difficulty stands in the way of the introduction of the hand into those parts. As it passes up it is guided by the forefinger, which glides along the cord, while that is tightened by the other hand. The reader must expect to find instances in which the os and cervix uteri actually gripe the chord ; and that he will be, in such a case, necessitated to introduce only one finger at first, then a second, and a third, which CONDUCT OF LABOR. — HOURGLASS. 301 gradually conquer the resistance of the circular fibres of the os and cervix uteri, so as to make way for the whole hand, which at length is found to have entered into the cavity of the womb. But the pres- sure required in this operation has put the vagina, even the womb itself, on the stretch ; so that were he not to resist its rise by pressing the abdomen with the other hand, the fundus would be pushed up to the scrobiculus cordis, and his arm pass inwards as f&r as the elbow. In general, it appears to me that the uterus, in retained placenta, con- tracts by its cervical or lower horizontal fibres, while its longitudinal contraction does not take place at all. It is, indeed, extremely common to feel the womb, like a large intestine, pretty firmly contracted as to its transverse diameter, while from the fundus to the os uteri the length is not much less than before the commencement of labor. Certainly it must have happened to many practitioners to make this remark of the cases in which they were obliged to introduce the hand, for the extraction of the placenta. Let the operator always stop the womb from rising, by counteracting it with one hand placed on the abdomen, over the top of the fundus, in order to push it downwards towards the hand which is within. Most probably the placenta is to be found wholly or partially detached ; if not, let the detachment be effected, taking great care not to use sudden and indiscreet force, so as to hazard the leaving any of its lobuli in the cavity of the womb. When- ever all the adhesions are certainly overcome, the mass should be grasped in the hand, which may then be gradually withdrawn, hold- ing the obnoxious placenta in its grasp ; or, if the womb is suffered to push the hand out, so much the better. This operation it has been my fortune to be compelled to perform a good many times ; and I can safely say I have never seen any bad results from the practice. I re- peat, it may be done so gently and dexterously, as even to occasion but little pain. No patient for whom I have performed this service has died. When the last portions of the child quit the uterine cavity, being expelled by the muscles of the organ, it generally happens that the placenta is completely detached from the uterine wall by that same contraction. This, however, is far from being always the case. When the womb does not displace the placenta by the force of the last expulsive effort, it does not follow that we are to expect an hour- glass contraction. On the contrary the hourglass is a rare event, while the continued adherence, total or partial, is a common one, the partial being more common than the total adherence. If, in such a case, there be no flooding or other symptoms indicating our 302 CONDUCT OF LABOR. UTERUS AFTER DELIVERY. intervention, we ought to wait for one hour at least. It is not wise, I think, to wait longer, and my multiplied experiences teach me that it is not rash to proceed to the delivery of the secundines. To do so the whole or part of the hand must be passed upwards, so as to reach and peel off the placenta. The cord furnishes a most convenient means of pulling out the placenta, but should never be used for that purpose without a very careful reflection on all the circumstances. If the after-birth is still attached, and the uterus firm, to pull at the cord is to endanger the breaking it off even with the surface, which is an embarrassing and rather disgraceful accident; but if the womb be not firmly contracted, it is so flaccid, that, like a wet bladder, it may be turned inside out. I have seen a womb that was turned inside out by a midwife in this way, a case of great interest, that will form the subject of a future page. To any individual who has seen a womb at full term, nothing would seem to be easier than to invert a relaxed uterus. Wherefore, no man of discretion ought to draw by the umbilical cord, without having first ascertained that the womb is well contracted; and even then, the force he may venture to employ by its means is an exceed- ingly limited one. Womb after Delivery. — W T hen the placenta is delivered, the hand should be soon placed on the patient's hypogastrium, for the purpose of ascertaining whether the uterine globe is firm. If you for- get to do this, you will incur the dreadful hazard of leaving your patient with an inverted womb. This lately happened here to a friend of mine, who did not discover the accident until five weeks after the event. The woman suffered the greatest distress, and the greatest weakness from loss of blood, but recovered at last. It ought to feel through the integuments about as large as the fist; but there is great diversity in regard to the magnitude of the organ immediately subsequent to delivery. The smaller it is the better for the patient, who, with a well contracted uterine globe, may be safely pronounced beyond the reach of danger from effusions of blood ; or at least, from effusions that can with propriety be denominated uterine hemorrhages. In feeling for the globe of the womb, we should always endeavor to ascertain that the fundus has not fallen in, making a deep concavity like that in the bottom of a junk bottle. Such an indentation is the first beginnings of inversion of the womb, and it may readily be de- tected where the belly is loose, thin, and flabby. If, in any case, CONDUCT OF LABOR. AFTER-PAINS. 303 such an indentation should be discovered, the rule of practice ought to be to introduce the hand and take the placenta bodily away, for- bidding the woman, meanwhile, to make even the least expulsive effort. After the extraction of the after-birth, great care should be used to make sure that the proper orbicular form of the organ is pre- served. After-pains. — Inasmuch as the pains of labor alternate with inter- vals of rest or inaction, it follows that the pains which women suffer, whether before or after delivery, depend upon one and the same cause, namely, the alternate action of the womb. The organ, after delivery, grows alternately small and large for some hours ; expanding to double the size of the fist when the pains are off, and reducing itself to the smallest size when they return. Every interval, or moment of expansion, permits a small quantity of blood to accumulate in the cavity, which is soon forced out by the returning pains. The woman feels the gush of warm fluid issuing from the vulva, and is very apt to say that she is flooding or flowing. An inspection of the counte- nance and an examination of the pulse are perhaps sufficient to indi- cate the course of the practitioner. If the face is not pale, and the pulse not weak or small, he will be sure she is not bleeding too freely; but if they indicate the existence of too considerable a discharge, the amount of it ought to be ascertained with the most rigorous precision. There are few nurses who are competent to decide upon the nature of the discharge; as whether it amounts to what might be denominated hemorrhage or not. I was called in haste to attend a woman whom I found just delivered of a child ; I received the after-birth, which came off spontaneously, and observed that the sanguine discharge was very great, but the woman, although feeble, was not sunken. The uterus contracted well, and I left her in a comfortable and usual state. In about two hours I was summoned again, and found her very faint, with extremely feeble, slow pulse. Placing one hand upon the hypo- gastrium, I found the womb not dilated, and then inquired of the nurse as to the amount of the lochia. She assured me that it was not greater than it should be. She had examined carefully into the cir- cumstances and found all right. Distrusting her account, I determined to learn for myself whether a large effusion had taken place, and found an immense quantity of coagula lying upon the bed, which the nurse had either not seen at all, or disregarded. This case, which after- wards caused me great trouble and anxiety, has influenced me ever since, and now I always feel unwilling to take information at second 304 CONDUCT OF LABOR. — HEMORRHAGE. hand upon the important subject of profuse uterine discharges. I think it the duty of the Student early to resolve to learn accurately whatever may have an injurious or dangerous tendency for the patient to be committed to his charge. Hemorrhage. — It may be stated as an axiom in obstetrics, which has almost no exception, that a well contracted uterus cannot bleed; and all obstetricians habitually feel secure when they find the organ hard, and of a small size. Nevertheless the state of contraction may soon be followed by so absolute a relaxation of the contractile forces of the uterus, that the gentlest infusion of blood into its cavity is capable of distending it again, if that fluid be prevented from escaping at the os tincse or at the vulva. But if a coagulum should fill the vagina, or stop the mouth of the womb, or if the napkin should be too strictly pressed against the genital fissure, preventing the escape of fluid therefrom, the blood which flows into the womb will gradually distend it to that degree, that, without losing a spoonful externally, the woman may effuse enough blood into the uterine cavity to expand it very greatly, and to cause fatal syncope. Case. — I was called, about three years ago, into the country, to assist a practitioner in a difficult labor. When I arrived, the child had just been delivered with forceps. The placenta was adherent. After waiting a sufficient length of time for its spontaneous extrusion, I removed it, and the womb contracted well. In the course of half an hour my attention was attracted by a sort of gurgling sound from the bed, which caused me to draw near to the woman, whom I found already quite fainted away when I approached her. She was very pale, and the pulse could not be felt at the wrist. The discharge was inconsiderable ; but on placing the hand on the hypogastrium, the womb was found enormously distended, and full of blood. Two fingers were now carried into the os uteri, which was found to be tamponed with a very firm clot. This I broke up and brought away, when out rushed a large quantity of grumes, mixed with fluid blood, and the womb returned to its proper dimensions. She had no return of the symptoms. I could cite many examples from my case book, of violent hemor- rhages, both concealed and open, which have fallen under my notice in females where the uterus had contracted perfectly well after the delivery of the placenta. One case is so remarkable that I cannot resist the inclination to publish it here. CONDUCT OF LABOR. HEMORRHAGE. 305 Case. — Mrs. S. was delivered of her first child after an easy labor. She had a very good getting up, and on the fifteenth day walked down stairs. Some words of an unpleasant character passed between her and her husband. She became violently excited with anger; then burst into tears, and ran up stairs, where she threw herself on the bed. She was shortly afterwards found in an apparently dying state. When I reached the house there was no pulse ; great coldness, and the greatest degree of paleness. I found the womb filled with blood, and reaching above the umbilicus. Dr. Dewees was so kind as to visit this patient with me, and assist me with his valuable counsel. She recovered, but suffered a long time under the symptoms produced by this excessive sanguine discharge. This case will show the Student that even where the uterus has contracted so much as to sink down below the superior strait, it may be afterwards enormously distended by influent blood ; and the reflection arising from it, though an unpleasant one, is a very just one, that even w r here we succeed in getting a good contraction, we can have no sense of absolute security against concealed or open hemorrhage, in a patient whom w 7 e may have put to bed ever so comfortable, and apparently safe. The influence of position in determining the momentum of blood in the vessels is well known to the profession ; but there are few cases where it is of more consequence to pay a profound regard to this influence, than in parturient women. A uterus may be a good deal relaxed or atonic, and yet not bleed, if the woman lie still, with the head low; whereas, upon sitting up suddenly, such is the rush of blood down the column of the aorta, the hypogastrics, and the uterine and spermatic arteries, that the resistance afforded by a feeble contrac- tion is instantly overthrown, and volumes of blood escape with an almost unrestrained impetuosity. The vessels of the brain under such circumstances become rapidly drained, and the patient falls back in a state of syncope, which now and then proves immediately fatal. I may be excused for stating here (Aug. 1841), that I have never met with one of these sudden and fatal hemorrhages in my own practice. It is, perhaps, due to the special attention I have always considered it a duty to pay to this point, that I have hitherto avoided so serious a misfortune. Surely, I have, in a multitude of persons, by a prompt attention to the state of the womb, turned aside the stroke of death by proceeding without delay to empty the organ by turning out of its cavity with my fingers the masses of coagula with which it was filled. If you leave your patient soon after her deliverance and are hastily recalled to see her w r ith an announcement perhaps that she is dying, 20 306 CONDUCT OF LABOR. HEMORRHAGE. your first duty on reaching her bed-side is, to examine the hypogaster in order to ascertain if the uterus be firmly contracted or not. Case. — In conversation with my late venerable friend Professor James, upon this very subject, he informed me that he delivered a lady a few years before, after an easy natural labor. The uterus con- tracted well, and all things seemed as favorable as possible. As the accouchement took place early in the morning, he was, subsequent to the event, invited to breakfast down stairs, whither he proceeded, after having given strict caution to the lady on the subject of getting up. "While the persons at breakfast were conversing cheerfully, and exchang- ing felicitations upon the fortunate issue of affairs in the lying-in room, the nurse was heard screaming from the top of the stairs, "Doctor, Doctor, for God's sake come up!" He hastened to the apartment, and the lady was lying across the bed quite dead. It was found that, soon after the doctor went below, the lady said to the nurse, "I want to get up." "But you must not get up, madam, the doctor gave a very strict charge against it," replied the nurse. "I do not care what the doctor says," rejoined the patient ; and thereupon arose, and throwing her feet out of the bed, she sat on the side a few moments, reeled, and fell back in a fatal fainting fit. The remarks of Dr. James, as he related the occurrence to me, have made upon my mind a deep impression of the vast consequences of careful and well- timed instruction of the nurses ; who, if they could have the dangers of mismanagement fully exposed to them, would surely avoid some accidents that every now and then are attended with very shocking results. Large discharges are not apt to occur when the womb has once contracted pretty firmly. But there are precautions which ought always to be observed : for example — Case. — I left a woman half an hour after the birth of her child. She was as well as could be desired. I gave the usual directions. In a short time her husband came running to me, in the street, where he met me, and said his wife was dying. Upon hastening to his house I found her, in fact, pulseless, pale, and completely delirious, with a constant muttering of incoherent phrases. Upon inquiry, the following occurrences were found to have taken place. She felt some desire to pass the urine. The nurse told her to get up. "But the doctor says I must not get up." " Oh, never mind what the doctor says, it won't hurt you; get up." A chamber-pot was placed in the bed, and Mrs. CONDUCT OF LABOR. HEMORRHAGE. 307 F. was lifted upon it, in a sitting posture. She fainted in the woman's arms, was held up a short while, and, when laid down, the vessel was discovered to be half full of blood. She had nearly died ; and did suffer long and severely in consequence of this imprudent disregard of orders. When I left her, the uterus was well contracted ; but the change of momentum in the arterial columns produced the hemorrhage, than which I have scarcely seen one more dangerous. Case. — It is of the highest consequence to secure a powerful con- traction of the womb after delivery, in all those women who have suffered severely from floodings, occurring soon after the birth of the child. A lady in three successive labors, of which the first occurred on the 30th of December, 1819, and the last on the 28th of September, 1824, which were rapid and easy, was brought almost to the gates of death by enormous discharges, which commenced about five minutes after the birth of the foetus. I saw her lie pulseless, and as near as possible to dissolution in those labors. In two subsequent confine- ments, she took one scruple of ergot, just as the foetal head began to emerge. This was given to her, not for the purpose of aiding in the expulsion of the child, or placenta, which had never occasioned any embarrassment in antecedent labors; but, by constricting the womb permanently, to save her from those dangerous losses ; and I am pleased to say, that in both instances, she experienced none beyond the ordinary amount of effusion. I could cite very numerous examples of similar results. Sitting up too soon. — As regards the danger of sitting up soon after delivery there are some important suggestions for the Student that ought not to be here omitted. Certain women are met with who pass through the conflict of partu- rition unscathed, and who are quite as competent to the performance of their daily toil on the following day as the Chief's wife who so much excited the astonishment of Hearne on his Northern Journey. I have found that many of my patients, and some in the class of what are called the " upper ten thousand," were completely destitute of all symptoms of indisposition as the halest Potowattamie or Ottowa. Such people might get up, and I have seen very elegant women get up and "be about" on the third day without pretence of after indispo- sition. Still it is a safe rule to advise the keeping of the bed for many days, since to leave the bed is to go forth a la chasse after some malady. Hemorrhages, chill, prolapsions, and an evil train attend those impru- 308 CONDUCT OF LABOR. — CLOT IN THE HEART. dent women who leave the lying-in couch too early. A rest of nine days is a short rest after nine months of fatigue crowned by the ex- hausting conflict of a labor. But it is not merely to the treatment of the ordinary cases that I designed to call the attention of the Student. My warning is directed against the mismanagement of those women who have lost too much blood in the parturition, and particularly to such as have lost a great quantity. It is well known that the coagulability of the blood is greater in proportion as any hemorrhage progresses — therefore a woman who has lost during her labor 40 or 80 ounces of blood has the rest of it more coagulable than it was before the flooding commenced. Again, faint- ing consists in the too little intensisty of the pressure of the blood in the brain, — and a woman just gone through a flooding experiences a sensa- tion of faintness from lessened vascular distension of her encephalon. If she suddenly assume an erect position the tension becomes instantly lessened in consequence of the gravitation of the blood. But — and this is the danger, — if she faint badly while her blood is become thin and highly coagulable from hemorrhage — the scarcely moving current partially stops in the heart, and when she comes out of the deliquium, if ever, she does so with a coagulum in the auricle and ventricle — she has got a false polypus in the cavities — and she will surely die. In the early part of 1844, a young and beautiful lady gave, pain- fully, birth to a daughter. She lost a large quantity of blood at the separation of the after-birth — and was pale and weak up to the third day. On the morning of that day her physician found her comfortable at 9 o'clock. The pulse was 90 per minute. The milk was begun to be abundant and the prognosis favorable. Half an hour after the Doctor had withdrawn from her apartment, he was recalled and found her apparently dying — the pulse at least 160 — the anxiety intense and the paleness mortal. She rallied from this lowness — but the pulse remained ever rapid, small and irregular until she died with the thorax full of water about the 20th day post puerperium. Upon being informed of the suddenness and the manner as well as the occasion of her illness, I said she had coagulated the blood in her heart during the deliquium, that the chordae tendinias might thresh it partially into shreds, and that it would terminate her existence. — The difficulties in the pulmonic circle connected with the presence of the coagulum in the right ventricle and auricle, doubtless led to the great hydrotheracic deposites, and the examination of the body after CONDUCT OF LABOR. — TAMPON. 309 her death made manifest the truth of my diagnosis. — But, it was unnecessary to use the bistoury to reveal an anatomy which the reason discloses as well as the scalpel — what M. Serres calls Transcendental Anatomy goes farther and surer than the dissection. In the present example — a woman exhausted with flooding — but with a pulse at 90, rises from her bed and faints — she recovers with a tumultuous pulse beating 160, and continuing so nineteen days until her death — what else could occasion these phenomena except what the Transcendental Anatomy demonstrates to be a false polypus in the heart! Tampon Never. — I repeat the opinion already expressed, that the blood that issues from the placental suface of the womb after de- livery at Term, ought to be permitted to flow freely out from the vagina. After it is effused it is of no use to the woman. What is the reason that a woman does not bleed to death after the placenta is detached? It is not because a coagulum is formed, by which the effusion is arrested. She is saved by the condensa- tion of the uterine tissue, which is not only sufficiently diminished in volume to close the small orifices of the vessels on the placental surface, but even to close the largest sinuses that may be opened during the Caesarian section, or in extensive lacerations of the womb. I saw, in a Caesarian operation, the scalpel open the uterus imme- diately over the placenta — an incision large enough to permit me to extract the child with sufficient facility. The cut was, of course, through the most vascular part of the organ. I need not say, that the blood bubbled up from the incised surfaces very rapidly; but it wholly ceased to flow as soon as the placenta was removed from the womb so as to permit that organ to contract. The condensation of the womb in contracting, shut up the cut vessels as completely as if ligatures had been applied to them. I repeat again, that a very firm clot, shutting the mouth of the womb, may serve as a tampon which shall wholly prevent the escape of blood from the cavity, which expands as it continues to receive the effusion, until the womb becomes fully as large as at the sixth month. Such clots should be broken up, and removed. They are as dangerous as, but not more so than the arti- ficial tampon, when used after delivery at term. I have never used a tampon after delivery at term ; but I have seen them used, which came very near causing the patient to sink, by detaining the effusion within the cavity. The principle is false, and the practice dangerous, which resorts to such a mode of arresting uterine hemorrhage, at term; he 310 CONDUCT OF LABOR. — COAGULA. who resorts to it, does so under the ignorant presumption that uterine- like chirurgical hemorrhage is to be arrested by coagulation of the outflowing blood. If it should be said here, that women very com- monly do discharge utero-morphous clots after delivery, I admit the fact ; but I subjoin, that but for a sufficient degree of irritability in such uteri, the clots would become so large as to require for their formation a wasteful, and even dangerous or fatal extravasation of the vital fluid. Strong uteri never permit them ; weaker ones allow pretty large ones to be formed, and very feeble wombs fill until the woman faints or dies. Turn out the Clot. — I should feel happy if I could impress upon the mind of the Student, in such a manner as to make it ever present to him when the occasion demands, that the only certain mode of ar- resting uterine hemorrhage is to empty the womb and cause it to con- tract. If a woman have alarming discharges of blood before the delivery of the child, let him take away the child, if he can. If she bleed before the after-birth is withdrawn, let him withdraw it. If she bleed after delivery, let him introduce his fingers into the uterus and break to pieces the firm coagula that he will find in it, or in the vagina, and then by frictions of the hypogaster, or by cold, by pressure, by ergot, and by all the means in his power, let him compel the womb to contract ; then, and not until then, will his patient be safe. Binder. — Case. — I attended Mrs. J. A. S., confined with her fifth child, in a labor that was perfectly natural, relatively to the birth of the child, the delivery of the placenta, and the symptoms that imme- diately ensued the parturient state. Having waited about half an hour, I took my leave of the patient about two o'clock in the morning, and had proceeded a good way to- wards my house, when I was overtaken by her husband, who entreated me to hasten back to the lady, as she seemed near dying. Upon returning to the house, I found my patient without pulse, the face of an excessive paleness, and the whole state expressive of the last degree of sinking or prostration. The idea that immediately became obvious was, that, she must have had a large effusion of blood: but upon placing the hand on the uterine region, the organ was found well condensed; while, upon careful examination of the bed, no very considerable extravasation of blood was detected. I found that the abdominal parietes were very remarkably flaccid ; to such a degree as to strike me, forcibly, as affording incompetent sup- CONDUCT OF LABOR. COAGULA. 311 port to the viscera within; indeed, the contractility of the abdominal muscles and integuments was so very slight, that it appeared to me the bowels could have derived almost no support from their pressure. After exhibiting such restoratives as were at hand, I folded two large towels into squares, and placing them upon the abdomen, as com- presses, secured them by a bandage, which retained them in situ, and thus afforded such a degree of support to the contained viscera, as I deemed sufficient to obviate the sinking and fainting tendencies which always ensue from a loss of this support or pressure. I enjoined rest in a horizontal posture, removed the pillows from under the head, and when the forces of the constitution rallied there was no further alarm or distress. It has happened to me many times to meet with this syncopal state, after delivery, unaccompanied with hemorrhage, either internal or external ; and in all parturient persons, who are enormously distended, or who are prone to such faintings after delivery, I take the precautions suggested by the above case in good time ; and can safely say, that such precautions generally result in success. The weakening effect of a removal of pressure or support from the contents of the abdomen, is noticed not only in labors, but in tapping the abdomen for dropsy. It is always deemed necessary, in tapping very distended persons, to pass a broad roller round the abdomen, so as to constrict it in proportion as the w T ater flows off. In cases of para- centesis, where this precaution is not observed, the patient is very apt to faint, and evidently from the same cause I have mentioned, namely, the want of pressure on the contained organs. I had occasion, more than two years ago, to verify this principle in a case. A young w t o- man, excessively distended with ascites, was tapped ; the water flowed off very rapidly : in proportion as it escaped I tightened the bandage, and she made no complaint of faintness. In order to test the effect of relaxing it, I withdrew all pressure for a very short time, the water still flowing, and she immediately began to grow sick and faint; w 7 hich symptoms ceased as soon as I renewed the pressure with the bandage. It is w r ith the greatest confidence, both as to its neces- sity and efficacy, that I therefore recommend, that a bandage should be early placed around the abdomen of such patients as are prone to fainting after delivery, as the compression, all things being ready prepared, may be applied soon after the birth, without disturbing the patient. It is well worth the Student's while to bestow some sober thought upon the subject of the binder for a newly delivered woman. As a general precaution, it is doubtless a laudable one to bind up the 312 CONDUCT OF LABOR. DIET. "weakened and exhausted abdominal cavity. But, it is questionable as to how long it should be used. Certainly after the first days of the confinement, it is not to be held necessary as a preventive of syncope or hemorrhage; nor has it any special usefulness beyond the doubtful one of restoring the woman's shape. But as to this, I think that Asdrubali is very correct in his assertion, that it cannot at all restore the figure, whose restoration depends upon the vital contraction of the muscular and other tissues that have been relaxed by the gestation. I fear that much of the too general complaint of prolapsus and retrover- sion of the womb among American women may be attributed to the use of bandages worn so tight, and so long, as to drive the recovering uterus to the bottom of the pelvis or even overset it backwards into the hollow of the sacrum. Diet. — The diet of a woman recently delivered, ought to be very light, and of easy digestion; tea, bread, gruel, vegetable jellies, and panada suffice, and are the safest materials during the three or four first days of the accouchement. Circumstances may demand a more liberal allowance; but, for persons who have small lochial evacua- tions, or who are of an excitable constitution, the simplest elements of nutrition only should be prescribed. For a surgical patient, both before and after the completion of the operation, a regimen is deemed of vital importance ; and yet the shock to the constitution, and the irritative influences of the w r ound, in severe or capital opera- tions, are not greater than those developed by many instances of labor : are not dietetic precautions equally proper, then, in both cases ? In addition to these considerations, it ought to be remembered that during the months of gestation, the fluxional determinations have been to- wards the uterus; but now the wave of vital fluids is marching towards another set of organs, and great disturbances are, many times, occa- sioned by this mutation of directions. The effort of the constitution produces fever, which commences simultaneously with the irritation of the mammary glands; but, happily, when those glands are enabled to throw off an abundant secretion, the whole constitution is relieved by the evacuation, and the fever suffers a crisis, as well marked as that of a bilious remittent or any other febrile disorder, that goes off by a profuse diaphoresis or diarrhoea. Let the body, then, be pre- pared for this fever, by a correct course of diet ; and when that crisis has been completed, much of the hazard of an accouchement will be already overpassed, and a reasonable indulgence in stronger food be- come safe and proper. CONDUCT OF LABOR. NURSING. 313 Suckling. — The child should be put to the breast as soon as the mother has recovered sufficiently from her fatigue and exhaustion. This is a natural course — it is, therefore, the best one ; for by the act of sucking, the new determinations, about to arise, are invited to, and restrained within their proper bound : the vital wave ought to come hitherto, but no farther. Such a course is useful for the child which generally procures, from the earliest lactation, some saline fluids that have a favorable influence on its digestive tube; and for which ought not to be substituted that pernicious compound, molasses and water, which every child in the country is doomed to swallow, at the cost of a sour stomach and flatulent bowels, displayed in the almost uni- versally resulting symptoms of colic, green stools and vomiting. The antediluvian mothers had no molasses and water for their children, who lived, nevertheless, a thousand years. Certainly nothing can be more conformable to the dictates of nature, than an early application of the infant to the mother's breast. If we could suppose a woman in a state of nature, to be delivered alone, under the shade of some primeval forest, and unsuspected, observe her conduct, we should witness the instinctive movements and promptings of nature, that would far better guide us in the management of such affairs, than the crude conceptions of those, who are ever ready to boast of the excel- lence of art or skill, over the sure suggestions of instinct. Such a mother would soon be aroused from the weakness and languor that succeed the pangs and throes of child-birth, by the cries of her help- less offspring. She would take it, as soon as a little returning strength should permit, into her arms, and the newly-born child would proba- bly not nestle a moment on the maternal bosom, without finding the source of its future aliment : the very anatomical structure, both of the maternal arms and breast, and the instinctive motions of the child's head, would bring its lips speedily in contact with the nipple. But we, wiser than our great instructress, often keep the new-born child away from its natural resting place, and deprive it of the most appro- priate nutriment for two or three days, in order to eschew sore nip- ples, or to propitiate some other imaginary evil; while we allow the breast to fill almost to bursting, and actually to inflame from disten- sion, before we admit that preparation to be complete, which our pre- sumptuous interference, in this manner, vitiates and troubles. The child ought to be put to the breast as soon as the mother is strong enough to take it. Medicine. — It is a good custom to give an aperient medicine on 314 CONDUCT OF LABOR. LOCHIA. the third day, or about seventy hours after delivery ; while, in most cases, it is safest to defer the administration, at least up to this period. The perturbations of vital action in the abdominal viscera, occasioned by medicines administered too early, are observed to result in symp- toms of congestion, and of peritoneal fever, in not a few instances, particularly where an epidemic tendency to the latter malady exists. It should be well understood in the lying-in apartment, that no medicines are to be given to the mother or the child, without the sanction or advice of the medical attendant. In our part of the country, it is exceedingly common for the nurse to take upon herself the func- tion of prescriber, and to administer a dose of severe cathartic medi- cine, upon her own responsibility; which, however great and important she may deem it, remains, after all, with the physician. He it is who bears the burthen, and undergoes all the trouble and anxiety and responsibility of the management. He ought, therefore, always to direct that no interference with his rights should be suffered to take place. There are many reasons why he should be the sole director of the case ; for it is not a matter of indifference what particular article is selected, any more than it is of little consequence at what moment the medicine (if any) be administered. Castor oil is the article in most request, for this period of the con- finement ; and in a dose of half an ounce, operates sufficiently well. Where the castor oil is particularly disagreeable, a proper quantity of magnesia and rhubarb ; of infusion of senna ; of Epsom salts ; of Seid- litz powders, may be substituted; but, in general, the oil is to be pre- ferred, because of the great certainty and moderation with which it operates on the bowels. Lochia. — The lochial discharges grow gradually less abundant, and of a paler color. The tone of the womb itself must determine, in a great measure, the duration and amount of the discharge. It dis- appears in the third week, and sometimes, earlier. Not a few women continue to have a show in the fifth week; and, in fact, the Jewish women had their purification at the fortieth day, which probably might be founded on observations as well suited to the inhabitants of this country as to those of the Holy Land. Sitting up. — A woman who has gone through the fatigues of preg- nancy and the pangs of labor, is one much exhausted, and requiring a long repose. The constitution of society will not permit us, in the majority of CONDUCT OF LABOR. ANESTHESIA. 315 cases, to insist upon a sufficiently long rest after labor; for the wives of the poor and the thrifty will, or must rise from the lying-in bed sooner than those ought, who have a due respect for either health or beauty. To rise before the fifth day is to go forth to seek disease — which is less apt to attack an individual who is protected by warm coverings from the weatherly influences, and by recumbency from the circulatory and nervous influences that tend to disorder the health. If a woman will rest long after her labor she will recover more per- fectly. If she leaves her bed too soon, she will recover less perfectly, and thus not only suffer the future disadvantages connected with bad health, but she will lose her bloom earlier in life. It appears to me advisable to let her set up only on the tenth day, and to ride out not earlier than the twenty-first day, in summer, and at the end of the month in winter. She should not be held to be clean until the lapse of the fortieth day. Etherization. — In speaking of the various points in the Conduct of a labor, I cannot well eschew to say something upon the employ- ment of those anaesthetic agents, whose recent irruption into the domain of Medicine and Surgery has been so sudden, violent, and overbearing. To avoid altogether any notice of these agents, w T ould have been more consonant with my taste as well as with my views of medical duty; but as I feel that those w T ho may please to have this book will surely expect to find a record of my opinions on anaesthesia as an ob- stetric resource, I feel constrained to overcome my reluctance to say anything concerning it. In Philadelphia, the use of ether and chloroform in Surgery and Mid- wifery has made no real progress, notwithstanding the very numerous reports upon the benefits derived from those agents in Europe and in parts of the United States. A few of our surgeons in this metropolis have applied the ether inhalation in their surgical cases — and some persons in labor have likewise been rendered insensible to their pain by breathing the vapor of chloroform or ether. I am not able to say in how many instances this recourse has been had here; but I should suppose, that not fewer than forty to sixty women have been subjected to it on account of labor ; and I believe the practice does not become more common and general in our community ; and that fewer women in labor will have been etherized in the last than in the first six months of 1848. 316 ANESTHESIA IN MIDWIFERY. I do not feel inclined at all to deny that there may be instances of severe suffering for women in labor, that ought to be mitigated or even wholly obviated by casting the woman into the profound anaes- thesia of chloroformization. But what I do desire to say is this, viz: — that having carefully studied the reports upon etherization and chloroformization, whether those of this country or those produced in Europe, I remain as yet unconvinced — either of the necessity for the method, or of its propriety. 1st. As to its necessity in ordinary cases of parturition. The ave- rage duration of labor is four hours, and I have shown at page 252 that the number of labor pains is about fifty; and that they last, each about thirty seconds, so that the parturient woman really suffers from labor pains about fifteen or sixteen minutes and no more — and these sixteen minutes are distributed among the four hours of a labor of mean duration. It has never been pretended that the motive for the anaesthetic practice has any connection with the other pains of women in labor, but only with the suffering from contraction or labor-pains ; for, though we may well suppose, that women suffer from painful sensations independent of those arising from the actually contracting womb, yet we find them in general, easy, complacent, and but too happy when the pain is off. Hence the ether is exhibited for the pain and for no other motive. I contend, that it is to an exaggerated notion of the nature of labor- pains we owe the introduction of ether into our art; for if the mean of labor-pain be only fifteen minutes in all, there can be no necessity in the average of cases for its exhibition. I should find the objection to it less and the inducement greater, were the fifteen minutes of pain to be always fifteen consecutive minutes. When they are distributed through two hundred and forty minutes, or four hours, I look upon the exhibition as unnecessary and uncalled for. 2d. The representations that have been made by the friends of the anaesthesia, of the harrowing distress endured by women in childbirth, do not consist with the general state of facts in the case ; and it is quite as true, that a lying-in room is, for the most of the scene, a scene of cheerfulness and gaiety, instead of the shrieks and anguish and despair which have been so forcibly portrayed. Few women lose their health or their lives in labor, and the dread of future sufferings is insufficient to prevent the increase of the family. As to the necessity of the Letheon practice, the birth of the past myriads of the race shows that it is not necessary. ANESTHESIA IN MIDWIFERY. 317 The propriety of resorting to the use of chloroform and ether as means of obviating the pain and hazards of labor, is a question to be settled by an estimate of the safeness as well as necessity of it. It were well, before making up his mind upon this point, were the Student to make himself well aware that the encephalon is a compound organ, or a compound bulbous nervous mass ; part of which (the Hemi- spheres) are devoted to the offices of intellection; part, the cerebellum, to the duty of coordinating or regulating the movement, or the force which is generated perhaps by the whole nervous mass; a part, the tuberculaquadrigemina, to the faculty of seeing or vision; and a part, the medulla oblongata, to the important office of governing or giving force to the act of respiration. Thus we have the brain of intellection and those of coordination of force, of vision, and of respiration. They might be denominated the thinking, regulating, seeing, and breathing bulbs of the nervous mass. Now, it appears from many numerous reports contained in the Comptes Rendus of the French Institute, and from papers in various journals containing accounts of experiments made both in them and in animals, that to breathe for a few minutes the vapor of ether, or of chloroform and various volatile liquids, is to cast the subject into an insensibility called anaesthesia, so profound that the cautery, whether actual or potential, the bistoury, the ligation, or the forceps are equally incapable of exciting a sense of pain. Nay, more, that the patient in some instances, looks upon the incision of his flesh without feeling the knife. Very soon after ceasing to inhale the vapor the insensibility disap- pears, and the individual upon recovering the use of his faculties, is with difficulty persuaded to admit that he has been subjected to a severe operation, and the mother is incredulous as to her having borne a child during her sleep. Such are the facts. The Student ought to know them. Half an ounce to an ounce of ether poured upon a sponge, and held to the mouth and nose, or a drachm to two or three drachms of chloroform administered in the same way, bring on the insensibility in from three to ten minutes, less or more. The insen- sibility once produced may be maintained according to the pleasure of the physician, by repeating the application of the moistened sponge from time to time upon any manifest signs of returning consciousness. The statements show that the power of these ansesthetics is capable of abolishing the sensibility without greatly interfering with the motor power of the subject — or it may abolish the motor power and allow the sensitive power to be acute as in health. The inhalation may 318 ANESTHESIA IN MIDWIFERY. produce anaesthesia of the thinking brain, yet leave the co-ordinating, breathing and seeing brains intact — or it may put a temporary end to the power of the cerebellum and tubercula quadrigemina without influ- encing the other parts of the encephalon. In short there is no ascer- tained law of progression in the activity or power of the anaesthetic agent, and no man knows, when he begins to administer the vapor, upon what part of the brain it will proceed to exert its benumbing power. M. Flourens has shown, that all the other parts of the brain may be safely suspended of their forces, provided the medulla oblongata be unattacked by the agent, and that as long as the medulla oblongata retains its energy it is capable of recalling the other bulbs to life and activity through its own force, provided the further inhalation of the letheon is arrested. Hence he calls the medulla oblongata the vital tie, (le nceud vital,) since it binds the rest of the encephala with its " silver cord." Now I have to suggest to the Student the propriety of asking what would be his feelings provided in any such case this silver cord should be loosened : and I ask him whether, if the anaesthesia should proceed at first, or secondarily, to attack and overthrow the power of the medulla oblongata, his patient would not be instantly deprived of life! For if to breathe is to live, to be deprived of the uses of the medulla ob- longata is to die — since on that nceud vital depends the whole business of the oxygenation of the body. Many, and but too many examples of the power of these tremen- dous agents to overthrow, almost instantly, the force resident in the medulla oblongata are spread upon the records of medicine in the last two years. I do not well understand how those persons can recover their composure or their complacency who, by an unnecessary and inappropriate resort to so dangerous a process, have seen the victims of this extraordinary power struck lifeless before their eyes. It behooves not me to enter into the lists with the surgeons who cast their patients into the deep insensibility of etherization before perform- ing their operations — suum cuique tribuito is a proper law for me in this place. But I cannot avoid the feeling of astonishment which seizes upon me w 7 hen I read the details of cases of midwifery that have been treated during the profound Drunkenness of etherization. To be insensible from whisky, and gin, and brandy, and wine, and beer, and ether, and chloroform, is to be what in the world is called Dead-drunk. No reasoning — no argumentation is strong enough to point out the ninth part of a hair's discrimination between them-- except that the volatility of one of the agents or its diffusibility as a ANAESTHESIA IN MIDWIFERY. 319 stimulant narcotic, enables it sooner to produce its intoxicating effect, which is sooner recovered from. I showed in the first part of this section why I deemed the use of etherization in Midwifery unnecessary; in the second part I have endeavored to show why it is improper. I have by no means said what I am inclined to say as to the doubtful nature of any processes, that the physician sets up, to contravene the operation of those natural and physiological forces that the Divinity has ordained us to enjoy or to suffer. The question is often propounded as to the Benefi- cence that ordained woman to the sorrow and pain of them that travail in childbirth. It ought to be taken for granted, without any, the least, disposition to what is called canting, that some economical connection exists betwixt the power and the pain of labors. While, therefore, we may assume the privilege to control, check and diminish the pains of labor whenever they become so great as to be properly deemed pathological, I deny that we have the professional right, in order to prevent or obviate them, to place the lives of women on the hazard of that progress of anaesthesia, whose laws are not, and probably can never be ascertained so as to be foreknown. Notwithstanding I have expressed the above opinions in regard to etherization in Midwifery, which might suffice to expose my sentiments upon that topic, still my respect for eminent brethren who think differently, calls upon me to acknowledge their equal rights, and probably superior claims to the confidence of the Student. Professor Simpson, of the University of Edinburgh, it is well known, is among the most distinguished and able advocates of the anaesthesia in our art. I will not, therefore, refrain from laying before the reader the following letter from that eminent gentleman, with my answer to his communication. Letter from Professor Simpson. Edinburgh, January 23d, 1848. Dear Sir: — By private letters from America, brought by the last steamer, I hear that in most of the cities of the Union, your chemists had failed in preparing proper chloroform; and that consequently, most experiments tried with it had been unsuccessful. In Great Britain, and on the Continent of Europe, chloroform has everywhere entirely, or nearly entirely, superseded the use of sulphuric ether, as an anaesthetic agent. The want of success which has attended its employment in America is, perhaps, owing in a great measure to an error of my ow'n, viz: to my not stating in my original account of 320 ANESTHESIA IN MIDWIFERY. it, the proper method of purifying it. This and other omissions were owing to the haste with which my first paper was drawn up. I will feel, therefore, deeply obliged by your taking any measures that you may deem fit, to circulate amongst American medical men the formula which I inclose for the preparation of chloroform. It is the formula used by Messrs. Duncan and Flockhart, our Edinburgh druggists, who have already manufactured enormous quantities of it. They always now are able to produce it as heavy as 1500 in specific gravity. Their first distillation of it is made in two large wooden barrels, with a third similar barrel as a receiver. They throw hot steam into the two first barrels, which serves to afford both sufficient heat and water for the process. They employ sixty pounds of chlo- ride of lime at each distillation, and have been able to manufacture three hundred ounces of chloroform a day. Each ounce of the chlo- ride yields, in the long run, about half an ounce of chloroform : con- sequently, to obtain three hundred ounces, (as above,) about six hundred ounces of bleaching powder are required. At first they could only make ten or twenty ounces per diem, then they rose to sixty, and latterly, enlarging their barrels, they can make, as I have said, three hundred ounces in the twenty-four hours. Various other chemical houses in Edinburgh, Liverpool, Glasgow, York, London, &c, are busy manufacturing it in great quantities. They keep their formulas as secrets. But none of them make so good an article as Duncan & Flockhart, whose formula I append. The statements which I have already made, may show you to what an extent the chloroform is used in this country ; and our chemists tell me that the demand for it steadily increases with them. In Surgery its use is quite general, for operations, painful diag- nosis, &c. My friend, Dr. Andrew Wood, has just been telling me of a beautiful application of it. A boy fell from a height, and se- verely injured his thigh. It was so painful that he shrieked when Dr. Wood tried to handle the limb, and would not allow of a proper examination. Dr. W. immediately chloroformed him — at once ascer- tained that the femur was fractured — kept him ansesthetic till he sent for his splints — and did not allow his patient to awake till his limb was all properly set, bandaged, and adjusted. In Medicine its effects are being extensively tried as an anodyne, an anaesthetic, a diffusible stimulant, &c. Its antispasmodic powers in colic, asthma, &c. are everywhere recognized. ' In Midwifery most, or all of my brethren in Edinburgh employ it constantly. The ladies themselves insist on not being doomed to ANAESTHESIA IN MIDWIFERY. 321 suffer, when suffering is so totally unnecessary. In London, Dublin, &c, it every day gains converts to its obstetric employment, and I have no doubt that those who most bitterly oppose it now, will be yet, in ten or twenty years hence, amazed at their own professional cruelty. They allow their medical prejudices to smother and over- rule the common dictates of their profession, and of humanity. No accidents have as yet happened under its use, though several hundred thousand must have already been under the influence of chlo- roform. Its use here has been a common amusement in drawing- room parties, for the last two or three months. I never now apply it with anything but a silk handkerchief. In surgical cases and operations, the quantity given is not in general measured. We all judge more by the effects than the quantity. Generally, I believe, w T e pour two or three drachms on the handker- chief at once, and more in a minute, if no sufficient effect is produced, and we stop when sonorous respiration begins. Not unfrequently spasms, rigidity, &c, come on, but they disappear as the effect in- creases, and none of us care for them any more than for hysteric symptoms ; nor do they leave any bad effect. But the mere appear- ance of them is enough to terrify a beginner. I shall be glad to hear how the cause of anaesthesia gets on among you, and I remain with great respect, Very faithfully yours, J. Y. SIMPSON. To Professor Meigs. The following is the formula for Chloroform, communicated by Pro- fessor Simpson : Take of Chloride of Lime in powder, 4 pounds. Water, .... 12 a Rectified Spirit, . . 12 fluidounces. "Dumas." The chloride of lime and water being first well mixed together, the spirit is added. Heat is then applied to the still, (which ought not to be more than a third full,) but as soon as the upper part of the still becomes warm, the heat is withdrawn, and the action allowed to go on of itself. In a short time the distillation commences, and when- ever it begins to go on slowly, the heat is again applied. The fluid which passes over, separates into two layers, the lower of which is Chloroform. This, after having been separated from the weak spirit forming the upper layer, is purified by being mixed with half its mea- 21 322 ANESTHESIA IN MIDWIFERY. sure of strong sulphuric acid, added gradually. The mixture, when cool, is poured into a leaden retort, and distilled from as much car- bonate of baryta by weight, as there is of sulphuric acid by mea- sure. The product should be allowed to stand over quicklime for a day or two, and repeatedly shaken, and then re-distilled from the lime. Reply to Prof. Simpson's Letter. Philadelphia, Feb. ISth, 1848. Dear Sir: — I have to acknowledge the favor of your letter of Jan. 23d, which I received yesterday. The chemists in this country have produced very perfect chloroform, of the specific gravity of 1450, as I am informed, and which is much employed in dentistry operations, and to a considerable extent also in surgery. I presume you will, ere this date, have received copies of Prof. Warren's pamphlet on " Etherization," which may inform you, very fully, as to the use of the anaesthetic agent in the Massachusetts General Hospital, and in Boston. That eminent gentleman is more reserved as to the obstetric employment of the agent ; much more so, I understand, than either Dr. Channing, Dr. Homans, and other prac- titioners, who make use of it very commonly. In New York, as I learn, the surgical application of chloroform is common, while its obstetrical use has not as yet acquired a general vogue. In Philadelphia, we have the Pennsylvania Hospital, with more than two hundred beds. A very considerable amount of surgical practice, which renders that house a favorite clinical study for medical students of the United States, has not, as yet, furnished a single example of the exhibition of chloroform or ether as anaesthetic agents. The Sur- gical Staff of the Institution have not become convinced of the pro- priety of such a recourse in the operations performed there. In the Jefferson College, to which I am attached, as Professor of Midwifery, etc., there is a medical and Surgical Clinic held on the Wednesday and Saturday of each week. The resort of surgical cases there is very great, and a Clinical day rarely passes without some sur- gical operations before the classes. The clinical professors, (in sur- gery,) Drs. Mutter and Pancoast, almost invariably employ the chlo- roform, and the successful exhibition of the article has entirely confirmed them in their opinion of its great value. Some of the ope- ANESTHESIA IN MIDWIFERY. 323 rations have been of the gravest character, and no serious event has occurred to check the career of the remedy. As to its employment in Midwifery here, notwithstanding a few cases have been mentioned and reported, I think it has not yet begun to find favor with accoucheurs. I have not exhibited it in any case ; nor do I, at present, know of any intention in that way, entertained by the leading practitioners of obstetrical medicine and surgery, in this city. I have not yielded to several solicitations as to its exhibition, addressed to me by my pa- tients in labor. As to the extension of the anaesthesia in the Southern and Western States, I am not at present enabled to give you information. I be- lieve the practice is slowly gaining converts, and that it will become more and more common ere long. You may perhaps feel surprised at this admission on my part, see- ing that I am still a recusant ; and I ought, therefore, to be ailowed to explain myself, lest I should continue to appear unreasonable in your eyes. Having carefully read the Comptes Rendus of the Royal Academy of Medicine of Paris, which contained full reports of the copious discussions on the question of the Letheon, a few months since, and having also seen the English and American Reports in the Journals, and particularly having read your own pamphlet of " Remarks," &c, I may not properly be accused of ignorance of the power, effects, or motives, in relation to chloroformization in surgery, or ob- stetricy. The copy of your own pamphlet, for which I now beg leave to thank you, would necessarily have put me au niveau on the subject. Not being myself engaged in the practice of surgery, proper, I pre- fer to avoid any expression of opinion as to the propriety of the prac- tice; and I do this upon the principle, suum cuique tribuito. It would be an impertinence in me, were I to interfere with the conduct of the surgeons. But, in midwifery, to which a long and extensive practice has enured me, and rendered me a familiar, dispassionate witness of its various forms and phenomena, I am less liable to misconceptions. And here allow me to say, I have been accustomed to look upon the sensation of pain in labor as a physiological relative of the power, or force ; and notwithstanding I have seen so many women in the throes of labor, I have always regarded a labor-pain as a most de- sirable, salutary, and conservative manifestation of life-force. I have 324 ANAESTHESIA IN MIDWIFERY. found that women, provided they were sustained by cheering counsel and promises, and carefully freed from the distressing element of terror, could in general be made to endure without great complaint, those labor-pains which the friends of the anaesthesia desire so ear- nestly to abolish and nullify for all the fair daughters of Eve. Perhaps, dear sir, I am cruel in taking so dispassionate a view of the case ; and it is even possible that I may make one of the number of those " amazed" converts of whom you speak in your worthy letter to me. But, for the present, regarding the pain of a Natural labor as a state not, by all possible means, and always, to be es- chewed and obviated, I cannot bring myself to the conviction that of the two, whether labor-pain or insensibility, insensibility is to be pre- ferred. If I could believe that chloroformal insensibility is sleep indeed, the most considerable of my objections would vanish. Chloroform is not a soporific ; and I see in the anaesthesia it superinduces, a state of the nervous system, in no wise differing from the anaesthetic results of alcoholic potations, save in the suddenness and transitiveness of its influence. I freely admit, for I know it, that many thousands of persons are daily subjected to its power. Yet I feel that no law of succession of its action on the several distinct parts of the brain has been, or can be hereafter ascertained, seeing that the succession is contingent. Many grave objections would perhaps vanish, could the law of the succession of influences on the parts of the brain be clearly made out, and its provisions insured. There are, indubitably, certain cases in which the intellectual hemispheres are totally hebetized, and de- prived of power by it, while the co-ordinating lobes remain perfectly unaffected. In others, the motor cords of the cerebro-spinal nerves are deprived of power, whilst the sensitive cords enjoy a full activity, and vice versa. In some instances, the seeing brain enables the patient to look upon the application of a cautery that he does not feel, while it sears him, or of a bistoury whose edge gives him no pain. In others, the influ- ence of the agent upon the sources of the pneumogastric and phrenic nerves is dangerously, or at least alarmingly, made manifest by modi- fications of the respiratory force. It appears to me, therefore, quite certain, that there is no known law of succession of the ether-influ- ences on the several parts of the brain. It is known that the con- tinued aspiration of the vapor brings at last, the medulla oblongata fully under its anaesthetic power, and the consequent cessation of re- ANAESTHESIA IN MIDWIFERY. 325 spiration, which determines the cessation of the oxygenation of the blood, and thereby of the brain, is death. M. Flourens' experiments, and others, especially those by the younger Mr. Wakley, of the Lan- cet, prove very conclusively that the aspiration of ether or chloroform, continued but a little longer than the period required for hebetizing the hemispheres, the cerebellum, the tubercula quadrigemina, and the cord, overthrows the medulla oblongata, and produces thereby sudden death. I fully believe with M. Flourens, that the medulla oblongata is the nceud vital, and that, though later brought under the power of chloroformization, it is always reducible under it. Hence I fear that in all cases of chloroformal anaesthesia, there remains but one irrevo- cable step more to the grave. I readily hear, before your voice can reach me across the Atlantic, the triumphant reply that an hundred thousand have taken it with- out accident! I am a witness that it is attended with alarming acci- dents, however rarely. But should I exhibit the remedy for pain to a thousand patients in labor, merely to prevent the physiological pain, and for no other motive — and if I should in consequence destroy only one of them, I should feel disposed to clothe me in sackcloth, and cast ashes on my head for the remainder of my days. What suffi- cient motive have I to risk the life or the death of one in a thousand, in a questionable attempt to abrogate one of the general conditions of man? As to the uses of chloroform in the medical or therapeutical treat- ment of pain, the question changes. There is no reasonable therapeia of health. Hygienical processes are good and valid. The sick need a physician, not they that are well. To be in natural labor, is the culminating point of the female somatic forces. There is, in natural labor, no element of disease — and, therefore, the good old writers have said nothing truer nor wiser than their old saying, that "a meddlesome midwifery is bad." Is chloroformization meddle- some ? Your countryman, old Thomas Rainold, in " the Woman's Booke, or The byrthe of Mankynde," at fol. LIII., says, " Very many be the perilles, daungers, and thronges, which chaunce to women in theyr labor." These are the cases requiring our therapeutical and chirur- gical intervention. You will, my dear sir, think me a hopeless recu- sant, if I decline the anaesthesia here also. I pray you, therefore, allow me to state my reasons for such recusancy. If I were amputating a limb, or extirpating a tumor, I should see all the steps of my incisions, ligations, &c. But if I apply my for- 326 ANESTHESIA IN MIDWIFERY. ceps in a right occipito-posterior position, (fourth of Baudelocque,) I know that I thrust the blade of the male branch far upwards betwixt the face of the child and the upper third of the vagina, which, in this case, is already greatly expanded, and that the extremity of the blade is separated from the peritoneum only by the mucous and condensed cellular coat of the tube. Now, no man can absolutely know the pre- cise degree of inclination his patient will give to the plane of her superior strait, while in pain ; an inclination to be modified by every movement of her body and limbs. Under such absolute uncertainty, the best guide of the accoucheur is the reply of the patient to his interrogatory, "Does it hurt you?" The patient's reply, "Yes," or "No," is worth a thousand dogmas and precepts, as to planes and axes, and curves of Carus. I cannot, therefore, deem myself justi- fied in casting away my safest and most trustworthy diagnosis, for the questionable equivalent of ten minutes' exemption from a pain, which, even in this case, is a physiological pain. Having thus, in my own defence, and not as attacking your opin- ion, set forth the motives that have hitherto served to restrain me from the administration of chloroform, I desist from giving you any farther trouble in this line of thought. I have, sir, a far more pleasing duty to perform, in saying that your name is as well known, perhaps, in America as in your native land, and to congratulate you on the ex- tension of your fame. I had the pleasure to read your interesting letter to my class, consisting of several hundred young gentlemen, who listened to your words with the same respect they would have paid to you, had they been pronounced by your own lips. They will disperse themselves in a few days hence, over all the States of the Union, and thus will have it in their power to report the latest dates of your opinions as to chloroform. I shall also allow it to be pub- lished on the first proximo, in a medical journal of extensive circu- lation. You will herein perceive the readiness with which I assist in disseminating your views. It is not without regret that I find myself opposed to your opinions in the case. That difference ought not, however, in the least degree to affect those sentiments of respectful consideration and real esteem with which I am, dear sir, very faith- fully, your obedient servant, CH. D. MEIGS. PflOFESSOR SlMPSOS, &c. FACE PRESENTATIONS. 327 CHAPTER XI . FACE PRESENTATIONS. 73. In cases in which the usual dip of the occipitofrontal diameter fails to take place, but, on the contrary, is reversed, so as to allow the chin to depart far from the breast, the head may be actually turned over backwards, permitting the child's face to fall down into the pelvis. In face presentations, as deline- ated in Fig. 73, annexed, the chin is on one side, and the top of the forehead upon the other side of the pelvis. The face seems to be looking directly downwards into the exca- vation of the lower basin. This could not be the case without com- plete departure of the chin from the breast, {see the figure,) and an absolute overset of the head back- wards, as in a person who should be looking upwards at an object di- rectly overhead. These are what are denominated Face Presentations : a sort of labors that are thought less unnatural and dangerous, now, than in former times. I am clearly of opinion that face cases may w T ell be included among the natural labors, except where some failure in the powers of the woman should cause us to convert them into preternatural ones, obliging us to turn and deliver by the feet ; to restore the vertex by some serious operation; or to extract with the forceps, or other instrument. The foetal head being an oval, five inches long, from the vertex to the chin, and more than three and a half inches wide at the widest part, it ought to make no difference, as far as the mere head is concerned, whether the chin or the vertex advances first in labor, because, in either 328 FACE PRESENTATIONS. case, the same circumferences of the head are presented to the planes through which they are to be transmitted. The foramen magnum of the occipital bone being nearly equidistant from the vertex and chin, and situated on one side of the oval, the peculiar difficulties and hazards of these labors are attributable, rather to the nature of the articulation by which the neck and head are conjoined, than to the form of the head itself, when advancing with the face downwards. The nature of this articulation is such, that extension of the head cannot take place so well as flexion : hence the requisite dip of the occipitofrontal diameter is not effected without difficulty, and the con- sumption of much time. Let the reader figure to himself the state of the spinal column of a child, urged on in labor by powerful uterine contractions, directed to its expulsion with the face in advance. The inferior-posterior part of the head is pressed against the back of the neck, or betwixt the scapulae, which could not be the case without bending the cervical spine backwards, like a bow, while the dorsal and lumbar vertebrae- are curved in the opposite direction, causing thus a double antero- posterior curve, on which, in consequence of the elasticity of the two arches, much of the expulsive force is vainly expended; so that, though the power may be as great as in a common labor, it produces much less effect than in a common labor; a great part of every pain being occupied in reproducing the greatest amount of curvature; for the elasticity of the two curves is such that they are straightened as soon as the pain subsides, at least in some measure, while the rest of the pain is used in pushing the face onwards. A child in utero is in a state of universal flexion, as I have already remarked. It cannot be in extension, as supposed by the old authors, whose rude cuts accompanying their crude descriptions of labors, are calculated to excite a smile of pity in any modern obstetrician. In this state of flexion, the chin approaches or even touches the breast. Such a flexion in a head labor, always gives us a vertex position. But if the chin, instead of approaching, depart from the breast, there is a tendency towards the face presentation. Let the Student consider that when the chin departs from the breast, it does so by slow degrees, and not suddenly, nor wholly, at once. Hence he should, in face presentations, whose whole progress he has opportunity to supervise, expect to touch at first the top of the forehead as the lowest point; or presenting point. As the labor goes on, the head continues to turn over more and more completely, until it is at last, FACE PRESENTATIONS. 329 Fig. 74. quite overset backwards ; as may be seen in the annexed drawing, in which, in addition to a face presen- tation, there is a prolapsion of the left foot. If, in such a labor as this, the foot were thrust back into the womb during the absence of a pain, w r e should have a very bad case of face labor, with the chin to the sa- crum, and the forehead to the pubis. When the face presents, the face does not enter the excavation with the fronto-mental diameter parallel to the plane of the strait. On the contrary, the frontal extremity of that line is lowest at first, but the mental extremity of it comes at length to be lowest at least as regards the successive planes through which it passes in the lower part of the pelvis, as may be seen on re- ference to the neat figure which is annexed. The direction taken by the face, as it proceeds, in such a g ' labor, is worthy of the closest attention of the practitioner. Should the chin enter the supe- rior strait near to the acetabulum, it will afterwards rotate towards the arch of the pubis, and, es- caping under that arch, will rise upwards over the pudendum, so as to allow the under aspect of the chin and the throat to be applied to the arch, and to the front of the symphysis, while the remainder of the head is evolving itself from the os externum. In such a birth the part that first emerges is the chin;, then the mouth, the nose, the forehead, the crown ; and, last of all, the vertex, which escapes over the fourchette, whereupon the flexion of the head immediately becomes complete again. This is the most favorable direction for the face to take, and it will generally be found that a well-formed pelvis is capable of transmitting a child of moderate size, almost as speedily and safely, in such a 330 FACE PRESENTATIONS. labor, as if it were a vertex presentation. Let it be remembered that the symphysis of the pubis is only one inch and a half long, and of course, if the chin should escape under the arch, the neck is so long that the throat can apply itself against the inside of the symphysis, allowing the chin, nay the whole head to be born, before any part of the thorax of the infant begins to plunge into the excavation. Figure 76 may serve to show how the chin, in a favorable case, comes at last to the symphysis pubis, slides down behind it, and at length begins to emerge underneath the crown of the pubal arch. Look at the figure, reflect that the occipito-mental diameter is five inches, and the pelvis only four and a half; and that as soon as the chin begins to come forward under the arch the five inch mento-occi- pital diameter is coming with its mental extremity out beneath the arch. Fig. 76. Fig. 77. The next figure (Fig. 77), shows how the chin rises upwards in front of the pubis as soon as it begins to escape beyond the arch, and thus allows the head to roll out of the excavation. The three outline heads show the three successive positions of the cranium after the chin has once come under the arch. A very contrary state of things from the foregoing obtains, where the chin, instead of revolving towards the front, turns towards the back part of the pelvis. Here the forehead must appear first ; then the nose; next the mouth; and lastly, the chin escaping from the edge of the perineum, retreats towards the point of the coccyx, allowing the crown of the head to pass out under the arch; and finally, the vertex emerges, which concludes the delivery of the head. I say that the forehead appears first, not that it is born first, for the part FACE PRESENTATIONS. 331 first born is the chin. When the chin has escaped, and begun to retreat behind the perineum, the mouth becomes delivered, then the nose*^nd eyes, top of the forehead, crown, and lastly the vertex. This must be the case, considering that the occipito-mental diameter is fully five inches long, and that there is no antero-posterior, oblique, or transverse line of such length in any part of the lower excavation. It is impossible then to see-saw a diameter of more than five inches within the excavation. Therefore, if the mental extremity of the occipito- mental diameter descends first, it must escape first, and the occipital extremity last. But, while the chin is sweeping, slowly and painfully, down the curve of the sacrum, and especially, when it is got so low as the edge of the perineum, the breast of the child is entering the pelvis, where the space it should occupy is already taken up by the perpendicular diameter of the head. Imagine the enormous exten- sion of the os externum, required for the exit of the child, in such a case! Figure 78 shows the difficulty that is produced by a rotation of the chin backwards, in so clear a light, that I hope it may greatly assist in teaching the young Student how extremely important a mat- ter it is to give all possible aid and assistance to nature, in her at- tempts to turn it towards the front of the pelvis. The cause of face presentations is not perfectly well understood ; it is, however, probable, that they are more commonly occasioned by an obliquity of the womb than by any other cause. For example, let the womb, at the onset of labor, be so oblique as to throw its fun- dus far down to the left side, the child presenting by the head, and the vertex to the right side of the pelvis: the direction of the expul- sive force operating on the infant, will propel its head against the edge or brim of the pelvis, and either cause the head to glance upwards into the iliac fossa, so as to let the shoulder fall into the opening, or it will be turned over, so as to let the face fall into the opening, and thus produce a face presentation, in which the chin is near to the left acetabulum, and the forehead to the right sacro-iliac junction. It is easy to set this in a clear light, especially if it be accompanied with demonstrations on the phantome. In my opinion, it would be right to admit, in a systematic arrange- ment, only two original positions of face-presentations: viz., one with the chin to the left, and one with it to the right of the pelvis; it being always understood, that the position is not necessarily exactly transverse, but that the chin may be variously addressed, sometimes, and indeed most generally being so far back as to be near the sacro-iliac symphysis, 332 FACE PRESENTATIONS. and sometimes more anteriorly, or near the body of the pubis. By ad- mitting these two positions only, the Student's mind is relieved from the burden of unnecessary artificial distinctions ; and should he in practice rest upon them, it will be easier for him to comprehend the practical doctrines relative to the case. Thus, in all face cases, the great doc- trine is to bring the chin to the pubic arch, because the chin, being the mental extremity of the five inch mento-occipital diameter, may escape by gliding an inch downwards, behind the symphysis pubis; whereas, if it be directed backwards to the sacrum, it must slide five inches down the sacrum and coccyx, and from three to three and a half inches over the extended perineum, before it can be born; but, five inches and three inches make eight inches. The child's neck is not eight inches long. Therefore, before the chin can slide dow T n the sacrum, and off the anterior edge of the extended perineum, a good part of the child's thorax must be pressed or jammed into the exca- vation along with the head, the vertical diameter of whic^ is more than three and a half inches. See Figure 78, on p. 338. If we should adopt four positions, we must have a doctrine for each ; but with the two only, there is a necessity for only one doctrine — namely, to bring the chin to the arch of the pubis, if practicable; if not, let the forehead come, and do our best with it. Face presentations are accidents; and, perhaps, they are so unlikely to happen, in consequence of the normal lawof fcetal flexion, that they ought to be regarded as examples of preternatural labor. Yet, when we come to reflect, that the female can expel the child with but little more difficulty, in this case, than in vertex positions, it seems alto- gether proper to regard them as natural cases. But I have said that they are accidents, and I believe that they are chiefly caused by deviations of the axis of the womb. I beg leave to repeat, that if a female have a very great right lateral obliquity of the womb, and the vertex present towards the left side of the pelvis, it may be impelled against the brim in such a manner as to glance above it, and allow the forehead to fall into the opening, which state could not exist long with- out being followed either by the descent of the face, or the inducing of a shoulder presentation. It should not be forgotten that, from the chin to the vertex is a distance of five inches, which none of the dia- meters of the straits will take in, in the living subject: therefore, if the vertex should rise above the brim, and let the forehead fall into the opening, the chin w T ould gradually come down. Let not the Stu- dent then expect to find the face looking full down into the excava- tion, at the beginning of these cases; but rather, let him expect to find FACE PRESENTATIONS. 333 it coming more and more completely down as the labor draws to its close ; hence, all face cases are at first cases of forehead presenta- tion, and whenever the chin departs from the breast in a labor, let him take heed lest it lead to a face presentation. I propose to the American Student to adopt Dewees' recommenda- tion, to have only two face presentations, and to let the first be that in which the forehead is to the left and the chin to the right side of the pelvis — while the second position is that in w T hich the forehead is to the right and the chin to the left side of the pelvis. Let this be the decision, and let the Student, when he finds the chin disposed to address itself to a point in rear of the transverse diameter, still con- sider it as a first position, or a second position, as the case may be. Suppose a case of face presentation to be caused by a right lateral obliquity of the womb, the point of the head being repelled above the edge of the strait: the womb, in its oblique state, leans to the right and forwards, and not directly towards the right ; whence, if the accident occur in the manner supposed, the chin could not fail to be placed to the right, and a little forwards ; the same thing is true of cases caused by left lateral obliquity — mutatis mutandis — as before stated. This furnishes a striking manifestation of the wisdom which, in giving form to the pelvis, even provided us herein a remedy for the accidents that might occur to thwart or prevent the parturient act. Should the chin be towards the posterior part of the pelvis, and not susceptible of being directed towards the front of the pubis, the most serious mischiefs might be expected to occur ; whereas, when the chin advances tow T ard the pubis, little embarrassment is, in general, to be apprehended. If we could know, antecedently to the descent of the presenting parts, what they are, it might be supposed that we could easily restore them when wrongly placed, to their proper situation ; but, while the presenting part of the child is above the brim, it is very rare to have such a good degree of dilatation as to admit of the hand being intro- duced, in order to effect the needful changes. The womb opens as the part comes down, and only as it does come down. Hence, when a face case is ascertained to exist, it is mostly (I say not universally) too late to return it into the abdomen or superior basin ; and as to attempt- ing to bring down the vertex, after the head has once sunk well into the excavation, I regard it as a rash, if not an impossible operation; rash, since it could not be done without very great violence ; and generally, impossible, since we cannot turn, or see-saw a diameter of full five inches, in a pelvis furnishing less than that space. Where it 334 FACE PRESENTATIONS. is possible to push the whole mass back, and bring down the vertex, let it be done, if deemed really necessary; but the opportunity to do this good action will rarely occur in practice. Dead, and half putrid children, in whose tissues there is scarcely any resiliency or resisting power left, are not so unapt to come face foremost as living children, in whom departure of the chin from the breast occasions such a great extension of the head as to be painful, whence the child opposes the wrong tendency, by acting with all its strength, to get the chin down, or the head flexed again. Let me repeat that it is not to be expected, that, at the very beginning of a labor, the face of the child shall be found looking directly down- wards. When the examination is made early in a labor, the os uteri being dilated very little, the accoucheur ordinarily rests content with ascertaining that the head presents, and does not endeavor to complete the diagnosis as to position. Hence there is almost always a mistake in the diagnosis and prognosis, for it is the forehead that is first felt: and the face itself does not appear in the excavation for some time after the commencement of the parturient throes. The head turns over only by degrees, and allows first one eye to be felt and then the other, the nose, the mouth, and the chin. In order to exemplify these processes, I shall cite some cases from my record-book. On the 5th day of February, 1830, 1 was called to attend Mrs. , in labor with her second child. When I reached her house, it was half past six o'clock in the morning. She told me that she had had pain for a day or two, but was seized with regular labor-pains at four o'clock this morning. Upon making examination per vaginam, I found the os uteri from one inch and a half to two inches in diame- ter, with the edges thin and ductile, and the membranes protrud- ing through them very tensely during the pains. I could, at first, just feel the even smooth surface of the fetal cranium, which seemed to be resting or lodged upon the top of the symphysis pubis, and not in the least degree engaged, or entered into the superior strait; this was all that I learned from this first examination, and was all that I wished to learn. As the pains were regular and good, I expected soon to find the head engaged within the passage; but I observed that the uterus was very large, as if distended with an undue amount or excess of liquor amnii. At nine o'clock A. M., the pains, although regular and of increasing severity, had not caused the head to engage in the slightest degree: it remained exactly as at the first Touching. These circumstances FACE PRESENTATIONS. 335 led me to suspect that the womb was unprovided with a proper degree of energy, on account of its being distended beyond its just dimen- sions. I, on this hypothesis, deemed it advisable to rupture the ovum, in the expectation that, as soon as the womb should condense itself a little by the flowing off of the waters, it would acquire such vigor as to compel the head to engage in the strait, and thence pass speedily into the excavation, as I had repeatedly observed to be the case in other persons. Upon rupturing the ovum, there came off a very great quantity of water; I should think nearly two quarts in all; but the head did not advance until three or four pains had acted upon it ; after which it came slowly down, and I felt a suture; but as yet no fontanel was distinguishable. The examination induced me to suppose it was a vertex presentation of the first position, in which opinion I was most egregiously deceived, in consequence of the very careless manner in which I made the investigation. At eleven o'clock I made a more careful inquiry, and was distressed to find that the left side of the os frontis was in the middle of the excavation, and that, by passing the finger very strongly up towards the left sacro-iliac junction, I could feel the left orbit and the nose, beyond which it was impossible for me to reach, in the then state of the organs of generation. It seemed, on account of the advanced state of the labor, too late to turn, even if that could have been considered the best recourse ; and I was the more averse to such a proceeding, considering that I had before delivered her of a large child, and also that the waters were now drained off, and the uterine contractions powerful. As she had by this time become heated, and very much disquieted with her pains, from which the suffering was severe, I gave her thirty drops of laudanum, and soon afterwards took twelve ounces of blood from the arm. She also got an enema of flaxseed tea and olive oil. The head was now fairly engaged, and the face was becoming more and more the presenting part, notwithstanding my repeated endeavors to push it up, by forcibly pressing against the ossa mala- rum during each pain ; and I became thoroughly convinced that it was impossible to force up the face and bring down the vertex by the employment of any legitimate force, or by mere dexterity. The pains had become so dreadfully severe, and the poor woman suffered such agonies, that I really entertained serious apprehensions that the womb might rupture itself or the vagina, in its vain efforts to carry on the parturient processes, lashed as it was into a rage of ex- citement by the obstacles to delivery. 336 FACE PRESEXTATI G 1 K5 . A: my request Dr. James, at that time Professor of Midwifery in the University of Pennsylvania, was invited to see the patient, and arrived at two o'clock in the afternoon; and after having examined the case, left me, with encouragement to hope that the vertex might come down after some further efforts of the womb. Dr. J. was to return to me at half past four o'clock. In the mean time I provided myself with the long right-hand blade of Davis's oblique forceps; and when the professor returned, at four o'clock, it was found to be vain any longer to expect the descent of the vertex. I therefore introduced the blade above mentioned behind the right ramus of the pubis, got it upon the left parietal bone, and, using it as a vectis, drew down with it during the pains. The head advanced very much by this aid, and began to press upon the peri- neum; but there it stopped, and seemed no longer affected by the I next attempted, with my French forceps, to introduce the male blade behind the left obturator foramen. I was foiled, but Dr. James succeeded in adjusting it. Every attempt to adjust the female blade, whether made by Dr. James or by me, proved fruitless. They could not be made to lock; nevertheless, I attempted to deliver with them by securing the joint with one hand, and by this means the head again advanced, but soon stopped. The forceps were now aban- doned, after vainly attempting to make them lock. I next resorted to the oblique vectis again, and with it caused the head to advance so much, as to put the perineum in a state of tension. The face turned to the pubic arch ; the chin emerged from the genital fissure ; and as the successive portions of the face came forth, the chin rose up to the mons veneris, and allowed the fourchette to slip backwards off the vertex, which immediately retired towards the coccyx. The child was born, but the cord, which was tight around its neck, did not pulsate; the infant, however, began at length to gasp, and, after having been well dashed with brandy, cried lustily. It s born at half past six o'clock P. M., so that the labor was found to have continued about fourteen or fifteen hours. A: the time I last put on the vectis the child's face was in the left sacro-iliac corner of the pelvis. Both Dr. James and I expected that the rotation would inevitably carry the chin to the sacrum, to be consequently delivered at the perineum. I have every reason, there- fore, to suppose that the vectis was the chief means of giving the head m favorable a rotation, a result attributable to the admirable curve of Dr. I :lique blade. FACE PRESENTATIONS. 337 The perineum was not hurt; the placenta came off in twenty- minutes ; and the mother found herself very comfortable, considering her great fatigue. The face was one enormous suggillation, carried to the extent of producing numerous blebs or vesications on the eyelids and cheeks. The mouth was excessively swelled, and the left eye completely closed. The face was, on account of this state, directed to be fre- quently bathed with cream. This infant was carefully weighed on the evening of its birth, and was found to weigh nine pounds and three-quarters. On the sixteenth day after delivery, the woman was down stairs to dinner, and had no subsequent indisposition. In giving the details of this case, I am liable, as I well know, to the charge of having, in an important matter, anticipated my subject. But although I have not yet come to the formal consideration of in- strumental cases, I feel pretty well assured no evil will happen to any Student for having, by reading the foregoing relation, in some degree anticipated the regular and formal consideration of obstetric operations. The cut, Fig. 78, which represents the foetal head, in a face labor, thrown back to that degree as to press the occipital bone against the interscapular space, suffices to show how well founded were my fears lest the forehead, instead of the chin, should rotate to the front, to pre- vent which is the chief doctrine of this obstetric topic; and I would again urge the Student to take the first opportunity that may present itself, of testing the doctrine, by trying to deliver on the machine, or phantome, with the chin backwards, in a face presentation. By so doing, he will at once have a demonstration of the point of practice to be adopted, and never afterwards be in the least danger of making a mistake, or committing a blunder in this matter. Seeing the great and merited reputation of the late Professor De- wees, of Philadelphia, and the general recourse to, and reliance on his obstetric precepts, I feel constrained to warn the Student of one error in his System of Midwifery, 2d edition, 1828. He is speaking at p. 328, of the instrumental delivery of a face-labor. " Should the forceps be determined on, we must apply them over the ears; that is, one blade behind the pubis, and the cither before the sacrum ; they must be so applied that the concave edges must look towards the hind head, which must be brought under the arch of the pubis, and not the chin, as directed by Smellie." This operation would inevitably, if successful, bring the top of the forehead and the crown of the head under the arch, and the chin to the 22 338 FACE PRESENTATIONS. sacrum and the coccyx as in Fig. 78. To deliver it, would imply that the child's throat should stretch to a length beyond eight inches ; or that the thorax and head should both be in the excavation together. I should not have noticed this lapsus of my celebrated townsman, but as evidence of my respect for his great reputation, and because I know that it was lapsus pennse, and not a precept that he would follow in practice. When such authorities happen to fall into even a small error, it is proper to point out the error, lest a great name should mislead the early beginner, or Student. I should think no long disquisition would be required to convince the Student who will carefully ex- Fi s- 78 - amine the Fig. 78, that in a face presentation with the forehead to the pubis, and the chin to the sacrum, it must happen that a considerable part of the child's thorax shall be jammed, together with the cranium, into the pelvis. The same cut shows that if the occipito-mental diameter be re- versed, so that the mental extre- mity of it, instead of the occipital extremity, enters the pelvis first, it must leave it first, for it cannot be reversed within the excavation. Further, let the Student examine the drawing, to see how the chin must in these unfortunate presentations slide down the posterior surface of the pelvis, from the promontorium to the point of the coccyx, and so over the perineum, until it escapes from the vulva, over the four- chette. In examining Fig. 75, he will readily perceive how easy it is for the mental extremity of the oblique diameter to begin to escape, since it has only a slide of one inch along the symphysis pubis to make before it emerges; whereas, in the reverse position it slides five, six, or even seven inches over bone and resisting tissue, before it can begin to be born. A case of a"*different kind occurred to me on Wednesday, the 17th of February, 1830. Mrs. M. was in labor with her seventh child, having been taken at four o'clock A. M. with the pains, which con- tinued to increase up to the time when I arrived, which was about half past six o'clock. The pains were strong; the w T aters gone ofT; and the head pretty low T down in the pelvis. At my first examination, I mis- FACE PRESENTATIONS. 339 took the presentation, thinking that it was a vertex case ; but as the pains seemed to have no good effect, I examined again, and could feel the root of the nose directly behind the symphysis pubis, and the super- ciliary edges of the orbits upon each side of the symphysis of the bone. Upon this discovery, I endeavored to turn the forehead towards the left, by raising the os frontis, and pushing it in the proper direction; but as soon as each pain came on, it forced the presenting part back again into its former position. I next endeavored, by simply pushing up the forehead during the absence of a pain, and sustaining it while the pain was active, to cause the vertex to descend along the curve of the sacrum, and the perineum : but I could not succeed here any better than in my attempts at rotation; the pains drove it back, mau- gre all my wishes to the contrary. As the chin was so far departed from the breast, I had good reason to fear that the head must turn quite over in extension, and thus give me a face case to manage, for as I could feel the superciliary ridges on each side of the symphysis pubis, there was some likelihood of a complete overset of the head, provided the cranium was not too large. The patient, who had met with no such difficulties in her former labors, and to whom I was a stranger, now became greatly alarmed and distressed ; so much so, indeed, that I judged it most prudent to explain to her the true situation of affairs, and encouraged her to look for relief after a reasonable time. I told her that she could be deli- vered by her own unassisted efforts, but that it would take a good deal of time and much pain; but that I could speedily deliver her with the help of an instrument, which would add neither to the hazard or pain of her condition. She clapped her hands, trembled violently, and uttered exclamations indicative of the greatest dismay, and even terror, but at last agreed to be guided by my opinion. I introduced the right-hand long blade of Davis's oblique forceps, with which I caused the head to make a considerable advance; but it again stopped, and I applied the long forceps: with the aid derived from this instrument I drew the head downwards so as greatly to extend the perineum; upon observing which I deemed it prudent to remove the forceps, lest I might rupture the perineum, which was about to undergo, unavoidably, a very great distension, and which I was not inclined to augment unnecessarily. After removing the for- ceps I reapplied the vectis, as before, and it very greatly assisted me to bring the head onwards as far as was requisite. As soon as I withdrew the vectis a pain came on, by which the head was expelled, the vertex passing out over the fourchette, upon which it immediately 340 FACE PRESENTATIONS. completed its act of extension, and allowed the crown, forehead, nose and chin successively to escape under the pubic arch. The child was born alive, and the after-birth followed in ten minutes. Upon the infant's forehead was an enormous black suggillation, which disappeared in the course of a few days, and was followed by no inconvenience. Of the above case it is proper to remark that the mother was very w 7 ell formed, and the pelvis large ; the child of medium size ; and although it did not become actually a face presentation, but was rather a case of presentation of the forehead, it still serves to illus- trate my observations on the difficulty of converting face presentations into those of the vertex. I think that, but for the aid of the instru- ments, it must have at last brought the face from behind the top of the symphysis pubis to look fully down into the excavation ; for the difficulty of bringing down the vertex, although not insuperable, was exceedingly great. In the course of my practice I have met with a considerable number of cases like the one whose relation I have just given, but it seems unnecessary to cite them here, as I presume this one may suffice to explain the nature of the mechanism of such a labor. I find, in my case-book, another example of face presentation, which I shall not deny myself the privilege of laying before my reader in this place, because it offers good encouragement to those who may happen to meet with such untoward sorts of labor in the commence- ment of their practice. October 11th, 1830. Mrs. C. W., aged twenty-six, was in labor with her first child. I was called at twelve o'clock at night. She had been poorly throughout the day, but kept about until bed-time. At ten, P. M., had a violent pain and large discharge of waters. She lay on her left side. Upon Touching, I could not reach the os uteri, nor feel any part of the child. Upon causing her to turn on the back I was enabled, by pushing the finger very far upwards and back- wards, to hook the anterior lip of the os uteri, and draw it, by means of the finger, downwards and forwards, into the centre of the plane of the upper strait: I could then touch the child's cranium, but I could not touch a sufficient portion of it to learn what part of the cranium it was. Not long afterwards I felt, in the left anterior part of the upper strait, a ridge or edge, which I soon made out to be the super- ciliary edge of the orbit of the left eye, the globe of which soon came within my reach. I could not touch the anterior fontanel. Here, then, was a case which, like that just now related, was to FACE PRESENTATIONS. 341 become a face presentation at last, if I should prove unable to pre- vent it by failing to restore to the head its lost flexion. I vainly tried to do this by pushing up the forehead, and holding it up during a pain. It always came back to its place, in spite of whatever efforts I could make. I next introduced the whole hand, except the thumb, took hold of the vertex by a fair purchase, but could not turn it down- wards ; and at length, becoming convinced of the impossibility of succeeding, resolved to abandon such irritating interference. As the head sank lower and lower, there was an obvious tendency of the chin towards the left sacro-iliac junction. I opposed this move- ment of the head by pressing the finger on the right side of the nose, which kept it from turning to the left, and at last brought it to the obturator foramen. The face came more and more down into the excavation, and began to swell very much. The lips became exces- sively tumid, and the whole face at last felt like a tense bladder. By the force of the pains, alone, the chin w T as afterwards slowly brought to the os externum, and applied itself to the top of the pubic arch, under which little by little it emerged, and then rose up towards the mons, permitting the front of the throat to take its place under the arch, and thus allowing the vertex to escape last from before the fourchette. See Fig. 77, p. 330. The placenta came off in six minutes. The infant was very weak, and its face greatly swollen, and black with the suggillation. It soon cried loudly, and I found that on the 14th, that is three days after its birth, it was in fine health, and wuthout any swelling of the face. The mother had a very favorable getting up. The net weight of the infant was nine and a half pounds. The mother was a large and very powerful woman. Madame Boivin informs us in her Memoires sur VArtdes Accouche- mens, page 276, that out of seventy-four cases of face presentations, fifty-eight children w T ere born naturally. Of these, forty-one were delivered without any assistance, and seventeen, by restoring the vertex to the centre of the excavation ; a success almost incredible. Fourteen cases required the turning and delivery by the feet, while only two were extracted by the forceps, and in one of the latter cases the mother had convulsions. "Thus," says the learned lady, "although presenting by the face, the child may be born alive and naturally, provided the head be not too large, if the parts of the mcther are well formed, the pains strong and good, the woman resolute and healthy, and no accident occur during the course of the labor." 342 FACE PRESENTATIONS. Madame Lachapelle, whose vast experience, gained while at the head of the Maternite Hospital at Paris, is yalid claim to speak as from authority, and whose thorough knowledge of the theory of mid- wifery must confirm those claims as rights, gives us only two sorts of face presentations : one in which the forehead is to the left and the chin to the right of the pelvis, and the other in which the forehead is to the right and the chin to the left. She says she never met with Baudelocque's first and second positions ; and Dr. Dewees, who asserts that his list comprises near nine thousand labors, also informs us that he never met with them. It will be remembered by the reader that the second case which I related in this chapter, that of Mrs. M., was one in which I felt the root of the nose behind and above the symphysis, and the two orbits on each side of it; and he will admit that although the vertex was at last restored so as to escape first, yet this was a real example of a face case of the rarest occurrence. Smellie gives us at least four examples of the face presenting in Baudelocque's first or second position; and assuredly no English or American Student of midwifery will be disposed to call in question the accuracy or candor of that admirable author, notwithstanding that Madame Lachapelle tells us she finds no very evident examples of such face positions in any good collection of cases. For my own part, I do not perceive the great importance of dwell- ing with much emphasis upon all the possible positions of the face. It cannot be doubted that they are each possible, inasmuch as, where the child's head is not disproportionately large, the mass of the head is observed to rotate upon the cervical axis, as I before remarked, some- times threatening to carry the chin towards the sacrum, and some- times flattering the accoucheur with the prospect of its speedy arrival at the pubis. The more important and useful knowledge is that which teaches us the nature of the accident, and the appropriate indications of treatment. But we have already seen that the acci- dent consists in an excessive departure of the chin from the breast, or failure of flexion; that is the first principle: and the chief indication founded upon it is, to restore the flexion by pushing up the forehead and bringing down the vertex; and where that cannot be done, the next indication is, to rotate the chin to the front so that flexion may take place as soon as possible after the chin has emerged. I am not capable at present of stating the number of face cases I have had occasion to treat. The number has been considerable. The result, as to my opinion, is, that they are rarely formidable when the great precept of bringing the chin to the pubis can be obeyed and fulfilled. FACE PRESENTATIONS. 343 Certainly, I have not been in a majority of my cases called upon to use any extraordinary measures of relief. I have a word of counsel for the Student as to the care of his own reputation in the conduct of such cases. There can rarely be met with a more disagreeable spectacle than that of a new-born child's face, born after a bad face labor. It is frightfully suggillated, and often covered with blebs filled with yellow or bloody serum, the lips are completely ectropied, the eyes closed by infiltration of the palpe- bral, and the nose enormously swollen. By-standers cannot compre- hend why these appearances should exist in a neonatus that has been tenderly treated — and are therefore too apt to assign as the probable cause the rudeness and brutality of the medical man. As soon as the young beginner has surely made his diagnosis, let him announce the probability of a swollen and blistered face, notwithstanding the gentleness of the treatment which he is about to administer. In this way he may save and augment not only his own credit, but that of his art, a pleasing duty for every true scholar. As I shall have occasion to revert to the consideration of face posi- tions when I come to treat of the various uses of the forceps, I shall close the present chapter, in order to take up the consideration of those labors in which the child presents the breech, knees, or feet, when descending. 344 PELVIC PRESENTATIONS. CHAPTER XII. ON PRESENTATIONS OF THE PELVIC EXTREMITY OF THE FCET17S. As the length of the gravid uterus, at full term, does not exceed twelve inches, and as a well grown foetus is nineteen or twenty inches in length, it is evident, as I have already said, that it must, while in utero, be folded up in a very compact form, and that it will be an oval body, one of the extremities of which ought to be directed to- wards the orifice of the womb, and the other to the fundus. The most natural position of the foetus is certainly that in which the head points downwards ; so that the vertex, or some other part of the head, may, in labor, advance first. But it happens that about one in every forty-five or fifty cases presents the other extreme of the ovoid to the os uteri ; and, in doing so, it is a matter of mere chance whether the breech, or the knees, or the feet, prove to be the presenting part. In strictness, the breech ought to descend first in these labors, but if the feet happen to be near when the membranes give way, they are quite likely to fall into the opening, and pass, soon afterwards, out at the vulva ; so that, supposing the breech presentation to be, after those of the vertex, the most natural, we may properly include, in the account of the presentations of the pelvic extremity, those of the knees and feet, and regard them as mere accidents of the pelvic presenta- tions, and all to be included under the head of natural labors. Agreeably to the doctrine expressed in a former page of this work — a doctrine that announces two essential presentations of the foetus, one a cephalic, and the other a pelvic presentation — each of them is liable to the accidents appurtenant to their form, firmness, &c. It is not an easy matter to determine why the breech presentation occurs about once in forty-five or fifty labors, and it is far less easy to say what is the reason that certain women are prone to this sort of labor to such a degree as to bring all their children so. I knew a woman whose children, three in number, were all born with the breech presentation, and it is by no means very rare to meet with persons PELVIC PRESENTATIONS. 345 who have been similarly situated in more than one of their labors. Dr. Collins, of Dublin, in his Practical Midwifery informs us, that one woman who was delivered at the Dublin Lying-in Hospital had pre- ternatural presentations in every one of her labors, and she had given "birth to nine children. While that gentleman was master of the Dublin Hospital, sixteen thousand four hundred and fourteen women were delivered, of whom three hundred and sixty-nine had presenta- tions of the breech, feet or knees ; making rather more than one such labor in every forty-five cases. Out of 54,723 labors stated by Baer, Bland, Merriman, Boivin, Lachapelle and Nagele, there were 1694 cases of breeeh, feet or knee presentations, which gives us one pelvic presentation in thirty-two and one-fifth cases nearly. It is commonly assumed that about one in forty-eight, or more generally two in 100 cases will prove to be pelvic presentations. Causes of Pelvic Presentations. — The causes which produce these presentations must be purely accidental. The natural present- ation is that of the head, which is turned towards the os uteri from the earliest period of pregnancy. The attachment of the navel string is nearer to the pelvis than to the head of the child, the head there- fore hangs downwards; but when the cord, by the growth of the ovum, has become of a very considerable length, the child ceases to be dependent from it, for the cord is not unfrequently from twenty to thirty inches long. It seems very probable that while the fcetus is yet small, it may change its position in the uterus; but if it happen to turn as late as the fifth month, it will be apt to retain the attitude it may then acquire till the end of the pregnancy, as its length does not admit of its changing again very readily after that period. It is not to be doubted, however, that the attitude may be reversed, by certain extraordinary or violent movements of the mother, at a later period, so that the head, which was originally at the os uteri, may be brought to the fundus, and vice versa. Some persons will not agree with me in regarding the pelvic as a natural labor, but, notwithstanding that the breech presentation is met with only once in forty-five or fifty labors, I am not inclined to regard it as a preternatural case, for I cannot discover any reasons for classifying it with that sort of births, in the mere fact that the head does not present. The breech composes one end of the foetal ovoid; and a breech labor requires, for its complete success, no greater dila- tation than that demanded for the passage of the head : it may be effected without any aid, and is, perhaps, not really fraught with 346 PELVIC PRESENTATIONS. greater danger for the mother than the other, the common vertex pre- sentation. It is, however, far more dangerous for the child than the vertex case; and as the object of parturition is the safe birth of the infant, it might be absolutely proper to include, in the class of pre- ternatural labors, all those in which the child is exposed to unusual hazard. Still, many breech presentations terminate favorably with great celerity and without any artificial aid, whence I look upon them as not really preternatural. In former times these presentations of the pelvic extremity of the foetus were regarded as much more serious events than they are at the present day. That sprightly and most delightful old book — the first Midwifery book ever printed in England — I mean the Byrth of Man- kind, by Thomas Rainald, Lond., 1565, ab Fol. liiii., has the fol- lowing : " Agayne, when it proceedeth not in due tyme, or after due fashion, as when it commeth forth with both feete, or both knees together, or els with one foote onlye, or with both feete downwards, and both handes upwardes, other els (the whiche is most perillous) sidelong, arselong, or backlong, other els (having two at a byrth) both proceade w r ith theyr feete fyrst, or one with his feete, and the other with his head, by those and dyvers other wayes the woman systayneth great dolour, payne and anguishe." Thomas Rainald would be very much surprised and comforted could he see what facilities modern science has provided for the obvi- ation of all these terrible occasions. The danger to the child, here, depends on its liability to asphyxia, from several causes: first, the compression of the cord, which is pressed betwixt the child and the parts from which it is escaping; second, the detachment of the placenta before the head is born, by which the uterine life of the child is destroyed before its birth ; thirdly, the compression of the placenta itself betwixt the uterine parietes and the head of the infant ; or fourthly, the constriction of the placental superficies of the womb during the time that the child's head, still remaining in the vagina and lingering there, ceases to distend the uterus, which closely contracts on the after-birth, and even if still retaining its connection with it, yet suspends all the utero-placental operations on which the foetus depends for existence, antecedently to the establishment of respiration. The last named cause is, I presume, the one chiefly to be feared ; and I have long deemed the pressure upon the umbilical cord, in breech cases, a matter of small moment as to the child's security, in PELVIC PRESENTATIONS. 347 comparison with the asphyxiating influence of the compression, de- tachment, or constriction of the placenta by the reduction of the su- perficial contents of the placental seat. It is probable that that seat, which is eight inches in diameter before the commencement of the labor, is diminished to a diameter of four or even perhaps three inches by the time the head is driven out of the womb. Under such a re- duction no valid placento-uterine inter-communion can be supposed possible. The breech may descend into the excavation, and it may even pass through the vulva, without the least danger of compressing the cord; but when the body of the child has sunk so low as to bring its navel down into the bony pelvis, there is danger that the arteries of the cord may be completely obstructed for a period long enough to give the child a fatal asphyxia. Such an event is far more likely to occur where the feet present than where the breech advances; because, in the latter case, the thighs, and generally the legs, are extended along the front of the body in such a manner as to protect the cord from pressure, its vessels being fully guarded by its position betwixt the thighs, during all the time the body is- escaping, thus enabling the infant better to bear the temporary pressure on the cord for the short time it is compressed only by the head, while that part stops in the excavation: longer pressure by the head would easily extinguish the remains of a life that was already about to expire from preceding obstruction of the circulation. In general, the danger for the child is not great until the head has sunk down into the excavation, because it commonly does not take a great deal of time for the whole of the body to pass through the canal of the pelvis; but the head, being subject to arrest while in the passage, may then fatally compress the cord betwixt itself and the bony sides of the pelvis. We know that the prolapsion of the cord in an ordinary labor, is very apt to occasion the death of the foetus ; and it is therefore easy to perceive that such compression of the cord, between the foetal head and the pelvis, is the real cause of the loss of the infant. From this we might naturally suppose, that the children that are lost in breech and footling cases are lost from the same cause, to w T it, a compression of the cord. But I believe, upon evidence, that the placenta is often detached as soon as the head or breech leaves the uterine cavity; and if so, then the child is rather lost from the suspension of the placento- fcetal circulation by the aforementioned detachment, than from the compression of the cord only. 348 PELVIC PRESENTATIONS. Fatalities in Breech Cases. — I think it probable that more than one child in every five that presents by the breech, or feet, or knees, perishes in the birth. In large lying-in hospitals, perhaps, the pro- portion of fatal cases is rather less unfavorable, in consequence of the prompt attention always paid in such establishments to the parturient female, and to the greater skill and dexterity acquired by abundant opportunities of practice. Of Dr. Collins's cases, 369 in number, of breech, feet, and knee presentations, 234 were born alive, and 135 were born dead- — some of which were putrid, premature, &c. In Dr. Cazeaux's Traite Theorique et Pratique de VArt des Ac- couchemens, a work published in Paris in 1840, and which is said to enjoy the very highest favor in France, there are the following re- marks upon the subject of the danger to the foetus in pelvic presenta- tions. I translate it as containing a late novelty upon the sub- ject. " Delivery by the pelvic extremity is very dangerous for the child. The statistical results furnished by Madame Lachapelle prove that out of eight hundred and four presentations of the pelvic ex- tremity of the foetus, one hundred and two children were born feeble, and one hundred and fifteen were born dead. The proportion of dead children to the whole number is one-seventh; whereas, in 20,698 vertex positions there were only 668 dead born: which is one in thirty, or about one-thirtieth. As to the prognostics of the several sorts of pelvic presentations, it has been remarked, that when the breech comes down first, the number of dead born is about one to eight and a half, which is an eighth and a sixteenth. In footling cases, one out of six and a half die, a sixth and more ; and lastly, for the knee cases, one out of four and a half." M. Cazeaux goes on to say, that the above is not a fair representa- tion of the dangers to the child, in these cases; for these results do not exclude those cases of dead born that are not properly assignable to the pelvic presentations as causes of the death ; the statements ought to exclude putrid foetuses and deformed children ; and he states, as the opinion of M. P. Dubois, that, " setting aside all the cases in which the children appear to have been lost from causes not connected with the presentation, M. P. Dubois has arrived at this result, that in labors with footling presentations, there dies one child out of eleven, whilst in presentations of the head there dies one out of every fifty. It is plain that the difference is frightful." Cazeaux, p. 359. Diagnosis. — It is a question whether the nature of the presenta- tion can be discovered by reference only to the movements of the PELVIC PRESENTATIONS. 349 foetus in the latter stages of gestation. Some persons have foretold that the child was improperly placed, judging it so to be by feeling a greater degree of motion in the pelvic region, than in the upper part of the uterus. It seems not difficult to believe that if the mo- tions of the child should be chiefly felt towards the cervix uteri, they ought to be accounted for by referring them to the presence of the feet in that quarter. However, I feel assured that those patients whom I have attended, and whose labors were accompanied with this pre- sentation, were in general utterly unsuspicious of it in pregnancy; and are, commonly, ignorant of it until the child is born. It is not rare, indeed, for women to fear that the child is to be born double, as it is called, when the vertex really does present ; and some patients are quite convinced the child is wrongly placed, until labor comes on to prove their fears ill founded. There may be some certainty, per- haps, of a diagnosis derived from the stethoscope applied to different parts of the uterine region; for, if the child's head be directed towards the fundus uteri, there will be, in consequence, a pulsation of its heart at a higher level than if the head occupy its more natural position — probably near the navel ; but there will always remain some liability to wrong impressions, if they be derived from auscultation alone. The surest way is that of the Touch, which is scarcely to be confided in except at the commencement of labor, or at a period when the pre- sentation can be touched with the tip of the finger. When the breech can be reached per vaginam, it ought to be recog- nized by its mass filling up the pelvis ; by its softness, and its fleshy feel, so different from that of the foetal head ; by the tubera ischii ; by the point of the coccyx, the anus, and the organs of generation, male or female ; by the spines of the sacrum, and by the sulcus found be- tween the nates and the thighs, which tend upward from the presenting part — I may add, also, by the meconium, which is often discharged at a pretty early stage of labor, and comes away with the waters on the hand of the accoucheur : but let not the young accoucheur be deceived by this symptom, since it is possible for portions of the meco- nium to come away even in the best vertex position. It is also to be observed, that the form of the bag of waters is commonly not so much like a segment of a sphere in the presentations of other parts than the head. In breech presentations, it is more like an intestine in shape, sometimes descending to the very orifice of the vagina, and yet not very considerably dilating that passage. Notwithstanding we ought to be able clearly to distinguish betwixt the breech and the head presentations by the first touch, it is, I think, 350 PELVIC PRESENTATIONS. not very uncommon for us to make a great mistake, if I may judge from the instances of mistakes that have come under my knowledge ; but I am sure that such errors are the results of mere carelessness, and they could therefore always be avoided. Let it not be here un- derstood that when the true nature of the presentation is known, it ought to be communicated to the patient ; on the contrary, it should be carefully concealed from her, as not calculated to promote her easy deliverance, since she attaches to the circumstance the idea of greater suffering or danger, which, by depressing the powers of her mind, would be very apt to affect, in an injurious manner, the pains or the voluntary efforts that she ought to have in their greatest vigor. "While the nature of the case, then, is carefully concealed from the patient, it should be formally announced to her husband, or to some respon- sible person, and all the hazards of such a situation for the infant should be explained, in order that if any untoward event should cause the infant to be still-born, no unjust imputations might lie against the candor, the skill, or dexterity of the accoucheur. Not to Bring Down the Feet. — When the breech is found to be the presenting part, it is very natural to suppose that, could the feet be brought down, they would give us the command of the child, so that we could very greatly assist in its delivery ; and this is quite true: nevertheless, it is bad practice to bring the feet into the vagina, except for some very well understood and sufficient cause. When the child descends double, as it is called, the parts yield very slowly for its advance, and this tediousness is a necessary consequence of its bulk, and the yielding nature of its structure : unlike the head, which is hard and firm, this part, when urged downwards by the pains, gives way before them, and is compressed so much that each pain is half lost before the part becomes firm or condensed enough to make it act as a dilater. This slowness is greatly to be deprecated ; and all proper means to obviate it may be safely resorted to, such as a venesection, or the administration of a clyster or a dose of castor oil, &c. ; yet this very slowness, and the great size of the breech, serve as means for the child's security at the last moments of labor. By their means the os uteri, vagina and vulva are so completely opened, and so entirely deprived of the power of resisting, that, when the head comes to take the place of the body in the excavation, a very little force of the woman's straining serves to extricate the head, or at least the complete dilatation enables the accoucheur to employ his hand or his forceps to extract the head in time to save the child PELVIC PRESENTATIONS. 351 from an asphyxia, which is almost sure to affect children that are not born very soon after the escape of the shoulders, during the time the head is in the vagina ; and the placenta would be so completely squeezed by, or even separated from, the womb, that the utero-pla- cental functions must cease to be performed. The impatience, which can scarcely be avoided by persons wit- nessing the throes of the mother or the struggles of the child, also exposes us to the danger of doing it a great harm by pulling strongly by the breech, shoulders, &c, in order to get both mother and infant the more speedily released; but if any one will take the time to reflect that the spinal marrow may be greatly injured by a violent extension of the neck, it will be evident to him that no very great amount of extracting force ought to be applied. It is best, therefore, as a gene- ral rule, to permit the breech to descend, and not in any manner to interfere with the feet until they are spontaneously born. Any ex- tracting force has an invariable tendency to slip the arms upwards, so as greatly to embarrass the last and most important act of the breech labor. When the child is wholly expelled by the uterine con- traction, it is pushed out of the womb in consequence of the approach of the fundus to the cervix of that organ. In that natural process, if the arms happen to be resting on the sides or abdomen of the child, they ought to descend pari passu with the parts on which they rest ; but if the child be pulled out, then, as the fundus uteri does not press with a proper power upon the head, the arms will naturally slip up over or along-side of its head, where they sometimes are so firmly fixed as to make it a very difficult matter to bring them down. Hence the soundest discretion teaches us to let the womb push forth the breech as we let it push forth the head, without laying hold of it to drag it downwards as soon as the least purchase can be had on the presenting part. The legs, in a breech presentation, may be turned upwards on the child's belly, or they may be flexed on the thighs, so as to bring the feet very near the nates. If the breech engages in the pelvis, or be- gins to pass the circle of the os uteri, the feet disappear, rising as the nates descend. There is no danger of injury to the hip or knee- joint, if the child be trusted to the natural powers employed for its birth or expulsion ; but whenever much force is employed by putting the fingers in the groin, we do incur the hazard of breaking or dislo- cating the thighs. The breech may have one of four positions : 1st. The child's back to the left acetabulum of the mother ; 2d. To the right acetabulum ; 352 PELVIC PRESENTATIONS. 3d. To the pubis : 4th. To the promontory. These several positions are easilv discriminated in practice by the Touch, which ought not to mislead any attentive or considerate practitioner, since by the Touch it is easy to learn where are the coccyx, the tubera ischii, the genitals, the sulcus betwixt the thighs, the sacrum, &c. &e. As the escape of the breech occasions a great distension, the peri- neum requires very steady support by pressing a sort napkin against it, for the purpose, first, of resisting the too rapid advance of the breech, and second, in order to give to its movement that curvilinear direction which ushers it into the world in a course coinciding with the line of Carus' curve. The Fig. (79) exhibits to the Student the appearance of bending which is acquired by the pelvic extremity of the trunk while passing outwards in a breech labor. It is manifest that the perineum may be here sub- jected to a great degree of distension. As soon as the body is so far born as to permit the navel string to be' reached, it is to be drawn downwards a little, so as to free it from the danger of being broken off, or the greater danger of a too early detachment of the placenta. It is easy to draw a considerable loop of it downwards by pulling at the yielding por- tion, as in Fig. SO. As soon as the feet are delivered and extended, they, as well as the body, should be wrap- ped in a napkin, in order that the skin may not suffer any injury, and also for the purpose of enabling the ac- coucheur to hold it more firmly, which he could not otherwise do on account of the viscous nature of the sub- stances that adhere to it soon after it First Position. — In the first posi- tion of the breech, the child's left hip should rotate to the left towards the pubis, so as to allow the sacrum to glide down along the left ischium, Fig. so. PELVIC PRESENTATIONS. 353 Fig. 81. and the right hip to fall into the hollow of the sacrum. Fig 81 shows the pelvic presentation in situ before rotation, while Fig. 79, above, exhibits the appearance after rota- tion has taken place. But after the hips are fully delivered, they re- cover the obliquity of their former situation, and the body continues to descend so, until the shoulders, en- tering into the pelvis in an oblique direction, come to rotate as did the hips, the left shoulder advancing to the pubis and the right one fall- ing back into the hollow of the sacrum. In Fig. 80 may be seen where the right shoulder has come to the pubis and the left to the sa- crum. When the shoulders do not come down well, a ringer should be passed up so far as to reach above the one that is nearest at hand, to depress it by drawing it along with the finger, which commonly suffices to cause the arm to escape. But if the arm does not descend readily, let the finger be slid along its upper surface to a spot as near as may be to the bend of the elbow, and then the elbow may be drawn downwards with considerable force, and without any danger of fracturing the os humerus. One arm having escaped, there will be little difficulty or delay in getting the other down, especially if care be taken to move the body in a line of direction opposite to that part where the arm is detained. As soon as the arms are delivered, an examination should be made in order to learn how the head is situated. If the face is found in the hollow of the sacrum, and the chin well down towards the fourchette, it is well. The child's body ought now to be raised upwards on the practitioner's arm, to a height sufficient to enable the longest axis of the head to become parallel with the axis of the vagina, and the patient pressingly exhorted to bear down and force the child out of the passage ; for at this time the head is not in the womb, but in the vagina, and for its expulsion there is required rather the effort of the abdominal muscles than that of the uterus, which doubtless does, in many instances, partially close its orifice above the vertex, in this stage of a footling or breech case. If the patient therefore does not make a very great effort of bearing down, or expulsion, the head 23 354 PELVIC PRESENTATIONS. must remain in the passage, during all which time the child is ex- posed to the risk of perishing by asphyxia. It is true that the pres- sure of the head upon the parts tends to produce a violent tenesmus, which compels the woman to strain very much; but it is also true that in some instances she will not make the smallest effort, unless urged or commanded in the most earnest manner by the physician. Some aid may be given at this critical moment by drawing the child downwards; but the attendant should always carefully reflect, while employing any extractive force, that the child's neck will not bear a great deal of pulling, without the most destructive effects on the spinal marrow. Certain it is that the infant in the birth will not safely bear more force applied to its neck than one after the birth, a reflection that ought to regulate the physician always. The infant will not safely bear a more violent pull by the neck in this situation, than it would if dressed and lying in its mother's arms. Such a reflection would be a very safe one for the occasion. If all his exhortations fail of causing the woman to assist him by bearing down, let him endeavor to preserve the child from suffocation by passing two of his fingers upwards until they reach the two max- illary bones, and cover the nose ; by doing this the backs of the fingers, pressing the perineum backwards, serve to keep an open com- munication with the air, and the child can breathe very well until the tenesmus comes on. I have kept a child alive in this way, breathing and sometimes crying, for twenty or twenty-five minutes before the birth of the head, and thereby saved a life that must have been lost but for this care. At last the head descends and escapes from the vulva very suddenly, after which, the placenta having been duly attended to, the delivery is complete; whereupon the patient may be put to bed. Second Position. — The rule for managing this case is the same as that for the first position. Here the sacrum of the child is to the right acetabulum of the mother. The right hip to her left acetabulum and the left one to her right sacro-iliac symphysis. As the presenting part descends the right hip comes to the pubis and the left falls into the curve of the sacrum. Third Position. — Here the sacrum of the child lies behind the pubal symphysis — its right trochanter to her left ischium, and its left trochanter to the right ischial plane. In any such case there will be rotation converting the case into one of the first or the second PELVIC PRESENTATIONS. 355 position, as accident may determine. It requires no further observa- tion in this place. A few years ago I was engaged to attend a young woman in her first child-birth. When she fell in labor, I discovered that the breech presented. Her residence was about three-fourths of a mile from my house. I was very much inclined to send for my forceps, for fear that when the head should come at last to occupy the vagina, I might be unable speedily to deliver it. But as she was exceedingly delicate and timid, and her friends anxious, I deferred sending for them lest needless alarm should be the consequence of bringing them to the house. The labor proceeded very favorably until the shoulders were free, and then, notwithstanding the head took the most favorable position, I found that no exhortations or entreaties could suffice to make the woman bear down, and the child soon became threatened with asphyxia, which I obviated by admitting the air freely to its mouth and nostrils, by pressing off the perineum. The child cried, and 1 felt a hope that the forceps, which I now sent for, would arrive in time for its succor. The instruments were placed in my hands in the shortest time possible. In two minutes after I received them they were applied, and the head withdrawn, but it was too late to re- suscitate the child. I have never since failed to order my forceps to be placed within my reach in any case of footling or breech labor, and I feel well assured that the consequence of this care has been the saving of several lives that must have been lost but for this precau- tion. I have lost but one child in pelvic presentation in the last three years, and that was one which was a vertex case, but which I brought footling in consequence of hemorrhage from placenta prsevia, and in which I was obliged to deliver the head with the forceps, as the woman was so exhausted by loss of blood that she could not bear down. It is my unfailing custom to order a forceps to be got in readiness as soon as I ascertain that the presentation is not one of the head ; and I feel well assured that such a precaution, if generally observed, would preserve many a life that is now lost, either by delay in the delivery of the head, or by pernicious attempts to extract by pulling at the neck, to which the temptation is so strong in moments of great anxiety for both parent and offspring. It is so unpleasant an event in the practice of midwifery to lose a child in the operation, that the accoucheur ought to take all the precautions possible to free himself from reproach, which he shall scarcely escape, in consequence of the utter ignorance of the nature 356 PELVIC PRESENTATIONS. of parturition even in what is called educated or good society. On the 11th September, 1848, I visited a primipara lady in labor, at 7 A. Iff. She had been in sharp pain from 10 P. Iff., nine hours. The os uteri was not so large as the end of a finger. Upon ausculting and examining by palpation the uterus I determined a pelvic present- ation at 12 Iff. : I thought the labor would continue until morning, so slow was the dilatation, but at 5 the membranes gave way and all the liquor amnii came off, the os uteri being still rigid and irri- table. The bands of the upper os uteri were more tense and unyield- ing than those of the os tincae proper. The child was still in health, as ascertained by the regular action of the heart. I had announced all the hazard for the child early in the day. My forceps was :.: hand; at 8 P. M. the head was thrust into the vagina, and, as I failed to deliver it with my hands, I applied the forceps and speedily drew out the head. The child was quite dead. There was no motion of the heart. When I drew down the feet I found there no vital tension in the limbs. Now I feel sure that this child perished by asphyxia from the unmitigated pressure of its placenta against the head consequent to the discharge of the waters. It perished of course before the operation. Now, could I by any careful obstetrical measure have saved it ? I regretted, upon finding it dead, that I had not repeated my auscultations, after the crevasse of the ovum. Had I done so, I should have been able to announce the less of the child long before the midwifery operation be- came possible. I do not suppose that I am blamed by its friends, : it a young accoucheur would feel less uncomfortable in such a case for having announced his prognosis. Hence let the Student remember to auscult often towards ::.- :sr of pelvic labors. Fourth Position. — In those cases in which the sacrum of the child is t ed towards the mother's back, it is highly desirable so to con- duct the labor as to effect a complete rotation of the child by the time the head begins to get pretty low in the excavation. If this change does not take place spontaneously, or by the skillful interference of the accoucheur, it must happen, at the last and important stage, that the face will be to the pubis, and then there will be some difficulty in obtaining the requisite dip of the head or its due flexion. I: is exceedingly dangerous for the child to be so situated, but happily there is a method by which it may be hopefully assisted. As soon as the shoulders are fairly freed from the vulva, the edge of the perineum tends to compress the neck :: the child, and force it PELVIC PRESENTATIONS. 357 upwards against the arch of the pubis. In some cases the perineum is so strong or elastic as to exert a considerable power in this way ; and it is clear that if it be not counteracted, the chin may be lodged upon the top of the symphysis of the pubis, and wholly prevent the flexion of the head from taking place. Under such circumstances the child will speedily perish. The indication is then to push the perineum back again, or carry the child far back towards the coccyx, and afford space enough to let the chin descend, either spontaneously or by pulling it down by introducing the fore and middle fingers of the right hand into the mouth. As soon as the chin is well brought down, the woman should use all her power to assist in the expulsion of the head. I have found that the best attitude for the mother, in this kind of delivery, is that which is advised for forceps operations, to w r it, that in which she is placed on her back, with the hips brought quite over the edge of the bed, the feet being supported by two as- sistants ; so that, when the shoulders are delivered, the child may be supported almost in a vertical posture by the left hand of the accoucheur, while his right hand aids in the delivery of the head. I am sure that much greater command of the labor may be had in this position of the patient than in any other that can be devised. But, as I have already observed, we should endeavor to manage the case so as to get the face into the hollow of the sacrum, instead of letting the chin come to the pubis. If, therefore, the breech sink into the excavation in this unfavorable manner, we should, by pres- sure with two or three fingers, endeavor to force that hip which is nearest the front towards the symphysis, and if w T e succeed in effect- ing its delivery in that position, we should, with a proper degree of force, continue to turn the forward hip more and more round, so as to bring the child's spine at least as far in front as the ramus of the ischium or pubis ; so that when the shoulders begin to enter, they may enter obliquely, and after they have passed down, the head may also enter obliquely, or at least transversely. For example, let the sacrum be towards the mother's back, the child's right hip will be on the right ischium of the mother. We might try to get the right hip towards the ramus of the ischium, then towards the ramus of the pubis, and, as it advances, cause it to emerge just under the arch. When fully emerged, the hip should be turned more and more to the left of the mother, so as to let the right shoulder enter the brim at the left acetabulum and escape under the arch, in doing which the child's face will enter near the left sacro-iliac symphysis, and at last slide into the hollow of the sacrum, as in a second position of the breech. 358 PELVIC PRESENTATIONS. Where this desirable rotation cannot be gently effected in conse- quence of the grasping force of the womb holding the child's body tight during a pain, we ought to watch for an opportunity during the absence of a pain, to push the child's body upwards again as far as we conveniently can, and then draw it downwards, endeavoring, while pulling it downwards, to twist or rotate it in the manner that is required. If, on the other hand, we endeavor to bring the left hip to the pubis, we shall also get the left shoulder there; at last, compelling the face to enter at the right sacro-iliac symphysis, we shall terminate the labor in the first position of the breech. I shall here relate a case taken from my record book, which may serve to show the Student what a great rotation may be effected by the hand of the practitioner, in cases of the fourth position. Tuesday, October 5th, 1830. Mrs. J., a young woman in her first pregnancy, sent for me at eight o'clock P.M. The waters came off at five o'clock P. M. The os uteri, at my arrival, was almost com- pletely opened. I touched the breech and feet ; the toes were towards the left acetabulum. At a quarter before nine o'clock I disengaged the right foot, and then the left one. At nine the arms were both delivered, the left one escaping first along the perineum and the right one under the pubis. I could not effect any further rotation, and was sorry to find the chin immediately behind the symphysis pubis. I then turned the child's body, and pulling the chin well downwards, I pressed the face with two fingers, on its right side, and with great ease turned it into the hollow of the sacrum. I next made a channel by passing up two fingers to the superior maxilla so as to admit air freely to the nose, and the infant breathed ; there was a total cessa- tion of pulsation in the cord. The child breathed and cried at least for twenty minutes before the head was extracted, which I could not effect until I carried its body upwards towards the mother's abdomen, and rolled her over on her right side, which gave me far better power to aid her with my right hand. The infant was born living, and did well. I shall cite another instance which occurred very recently. On Thursday, July 14th, 1836, Mrs. was seized with labor pains, which came on with the rupture of the membranes. At six o'clock, I made an examination, and found the left foot in the vagina, accompanied by the umbilical cord, which pulsated. The toes were directed to the pubis. I could reach the breech of the child, but the right foot was so high up that I could not touch it. In a short time the left foot came quite down ; and in order to rotate the body I drew PELVIC PRESENTATIONS. 359 moderately upon the foot, which caused the left hip rapidly to approach the pubis. I could not even yet get at the right foot, wherefore I per- mitted the child to descend with that limb pressed upwards against the belly ; the left hip came under the centre of the arch, and, as soon as I could command it, I turned it more and more round, so that when the arms w T ere delivered I found the face in the sacrum, soon after which the head was expelled. I immediately ascertained, that there was a second child ; pains came on, and in fifteen minutes after the first one was born, I broke the membranes of the second, which presented the nates and the right foot. The foot prolapsed, but the other limb was pressed against the child's belly, so that I could not get it ; the sacrum was to the right acetabulum. When the shoulders were delivered I found the child's face rather transversely directed towards the left ischium. I brought it into the hollow of the sacrum, soon after which it was also expelled. Both children are well. It is so easy a matter, in general, to cause the body to rotate during its transit through the pelvis, that it very rarely happens, if the phy- sician is called early, that the face at last is found towards the pubis. With regard to the presentations of the feet and knees, I do not feel that it is necessary for me to enlarge upon them, before I close this chapter, inasmuch as the footling case is a mere accident happening in a pelvic presentation, and which, moreover, can never prevent it from being at last a pelvic presentation — for all footling and knee cases are certainly breech presentations. I may remark, however, that the knee presentation is found to be embarrassing from the tend- ency there is to a sort of arrest, in consequence of the knees abut- ting against the sides or parietes of the pelvis, which is sufficient to prevent the descent of the child's nates, so that they, being thereby thrust over to the opposite side, cannot enter the excavation. Hence, where the knees present, it is advisable to convert it into a footling case, which can be done by pushing the whole presentation upwards, during the absence of pain, in order to gain space enough to bring down the feet. The Student will perceive, if he refers to the axis of the womb and that of the vagina, that in a knee case, in which the child's back is towards the left front of the mother, the thighs would be very greatly extended, or bent backwards, before they could emerge from the ex- ternal organs ; an extension that must be very difficult to effect where the legs are bent up on the back of the thighs — for in such circum- stances the rectus femoris, and indeed the whole quadriceps muscle must be put excessively on the stretch. It is a good rule, therefore, 360 PELVIC PRESENTATIONS. in knee presentations, to get the feet down as soon as it can be pru- dently done; whereas in the well defined breech cases, the feet ought not to be brought down, except for some valid and well understood cause. In order to distinguish the feet from the hands, for which they are sometimes mistaken, it is only necessary to give attention to the sen- sations imparted by the operation of Touching. The even range of the ends of the toes, and their shortness, compared with the length of the fingers ; the closeness of the great toe to the one next to it, in contrast with the wide separation of the thumb from the fore finger; the ankle, and the heel, are marks that might be supposed sufficiently prominent to guard us against even the danger of mistake ; yet, very great atten- tion is in some instances required, to enable us to aver positively that the presenting part is, or is not the foot. As the footling is but a deviation from the breech presentation, its positions are like its original form ; namely, the heels to the left ace- tabulum ; the heels to the right acetabulum; the heels to the pubis ; and lastly the heels to the sacrum. As the treatment is precisely the same as in presentations of the nates, I shall not detain the reader by any further remarks upon the management of them. PRETERNATURAL LABOR. 361 CHAPTER XIII OF PRETERNATURAL LABOR. Any labor that cannot be brought to a safe conclusion by the natural powers of the system might properly be denominated a pre- ternatural labor; and as the causes that might prevent the accom- plishment of the parturition save by the intervention of our art, are very numerous, it follows that there are a great many kinds of pre- ternatural labor. Causes. — A labor may be accidentally changed from a natural to a preternatural one; or it may possess a preternatural character from the very beginning, and be unavoidably so. Thus, a woman may have brought her child almost into the world without any appearance of disorder or danger or uncommon distress, and be then suddenly attacked with convulsions, apoplexy, hemorrhage or laceration of the womb, &c. &c, either of which occurrences completely changes the character of the labor. Or, she may, in consequence of disease or accident, be found incapable of bringing her child into the light without surgical aid; as, where the passages are closed by stric- ture, or by some fibrous tumor, or by a deformity of the bones of the pelvis. Lastly, the labor may be preternatural because there pre- sents at the strait some portion of the child which cannot pass through it, but must be put aside in order to let some other part advance, before the labor can be brought to a close. For example, if the arm or shoulder should present, it is necessary to put them out of the way and bring the head back to the opening, or else the feet must be brought there, the child being for that purpose turned quite over; for have we not learned that one or the other of the extremities of the fcetal ovoid must advance, in order to admit of the escape of the child? It appears from the above that the causes which constitute preter- natural labor are very various; and it is reasonable to infer that the medical and obstetric treatment of the several cases will be founded 362 PRETERNATURAL LABOR. upon the peculiar and distinguishing character of each individual example of the labors. The subject, therefore, embraces so wide a field of discussion and detail, that it will be requisite to treat it according to the nature of the several causes that happen to interfere with the usual process of child-birth, and I shall endeavor to describe the different sorts of preternatural labor according to the circumstances which make them what they are, and point out the modes of treatment most suitable to their several natures. Before entering fully upon the subject I think it advisable to lay before the Student a tabular view of a great number of labors that were observed and recorded under the direction of the late Madame Lachapelle of the Maternite Hospital at Paris. I wish the Student to look over this table in order to see what was the frequency of different sorts of labors in that series which is here tabulated by that distinguished person in her work. — There were observed 22,243 labors, of which 15,809 were first positions of the vertex, &c. &c. Comparative Statemen t of the Different Positions observed from Jan. 1, IS 12, to Dec. 31, 1820 (Nine Years'), by Madame Lachapelle. Positions. o to lb ■ - b a5 "3 J5 <2 o H S3 ""^ 2 > HJ TD — -a T2 o~£ o S, '5 o c^ JS o ^3 ci ~ m < Q o u O 2T^8 4 3d. Feet 4th. Feet 4 4 4 1st. Knees 6 6 4 1 1 2d. Knees 3 3 1 1 1 3d. Knees 4th. Knees 3d. Right shoulder 41 8 33 20 5 6 10< 7 4th. Right shoulder 24 3 21 11 3 3 >Th+T 5 A 3d. Left shoulder 19 1 18 9 2 1 4th. Left shoulder 34 34 23 7 4 Unascertained 520 517 3 39S 11 80 31 Total 22,243 21,975 268 3 20.64 633 130 837 PRETERNATURAL LABOR. 363 Perhaps it matters not which kind of preternatural labor is here first treated of, for there is no natural order or method of their oc- currence; each one might be the subject of a separate monograph. Yet I have chosen to commence with the account of presentations of the shoulder, in which the operation of Turning is generally consi- dered to be inevitable as a part of the treatment ; and since that ope- ration is not unfrequently resorted to in other specimens of preterna- tural labor, I deem it of some advantage to take an early opportunity of describing it in this connection. I have already said that, in order to constitute a natural labor, one of the extremities of the foetal ovoid ought to present at the opening; and I have treated of the pelvic presentations as being natural ; and I have supposed that the knee and footling cases are but accidents or deviations of the natural pelvic presentation. In presentations of the head there is also, I said, a liability to de- viations, by which the head glances off from the brim of the pelvis, and is either turned upwards into the costa of the ilium, or rises above the top of the pubis. In a case where the direction of the uterus is very oblique, so as to allow the fundus to fall far down into the right flank of the patient, the child, if pressed by the contractions of the fundus, might be pushed towards the left side of the brim of the pelvis in such a manner as to make it doubtful whether the head would enter the strait, or slide upwards on the left side of the womb. For the most part, it fortu- nately happens, even in the very greatest lateral obliquity of the womb, that the head is not deflected, but enters the strait; but in a few examples it is found to rise upwards, instead of engaging. When this takes place, it must almost inevitably happen for the shoulder to fall into the cavity from which the head was turned away, and as the shoulder is a projecting part it is very liable to maintain the position in which it is once ensconced. The shoulder, therefore, when the head glances off, descends or engages in the superior strait, and is pushed downwards by the uterine contractions as far as it can pos- sibly be urged, and then it stops. The strait being jammed full of a mass, composed of the shoulder, arm, neck, throat and part of the thorax of the child; and when no additional portions of the child can be pressed into it, a total arrest of the progress takes place, and the woman, after vain struggles, protracted according to the strength of her constitution, sinks at last, without the possibility of rescue from death except by the skillful aid of the obstetrician. There can scarcely be any need for me to enlarge upon the im- 364 PRETERNATURAL LABOR. practicability of delivery here except by art; for even could the shoulder be pushed down as low as the vulva, it would happen, at last, that the head would be again brought to the strait from which it had been turned off, but it would be accompanied by the child's body, either of which, alone, is sufficient to fill the plane and the excava- tion, so that the two together could by no means pass through. The remedy is either to push the shoulder out of the way and to bring the child's feet down so as to deliver it footling, or to restore the head to its proper place. There is, even where the operation is impracti- cable, an exceptional escape from death under these circumstances by the very rare occurrence of what is called spontaneous evolution of the foetus, to be hereafter described. I ought to remark that while the shoulder presentation is a deviation or accident occurring in an original head presentation, so it may hap- pen that, instead of the shoulder, the hand or elbow may come down, but in fact they are mere circumstances of a shoulder case, and when they are advanced to a certain degree, it is the shoulder, after all, that fills the strait and the excavation, and which constitutes the pre- sentation. The hand and arm are merely prolapsed, ana their pro- lapsion adds nothing to the difficulty of the case ; indeed, their prolap- sion serves as a means of guiding us in our diagnosis, and does not at all oppose the successful treatment of the labor. In the manage- ment of a pelvic presentation I should, in general, prefer that the feet should not prolapse ; in a shoulder presentation it would be rather a favorable circumstance for the arm to prolapse. Case. — Some months since I was in attendance in a labor case, in which, though the os uteri was very much dilated, and completely dilatable and distended with the bag of waters, I could not with the index finger touch the presentation. The patient was very much flexed, which relaxed her abdominal integuments. Upon placing my hand over the right iliacus muscle, I distinctly felt the orbicular mass of the child's head under my palm. Introducing the fingers again, I waited until a pain came on. As soon as the bag of waters became tense from the pain, I pressed, with my left hand, the head out of the right iliac fossa towards the chasm of the superior strait. I then ruptured the ovum, and exhorting the woman to " bear down, bear down," I had the pleasure to find the head driven quite into the excavation, and to find it born after a few minutes. Doubtless I pre- vented the shoulder from coming to the os uteri by pushing the head to it. PRETERNATURAL LABOR. 365 Fig. 82. Two Shoulder Presentations. — Two Positions for each Shoul- der. — As there are two shoulders, a right and a left one, there must be a set of positions for each shoulder; but in determining what is the position of the shoulder, it is also necessary to determine the situ- ation of the child's head. In speaking of natural labor with the vertex in the first position, I endeavored to explain the causes which give a greater number of first positions. The same reasons operate to produce, in shoulder presentations, a greater proportion of instances in which the head is to the left side of the pelvis, than those in which it is to the right side. Now if the right shoulder presents at the strait and the head is to the left, as in Fig. 82, the face of the child, and its toes and feet will look towards the mother's back; but if the same shoulder presents and the head is to the right side of the pelvis, the face and front of the child must look towards the mother's front: so of the left shoulder in the first posi- tion, the face will look in front, and in the second position it will look towards the mo- ther's back. By speaking therefore of the posi- tions of the two shoulders separately, we get a better and less complex idea of this sort of labor than we should have were we to enume- rate a set of positions without such a division. I think that the form of the foetus and the capacity of the womb are such as to make it unnecessary to establish more than two positions for each shoulder: for example, for the right shoulder a first position, or that in which the head is to the left, looking backwards, and a second in which the head is to the right, and looking front ; for the left shoulder a first position, wherein the head is to the left, looking front, and a second in which it is to the right, looking towards the back of the mother. This will, I think, be quite sufficient; and gives us four positions for the shoulders, hand or elbow. It is not to be denied that the head might be in front, looking to the left or looking to the right side of the mother, giving us in the former case a right shoulder, and in the latter a left one, in the strait; but it is needless to enumerate such a position, as the contractions of the womb and abdominal muscles would soon turn it into one of the attitudes I have before pointed out. Diagnosis. — The signs by which a shoulder at the strait may be 366 PRETERNATURAL LABOR. diagnosed, are, 1. The want of the regular form of the bag of waters, which in all preternatural presentations is without that proper convex shape that we notice in favorable instances of natural labor. When the membranes pass down into the vagina shaped almost like an in- testine or of a cylindrical form, there is good reason to think there is something untoward in the posture of the infant. 2. The spinous process of the scapula; the clavicle; the round-shaped shoulder; the axilla; the ribs; the arm, distinguishable by its size from the thigh. Should the attendant retain any doubts, let him never omit to remove those doubts by the introduction of his hand into the vagina, where he will be able freely to examine the nature of the presenting part, and learn its true position.' No person is excusable for mistaking the diagnosis who knows he can command so infallible a method of making a correct one. The diagnosis can always be made in good time, — that is, as soon as the dilatation will admit, and until then nothing can be done. Turning.-— Having ascertained that a shoulder is at the strait, there remains but one determination for the practitioner, and that is to put it away and bring another part of the child to present. This necessity, and the hazard in which, consequently, both the mother and child are involved, should be plainly and seriously laid before those who have the best right to know her case ; namely, her hus- band or parents, or such near relatives or friends as may seem to be, for the time, in loco parentis for her. The necessity for interference ought also to be explained to the sufferer herself, but in the gentlest and most cheering manner possible. If it be within the bounds of possibility to do so in good time, a medical brother ought to be in- vited in order that his counsel may be taken, and particularly that the friends, and the patient also, may have no doubt left in their minds as to the propriety of the operation, nor claim the least right to find fault afterwards with the physician, should any untoward event follow the plan he had recommended. The act of turning to deliver by the feet is fraught with danger, for there is danger* of uterine lace- ration or of fatal contusions of the parts of the mother and of failure to succeed in effecting the version and great danger of destroying the life of the child in the act of turning. In early times, our ancestors who did not understand the mechanism of labor used to wait, after pushing the shoulder back into the body, in hopes the head might descend. For example here is the doctrine of Thomas Rainold, to be found at fol. 65 of his Woman's Booke : " And yf so be that it appears PRETERNATURAL LABOR. 367 and comes forth first the shoulders, as in the XI figure, then muste ye fayre and softlye thruste it backe again by the shoulders till suche tyme as the head comeforwarde." It may be that those old practitioners of the days of Queen Elizabeth, may have sometimes succeeded by pushing up the presenting shoulder in getting the head at last to come to the strait again; but such an event appears to me in any case most improbable. But no operation can be performed while the os uteri is so closed as to refuse admittance to the hand. It cannot, and must not, be forced. The mouth of the womb must be dilated or dilatable before any operation is lawful ; it must be dilated or sufficiently yielding to allow the hand to pass upwards into the uterine cavity ; of this degree of dilatability the obstetrician is the only judge. He must never run the risk of tearing such an important organ, since its laceration by his hand would be much increased by the following birth of the child, and place the woman in danger of sudden death ; or he might con- tuse the parts so much as to establish a very dangerous inflammation of the organ. So important is it to judge aright concerning the time to be chosen for the exploration of the womb, that it is thought to be the most responsible duty of the physician in the whole case. If he proceed too soon, the most lamentable consequences are apt to ensue; and if he defer the procedure too long, the difficulties and dangers are greatly enhanced by the delay, while the patient also suffers use- less and pernicious pain. The bladder and rectum should be evacu- ated before the operation. The position should be carefully ascer- tained ; this can be done by the introduction of the hand, if necessary, into the vagina; and if it be certain that the left shoulder presents with the head on the left side of the womb, then he must make choice of that hand which can most conveniently be employed in the opera- tion. The rule is to use that hand whose palm, when open in the cavity of the w T omb, would look towards the face or breast or belly of the child, which, in this instance, would be the right hand ; for it is clear that if the left hand were used, it would not apply the palm to the front of the infant, whether it were carried up before or behind the child's body. The best position for the patient is that on the back, with the end of the sacrum brought quite over the edge of the bed, the feet and knees being carefully supported by assistants, one holding each limb, which should be properly flexed. The woman ought*to be carefully covered with a sheet or a light blanket, according to the season of the year, and some thick cloths should be placed on the floor, under the 368 PRETERNATURAL LABOR. foot of the bed, to receive any discharges of water or blood that might accompany the operation. Everything being fully prepared, the operator's arm should be bared to the elbow, and well anointed with lard, while a sufficient quantity of the same material should be applied to the external parts. During a pain, two fingers, and then three, of the left hand, should be passed into the vagina, to be followed by the little finger, and afterwards by the thumb, strongly flexed into the palm. The hand having gained possession of the vagina, may then rest until the pain is gone off, after which the presenting part must be pushed upwards and leftwards, the fingers and whole hand, in pronation, following the receding shoulder into the cavity of the womb. The shoulder being moved somewhat to the left as it mounts upwards, when the hand is fairly introduced it ought to be opened and glided along the breast or abdomen towards the feet or knees of the fcetus, which will be looked for on the right and superior portion of the cavity. In searching for the feet, the contrac- tions of the womb are excited, and pains are produced, especially if the waters are much drained off. During these contractions it is ab- solutely necessary to open the hand, lest the uterus, from the violence of its own action, might be torn on the knuckles ; and the hand ought never to move except the organ be in a state of relaxation. At length, after more or less research, one or both feet, or a knee is found, and whether it be one or the other, it should be taken hold of; for it is nearly a matter of indifference whether it be one foot or both, or one knee that is used as the point on which to act in turning the child. Dr. Collins, p. 69, remarks on this point that, "it is quite sufficient to bring down one foot," and I find that Dr. Simpson of Edinburgh is of the same opinion — deeming it far more injurious to make perverse attempts at exploration, than to deliver by one foot only. I say nearly a matter of indifference, because, the object being to turn the child as soon as practicable, with proper caution it may be effected in either of these ways : it is always desirable to get the hand out of the uterus as soon as may be, and it is far better to turn by one foot or by a knee, than to incur the risk of laceration or contusions of the organ, by a tedious search after the other foot, which, if it be not originally near its fellow, is very hard to be found by any search for it. The inexperienced student can have little notion of the extreme difficulty there is to move the hand about while it is compressed betwixt the womb and the Thild ; a short experiment of this difficulty would suffice to convince him of the propriety of the foregoing directions. If he should use the knee as a point of traction, it would be very easy, PRETERNATURAL LABOR. 369 when the version is nearly complete, to draw the foot down. If he use only one foot to turn by, he will have nearly all the proposed advantage of the breech presentation combined with the greater facility enjoyed in manipulating in the footling case — that is to say, he will have the abundant dilatation, and the power of traction by the limb. Having found the foot, if a pain comes on immediately, and be- comes a severe one, the foot should be let go, and caught again after the pain is gone off, according to the discretion of the operator. During all the time he is passing his hand up and exploring for the child, either his own unoccupied hand or that of an assistant should be applied to the abdomen, in order, by pressing the womb down- wards, to keep the os uteri within the strait ; and when he is ready to turn the child, his own hand only should be used by the operator to press on the outside of the abdomen, so as to favor the version by pushing the breech of the child downwards, while he also draw T s it downwards by the feet or knees. If the hand ought not to move during a pain, it w r ould, a fortiori, be the height of rashness to attempt to turn the child with the womb in a state of contraction. The time for turning ought to be chosen as soon as the pain has gone off. Then the womb feels yielding and soft as a wet bladder, and the part held in the hand may be drawn towards the os uteri slowly and gently, but firmly, and, if possible, brought quite into the vagina, or even to the vulva. External pressure with the free hand favors this version very considerably, and ought never to be neglected. It is easy to ascertain if the version be complete by external taxis, and by noticing how far the child is drawn downwards, and judging of its length as compared with the length of the uterus, as well as by noting the effect of the next pain, which propels it if it be turned, but does not move it if it be still transversely fixed in utero. The Student should remember that the child from the extremity of the buttock to the crown of the head is between eleven and twelve inches in length. Hence his hand placed on the abdomen will inform him whether the uterus is of this length or no. If he find the buttock at the os uteri and the uterus not so long as it should be under the circumstances, he will know that the version is not yet completed, and take his measures accordingly. Wherever it is possible to make choice of a foot to pull on, w T e should select that which is nearest the front of the pelvis. In the present case it would be the right foot, because in drawing upon that one, the right hip would come under the pubic arch, and favor very 2i 370 PRETERNATURAL LABOR. decidedly our wish to bring the vertex at last to the pubis, and carry the face to the hollow of the sacrum ; whereas, should we draw down upon the left foot, the child's face would, at last, be very sure to come to the pubis. Under all circumstances the practitioner is only called upon to do that which he can do, and not that which he would but cannot da; therefore when he can only find the most unfavorable foot let him draw by it and meet the consequences. As soon as the turning is complete, the case has become a footling one, and must be treated as if it were originally so ; that is, it should be left to the expulsive powers alone, if they are sufficient, for it is always bad and almost always unnecessary to draw out the body ; it should be expelled by the pains. The arms must receive such assist- ance as they may need ; and the head, being properly situated in the vagina, ought to be expelled by the womb with such aid, from slight tractions, as the obstetrician may adventure with safety to make. In going about to perform this operation, the medical attendant ought to reflect upon all the dangers incident to it, and clearly under- stand, beforehand, that what is most desired in it is, not speed, but safety ; festina lente ought to be the motto. As to the difficulties of it, they are so great, in a womb long drained of its waters and lashed into fury by a long period of unavailing irritation suffered previously to the operation, that nothing but practical experience of them can make them known, unless indeed the fact be understood that it can- not, in some instances, be effected at all, and that we are obliged to extract the child double, after having removed the thoracic viscera, as well as those of the abdomen, by the crotchet and perforator ; upon doing which the foetal remains may be drawn forth. I have, after having had my hand in the womb, found it so com- pletely benumbed by the pressure, as to be unable to feel with it or to close it; in such a case, the other ought to be made use of, however ill adapted either for the exploration or seizing the feet, &c. The child being delivered, the mother must be drawn up into her bed, so as to enable her to stretch out her feet, and as soon as the placenta is taken away, she should be bandaged and put to bed properly. A grain of opium, or a dose of laudanum consisting of twenty or forty drops, is very soothing and calming, after such high excitement and fatigue, and ought not to be withheld from her. A cup of tea or gruel may next be presented to her, and a short sleep, if she can take it, is followed by a comfortable state, for the before exhausted woman. PRETERNATURAL LABOR. 371 There is very little difficulty in this operation, if the waters are not gone off; they should, therefore, be always left whole if possible until the moment for the interference is at hand. Could we, indeed, always have the privilege of rupturing the ovum at the time of carry- ing the hand into the womb, we should avoid much difficulty, and a large moiety of the danger of doing mischief. Unfortunately, how- ever, turning is rarely determined on until the waters are lost, and then the danger is necessarily greater. There are many very ignorant persons, who are generally the more presumptuous the more they lack knowledge, into whose hands women are so unhappy as to fall on the occasion of their child-birth. If, in a shoulder presentation, the hand happens to prolapse, they, finding a very convenient handle, make use of it to pull the child away by; and I have seen a case in which an unfortunate woman had been so treated: the arm was wholly withdrawn, and the acro- mion process of the scapula was actually under the pubic arch ; so violent were the tractions that had been made on the hand and arm. This was done too with a rigid os uteri, which, after yielding a reluc- tant passage for the arm and point of the shoulder, was now grasping the parts above it with a strength like that of a rope, and which after- wards resisted, for a long time, all attempts to pass the hand along betwixt its circle and the child. To one unaccustomed to the incidents of the lying-in chamber, it would be, perhaps, vain to attempt to convey an idea of the resist- ance sometimes met with in the circle of the os uteri. Dr. Collins in speaking of one of his cases in Dublin Hospital says, at p. 67, "The mouth of the womb was absolutely as firm as a piece of thick leather, and embraced the arm of the child as tightly as a ligature could be applied without cutting the part." There cannot happen anything but evil from pulling at the hand and arm. Such force cannot pull the child down, for it is too large to pass doubled. The arm, actually, is not in the way; for the hand of a practitioner and the arm of a foetus at term, can never equal in size a circle sufficiently large for the head to pass through it. The lack of space is not in the faulty construction of the pelvis, but in the rigid constriction of the os uteri and vagina, which, if too rigid to admit the hand, is also too much so to allow the child to escape. That rigidity can be overcome. It cannot be needful to excise the arm, or twist it off at the shoulder joint, a horrid practice, which seems to have received a salutary check from a judicial investigation, that was had a few years since in France : a practitioner there, finding it im- 372 PRETERNATURAL LABOR. possible for him to deliver in an arm presentation, cut it of! at the shoulder joint, and nevertheless the child was born alive. The ob- stetrician was justly prosecuted on a charge for maiming. If the os uteri will not admit the hand of the accoucheur, it is be- cause it is not dilated or dilatable. Let the proper measures, then, for effecting the requisite change in the uterine tension be resorted to. These are bleeding ; the warm bath ; antimonials ; emollient enemata, followed by enemata of laudanum; and patience, though last, not the least of the resources for such an occasion. Women in labor bear venesection remarkably well; and they demand, in some instances, very great abstractions of blood in order to get the full benefit of the relaxing efficacy of that remedy. A patient bled ad deliquium animi will be more capable of undergoing safely the ope- ration of turning, than one left to the unmitigated excitement of use- less labor pains. It will have been seen that in a preceding page I have strongly expressed my dissent as to the anaesthetic practice in midwifery. If there could be a case to render a complete anaesthesia by ether or chloroform a desirable condition for the patient and the practitioner, this is the case par excellence; certainly a complete anaesthesia might have the effect to abolish the voluntary power of the mother, and thus taking away the injurious force of the abdominal muscles and diaphragm, leave her to the sole influences of the uterine powers which are not annulled even by the deepest chloroformal insensibility. Professor Simpson and other distinguished gentlemen warmly advo- cate the induction of anaesthesia in these cases ; let the Student give heed to the opinions of these meritorious men, but let him be the sole judge of his own duty in any and in every case. The warm bath is a safe and easy remedy for the obstinate con- striction of the orifice, as it is for all spasms and other congenerous disorders. Tartar emetic, in doses of the eighth or sixteenth part of a grain, repeated every thirty or forty minutes, conduces very power- fully to the reduction of the spasm or rigidity, and it may be very safely resorted to in the management of our case. Much reliance is also to be placed on the power of the belladonna ointment applied to the cervix uteri, in which it often most speedily induces a complete local anaesthesia. Copious enemata of infusion of flaxseed, with a portion of castor oil to render it somewhat more aperient, should be had recourse to, and they may be followed by anodyne enemata, composed of an ounce of flaxseed tea or starch, with from fifty to eighty or one hundred drops of laudanum. We should also not for- PRETERNATURAL LABOR. 373 get that patience ought to work her perfect work, and no more: the accoucheur must be the sole judge of how far patience ought to go. I should think that there can never be the least use in attempting to return the arm. The arm will be withdrawn by the version of the child. It goes upwards into the womb as the head rises and the breech descends. It would be always prudent to secure it by a noose, for the purpose of preventing its going too high within the cavity, where its presence might cause some embarrassment in the delivery of the head. P. Cosgreave, Esq., in the Lancet of 1828-9, p. 298, informs us, however, that he has never lost a child in an arm presentation. His method is to push up the arm during the absence of the pain, and return it into the womb and hold it there ; after which the spontaneous evolution takes place, and the infant is born by the spontaneous powers of the womb. Mr. C. must certainly be regarded as a very fortunate practitioner, to have met only with cases in which he could restore the arm to the cavity in this way, or in other words turn the child without searching for the feet. I am not aware of the number of his cases. I cannot therefore judge of the comparative success. Some persons have imagined that in the conduct of some of these dreadful cases of shoulder presentations, great facility in delivering the woman is obtained by amputating the arm, or wrenching or twisting it off by sheer brute force. Indeed I am aware of an instance in which the doctor tore off in utero, the arm of a child which was afterwards born alive, with the end of the humerus projecting below the ragged and torn edges of the wound. The arm was hidden, but afterwards discovered. The people interested were made to believe that the lost arm had been destroyed by absorption. Such a course of proceeding is to the last degree unjustifiable. Unjustifiable before the outraged family, and unjustifiable as bringing unmerited discredit upon the whole profession of physic. If in any case it were deemed necessary to remove the prolapsed arm, it ought not to be done without an antecedent announcement of the purpose, and its motives. For my own part, I cannot understand what are the motives should lead an accoucheur to do so barbarous an act. The extirpation cannot be deemed needful to provide space in a pelvis, since the arm of a fcetus can never fill up a pelvis so as to prevent the introduction of the accoucheur's hand for exploration and version. Whenever it is done, it is done with a view to make space in soft parts, but those soft parts will dilate in due time, and under wise treatment. My clear opinion is that the amputation of the arm 374 PRETERNATURAL LABOR. in shoulder presentations is a mala-praxis, and that it ought to be discountenanced and protested against. Spontaneous Evolution of the Fcetus. — It has happened that the operator being unable to turn the child, was compelled to abandon any further and useless attempts to deliver. In such instances, the woman sometimes delivers herself by what is called spontaneous evolution of the fcetus. It is very important for the Student to understand clearly what is meant by spontaneous evolution of the child, and it will not be diffi- cult for him to do so, if he will bear in mind the fact : 1st, that there is a superior strait, and 2d, that the child's head and its body cannot be within the plane of that strait at the same time. Now when the shoulder has presented, and the arm fallen down, has allowed the shoulder to be forced, or drawn quite out underneath the triangular ligament of the pubis, it happens that the side of the child's neck lies against the inner aspect of the symphysis of the pubis. But, if the side of the neck is pressed against the wall of the symphysis, the head of the child will lie upon, and even project over and beyond the horizontal part of the pubal bone, making a hard orbicular tumor that may be felt there with the hand, if it be laid on the hypogaster. Now, things being situated as above, let the Student conceive that the trunk of the child's body still contained in the womb, is thrust by the continued contractions more and more downwards, the head rest- ing upon or beyond the brim. The effect of this downward thrusting force will be to push the shoulder farther and farther out beyond the crown of the arch, and the head more and more over the top of the bone, leaving a space in which to thrust the trunk of the child. If it be a left shoulder case in the second position, the third rib will come out at the vulva, then the fourth, fifth, sixth, seventh, and so on until all the left side of the thorax is pushed out, after which follows the left flank, the left ischium, and trochanter; upon the escape of which the left thigh and leg are delivered, followed immediately by the right thigh and leg, then the right arm, w T hereupon nothing remains but the head, which is speedily born. Such is a spontaneous evolution. It differs from Version or Turning in this — that in turning the head goes up to the fundus, while the buttock comes into the passage. Here the head is held close to the plane of the strait, by the shoulder which has got under the arch, and even projects beyond it, so that the head is, as it were, tied fast to the brim so it cannot rise. Here I repeat the figure of the double headed fcetus, which I already PRETERNATURAL LABOR. 375 Fig. 83. have given at page 189, Fig. 61. Let the Student see in this figure a case in which evolution was indispensable. For example, suppose the right head to have presented, and to be delivered. That head would be held close to the vulva by the left head and body — the left head and body could not possibly be in the plane of the strait at the same time. It would be impossible to deliver by Turning — for the delivered head ties the undelivered one to the plane of the superior strait. Of course then it only remains that the undelivered head shall be forced over the horizontal ramus of the pubis to allow the trunk to descend by evolution, as I have described that process in the shoulder case. As soon as the trunk is born, the remaining head may be brought away. Dr. PfeifFer, who showed me the spe- cimen, delivered the woman, as I found upon inquiry, by compelling the evolution of the body of the fetus. Here is a repetition of the figure of Dr. Rohrer's case, given at p. Fig. 84. 376 PRETERNATURAL LABOR. 190. Let the Student observe, that such a vast fluctuating tumor on the vertex of the child, could never be the really presenting part; that it must necessarily deviate, and go up in the iliac fossa, allowing the true head to present, and making that, of course, a face presenta- tion. I say, of course, for the head would be of course in extension. Well, — the labor going on, — the head is born in face presentation, — giving the face the appearance of suggillation — of which I have made a good representation in the figure; but the head being born, the tu- mor, larger than the head, remains above the strait, in the same way as the second head of the double headed foetus of Dr. PfeifTer's did. Here, then, is a case in which evolution is indispensable, and Dr. Rohrer informed me that this was w T hat he brought about, — after doing which he was enabled, with very violent force of traction, to pull away the caput succedaneum — as you see it in the figure. I was called some time since by a friend of mine to assist him in a case of difficult and alarming labor. The woman was small, feeble, and highly nervous, the mother of several children. The doctor, finding the labor very slow, had administered a dose of ergot, which had brought on a most violent ergotism, to that degree, indeed, that I had great reason to fear she might speedily die from the mere excess of pain and irritation, if not from laceration of the womb, which appeared to me imminent. I have rarely witnessed a wilder expression of agony than here. I found the left shoulder down, in the second position. The indica- tion was to turn and deliver by the feet — which I was requested to attempt. Protesting beforehand that I deemed success impossible, I reluctantly consented to make an attempt. With great difficulty I passed my right hand through the os uteri; but it was completely pin- ioned and held fast and immovable by the muscular contraction, and I was but too happy to extract it without having caused a laceration of the cervix. The waters had long gone off. The child was dead. I concluded it was impossible to turn, and I felt equally concerned that she would die before evolution could take place spontaneously. I opened the thorax at the axilla, and broke up the tissues within both pleural cavities. Then, by means of the crotchet, I drew down rib after rib, — the flank, the hip, and the buttock, so that I got the left thigh and leg down; then the other extremity, which completed the evolution. The arms came down and I delivered the head. The woman recovered happily. I relate the case in order that the Student, reading it, may have a PRETERNATURAL LABOR. 377 clearer idea of what is meant by evolution in contra-distinction to turning of the child. Hemorrhagic Labor. — Labors are also rendered preternatural by the occurrence of hemorrhage from the womb; for, although it is very common, and not unfavorable for the parturient woman to have an issue of blood during some part of the process of child-birth, it is not either safe or natural for her to lose so much blood as to give to the flow the character or title of hemorrhage. In general, the quantity lost antecedently to the birth of the child does not exceed an ounce, and it is commonly even less than that. The occurrence, therefore, of a show of blood need not, and does not excite any alarm or even surprise, unless it goes beyond the ordinary amount. But where the effusion becomes excessive, great alarm is felt, and there is more or less real danger according to the cause of the accident. I have already expressed my opinion of the mode of connection be- tween the placenta and the womb ; and the Student will have seen that I do not admit that any very krge vessels pass from each to the other, interchangeably. Hence, when blood escapes from the uterus, it must be, I think, in consequence of a hemorrhagic nisus or san- guine determination, like that which sometimes causes the effusion of blood from the Schneiderian membrane, in those cases of epistaxis that come on spontaneously. We often see very copious outpourings of blood in epistaxis, where we can have no reason to suspect any rupture of vessels or solution of continuity in the membrane. The same thing takes place in the pulmonary hemorrhage, and in haema- temesis. But as the womb, from its very constitution, is prone to the hemorrhagic affection, it is more liable than any of the organs to losses of blood, without the suspicion of rupture of its tissues. Never- theless, there is reason for believing that in some cases of profuse bleeding the delicate tissue of the uterine veins has been ruptured. The gravid womb is filled with the ovum, which is really connected with the containing organ only at the placental superficies. All other points of the ovum, except the placental portion thereof, adhere so slightly as to be most easily capable of detachment. The placenta itself may commonly be separated with great facility from the surface on which it sits. When the chorion is detached from the womb, very little or even no blood escapes; but when the placenta is torn off, the womb generally, not always, bleeds very freely. Hence, large effu- sions of blood, in labor, indicate that the placental surface of the womb is exposed by the separation of the after- birth from it. 378 PRETERNATURAL LABOR. If the after-birth is torn off, or in any manner separated from its place, the womb still remaining undiminished in size, it is evident that the blood may continue to flow for an indefinite period, and that the woman may be brought into great danger thereby — for the bleeding orifices may continue to have, for an indefinite term, the same degree of aperture as that which first caused them to bleed. Supposing the superficial content of the gravid uterus to be two hundred square inches, and that of the non-gravid womb to be only three square inches, then it is evident that the great desideratum in uterine hemor- rhages, before delivery, is to empty the organ as soon as practicable, in order to reduce its superficial content, as nearly as may be, to the smallest number of square inches, or the non-gravid state. In treating the cases of alarming hemorrhage, therefore, we should ever keep in view the fact, that if the womb be allowed to contract or condense itself, its own muscular fibres will, by their contraction, lessen the calibre of all the blood-vessels that are distributed on or in the organ, and in proportion to this condensation or contraction will be the cer- tainty of arresting the sanguine effusion. It is not only the orifice that is closed, but the whole tractus of the vessel is constringed. If a labor should commence ever so favorably, with the child pre- senting the vertex in the first position, and the pains should propel the child downwards, so as to give reason to think the process about to terminate in the most happy manner, yet it might happen that hemorrhage should commence, and continue so abundantly, as to make it absolutely necessary to deliver the child, in order to let the womb contract perfectly. This delivery by artificial means converts the labor, which commenced naturally, into a preternatural one. We should hardly be inclined to call that a preternatural labor which, though accompanied with a great effusion of blood, should terminate well, without any assistance on the part of the accoucheur. There may also be a very copious and dangerous effusion of blood between the birth of the child, and the delivery of the after-birth; and even when the after-birth has been discharged, the flow of blood may be so considerable as to involve the woman in the greatest danger. In the management of all these kinds of bleeding, the same indica- tion is to be kept always in view; to wit, the condensation or con- traction of the womb ; for when that organ is fully contracted and condensed, the blood does not flow so abundantly as to endanger the patient, except in some very rare, and almost unheard of cases. But among the causes of uterine hemorrhage, there is one which has been called the unavoidable cause, which is, perhaps, the most PRETERNATURAL LABOR. 379 dangerous and difficult to manage: I mean that case which depends on the situation of the placenta happening to be on the cervix and os uteri. This is essentially a hemorrhagic labor, inasmuch as the mouth of the womb must not only dilate, but must dilate completely, in order to admit of our carrying out the great principle, the final condensation of the womb. Such a hemorrhage begins very mode- rately, but as larger and larger portions of the placenta continue to be detached with every successive dilating pain, it follows that the nearer the womb is to its complete dilatation, the more profuse and dangerous will be the hemorrhage. Every considerable effusion of blood in labor does not demand the manual or instrumental assistance of the accoucheur. A woman may shed a quart of blood, and yet the pains may suffice to expel the fetus in a natural way, after which the flow ceases. It is the effect, or the probable effect, of the bleeding, that renders it needful to interfere. If the pulse begins to grow small and frequent, the patient becoming w T eaker, the countenance paler, and the pains less energetic, we have to resolve what course we must take, and then resort to some of the numerous expedients for checking the discharge. If the pulse in uterine hemorrhage be full and throbbing, and the constitution not affected with debility, we may, with great safety and propriety, have recourse to a bleeding from the arm, in order to lessen the momentum of the blood, which, by its too great impetuosity, tends to keep up the flow and the determination to the womb — just as we would bleed in a pleurisy or hsemoptoe, with a similar view. Such a course, however, would be very strongly contra-indicated in the case of a feeble pulse, and a general state of weakness, faintness or sinking, w T here there would be no reasonable ground to hope for relief by the use of venesection. The application of cold to the hypogastric region, is often found to have a good effect in checking the sanguine effusion, and should be freely resorted to by stuping the lower belly with napkins, hard wrung out of cold vinegar and water; the application being renewed from time to time, until we are satisfied that success is, or is not, to crown our efforts. During the employment of the above mentioned means, the patient ought to be placed in a horizontal posture, with the head very low, and the body covered only with sufficient bed-clothes to keep her comfortable, — the apartment should be freely ventilated, and the patient allowed to take any reasonable quantity of iced water, or lemonade, w 7 hile she at the same time makes use of the infusum rosae rubrse with elixir of vitriol, or the plumbi acetas with opium. 380 PRETERNATURAL LABOR. Such are the general means for repressing the sanguine movement towards the womb ; but these means do not suffice always, and we ought to examine by the Touch, in order to make sure, if possible, of the cause of the hemorrhage. If, upon inserting the finger within the os uteri, no portion of the placenta can be felt, and the membranes are found to be unbroken, we may perhaps resolve to rupture the ovum, with a view to diminish the size of the womb by letting its waters run off. If a quart of w T ater should escape from the organ immediately after the breaking of the membranes, the superficies of the womb, and of course the placental superficies would be sensibly lessened, since the organ contracts as soon as the escape of the waters permits it to do so. This is the method proposed by Louise Bour- geois, a female practitioner in France, many years ago, and it is found to answer perfectly well, in many cases. There are circumstances, however, that might well induce one to defer to the latest period the breaking of the ovum; such as a known bad presentation of the child, requiring it to be turned. In such a case, no prudent person would be willing, without an absolute neces- sity, to permit the water to escape from the womb previous to dilata- tion, since the operation of turning is vastly more difficult, when per- formed in a female from whom the waters have been quite evacuated, than in one in whom they are still present. Hence, if the mouth of the womb be still very rigid and undilatable, rendering it impossible or improper to introduce the hand for turning, any prudent person would give a very deep consideration to the question, whether the membranes ought to be broken or not ; and would certainly feel in- clined to defer, till it should become unavoidable, the rupture of the membranes. If, upon rupturing the ovum, the flow of blood should not be stayed, and the os uteri should still continue to be so rigidly contracted as to make it impossible to turn the child, recourse should be had to the ergot, in very small doses, with a view of producing a feeble ergotism, or tonic contraction of the womb, not severe enough to injure the child, but yet, so strong as to condense the uterine tissue sufficiently to arrest the flow of blood from its vessels. With this purpose, five grains of the secale cornutum, in powder, ought to be administered every half hour or every hour, according to the pressing nature of the demand for its aid; or a teaspoonful of the vinous tincture of the same article might be exhibited, at proper intervals, with the same view. There is, in general, under these circumstances, a strong disposi- PRETERNATURAL LABOR. 381 tion to make use of mechanical means of stopping the hemorrhage, such as the application of napkins to the vulva, strongly compressing the orifice; and also the plug or tampon, which, filling the vagina, is supposed to favor the coagulation of the blood. But, if it be remem- bered that the bleeding orifices of the placental superficies on the womb, are near the fundus uteri, and that the extravasated fluid trickles down, betwixt the chorion and the womb, from the fundus to the orifice, I think it will be seen that such mechanical means can scarcely exert any other than injurious effects in the case. They may enable us to conceal the fact both from the patient and from ourselves, that the vital fluid is escaping in a dangerous abundance; but common sense ought to show us, that while we may prevent the fluid from falling out of the orifice of the vagina, by plugging that orifice with sponge or other materials, we do not prevent it from flowing back upon the outer surface of the ovum and the placenta, both of which it detaches more and more completely from the womb, leaving the woman exposed to greater hazard than she would incur were we to permit the blood to escape as fast as it is effused. Such methods, assuredly, will not favor the arrest of the effusion by coag- ulation ; the source of the flow being too distant from the remedy. It is, in general, better, in uterine hemorrhage, to let all the blood that escapes from the vessels, also escape from the vagina. When the uterine superficies is diminished, the bleeding is stayed. The application of cloths, wrung out of iced vinegar and water, to the hypogastrium, is of greater avail, and far more safe than the tampon. I would gladly urge upon the Student the necessity of the greatest caution in the employment of so dangerous an agent as the tampon, except in the early stages of gestation, or where the capacity of the womb is not sufficiently great to admit of its containing a great quan- tity of blood. No hemorrhage is so dangerous as the concealed he- morrhage. Whenever it is clearly ascertained that the period has arrived for the delivery to be hastened, which is known by the state of the patient's strength, the pulse, the color of her lips and cheeks, and by the dilatation or dilatability of the mouth of the womb, preparation should be made for the operation by placing the woman at the foot of the bed, as in the case before mentioned. The choice of means, whether it is to be of the hand or the forceps, will turn on the degree of advancement of the head, which is readily seized by the forceps, if low in the pelvis, but which is to be pushed away to make room for the search after the feet, provided it be still within or above the 382 PRETERNATURAL LABOR. brim of the pelvis. In all cases wherein the vertex is to the left side of the antero-posterior diameter of the pelvis, the left hand is to be used; while the right hand is adapted for turning, in all examples of labor where the vertex is to the right half of the pelvis. The operation differs, in no respect, from the one already described, except that the head must be pushed out of the way, instead of the shoulder. If the head should have already occupied the upper strait, that strait would be nearly filled with the mass ; the hand could not be carried up along-side of it. The palm of the hand, therefore, being placed under- neath the head, would push it gently upwards, in the absence of pain, and carrying it to one side, it would be retained on the brim, by the wrist or arm of the physician, which occupies the space recently in possession of the head. The exploration or search for the feet would be conducted as in the case already treated. When I come to speak of the use of the forceps, I shall say what is requisite concerning the indications and manner of its use in the hemorrhagic affections ; wherefore, it seems by no means needful for me to anticipate here, what I shall feel obliged to say in a future page of this book. Placenta Previa. — The unfortunate location of the placenta on the cervix and the os uteri is an accident which does not very fre- quently happen, and which, when it does occur, can scarcely ever fail to produce much anxiety and alarm among all those who under- stand the case, and feel any interest whatever in the mother and her offspring. The after-birth may cover the os uteri so exactly, that the very centre of the placenta may correspond to the orifice. The danger is enhanced by as much as the location is more central, that case being the least dangerous in which the edge of the placenta is nearest to the os uteri. The occurrence will not probably be discovered until about the seventh month, a term at which the cervical portion of the womb begins to expand, in order to become a part of the general containing cavity for the ovum; and it is in some instances not discovered, or even suspected to exist, until the labor at full term comes on. In a majority of cases, however, it happens that as soon as (in the seventh month) the cervix begins to stretch, parts of the placenta are broken off or detached from the surface of the womb, and a flow of blood, more or less violent, ensues, but which stops as soon as the patient lies down, or makes use of a venesection or some cooling drinks. The flow having been concluded, it is thought to have depended upon some PRETERNATURAL LABOR. 383 strain or shock, &c. &c, and the patient, having recovered, goes about her usual occupations. In a short time, a further expansion of the cervix detaches a fresh portion, and the exposed womb bleeds again. These attacks of bleeding are renewed again and again, until, by their violence or the weakness they produce, such an alarm is taken, that an examination per vaginam is proposed, and acceded to, when the cause of so much bleeding is discovered in the fact of the untoward location of the after-birth. It does not invariably happen that the woman bleeds previously to the attack of labor pains, but it is far too general an occurrence not to cause the danger of such fre- quent repetitions to be kept before our eyes, until the patient is finally delivered. The loss of blood by repeated attacks, during the last two months or six weeks of gestation, renders the subject of them far less capable of bearing the frightful effusion with which she is me- naced for the day of her parturition ; and a woman who should go into labor with a good stock of strength, could bear, without injury, a very copious draught on the sanguine mass, whilst another one, with vessels already drained, should sink, from the further exhaustion of a few ounces. I saw, about two years ago, a woman drained nearly to the last drop that could be spared in a labor that had been preceded by many attacks of bleeding from a placenta prsevia. Hemorrhage arising from the presence of the placenta at the os uteri, called placenta prsevia, is also denominated the unavoidable hemorrhage. The case should be always suspected to exist when pregnant women are attacked with hemorrhage between the seventh month and Term; and the existence of it should be verified or dis- proved by an examination. If it be found to exist, then the friends of the patient, but not the patient herself, ought to be notified of the nature of her position ; full instructions ought to be given for the management of any future attacks in the physician's absence ; and the services of another medical practitioner should be retained for all sudden emergencies, during the absence of the regular attendant. By such attentions as these, the patient might confidently expect to secure the services of at least one medical man, should her own regular physician happen to be engaged when her time of suffering arrived. When the placenta is previa, it will be almost certain to produce a bleeding before labor comes on. But that bleeding will be far more likely to occur in a woman who exposes herself to fatigue and various causes of excitement, or to accidents, than in a woman who keeps herself quiet, carefully avoiding to make any great exertion, or 384 PRETERNATURAL LABOR. to experience severe emotions of the mind. In all cases of a strong predisposition to bleeding, an increased momentum of the blood aug- ments the predisposition. Hence, cooling diet, gentle aperients, small venesections, and repose, and relaxation from labor especially, ought to be very carefully prescribed for our patient. The friends should be enjoined to give us the earliest notice of the attack of labor pains, or flooding, so that, all preparations being complete, we may have nothing to embarrass us in the exercise of our judgment, during the actual progress of the labor. The hazard of perishing to which the patient is exposed, depends on the dilatability of the os uteri, and the strength of the pains to be employed in dilating it. If it be soft, and the pains strong and good, the dilatation may be completed so rapidly as to prevent the effusion of any very great quantity of blood. If, on the contrary, it be rigid, and yield very slowly to the feeble contractions of the fundus, the loss of blood may be very great, and the woman sink before the mouth of the womb becomes prepared for the introduction of the hand. It must be prepared before the hand is introduced. There is no more important doctrine, in operative midwifery, than that which avers that we must never presume to force the uterus until dilatation or dilatability abstracts from the operation of turning one of its most objectionable characters. Dr. Collins, in his late work, speaks so sensibly upon this subject, that I shall not refrain from quoting the following passage from page 93 of his book. "I know of no circumstance so much to be dreaded, as the forcible introduction of the hand where the parts are in a rigid or unyielding state; for* although turning the child is the established and most de- sirable practice, yet the success of this operation will mainly depend on the judgment of the practitioner in selecting the most proper and favorable time. Cases will happen where he is obliged either to suffer his patient to sink from loss of blood, or proceed to deliver when the parts are in an undilated and rigid state, in order to afford her the only chance of life; but dire necessity should alone compel him to hazard the consequences of such violence." Such is the language of an eminent author, who has witnessed a vast number of labors, and whose ample experience gives him a title to speak as of authority upon this and all other subjects con- nected with midwifery. The time for delivery having arrived, the woman, if sufficiently strong to bear it, should be brought to the edge of the bed, and placed on her back; otherwise, she should not be moved, but attended to as PRETERNATURAL LABOR. 385 she lies. If the head present, and the position be unknown, we ought to infer that the vertex is to the left acetabulum, which is the most common one, and of course commence the operation with the left hand. The palm of the left hand easily applies itself to the face, breast and abdomen of the child lying in the first vertex position — and of course that is the hand most conveniently applicable to the operation of turning. In some instances, as when the patient is not very fat, we may detect the position by external exploration, for we may trace the curve of the spine of the child from the buttock to the head with our hands applied to the belly of the parturient patient during the absence of the pains. — It is very desirable, in this operation, to use the hand first, with which the whole operation is to be effected — and not intro- duce it and take it away in order to introduce the proper one. — Time and blood, are both liable to irreparable loss by such manoeuvres. By means of the fingers, we soon learn which side of the uterus is detached from the placenta, and then conduct the fingers in that direction, dilating the womb as we proceed, and carrying the fingers as far upwards as we conveniently can, betwixt the womb and the chorion. Tr^ membranes may then be ruptured high 'up in the uterus, and the feet immediately sought for; the child should be turned as speedily as possible, with proper regard to its safety and that of the mother; and the legs, and even the thighs, should be drawn into the vagina, not only with the view of expediting the delivery, so as to permit the womb to contract, but also in 'order that the thighs or body of the child being come into the cervix, may, by compressing the bleeding parts there, arrest or impede the flow, and thus save for the patient as many ounces of blood as possible. It is to be remem- bered that it is the loss of the last half pint of blood that kills the patient. I think that no prudent person would undertake to pierce the placenta, in order to get the hand within the womb. There never can be so much difficulty in detaching, as there would be in piercing the organ; and these two objections lie against perforating it, namely, that the rupture or laceration of its vessels could not but be destruc- tive to the child, which would bleed to death ; and also, that if the feet should be dragged through a perforation made in the placenta, the final delivery of the body and head might be very much retarded, by having that mass to pass through, in addition to the other obstacles to the birth; and further, it is evident that in perforating the placenta and extracting the child through its centre, the organ could scarcely fail to be very completely detached from the womb, while only a par- 25 386 PRETERNATURAL LABOR. tial detachment is required if it be made on one side. It is best, therefore, in all cases, to pass the hand betwixt the placenta and the womb, and not through the placenta. A strong desire to reinforce the tonic contractility of the womb w r ould induce me, always, to exhibit a portion of the secale cornutum, in these cases, taking care to time the dose so as to secure its ope- ration for a period subsequent to the delivery of the child. The ergot should be in readiness, and given as soon as the turning is completed. If it should operate successfully upon the uterine muscular fibres, it could not but afford additional hope of preserving the patient, at least, from the danger of a good deal of drainage, if not from a more violent and rapid effusion subsequently to the delivery. So confident am I in the power of the ergot administered in this way, that I venture to recommend it very strongly. Many persons, who were constitutionally prone to hemorrhage after delivery, have escaped well, from having taken the spurred rye, in the last moments of labor, in order to secure a tonic action of the uterus after delivery of the child. I need not reiterate my opinion that the operator should not be unpro- vided with the forceps, with which to extract the head, in case of any uncommon or dangerous delay in its delivery, as I have already stated my opinion that such means of security ought to be provided for every instance of breech labor, or preternatural presentation, of whatever species. Fortunately, for us, we do not have to contend with a great many cases of placenta prsevia. I have seen six cases of these accidents, in which the orifice was completely covered by the after-birth, and several others in which the edge of the placenta was located on the cervical portion of the womb, and occasioned a certain degree of hemorrhage, during the dilatation, but not to any dangerous or alarm- ing extent. Dr. Collins mentions, that eleven cases occurred during his master- ship of the lying-in hospital, equal to one case in one thousand three hundred and ten labors, since he had sixteen thousand four hun- dred and fourteen labors during his mastership. It is rather a surprising circumstance that Mauriceau, who was so largely engaged in midwifery practice, and who witnessed a good many cases of placenta praavia, should have been supposed to be ignorant that the original attachment of the after-birth was on the cervix. It has been asserted that this distinguished writer always supposed, that when the placenta was before the child, it was owing to an accidental detachment of it from the fundus, in which it had PRETERNATURAL LABOR. 387 fallen down to the orifice, so as to get in advance of the presenting part ; and yet, he very distinctly gives directions how to pass the hand, so as in the easiest way to get it by the placenta, when the operation of turning has to be performed; and the twenty-eighth chapter of his second book is devoted to a very full account of the mode of delivery in such cases — and he gives at full length the de- scription of twelve cases of placenta prsevia most admirably managed by himself, which are in the first volume. The celebrated Levret gives us, in his article on placental presentations, an elaborate resume of the history of opinions on that accident which had been expressed by writers antecedent to him. It seems that many practitioners had treated the case, and well too, but without possessing such correct notions upon it as are entertained at the present time. It will have been perceived that I have not, in this article on pla- centa prsevia, adverted to the new method of treatment which has been so strongly advocated by Drs. Simpson, Radford and other emi- nent persons among the brethren, in England and in this country. I mean the total separation of the placenta, by the hand of the accouch- eur as a certain method of putting a stop to the effusion of the blood. The journals and other publications, in which this treatment has been set forth and recommended, contain the relations of numerous cases in which the placenta was either accidentally or designedly separated from its place on the womb, and in which the blood ceased to flow immediately after the complete detachment of the after-birth. The good success of this practice has begun to render it very popular, and I think that too much confidence is reposed in its power to arrest this most dangerous flooding. It has been supposed heretofore that alarm- ing uterine hemorrhages proceed from patulous orifices of vessels of the womb, and that the essential remedy for these effusions consists in the condensation of the uterine texture under the active contrac- tility of its muscular fibres. But the advocates of the new practice in placenta prsevia explain their success and urge the adoption of their method upon the new ground that the blood flows, not from the uncovered portion of the uterine placental superficies, but from the uncovered surface of the placenta itself, averring that while a part of the placenta is detached and the rest of it retains its adherence to the uterine surface, the blood of the uterus continues to pass into the cells of the placenta from whence it escapes into the cells of the detached portion, issuing in torrents from its free surface, and the idea is en- tertained that by w 7 holly separating the placenta from the womb, no 388 PRETERNATURAL LABOR. more blood can gain admission to the cells of that tissue, and there- fore no more blood will be lost. Entertaining these views, which I have already at page 172 expressed as to the constitution of the placenta, and its connexion with the uterus, it is clearly impossible for me to admit the truth of the foregoing explanation of the hemorrhage in placenta prsevia. To say that the detachment of the placenta, without any consequent reduction of the superficial contents of the uterus, could arrest a hem- orrhage by breaking of! the curling arteries (as they are called), of the womb, appears to me quite unphilosophical — for there are thou- sands of facts of ante-partum and post-partum hemorrhages to prove that the arrest of hemorrhage is the consequence of condensations of the womb under its muscular contraction. The incision of the womb in a Cesarian operation, often cuts through the most vascular part of the organ, and as the bistoury sinks into the tissue, the blood spurts from numerous divided vessels; but as soon as the child and the secundines are taken out of its cavity and the organ allowed to contract, the immense orifices are nullified by the condensation of the texture: — a cut of five inches in length being immediately reduced to a length of not more than two or two and a half inches, and its incised edges scarcely allowing of the smallest sanguine exudation. This I have observed to happen in the case of Mrs.Raybold, whose case is related in this work. To separate the placenta, and not allow the womb to contract, is to gain nothing, for the hemorrhagic moli- men, or the mere traumatic flow, cannot be supposed to cease merely because the curling arteries (so called) are broken ofF. Further, in placenta prsevia the effusion is in many instances most dreadful long before the hand of the accoucheur can be passed up- wards, in order to turn and deliver. Nay, it is alarmingly great in some samples, while the os uteri is still not larger than a quarter dollar. But as the placenta is eight inches in diameter, it seems to me not possible to detach the whole viscus with a finger, which is not long enough to reach the very circumference of a centrically im- planted after-birth, and, a fortiori, not long enough to reach to the remote edge of one not centrically implanted. If the os uteri be dilated, or dilatable enough to introduce the hand for turning, the time has arrived for this operation, and there is then assuredly no occasion to detach the placenta. Let the operation be performed at the earliest possible period, for the indication, as in all dangerous uterine hemorrhages, is to let the womb contract, which PRETERNATURAL LABOR. 389 it cannot effectually do until the ovum is extracted or expelled from its cavity. When that is done, it speedily draws itself to the smallest pos- sible cubic content. Messrs. Simpson, Radford, and the other gentle- men who advocate the new method in placenta prsevia, very earnestly recommend the prompt separation of the whole of the placenta; and they are persons whose opinions are justly to be esteemed of the greatest w~ eight ; but notwithstanding the profound respect with which I receive any statement of theirs, I cannot but think that in any case in which it is possible to detach the whole of the placenta, it would be also possible to introduce the whole of the hand, and thus commence at once the operation of turning, which ought to be esteemed as the essential indication of treatment in placenta prsevia, and which the earlier it is done, so much the greater chance does it give both of rescuing the child and saving the woman from fatal losses of blood. Heretofore in turning for a shoulder presentation, I have found the placenta lying at the fundus uteri wholly detached and without any immediate hemorrhage; but I have seen a vast number of most dangerous post-partum hemorrhages occasioned by coagula filling the vagina and acting there as a tampon, allowing the uterus to expand again with influent blood and rendering the orifices of vessels upon its placental superficies nearly as patulous as before the birth of the child. I cannot suppose, therefore, that w r hen I have found the pla- centa wholly detached at the fundus uteri in a labor, hemorrhage failed to occur because of that detachment; nor can I suppose that in pla- centa prsevia, hemorrhage is arrested because of the artificial detach- ment ; but rather in both cases from association of the hemorrhagic molimen. Concealed Hemorrhage. — There is another kind of hemorrhage that is met with in parturient women ; I mean the concealed hemor- rhage. It may take place from the placental surface, and continue to a dangerous extent, without detaching the circumference of the after-birth from its connection with the womb. In this case, the whole placenta is separated from the womb, with exception of its rim; and the distensible material admits of so large a quantity of blood being effused, as to make it take the appearance of a bag filled with blood, and depressed into the uterine cavity. I have never met with a sample of this kind of bleeding; but the phenomena that accompany excessive loss of blood would give intimation to an intelligent phy- sician, in such a case, sufficiently clear to engage him to proceed aright in lessening the bleeding superficies, either by merely dis- 390 PRETERNATURAL LABOR. charging the liquor aranii, or by turning, or delivering with the forceps. The symptoms, under such circumstances, would be weak- ness; dull pain in the womb; suddenly increased size and tension of the organ; frequency and smallness of the pulse; paleness ; yawning and sighing; and syncope. The occurrence of such phenomena, in a pregnant woman, if alarmingly great, would, I think, be a full war- rant for opening the ovum, or for an expeditious delivery; the latter, always, however, to be held in reserve until the womb is dilated or dilatable. Such a case, however, deserves to be profoundly consi- dered before proceeding to the adoption of an extreme measure. The ergotic action might be, with great prospect of advantage, re- sorted to, in case the hemorrhagic symptoms should not abate upon the discharge of the liquor of the amnios. Post-Partum Hemorrhage. — The hemorrhages that take place between the delivery of the child, and the expulsion of the placenta, are frequently to be met with, and are so violent, as to excite great alarm in the patient herself, or her friends who happen to witness the distressing symptoms that accompany the accident. I think, that, in a very great majority of labors, the placenta is quite detached by the time the child's head has emerged from the vagina, and that the separation frequently takes place still earlier. In such women as have feeble pains, with long intervals, the effu- sion of blood is sometimes very great, and a large quantity frequently is found to be expelled immediately after the child is born, being evi- dently the result of hemorrhage taking place in the intervals between the pains, yet detained behind or above the presenting part, until the delivery of the child is completed, when it rushes forth with great violence. If this is a correct statement, then it may, a fortiori, happen, that the effusion may go on rapidly as soon as the body of the child has escaped. The womb, in many instances, is perfectly passive for some time after the great effort it has made, and the placental super- ficies being exposed, a torrent of blood issues, which suddenly fills and distends the womb, and the woman faints and dies without any one perceiving that she has flooded at all. I believe that the blood would always flow out of the vagina, were it not that a firm clot occa- sionally happens to stop the os uteri, like a tampon, so that none can escape ; and if the womb be deprived of its irritability, its fibres will offer no resistance to the fluid which is poured into the cavity, and which, being sealed up by a coagulum at the os uteri and in the PRETERNATURAL LABOR. 391 vagina, must distend more and more, and with a rapidity that aug- ments as the placental surface grows larger and larger. A careful practitioner ought not to allow such an event to take place, in his presence. He will frequently place his hand upon the hypogastrium of his patient, and ascertain whether the womb be pro- perly contracted, and enforce its contraction, if necessary, by frictions, and by gently pressing the womb with his fingers applied to the lower part of the abdomen. The irritability of the organ is readily excited into effect by this means; and when the womb becomes properly con- densed, there is little danger of any effusion taking place. It should be an invariable custom to place, after the child is born, the hand on the mother's abdomen, to make sure of the contraction of the uterus. This custom will always give prompt information of the existence, or non-existence, of a tonic contraction ; and he who fails of attention to this point will, sooner or later, have reason to regret the neglect of so salutary a precaution. But when flooding comes on, whether after delivery or antecedently to it, the same principle is applicable, namely, to empty the cavity as speedily as possible consistently with prudence. Let the placenta be taken away, and, after its removal, let pressure be made on the hypo- gastrium by the hand, or by a compress and bandage, and the pres- sure continued until the signs of hemorrhage have completely ceased. After having removed the placenta, or after having turned out from the cavity of the womb a pound of coagula, more or less, the woman cannot be deemed safe until the lapse of an hour or more shall have given assurance that no repetition of the hemorrhage can take place. I have, on a great many different occasions, found myself compelled to turn out the clot again and again, to prevent the patient from falling into fatal syncope. Let the Student therefore take heed, that while he may have saved his patient from fatal hemorrhage at ten o'clock, she fall not into the same hazard again at half-past ten or eleven, or at half-past eleven, being careful not to quit her apartment till he can clearly pronounce her safe. It happens that the womb is incapable, sometimes, of separating the placenta wholly from its surface; but if it be half detached, there may flow a great quantity of blood, while the uterus continues unable to expel the after-birth. The duty of the medical attendant here is to separate it entirely, by introducing his hand, and gently detaching it with his fingers, taking every possible care not to leave any portion behind, which, by keeping up a continued irritation, would tend to maintain a hemorrhagic nisus, or even dispose the patient to metritis. 392 PRETERNATURAL LABOR. He will separate the placenta here, in order to let the uterus contract, for the suppression of the hemorrhage, which it will do as soon as it can thrust the placenta forth from its cavity. Let it be always re- membered that the hand is not to be introduced unless real need for it exists. The greatest care should be taken in this case to keep the patient quiet, and strict order should be given not to lift her head from the pillows, until all the appearances of danger are gone. Any attempt to sit up in bed, or even to turn, for a woman excessively reduced by hemorrhage, is dangerous, since any muscular effort, by occasioning faintness or exhaustion, invites a renewal of the hemorrhage and de- bility, which are both to be deprecated. Hour-Glass Contraction. — I have met with several examples of the hour-glass contraction of the womb, of which I have spoken at p. 299. This depends upon the contraction of the womb at the upper limit of its cervical portion, so that the after-birth is contained, as it were, in a separate cell, or the contraction may take place so as merely to include the placenta, still retaining its original connection with the uterus. The finger may pass up to the constricted point, and find the cord closely embraced by it. If no bleeding comes on, it is proper to wait an hour, to see w T hether the co-ordinate action of the muscular fibres will not overcome the horizontal constriction; but, if an hour elapses without the least change in the case, we have reason to infer that two, or even four hours, may not suffice to remove the difficulty, and we are always justified in taking away the secun- dines in that time, even should we not be prompted to do so earlier. It is, in general, not difficult to overcome the stricture, by introducing, first, the hand into the vagina, and then inserting one, then more fingers along-side of the cord, until a sufficient portion of the hand is introduced to command the placenta. I have never yet met with an hour-glass contraction in which I was not compelled to separate the placenta with my hand. I can not well conceive of an hour-glass contraction, independently of a preternatural adherence of the after-birth to the womb. I suppose that when the after-birth is so firmly attached that the con- tractions of the womb cannot slide it off, the substance of the placenta acts as a soft splint — counter-extending the utero-placental superficies. The rest of the womb, having nothing to antagonize it, contracts as usual, leaving the placenta shut up in an upper cell. It usually con- tracts at the upper extremity of the cervix ; sometimes, as where the placenta is situated upon the side of the womb, and cannot be dis- PRETERNATURAL LABOR. 393 placed by its contractions in consequence of the preternatural adher- ence, the cell in which it is contained is on the side of the womb, and the fingers, in dilating the constricted part, must be conducted to the right, or to the left, or to the front, or backwards into the chamber containing the after-birth, as the case may be. If this explanation be just, there is no very well founded reason to hope for the spontaneous expulsion of the cake — for the adhesion will not give way after the birth of the child, if it would not before that event. Thus the indication in hour-glass womb is, perhaps, to deliver at once, and I now heartily and warmly advise the Student to intro- duce his hand to separate the placenta, as soon as he can clearly determine that the real hour-glass contraction does exist. He will be compelled to do so, sooner or later — and the sooner it is attempted, the easier will it be effected. What can be more disagreeable, or even distressing, than be com- pelled to carry the hand and half of the forearm into the body of a patient already weakened and exhausted by the labor, and above all, to be obliged to remove from the womb w T hile the female is agonized, the adhering mass, which sometimes is so closely united as to be apparently confounded with the texture of the womb. I am sure that in performing this painful office, one is occasionally obliged by a sense of duty to the patient to continue the effort to get off the placenta, even w T hen far from certain that one is not either leaving portions of the lobules still united, or perhaps injuring the vital tissue itself; all that can be expected of any practitioner, under such circumstances, is that he should faithfully do his duty according to his ability. If he cannot get off the whole after-birth, he must leave portions of its lobules. Let him, however, always try to get every vestige of it off. To leave an ounce adhering is better than to leave a pound, and he can and ought to protect his own credit against any untoward results, by a full and candid statement of the difficulty he has met with, and of the imprac- ticable nature of the case. I have taken away a great many such, and none of the women have failed to recover, even where I was cer- tain that my utmost care and desire to succeed in removing the whole had been in vain. The Student will learn in practice that he will rarely meet with these vexatious adhesions, in cases that go on regu- larly and with a proper celerity, but if he have a labor that gives him great trouble and long detention, from irregular action and feebleness of the pains, he may justly fear that the after-birth will not come off easily. I doubt not that a very firm adhesion of the after-birth is capa- ble of greatly impairing the regularity and strength of the uterine con- tractions. Such an after-birth, by preventing that part of the womb 394 PRETERNATURAL LABOR. in which it is from contracting in due proportion with the other parts of the organ, is very probably the cause of most of the difficulty we have to contend with throughout the whole parturient process in such a case. Hemorrhage following the After-birth. — The application of a compress, made by folding one or two napkins, and securing them upon the lower part of the abdomen by the common bandage, is a precaution that ought never to be overlooked where there is a great disposition to hemorrhage. Such a pressure not only prevents the womb from filling again, but it tends very successfully to secure a firm tonic contraction of the organ. The sacchar. saturni, combined with opium, in doses of three or five grains of the former with from half a grain to a grain of the latter, repeated in an hour, offers us a very useful resource in the styptic influence of the acetate of lead. Infusion of red rose leaves, with elixir of vitriol ; powders composed of five or ten grains of sulphate of alumine, with a few grains of nut- meg ; and the application of cloths pressed out of cold vinegar and water to the pubes ; all these are measures that must be sometimes resorted to, when the flow of blood continues after the delivery of the secundines has taken place. Violent and dangerous effusions of blood sometimes come on soon after the delivery of the placenta, and at a time when the labor is sup- posed to have been terminated in the most successful and fortunate manner. If half an hour elapses after the delivery of the after-birth without any flooding, we shall rarely meet with it, and may, for the most part, consider the patient safe. Nevertheless it does, sometimes, come on many hours later ; or even many days are passed, without any apparent tendency to the accident, before the female is attacked. The causes of this bleeding are to be sought for in the relaxed state of the womb, arising from loss of power in its muscular portion. They are almost invariably connected with an excited and impetuous circulation, by which the blood is propelled w T ith such power and momentum into the uterine arteries, as to force open their extremities, when they are not sufficiently supported and constringed by the mus- cular contractility of the uterus. Such an attack ought to be foreseen, in the state of the pulse, and obviated by the use of such measures as may serve to abate the violence of the blood's motion; and the patient ought not to be abandoned by the physician, until he has become fully satisfied that the danger is past. Let the patient lie in a truly horizontal posture ; PRETERNATURAL LABOR. 395 let blood be taken from the arm if required ; let cool drinks be given, and cold water applied to the face and forehead ; and let great care be taken to ascertain, from time to time, by the touch, externally, whether the womb is firmly condensed or not. It is not good, I think, to allow the napkins, that are often applied to the vulva, to be too firmly pressed to the parts; they serve, when so pressed, as a sort of tampon, which enforces the coagulation of the blood in the vagina, and that itself is often a dangerous tampon. The blood which cannot escape accumulates in the womb, and brings on a concealed hemor- rhage, that is likely to increase with a frightful rapidity that may sink the patient irrecoverably by the time it is discovered. When blood has once escaped from its vessels, it is of no further service in this case at least, and therefore, the sooner it is got rid of, the better for the sufferer. I have governed myself as much as possible by the rule acted on and enforced in his lectures by the late Professor James, which was, " Don't leave your patient for one hour after the termination of the labor." The pressure of business upon a medical man in a large practice will sometimes make it impossible to stay so long near the lying-in woman, but when under the necessity of leaving her, he ought always to make arrangements for his recall in case of need. Leaving a newly-delivered woman a few minutes after the deliver- ance, he exposes himself to the shock of hearing, upon his return to his house after one or two hours, that "Mrs. B. wants him imme- diately, as soon as possible — has sent again and again — they think she is dying!" I have many times been saluted with such messages, and it would be difficult to express the sensations they excite. It is true that most of the cases are neither fatal nor even dangerous, yet occasionally a woman is found to sink and die, almost without warning, from effu- sions of blood which either flow out upon the bed, or are retained within the vagina and womb, distending them enormously without giving rise to the least suspicion in the friends or nurse that the woman is bleeding. In case of being summoned in this sudden manner to return to the patient, it is obviously the first duty of the physician to make sure of the state of the womb ; and accordingly, as soon as he reaches the bedside, he should place his hand on the hypogastrium in order to learn whether the organ is too much distended : if it be found too large, his course is plain — he must break up the clots which fill it and press them out ; if it be not too much distended — and yet there are those 396 PRETERNATURAL LABOR. signs of weakness "which show that the patient has lost too much blood while no great external or open flooding has taken place — he should still act as if there were really a hemorrhage. Let him then introduce one or two fingers into the vagina, and he will be almost sure to find that the tube is filled to distension with a very solid clot, a clot as large perhaps as a child's head, and extending up into the womb. Upon tearing this clot with his fingers and pressing at the same moment with the other hand on the lower part of the belly, exhorting the woman to bear down, the coagula are expelled with more or less violence, and the woman immediately expresses herself as relieved. I must reiterate in this place the injunction, never to forget that in uterine hemorrhage all proper measures must be taken to cause the womb to contract; never to forget that with a condensed womb there is no hemorrhage, nor that the womb will nearly with invariable certainty contract or condense itself, if some antagonist or distending force does not prevent. Remove or withdraw, therefore, the antagonist force, and the patient is saved. The bandage for the abdomen ought never to be omitted in these cases of flooding, for the belly being suddenly evacuated of the con- tents of the womb, there is produced a feeling of inanition and weakness, that often is, alone, able to bring on faintness, or a state approaching to it; and that is highly conducive to the increase of uterine hemorrhage. I have already, in my remarks on labors, spoken on this topic, and will refer my readers to pages 310 and 312 of this volume. I have long been impressed with the beautiful simplicity and the truth of the following affecting story, from the pen of the celebrated Mauriceau ; and as his writings are little known in the United States, I have, on that account, as w 7 ell as for the intrinsic practical import- ance of the case, resolved to translate it for this part of my work. Those who read it will, as I think, agree with me, that it conveys a most instructive lesson to the student of midwifery, and, if I am not mistaken, will need no other apology for its introduction here. "Many women (says Mauriceau, liv. 1, p. 158) have perished, together w T ith their offspring, for want of prompt assistance on such occasions [hemorrhage] : and not a few have escaped from an other- wise inevitable death by early succor; while their children have re- ceived the holy sacrament of baptism, of which, but for that aid, they would have been deprived. Guillemeau, in liv. 2, chap. 13, of his De V Accouchement, mentions six or seven cases confirmatory of this truth, in most of which it is seen that both the mothers and their children PRETERNATURAL LABOR. 397 were the bloody victims of want of promptitude in delivery under such circumstances, while some of them escaped in consequence of early assistance ; but, that I may confirm this doctrine by the results of my own experience, I shall relate one case, among many, that is very remarkable ; and the remembrance of which is so vividly im- pressed upon me, that the very ink with which I now am writing, in order to make it known for the benefit of the public, seems to me to be turned into blood; for on that piteous and fatal occasion, I wit- nessed the effusion of a part of my own vital fluid, or, to speak more correctly, the whole of what resembled the blood of my own veins. "It was sixteen years ago that my sister, who was not yet quite twenty-one years of age, about eight months and a half gone with her fifth child, being at the time in excellent health, was so unfortu- nate as to hurt herself, though, to all appearance, very slightly, by a fall on her knees, the belly at the time striking the ground ; subse- quent to which she passed a day or two without experiencing any considerable inconvenience, so that she neglected to keep herself as quiet as she ought to have done ; but on the third day, at about eleven o'clock in the morning, she was suddenly seized with strong and fre- quent pains of the belly, which were also accompanied by a great discharge of blood from the vagina. She immediately sent for the midwife, who was not too well versed in her occupation, and who, when she arrived, informed my sister that it was necessary, before delivering her, to wait until the pains should spontaneously open the mouth of the womb, assuring her, that she had nothing to fear from the accident, and would be soon delivered, because the child pre- sented very favorably. In this way she fed her with vain hopes for three or four hours, until, the flow of blood continuing very great, the pains began to leave her, and the poor lady fainted away several times ; upon seeing which, the midwife requested that a surgeon might be sent for to assist her. They came immediately to my house, to notify me of the affair; but being unhappily from home, they called in one, who, they supposed, was one of the ablest obstetricians or surgeons in the whole city at that period, and he was immediately taken to my sister's residence, where he arrived about four o'clock in the afternoon. Having seen the state she was in, he contented himself with merely saying that she was a dead woman, for whom nothing was wanting but the last sacraments of the church, and that it was absolutely impossible to deliver her. To all this the midwife readily agreed, for she thought the opinion of this man, so universally esteemed, must be, beyond doubt, correct. As soon as he had pro- 398 PRETERNATURAL LABOR. nounced his judgment, he went away, refusing to stay any longer ; and in this deplorable condition, and without offering the smallest succor, he left this female, whose life, as well as that of her child, he could certainly have saved, had he delivered her then, which he might easily have done, as will be seen by the sequel of this history. "After the judgment of a person of such great reputation, added to that of the midwife, every one who was present thought that since M. could do nothing for her, there could be no other recourse, in so great a misfortune, than placing confidence in God, to whom alone everything is possible. " They now endeavored, as well as they could, to console my poor sister, who with a passionate earnestness desired to see me, that she might know whether I also would pronounce the same judgment upon her; and whether her disease, which was constantly growing worse, was beyond all remedy ; for her blood was steadily flowing in great abundance. At last, I returned to my house, where they had been a long time before, to tell me this bad news; and where, most unfortunately, I w^as not to be found at the time, as I have already related. As soon as I heard of it, I hastened to her house, and upon arriving there, I saw so piteous a spectacle, that all the passions of my soul were agitated at the sight, with many and different emotions ; after which, having somewhat recovered my composure, I approached the bed of my sister, who had just received the last sacraments; and being there, she implored me again and again to assist her, saying, that she had no hope but in me. After I had learned from the mid- wife all that had happened, and she had told me of the opinion of the surgeon, who had seen her more than two hours before, for it was now past six o'clock, I perceived that the blood still continued to flow profusely, and without ceasing, though she had already lost more than three quarts, and, what is remarkable, more than forty-eight ounces wuthin the two hours since the surgeon left her — as I supposed from the quantity of the napkins and cloths which were all saturated with it; which blood, by remaining in her body, had she been time- ously delivered, w r ould, beyond doubt, have saved her life. I also saw that she was seized almost every minute with sinking turns, that were increasing; which convinced me that she was in far greater peril than she could have been had they not lost the opportunity of delivering her two or three hours sooner, which w T as both possible and of easy execution ; for at that time she had almost the whole of her strength, w T hich she afterwards lost by the continual effusion of her blood. Wishing to know whether it was true that she could not PRETERNATURAL LABOR. 399 be delivered, I found, upon examination per vaginam, the orifice of the womb dilated, so as easily to admit two or three fingers. Having remarked this, I made the midwife examine her again, in order to ascertain whether the os uteri had been in the same state when the surgeon stated that she could not be delivered; and whether she was still of his opinion: she told me ' Yes,' and that the parts had re- mained unchanged ever since he had gone away. As soon as she made this declaration, I perceived her ignorance, and what had been the difficulty with the surgeon. Touching this, I told her of my as- tonishment that they had both been of such an opinion, as I was of a wholly different opinion — for it would have been as easy for him to deliver her then as now; which I should, in truth, have immediately done myself, could I possibly have commanded my judgment, long vacillating upon this resolution, which, from the loss of all hope from other quarters, I was at last constrained to adopt. What hindered me was, not the prognostic of the surgeon, celebrated as he was, w T ho had persuaded everybody that to deliver her was impossible, (for it would seem like rashness to resist the dicta of those w T ho are looked upon as oracles,) nor the weakness of the patient ; but it was chiefly the quality of the person, who was my own sister, and whom I tenderly loved, that agitated my mind with various passions. For my mind was so preoccupied with seeing her ready to expire before my eyes, from the prodigious waste of that blood that sprung from the same source as my own, as to make it impossible for me to come to an immediate resolution and action. This obliged me to send in- continently for the surgeon, who had left her so long before, and beg him to return to her house, so that I might show him how easily she could be delivered — and by making him understand and confess that there is no hope on such occasions except in prompt delivery, induce him to operate, instead of leaving the mother, as he had done, to despair, and allowing her infant to perish without baptism, which it might have enjoyed had he obeyed the requirements of the art, which are, that if both cannot be saved, we should, at least, try to save the child, if that be possible without doing anything prejudicial to the mother. But he would not come back for all the prayers and solici- tations that could be offered; and excused himself by saying, that it would be impossible to do anything in such a situation. As soon as I learned all these things, I sent for another surgeon, w T ith whom, had he come in time, I should have concluded in favor of the necessity of the operation, of the possibility of which I could have satisfied him ; but, as misfortune would have it, he was absent from home. Mean- 400 PRETERNATURAL LABOR. while, at least an hour and a half more elapsed, during which the blood was incessantly flowing, and the faintness increasing more and more. Finding myself, therefore, hopeless of the aid of the persons I had sent for, I resolved to deliver her myself immediately, for I had not been able to resolve upon it, except in this extreme necessity, for the reasons already given; which, indeed, was somewhat too late for the mother; for, had I been able to command myself sufficiently to proceed to the delivery at my first arrival, there was great reason to hope for her safety, as it afterwards proved as to her child, when I had completed the task in the following manner : — " I introduced two fingers into the orifice of the womb, which was open enough to receive them ; I then gradually inserted a third, and little by little, the ends of all the fingers of my right hand, with which I so dilated the orifice as to admit the whole hand, which is readily to be done on such occasions, because, as has been already said, the abundant discharge of blood moistens and relaxes the entire womb very much. Having introduced my hand very gently, I found that the head of the child presented, and that the waters were not yet gone off, which obliged me to break the membranes with my finger nails. Having done this, I immediately turned the child so as to draw it down by the feet, which I easily effected, as I shall describe the ope- ration in the 13th chapter of the second book. The operation was effected in less time than it takes to count a hundred, and I protest upon my conscience, that I never in my life performed an accouche- ment (of a preternatural case) with greater ease and expedition, or less pain to the mother, who never complained in the least during the operation, notwithstanding she then was quite herself, and knew perfectly well what I was doing. Indeed she found herself quite relieved, as soon as I had delivered her, whereupon the flow of blood began to cease. "As to the child, I delivered it alive, and it was instantly baptized by a priest who was in the chamber. The patient, and all the by- standers, who were numerous, then perceived very clearly that the surgeon and midwife, who had pronounced it impossible to deliver her, had done so without any good reason. " The operation was performed in good time to procure baptism for the child, who received it, praise be to God, as I just now said ; but it was too late to save the life of its mother, who died an hour after its birth, in consequence of having lost too great a quantity of blood, for she fell into a great swoon, like those she had had pre- viously to the delivery. The flow of blood ceased, it is true, but PRETERNATURAL LABOR. 401 there was not enough left in her body to resist these frequent syncopes, which she could doubtless have done, had the surgeon, who saw her first, delivered her three full hours earlier, as he could have done, without doubt, as easily as I did it; since which time she had lost, without exaggeration, more than eighty ounces of blood, twenty of which, had it been reserved, would have insured her escape ; particu- larly, as she was a young woman, of a good constitution, free from all disease or inconvenience at the time she was attacked by this fatal accident, which happened, as before said, at eleven o'clock in the morning. She was delivered at seven in the evening; but the operation was unsuccessful for her, because she had been drained of blood: she died an hour afterwards, in full possession of her senses, and speaking until the last moment of her existence, which was at eight o'clock, P. M." Convulsions. — Among the severe and dangerous disorders to which pregnant and parturient women are liable, may be classed the puer- peral convulsion, as one of the most dreadful. It never occurs without carrying dismay among all those w r ho take a near interest in the patient; whom it exposes to the greatest risk, by the violent affections of the brain with which it is connected. Dr. Collins {Practical Treatise, p. 199), says, "there are few cir- cumstances more calculated to alarm the practitioner or excite terror in the friends of the patient, than the occurrence of convulsions dur- ing the progress of labor; and the result both with regard to the mother and child proves the danger serious." I have already spoken, in a former page, of the excited state of the blood-vessels that accompanies labor, and I think, that, in view of the rapidity and momentum of the circulation produced by that state, no surprise ought to be felt at the occasional appearance of convul- sions. If the extreme violence with which the blood rushes during labor along the arteries of the encephalon, be taken into consideration, it will be seen that the brain must, in such an excited circulation, be brought into a state of the highest nervous activity, and the function of innervation become so considerably and irregularly augmented, in consequence, that the muscles of the body fall readily into convulsive movements. The activity of the functions of the brain and spinal marrow is always increased, proportionally, with the quantity of blood circulating through those structures ; a woman, therefore, in whom the pulse is uncommonly hard, frequent and large, ought, cceteris 26 402 PRETERNATURAL LABOR. pmibus, to be more obnoxious to the convulsion than a woman in a directly opposite state. Accordingly, I think it will be very rare to meet with the malady, except in such as have a very bounding and tense pulse. Let it be early obviated. The long-continued pressure of the womb upon the great vessels in the abdomen, cannot fail, in some women, to retard, to a certain extent, the flow of the blood in the branches of the aorta below the point compressed by the womb, as has most judiciously been observed by Puzos, and we daily witness the effect of that pressure on the veins and absorbents, in the temporary varices of the veins, and in the cedematous limbs, of the later stages of pregnancy; which symptoms are observed to vanish with the removal of the cause of pressure. This removal takes place by the birth of the child, and the subsidence of the womb into the excavation of the pelvis, after delivery. The same causes of pressure, by impeding, in any degree, the downward flow of the aortic blood, must give to the mass of blood a disposition to mount upwards, and linger in the vessels of the brain and upper parts of the body. They occasion a congestion and irritation of the brain, characterized by headache, confusion of thought, vertigo and delirium, resulting in convulsion or apoplexy. The merest tendency to such results is worthy of the most solicitous regard and anxious attention. Let a pregnant woman acquire the habit of congestion in the brain, and if, as soon as the efforts of labor come to superadd their power to a dangerous predisposition, we omit all regard and care for such symptoms, there will be more than a probability of our having to contend with the disorder now under consideration. It is far better to ward off than to cure an attack of puerperal con- vulsion. No one can look upon the case, with due comprehension of its nature, and not fear that a fatal effusion or extravasation will take place during the attack. It is very well known, that not a few instances do occur wherein the fatal blow is struck at the very onset, and that some women never speak, nor exhibit the smallest sign of reason or sensation from the moment of invasion, but sink at once into the ster- torous apoplectic sleep that leads rapidly to the sleep of death. The state of pregnancy, for some women of a very irritable consti- tution, is rather a pathological than a physiological condition. The woman labors under constitutional irritation from the commencement of her pregnancy, and never feels well until she is delivered. She is fretful and peevish ; ceases to be amiable ; and after the conservative powers of the constitution are at last defeated and overthrown, the fruits of the disorder are seen in puerperal insanity or convulsions. Such a state both causes and maintains a vitiated condition of the cir- PRETERNATURAL LABOR. 403 culation, which should be met by venesections, repeated according to the enlightened judgment of the medical attendant, by purgatives or aperients; by counter-irritants : by a judiciously regulated diet; by regulated exercise; by baths; by proper clothing; and by the removal or prevention of all causes of mental solicitude or excitement. But in order to the suitable prescription of all these agents, the physician ought to see the patient occasionally, before the completion of her term. Hence, the public ought to know, that counsel should be taken of the physician, from time to time, for all pregnant females who do not enjoy good health during gestation. If such counsel were sought for at an early period, the attack of convulsion would not, in general, take place. Most of the cases come on when not in the least expected or antici- pated, and, as I have already expressed it, "the fatal blow" is the first and the last one; the patient sinks at once into coma, and dies, without ever recovering her senses. The attack of convulsions has been supposed to have some con- nection with the irritation of the nervous system occasioned by the dilatation of the os uteri. Possibly this may in some examples be true. We meet with many cases where the os uteri is fully dilated before the seizure, and a small proportion are met with in persons who have already been delivered. At page 200, Dr. Collins, in speak- ing upon the idea that the dilatation of the os uteri is causative of the disorder, says, "This fact might be brought forward to support the opinion, that puerperal convulsions were caused by the irritation pro- duced in the dilatation of the mouth of the womb. This, however, is not the case, as we not unfrequently find patients attacked when the os uteri is completely dilated and all the soft parts relaxed. I conceive we are quite ignorant as yet of what the cause may be ; nor could I ever find, on dissection, any appearance to enable me to even hazard an opinion on the subject." Since the introduction of ether-inhalation in Surgery, and the pro- posal to use it in midwifery, the anaesthetic powers of the ether and other articles employed in that way have served to shed no little light upon the state of the brain in our eclampsia. In my " Letters to the Class," sub voce, I have expressed my views upon the nature of the alterations discoverable in the functions of different parts of the en- cephalon during eclampsia. While I admit that the attack, or onset, is caused by long-continued determination to the head by the rapid revolution of the blood, excited by labor, or by the too intense perception of the pains of labor, I conclude that the profound insensibility ought to be regarded as an 404 PRETERNATURAL LABOR. anaesthesia caused by the presence of much black blood in the brain ; that when the black blood grows blacker and blacker, so as to render the patient dark as an Ethiop, the convulsion is nearer and nearer to its close; that as soon as the black blood comes to cir- culate freely in the cerebellum, the convulsions cease — and that if it pervades the medulla oblongata, the patient dies for want of power in the sources of the vagus nerve. An individual perishes very soon from inhaling ether or chloroform, which is capable in certain persons of carrying its anaesthetic force first upon the respiratory brain. But, if the respiratory brain forget to cause the respiration! The author before cited, Dr. Collins, in a foot note on p. 200, states, "that of nineteen cases recorded by Dr. Joseph Clarke, sixteen were first children. Of thirty-six by Dr. Merriman, twenty-eight were first children. Of thirty by himself, twenty-nine were first children. So that of the eighty-five cases, seventy-three were first pregnancies." In seventeen cases of convulsions under my own notice, ten were first pregnancies, and one not known. Under the dreadful circumstances of this disorder, one reflection ought to strike very obviously the mind of the medical attendant; it is, that if the woman were not pregnant, she would not be assailed by the disease; and the inference very justly follows, namely, the pregnancy ought to be terminated in order to put a stop to the malady. For whether the assault has depended remotely on mere pressure on the great vessels, or on that more metaphysical state called sympathy of the brain and womb, we shall enjoy a far better prospect of rescuing the woman if she can be delivered, than we shall if the womb remains unemptied. But can we deliver — ought we to deliver — when and how shall we deliver, the woman? We can deliver if the womb is dilated or dilatable. We ought to deliver provided we find that the discordant operations of the womb and constitution are likely to fail of bringing the child into the world : for although the womb sometimes acts with great power during convulsion, and is successfully aided by the vio- lent, irregular and spasmodic constriction of the abdominal muscles, and other accessory forces of parturition; it also happens, that the child, in some other instances, makes no progress at all, and the con- vulsions return at short intervals, affording but smallprospect of escape for the patient, inasmuch as they will be likely to continue until the pregnancy is brought to a close by the delivery of the entire ovum. It is, therefore, always desirable that the patient should enjoy the benefits of as early an accouchement as possible, but it must never PRETERNATURAL LABOR. 405 be forgotten that the attempt to effect it must be regulated, entirely, by the fitness of the parts for the operation. There can be no excuse for forcing the hand into an undilatable os uteri, under any circum- stances; and if the medical attendant be ever so anxious to give his patient every possible chance of safety, he will not be excusable, if, on that account, he rather adds to, than diminishes, the risks of her frightful disorder, by intempestive violence in the introduction of his hand. It is true to say that " anceps remedium melius quam nullum ;' ' but let not this trite aphorism lead us to the commission of positive mis- chief, under the impression that we are about to emply a doubtful remedy. Happily for us, however, delivery is not the only resource to which we can apply in our anxious wish to put an end to the danger and distress of the scene before us. What are the circumstances of the case? The patient has, perhaps, complained of severe pain in the head; she is under the excitement of labor; she is heated; the pulse is hard, full and bounding, and greatly accelerated. On a sudden, the muscles of the whole body become convulsed, and the patient writhes, and every feature and every gesture are horribly distorted; the respiration is attended with a hissing noise, and froth issues with violence from betwixt the teeth, which are firmly closed by spasm, giving rise to the peculiar hissing sound above mentioned. The eyes are rolled upwards, or moved in opposite directions; and after a greater or less duration of the paroxysm, the patient sinks into a stertorous sleep, or profound coma, from which she is roused only by a renewal of the convulsive movements, or to mutter in the in- tervals incoherent or inarticulate sounds. Here, then, we have the proofs, as they are the results, of a preternaturnl development of the innervating functions of the brain and spinal marrow, which are caused or maintained by an undue momentum of the cerebral cir- culation. The remedy is, first, to remove the cause by delivery ; and second, to moderate the effect by venesection and evacuants. By the abstraction of blood, we can weaken the force of the circulation of the whole system ; we can make the heart beat gently, and cause it to send the blood in a milder current into the vessels of the brain ; we can thus diminish the innervative function of that organ, and control the muscular excitement, while, at the same time, we abate the hazard of extravasations of blood taking place in the substance of the brain, or of the effusion of water into its ventricles. If there be a case of disease in which bold and daring employment of the lancet is demanded, it is the case of the puerperal convulsion. It is scarcely worth while, almost, to open a vessel to draw off eight or 406 PRETERNATURAL LABOR. twelve ounces of blood. The patient ought to lose from thirty to sixty ounces at one venesection, if possible; and if signs of faintness appear, they should be hailed as the harbingers of success. They will not appear, unless the brain is already, in some measure, freed from its state of tension; unless the blood is no longer pushed upon it with such force as to excite it beyond measure ; and if the mischief at the onset was not too great, there will be a greater chance of saving the patient provided they come on. While we endeavor by the use of the lancet to diminish the mo- mentum of the mass of the blood, which is propelled in vast quantities upon the brain,. we ought not to omit the use of other available means of moderating the turgescence of the vessels of that important organ. The general bleeding should be followed, very soon, by the applica- tion of cups to the temples and back part of the neck, and the hair ought to be cut off, and shaved clean, so as to admit of the application of leeches to the scalp, and the subsequent use of ablutions of the head with iced water and vinegar; or the use of an epispastic, with which the scalp should be covered, if the coma and other symptoms of local disorder are not in a favorable train of abatement. Sinapisms ought to be freely applied to the lower extremities, and to the abdo- men; and the location of them should be changed, from time to time, so as to keep up a constant irritation of some distant part, with a view of diverting the sanguine mass from the cerebrum. Enemata of salt and water, or of jalap mixed with water, may be made occasionally, as a further means of diversion to a safer part of the body. During the administration of so energetic an antiphlogistic treatment, it is in course to observe the most rigorous regimen : indeed, until the dan- gerous symptoms are gone off, very little aliment is admissible : solu- tions of gum, portions of barley or rice water, and where absolute weakness demands it, sago or arrowroot jellies, may be given occa- sionally, yet with great caution. Darkness, repose, silence, should all be considered essential prescriptions, in a case where so important an organ as the brain is concerned, and where the slightest irritations are sufficient to turn the scale in an unfavorable manner. Long-continued ill health may be, in general, expected to follow severe attacks of puerperal convulsions : and nothing but the most constant care and watchfulness can avert many evil affections, the sequelae of a state the most unnatural and trying to which the female constitution is obnoxious. I shall relate some cases of puerperal convulsions that have fallen under my notice, with a view to illustrate for the Student the mode of PRETERNATURAL LABOR. 407 proceeding under such circumstances. I find in my case-book the following entry, for example : Case.— March 13th, 1838.— Mrs. M. in labor, first pregnancy. I was called on Sunday night, at two o'clock. She lacked fifty-nine days to the completion of her term ; was in strong labor pains, evidently of the dilating kind. They returned every five or six minutes. She was sitting up in a chair with her hands very cold, complaining of intense pain of the head. The pulse was very large, and as hard a one as I ever felt ; it beat one hundred and fifteen times in a minute. In consequence, of the circumstances above mentioned, I bled her to the amount of fourteen or fifteen ounces : upon which the pulse was softened, and the headache became milder. It had been most violent at the inferior occipital region, which it now abandoned in order to occupy the forehead, temples and crown. Notwithstanding the bowels had been moved, I gave her some magnesia, seeing she had vomited several times ; hoping that some alvine discharges would assist in calm- ing the violent disturbance of the circulation to the brain. In the morning she got an enema which operated freely, yet the headache continued to be severe, and the pulse somewhat tense. There w 7 as not a great degree of heat, and I expected to find a dimi- nution of the vascular excitement from a severe flooding, which came on at eight o'clock. At nine A. M., the os uteri was about the size of a dollar, hard and unyielding. At twelve o'clock my patient complained of severe pain in the head, and said to me, "I can't see you; I feel quite confused." As soon as these symptoms were made known to me, I was fearful of the ap- proach of a convulsion, and immediately proceeded to tie up the arm ; but before the blood began to flow from the vein, which was opened, she had a most violent convulsion. I allowed the blood to flow until the pulse became reduced, and then the convulsion went off. I did not take more than eight or ten ounces, which was a very small quan- tity, in view of the effect to be produced, and actually produced by the operation. Sinapisms were applied to the feet. Mrs. remained in a state of insensibility for twenty or thirty minutes after the disappearance of the convulsive movements, and then recovered her senses. She now had a very considerable flooding, which con- tinued to trouble her during the morning. As soon as the spasms ceased, I ruptured the membranes, and the foetus, which was dead, was expelled at half-past twelve o'clock. It was living at seven in the morning. 408 PRETERNATURAL LABOR. She had no more spasms or convulsions after this, but the pain, like a clou (or nail in the head), was so violent that I ordered leeches to the temples in the afternoon, and gave her a proper dose of salts and magnesia. The pulse continued to abate of its violence regularly. The medicine operated freely ; but at seven o'clock the following morning, she was leeched again on account of pain in the head, and was perfectly comfortable from that time. This woman was dressed and walking the floor within four days after her accouchement. As regards this case, I presume any one of my fellow practitioners would readily say that it was well managed, notwithstanding the smallness of the second bleeding, since I resorted early and promptly to the use of proper remedies. I conceive that the resort to venesec- tion in the first visit was highly expedient, and though it did not ward off the threatened convulsion, it doubtless mitigated it, and rendered it more manageable by the subsequent treatment. The only real resource in the puerperal convulsion, is in the use of the lancet; and the rule ought to be established, that a woman is menaced with convulsions, if she is affected with headache near her term, especially if that headache be referred to the crown, or to some point (clou) that could be covered with the end of the finger. I intend never to hear such complaint without pondering upon the value of the indication it throws out, namely, that the lancet, the lancet, and nothing but the lancet, is worth your confidence. I shall make these same reflections in similar circumstances of pregnancy even when not advanced be- yond the sixth month, having lately had occasion to witness a despe- rate attack in a young primipara five months gone in her gestation. Case.— March 13th, 1838, called to Mrs. at six o'clock this evening. She was sitting in her parlor. She expects her labor every hour, the time being out. I said, " How d'ye do?" " I feel weak," she replied. "I can- not see more than half of anything I look at; I can only see one-half of your face: I can see only one of your eyes." I asked her to cover her right eye with her hand. " Can you see the whole of my face now ?" " No!" " Cover your left eye ; can you see properly now ?" "No; I can see only half." "Have you any pain, weight or dizzi- ness of the head ?" "No!" "Any sick stomach?" "No!" "How long have you been so?" "About half an hour!" " Were you ever so before?" "No!" "Any numbness or want of feeling in the hands?" "No; but my hands are cold." The pulse was about PRETERNATURAL LABOR. 409 eighty-five, and a little tense, yet moderately so. The bowels not bound. She now went up stairs, and I took four ounces of blood from the arm, having bled her eight ounces six days ago: when I had bled her she could see the whole of my face, or the whole of any object she looked at. She did well. It is also a curious circumstance, and one well worthy of your attention, that the blackening of the blood, or its conversion into venous blood by the interruption of the respiratory or oxygenating function, should be the means provided and designed by Providence for the cure of the paroxysm. When the whole sanguine mass has become carbonated, the brain and the spinal cord must cease to innervate the muscles convulsively; and the speedy relaxation of every rigid muscle permits the restoration to the lungs of their oxy- genating power ; so that, in a few moments after the countenance has been black and deformed in every feature, we have the pleasure to see it recover its whiteness, though ghastly pale ; while the brain, I mean the whole brain, wakes up to the renewed performance of its organic as well as its intellectual offices. When, therefore, in look- ing upon these frightful scenes, you see the face of your patient grow- ing darker and darker, you will discover in that very circumstance, the hopeful announcement of a speedy close of the distressing exhi- bition. I think that, in a majority of cases, you may expect to find the whole brain recover soon after the ceasing of the convulsive innerva- tions; but this is not always the case; for, in some patients, I have noticed a profound coma to succeed the convulsions; the hemispheres, the cerebellum, and the tubercula quadrigemina, remaining oppressed and extinct, as to the power, while the medulla oblongata and the spinal cord had resumed a quasi regular exercise of their forces. In a case that fell under my care in this city, a few years since, the lady had convulsions, which occupied the hours from about 11 o'clock A. M. till near 5 P. M. During these convulsions she gave birth to a dead foetus of seven months; remaining wholly unconscious during the process. I say unconscious, though she moaned a little, during the labor pains, like a person disturbed by some distressing dream, or like one under the influence of ether in a surgical operation. Some hours after the last convulsive attack, and after she had been lying profoundly still, as if asleep, she moved with spontaneous or voluntary motion, showing that the cerebellum was aroused to its true office of directing or co-ordinating the power extricated in the brain and spinal 410 PRETERNATURAL LABOR. cord. She soon afterwards spoke and recognized the Toices of friends, and was perfectly reasonable ; showing that her hemispheres had waked up to their office of intellectual perception and combina- tion. After having for some time spoken, and spoken well, she said, " How dark it is — why do you keep it so dark ? " " It is not dark," replied I ; " do you not see the candle?" " Oh no, there is no candle here." " Yes, dear Mrs. , here is the candle ; see — I hold it just before your face." Her beautiful eyes were open, and she turned them at will, to look for the light which shone into their large dark pupils. " Do you not see the light?" said I again. " Oh no, Doctor ; why do you say so? I'm sure there's no light here." She was totally blind : that is to say, hertubercula quadrigemina were still oppressed, while the rest of her brain had recovered, being liberated from the thraldom of the congestion. After some time, the dawning light of day having considerably increased, she perceived it, and cried out, " Why, it's daylight!" and I then knew that the tubercula quadrige- mina had also recovered. There is a useful moral in this statement — it is that we should look to it, in the conduct of all such cases of disease, that all the parts of the brain recover — and that in so far as our measures may have effi- cacy, we fail not to employ them to the entire subduction of even the last vestiges of morbid action, or oppressed or suspended power. These vestiges of disease we may clearly discern in the intellection, and in the muscular innervations. The successive recovery of the different parts of the brain in this case is interesting, as it is analogous to the incidents observable under etherization. When a patient is subjected to the inhalation of ether, the different parts of the brain are affected in succession ; but not always in the same succession. The sensitive cords of the cerebro- spinal axis are, in etherization, plunged into a state of insensibility — leaving the hemispheres capable to perceive and understand what the quadrigeminal tubercles see of any operation that the surgeon is per- forming. Or, the motor fibres are put asleep, yet the sensitive ones communicate to the conscious mind the painful impressions which the mind perceives — but which it forgets, as it forgets a painful dream. If the etherization go very far, the hemispheres, the cerebellum, the tubercles, and the motor and sensitive cords, are all hushed in a profound state of aperception, both of the direct and the reflex influ- ences or impressions: the medulla oblongata alone continues to do its work of irradiating the parts that are under the control of the pneumogastric. If the ether be given long enough, and in quantity PRETERNATURAL LABOR. 411 sufficiently great to quell its force of innervation also, the patient dies. Hence the medulla oblongata is called by M. Flourens the life-tie — the vital knot — le nceud-vital. The oxygenating power depends upon it, and without oxygen — no neurosity. Take away the ether in good time ; admit the pure atmosphere to the lungs, and the functions of the whole brain are revived — so, in our eclampsia, as soon as the abnormal state of the encephalic circulation gives place to a normal, or, one more nearly normal, the brain wakes up to its duties again, and the patient sees, hears, speaks and acts, with the most perfect co-ordination of all those vital forces that are dependent on the brain and cord. If, in etherization, we press the administration of the drug to the point of quelling the vital-tie of the medulla oblongata, she will die, and we will find no neucroscopic lesions in the encephalon. So, likewise, in the speedy dissolution under eclampsia puerperalis ; the autopsia discloses no lesion of any part of the brain. Are we sur- prised that the woman should die without perceptible physical lesions of the brain? We are not at all surprised if she disclose none such when destroyed by ether-inhalation. May not the brain perish under the one influence as well as under the other, and yet, dying, leave no sign ? In eclampsia, there is always abolition, for the moment, of the power of the hemispheres, always of the tubercula quadrigemina, and always (perhaps!) of the cerebellum. All these revive, and are extinguished again and again, as the paroxysms are repeated or sus- pended by turns. When the case has come to its close, and the patient is restored, where are the lesions ? No trace of them remains. But — and here is the explanation — if the medulla oblongata be affected equally with the others, the patient dies, because the sources of the respiration are cut off. There are many circumstances, the concurrence of which tends to the development of the eclampsic convulsions of pregnant, puerperal, and lying-in women. For many women, the whole state of gestation from conception to labor, is a state of nervous excitement or hyper- esthesia, which renders the subject specially obnoxious, under the application of exciting causes, to convulsive or irregular, non-con- formable innervation. Whether this too susceptible nature depends upon an altered crasis of the neurine, or whether it arises from modi- fications of the blood, developed during the gravidity, remains to be ascertained ; and it contains questions full of interest to the patholo- gist and the therapeutist. 412 ' PRETERNATURAL LABOR. • Cramp. — I do not remember to have met with any published state- ment of cases of cramp in the legs as causes of Preternatural labor, and yet having met with examples of it in my own practice which rendered the use of forceps absolutely indispensable, I have thought fit to relate them in this book. There is no need for great surprise at the announcement of this cause of preternatural labor, since it is well known that the compression or tension of a nerve may give rise to pain so great as to disturb in the most violent manner the functions of life. The head of the foetus in descending may be impelled with so great a degree of force against certain of the internal sacral nerves, as to render the patient almost or quite frantic from the agonizing sen- sations developed thereby. Under such intense suffering, the womb may cease to act, or act inefficiently, and the practitioner, seeing that the distress of his patient is greater than she should be permitted to bear, hastens to extend to her the most prompt and efficient means of relief. Without further discussions of the reasons which, a priori, should include the violent cramps to which I refer, among the causes of pre- ternatural labor, I beg to refer the Student back to page 29, for ac- counts of the cases, which I have no occasion to repeat in this con- nection. Prolapse of the Cord. — There are other circumstances that may suffice to convert a natural into a preternatural labor. Among these may be mentioned the prolapsion of the umbilical cord. The cord very rarely gets down below the presenting part of the child, and we have reason to be astonished at the rareness of the accident, when we consider the great length of that part of the secundines. The cord is sometimes found to be six feet in length. The mere falling of the cord could not, under any circumstances, interfere with the ability of the woman to deliver herself, because it could not inconveniently oc- cupy any space in the pelvis to the hinderance of the birth. The importance of the accident is relative only to the child, and not to the mother. The child is placed in imminent danger of dying by as- phyxia, from pressure on its umbilical vein and arteries when they fall below its head in labor. Hence, the necessity of expediting the delivery by manual or instrumental means, and the conversion of the natural into the preternatural kind of labor, either by turning or the forceps. I do not wish to be understood as advising a resort to art as an PRETERNATURAL LABOR. 413 invariable rule of practice in such cases; for it fortunately happens, In some instances, that the pelvis is large and roomy, the os uteri dilates rapidly, and the pains are sufficiently strong to assure us that the child will be born so speedily by the unaided powers of nature, as to make it unnecessary for us to interfere. The child has so good a chance for escaping uninjured, in a rapid delivery, that it is more advisable to confide in that chance, than to expose both the woman and the child to the hazards of a forced delivery. We also have the advantage of being able, by touching the prolapsed cord, to ascertain the state of the foetus : if the pulsations continue vigorous, we shall suppose the child to be doing well, and if they become faint and feeble, we shall be able to resort to the forceps or to turning, as the case may be. When the prolapsed cord has no pulsation and is cold, the child is dead, and of course no steps need be taken on account of the prolapsion, which, in that case, becomes a matter of indiffer- ence. Prolapsions of the cord rarely take place after the mouth of the womb has become well dilated. The cord is probably down, in these cases, before the labor begins ; it is found protruding through an os uteri not larger than a half dollar. Such an os uteri is inac- cessible to the hand; therefore the accoucheur can by no means return the fallen cord into a cavity to which he cannot have access. He makes vain attempts to succeed by pushing the cord back within the constricted circle of the mouth of the womb, from which it again immediately escapes. If he could carry the cord quite above the head, it would stay there. It is evident, therefore, that with the hand alone, little success can be expected, in even the most patient endeavors to get the prolapsed organ in a place of safety. I have succeeded with my hand alone, but have much more often failed. Many various methods of repositing the cord, or putting it back into the womb, above the foetal head, have been proposed ; they have mostly been found ineffectual, the cord being apt to fall down again, even after it had been put into the proper place. I have never yet had an opportunity to try a method which I beg leave to propose to my readers, and which is as follows: Take a piece of riband or tape, a quarter of an inch wide and four or five inches long. Half an inch from the end, fold the tape back, and sew the edges so as to make a small pocket. Then fold the other end in the opposite direction, and sew that also, to make a pocket of it. Now if the cord be taken in the tape, and held as in a sling, a catheter may be pushed into one of the pockets, and that one thrust into the other, so that we shall have the cord held as in a sling, which is itself supported on the end 414 PRETERNATURAL LABOR. of the catheter or womb-sound. Let the catheter be now pushed up into the womb, beyond the foetal head ; it will carry the secured portion of cord with it, and the catheter being withdrawn, the tape is left in the uterine cavity, where no harm can be occasioned by its presence. If required, several such tapes could be secured round the cord, and all of them fixed on the end of the same catheter, and pushed at the same moment far up within the cavity of the womb. Fainting. — Fainting or syncope, when often repeated in labor, is sometimes of so alarming a nature as to induce the practitioner to be willing to expedite the birth of the child, in order to put an end to so threatening a symptom. No prudent person, however, would be led to perform so serious an operation as Turning, or the application of the forceps, without being first fully convinced of its necessity. Of the degree and imminency of the danger here, none but a medical person can be supposed a competent judge, and the case must be left in his hands, strengthened, as he should be, by the counsels of a professional brother. I shall feel satisfied, therefore, to have merely referred to this cause and to leave it to the discretion of the attendant physician, without any additional remarks. Hernia. — A hernia, especially if of a kind liable to strangulation, might be a warrant for the accoucheur to hasten the moment of relief by the employment of the resources of art. We have also, in a few very rare instances, the dreadful accident of laceration of the womb or vagina to contend with. Of course, as soon as either of these acci- dents is known to exist, we should resolve to take the management of the delivery into our own hands, in order that we may, at least, save the infant, while we can also offer some faint chances of hope for the safety of the patient. Anemia. — Among the causes of preternatural labor, I ought not to omit a reference to a state of anaemia frequently met with in the pro- gress of pregnancy, and which, when it has attained a certain degree of intensity, is sometimes attended with circumstances of such grave consequence as to render the labor, when it does come on, thoroughly preternatural. The state of pregnancy is, as I have elsewhere re- marked, for certain women, not a purely physiological, but an emi- nently pathological one, and for the most part, the constitutional dis- turbances in them manifested, are chiefly referable to a state of the haematosic power. The woman who develops the uterus and its con- PRETERNATURAL LABOR. 415 tents in gravidity, is not unfrequently found to be incapable of sup- plying the requisite quantity of blood for the ordinary wants of the constitution, and for the extraordinary demands of gestation. In some of the cases, so great is the destitution of the solid consti- tuent of the blood, which ought to amount to 210, while the watery part should be 790, that the solid portion is reduced perhaps as low as 100, or 150, while the watery element is increased in the same ratio. But, inasmuch as the blood is not only the pabulum of the body, but also its oxygeniferous medium, it is clear that in this state, there is not only a great debility from the failure of supply for the nutri- tive accretions, but a great derangement in the action of the nervous forces, for want of a thorough supply of oxygen. I am not more tho- roughly convinced of any principle in physiology than this, namely, that the stream of nerve force, conducted along the nervous fibrils to the distal points in the organs, is in a ratio with the changes produced in the neurine by the contact and combination, with oxygen. A perfect blood, viz., blood consisting of 210 solid constituents, and 790 water, is capable of taking out of the respired air in the lungs, the amount of oxygen required by the constitution of the indi- vidual, greater or less according to the exigencies of it under action or repose, whether physical or psychical. Such a blood can take from the atmosphere any quantity of oxygen required, since the blood, being perfect, is in a fit condition to take up a supply equal to the demand. Such blood is thoroughly and physiologically oxygeniferous ; but if the solid content of the blood be reduced one-half, and the aqueous element be increased proportionably, the blood, although still oxygeniferous, is far less oxygeniferous; and, though capable of taking oxygen out of the respired air in the lungs, is incapable of taking a supply equal to the demand. Therefore, when the nervous mass would send down its streams of biotic force to the distal points in the organs, those streams will be feeble, irregular and incompetent to the perfect manifestations which are required to constitute a healthful play of the said organs. This is the fact with regard to all highly anse- mical patients, whose debility is evinced not only in their diminished muscular energy, but also in the imperfectness and irregularity of their sensational, nutritive and secretory forces. The circulation, the respiration, and the innervation constitute a trinity of forces, mutually dependent, and incapable of existence the one without the other. But in anaemia, the respiration cannot do its office of breathing upon the blood, which, from its diluteness, cannot be perfectly oxygeniferous. Here is a failure, then, in one side of the triangle. But an imperfect 416 PRETERNATURAL LABOR. blood gives an imperfect innervation. This is an attack upon another side of the triangle. An imperfect innervation implies incompetent power of the circulation. This is an attack upon the remaining side of the triangle, which is equivalent to saying, that in anaemia, the lungs, the brain and the heart are cast into a pathological condition, the prime element of mischief consisting in a diminished crasis of the blood, — for "the blood is the fluid body, and the body is the fixed and rigid blood." Now, a woman, whose lungs, heart and brain — which constitute, as it were, a triune centre of life — have become disordered by anaemia, goes through her pregnancy with difficulty and hazard, aggravated in proportion to the intensity of the disorders of those prime seats of her life forces. She, in an especial manner, becomes the early subject of those infiltrations of the cellular tissue that are denominated (Edema Gravidarum. A pregnant woman in this state, daily loses, or daily wastes, by its escape into the subcutaneous cellular tela, a great quan- tity of the serum of her blood, requiring for its reparation, a conse- quent effort of her hsematosic power which serves to exhaust the organs in which that haematosic force resides. Besides this, much diseased action results from the presence and pressure of the water of infiltration. Among the evils of the anaemical state, one chiefly to be dreaded in the pregnant woman is weakness or flabbiness of the muscular textures that, to a greater or less degree, invariably attends an aggra- vated anaemia. I do not allude to the weakness and flabbiness of the muscles of relation, nor even to those of digestion, for they might be- come so without seriously compromising the security of the patient. I allude rather to extreme relaxation and flabbiness of the muscles of the circulation. My clinical experience has presented to me a con- siderable number of examples in pregnant women, in whom the mus- cular structure of the heart had become so relaxed by anaemia as to permit the heart itself, in all its cavities, to be greatly augmented in volume, — to such a degree indeed as to allow its impulse to be per- ceived over large portions of the thorax. I feel well assured that many instances of this sort are misconceived of by the practitioners as being primary maladies of the heart itself. I have seen them so treated ; and have so treated them myself. But multiplied observa- tions have convinced me that the supposed diseases of the heart often prove to be merely anaemical relaxation of its muscular texture, which are perfectly recovered from when the anaemia wholly disap- pears. During the relaxed condition of the muscular substance of PRETERNATURAL LABOR. ANJEMIA. 417 the heart, its walls yield to the lateral pressure of the blood forced into its cavities ; and its valves, having their edges too far separated by these dilatations, become incompetent for their offices. They no longer completely prevent the reflux of the blood, or its regurgitation against the current. Hence the loss of rhythm, hence the violent palpitations, hence the accumulation upon the pulmonic side, and hence the inability of the systemic side, to carry on the arterial injec- tions to the brain and to the whole constitution. Hence the violent oppression of the respiratory power, and the half asphyxiated condition of the patient whenever she happens to be called upon for extraordi- nary exertions of muscular force, or extraordinary exercise of percep- tive or intellectual power. The Student ought, in this representation of the state of the anaa- mical gravid patient, to perceive to what great risks she is exposed of serous effusions into her pericardium at least, if not into the pleuric cavities. She is prone to these effusions already in consequence of her anasarcous condition; and when, to the difficulties arising from a relaxed and dilated heart, a thin, watery and therefore imperfectly oxygeniferous blood, and all the sequelae thereupon depending, he supposes the presence of a quantity of serum within the chest, he will obtain a startling view of the dangers of the parturient ansemical pa- tient, and he will be ready to regard the labor which shall terminate such a pregnancy as a preternatural one, even should it not require his aid by the hand or by means of instruments. Case. — In 1841, I attended Mrs. S. R. during her first pregnancy. She was about twenty-two years of age — a short, but stoutly made woman. She was about six months gone with child when I was first called to see her, and was recommended to me by a medical friend, who declined to take charge of her case, supposing her to labor under disease of the heart, which rendered her situation extremely precarious. So great was the embarrassment of both the circulation and the respi- ration, that my esteemed friend had great cause to apprehend she might die in labor, from the exertions she should then be called upon to make. There was already great CEdema gravidarum; and slight muscular effort in moving about her apartment, served dangerously to augment the respiratory and circulatory embarrassment. I shall cite from my work on " Females" a notice of this case, which I am de- sirous to present to the reader of this volume. It may be found there, together with other observations on anaemia in pregnant women, at page 505. 27 418 PRETERNATURAL LABOR.— ANEMIA. " She presented all the appearances of great dilatation of both the auricles and ventricles of the heart — the impulse of which was per- ceptible to the right of the middle of the sternum. The pulse, except when she was in a state of recumbent rest, was large, gaseous, un- steady and very sudden. The face and whole surface were pale and flabby, the cornea nearly uncovered of the upper palpebra. The respiration was troubled, and on the least motion or emotion, precipi- tate and difficult. At the end of the seventh month, the lower limbs became considerably infiltrated, and the power of muscular motion much curtailed in consequence of its being always attended with violent beating of the heart, breathlessness, and uneasy sensations in the head, as pain, vertigo, noises and dimness of sight. "The progress of the pregnancy was accompanied with aggravation of all these appearances. " On different occasions she had attempted to walk in her house, and had fallen on the floor in a state of insensibility. I, being hur- riedly notified of such an accident, arrived on one of the occasions, at the house, soon after she was taken up from the floor and laid upon the bed. "I found her absolutely pale, scarcely able to speak, and completely blind when I arrived. She knew my voice, and opened her eyes to look at me as I spoke: — the eyes were bright, the pupils natural, but she was wholly without sight. She complained of some degree of fulness of the head. The pulse was still agitated. In a short time the sight returned and was perfect as before. 1 do not recollect how many times she actually fell in this manner, and with such following phenomena, but the accident was repeated several times. In nearing the term, the swelling of the limbs from oedema was greatly augmented, so as to affect the thighs, and the buttocks, and labia; the pericardium became also the seat of a dropsical effusion, so that a complete or- thopnea soon declared itself. " My patient could not lie down day nor night. If she sat up with a pillow against her back and shoulders, the oppression became so dreadful, she was obliged to throw them away; but, requiring some support, she placed her back against one of the posts at the foot of the bed : leaning on the slender cylindrical bed-post, she could find the needful support or rest without the oppression brought on by pil- lows or cushions. Here she sat day and night for many days, with very bad thin blood, which was imperfectly oxygenated, and so, greatly increased the disorders of the innervation. Her condition was truly deplorable, and it was difficult to imagine that the heart could PRETERNATURAL LABOR. ANAEMIA. 419 ever recover its form, consistency and power, should she even escape death in the impending conflict of labor. In fine, labor came on, and in due time I delivered her with the forceps in order to save her from the necessity of exerting any voluntary force. " This young woman is now in the enjoyment of perfect health, hav- ing since given birth to several children, without any accident or extraordinary trouble whatever. Nor does she at present labor under any disease of the heart. Case. — Many years ago I had charge of the case of Mrs. F. B., who was at that time the mother of two children. She had been in delicate health since the birth of the last one, and came under my care during the last sickness of a medical friend, who had treated her many months as laboring under disease of the heart. To rise from her bed, and take a seat upon the sofa, was sufficient, on many occa- sions, to develop signs of approaching asphyxia by the disordered circulation consequent upon even the most moderate muscular exer- tion. I frequently observed the respiration and the heart's action to be so violently disturbed by these moderate efforts as to excite in my mind apprehension of her imminent death. The pulsations of her heart were discoverable far to the right of the sternum, as well as in the left side of her chest. She was deadly pale ; her lips swollen and blue ; and to lay the expanded palm upon her breast was to discover under it a quaking and a tremulous motion like that perceived upon pressing on a quagmire. After a long treatment her health amended somewhat. She conceived, and proceeded with doubt and difficulty to the term of her utero-gestation. I very confidently expected she should perish in her approaching labor, during the greater part of which she was obliged to be raised upon pillows on account of a distressing orthopnoea. As the labor drew very nigh its close, it was necessary for her to take a lower recumbent position for the greater convenience of her delivery. I expected constantly, during the progress of her labor, to find her convulsed, and in fact the crisis which was brought about by the last uterine contraction, and the final strong tenesmic effort of expulsion which brought her infant to the light, was instantly followed by a short but most frightful convul- sion, which, as it retired, left her apparently moribund. Somehow, — I know not how, — yet by the spontaneous powers of the constitution, she soon revived from this condition, and had no further serious trouble during her lying-in. In fine, this lady recovered a state of robust health. Her vast dilated heart, which seemed to me as large 420 PRETERNATURAL LABOR. ANEMIA. as a quart measure, regained its normal generical magnitude and force, so that a few years afterwards, she ran before me as light as a girl to the fourth story of the Washington Hotel without drawing a long breath on reaching the top. Her heart, I feel perfectly assured, was sound and well again. This was a case of eenemia gravidarum, and the labor was preter- natural, for it was orthopnoeic, and it was followed by a terrific con- vulsion. With regard to the treatment of labors rendered preterna- tural, by aggravated degrees of anaemia, I have only this counsel to give to the Student : 1 . That he should clearly disclose to the friends of the patient, the whole extent of the perils by which she is sur- rounded, while he gives to herself the reasonable assurances of his hope to conduct her safely through the whole, course of her labor. 2. That in the Conduct of the case, he should take all possible precau- tions to avoid undue excitement of the nervous and vascular systems, forbidding the bystanders to exhort her to bear down, and frequently advising her to bear her pains patiently, waiting for their dilating effects, and so continuing until the presenting part, having come within reach of the hand or the forceps, may be gently drawn away almost without any spontaneous assistance of her own. If there can be found a case, in which the power of the forceps can be deemed more beneficent than in another case, it is that in which a parturient woman, with an immensely dilated heart, disparted valve, with cel- lular infiltration, and serous effusions within the chest, has barely power to live, but not enough both to live and expel the child from the womb. Perhaps it may not be inapposite in this place, to say that precau- tions should be taken, during the progress of the pregnancy, whereby to obviate these awful conditions of the pregnant woman at full term. It is true that the woman maybe greatly infiltrated in pregnancy with- out having a dilated heart, and such infiltrations readily disappear after the birth of the child; but they almost never disappear without leaving the patient pale and chlorotic — or, in other words, anaemical. I shall think that the woman excessively affected with oedema gravi- darum, should always be held to be threatened with relaxation or flabbiness of the muscular fibres of the heart, and the thereupon dependent disorders of which I have spoken. In order to overcome the oedema, it might in some cases be necessary, and no doubt is often effectual, to draw blood from the arm, to regulate the diet carefully, to entertain a soluble state of the bowels, and more than all these, to command the patient for a week or more than a fortnight even, to take PRETERNATURAL LAROR. EXHAUSTION. 421 an unintermitted horizontal rest upon her bed or couch. To rest for a long time, and in doing so to avoid the dorsal decubitus as much as possible, is to put a stop to the progress of the infiltrating secre- tion, which I believe in true oedema gravidarum always begins and ends in the most dependent parts — to wit, the feet and legs. The circulation in such a posture, becomes more and more moderate, and the aqueous humor already effused, being now dispersed almost over the whole of the subcutaneous cellular tela, is imbibed by thou- sands of absorbing orifices, to whose action it could never be exposed while accumulated solely in the lower part of the trunk and in the inferior extremities. I confidently recommend this mode of treat- ment, and I assure the Student that I saw a young lady, a primipara, who in October, 1848, was five months past gone with child, in whom the oedema gravidarum had distended not the legs only, but very much also the pudenda; in whom the whole of the dropsical effusion dis- appeared in some ten days of a horizontal recumbency which she ob- served in consequence of my recommendation. These dropsical effusions should not be regarded by the Student as always the signs of an hydropic diathesis, but rather, as I have elsewhere explained, as the results of mechanical pressure and obstructions upon veins and absorbent trunks. Where the oedema has become very great, and the ansemical condition aggravated, there arises a real hydropic tend- ency or diathesis which leads to effusions into the belly or into the chest. Common experience and observation show very clearly the pro- priety there is, in all those cases where the anaemia has become thoroughly established or well set in, to prescribe for the patient the use of ferruginous tonics. It is scarcely necessary for me to repeat in this place, that the article most suitable for the occasion is the metallic iron of Mr. Quevenne. It may be given in doses of two grains in the form of a pill, to be taken immediately after meals three times a day. Exhaustion. — Labors are rendered preternatural by the occurrence of what is called Exhaustion. The causes of exhaustion are nume- rous. Any disproportion between the child to be born, and the straits or the excavation of the pelvis, might, by protracting the vain efforts of the woman, serve to exhaust her forces. This disproportion may be absolute or relative. The child may be preternaturally large, to that degree indeed as to make it impossible, or nearly impossible, for it to pass unreduced in magnitude through the parts of the female. 422 PRETERNATURAL LABOR. — EXHAUSTION. Or the child may be of the normal size, while the pelvis is of under size, though in other respects well fashioned. Again, both the child and the pelvis may be duly proportioned to each other; yet the child may so present itself to the passages, as to retard or render impossi- ble its exclusion without extrinsical aid. Thus the child may pre- sent its head in extension at the superior strait, and descend in face presentation, with its chin to the sacrum and its forehead to the front of the pelvis; and it would prove a very extraordinary circumstance should the woman fail to fall into the state of Exhaustion, un- less delivered by the hands of the accoucheur : or there might be in the labor, a departure of the chin from the breast; or there might be such an occipito-posterior position of the head as to cause the two extremities of the occipito-frontal diameter to become immovably fixed upon opposite surfaces of the pelvis, constituting what is called arrest, and ultimately impaction, of the cranium of the foetus. An unturned or unevolved shoulder presentation, or a prolapsion of a hand or a foot along with the head ; or the impaction of the parts of two children at the same time in the pelvis, — might serve to exhaust the expulsive as well as the vital powers of the woman. In addition to the above causes of this kind of preternatural labor, we ought not to omit to mention rigidity of the vaginal cervix, whether simple rigidity, or whether rigidity arising from carcinoma, or the remains of uncured inflammation of the os uteri. In addition to these causes, the dynamic action of the womb may be contravened by a rheumatical state of the organ, or by the intrusion of a loop of intestine betwixt the front aspect of the womb and the contracting abdominal muscles, occasioning, during the labor throe, such great pain in the prolapsed loop of intestine, by compressing it between the hardened globe of the uterus and the contracting abdominal muscles, as to destroy the complacency of the constitution, and to overcome the proper conform- ableness of the innervations ad par turn. It is scarcely necessary for me to enumerate, in this connection, all the possible causes of exhaus- tion in labor; it is better that I should say to the Student that the parturient action of the uterus and accessory muscles, is effected at a certain expense of power developed in the nervous mass of the patient, and that while a woman in ordinary labor, and even in very severe and long protracted labor, is generally found to be capable of evolving from her nervous mass, and of sending down to the uterus and adjuvant muscles, an amount of innervative force sufficient to enable them to overcome all obstacles to the birth of the child, yet these obstacles are in some instances so rebellious, and so inexpugna- PRETERNATURAL LABOR. EXHAUSTION. 423 ble, that the sources of the nerve streams become utterly exhausted, and the cerebro-spinal axis refuses any longer to repeat vain attempts to deliver, the woman lying motionless, feeble, and in a state which, to be truly denominated, should be called the commencement of the moribund state. Let the Student consider a little the condition of the parturient wo- man as above represented. He will see that she has long suffered the extreme of sensative distress or pain; that her heart and lungs and brain have co-operated in vain for the effectuation of her deliver- ance; that the lungs have breathed at a greatly increased rate upon the blood to charge it more abundantly with oxygen; that the heart's action has been enormously augmented in frequency and force, in order to hurry this oxygeniferous blood to the brain ; that the brain, combining with its oxygen, has evolved and sent down to the struggling organs and to the whole constitution, torrents of nervous force, so that not they only, but the whole constitution, have been actuated to the highest possible strain of their life-forces. Let the Student conceive that this force-production and this actuation under its stimulations, must come to a certain end, and that in doing so there will be found not disorders only, and feebleness and anaesthesia of the living solids of the body, but disastrous changes in the crasis, mixt, or constitution of the blood. And herein he will see a representation of the state of the woman lying in exhaustion after vain attempts to deliver herself in a protracted labor. The heart has lost its force and increased its frequency, for the sources of its innervation are greatly diminished, and its own physical structure has become changed in impression, ability and power. The respiration is hurried and short, for the diaphragm, the respiratory piston, makes short strokes frequently re- peated — for its power is nearly done. These states of the respiration and circulation necessarily involve disordered and diminished evolution of life-force in the nervous mass, and the blood, the fluid body, be- comes fatally changed. Let the Student take heed, therefore, of the beginnings of exhaustion, for she who has gone far into it is irreco- verably gone into it. It is exigent to deliver her, and that in the manner least likely to consume her feeble remains of life power. Ex- haustion is preternatural in labor, and even if it were not so, the duty becomes incumbent on him to render the labor preternatural by de- livering with the vectis, the forceps or the embryotomy forceps. Let him bring the chin to the front of the pelvis ; or let him use the vectis; or let him reduce its magnitude with the perforator, in order that the child may be born; or let him extract it with the forceps. Let him, 424 PRETERNATURAL LABOR. EXHAUSTION. ■where there is departure of the chin and consequent impaction, restore the chin to the breast, or convert it altogether into a face presentation ; let him convert the occipito-posterior into an occipito-anterior position ; let him return the prolapsed arm above the head ; let him put away the foot, and give space for the head to descend through the pelvis ; let him turn and deliver, or promote the spontaneous evolution of the fcetus ; let him disengage the prolapsed loop of intestine from betwixt the womb and abdominal muscles; let him reduce the size of the hydrencephalic head of the fcetus, in order that it may pass the straits; let him take away from the woman any further necessity to evolve biotic force for the expelling womb and abdomen ; let him take away from her agonized nervous mass all further occasion to perceive the irritation, the pressure, or the pain, and then, tenderly placing her upon her pillows, wait until perchance her blood may be redeemed from its perilous disorders, and her neurine again come to send down its streams of biotic power to all her organs and organisms, with a lessened, conformable and normal intensity. Signs of Exhaustion. — There is a great difference between ex- haustion and the mere cessation or suspension of labor pains. The woman may fall into labor, and after proceeding many hours towards the accomplishment of her delivery, she may stop for many hours to commence again, and again to cease, the work of expulsion. The act of labor being established, does not necessarily imply that the effort shall be continued until the completion of the process. A woman may be in labor during several hours daily for a whole month, dilating her os uteri to the size of a half dollar, and then closing it again so that it shall become as small as before the commencement of the process ; so a woman, even in advanced labor, may cease to labor for hours, or for many days, and yet suffer no perceptible illness. Such a case is not sickness. It is not exhaustion. Hence I warn the Stu- dent that he ought not to commit the serious mistake of concluding merely from the cessation of the pains, that the woman is in a state of exhaustion, or even beginning to fall into that dangerous state. I know not why it happens, as it often does happen, that labors begin and cease without any apparent indisposition ; but I know that the records of a man's practice should furnish him with many instances of the kind. To know the state of real exhaustion, let him look upon the con- dition of the vital triad — the brain, heart, and lungs; or, in other words, the innervative, the circulatory, and the oxygenating functions. PRETERNATURAL LABOR. EXHAUSTION. 425 He will discover the condition of the brain by the psychical signs — illusions, hallucinations, delirium, altered temper; and by the physical signs, loss of co-ordinating power in the cerebellum, seeing power in the quadrigeminal tubercles ; the respiratory power in the state of the respiratory bulb ; by lessened intensity of the nervous force in general. The embarrassment of the circulation is discoverable by lessened power of systemic injection, and augmentation of the frequency of it — the oxygenation shows its failure by change of temperature, and of colorific power, all of which must be studied and profoundly studied and understood in the manifest action of the mind and the whole physical conduct and aspect of the patient. In a difficult labor tending to exhaustion, there will first be discoverable a most marked violence in the effort of the arterial pulse, which becomes voluminous, hard and frequent — beating about 110 pulses per minute. Whenever, after some time of protracted and fatiguing efforts with such a state of the pulse, the contractions of the heart are found to be repeated 120 to 140 times a minute, the volume of the artery becoming re- duced, the temperature being also lessened, with a dry mouth and parching thirst, loss of courage and resolution on the part of the poor woman, the presenting part in the meantime making no progress whatever, exhaustion has begun, and has already proceeded even too far. Exhaustion is not likely to arise from the resistance of the soft tissues only. Even the most rigid cervix uteri gives way when the strength begins to go down. So also the most resisting perineum yields before the constitutional force is abolished or overthrown. Bat the impacted head, the unturned shoulder, or the impracticable pelvis, can never give way, and the efforts of the nervous, circulatory, and oxygenating forces must ever fail in presence of such inexpugnable resistance. In such instances the sources of the innervation must, sooner or later, become wholly exhausted, and the woman be lost. In the beginning of exhaustion, to deliver is to save the mother. A too long procrastination of her deliverance is most apt to insure her death. Exhaustion not being likely to ensue in consequence of soft resist- ance only, we have, even in the most obstinate cases of soft resistance, little to fear from contusion and a coincident irritation or shock; nor have we ground to look for dangerous sloughings at a later period. But when exhaustion arises from vain attempts to overcome the re- sistance of solid bone, we have, in addition to the direct effect of such efforts, in vitiating the blood and modifying the crasis of the nervous 426 PRETERNATURAL LABOR. DESCENT OF BOWEL. mass, much mischievous impression upon the whole nervous system, radiating from parts engorged, contused or ruptured. Engagement of a loop of intestine in front of the womb. — The gravid uterus, at full term, lies behind the abdominal integuments and quite in front of the mass of intestinal convolutions and the transverse colon. It sometimes happens that a portion of the mesen- tery or mesocolon, I know not which, becomes so relaxed or elon- gated in the direction of its radius, as to permit a considerable por- tion of the intestinal tube to fall over the front aspect of the womb, and when once engaged there, to be driven down by the expulsive force of the belly, as low as, or even lower than, the umbilicus, where it is pinched, or compressed, or perhaps in a sense stran- gulated, by the contraction of the abdominal muscles in the labor throes. The Student will readily conclude that so distressed a con- dition of an important organ could not but introduce modifications in a labor. In such a case his attention will be drawn to the extreme suffering of his patient during her pains, which, instead of propelling the child rapidly, as might be expected in view of the intenseness of her distress, cause it not to advance even one tittle, while cries, jacti- tation, and the most disheartening expressions leave him at a loss to imagine the cause of delay, the more particularly when he finds not, in the position, the presentation, or the state of the soft parts, causes that might arrest the progress of the parturition. He ought to in- quire as to the existence of such possible causes. If he find them not by his vaginal exploration, let him ask questions as to the place and kind of pain, and he will discover that the woman has intestinal pain, and that that pain is situated between the womb and the integu- ment. Without making further special observations on this accident, it will suffice me here to say that, about four years since, I was in at- tendance upon a primipara lady occupying a high social rank in this city ; that the labor had proceeded without any untoward circumstance to an almost complete dilatation of the cervix uteri, when my patient began suddenly to complain most unaccountably of her pains. She became excessively agitated, and being a person possessed of great self-control, I was astonished and much alarmed by her moans and agitation. I could discover no just grounds of so great a distress in the condition of the presenting parts, or the textures within the pelvis ; but after careful inquiry, learned that the pain was in the uterine globe just above the umbilicus. She had not been affected with rheu- matismus uteri during her gestation or the antecedent part of her PRETERNATURAL LABOR. CARCINOMA. 427 labor; I was obliged, therefore, to fall back upon the painful appre- hension that the texture of the uterus was about to give way at the seat of this pain, for that is what the practitioner ought to apprehend under such circumstances. Approaching the lady's bed-side, I re- quested permission to examine the abdomen by palpation, for which the nurse prepared her by uncovering her of all save the under gar- ment. Upon touching the belly, I found an irregular eminence in the place complained of. Gently percussing it, I discovered from its sonorousness that it was a considerable loop of intestine fallen down there, and which, being compressed between every uterine and abdominal contraction, had given rise to the agitation and pain. As the integuments were thin, I was enabled by a sort of taxis to push the loop upwards from its dangerous position, whereupon the labor pains became again normal, and the parturition thenceforth proceeded steadily and towardly to a happy conclusion. I have never met with a similar example. This was altogether an unnatural state for a wo- man in labor, and therefore I consider this woman's labor altogether a preternatural one. I thought it best to make this relation of the case, which, should such a one occur to an inexperienced practitioner, might cause him to regret that he had not been forearmed by thus being forewarned. I venture to remark, that the interruption to the progress of the parturient efforts here, ought to be assigned to the same category of influences as those already mentioned by me as depend- ing on the fall of a portion of intestine below the head in labor. Carcinoma Uteri.— Carcinomatous degeneration of the cervix and os uteri does not, unhappily, always obviate the power of fecundation and conception. A lip of the os tineas may be even far gone into carcinomatous degeneration without exciting suspicious discharges of mucus, sanies, or of blood, and even without developing such a de- gree of sensibility of the part as to preclude the consent of the female to cohabitation. The development of heterologue tissue in the cervix uteri is, in some instances, as slow and torpid as the development of similar tumors in the breast and other parts of the body. To become pregnant under such circumstances, is a great misfortune indeed, for gestation changes the whole life-activity of the uterus, which becomes greatly exaggerated in force and intensity, which is altered in form and density, and fatally tends, pari passu, to the augmentation of the heterologue life which has established itself upon the vaginal portion of the organ. Hence, the torpid and sleepy carcinoma takes upon it the more ferine life of the open cancer, and when the foetus, if ever, 428 PRETERNATURAL LABOR. CARCINOMA. has attained its full growth, and the labor has begun, let the Student imagine the awful condition of the patient, one-half of the circum- ference of whose cervix uteri has become a mass of heterologue tissue, filled with the caudate cells, and the silvery bands of the cancerous malady, utterly unsusceptible of dilatation, almost frangible from its solidity, and exquisitely sore and painful. If such a womb should ever be opened, the dilatation of the mouth of it must be effected at the expense of the unaffected half of it, which is its only dilatable portion. If the circle of the os uteri must in labor become a circle of twelve or thirteen inches in circumference, in order to permit the escape of the head, what must be the unspeakable agony of the pa- tient, half the circumference of whose os uteri has become perfectly undilatable through carcinomatous degeneration. Case. — I saw, in the early part of the year 1847, a wretched human being, whose cervix uteri and vagina, the seat of a frightful ulcerated carcinoma, had just been torn to pieces by the escape of a full-sized foetus at term. Case.— On the 18th of March, 1848, I was called at 11 P.M. in consultation to a pregnant lady. She was thirty-three years of age. She has not had a child during the last fourteen years, having pre- viously given birth, I believe, to two children. Throughout the whole course of the present gestation, she has suf- fered with distressing, most distressing, nausea and vomiting. She is pale and emaciated. Has had frequent bloody vaginal discharges from the beginning of the pregnancy until now — expects her ac- couchement about the tenth proximo. At six P.M. she was attacked with flooding, since which time she has lost probably more than eight ounces of blood, which still con- tinues to ooze slowly away. They showed me a hard vaginal coa- gulum, larger than the whole thumb. lg " Figure 85 annexed, represents the size of the os uteri and the thickness of its edges: the posterior lip, which is much thicker than the remainder of the circle, is seen on the left side of the plan; this lip is prolonged into a tumor that bleeds at the slightest touch, and is evidently a mass of carcinomatous tissue in open ulceration. Figure 86, half size of nature, gives a correct notion PRETERNATURAL LABOR. CARCINOMA. 429 of the profile of this tumor, and of the degree of the aperture of the os uteri, in which the child's head is represented as pressing upon the Fig. 86. cervix and os. The tumor is seen in profile descending into the vagina. Figure 87 gives a front view of it. The tumor is hard 3 wholly undilatable, so that the whole of the dilatation hitherto effect- ed, has been effected at the expense of three-fifths of the circle, the remaining heterologue two-fifths not having furnished anything to the dilatation, or if anything, an unconfutable proportion. Agreeably to the decision in consultation, she got an enema of forty-five drops of laudanum mixed in a fluidounce of clear-starch. March 19th, 12 M. She slept well after the enema, and has had no pain to-day. 21st. Has continued well up to 3 P.M. to-day, when she was seized with the pains of labor, attended with inconsiderable hemor- rhage. I was again summoned to the consultation at 5J P.M. The os uteri was dilating. The tumor was now found nearer to the left ischium, as if the womb had been rolled upon its axis. As the pains increased, her distress became very great indeed, — I may say un- speakably great. The child had attained to within twenty days of 430 PRETERNATURAL LABOR. — CARCINOMA. term, and it was apparent that full two-fifths and more of the cone of the cervix uteri could not furnish any material for the necessary dilata- tion. Hence there must be the greatest danger of rupturing the tissue, and accordingly, at six o'clock in the afternoon, the whole projecting mass of the tumor came away into the hands of the gentleman in attendance, who handed it to me, and of which a good representation is given in Figure 87. Fig. S7. The lady was a person of admirable temper and manners, but the greatest courage and the utmost stretch of her Christian fortitude and patience could not conceal from the anxious spectators the extremity of her agony. There was no great increase of hemorrhage after the separation and escape of the tumor, but the bag of waters was thrust down far out- side of the ostium vaginae, soon after which, at 6| P. M., the child was expelled. A solution of morphia was administered to her, and she became composed. At one o'clock in the morning, she was seized with a rigor, which soon became a violent ague, which lasted more than one hour, whereupon febrile reaction ensued, with a pulse at PRETERNATURAL LABOR. VARIOLA. 431 180 beats per minute. This febrile condition was attended with violent pain, and intense sensibility of the abdomen to pressure. There had been very little discharge since the expulsion of the child, and the mass of the uterus was well and firmly contracted. Upon the establishment of the febrile reaction, she was bled to the amount of twenty-two ounces with great relief to her distress, and without the least appearance of syncope. Wednesday, March 22d. At one o'clock to-day she suddenly began to sink. She was in the full possession of her intellectual powers, and had not the slightest pain. She died in the afternoon. Upon examining the body, about twenty-four hours after death, there was no trace of hemorrhage in the belly, nor any marks of peritonitis. These figures were drawn by Mr. Gihon, from the preparation now preserved in my collection. Small-Pox. — There can scarcely be a more disturbing cause of a parturition than small-pox existing in the system of a woman in la- bor; not because it modifies the presentation or position of the child, nor because it dangerously interferes with the action of those dynami- cal forces by which the product of the conception is discharged from the womb. A labor, or, to speak more definitely, a perfectly normal parturient act, in itself not necessarily dangerous, nor fatal, may have a mortal result, for, the woman who has been confined cannot be said to have completed the act of childbirth, as relative to herself at least, until she shall have recovered a healthful non-gravid condition. I think it is right, therefore, to regard as a preternatural labor any one which from some complication, whether of disease or accident, ex- poses the mother after delivery to the most imminent danger of death. I will not say that every woman who gives birth to a child while laboring under small-pox must inevitably perish, since my clinical experience has shown me that the contrary may, rarely, be the case. But I do hold to the opinion, that a pregnant woman, laboring under a considerable attack of small-pox, is far more likely to be lost than saved, whether she miscarries, whether she be prematurely confined, or whether she give birth to her child at the full term of utero-gesta- tion. A pregnant woman may be attacked with small-pox even in its most direful confluent form, and yet recover well, provided labor does not come on in the course of the disease; but, if she be confined or suffer abortion, she shall hardly escape death by hemorrhage from the womb, or by metro-phlebitis coming on early after the detachment and expulsion of the placenta. 432 PRETERNATURAL LABOR. — VARIOLA. A late author on obstetrics has expressed the opinion that the bleeding orifices upon the inner aspect of the womb — those, to wit, which give issue to the lochia — cannot be restored to a non-gravid health save by the intervention of an adhesive inflammation of those vessels. That adhesive inflammation is phlebitis. And he further expresses the opinion that the milk-fever of women, and the same milk-fever which is known to affect our domestic quadrupeds after their parturition, is the constitutional disorder developed by the purely topical and limited phlebitis affecting the uterine orifices above men- tioned. This opinion appears to me to be worthy of respect, upon a simple annunciation of it, as well as from the confidence to be reposed in the judgment of the author in question. If, now, the Student will consider for a moment the nature of that direful malady of which we are speaking, and reflect upon its unques- tioned power to modify the crasis of the blood, he will feel no surprise to observe, as he will in future have melancholy opportunities to do, the tendency of the variolous poison either to set on foot, or to aggra- vate any necessary anormal phlebitic affection to which the parturient female is liable; nor will he feel any greater degree of surprise to find that the modified blood of the variolous patient continues to ooze from the parietes even of a well contracted uterus after delivery, and that his haemostatic agents are all alike futile in opposition to the tend- ency of the vessels to allow of protracted and ultimately fatal losses of the vital fluid. My principal design in introducing this section here is, in the first place, to point out the great necessity there is for pregnant women to avoid the contagion of variola; for I think I am quite correct in stating that the sentiment of the profession is almost unanimous, that the woman who is confined during small-pox, dies. This is the general rule. The exceptions are here and there a few cases, in which she escapes as by miracle. I must take the liberty to reiterate my opinion that she dies either from the ooze, or from phlebitis, which is essen- tially endangitis. I could have no design, in this place, to set forth any precepts in regard to the Conduct of labor, in a woman suffering under small-pox. I have already said that that malady is not to be supposed to modify either the presentation, the position, or the dy- namics of any labor. Now let the Student beware not to expose his gravid patient to the least danger of variolous infection ; and, therefore, let him never dare, under any circumstances, to vaccinate a pregnant woman, or one recently confined. To give this precept is the essential motive I had PRETERNATURAL LABOR. VACCINATION. 433 for introducing this article into my work, and I am the more desirous to attract the attention of the Student to this point, because I know that the brethren in general are not in the least suspicious, that to vaccinate a pregnant woman is to expose her to great hazard. I re- iterate the assertion that the virus of small-pox is eminently inimical to the life of the pregnant female, and I aver that the virus of the vaccine inoculation is little less so than unmitigated small-pox. If the Student will take two clean lancets, and plunge the points of them into a mature small-pox pustule, he may send one of them a hundred leagues eastward, and with it inoculate an unprotected indi- vidual, who will receive from it the infection of unmodified variola; and consecutive inoculation from this line would repeat variola for centuries. Let him send the other lancet a hundred leagues west- ward, and with it inoculate the udder of a healthy cow. He will in this way communicate to the animal a vaccine infection, from which vaccine inoculations of human beings may be consecutively repeated, for centuries. So that the variolous pustule in the human being has communicated the vaccine infection to the cow, which vaccine infec- tion may likewise be repeated, without modifying it further, through an unknown series of human bodies. The generical force of the inferior animal has modified a poison produced by the generical force of the human being. It has changed it, not destroyed it. It retains a portion of its variolous power inimical to the pregnant woman, and to expose such an one to its rage is a gross imprudence and misapprehension which I hope no Student reading this book will ever be guilty of. The shocking spectacles of distress that I have witnessed, from the vacci- nation of pregnant females, have so impressed my mind w r ith the enormity of the imprudence, that nothing, I think, could tempt me to commit it myself. The most furious adenitis, which is endangitis, and which, in other words, is pyogenic fever, is one of the conse- quences likely to result from every true or spurious vaccination of a pregnant female. I am firmly convinced that it is far better for the physician, during the epidemic of small-pox, to leave his pregnant patient to the chance of a natural infection, than certainly to bring her within the scope of its virulent power by a vaccine inoculation, which is but a variolous inoculation modified by the generical force of an inferior zoological genus. If I venture to put forth such opinions as the above, it is hardly incumbent upon me further to protest against the temerity of those who, during the existence of a small-pox epidemic, recommend, and even proffer, what is called re vaccination, to those who, having 28 434 PRETERNATURAL LABOR. TWINS. been already vaccinated, might be held to be protected; I mean to pregnant women. I have seen pregnant women, very nigh to term, unnecessarily revaccinated, with consequences so terrific that I think I would not, for a thousand golden crowns, vaccinate any woman, knowing her to be pregnant. Twins and Triplets. — In Churchill's System of Midwifery, Phila. ed. 1846, p. 411, there are statistical statements on the subject of twin and triplet pregnancies. Dr. Churchill states that out of 448,998 cases of pregnancy we have 5,776 cases of twins, or one in 77f , and 77 cases of triplets, or one in 5,831 cases. A case that occurs only once in 77 labors, and in the course of some men's practice not so fre- quently, will be esteemed to be preternatural, for that is natural which occurs constantly, that is more nearly natural which occurs frequently, and that is preternatural which occurs very rarely. A triplet labor, which, according to Dr. Churchill, occurs only once in 5,831 cases, will certainly be admitted to be an unnatural labor, or, to use a tech- nical phrase, a preternatural labor. I shall not err then in setting down twin and triplet cases as cases of preternatural labor; at least I find it more convenient to arrange them here than to give a separate chapter on the subject. As a general rule, a twin labor is not suspected to be so until after the birth of the first child, for a woman carrying twins in the womb is found frequently not to be larger than she who carries but a single one. Two children of six pounds weight each, do not weigh so much as a single child of twelve pounds and a half, and the liquor amnii of the double pregnancy may be far less in quantity than the liquor amnii of a uniparous womb. If a woman in the latter weeks of her pregnancy should become very lusty, as it is called, or if the abdo- minal walls, becoming weakened, allow the uterus to fall far forward, so as to make the belly a little pendulous, that circumstance may give rise to misapprehension, and the woman is apt to fear that she will be so unfortunate as to give birth to twins. In practice the Student will find that ten women shall fear twin labor, for one that shall really suffer it ; and that in ten twin labors, there shall be only three or four in which twins shall be suspected to exist. It is not difficult in the pregnancy to ascertain the existence of twins, since the use of the stethoscope serves to reveal the pulsations of two distinct hearts, and, moreover, during the flaccid states of a womb, if a woman lie upon the back, the feet drawn up, it is not difficult by external PRETERNATURAL LABOR. TWINS. 435 palpation to detect the existence of two distinct, orbicular, hard heads. Although I prefer to speak of twin and triplet labors in the chapter upon preternatural labors, I am ready to admit that many women giving birth to twins, find themselves delivered promptly and with little pain, especially when the children, as is usually the case, are under size; nevertheless, in twin labors with large children — and I have seen two children the sum of whose weights was sixteen pounds and a half, and where the ova contained a very extraordinary amount of liquor amnii — the process of parturition is exceedingly slow, dis- heartening and painful; the overloaded uterus acts feebly and irregu- larly, labor is long in establishing itself, the excessive extension of the muscular tissue of the uterus prevents the organ from propelling the point of the ovum into the cervix and through the orifice of the os ; the bag of waters is therefore slow in being formed. It rarely happens that the waters of both the ova come off together. If the amniotic sac which contains the first child or the presenting child should have discharged its fluid contents, then the expulsive power of the uterus must be communicated to the advancing child by means of the unbroken ovum of the second birth; such an elastic and compressible medium for the communication of the expulsive force, must frequently have the effect of decomposing and rendering futile the exertion of it. If the membranes of the first child remain whole, and those of the second child be first broken and discharged, as sometimes happens, the same effect is produced. I have seen a labor in which the first child pushed the placenta of its brother before it into the world. In case both ova are ruptured, the lowermost child must be thrust down by the uppermost child; but, as the uppermost child is never directly above the lowermost, its force must be com- municated laterally. It acts obliquely upon the body of its mate; and the practitioner who finds an os uteri ductile and non-reluctant, is ordinarily embarrassed to make up his opinion as to the cause of the slowness of a labor, whose slowness seems inexplicable, since where the resistance is small and the woman in good health, he expects the advance to take place at a certain usual rate. He might be tempted on this account to exhibit some ergot, or administer some stimulants, or exhibit some provocative to increased uterine action. He ought to do no such thing; the duty of an accoucheur is to inquire into the cause of the slowness. Let him rise from his seat and apply his ear to the abdomen of the woman; if he finds the foetal heart, let him ascer- tain its place, as relative to the top of the symphysis pubis, nearer or 436 PRETERNATURAL LABOR. TWINS. Fig. 88. more remote from it in the hypogastrium ; and knowing where the head is, then with his hand upon the abdominal uterine tumor, he will at once come to the conclusion that the womb contains one child, or more than one child. In the latter case, let him find the heart of the second child, and the position of that heart will afford him a tolerably good diagnostic as to the presentation of the second twin, as offering either a cephalic or a pelvic presentation. If the accoucheur then finds that the uterus is overloaded, and that it is acting at a great disadvantage in consequence of its being compelled to communicate its expulsive force through the body of the first child obliquely to that of the ad- vancing twin, he will understand his case, and act accordingly. In twin labors the children present both by the head, or one by the head and the other by the breech, as in Figure 88. In case the children present both by the head, there is risk that when the first head shall have fairly sunk below the plane of the superior strait, the other head may, by the expulsive action of the womb, be thrust down- wards into the superior strait against the throat of the first child, which it crushes against the opposing wall of the pelvis, and thus locks the lower head, which cannot descend because the thorax to which it is attached can- not enter the brim, on account of the presence there of the second head. Let the Student imagine the difficulty of treating such a case, for the first head fills the cavity in such a way as to prevent his passing his hand up, and he w T ell knows that when the foetal head is fairly within the excavation, it is an extraordinarily difficult, and often impossible thing to thrust it again above the superior strait, in order to turn and deliver. I am happy to say that my clinical experience has never furnished me with an example of this sort; a case of the kind occur- red to one of my brethren here a few years since, which embarrassed him greatly; he could neither return the first head nor displace the second; he took the measure, therefore, of decapitating the lowermost child, and, after its head was removed, the second child was delivered, and the headless trunk of the first one followed it. In case the first child should present by the breech and descend PRETERNATURAL LAROR. TWINS. 437 through the pelvis, there is always great reason to fear that the second child, presenting by the head, might have its head urged down faster than the head of the breechling; if it should be jammed into the pelvis before the other head can get possession of it, it would present another example of the process in which one head is keyed by another. There is less danger in this case than in the former, because the trunk of the child would not form an insuperable obstacle to the passage of a hand, whereby to displace the keying head. It has happened to me, on different occasions, to find the woman becoming so much fatigued, so much worn out, indeed, by the pro- tracted efforts of a twin labor, that I felt obliged at the last to give the assistance of my forceps, both for the first and second child. A labor with twins is one in which there may be either one or two placentae; it sometimes happens that both the children are contained in a single chorion, but each child must have its own amnion ; if there are two chorions, there will be two placentas, and these placentae will be situated in different and opposite parts of the uterus. A labor in which there are two separate placentae, and in which the first pla- centa is detached and discharged with the child, is one in which the placental superficies is likely to bleed, for there cannot be perfect condensation of the placental superficies of such a womb. A twin labor in which there is a single chorion and a single amnion, is one which could scarcely fail to give birth to a specimen in terratology, for there is nothing that prevents the fusion of the parts of the twins in the same amniotic sac: whereas such fusion of parts is impossible in two separate amnia. Chang and Eng must have existed in a single amnion: so did Reta Christina. The same must have been the case with Dr. Pfeiffer's double headed infant, to which I refer the Student, and with my specimen of the omphalodyne, contained in the museum of Jefferson Medical College. One never has charge of a twin labor without feeling some anxiety with regard to the hemorrhage likely to follow the birth of the first child, and the accoucheur should not dare to leave the woman until she be safely delivered of the second. As a general rule, the same contractility of the uterus which expels the first child, after a slight pause, resumes its operation for the expulsion of the second, just as happens as to the expulsion of the after-birth in a uniparous labor: and we may therefore expect that within the hour the presenting part of the second child shall descend through the os uteri into the vagina. I think I have never waited so long as an hour. When the membranes have already been ruptured, I have found the child to descend earlier 438 PRETERNATURAL LABOR. TWINS. than that, and when they had not already given way, I have ruptured the oYum within twenty minutes. As my own experience in this particular has been fortunate, I venture, upon that ground, to advise the medical Student to follow the same course. Some persons prefer to wait for a longer time, and I admit, if the patient be carefully ob- served, if there be no signs of hemorrhage or faintness or other exi- gent motive for interfering, he might feel himself justified in waiting for a longer time than that I have indicated. Let him always make the diagnosis as to the presentation before he proceeds to rupture the ovum, and should he find a cross birth, a possible event, let him hasten to pass his hand high up on the side of the ovum, penetrate it there, and seize the feet in order to turn and deliver. In these cases there ought to be a good light on the patient's face, for the hemorrhage is sometimes astounding, and the earliest indica- tions of it may, on certain occasions, be detected in the expression and tint of the countenance. Whenever hemorrhage is suspected to have begun, or is known to have commenced, there should be no hesitation in rupturing the membranes ; the discharge of the second sac fulfils Louise Bourgeoise's commandment, to let the water off in order that the womb may condense itself. The accoucheur, under such circumstances, would act according to the indication ; if the hemor- rhage is sudden and startling, he would turn and deliver, provided the head is above the superior strait ; he would seize and extract it with the forceps, provided it were in the excavation. As soon as the second child is born, pressure should be made upon the hypogastrium to promote a tonic contraction of the uterus ; the lately over-distended, but now relaxed, belly, should be sustained by a proper binder and compress, and the placenta or placentas should be carefully extracted. In triplet labors the same causes of slowness in effecting the earlier operations of parturition exist, as in the twin case ; the expulsive power is even more decomposed, since it is communicated through three bodies ; there is the benefit in general, however, that triplets are smaller than twins, and the distension of the cervix uteri, the vagina, and the external organs, is not so great as in uniparous or twin labors, in consequence of which, the last pains are less distressing. I saw a lady in labor, in this city, however, who gave birth to triplets, the sum of whose weights was twenty-one pounds and a half; they were fine children ; the mother had nearly lost her life from an exhausting hemorrhage, which followed the birth of the last child. The super- ficies of the placenta, required for the aeration and support of three CONDUCT OF PRETERNATURAL LAROR. 439 such children, must have been very vast, and a most powerful con- traction of the uterine globe would be required to constringe the uterine orifices after such a labor. I have never seen a case in which four children were delivered at one birth. Fig. 89. Management of Preternatural Labors. — Preternatural labors may be terminated with the hand alone, or b}- means of instruments. The simplest of midwifery instruments is the fillet, which consists of a riband of silk or linen. The fillet is chiefly employed as a means of drawing down the buttock, in cases of breech labor, where the pains are incapable, with- out assistance, of completing the delivery. A very good fillet may be made of a strip of linen some three inches wide and twenty-eight or thirty inches in length. It is not always a very easy matter to apply it — and there is great difficulty to get it adjusted in all cases, except when the breeeh is quite low in the excavation and completely out of the circle of the os uteri. Previously to making any attempt to use it, it should be prepared by drawing it through the hand, filled with a good quantity of lard — or else it may be soaked in thick flaxseed tea, or in white of eggs. Without this precaution it will not pass over the thigh of the child, or it will rub the sur- faces so as to endanger their excoria- tion. In order to make use of the fillet, let it be passed over the thigh that is nearest to the pubis. Roll up four or five inches of one of the ends of the riband into a roller, which may be passed into the vagina, and pushed with one or two fingers between the belly of the child and the front of the thigh which is in contact with the belly. The point of the finger will carry the little ball or roller across the groin either inw^ards or outwards, as the case may be, and w r hen it has got free from the pressure of the surfaces of contact, the roller or ball at the end may be brought out at the ostium vaginae, and the remaining portion passed upwards, so as to get the fillet arranged to allow the two free ends to be tied. 440 CONDUCT OF PRETERNATURAL LABOR. The drawing, Fig. 89, shows the appearance of the fillet, when rightly placed, and the mode of operating with it. The efficacy of its action would be greatly enhanced by placing it upon the groin that is farthest from the pubal arch — but that is a feat of dexterity that can rarely be performed. In drawing downwards, one should act only during a pain, or coincidently with a tenesmic effort of the patient, and it should never be forgotten, that the neck of the thigh bone is a very fran- gible thing in the unborn foetus. This caution is necessary, in order to prevent a fracture or dislocation of the hip-joint. The mere re- membrance that such an accident might happen would prevent any prudent person from exerting an undue force with the fillet. Notwithstanding the reasonable dread of doing mischief by violent and untimely tractions — it is true that very great assistance may be given to the woman in labor by this simple implement. The fillet is also applied, on some occasions, to the wrist in pro- lapsion of the hand, in order, by means of it, to keep the hand down at the side, when we turn to deliver in shoulder cases. I have never found it necessary to take any such precaution ; as I have always thought that I could bring down the arm, in case it should be lifted along side of the head, and I have not chosen to embarrass myself with the string. The fillet is also by some writers recommended as a means of securing one foot that has been brought out at the vulva in turning, w T hile the hand is passed upwards again to seek for the other foot. I do not think it necessary. Indeed, when I have got one foot down, I care not much to bring down the other. If it be left in the womb, we have rather an advantage by it ; since, in such a delivery, we have the benefit of both the footling and breech labor. Turning. — The Student has learned that the most natural labor, one in which the vertex presents, in the first position, may suddenly become a preternatural one in consequence of the coming on of hemorrhage, a series of bad fainting fits, convulsions, &c. &c, and which establish the indication to proceed at once to the delivery. Fig. 90 serves very clearly to express the situation of the child presenting in the first position of the vertex. It may be that this child's head had in a good measure occupied the circle of the os uteri before the accident occurred which established the indication to deliver by turning. If the head had wholly escaped from the circle, the indication to deliver by turning must have been considered CONDUCT OF PRETERNATURAL LABOR. 441 Fig. 90. wholly set aside in favor of a forceps operation; for in general, when the head has once escaped from the os into the vagina, it cannot be thrust into the womb again, for the cervix uteri will by that time have contracted pretty strongly around the neck of the infant. Hence the rule of practice is to turn and deliver if the head be still in the womb ; but if it be in the vagina, we are to extract it by means of the forceps. In fact, if it be wholly in the vagina, it is below the superior strait ; but to at- tempt to return the head through the superior strait and through a con- tracted os uteri also, is a thing too preposterous to be thought of. The drawing above mentioned, Fig. 90, will show to the Student what he will have to do if he makes up his mind to turn. It will show him, namely, that he will be obliged to thrust the head out of the plane of the superior strait, which it occupies, in order to let his hand pass upwards in exploration; he will see by inspecting the figure Fig. 91. Fig. 92. that he must seek for the feet in the right and posterior portion of the upper part of the womb ; he must push the head, therefore, upwards and to the left, and not upwards and to the right, and he must grasp 442 CONDUCT OF PRETERNATURAL LABOR. the feet with the palmar and not with the dorsal surface of the hand. Which hand shall he use ? Let him look at the figure, and he will see that in this labor he must use the left hand, and carrying that hand upwards according to the directions given in my article on Turning at page 366, he will find the feet one or both as in the figure, and grasping them firmly with the thumb and fingers, he will draw them downwards towards the os uteri, assisting his left hand by means of the right one pressed upon the fundus of the womb upon the outside. In this way, drawing the feet downwards, he keeps the head above the plane of the superior strait by means of his wrist and palm, a precaution he must by no means overlook, lest the head, urged down- wards by the force of the contractions, should become engaged in the pelvis together with the foot, as seems about to happen in the drawing annexed, Fig. 92. If, through forgetfulness of duty or the want of a proper dexterity, he should permit this accident to happen, he would procure for himself superabounding vexations, for his patient a great increase of pain and hazard, and for the child an almost certain death. Let him never forget, therefore, while drawing down the foot, that he must keep the head up if possible. After drawing the feet through the ostium vaginae, and w 7 hen the Fiff. 93. Fig. 94. turning is completed, which he will know by an exploration with the right hand of the form of the abdomen, and by perceiving that the CONDUCT OF PRETERNATURAL LABOR. 443 Fig. 95. hips of the child are now engaging in the excavation of the pelvis, he should, if he draws at all by the limbs, make his chief effort of traction by means of the right leg of the child, as in Fig. 93. By acting in this way he will cause the child's face to turn towards the left sacro-iliac junction. Before the turning, it looked towards the right sacro-iliac junction. Let him look again at Fig. 93, in order to see how he would make the face of the child come to the front of the pelvis if he should incautiously make his tractions upon the left foot only. When he has extracted the child as far as the navel, let him do what is represented in Fig. 94, that is to say, let him carefully draw down a considerable loop of the umbilical cord, setting that organ at liberty, so that no danger may be incurred of breaking it or tearing it out by its roots at the umbilical ring. The patient should certainly be now turned upon her back, and the child's legs should be wrapped in a napkin in order to hold them firmly. As soon as a good part of the thorax is expelled, let him pass two fin- gers upwards to the top of the shoulder that is most conveniently within his reach, raising the body of the child up- wards towards the pubis if he desires to get at the posterior shoulder, or de- pressing it towards the sacrum if he wishes to act on the anterior shoulder. Sliding his fingers from the acromion as far as he can towards the bend of the elbow, let him force the elbow down- wards, causing it to sweep along the breast of the child. As soon as the elbow is withdrawn, the hand will come forth and the shoulder be extricated, after which let him proceed in like man- ner with the remaining shoulder, using the fingers of the other hand, as in Fig. 95. Both shoulders being delivered, let the Student next raise the trunk of the child upwards towards the mother's abdomen, a precept which has been forgotten in the annexed design, Fig. 96. It is extremely important not to forget this rule of practice. What the Student wants at this point, is, a great degree of flexion of the head ; let him carry the breast away from the chin by turning the child's trunk upwards 444 CONDUCT OF PRETERNATURAL LABOR. Fig. 96. towards the mother's abdomen, as above directed, and then intro- ducing one or two ringers as far as the child's mouth, let him pull the chin downwards towards the uplifted breast of the child — thus re- storing the chin to the breast. As a general rule, this manoeuvre will effect the flexion that is to be desired ; — not always so, however, for the mouth some- times may be opened very wide, and the upper maxilla will not descend to close upon the lower. Let the Student, in this case, push the vertex upwards by means of two fingers inserted behind the symphysis, and then with a finger on each side of the nose, let him pull the superior maxilla downwards, to make it shut the mouth. The occipito- mental diameter, see-sawed in this manner, will be made to coincide with the axis of the inferior strait, whereupon pulling by the shoulders with one hand, and with a finger in the mouth with the other, the head may be withdrawn in a direction coinciding with the curve of Professor Carus. Should the resistance to the escape of the head be too considerable, and the child's life be placed in danger from the delay, two fingers of the left hand should be passed into the vagina as high as the malar bones, one on each side of the nose. The fingers being now some- what flexed, will thrust the posterior wall of the vagina away from the mouth and nostrils, giving free access of the atmospheric air to those orifices; the child will immediately begin to cry, though unborn, giv- ing time for the patient to rest, and for the accoucheur to consider of his duty. I have heard this vagitis vaginalis for many minutes, and, indeed, have in this manner enabled the child to continue breathing until my forceps could be brought, from a considerable distance, wherewith to deliver the head. As to the manner of applying the forceps in this case, I refer the Student to the chapter describing the uses of that instrument. The Student ought very carefully, yet very promptly, to decide upon the line of duty under the sometimes very sudden emergencies of this sort of labor ; to set the matter before him in a clearer light, let me reiterate the precept, to turn and deliver if the head be not in the vagina, and to deliver by the forceps if it is wholly expelled from CONDUCT OF PRETERNATURAL LABOR. 445 the mouth of the womb. If he should make a mistake as to the point of duty, he might inflict a serious injury upon his patient, by passing the blades of his instrument within the contracting bands of the cervix uteri ; or, on the other hand, he might allow her to bleed to death from hemorrhage, while expecting the return of the messenger sent to bring his forceps from the distance of half a mile. I was sent for to assist a gentleman waiting upon a woman in labor. I arrived at the spot in a very few minutes, and found both the child and the mother dead upon the bed; my friend, the accoucheur, told me that he had been sent for with an urgent request to hasten to the house, but being absent from his office, a considerable delay occurred ; when he came to the bedside, he found the woman flooding danger- ously, and much exhausted by the loss. Perceiving the exigency of her circumstances, he despatched a messenger in haste to bring his forceps, from a distance of more than half a mile ; in the meantime the flooding continued. When the forceps were put in his hands, he was baffled, as he told me, in adjusting them — the head retreating upwards whenever he attempted to apply them : after the loss of an additional portion of time — a fatal loss — he succeeded in seizing the head, and delivering the child, which was dead. The mother expired very soon after the birth of her infant. Some years ago, I was engaged by a tailor to take care of his wife in her approaching confinement ; he was an avaricious fellow, who disliked nothing more than the payment of a fee. In the middle of the night, his wife was seized with the pains of labor, which immedi- ately became violent and expulsive. He ran for an old woman in the neighborhood, who arrived just in time to receive the child, which she severed, and immediately proceeded to wash and dress it, leaving the woman lying upon the bed. "A-hah!" said the tailor, "this is a very good thing; we'll cheat the doctor out of his fee." And so he rejoiced and was very glad ; but in a short time the poor woman fainted, and remained for a long time insensible ; whereupon, taking the alarm, he came for me in furious haste, telling me that his wife was either dead or dying, and begging me, for God's sake, to give her speedy assistance. I very soon reached the apartment, and found her speechless and pulseless, and pale, and lying in a puddle of coagula and fluid blood ; placing my hand upon her abdomen, I found that there was another child there. I now took away all her pillows; opened the windows ; dashed water freely upon her face and neck ; and with difficulty succeeded in getting down a few swallows of strong brandy and water : the head presented, I ruptured the membranes, 446 CONDUCT OF PRETERNATURAL LABOR. and passing my hands upwards to the feet, seized them, turned, and delivered the child; and immediately afterwards removed the pla- centas. I was for some time doubtful whether she would live or die, but she finally rallied under stimulation, and got quite well. I think that four minutes had not elapsed from the time that I reached her apartment until the child was delivered. Suppose that I, like my friend mentioned in the former case, had sent to my house for the forceps, would my patient have survived ? Suppose that he, in- stead of sending for his instruments, had immediately delivered her by turning, would he have lost both the mother and her child? It is said, that it is the last straw that breaketh the mule's back. It might as well be said, that it is the last ounce that kills in the uterine hem- orrhage. Having now described the operation for delivery in preternatural labors, the head presenting in the first vertex position, I have to indicate the method of proceeding in the other positions of the vertex. In all important particulars of the management, the former directions may be regarded as sufficiently full. But, as in the second position, the face of the child looks towards the left sacro-iliac symphysis, it is necessary, on that account, to employ in the turning, the right hand, and not the left hand, as before. By introducing the right hand, for the operation, the head will be pushed out of the plane of the strait to the right upwards, and made to lodge in part upon the brim, and in part upon the wrist and inner face of the forearm, while the fingers, going up along the breast and belly of the child, seek for, and at length find, the feet. When caught, one or both the feet are to be brought out at the os uteri into the vagina, and so through the ostium vaginae. Due care should always be used, not to force the version while the uterus is contracting. It may be expected to contract several times during the act of turning. Inasmuch as the face looked to the left sacro-iliac junction at the beginning, it might be expected, when completely turned, to look towards the right acetabulum, and it would probably do so, if care were not taken to draw chiefly upon the left foot ; by doing which, the left trochanter will be brought to the arch, and then it may, as soon as it has completely come forth, be forced over towards the right ischial ramus, which will serve to bring the left shoulder also to the right acetabulum, when that part begins to engage. The face of the child will of course, under these circumstances, be turned to the right sacro-iliac junction, and finally sink into the hollow of the sacrum. PRETERNATURAL LABOR. SHOULDER. 447 I need not here reiterate directions, already sufficiently explained and insisted on in the former article. The operator may find the child that he is about to turn, present- ing in the fourth position of the vertex, in which case the forehead will look to the left acetabulum and ^the vertex be directed to the right sacro-iliac junction. In order to turn in this position of the child, he should employ the right hand, which, passing up on the left side of the pelvis, between the face and the brim, thrusts the head towards the right and anterior semi-circumference of the strait, where it must be resisted by the wrist or arm, w T hile the fingers explore the cavity in search of the feet. If the child were turned without being rotated upon its axis, its face, after the version, would be at the right sacro-iliac junction, and this would be well ; but still, in order to ensure an occipitoanterior position of the vertex after turning, it would be safest to act chiefly upon the left foot in making the trac- tions. I shall not repeat the directions for the other parts of the pro- cess. In the fifth position the fontanelle is found at the left sacro-iliac junction, and the top of the forehead at the right acetabulum. If the woman w r ere lying on her left side and the accoucheur seated with his face turned in the opposite direction to hers, he might, very conveni- ently, employ his right hand in version, for the palm of the hand slightly pronated would glide along the right side of the breast and abdomen of the child in search of the feet, which then might readily be drawn down. The child, having been completely turned, would have its face addressed towards the left posterior part of the womb ; in making the last tractions, therefore, the Student ought to be advised to draw chiefly upon the right foot in order to bring the right trochanter to the pubic arch, and, as soon as it shall have been fairly expelled, turn the trochanter towards the left ischial ramus, which will secure the descent of the shoulder in the neighborhood of the left acetabulum, and the subsequent engagement of the head in an occipito- anterior position. There is no necessity for repeating the minute directions as to the conduct of this version. In cases of version in the third and sixth positions, cases never likely to occur, the accoucheur could use either the right or the left hand, as he might deem most convenient to himself; the choice being indifferent, the occipitofrontal diameter of the child coinciding with the antero-posterior diameter of the pelvis. Turning in Shoulder Presentations.— The turning and delivery 448 PRETERNATURAL LABOR. — SHOULDER. Fig. 97. of the child in head presentations, are less difficult than in the ope- ration which is required for version in shoulder cases. In a former part of this volume, I have stated that there are two shoulder positions for each shoulder, making four in all. There are two positions for the right shoulder. In the first the head of the child is on the left side of the pelvis, as in the annexed Figure 97. This figure represents a shoulder presenta- tion with the right hand prolapsed ; the palm of the hand will look to- ward the mother's back and its dor- sum towards the front of her pelvis; the face looks backwards, and the feet of the child are in the back part of the womb, so that in seeking for them, the accoucheur should pass his hand along the breast of the child, and expect to find the feet not far from the sternum of the infant. To pass the hand between the child and the pubes would be to make a distressing mistake, for it would be impossible to turn the child in that way, and it would be wrong to expect to find its feet lying upon its back. To perform version the woman should lie upon her back, the hips being near to the edge of the bed, the thighs abducted, and strongly flexed upon the pelvis: the right hand should be chosen, (to look at Fig. 97 is enough to show that the right hand is the preferred one,) for the points of the fingers easily direct themselves towards the pelvic extremity of the foetus ; and the moderate supination of the limb applies the hand to the breast and abdomen of the child; the fingers could scarcely close between the abdomen of the child and the posterior aspect of the womb, without grasping the feet or knees, whereas, to use the left hand w T ould be to point the fingers towards the cephalic extremity of the foetus, and if the feet should be caught in that way, it would be ne- cessary to let thern go again. Therefore, in the first position of the right shoulder presentation, the Student will be careful to employ his right hand for version. Suppose the Student, in performing this version, should take hold of the left foot of the child, he would (let him look at Figure 97), cause it to revolve upon its axis and bring its face towards the mother's abdo- men. This is what he desires not to do, for the chief intention which he should set before him, is that of bringing the vertex to the symphy- PRETERNATURAL LABOR. SHOULDER. 449 Fig. 98. sis, and the face to the sacrum. He ought to get both feet, if possible ; having both feet in his hand, it will be in his power to draw the child by the right foot, which will bring the right trochanter to the pubic arch, and the right shoulder to the left acetabulum, which will let the face come into the pelvis looking backwards towards the left. The second position of the right shoulder presentation is neatly figured in the accompanying drawing, Fig. 98. It represents the body of the child very much compressed by the contracted womb, from which the waters have been expelled, and the hand of the accoucheur, which is here the right hand, partially engaged in the cervix uteri, seeking for the feet. It would be as well, in this particular labor, provided the patient w T ere lying on the back, to use the left hand in version ; but, if she were lying upon her left side, the right hand would be far more convenient than the left, since, introduced between pronation and supination, it would apply itself to the breast and abdomen of the child. Fig. 99 shows the process of operation, which is here being pro- perly conducted, for the tractions are being made upon the left limb, which would serve to roll the child upon its axis so as to turn its face towards the posterior semi-circumference of the pelvis. The left shoulder presentation has, likewise, two positions. In the first of them, the head is directed towards the left side of the pelvis, and the face of the child looks front. In the second, it is directed toward the right side of the pelvis, the face looking backwards. In the first position, the left arm being down, the feet should be found between the belly of the child and the anterior wall of the womb ; the rule obtains, therefore, in this as in all cases, of passing the exploring hand upwards along the front of the child's body. If the woman 29 Fig. 99. 450 PRETERNATURAL LABOR. SHOULDER. Fig. 100. were lying upon her left side, with her knees drawn up with a pillow between them, the palm of the right hand would readily apply itself to the anterior aspect of the foetus : the left hand would be highly in- convenient for this operation; it might be used in the dorsal decubitis, but not so conveniently as the right. The child's face is looking to the front ; it ought to be rolled upon its axis so that the face may look backwards, giving it at last an occipitoanterior position; therefore, let the operator make his chief efforts upon the right inferior extremity, which alone can roll it upon its axis. In the second position of the left shoulder presentation, the face is on the right side of the pelvis looking backwards, the left shoulder downwards, the hand or elbow prolapsed or not; it is indifferent whether they be or be not prolapsed. Figure 100 explains the operation: the left hand is employed, for its fingers go out. towards the pel- vic extremity of the child, and its palm, in easy pronation, adapts itself to its anterior aspect. If the Student should draw the child down by the right inferior extremity, he would roll it on its axis. This would be wrong, since the child's face is already back- wards; let him, therefore, make his chief tractions by the left limb, in order to bring the left inferior ex- tremity to the symphysis, which, after it is born, should be twisted towards the right ischium, which will serve to bring the face into the hollow of the sacrum at last. I ought not to omit some reference to an accident which occasion- ally happens, whether in version or in original pelvic presentations. I allude to the locking of the head above the brim of the pelvis, which becomes keyed there by the forearm; the elbow being elevated, and the hand projecting backwards beyond the nucha, serves as a key to prevent the head from sinking into the excavation. When the pres- sure, in consequence of aggravated contractions of the womb, be- comes very great, it is nearly impossible to disengage the hand from behind the neck, by depressing the elbow by means of the fingers in the way formerly pointed out; — it is easier to break the delicate bone of the humerus than to bring the elbow down. Dr. Dewees' method, PRETERNATURAL LABOR. SHOULDER. 451 one upon which he very strongly insisted in his lectures, was to pass two fingers upwards in front of the shoulder-joint, and two fingers up against the opposite scapula. By means of the pressure in contrary directions of these two opposite hands, the thorax of the child is made to revolve upon its axis one quarter of a circle ; the hand is disengaged from behind the throat by this rotation, and immediately afterwards brought down by pressure at the bend of the elbow. It has been proposed to restore the head to the brim of the pelvis, in cases in which it has deviated, so as to allow another part of the foetus to present itself there. I have on different occasions attempted to succeed in this version by the head, but have always signally failed, with the exception of a case which I have already related in a former page of this work. In that instance I succeeded by means of pressure made upon the external surface of the abdomen. The attempts might always be made with propriety in those cases in which the contrac- tions of the w T omb have not as yet driven the presenting parts firmly into the opening. With a loose and flaccid uterus, the Student might have the good fortune, after lifting the shoulder out of the way, to lodge the head fairly in his palm, and pushing the fundus uteri in an opposite direction so as to raise the breech of the child, draw the head to the abdominal strait and let it engage therein. I think no very violent efforts should be made to effect this kind of version. 452 DEFORMED PELVIS. CHAPTER XIV. PRETERNATURAL LABOR FROM DEFORMED PELVIS. The thirteenth chapter of this volume, on the subject of preterna- tural labor, has been drawn out to so great a length, that I brought it to a close upon the last page; and I did so because I have at present to enter upon the consideration of those preternatural labors that are rendered so by deformities of the osseous pelvis, and also by fleshy and fibrous or other tumors, that, growing from the walls of the pelvis, or that, having fallen down into its cavity from above, impede, obstruct, or wholly prevent the completion of the parturient act. In a former part of this work, to wit, in Chapter I., I have already treated of the pelvis as normally constituted. The Student, from reading that chapter, has become acquainted with the dimensions of the planes of the two straits, and the capacity of the excavation. The Student knows that the osseous frame consists of a soft gela- tinous material which hath become rigid and extremely solid and com- pact by the deposit within it of portions of phosphate of lime. He knows that to macerate a bone in a strong acid solution is to dissolve out from it entirely the whole of its calcareous and solid matter, leaving to the bone its pristine form and dimensions, but leaving it, at the same time, compressible and flexible in every direction ; for all that is left of the bone after the maceration is a gelatinous mixed with a proportion of fibrous and cellular material. Now the child that is born may become, in one of the early years of its existence, the subject of a disease one of whose most prominent characteristics is to prevent a deposition of the calcareous phosphate in the substance of the gelatinous framework of the bone; not wholly, indeed, but to such a degree as to leave the bone softish and com- pressible, or flexible. Again, a child may grow up in apparent health, having conformably developed all the parts of its constitution — its phosphatic deposits having been rendered complete up to a certain term, and giving to its bones a due degree of solidity and firmness; DEFORMED PELVIS. 453 whereupon it shall be attacked with disease, whose effect shall be to remove from the gelatinous framework of its bones a large proportion of its calcareous solid. These two cases present examples, the one of a suspension of the process of deposition, and the other of a removal of the phosphates already deposited. The former is Rachitis, or Rickets. The latter is Mollities-ossium, or softening of the bones. The effect is the same in either case. In rachitis, the child continues to grow without re- moval of the ancient phosphate, and the bone bends or is crushed. In the latter, the ancient phosphate is removed, and the bone bends, or is crushed. It bends, or is crushed under superincumbent weight. If the child laboring under rachitis should recover from that malady, it would regain its power to solidify its bone, by depositing calcareous matter within its intimate structure. But, should the solid matter be replaced while the bone in its plastic condition is pressed or bent out of its due shape, it might regain the most consummate health, and remain ever after affected with deformity of the bone in question. If the humerus, the radius, the femur, or the tibia, should regain its solid phosphate, those several bones would be found arcuated — bent like a bow — and remain ever so. If the ossa innominata, which consist of the ilia, ischia and pubes, should be the seat of the soften- ing processes, and if, during a long-protracted illness, the child should lie chiefly upon her right side, or upon her left buttock, the sacro-pubal diameter of the pelvis would allow its pubic extremity to be turned towards the right side of the child, and vice versa. This would pro- duce what is called the obliquely-deformed pelvis — dass schraage verengte beckens — of Professor Naegele of Heidelberg. The Student will perceive that such a pelvis as this must lose a portion of that diameter which extends from the left acetabulum to the right sacro-iliac symphysis, provided the pubis be deflected to the right side, and so, mutatis mutandis. In case the Student should be charged with the conduct of labor for a woman affected with right oblique-deformed pelvis, he will per- ceive the necessity there is to direct, if possible, the vertex of the child to the right rather than to the left acetabulum of the mother ; for as the occipito-frontal diameter of the foetus exceeds its bi-parietal diameter, he would sedulously endeavor to make the greatest diameter of the head coincide with the greatest diameter of the pelvis, in order to render the delivery comparatively facile, which would be difficult, laborious and even impracticable, were he to persist in attempts to force the long diameter of the head through the contracted diagonal 454 DEFORMED PELTIS. Fig. 101. of the pelvis. This is one of the cases in "which turning and delivery by the feet are allowable in the deformed pelvis. Having made a perfect diagnosis of the deformity, he will find him- self able, in performing the act of version, to adjust the smallest dia- meters of the foetal cranium in such a way as to make them coincide with the smallest diameters of the pelvic passages. The annexed figure is taken from Professor Naegele's work on the oblique deformed pelvis. It is seen, by inspection of the figure, that if the ver- tex of the child should be directed towards the left acetabulum, the dimen- sions of the pelvis are so much diminished by the fall of the pubis towards the right, that little expect- ation could be indulged of the descent of the cranium below the plane; for the antero-posterior diameter of the cranium exceeds four inches and a half, while the bi-parietal diameter is 3.88. I subjoin the figure of a pelvis preserved in my collection (Fig. 102). It will be seen that it is right oblique-deformed, like that de- Fig. 102. DEFORMED PELVIS. 455 scribed by Professor Nsegele. I give the figure of it in order that I may set down on this page its dimensions, which I now carefully measure. From the promontory of the sacrum to the top of the symphysis pubis, 3.6; from the promontory of the sacrum to the point of the coccyx, 3.5 ; from the right acetabulum to the left sacro-iliac junction, 4.1; from the left acetabulum to the right sacro-iliac junction, 2.7; from the top of the right ischium to the top of the left ischium, 3.7; from the inner lip of the right tuber ischii to that of the left tuber ischii, 3.5; from the point of the coccyx to the crown of the pubal arch, 4.2 ; from the point of the coccyx to the inner lip of the left tuber, 1.9, to the right tuber, 3.5 ; the length of the symphysis pubis, 1. I shall proceed now to speak of other deformities of the pelvis. Rachitis or Mollities does not ne- cessarily affect the whole of a bone. The figure 103, which I subjoin, represents the plane of a superior strait like the figure 8. It is evident upon inspection that the posterior semi-circum- ference of the pelvis has not suf- fered at all in its form, as the Student may perceive by comparing it with Fig. 104, which I have Fig. 104. taken from the pelvis of an Egyptian lady of rank from the tombs of Thebes, which pelvis was presented to me by my friend, Samuel George Morton, the distinguished author of the " Crania Americana." This pelvis, which is one of the most perfect specimens of the female pelvis that I have ever seen, may serve here as a means of comparing 456 DEFORMED PELVIS. the posterior semi-circumference of the badly deformed pelvis, Fig. 103, with the posterior semi-circumference of this most perfect Egypt- ian form. It shows that the deformity in Fig. 103, has arisen from rachitis or mollities affecting chiefly the pubal and ischial portions of its ossa innominata, which, having fallen inwards upon the promon- torium of the sacrum, have so reduced the antero-posterior diameter of the superior strait as to render the passage wholly impracticable for the full-grown foetus. In such a pelvis as this, the pregnant woman ought to be advised to submit to an early abortion, whereby she w T ould be preserved from an ultimate direful necessity to undergo a frightful Csesarian operation, because, when the antero-posterior diameter of the pelvis is only an inch and a half in length, it is impossible to extract through it a full- grown foetus, except that foetus be either of an under size or else in a state of absolute decomposition ; circumstances not to be expected, and therefore not to be relied upon, nor scarcely to be hoped for. Dr. Simpson's late case, published in an English Journal, might serve rather to mislead the practitioner with vain hopes of an unparalleled good fortune like that which his patient enjoyed, than as a precept to be generally followed. I annex the figure of another pelvis (Fig. 105), in which the dis- tortion has attacked the sa- crum itself, as well as the pubes and ischia, and par- tially the left ilium. In such a pelvis as this, pro- vided the antero-posterior diameter should not be re- duced below three inches, good hope might be enter- tained of extracting a living child by means of dexterous and most patient use of the obstetric forceps ; especial- ly should the child be rather under size and one in which the progress of ossification had not gone so far as to render the bones of the cra- nium very firm and resisting. But, as a child's head in its bi-parietal diameter, according to my measurements, will average 3.88, and as, in a series of three hundred heads, I found but one under 3.50, there will be in general but faint prospect of extracting a full-grown child alive. The records, however, contain abundant examples of cases DEFORMED PELVIS. 457 in which the fetus at term was spontaneously expelled in pelves re- duced as low as 2.50. In the treatment of such a case as the one now under consideration, the least reflecting Student must perceive that, in adjusting the position of the head, it would be desirable for him to bring the bi-parietal diameter, which is the smallest diameter of the head, in coincidence with the antero-posterior, which is the smallest diameter of such a pelvis; and further, that in any attempt to assist the natural powers by means of the obstetric forceps, it would be preposterous for him to think of adjusting the blades upon the sides of the head in that direction. The pelvis is already, perhaps, fatally small. To apply the blades of the forceps, then, would be considerably to increase the necessity for the reduction of the transverse diameter of the head. Common sense, therefore, would teach him that if he must apply the additional force, it must be applied to the face and occiput of the child. The blades of Davis's forceps, even when the handles are perfectly shut, are 3.9 asunder. It would be impossible, therefore, to extract the forceps in that direction, much more the head contained within them. I believe that the practitioners of midwifery in England are less familiar with the use of the forceps than those of the continent or of the United States. I think them quite too prone to refer to the aid of the crotchet and perforator; and I cannot but indulge a disposition to dissent from their almost invariable habit of adjusting the blades upon the sides of the head, much preferring the practice of the continental physicians and those of the United States, who seize the head upon the sides of the pelvis — a practice as to the safety of which I con- fidently speak from multiplied opportunities in my clinical experi- ence. This is a case, also, in which, perhaps, more properly than in other cases, the precept should be observed of attempting to deliver by turning. Those who, in restricted pelvic diameters, propose the re- sort to turning as a means of saving the child, and at the same time of preserving the woman from much pain and greater danger, insist upon it that the chance of preservation is greater, because when the child has been turned and drawn away, so as to allow the head to come to the narrowest part of the pelvis, the cranium yields, allows its diameters to be reduced, and may be disengaged from a narrow strait, through which it could not be driven if the head were the presenting part. The idea is this : when the head is drawn through by means of traction exerted upon its neck, it undergoes a process which, as I take it, is not wholly unlike that called wire-drawing, whereas, when the head 458 DEFORMED PELVIS. presents, such a process of wire-drawing cannot be supposed readily to take effect. A portion of metal can readily be drawn through the apertures of a wire-plate, which no art could drive through it from the other side. I am not prepared in this place to go so far as Professor Simpson of Edinburgh, in recommending a resort to version in bad pelves, and my hesitation arises from this, that the mensuration of the pelvis being rather a non-dependable process, there is reason to fear that the incautious and inexperienced accoucheur might, by too free a recommendation of it, be led to institute this method in cases where the reduction of the diameters is so considerable as to render an ex- cerebration indispensable for the delivery. I admit that it is possible to effect an excerebration in the footling case ; but in every case of a badly deformed pelvis, that operation implies an exceeding great risk of detruncation — an accident the most to be deprecated, for what occasion can arise for embarrassment and vexation greater than that which he experiences who is condemned to the task of extracting a detruncated head through a very much reduced superior strait of the pelvis ! In Dr. Lee's 3d Report Clinical Midwifery, p. 74, 3d ed., he gives the account of several cases of footling labors, occurring in deformed pelves, in which he was obliged to diminish the head by opening the cranium through the occipital bone. In some of these cases, that able and most dexterous practitioner frequently found himself greatly embarrassed in effecting the operation. To read his accounts of the cases w T ould be sufficient to put the Student upon his guard against the risk of encountering those embarrassments from version in de- formed pelves of which I have spoken. Here is another pelvis, Fig. 106, in which the rachitis has attacked the whole organ, for the last lumbar vertebra, as well as the ilia, ischia andpubes, are all changed in shape. The horizontal portions of the pubes have become al- most parallel, narrowing, of course, the antero-posterior diameter of the pelvis, and approximating the extre- mities of the transverse as well as the oblique diame- DEFORMED PELVIS. 459 ters, so as to render hopeless any attempts to extract the living child through it. It appears to me to be needless to follow the example of those writers who have reduced the deformities of the pelvis into a sort of classifi- cation. It is evident that the softening of the bones, which, as I have already said, may attack the whole or any part of the osseous struc- ture of the basin, may yield every conceivable degree of irregularity of form ; and those that I have already spoken of in this article are sufficient to show the Student what is the nature of these deformities; and as he is already acquainted, from a former chapter in this volume, with the mean dimensions of the foetus, he maybe regarded as already qualified to give his judgment upon questions of the obstetrical ope- rations arising under pelvic deviations. It is necessary that he should be aware of the methods which are adopted for ascertaining in the living woman the dimensions of the pelvis. As a general rule, the indicator finger of the accoucheur will scarcely be found capable of extending further than three and a quarter inches or three and a half inches beyond the crown of the pubal arch. It is true that by the introduction of half the hand, the palp of the indicator finger can be made to explore a region four and a half inches distant from the crown of the arch ; but, as the introduction of half the hand in the woman not in labor, or affected only with the earliest stages of labor, is so painful as to excite the greatest repugnance and resistance on the part of the patient, the vaginal taxis is generally preferred with the indicator alone. Suppose there should be some suspicion of a degree of deviation of the pelvis — one in which the pubis has retreated towards the sacrum, or one in which the pro- g ' 107 ^ montorium has descended towards the sym- physis pubis. If he should carry his indicator finger as in the annexed figure, directing it to- wards the promontory of the sacrum, and in vain therewith endeavor to touch the sacro-vertebral angle, his exploration will teach him at once and clearly that his patient has nothing to fear on this head; but if he can readily touch it, as in the figure, then he has a deformed pelvis, proportion- al to the facility of the touch. If, again, the point of the coccyx, which can always be touched with the indicator finger, is found not to approach too close to the crown of the pubal arch, uneasy apprehensions on 460 DEFORMED PELVIS. Fig. 108. this head are at once set aside. As for the mensuration of the transverse diameters of the inferior strait of the pelvis, the least tact, with but little experience, would show that that strait is or is not normal, and to what degree, if deviated at all. If, however, upon introducing the index finger, it should at once encounter the sacro-vertebral angle, pressing the point of the finger against the protuberance, and lifting its radial edge up to the crown of the arch, with the finger nail of the other hand he can mark the point of contact with the top of the arch, and then, measuring the distance to the point of the finger, he will have an accurate report as to the antero-posterior diameter. It appears to me that there is no necessity for the Student in this country to trouble himself to make a provision of callipers to measure the pelvis externally, in order to get a report of the internal diameters of it, nor need he, in my opinion, procure any intro-pelvimeter, which is more apt to mislead him than his hand is; and which, moreover, is, both inconvenient and painful in its application. Nevertheless, if he should be inclined to avail himself of the use of the callipers, he will perceive in the annexed figure the mode of its application. Applying one of the buttons of the calliper to the symphysis pubis, and the other to the spinous process of the fifth lumbar vertebra, the scale will mark the space by which the buttons are divided. Let him subtract from that space half an inch for the thick- ness of the symphysis pubis, and two and a half inches for the space between the sacro-vertebral angle and the spinous process on which the button rests, he will have three inches to deduct from the whole sum ; the remainder is to be taken as the antero-posterior diameter of the plane of the superior strait. If he will please to refer back to Fig. 103, in which the pubis projects in consequence of the parallel- ism of its horizontal rami, he will at once perceive the futility of an attempt to deduce the internal capacity of the pelvis from an external measurement. The great matter is for him to determine the indication of treatment DEFORMED PELVIS. 461 in the case, and that indication must clearly arise from a consideration of the actual state and wants of the patient, and not from any rules or precepts that can be set down in any book whatever. A gentleman might, for example, be impressed with the propriety of trusting to the unassisted powers of nature in a patient whose antero-posterior diameter at the superior strait is three or even less in the drawing, which is from my camera lucida. The figure cannot represent the head curve of this vectis, which is faulty in consequence of the slightness of that curve ; still it is an instrument of which one might make a fortunate use in a case of labor requiring nothing more than the vectis. The form of the hook at the other end of the handle, and the sharpness of its point, though they may perhaps entitle it to the character of the blunt hook, might leave one, upon a narrower examination, under the impression that the Chamberlens must have employed it rather as a sharp crotchet than as a modern blunt-hook. Fig. Ill represents, probably, the second attempt of the inventor to carry out his happy idea of the obstetric forceps ; it consists of two Fig. ill. separate pieces, both terminated by blunt-hooks at the handles; both possessing the old curve, and capable, therefore, of grasping the head, when once applied to it while lying within the genital passages. I say separate pieces, since the two pieces may be taken apart by unscrewing the pivot, which in the figure is seen passing through the lock. The right hand branch was forged out of one piece of iron, like the vectis at Fig. 110 ; but the left hand branch was a piece of thick iron wire carried out to the extremity of the clam, and then re- 478 THE CHAMBERLEN FORCEPS. turned towards the lock, where its extremity, being flattened, forms the square head for the reception of the screw-pivot. If this instrument, as I suppose, does really represent Chamberlen's second attempt at invention, it must be regarded as a remarkably successful effort; for, setting aside some imperfection in the amount of the old curve or head curve, it presents us with an apparatus, a true obstetrical forceps, of which the counterparts, being separately introduced and then locked by screwing in the pivot, may be so per- fectly adjusted upon the foetal cranium as to give the operator complete power over it. The fenestra is very good : the curves, however, are extremely faulty. Not so with the forceps, Fig. 112, which is in all Fig. 112. respects an admirable instrument as to the head curve, as may be seen by inspecting it in the drawing. The iron of which it was forged is, it is true, rather clumsy and heavy, but scarcely more to be con- demned, on that account, than the heavy Berlin forceps of Professor Siebold. It had no pivot joint, but the two compartments were fast- ened together by a strong flat braid, like that represented in the figure, which, being passed through the hole drilled in the lock of the instru- ment, and afterwards wrapped around the handles, would serve, after the adjustment of the blades upon the head, to hold it quite securely, and prevent even as much rocking motion as attends the use of the common English joint. Fig. 113 shows the last and most perfect form of the obstetric for- Fig. 113. <& <& THE CHAMBERLEN FORCEPS. 479 ceps of the Chamberlens. It has what is now called the German lock, for the left-hand blade, or male blade, or lower blade, for these are synonymous terms, is provided with a fixed pivot to receive upon it the female or upper blade, as may be seen at Fig. 114, in which the Fig. 114. pivot is represented, the handle being terminated by the bending up- wards of the iron. I have never delivered a woman with one of these old Chamberlen instruments, and while I should much prefer an instrument made by a modern artist to either of these early specimens of the invention, I would not hesitate in any case, where the vertex was at the pubal arch, to employ either Fig. 112 or Fig. 113, if my Davis' forceps was not at hand. The instrument is scarcely inferior to the Haighton forceps in use in England at the present day. In 1733, Dr. Samuel Chapman published a " Treatise on the Art of Midwifery," &c, in which the forceps of the Chamberlens was given to the world, and from that time to the present day it has undergone many modifications of form and size, and mode of coaptation : almost every distinguished practitioner or writer selecting some particular fashion as most in accordance with his especial views. The instruments first employed had only one curve, that which applied itself to the head of the child in order to grasp it — and this is called the Old Curve; it ought to be called the Head Curve — so that the profile view of it represented a straight instrument. Such a straight instrument could be easily applied to the head whenever it had de- scended quite into the excavation, or whenever the ear could be touched by the point of a finger introduced into the vagina. But in all cases where the head was arrested while in the superior strait, a forceps possessing only the old or head curve could not well be em- ployed in its extraction, because the pelvis is itself curved, and hence when the points of the instrument should have mounted up sufficiently far to be on a level with or above the plane of the superior strait, the handles would necessarily press the edge of the perineum back too much towards the point of the coccyx. This pressure is both hazardous and painful, and endangers an early contusion of the perineum, or 480 THE FORCEPS. — THE NEW CURVE. even its laceration. To effect such an adaptation would in all cases be found difficult, and in cases of rigid perineum, quite impossible. From the period of the publication of this invention by Dr. Samuel Chapman, up to the middle of the seventeenth century, several new forms, deserving perhaps to be called improvements, were offered to the profession. For a history of these various modifications, which it is not necessary for me to present in this work, I refer the Student to Dr. Mulder's Historia Literaria et Critica Forcipum et Vectium Obstetriciorum, in which he will find very accurate drawings of a great multitude of forms and dimensions of obstetrical instruments, down to a late period in the history of that apparatus. To look at Mulder's account is enough to excite a smile in the reader at the am- bition which proposes to build up a solid reputation rather by spoiling than by improving an implement already perhaps perfect. Professor Asdrubali, in his Trattato Generate di Ostetricia Teoretica e Prattica, vol. iii. p. 180, refers to Professor Manni's examination of the history and properties of the obstetric forceps, and he says: " Dopo questa correzione portata nel forcipe dagli Ostetrici di Londra e di Parigi circa la meta. del passato secolo, parea questo stromento giunto alia sua perfezione, ma lo spirito umano, sempre irrequieto piu per l'ambizione di distinguersi, che per giovare ai suoi simili, ne mise fuori una serie numerosa dei gia riprovati, e talvolta piu meschini di quelli." And he names the forceps of Loder, Galletti, Santarelli, Steidele, Johnson, Orms, Denman, Smith, Lowther, Osiander, Eckard, Stark, Bush, Siebold, Thenance, Du Bois, Mursinna, and Brunninghausen; and concludes that all these modifications do not exhibit any real improvement upon the forceps of Smellie and Levret. Dr. Smellie of London, and Dr. Levret of Paris, both conceived at about the same period, that is about the year 1750, the idea of giving to the blades a new curve on the edges, so as to adapt them to the axis of the superior as well as to that of the inferior strait; and ac- cordingly they produced the forceps with New Curves, which are al- most universally in use at the present day. Smellie used for common purposes his short straight forceps, fearing that too general and indis- criminate an employment of the long curved one might prove mis- chievous ; while Levret recommended his long and powerful instrument as being equally adapted to all cases proper for forceps operations. Smellie's instrument was united by the reciprocal notch called the English joint or lock, and Levret's was joined by a pivot and mortice, with a sliding plate, to secure it when united. Both the instruments THE FORCEPS. 481 were provided with fenesters, but of an insufficient size to do much more than serve to render them lighter. The French forceps, somewhat modified by Pean, has great vogue in this country at the present time, under the denomination of the Baudelocque forceps. It is two inches longer than Levret's, and is constructed without the bead or raised line that runs round the inner or foetal face of the clams, and which, in his, was found inconveniently to cut or contuse the scalp of the infant. The obstetric forceps consists of two pieces or branches, a right and a left one, intended to be introduced separately between the sides of the head and the parts in which it is contained ; but alw T ays so ad- justed as to let the concave edge of the new curve look towards the front of the pelvis, to suit the curvature of which, it w T as originally contrived or invented. The part that is called the blade of clam ought always, if possible, to be applied on the side of the head, and not on the crown or occiput, and the extremity of the clam should reach up at least as far as the chin. Hence, in constructing a forceps, it should be always considered necessary to make the clam, or blade part, suf- ficiently long to reach at least from the child's vertex to its chin; a distance of about five inches in the uncompressed state of the head, but w T hich is much increased in some cases where the head is subjected to severe and long-continued compression in the passages. But while the head itself requires that the clams of the instrument should be five inches long, the different positions or situations in which the head is found at the time the forceps becomes necessary, demand that there should be given to the instrument length enough to embrace the head, whether it be high or low T in the pelvis; and that in introducing them, the lock or joint should not be carried within the orifice of the vagina. There must also be a handle of sufficient length and strength to admit of its being used with facility by the operator. The forceps therefore is divided into the blade or clams, the joint or lock, and the handles. The proportion of these several parts has been adjusted in various ways, according to the taste or judgment of the several makers of them. Dr. Smellie, who generally employed his short straight forceps, constructed them of the length of eleven inches, w 7 hile to his long curved forceps he gave a length of tw r elve and a half inches. The French or Baudelocque forceps, in very general use in this country, is a powerful instrument. The specimen that I have before me, and which is made by Messrs. Rorer, is exactly eighteen inches in length, the pivot or joint being very nearly midway from the end of the clams to the end of the handle. The ends of the clams ap- 31 482 DAVIS' FORCEPS. proach within three quarters of an inch when the handles are closed or pressed together, while the greatest distance between the clams is not quite two inches and a half. The blade or clam has an open fenester which is not quite an inch wide at its widest part, but which is six inches long, growing narrower as it approaches the lock, where it is not three-tenths of an inch in width. The lock or joint consists of a pivot in one branch, and a notch in the other. The pivot is fixed into its own blade by a screw, the top of which is a thumb piece, by means of which it may be screwed into or withdrawn from its place. The notch in the other blade is adjusted so as to receive the pivot into the left or outer side of the instrument, and the top of the notch, being countersunk, receives a conical shoulder at the bottom of the thumb piece of the screw, by which means it is made perfectly secure against any motion except that of opening and shutting the instrument. The end of each of the handles is curved outwards, so as to make a blunt hook, that may, upon occasion, serve all the purposes for which the blunt hook is used in midwifery. The weight of the specimen is two pounds and seven-eighths of an ounce. This powerful instrument, in skilful hands, may be made use of to overcome very great obstacles; but, in careless or unskilful applica- tion, may be the cause of great mischief. It has been objected to by many prudent persons on account of the great weight of metal, and the severe pressure of the child's head, that may, almost uncon- sciously by the operator, be made with it. The late Dr. James very rarely used any other than a short-handled straight pair, called Haigh- ton's forceps: yet I have had occasion to witness the application, by him, of a pair modelled upon the plan of the Baudelocque forceps. It cannot be doubted that all the benefits of the small forceps may be obtained in the use of the large ones; and those who cannot con- veniently command a variety of instruments, would do well to fami- liarize themselves with that which I have above described. It has been well remarked by Baudelocque, that it is not so much the instru- ment that is to be looked to, as the hand that uses it. The most convenient forceps that I have ever employed, and that which I commonly make use of, is the instrument recommended by Professor Davis, of the University of London. The instrument now before me is the one described in Davis' Operative Midwifery, and was made by the late Mr. Botschan of Lon- don. It weighs ten ounces and three quarters, and is in length twelve inches ; its joint is the English joint, composed of a notch in the DAVIS' FORCEPS. 483 upper surface of the left and in the lower surface of the right branch. When the handles are closed, the ends of the clams are seven-tenths of an inch apart, while the fenesters, at their widest part, are two and three-quarter inches asunder. The broadest part of the fenester is equal to two inches, and its whole length five inches. From the ex- tremities of the handles to the lock or point where the branches cross, is four and a quarter inches. After the branches are crossed, they do not divaricate, but proceed in parallel lines one inch and a quarter: hence, if a foetal head be ever so considerably elongated by the pressure of the parts, the clams are sufficiently capacious to contain it, being seven inches long. In this instrument, such are the width and length of the fenestra?, a large part of the parietal protuberances jut out through them w T hen they are fixed on the head. Indeed, the foetal head, when held within the grasp of this instrument, if it be properly adjusted, can hardly sustain any injury from it, so admirably is it modelled upon the curves of the cranium. I have several times delivered from the superior strait with Davis' forceps, an operation for which it is peculiarly well adapted by the boldness of the new curve, particularly upon its convex or inferior edge. I am quite free to confess my preference for this over all other instruments for the safe delivery of the child, because, as I repeat, I think it almost out of the bounds of possibility to injure the foetus with it, provided it be perfectly well adjusted, and used with common discretion. I have not myself employed the German forceps of Siebold, because I have considered that the handles are very clumsy, and so widely separated, when the instrument is adjusted on the head, as to expose us to the hazard of compressing the cranium too violently. I have also thought the handles too much curved. But the author of the instrument is justly celebrated for his skill; and I am also aware that this is the instrument preferred and often used in our city by Dr. R. M. Huston, whose judgment and skill demand my highest respect. This gentleman, who is frequently called upon for consultation, has informed me that his success with Siebold's forceps, modified by him- self, causes him to esteem it above all others. It ought to be observed that Dr. Huston's forceps, although modelled upon that of Prof. Siebold, is very different from it in regard to its lightness and manuability, in consequence of the great length of the lever. This is, perhaps, a fault, if it be true, as I believe it to be, that the obstetric forceps is not a compressor, but only a tractor. Shorter handles, which lessen the power of the lever, diminish the hazards to which the child is exposed 484 HUSTONS FORCEPS. from the compressive action of the instrument, which in all cases per- haps is too fearfully great. Short handles do not prevent us from holding the child securely: with short handles it is possible to make traction to an extent that is dangerous. My specimen of Siebold's forceps, manufactured at Berlin, weighs twenty-seven ounces and a half, while the instrument of Dr. Huston is but twenty-one ounces in weight. Fig. 115 is a representation of this forceps modified from Siebold's, which I have taken from Huston's edition of Churchill's " Midwifery." Fig. 115. Upon looking along the convex edge of the new curve of Huston's forceps, it will be seen that the line is almost straight from a point a little beyond the posterior terminus of the fenestral opening, to the handle, so that the instrument is more seemingly than really curved— for the instrument, strictly speaking, is the clams. The clams are not very much bent, especially the concave edge of the new curve. I subjoin here a drawing, Fig. 116, taken in the camera lucida, of my Davis' forceps made by Botschan, applied to the head of a child. It will be seen by inspection of the concave edge of the new curve DAVIS' FORCEPS. 485 that that edge is not very much bent, while the convex edge of the curve represents almost the quadrant of a circle ; and as the convex edge turns down to join the handle, which springs mainly from the concave edge, and is continuous therewith, it follows that when the instrument is introduced into the cavity of the pelvis, it rests easily therein, because it does not strain back the anterior edge of the peri- neum towards the anus, and even towards the point of the coccyx, as must happen when the head is seized high up in the pelvis with any other instrument. The edge of the perineum, in using this instrument, comes forward almost as far as the line which is con- tinuous with the concave edge of the curve. The great advantage attending the use of Davis' forceps, is found in its light- ness, weighing, as I said, ten ounces and three quarters; in the shortness of its handles, which, while they afford all the requisite purchase for making even the most pow- erful and dangerous traction, yet from the shortness of the lever, serve to guard the child against the mischiefs of com- pression. I reiterate the expression of my opinion that the obstetric forceps was never designed to act as a compressor, but only as a tractor. Dr. Davis' for- ceps is forged in such fashion as that its interior face is per- fectly adapted to the rotundity of those parts of the head which it touches; and the fenestras are so vast as to permit considerable por- tions of the parietal protuberances to project as segments of curves outside and beyond the fenestral openings. It would also be true to say that the instrument, when accurately adjusted upon the sides of the cranium, scarcely touches the maternal tissues within the pelvis. The exterior curves are also arranged so accurately that the tissues of the mother can never touch the edges of them ; so that they cannot be cut by them, the surfaces of contact being everywhere broad and 486 gently rounded. The admirable form of the old curve or head-curve enables the instrument to touch very large portions of the cranial surfaces, pressing them equably, and not unequably: so much so indeed, that when the instrument is accurately applied, it would be a very difficult matter to do with it the least injury to the fetus, since it can scarcely slide. I prefer it for ordinary cases to all the other instruments. Each blade of this forceps is provided with a supplementary coun- terpart much narrower than the principal blades, which may often be usefully resorted to in cases where, after easily adjusting the first blade, the apposition of the second blade is found to be difficult, dan- gerous, or impossible, in consequence of that portion of the head which the blade ought to cover, being driven or jammed with violence against the bony side of the pelvis. Under such circumstances, a narrow blade might admit of adjustment, whereas a broad one could by no means be with safety applied. I desire the Student to have a proper idea of the meaning and in- tention of the accoucheur in using the obstetric forceps. His course as a practitioner will take its color much from the impressions he receives concerning the nature and design of this valuable instrument. If I were possessed of such place and reputation as might give to my opinion any character of authority, I do not know in what manner I could exercise such authority more favorably to the interests of hu- manity, in this particular line, than by establishing the doctrine that the obstetric forceps is the child's instrument; that the perforator, the crotchet, and the embryotomy for- ceps, are instruments for the mother; and that the Caesarian operation is an operation to be performed for the benefit of the parturient woman. If a woman in labor is in a situation demanding immediate delivery by instrumental means, and that without any reference to the claims or interests of the child, it is clear that to lessen the volume of the cranium by perforation, and to extract it with the crotchet or with my embryotomy forceps, is the safest as well as the swiftest method that can be employed; and every accoucheur would prefer this method in a case exhibiting undeniable proofs of the death of the fetus. Hence I repeat that the obstetric forceps is designed to save the child, and that the relief which it gives to the mother is but an appurtenant to it. It is true that in the conduct of a labor, the accoucheur shall often come to the conclusion to deliver with the forceps on account of some excessive pain, inability, or danger, to which his patient is exposed ; 487 and this in cases where he would not adopt such a resolution from views relative to the safety of the child alone. In this sense, then, the Student might reply that the forceps is the mother's instrument ; to which I answer, nay, but it is the child's in- strument ; and I select it for my operation because it makes the child safe, which could not be were I to use the mother's instruments — to wit, the perforator and the embryotomy forceps. I dare not to use the mother's instruments in contravention of the rights of the child, but I may with the child's instrument relieve the mother, and save her, while I do it no injury. If the Student should take his impressions of duty from studying the English books of midwifery, he w r ill go into the world believing that the obstetric forceps is the mother's instrument, and he will use it for her, and for her alone; whereas, should he adopt the views above set forth, and w T hich I deem to be perfectly sound and wholesome, he will enter upon his career feeling and knowing that he possesses an apparatus with which to rescue the child when in danger ; and he will employ this instrument as often from indications relative solely to the child, as from indications relative solely to the mother. The obstetric forceps is designed to be applied only to the cranium of the child. It should never be applied to the pelvic extremity of the foetal ovoid. The blades are to be applied to the sides of the head, the extremities of them passing up nearly as far as the chin. See again Fig. 116. They may be applied to the head in occipitoanterior and in occipito- posterior positions of it, and also in the transverse positions which it sometimes assumes. They may also be applied to the head in face presentations, whether the chin be to the pubis or to the sacrum; and their consummate conservatism must be frequently appealed to, for the succor of the child, in those pelvic presentations in which the head cannot be extricated by the hand alone. When properly adjusted in a suitable case, they give to the surgeon control at will over the progress of the labor. I have said that the forceps is not a compressor, but merely a tractor. I might have said, that w 7 hile it is a tractor, it is also a double lever. In order to get a good idea of the lever-like action of the forceps, let the Student endeavor to deliver the foetus on the machine ; and, for this purpose, let him employ a Baudelocque or French forceps. Hav- ing grasped the head, let him take hold of the blunt hook of the left hand branch, and pull by that alone ; and, as he pulls, very gently, let him move the hook towards the left side ; and having carried it far 488 FORCEPS NOT A COMPRESSOR. enough over in that direction, let him take hold of the blunt hook of the right hand branch, and pulling gently, or even by merely holding on enough to keep the clam of that branch from sinking into the pel- vis, if he carries the handle over to the right side, he will find what is meant by, and what is the great and efficacious power of the lever- like operation of the forceps, when moved, from handle to handle; for, as he carries the said hook to the right, the blade of the other half of the forceps will be seen to emerge from the pelvis ; and so, by alter- nating the lever-like motions, he will at last find that the forceps is withdrawn wholly from the pelvis, bringing away in its jaws the head of the young child unhurt by compression. The compressive action of the instrument is not needed, further than to cause it to hold the head firmly and steadily, while the lever or lateral, or the extracting or vertical power is applied through it. It is never applied to the foetus in breech or footling cases, until all parts of the child save the head, are born, for the delivery of which, under such circumstances, it is frequently required ; nor can it ever be required in those presentations which are manageable by the hand, the noose, or the blunt hook. One of the most dangerous errors relative to the forceps that a Stu- dent could take up, would be the opinion that the forceps is, in its very design, a compressive instrument: it is not so; the forceps is not a pincers, it is an extractor — it is a real tire-tete; and I think it ought to be established as a principle in obstetrics, that where there is not space enough for the descent of the head without the forceps, there cannot be produced a due proportion by merely squeezing the head down to the required dimensions by such an instrument. Lest, how- ever, I might by the above give a wrong impression of my views, it is needful that I should state, that a head, by long pressure of the pains, may be so moulded and reduced in diameter as to be squeezed through a pelvis smaller than the head was at the commencement of the tra- vail: whenever, therefore, the pains cease, or are insufficient to reduce it, the forceps, used as an extractor, may assist to that end; they should never squeeze it merely to compress and diminish its dimen- sions ; they should always embrace it firmly enough to hold on and draw it down, so that the passages may mould it as it descends. The celebrated Baudelocque, in order to learn, by inspection, the effects of direct pressure by the forceps, procured nine still-born chil- dren, and by moulding their heads in the hand restored them to the shape of the uncompressed head. He also procured three forceps of the very best quality, and as nearly alike as possible : he then applied FORCEPS NOT A COMPRESSOR. 489 the instruments over the parietal protuberances, and squeezed the heads until the handles were brought into contact, and tied firmly with a string, so that each head might be accurately measured while under the compression, and then compared with its dimensions before the instruments were applied. Such was the force employed in bring- ing the handles into contact, that the instruments, though very choice ones, were all spoiled by the experiment. The instrument was sub- sequently applied so as to embrace the forehead and occiput, and the results ascertained. These excellent experiments, for the particulars of which I must refer the Student to VArt des Accouchemens, Part IV., chap. L, are commented on by Baudelocque as follows : "It may be concluded from these experiments: 1st, that the reduc- tion in size of the fcetal head, included in the clams of the forceps, differs according to the different degrees of firmness of the cranium at birth, and to the more or less complete closure of the sutures and fontanels. 2d, that this reduction cannot in any case be so consider- able as has by accoucheurs been supposed, and that it can with diffi- culty, and very rarely, exceed four or five lines, with the instrument acting upon the sides of the head. 3d, that the degree of reduction should never be estimated from the distance remaining between the ends of the handles when they are pressed together in the act of de- livering the head, nor from the amount of force employed to bring them towards each other. 4th, and lastly, that the diameters which cross the compressed one, far from increasing in proportion to the diminution of the compressed one, do not in general augment to the extent of a quarter of a line, and in fact are sometimes even lessened." The above-mentioned results, procured by so distinguished a writer as Baudelocque, ought to suffice for removing any lingering disposition we might have to regard the forceps as a compressing instrument, and we should then be fully on our guard against the propensity to use it for such an object; but let it be considered that the head does not fill up the pelvis as a nail fills up the hole into which it is driven, but that it is always caught and arrested by two or perhaps four points on which it is impelled, and we shall see that if we do use it to squeeze and reduce the size of the head, we shall only reduce those diameters that are already small enough, and augment those that are already too large, for it cannot be adjusted on the points that are in such close contact as to constitute a real arrest. The most proper view to take of the instrument is, that it is a substitute for proper labor pain, sup- plying the want of expulsive force when wholly absent, or aiding it when its force is insufficient to effect the delivery of the woman. Im- 490 TO USE THE FORCEPS. possibilities are not to be expected from it; yet in all those cases where it is inapplicable, we are compelled to resort to other measures of a far less pleasant character. It is common to apply the forceps to the head only after it has got fairly into the excavation, and the nearer the head is to the external organs, the more easily may the instrument be adjusted upon it. Hence, whenever, in the management of a labor, we begin to perceive the signs that indicate the use of instruments, we often feel at liberty to wait until the presenting part can take an advantageous position, preferring to lose a little time, for the sake of acquiring greater facility and assurance of safety. Whenever the head has sunk so low as to get the vertex just under or behind the sub-pubal ligament, we ex- perience little difficulty in placing the two branches, successively in- troduced, into their proper positions, because the rotation is completed, and the bi-parietal diameter does not occupy the entire transverse dimension of the pelvis ; but when we have to apply it before rotation has taken place, there is frequently great difficulty in getting either the first or the second branch directly over the side of the head; but if we fail to adjust the branches accurately in opposition, we either cannot make them lock, or we lock them in such a way that the edge of the instrument contuses or even cuts the part of the scalp or cheek on which it rests, leaving a scar, or actually breaking the tender bones of the cranium, while the other edge cuts the womb or vagina, by its free and projecting curve. In fact, the forceps is designed for the sides of the head; and if, under the stress of circumstances, we are com- pelled to fix them in any other position, we shall always feel reluctant to do so, and look forward with a painful anxiety to the birth, in order to learn whether we have done the mischief we feared, but which we could not avoid. I ought also to mention, that cases occur in which the forceps is clearly indicated, but in which, upon trial, we can by no means apply them; the size and position of the head are such that we cannot by force or dexterity get the blade of the instrument betwixt it and the bony passages; in such a case proper skill and judgment ought to be employed, and then, when we cannot succeed, we must be con- tent to think that we cannot, and that no one else can ; and afterwards, we must resort to other means of relief. Further, we can sometimes adjust the forceps perfectly, but cannot effect the delivery, because the parts are too small. Here, also, we ought to suffer no feeling of mortification to vex us for want of success ; we should feel assured that we have exerted a sufficient degree of strength and dexterity, a TO USE THE FORCEPS. 491 degree equal to what we ought to consider safe ; and being then con- vinced or satisfied that our duty has been, in so far, done, we lay aside the forceps to resort to ulterior measures. I have already said that the instrument is made for the head, to which alone it can be safely applied. It would crush or cut the breech, and the sides or the belly, if applied in breech presentations to those parts. The forceps cannot be applied unless the parts are favorably dis- posed ; for instance, the os uteri must be dilated and gone up over the head. The vagina and perineum also must be in such a condition that we need have no fear of lacerating any of those parts ; else, the operation is contra-indicated. A man shall hardly be justified who inserts his forceps within the os uteri. He must wait until the circle has risen above the parietal protuberance and can no more be felt. The pains must have been proved insufficient for their office, or the exigent demand for delivery, arising from hemorrhage, convulsion, or other states, must establish the indication. We should find ourselves inexcusable, if we should be led to use them where the pains are still of vast force, and where they fail of success on account of a preternatural resistance. If we judge that the power of the pains is already as great as the patient ought to bear, we ought not to apply the forceps, in order to add to the forces which are already perhaps of a dangerous degree of intensity. The motive for the use of the operation should be clearly under- stood as referring both to the mother and child ; to the mother alone; or to the child alone. The consent of responsible and interested persons should be obtained; the motives for the operation should, if possible, be clearly explained to the woman herself, and truthful, yet reasonable, promises should be made to provide for her safety and comfort, both of them requiring the operation to be done. If time permits, some professional friend should be invited to witness and sanction the operation. The position of the presentation should be well known ; and if needful, should be verified by the introduction of half the hand or the whole hand into the passage. The bladder and rectum should be evacuated, the latter by an enema, and the former by the catheter; the last precaution ought never to be neglected. The bed should be prepared by bringing the end or side of it quite to the end or side of the bed-stead, and then covering it with blankets and sheets of sufficient thickness to prevent the bed from being soiled. 492 TO USE THE FORCEPS. Part of a sheet should reach down to the floor, on which some cloths ought to be placed, to receive the fluids that commonly escape during the process of delivery. The patient ought to be brought to the side or end of the bed, as the case may be, lying on her back, with the end of the sacrum pro- jecting far enough over the bed to admit of the most unrestrained access to the parts by the hand and the forceps. While lying in this manner the feet should rest on two chairs or on the laps of her assist- ants, sitting with their backs turned to the patient, and far enough from each other to allow the operator to stand or sit between them ; the patient always being covered with a light sheet or blanket, accord- ing to the temperature of the apartment. The instruments, at all seasons of the year, should be placed, be- fore using them, in a bowl of tepid water; and, when ready, they should be anointed with sweet oil, which adheres to them better than lard. Lastly, the parts should be freely anointed with lard. The forceps are differently applied, according as the head is differ- ently placed. If the vertex present, and rotation have taken place so as to bring the point of the head just below or behind the sub-pubal ligament, the left hand blade is to be taken in the left hand, and the fore and middle finger of the right hand should be passed upwards as far as conveniently can be done, betwixt the left ischium and the child's head, somewhat towards the posterior part of the pelvis, or towards the left sacro-iliac junction. The branch should be so held as to cross the right groin, in a direction from above, downwards and inwards, so as to let the point of the blade be near the vulva, in w T hich it is next gently and slowly introduced, allowing the concavity of the old curve to be in contact with the convexity of the head. In proportion as it immerges, the point is directed upwards towards the plane of the superior strait, the handle coming downwards as the introduction pro- ceeds, and care being taken to direct the point by the two fingers as far as they can reach. If any obstruction or difficulty is met with, let it be overcome by gentleness and dexterity, and not by force. For example, if the point comes in contact with the ear, that organ might very easily be lacerated by any rude force, and a great deal of caution ought to be observed in order to protect the child from such a maiming, and the medical attendant from such a disgrace. At length the blade is introduced sufficiently far to show that the point is TO USE THE FORCEPS. 493 nearly even with the chin, and the old curve in contact with the side of the cranium, and face, and that it covers the ear. The end of the handle should now be depressed a little, and given in charge to one of the assistants, while the right hand branch is taken in the right hand, and the fore and middle fingers of the left hand are introduced into the vagina, on the other side, as in the case just described. The branch is laid across the left groin, looking from above downwards and inwards, and the point of the blade is passed into the vagina above the first branch. This one should also be at first directed towards the sacro-iliac junction of the right side, and elevated as it proceeds so as to be brought at last into exact opposition to the left hand branch. If any difficulty occurs in getting it forwards enough, the two left hand fingers that are guiding it will serve to slide it edge- ways into the proper position. The branches are now to be joined at the lock ; and the union of the branches is very easily to be effected if the opposition of the two counterparts is accurate. If the opposi- tion be inaccurate, the locking is impossible and ought not to be at- tempted by violent force. When locked, let the handles be brought near enough together to make sure that the head is firmly grasped, and then the instrument is to be withdrawn a little, in order to effect its more complete adaptation to the convex surface of the cranium, which it grasps or contains within its jaws. If the handles come not near enough into contact, that circumstance proves conclusively that the head is not properly seized ; and nothing further should be done until the error be corrected. If they gape more than an inch and a half at the ends, they are not adjusted upon the parietal bones ; but are obliquely fixed upon the frontal and occipi- tal regions. They ought to be a little more than an inch apart at the ends of the handles. "Whenever, during the process of introduction, a pain comes on, all action ought to be suspended until the pain has ceased. If this pre- caution be not observed, there is great danger of contusion, or lacera- tion by the blades of the instrument. It very frequently happens that the first or left-hand blade passes readily up to its proper position, and takes its place on the side of the head and face, without communicating the least disagreeable sen- sation to the patient, or causing the smallest embarrassment to the accoucheur; but, when he attempts to put the other blade into posi- tion, he either fails to insert it as deep as the other, or having done so, finds himself baffled in every effort to lock the joint. 494 TO USE THE FORCEPS. Fig. 117. The first blade has perhaps taken up so much space as to have thrust the head strongly over against the right side of the pelvis; leaving no passage betwixt it and the cranium along which to make the second blade glide. Upon the failure of discreet efforts, both of the counterparts should be gently withdrawn. Perhaps a new pain may now succeed in forcing the presenting part a little onwards: or, perhaps, after with- drawing the right-hand branch, the surgeon may succeed in using the left blade as a vectis so successfully as to bring the head into a bet- ter attitude; so that when the attempt to adjust the clams is renewed, no difficulty is found to remain. He shall often succeed in adjusting the right blade as a vectis, when he shall have withdrawn the left hand blade. When the two parts of the instrument are introduced far enough, they may be so imperfectly arranged that the concave edges of the new-curve may be almost in contact, while the convex edges divaricate very much, the ends of the handles having their flat surfaces obliquely placed, as in Figure 117. This could not happen except w T here the accoucheur has placed the instru- ment too near the occipital surface of the head, and too far from the bregmatic surface. An inexperienc- ed person is very apt in this case to suppose the very reverse, or that he has placed the convex edge of the new curve too far from the pubis and too near the sacrum : whereas it is really too near the pubal and too far from the sacral region of the excavation. If he makes this mistake, which, I repeat it, he will be apt to make, he would do well to remove the blade entirely, and give himself time to reflect anew upon the position of the child's head, and the relation of its right and left ears to the pelvic- walls. In this way, having mastered the topography of the case, he will be likely to succeed upon renewing his attempt. It w r ould be far wiser and far more charitable to do so than to make a barbarous and most unjustifiable endeavor to extract with forceps oblique and not in apposition, which they never can be when not in opposition. TO USE THE FORCEPS. 495 Should he now succeed in making the adjustment, the handles will point parallel to the left abducted thigh in vertex labor in the first position, the head incompletely rotated ; or, vice versa, to the right thigh ; or, when rotation is complete and extension begun, they will point coincidently with the mesial line of the trunk. In proportion as the extension of the head makes greater progress, the handles rise upwards towards the woman's belly, for the head, bringing the forceps along with it in its descent, must pass out in coincidence with Carus' curve. The end of the handles in rising describes that same curve with a greater radius. The instrument being now adjusted over the sides of the child's head, as in Fig. 116, let care be taken, before proceeding, that no external part be caught or pinched by the lock or joint. This is as- certained by passing the fingers round and within the orifice of the vulva. In general, no attempt to extract should be made until pain or tenesmus comes on. When the woman is ready, therefore, let the handles be held in the left hand, while the middle finger of the right hand is placed in front of the joint or crossings, to assist in the ex- traction, while the index finger is to be pressed against the child's head, and always retained in contact therewith, during the extractive effort. The finger ought always, in this state, to touch the head; but if it leaves it, it is because the blades are slipping off, in which case traction should cease until they are adjusted again. While the finger remains in contact with the head, there is no slipping of the instrument. It is shameful to let the forceps slip off the head and fly from the vulva with a suddenness sufficient to lacerate the parts in the most frightful manner. The most successful mode of using the instrument at first, is to employ it as a lever, by moving it from handle to handle, exerting at the same time enough extractive force to prevent the opposite blade from plunging deeper into the parts, while we move the handles to the right, or to the left. Let me here repeat that, in exhibiting to my class a demonstration of the lever-like action of the forceps, after having adjusted the instru- ments on the head, in the phantome, I take hold of the blunt-hook of the left-hand branch, and leaving the other untouched, I draw that branch a little out, and at the same time carry it over towards the left thigh ; in this action the blade of the right-hand branch is found to be withdrawn considerably, bringing the head along with it. I next take hold of the blunt hook of the right branch, and drawing a little downwards, I carry it over towards the right thigh of the phan- 496 TO USE THE FORCEPS. tome, by which the blade of the left branch is withdrawn in like degree, bringing the head, which it grasps, along with it; so that by- several successive movements of the sort the head is soon found to emerge completely from the vagina. One trial of this method on the phantome will show the Student how powerful is the action of the forceps used in this way. In this way, as one blade emerges, the other does not become immerged. In practice, all attempts at extraction ought to be made in conform- ity with the natural processes and dispositions or tendencies of the healthiest labor: there ought to be no hurry, no impatience, no tem- per exhibited by the operator. In natural labor there are intervals of rest; in artificial labor there ought also to be good intervals of rest ; which are required both for the physical relief, and the moral relief of the patient. Her mind is strained to the highest tension, by the mere thought that she is under the Operation, and the tissues against which we are dragging the child, yield better, for a minute or two of rest, repeated from time to time, as the case admits or demands. It should not be forgotten that the forceps embraces the head in a direction from the vertex to the chin ; nor that, when the head is evolved under the stress of the instrument, it ought to undergo the same mutations as it would if expelled by the natural pains. Hence, as the vertex emerges, and rises towards the front of the pubis, the ends of the handles must be permitted to rise along with it. They must never be prevented from taking the direction which the emerg- ence of the head naturally tends to give to them. In the last moments of the delivery of the head, during its extension, the inferior part of the occipital bone rests in contact with the mons veneris. If the forceps is still upon the head, in this situation its handles will almost touch the abdomen of the mother. A goodly proportion of the examples of forceps operations met with here, are, as I think, rendered necessary by rigidity of the soft parts, to overcome which, the expulsive faculties have been exhausted by vain efforts. Let it be well borne in mind that though the expulsive powers of the womb are enormously great, they sometimes fail of success because the vagina is not dilatable, or the perineum will not yield, or the labia will not suffer elongation; or all these obstacles may be in combined opposition to the delivery: remembering these things, we should not impatiently urge nature beyond her powers, lest we do injury where we are most solicitously endeavoring to do good. By rude and untemporizing exercise of strength, we incur very great TO USE THE FORCEPS. 497 hazard of rupturing these organs, and of bringing ourselves into some discredit, and of maiming the patient most injuriously. It is very true that the forceps acts as a dilator by separating the sides of the vagina and of the vulva before the advancing head ; but, on this very account, and because it is so powerful a dilator, we are bound to ex- ercise the greatest prudence in the use of it. I have, in many in- stances, refrained from the use of the forceps, in cases where they were, on other grounds, strongly indicated, because I could appreciate the unreasonableness of any attempt suddenly to dilate the external organs, which I perceived to be far more frangible than dilatable. It not unfrequently happens, that, in cases where the head has suffered a long arrest, and the natural powers have proved incompetent to its effectual advancement, the application of the forceps, and very moderate tractions with the instrument, will put it in rapid motion, so as to leave no doubt of its speedy expulsion under the natural powers. In such cases I have been accustomed to remove the forceps, and allow the child to be born by the spontaneous exertions of the womb. I do this with the view of sparing pain to the mother, and under the conviction that the organs are less likely to suffer contusion, or lace- ration without, than with, the instrument. But it ought not to be done except under full conviction that the expulsive powers, thus set in renewed activity, will be successful, since it is very mortifying to withdraw them prematurely, and be obliged to reapply them. Inasmuch as we cannot exert any very considerable tractile force, without compressing the head with a severity proportioned to it, we should occasionally relax our hold on the handles, in order to let the blades cease from pressing the cranium. The effects of the pressure are rendered less dangerous for the child, by being occasionally inter- mitted. The same reasons are conclusive against the practice used by some persons, of tying the handles with a fillet, which makes it impossible to relax the grasp of the clams, without the trouble of untying the fillet every time such relaxation happens to be thought of. Extreme caution is required for conducting the last stages of the operation with safety. The perineum should be well supported with a napkin held by the operator, or an assistant; and the delivery of the head should be deliberate and slow, and the patient exhorted to lie as still as possible. In delivering a lady rather advanced in life, of her first child, I was using a moderately strong traction while the head was passing out. On a sudden she threw up the pelvis, which changed the line of movement of the head ; as I had the handles of the forceps pretty firmly grasped during the muscular efforts I was 32 498 FORCEPS. — NO ROTATION. making, I could not let go soon enough to prevent the head from lacerating the perineum very severely. I felt then, and still do feel confident, that the perineum w T ould not have been torn but for the very unexpected and violent movement of her pelvis. She recovered from the effects of the laceration in about three weeks. As soon as the head is delivered, the forceps are to be removed and handed to an assistant, while we take care to attend to the delivery of the shoulders, and finally, receive the child, which is to be done as in the most natural labor. A more difficult operation than that just described is the application of the forceps where rotation of the head has not taken place. The first, and one of the most important steps here, is to ascertain accurately — I say with absolute accuracy — the situation of the foetal head. If the finger can reach the posterior fontanel, w T e ought to be able to appreciate, from that point, the relative situation of all the other parts of the cranium. If any doubt, however, remains upon the mind, after an attempt to discover the truth by the employment of the finger alone, the whole, or one half of the hand should be introduced into the vagina, so that by grasping the cranium with several fingers, we may become positively sure that our diagnosis of the position is correct. We will suppose the examination to have resulted in ascer- taining that the vertex is in the first position, i. e. directed to the left and front side of the pelvis. The patient is to be placed upon the back, as in the other case, and the point of the left hand branch of the forceps, guided by two fingers of the right hand placed in the left posterior part of the vagina, is to be passed upwards in front of the left sacro-iliac symphysis. The end of the blade being conducted up to the child's chin, it will be found that the pivot of the blade will look upwards and to the left, and the handle will be inclined towards the left thigh of the patient. The blade being properly adjusted, an assistant should be put in charge of the instrument, while the right hand branch, guided by two fingers of the left hand, is next to be introduced into the right and lower part of the vagina, and gradually conducted forwards along the side of the head, to the right side of the chin, so as to cover the ear; the notch being just opposite to the pivot. If the blades should not be found opposite to each other, they will not lock ; they must be placed in opposition by bringing one of them more to the front of the pelvis, or pushing the other more towards the sacrum, and when they press upon the opposite sides of the head, there is no difficulty in uniting them. When the branches are locked, they are inclined to- FORCEPS. NO ROTATION. 499 wards the left thigh of the mother, the pivot still looking upwards and to the left, and the handles having an appearance of awkwardness in this situation, which, to a tyro, communicates a feeling of doubt as to their being well placed. They look as if they were crooked, but this very awkwardness is. the best evidence of their being situated right. When ready to proceed with the extraction, advantage should be taken of the first pain, not to rotate the head by twisting the vertex to the right, but by moving the instrument from handle to handle, using at the same time a proper degree of traction. The rotation takes place as the head advances, and the vertex very soon comes under the pubic arch, without any particular effort being made to ro- tate it. As soon as the vertex reaches the pubis, the peculiarities of this application of the forceps cease, and the remaining steps of the operation proceed as in the first described case. The vertex may present in the second position, in which case the posterior fontanel is towards the right and front of the pelvis. Let the woman be placed as before: after introducing two fingers of the right hand into the left side of the vagina, the left hand branch of the for- ceps is to be conducted into it towards the fourchette, the point of the blade sweeping upwards towards the child's chin, covering part of the ear, and coming off at the vertex. The handle will look towards the right thigh, and the pivot will point upwards, and towards the right. The handle of the forceps should be very much depressed in this case, because, as the lock portion of the branch is inclined towards the right, it leaves scarcely space for the introduction of the female counterpart, which is to be introduced on that side ; but a considera- ble depression of the handle affords a more abundant space for that purpose. The branch, being correctly placed, is put in charge of an assistant, while the right hand blade, being guarded by the introduc- tion of two fingers, is passed into the vulva at its lower or back part, and its point turned upwards and towards the left, as the handle sweeps downwards and towards the right. The joint is brought into apposition and locked. As soon as a pain comes on, traction, combined with the lever-like action, must be instituted, and as the head descends, the mechanism of the pelvis compels the vertex to rotate towards the pubis, under the arch of which it soon begins to jut. This being effected, the peculiarities of the operation are removed, and its remaining conduct is to be fulfilled as before. In those cases in which the vertex, instead of coming to the arch, 500 FORCEPS. — NO ROTATION. rotates backwards and falls into the hollow of the sacrum, the forceps will be more likely to be required, because the difficulties of expul- sion are greatly enhanced by the position. In this, as in all the occi- pitoanterior positions, the vertex must escape first, notwithstanding it be directed backwards towards the sacrum; but in order to do so, it must glide down the sacrum and coccyx, and along the perineum, after having distended it enormously, until the fourchette slides back- wards and upwards behind the occipital bone of the infant. In order to effect this, the occipito-mental diameter of the foetus must become parallel with the axis of the inferior strait, or at least it must become nearly so. Such, however, is the violence of the flexion required for that purpose, that much time is lost before it can be effected; and the woman is, in many of the instances, exhausted, and the pains gone, before it can be completed. The position is ascertained by feeling the large fontanel behind the pubis, or just within the arch, while the sagittal suture runs backward towards the sacrum. When it is found that the forceps will be required to extract the head, let the male branch, held in the left hand, be introduced into the back and lateral part of the vagina, and conducted towards the chin as far as possible, carrying the instrument up near the left sacro- iliac junction at first, and gradually bringing it forwards so as to apply it accurately to the side of the head. The oblique diameter of the head dips so much towards the sacrum, that it is impossible to embrace the head properly without depressing the handle very much, and thrusting the edge of the perineum very far back, which, though not a little painful, cannot be avoided ; otherwise the head will be grasped coincidently with its perpendicular and not its oblique diameter. The instrument being held in this way by an assistant, leaves a sufficient space on the right side of the vagina for the introduction of the female branch, which being adjusted and locked in the male branch, leaves the handles very much depressed. Having been well satisfied that none of the external parts are pinched at the lock, and that the head is firmly grasped, the first movement in extraction should be to raise the handles up a little, with a view to compel the chin to approach still nearer the breast, and in that way permit the vertex to glide down the sacrum and coccyx, assisting its descent by means of the lateral or lever action of the forceps; the intention of the operator should be to draw the vertex off the sacrum, perineum and fourchette, to let the head extend backwards on the outside of the pelvis. FORCEPS. — OCCIPITO-POSTERIOR POSITION. 501 As the perineum must, in this labor, be enormously distended, it behoves that great care and patience should be exercised, lest it might give way. It should be well supported, and as soon as the vertex clears the edge of the perineum, the handles ought no more to be raised, but on the contrary depressed, in order to let the head extend backwards — a movement exactly the reverse of what takes place in the occipito-anterior position. The head being delivered, the shoulders rotate in the excavation, and the right or the left one comes to the pubic arch, so that the rest of the process is concluded as in a first or second position, except that the front parts of the child, instead of the back parts of it, come out towards the front of the pelvis, which makes no difference of any import. The application of the forceps for the occipito-posterior position, say the fourth or fifth, where rotation has not taken place, is more difficult than the one just above treated of. The blades are with much less facility applied, and indeed cannot take hold along the oblique diameter so completely as is to be desired; they rather seize the head along its vertical diameter at first, and are gradually brought into parallelism with the oblique one, as extraction proceeds. Reflection upon this circumstance is very needful, at the time of the operation, lest the infant's head be, by want thereof, contused and ground, and even cut by the blades. The introduction takes place as in a first or second position, the fourth corresponding to the first, and the fifth to the second. The handles must be well depressed in this case, and it will be allowable to make prudent efforts to rotate the vertex into the hollow of the sa- crum — it being always understood that, in such labors, all hope of bringing it to the pubis, has, after experiment, failed. The head is sometimes situated transversely, the vertex resting against one, and the forehead against the other, ischium. Let us sup- pose the vertex at the right ischium. It is intended to apply the male blade to the left side of the head, with the concave edge of the new curve looking towards the occiput. Let the left hand branch be therefore introduced into the left and posterior part of the vagina, and as the point enters more and more, the handle should be depressed, until the curve applies itself on the left side of the head in a direction from the vertex to the chin, or as nearly so as may be practicable. It should be understood, however, that the blade will scarcely apply itself in that direction, because the chin is not so near to the breast as it ought to be. When the blade is adjusted, its pivot looks to the right, and lies in a horizontal posi- 502 FORCEPS. — TRANSVERSE HEAD. tion, while the handle juts out very obliquely towards the right thigh, which is much abducted. As the left hand branch projects towards the right, there will be some difficulty in finding room for the introduction of the right hand branch; yet t>e other can be temporarily pushed out of the way, so as to let the point enter at the inferior and right side of the orifice of the vagina. When the curve is applied to the convexity of the cra- nium, it must be pushed upwards, backwards, and towards the left, so that its point may approach the chin, and the notch be brought in apposition with the pivot, and so locked. The head being firmly held, may be moved in the direction from handle to handle, and mo- derately rotated, so as to dislodge it; and the tractions being soon com- menced, it is found to descend, the forceps rotating along with it, until the pivot turning to the left becomes vertical, and the fontanel appears at the arch. Now it appears, that in all the operations I have described, the male or inferior blade is to be first introduced, without doing which the female or upper blade cannot be introduced, without getting it below the inferior blade. There is one position of the head, however, in which it is proper to introduce the female blade first — and there is but one — which I shall proceed to treat of. The position to which I allude is that in which the vertex touches the left ischium, and the forehead the right ischium. It is clear that when the instrument has grasped the head in this position, the handles will project very much towards the left thigh, in abduction; but if we introduce the male blade first, inasmuch as its handle will project towards the left thigh, it will occupy all the space on that side, and hinder or prevent the insertion of the second branch, for there is no place for the handle to be depressed in. To avoid this difficulty, therefore, take the female or upper blade in the right hand, and introduce it into the posterior and right side of the vagina, con- ducting its point as near as may be to the chin, and over the face to the right side of the head behind the pubis, leaving the handle to pro- ject towards the left thigh. Next take the male blade into the right hand, and, turning the concave edge of the new curve downwards, insert the point into the right side of the vagina, below the female branch. Let the foetal face of the clam apply itself to the convexity of the head, and slide it onwards, and in proportion as it enters, make it sweep round the crown of the head towards the back of the pelvis. In effecting this, the handle comes gradually down as the clam gets on the left side of the cranium, and at last the lock is found FORCEPS. — FACE PRESENTATION. 503 to be where it ought to be, namely, under the upper or female blade, ■with which it is then locked. When we have ascertained that the head is properly held, or grasped, we may proceed, as before, to move and to attempt to rotate it, and then deliver as soon as the vertex emerges from beneath the symphy- sis pubis. Among the sixteen thousand four hundred and fourteen women delivered at the Dublin hospital, under charge of Dr. Collins, thirty- three had face presentations, and four of these had still-born children, which is a little less than twelve per cent, of mortality in this labor. I have said enough in my observations on Face Presentations, at page 327, et seq., to make it unnecessary for me to repeat anything here in relation to the difficulties of that sort of birth. It is merely proper for me to remark that the forceps, w T hen their use is indicated in this labor, must be applied to the sides of the head by carrying the points of the blades up to the vertex nearly. In those examples in w T hich the chin comes to the pubis, the handles need not be very much depressed ; but in those in which the forehead is at the pubis, the handles must be at first very strongly depressed, and as the case pro- ceeds, they must be strongly elevated, so as to get the chin down to the fourchette, over which it must slip, and then begin at once to approach the breast again, in the act of flexion. As soon as the chin is free, we allow the handles to descend again, while we continue the traction until the head is completely emerged. I shall take this oppor- tunity for stating, that I conceive it to be impossible to have a better instrument for this particular labor, than Davis' forceps, as made by Botschan, 35 Worship street, London. This instrument holds the head as in a basket, and is far less likely than any other with which I am acquainted, to bruise or in any way injure the child. Figures 75 and 78 show very clearly the difference between a face case, in which the chin comes to the pubis, and one in which the forehead is there, and may well show the manner in which the head is to be taken hold of by the forceps. The head is said to be locked, whenever two opposite sides of it are caught by two opposite sides of the pelvis, and held so firmly there, that it can descend no lower, and either cannot, or cannot with- out great difficulty, be pushed upwards again into a freer or larger space. In general, when the head is thus locked, it is in its transverse or bi-parietal diameter, one parietal protuberance being held at the pubis, and the other at the projection of the sacrum. Supposing the pelvis to be only three and a half inches in its antero-posterior dia- 504 FORCEPS. — LOCKED HEAD. meter, and the head to be three and three quarters in its smallest dia- meter, then it might happen, as it does in fact happen, that the cone of the head should be driven, by the force of the pains long continued, into the narrow pass, the delicate bones of the head giving way, and becoming indented under the pressure of the promontory of the sa- crum, and moving downwards until it becomes immovably fixed and held fast by the opposing points of the pubis and sacrum. This state would constitute what is called a locked head. Many evils result from this locking of the head. For example, the woman, after vain efforts and very great suffering, becomes feverish, and at length loses her pains altogether; or a state of constitutional irritation comes on, marked by a frequent, small pulse, coolness of the extremities, sunken or cadaverous appearance of the face, delirium, jactitation and vomit- ing, which, if not soon relieved, is followed by death, which hastens at rapid strides to end the strife. The pressure destroys the child; it also produces the death of the parts of the mother that are compressed betwixt the pubal or sacral bones and the child's cranium; or it causes inflammation to take place, to be succeeded by sloughing and its con- sequences. Or, the urethra being effectually compressed betwixt the cranium of the foetus and the symphysis pubis, a total suppression of urine takes place, followed by its very serious consequences; or, lastly, the soft parts, perhaps the vagina, or possibly the womb, being pinched as above stated, may give way during a pain, and the laceration, once begun, may extend so far as to allow the child to escape into the peri- toneal sac. Whenever, then, the head is found to be so situated that it will neither advance nor retreat, it may be said to be locked, and the case ought to command the greatest care from the medical attendant. It is manifest, that if the arresting points of the pelvis touch the head at its parietal protuberances, no possibility exists of applying the forceps in that direction ; there is not space enough to admit of the blades, and if they are to be applied to the head, it can only be on those parts that are free from great pressure, as the forehead, upon one side, and the occiput on the other; and this must be done notwith- standing any fear we entertain of contusions upon the face, of which there is some risk, but which very risk becomes less as it is the more constantly borne in mind. When the attempt to deliver in this case is about to be begun, the forceps should be well pressed together, so that, when the lever-like movement takes place, their blades may not be allowed to slip or slide upon the forehead, which would thereby be very liable to excoriation, FORCEPS. LOCKED HEAD. 505 or even to be cut by their edges, formed, as is well known, for applica- tion to a convexity different from that of the face. The motion from handle to handle, assisted by a sufficiently powerful traction, will, ordinarily, succeed in disengaging the head, and getting it down into the excavation; upon which the blades ought to be removed, and, if the pains are revived and prove strong enough, they need not to be reapplied; but, in the lack of a proper force, they should be adjusted anew, and on the sides of the head, which is the part for which their curves were fashioned, and to which only they are really adapted. In making compression, let it be carefully remembered that that compression is not designed for the purpose of diminishing the dia- meters, but only to hold the object more securely or steadily; any amount of compressive action beyond this indispensable one, is mis- chievous, as tending to augment the difficulty, by forcing the parietal protuberances more decidedly against the arresting points. I suc- ceeded by this means in drawing a head through a pelvis so faulty in its antero-posterior diameter, that I could readily touch the sacrum, by introducing only the forefinger into the vagina. The patient was a very small woman of color, to whom I was called in consultation by a young medical friend; the child was dead, but not injured by the instrument. So great was the difficulty, that I at one period en- tertained very seriously the idea of performing the embryulcia. If I had known the child to be dead, I should have greatly preferred to do so. In these cases, the operator, who alone can estimate the degree of force he employs, is the sole judge as to whether that force is too great to be compatible with the safety of the woman: should he, upon a due consideration of it, deem it wholly unsafe to proceed, or im- practicable to succeed by any legitimate exertion of his strength, there remains the resource, sad as it is, of the perforator. Now that we have the advantage of the stethoscope, we can, with great cer- tainty, determine the question of the life or death of the foetus in utero ; and where we find, upon auscultation, that its life is extinct, we need have but little hesitation in applying the perforator, in order to reduce the size of the skull by extracting its contents. In doing this, how- ever unpleasant the operation, we remove much of the danger arising from a further continuance of the pressure on the soft parts of the mother. In case the stethoscope reveals the fact that the foetus is still living, we should feel constrained to wait so long as to overstep, per- haps, the boundaries of prudence. But it does not always happen that the head is locked in the direc- 506 FORCEPS. PELVIC PRESENTATIONS. tion and situation above pointed out. The vertex may be jammed down behind the pubis, and the forehead in front of the promontory. Here the forceps can be legitimately adjusted; and they admit of the application of a greater force, and it will be probably found less dif- ficult to unlock and rotate the head, in consequence of the greater con- vexity of the points of arrest. Some degree of rotation ought to be given to the head by means of the forceps until they succeed in get- ting it down into the excavation, whereupon the vertex maybe rotated back again to the arch of the pubis, and so withdrawn. Impaction of the head cannot take place at the superior strait; the shape of that opening is such that its whole circumference cannot be filled by the head of a child; there would always be found a part of it in which not only the blade of a forceps, but a couple of fingers, would find passage; but after the head has sunk below the strait, the conical figure of the excavation perhaps admits of its whole circum- ference being occupied by the head, which fills it up completely, and so completely, that the forceps can find no space in which to pass. Let the attempt, however, be made, and in every unavoidable case, where it fails of success, the head can be opened, and the skull made to collapse. It only remains for me to relate the manner of applying the forceps in breech or footling cases, wherein the head refuses to come away after the shoulders are delivered. I have already said, that it is my invariable rule to have the forceps in readiness in every instance in which I discover that the head is to be the part last born. When the instrument is wanted for such a use, it is wanted sud- denly — immediately; and the medical attendant fails in his duty, who finds himself in want of forceps for this purpose, and is obliged to send for them ; for a child perishes while a messenger is going a hundred yards, or putting on his boots. There is no need of my going again at length over the causes that render the forceps necessary on these occasions. It is enough, that the expulsive powers are wanting, either from disproportion, from cessation of efforts both voluntary and involuntary, or from mal-posi- tion. If the head continues undelivered but a few minutes, the child is lost. Supposing that the shoulders are delivered, and the face in the hol- low of the sacrum; let a napkin be wrapped round the body of the child, including the arms, which should be placed against its sides, so as to keep them out of the way. Then, giving the body to an assistant, let it be held in a position nearly perpendicular, by the thighs FORCEPS. PELVIC PRESENTATIONS. 507 or hips, so as to press the nucha against the arch of the pubis ; or its back may be carried over nearly in contact with the mother's abdo- men, to get it out of the way. The left hand blade, guided by two fingers of the right hand, is then to be passed in at the left side of the vagina, and applied to the head, covering it in the direction from chin to vertex. The right hand branch is next introduced, with simi- lar precautions, into the inferior and right side of the vagina, and so conducted on to the head as to embrace it from chin to vertex. As soon as the instrument locks, the tractions are to be commenced, and there will be, in general, little delay in the extraction, if the handles be raised as the head emerges; they requiring to be elevated, just as is needful in the delivery of occipito-anterior positions. If an ac- coucheur should attempt to perform this operation for a patient in any other than the dorsal decubitus, he would find himself greatly embar- rassed. But — if the child be unfortunately born with the toes towards the pubis, and rotation in the subsequent stages cannot be effected, so that the face is uppermost; if in this case, vain attempts to deliver by the hand have been tried; then, let the woman lie on her left side, with the thighs strongly flexed; let the child be turned bac^: as far as it can be done with safety to its neck, so as to bend the neck very much backwards. By giving to it this position, the forceps can be introduced in front of the child, the left hand branch being first passed up on the left side of the chin and carried as far as the vertex ; while the female branch is introduced upon the opposite side so far as to allow of its being locked w T ith the pivot. As soon as the head is pro- perly seized, let it be drawn downwards in such a direction as to cause the chin to emerge under the arch; to which end, let the handles be at first somewhat lowered. Where, however, it can be effected with proper celerity, it is better, for this application of the forceps, to bring the woman to the edge of the bed, and allowing the perineum to project beyond it, cause her feet to be supported in the usual manner. The child, wrapped in a napkin, can be well entrusted to a kneeling assistant, as it is held nearly in a vertical or standing position. The branches of the instru- ment have, by this means, free access to the left and right sides of the vagina, and they lock with the greatest ease in front of the throat. Except in such a position of the woman, I cannot conceive how it would be practicable to use the long forceps ; but Haighton's or Davis' forceps could be applied while on the side very easily. I say nothing here in regard to the operation of Symphyseotomy, 508 SYMPHYSEOTOMY. commonly called the Sigaultian section, — an operation which was proposed and performed by M. Sigault, in the year 1777. The proposition to increase the dimensions of the planes of the pelvis, by cutting asunder the symphysis pubis, excited, soon after the promulgation of it, a great sensation throughout Europe, and many operations have been performed with various success. It is probable, however, that the increase of amplitude of the planes of the pelvis is not so considerable as the friends of the section at first hoped for, and the dangerous traction of the tissues behind the pubis, and the gaping of the sacro-iliac junctions, one or both, were causes of ill success that have allowed it at last to fall into complete desuetude. So far as I know, the operation has never been done in this country. I feel not the least inclination to recommend the performance of it, and I refer the reader, who may feel interested in inquiring into this method, to M. Baudelocque's work on midwifery, and to the curious work — Essais Historiques Litteraires et Critiques sur VArt des Accouche- mens, par M. Sue, le jeune, Paris 1779, 2 vols. 8vo. Dr. Churchill, in his " System of Midwifery," p. 376, gives the statistics of the opera- tion, as it has hitherto been done, and, in the most emphatic manner, discourages and condemns it. Before I close this chapter, I beg leave to reiterate the expression of an opinion which I have already uttered at page 486 — it is, that the obstetric forceps is the child's instrument; that the perforator, the crotchet and the embryotomy forceps, are the instruments for the mo- ther; and that the Csesarean operation, in its spirit and intention, should be devoted absolutely to the conservation of the mother alone. In saying so, I am not insensible of the great satisfaction to be enjoyed by that surgeon who, under the distressing duress which should alone compel him to subject a living woman to the Csesarean section, is rewarded with the happiness of rescuing both the child and its parent from the jaws of an otherwise inevitable grave. I hold that no man has a right to subject a living, breathing, human creature to so great a hazard as that attending the Csesarean section, from views relating to any other interests than those of his patient. I believe that the Csesarean operation ought not to be performed in any case, whether the child be living or dead, in which, under the dictates of a ripe and sound judgment and perfect knowledge of the principles of midwifery, a decision may be obtained that a delivery per vias naturales is less dangerous to the mother than that by vivi- section. Now, as to the question concerning the pelvis through which it is CiESAREAN SECTION. 509 possible to deliver, I think it impossible to fix, as some writers think it desirable to do, a minimum aperture through which a woman may be safely delivered. Elizabeth Sherwood was delivered in a pelvis of one inch and three quarters, and I twice delivered Mrs. R. with a pelvis of two inches; but to say that a pelvis one inch and three- quarters is the lowest through which a woman can expel a child, is to speak contrary to the record. Indeed the dimensions of a pelvis, which by their reduction render a Caesarean section indispensable, are variable dimensions; these dimensions never can be fixed and prescribed by precept or law, for one woman may have strength and courage and endurance to enable her to bear a delivery in a pelvis of one inch and three quarters, as in Elizabeth Sherwood's case, whereas, in another woman the lapses of her strength may be so rapid, and the exigencies of her condition so urgent, that if she be not promptly relieved, she will be inevitably lost. Hence, it appears that my as- sertion is a correct one, that the dimensions demanding the Csesarean operation are variable dimensions. If we go down to diameters of one inch and a half, or to diameters of one inch, then the question of delivery per vias naturales is set aside. But we may find a case in which a woman, having a pelvis of two inches and a half, ought to be delivered by the section, because, in our judgment, we conclude that she cannot live long enough to escape by the slow process of a crotchet operation. I should not hesitate, therefore, to recommend the Caasarean operation in a pelvis between two and two and a half inches in one case, nor would I hesitate in another case to recommend an embryotomy operation in a pelvis somewhat below two inches in its diameters. I have been present in a consultation in which urgent demands and pressing arguments were in vain proffered to induce me to con- sent to a Csesarean operation; these arguments were based chiefly upon the claims to superior right of the child. In that case, as in all others, I was actuated in my opposition to the operation, by the firm opinion that the child has no fixed claims whatever, if they come to conflict with the right of its more important parent, and I regard my- self as not guilty of inhumanity in indulging or in expressing this sentiment, and I repeat a sentiment expressed upon page 469, in the quotation from Tertullian: " Atquin et in ipso adhuc utero, infans tru- cidatur necessarid crudelitati, quum in exitu obliquatus denegat partum, matricida qui moriturus" It appears to me to be a very important matter that the medical profession should have just views as to the performance of these grave 510 CESAREAN SECTION. and direful operations. As I have great reason to think that many gentlemen, my brethren, have not given themselves time to reflect upon all the points of the indications, I am the more desirous to have an opportunity to state my own convictions in the matter, and I should be glad in the most emphatic manner to enter my protest upon the records of Obstetrics, against the Csesarean operation being performed with any other views than those relative to the conservation of the mother, with the salvo always, that to save the child is a great addi- tional good fortune. I believe that he who performs the Csesarean section upon views relative chiefly to the conservation of the fetus, flies in the face of the soundest doctrine ; and I cannot understand how the conscience of such an operator should ever be appeased under the pungent reflections that must follow a death not rendered inevitable by the exigencies of his patient. The number of cases of deformed pelvis met with in the United States, appears to be far less considerable than those met with in England or in the Continent of Europe. EMBRYOTOMY. 511 CHAPTER XVI. EMBRYOTOMY. The implements employed in Embryotomy, or those operations in which the body of the foetus is cut by the surgeon, are various. They may, however, be all comprised under the denominations of: 1st, the perforator; 2d, the crotchet; and 3d, the embryotomy forceps. In cases, very rare ones, in which the decapitation of the child is re- quired, a knife of a peculiar form is to be had. I witnessed the de- capitation of a foetus thirty-five years ago, in 1813, and fortunately have seen no such operation since that one. Perhaps there is nothing to be met with in the very troublesome and anxious profession of an obstetrician, that is more painful to his feelings, than the management of a case of labor in which it is re- quired to mutilate the child, in order to extract it from the maternal organs. It is fortunate that this odious duty does not occur very fre- quently; and we are indebted to the inventor of the forceps, Cham- berlen, for an exemption from it in the present age in numerous in- stances, in which, without the important uses of that instrument, we should be compelled to resort to the perforator and the hook, which comprised nearly the sum of the instrumental resources of the ancients. We are also in modern times highly favored by the application of the stethoscope or direct auscultation, in acquiring greater certainty rela- tive to the life of the foetus, whose state of life or death can now be very accurately determined by that means; thus relieving the mind of a most painful solicitude by the certainty of its death, if that event should have happened, in cases in which we are compelled to apply destructive instruments for its delivery. When the foetal head is driven into the pelvis, and arrested there in consequence of disproportion of its diameters to those of the bony canal through which it is to be transmitted, if the arrest cannot be obviated by the hand, the lever or the forceps, there is danger that the mother may suffer so much constitutional irritation from the fruit- 512 EMBRYULCIA. less efforts she makes, and the agonizing pain she endures, as to sink into exhaustion, and perish with the child still undelivered; and this, not only in the case of a cephalic presentation, but also in that of the feet, or that of the breech — in short, in all situations where the head cannot be got away through the pelvis except after it shall have been reduced in its magnitude. But even in those instances in which the woman is not threatened with exhaustion, she is liable, from the pres- sure of the head, to suffer inflammation or gangrene of the soft parts, which are contused by it, or she is exposed to the danger of lacerations of the womb itself, or of the vagina, wdiose consequences are greatly to be feared and deprecated. Exhaustion — manifested by cessation of the pains, smallness and great frequency of the pulse, a haggard and sunken countenance, anxiety, jactitation, coldness of the extremities, profuse viscous sweats, and delirium — may come on, in labors that are drawn out too long from smallness of the pelvis, and from rigidity of the soft parts; cases in which we may discern, very clearly, the necessity of immediate delivery, to rescue the woman from impending death. When such signs are present, and the child is known to be dead, if the ergot and the forceps are found, upon trial, to be unavailing, re- course must be had to the most speedy means of relief, to wit, the opening of the head and discharge of its contents, with a view to the collapse of the cranium. This object is effected by the introduction, into one of the fontanels or sutures, of the perforator, commonly called Holmes' perforator, the blades of which being afterwards opened, make a free incision, through which, if enlarged by a crucial cut, the cere- bral contents are either extracted at once, or allowed to escape slowly under the pressure of the pains. As soon as the opening is made, it is common to push the perforator deep into the cavity of the cranium, or to introduce a crotchet so as to break up the textures within, and then, seizing the head by means of the sharp hook, which is applied to any convenient situation on the outside or in the inside of the skull, to drag it through the vulva, and deliver it; after which, if the woman has not suffered too severely, she soon recovers of the effects of her preceding fatigue and severe pains. This is the simplest and easiest case of embryulcia, and is one that any humane practitioner would or might perform without hesitation, upon the proper grounds for the proceeding being fully set forth to him. Yet, notwithstanding the facility with which the operation of em- bryulcia may be performed, it is one so unnatural, and so shocking to EMBRYULCIA. 513 the feelings of all concerned, that it ought not to be done without very satisfactory reasons for it ; and in general, not wi hout consulta- tion and agreement with a medical brother. In those instances in which it becomes necessary, during the life of the child, to resort to this mode of delivery, the most formal consultation ought to be regard- ed as indispensable ; and no consultation can be supposed properly to result in such a proceeding, except upon the most urgent and clearly understood reasons for it. There are gentlemen in the profession who boast that they never have performed this operation. It may be very true; but the reason is that they resolutely decline to do their duty, which they throw upon some not more unfeeling, but more merciful brother. There are cases of labor occurring in women with deformed pelvis that are plainly impracticable with an unmutilated child. For ex- ample, if a woman have the pelvis occupied with an exostosis, or if the diameters of that canal are changed and spoiled by rachitis or by malacosteon, the child contained within her womb cannot escape whole per vias naturales. If the promontory of the sacrum comes within two inches and a half of the symphysis pubis, the child cannot pass the strait alive, because its own smallest diameter is more than three and a half inches; and indeed, if the pelvis have three inches of antero-posterior diameter, it cannot be born alive, unless it be un- commonly small, and moreover possessed of a very incomplete ossifi- cation of the cranial bones, and great laxity of the suture lines that unite them: such a head might, by long pressure under a very power- ful worab, be at length forced down through the strait, after it should have been moulded into the proper form by the force applied to it. Yet, when we come to consider that the bi-parietal diameter is 3.88 inches, we shall entertain little hope of getting the head down, in a pelvis of three inches. It is very true that Solayres and Duges and others have been fortunate enough to meet with cases in which the head at term has been born in a pelvis of two and a half inches from front to rear; but it is not to be expected that success can attend labor in a female whose pelvic deformity even approaches to tw T o inches and a half in its smallest line of diameter. The exceptions but prove the general rule. (See Monthly Journ. Sci., July, 1847, for Dr. Simpson's case.) Such a pelvis is not fit for the forceps, since it is too small for them to be withdrawn when locked. The question must always be, there- fore, between the perforator and crotchet on the one hand, and the Caesarean section on the other. But this is only to be considered as 33 514 EMBRYULCIA. relative to the living child. Of the dead child, no question can arise as to the mode of its delivery, except that of the perforator, and whether sooner or later. The dead child must always be withdrawn per vias naturales, if there be space enough to extract it through with equal safety. But even where the child is known to be dead, we may be compelled to perform the Cesarean operation, if we would deliver the woman at all; since deformity may reach to the degree of shutting up the passage, even against the perforator. There is, in the museum of the University of Pennsylvania, a pelvis so distorted, that the hand could not possibly have directed an instrument to the head, in a manner to enable the surgeon to open and extract it. The woman from whose remains the pelvis was taken, died in the Almshouse, resolutely rejecting the Csesarean operation, and preferring to it the death which she knew to be inevitable. The practitioner who may be in charge of a case of labor where embryulcia is indicated, must be guided by his judgment and the counsel of his medical brother as to the signs which compel him to undertake the delivery. I have already enumerated them — and they are easy to be understood. There is, in general, far more danger of the operation being deferred too long, than of its being performed too soon, since, if it be not performed in time to save the life of the mother, it would be as well not to do it at all. I know that, in utter- ing this sentiment, I am liable to the imputation of wantonly encou- raging the use of this dreadful operation, but I wish to disclaim such an intention. I hope that no man living is reasonably more reluctant than I am to use any obstetric instrument whatever; and I fear that the resort to its employment is often had very unnecessarily and rashly. But I think that, when the case under consideration arises, we ought to act so promptly and so understandingly, that we may, on the one hand, derive a perfect success from it, and on the other, stand acquitted, in our own judgment and in that of others, from the charge of any rashness or precipitation. I shall strive, therefore, while I reiterate the opinion, to clear myself by repeating, that all such cases require a medical consultation. To mutilate the child, and then lose the mother, is a real misfortune, both for the practitioner himself and for the profession, which, from such results, is in danger of falling into disrepute. It is to be understood, then, that where all other instrumental means fail — where, after due reflection upon the circumstances that hinder the delivery, a conclusion is formed that the mother and child must both perish, unless the latter be withdrawn by the assistance of in- EMBRYULCIA. 515 struments that mutilate it — where the Cesarean operation is inad- missible, or rejected by the patient, we have the remaining and very- sure resource of the operation of embryulcia, or embryotomy; and we can venture to encourage and cheer the unhappy and suffering female with the prospect of speedy relief by its means. I have had occasion to feel, in common with other practitioners, how dangerous an instrument is the sharp crotchet. The force to be employed on it, in extraction, is so great that, should the point slip or tear out from the bone, it is always jerked downwards several inches, and is very apt to catch in some of the soft parts of the mother, which are ploughed up and lacerated by it. How easy it would be to lace- rate the vagina, or even the lower part of the womb, by the slipping of the point; and nevertheless, he who uses the crotchet, and is per- fectly aware of the risk, is under the necessity of running that risk whenever he takes the instrument in his hand to deliver with it. There is no part of the cranium to which it can be applied without some hazard of its losing its hold. This is most apt to occur from the faulty manner in which the crotchet is generally made, namely with iron and not with steel. With a point of soft iron there is no real security; because the point soon becomes dull, and does not maintain its hold of the bone. The point ought to consist of well tempered steel, and should be made as sharp as possible — but very much beveled. There is a vast variety of instruments prepared for the delivery of the head in cases of deformed pelvis. Dr. Davis of London has in- vented a great number of them, some of which I have had occasion to use, but with less satisfaction than I expected to have, from the strong recommendation bestowed upon them. I am now well con- vinced, that a great apparatus of this sort is not at all necessary, as I think will be conclusively shown in the sequel of this article, in which I shall describe an instrument capable, with the occasional aid of one sharp crotchet and a perforator, of effecting the delivery of the head in the most restricted pelvis from which delivery is at all possible. As this volume is not designed to be drawn out to a great length, I am constrained to make many of the remarks that I could otherwise find occasion to offer, more brief than is compatible with a copious detail of the subjects. But, notwithstanding this necessity, I am in- duced to give at length, the history of a case of labor in a deformed pelvis that was under my notice in the year 1831. It was drawn up by my friend Dr. George Fox, and published in the North American Medical and Surgical Journal, vol. xii. p. 484. It may, perhaps, serve sufficiently well to set forth the difficulties and embarrassments 516 EMBRYOTOMY. MRS. R.'s CASE. with which such cases are surrounded, and the success of it, probably the most difficult obstetric operation ever successfully performed in this country, may encourage those who shall hereafter have the mis- fortune to contend with similar cases, to hope for success in the midst of the greatest obstacles. I consider it more instructive than any merely didactic remarks that I could compress into these pages. "On Tuesday, June 14th, 1831, I was called about seven, A. M. to see Mrs. R in labor with her first child: this is stated to have commenced about one A. M. The pains, as are usual in the commencement of labor, were feeble, short, and at about ten minutes' interval. Upon examination per vaginam, the projection of the sa- crum was immediately felt: not, however, suspecting the deformity which was subsequently found to exist, this was not at the time par- ticularly attended to; the os uteri was sufficiently dilated to admit the finger and feel the protruding membrane. I was struck with the form of ihe sacrum : the rectum being very much distended with feces, I thought it might, in part, be occasioned by this. Directed ol. ricini one ounce, which was taken immediately. At noon found, upon ex- amination per vaginam, that the membranes had ruptured, the head presenting: she was not aware at what time the waters had escaped. In the evening, the rectum being unloaded by the operation of the oil, I made a more minute examination, and was sensible of great deformity of the pelvis, though not to the extent we afterwards ascer- tained, the pains not being at all active. As it was late, I determined not to ask the assistance of my medical brethren till the following morning; therefore directed an anodyne (which I subsequently ascer- tained was not taken, from her dislike to laudanum and fear of its retarding her labor) and left her for the night. Was called up about one o'clock the next morning, her pains being more frequent and stronger; found the os uteri rather more dilated, and the external parts very rigid, preventing an accurate examination of the pelvis. I remained with her some hours; subsequently called upon Dr. James, late Professor of Midwifery, &c, in the University of Pennsylvania, who met me in consultation at half past eight A. M. In consequence of the rigidity of the soft parts, we found it impossible to make any satisfactory examination ; we therefore concluded it best she should be bled and take an anodyne — that we would meet in the afternoon: she was accordingly placed erect in bed and bled to incipient syncope, which was after losing about fifteen ounces; twenty drops of laudanum were soon after given. In the afternoon Dr. James again saw her: from as accurate an examination as we were capable of making (for 517 the external parts still continued rigid, though somewhat relaxed since the bleeding), we came to the conclusion that there were not at most three inches in the antero-posterior diameter; that laterally there was rather more room, on the left more than on the right; the posterior lip of the os uteri was swoln and succulent, forming a cushion in front and a little below the projection of the sacrum; the head was present- ing to the left side — its exact position could not be determined. On account of the unusual interest of the case, Drs. Meigs and Lukens were invited to attend ; Dr. James, not feeling quite well, did not meet us that night. The result of the examination of these gentlemen w r as, that there was not more, if as much, room at the superior strait as we supposed; they coincided with us in the opinion that it w r as impossi- ble the child should be born alive per vias naturales: our next object, therefore, was to ascertain whether or not the child was living; this was rendered certain by the application of the stethoscope ; the pulsa- tions of the child's heart were distinctly perceived, whilst the pla- cental souffle was also very evident; the pains continued as they had been most of the day, recurring every four or five minutes. We re- mained with her some hours, when we ordered her an opiate, and agreed to meet at four A. M. The result of this meeting was, that, as the proper means of proceeding were of such immense importance, further advice should be had, and that we should meet at half-past eight o'clock A. M. Dr. Physick was called on, but was confined to the house by sickness ; Dr. Dewees was also called for, but was absent from the city. At half-past eight A. M., Dr. James met us, Dr. Hew- son being added to the consultation: it was agreed, as before stated, that it w r as impossible the female should be delivered of a living child per vias naturales ; the question then was, whether the child should be sacrificed to save the mother's life, or an attempt made to save both mother and child. It was concluded, as the strength of our patient was good, her pulse only eighty-four and strong, as there were no symptoms of constitutional irritation, no injury would result from a few hours' delay; we therefore separated to meet at twelve M. "The consultation was held at the appointed hour; by this time, after repeated and the most accurate examinations that the case ad- mitted of, we were unanimous in the opinion that there w r ere not more than two inches in, the antero-posterior diameter, most probably only one inch and three-quarters. The different methods of proceeding which have been proposed in similar cases were duly and maturely considered, namely, the division of the symphysis pubis, the Csesarean operation, and cephalotomy: the first was considered inapplicable to 518 EMBRYOTOMY. MRS. the present case; the Cesarean operation was thought to be attended ■with so much risk to the mother, as almost to be necessarily fatal, some of the most distinguished surgeons being decidedly opposed to its performance. Dr. Physick, who was called upon in the course of the morning by Dr. Meigs and myself to ask his opinion on the pro- priety of this operation, was decided and positive in his opposition to it. Under the weight of such authority, the idea of the Csesarean operation was abandoned. It was therefore concluded, after the most mature deliberation, and upon viewing the case in all its bearings, that the life of an imperfect being (for it was again ascertained that the child was living and apparently vigorous), should be sacrificed to save the life of a wife and daughter, and that the operation should be immediately commenced, by opening the child's head, breaking up the brain, and allowing some hours to elapse before attempting ex- traction. At my request, with the approbation of our colleagues, Dr. Meigs consented to perform it. Drs. James and Hewson, having pro- fessional engagements, were at this time obliged to leave us, to meet again at six o'clock P. M. Preparatory to the operation, the rectum was unloaded by an enema, the urine drawn ofF by a catheter, and an anodyne administered; her pulse was one hundred and four. The consent of the patient, her husband and friends, having been obtained, she was placed at the foot of the bed (which had previously been ad- justed), the hips being on the edge, so that the perineum was perfectly free, an assistant supporting each leg. Dr. Meigs then took his seat directly opposite ; made another examination preparatory to beginning the operation. After having some time carefully examined, he called me, and subsequently Dr. Lukens also, to make another examination, the result of which was, that the operation of cephalotomy, if not altogether incompetent to the delivery, would be attended with as much risk to the life of the mother as the Csesarean operation : it then appeared to us impossible that the cranium should be removed and the base brought through the superior strait, without the most violent exertions and great danger of lacerating the cervix uteri, vagina, &c. ; that, taking this view of the case, it was better to call our colleagues again together, at as early an hour as possible, to reconsider the pro- priety of performing the Csesarean operation: the child was again ascertained to be alive. " Accordingly, at five P. M. we again met. Dr. J. Rhea Barton at this time saw our patient. Our first object was to ascertain respecting the life of the child, and upon applying the ear and the stethoscope, no pulsation was perceptible in any part of the uterine region; it was EMBRYOTOMY. MRS. R.'s CASE. 519 then unanimously agreed (the female not having felt the child for two or three hours) that it was dead: there was now no further hesitation as to the propriety of cephalotomy, which was immediately performed by Dr. Meigs, who employed the utmost assiduity and care in the management of the operation, on whose skill and unwearied attention the success of it is mainly dependent; to him I am also indebted for the following account of the difficulties, &c, which were experienced in the accomplishment of the delivery of the child. " * The woman being conveniently placed on her back, with the perineum projecting beyond the edge of the bed, and the legs and feet properly supported by an assistant on each side, I took my seat for the purpose of proceeding with the first part of the operation, the perforation of the cranium. " ' A suture crossed the pelvis from front to rear, but its edges were overlapped, and could afford no facilities for the operation. This suture was the right leg of the lambdoidal, as was afterwards ascer- tained. " l With Botschan's improved craniotomy scissors, I endeavored to penetrate the solid bone in the centre of the strait, but, owing to the narrowness of the passage, and the constant interference of the os uteri, the lips of which were nearly in contact antero-posteriorly, I dared not to give to the instrument that rotatory or drill-like motion which was necessary, for without such a movement it was impossible to make any progress, as the head rose upwards and rolled freely in the superior basin whenever any considerable pressure was applied by the perforator, though the womb seemed to be pretty firmly con- tracted at the same time. " ' Finding this mode of proceeding unsafe for the woman, I begged permission to leave her a few minutes in order to procure an instru- ment better adapted to the purpose in hand. Accordingly, Mr. Rorer furnished me with a large trocar, and having guided it with two fingers to the proper situation and kept it securely by retaining the fingers in contact with the head, I was able gradually to drill a hole through the bone, the head being pressed from above against the strait by Dr. Lukens. Two other perforations were made near to the first one, in the same cautious manner; after which, I again introduced Botschan's scissors, and having opened them, found that I had made an incision of about an inch and a half in length. Through this a slender blunt hook was introduced into the. cavity of the cranium, and the brain very freely broken up. " c The poor woman, who was already very much exhausted by 520 EMBRYOTOMY. many hours of labor, now took an anodyne and was left to her repose, in order that the medullary matter might be gradually pressed out, and the cranium allowed to collapse so as to come more in reach of the instruments. " ' At ten o'clock P. M., I again met Drs. Fox and Lukens, and the patient being disposed as before upon her back, I introduced a crotchet into the cavity of the cranium, and spent some time in extracting the medullary substance, not much of which seemed to have been ex- pressed during our absence; the head still continued on the superior strait, except a portion of the hind head, which was pressed down into the excavation to the left of the promontory, where there appeared to be the largest space. " * Having removed a considerable quantity of the cerebral sub- stance, I fixed the tooth of the crotchet into the cranium, and guarding it on the outside with a finger, exerted a very great amount of force, which had not the least effect in drawing it lower down. " 'It soon became evident to me, from several trials of this kind, that no exertion of mere strength could be of any avail to drag away the head, and that if it was to be delivered at all, it must be piece- meal : but as the child had been dead only a few hours, and its skull bones were still firmly united to their inner and outer membranes, it will be readily conceived that the removal of the bones was a most difficult matter, not only on account of the firmness of their connec- tions, but also on account of the narrowness of the passages, the great hardness of the skull, and the great danger of wounding the parts by the slipping of the crotchet, which, under the circumstances, could be best applied on the interior of the skull, and from the swoln and suc- culent state of the lips of the os uteri, whose inner surfaces were in contact, and presented to the touch the idea of a long fissure instead of preserving a round or oval form : last and not least, the perineum was so strong and unyielding, that the greatest inconvenience arose from its pressing the fingers against the arch of the pubis with such force and by long continuance so painfully, that no one could endure for any great length of time to keep up the necessary extension. " 'Being possessed of one of Dr. Davis's osteotomists, I expected to derive great advantages from its employment in the case, and ac- cordingly introduced it with the view of cutting away portions of the bone, but the constricted state of the parts rendered it impossible to make use of it consistently with a humane regard to the safety of the patient. " < Having ascertained, then, by fair experiment, that mere force EMBRYOTOMY. MRS. R. S CASE. 521 could do nothing in the delivery, I resolved to pursue the intention of breaking up the head by means of the crotchet; and it was with great fatigue to the woman that I picked out altogether about as much as would equal the size of one of the parietal bones, the portions consist- ing of fragments of the right parietal and part of the frontal bone. " * Finding, towards morning, that the progress of the operation was exceedingly slow, I went out and procured a pair of straight tooth forceps, with which I could take a firm hold of the bone and twist off portions, which, after they were broken away, often took a good while to separate from their adhering membranes. " ' At four o'clock the woman was so much fatigued, that we agreed to give her an anodyne draught, and leave her to recover strength by means of a few hours' rest. " * The attempts at extraction had now continued from ten o'clock P.M. until four A.M., and I think the whole of the bone removed would not much exceed in quantity one parietal bone at full term ; it seemed impossible to proceed with greater rapidity, and I often ad- mitted a doubt whether I should be able to deliver her before death should come to her relief. " 'Throughout the day, on Friday, the attempts at extraction were repeated, in presence of the gentlemen last named, and also of Drs. James and Hewson, who became fully satisfied, that no greater pro- gress could at present be made, considering the circumstances of the woman. " ' Early in the afternoon, symptoms of fever became very manifest ; the pulse rising to one hundred and twelve strokes in the minute, with considerable firmness and volume ; this state of the circulation being coincident with a distressing eructation partaking somewhat of the character of singultus, and a great distension of the abdomen, as well as of the womb itself, from gases extricated within them. She com- plained also of great soreness of the belly, on which account she had it bathed frequently w T ith cold vinegar and water, leaving the surface exposed to the air. " 'In order to counteract this new state of things, she was bled six ounces, and took a portion of castor oil. " * Dr. James, who had witnessed in the morning the difficulty with which the extraction of portions of the cranium was effected, was good enough to supply me with a complete set of Dr. Davis' cranio- tomy forceps, and returned to the house in the afternoon to our assist- ance. These instruments were applied, but they were incapable of effecting so much as even the straight tooth forceps. The teeth of the 522 EMBRYOTOMY. — MRS. R.'s CASE. instrument could not be made to penetrate the skull, although most accurately adjusted; and notwithstanding the handles were brought so nearly together, that the style on the one handle went quite to the bottom of the socket in the other, every attempt to extract with them resulted in the slipping of the bone out of the gripe of the instrument; a proof at once of the hardness of the bone, and of the impossibility of bringing it down in its then condition. ■ " l Putrefaction now rapidly advanced, as indicated by the odor of the discharges, and my only hope for the escape of the patient rested on the opinion, that she might be supported a few hours, Until the softening of the tissues should enable me to draw down larger portions of bone by admitting of the pericranium and dura mater being peeled off with a finger nail, while the bone should be secured, and drawn down with the forceps or crotchet. " ' But such was the unpromising state of affairs, that the poor creature resolutely refused to make any further effort to escape, saying she knew that she must die, and would rather die than exert herself any further, and begged in the most piteous tones that all further at- tempts to deliver her should be abandoned, yet expressing her thanks for the efforts that had been already made. " ' She was at times slightly delirious. After explaining to her the increased facility which began to exist from the rapid decomposition of the foetus now going on, and endeavoring to reassure her with a promise to deliver her in the course of the night, she was again left to rest three or four hours under an anodyne draught. During the whole period that has now been spoken of, the anterior lip of the os uteri was behind the triangular ligament of the pubis, and the posterior low down beneath the promontory, and strangulated, as it were, or buttoned by the part of the head that lay on the strait and partly within it; yet so swelled, that their inner surfaces continued nearly in con- tact, except when parted by the introduction of the fingers. " ' The perineum seemed to have acquired no disposition to relax, notwithstanding all the handling to which the parts had been subject; and, excepting that the bones were more easily detached now than before, no greater comfort or facility was enjoyed by the operator than at the commencement. " ' At ten P. M. I again met Drs. Fox and Lukens, and the patient, after much entreaty and argument, resigned herself unwillingly to the further prosecution of our attempts to deliver. The remains of the head were still high up, but some of the broken edges came lower down. I got hold of a piece that descended behind the pubis, and EMBRYOTOMY. MRS. R.'s CASE. 523 with the tooth forceps pulled it downwards, detaching the membranes as it advanced, and found that it consisted of all the remainder of the right parietal bone. I next got away nearly the whole left parietal, and afterwards with the crotchet removed first the right, and then the left orbitar portion of the os frontis, which was all that remained of that bone. I then got away with the crotchet and forceps the right superior maxillary, and afterwards the left superior maxillary bone. I subsequently twisted off the greater part of the broad portion of the os occipitis, and the squamous parts of the temporal bones; so that I had nothing left now but the base of the skull and the lower jaw, which latter I left as a point on which to exert the tractions that were soon to be required. " ' If the estimate made by all the gentlemen, that the strait was not more than two inches in its antero-posterior diameter, should prove correct, I was fearful of meeting some difficulty in bringing the base of the skull, which was- two and a half inches, through it; but when I had reduced the head so as to leave nothing more than the base of the skull and the lower jaw, I fixed a blunt hook into the latter, and, with a finger to antagonize it, drew the mass down towards the point of the coccyx, and had the satisfaction to find that it was got quite through the strait. My hand being now introduced into the vagina, I got a firm hold of the neck, and with the exertion of the greatest strength, gradually brought the button-like remainder of the head out at the vulva, while the point of the thorax, of course, was entering the narrow pass. The head was delivered at a quarter after one o'clock, and having succeeded in effecting the most difficult and dan- gerous part of the operation, we gave her some ergot; then fastening a twisted towel round the neck of the foetus, I renewed the extractive efforts, which in twenty minutes enabled me to deliver the shoulders, and in twenty minutes more, the hips — the child being completely withdrawn at five minutes before two o'clock, which was forty minutes after the head was delivered. " 1 1 found that, under the stimulation of the ergot, she was enabled to bear down very strongly, considering her exhausted state, and at all events the chief object of its exhibition was secured, namely, a firm contraction of the womb, and an effectual separation of the pla- centa, which came into the os uteri soon after the delivery. " ' Large quantities of gas of the most putrid odor followed the extraction of the child, showing the enlargement of the womb, before spoken of, to have been owing to its extrication by the putrefactive processes going on in the uterine cavity. 524 " ' The cord was shrunk and black, and the placenta, which was likewise black, and so filled with air as to crepitate under the fingers, was so horribly noisome that it was scarce possible to endure it during the requisite handling of it. No blood followed the placenta. " * The body was soft and putrid, being completely emphysematous and crepitating like the placenta. The cuticle was peeled by the pressure and friction. " ' The child was rather above the medium size. " * After washing the poor creature with a sponge dipped in claret and water, and making her as dry and comfortable as possible, she got an anodyne and was left to rest, being unable to speak above a whisper, and with a pulse feeble, but beating only one hundred and two strokes per minute. " * The whole difficulty in delivering a child through so contracted a pelvis, can scarcely be conceived of by one who has not been en- gaged in such an operation. The constant and perplexing apprehension of injuring the mother, either with the instruments employed, or with the sharp and ragged edges of the bones which must be withdrawn, and sometimes violently broken off with the sharp tooth of the crotchet, involves the operator in the most painful and unremitted attention and watchfulness, which alone, when long continued under compul- sion, is a real torture. The confusion also in the parts, arising from the ragged remains of the scalp and the inner and outer membranes of the cranium blending themselves, as it were, with the lips of the os uteri, and covering and concealing the bones, is a source of great embarrassment, where those fibrous tissues retain so much firmness and compactness. " ' Doubtless, could we have known that the woman would have been able to bear the fatigues of labor so long, we should have de- ferred the efforts at extraction for twenty-four hours after the perfora- tion of the head; but such was not the opinion to be gathered from the actual phenomena. " ' It has been seen that no great loss of time took place, after the softening of the tissues rendered it possible to break them up with some facility, whereas the process previously was exceedingly slow and tedious. The perforation was deferred as long as possible, which saved us from the dreadful and cruel operation of cephalotomy in a living foetus. The child died from long-continued pressure.' "June 18th (Saturday), nine A. M. Our patient says she feels quite comfortable; had some sleep after we left; pulse one hundred 525 and twelve, rather more feeble ; skin moist, tongue slightly furred ; clean linen, &c., was put on her, and she was moved up in bed. The bladder was emptied by the catheter; fomentations with flaxseed mucilage directed to be applied to the vulva; the most perfect rest and quiet strictly enjoined; as diet, arrowroot and oatmeal gruel, tea and toast. "Evening. Remains much the same; bladder again emptied; mucilages continued; an anodyne to be given at ten P. M., if at all restless. " 19th, nine A. M. Passed a comfortable night, pulse ninety-four, skin pleasant, tongue slightly furred, lochia almost natural; free from pain; slight soreness over pubis to left side; directed warm brandy to be applied over soreness, a Seidlitz powder to be given, and re- peated, if necessary; continue other means. "Evening. Medicine not having operated, an enema of warm flaxseed mucilage was directed, and an anodyne at bed time. "20th. Rather restless in the early part of the night; enema ope- rated freely; feels very comfortable; no pain; pulse seventy-six; skin pleasant; tongue continues slightly furred; countenance good; spirits cheerful; continue as before. " 23d. Our patient continues to do well, usually rests well at night ; free from pain, although the soreness in uterine region continues; secretion of milk copious; feels so comfortable that she has taken an infant to nurse ; pulse rather more frequent than natural ; tongue clean and moist, bowels costive ; passes urine without difficulty — the cathe- ter was used three times daily till last evening, when it was found to be unnecessary; lochia serous; directed ol. ricini one ounce. Muci- lages to vulva to be continued, mucilaginous injections per vaginam ; continue diet, and perfect rest in horizontal position. " From this time our patient continued rapidly to improve ; in three weeks from the time of her delivery, was so well as to be per- mitted to go down stairs, and in a short time resumed her ordinary avocations. " The subject of the preceding case is a native of Ireland, aged about twenty-two years, of small stature, not exceeding four feet and a half; is stated to have been a healthy child till her third year, when she received an injury by a fall, after which she was unable to stand or walk for two or three years; at the expiration of this time she re- gained her strength, and was subsequently considered an active child. Upon examination, we found the femur and tibia of each extremity very much curved, forming a considerable arch forward ; at the lower 526 MEIGS' EMBRYOTOMY FORCEPS. part of the spine, there was a cavity sufficiently large to admit the hand corresponding with the promontory of the sacrum internally; the bones of each arm partook of the general disease. It was evident she had in early life labored under rickets." In cases where the diameters of the pelvis have been so much diminished by rachitis or mollities ossium as to render the descent of the fcetal head impracticable, it has been the universal custom either to perform gastrotomy, or to lessen the size of the cranium by evacuating its contents, and then to make extraction by means of the sharp crotchet. The method last spoken of is a good one, perhaps, and succeeds well enough where the diminution of the pelvic passages is not too considerable: nevertheless, we find, upon reference to the records, that a great many women have been the victims of such untoward labors, owing, measurably, to the violence done to the soft parts during the forcible extraction of the head, which was, perhaps, insufficiently reduced in size to admit of its transmission with safety to the mother — and probably in no less degree to the wounds that have been in- flicted by the slipping of the crotchet — a very common, and often unavoidable, accident in its employment. The crotchet, to say the least of it, is a detestable instrument. The firm bony structure, composing the base of the fcetal skull, is nearly two inches and a half in its transverse or smallest diameter; mere excerebration, therefore, cannot be regarded as furnishing a good security against fatal contusions from the forcible extraction of such a body from a pelvis whose smallest diameter is not exceeding two inches in length. Such a body as the base of the skull must, in order to pass through such a pelvis, present itself in an inclined attitude, or with a dip, but this dip or inclination can be only imper- fectly communicated to it whilst all the bones of the cranium retain their connexion with each other. To enable such a base to pass downwards safely, the skull ought to be taken to pieces, and those pieces removed in succession. In some instances, this successive ablation of the cranial bones has been effected by the crotchet, the point of which was used to pick out the bones, sometimes in portions not larger than the finger nails ; as, for example, in Elizabeth Sher- wood's labor, impressively narrated by Dr. Osborne. Those who have perused that account, will remember the extreme perplexity of that practitioner, and the infinite pains he took in his anxiety to avoid injuring her with the crotchet. He could not get the base of the cranium down until he had removed all the rest of the head. 527 Having had occasion to observe the difficulties and perplexities arising from labor in deformed pelvis, as they occurred in Mrs. M. R., the case above related, whom I have now delivered in two ac- couchements, I venture to lay before my professional brethren the impressions I derived from observing and conducting those two labors. There is reason to believe that no other female has ever been safely delivered in this country, under the disadvantages of a pelvis measur- ing only two inches from sacrum to pubis, which, by the judgment of persons of the highest claims to confidence, is the extent of Mrs. R.'s case. I speak this, however, under liability to correction. All the gentlemen then consulted, agreed that the diameter was as above mentioned. Her second accouchement took place in the month of June, 1833, the child having reached the full term of utero-gestation, an event which I greatly deprecated, having vainly urged, with the advice of Dr. Dewees, the operation for inducing premature delivery. The experience I had acquired in delivering her in the first labor, convinced me that the crotchet was not to be relied upon in her case ; not only because of the danger from contusion in extracting the skull, and from wounds made by the point of the crotchet, but also from the loss of time requisite for picking out the head bit by bit. The patient had almost fallen a victim to exhaustion in the first instance. In reflecting upon the facts that had occurred in 1831, 1 found that the problem about to be solved in the second labor, was not, a head being retained above a pelvis too small to transmit it, to extract said head — but the question was, to extract said head with the smallest loss of time, and least possible risk to the mother. I had already ascer- tained that the Caesarean operation would not be submitted to. I supposed that the head might be four inches in its bi-parietal diameter, and I knew that the pelvis was only two inches. Under such circumstances, the vertex will not present, but the crown of the head will be the presenting part : but since the cranium cannot recede farther than is necessary to bring it in close contact with the posterior part of the mother's abdomen, there will be two inches of the head lying upon the plane of the superior strait, and two other inches pro- jecting in front of the symphysis pubis: or, in other words, the crown of the head will repose upon the top of the symphysis pubis — part of the head being behind, and part in front of that bone. There is a very important principle in the management of such a 528 MEIGS EMBRYOTOMY FORCEPS. case, which is, that all that part of the cranium which lies in contact with the mother's back, is perpendicular to the opening of the strait, Fig. 119. Fig. 118. Fig. 120. and may, when the skull has been opened, be seized with a straight forceps or pliers, like that represented in the engraving Fig. 118, whereas, all that part of the skull that lies horizontally over the open- ing, can be taken hold of with a curved forceps or pliers, as is seen in Figure 119. Long before the occurrence of Mrs. R.'s second labor, I caused the proper instruments, Figs. 118, 119, and 120, to be prepared by Mr. John Rorer, the eminent surgeon's instrument maker. By means of this apparatus, I encountered but little difficulty in de- livering this patient, whose first accouchement had cost me so much toil and anxiety. The invention is my own. I published it soon after the event spoken of, in a Baltimore Journal, and it is now known and used in this country as my embryotomy instruments. Mulder, nor any other author has described or proposed it. I look upon it as a 529 most important contribution to the operation in midwifery. In a great majority of the cases it supersedes the crotchet, and mitigates the danger of the embryotomy operation in a remarkable manner. I have found, upon applying the test of practice, that when the thin portions of the cranial structure are taken hold of, either with the straight or curved forceps, they can be broken up with great ease, and removed with sufficient celerity; so much, indeed, that a head may be reduced to a very small remainder in a short time. I believe that if early arrangements are made for delivering the patient by this method, no danger will exist, of exhaustion or excessive constitutional irritation being produced, before the extraction of the foetus can be completed. From the foregoing remarks, it seems to be very clear, that the practitioner, in undertaking to deliver a patient with excessive distor- tion of the pelvis, ought to proceed to his operation with a full under- standing that, after perforation, he is to remove all the posterior parts of the presentation with the straight pliers, and all the anterior and lateral ones, with the curved pliers; making attempts, from time to time, to draw the head down, as he finds reason to believe that it is sufficiently broken up. Such are my views of the mode that ought to be adopted. I, at least, am fully of opinion that Mrs. R, could not have been rescued by me, had I relied only upon the crotchet for her delivery: w T ith my embryotomy forceps, I should not hesitate to promise to deliver speedily in a pelvis of two inches. It is proper to observe, that the female constitution suffers less in the first hours of labor, in which the head cannot engage, than in those wherein the head sinks low into the excavation. This depends upon a well known principle, namely, that the contractions of the womb are violent and powerful in proportion as that organ becomes smaller or more condensed. If the head becomes arrested in the excavation, and particularly after having escaped from the uterine cavity, it is urged with great power upon the tissues, which resist its further descent. Under such circumstances, constitutional irritation is rapidly deve- loped; whereas, under the more lenient exertions of the uterus, w 7 hile the entire fcetus is contained within its cavity, not only is the impul- sion of the head against the resisting tissues far more moderate, but in the intervals of the pains no pressure exists. Hence a woman remains long in labor, with little constitutional disturbance, in the kind of cases I am discussing. These observations are illustrated, and their truth confirmed, by reference to some of the most celebrated examples of such labors, which are recorded in the books. Whenever, therefore, a woman has fallen in labor, who is known 34 530 MEIGS* EMBRYOTOMY INSTRUMENTS. to have an impracticable pelvis, and in whom the Caesarian operation is rejected — if the perforator is to be resorted to, it should be applied as soon as possible, in order that, the child having ceased to exist, all the facilities derivable from incipient decomposition of the foetus may be enjoyed. Twenty-four hours after the death of the foetus, the firm- ness and cohesion of its soft parts are so much lessened by maceration in an elevated temperature, equal probably to 99°, that the extraction of the pieces of bone becomes exceedingly easy. I should, therefore, in such difficult cases, recommend that all attempts to deliver should be delayed, if possible, for twenty-four hours after the perforation of the head. This recommendation is founded on what I have experi- enced of difficulty in getting out the portions of bone after I had broken them up, when I made the attempt antecedently to the occur- rence of signs of decomposition. The patient can be quieted with anodynes, and supported with light nourishment, and, if needful, may, by venesection and cold drinks, be kept tolerably free from vascular disturbance during the whole period of such delay as may be deemed advisable. The engraving, Fig. 108, shows the form of the perforator that I employed in Mrs. R.'s case. It is a trocar or drill, ten inches in length from the handle to the point. I was obliged to make use of such means of penetrating the skull, since no suture w T as practicable, and the common Smellie's scissors could not be made to perforate the solid bone, any direct pressure causing the head to roll, or move up- wards, and any rotatory or drill-like motion with it, being impossible without great danger of wounding the lips of the os uteri. The same cut exhibits both the straight and curved pliers. They are eleven inches in length; the gripe is serrated, and the sides of the mandibles are rounded, in order that they may not pinch any tissues except those intended to be included in the bite, w T hich, on account of the serrae, is very sure and strong. I learned, after the events above described, that this patient again became pregnant, that the child presented the breech, which would make delivery per vias naturales absolutely impossible, that she was under the care of Dr. Nancrede of this city, and was safely delivered of a living child, by means of the Caesarean operation, performed by Professor Gibson of the University of Pennsylvania, assisted by the late Dr. Beattie, Dr. Nancrede and others. In a subsequent or fourth pregnancy I saw her, the history of which case was again drawn up and given to the public, in the American Journal of the Medical Sci- ences, by Dr. George Fox, to whom I am indebted for the relation MRS. R.'s CASE. CESAREAN OPERATION. 531 already above given to my readers, and from whose interesting "Ac- count of a Case in which the Ccesarean Section, performed by Dr. Gib- son, was a second time successful in saving both mother and child," I take a portion, with a view to make it more extensively known by means of this volume. As Dr. Fox's paper is partly occupied with the preceding histories, I shall commence at p. 17 of his statement. " Toward the latter end of August last, Mrs. R. called on me, and stated she had nearly completed the seventh month of pregnancy, and was desirous that I should again attend her; this I agreed to, upon condition that she would consent to the performance of any operation which should be deemed most advisable. Dr. Meigs kindly consented to attend with me. " Premature labor, in her then advanced state of pregnancy, we considered would be attended with as much difficulty, and much greater danger to the patient, than at the full period. " Under the impression that the Cesarean section would be most proper, we endeavored to prepare her system for this operation, should it be concluded upon, by a regulated diet, such as would be least stimulating, attention to her bowels, &c. : accordingly, for some weeks previous to labor, her diet was restricted chiefly to milk and farinaceous articles. " On Sunday, November 5th, 1837, 1 was sent for by Mrs. R. about five o'clock A.M. On my way to her house I stopped for Dr. Meigs. We found her laboring under a good deal of mental excitement, with a pulse of 116; countenance anxious and pallid; and apparently in a much more unfavorable situation than in either her first or second accouchement. Her pains had commenced about three hours previous to calling upon us; they were slight, recurring at an interval of about ten minutes; upon an examination per vaginam, the os uteri was found pretty well dilated, swollen, and succulent, as in previous la- bors ; the head presenting to the left side of the pelvis ; the membranes had been ruptured. Upon inquiry we learned that on the evening of the Friday previous there had been a considerable discharge of water from the vagina, which continued throughout the following day; but as it was unattended with pain, she had not thought it requisite to send for us: this discharge was not produced by any exertion on her part. After remaining with her some time, finding that her pains were not urgent, we concluded to meet at nine o'clock, and invite Professors Gibson and Hodge to join us in consultation. " 9 A. M. Met Drs. Meigs, Gibson, and Hodge. We found our 532 MRS. R.'s CASE. — CESAREAN OPERATION. patient much the same as when we left her, excepting that the pains were rather more urgent and frequent. Upon an examination of the case in all its bearings, we determined to advise the Csesarean section, as best under the circumstances. I accordingly stated to the patient our views of her case, and after some little hesitation obtained her consent to the performance of this operation ; previous to which, upon an examination of the abdomen, we were struck with the complete anteversion of the uterus; the old cicatrix was dark-colored, hard, and puckered, about five inches in extent ; adhesion had apparently united the integuments and uterus for a space of four or five inches, from near the pubis up towards the umbilicus. "We now ascertained, by applying the ear to the uterine region, that the child was living. Our patient's bowels having been opened by an enema, and her bladder emptied, she was placed upon a table protected by a matress, on her back, with her hips at the edge, and the operation immediately performed by Dr. Gibson, in the presence of Drs. Meigs, Hodge, Norris, C. Bell Gibson, and myself. Dr. Norris and myself making firm pressure upon the sides of the abdomen to prevent protrusion of the intestines, Dr. Gibson commenced by making his incision with a scalpel, through the integuments, muscles, &c, extending from an inch and a half below the umbilicus, nearly down to the pubis, directly through the old cicatrix; the uterus was found connected with the integuments by strong adhesions, for a space of about four inches ; the incision into this organ was made near the fundus, and extended down five or six inches; that portion which was adherent was much attenuated, being scarcely one-fourth of an inch in thickness. To ascertain the extent of these adhesions, Dr. Gibson with his scalpel dissected up the integuments on one side, until a knuckle of intestine protruding satisfied him of their extent, which might be about half an inch. "When the section of the uterus was completed, the placenta was seen immediately under the line of incision, and partially detached by the separation of the lips of the wound. Dr. Meigs, standing on the left of the patient, now introduced his left hand towards the right side of the womb, displacing the placenta no more than was necessary during the exploration, yet detaching a considerable portion of it, as it filled the wound in the organ; he first extricated the left foot and hand, which were found near each other ; the breech soon followed, succeeded immediately by the shoulders, and lastly by the head, after a few moments of resistance, by the contracting edges of the cut, which grasped the neck of the child, and the hand of the operator, with great MRS. R. S CASE. CESAREAN OPERATION. 533 force. The placenta was soon after removed through the incision, and the cord tied and cut ; the hemorrhage from the uterus was at first considerable, but ceased upon the contraction of that organ, after the removal of the child and placenta. The external wound was brought together by six sutures (introduced from within outward), and adhe- sive strips, and a compress placed over it ; a broad band, to support the abdomen, was now applied around it ; the pressure of its sides, to prevent protrusion of the intestines, was continued until the exter- nal wound was closed. "The child thus born was a boy of good size, but in an extremely feeble state: some time elapsed before perfect respiration was estab- lished, but happily the efforts of Dr. Meigs were completely success- ful, and all anxiety on its account ceased. "Our patient bore the operation well, scarcely murmuring; in fact, she says, she suffered but little more than with one labour pain, her pains usually being uncommonly severe. Her position was not altered, excepting that her lower limbs were now supported by another table. Her pulse immediately after the operation was 96, just before 112. She is enjoined to lie perfectly still, not on any account to move ; to be permitted to take nothing but small portions of barley water; and, in case there is much pain, a teaspoonful of the following: R. Sulph. morphias, gr. ij ; aquae, £i. M. ft. sol. " Soon after the operation, Messrs. J. Forsyth Meigs and Skelton arrived ; these gentlemen assiduously devoted themselves to our patient during the first five days and nights, so that had any unfavorable symptom appeared we should have had immediate notice. " 1 \ P. M. Feels quite comfortable ; after pains very slight ; pulse 80. "4 P. M. Pulse 88 ; has taken one teaspoonful of morphia solu- tion. 10 P.M. Met Dr. Meigs. Pulse 88; skin pleasant; gentle moisture; tongue clean and moist; some flatulence; not much sore- ness ; after pains moderate ; urine drawn off by the catheter, six ounces ; directed solut. morphise to be given every three hours if there is much pain, and a small portion of lime water occasionally for the flatulence. "6th, 10J A. M. Met Drs. Meigs, Gibson, and Hodge. Mrs. R. passed a restless uneasy night ; was unable to sleep, though not in pain; took a dose of morphia at 11 \ P. M., and another at 5 A. M., also lime water twice. Her pulse is 85 and soft ; skin pleasant ; slight distension of abdomen, without any increase of soreness; urine by catheter five ounces, of natural appearance. \\ P. M. Symptoms all favorable ; pulse 88. 4 P. M. Pulse 92. 8J- P. M. Met Dr. 534 MRS. R.'s CASE. — CESAREAN OPERATION. Meigs. Pulse 94 ; skin and tongue moist and pleasant ; countenance good ; no expression of anxiety ; considerable tympanitis ; complains much of flatulence ; no after pains ; lochia free and natural ; urine by catheter ten ounces. At this time a catheter was introduced into the rectum, which caused the discharge of a large quantity of gas, render- ing her much easier, and completely relieving the tympanitis. Directed a tablespoonful of the following mixture to be given every two or three hours: R. Bicarb, potassae, 5ij ; sulph. morphiae, gr. ss ; aquae menthae, p. §vj. M. ft. sol. "7th, 10 A.M. MetDrs. Meigs and Gibson. Our patient had a very good night ; slept comfortably, without an opiate ; pulse 78 and soft ; countenance good ; respiration natural ; skin pleasant ; tongue slightly furred, but moist ; urine by catheter eight ounces. 4 P. M. Pulse 82 ; no pain or tenderness ; has slept through the day; expresses herself as feeling comfortable. 8J P. M. Pulse 84 ; no return of tympanitis since the introduction of the catheter into the rectum last evening; urine by catheter eight ounces; continued mixture. " 8th, 10 A. M. Rested well all night ; secretion of milk natural ; the infant was put to the breast during the night; pulse 100; skin pleasant, moist; tongue slightly furred, moist; urine by catheter eight ounces ; wound was examined without removing dressings ; suppura- tion is commencing ; there has been throughout a slight oozing of bloody serum ; she is this morning removed to another bed. 2 P. M. Pulse 92 ; secretion of milk increased so much as to cause some uneasiness to her ; breasts are directed to be well drawn. 8J- P. M. Pulse 92 ; breasts relieved by drawing ; urine by catheter ten ounces. " 9th, 10 A. M. Slept soundly all night ; appears very comfort- able ; pulse 97; skin pleasant, moist; secretion of milk abundant, lochia natural ; urine by catheter eight ounces. 6 P. M. Pulse 96 ; skin moist ; abdomen flaccid, free from all pain or tenderness ; no flatulence ; urine by catheter eight ounces; directed the mixture carb. potassae to be omitted ; she had taken it occasionally, on account of flatulence, since the evening of the 6th; to-night, is permitted to take arrowroot gruel ; has been restricted to small portions of barley water until this time. " 10th, 9 A. M. Slept comfortably ; having some return of flatu- lence, took two doses of potash mixture in the course of the night ; relished gruel ; external organs were washed with weak wine and water, much to her relief; pulse 104; skin moist; urine by catheter eight ounces. 1 P.M. Pulse 100; wound dressed for the first time; 535 it extends from half an inch above the pubis to one and a half inches from the umbilicus ; adhesion has taken place at the upper and lower ends; discharge slight, bloody, dark-colored; at the upper end of the cicatrix from former operation, on the right side of the incision, it is slightly inflamed, of an erysipelatous appearance, and ulcerated, for the space of two inches ; I removed a stitch from this point, which seemed to be a source of irritation, also one from the upper end ; washed the parts and applied fresh adhesive strips, leaving a sufficient space for the free escape of pus; a piece of lint, spread with cerate, and bandages were then applied ; she complained of no pain or fatigue. Bowels not having been moved since the operation, an enema of warm flaxseed mucilage is directed ; breasts, which are somewhat trouble- some, to be well drawn ; the child would nurse, but from the mother's position it is difficult and fatiguing ; consequently, we rarely put it to the breast, having from the first had a wet nurse for it. 6 P. M. Pulse 100 ; skin pleasant ; no pain ; all her symptoms are most favor- able; urine by catheter ten ounces; enema not having operated, another to be administered. " 11th, 9 J A. M. Slept well, but in consequence of some pain in the evening, caused by the enema (which operated freely), she took two doses of morphia solution; pulse 96; tongue less furred, moist; urine by catheter eight ounces; abundant secretion of milk; no un- favorable symptom; slight dark-colored discharge from wound; fresh cerate applied; asks for increased diet ; is to be allowed the soft part of six oysters and a biscuit, in addition to the gruel. 6 P. M. Pulse 96 ; urine by catheter six ounces. " 12th, 10 A. M. Rested well; took one dose of morphia; pulse 98 ; skin pleasant ; has passed water twice through the night without the catheter; the wound looks well, healing; inflammation about the old cicatrix much diminished ; I removed three more stitches, and ap- plied fresh adhesive strips to lower parts of it; diet, milk, eggs, and oysters. u 13th, 10 A. M. Pulse 96; no pain; skin natural; tongue clean; slept well; wound looks well; removed the last suture, and applied fresh dressings. " 15th, 10 A. M. Has slept w T ell for the last two nights; pulse 96, soft and pleasant; skin and tongue natural; countenance good; very cheerful ; spirits throughout have been excellent. Wound looks well ; adhesion perfect above and below; is filling up rapidly; inflamma- tion of right edge subsided ; suppuration moderate, lighter color ; 536 lochial discharge has ceased. This morning, for the first time, she complains of her position, which has been altogether upon her back; upon examination, a small slough (size of a cent) is discovered upon the sacrum; inquiry had frequently been made upon this point, but the fear of being moved induced her to conceal the pain and sore- ness until this time ; her position is now changed to the side, hips being protected by adhesive plaster; a poultice of bread and milk to be applied to slough; diet as before. 5J- P. M. Much more easy since change of position ; pulse 92; has for the last two days suckled her infant. " 17th, 10 A. M. Pulse 84; bowels were opened yesterday by an enema; slough separating, superficial, does not complain of it; wound looks healthy ; suppuration slight. "25th. Has been very comfortable since last report; no pain or tenderness; pulse 88; wound nearly closed, a small opening merely remaining about the top of the old cicatrix; the discharge from it very slight ; bowels being confined, she is requested to take ol. ricini E} ; to-day is permitted to sit up in the bed. " We have conceived it unnecessary to head each daily report, 'Met Drs. Meigs and Gibson,' we having continued to meet regu- larly during the first week; after which time, Dr. Gibson saw her occasionally, during the progress of the case, as convenience or incli- nation dictated ; Dr. Meigs continued in regular attendance some time longer. "December 26th. Mrs. R. has continued perfectly well; soon after date of last report was permitted to leave her bed ; the slough on the back soon separated and caused but little inconvenience; the incision in the abdomen has healed, with the exception of a small fistulous opening, which is occasionally touched with lunar caustic ; her diet has for some time past been generous. " February 21st, 1838. The fistulous opening heretofore noticed continued a source of annoyance till the 10th inst., since which time it has been entirely closed ; the cicatrix is now complete, and looks healthy. " Remarks. — Our patient had a better ' getting up* than many females after an ordinary accouchement; her sufferings after the ope- ration, were slight indeed ; in twenty days from the day of its perform- ance, she sat up; and for some days previous, constantly nursed her infant. The adhesions connecting the uterus and abdominal parietes in front were so extensive, as almost to have permitted the MRS. R.'s CASE. CESAREAN OPERATION. 537 performance of the operation, without necessarily opening the peri- toneal sac ; very much diminishing its dangers. It may be worthy of notice, that nine months subsequent to the former operation, during lactation, the menstrual discharge returned, healthy and natural in every respect. During the progress of the case, the patient was visit- ed by many of our medical friends. " The infant has grown finely, not having had an hour's sickness since birth." 538 INDUCTION OF LABOR. CHAPTER XVII INDUCTION OF PREMATURE LABOR. In cases of deformed pelvis in which the reduction of the diameters has not gone too far, the child may be rescued, if it be delivered at a period between the attainment of its viability and the completion of term, if the development of it shall not have rendered it too large to pass through the contracted passages. The foetus in utero is understood to be viable or livable at the com- pletion of the seventh month ; at that period the foetal characters of the heart have begun to approach towards those of the respiring child, and the pulmonary vesicles have become so thoroughly developed, that most of the children born at that term are free from the danger of atelectasis pulmonum. For a woman with a bad pelvis — with a pelvis reduced, for instance, to three inches in its diameter — it is very good fortune to be prematurely delivered, if the uterine gestation have not gone beyond the eighth month; for the head of the child at that time is both small and very ductile. The observation of cases in which women with deformed pelves have given premature birth to living children, led at length to the adoption of operations by means of which the child is ushered into the light, at times supposed to be so well chosen, that the disproportion between the foetal head and the contracted pelvis should not render its escape impossible. Dr. Denman in the tenth section of his twelfth chapter, treats of the propriety of bringing on premature labor, and the advantage to be derived from it. The first information which he obtained upon the subject was derived from Dr. C. Kelly, who informed him that about the year 1750, there was a consultation of the most eminent men in London at that time, to consider of the moral rectitude and the advantage to be expected from the practice ; which, it appears, met the general approbation. The first case in which it was necessary and proper, was terminated successfully by Dr. Macauley. Dr. Ma- cauley had performed it several times, and sometimes with success, INDUCTION OF LABOR. 539 and Dr. Denman relates the case of a lady of rank whom he attended with Dr. Savage, in consultation, in which the operation proved suc- cessful. Dr. Lee, in his Clinical Midwifery, 2d ed. p. 81, relates the history of the operation in the labor of Mrs. Ryan, set. twenty-one, primipara. — She lost the child after an embryotomy operation. In her second labor, Dr. Lee opened the membranes at the eighth month : he per- forated the head. The third labor was brought on at seven months and a half, the feet presented ; child lost. Fourth labor, induced at seven months, footling ; child dead. Fifth labor, induced at the seventh month ; the child, born alive, died in sixteen days in convul- sions. Seventh labor, induced at seven months and a half, the feet presented; child lost, great force required. Eighth labor, induced at seven months and a half: feet presented, child dead. Ninth labor, induced at the seventh month, the feet presented, child lost. Tenth labor, membranes perforated at the seventh month: child lost. Ele- venth labor, induced at the end of the sixth month: child dead. Twelfth labor, induced in the seventh month: child dead. Thirteenth labor, at the end of the sixth month labor induced: child lost. Four- teenth labor, seventh month: child extracted alive, but soon died. Fifteenth labor, seventh month : child lost. I have cited this case of extraordinary perseverance, on the part of Dr. Lee, as much to show the resolute energy of that gentleman, as to show what may be ex- pected in many of the cases of induction of premature labor. It is not to be doubted that the operation is legitimate, and that he who does it properly acts within professional rules and usages; but, inasmuch as every premature labor furnishes some just grounds of apprehension, both for the parent and child, I am very clear in the belief, that well understood motives alone can justify the accoucheur who performs it. A woman may lose her child in labor, and so on throughout a succession of labors, from faults not at all relative to the state of the pelvis. A lady was under my care in this city, w T ho, in sixteen pregnancies, had given birth to only one living child; she then gave birth to two children, of which the first was born a little past the eighth month, whereas the gestation of the last son continued until the close of the ninth month. There was never suspicion of the least fault in the dimensions of the pelvis. A lady of this city, out of eight children lost seven in labor. It was proposed to her, previous to the birth of her ninth and last child, to submit to the induction of premature labor. I had been long convinced that the cause of the death of the children, in this person, was a cause relative to the action 540 INDUCTION OF LABOR. of the uterus, and not to the resistance of the pelvis; for children, the transverse diameter of whose heads amounted to full four inches, had been expelled, or drawn through it with the forceps. I had al- ways maintained that the loss of the children was occasioned by the preternatural energy of the uterine contractions, which, from the be- ginning to the end of the parturient effort, were of a character de- serving truly to be called ergotic ; the contractions of the uterus were permanent, and, as the children were large, the placental circulation was always suspended by the pressure of the afterbirth against the trunk of the child's body, so that when born, it was born dead from asphyxia. The deep interest which I took in the misfortunes of the parents, thus deprived of the comfort and hope of offspring, did not prevent me from resisting the proposition to bring on labor prematurely, and I felt prompted, from a desire I had to explain myself to the gentleman interested, to address to him a letter, of which the following is a copy, and which I publish here w T ith a view to send it forth, not as an argu- ment against the induction in cases suitable for it, but as a caution to such as might feel tempted, unnecessarily, to resort to this method of saving the child. The following is the letter which I addressed to the gentleman in- terested, who, being himself a physician, had assisted at the very large consultation of physicians summoned for the purpose of deciding the question as to the induction of premature labor in the case. Thursday, August 11th, 1843. My Dear E., As you appeared yesterday to be at a loss to decide upon the steps proper to be taken in the approaching crisis, and as I suppose rather inclined in favor of the operation for the induction of premature labor, I think I shall feel better satisfied if I lay before you in writing the reasons which compel me to entertain an opinion perhaps wholly con- trary to your own sentiments and wishes, yet maintained, as I think, for your real interest and happiness. I prefer that you should have this written statement both for your own greater satisfaction and also in order that I may not be at all misunderstood. Opinions thus de- liberately expressed and defended, are safer than those delivered viva voce. I am sure that you already know that I approve of the operation for inducing premature labor, in all cases where it is not performed too early to admit of the viability of the child, and where the withholding INDUCTION OF LABOR. 541 of it altogether, involves the mother in the certain necessity and risk of a severe embryotomy operation. If the antero-posterior diameter of the upper strait is below 3J inches, there is always the greatest probability that embryotomic instruments will be required ; I say the greatest probability, for it is certain that children have been born without their aid in cases of pelvic deformity even greater than this. Such a deformity then, if it does not go too low would warrant the operation, and recommend it as an act of pro- fessional duty. Now my opinion on this point is, I hope, very clear. But where the pelvis is of such magnitude as to admit of the transit of the foetal head, and further renders the application of the forceps practicable, I hold that no man would be justified in inducing prema- ture labor, without exigent necessity arising out of some well under- stood, highly probable peril of the mother herself. In the case in question we have seen delivery effected in a labor of four hours with a foetal head of dimensions which may, without exag- geration, be termed enormous — for a head of four and a quarter inches in the bi-parietal diameter is equal to the largest head I have ever seen at birth — and is just nine-twentieths of an inch above the average mag- nitude. The history of the past labors shows that the difficulty does not depend upon the smallness of the pelvis, either actual or relative. The history of hundreds of labors issuing happily, will show that the fcetus can bear longer and severer pressure of its cranium than ever has been borne in our case. In fact the history of these labors, as I know that history, shows that the evil has been in the uterus and not in the pelvis. This perhaps you may not admit. Peradventure a premature labor might be marked by a character of uterine action different from those that have fallen at term. But shall a man feel justified to enter on an important operation, one ad- mitted to be dangerous to the mother and uncertain for the child in the proportion of 50 per cent., upon the ground of a mere peradven- ture ? I cannot think so. I am not much accustomed in my medical transactions to be guided by what are called authorities. In the first place every case of dis- ease, and every case of surgical disorder or accident, is a speciality. The action upon each case should be determined by judgment held upon the case, and not upon reported cases. Besides I conceive myself to be capable, after the clinical experience I have had, of judg- ing for myself; of making up my own opinion of what is my duty in every instance of disease submitted for my opinion. Were I, however, 542 INDUCTION OF LABOR. very readily inclined to follow the masters, I know not where I should look to find an authority for this operation. The only one that has the least resemblance of favoring it is that of Denman, who twice in- duced a premature labor successfully for women who had previously lost their fruit in utero in the seventh month. The cases, you see, are not parallel, and if they were I should not be moved by them, for I have seen a woman lose four children in successive pregnancies, from the sixth (or fifth) to the seventh month, who yet bore children after- wards at the full term, and in good health. Dr. Denman's patient might have done likewise, and I think he was not justified even by his good fortune in the dangerous operation he performed ; I think he acted like a rash and injudicious man, whose success is no palliation of his error. To force or invite the womb to enter into action before term, is to do violence to the organ by a voluntary interference with the law of its organism. It is a rule universally accepted that we must not do violence to the womb, except upon urgent necessity; I adopt and teach this rule, and I can never feel myself justified in recommend- ing such action unless I can have very clear perception of the neces- sity for it, as relative both to the mother and fetus. So it is pretended that such exigency exists in relation to your lady. I believe you have taken too flattering a view of the operation even as it relates to the child itself. A child is esteemed to be viable at the end of the seventh month. It is, I say, esteemed as viable, yet the facts show that a very large proportion of seven months children fail to live long. Indeed it is understood that fifty per cent, of the whole sum of human progeny is lost at the end of the sixth year after birth, and how much greater the percentage in the cases of premature parturition. If you will examine the results of the operation in Dr. Churchill, you will observe that he states in all 945 cases of the induction; I suppose that many of the 945 cases are restatements, i. e. they are cases stated over and over again, but admitting that there have been 945 operations in fact, we still find that only 536 children lived. Lived, I say, but no man knows how long; and it is not uncharitable to say that if we knew the whole truth we should be obliged to make a very large subtraction from the number of 536. I have not the least belief that near one-half have been saved! and it is admitted that many of the operations were unnecessary and even preposterous. Dr. Chailley tells us that of the 211 cases collected by Stoltz though more than one-half of the children were living, one in fifteen of the INDUCTION OF LABOR, 543 women died. Such a result proclaims the operation to be dangerous. It is true that we cannot here decide as to the difficulties and dangers of these 211 cases, and it may be true that the operation is less dan- gerous for a woman with an ample pelvis than for her who has a de- formed one, and that in our own case the danger would be less on account of the known capacity of the organ. Be it so — but the argu- ment is a felo de se, for it goes to show that it is not demanded by Mrs. E., but only by the child. Has the child claims? Yes! but the claims of the mother are paramount. Is it demanded as referable to the gratification of an anxious desire to have a living offspring? That is a holy and righteous desire, God grant it may be satisfied, but the function of the surgeon and accoucheur appertains to the health of the patient; the happiness of the patient is the gift of God. The surgeon cannot lift the veil of the future, and if he could he would perhaps be even more reserved than he is now as to the institution of attempts, whose object goes beyond his true vocation. Let him adhere to his vocation, which is fulfilled when he preserves or restores the health of his clients. The mother is his client in the paramount degree. Let us essay to set in order some of the reasons for waiting until labor shall begin spontaneously in this case. 1. She has given birth to one living child. 2. She has had one unassisted delivery. 3. She has had children of enormous magnitude. 4. There is great reason to suppose, even if it be not absolutely true (as I believe) that the fault is in the nature of the uterine fibre, and not in the form or dimension of the pelvis. If so, then no opera- tion is admissible. 5. She has recovered well. 6. She has been delivered of a child beyond the average size, in a labor of only four hours. 7. No man knows whether the child now in utero is above the average size. 8. If there is a breech, knee, or shoulder presentation, what should we gain by a violence done both to the mother by the operation, and to the child by hurrying it into the struggle before it is completely developed and prepared for the strife. 9. Who knows if it be or be not a twin pregnancy? if it be a twin pregnancy, what vain, what poignant regrets over a step signally false!! 544 INDUCTION OF LABOR. 10. Possibly she may spontaneously enter on labor at eight months and a half. 11. Do we know that it has not already a prolapsed cord ? 12. Suppose the operation done and the lady attacked with the chill so common in the case — suppose her the victim of a metritis — with a living orphan child? cui bono! But, my dear E., I will not continue to string together objections; they are all comprised in the single fact that she is a fit subject for a forceps operation, if that should be demanded by the circumstances. This fact is an unanswerable one in my estimation. It is true I could set forth reasons of a moral complexion for refusing intervention, but I shall refrain considering them, as equally obvious to you and to me. I pray you, however, in this matter, not to misapprehend me; I have no doubt of the morality of the induction; nor of our legal right to do it, under the diploma given by the authority of a state. I look upon that diploma as an authority given to me by state commissioners, and in the name of the state, constituting me judge, to act at my peril under the indications of an upright and enlightened conscience, and judgment. But the spirit of my commission is caveat as to all rash- ness and irregularity of proceeding. I hope the effect of this letter may be to lead you to submit with readiness to the voice or will of the consultation, which was not given in favor of the induction. We admit we do not know, and no man can know, what the result will be, but I trust you will believe that should it be fortunate I shall greatly rejoice in your mutual happiness: if it should be unhappy again, I shall sympathize in your distress. I shall in any event steadily adhere to this, viz. : that it is better to suffer the ills that Providence sends for our chastisement, than by rash and ignorant measures of precaution against them, make them tenfold more intolerable. I am, &c, The following notes were furnished to me by my friend, who was present at the birth of the ninth child. The history of the labor and the measurements of the foetus, as well as its weight, serve, I think, fully to confirm my opinions in opposition to the proposed operation in the case. INDUCTION OF LABOR. 545 NINTH ACCOUCHEMENT. August 29, 1843. — Eight months and one quarter {or one-third at most) of utero-gestation. Labor commenced about seven P. M., a short time before reaching home after a long ride. Quarter past seven. — Reached home, and went immediately to bed ; pains recurring, at intervals often or fifteen minutes, until eight o'clock, when they became more frequent and of shorter duration. 8J P. M. — Dr. Hodge arrived ; found os uteri size of half a dollar. ; 9 P.M. — Vs. 3xxv ; Dr. Meigs arrived during the operation. 20 minutes past nine. — Gave 40 grs. Dover's Powder by enema. 45 minutes past nine. — Gave 35 drops laudanum, by mouth. 50 minute's past nine. — Pains recurring ; membranes protruding ; os uteri fully dilated. 55 minutes past nine. — Pains on and off; intermitting; uterus re- laxes after pain, which is unusual in her case. 10 P. M. — Pains every few minutes. 10 minutes past ten. — Cramps in left leg during pain. 20 minutes past ten. — Anodyne effects decided; patient complains of feeling sleepy ; pains continuing regular and natural until 5 minutes before eleven — when a strong pain came on, with bear- ing-down efforts. IIP. M. — Good pain ; head descending rapidly; membranes rup- tured. 5 minutes past eleven. — Child born ; no accident or artificial inter- ference ; weight seven and one quarter pounds, dressed. — Male. Bi-parietal diameter 3 T 6 ^. Occipitofrontal 4j%. Head 'j « -mental 6A i Bi-temporal 3. 1 0' 35 546 INTER SI ON. CHAPTER XVIII INVERSION OF THE WOMB, Inversion of the womb is that state in which the uterus becomes turned inside out. Inversion is incomplete or complete. When it is incomplete, the vault or concave of the fundus has fallen down into the cavity of the body, of the neck or the vagina cf which it may occupy the upper extremity. When inversion is complete, the vault of the fundus has come quite out through the os uteri, followed by the corpus and the cervix. In this case the womb is inside out, as a stocking is that has been turned inside out in drawing it off the foot. The accident is a rare one. Yet the consequences of it are so terrible, that the accoucheur ought not in his practice to lose sight of the possibility of its occurrence, nor fail ro guard his patient against it. When the womb remains relaxed or uncontracted after the delivery of the child, no attempt ought to be made to take away the after-birth by pulling at the navel string. Should the placenta be still adherent to the fundus uteri, any tractions exerted on the cord would tend to draw forth the after-birth, which might, perhaps, drag the fundus uteri along with it, and thus turn the organ inside out, or invert it. Inver- sion of the womb is one of the most dangerous accidents that can happen to a lying-in woman; it is always attended with severe pain, and the most violent hemorrhage ; and, if not early remedied, becomes soon irremediable, since it would be as easy to turn a non-gravid womb inside out as to restore forcibly an inverted one, when many days or hours have elapsed after the occurrence of the inversion. Those who have had the hand in utero, in turning, can well appre- ciate the exceeding laxity of the womb when not affected with the pains; they can readily conceive that the mere weight of the after- birth, still attached to the fundus, might, were the woman standing upon her feet, cause a commencement of inversion, which could be- INVERSION. 547 come complete by means of the woman's strong voluntary efforts to bear down her pains. It is not to be doubted, that instances of inver- sion have occurred in which the practitioner deserved no further blame than that of not taking the proper precautions against its occurrence, by commanding the patient to preserve the horizontal posture, and abstain from all bearing-down efforts. Notwithstanding the occurrence might take place spontaneously, and immediately after the birth of the child, yet, in a major part of the examples, it has been produced by an improper haste and impa- tience to get away the after-birth. I have seen but three persons who have had inversio uteri, and they are recovered; one, Mrs. S., w T as already the mother of tw T o children when she again became pregnant of the child born in June, 1831. It seems that, having, on both the preceding occasions, suffered severely from the method adopted by the physician in removing the after-birth, and supposing that a midwife would deal more gently with her, she engaged an old woman, much accustomed, as it was said, to the care of women in labor, to attend her upon this occasion. The child was born by a very easy labor, but the after-birth not coming away so promptly as it w T as desirable, tractions were made upon the cordw T hich caused the after-birth to come into the vagina. This gave the patient exquisite pain. The midwife, who could not understand why the woman should suffer so severely, made haste to draw the placenta forth by the cord, which made her cry out so loud that it was said her voice w 7 as heard in the street. When the mass came away, the good woman found it still adhering to something; she could not take it up, and put it into a basin. She therefore continued to pull at it w r ith great force, not knowing that she held in her hands the after-birth still adhering to the fundus of the womb, which was now completely drawn forth and turned inside out. The hemorrhage was enormous, and the patient soon sunk into the extremest weakness and exhaustion. Half an hour elapsed before she thought proper to con- fess her incompetency to manage the case. I w r as sent for, after she had acknowledged her ignorance of the method of proceeding, and when I arrived, the pati°nt w T as without pulse, very cold, suffering the extremest distress, with constant jactitation, and a thirst that was unappeasable. To all appearance the woman was in the agonies of death. I found the globe of the womb hanging down full half w T ay to the knees, and still invested with the placenta and membranes, 548 INVERSION. except where they had been torn and broken by the attempts of the midwife to pull the entire mass away. I endeavored to push the whole womb and placenta back into their natural position, but finding I could not succeed, I sent for my vene- rable friend Dr. James, who speedily arrived. Dr. James now made an attempt to reposit the womb, but he also failed. By his advice I removed the placenta, but could not force the uterus up into the pelvis. In making the attempt to restore it to its place, I followed the me- thod recommended in the books, that is, I compressed the organ in both the hands in order to reduce its size. At last I observed that the more I handled it, the firmer and harder it became ; in short, that I excited in it the after-pains, just as we excite them by frictions on the hypogastrium after the child's birth. I therefore inferred that the proper way of proceeding would be to let it rest, and as soon as the relaxation of the organ should be complete, as it is in the intervals between the ordinary after-pains, to endeavor to indent its fundus^ like the bottom of a bottle, and then carry it upwards. I found, upon ob- serving it, that the womb repeatedly expanded or relaxed, and then contracted again, being soft in the former and hard in the latter state. Taking, therefore, the moment of the completest relaxation, I indented the fundus with one finger, and, as it became more and more concave, I applied each of the fingers in succession, until I found that the pro- gress of the fundus inwards was impeded by the os uteri, which, although it was completely inverted, yet resisted for some time the attempt at reposition. By a resolute perseverance I finally had the pleasure to overcome the resistance, and the peritoneal surface of the fundus was pushed upwards beyond its os uteri, and at last the womb was found to be completely restored to its natural position, but still containing my hand, which was now up as high as a little above the umbilicus. As no contraction came on immediately, I retained pos- session of the cavity of the womb, which I gently excited by moving my fingers within it, and finally a contraction came on which I suf- fered to push my hand out into the vagina. Upon withdrawing the right hand, I felt with the other the womb very firmly contracted in the lower belly, and enjoyed the satisfaction of complete success in this distressing case. I have said nothing of the brandy and volatile alkali that were o-iven to the woman to keep her from dying. She took a very large quantity of these articles, besides laudanum, before I left her, which I was obliged to do in order to attend to another patient; and I feel INVERSION. 549 under great obligations to my friend Dr. George Fox, "who came at my request and took charge of Mrs. S. for the remainder of the time that she continued ill. Her situation when I gave her up to his care was nearly desperate, from anemia; nevertheless, by the administra- tion of proper restoratives and the judicious exhibition of stimulants during several hours, she rallied, and, in no very long time, recovered a good share of health. From that period she was, for a long time, not quite regular as to the catamenia, which appeared at uncertain periods, and less abund- antly than before her dreadful accident. Since the occurrence of the above recited events, Mrs. S. has been twice safely delivered of healthy children by my friend Dr. Bache. It is worthy of remark that the placenta was adherent in these cases also ; and Dr. B. was not able to effect the delivery of the after-birth, until he had separated it from the womb by the introduction of the hand into its cavity. I cannot refrain from mentioning here the case related by Mr- Charles White, of Manchester, in which he succeeded in restoring an inverted womb to its natural state by compressing it and then push- ing it up. In his case I am not very sure that the inversion was com- plete, since, although he represents the inverted uterus to have been as large as a child's head, it was never expelled through the external organs, and it is improbable that if fully inverted, it could be retained in the excavation. Mr. W. regards his method as of the very highest importance, and thinks he should never have succeeded but for the compression of the womb in the hand. I am ready to admit that it might happen that a tonic contraction of an inverted uterus should come on at once, and last so long as to prevent the employment of the plan that I suggest; but I think it probable that it would always be practicable to return it, in any case where it had not been inverted more than four or five hours, by wait- ing for the moment of its greatest relaxation, and then first indenting the fundus, and afterwards pushing it steadily upwards through the os uteri, and so into the abdomen again. It has been stated that when the womb is only half inverted, the woman is liable to greater pain and danger than where it is turned completely inside out, in consequence of the strangulation of the part that is griped by the os and cervix uteri. It is thought by some per- sons good practice, in such cases, to make, the inversion complete. I am unable to speak of this point from any experimental knowledge 550 INVERSION. that I possess, nor do I know that the probabilities of recovery would be greater with a complete than with an incomplete inversion. If there be any ground to hope for a spontaneous replacement, as I shall hereafter contend, it seems to me that it would be wiser to let the incomplete inversion alone, trusting it to the power of nature, rather than incur the hazard of wholly inverting it, which would greatly lessen the prospect of a future spontaneous cure. Of course I am understood as recommending this confidence, or rather hope in nature, only for those in whom every reasonable at- tempt to restore by the hand has utterly failed and been abandoned. A careful and attentive practitioner of midwifery will never fail, after the delivery of the placenta, to examine by palpation of the hy- pogaster, the state of the uterine globe ; and there can exist but few individuals in whom such an examination would not disclose the ab- sence of that proper degree of convexity of the fundus uteri, should it exist, which is the sure demonstration of the truth that inversion, either incipient or complete, has taken place. Inversion can only take place by the falling in of the dome of the uterus, and such fall is sure to show the upper part of the organ con- cave instead of convex, upon palpation of the hypogastric region. I delivered a woman some time since who was moribund with he- morrhage from placenta prsevia; when I turned the child and brought it away by the feet, the womb, which was as flaccid as a wet ox bladder, sank inwards, allowing the placenta to come forward to the os uteri. I took the placenta away, and the dome of the uterus came into the vagina. I pushed it back: it made no resistance, and when I withdrew my hand, it followed it again. The patient expired in a few minutes. I considered her to be dying w 7 hen I reached her bedside. The utter flaccidity of this uterus has convinced me that the cases reported of spontaneous inversion may be really so, and independ- ently of any rash manoeuvres; for the atonicity of the muscular ap- paratus may be so complete that the rest of the component tissues of the womb can by no means prevent it from becoming inverted under the slightest efforts of breathing, of tenesmus, or even of change of decubitus. I have recently seen a lady whose womb was inverted about two years ago at her confinement. I am informed that she had a very profuse hemorrhage, and was thought to be in extreme danger. She gradually got better, however, but remained subject to frequent at- tacks of hemorrhage, by which her strength became greatly reduced. INVERSION. 551 At length a physician whom she called in made an examination, and found the womb inverted. In this case the womb hangs into the vagina, and is, I think, turned completely inside out; it is not much larger than the healthy non-gravid womb — does not appear to be very sensible on pressure, but bleeds very easily. By careful regula- tion of the diet, strict attention to her bowels, and the use of astring- ent injections, under the care of her physician, Dr. Mcehring, the hemorrhagic tendencies have of late been happily counteracted, and she is acquiring a more decided state of health. She goes freely now about the house, and even about the city. This I regard as a very consolatory case, as it furnishes additional ground to hope for the escape of our patients with life, even where the inversion is incurable. Without altering the above paragraph, 1 shall now state, that subse- quently to my visits and examinations, this patient was seen and ex- amined by Dr. Hodge, Professor of Midwifery in the University of Pennsylvania. Dr. Hodge has assured me that he had no doubt of the diagnosis, which was an inversio uteri. Dr. J. Warrington, a practitioner and lecturer on midwifery, had charge of her after- wards, and made the same diagnosis, of the correctness of which he entertains no doubt. After her health had greatly improved, she manifested symptoms of pregnancy, and proved to be pregnant by miscarrying of a foetus of near five months. Here, then, was a case of spontaneous replacement of an inverted womb. Of the third case that I met with, the following is the recital. May 5th, 1841. I this day saw Mrs. S., aged twenty-seven, resid- ing in Marshall street. This lady is the mother of two children, the youngest of which was born five weeks ago. My friend Dr. Levis, who was in attendance and who invited me to the consultation, in- formed me that the infant was born some time before he reached the house, so rapid was the parturient process. He found the lady lying on her back near the edge of the bed — the feet resting upon chairs, as if she had scarcely found time to get upon the bed, before the eruption of the child, which a woman was holding in her hands in order to keep it out of the great pool of blood in which she was bathed. The child's head, indeed, was quite born before she got off the pot- de-chambre. Upon seeing how great was the hemorrhage, the Dr. pressed his hand upon the hypogastrium, and finding the womb strongly contracted, he removed the placenta, which he found already in the vagina. After the delivery, she flooded a good deal, and was very weak; but had in a fortnight recovered considerably. After this, she was seized 552 INVERSION. DR. HATCH'S CASE. with flooding of a severe character, since which time she has not been free from bloody discharges, which are at times quite copious. Two days ago the doctor examined the patient, and found a tumor projecting from the os uteri, which he suspected to depend on an in- version of the organ. The woman is very feeble, and has fits of hysterical delirium fre- quently. Upon making the taxis, and upon examining by the speculum, the tumor so closely resembled the appearance presented by the common uterine polypus, that it was difficult, considering its size, resistance, color and surface, not to believe that it must be a polypus of the womb which had existed throughout the pregnancy, a circumstance hardly possible, however, to believe. In order to test the nature of the tumor in such a way as to have no shadow of doubt, I introduced half the right hand into the vagina, so as to enable me to carry two fingers quite far up into the cul-de-sac behind the cervix ; having done this, I moved the fingers forwards so near to the upper margin of the pubis, that my left hand, laid on the hypogaster, was a very small distance from the fingers of the right. They approached so near to each other as to render me perfectly sure that no womb was interposed betwixt them, and therefore that the tumor below was the womb, and nothing else. She was informed of the nature of the accident that had befallen her, assured of the utter impossibility of any reposition of the organ, and comforted with the expectation of a gradual diminution of the hemorrhagic tendency, with its final cessation, and recovery of health. Directions were given as to rest, diet, topicals, &c, and then, after some ten days, she dismissed her medical attendants, to call in Ho- moeopathic skill and doses, and, post hoc, sed non propter hoc, she gradually got rid of her discharges, as the womb condensed itself more and more, and at last became pretty well recovered. This lady, upon recovering in some degree her health, went on a journey to the western states, and came back in good health. Some time after her return to Philadelphia, she was found to be pregnant, and was attended in her accouchement by Dr. Levis,. who delivered her of a healthy child. I have received a letter from Dr. Hatch, of Kent, in the State of Connecticut, which I here present to the reader. Dear Sir: — I respectfully submit to you the full history of a case, to which, you may recollect, allusion was made while passing a social 553 evening at your house during the session of the American Medical Association at Philadelphia, in May, 1847. On the 22d of August, 1845, Mrs. H., aged twenty-four years, was delivered of her first child. The labor was easy and natural: the placenta was expelled, without interference, about twenty minutes after; the flow was rather copious, yet not enough to cause any alarm- ing depression of the system. Fourteen or fifteen hours after, she was seized with pains (said her nurse), of unusual severity for after- pains, which continued with great frequency for from two to three hours, when they suddenly ceased, and Dr. Beardsley, an elderly gentleman of the profession living near, w T as called in, being myself at the moment out of the village, who, on my arrival shortly after, gave the following account : — " The patient was very much exhausted, surface cold, pale, and covered w r ith a profuse clammy sweat; con- stant tendency to faintness, and with a pulse so small and frequent as to render it difficult to count it. I gave diffusible stimulants, and employed, thoroughly, warm stimulating spirituous embrocations to the skin. Slight reaction coming on, I perceived within the vagina a tumor which protruded from the vulva, of a size one-third larger than a goose-egg, having an uneven surface consisting of little emi- nences at irregular distances from each other, which I judged to be the inverted uterus." We made an effort to replace the organ. Carrying my hand within the vagina, after inspecting the presenting surface, which I found to be, as I suppose, the womb, the thumb was applied to the fundus, which I w T as able to carry within the body of the organ at least two inches; when at this point, it met with unconquerable resistance, and produced much uneasiness to our patient. Our efforts at its reduction w T ere suspended, and an opportunity allowed for rest. The fore part of the following day Mrs. H. was comfortable. In the afternoon she became restless: in part doubtless from retained urine. On being raised up, she experienced increased sensation of pressing down, when it was ascertained that the tumor had again, in part, protruded. Being returned to a recumbent posture, the tumor was pressed from its bear- ing on the urethra, and the bladder was- relieved. A messenger was dispatched to New Haven, a distance of fifty miles, who arrived with Professor Beers, of the medical institution of Yale College, about the commencement of the fifth day of the case. I continue the story by copying from a letter this day received from Dr. Beers, who, in order to make a connected history of the case, transcribes a portion of a letter I addressed him, which transcript is 554 INVERSION. — DR. given in substance above. Prof. Beers writes as follows: " The fore- going relation of this case was communicated by Dr. Hatch in a letter to me, eight months after its occurring, coming down to the time when my own observation commenced, which was on the fifth day from her accouchement. The tumor was found as above described; its size w T as that of a healthy, well-contracted uterus ; a week after delivery it manifested the elastic, firm feel of that organ — had feeling, but not highly sensitive. The patient bore continued and forcible pressure with little complaint; the abdomen was soft, not full; the uterus could be felt when firmly pressed up above the pubis, and subsided into the vagina when the pressure was removed. There was no doubt of its being a case of complete inversion of the uterus. " The comfortable state of the patient — her anxiety, with that of her friends, and her fortitude to bear any operation which was deemed prudent — induced the council, with scarcely any expectation of suc- cess, to attempt its restoration by mechanical force, carried as far as it should be found could be borne with safety. For this purpose, two instruments were procured with smooth, turned heads, like that of a common walking cane, the larger about two inches in diameter, and the smaller of half that size. The smaller was most used, as it was found better to retain its place on the tumor; the head of the staff was applied to the centre of the tumor, which was the fundus of the uterus; moderate, continued, and at length firm pressure was made in the direction of the axis of the pelvis. The head of the instrument indented perhaps an inch or more into the tumor, and the whole pressed so high that it might be felt above, or even with the pubis. The in- verted fundus and body of the uterus were pressed into its more soft and yielding neck, so that it could be felt as it is in parturition, pro- jecting around the more solid part of the tumor, giving flattering hope of ultimate success. This was continued four or five hours. After its removal, and several hours' rest, it was found that no benefit was derived from the operation, the parts having returned to the same state as before the attempt." I am enabled to add that Dr. St. John, of New Melford, was of the council in attendance upon Mrs. H. ; a gentleman whose accuracy in diagnosis commands of his professional brethren about him very high respect, and who authorizes the statements here offered. I have introduced the accounts of the gentlemen who saw this in- teresting case, that, in the mouth of two or three witnesses, its true nature may be established. I follow with its subsequent history, which may be considered to lend an item of some interest in support of the 555 position you maintain, in a recently published work, regarding the possible spontaneous reposition of the inverted uterus. The convalescence of Mrs. H. was slow, but in four or five weeks she was able to walk across her room, and gained strength steadily thereafter; was soon able to ride out ; but when in an erect position, suffered a sense of dragging weight in the pelvic region, and often spoke of the tumor as not having sensibly diminished in size, and was continuing to occupy a low position. Between nine and ten months had passed in this way, since her misfortune, when I was informed that the tumor had then lately so changed its location, " that she knew not what had become of it." In the month of February, 1847, she had a profuse menstrual flow, the first considerable evacuation of the kind she had experienced since in this state; and in March a second eruption still more abundant occurred, from which she was somewhat reduced. Nothing of the kind recurred, and she passed the following spring and summer seasons in good health. Early in the winter, I think in December last, I was applied to for my opinion as to the question of her pregnancy, and was led to concur with the patient herself, in the belief that such was probably her condition. No ex- amination per vaginam was had. On the 23d of May last, at four o'clock P. M., Mrs. H. was attacked with a hard chill, and a sponta- neous rupture of the membranes immediately ensued. Slight pains came on and recurred at very short intervals till six o'clock, when she was delivered of a boy, whose weight was nine pounds and six ounces. Very slight pains followed at intervals of from twenty minutes to two hours. There being no considerable hemorrhage, I patiently, but watchfully, w T aited, while as a precaution, perhaps unnecessary, I introduced the staff spoken of by Prof. B. by the side of the cord, within the uterus, till it rested gently on the fundus, nor till six o'clock next morning, did the placenta descend — wdien it lodged low in the vagina, and was removed. The patient and her child are now well. Yours, w T ith high regard, JOHNSON C. HATCH. Kext, Connecticut, July 1st, 184 S. I have already announced, in a note to M. Colombat's Diseases of Females, and in my Letters on Females and their Diseases, p. 239, the opinion that there are instances of inversio uteri, in which, by means of some power, the processes of which are at present not known or understood, the womb reposits itself. The two cases of such occur- rence that I related in my "Letters," and the case now given upon 556 INVERSION. MR. CROSSE. the authority of Drs. Hatch, Beardsley, St. John, and Beers, appear to me to be quite sufficient to establish the facts. It is true that Mr. Crosse, of Norwich, in England, in his valuable work, entitled An Essay , Literary and Practical, on Inversio TJteri, at p. 177, does not agree with me in the opinion that the first two cases here recited are really cases of spontaneous reposition. " It is easier," says he, " to cast a doubt over the reality of these spontaneous reco- veries, than to remove the obscurity that pervades the subject gene- rally." Dr. C. also hints that I and my friends may have mistaken a polypus for an inversio uteri. Mr. Crosse's words (note), p. 177, 2d part, are as follows : " First Case. — The disease dated from her delivery, two years before, and had existed for that length of time, when Dr. Meigs was consulted. He took the greatest pains to discriminate, and remained under the absolute conviction of its being inversion of the womb ; several others concurred in the same opinion. Fruitless attempts were made to reduce the part. Four years afterwards she became preg- nant. Second Case. — Nearly five weeks elapsed after delivery before the patient was examined and the vaginal tumor investigated by the speculum, and also by the hand introduced into the vagina, till two fingers passed within the cervix uteri and reached the limit of the cul- de-sac, enabling the investigator to convince himself that the tumor within the vagina was i the inverted womb and nothing else.' After a temporary absence, this patient returned, became pregnant, and gave birth to a child. Hence Dr. Meigs concludes, that the inverted womb 'may reposit itself in some rare instances.' (Colombat de VIsere, Dis. of Women, translated by C. D. Meigs, pp. 182-4.) The deficient account of the method of diagnosis in the first case is, in some degree, supplied in the second; but there is still an absence of that minute detail of proceedings which, in the present day, is alone calculated to convince the skeptical reader. It may be asked, if we suppose in either case there was polypus, and not uterine inversion, c What became of the polypus?' Perhaps it may be answered, that it is more easy for a polypus to be separated and thrown off than for chronic inversion of the uterus to reposit itself spontaneously. W hilst the question remains undecided, and further evidence is needed, we have only to take care that the right rule of practice prevails. Vel- peau, one of our best authorities on chronic inversion, remarks : — 'Des faits de ce genre ne doivent etre considerees que comme d'heu- reuse exceptions ; il n'est pas aucunpraticien sense qui oserait comp- ter sur depareilsresultats.' (Lemons Orales de Clin. Chir., ii. 427.)" INVERSION. — MR. CROSSE. 557 It ought not, perhaps, to expose me to a charge of excessive con- fidence in my own perceptions and judgment, if I should say that in both the cases I took the greatest pains to make the discrimination — that I have treated many cases of uterine polypus, and that I have practised as an accoucheur, and been largely engaged in treating the diseases of females, for many years past. Under such circum- stances, and supported by the coinciding opinions of Drs. Moehring, Hodge, and Warrington, I aver that no mistake was made. I am now strongly confirmed in my belief by Dr. Hatch's case, which seems to me to preclude all cavil as to the question. Mr. Crosse cites Velpeau's words, who says that "facts of this kind may be perhaps regarded as the happy exceptions to a general rule ; but there is no intelligent practitioner who would dare to rely upon such results;" and Mr. C. adds, "If we subtract all errors and admit only the well-authenticated cases, it may still be remarked that spon- taneous replacement is too rare an occurrence to have any influence upon the correct rule of practice, viz., the effectuating by art the re- duction of partial inversion of the womb in all its different degrees." These remarks are just and true. Yet as cases do occur in which, from the lateness of the detection of them, or from other causes, the reduction is found to be impossible, it is a most important and con- solatory reflection, that there remains the hope of a spontaneous re- placement, while we are guarded against the danger of making a discreditable prognosis. There is certainly very little hope for a wo- man affected with irreducible inversion of the womb, except this very case of exceptional hope, which I have endeavored to establish, and which, I think, ought not to be gainsaid after the testimony in its favor now given. Moreover, there is very little risk that any person worthy the name of Physician, would ever desist from every reasonable at- tempt at chirurgical reduction, on account of any degree of confidence he might indulge in a possible spontaneous replacement of the inverted womb. 558 PUERPERAL FEVER. CHAPTER XIX PUERPERAL FEVER. Puerperal fever, child-bed fever, puerperal peritonitis, peritoneal fever, and other names, are terms applied to a dangerous form of in- flammation to which lying-in women are exposed, and which pro- bably occasions a far greater amount of fatal results than any other disorder met with in the whole range of obstetric practice. In former times very imperfect views were taken concerning the nature of these violent affections. Seeing that they were accompanied with an early sinking and rapid extinction of the vital powers, recourse was too soon had to supposed means of sustaining the strength of the patient. Hence, wine, bark, opium and heating methods in general were resorted to, but without other effect than to increase the inflam- matory congestions which were the real causes of the apparent de- bility, and precipitate a fatal result which might, in numerous in- stances, have been averted by measures founded on juster views of the pathology of the case. There has long been a very great differ- ence of opinion among medical men in regard to the proper mode of treating this disorder, and I am unable to repress a feeling of deep regret on account of the continuance of that difference at a period when the light shed upon the subject by numerous and careful exami- nations of the bodies of victims, has left no doubt upon the mind as to the real and essential nature of the disease, now universally ad- mitted to be inflammation of the womb, of its appendages, or of the peritoneum — and sometimes of all of them together. There is good reason for believing, however, that sounder views of the nature and treatment of child-bed fever are extending rapidly in the republic of medical letters, and the day, it is to be hoped, is not far distant, when such works as those of Alexander Gordon, of Hey, and of Robert Lee, will be able to establish a firm conviction of the reasonableness and truth of the doctrines and practice they severally set forth; and that a very great reform may be soon effected in the PUERPERAL FEVER. 559 treatment of these cases, to the advantage of the public and to the greater honor of the medical profession, whose highest glory it is to reduce the amount of the per centage of fatalities in the various forms of disease entrusted to medical care. Considering the state of the patient's constitution immediately after the fatigue of gestation, the excitement and efforts of labor, the altered and diminished tension of all the parts contained within the abdomen and pelvis after parturition, we ought not to feel surprised at the fre- quent occurrence of inflammation in those parts. The womb itself has been suddenly reduced from the gravid to the non-gravid state ; it has thrown off the large mass of the placenta, leaving the surface to which it had been attached bleeding, and re- quiring a sort of healing process. Many orifices filled with plugs of coagulum, some entering a considerable distance into the veins, are found gaping upon its inner aspect. These orifices are the openings of tubes communicating with the veins of the womb; they are lite- rally open veins lined with the membrana vasorum commune, the En- dangium. It is probable that these orifices never close after any labor, except by the intervention of an adhesive inflammation. The muscular tissue is about to be reduced so much as to be no longer distinguishable by the anatomist's eye; large veins and sinuses are to be crushed and rendered invisible ; absorbing vessels, nerves and membranes, all are about to be put upon the reduced establishment, and this by a process of the most active absorption, for the womb is to be reduced from its post partum weight of a pound and a half to its non-gravid weight of two ounces and a half, requiring an immense activity of its absorbent vessels, and probably a vast operation of exosmose. These circumstances, I say, should prevent any surprise, if, in the midst of so great a revolution of the reproductive tissues, violent disorders should make their appearance. There is, in fact, greater reason for surprise when we find a child- birth not followed by inflammation, than when we meet with the most violent and destructive cases of that affection. The peritoneum, a serous membrane known for ages as one of the tissues most ready to take on inflammation, undergoes, in labor and during the lying-in, changes of the greatest importance. Its great extent may be known by computing the superficial contents of that portion of the serous membrane which invests the alimentary canal. This canal is about forty feet in length, and its outer coat is com- posed of peritoneum. If cut up from end to end by the enterotome, it would be at least four inches wide and forty feet long, affording a 560 PUERPERAL FEVER. superficies of more than thirteen feet, to which should be added the superficial contents of the remainder of the membrane, where it in- vests the liver, the epiploon, the mesentery and mesocolon, besides the ligamenta lata, and all the other parts which derive from it their serous covering. This vast surface inflames rapidly and totally, and passes through the stage of inflammation with extraordinary speed. It cannot happen that it shall ever be extensively inflamed without a coincident exhibition of the greatest disorder in the functions of the nervous organs directly implicated in its structure, or possessing with it physiological relations that could not be safely disturbed. The peritoneum is the investiture of the abdominal organs ; the peritoneal coat of the stomach is as truly a part of the organ as its muscular or mucous coat; the same is true as to the peritoneum that invests the liver, that of the spleen, and the same truth is of the utmost import when it is stated with regard to the peritoneal coat of the whole ali- mentary apparatus. It is clear that extensive or universal inflamma- tion of the peritoneal membrane is inflammation of all or many of the organs contained within the cavity 01 the abdomen. A great puerperal peritonitis, therefore, may be properly regarded as a com- plex inflammation of a vast number of organs indispensable to exist- ence ; why should we be astonished, then, to see the power of the nervous mass sink under the invasion of causes of destruction so great and so pervading. Seeing that the superficies of the peritoneum is equal probably to thirteen or fourteen feet, we should have abundant reason to dread so extensive an inflammation, from the constitutional irritation which it alone would produce; but when, in addition to that consideration, we take into view the great effusions which may ensue, the suppurations, the interruption of the intestinal functions, the depravation of the actions of the liver, &o., which are occasioned by it, we have still greater reason to deprecate its attack, and to seek for the justest views of its nature, and of the remedies most appropriate for its cure. Peritoneal inflammation occurs more frequently in women in child- bed than in any other class of persons. It generally follows labor within from two to four days ; but it may occur either earlier or later; sometimes making its attack even before labor begins, and being de- ferred in other cases until the third week of the confinement, or even later. The subject is predisposed to it, probably from various causes, among which are the severe pressure which occurs during the expul- sive efforts for delivery; the extreme distension which the membrane PUERPERAL FEVER. 561 has suffered in the last weeks of gestation; the violent excitation of the womb itself by labor pains ; the complete relaxation of the mem- brane and its adjacent tissues, following the birth of the child, and, lastly, the modifications as to the state of the Endangium of the uterus, particularly that portion of it which remains open on the inner sur- face, giving issue to the lochial discharge. The pressure produced by the bearing down of the woman in labor is often so great and so long continued, that an effect analogous to contusion cannot fail, in many instances, of taking place ; since the whole power of the abdominal muscles is expended in propelling the uterine fundus towards the os uteri. Such contusions of con- tiguous portions of the peritoneum would be readily followed by in- flammation, and the more readily in proportion as these efforts might have been greater or longer continued, and, in fact, we do find that bad labors are more apt to be followed by peritoneal fevers than easy or good ones. The peritoneal coat of the womb is greatly expanded or stretched in the last stages of pregnancy. The broad ligaments and the liga- menta rotunda, are drawn up on the sides of the uterus to a consi- derable height, w r hile the portion of the membrane that lines the front and sides of the belly is also put greatly on the stretch. This ante- cedent tension could not but increase its natural proneness to take on inflammatory action, if exciting causes should be applied to the peri- toneum, when after delivery so great a relaxation has taken place. The womb itself is left after labor with so great a disposition to inflame, that very slight occasional causes suffice to set that disorder on foot in the structure of the womb itself, which may serve as the radiating point for a peritonitis that shall involve the whole extent of the serous tissues of the belly. It is very common in the post-mortem examination of puerperal fever cases, to find the results of inflamma- tion not only on the serous coat of the uterus, but also in its proper structure, as well as in that of the ovaries. These results are evinced in the effused pus found in the substance of those organs, and in their veins. There are many examples to be met with of fatal puerperal dis- ease in which the peritoneum alone discloses the evidences of grave lesion; there are also very numerous instances of like fatality in which the uterus itself appears to be the only organ affected in these uterine cases ; it is probable that the ipsissimus morbus is Endangitis, com- monly called metro-phlebitis. I advise the reader to consult upon this head, the volume on puerperal fever, published here by Haswell & Barrington, in which he will find the precious writings of Gordon, 36 562 PUERPERAL FEVER. Hey, Armstrong and Lee. That work alone should suffice thoroughly to indoctriuate him in regard to the nature, signs, causes and cure of child-bed fever. The relaxation of the peritoneal membrane that follows delivery and the reduction of the womb to a small size, is, beyond doubt, one of the most fruitful sources of inflammation of the membrane. The sanguine determinations are also greatly affected by the relaxation of the muscles and integuments of the belly, consequent upon the com- plete contraction of the womb. It will not be denied that the blood that escapes from the aorta by the cceliac and the mesenteries, as well as that which passes along the spermatic and uterine arteries, will meet less resistance to its flow where the tegumentary and muscular tissues of the abdomen are quite flaccid and devoid of tone, as after child- birth, than where they are in a state of great tension, as before labor commences; but if the blood of the chylopoietic organs reaches their capillary vessels with less resistance or greater facility, then those organs will be more liable to sanguine affluxions, engorgements and irritation, on account of this very weakness and relaxation. A similar liability exists for patients who have been tapped for ascites. Such patients are extremely apt to be seized with peritonitis, which, however it may be in a measure considered as a consequence of the wound made by the trocar, is, nevertheless, more apt to ensue in such as are not carefully bandaged after the tapping, than in those who procure a proper degree of compression by a bandage which serves as a substitute for the tone, or rather resistance of the muscles and integuments, which is almost wholly abolished, at least for some hours or days, by the drawing off of the water from the peritoneal sac, as it also is after delivery. Let us suppose the case of a woman who has just given birth to a child of eight or nine pounds weight. She has had perhaps sixteen ounces of water in the womb, and an after-birth weighing a pound. Previously to the birth of the child, the greatest or vertical circumfer- ence of the womb was about thirty-five inches, and its horizontal cir- cumference twenty-five inches; after delivery it becomes so reduced as to jut but little above the plane of the superior strait, whereas, before the accouchement, it rose as high as the xyphoid cartilage. The change in the state of every part of the sanguiferous apparatus within the belly after delivery, is very great indeed, and the forces which impel the blood into those vessels being equal to, if not greater than they were before the resistance was lessened by the delivery, it follows that PUERPERAL FEVER. 563 the stroke of the ventricle upon the aortic column must necessarily pro- pel a large proportion of blood into the less resisting tissues or vessels. Every blood-vessel, whether arterial or capillary, may justly be re- garded as a hollow cylinder, containing within its calibre a column or cylinder of incompressible blood, which, by a slight effort of the imagination, may be conceived of as reaching backwards from the capillary or arterial tube itself to the origin of the aorta. Suppose the capillary to be dilated, distended, or engorged with blood, as it confessedly is when in a state of inflammation. Suppose also the ventricle to contract with febrile force in such a way as to propel its contents, amounting to one ounce of blood, suddenly into the aorta; of course that portion of the blood amounting to one ounce that was in the aorta and nearest its valves, was moved downwards to make place for the following wave, the ounce next to it in advance was moved at the same time, and by the same blow, and so on to the last ramification of the artery, and far onAvards into the capillary system of vessels. It is easy to see the globules in a transparent membrane placed under a microscope, move forwards per saltum with each suc- cessive systole of the heart. Let us now suppose a portion of the peritoneum, say two inches square, to become inflamed from any cause, is it not easy to conceive that every successive blow upon the arte- rial column struck by the ventricle, will drive hundreds of columns along the capillaries, like so many wedges into the contiguous capil- laries, and that the inflammation will spread, as fire in dry grass, in every direction, and with every succeeding blow, until the whole extent is involved in the desolation? Such and so great is the rapidity with which this serous membrane inflames, that many cases are recorded in which death was brought about within thirty hours after the attack, with great deposits of effused lymph or sero-purulent effusions into the cavity of the peritoneum. Puerperal women are not the only subjects and victims of peritonitis, for non-gravid women, and the male sex of every age, are liable to the disease, which, however, in them, proceeds with far less haste to its destructive termination. Taking this view of the tendency which the relaxation, or want of tone or support, occasioned by delivery, gives to attacks of peritonitis, I find it not surprising that those women who get up too soon, or sit up too long, should suffer more readily than those who preserve a hori- zontal posture for several days after childbirth. A woman who gets up very soon, is much exposed to the dangers of flooding, from the sudden engorgement of the uterine vessels occasioned by a vertical 564 PUERPERAL FEVER. position. The hemorrhage that often comes on in consequence of this imprudence, is an effort of nature to relieve the engorgement of the abdominal and uterine blood-vessels, produced by a too early- getting up ; but, where this relief is not procured by evacuation of the engorged vessels, inflammatory excitement may supervene, espe- cially if the centripetal determination of the blood is augmented or reinforced by the occurrence of chills, to which the woman is more obnoxious out of bed than in it. Not a few of the cases of peritoneal inflammation that have come under my notice, were clearly attributa- ble to the imprudence of the patient in getting too soon out of bed. Such an act of imprudence ought not to be permitted. Vascular excitement, from whatever cause produced, may become fixed upon the serous membrane of the belly as an inflammation possessing all the dangerous characteristics of child-bed fever; a for- tiori, such inflammations are more likely to attack the tissue of the uterus itself; hence, in seasons of an epidemic prevalence of child- bed fever, the physician, who ought to be truly the guardian of his patient, should feel bound, more than in ordinary times, to protect her from the dangers by which she is surrounded by the most careful and precise directions and orders relative to her management in the lying-in. A common milk fever, therefore, ought not to be permitted to become very violent, lest it might produce the result just mentioned. It should be fully and promptly reduced by venesection and cooling purgatives, and above all by a strict observance of the horizontal position. Fever of any kind coming on soon after delivery includes at least a risk of an attack of peritonitis. Improper diet, and whatever might occasion indigestion, should be carefully avoided, lest the intestinal irritation, if severe, should be- come peritonitis in one predisposed that way. I speak upon this point from my own observation, having recently seen two women, both of whom had peritonitis from indigestion occasioned by the use of a kind of food which is very generally given to lying-in women. Great care should be taken to avoid all kinds of indigestible food. Costiveness, a very common complaint towards the close of preg- nancy, should be obviated by the administration of gentle aperients or enemata. An overloaded state of the bowels might very reason- ably be supposed sufficient to excite irritation in the abdomen, which, in individuals predisposed to peritoneal inflammation, would become fixed at last upon the serous surface. Suppression of urine, an occurrence frequently met with in obstetric practice, should be carefully watched, since an undue degree of dis- PUERPERAL FEVER. 565 tention of the bladder can scarcely take place without endangering the life of the lying-in woman, from the tendency which accompanies it to excite the first movements of peritoneal or metritic fever. It should always be regarded as a part of the duty of the medical attend- ant, to inquire into the state of the bladder after the labour is over; and it is far better to resort at once to the catheter for relief, where there is any reason to suspect an accumulation of water, than to con- fide in the various diuretic drinks, or even to the enema, which, although less disagreeable, are far less certain remedies than the catheter. It is scarcely ever proper to defer a recommendation of the use of the catheter, where many hours have elapsed after delivery without a urinary evacuation; even if the patient complains of no pain. I have observed, in some instances, a very great collection to be unattended with decided pain. It is highly important to pay strict attention to the after-pains of w T hich puerperal woman so commonly complain. If they go off per- fectly — leaving intervals between the contractions; and especially if, in those intervals, there is no soreness of the hypogastric and iliac regions upon pressure made thereon with the hand ; or if the woman can cough without producing pain in the hypogaster ; or if suddenly drawing up the thighs or rotating the lower extremities produces no pain in the lower belly, they are of little consequence ; but w T hen they do not leave the patient w 7 ith good intervals of freedom from pain, they should be held suspected, and be quelled by anodyne doses, by enemata, and even by the use of the lancet. Obstinate al'ter-pains, par- ticularly those which continue for several days, not very rarely serve as the masks of a peritonitis, which is the more dangerous from having, by its insidious approach and attack, beguiled the unwary practitioner, until his means of resistance, w 7 hich at the beginning might have proved completely adequate, have, by procrastination, lost all efficacy. In urging the attention of the student to this point, I by no means wish to be understood as asserting that it is always easy to discriminate between after-pains and the early stages of a peritoneal fever — on the contrary, it is on account of the difficulty of making such a diagnosis, that it becomes important to attend sedulously to the symptoms. Those peritoneal fevers, and they are not few, which are connected with an inflammation of the uterine sinuses, are the most dangerous; and I have no doubt that some of the very distressing after-pains w r hich we meet with in practice, but which w T e subdue, are occasioned by a high degree of inflammatory irritation of the uterine texture, whose course being happily checked leaves us without any fatal or 566 PUERPERAL FEVER. post-mortem evidences of its existence. I am free to say, that I have often been very much embarrassed to decide whether my suffering patient was affected with mere spasmodic contractions of the womb, or with rheumatismus uteri, or whether she laboured, in addition to such spasm, under an inflammation of that organ. I have many times abstracted blood freely for the relief of the symptoms, and, obtaining complete relief, have remained still uncertain whether my remedy had put a stop to spasm merely, or whether it had overcome an inci- pient inflammatory excitement of the uterus and ovaria, by which the patient was exposed to the greatest dangers of fatal peritoneal fever. I beg leave to repeat, that after-pains ought to be carefully w T atched, and when accompanied with an excited circulation and tenderness of the hypogastric region, should be met by free depletion as the chief of remedies. There are other remedial measures that need not be again spoken of here. There is, unquestionably, an epidemic influence or atmospheric constitution which sometimes, in extensive districts of country, in villages, in towns and cities, and especially in crowded lying-in hos- pitals, determines by an unknown force the attack of child-bed fever, and so modifies the pathogenic conditions as to hurry numerous vic- tims to the grave, and this notwithstanding the employment of the most reasonable methods of cure. From the coincident prevalence of child-bed fever and erysipelas, it has been, by some, supposed that there is a unity of causes for the two diseases. Be it so: the cause remains not the less unknown, nor can I bring myself to the convic- tion that that epidemic cause can in any degree modify the science and the art of the practitioner who is charged with the cure. If me- tro-phlebitis and metro-peritonitis, be truly inflammation, they are so under every possible modification of the atmospheric or epidemic constitution; if that epidemic constitution is inflammatory or sthenic, the indication for the treatment leads to the employment of the anti- phlogistic resources. Happily for us, under such a taxic constitution of pathogeny, our therapeutical resources, of an antiphlogistic kind, prove to be the obedient servants of our will; under ataxic forms of the epidemic pathogeny, our therapeia can never change the truth into a lie, teaching us that these same inflammations are to be cured by a mode of treatment contrary to the truth, both of physiology and pa- thology. Experience gives us no records of cheering success in the treatment of ataxic epidemics of child-bed fever, by means merely of alteratives, and stimulants, and alexipharmics, and tonical articles from the materia medica. If we cannot cure by venesection we shall in vain attempt to cure. PUERPERAL FEVER. 567 There appears to me to be a growing disposition on the part of the profession to look to contagion as one of the causes of what is uni- versally admitted to be an epidemic disease, and the facts that have been set forth in confirmation of this idea are sufficient to startle the most imperturbable mind. For my own part, however, notwithstanding I have given to these statements all the attention which the authors of them demand at my hands, I remain hitherto unconvinced of the powers of contagion to extend this fatal disease. A great experience has not enabled me to perceive that I have been the means of dis- seminating this malady among lying-in women, to whom I had given professional aid while attending upon dangerous and fatal attacks of the malady, or after making or witnessing autopsic examinations of the bodies of the dead. The chain of causation is too fine to be dis- cerned, and as I w T holly reject the doctrine of contagion in yellow- fever, in Asiatic cholera, in measles, and in scarlatina, I remain equally recusant as to the contagion of puerperal peritonitis, and me- tro- and crural phlebitis. Puerperal fever, generally, is ushered in with a chilly fit, more or less considerable, and of various duration, but ordinarily not very long ; the pain which accompanies it commences in the hypogastric or one of the iliac regions, and increases and extends its limits as the fever augments. The fever is occasionally very high, while the pain is not very intense, and in the epidemic cases of the malady, some women are met with who do not even complain of pain at all, notwithstanding the most active inflammatory changes are going on in the abdomen, as disclosed by post-mortem examinations. The vascular system, when moved by peritoneal inflammation, reacts with the greatest promptitude ; the pulse acquires a frequency of rarely less than 120, and commonly 140, strokes per minute. In the early stages of this vascular reaction, in sporadic cases, the artery is full, strong, and possessing the characters of the synochus fortis pulse : but this high grade of energy is soon passed; the pulse acquires greater frequency, with diminished hardness and volume. If the in- flammation, like a rushing fire, seizes on the whole serous membrane, or attacks the mass of the uterus, the constitutional irritation which is produced by it rapidly exhausts the vital powers, and the patient sinks very much in the way that those surgical patients perish who have suffered extensive laceration or fatal injuries of some great ar- ticulation. All remedies are useless when the whole nervous and vascular systems have suffered a shock sufficient to overthrow their functional power, and the patient sinks rapidly, in despite of the cor- 568 PUERPERAL FEVER. dials, the opiates, the counter-irritants and other appliances which are, in a sort of desperation, resorted to by the medical attendant. A child-bed fever should be cured very soon, or it will scarcely be cured at all ; and why should we expect to cure a peritonitis which we have reason to suppose connected with an inflammation of the whole serous membrane? If a small part of that membrane only be affected^ as is the case in the commencement, we may hopefully en- deavor to effect a resolution of the inflammation by bleeding, &c, but when it has had time to be wholly involved in inflammation, I think any experienced practitioner will agree with me in expecting the inflammation to result not in resolution, but in effusion; which effusion ends in death very commonly. Such is the rapidity with which the peritoneum becomes universally involved in inflammation, that not a few persons have, in their writings, brought into some discredit the use of the lancet as a remedy, their own judgments having been staggered by the vain employment of the remedy in stages wherein the loss of blood could not do good, and seemed only to precipitate the fatal result. A woman, for example, may be attacked with the disease after the physician has seen her in the evening; the nurse, who supposes that all pain in the abdomen is after-pain, and all fever, milk fever, does not become alarmed, and when the physician arrives, he finds the patient already far advanced in, or at least on the point of, those effusions into the peritoneal sac, which, w 7 hile they put an end to the pain, also seal the fate of the unhappy mother. Such events have occurred under my own practice. I would earnestly endeavor to impress upon the mind of the student of medicine the vital importance of great promptitude in his attention to the earliest signs of this dreadful malady, especially during the epidemic prevalence of it. I would convince him that the principal feature in the disease called child-bed fever is peritonitis or metritis, or metro-phlebitis — that the inflammation is so acute, and the tissue in which it is seated so inflammatory, that the malady is capable of hurrying through its curable stages more rapidly than even the re- doubtable croup, and what is of still greater moment, that it is in the incipient stages nearly as curable as croup, and that the remedy, or I might say the cure, consists in the bold and judicious em- ployment of venesection. Let me ask, what can be the value of any remedy short of venesection, in a malady like this — which pre- sents a case of pure inflammation — occupying, or making haste to oc- cupy, not a few square inches, but many square feet of a membrane that serves as the investment of the most important organs? In what PUERPERAL FEVER. 569 light, save as mere juvantia, can any reasonable man regard the few grains of calomel and opium, or ipecacuanha, or the few drops of spirits of turpentine, which are by some persons given as remedies for such wide-extended mischief? Nothing but abstractions of blood can have an immediate and potent influence on the circulation, and reduce the momentum of the blood to such a degree of moderation, as may con- sist with a resolution of the inflammation. Nothing short of these venesections can diminish the force of the blows which the irritated, I might say the infuriated, ventricle strikes upon the columns of blood which it is driving like so many riving wedges into the tissues, to disorganize, to tear them to pieces, and overwhelm them with the torrent of circulation that it urges upon them, while their power to resist succumbs to every successive blow. Every systole of the heart is an effort for the development of the tissues in which the torrent of the circulation last arrives. The pathological modifications brought about by the hyperneuric and hyperaemic modality of the inflamed points are always exaggerated forms of development. The inflam- matory deposits, effusions, extravasations, new tissues and heterologue materials made manifest in a local inflammation, are specimens of teratology; they are all monstrosities. The duty of the physician is to prevent or lessen the preternatural operation of this development force. Peritonitis always has one or the other of these two termina- tions — resolution or effusion ; with the former the patient recovers, with the latter she dies. Dr. Gordon tells us, that it is not merely bleeding the patient that will save her. She must be bled copiously — so copiously as to give to the disease a definitive check. He tells us that where the woman is bled timidly, no available impression is made, that the disease advances and soon becomes indomitable. Twenty-five or thirty ounces drawn from the arm, early in the attack, rarely fail to make so powerful an impression on the disorder, that the juvantia, such as calomel, opium, &c, hardly fail to effect the remainder of the cure. All the experience I have had in regard to the course and treatment of this malady, leads me to concur fully with the instructions of Dr. Gordon on the subject, and it is alw r ays with regret that I reflect on the published opinions of Gooch and others, who appear to bring into distrust the best of all possible resources for the management of this violent disease. I scarcely can find words to express my admiration of Dr. Gordon's work upon Puerperal Fever. May I not venture to say that the subject cannot be well understood, until the physician or student has read that work, and read it carefully? Its publication was 570 PUERPERAL FEVER. the turning point of the great therapeutical reformation going forwards in the treatment and knowledge of child-bed fever; and mankind owes an iinpayable debt to the author for the benefits he conferred on the race, by its clear, candid, and most important revelations of medical truths. To it we are, I suppose, really indebted for the luminous and satisfactory w T ork of Dr. Hey upon the same subject. And, doubtless, Dr. Robert Lee, whose principles and modes of treatment are so ex- cellent, would not dissent, if the palmam qui meruit fer at should be tendered to Gordon, who led the way at least, by his early publi- cation, to a philosophy of this disease, which Dr. Lee, in his " Re- searches," &c, has so successfully illustrated and explained. Dr. Gordon gives a table of the cases, with the names of the pa- tients, and the results of his practice, from December 1789, till Octo- ber 1792. They were seventy-seven in all, of whom there died twenty-eight patients, which is equal to one fatal case in every two and three-fourths of the cases submitted to his care. It should be remarked that when he had fully convinced himself of the propriety of the lancet, he was more successful, for his fatalities occurred among the early opportunities enjoyed for clinical observation and study. It was not until the fatal result of the expectant practice had astounded him, that he obtained permission to examine the body of one of the victims. The undeniable evidences therein discovered of raging inflammation induced him to adopt a bold antiphlogistic treatment. He had lost nineteen out of the first thirty-eight cases encountered in the epidemic. His thirty-eighth case afforded him the material for dissection; he afterwards attended thirty-nine cases of the malady, of which he lost ten, and saved twenty-nine. When he took away only ten or twelve ounces of blood, the patient died; "but when I had courage to take away twenty or twenty-four ounces at one bleeding, in the beginning'of the disease, she never failed to recover." I am almost ready to say, that the case of peritonitis which will not admit of the use of venesection, is hopeless — that all other medical measures are trivial, when compared with its prompt and salutary influences; and also, that I can with difficulty conceive of a case of the disease, in which the lancet would be inadmissible in every period of its origin and progress : there should be found some point of time in which it could be resorted to. While I profess in the strongest terms to confide in the lancet, as the first and chief remedy, I would not pretermit any mention of leeches, which, as a secondary and sub- servient prescription, will be found of the greatest utility in the manage- ment of the cases. They should be freely employed, by scattering PUERPERAL FEVER. 571 them over the parts of the abdomen most affected with pain and sore- ness. Cataplasms and warm fomentations may be advantageously used after the removal of the leeches, and the bowels should be well evacuated by means of enemata, or by doses of calomel and castor oil, to be followed, after the operation, by doses of calomel and opium, or calomel and Dover's powder, w T ith w T arm mucilaginous drinks. These serve, after the evacuation of the bowels, to promote perspira- tion, which, when properly excited or produced, counteracts, in an eminently useful manner, the internal disorders of the circulation. In regard to the power of mercury, I believe that it is able, in large doses, to exercise upon the nervous mass an influence, the operation of which serves to diminish the plasticity of the blood. I know of no objection, therefore, why the Student should not, after the great, in- dispensable venesection, give full employment to the aplastic proper- ties of the mercurial preparations. By means of the judicious, bold administration of mercury as an adjuvant, of the prime measure, the venesection , patients may be rescued from a death which the venesection could not, perhaps, arrest. I feel very sure that the whole body of medical men are under the greatest obligations to Dr. Robert Collins of Dublin, late Master of the Lying-in Hospital of that city, for the work which he has recently put forth. That work is the result of a long and most attentive and recorded experience; and, taken as a whole, may be justly regarded as one of the really valuable contributions to medical science of modern times. While, however, I am thus ready to profess very cordial admi- ration of the work, I cannot suppress a feeling of regret on account of what he has given us on the subject of puerperal fever. During the seven years in which Dr. Collins was master of the hos- pital, there w T ere delivered in the institution sixteen thousand four hundred and fourteen women, of whom one hundred and sixty-four died; of this number, fifty-six died with puerperal fever. The whole number of persons who were attacked w T ith the disease was eighty- eight, so that two out of three cases, nearly, were fatal. Dr. Collins says, at page 390, "The extreme difference of opinion, and the very opposite measures recommended by practitioners, arise, chiefly, I am satisfied, from their treating every variety of puerperal fever as one and the same disease, whereas, there is, perhaps, not any other which exhibits a greater diversity of character, in different situations, and even in the same situation at different periods. In some, the fever is accompanied by symptoms indicative of the most active inflammation, such as to forbid the least delay in the free use 572 PUERPERAL FEYER. of venesection, and the decided employment of antiphlogistic mea- sures. This form of disease, which is by far the most manageable, is generally met with in private practice. Puerperal fever, when epi- demic in hospital, is directly the reverse ; at least, in four epidemics which I have witnessed, the symptoms were usually of the lowest typhoid description, the pulse being so feeble and indistinct as to make you dread, in many, even the application of leeches; the patients, in several instances of this form of the disease, exhibiting somewhat the appearance of those laboring under cholera." Dr. C. informs us, also, at p. 392, that when he was assistant, in 1823, the fever raged to an alarming extent, and that in that epidemic the Master used venesec- tion with great frequency, and in the promptest manner. The effect on the patient, and on the mortality, convinced Dr. C. fully of the inexpediency of adopting this treatment. I have cited this most respected author, in order that the reader may be put in possession of some of the grounds of his objection to the employment of the lancet in epidemic puerperal fever, and I admit that his authority is deservedly very high. But I take the liberty to remark, that he gives us no details of the epidemic in 1823, and w r e are left in the dark as to the mode in which the antiphlogistic treatment was carried out. We are not told the quantity of blood taken in the cases which proved fatal. This is a circumstance to be regretted, since the friends of the practice agree in opinion, that a very large bleeding only, is to be depended on in the cure, and that, early in the disease, within six hours from the commencement of the malady. It is highly important for the reader to observe, that Dr. Collins lost fifty-six out of eighty-eight patients, under a system of treatment which consisted in giving, at the beginning, a draught composed of castor oil and spirits of turpentine, of each half an ounce. In some cases, twice the quantity above mentioned was given. " Where the state of the patient was such as to encourage a general bleeding, we used the lancet ;" but the doctor is satisfied, that in hospital it is bet- ter to apply three or four dozen leeches, and place the patient in a warm bath. Stuping the belly with flannels wrung out of water as hot as the patient can bear it, is another favorite remedy with him. This, followed by leeches after from four to six hours, is highly recom- mended. In some cases, from ten to sixteen dozen leeches were used. This was followed by the very free use of calomel and ipecacuanha, in doses of four grains of calomel and as much of ipecacuanha, repeated PUERPERAL FEVER. 573 until, in some instances, the patient had from three to five hundred grains of the mercurial medicine. Such are the most marked features of a plan which, at most, has not great success to boast of, inasmuch as fifty-six out of eighty-eight cases were fatal. At page 399, commences an account of cases of recovery from puerperal fever. They appear to have been taken indiscriminately from the record of successful cases. Of these cases, amounting to nine in all out of the twenty-nine cases, only two were bled, and they each lost fifteen ounces from the arm. The others were treated with leeching, &c. At page 424, commences the account of fatal cases of puerperal fever. These also seem to be taken indiscriminately from the record, and are eighteen out of the whole number of fifty-nine fatal cases, of which only one was treated by venesection. She was leeched the first day, and again in the night, with eight dozen leeches in all. On the second day, she lost, at two bleedings from the arm, forty-seven ounces of blood, and was leeched afterwards. In all, she lost, by venesection, forty-seven ounces, and had fourteen dozen leeches, five warm baths, four hundred and sixty grains of calomel, and twenty- three grains of opium, constant stuping, and occasional draughts of castor oil and turpentine. In regard to this case, I have to remark, that it does not present a fair specimen of the value of venesection in puerperal fever; — it was resorted to too late, for nothing can save a patient if the disease is allowed to get fully in possession of the tissues before it is properly attacked ; and the other seventeen cases of mortal termination are equally useless as evidences of the impropriety of the lancet as a remedy, since it w T as not employed in one of them. If the woman, who w-as so freely bled, and afterwards bore leeching, had been so well blooded on the first day — what would have been the result ? Leeches and calomel, it is true, were freely resorted to, but I am constant to the opinion that they are unw r orthy of trust, as prime agents, in this most violent and destructive disorder. I have taken, perhaps, a liberty with Dr. Collins's work on this occasion ; but I feel assured that a gentleman so candid as he, and occupying so exalted a station, will look, should it ever meet his eye, with indulg- ence upon an opinion which, while it differs from his own, does not disparage his great, admitted, and acknowledged merits towards the entire profession — merits which I gladly avail myself of this oppor- tunity to proclaim. 574 PUERPERAL FEVER. So great is the influence exerted by peritonitis upon the san- guiferous apparatus that, even where we succeed in effecting a most hopeful and flattering reduction of the pulse by a first bleeding, the blood-vessels soon come to be excited again, and the torrent of the circulation sometimes resumes its violence in an hour, or even less. Such a reaction should be met and quelled by repetition of the bleeding again and again, until it is deemed no longer needful or safe to abstract blood. When the power of the heart's contraction is sufficiently abated to cause it to propel its blood into the aorta with a gentler and more healthful momentum, the capillaries, which are the seat of the inflammation, will become capable of throwing off the masses of blood which have oppressed them, and the constitutional disorders that arose from, and then progressed pari passu with, the peritonic irri- tation, will subside as it subsides, and disappear as it disappears. Among the most sensible and philosophical treatises on puerperal fever that have appeared of late years, I look upon the work of the younger Baudelocque as one of the most to be esteemed. This was a prize production, crowned by the Royal Society of Medicine of Bordeaux. Dr. Baudelocque, after examining the objections of nu- merous authors to the use of the lancet as a prime dependence in the treatment, and especially to the employment of it at any other than the earliest period, cites, at pages 312 and 313, two cases from Delaroche, in confirmation of the propriety of trusting to venesection, whenever the symptoms clearly call for it. He says, "Be this as it may, while I acknowledge that nothing absolute can be determined as to the stage beyond which the lancet is no longer admissible; that we must pay due regard to the intensity of the dis- ease, the rapidity of its progress, and the effects obtained from the antecedent treatment ; I cannot but recommend, along with the authors heretofore mentioned, that recourse should be had to bleeding as soon as possible after the commencement of the attack; and I am thoroughly convinced, that the loss of a few hours is sufficient to render fatal an attack of peritonitis over which an early bleeding would have triumphed." M. Baudelocque speaks so well on this subject, that I cannot with- hold the following paragraph, which is worthy of all praise. At page 315, he says: "The utility of venesection being once allowed, it is important to consider the quantity of blood that is to be drawn. Setting aside some circumstances, of which I shall speak presently, I believe that the sanguine evacuations ought to be very abundant. They ought to be PUERPERAL FEVER. 575 effected in such a manner as to arrest the march of the malady, to make it miscarry, if one might use such a phrase, to prevent it from reaching a second stage. Perhaps the reason why the proper results of venesection have not been in some cases obtained, is that the ope- ration has not been done as above recommended. Considering the violence with which the disease attacks, and the extent of surface that becomes inflamed, one is easily convinced that success will not follow the abstraction of a few ounces of blood. The most that could be expected in that way, would be to lessen for a moment the violence, and retard the progress of the peritonitis, which soon rouses itself to move on with augmented speed." Again, at page 317, he says, " As to the feebleness of the woman, great care ought to be taken in order not to be misled by the state of the pulse. Its very great frequency, its smallness, are no motives for the proscription of vene- section. The pulse should be compared with the commemorative circumstances. We ought to bear in mind that one of the characters of puerperal peritonitis is this very frequency of the pulse. It may be contracted, not well developed, small and concentrated; but at the same time it is hard. There is great danger of being led into error by this pulse, which is found to become developed, and to lose its frequency, after the use of the lancet, and sometimes even during the flow of the blood." Dr. B. does not at all think that the occurrence of puerperal peri- tonitis in hospitals forbids the employment of bleeding as a remedy. See his remarks at page 318, which it is quite refreshing to read after so much false doctrine as we have had lately upon the management of this dreadful disease. There are no considerations relative to the treatment of puerperal fever, that I regard as claiming to be compared in importance with those that concern the use of blood-letting; yet, as it is not possible for me to give, in this work, my views, and the reasons for them, at full length, I shall say no more here upon the use of the prin- cipal remedy. I beg to refer the reader to the article on puerperal fever in my "Letters to the Class" — Letter XLI. — but I shall go now to the explanation of some circumstances which I think deserving of the reflections of the Student, and the most careful observation of the practitioner. One of the early symptoms of a peritonitis is flatulent distension of the bowels, or tympanitis. It is a source of infinite mischief, and very difficult of removal. Tympanitis consists in inflation of the 576 PUERPERAL FETER. intestinal tube, and not in the inflation of the peritoneal sac. as some are inclined to suppose. The air of which the swelling is composed, is extricated from the food or drinks of the patient while in a state of fermentation — a fermentation that could not exist except where the digestive force is impaired, but which force is necessarily impaired where the pulse is at 130 or 140. and where the alimentary tube is invested by a peritoneal coat — already a prey to active inflammatory disease. But not only is the digestive force greatly impaired ; the alimentary tube, whose outer investment consists of peritoneum, re- fuses to contract ; the gases that are developed simply distend portions of the tube, whose muscular fibres, like all muscles whose integu- ments are inflamed, either refuse to act, or act so feebly as to suffer the canal to be puffed, or completely blown up, like a bladder, by the lateral pressure of the gases of the bowels. In a puerperal woman with peritoneal fever, it is not uncommon to find the abdomen as large as at the seventh or eighth month of gestation, from inflation of the bowels. They become so tense with the tympany, as to resound upon percussion like a drum. They in this state prevent, in a mea- sure, the play of the diaphragm, whose concavity is at the same time lined with an inflamed peritoneum, that in a degree cripples its power, and the patient soon begins, on these accounts, to have dyspnoea, with panting respiration, while the capillary system of the whole intestinal canal, which is put upon the extremest stretch and tension, grows rapidly less and less able to get rid of its load of blood by any other process than effusion, I have seen some women dying with child- bed fever, who sank rapidly, and evidently more rapidly, from the great degree of irritation occasioned by the tympanitic distension of the bowels, their respiration being not dissimilar to that occasioned by hydrothorax. In all febrile affections, a tympanitic distension of the alimentary canal is greatly to be deprecated, and in none more than that of which we are speaking. In peritonitis it adds new dangers to those which are already so imminent, and should be carefully obviated by proper remedies. Now it may be said that there could be no tympanitis in a case in which the peristaltic fibres of the bowels should continue in the regular exercise of their functions : but where a tract of the jejunum or colon is fully inflated, there is, for the time being, a total suspension of the peristaltic movement of the muscular fibres of that portion of the tube ; they being in a quasi state of paralysis, or inac- tion at least, so as to permit the extricated eases of the canal to inflate it. In order to obviate this evil, we are obliged to make use of ape- PUERPERAL FEVER. 577 rient medicines, or even purgative doses, to stimulate the peristaltic fibres into a degree of activity sufficiently great to enable them to ex- clude or pass onwards the gases with which they are distended. For this end calomel and opium, followed by moderate doses of oil, are highly appropriate — or we can rely on doses of infusum rhei, with addition of small portions of potash or soda — or magnesia with mint- water — or a solution of manna, with addition of magnesia, and oil of anise-seed. I have on many occasions found the introduction of a catheter into the rectum capable of drawing off the w T hole of the air of the tym- pany. A most distressing tension of the abdomen, after delivery by the Csesarean operation, was suddenly and completely relieved by the introduction of a female catheter a few inches into the rectum. The bowel had not power to overcome the sphincterian contraction, and the patient was dangerously inflated in consequence ; the catheter, when passed above the sphincter, permitted the gas to rush out of the tube with a hissing noise. It is an excellent resource, unattended w T ith pain or the least inconvenience. See the case of Mrs. R. at p. 534 of this volume. I am far from desiring to be considered in favor of very active purging as a remedy in peritonitis. It would be obviously improper to enter upon the management of a case of the malady without pro- curing a sufficient evacuation of the feculencies that are generally accumulated in the bowels of lying-in-women: that should be always attended to; and when the physician is satisfied that they have been removed, he should abstain, as a general rule, from the use of strong purges; but if the tympanitic state of the patient requires it, he should by no means withhold the aperient medicines which have been re- commended, or even the strongest purgative doses. I have seen cases of puerperal peritonitis in which, very soon after the invasion of the malady, the belly became frightfully tympanitic ; an injection will serve under such circumstances to evacuate the con- tents of the rectum, and perhaps of the lower part of the colic sigma, giving rise to a copious feculent dejection. But, from this time forth it has been utterly impossible, by any therapeutical or chirurgical process, to procure another evacuation: the patient sinking into the arms of death, and perishing evidently from this extraordinary degree of meteorismus. The most active enemata, composed of senna, of jalap, of common salt in large quantities ; the introduction of the stomach tube far into the bowel ; large doses of calomel, infusion of senna, or croton oil, or elaterium, proved alike inadequate to the ex- 37 578 PUERPERAL FEVER. pulsion of the distending gases. It is desirable that the Student, who ■will in his career have probably some occasions to be baffled as well as surprised at the failure of his therapeutical resources in such cases, should have a clear view of the cause of his embarrassment. Let him roll up a sheet of paper in a cylindrical form, so as to represent a portion of intestinal tractus, and then let him bend it at an acute angle, and he will see that the calibre of the bowel bent in this way is as effectually closed as if a ligature had been passed around it and tied. Let him further consider that while the lateral pressure of the gases has the effect enormously to distend the conjugate diameter of the intestine, their pressure also tends to elongate the bowel, which, as it cannot go forth from the abdomen, is compelled to turn short upon itself to become angulated, and thus it produces an angulated stricture, like that which he makes by bending a cylindrical roll of paper at an acute angle. I have seen three such angulated strictures in the colon of a young person, who died in this manner tympanitic; and I had the misfortune in 1848 to witness the loss of a most valued patient, a loss which I feel convinced might have been avoided but from this angulation of the colon. It is frequently found, that, even in those cases where we feel as- sured the peritonitis has received, by the lancet and other means, an effectual check; where the pain is all gone, and even the soreness removed, the patient continues to have fever, which may last many days. Under these circumstances the use of James' powder, or the golden sulphur of antimony combined with nitre and calomel, is of the greatest value. These medicines very generally give rise to co- pious diaphoresis, which may be maintained by draughts of warm herb tea, such as the balm, or sage, elder or linden blossoms, or by copious draughts of barley-water, and a careful adjustment of the bed-clothes to the condition or circumstances of the patient. During the whole period characterized by active inflammatory symp- toms, the diet ought to consist of barley-water, very thin gruel, or arrow-root, and such like articles. A greater degree of indulgence may be allowed after the fever has quite disappeared. Rest, in a recumbent posture, is one of the essentials of the suc- cessful management of the case. The nurses should be forbidden to raise up the patient even in bed — for if an early getting up from bed may serve as the exciting cause of the disorder, it would surely be very dangerous to get into a vertical or sitting posture while the in- flammation is in full activity. For the most part the lacteal glands do not secrete much milk in PUERPERAL FEVER. 579 women in peritoneal and metritic fevers. It is always a hopeful sign when the breast continues to be full under'this disorder; neverthe- less, the secretion of milk gives no assurance of safety. The lochial discharges are also very much diminished, and some- times wholly disappear during the greatest intensity of the malady. Tepid vaginal injections of mucilage, of flaxseed, or of milk and water, may here, with prospect of benefit, be made use of, where the patient can bear so much handling. The discharges which are checked or suspended, during the onset and greatest violence of the complaint, re-appear upon its decline or cessation. Blisters are, by some practitioners, held as favorite applications in puerperal fever. I doubt not they may, in proper circumstances, con- tribute greatly to the safer and more speedy cure of the inflammation; but I think I have seen blisters applied too soon in some cases, and I have reason to suppose that, if not properly timed, they are capa- ble of adding to, instead of diminishing, the constitutional disturb- ance, already too great. If applied very early, they increase the fever and irritation, and continue to be in the way of other more useful remedies; they confound the diagnosis — which should be often re- peated — by rendering the practitioner unable to discriminate between the pain produced by the cantharides and that arising from the inter- nal disorder, which is greatly to be deprecated, since his opinion and practice in the case should be very much governed by the degree of pain — as it is in pleuritis. A bUster, applied after a due reduction of the force of the circulation, and an ascertained diminution of the pain and soreness of the belly, may haply bring about a resolution in cases which, but for the well-timed prescription of such a remedy, would tend to a fatal effusion. I do not think that the malady is at all disposed to result in gan- grene or mortification. The affected parts are too important and too numerous to be the subjects of such terminations; the patient dies before they can be effected. The adhesive inflammation is found to have exerted its salutary power in some of the examples; but the ad- hesions are very partial, the far larger portion of the membrane hav- ing poured out vast quantities of a sero-puriform liquid, containing a great abundance of flaky matter, which appears to consist of coagu- lated albumen, and which is found floating in the fluid contained in the peritoneum, or adhering like a croup membrane to the peritoneal surface of the bowels, liver, stomach, etc. A woman who labors under an acute peritoneal fever is generally found lying on the back, with the knees drawn up ; the hands are 580 PUERPERAL FEVER. rarely to be seen crossed on the abdomen — they are laid by her side, or across the breast, or they are employed in holding up the bed- clothes, whose weight is apt to give pain if pressed on the belly. Every attempt to put down the legs, and to draw them up again, or to rotate the legs, is productive of pain, because there is implied in such motions a contraction of the psoas and iliacse internee muscles, as well as the recti and oblique muscles of the belly; but the contraction of any one of these muscles occasions a change of relation of parts of the inflamed peritoneum. Efforts to cough in like manner pro- duce poignant distress. The woman, therefore, moves unwillingly. She lies remarkably still, and if affected with jactitation and restless- ness, she expresses it only by flinging her arras about, and by fre- quent rotations of the head. She always endeavors to keep the abdomen and lower limbs quiet; for she learns that every movement of them is distressingly painful. Hence the mere decubitus is im- portant as a diagnostic sign. To find an improvement in the patient's ability to move herself, with a corresponding improvement in the circulation, is of the most favorable augury ; but to observe the pulse increasing in frequency while it also becomes more feeble, with diminished heat of the mem- bers and augmented heat of the body; to discover a disposition to singultus, with an eructation of fluids into the mouth, an anxious ex- pression of countenance, high and frequent respiration, with increased ability to move the legs, and diminished pain on pressure, is to perceive the cessation of inflammation of the peritoneum; but it has ceased not by resolution, or a return to health — it has come to one of its natural terms in effusion. The inflammation is at an end, and the patient begins to die. It would seem that the forces of the living economy have exhausted themselves in the struggle with this malady, and, though they conquer it at last, they are themselves de- stroyed in the moment of victory. There soon comes on a vomiting, | or rather a frequent eructation or gurgitation of fluid, green at first, and at length black; the patient mutters, she picks the bedclothes, she clutches atmusccevolitantes; the diaphragm labors in vain to carry j on the work of respiration ; the hands and feet acquire a livid hue, and are clammy; the pulse becomes a thread, it ceases in the wrists — and she dies, probably in the act of regurgitating from the stomach the last draughts which the anxious hand of friendship or love has tendered as a solace or a hope. It is altogether a most melancholy scene ; for, connected with all the moral distress which such a fatality lavishes on relatives and friends, there is generally a sharper pang for the PUERPERAL FEVER. 581 hapless infant, which, deprived at the moment of opening its eyes on the great theatre of the world, of the needful help of its mother, is destined to bear for years the bitter fruits of her death. There is scarcely a case of disease terminating in the decease of the patient which produces such a general sympathy as this — and indeed all those which occasion the loss of patients in child-bed. I am very sensible that I have made but a slight sketch of puerperal fever. It is a subject that could be better discussed in a volume than in a few pages ; but I have preferred saying a few words upon the sub- ject, even at the risk of making a very meagre article, if I could, by this means, bear my testimony against every doctrine which shall teach that this most acute, extensive and dangerous inflammation is to be combated by any means short of the most signal and active of those which are called antiphlogistic. In taking charge of ordinary cases of illness, the patient and his friends are already aware of threatened danger: in taking charge of an accouchement, the physician assumes the conduct of a health- ful and truly physiological process. A woman lies down on the lit de misere in order that she may give birth to a child ; an attack of puerperal fever too often converts it into her bed of death. A man goes to his bed in fever under the apprehension of approaching death; he is rescued by the physician, but the accouchee who perishes is lost. There is a great difference in the sentiment connected with the cases. Since this chapter went to press I received a letter from Dr. Collins, dated Merion Square, Dublin, Jan. 2d, 1849. I am led by my desire to show my profound respect for that dis- tinguished gentleman, to do what perhaps I have no right to do in publishing a portion of his private letter to me. Very certainly I desire in doing so only to allow that author to speak for himself to my reader, because I have ventured to differ from him in my views as to the application of a vehement antiphlogistic method in child-bed fever. In his note to me, Dr. C. points out the difference betwixt such cases as Gordon and Lee treated, and such as came under his care at the Dublin Lying-in-Hospital. It appears to me that I ought to be par- doned then for taking this public liberty with a private letter, which, though it refers to another work of mine, yet has also a relation to these pages, in which I could not avoid setting forth opinions similar to those I had expressed in the volume to which he alludes. The Student ought to procure and read Dr. Collins' work, and then he will be able to judge for himself, for he will have the observations as well as the cases to judge by. The following is the letter of Dr. Collins. 582 PUERPERAL FEVER. "My Dear Sir: Merio^t Square, Dttblix. January 2d, 1849. At pages 609-10 you compare the mortality in puerperal fever under my treatment, and that of my distinguished friend, Dr. Robt. Lee of London; to prove the greater success, where general bleeding had been more frequently adopted by him. The great and markedly distinguishing feature between Dr. Lee's cases and mine, has, however, been overlooked; as mine were all Hospital Patients; whereas his were all treated at their own dwellings. This was also the case with the late Dr. Gordon's patients, to whom you so deservedly allude. The disease with us, and I believe universally, is as different in hospital and out of hospital, as it is possible to imagine. Please look to my observations, pages 390-1-2, &c, where I have stated the patient to be little more than shadow, and to exhibit the appearance of those laboring under cholera; so as to make us dread even the application of leeches. The fever is of the lowest typhoid character, with the pulse so feeble and indistinct, as to totally prohibit general depletion. This form of the disease is singularly intractable and truly fatal; whereas the inflammatory form of puerperal fever, such as usually met with out of hospital, may be treated with consi- derable success. I have a work in the Press at present containing the results of the late Doctor Joseph Clarke's private practice in Dublin, for a period of nearly fifty years, including 3847 births, which I consider of great value, as hitherto we have no minute data relative to patients in the highest ranks of society. I have given in it an extremely interesting correspondence between Dr. Clarke and some eminent professional brethren, on the occurrence of puerperal fever in private practice, in London, Dublin, and Edin- burgh. I should have stated that few physicians have witnessed the results of general bleeding to a greater extent than I have done, as the master of the hospital who preceded me, and to whom I was Assistant, was a strong advocate for it ; but the mortality was so frightful, he was forced to abandon it. He bled instantly and copiously, but with the most fatal results. Such is the character of almost all our hospital epidemics." ATRESIA VAGINA. 583 CHAPTER XX. OF ATRESIA VAGINJE. The obstetric physician will be likely, in a long career of practice, to encounter cases of atresia of the genital organs. Some of the cases are capable of giving rise to extreme distress, and even of bringing the life of the patient into danger. Atresia, or closure, or obturation of the vagina or cervix uteri, may occur as a congenital malformation, or it may take place in infancy or childhood, and may even occur in persons who have borne children. The obturation may be discovered to exist in any part of the canal of the vagina, whether at the vulva or whether at the uterine extremity, or whether midway of the tractus of the tube. In the congenital cases there may have been fault of development, the mucous tissue having totally failed to be constructed. In infants or young children a slight vaginitis might suffice to determine the cohesion of the opposite w T alls of the vagina, the occurrence remaining undiscovered until a full puberty, or the state of marriage, should lead to the disclosure of the fact. To show that it may occur in women w r ho have borne children, I refer the Student to the following case. Case. — A woman, from a distant part of the country, came to the city, in the spring of 1837, in order to consult Dr. Randolph, who was good enough to invite me to see the patient with him. Her story was as follows. More than two years have elapsed since she gave birth to a healthy child ; the labor was extremely rapid, so much so, indeed, that the infant was born before the physician could reach the house. The after-birth did not come away for an hour, during which time there was flooding. It was at length removed by force. The woman be- came very w r eak. In a few days she was attacked with inflammation of the vagina, accompanied with enormous discharges of matter, and great thick pieces of flesh, to use her own account. She was never 584 ATRESIA VAGINA. examined by her physician, who, however, directed washes, injections, etc. After a long and exhausting hectic, attended with extreme emaciation, her discharges grew less copious, and she gradually, at the end of some months, got well. There was, however, no vagina, not even a cul-de-sac; there was simply the genital fissure. Of course, no catamenia could appear; but, after several months of good health, she began to complain of pain or misery in the hypogastric and pelvic regions. The pains recurred with periods of a month, and having at length become intolerable and persistent, she found her health de- clining, and came, as before said, to consult that able and eminent surgeon, Dr. Randolph. There was a tumor in the hypogastrium, which reached half-way up to the navel ; it was of a firm and resisting feel, not unlike a con- tracted womb soon after delivery. As there was no vagina, the finger was passed into the rectum, where it came in contact with the same tumor, which seemed to occupy the excavation as it is occupied by a child's head, filling the cavity entirely. Upon separating the labia, there was nothing but the genital fissure ; there was no way for a common probe to pass upwards. A sound was introduced into the bladder, and retained there until a finger was also introduced into the rectum: the only texture that separated the finger and the sound seemed to be, upon careful examination, the walls of the urethra and the coat of the bowel; there was no vagina to be felt. Hence Dr. Randolph and I agreed in opinion that the vagina had been wholly destroyed by the sloughing process which took place shortly after her confinement. We entertained no doubt as to the nature of the tumor that occupied the pelvis and lower part of the abdomen: it was the womb hermetically sealed, and retaining in its cavity the accumulated menstruations of nearly two entire years. After much diligent search, we were unable to discover the cervix, or os uteri; but we supposed they might possibly be turned upwards towards the top of the pubis, so as to elude any investigation made through the rectum alone, the only possible way of making research. No vestige of a vagina was discoverable by the taxis ; nevertheless, supposing it possible that the whole tube might not have been de- stroyed, and that haply its upper extremity might be reached by the bistoury, Dr. Randolph operated with a view to make an artificial vagina, and discover the remainder, if any, of the original one. Introducing a strong metallic staff, slightly curved, into the bladder, he took his seat in front of the patient, who laid on her back, with the knees drawn up and separated. I held the stafT firmly, while, with the forefinger of his left hand in the rectum to serve as a guide, ATRESIA VAGINA. 585 by horizontal strokes of the bistoury he dissected the tissues betwixt the rectum and urethra, and carried his incisions up very nearly to the substance of the womb itself, without having wounded either the rectum or the urethra: when he had completed his incisions, the whole finger could be passed upwards to the bottom of the cul-de-sac he had formed by so skilful and accurate a use of the bistoury. In consequence of our uncertainty relative to the situation of the os uteri, and from his having successfully removed so considerable a portion of the barrier which opposed the escape of the contents of the uterus, Dr. R. suspended his operation at this point with the following views. It w T as resolved to keep the passage open by the use of a bougie, made as light as possible, and of a size sufficiently large. The bougie was made of silver gilt, about four inches in length, and as large as the thumb, its weight not more than two drachms, being hol- low. We indulged a hope that, by using this bougie a few months, the progress of the case would be such as to bring the os uteri to the extremity of the instrument, by means of the increasing expansion of the uterine globe, and that the contents of the womb would discharge themselves into the artificial vagina, or that they might be discharged by a future incision. The lady returned to her own country, and after an absence of three months came back to the city, still suffering under the same misery, with an increased magnitude of the uterus, but without having had any discharge from the vagina. She had constantly worn the bougie. Upon examination, we found that the new vagina was now covered by a smooth surface, resembling a mucous membrane ; the upper end of the bougie, when withdrawn, was co- vered with a sort of muco-purulent matter, tinged with blood. The sufferings of the patient from the distension of the womb w T ere very great, and it was on that account agreed to puncture the organ in order to draw off its contents. On the eighth day of July, 1837, Dr. Randolph, and Dr. R. M. Huston, who had been invited by us to wit- ness the operation, met me at the lodgings of the patient. The tumor, felt through the vagina, was hard and resisting, like an enlarged ovarium ; it was softer and the walls thinner, when ex- amined through the rectum. At Dr. Randolph's request I now made use of a curved trocar, enclosed in a canula, in order to puncture the womb. The trocar was about five inches in length, and of the size of a small writing-quill. The patient was laid on her back near the edge of the bed; I introduced the forefinger of the left hand into the rectum, and having directed the end of that finger to a part of the 586 ATRESIA VAGINiE. tumor that felt most yielding, I carried the point of the trocar along it, and having given it a direction as nearly as possible perpendicular to the surface of the tumor, pushed it through the resisting tissue until I found it had freely entered the cavity of the uterus; the trocar was now withdrawn, leaving the canula in place. There issued from the open end of the tube a dark red viscous material, with- out odour, of the consistence of meconium, and as adhesive as that substance. The puncture was scarcely felt. In twenty-four hours, during which the canula was permitted to remain in situ, pro- perly secured, about twenty-five ounces of this fluid were discharged: the uterine tumor had disappeared from the hypogastrium, and the mass, as felt in the rectum, was greatly reduced in size, and far more movable. As all the liquid seemed to be now evacuated, the canula was withdrawn : no discharge followed its withdrawal. The patient had no symptoms attributable to the puncture. She rapidly recovered her strength, and left the city with renovated health, and nearly free from the misery which had so long embittered her existence. In the course of about a month after returning to her home, she had a very copious discharge from the vagina, of a fluid of a consistence similar to that which had flowed through the canula, but of a whitish color, after which her health greatly improved. On Tuesday, the 12th of December, 1837, the patient, while on her way to the city, for the purpose of further advice, discharged from the vagina about twenty- five ounces of a substance in all respects similar to that which passed off when I used the trocar to puncture the womb. I w 7 as informed in 1841, that she has menstruated regularly and has recovered a very comfortable health. I refer to the ninth letter, page 83, of my " Letters to the Class," for a fuller account of cases of obstruction of the vagina, than it would be possible for me to introduce into the present work. Before I close this article, however, I shall take occasion to mention that a careless inspection of the surfaces of the bottom of the vulva might, in some instances, mislead the practitioner as to the existence of an atresia. A lady, already four months married, was presented to me for examination on account of incapability of consummating the marriage rite. Upon inspecting the surfaces, I found in the usual place, at the bottom of the vestibulum, to wit — what I supposed to be the orifice of the urethra; while the tissue falling downwards and backwards within the genital fissure, seemed to be the anterior wall of the vagina which had cohered with the posterior wall. The apparent fossa naviculars w T as shallow, and upon stretching it downwards, some ATRESIA VAGINA. 587 appearances of a rapheof cohesion was discovered, extending in a semi- circular direction nearly up to the supposed orifice of the urethra. In order to relieve the patient, I made some slight incisions into the sup- posed raphe, thinking thereby to destroy adhesions and make an opening into the vagina. But owing to the extreme restlessness and agitation of the patient, it was impossible to proceed with the proposed opera- tion. On a subsequent occasion it was ascertained that the supposed orifice of the urethra was the natural opening at the top of the hymen, w r hich was a very dense, fleshy membrane, an eighth of an inch in thickness. The true orifice of the urethra was afterwards found concealed in a small fold just above this aperture. It was proved to be the urethra bypassing a catheter through it into the bladder, while the inferior aperture, scarcely larger, permitted the introduction of the catheter into the vagina. The hymen was destroyed by a stroke of the scissors, and the vagina, an exceedingly narrow one, subse- quently dilated with the gilt bougie. I have never seen so deceptive a case, and I cite it here in order to put the Student upon his guard against the mistake which I com- mitted. 588 ERGOT. CHAPTER XXI. ON ERGOT. I am inclined to say a few words as to my opinions upon the secale cornutum as a therapeutical agent of great power in labors. It is needless for me to say anything here as to the nature of this substance, which is fully described in a book universally in the hands of the phy- sicians of this country: I mean "Wood and Bache's Dispensatory." There is also a very full account of it in Cazeaux's new work, Traite Theorique et Pratique de VArt des Accouchemens, commencing at p. 395. I have had occasion many times to witness, during a long-con- tinued practice of midwifery, the effects of the secale, whether ad- ministered with my own hands or by those of others. It has frequently been the subject of conversation among my medical brethren here ; and I feel very much persuaded that the general opinion of those gen- tlemen is one that may be stated as distrustful of the ergot, not as to its want of power, but as to the dangerous nature of that power, whe- ther as regards the woman or the child she is bearing. The late professor, Dr. James, was perhaps less fearful of its mis- chievous qualities than Dr. Dewees ; the former resorting to it not unfrequently when a failure of power existed, and the latter always preparing against its use the most careful array of objections, except under circumstances pointed out in his "Midwifery." Those who have perused the little volume published a few years ago by a Dr. Michel, an English practitioner, who w T rites in favor of the use of ergot, will feel surprised to witness the audacity with which one person exhibits it at the very onset of labor, or as a preparative or aid in turning, etc., and the extreme precaution recommended by Dr. Dewees, who never sanctions its use as an aid to expulsion, unless the os uteri is fully dilated, and the child already pressing out the perineum. Within a few years a good many persons continued to doubt whether the article really possesses the singular and sole quality of exciting ERGOT. 589 the contractions of the womb. I have not lately heard of any objec- tions to it on that score, but they rather arise from the uncontrollable force which it awakes in the womb, leading, as is supposed, to dan- ger of lacerating the organ when the resistance to its expulsive effort is too great, and very commonly to the death of the child. It is true that I have known laceration of the womb follow the ex- hibition of ergot, and have on occasions stood by with fear, and expected that horrible result. This is a rare event, however; whereas the death of the foetus from the rash exhibition of the medicine is a common one, which is reasonably to be looked for, and for the reasons which I am about to state. In the case of a feeble and attenuated patient, with relaxed and weak tissues, whose labor is lingering merely from want of power, and not from unnatural resistance, I can imagine that the ergot might be safely administered at almost any stage of the labor. But in a woman in good health, whose labor is slow for want of proper rotation of the head, or rendered^lingering by rigidity of the os uteri, vagina, or perineum or vulva, or excessive relative magnitude of the head, the greatest degree of consideration should be given to the whole case before resorting to the ergot, in order to decide which is preferable, the secale, or the forceps or vectis. Suppose the child so situated or so large that an enormous force is required for its expulsion, and that antecedently to that expulsion some changes ought to take place in the direction of the vertex, etc. ; no prudent practitioner would blindly urge his patient to destruction by giving her ergot, without first changing the direction of the head to the required position; and if the soft parts should oppose, by an ex- cessive rigidity, the birth of the child, he would by the use of the lancet and warm bath, or by stuping the parts, &c, make some prepara- tion for the exertion of the terrific energies of the medicine. Let us think for a moment upon it. A labor is effected by the contraction of the muscular fibres of the womb, aided by that of the abdominal mus- cles. If all the power employed in a labor could be accumulated in a single pain, lasting as long as all the natural pains do, few women pro- bably could escape with life from so protracted an agony, except that small number who are met with, and whose organs, happily for them, make no resistance, but open spontaneously like a door to let the foetus pass out. Now the influence of ergot in a full dose is such, that it excites in the fibres of the womb a contraction or tonic spasm which is called ergotism, and which, when once begun, does not cease until the child 590 ERGOT. is expelled, or until the organ has parted with all its irritability, and the spasm ceases from sheer want of power in it to contract. This contraction is so great, in some cases, as to split or lacerate the womb on the projecting parts of the child, or, what is more likely, to tear off the connection between the vagina and uterus, so as to force the child through the rent into the belly. Such a pain may last twenty minutes or even half an hour, without a moment's suspension. Imagine the feelings of the woman. By a beneficent law of the economy, the pains of a labor are short, not lasting more than thirty or forty seconds in general, and returning once in three or six minutes. Under such pains or con- tractions, however powerful, the foetus is safe ; for, as soon as the con- traction is over, it lies in the womb free from pressure, and the pla- centa, which, during the contraction had been violently compressed betwixt the womb on which it lies and the child within the cavity — that placenta, I say, recovers its circulation, and continues, during the absence of the pain, to perform all the branchial offices which belong to it. But, if an ergotic pain is produced, to last thirty minutes, in a case where the placenta is on the fundus uteri, and to be jammed for thirty minutes against the child's breech without an instant of relaxation, who can doubt that its circulation is either wholly or nearly abolished, and that when the child emerges at last from the mother's womb, it will emerge quite dead, or iu a profound asphyxia, from the long suppression of its placental circulation? Multitudes of children are born dead from this very cause, by the imprudent exhi- bition of a medicine, which as certainly excites spasm of the womb, as mix vomica does of the other muscles of the body. Now what I want the Student to reflect on is this question. Shall I in this case give a dose of ergot which will excite a spasm of the womb, hoping that spasm will bring the child into the world? Is the child ready — is its head through the strait — has its head undergone the rotation — is the vertex under the arch of the pubis — is the exter- nal organ in a dilatable state — in short, is there anything here that could prevent the child from emerging at once, if the whole of the contractile fibres of the womb could be thrown into a strong spasmodic action? No! Then the ergot may be given; for, if the child begins to move as soon as the womb begins to move, it will be born soon, and escape the asphyxia which would certainly overtake it, were it to remain inside of the body, while a long ergotism should be ex- hausted in vain. The power of the ergot is exerted upon the whole muscularity of the uterus ; the contractions that take place under ERGOT. 591 the influence of ergotism affect the fibres of the cervix as truly as they do those of the corpus and fundus; the question then recurs, shall I give ergot in this case in order to produce violent contractions of the cervix uteri, not doubting at all that the whole of the cervix will be thrown into spasmodic or ergotical contraction, but confiding in the superior power of the greater mass of muscular material contained in the fundus and body? Michel's cases show that when he administered ergot in the undi- lated uterus, containing an unbroken ovum, the superior power of the fundus and body rapidly overcame even the ergotism of the cervix, and many of his patients appeared to have escaped well from the rude trials to which he exposed them. There would certainly be less danger in administering ergot in a case where the ovum is un- ruptured, than in one in which the waters have been already expelled, since the uterus, in such a case, could by no means mould itself upon the anfractuosities of the child's body. The practitioner who should dare to drive the uncovered head of a foetus against a rigid cervix in spasm by means of the mad force of ergotism, is, to say the least, a most untrustworthy practitioner, one who recklessly exposes his patient to the danger of uterine lacerations, and is indifferent to the poignant distress which cannot fail to result from such an administration. For my own part, I can say, that I rarely give ergot as an expul- sive agent: I chiefly employ it at the moment of, or just before the birth of the child, in order to secure, if possible, a permanent or tonic contraction of the womb, after labor, in women who are known in their preceding labors to have been subject to alarming hemorrhage. Of this I have before spoken in this work, and shall take occasion to speak further of it hereafter. Upon the whole, I must say, that I feel far more comfortable, and free from apprehensions for the child and the mother, wdien I deliver with the forceps, than in waiting the result of a dose of secale cornutum. The medicine may be given in doses of twenty or thirty grains of the powder, mixed in half a cupful of hot water; or half a drachm may be mixed in six spoonfuls of w r ater, of which one may be given every ten minutes. I think, however, that when one resolves upon using the article, it is best to give at once a good dose of twenty or thirty grains. A forceps ought to be at hand. In some cases, when the ergotism is produced, not the smallest tendency to expulsion appears, but the child is held still, under a firm and equable pressure exerted upon all the parts of it still retained in utero. It would die very soon if 592 ERGOT. not released. Hence I said a forceps ought to be at hand, to save it, if possible, from the fatal grasp of the infuriated organ. The use of ergot has very much diminished in Philadelphia in the course of the last ten or fifteen years. Few practitioners, when I was first engaged in business in this metropolis, were unprovided with a portion of ergot, which was given in almost every case of slow labor; the number of still-born children, I doubt not, was greatly increased by this pernicious practice. At the present day, I think, it is rare for the practitioner to carry portions of ergot about his person. I advise the Student of medicine to be provided with a sufficient quantity of secale cornutum in any case in wmich he is made aware of the tendency of the patient to faintness and flooding after delivery. I think that no woman, who is known to have a tendency to flood dangerously after the birth of the child, should be left without its conservative influences. To give ergot some three or ten minutes before the child is born, is certainly not to expose it to the least dan- ger from the ergotism, for it is extremely rare to observe the thera- peutical force of the remedy until from twenty to thirty minutes have elapsed after its exhibition : now women who flood after delivery, rarely do so within the first twenty minutes, and, as the power of the article extends to the vacant uterus, and is perhaps no less forceful there than in the gravid womb, a well-timed administration of the drug is almost invariably successful in obviating the tendency to hemorrhage. It is true that I have exhibited the secale in some instances at the very close of the labor for women whom I had known to flood dangerously before, and in whom no good effect was produced; but it is still quite true that, in the vast majority of instances, and they are very nume- rous, in which I have made use of this precaution, my patients have been preserved from the alarm, and the exhaustion, and probable danger to which I have deemed them exposed ; so that, in fine, I have no conviction stronger than this, namely, that the late administration of ergot for hemorrhagic patients is salutary and needful. I trust that no reader of this work will ever commit the imprudence of administering secale cornutum with the view to force a child through a too narrow pelvis. I have said already enough, perhaps, as to the necessity of ascertaining beforehand the amount of probable resist- ance to a successful ergotism, to guard him against so gross a mala- praxis. I am painfully aware of several examples of fatal rupture of the womb brought on by the furious excitement of ergotism, generated in order to overcome the resistance of a contracted pelvis. As to the influence of the ergot on the constitution of the female, ERGOT. 593 I am entirely unaware of any poisonous power that it can exert. I have seen a few women affected with slight vomiting after its exhibi- tion, but was unable clearly to trace the accident as an effect of the medicine. It appears to me that its sole therapeutic force is exerted in stimu- lating the muscular action of the uterus. It is sometimes given for the purpose of procuring abortion ; but for the most part, happily for humanity, in vain. It is useful to ex- hibit it for the purpose of rousing the torpid muscularity of the uterus for the expulsion of hydatids, and of the dead ovum or mola; I have succeeded in this administration of it. It is highly useful in the he- morrhage of abortions, often provoking a speedier expulsion of the remains of the ovum, and, when that effect fails, succeeding in arrest- ing the hemorrhagic molimen by its power of condensing the uterus, of which a philosophical rationale is found in its ability to diminish the hyperemia of the uterine circulation. To show that it may be taken in large quantities without injury to the health of the patient, and at the same time without exciting in the least degree the contractility of the child-bearing organ, I shall lay before the reader the following case, that of Mrs. R., at the 82d page of the 2d edition of "Clinical Midwifery," by Dr. Lee. "(Case 29.) Mrs R. again became pregnant about the end of December, 1837. 'On the 17th January, the catamenia not having appeared, she began taking secale cornutum for the purpose of pro- ducing the expulsion of the ovum.' She began by taking twelve grains four times a day in infusion. This having produced no effect in six days, the dose w T as increased to fifteen grains four times a day. In six days more this was increased to a scruple four times a day. In six days more this was increased to twenty-five grains without any effect. The dose was then increased to half a drachm four times a day. Mrs. R. then left off ergot for one week; when she again re- sumed it, she took one-drachm doses four times a day for four days, and this having produced no effect whatever, she left off taking it alto- gether. Mrs. R. therefore took seven ounces of ergot of rye, which was all procured at Butler's, Covent Garden. Labor not having fol- lowed, I perforated the membranes," etc. etc. 38 594 MILK-FEVER. CHAPTER XXII OF MILK-FEVER. The mammary glands, which in the virgin state are small and to a great degree undeveloped, participate in the new movements of the constitution that are established in the pregnant woman. The tissue of the glands begins early to expand, and the breast becomes sensi- bly larger very soon after the conception takes place; the areola and nipple assume a darker hue, and indeed turn almost black in some persons. These changes do not take place without producing a sense of soreness or aching of the part. So great is the increase of vital force, that some women find a considerable secretion of milk in the breast, as early as the sixth, seventh and eighth months; but, for the most part, no milk is formed so soon. If a healthy woman should miscarry at five months and a half, it is to be expected that her breast will fill with milk, within seventy or eighty hours after her delivery, and, a fortiori, secretion may be expected if she be confined at the sixth month or later. I have seen a woman whose child was born at five months and a half who served as a most excellent wet- nurse. I have found milk in the galactophorous tubes of a young woman, whose body was exhumed for examination by a jury, although she had been confined at a little past five months. During all this time the organ, though more firm and protuberant than in the non- gravid state, does not become positively hard, but is soft and yield- ing under pressure; for the increased size is owing more to an in- creased deposit of adipose matter on the breast exterior to the fascia of the gland, than to the swelling, enlargement or engorgement of the glandular tissue itself, at this early stage. Such are the phenomena relative to the breast in pregnancy. Let us now endeavor to account for them, by a reference to the in- ternal structure and uses of the apparatus which nature has arranged for the support of the new-born product of the gestation. The breast appears at an early stage of the foetal existence, but MILK-FEVER. 595 does not become prominent until the period when the girl is passing into the womanly state, and even then the substance of the gland is more solid and condensed than when prepared for the production of milk. The adipose structure is very abundant upon the breasts, so that, in general, fat women have them of great size, without at the same time having a larger share of the glandular material than some other women of a meagre constitution ; and, indeed, it does not appear that the largest breast is to be depended upon for the pro- duction of the greatest quantity of milk. A breast of middling size is to be preferred in choosing a wet nurse. A layer of adipose matter is to be found immediately under the skin in dissecting the breast, and this adeps exists there in masses or lumps, separated from each other by cellular digitations which unite the skin to the parts beneath it, constituting a sort of membranous fascia or division, by which the different portions of the gland are made up into packets or bundles, and by which, as Sir Astley Cooper says, the gland is slung upon the chest. Underneath the fatty layer are to be found the lactiferous glands enclosed in their true fascia. The whole gland is so formed, as to resemble somewhat a placenta, being circu- lar, thinner at the margin than at the centre, and consisting essentially in a great number of small grains, the size of millet seeds, which are enclosed in separate packets or bunches by the cellular laminse, which thus break it up into lobes or nodules, each, as it were, enclosed in a cellular fascia. The exterior surface of the whole gland is enclosed in a condensed cellular texture, which constitutes a fascia for it, but is far more ductile or distensible than the fascial coverings of some other parts of the body. The gland thus constructed is supplied with blood from the intercostals, the external mammary, and the in- ternal mammary arteries. The nerves of the breast are also derived from the intercostals and from branches that proceed from the axillary plexus. It has also an abundant supply of absorbents. The granules of the breast, or its acini, give out, each of them, a tube or lactiferous duct, which, uniting with others from the same bunch or packet of grains, at length form a lactiferous duct which proceeds towards the areola and nipple, so that each packet or nodule of acini sends its own excretory tube to the nipple, and has no connection with the circum- jacent nodule. In the same manner the lobuli of the placenta send, each of them, its vessels towards the cord without communicating with the adjacent lobules. The lactiferous ducts soon become, by the union of so many primi- 596 MILK-FEVER. tire excretory tubes, quite large; and they become the larger, the nearer they approach the areola and nipple, in which they contract, and each tube sends its own duct to the nipple, on the extremity of which it opens, in order to pour its fluid into the infant's mouth, when it is draw T n forth by the suction of the child. It is stated by Haller, in his great work, and confirmed by other and later writers, that, in addition to the lactiferous tubes, which may be regarded as the efferent ducts of the acini and the packets, the galac- tophorous vessels are also composed of numerous excretory or efferent ducts w y hich take their origin from the adipose cells, and convey thence a material that helps to make up the constitution of the milk. I do not know that this question has been settled by any of the minute anatomists in America or elsewhere. The number of tubes opening on the extremity of the nipple amounts to fifteen or twenty, and each tube is lined, according to the opinion of Bichat, with a mucous membrane, since, he says, the orifices of all the glands are furnished with a mucous surface. Such being the construction of the mammary gland, it follows that its nervous and vascular apparatus, having extensive communication with the rest of the system, must endow it with the faculty of awaken- ing numerous and powerful sympathies in its diseased affections. The woman who approaches the term of her gestation feels the breasts grow quite heavy — they are rather firm in consistence, the areola becomes blacker and blacker, as she approaches her accouche- ment: after the child is born, she observes no change in them until the second, or more commonly the third day, so that, until forty-eight or seventy-two hours have elapsed, we have no reason to look for any fluxional movement in that direction. But about this time the breasts commence swelling, they ache, and suffer shooting pains throughout their substance : the swelling goes on until the skin of the mamma fairly shines with the tension ; blue veins, that are very broad, are seen creep- ing in every direction over the superficies of the hemisphere, and even the nipple partakes of the engorgement. The breast is now painful to the touch, and each one stands out so firmly and so hard from the thorax, that the woman is often obliged to lie upon the back for more than an entire day, being unable to bring her arms together on account of the pain the breasts would suffer in their approximation. In this state the breasts may be compared to two great phlegmons upon the most sensitive part of the body, and we need feel no sur- prise at finding such a state of the glands accompanied with fever, and even violent fever. Accordingly, it is very generally the fact, MILK-FEVER. 597 that a woman does not get her milk without at the same time getting a fever with it, and this fever is called the milk- fever. I have not the least doubt that I have, on various occasions, observed the beginnings of a fever, which proved to be the milk-fever, and in which during many hours not the least appearance of engorgement, heat or painfulness of the breast was discoverable, signs which, however, afterwards manifested themselves, and which, together with the usual terminations of the fever in copious perspirations, after the usual course of nineteen or twenty hours, left no doubt upon my mind that the fever was milk-fever. In a good moiety of the cases, this, like other kinds of ephemeral fever, is ushered in with rigors, headache, and pains in the back and limbs. These pains are often intense, but the true type of the fever is, that it is an ephemera which declines soon, after a short and vio- lent hot stage, that gives place to a copious sour perspiration. If not before, then as soon as the milk-fever begins, the patient ought to take some aperient medicine, such as castor oil, salts, Seid- litz powders, or salts and magnesia: it is always cooling and calming for a feverish patient to have the bowels moved freely, and in this particular fever it is highly commendable to be watchful against any excess of violence in the febrile excitement. For my own part, when I find in a milk-fever that the pulses are strong and large and fre- quent, the calorific functions in high exercise, and the head and back and limbs aching, I rarely fail to let blood from the arm. This is the surest and most prompt method of relieving the present distress, and by far the most certain means of obviating the dangers which accom- pany all fevers in a newly-delivered woman. As I have said above, the nature of the fever is to be an ephemera, yet it but too often happens that this ephemera is converted into a long-continued fever or a remittent, during the course of which, various organs, and particularly the peritoneum and the womb, are excessively liable to be attacked. To take eight or ten ounces of blood, then, and to give a smart purge, is a very safe and commendable proceeding in all cases of milk-fever that are a little severe. I had, not long since, a young lady under my care in her first lying-in. The labor was very painful, and lasted about twenty-four hours. On the third day she had a rigor, heat, swelled and painful breasts, and a great quantity of milk. Instead of going off in eighteen hours, this fever lasted nine days, when there was a complete solu- tio morbi. I supposed her to be now well: but no — she was at- 598 MILK-FEVER. tacked next day with all the symptoms of endocarditis, from which she barely escaped with her life. As the endocarditis went down, it was followed by a couple of very large and painful swellings, one over each sacro-iliac junction, both of which seemed to be doomed inevitably to suppuration. During the existence of these swellings, she had constant hectic ; but both of them were slowly and with diffi- culty discussed : after which she regained her health most perfectly, having lost her milk. For several days the friends of this lady de- spaired of her cure, and she did suffer the most distressing pains and weakness. Now I have related this case to show what may become of the most simple form of milk-fever, and the necessity of observing it, not so much on its own account, as on account of the conversions and depravations to which it is liable. I think that one of the fruits of the statistical methods which have become fashionable of late years, is the establishment of what, per- haps, might be properly called pathological Ontology. It seems to me that the tendency of modern writings is to make the Student and early practitioner believe that each disease is one and the same, saving the modifications that occur in its phases, from beginning to end. I pre- sume, however, there are few practitioners w T ho, from age and much clinical experience, have become familiar wdth the changes that take place in the diseased constitution, that are not aware of what has been called by a writer, the " conversion of disease." A disease may begin in the alimentary apparatus and end as a disease of the respiratory apparatus; a curable disease of the brain may, during its existence, introduce modification of the health of the respiratory organs, which being curable, nevertheless, during its ex- istence, brings about maladies affecting the kidneys, the spleen, the liver, or other noble parts of the body. It is difficult for me to con- ceive of a person dying of a single disease, for I firmly believe that life consists in the trinity of powers residing in the circulatory, oxy- genating and innervating organs; I am not surprised, therefore, to find a patient, who being seized with a rigor, the consequence of an overloaded or irritated mammary gland, is subsequently attacked with inflammation of the broad ligaments, uterine veins, or the peritoneum, in consequence of the increased simple momentum of the blood, and the modifications of the nervous force dependent upon the febrile con- dition. I need say nothing as to the changes in the crasis, or the mixt, of the blood itself, affected by the violent thrashing force of the ventricles and the impetuous rush of that fluid through the arteries and capillaries of the body. INFLAMMATION OF THE BREAST. 599 When, therefore, I find a lying-in woman with a synochus fortis pulse, notwithstanding I regard a status of the mammary gland as the cause of the phenomena, I tremble lest the force of the circulation should overcome the feeble barriers which the physiological condition of the fatigued and exhausted child-bearing organs offer against its violence. I, therefore, make haste to reduce the violence of milk-fever within safe limits, by employing the only sure and the most effectual of all therapeutic resources against it, to wit, that of venesection. I deem it advisable to say here, that, whereas the practitioner occasionally meets with seasons in which the constitution of the air highly favors the occurrence of child-bed fevers, he ought, as soon as he discovers such a propensity among his lying-in patients, to put not only the nurses who may be under his guidance, but also some of the responsible members of the family, upon their guard, in order that the very earliest intimations may be given to him of the attack of milk-fever. This is rendered necessary by the circumstance that milk- fever begins with intense rigors, and even with shaking ague, in many- cases; and that it. ought always -to be regarded as uncertain for puer- peral women where the blow may fall whose signal is a chill. It may fall safely and harmless on the gland of the mamma, or it may descend w T ith irresistible and destructive violence on the veins of the womb or its muscular structure, or to light up a broad and raging flame of in- flammation in the whole peritoneal membrane. How needful is such a precaution, in view of the exigent demand for a bold, prompt and liberal use of the lancet. When the breast is filled to distension with milk, the whole organ becomes heated, and of an increased sensibility. This excitement of course extends to the areola and the nipple. This last-mentioned organ is also subject to be contused by the action of the child's gums, betwixt which it is pressed with considerable force : besides this, the suction power of the infant's mouth, equal to a weak cupping, attracts into its vessels a great quantity of blood, which, by frequent repetition of the suctions, establishes at last an engorgement, and even a positive inflammation of its skin and areolar tissue. The nipple, once in- flamed, is readily excoriated by the suction and friction to which it is exposed, and thus is established that painful affection called sore nip- ples. Sore nipples maybe an affection either of the cylindrical part of the nipple or of the extremity of the organ ; the former is of less evil consequence than the latter. When the mass of the nipple has once become inflamed, hard and highly sensitive, it is common to find a 600 INFLAMMATION OF THE BREAST. quantity of exudation matter, like croup membrane, adhering to the very extremity of the mammilla; when this exudation matter falls off, the surface is left raw, having lost its epithelial covering. If the child be not frequently applied, and the gland be very productive, the heat, painfulness and tension of the whole breast are distressingly aggravated by the collection of milk within the galactophorous canals. There is no hope under these circumstances that the great hypere- mia and hyperneuria of the mammillary process shall become less ; the causes act and react mutually, and the inflammation, turning inwards upon the milk tubes of the nipple, spreads, by continuous and contigu- ous sympathy, into one or more of the large canals, which are already over-distended, and, therefore, in a morbid state. The foundation for mammary abscess is very commonly laid in this train. For the most part, the excoriation occurs near the base of the nipple, in a fold or wrinkle of the skin which half encircles the part, and which, when placed in the child's mouth, is to the most exquisite degree painful. Tears are seen to roll down the cheeks of the patient every time she takes her nursling to the breast; and she comes at last to lose her spirits, and to grow moping and melancholy, to such a degree as greatly to retard her convalescence, or even to cause the attack of a fever of a serious nature. There can be no surer proof of the difficulty of curing any disorder than that drawn from the vast variety of remedies for it. It is well known that the remedy for intermittent fever is the Peruvian bark, or its preparations — everybody is agreed on that point: so also mercury is a proper remedy for lues — which few persons doubt. But, as to sore nipples, the whole world seems to have been ransacked for cures, and in a thousand lying-in rooms we shall find a thousand different cures, which, after all, are not capable of curing the malady. For my own part I do not believe in the cucumber ointment so praised by Velpeau, nor the unguentum populeum, nor the lead-water, nor the castor oil, nor the borax and brandy of Sir Astley, nor the infusion of green tea, nor the slippery elm bark. I make it a point to examine the sore nipple for myself. If I find an excoriation or an ulcer seated upon a nipple actually turgid with inflammation, and highly sensible to the touch, I advise some blood to be drawn by a circle of leeches set on the white part of the breast just beyond the areola. This leeching, followed by an emollient poultice of flaxseed mixed with crumbs of bread and milk to cover the whole nipple and areola, is soon followed by a reduction of the inflammation. When that is sub- dued, the crack, fissure or ulcer begins to heal very kindly under the INFLAMMATION OF THE BREAST. 601 gentle stimulation of a weak solution of nitrate of silver. After this, the cucumber ointment, or a true pommade made with scraped pippins stewed in prepared lard or any proper base of an ointment, causes the cure to be soon effected. As this ointment is a very useful one in many occasions of disorders of the breast, I will not refrain from giving the Student the following formula for its preparation, and though I am no great believer in the virtue of salves, I shall not blush for having descended to so small a particular as this. I beg leave to say that, as the ointment cools, it should be constantly stirred or moved with a wooden spatula, which serves to give it a granular character. B. — White wax, two ounces. Deer's suet, six ounces. Oil of almonds, two ounces. Scraped pippins, four ounces. Dried currants, two ounces. Alkanet, one drachm. Mix. — Melt in a water-bath, and simmer for a sufficient length of time ; strain the hot liquid, and beat it in a mortar or on a slab to make a proper ointment. In those cases w T here the pain is very great, a present means of relief or palliation is to be found in touching the sensitive part with lunar caustic, which, though it smarts for a few moments, is soon followed by a diminution of the sensibility and pain. Let the caustic touch only the excoriated part; if it act on the parts not already ex- coriated, abrasions of the sound epithelium follow, with a correspond- ing enlargement of the sore. In applying the nitrate of silver, one should use a very fine-pointed camel-hair pencil, which, being moistened with water, may be touched with a portion of solid nitrate, until the water in the brush shall have taken up a sufficient quantity of the salt ; with this delicate point, the cracks or fissures, being slightly stretched apart, may be accurately touched on the granulations, so as to avoid the risk of destroying by the caustic the tender margin of cicatrization whose white band girdles it ; to take a coarse piece of solid nitrate is to put off the cure for a whole day, which is a great evil. The late Dr. Physick, whom I consulted in regard to a most painful excoriated nipple, taught me that I should cure it as I would cure an incised wound or any ulcer — that is, by bringing the edges as nearly as possible into contact. A bit of fine ribbon, called taste by the shopkeepers, was thinly spread with adhesive plaster; and very narrow strips of the plaster, several inches in length, having been 602 INFLAMMATION OF THE BREAST. prepared, were applied in a direction transverse to the fissure or crack so as completely to close the wound or ulcer; the strips were removed for the purpose of giving suck, and always replaced immediately after- wards. The method of the good surgeon was rapidly and completely successful, as I have found it to be on numerous other occasions since that time. During the process of cure of sore nipples, very great comfort is obtained by causing the child to suck through the artificial nipple made by covering a proper shield of pewter with the nipple of a heifer. Such artificial nipples are prepared in great perfection, and sold by the apothecaries in this city. They prevent the direct contact of the child's gums and tongue with the diseased organ, and thus allow the parts to heal with great celerity in some instances. It sometimes happens that the child refuses such a nipple, but in the great majority of cases the infant takes it well, and the pain and inflammation soon afterwards disappear. There is also a variety of shields or caps for covering the nipples, in order to prevent them from being pressed or rubbed by the dress of the patient. When the breasts are filled with milk, their lactiferous tubes are liable to over-distension, to such a degree as to excite in them an in- flammatory action. They are also, in this state, liable to injury from the pressure of a tight dress, or from the use of a dress so loose as to allow the heavy organ to be suspended by its own tissues, which is painful and irritating to the last degree ; or it is exceedingly liable to be injured by the mother lying upon it in her sleep, or by the child bruising it by bumping its head against it. Lastly, as I have already said, the irritation of a sore on the end of the nipple is readily propa- gated along the course of the milk-tubes into the substance of the breast, so as to produce there a more or less violent inflammation. Cold and damp air, to which the woman sometimes imprudently ex- poses the organ while in the act of suckling the child, especially if while in a state of perspiration, is a pretty frequent cause of the difficulty; and, indeed, there are to be met not a few females who possess what may with great propriety be called an irritable breast, and to such a degree that the slightest exciting cause, as cold, pres- sure, distension or the like, establishes the inflammatory action at once. Some people are so plagued with frequent attacks of milk-fever or weed, that they are compelled to wean the child in order to get rid of the milk and the irritability which it brings along with it. I know a lady who has had the breast so irritable, that whatever cause hap- pened to excite a too active movement of the blood in the vessels, WEED. 603 would seem sufficient to establish so great an affluxion to the breast as to inflame it to her great distress, trouble and disappointment. The Student ought to be made to understand, that, after entering upon the practice of medicine, he will very often be called on to give his opinion for nursing women, whom he will find complaining of headache, pain in the back and limbs, with a very frequent, full and hard pulse; these symptoms having been ushered in with a chilly fit of one or two hours' duration. He will rarely fail, under such cir- cumstances, to make at once a correct diagnosis, if he ask the question, whether there is pain in one of the mammary glands ; and if answered in the negative, let him not give up the inquiry — but let the gland be pressed betwixt the thumb and fingers. If there is any soreness there, it will in this way be readily detected. A small lump is very likely to be found, as big as a nutmeg or larger, which alone is sufficient cause and explanation of so much constitutional disturbance. The inflammation and obstruction of a single galactophorous tube are suffi- cient to produce chill, fever, cephalalgia, and pains in the limbs, like those of break-bone fever. , Whenever the milk-fever, or the fever arising from an irritated state of a part of the mammary gland, is very great, the patient ought to be bled. Eight or twelve ounces will mostly be enough for one ope- ration: a smart purgative should be afterwards given; the patient directed to put a poultice of milk and bread upon the painful part of the breast, and to keep her bed. It would be most unfortunate for her to refrain from suckling the child, which ought to go to the breast whenever it is found to fill up with its milk. In the course of a few hours after the bleeding and the operation of the cathartic, fifty or sixty leeches should be applied near the painful part, unless the local disorder should by that time be greatly reduced in intensity. These leechings are highly useful, and ought to be repeated daily in those cases which seem not to require or admit of the employment of the lancet, but which at the same time demand the local abstraction of blood. In one patient here I had a large number of leeches applied to the breast: they were useful, but did not cure the pain and obstruc- tion. The leeching was repeated seven times before the inflammation gave way. In a subsequent confinement, they were applied nine times before they succeeded in relieving the distended, hardened and painful tissue of the breast. As I have already said, the mammary gland is suspended upon the skin in front of the thorax; whenever it becomes heavy from 604 WEED. engorgement or from obstruction of its milk tubes, it tends to fall downwards from its weight, and in doing so the natural relations of tension of its integral parts are disturbed, I might say destroyed. To explain myself fully, I will say that the gland is dragged, pulled by its weight, and that the nerves and blood-vessels of supply are put uneasily and even pathogenically to the strain, just as happens to the testis in a hernia humoralis. I should think no surgeon at the present day would treat a hernia humoralis without the aid of a suspensory bandage, and I am equally sure that no thoughtful practitioner would undertake to treat a violent case of mammary inflammation or mammary abscess without pro- viding some proper means of suspending the organ or of preventing its fall downwards; a fasciola or strophium of some sort should be resorted to in every such case, and I advise the Student to make use of a fasciola or strophium consisting of a strip of patent adhesive plaster, sixteen or eighteen inches long, and little more than an inch in width. Let one end of this adhesive strip be carried far back and high up under the axilla, and affixed to the skin there ; then let the breast be raised up by the hand to its normal position, and while so supported, let the plaster be brought round underneath the hemisphere and carried upwards until the end applies itself as high as the op- posite clavicle. One such strip will be in many cases found sufficient to cure even a violent inflammation of the mammary gland, just as a considerable orchitis is often cured by a suspensory bandage alone. I exhort the Student of medicine to make himself acquainted with the uses of the breast, to know T the nature and sources of its circu- lation, innervation and absorption, as well as its secreting office, in order to prepare himself to combat fully the ills that menace those persons who confide to his skill and conscientiousness the preservation of their health in the lying-in-room. It is difficult to form an opinion of the amount of poignant distress, depression of spirits and actual loss of health attendant upon some of the cases of mammary abscess, which from beginning to end occupy months; besides ruining the gland, to the great detriment of the patient in future confinements. A mammary abscess is a very serious matter, demanding a con- scientious regard to the fulfilment of all the duties incumbent on the practitioner in the case, yet often treated with neglect and indifference. Lying-in women are managed by their monthly nurses or friends, and it is very difficult for the physician to make either the patient or her attendant understand the true wants of the case. I am very sure that a great proportion of the mammary abscesses that I have met with in MAMMARY ABSCESS. 605 my life have been the results of over-distension of the milk-tubes; nor can I well understand that one or a dozen galactophorous tubes, as large as swan quills, should be filled to their utmost capacity for seve- ral hours with milk, without determining in their mucous and fibrous structures such a hypereemic and hyperneuric condition as to result in the establishment of inflammation of those tissues. But such in- flammation passes through such tissues to the gangue of cellular tela by which they are invested ; heat, swelling, pain, and redness of the parts follow upon such an engorgement, commonly in the course of a few minutes, or certainly in the course of a very few hours: a con- dition likely to be aggravated by the increased distension which a failure to draw off the milk, whether from ignorance or timidity, in- variably produces. I believe the Student cannot possibly become too vigilant and anx- ious to explore, and therefore to obviate, the mischievous tendency of the engorgement now spoken of; he should give such directions as to emptying the breast, either by the aid of the nipple tube, the breast- pump, or other method, as may save his patient from the certainty of developing mammary abscess. A mammary abscess for a lying-in woman is a great misfortune; it almost deserves to be called a catastrophe; and for a woman, indeed, who has a bad constitution, or who is affected with a strumous habit, or is at all prone to tuberculosis, a mammary abscess is a circum- stance replete with alarm and danger. If the suppuration be very deep- seated, it sometimes happens that many days, or even weeks, are passed before the matter of the abscess makes its way to the surface ; in the meantime, a constant fever, exhausting perspirations, and a state of the constitution that can only be truly characterized as hec- tical, attends the painful and reluctant progress of the suppuration outwards. But, suppuration, when it takes place, often attacks several of the different loculi in which the independent packets and bundles of the milk-tubes, and granules of the gland, exist; so that a -woman is affected with an abscess which is really multilocular in its nature, and. which, when evacuated, allows the cavity to be con- verted into winding and many-celled sinuses, difficult to cure and often lasting for weeks and months. I need not allude to the ex- haustion, the pain, the hectical fever, and the wasting discharges of suppuration. I repeat that it is almost a catastrophe for a lying-in woman to be attacked with a mammary abscess, and particularly if regard be paid to the great domestic vexations often produced by it. The young child is often the victim of such an accident, and the 606 MAMMARY ABSCESS. whole household is sometimes kept in a state of disquietude for an entire year, by the dissatisfaction engendered from the necessity of frequently changing the wet-nurse, who is brought in to relieve the woman herself, or to preserve the child from the dangerous conse- quences connected with artificial alimentation. An abscess is a circumscribed cavity containing pus; one of the causes of the pain is the tension, and it is desirable that the character of the abscess should be abolished, as soon as it may be done conforma- bly with the interests of the patient. As soon as the abscess is opened by the bistoury, or by the natural process of absorption, it ceases to be an abscess and becomes a deep-seated ulcer; the tension and pres- sure are, therefore, either greatly lessened or wholly removed. In the treatment of mammary abscess, however, it appears to me not desira- ble, in general, to draw off the matter from a great depth below the tissues, because in doing so, the fistula, through which the matter es- capes, and which is made by the lancet, is almost sure to become sinuous, and to convert the abscess into a fistulous ulcer. Hence, I should deem it advisable, in the conduct of such cases, to wait rather longer than in some other abscesses for the rising of the pus to a point near enough to the surface to obviate this risk. During the progress of the suppuration, great comfort is obtained, first, from supporting the gland by means of an adhesive fasciola, or strophium ; and, secondly, from dressing it with emollient poultices. I think that poultices are more useful if they contain the petals of chamomile, or hops, or crushed onions; for the use of these agents, as it appears to me, serves to prevent the formation of those eczematous blotches and patches which are apt to follow the simple poultice of bread and milk, of flaxseed, of slippery-elm, or other emollients. I do not think that anything can be more suitable for the treatment of this part of the case than the poultice composed of equal parts of slippery-elm flour, flaxseed meal, or crumbs of bread, and chamomile petals. As soon as the breast is opened, whether spontaneously or by the surgeon, poultices may be abandoned, and a practice introduced of compressing the breast against the arch of the ribs by long narrow strips of adhesive plaster, which cross it in various directions, take firm hold on the thorax to compress it, and hold it still. The effect of the compression is to counteract the development force of the still re- maining uncured inflammation of the tissues. There is no antiphlogistic that can compare with the power of mechanical compression for cases in which it is possible to adjust it, and it is possible to adjust it for the female breast. Every day dur- MAMMARY ABSCESS. 607 ing the treatment, and indeed several times a day, a delicate cereole, made of cere-cloth, should be introduced into the opening and con- ducted to the bottom of the tube or sac. If the cereole be not dis- proportionately large, it gives no pain, and its withdrawal is followed by gushes of pus or sanies, whose detention in the bottom of the tube or sac reconverts the malady, restoring it to the nature of an abscess, for an abscess is a circumscribed cavity filled with pus. It appears to me that, managed in this way, there will be found few samples of gathered breast obstinately to resist the treatment. In many instances where the suppuration makes its way to the surface, within or near to the margin of the areola, milk is found to escape along with the pus, and a troublesome milk-fistula is generated by it; sometimes these fistulas of milk continue to flow for a great many weeks, accompanied with a very small quantity of purulent matter, and a portion of sero-pus or sanies. To shut up the orifice with adhesive plaster is to re-form the abscess, since it reproduces a circumscribed cavity, and the abscess opens again and again — a cause of great vexation. I have found them, I think always, yield upon the daily introduction of a delicate cereole, made of cere-cloth, which should be carried to the bottom of the cavity, and withdrawn from time to time to allow of the escape of the contained fluids, but to be replaced immediately afterwards. It generally happens very soon that the cereole goes less and less deeply into the tube which, filling up with granulations from the bottom, at length precludes the possibility as well as the necessity of its introduction — for the fistula is cured. In the winter of 1840, I attended a lady confined with her first child. She was so extremely modest, that, several days after the birth of the infant, being seized with inflammation of part of the gland of the left breast, she would not allow the nurse to inform me of the accident, lest I should wish to examine the part. In this way, she continued to bear the pain for several days, until it became so great that my attention was called to it. I advised the use of leeches. Compliance with this order was deferred for two or three days, and when at last yielded it was too late to do any good. The breast suppurated near the posterior surface, almost down on the fascia; the pus was long making its way to the surface, which it did at length, and was evacuated by an incision. The case altogether was rendered a most embarrassing one by the timidity and nervous- ness of the patient, who became so very ill as to excite in me the most painful solicitude. I was for many days anxious on account of 608 MAMMARY ABSCESS. a very wearying short cough, for which I could discover no explana- tion upon a most careful auscultation of the thorax. The pulse was always above one hundred and ten. Upon going to see her one morning, I found her with the most singular respiration and pulse that I had ever seen, connected with any exterior disorder of the breast. Her pulse was not less than one hundred and sixty beats a minute, and the respiration was more than one hundred times a min- ute. Her hands were covered with moisture, and from her emacia- tion I felt the greatest inquietude upon finding so strange a state of her circulation and respiration, which, she told me, had come on shortly before, having been of the same character once or twice some hours previously to my visit. After looking upon this strange scene for a minute or two, and after repeating the auscultation, I begged permission to examine the breast, which had been more painful. I found a new abscess point- ing up under the skin. As soon as I opened it, and with a bistoury cut up a bridge of skin which strongly bound two other orifices, her strange respiration gave instantly place to a very calm and deliberate one, while her pulse also recovered a far more natural rate. This lady having lost all her milk, took in a wet nurse, and after some time recovered a very perfect health, after the most distressing and pro* tracted illness brought on by a simple, but neglected, inflammation of the lactiferous gland. In the second volume of Bright' s Medical Reports, p. 459, there is related a case of what he calls hysteric dyspnoea. "I was passing," says he, "through the wards of George's Hos- pital one day during last winter, when one of the surgeons requested me to look at a female patient who had a formidable disease of the mamma. She had been seized with alarming dyspnoea: her respira- tion was performed with most unusual effort, but it was not so much hurried as laborious; and she complained of a constriction across the chest which was altogether unconquerable. Pulse very quick. It had been believed by some that she suffered an attack of pneumonia; but there was no cough, and the breathing was rather with effort than with pain or difficulty. Her feet were quite cold, her pulse weak. She was in a state w T hich might have resulted from sudden effusion into the chest, or the bursting of an aneurism. This was hysteria, and assafetida was its cure." I wish the Student to compare Bright's case with mine given above, the slowness of the respiration in his with the frightful acceleration in mine, and all co-existent with formidable disease of the mamma, THE BREAST. 609 and then observe that my patient was instantly and completely re- lieved by the bistoury, while Bright's was cured by assafcetida. I should think he would come to the conclusion that neither of the cases was really to be arranged among the hysterical disorders, but were the results of irritation of a gland, having so large a supply of nerves from within the thorax itself. It is highly advisable to wean the child, when sufficient time has been allowed to ascertain the probable long duration and great seve- rity of a mammary abscess. This ought not to be done too early, because the suction of the breast by the child is a great and curative resource in the management of the disorder; when the inflammation confines itself to only a part of the breast, the other portions of the gland continue to furnish a good abundance of milk, and that milk ought to be regularly taken away, lest its accumulation should add to the difficulty already too great within the inflamed packets, or even invite the inflammation into the still healthy structures. For counter-sunk nipple and inverted nipple, I refer the Student to my letter on the Breast in my work on Females and their Diseases, p. 643. To the same letter I beg leave to direct his attention for a fuller statement of this subject, than I find occasion to present in the present volume. I shall close this article, by advising every Student who intends to practise midwifery, to dissect the breast for himself, after having most carefully studied " The Anatomy of the Breast, by Sir Astley Paston Cooper. London, 1840, 4to. with a vol. of Plates." This work is really a legacy to those whom in his dedication he calls "My dear Brethren." It is prepared with an elegance and liberality and pro- fuseness of illustration worthy of that great surgeon. The republica- tion of it in the United States, in a style fully equal to that of the London edition, would be a very great benefit not only to the profes- sion, but to thousands of suffering females, whose disorders of the breast would be more fully understood, as soon as that work should find its way, as assuredly it would, through the country. 39 PART IV. THE HISTORY AND DISEASES OF THE YOUNG CHILD. CHAPTER XXIII. The child in utero, as has already been stated, requires for its com- plete development a lapse of nine months, or two hundred and eighty- days, less or more. It becomes viable at seven months. Some children have lived, that have been born much earlier than this ; yet it is true to say that viability is attained at the seventh month. The viability of the foetus depends upon the evolution and perfec- tion of its organs to such an extent as to enable it to live a respira- tory life. This it could not do until its lungs should be sufficiently evolved to enable the air-cells to receive the atmospheric air, while they should become fitted also to make the transfer of oxygen to the blood and of carbon to the expired air. If a child should be expelled while its air-cells were still undeveloped, it would necessarily perish immediately from asphyxia; new-born children expelled before their time die, not because they have a complete but because they have a partial atelectasis pulmonum. The heart of a child, in the earlier of its embryonal periods, is a straight tube ; it soon becomes tortuous, and afterwards makes two cavities, which are one auricle and one ventricle. The progress of the uterine life brings the foetus daily nearer and nearer to the condi- tion of the breathing mammal; but it does not attain this condition, as a general rule, until the seventh month of gestation. If the child should be driven into the w r orld before the completion of the organi- zation of its heart, it could not be deemed viable or liveable, because it could not successfully carry on the work of oxygenating its brain and nervous mass. The septum ventriculorum of the foetus in utero is early completed: if the septum auricularum should be also completed before the period VIABILITY. 611 of its birth, the child would necessarily be born dead, because there is no other route by which the oxygenated blood of its placenta could be submitted to the action of the systemic ventricle, save that in which it traverses the right auricle, passing through the foramen ovale to the systemic ventricle, and that which it performs when driven by the right ventricle into its aorta through its ductus arteriosus. The red- blood of its ductus arteriosus enters the aorta below the giving off of the carotids and subclavians: that blood can by no means reach the brain, but goes into the tissues below, where it gives up its oxygen or returns to the placenta to take an additional charge of it: therefore none of the oxygeniferous blood of the child can reach the brain, save that which comes into its systemic ventricle through the foramen ovale and the left auricle. A child, therefore, whose foramen ovale should be completely closed — to suppose the case — would necessarily perish in utero with asphyxia, for asphyxia is black blood in the brain; nothing else is asphyxia. The neonatus, therefore, is necessarily born with an open foramen ovale; but the foramen ovale is covered by a valve on the left surface of the septum: this valve serves after its birth as an operculum or lid to shut the passage. It is probable that the first inspiration of atmospheric air, coinciding with the descent of the diaphragm and the expansion of the thorax in every direction, serves to carry off to the lungs through the pulmonary artery, a great efflux of blood, which, antecedent to that first act of respiration, chiefly but not wholly flowed off through the ductus arteriosus. The constantly augmenting facili- ties of this pulmonary circulation soon set aside any further necessity for the transitive agent — the ductus arteriosus, whose deserted channel soon becomes a ligamentous band. The increased amount of blood thus determined to the lungs, must have the effect of throwing a greatly augmented quantity of fluid upon the right auricle and ventricle ; not to say that the right side of the heart carries on a greater circulation after birth than before birth; but the right ventricle cannot but carry on a much greater amount now, because it carries on the whole, whereas, before birth it carried on only a moiety. The escape of the blood from the right ventricle into the pulmonary artery is probably effected with a facility greater than was that of its propulsion into the aorta through the ductus arteriosus; and I can imagine that now, the pressure of the two symmetrical parts of the heart being equalized, the valve of Botali instead of floating upwards into the left auricle, is by this equalization of the pressure, shut down as the 612 N ON- VIABILITY. operculum of the foramen ovale ; so that, although the child is neces- sarily born with an open foramen ovale, the equalization of force in the two ventricles serves to close it immediately after the first act of aspiration. The Student need, therefore, suffer no disquieting doubts or uncertainty in regard to the openness of the foramen ovale in the healthy neonatus at term. In the non- viable child, previous to the seventh month, the valve of Botali is incomplete and has not a perfect operculum; it cannot thoroughly cover the orifice of the foramen ovale. If the child, there- fore, be born without a complete valve it will probably die from as- phyxia, from the mixture of its black and red currents in the systemic ventricle; a child, therefore, whose heart is incomplete is non-viable. A child is rendered non-viable in consequence of many faults of development. The astomatous child is non-viable, as is that in which the oesophagus has failed in part of its development, rendering the cavity of the stomach inaccessible to aliment. The anencephalous child is non-viable, since important parts of its organization are wholly wanting; the acephalous foetus dies of course. The child is non- viable in which ectopy of important organs, as for example ectopy of the liver and the whole alimentary canal in the root of the umbilical cord, exists; for the cord being deciduous must fall off in the course of a few days, leaving the vital organs exposed to inevitable ruin. The child is non-viable in whom large portions of the rectum fail to be developed, although a few T examples are met with in which the surgeon, by a dexterous operation, has saved the life of the child la- boring under imperforate rectum; probably those that have been thus saved, have failed to produce merely a short tractus of that intestine. Many children perish in the womb from disorders affecting impor- tant parts. Doubtless in the early stages of embryonal life, very slight derangements in the structure of the omphalo-mesenteric vessels, or of the duct of the umbilical vesicle, might and do deter- mine the death of the new being. Children also perish in the w T omb from diseases affecting parts within the cranium, for the child lives by its nervous mass as truly as the breathing animal does. Diseases of the kidney and liver and alimentary apparatus, prove the not unfre- quent causes of the death of the child in the womb. Various affections of the mother produce the death of the child ; passions of the mind and physical distempers, to which she is subject, bring it into danger, or destroy its tender existence. Various diseases affecting its umbilical cord, modifications of its placenta, whether as to insufficient magnitude of that organ, or modifications induced by STILL-BORN. 613 the deposit of calcareous carbonates upon the uterine surface of the placenta, or the establishment within it of the disease, called hydatid degeneration of the organ, or partial detachment of the placenta, serve to destroy the young child before it is born. The child, when it is driven into the world, is sometimes found unable at once to establish its respiratory life ; it lies still and pale, being perfectly motionless; there is little tension of its muscles; if handled it appears to be flaccid, or, to use a common phrase, limber, like a person who has fainted. If the cord be taken between the finger and thumb, nigh to the navel, the Student will be able to judge whether or no the heart is beating. If the heart is beating, the pulsations w T ill be felt by the finger and thumb by compressing the cord, in w r hich are the two umbilical arteries; if the pulsations are vigorous, and repeated at the rate of about one hundred and forty pulses per minute, no alarm need be felt as to the security of the infant. In a few T moments the diaphragm will receive its nerve-stream; it will descend, compelling the air to enter the lungs; the oxygen of the atmospheric air, combining with the blood of the pulmonary circula- tion, will hasten to the systemic ventricle which, injecting it into the brain, extricates there an explosion of vital force, which irradiates with instant life every nerve fibril in the constitution. This new and pow- erful infusion of vital force is made manifest by struggles, by outcries, by rapid coloration of the surface, and by all the signs that indicate an established respiratory existence. As soon as the child is found fully to have established its respiration, steps should be taken to sever it and remove it from the mother's couch. As before directed, a ligature should be put upon the umbili- cal cord, at the distance of an inch and a half or tw T o inches from the navel. Tying of the cord is not an indifferent matter, and it is ne- cessary to examine the ligature that may be presented for the purpose before employing it; it should be strongly jerked between the two hands, in order to test its strength. It ought not to be less than ten or twelve inches in length; a portion of ligature four or five inches long cannot be firmly held, for it becomes slippery in the moistened hands. If it be not of sufficient strength it may, in tying the first or second knot, give way, and allow the two hands to separate with violence, which exposes the accoucheur to the risk of tearing the cord out at its root. When the cord is passed around the umbilicus it should not be tied without taking the greatest care to avoid this sudden separation of the hands that are employed to tie it, upon the possible breaking of the ligature. The cord should be ten or twelve inches 614 SEVERING THE CORD. long, as I have said, so that, being held in the hands and the knot arranged, it can be fastened by separating the radial edges of the hands, rolling them both outwards in supination, without a direct steady pull. I never think to tie an umbilical cord in any other man- ner than this, and more particularly as my early experience placed me repeatedly in danger of destroying the child, by suddenly jerking its navel string, from the breaking of improper ligatures placed in my hands. In applying the ligature to the umbilical cord, one may be em- ployed or two. If it should be a twin pregnancy, there surely ought to be two ligatures, lest, if there be a common placenta, the second child should suffer a dangerous loss of blood, from the untied end of the cord. In those cases in which the placenta is known to be de- tached and pushed into the os uteri, it is better to have only one liga- ture, for, in that case, the blood of the placenta is discharged in considerable quantities from the cut extremity of the cord, thus serving to diminish the magnitude of the placental mass very considerably, and enabling the woman to thrust it forth with less effort and less pain than would be otherwise required. On the other hand, if before proceeding to the severance of the child, the uterus is found to be still very large, in consequence of con- taining the placenta in its cavity, it is better to apply a second liga- ture ; by doing this the Student would restrain the evacuation of the placental blood, and thereby keep the organ fuller, more plump and solid, which would enable the uterus more readily to slip it off from the utero-placental superficies than it could do if the placenta, by the evacuation of all its blood, should become flaccid, like a wet, soft sponge. The child, being removed, should be washed and afterwards dressed. It should be washed in tepid water at all seasons of the year. The body of the new-born child is usually covered with a flaky, unctuous matter, or induitus that is insoluble in water, and is not acted on by means of soap; it readily incorporates, however, with oil or lard or the yelks of eggs. One or two yelks of eggs, beaten up and rubbed over the whole surface of the child, suffice to make an emulsion of the white induitus of the child, which is afterwards readily washed away by means of soap and water ; or the whole child should be carefully and thoroughly anointed with a handful of lard, which also incorporates readily with the viscous matter in question, and which is readily washed off afterwards by means of soap. If the attending nurse is inexperienced, the Student should direct her to use, not a piece of DRESSING THE NAVEL. 615 linen or muslin, but a portion of soft flannel as the wash-rag for the purpose of cleansing the child's body; either linen or muslin slides over the surface and fails to pick up every portion of the induitus, whereas every particle of it is taken up by means of a wash-rag made of the bit of flannel. In cold weather the child should be washed in a warm room, and sufficiently near to the fire ; but its surface burns readily ; let the Stu- dent take heed, therefore, that its body is not exposed to be blistered, as I have seen them blistered, by being held too near an open fire or grate. As soon as the child is thoroughly washed, a piece of linen, four inches wide and eight inches long, should be doubled to make a square disc ; in the centre of this disc a slit should be made with a pair of scissors — it is best not to cut a round hole in it. Through this slit let the remnant of the navel string be passed, so as to let the double disc of linen lie upon the belly of the infant ; the cord should be laid down flat upon this disc pointing upwards towards the scrobicle, the linen should then be turned up so as to cover it, the right side of the piece should be turned over the cord towards the left, and the left side of the piece should be turned over covering the right, which will effectually envelope the navel string, which is all the dressing it can require. The object of this dressing is to receive the discharges which exude from the navel string, and to prevent the cord from ad- hering to the child's dress, to which, without some such precaution, it would soon become glued and thus be liable to be torn off earlier than the period at which the natural process would otherwise detach it ; there is no other use in dressing the navel string of which I am aware. As soon as the cord is thus dressed, the belly-band, which is usually made of a strip of flannel four or five inches in width, should be put over it, and the end, carried around the body, may be pinned either at the back of the child or at the sides. After this the child should have a shirt large enough to come down nearly to the hips ; if it is too long, it w T ill be constantly wetted with its urinary dis- charges. Next comes the petticoat, which is usually, in this country, made of flannel, and which has or has not, according to the taste of the mother, a shoulder strap, but which always has a proper waistband. Some persons do not employ the petticoat, but a good many women still use here the barracoat from the Portuguese, barra, an ell of cloth. It is a yard of flannel, more or less, of which one end is fastened around the waist, and the other brought up and pinned in front, so as 616 DRESS. effectually to cover up the lower extremities of the child— a conve- nient and facile mode of dressing it in cold weather. The last covering is the frock. I should hardly deem it neces- sary to mention it here, were it not, in the first place, that I am writing for Students, who ought not to go to the lying-in room without being provided with some information upon particulars, which, though they be of minor importance, are not without their influence upon the comfort and safety of his patient and upon his own success and repu- tation. But, more than this, I mention it, because I desire here to enter my solemn protest against the folly, the stupidity, and I might say the iniquity of the fashion which induces so many persons, pos- sessing in other respects good sense and good education, to dress their new-born children less wisely than an Osage Indian mother, or the most savage Esquimaux. A child that is born does not surely belong to its parents until it has attained its sixth year ; it seems to me that such a child is but a loan, on condition of becoming property, provided it be wisely and safely conducted up to the sixth year of its age, for one-half of the annual product of child-birth perishes in six years. It cannot be that this amazing mortality is an inevitable concomitant of the state of existence, but it must be a result of ignorance and carelessness as to the hygienical conduct of the neonatus and the young child. It is true that a multitude of children are brought into the world endowed with such a feebleness of constitution, or such hereditary depravation of it, as to render protracted existence and maturity impossible, but the population abstracts would find an immense aug- mentation were a sound discretion to preside over the hygienical management of newly-born children. Now in the United States, from Carolina to Maine, and from the Atlantic board to the western limits of Missouri, Iowa, and Wisconsin, little children are dressed in frocks without sleeves, or having only pretended sieeves, which are really nothing more than shoulder-straps and while the backs and bo- soms expose nearly the whole of the thorax. There would be no objection to such habits for children born between the 10th of July and the autumnal equinox, it would even be advisable so to dress the summer children, in a climate notorious for its intense light and heat ; but to dress children in the same manner, whether born in July or February, is an imprudence which no power but that of Fashion could compel sensible women to commit ; but Fashion has a power that transcends the dictates of wisdom and of common sense. I wish in this volume that the Student should know that I have in- variably, for a long series of years, combatted, as far as in me laid, DRESS. 617 this vicious custom ; I have found a few sensible mothers who would listen to and obey my injunctions, but I have found a vast number of children to suffer, and a multitude to perish, from their disregard of the dictates of common sense. I beg the Student, therefore, to take this matter into his serious consideration and to satisfy his own judg- ment upon the question, whether a child is safe, the whole of whose tender extremities is exposed to temperatures approaching to and sometimes lower than the freezing point. The arms of a child are supplied with blood mainly by the delicate tube of the humeral artery. Much of the blood returns in the super- ficial veins, and great masses of it, either upon the skin or in the fingers, to resist the constringing effects of cold require a power of the circulation, probably amounting to what might almost be called pathological reaction. The superficies of the body covering the lungs, is also often chilled, for the infant, " mewling and puking in the nurse's arms," always has the whole front of its chest wet with the excretions of its mouth ; such a condition can scarcely fail to expose it to attacks of pulmonary catarrh, of tracheal and bronchial inflam- mations, and coryza. One of the causes most destructive to health is cold, especially damp cold, and the new-born child ought to be carefully protected against it by dresses, covering its chest up to the throat, and its arms, down to the wrists, and its legs and feet. I believe that in Europe, where the people by long residence have been compelled to learn the nature of their climate, one would scarcely meet with a child, from the royal infant to that of the beggar, that would not be found better protected against weatherly influences than the children of the United States mothers. The pretext for this improvident exposure of the neonatus is, that it should be early hardened; but I submit to the intelligent Student the question, whether the surest way to harden a child is not that way which shall conduct it through the first six years of its existence with- out fever, inflammation, or other disease. If a child be properly co- vered up and daily exposed to the sunlight in the open air, it will have the best chance of acquiring what is called a hardened consti- tution ; there is little hope that a delicate child, otherwise cared for, shall pass to the end of the first month of its life without some degree of coryza, some pulmonary rhonchus, or some reactive effort of its vascular constitution, struggling against the constringing effects of cold damp, from which it cannot be protected except in overheated apartments, which themselves are almost as much to be deprecated. 618 FOOD. If a child, protected like a sailor on an Arctic voyage, or like the rudest workman, should be daily sent sub dio, to breathe the stimu- lating and exhilarating air of the streets or country, and its diet should be properly regulated, there are few diseases to which it would be liable, save those essential maladies which, to use the language of Willis, — " homini omni, soli et semel contigit offici." I mean measles, small-pox, scarlet fever, whooping-cough, etc., for I am very sure that the catarrhs, the pseudo-membranous croups, the bowel complaints, and many even of the cases of tubercular meningitis, are the results of management, scarcely wiser than that bestowed upon the child of the Ottawa, or the Shoshonee. With these observations on the dress of the child, I shall dismiss the subject, after proffering one more remark; it is, that the people of the United States seem all hurried onward by the universally pervad- ing desire to do what is here called go-ahead; they are notoriously regardless of the care of their health, and this is attributable, perhaps, to the state of the people, who have but yesterday, as it were, con- quered their lands from the swamps and the forest, and have been too busy with progress to attend to the minor concerns of the savoir vivre. I hope that no distant generation will be left to discover some portion of the agreeable to mix with the overflowing cup of the useful in the United States. In that case the mortality reports will be less redund- ant with the infant proportion, and the whole female American race will present a spectacle very different from that which we now behold, since it is rare to meet with an American wife, the mother of three children, not already broken and ruined in health, by her servitude to the laws of fashion and the raging spirit of progress. Let us now turn our attention to the alimentation of the child. It might be enough to say, for the information of any man of sense, that this is a generical process, for the child was made for the breast and the breast was made for the child, and nothing else, in this line, w T as made for either; therefore, when the child is fed otherwise than at the breast, it is fed by a suceedaneum; every succedaneum is, by comparison, infinitely inferior in value and properness to the generic food which the Author of Nature supplied for it, and so constructed its organs and parts as to fit them to receive it and to be developed by it. I shall not take the trouble, in this volume, to repeat the analyses and the obser- vations upon milk which I have already printed in another work, nor indeed does it require any argument to show that, inasmuch as the proportion of oil, casein, albumen and water in the milk of the differ- ent mammiferous creatures varies according to their genus, so the young FOOD. 619 of each genus is adapted to the reception of the sort of aliment de- voted to its generical nature. It is true that a young child who has lost its mother must be fed, and it is better for it to be fed with cow's milk or goat's milk than not at all ; but I hold it to be a sacred duty for all those persons whose circumstances admit of it, to provide the new-born child witk the milk of a human nurse, and not to expose it to the hazards — I should say the dangerous risks — of distressing illness and impending death, that threaten the great majority of those children that are brought up on the spoon or biberon. The neonatus comes into the w T orld full of instinctive desires, it will take food soon after its birth, and will satisfy its instinctive crav- ings to absolute satiety. But I beg the Student to remark, that while the Divine Author of Nature has ordained that children shall be born, he has also ordained that the plenary abundance of their food shall not, as a general rule, be provided for them until the third day after birth. It is not necessary, therefore, to feed the child as soon as it is washed and dressed ; I look upon it as a direct flying in the face of Providence, as acting in direct contravention to the law of nature, which is but the command of God, to fill the stomach of the new-born infant with mixtures of saccharine matter, of gruel, or of the milk of quadrupeds: surely He who made it knows better its true wants than those who, doubting His wisdom and foresight, make haste to test its digestive powers by these detestable mixtures, instead of waiting the fullness of His own time. I have warned the Student, however, that hereafter he will encounter much trouble and vexation in consequence of the early and improper feeding of the infants under his care, and I exhort him by careful consideration to inform his mind as to the medical duty in such cases. He will never err, he will never go astray as a physician, who ascertains clearly the physiological laws of the function or functions placed under his surveillance, as he who in his hygienical ordinances is the best expositor of nature's laws, will be the safest and most successful physician; and it is certain that no human sagacity or skill can ever equal the perfection of those operations that are instituted and effected in accordance with the generical nature of the subject of them. It is a mistake, and it is a grave mistake, to suppose that the neo- natus is in danger of starvation that is kept until the third day by the supply furnished it from the mother's breast, for there is always, after the birth of the child, to be found some small quantity of mammary 620 FOOD. secretion, which, though it be not properly deserving to be called milk, yet it is possessed in a measure of the properties of that fluid. The earliest secretions of the milk gland are loaded with a vast abundance of colostrum grains, which are to be seen thickly strewn over the field of the microscope, mixed with vesicles and oil globules floating in the serum lactis. Probably the imbibition of this colos- trum by the child has some economical relation to its conservation. The colostrum disappears in the course of a fortnight or at most three weeks after the child's birth; I cannot imagine that it is a mere ex- cremental matter, for the breast is not an excrementitious it is a re- crementitious organ, and all that it produces is designed for the advan- tage of the new-born child. With these views I am quite clear in advising the Student to direct his patient to take the nursling to the breast at the earliest convenient moment. I have many times seen a child drawing vigorously at the breast within a quarter of an hour after its birth, and I believe to take the child to the breast is the most natural thing for the mother to do. To illustrate this opinion, let me invite the Student to consider the circumstances that might have attended the apparition of the first- born of mankind. The common mother of mankind had perceived the strange sensations and modifications of her form, dependent upon an advanced stage of her first gestation. She resided, perhaps, in some warm sunny valley of the Caucasus, bounded by an amphithe- atre of lofty mountains, and enriched with a varied landscape, tinted with every hue and form of tree and flower and grassy mead. A transparent fountain arose, perhaps, near the bower, in which Adam had left her sleeping at the uprising of the morning. He may have climbed some lofty, distant cliff to gather for his bride its Alpine blossoms, or return, loaded with fruits for the object of his tender care. In the meantime she is seized with the pangs of the first human travail — the terrible fulfillment of the curse on her early disobedience ; alone, unaided, in a purely natural state, with that in- herent health and strength which we may conceive of as appertain- ing to a creature which had issued perfect from the hands of her maker, she advances through the unknown conflict, and at the mo- ment of its consummation, becomes insensible from the keenness of her anguish. In a few moments she is recalled to her senses by the voice of the new-born child ; and, raising her languid head and inclining her bending body feebly supported upon the elbow, she perceives the helpless child of her bosom lying upon the grassy floor of the bower near her. It is not necessary to paint, indeed, FOOD. 621 it is impossible to imagine, the intenseness of the parental emo- tions which must have now agitated her bosom; these, instinct alone, would prompt her to put forth her hands and lift her first-born from the earth on which it laid weltering. She would take it up in her hands, her forearms were fashioned that they might be its cradle, its face would fall against her bosom, and it is probable that but a few moments elapsed after the birth of the first-born, until his mother experienced the sensations which only a mother can know, who pours the rich nutritious stream of life out of her own breast for the sustentation and comfort of her new-born offspring. It is perfectly natural, I repeat, that a mother should take the child to the breast at the earliest pos- sible period after its birth. Every human direction and counsel in contravention of this most evident law of nature, must be erroneous, save when it is founded upon views relative to the actual state of the mother or child, as setting aside, for the moment, the operation of those natural laws. Some information should be given to the inexperienced mother or nurse, in regard to the alimentation of the neonatus. I believe that pure instinct is more unerring than reason, and a better guide in all those cases in which instinct is designed to preside. I therefore look upon it as a tyrannical thing on the part of any physician to prescribe precise intervals between the applications of the child to the breast. I have no idea that any physician can be competent to decide upon the degree of activity of the digestive powers of any specified neona- tus. The principles of conduct here, are principles to be derived from a knowledge of the wants of the child ; a child may want the breast again in two hours, or it may not want it again in six hours. It is therefore preposterous on the part of the physician to say, as I have heard him say, that the child must be applied to the breast every three hours, or every four hours, according to his unerring wisdom. I advise the Student to direct the child to be fed when it is hungry, and allow it to be governed, as to the quantity it takes, by its instinct, which is superior to his reason. It is probable that the child within the month, w r hose stomach can scarcely be supposed to hold, when perfectly satiated, more than three or four fluidounces of milk, will be able to digest and discharge the major part of this quantity into the duodenum, in the course of some three hours after its assumption, and it is probable that the feeling of hunger will begin to return long before the organ becomes com- pletely empty. There are but few new-born infants that are incapable of rejecting a part of the ingested milk; the stomach in this w T ay re- 622 food. lieves itself of any excess, which the appetite might induce it to swal- low. I have no doubt that a considerable portion of the ingested milk passes as milk and not as chyme through the pylorus. These con- siderations, together with observation of the facts, have induced me, in general, to say that the child might be applied to the breast about once in three hours, but I am far from prescribing three hour intervals as an absolute rule of conduct, and I have no objection to see the child again applied to the breast within two hours after having thoroughly satiated its desire for food, for I repeat, I rely upon its instinct, which was provided for it before the invention of Physic and Surgery. The dental formula of animals is the index to their nature, espe- cially to the nature of their alimentation. This mere fact is sufficient to make it apparent that the child should be fed upon fluid aliment, up to the time at least of the establishment of its dental formula; and nothing could be more stupid than the conduct of those that feed young. babies with bits of fat ham, minced chicken, and other arti- cles of food for which the child does not become fitted until the period when nature announces it to be so, by the establishment of an ap- paratus of mastication. As a general rule, the child ought to be nursed at the breast until it is twelve months old ; if the twelve months should happen to elapse about the beginning of June, it ought to be kept at the breast until the autumnal equinox, since experience declares that in the U. S. very few children can be severed just at the outburstingof the summer heats, without becoming subject to some degree of digestive derangement, which, when once begun, is not readily removed where the child is nourished artificially, but w^hich either does not attack, or is readily overcome, if the supply be of the kind of food which is natural to it. As to the nursing of the child, notwithstanding I deem it a sacred duty on the part of the parent to fulfil this obligation, yet it is ques- tionable whether the obligation is not really set aside where the pro- vocation thereto arises from a dangerous condition of the maternal health. If a man marry a wife having a hereditary claim and expect- ation to perish with pulmonary consumption, it would be better, both for her and the infant, to dispense with the giving of suck. It is probable that the infant has already caught a touch of the taint or the diathesis, almost in the act of conception, and if not then, within the course of the uterine gestation. The sooner all influences of the mother's life over it shall pass away, the greater is the hope of its escaping the terrible fate before it; and on her part, it may be said food. 623 that the rudest and strongest health is oftentimes much diminished and shaken by twelve months of lactation, but, for a person having in the lungs the invisible seeds of a tuberculosis, to subject such a one to the exhausting processes of the long lactation, is to nurture and call them into a fatal activity. I do not mean, in these expositions, to recommend that the lying-in woman should at once begin to throw back upon her constitution the fluxional movement towards the mammary glands, which can only be normally counteracted by the physiological action of the gland. Her own safety exigently demands that she should favor its fluxional move- ment for a few weeks, but after four or six weeks she ought to let her milk slowly dry away, and provide for her child a wet-nurse of un- questionable qualities. I can conceive that, by proceeding in this manner, a family line might cast out of its stock even the tuberculous diathesis, in the course of a few generations; but it is melancholy to contemplate the misery which is in store for those, who, preferring the enjoyment of their natural and praiseworthy sentiments, turn a deaf ear to the warning voice of experience and prudence. Counsel, however, is to be given by the physician who is to be all things to all sorts of people; and it must be, that he shall have to counsel those whose circumstances forbid them to defray the extra expense of w r et-nursing. Under such circumstances the child must be fed ; milk is its food, and the best succedaneum for its mother's milk is the milk of the cow — indeed, there is none other to be had in the United States; it would be in vain in this country to recom- mend either the use of asses or of goat's milk, which, in various coun- tries in Europe, is abundantly provided for those who may find occa- sion to employ it. With regard to the artificial alimentation of a child, the Student should reflect a moment, and he will come to the conclusion that the act of digestion is much assisted by the admixture with the food that is ingested, of a due proportion of saliva. The saliva, though not so essential in the digestive evolution as the liquor gastricus, is a very indispensable agent in the act. A child that draws its milk from its mother's breast by the suction power of its mouth, may be almost said to masticate it, and in doing so occasions a stream of saliva to pass into the mouth, which it swallows along with its milk. The proper excitant of the salivary glands is firstly, perhaps, the presence of alimentary matters in the mouth, and secondly, still more powerfully, the motion of the tongue and cheeks and gums, in eating. 624 THE UMBILICUS. Now, a child that is fed from a spoon may be almost said to hare the food poured down its throat without swallowing it, and the same is true of the infant that takes its aliment from the edge of a bowl or cup. It is far more convenient and proper, in all cases of artificial aliment- ation, to simulate as closely as possible, the functions, and I believe that the child will digest its gill or half pint of food more safely and successfully, if it be taken through the biberon than if taken out of a spoon or cup. Let the Student give ample attention to these con- siderations, and judge for himself whether the remarks be well founded or not, and thereupon base his professional counsel. Without going into an examination of the different kinds of food, I prefer to request the attention of the Student to the opinions which I have expressed upon this subject, in my work upon Diseases of Children. Of the Navel. — The navel being dressed in a manner heretofore described, it is usually left thereafter to the care of the monthly nurse or attendant, and the physician is rarely called upon to interfere, ex- cept when it becomes the seat of some diseased action. The remainder of the umbilical cord, left after the severance of the child, soon begins to dry; the water of the Whartonian jelly contained in it, escapes through the inorganic pores or crevices in the amniotic coat; the vein usually contains a small coagulum of blood, and the arte- ries become collapsed and entirely desiccated. In the course of from four to seven days, the cord has become so dry and thin as to resemble a piece of transparent, yellow horn; the absorbents at the level of the demarkation early commence to cast off the slough, by establishing a crack or fissure all around its root, the fissure growing deeper and broader from day to day, allowing the desiccated vestige to fall away, leaving a small spot of raw surface, often not bigger than the head of a pin, for most of the wound becomes incarned or cicatrized as the process goes on. While the child is in the womb, and even at the moment of its birth, the navel protrudes, often to the length of half an inch; but the two arteries, whose cut ends are attached near the surface of the new formed cicatrix, act as cut arteries always do, by retracting and serving to draw the navel inwards and downwards in the direction of the urachus. The remainder of the vein, which becomes a cord passing alono- the ed^e of the falciform ligament of the liver, is also, but in a less degree, retracted. These vessels serve in this way to draw the navel inwards and to make the dimple of the umbilicus ; but the deepest THE MECONIUM. 625 pit of the dimple will look downwards towards the bladder, for the retractility of the arteries is the greatest. When the retraction thus effected is perfect, the tissues are drawn strongly inwards towards the inner aspect of the belly, and the vacuity in the linea alba, con- stituting the umbilical ring, becomes perfectly closed; but if this retraction be incomplete, then a plug of tissues contained within the circle of the umbilical ring prevents its absolute closure, and leaves the child liable to be affected with exomphalos or pouting of the navel. It is clear that in order to aid this retraction and complete it, a proper compress should be adjusted over the umbilicus and retained by the belly-band, whose use ought to be continued as long as its use is indicated. If the child is quiet, little given to crying and straining with tenesmus, and if the dimple of its navel be perfectly w r ell formed, the belly-band may be left off at the end of a month, but the least disposition to protrusion, or a wintery season, furnish oc- casion for its longer continuance. Of the Meconium. The meconium of the child is a dark, viscous green, diffluent matter which is contained in its colon and rectum at the period of its birth. The quantity is sometimes very great, and its first alvine discharges consist wholly of this material. Three or four of the first evacuations serve in general to carry it all off; occasionally it is so adhesive as not to quit the surfaces of the bowels; perhaps it is lodged in the cells of the colon, so that the bright bile-tinted stool of such a child, seen upon its napkin, induces a belief that the meconium is all purged off, whereas subsequent dejections show that no inconsiderable quantities have been detained in the intestine. When the meconium comes off freely, and seems to be entirely discharged, giving place to excretions of a healthy hue and consist- ence, no medical precautions can be deemed necessary; but if the child is uneasy, crying, fretful, affected with griping pains, which are betrayed by its voice and by the frequent flexion and extension of its lower extremities, with an appearance of passionate impatience, and especially if some portions of the meconium seem to linger upon the napkin one after another, we should have reason to suppose that the sur- faces are still vexed and irritated by this excreted matter, w T hich ought to be removed by small portions of castor oil or some other convenient aperient. Children that feed many times a day will generally be found to require several alvine dejections per diem. A child that satisfies its 40 626 ALVINE EVACUATIONS. instinctive desire for food, generally does so by filling the stomach until it is quite distended, and it will often happen that some portions of the ingested milk will pass off through the pylorus into the intestinal canal too early to have been subjected to the influence of the gastric liquor. Such portions of milk will, therefore, appear upon the nap- kins in broken, fine coagula of a white color. Most children, after filing the stomach to distension, enjoy the happy faculty of regurgitating the excess, so that the stomach soon becomes relieved of its over-fullness, retaining all that it has received, and subjecting it perfectly to the gastric digestion. A child that in this manner rejects the superfluity and completes the digestion of what remains, will have small residue of its ingestions and, therefore, will have fewer alvine discharges, which shall be smaller in quantity than those of the child a portion of whose undigested milk passes into the duodenum and jejunum. Without being able to speak positively from careful observation, I venture to state that the neonatus in perfect health has three or four changes of its napkin daily, and I conceive that this is not too great a number; at the same time I presume that a child might be very well, having only one dejection per day, provided it is known to have the faculty of regurgitating the superfluous ingestion, and provided also it has the appearance of enjoying a complete health. I beg to inform the Student that he will meet with a good many children which shall have eight, ten, sixteen, twenty dejections per diem, and that he will often be called upon by anxious parents to prescribe for such seeming diarrhoea. The case to which I allude is not a diarrhoea, it is a case in which a child, nourished at a free and abundant breast, fills its stomach again and again with a gastromor- phous clot of milk, a major part of which being comminuted by the contractions of the organ, is driven off through the pylorus, because the child has not the power to get rid of it by regurgitation. When I am called upon to give counsel in such cases, I do not always take it for granted that the child is sick because the nurse or mother tells me it is so, nor do I admit that it has a disease because it has twenty stools per day. Under such circumstances I have often said let it alone, do not interfere with the case at all, except by re- gulating the amount of its food ; do not give it such frequent oppor- tunities to suck, and decide carefully when it shall have what is necessary for it and then put it away. If you give medicine to stop its diarrhoea — which is not diarrhcea, but repletion — you will make the child sick, for if the child continues to live in the same way, so ALVINE EVACUATIONS. 627 as to require twenty napkins per day, and you prevent the action of its bowels, by means of some astringent or narcotic medicines, you will make it really ill — it is a case for hygiene not for therapia. I do not fear that I shall mislead the Student by the above observa- tions, because, if he be a man of sense, he will judge for himself, and not from me ; he will inquire what is the nature of these dejec- tions, which are accused of being diarrhoea, and if he should find that they are such as I have above described, he will perhaps remember my words, and act in accordance with the indications that I have pointed out. If the stools consists of masses of slime — if they are altogether bilious, if they give evidence of an excessive acid saburra, then he will inquire into the particular wants of the case, and pre- scribe accordingly. The mucous, the bilious, or the acid saburra, may require only a teaspoonful of castor oil, a small quantity of rhubarb, a portion of magnesia, a half grain of calomel, or calomel with chalk; or perhaps he will be enabled to fulfil the therapeutical indication by prescribing a portion of lime water and milk, or a little soda or potash mixed with water alone, or mixed in infusion of chamomile or some other bitter or aromatic garden herb. Possibly he may find the fault to con- sist in ahyperneuric condition of the peristaltic fibres either of the small or of the large intestine, and he will correct such an hyperneuria by means of an anodyne draught. An anodyne draught for the new-born infant should consist of half a drop of laudanum in a teaspoonful of water ; to give half a drop of laudanum let him direct the nurse to put two teaspoonfuls of water into a cup and add one drop of laudanum thereto, which, being perfectly mixed and compounded, permits him to give in one teaspoonful of the mixture, just half a drop — the other should be thrown away. Sometimes the new-born child, instead of being troubled with too many dejections, is affected with costiveness. This costiveness is overcome either by a suppository of molasses candy, of a bit of castile soap, of a camel's hair pencil dipped in castor oil, and thrust just within the grasp of the sphincter muscle. It may be remedied by an enema of tepid water, or water quickened with a modicum of salt, or molasses or castor oil ; or the child may take a teaspoonful of a weak infusion of rhubarb, or a little magnesia, or a little rhubarb toasted in a saucer until it is slightly brown, or, what is better than all, a pinch of pure precipitated sulphur mixed in water, sweetened with honey, or honey of roses. Small portions of sulphur mixed with honey water, appear to me to operate upon the neonatus more kindly 628 ALVLN'E EVACUATIONS. than any other therapeutic agent, in this peculiar sense, and the use of it, continued for a few days, often serves to remove an habitual disposition to costiveness. The Student should judge, however, in the eases commited to his care, as to the cause of the constipation. He knows, or he ought to know, that the bile furnished by the liver is the natural eccoprotic, and that if that bile should be in just quan- tity and of due quality, it should take the place of all rhubarb, senna and purgative drug. If upon inquiry into this case then he discovers a deficiency in the abundance of the bile, or, such modifications of its tint and qualities as seem to call for his therapeutical intervention, let him judge as to the precise nature of that intervention. Let him ask himself what is the source of the blood, which gives rise to the secretion of bile, or from which the bile is secerned, in the eliminating apparatus of it — in the liver. He will see that the whole of this blood came from the aorta, through its cceliac and its two mesenteric arteries; that the chief torrent of it, after being passed through the capillary circulation of the intestinal tube, hath been collected again by the radicles of the great portal vein, which lets it into the liver to be distributed through the hepatic branches of the vena porta? to the capillary tufts in the acini, whence it is carried off again by the nascent radicles of the hepatic veins, which are to discharge it into the cava — and so his question is answered, for he will scarcely believe that the hepatic artery is the secreting tube, but only the nutritious artery of the liver. When, then, he finds a child disordered as to the action of its bowels and liver, I hope that he will cast his eyes upon this great system of what the ancients called the mesaraic circulation, so that, inspecting the whole field of it, he may discern in what point of it the pathoge- nic principle resides. I should think that he could not look upon a hyperemic condition of the capillary system of any large portions of the alimentary tube as matters of indifference ; for the performance of the secerning func- tions of the liver and the retardation in the movements of the great external portal system or of the great interior portal system, cannot but be regarded by him as proving sufficient causes of those modifications of the functions of the liver which he desires to cure. Under these views it will not always be for him inevitable to administer mercurial remedies for slight derangements of the bile. He will provoke the peristaltic fibre to greater or renewed action, with a view to remove those embarrassments of the portal or mesaraic circulation which he shall accuse of the hepatic difficulty, and he shall find there a tea- THE GUM. 629 spoonful of castor oil, or a pinch of rhubarb, or a modicum of magne- sia, or an innocent dose of precipitated sulphur, quite as effectual and abundantly more safe than the vaunted power of the mercurial dose in these affections. It appears to me that in the United States, there is an indissoluble alliance between the word liver and the word calomel, and that the idea of the alterative power of calomel springs spontaneously at the least suggestion of an hepatic or bilious derangement. I do not deny that calomel is a purgative, or that it produces the most deadly nausea when taken into the stomach, nor that it may therefore, upon proper occasions, be rightfully administered, even to young children; but a conspectus of the circulation and of the innervation in those parts which stand before the gate of the liver and which serve, as it were, as the propyla, admitting the torrents of circulation into it, out of which the bile is to be taken by it, ought clearly to point to states of those parts, as the mesentery, the mesocolon and the alimentary canal itself, as the often seats of those pathogenical influences which are discoverable only in modifying the bile. I beg the Student to get his neonatus through the month without mercury, if possible; since, though I deem mercury an admissible remedy, I consider it a most desirable thing for the young child to avoid its too dangerous and powerful influences — influences capable of making such a profound impression upon the constitution as shall be felt in long after years. For my own part, notwithstanding I have long been laboriously engaged in practice of my art, I feel very con- fident that I do not employ one hundred and fifty grains of calomel in the course of twelve months ; and that I find my patients not the worse off on that account, while I myself am preserved from an in- tolerable anxiety which its administration always excites in my mind. Of the Gum. — Children coming into the world — issuing from the soft and unctuous waters by which they have been surrounded — are washed clean and exposed to the stimulating effects of the atmospheric air, and are, besides, covered with clothes, all of which serve to irri- tate the tender and sensitive outer covering of the body, the derm ; moreover, the first copious indraughts of atmospheric air, changing the blood and converting it into tenfold more oxygeniferous streams, must have the effect almost of an intoxicating inhalation of nitrous oxide upon the child. The corpus mucosum of the skin becomes instantly reddened, and, in many children, so red as to present the appearance of engorgement or inflammation; and there are not a few of them, 630 THE GUM. indeed, in whom this first burst of dermal circulation and hyperemia is so considerable as to be followed, in the course of a few davs, by desquamation, like that which succeeds to an attack of measles or scarlatina. We should not be surprised, therefore, to observe slight inflammations and eruptions of the superficial tissues; there are few children, indeed, who fail, in the first three or five days after their birth, to be attacked with a slight papular eruption which is called red gum, — a case in which a central papule is environed by a red aureole. It requires no particular treatment, since, like a vaccination it tends to cure itself; common custom and usage, however, prescribe the administration of weak aromatic infusions, which are supposed to possess a diaphoretic quality. Infusions of catmint, infusion of fennel, or anise, infusion of saffron, etc. etc., are commonly resorted to, and as they do not much harm it is not always, perhaps, the pro- vince of the physician to object to their exhibition. This red gum, or strophulus intertinctus, differs from the other sort, strophulus albidus, which exhibits a larger papule, more nearly re- sembling the blister of varicella, though much smaller than the vari- cella. It is not surrounded by a red aureole like the strophulus inter- tinctus. In children affected with either form of these eruptions, it is highly important that the skin should be frequently powdered with some proper fecula, and there is none preferable to that of ordinary arrow- root. The application of the fecula, under such circumstances, ap- pears to me to possess a remarkable power to allay the hyperemic and hyperneuric condition resulting in this form of eruption. Sore Mouth or Aphtha. — In the course of a few days after the birth of the child, it is common to find it a little more sleepy than ordinary, and to hear the nurses say, "It is sleeping for the sore mouth," and soon after, upon examining the interior of the lips, the gums and the tongue, they are found to be overspread with very minute white flakes, that look like small curds of milk. These are aphthae, or the thrush, or the child's sore mouth. The white deposit consists of a small quantity of excretion, albuminous, or, possibly, the fibrine of the blood, which is held in contact with the surfaces from which it exudes by a delicate film of epithelium, so that with the finger covered by a bit of rag, the white speck cannot be wiped away. In a short time, — that is, in the course of a day or two, — the pel- licle of epithelium gives way and the crust falls off, leaving sometimes a minute sore, and sometimes a renewed surface of epithelium from which the crust has fallen away. THE GUM. 631 Of course this malady is the result of inflammation of the corpus mucosum of the interior of the mouth and lips, and it is, to all intents and purposes a true stomatitis-mouth-inflammation. In nine cases out of ten it cures itself, and it is, probably, in its nature, very like the strophulus intertinctus, or strophulus albidus, of which I have just spoken, which are affections of the mucous body of the derm, whereas this is an affection of the mucous body of the mucous membrane. It is usual to accuse the child as laboring under an acid saburra, and to furnish it, in consequence of that accusation, with a dose of physic, which for the most part it does not really deserve. But, inas- much as this mild stomatitis may rise to a considerable height, becom- ing in fact, a general and extensive inflammation of the tissues within the mouth, extending backwards into the fauces, and from the isthmus faucium into the throat, it is worthy of attention on such occasions, and should be treated in conformity with its nature. The custom among physicians and nurses in this part of the coun- try, is to attack the local malady by means of portions of borax and powdered sugar, of which a pinch is frequently to be put upon the tongue of the child, and it is supposed to have sovereign power as a remedy for this malady. There is little objection to the use of bi- borate of soda, and it answers a good purpose, being a substitute for severer and useless remedies; now and then, when the stomatitis rises to a great and dangerous height, it is useful to wash the mouth of the child with a mixture of lime water and fine Peruvian bark in powder, or to touch the irritated surfaces with a camel's hair pencil, dipped in a weak solution of nitrate of silver, of a strength ranging from one grain to two or three grains to the ounce of distilled water ; or a solution of sulphate of copper in combination with sulphate of quinia — two grains of the former and half-a-dozen of the latter in an ounce of w r ater, furnishes a mixture w T hich may be efficaciously applied by delicate contacts of the camel's hair pencil to the affected parts. If fever arise, or saburra or disorder connected therewith, let the Student bethink himself of the efficacy of his doses of calomel or magnesia, or aperative medicine of whatever kind. There is another kind of sore mouth which looks like this, and which is called muguet, and which is, I think, not so often met with in this country, as by some European practitioners. It is supposed to be a vegetable substance attaching itself to the interior of the mouth, and sporiferous in its nature, so as to be capable of greatly ex- tending itself when once planted there. It differs from aphthae or thrush by being uncovered, or having no investment of the stomatic 632 JAUNDICE. epithelium. I am not familiar with it, and refer the Student to the authorities for further information. Icterus. — The neonat is very liable, in the course of a few days after his birth, to be affected with a signal yellowness of the whole skin and eyes, and to have his urine so stained with bile as to impress its color upon the napkins when dried from the urinary discharges. The icterus of the young child doubtless depends upon the regur- gitation of bile from the pori biliarii into the returning branches of the hepatic vessels, whereby the whole mass of the blood becomes stained with its yellow coloring material, which begins to appear first upon the colorless adnata, and next upon the whole dermal surface. Such a state of the skin does not imply absolutely a disease of the liver itself, since there are certain irritations affecting the duodenum, pro- ducing some degree of engorgement round about the ductus communis choledochus, and passing up along that tube, which might w T ell suf- fice to detain the secreted bile in the pori bilarii, and cause its regur- gitation in the manner above indicated. A dose of purgative medicine, freeing the stomach and duodenum and jejunum of a saburra, and relieving them thereby of a troublesome hyperemia, seems to me likely to set the gates of the bile wide open, so that, the regurgitation no longer being affected, the constitution soon eliminates the coloring matter of the bile from the blood, and the skin recovers its healthful hue and tint again. My clinical experience must have furnished me with numerous examples of these early hepatic derangements, as they are supposed to be, but it has left with me no painful impression of the dangerousness or the troublesomeness of the affection, which is transitory, disap- pearing in the course of a very few days. In those cases in which the inspection of the dejections shows that the bile escapes freely through the ductus communis into the duode- num, I am willing to wait for the result of such outflowing of the liquid, and for the return of the liver to its normal functional rate. Whenever, on the contrary, I discover whitish or clay-colored stools, or stools tinted faintly with a whitish-yellow bile, I am willing to ad- minister to my patient some doses consisting of the sixth part of a grain of calomel, repeated three or four times a day, and followed by a convenient quantity of castor oil or magnesia, or other approved aperient. Coryza. — Many young children suffer severely, soon after birth, CORYZA OR SNUFFLES. 633 from attacks of coryza, commonly, by the nurses and old women called snuffles, and when the attacks are severe, morbid snuffles. Some children, indeed, appear to me to have come into the world giving evidences, with the very first acts of respiration, of the presence of this malady. I do not mean to say that they have coryza before they are born ; but rather that they are born with certain tend- encies which allow coryza to declare itself immediately after birth. Coryza or snuffles is a state of the mucous membrane of the nostrils and air-passages of the head in general, occasioning a great abund- ance of mucus to be excreted from them ; which, filling up the air passages and obstructing them, causes the child to breathe with diffi- culty, making a rattling or snuffling noise with every respiratory movement. Many of the cases, being very slight and going off after a few days, scarcely serve to attract the attention of the physician, and the wise women content themselves with applying the usual remedy, which consists, in this country at least, in the application of a little grease or tallow to the bridge of the nose. While it is perfectly true that coryza is in many cases a matter apparently of small moment, yet it is true that the Student, when he observes its existence in the little nursling, ought not to pass it by idly and without notice, for it is capable of producing the greatest annoyance in the lying-in room by interrupting the sleep of the baby, and thereby interfering with the repose of its parent, a circumstance always to be deprecated. But more than this, coryza may kill the child outright — a thing to be deplored in itself considered, and perhaps still more to be deplored on account of its possible influence on the health of the mother, who, in the early days of her lying-in, is easily moved by slight pathogeni- cal causes, which, when they but begin to operate, may have results the most disastrous. Let the Student, therefore, not idly regard a case of coryza in the neonatus, if he would extend his watchful care both over it and its hypersesthetic parent. An accouchee is not like anybody else, and things may kill her, which, under other circumstances, might pass by her as the idle wind. I wish the Student to understand that the new-born child has no reason, but only instinct ; that it is a purely instinctive creature, and implicitly obeys the provocations of its instinctive nature. It has an in- stinct to breathe, for which purpose it is supplied with two respiratory stigmata, to wit, its nostrils. It has another aperture, its mouth, which its instinct teaches it to use only as an agent of its alimentation, not 634 CORYZA OR SNUFFLES. as an agent of its respiration. I wish the Student to understand that if he will stop the nostrils of a new-born child with two plugs of cotton or lint, so that no air can enter into those respiratory- stigmata, the infant will surely die within from one to three days, because, its instinct teaches it to breathe through its respiratory- passages and not through its mouth ; and because the subject of the experiment will persistently close its mouth or its isthmus faucium, and perish under vain attempts to continue its respiration through the closed up nostrils. When children die from coryza, as they not unfrequently do, they die in the manner just pointed out, and I adjure the Student who shall read this passage, to give his careful and candid attention to the doctrines set forth in it, and, looking upon the child that is seri- ously ill with coryza, see how, after making repeated attempts to aspire air through the nostrils, it suddenly starts forward, throwing out its hands with an appearance of agonized distress, and then, opening its mouth widely, suddenly makes a full and complete aspiration of air, which, dispelling for a moment the sense of suffocation, permits again the renewal of its vain attempts to breathe through the natural open- ings. If it had reason to guide it, as a man has, it might breathe with perfect facility throughout the most dreadful attack of coryza, even coryza maligna; but it has only instinct for its guide, and that in- stinct teaches it to breathe through the natural openings. I will take this occasion to remark that the loss of life from coryza is to be observed sometimes in children many months old, and that a child even over two years of age may be lost in this way, as I have learned by disastrous clinical experience, and if the Student who reads these passages should find any hesitancy in his mind to admit the truth of my explanation, I believe that all doubt would vanish from him if he would please to make the following experiment. Let him con- press the alse nasi together with his thumb and finger, and then make half a dozen consecutive attempts to breathe, keeping his mouth shut at the same time ; he will find that the effort to send down the dia- phragm and expand the thorax will produce within the whole chest a deep feeling of distress, amounting almost to pain. But let him re- peat the attempts five or six times consecutively; and then, while making the last attempts, suddenly open the mouth and permit the air to rush in a torrent into the air passages, he will have the sensations which I attribute to the young infant when, after its repeated attempts to breathe through the nostril, it starts forward, throwing its hands wildly abroad and filling its lungs with air through the opened mouth. CORYZA OR SNUFFLES. 635 If the Student, after experiencing these sensations, will reflect upon the effect of such experiments, repeated through two or three consecu- tive days, by a tender infant just born into the world, he will agree with me, that stopping of the nasal passages is the thing greatly to be deprecated. I do not mean him to understand that in ordinary cases of coryza the child takes no air through its respiratory stigmata, for it does get that small portion on which it subsists in that way, up to the period, at least, in which the apertures, having become totally obstructed, compel it at last to make the sudden and convulsive aspi- rations through the mouth which I have attempted to describe. But the difficult and interrupted aspiration of air through nostrils only partially obstructed, is sufficient to diminish the amount of oxygen breathed upon the blood, and the torpid and imperfect innervation, pro- duced by the imperfectly oxygenized blood in the vessels of the brain, is followed by various derangements in the action of the organs whose force depends upon the regular supply of the vis nervosa. A young child, then, laboring under a considerable coryza, will have carboniferous blood in the systemic circulation; it will be pale, languid and unhappy, and is always exposed in consequence to attacks of pulmonary or cerebral or abdominal disorder. I look upon a child, whose nostrils are half stopped up whether by mucus, or by submucous infiltration, as in a state analogous to that of an infant laboring under a moderate degree of pseudo-membranous laryngitis; for the one or the other equally prevents the aeration of the blood with its necessary amount of oxygen, and all the consequences of such a state result. I ask the Student whether the constitutional disturbance arising from such a degree of disorder as exists in the Schneiderian surface in a case of coryza could possibly be so disastrous, were it not for the accidental interruption occasioned by it to the oxygenating power of the respiration. I should think that an inflammation ten times more violent w r ould be incapable of producing so great an amount of constitutional disorder through any other means than those above alluded to, for the reaction of the heart and arteries occasioned by it, and the distress of the nervous system, occasioned by the perception of it, would be nothing, I was going to say less than nothing — were it not for the accidental interruption to the oxygenation. Therefore, I repeat that the slightest attack of coryza is worthy to be regarded. But the question arises what shall we do for the cure of this case; how shall we free the Schneiderian membrane from its hyperemia and hyperneuria ; how shall we prevent its follicles from furnrshinig 636 CORYZA. this excessive amount of mucus, or how shall we take away the sub- mucous infiltration, which causes the cavities to collapse and defini- tively to close them? Will the vulgar remedy, greasing the nose, have this effect? Certainly the Student cannot rely upon such a therapia as that. Will he purge the child? Will he give it a warm bath? Will he apply a leech within the margin of each nostril? Will he give it diaphoretic remedies? Will he regulate the tem- perature of its apartment? Will he cause the aperture of the nostril to be kept free from the scales and incrustations produced at the orifice by the desiccation of the mucus that falls upon the very margin of the nostrils, and sometimes forms tampons or plugs running far back into the cavities of the head? It is well if he will do all these things; but experience, the best of teachers, will show him that such remedies have little power over the disorder, and the coryza goes on notwith- standing all his attempts. Will he produce a useful therapeutical im- pression upon the mucous passages by touching them with a delicate camel's hair pencil, dipped in proper solutions of nitrate of silver or other metallic salts ? Even these things fail, and often fail, but there is a treat- ment which experience, the best of teachers, has taught me never fails. I scarcely dare, in a formal work, pretending to a character of science, to say what this treatment is, and yet I must, with undoubting con- fidence, recommend the Student to adopt it. When a new-born child is seized with a coryza that attracts my attention, I invariably direct a skull-cup made of flannel, to be so constructed as accurately and perfectly to fit the form of the cranium. I direct this cap to be fastened upon its head, and to be left there for three days and nights, and I always feel sure that within about that time the coryza will have totally disappeared. I mean to say that the cap should fit the head closely — not loosely, for I desire that the air of the apartment should not pass freely under it. If the Student will try my method and fail, he can but be disap- pointed, which, I am confident he will not be ; if he adopts all or any of the other remedies that I have hinted at above, he will surely meet with disappointment many times — by my method never. It is hardly worth while to reason upon this subject, but let him read Dr. Denman's account of coryza, and the accounts contained in the treatises on the diseases of children, in order to learn how he can, in a better manner than that I have pointed out and more effectually, counteract the pernicious existence and tendency of this troublesome malady. CYANOSIS. 637 CHAPTER XXIV CYANOSIS NEONATORUM. I begin by requesting the Student to take notice that the title of this article is cyanosis neonatorum, or the blue-disease of young chil- dren, and that I have no design herein to treat of all the affections that may in anywise serve to contravene the aeration of the blood — for all such diseases are causes of cyanosis. There is so great a variety of maladies that interfere with the due aeration of the blood, that a volume, rather than a short article, ought to be devoted to their consideration, in any attempt to describe all of them. — Malformation of the heart and its vessels — unnatural states of the lungs, whether congenital or accidental — tumors — hydropic collections — tubercles — vomicae — congestion — inflammation — whatsoever, in fine, prevents the due exercise of the whole function of respiration, may be set down among the possible causes of cyanosis. My intention is to treat only of those cases that are coincident with permanency, after birth, of the characteristics of the foetal heart. In the four great zoological classes, the mammals, birds, reptiles, and fishes, the circulation is effected chiefly by the force of a com- pound heart, whose economical purpose it is not merely to carry on the circulation, dispensing the blood and caloric into every part of the system, but in a pre-eminent degree to convey oxygen into every part and point of the system. In lower grades of being, as in the insects, and annelides, air is ad- mitted to the trachea through open stigmata on the surface of the body. These lower creatures require no mechanical apparatus or circulating force, to compel the air to enter the interior recesses of the tissues. It permeates tubes that are always open to admit oxygen to the or- ganic molecules. The higher orders of creatures could not exist without a complete machine competent to fulfil this indispensable design and purpose. Hence the birds and mammals are provided with lungs and a double heart, or rather with two hearts, one carbon- iferous, or venous, and the other oxygeniferous, or arterial. 638 CYANOSIS NEONATORUM. In the reptiles there are, properly speaking, three hearts, of which one is venous, or carboniferous, another oxygeniferous, and the third mixed, propelling both the oxygenated and the undecarbonized blood. In fishes, the heart is absolutely venous, consisting of an auricle receiving the blood from the whole body, which it delivers into the single ventricle; whose office it is to inject this blood, in whole or in part, upon the oxygenating surfaces, called branchise, or gills, whence it flows off to the constitution, to return by the principal dorsal vein, to the auricle; the fish's heart, in this view, may be considered as a true pulmonic auricle and ventricle. T.he child in utero may, as to the nature of its sanguine circulation, be compared to the fish, or the batrachian. In very early stages of its embryonal life — not the very earliest — the heart consists of a double ventricle, equal to one ventricle, and of a single auricle. I say one auricle, since the auricular septum can hardly be said to exist, and the two auricular cavities are virtually one. I also said that it has a double ventricle, each of the cavities of which lends its energies to the systemic circulation. In the beginning, the pulmonary artery — which is really a ductus arteriosus — and the aorta equally concur in the production of the systemic circulation; both ventricles being required to give impulse to a circulation necessary to the rapid development of the constitution, and drive the blood to the distant capillary tufts of the placenta and back again to the heart. With the progress of the intra-uterine life, the pulmonary artery becomes developed upon the ductus arteriosus, which loses by degrees its transitive importance, and is laid wholly aside at birth as a no longer useful machinery of the circulation. The aeration of the embryonal and foetal blood depending on the placenta, a machinery is required to get the oxygeniferous blood of the placental tufts out of the venous into the systemic circulation of the child, and another apparatus to turn over its venous or carboni- ferous blood into a part, not the whole, of the systemic circulation, which alone can transfer it to the aerating tufts of the placenta ; there- fore, in the child somewhat advanced in its uterine life, there is of ne- cessity a crossing of the currents of oxygeniferous and carboniferous blood, in the right auricle, and a direct channel of transfer from the right ventricle to the aorta. The blood of the umbilical vein, mixed with that of the inferior cava, enters the posterior, right, lower segment of the right auricle behind the right extremity of Eustachi's valve, which conducts it across the cavity to the fossa ovalis, leading it through the foramen CYANOSIS NEONATORUM. 639 ovale. The current lifts Botalli's valve, which is on the left face of the septum, to pour itself out into the systemic auricle. The left ven- tricle receives it, and thence it is conducted by the carotids and vertebrals to the encephalon. This is the best blood of the foetus. It is not highly aerated ; probably, not so highly as that of the Reptilia, consisting as it does of the deoxygenated blood of the portal circulation, and of that of the lower extremities and pelvis, and animated only by the slight endow- ment of oxygen it could acquire in the placenta, from whence it is derived by the umbilical vein. Imperfectly aerated as it may be, it is to a certain extent, the oxy- geniferous fluid of the foetus, and is capable of developing the torpid innervations of the embryo and foetus, which are, perhaps, far inferior in intensity to those of the chelonians and other Reptilia; doubtless, far inferior to those of many tracheal creatures and infusorials. Having made its route to the encephalon and superior extremities, where it has given out its oxygen, the blood has become thoroughly venous, and returns to the right auricle, into which it plunges at the superior part of the sac, in front of Eustachi's valve, and opposite to the iter ad ventriculum dextrum, through which it flows, while the current from the inferior cava passes through the foramen ovale behind it, and at right angles to it. The right ventricle is filled then with the venous blood of the head and upper extremities, which it injects, by the pulmonary artery, vir- tually the ductus arteriosus, into the aorta, below the giving off of the carotids and subclavians. Thus it arrives again at the placenta. In this crossing of the currents in the auricle, there is a partial mixture, but it is presumed to be only partial. It is probable that a major part of the blood from the ductus venosus, mixed with that of the hepatic veins and inferior cava, is directed upon the head and superior extremities, though it is true that a portion of it turns over the aortic arch to be mixed with the current from the ductus arteriosus. It is, indeed, essential that this should happen, since otherwise, the whole of the digestive, renal, and pelvic branches, as well as those of the inferior extremities, would otherwise be as- phyxiated. This admirable arrangement, by which the systole of the left ven- tricle propels both the arterial blood to the brain, and the venous blood to the placenta, must necessarily persist throughout the gestative life; for, should it cease previously to the birth, the foetus would inevitably perish, while its persistence after birth, would be equally fatal. 640 CYANOSIS NEONATORUM. The foramen ovale affords the sole normal route of the arterial blood from the placenta towards the brain. Hence, the foramen ovale is persistent in the foetus. Hence, also, the child is born with an open foramen ovale. But the foramen is provided with an operculum or valve. The valve, called valve of Botalli, lies upon the left wall of the septum auricularum. When the valve is shut, the opening is closed. The lifting of the valve re-opens the aperture. If the valve be closed before the establishment of the respiratory- life, the child dies from absence of oxygen in its brain, for the oxygen of the placenta cannot reach the brain by any other route. The valve remains open for many days after the birth of the child, three, ten, twenty days; and it may be open seventy years in some cases. As, in the uterine life, aerated blood passes through the foramen, so, in the respiratory life, carbonated blood, if any, passes through the opening, to fill the left auricle. Whenever the left auricle is filled with venous blood, it is injected by the systemic ventricle into the brain and the whole system. Such injections produce cyanosis. Cyanosis is a state of non- aeration, more or less complete and universal. Cyanosis of the capillary system of the brain, is true asphyxia. The degree of intensity of the blue color in cyanosis, is not a certain criterion of the effect produced by the malady. One individual may tolerate a greater degree of cyanosis than another, with less inconvenience and distress than that other indi- vidual. I repeat that cyanosis, whether general or local, is a degree of as- phyxia of the parts exhibiting the phenomenon. Blue hands from cold weather, blue finger-nails from ague, from cholera, from drunken- ness, or etherization, is asphyxia of those parts severally. Asphyxia of the capillaries of the skin, or of the extremities, is not inconsistent with life. But, asphyxia of the encephalic capillaries, when carried to a certain extent, is mortal. Mortal asphyxia is always so because the capillaries of the brain are then the seats of the malady. This I consider to be true, because the asphyxiation of a limb by means of the tourniquet is not suddenly mortal, it does not speedily destroy life, it only arrests development; whereas carboniferous blood in the capillaries of the brain destroys life instanter, if it be wholly and only carboniferous. CYANOSIS NEONATORUM. 641 Many children at birth, or soon after delivery, discharge the blood of the right auricle into the left auricle, in consequence of asynchronous action of the heart. In such cases, to shut down the operculum or valve of Botalli, is to arrest the flow and cure the patient for the time being, or for all future time. In November, 1832, the year of cholera, I had charge of the case of Mrs. Taylor, No. 503 North Fourth Street. She was about seven and a half months gone with child, when she was seized with symp- toms of the prevailing epidemic. She was violently attacked, and became also affected with symptoms of premature labor, which at length led to the expulsion of the foetus. The child was alive, but began to turn blue under its respiration. As the cyanotic hue became more intense, the phenomena exhibited by its innervative forces turned more and more unnatural, so that, employing only faint and imperfect aspirations, often suspended; becoming convulsed, and having feeble, scarcely perceptible pulsa- tions, it seemed at the point of death. The young mother, who was still ill with her cholera, could not be insensible to the danger of the child, and I perceived that the com- plication of a psychological with her other irritations, might render the cure of her own malady more difficult, if not impossible. It became, then, in view of the mother's position, a matter of great moment to rescue the child from an apparently imminent death. These reflections, which I made at the time, gave me great pain; — for, while I deemed the state of the child one of partial asphyxia from the mixture of its venous with its arterial blood, the mixture being made by injection through the foramen ovale of the auricular septum, I could devise no treatment upon which to rely for obviating that injection. I was deeply concerned, and knew not what to do; suddenly I reflected upon the structure of the fcetal heart, and the route of the foetal circulation, and I said, if I bring the septum auricularum into a horizontal attitude, will not the blood in the left auricle press the valve of Botalli down upon the foramen ovale, and thus save the child, by compelling all the blood of the right auricle to pass by the iter ad ventriculum, and so to the lungs to be aerated? Having practiced midwifery for many years, I had on many occa» sions witnessed the fatal termination of cyanosis neonatorum, both in the premature and the mature child. I had seen children at five, and at five and a half, at six, and at seven months, vainly attempting to 41 642 CYANOSIS NEONATORUM. carry on respiratory life, and found them all to perish with the signs of cyanosis, whether from too large a foramen ovale, or from imperfect development of the respiratory machinery of the lungs by atelectasis. In the case now under consideration, I placed the child, which seemed nearly dead, upon a pillow, on its right side, the head and trunk being inclined upwards about twenty or thirty degrees. Upon placing it down in this manner, it became quiet — began to breathe more naturally; to acquire a better hue of the face, hands, and feet; until, in a very short time, it was quite well again, and did well; having no further returns of the attack of cyanosis neonati. I shall not conceal the satisfaction I derived from the successful result of my reflections, thus put into practice, in the case; for I thought, and I still think, that the child would have died inevitably, but for the treatment. In very many instances, during a long obste- tric experience, I had never made such a reflection upon the means of saving the blue child, of which I had seen so many cut off. I believed, and I still believe, that I was the first to invent the treat- ment; and thus the first case in which I put it in practice, was eminently successful. I am not aware that any other person had before suggested it, though in his account of cyanosis, M. Gintrac gives in case 5th an account of Dr. Wm. Hunter's patient, set. 8, who obtained relief from a paroxysm, by lying still upon his left side, which always relieved him. After his death, the ventricular septum was found to be wanting, or rather perforated near the base of the heart, so that the aorta received the injection of the right, as well as of the left ventricle. — Vide Gintrac, p. 33. Six years later, in my Philad. Pract. of Mid., edit. 1838, I pub- lished some remarks on cyanosis, or blue-disease, which being written in much haste, I did not at the time remember the circumstances of the above case, which occurred in Nov. 1832, in Fourth Street above Poplar, No. 503, in a child of Mr. Taylor, a builder, formerly of this city. Since the date of my first application of this method, 1 have had numerous occasions to put it in practice, and not a few opportunities of examining the state of the heart after death, in some of which, after vainly applying the treatment, I came to the conclusion that other causes, not patency of the foramen ovale, must exist, to contravene the curative tendency of the method. My publications — and my explanations to friends — with the lectures on the subject that I have now delivered to many hundred students of medicine, have rendered my treatment a popular one — to such an CYANOSIS NEONATORUM. 643 extent, that, in various States of the Union, the treatment is become a familiar one. Many monthly nurses have become acquainted with it, and I presume it is so divulgated throughout the land, that children suffering from the malady will very generally have the advantage of its application, if it be really advantageous, and this the more pro- bably, since no reasonable objection could be found to the putting of it in practice. I make these remarks, founding them upon various letters I have received from gentlemen in the differen Sttates of the Union; from conversations, and from statements made to me by medical Students on their arrival here, in the autumn, of cases treated by their instructors. This explanation w T ill show that I am warranted to say, that my invention has become extensively known, and is to a reasonable extent understood and practiced in this country; the more especially as it has been reported by many hundred Medical Students, that are now settled in the north, the south, the east, and the west. The following is extracted from a letter to me dated Pittsburgh, Dec. 7, 1838, from Dr. W. F. Irwin. " The second item of information derived from your work is that in which you lay down the only rational explanation and mode of treatment for that formidable disease of infants called ' morbus cceruleus.' During a practice of twenty-five years, I have had about tw T elve cases. In one family I lost two cases in succession, with an interval of two years. In this family there appeared to be a sin- gular tendency to the disease. From the mother's account I should conclude that out of six deaths in her family, five must have died of morbus coeruleus. In deference to authority I have generally pursued the plan recommended by the late Dr. Hosack, which may be seen in the Appendix to Thomas* 's Practice; and I must say that I was never satisfied with it, as it appeared to me to have no sort of adaptation to the then received pathology of the disease. In some cases, I have thought that a tepid salt bath produced a beneficial change in the color of the skin, and in the respiration. In two cases a tablespoonful of blood drawn from the cord seemed to have a good effect. In a case that occurred in August last — the child, which had been well for five or six days, suddenly changed color — had laborious and in- terrupted respiration at long intervals. I was sent for immediately, and ordered a warm salt bath, in which the change of color from blue to the healthy tint was remarkably rapid. The attending physician came into the room while I was engaged, gave some 644 CYANOSIS NEONATORUM. powders, and the infant died. In October last I had a strongly marked case in the afternoon at about six o'clock As soon as the nurse announced the condition of the child, I had the washing sus- pended, and ordered the child to be placed on its right side and to be left undisturbed until the following morning. At my visit next day, I found the infant healthy in every particular, and it has continued so until the present time. I have been so pleased with what I deem your philosophical mode of treatment and its success in the above case, that I could not refrain from communicating the result." I have now before me a letter from Paul F. Eve, M. D., Prof, of Surgery in the Medical College of Georgia, dated Augusta, Feb. 2, 1848. In this letter, Dr. Eve informs me that he was in attendance 22d Nov., 1847, upon Mrs. C, then affected with premature labor of an uncertain date of gestation. The child, a male, which was born after an easy travail, weighed between five and a half and six pounds. The testes were not yet in the scrotum. The respiration was at first carried on by sighs repeated once in five minutes. The child was once supposed to be dead, and given up as lost; but by breathing into the lungs it revived, and then upon being laid upon its right side, where it was kept during four days, it perfectly recovered, and was healthy at the date of the letter. It was not dressed for three days. Every motion, for some time after its birth, would produce the cyanosis. Dr. Eve is inclined to believe it was six and a half months in the womb. Feb. 11, 1848. Mr. S. C.'s son, set. 11 weeks. Very stout and healthy since his birth. Was vaccinated on the 3d instant, and has now a full sized vesicle and areola; slept badly last night. This morning was much agitated and cried long — became blue as to the whole face — moaned for a long time. His mother supposed he " was going into a fit," and could not otherwise account for his strange ap- pearance. (She has had six children.) The child was crying when I arrived. The upper lip was very livid, and the countenance wore an air of distress. I laid it down upon its right side; it became quiet and the livid areola vanished. I turned it on the left side, and the dark livor of the upper lip reap- peared. Upon rolling it on the right side again the color disappeared, but returned when I replaced the infant on its left side. I gave it a teaspoonfulof oil, with orders to lay it on the right side. Feb. 12th. Had a good night, and seems well to-day. In dressing it, the mother says, it became livid. She observed that it was on the left side, but upon turning it on the right it recovered and has been well ever since. CYANOSIS NEONATORUM. 645 Jan. 3d, 1849, I believe this child has had no indisposition since the foregoing date. In March, 1848, I attended Mrs. G. T , who was at the time delivered of a child at six months and ten days. It was deeply cyanosed for four days after its birth. The nurse kept it almost wholly reclined on its right side, and the infant, now about nine months old, presents a good prospect of a successful rearing of it. In this case, the child was certainly relieved when laid upon the right side. In the early part of the year 1848, I delivered Mrs. , Thirteenth Street, of a foetus at six months. It breathed well at first, and uttered loud cries. But cyanosis came on the third day. I many times caused the livor to disappear by turning it on the right side, and made it return by rolling the child gently over to the left side and vice versa, as often as I repeated the experiment. It died after some days. The foramen ovale was slightly open, and the lungs partially affected with atelectasis. Here is another letter, dated Antrim, Alleghany County, Penn., Feb. 11, 1848, which was addressed to me by Dr. S. Schreiner, a graduate of the Jefferson Medical College. "Mrs. A. S r was delivered on Tuesday, Jan. 11, 1848, at .7 P. M., of a male infant. Nothing peculiar transpired during the gestation or delivery. Parents healthy; mother quite lusty. Sup- posed weight of the child about eight pounds; it seemed of full age, healthy, and well to do. About 9 P. M., it seemed to have a violent attack of colic; cried violently. All attempts to pacify it were vain, until about midnight, when it became quiet, and was laid in bed behind the mother, where it remained until about 8 A. M. on Wed- nesday. At that time the mother awoke, and thinking it breathed strangely, asked the nurse to take it up, to see what was the matter. She did so, and observed that it was of a dark-purple hue ; the breath- ing seemed to cease; it was strongly convulsed, the fingers being clenched firmly against the palms of the hands." Dr. S. informs me that the child was now removed from the lying- in chamber, in order that the mother, after she had been told it was dying, might not witness its last agony. "Upon remaining so for some time, it gasped for breath, the purple discoloration faded from it, and the paroxysm was over. It remained quiet, without any motion whatever for about three hours, when the fit returned again; and again it did so, each paroxysm con- tinuing longer and increasing in intensity until Thursday (the following day), between four and five P. M., at which time I first saw r it. Dur- 646 CYANOSIS NEONATORUM. ing this time it had seventeen attacks, the duration of the last one being over forty minutes. The attacks returned at intervals of a little more than an hour. " Its appearance, when first seen, was as follows. It laid motion- less upon a pillow in the nurse's arms; pulse irritable; cheeks suf- fused with a scarlet flush; respiration short and quick; (it seemed as if fever was present;) dusky color of the skin, except the bright spot on the cheeks. Soon its face, then its body and limbs, became of a dark purple or nearly black color ; respiration, a short gasp at long intervals, gradually increasing until it was altogether suspended for twenty minutes ; pulse grew fainter and fainter, until it ceased at the wrist, and the heart only gave a heavy throb at long intervals. Gradually the pulse became (again) perceptible at the wrist — the discoloration vanished, and the paroxysm was over. " Though the parents and all present declared there was no use in attempting anything for its relief, they consented that a trial should be made. I had it laid in the position recommended by you in your course of lectures, and in your Phil. Prac. of Mid., upon the right side, at an angle of 30°, enjoining strict adherence to the position. " From its flushed appearance, and the congestion seemingly present, I should have recommended leeches, had they been at com- mand. I remained long enough for another paroxysm to have taken place, judging from the previous intervals, but it did not take place. During this time it attempted to cry, but made no sound whatever, though it seemed to cry violently. After this it passed some meco- nium, and took a little milk and water which it sucked from a rag placed in its mouth. I was told these were the first motions of the kind it had made for twenty-four hours. They had before poured some nourishment down its throat, but it appeared to bring on a fit, and they desisted. ■ I saw it again the next morning. It had two returns of the disease ; so very slight, however, as only to be observed by the face becoming darker; but they continued only a few minutes. I should not forget to mention, that after each of these, perspiration ensued; slight attacks first, but after the second very copious. " Pulse at this time appeared normal ; respiration easy, but somewhat quick. I saw it again to-day. Has had no return of the paroxysm, and is in excellent health, with the exception of an occasional attack of colic." I shall now offer some observations on the circulation of the blood, in order to sustain the position I have taken as to the influence of the child's attitude in curing it of an attack of cyanosis neonati; and I CYANOSIS NEONATORUM. 647 shall do this, not merely to defend my opinion and practice against the opposition of those who deny the utility of the precept, and the reasonableness of its doctrine, but because, while it has been, in my hands, the means of rescuing many children from death, it has also led me to entertain views of the pathology and treatment of certain disorders which I desire now to express, hoping they may become useful to the public, and to my brethren generally. This I shall do notwithstanding it may expose me to the charge of useless iteration ; for I desire not to ask the Student to turn back to the former pages of my book ; but rather, that he should perpend my explanation in this one chapter. In contemplating a living body, we are struck with the conviction of its complex nature and attributes. We behold it as consisting of various parts and organs, each endowed with powers of its own, and each charged with some especial function, the due and harmonious exercise of which by all the organs represents a state of health, while an imperfect or irregular performance of any of these offices is indi- cative of a condition of derangement, disorder or disease. In contemplating such a being, in whatever grade of the zoological series it may be stationed, we are compelled to admit that of its parts, some are of more and others of less importance. It has parts that might truly be called noble, and others that are common or vile. Whether it be an annelide, or insect, a radiate, vertebrate, reptile, fish, bird or mammal, the Ens, the living creature, the Verb — that which can do, be, or suffer, of it, is composed of the nervous mass of the creature, which is noble, and all the rest is vile, common and of less account. To look upon the Figures at page 4 of Milne Edwards' volume on the Invertebrata, wherein he has represented the nervous system of an earwig, a grasshopper, &c, one sees the real abstract animal, deprived of all save its nervous mass, which alone is the patible, sensitive, and perceptive being, while all the rest of the constitution of it being taken away, it has thereby lost only its servitors — its pre- hensile, locomotive, digestive, reproductive, aerating organs. The nervous mass — the creature — the Ens, is left entire — naked — alone, in an abstract state. This idea of a creature, abstracted from its armature, its engines and agents, is by no means a novelty, and it has the sanction of the wisest men — such as Cuvier, Lorenz Oken, and others. It is upon this idea of the creature, as consisting essentially of the nervous mass, that all modern zoological classification depends, and in fact, the 648 CYANOSIS NEONATORUM. whole regne animal of the illustrious French naturalist has derived the exact method and order of its arrangement from a view of the disposition of the nervous system of its integral individuals. In the higher orders of the vertebrata, the number and magnitude of the organs are greatly augmented above those of the simpler existences. A medusa, an actinia, a holothuria, or a polyp is, equally with the most elevated mammal, composed essentially of a nervous mass, which in some without, and in others with a centrical sensorium, exists either by means of disseminated nerve points, or by a ganglionic and filamentous system of innervations. In the human being, the nervous mass is the cerebro-spinal axis, and the sympathetic and plexual system, with all the nerve-fibres that blend their distal extremities, or reflect their fibrillar in the substance, or on the surfaces of the tissues. The heart itself and the stomach are but portions of the nervous mass, enveloped, like the gem in geology, in the gangue of the cellular, muscular, mucous, or fibrous tela. The same is true of the alimentary, respiratory, secretory, absorbent, sensual, and reproductive organs — of which an ultimate anatomy ought to seek to expose and make manifest solely the nervous portion of its mass. The whole brain and cord — the pneumogastric, the trifacial, and the phrenic nerve — all the arches of the great sympathetic — every ganglion "plexus, and fibrilla, are either conductors or generators of biotic force. But, whether conductors or generators, it cannot be denied that they are in a degree generators, since all nervous mass is a generator. In either case, the material vile parts which they innervate, owe, not their existence only, and their development to the nervous mass with- in them, but every modification of their vitality, every shade of their life modality, may be assigned to a status of the supplying and sus- taining: nervous mass. In the series of creatures, rising from the lowest infusorial, we find at the summit of the scale, man with his concentrated cerebral, or cerebro-spinal nervous mass, by means of which he is rendered capable not only of impression, but of conscious perception, and of free-will; of reason and judgment, with all the powers of the intelli- gent mind. It is for the conservation of this nervous Ens — this nervous mass, as Oken denominates it, that its servants and ministers the anatomical organs and histological tissues are added to it, as its endowments and CYANOSIS NEONATORUM. 649 properties. IT is the seat and source of their vitality. They are regulated and maintained in a co-ordinated life by ITS biotic force. When that biotic force fails, they fail likewise ; when it dies, they also perish; when it recovers its energy, they resume their powers, and perform their offices for its conservation — its protraction — its sensation — its consciousness — its free-will — its reason — judgment, imagination — its hope and its charity — its fore-thought — its retrospec- tion — its self-complacency, and its remorse. But what is this nervous mass? Oken says, " The origin of the animal is from the nerves, and all anatomical systems are only free evolutions or separations from the nervous mass. The animal is naught but nerve; what it is fur- ther, or in addition, is obtained elsewhere, or is a metamorphosis of nerves." " When, also, the other systems have been formed out of the identical nervous mass, still the whole animal body is naught but nervous mass, only, in a crude or inert condition. There is, conse- quently, no point upon the body, on which some nervous phenomena are absolutely wanting, or where they may not appear, under certain relations.' 7 — Physio -philosophy, page 330. I shall not encumber these pages with quotations from the autho- rities, to fortify the assertion that the nervous mass is the essential Ens. The asseverations of a thousand philosophers would not make more or less true, a proposition which commends itself to the mind, acting upon its own perception and judgment of a dogma declared to be true. Such a truth is not proved by evidence, nor established by any method of induction. It is a truth of reason — it is a truth of consciousness — it is in the same category with the cognition of our personal identity. Taking the dogma for granted, therefore, I shall proceed to show that the cerebro-spinal axis in man, is inert and powerless, nay, life- less, exanimate as of itself; and that it depends upon the influence of oxygen for its power to manifest itself in its life-phenomena. The same Oken has said that " the blood is the fluid body;" and that " the body is the fixed and rigid blood." These expressions are equivalent to the assertion that the histolo- gical materials of the body are derived from the blood, and no one will deny the proposition. Even the nervous mass itself is developed and maintained in volume, form, and weight, by supplies from the sanguine mass ; but the oxygen of the blood is the agent by which the force of nerves is brought into play. The oxygen taken up in 650 CYANOSIS NEONATORUM. the act of respiration, and carried into the arterial or aerated blood, is transferred to the brain by the arteries, and there its contact or im- miscence with the material essence of the brain, is followed by the extrication of the power, or nerve-force. In this view, an artery is not a mere sanguiferous tube, it is an oxygeniferous tube, and it car- ries that principle everywhere throughout the body. The respiratory organ, in this view, too, is but the oxygenating apparatus, though it thus produces the double effect of endowing the blood with its oxygen, and at the same time developing the animal heat, while it also eliminates a portion of the somatic carbon. The highest function of the respiration is the oxygenation of the nervous mass. M. Cerise, in his paper, Sur la Sur Excitation JVerveux, Mem. de VAcad. Roy. de Med., avers that to the blood in the brain, is due the extrication of the life-force, the nervous force. This doctrine is not true, if hypothecated as of mere blood; since carbonated or carboni- ferous blood — venous blood in the capillary vessels of the brain — is incapable of effecting the least evolution of power from the nervous mass. Oxygeniferous blood is all-powerful for its extrication. Hence, since blood, merely as such, cannot generate the life-force, while aerated blood can do so with absolute perfection ; we have a clear inference to the opinion that it is the oxygen which is the agent ; and that, by a plain induction of facts, all of which, without exception, concur to declare that oxygen is indispensable to the exertion of a life-force — -force-vitale. — Lebenskraft. Nothing lives, save in the presence of oxygen. It is even true that, the spiritual soul being present, all life is a result of a process of oxygenation. Hydrogen azote, chlorine, nor carbonic acid cannot evolve nor sustain life. Oxygen is the vitalizing, not the vital prin- ciple. It is the cosmic reagent for producing vitality out of nervous mass. Mons. Le Gallois has, at page 142, the following words: — " Life is produced by an impression of the arterial blood made upon the brain and the medulla spinalis, or by a principle resulting from this impression." Also, " The prolongation of life depends upon the continual renewal of this impression," &c. I suggest that arterial blood is not different from venous blood, save as containing a larger quantity of oxygen, and that it is the oxygen to which M. Le Gallois refers, and not the blood which contains it. If it be not a mere fancy in Oken to say that the " artery is an air- tube;" and, if it be true that the blood excites in the brain the forces CYANOSIS NEONATORUM. 651 which, irradiating the organs through the nerves, makes manifest in them the various motions, and allows in them the impressions and perceptions that we suppose to be life ; then it is conceded that modi- fications of the blood, as oxygeniferous, are capable of modifying the state of all the organs, and not of them only, but of all the histological integers of which the sum of a body is composed. Where the blood is healthful and normal, it will in so far as to a dependency upon the blood, produce a perfect innervation, and vice versa. Supposing the blood to consist of the four constituents fibrin, discs, albumen, and water, in the proportion of fibrin 3, discs 127, albumen 80, and water 790 to the 1000 grains — any change in the constituency of the blood cannot but modify its power to take up and carry oxygen to the parts, and so to the brain. A patient who has suffered from exhausting hemorrhage, whether traumatic or active, will, in consequence, be deprived to a certain extent of the ability to extricate the nerve-force. If, through any faulty arrangement of the great vessels of the heart, the venous blood returning from the systemic circulation, be thrown back upon the system, without being newly exposed to the oxygenating apparatus of the lungs, the nervous mass, failing of its supply of oxygen, will fail in part, or die, according as the want is less or more incompletely supplied. Air, that in a given number of cubic inches contains less oxygen than is required for healthful respiration, cannot be breathed without diminishing the power to extricate nervous force. Thus a traveler ascending a lofty mountain, finds his strength to be diminishing, in proportion as he rises above the sea level, and when he is at an ele- vation marked by 18 or 20 inches in the barometer, he finds so little oxygen in his aspiration, that he is compelled to stop, and even to sit down, after walking only a few feet — because the ordinary aspiration at 16 or 18 inches consisting say, of 20 cubic inches of rarefied air, is equivalent, in the amount of oxygen it contains, only to an aspi- ration, perhaps, of 6 or 8 inches at the base of the hill, where the mercury marks 30. The traveler pants for breath, which means to say that he breathes frequently, in order to get his required amount of oxygen. That amount which cannot be ingested with twenty res- pirations, he seeks for in forty or eighty respirations per minute, for without the requisite amount, he cannot extricate the nerve-force, nor will his muscles obey the dicta of his free-will — his volition — he is compelled to stop, to sit down, or even lie down, whereupon, con- 652 CYANOSIS NEONATORUM. suming less of his nerve-force, he recuperates for another effort. This was the case with the party of Dessaussure on Mont Blanc. That which happens to the traveler on the mountain summit, occurs to the ansemical girl at the sea-level. His blood cannot find sufficient oxygen in 20 inches of rarefied air; her blood will not receive it, though it be contained in the 20 inches. But, if the blood be as perfect as possible in its constitution, or crasis — and it fail to be exposed to the oxygenating pulmonary sur- faces, it can by no means excite in the brain those quantitative results as to the production of the nerve-force, that are required in all these cases, whether of a low barometry, an anaemia, or a want of oxygen; there is failure to supply the essential reagent — the oxygen. A copper and zinc plate, or a series of such plates, constitute no galvanic pile if plunged into milk, or olive oil. They are energized by immersion in a saline or acid solution ; so, the substance of the brain, the nervous mass, has no activity when bathed in streams of carboniferous blood ; it is quiescent ; it is indifferent ; it is aperceptive of the presence of such a fluid ; but, when the oxygeniferous stream of the arterial fluid is injected into its tissues, it instantly becomes instinct with life and power under the reagent, and streams of biotic force flow off through the nerves to all the subject organs; or the free- will has power to urge the innervations to their utmost bounds of strength and precision. An uninterrupted current of organic innervations, flows from the whole nervous mass, whether cerebro-spinal, or sympathetic. But there is a free-willing innervative force, that appertains only to the great bulbs of the spinal axis. What that free-will is, is known to God alone — it is an appurtenant and faculty of the soul, whose whole nature is unknown to us. St. Paul admits that we know not " what we shall be," when the soul shall have been disenthralled of the shackles and obstructions of the mortal body; we know not what we shall be, though we are conscious that we shall be. We do know, at least, that we shall be both conscious and free-willing existences. These, therefore, are qualities or faculties of the soul, exercised through the nervous mass, under the force of the great cosmic reagent Oxygen. From the foregoing, it appears that the presence of the arterial blood in the systemic vessels of the encephalon and spinal axis is as- serted to be a requisite for the evolution of the biotic force, as far as that force proceeds from the brain and cord. It requires no further proof, after the experiments of Wilson Philip and Legallois. CYANOSIS NEONATORUM. 653 I have already said that numerous explorations of the bodies of neonati have shown that the foetal characteristics of the auricular septum are not entirely laid aside until after the third day, and often not until after the tenth and twentieth day; and, that in some persons it remains unclosed until the latest date of advanced age. It is, how- ever, covered by its valve. This may show that there is no inevitable inconvenience connected with persistence of the opening after birth, which is a physiological, not an accidental, nor a morbid condition; it is common to all the placental animals, and in all of them continues during a certain por- tion of their respiratory life. In myriads of children, its openness is attended with no incon- venience; nor would any inconvenience result, even in the absence of the valve, provided such patency should not be followed by mixture of the venous and arterial blood, which could not happen under a co- ordinated innervation of the symmetrical halves of the heart. Gintrac, page 238, says: " Toute communication entre les cavites droites et gaudies du cceur n'est pas inevitablement suivie du passage du sang noir dans les voies affectees du sang rouge ;" and, at page 240 he says : " The auricles first, and next the ventricles of the heart, contract at the same instant of time. If their force is equal, and the apertures through which the blood is to flow, be unobstructed, the fluid will not deviate, one way nor the other; a perfect equilibrium prevails between the sanguine columns; they oppose to each other an equal resistance, and each one follows the course naturally belonging to it." These are undeniable facts ; yet an open foramen ovale is accused as the cause of cyanosis neonati. Is this a contradiction in terms? Let us inquire. The heart is a machine — a hydraulic engine, provided with an auricular septum and valve, under which, during nine months of foetal life, flows a stream of aerated blood — no one denies it. At birth, the stream, in some instances, becomes carboniferous — no one denies it. But that venous current cannot but inundate the encephalic capillaries, whence all the modifications, not only of the hue, but all the strange manifestations as to the nervous force — in the respiration — and in the muscular action, calorification, &c. &c, that we observe in cases of cyanosis. The heart is not an asymmetrical, but it is a symmetrical organ; it has a zygo-zoar nature. In health, the two symmetrical halves 654 CYANOSIS NEONATORUM. of it are innervated in the same times, and with equal force or in- tensity. But the synergy and the synchronousness may become asynergy and asynchronism, under circumstances of disease, or irritation, or faulty crasis or constitution, either of the organ itself, or of the nervous mass — or of the blood. The heart is the frequent seat of convulsive innervations, or of asynergic and asynchronous action. If the left auricle should act with greater force, or earlier, or more rapidly than the right, the blood in its cavity would press down the valve of Botalli, and cause the fluid to escape into the systemic ventricle only, and this is its natural state and rate ; but if the right auricle should act with greater force, in earlier time, and more rapidly than the left, it is not to be denied that the carboniferous blood would in part, and perhaps chiefly, escape into the left auricle from whence, being received into the systemic ventricle, it would hasten to deluge the brain, and the whole body indeed, with its non-oxygeniferous streams. Can anyone doubt that this was the case in the young girl, cited by Gintrac from Morgagni, Epist. xvii. No. xii. It is the first case in Gintrac. A girl died at the age of about sixteen years. She had been sickly from her birth; always breathing with difficulty, on account of her extreme weakness, and always exhibiting a livid color of the skin. The heart was small, and with a rounded apex ; the left had the ordinary shape of the right ventricle, while the right had the characteristic appearance of the left ventricle. But the pulmonary ventricle, although the largest, had the thickest walls. The right auricle was also twice as large, and more fleshy than the left. Betwixt these two cavities, was a foramen ovale large enough to admit the little finger. The valves of the pulmonary artery were morbid, leaving an opening not bigger than a lentil for the transmission of the blood. In this case, the largeness of the foramen ovale may be supposed to have some relation to the constriction of the pulmonary artery, whose constriction preventing the pulmonary ventricle from readily discharging itself, equally prevented it from receiving freely the dis- charges from its auricle. The auricle, therefore, injected the fluid into the left auricle, and thus kept the foramen free and large ; or, on the other hand, let us suppose that the foramen, being originally so large as to allow of the escape through it of most of the blood re- ceived in its cavity, there was not left a sufficient quantity to keep the orifice of the pulmonary artery duly open. In such case, the CYANOSIS NEONATORUM. 655 orifice of the pulmonary vessel would inevitably diminish in size, as in Gintrac's case just mentioned. There is no extension of any living tissue save by the power of an esoteric or antagonistic force. If all the blood of the auricle should flow off through the septum, the pul- monary artery would ultimately become a ligament, as happens in the transitive tube called ductus arteriosus. The passage of blood to the lungs, which in the case cited by Gintrac, w^as not bigger than a lentil, prevented a full aeration of the blood, a fault which was greatly magnified by the rapid escape of the already carbonated portions that could issue through Botalli's opening, without returning to the aerating surfaces in the lungs. There was faulty injection by the heart. Such injection would lift the light valve of Botalli, whether from asynergy, or asynchronousness of the systole; and the consequence would be a state of partial asphyxia of the child, which is what is called cyanosis, morbus coeruleus, or blue-disease. In cyanosis, an irregular, imperfect, feeble innervative force will show itself in the muscular system of the child, whether animal or organic; and sudden convulsions, lipothymia, suspended respirations, and pulsations, with blue color more or less intense and extensive, will complete the picture of the maladive condition: the child will be affected with asphyxia more or less complete. If the respiratory sources in the cerebro-spinal axis are deluged with carboniferous blood to the extent of wholly suspending the biotic extrication — death is the consequence — sudden death. Cyanosis in this view, is asphyxia, greater or less, according to the intenseness of the cyanosis. But the question now recurs, as to what is asphyxia. In my opinion, asphyxia essentially considered, is black blood in the capil- laries of the brain. Some physicians insist that asphyxia is black blood in the lungs. I contend that asphyxia is black blood in the brain. Asphyxia is a state of the brain in which that organ can- not extricate, or give out the life-force — the innervative force — the stream or current of nervous force — the biotic force — and I contend that it fails to do so, for want of oxygen to react upon the neurine. Cyanosis is the sign of the presence of non-oxygeniferous blood, which is dark or purple or black blood, as Bichat calls it. This purple, or dark hue of cyanosis, is caused by the presence of black blood only in the capillaries. But, when this dark hue of the cutaneous capil- laries is seen, it is evidence of a similar hue of all the capillary blood, 656 CYANOSIS NEONATORUM. whether in the abdominal, the thoracic, or the cephalic cavities and organs. This purple state of the blood is not fatal, except it exist in the brain, whose power it suspends. If it be chased out of the brain, by oxygeniferous streams of arterial blood, all the organs and tissues that lie under the control and dominion of the nervous system, immediately recover their power. If the brain dies, they all perish in its fall. If a man die, therefore, with asphyxia, he dies because he has black blood in the brain. A man may die from fainting, or lypothymia; and in this case he loses life, because the action of the brain is suspended. The sus- pension in this instance, appears to me to depend upon lessened tension of the encephalic mass from the sudden withdrawal of a portion of the blood that ordinarily distends its vessels, as in sudden violent hemorrhage, in certain pathemata mentis, rapid changes of posture, &c. &c. Asphyxia is lessened or suspended somatic innervation from pri- vation of the oxygen-reagent. Fainting is a similar suspension from reduced tension and pressure; either may be fatal; but each requires its appropriate treatment, which is different in each case. Asphyxia is essentially not a status of the trunk or members; it is a status of the brain, and only of the brain. The livid hue is a result or an accidence of the asphyxia. If the vessels of the brain be injected by the carotids and vertebrals with carboniferous blood, the intellectual, or perceptive, and the co- ordinating and motion-giving brains cease to do their office; if new injections fill these same vessels with oxygeniferous blood which chases out the former, the powers of the brain are reinstated, provided the mischief have not already gone too far. A man etherized, or affected with chloroform, is, to a certain extent, asphyxiated, besides being poisoned; the same is true of him, as of the well-digger, who descends into a well containing carbonic acid gas. The man in the well dies, not because his glottis is closed by spasm, as has been asserted, but because there is no oxygen in the well to be carried to the brain. It is indifferent to him whether his glottis be shut or open, since there is nothing to enter in that can do him good or harm; he dies from want of oxygen; and it may be, that the carbonic acid, if it enter his lungs, may do some mischief there; an indifferent mischief in the greater mischief. I said that asphyxia is black blood in the brain — not in the sinuses and veins of the brain, but in the capillary part of the vascular cyst of the brain. CYANOSIS NEONATORUM. 657 The greater part of the whole amount of the blood, which is vari- ously computed to be about thirty pounds, exists in the systemic part of the vascular circle. Only a small portion of it is in the venous side. In the lungs, for example, where the pulmonary artery is a vein, and the pulmonary veins arteries, there is a great excess of the aerated, over the quantity of carboniferous blood, for not only is the capillary system full, but the venous system is full. But the carboniferous blood of the femorals, of the iliacs, of the portal, and the cava, produces no asphyxia; nor is it true that in death from carbonic acid inspired in a w T ell, the demise depends upon the presence of black blood in the trunk or members; it depends upon its presence in the brain, par- ticularly the respiratory, oxygenating brain, whose pneumogastric branches, and all other sources of respiratory innervation, are sus- pended and cut off indeed, because their neurine is flooded with car- boniferous blood in which there is no power to extricate the biotic force — the nervous force. If it be true that there is a valve on the left side of the auricular septum, it must be that its purpose is to prevent regurgitation of the blood from left to right. It could have no other use or design. Even in a case where greater power of the right auricle impels a portion of the black blood through the valved orifice, any resistance offered by the valve must tend to diminish* or prevent the transit from right to left. If in any such case the plane of the septum auricularum be ren- dered horizontal, by placing the child upon its right side, the blood of the left auricle must tend to close the aperture by pressing the valve down, and keeping it down. The blood has gravitation, and its law of gravitation is as rigorous in the auricle, as it would be in a cup, or in the air. Its weight must shut the valve, or tend to shut it, if any valve exist. But, with a shut valve, all the blood of the auricle must pass to the right ventricle, and so to the lungs to be aerated. But, if the blood becomes truly aerated, it becomes oxygeniferous, and transferring the oxygen to the capillaries of the brain, will there excite the biotic force in a normal manner. All the irregular and diseased innervations depending upon the antecedent carboniferous quality of the blood in the encephalic capillaries must vanish before the steady innervative streams that proceed from a healthy brain, duly supplied with its quantum of oxygen. There are many of my medical brethren w r ho deny that my expla- nation of cyanosis neonati is correct, or even philosophical; contending that cyanosis is a status of the lung, or of the vessels of the heart, 42 658 CYANOSIS NEONATORUM. bringing about a modality of the lung alone; or a backing of the blood into the whole venous side of the circle and a detaining of it in the capillaries; while I aver that the condition of the lung, or of the trunk and members, is nothing in the category, which relates, in fact, only to the state of the brain. I am quite conscious that a man's opinion cannot determine the least of Nature's laws to operate this way or that. St. Matthew tells us, " neither shalt thou swear by thy head, because thou canst not make one hair white or black." While, therefore, one gentleman sees only in a contracted pulmonary artery, or in a transposition of vessels, a cause of cyanosis, I am not to expect that he will come over to my way of thinking, because I think so, even had I the authority and power of the man of Pergamus, w 7 ho ruled us for fifteen hundred years. I am, however, less concerned to witness the ac- ceptation of my rationale, than the adoption of my precept. If they will turn the cyanosed neonatus upon its right side and shut down the auricular valve, I ought to be satisfied; and indeed, one dis- tinguished author, Prof. Wood, recommends the practice, while he dispraises the principle upon which it is founded. Nevertheless, I admit that I sincerely desire to find a reasoned ac- ceptation of my rationale ; less perhaps on account of its application to the undeniable self-demonstrating instances of blue-disease, than to the treatment of certain obscure, and more questionable forms of the accident. In order to explain my meaning more clearly, I shall relate a case that occurred to me a few years since, and upon which I put a con- struction that w r ill not be admitted by those who oppose my rationale of cyanosis, either as to its mechanism or its real nature. A lady had given birth to a child, apparently healthy. She was soon afterwards attacked with fever, wdiich produced in her a series of distressing nervous symptoms. The young child, after many days, became indisposed with what seemed to be a bronchial catarrh, w T hich W T as rebellious under the treatment. Dr. Bridges saw the child with me several times. It grew alarmingly ill. It was affected with a vast, troublesome collection of unexpectorated bronchial mucus, that threatened speedy suffocation by filling the air-tubes and trachea. Upon entering the apartment on one occasion, I found it in the arms of the monthly nurse, sorely oppressed and nearly insensible. It was dying — or, rather, I deemed it dying. My impression from inspecting the child was, that it was moribund ; and I still believe that the condition was that of the moribund, and i CYANOSIS NEONATORUM. 659 that its life could not have been protracted beyond one or two hours, but for remedies employed to rescue it. After observing it for some time, and noticing a livid areola about its mouth, I took it from the nurse to inspect it more closely. The precise processes of thought by which I arrived at a conclusive opinion, have now escaped me; but I was led to imagine that the whole of the phenomena ought to be referred to a state of the brain, and not to a state of the bronchial mucous membrane. I supposed that the sources of innervation becoming modified by the presence of car- boniferous blood in the brain-capillaries, the organs had suffered in consequence of the cessation, or irregularity, of the administrative power. Upon cutting, in a surgical operation, certain branches of the trifacial nerve, the eye becomes instantly inflamed. Dr. J. Warren says that, under etherization, the conjunctiva is often injected with blood. The same thing occurs in ataxic fevers. So, in any hindrance of the current of the pneumogastric nerve-force, the lung might likewise become the seat of consecutive disorder. I was con- vinced that the child's foramen ovale admitted its venous blood to the systemic side of the circle, thus vitiating the biotic power of the nervous mass of the child. I turned it on its right side, and kept it there. In a few moments it was relieved, and in a very short time gave no further reason for alarm, or concern of mind. In fact, the right lateral decubitus cured it. In the month of January, 1846, I attended Mrs. H . . . . at the Indian Queen, South Fourth Street, in a confinement in which she gave birth to a healthy child. As she was ill many days with a fever, I gave but little attention to the child. It was between two and three weeks old, wdien I was summoned to it by three rapidly repeated messages. I found it in- sensible; affected at intervals of one to two minutes with convulsions, in which the head rotated to the right in strong extension; the right arm, stiffened, was elevated as strongly as possible by spasmodic innervation of the deltoid and triceps, while the left arm also stiffened, was pointed downward and outwards. The inferior extremities were also affected with rigid spasm. The mouth was open, and could not be closed, but by force. The pulse was feeble, and the respiration low T , except when troubled by the recurring spasm. Many persons surrounded the infant, which was on its back on a pillow, supported on the lap. The child had been well but a short time before. The attack had been a sudden one. 660 CYANOSIS NEONATORUM. Upon contemplating the child, which had two or three attacks of this spasm or convulsion while I was looking on it, I reasoned with myself as to the probable cause. There was no assignable hygienic causation. Its mouth was bluish, though not in a very marked degree. I took the child on its pillow, and laid it on my knees, in order the better to inspect it. I reflected as follows : here is a faulty innerva- tion of the muscles of the head, neck, arms, legs, and lower jaw ; with suspended consciousness. Are the parts in fault, or is the brain in fault? whence these irregular intromissions of nerve-force ? Is the nervous mass imperfectly oxygenated because the child sends its carboniferous blood into the left auricle, and so to the brain ? I laid it on its right side in the cradle, its trunk elevated at about 15°, and I said, "leave it in this position until I return. Perhaps it will die very soon ; but I have some reason to hope it may be saved, if you should not change its position. I shall be absent three hours. Do not venture to move it, until I come again." In the meantime while I remained, it changed its appearance speedily and visibly for the better; it had no return of the spasm. It fell into a calm sleep, and was perfectly well when it awoke. It required no further cure. Was this a post hoc, and not a propter hoc case? Who can say so? The treatment was reasoned beforehand, and the result looked for. As well might it be said that every therapeutical cure by emetics, cathartics, or narcotics, or diuretics, is a post hoc, and not a propter hoc cure. The blood in the auricle or ventricle, is not exempt from the laws of matter; it gravitates as absolutely there as in a teacup, or in the air. When I lay a child upon its right side, gravitation of the blood is inevitable ; and since the valve is as delicate as the arachnoid, the smallest drop resting upon it could close, as the slightest force could open it. I brought the plane of the septum auricularum to be a horizontal plane; I compelled the blood of the inferior cava to rise in a vertical current, to the fossa ovalis, and thus lessened the power of Eustachi's valve, to direct it upon the fossa ovalis. When I shut the valve down by the weight of the superincumbent blood, all the blood of the right auricle passed through the iter ad ventriculum, in order to be breathed upon in the lungs. It is probable that half a dozen systoles of the heart had scarcely been effected, before the oxygeniferous streams had reached the neurine, and waking into orderly and healthful CYANOSIS NEONATORUM. 661 force, the before hebetized innervations of the child, all the dependent organisms and organs resumed their healthful movements and life- manifestations. Nov. 20, 1847, I was called to the child of Mr. H , in Pine Street below Eighth. This child, a female, was born in October, 1847, and was now six weeks old. Upon reaching the rendezvous, I was pained to find the infant dangerously ill with catarrho-pneumonia, so far advanced, that I informed its mother it was probably too late to do it any great service. The bronchial tubes and the trachea were oppressed with a great quantity of mucus, which so obstructed the respiration, that the child coughed at every breath, which was very short, saccadee, and repeated sixty or seventy times per minute. Percussion and auscultation of the chest — careful examination of the abdomen — inquiries into the rate of the pulsations, both by feeling the radial pulse, and by aus- cultation of the heart, led me to the painful expectation that my friends were about to suffer the loss of their daughter. I prescribed for it, under the diagnosis of a catarrho-pneumonia. Some hours afterwards I repeated my visit. It was no better. Upon taking the child, which was on a pillow, and resting it on my knees, I found it in danger of suffocation. Every breath was that com- pound of coughing and crying, which I cannot describe, but which every physician has observed. Upon inspecting it, I observed a livid areola of the mouth. The feet were bluish, as well as the finger-nails. It is true that such blueness might depend, and did in part depend, on the saburral state of the pulmonary mucous membrane — smeared as it was with mucus, and the tubes partly filled up. As the attack had been sudden — too sudden to be conformable to the normal march of such maladies, I reflected that the fault might not be primary in the respiratory mucous membrane, or pulmonary texture, but in the brain, which had lost its power of maintaining the status sanitatis in the lungs. I deposited the infant on its side, as for the treatment of cyanosis neonati. It seems to me that the valve of Botalli fell down upon the foramen ovale, and that the carotid and vertebral injections of the brain immediately began to be thoroughly oxygeniferous. The administrative nervous mass commenced anew its government of its provinces, and, in a short time, the symptoms of the disease had vanished; I found in the morning of Nov. 21st, that no further treat- ment was necessary. I cured the broncho-pneumonia by shutting Botalli's valve, just as I should cure a conjunctivitis, by restoring the integrity of the trifacial branch cut off in a surgical operation on the 662 CYANOSIS NEONATORUM. face, and the loss of whose innervative current might have determined the conjunctival inflammation. The objectors do not deny that the foetal circulation, up to the first act of respiration, is through the foramen ovale, and the arterious duct, and that it is so indispensably, and only because the operculum is raised. They cannot deny that the aperture virtually exists after birth, even for many days — nay, in some, during a long lifetime. To deny that the two zygozoar halves of the heart may act asym- metrically and asynchronously, is to deny an admitted truth. To deny the effect of such dissidence in time and force, appears to me to be but a mere denial. I had many years ago charge of the health of a young woman, who labored under frequent attacks of cyanosis. She was often threatened with sudden death. In the intervals she appeared to be in good health, earning her bread by the needle. One day, while much indisposed, she sat up in bed, eating a din- ner of codfish. She suddenly fell on her side dead, in her 28th year. I found a foramen ovale, into which I could put a swan-quill. In the heart of the Archduke Joseph, the cyanosis had coincided all his life long w T ith an open foramen ovale. — See Gintrac, p. 228. If in my own heart there be an aperture as large as the end of my finger, it is indifferent to me in respect of my health, while the two auricles contract symmetrically. But if asymmetrically, then I am liable to sudden illness, or even sudden death. My patient probably flooded her medulla oblongata with carboniferous blood, and ceased to breathe in consequence of the annihilation of biotic force evolved from the medulla. How often have we seen similar states of the system brought about in attacks of puerperal eclampsia ? In this disease, an impetuous sanguine circulation gives rise to un- measured, I had almost said explosive, evolutions of biotic force. In eclampsia, the spasm and convulsion of the whole system, and par- ticularly of the diaphragm, which often makes aspirations of only three or four cubic inches of air, allow the carboniferous streams to overflow the encephalon. Under this want of aeration, the face gathers blackness apace — the protruded tongue is of a deep purple, and a true asphyxia intervenes between the life and the death of the patient; so that the sooner the blackness of the features and tongue comes to assure us of the arrest of the cerebral excitation, the sooner is the patient to be extricated from her perilous predicament. If the medulla oblongata be overwhelmed, she dies ; sometimes CYANOSIS NEONATORUM. 663 this is the case, and she dies outright, no trace of lesion being dis- coverable in the brain. Here we have no good and reliable sources of medication, save those that serve most rapidly and powerfully to diminish the momen- tum of the sanguine circulation in the encephalon, of which vene- section is to be before all others preferred. A proper venesection, executed before the asphyxia is established, in general prevents that consummation by substituting a state of deliquium for the otherwise inevitable asphyxia of the eclampsic paroxysm, a far less dangerous and more speedy way of escape: less dangerous, since the sanguine engorgements and retardations coinci- dent with the cyanosed state of the brain in eclampsia, expose the sufferer to inconvenient effusions or extravasation. As to the right lateral decubitus for the new-born child in cyanosis, no doubt rests on my mind, after multiplied experience since 1832, now sixteen years. I am not embarrassed by finding the treatment sometimes unsuccessful, because, when it is so, I can with confidence believe that failure to change the blood is effected through some other agency than that of an open and used foramen ovale. In the son of Mr. A. B , I detected the existence of cyanosis neonati, and relieved the child, but could not cure it by my method. A series of diseased innervations, bringing the whole constitution into ill-health, continued to manifest themselves, notwithstanding all the precautions I could devise, and I announced, long before the death of the infant, which lived for several months, in addition to a patent foramen ovale, the existence of an aperture in the septum ventri- culorum, which was verified by the examination of its heart after its decease. In a similar manner I announced in Mr. J. B 's child, an open foramen ovale, as the cause of convulsive attacks which led at last to an effusion within the encephalon with separation of the sutures, and evident fluctuation, which was verified necroscopically. Professor Wood will bear me witness of the sudden and marked and indubitable relief and cure of Mr. H. W 's infant, appa- rently dying with cyanosis, when it was placed in position. In the eldest son of Mr. S. B , jun., the respirations were but four to the minute ; the pulse was gone, and the child within two or three minutes of its death, nay, deemed by some to have breathed its last. The recovery was almost instantaneous. The same is true of Mr. H. K 's son, with the exception that 664 CYANOSIS NEONATORUM. the case was not so extreme; so also of Mr. Rich's child, Mr. J. W 's, and many others. I beg leave to refer again to the letter from Prof. Eve, at p. 644, reciting a case of cyanosis treated by him. A letter from Dr. Casey, of Hartford, Conn., informs me of a violent case successfully treated by the position. Dr. Hains of this city, and many others, have suc- ceeded in like manner. Prof. Charles A. Lee, of Geneva College, informs me that the treatment is well known in Western New York. I can by no means adopt the views as to the essential nature of the malady, set forth in Prof. Wood's late work on the Practice of Physic. That author, like others, appears to me to have mistaken the symptom, to wit, the blue color, for the disease, which, as I have so often said, is essentially a failure of innervation from absence of oxygen in the brain. He doubts the causation as dependent on the mixture of the two kinds of blood in the heart. I cannot understand that the leg or arm should suddenly die for w r ant of oxygeniferous blood; and I cannot perceive how the consti- tution can live, if the nervous mass, which is the essential Ens, be dead, or inert, as it certainly is when only the carbonized blood of the veins circulates in its capillary vessels. M. Gintrac himself, who originally made four kinds or species of cyanosis — of which the first consists of the melange du sang noir et du sang rouge, and the se- cond a coloration bleue egalement constitute par ce melange— comes to the true conclusion at last, that, instead of four species, there is but one, although he calls that one two. Prof. Rokitansky, in his Patholog. Anatomie, vol. ii. Part I. p. 510, gives an article on cyanosis, in which he treats at large of the various kinds of that affection, whether as depending on faulty development of the heart, or on causes extrinsical as to that organ. He says, "a distinction is generally drawn between an organic disease of the heart acquired in the later periods of life, occasioned by disease of the lung, and that form of cyanosis dependent upon congenital malformation of the organ. The latter is called cardiac cyanosis. It will appear that the essential cause and character of both are the same. Cyanosis occurring in cases of congenital malformation of the heart has been mostly attributed to the mixture of the two kinds of blood, or rather to the passage of the venous blood into the arteries either by way of the ventricles, or the auricles, or the vessels themselves; but, it has been common to refer this commingling of the currents and the ac- companying symptom of cyanosis to a deficiency as to the septa of the heart. We are of the opinion that cyanosis always depends, not CYANOSIS NEONATORUM. 665 upon the mixture of the two kinds of blood, which is, in many cases, problematical, and in some takes place in a directly opposite direction to w T hat is supposed, but on the impeded reflux of the venous blood into the heart and a consequent habitual, or, in some instances, inter- mittent engorgement of the venous and capillary systems ; and that herein all the varieties of cyanosis, however differing as to their original and acquired abnormal conditions of the heart and lungs, coincide, and may, without violence, be classed together." I shall not here reproduce all M. Rokitansky's arguments and statement of facts ingeniously brought to the support of this doctrine. I shall merely state that the opinions set forth in this chapter as to the consecutive nature or accidental nature of those contractions of the pulmonary and other orifices of the heart, appear to me undeniable, and that it is always reasonably to be expected that an uncured attack of cyanosis neonati w r illlead to a constriction of the pulmonary artery, just as the free expansion of the pulmonary artery, after the first as- pirations of the neonatus, leads to the abandonment of the ductus arteriosus and its early conversion into a ligamentum teres. Should this page be at some future day honored by the regard of that distinguished writer, the author would beg leave to direct his attention to the events and phenomena that occur in those cases in which a sudden coagulation of blood fills the right auricle and ven- tricles with a clot that is moulded by the cavities which it fills. Many examples are to be met with of these coagulations, some of which prove instantly fatal, wmile others admit of the prolongation of an ineffectual struggle for life during a period of from one to twenty days, according to my own clinical observation. Now in the instance of a cardiomorphous clot, as above proposed, the blood is most effectually detained in the venous side of the circle, far more so than can be hypothecated as of the intermittent forms of cyanosis, of which M. Rokitansky speaks. Yet as long as the patient continues to survive, he continues to thrust betwixt the outer super- ficies of the clot, or false polypus, and the inner walls of the auricle, tricuspid and ventricle, as well as the pulmonary artery, portions of blood that become thoroughly oxygenated in the lungs, for the re- spiratory effort is one of d esp eration, and the blood is probably charged to its very highest capacity with oxygen. It receives enough to maintain in the neurine the extrication of innervative force until the gradual augmentation of the clot cuts off the power of the circulation. In these cases the blue color, the cyanosis, the blaasucht, is scarcely 666 CYANOSIS NEONATORUM. to be discovered, the patient being on the contrary ghastly pale and sunken. If Prof. Rokitansky and Prof. Wood's views are just, then we ought to have in the case of the pre-euthanasial clot the most striking example of the cyanosed state, for, when the heart becomes thus tamponed with a cardiomorphous coagulum, the whole of the venous side of the circle is stopped, and the black blood backed into the capillaries. A small endocardiac clot must have the same power to produce mechanical obstruction as contraction of the pulmonary artery; a large one is equivalent to a ligation of the cava. I deny not that a constriction of the pulmonary artery may pro- duce cyanosis. Whatever restricts the aclion of the venous heart, must do so. Great collections of fluid in the thorax produce it. Pressure upon the heart from dropsy of the pericardium ; extensive injuries of the lungs from tubercular degeneration ; suppurations, and large vomicse; cynanche trachealis, or pseudo-membranous laryngitis; pneumothorax; atelectasis pulmonum ; a host, indeed, of accidents and diseases that ruin or disable the respiratory machinery, may produce cyanosis. But of these I have not spoken. I confine my proposition to the persistent use of the foramen ovale after birth, a use in which the blood of the veins takes the course originally fol- lowed by that of the placenta. There is no other treatment for cyanosis neonati than that I have suggested ; at least, there is no other reasonable treatment. Vene- section, emetics, purgatives, diuretics, soporifics, baths, counter-irri- tants, cannot cure it. When cyanosis has introduced epiphenomenal affections, they may be treated. These affections will be found to relate chiefly to a state of the pulmonary circulation and excretions. In some instances, I have applied a large leech or two to the region of the heart, in order, haply, to assist in overcoming the pulmonary or cardiac engorgement, so apt to coincide with failure or disorder of the biotic power of the medulla oblongata. In general, however, when the malady has depended on the injection through Botalli's foramen, I have been content to place the infant in the proper posi- tion, and trust to that alone for the cure. SUPPLEMENTARY. 667 CHAPTER XXV SUPPLEMENTARY. The introductory or prefatory letter, which is printed in the be- ginning of this volume, states that my vision has become much dis- ordered by a neuralgia, that has not only given me a great deal of pain, but has prevented me from being as accurate as I might per- haps have otherwise been in revising the proofs of this work. I find that at page 305 I have admitted a date (Aug. 1841), w T hich, though correct as understood of that date, is not to be taken as re- ferring to the present time, Feb. 1849. It is still true that I have not had occasion to regret one of those sudden demises after a good deli- very, in patients of my own. In one case that fell under my direction, I lost a patient in the hemorrhage that came on in a premature labor, and I was not only greatly shocked, but exceedingly surprised at the fatal result of a loss of blood, the quantity of w r hich did not appear to me to be sufficient to bring her life into great danger. After several gushes that took place before I could get the foetus away, she was very faint, and as she had long labored under an extreme degree of anaemia, I was aware that she could not well bear such great losses, as another or stronger woman might readily tolerate. Soon after one of the fainting-fits, she became uncontrollably rest- less and delirious, striving to get out of bed, and to sit up in it, the pulse uncountably frequent, and very small, the face being mean- while of a deathlike paleness. It required about half an hour of such a state of things to extinguish the last spark of existence, which termination occurred after heavy sighs, or efforts to respire. I wish the Student to reflect for a moment upon the above state- ment, and I ask him what explanation he can make or what rationale of the phenomena he can give better than the following hypothetical one, viz : The patient w T as anaemical. She flooded in the premature labor. 668 PROLAPSE OF INTESTINES. The blood left in the vessels after the hemorrhage, was greatly in- creased as to its coagulability. She had deliquium. During the almost complete arrest of the circulation pending the deliquium, the blood in the right auricle became a clot. A clot once formed and become firm in the heart, can never be dis- charged. It is the nucleus upon which additional strata of coagula are imposed. It may grow rapidly or slowly larger. It may instantly or gradually fill the whole auricle, tricuspid valve, ventricle, and pul- monary artery. The convulsive action of the heart compresses the clot — all the haematoglobulin is expressed, leaving the mass a dull yellowish-white cardiomorphous polypus consisting chiefly of fibrine. The heart, if completely tamponed or plugged up in this manner, ceases to beat. Such an endocardiac clot is as fatal an accident as a bullet lodged in the cavity of the organ. I have seen several per- sons die in this manner. At page 462, I alluded to the case of Mrs. R., under the care of Dr. Bicknell, of West Philadelphia. It appears that I omitted to relate the case as I supposed I had done. It was as follows: Mrs. E,. was in violent labor, which had continued long, but without any effect. Dr. B. requested me to visit her with him. The vagina was pressed forwards towards the symphysis pubis, by a tumor behind it, filling up the excavation of the pelvis, and pre- venting the descent of the head. I learned by examination that this tumor consisted in a great mass of intestinal convolutions that had fallen down below the strait, and that was kept there by the violent tenesmus, as well as by pressure of the gravid womb above it. Indeed the mass was to a certain extent incarcerated within the excavation of the pelvis. The efforts of the patient to bear down upon her pains were most violent, and the distress accompanying them apparently intense. I introduced my fingers into the lower part of the vagina, and thrusting the posterior wall of that tube backwards, got the points of the fingers beneath the tumor, which occupied the recto-vaginal cul- de-sac of peritoneum. A little patient manipulation caused portions of the gut to ascend into the abdomen, and in a short time the whole mass fled upwards above the brim, whereupon the expulsive efforts bond's instrument. 669 of the womb being no longer opposed by it, the child was speedily and safely born. Before closing this volume, I wish to make the Student acquainted with the appearance and use of an instrument recently invented by Dr. Henry Bond, an eminent medical practitioner of this city, and which is designed for the purpose of restoring the womb to its proper situation in cases of its retroversion. Fig. 121. The instrument, of which I 'annex a figure, half size, (Fig. 121,) consists of two arcs of circles of different radii ; the inner one is terminated by a small oval piece of ivory; the outer terminates in a small ivory ball. The exterior arc is formed at its lower extremity into a plate-piece in which is a mortice ; to the end of the plate-piece is attached an ivory handle, by which it may be conveniently held. See the figure. The inner or smaller piece is attached to a sliding- 670 piece, also morticed, and overlapping by its edges the morticed plate- piece, and secured by a clamp or pinch traversing the mortices, and fastened or loosened by turning the thumb-piece. If the thumb-piece be unscrewed, the clamp may be turned lengthwise, and the arcs are then easily separated. In order to use the instrument, the arcs should first be separated, and the ivory ball on the largest arc introduced into the rectum, while the oval one on the smaller arc should be introduced into the vagina. By sliding the smaller arc upwards, the two balls can be placed opposite to each other; or the vaginal arc can be set a quarter of an inch, a half inch, or an inch lower down than the one that is in the rectum. Upon being adjusted, and firmly secured by turning the thumb- piece, it is manifest that the two balls cannot be separated from each other, and that if they be moved upwards, parallel with the curve of the sacrum to the height of the promontorium, they must carry the retroverted uterus before them, and thus serve very effectually and easily to reposit the dislocated organ. In a difficult case of retroversion, which I lately saw in consultation with Dr. Bond, I in vain made repeated attempts, in which I employed great perseverance and force, to get the retroverted fundus out of the peritoneal cul-de-sac, the bottom of which it had forced almost down to the vulva. In this case, Prof. Simpson's wornb-sound could not be made use of, on account of the position of the os uteri, which w T as quite as high as, and close to, the top of the symphysis pubis, and so firmly pressed against it as with difficulty to admit of reaching the os tincse with the indicator finger. I could by no means succeed in several attempts that I made, to introduce the probe point of Dr. Simpson's womb-sound into the os, for the canal of the cervix uteri made an acute angle with the posterior face of the symphysis pubis, and being in close contact with the top of the bone, it is clear that I could not introduce the top of the probe into it. I did bend the womb-sound near to its probe-point, so as to give it the shape of a blunt hook, and, introducing the hook within the os uteri, endeavored to draw the vaginal cervix down the symphysis, but I could not make it move, and was obliged to abandon the attempt. Upon the failure of these efforts, the caoutchouc bottles were made use of as pessaries, as recommended by M. Hervez de Chegoin, in the Mem. de PAcad. Roy. de Med. They doubtless served very use- fully to effect a partial elevation of the fundus; in the mean time the engorged uterus, whose length could not have been much less than I bond's instrument. 671 five inches, became gradually less hypersemical, so that Dr. Bond was enabled, after three or four days, by means of the very ingenious in- strument whose figure I have here given, to lift the fundus out of its dislocated position, whereupon the unfortunate lady was immediately relieved of a most distressingly painful accident. A reviewer, in the January number of the British and Foreign Quarterly, treats Prof. Simpson, in my opinion, with uncalled-for seve- rity, on account of his womb-sound, of which I have above spoken. There is little danger to be apprehended of mischief resulting from the use of that beautiful instrument . in competent hands; and the facility with which an ordinary case of retroversio uteri may be re- lieved by it, together with the absolute safeness of its application, in the proper cases, are qualities so very valuable, and the whole opera- tion is so much less disquieting to the fastidious patient, than the ordi- nary methods of treatment, that I think the profession should feel in the highest degree indebted to Dr. Simpson for his admirable invention. As to the uses of it in diagnosis, it appears to me, since I have become acquainted with it, that it is an indispensable article in the apparatus of the physician and surgeon. And now, that I have come to write the last paragraph of this volume, I take occasion to bid the Student God speed in his arduous path, to exhort him so to direct his course, that he may elevate him- self to the highest rank of the Scholar-class, by which alone he can hope to reap the only and true reward of a life spent in the service of them that are in pain, in fear, or in danger of death. I beg leave to assure him that he can never know too much of the opinions and experience of mankind, gained during the lapse of ages, on the subject of Disease and its Remedies. INDEX. Abdomen, 168 Abortion, 211 causes of, 211 ergot to produce, 593 Dr. Lee's case, 593 hemorrhage during, 213 treatment of, 216 instruments in, 211 Puzot on, 216 symptoms of, 211 tampon in, 216 Abscess of labium, 79 of mamma, 603 Accoucheur, 17 conduct of, 245 Acephalous foetus, 193 Adherent placenta, 29S in hour-glass contraction, 392 After pains, 303 confounded with peritonitis, 565 Alimentation of the child, 618 artificial, 623 Allantois, ISO Allantoidal space, 183 Alvine evacuations of the child, 626 management of, 627 Alvus, 284 Amenorrhcea, 12S, 135 cautions in regard to, 129 causes of, 135 diet in, 146 treatment of, 137 Amnion, 155 Amussat, 227 Anasmia, 142, 414 as cause of amenorrhea, 135 preternatural labor, 414 cases, 414, 417 Anasmia gravidas, 207, 419 case, 419 Anaesthesia, 315 objections to, 411 Prof. Simpson's letter on, 319 reply to, 322 Analysis of healthy blood, 119 of menstrual fluid, 119 Anencephalous foetus, 193 Antagonism of corpus and cervix uteri, 162 Anus, artificial in infant, 183 Aphthae, 630 treatment, 631 Application of obstetric forceps, 492 difficulties in, 494 precautions in, 495 rules for, 490 43 Arm, prolapsed, 371 Collins on, 371 cut off, 373 torn off, prosecution for, 372 Arnold, Dr. Frederick, 17 Asdrubali, Prof., 196, 480 Asphyxia, 187 Atelectasis pulmonum, 610 Atresia vaginae, 583 causes, 583 case of, 583 simulated, 586 case of, 586 Auricular ligaments, 26 Auscultation, obstetric, 239 Average duration of labor, 279 Dr. Churchill's table on, 279 Dr. Collins on, 279 Axis of the pelvis, 46 E Bachman, Rev. Dr., 159 Bag of waters, 256 Ballottement, 239 Bar bone, 25, 36 Barry, Martin, 96, 153 Baudelocque, 46, 249, 269, 489, 508, 574 forceps, 481 the younger, 574 Bearing down, 255 Belly-band, 625 Bernhardt, 100 Biberon, the, 619, 624 Bichat, 179 Binder, 310, 390 necessity for, 311 case, 310 Births, most frequent at night, 248 Quetelet on, 248 Villerme on, 248 Buck on, 249 Bischoff, 101, 108, 153 Bladder, the, 48 depressed in labor, 289, 462 case, 289 distended, 220 as cause of retroversion, 220 case, 222 Blastoderm, 179 Blaud's pills, 145 Blood, healthy, analysis of, 119, 415 anaemical, 415 674 INDEX. Blood, menstrual, 119 Boivin, Mad., 118, 270, 278, 341 Bond, Dr. Henry, 215, 669 Bourgeois, Louise, 380 Breech presentations, 346 not dangerous to mothers, 346 fatality of, to child, 346 diagnosis of, 348 conduct of, 350 1st position, 352 2d position, 354 3d position, 355 case, 355 4th position, 357 cases, 358 fillet in, 439 forceps in, 506 Bremser, 208 Breschet, 155, 177 Brierre de Boismont, 119 Bright's case, 608 Broad ligaments, 39 Brugnone, 194 Buck, Dr., 249 Burdach, 104, 179 Caduca, 154 Cesarean section, Simpson's case, 456, 513 when demanded, 508 the mother's operation, 508 Mrs. R.'s case, 530 Carcinoma uteri, as cause of preternatural labor, 427 cases, 427 Carus, 17, 47 curve, 47, 294 Case, difficult, of embryotomy, 513 Dr. Lee's, of ergot to produce abortion, 593 Depaul's, of early detection of sounds of fcEtal heart, 242 of absence of uterus, Renauldin's, 129 of artificial rotation, 358 of breech labor, 3d position, 355 of Cesarean section twice performed, 531 of cephalic version, 364 of complicated milk-fever, 597 of compressed intestine during labor, 426, 668 of concealed pregnancy, 241 of cyanosis, Dr. Eve's, 644 Dr. Irwin's, 643 Dr. Schreiner's, 645 of death from sitting up too soon, 308 of depressed bladder, 289 of difficult face labor, 284 of ectopy, 193 of Elizabeth Sherwood, 509 of false pains, 262 of fatal uterine hemorrhage, 306 of forced evolution, 376 of forceps rotation, 462 of hysterical dyspncea, Bright's, 608 Case, of induction of premature labor, Dr. Lee's, 539 of laceration of perineum, 497 of laceration of uterus, 466 Mauriceau's, 466 of mammary abscess, 607 of Mauriceau's sister, 396 of Mrs. E., 540 of Mrs. R., 509, 513, 539 of narrow pubic arch, 293 of obliquity of the uterus, 296 of obliteration of vagina, 583 of oedema gravida?, 421 of relaxation of pelvic symphyses, 58 of retroversion in the virgin, 225 with pregnancy, 227 of rigid os uteri, 284 of simulated atresia vagina?, 586 of sixth position of the vertex, 58 of spasmodic closure of the womb, 202 of tumor in pelvis during labor, 464, 668 of turning for hemorhage, 445 Cases, of absence of uterus, 130, 131, 132 of anaemia gravidae, 417, 419 of angulation of the intestine, 578 of atresia vaginae, 583, 586 of breech presentation, 4th position, 358 of carcinoma uteri, 428 of cramps during labor, 29, 30 of convulsions, 407, 408, 409 of cyanosis, 641, 643, 644, 645 of difficult face labors, 334,338, 339, 340 of extra-uterine pregnancy, 236, 237 of gastric disturbance during pregnancy, 165 of hemorrhage, 304, 305 of successful use of ergot in, 306, 307 of inverted uterus, 547 of spontaneous replacement of, 550, 551, 552 of monstrosity, 189 Clarke's, 189 Pfeiffer's, 189 Serres', 188 Rohrer's, 194 of procidentia uteri, 85 of prolonged gestation, 196, 197 of retroversion, 221, 225, 227 of slow pulse during labor, 282 of use of the binder, 310 of vomiting during pregnancy, 165 Catamenia, 116 Causardine, M., 476 Cautions, 279, 281, 295 Cavity of the womb, 162 Cazeaux, 348, 588 Cephalodym, case of, 192 Cerise, Dr., his theory, 650 Cervix uteri, 87 antagonism of, with fundus, 162 carcinoma of, 427 dilatation of, 256 management of, during labor, 291 rigid, 284 Chailly, M., 203 Chamberlen forceps, 469 — 479 Hugh, 471 i INDEX. 675 Chamberlen, Mauriceau on, 471 Paul, 470 Hugh's, preface, 473 Chang and Eng, 437 Change of life, 116 Chapman, Samuel, 479 Child, alimentation of, 618 rules for, 621 causes of death in utero, 186, 611, 612 danger of, in breech presentations, 346 to preserve, in do do 364 danger of, from use of ergot, 689 dress of, 615 during labor, 267 history and diseases of, 610 how to treat, after delivery, 296 length of, 67 still-born, 613 washing of, 615 weaning of, 622 weight of, 67 Child's head, 61 bones of, 62 sutures of, 62 diameters of, 45, 63 fontanels of, 64 Child-bed fever, 558 Chloroform, 317 Prof. Simpson's letter on, 319 reply to, 322 Duncan and Flockhart's formula for, 321 medicinal effects of, 320 Chorion, the, 155 Churchill, Dr., 17, 279, 434, 508, 542 Circulation, in the fetus, 184 in the placenta, 175 of the female in labor, 281 Circumcision of the female, 78 Clarke's case of monstrosity, 189 Clarke, Dr., of London, 280 Classification in obstetricy, 18 Clitoris, the, 78 anatomy of, 79 absent in the Didelphis, 78 DeGraafon,78 Miiller on, 79 hypertrophy of, 79 Coagulation of the blood in the heart, 308 Cohesion of the labia, 75 nymphs, 77 sides of the vagina, 583 Collins, Dr., 205, 348, 368, 370, 384, 40 1 , 403, 404, 503, 571 letter on puerperal fever, 592 Colombat, 77 Colostrum, 620 Computation of term, 199 Nsegele on, 199 Concealed hemorrhage, 389 Conception, 150 definition, 150 Hippocrates on, 150 Galen on, 150 Conduct of a labor, 278 cautions in, 278, 281 cases, 282 definition, 278 Conduct of a labor, Dr. Clarke on, 280 Rainald on, 279 prognostic in, 280 venesection in, 183 Contractions of womb, hour-glass, 299, 392 painless, 170 ergotic, 589 Convulsions, puerperal, 401 Cord, the, 183 around the neck, 295 dressing of, 615 knots in, 187 length of, 183 not to be pulled, 299 prolapse of, 414 tying of, 613 Corpus luteum, 105 identity of with yelk of egg, 105 Coryza, 632 cause of death from, 634 treatment, 635 Cosgreave, P., 373 Coste, M., 90, 95, 100, 156 Costiveness during pregnancy, 169 Cosal bones, 32 Cramps during labor, 29, 412 causes, 29 during pregnancy, 169 Crupper bone, 31 Cuckoo bone, 31 Cuvier, 19, 78, 123 Cyanosis, 184, 637 causes, 637 Rokitansky on, 665 Wood on, 669 Davis, Dr. David, 17 forceps of, 482 Decapitation of the fetus, 611 Decidua, 154 vera, 155 reflexa, 155 Breschet on, 155 Hunter on, 155 Coste on, 156 Decubitus during labor, 283 dorsal, when necessary, 283 case, 284 in puerperal fever, 579 Deformed pelvis, 452 causes, 452 classification, 459 examination of, 459 forceps in, 457 specimens, 453 turning in, 457 relative frequency in U. S. and Europe, 510 embryotomy in, 513 Cesarean section in, 509 De Graaf on clitoris, 78 on ovaries, 96 Deliverance, 177 Delivery, of the shoulders, 295 676 INDEX. Delivery of the shoulders, 295 mechanism of, 53 of the placenta, 297 womb after, 302 artificial, frequency of, 362 Lachapelle on, 362 Denis, 119 Denman, 17, 53S De Paul,' M. on obstetric auscultation, 240 early detection of foetal heart, 243 Depressed bladder, 462 case, 289 Development force, 112 a generical force, 112 a genetic force, 112 of the foetus, 171 Deventer. 17 Dewees, 253, 215, 233, 450, 5SS error of, 337 Diameters of foetal head, 45, 63 pelvis, 44 Didelphis Yirginiana, 73, 158 anatomy of, 155 pregnancy in, 159 Diet,' 312 Digestive apparatus, disturbed during pregnancy, 166 Dimensions of pelvis, 44 mode of ascertaining, 450 Diseases of foetus in utero, 157 Distended bladder, 220 causing retroversion, 220 Doctrine of menstruation, 123 Dressing the child, 615 the cord, 615 Dubois, P., 345 Ductus arteriosus, 611 afterbirth, 611 Duncan and Flockhart's formula for chloro- form, 321 Duration of pregnancy, 193 in quadrupeds, 199 Painard-'s statistics on, 194 Brugnone ; s do 194 Earl Spencer's do 194 Grille- s do 195 Tessier's do 194 Winter's do 194 Eclampsia, 205 Ectopv, 193 Edwards, Milne, 208 Egs, human, 103 Emansio mensium, 134 Embryo, circulation of, 161 position of, in utero, 163 early, 151 Embryotomy, 511 auscultation before, 511 implements employed in, 511, 515 in exhaustion, 512 in locked head, 505 in deformed pelvis, 513 mode of performing, 512 Mrs. R. ; s case, 513, 531 Embryotomy, when impracticable, 514 forceps, 525 Emmenagogues, 138 Endangium, the, 141, 143 Endangitis, 561 Epidemic influence, 565 Ergot, 588 constitutional effects of, 592 dangers of use of, 559 "to child, 590 Dewees on, 555 effects of, 559 James on, 555 in post-partum hemorrhage, 307, 3S0. 592 in abortion, 593 Michel on. 555 Eschricht, 174 Etherization, 315 Eustachian valve, 1S4 Evolution, Cosgreave's plan, 373 compelled, 375 case of, 376 Pfeiffer's case, 375 Rohrer's, 375 spontaneous, 374 Excavation, the, 22 Exhaustion, 421 causes, 422 embryotomy in, 512 forceps in, 999 symptoms, 423, 424 Exomphalos, 153, 625 Extra-uterine pregnancy, 236 cases, 236, 237 Fabricius ab Aquapendente, 174 Face presentations, 59, 327, 332 only two positions of, 332 mechanism of, 59 management of, 60, 334 Dewees on, 333, 337 diagnosis of, 334 cases, 334, 339, 340 prognosis of, 341 Boivin on, 341 Lachapelle on, 341 sugillation after, 343 forceps in, 503 Fainting, 404 Fallopian tubes. 55 False pains, 260 causes, 260 diagnosis, 261 case, 262 ' Fecundation, 115, 149 vegetable, Schleiden on, 149 ovaric, 115 only during ovi-ponte, 123 ' Feet, to distinguish, 360 Female, circumcision of, 78 torso, profile of, 41 Fever, puerperal, 553 milk, 594 Fifth position, 57 INDEX. 677 Fillet, the, 436 when to be used, 436 mode of using, 436 First position, of the vertex, 51 of the right shoulder, 448 turning in, 44S of the left shoulder, 449 turning in, 450 of pelvic presentation, 70, 532 of the face, 332 Flexion, 51 in labor, 268 to assist, 2S7 Flourens, 10S, 111, 173, 1S1, 318, 325 Foetal head, measurements of, 45 bones of, 62 sutures of, 62 diameters of, 63 to grasp, 468 heart heard during pregnancy, 240 structure of, 184 Foetus, human, development of, 171 acephalous, 193 anencephalous, 193 causes of death of, 187 circulation in, 184, 611, 638 decapitation of, 511 diseases of, 188 monstrous, 188 cases, 189 position of, in utero, 183 of the whale, 176 Fontanels, 64 diagnosis of, 65 Foramen Botalli, 184 at birth, 611 premature closure of, 185, 611 Forceps, obstetric, 467 inventor of, 468 importance of, 467 Chamberlen's, 476 description of, 477 Dr. Samuel Chapman on, 479 old curve, 479 new curve, 480 Haighton's, 479 Mulder's history of, 480 Asdrubali on, 480 Smellie's, 480 Levret's, 480 Pean's, 481 Baudelocque's, 481 his experiments, 488 Davis' obstetrical, 482 Siebold's, 483 Huston's, 483 description of the instrument, 481 the child's instrument, 486 not a compressor, 487 handle to handle movement, 488 designed for the head, 490 rules for using, 490 difficulties in using, 494 precautions in use of, 495 manner of extraction with, 496 removal of, before delivery, 497 to effect rotation, 498 with vertex in hollow of sacrum, 500 Forceps, obstetric, in occipito-posterior positions, 501 with transverse head, 501 in face presentations, 503 in locked head, 505 in deformed pelvis, 457 placental, Dr. Bond's, 215 Forehead, application of forceps to, 505 Fossa navicularis, 81 Fourchette, the, 81 Fox, Dr. Geo., 512 G Galen, 152 Gardien, 17 Gastrotomy, in ruptured uterus, 467 Geburt, die des menschen, 40, 247, 275 Gendrin, 17 Generation, 150, 171 organs of, 71 Genitalia, 3 Germ, the, 114 extrusion of, 114 Germinal vesicle, 699 Gestation, 193 duration of, 193 prolonged, 196 cases of, 196, 197 Asdrubali's case, 196 Merriman's case, 196 tendency to menstruate during, 127 ovulation during, 126 Gibson, Prof., 530 Gifford, 17 Gintrac, quoted, 642 Gordon, Alexander, 558 Graafian follicles, 93, 103 cell, 103 Granular membrane, 95 Gravid uterus, appearance of, 201 Smellie on, 201 Grille, M., 195 Guiette, Dr., 24S Guillemeau, 17 Gum, the, 629 Hsematosis, 141 Haighton's forceps, 479 Haller, 118, 546 Hardening the child, 617 Hatch, Dr., case, 552 Head, foetal, measurement of, 45, 63 N flexion and obliquity of, 51 rotation of, 52 extension of, 53 restitution of, 53 bones of, 62 sutures of, 62 Head, transverse, forceps in, 501 locked, forceps in, 503, 504 Heart of foetus, 610 678 INDEX. Hemorrhage, uterine, 303 care in examination in, 303 causes, 304 cases, 304, 305 from rising suddenly, 306 case, 306 post-partum, 390 ergot in, 307, 380, 592 coagulability of blood after, 308 unavoidable, 999 treatment of, 379 before labor, 383 concealed, 399 precautions against, 394 Mauriceau's case, 396 tampon in, 396 in abortion, 213 treatment of, 216 Hemorrhagic labor, 377 causes, 377 management, 378 Henle, 107 Hermaphroditism, 79 Hernia, 414 Hey, 558 Hip bones, 32 Hippocrates, 68, 152 Hodge, Prof., 230 Home, Sir E., 151 Hooper's pill, 143 Horner, Prof., 229 Hour-glass contraction, 204, 299, 302 causes, 299, 300, 392 treatment, 302, 393 Human egg, 103 Hunter, John, 169 William, 177 Huschke's views, 101, 104, 114 Huston, Prof, 30 forceps of, 483 Hydatid degeneration of the ovum, 207 Milne Edwards on, 208 Pouchet on, 208 nature of, 208 diagnosis of, 209 treatment of, 209 Hydrometra, 210 Hymen, the, 80 imperforate, 81 simulating atresia, 586 no test of virginity, 81 Hypertrophy of the clitoris, 29 Icterus, 632 Impregnation, liability to, 128 Induction of premature labor, 538 history of, 538 dangers of, 540 in vomiting of pregnancy, 166 in deformed pelvis, 538 Dr. Lee's case, 539 Letter to Dr. E. on, 540 Inversion of the womb, causes of, 546 spontaneous, 550 Inversion of the womb, complete, 546 cases, 547 mode of reduction, 548 Mr. White on, 549 incomplete, 546 treatment of, 550 prognosis in, 657 Inverted womb, spontaneous replacement of, 551 Dr. Moehring's case of, 557 Dr. Levis' case of, 551 Dr. Hatch's case of, 552 Mr. Cross on, 556 Iron in amenorrhea, 144 Que vermes, 145 Irritable breast, 602 Ischial planes, 24 James, Prof., 308, 336, 395, 588 Jaundice, 632 Jewish laws, 128, 153 opposed to fruitfulness, 152 Jewish women, 128, 153 after delivery, 277 after menstruation, 128 Jews, laws of, 28, 152 population of, 152 John Ocularius, 246 Joints, pelvic relaxation of, 38 case, 38 Jones, T. Wharton, 100, 108 Jb'rg, 17 Kelly, Dr. C, 161 Labia pudendorum, 72 majors, 72 minora, 75 diseases of, 73 cohesion of, 75 differences of, 76 Labial thrombus, 73 abscess, 74 Labor, 245 definition of, 245 time of commencement of, 249 nature of, 249 cause of, 250 Baudelocque's theory, 251 caution as to prognostic in, 257 constitutional effects of, 256 outward signs of, 257 the child in, 267 flexion of the head in, 268 mechanism of, 272 completion of, 274 conduct of, 278 unassisted, proportion of, 278 average duration of, 279 circulation in, 282 INDEX. 679 Labor, venesection in, 283 anaesthesia in, 315 pain in, physiological, 328 hemorrhagic, 377 retarded, 699 preternatural, 361 Labors, most frequent at night, 248 Labor pains, 91, 245 cause of, 252 number of, 81,252 duration of, 252 dilating, 253 expulsive, 254 false, 260 periodicity of, 263 effects on bladder and rectum, 253 effects on constitution, 254, 256 actions of woman during, 255 Laceration of womb and vagina, 464 most frequent seat of, 464 symptoms of, 465 signs of, 466 conduct of, 465 case of, 466 gastrotomy in, 467 Lachapelle, Mad., 270, 342, 362 Lactiferous ducts, 596 Lady Webster's pill, 143 Laennec, 208 Lamotte, 17 Lawrence, Mr., 78, 85 Lee, Robert, 17, 108, 458, 539, 558 Legallois, quoted, 650 Letheby, 120 Levatores ani, 49 Levret, 17, 489 forceps of, 489 Liebig, Prof., 161 Ligamenta rotunda, 49 during pregnancy, 170 in retroversion, 171 lata, 49 during pregnancy, 170 Ligaments of the pelvis, 36 Linea ileo-pectinea, 22 Lochia, 275, 276, 314 Locked head, 503 forceps in, 505 embryulcia in, 505 above the superior strait, 450 Longings, 167 Lowenstein, 17 Lower pelvis, 22 M Macauley, Dr., 538 Macula germinativa, 95, 101, 117 Mammary abscess, 603 causes, 603 evils of, 604, 605 case, 607 treatment of, 603, 605 weaning in, 609 Mammary glands, 594 anatomy of, 595 Haller on, 596 Mammary glands, Haller on anatomy of, 596 during pregnancy, 595 after delivery, 596 suspension of, 604 Martin Barry, 96 Mauriceau, 17 case of his sister, 396 his account of Hugh Chamberlen, 471 preface of Chamberlen to his work, 473 Maygrier, 108 Measurements of the pelvis, 23, 45, 63 foetal head, 45 Mechanism of the pelvis, 51 of labor, 51 of the shoulders* delivery, 53 of 1st position of vertex, 53, 272 hip, 272 rotation, 273 extension, 274 restitution, 275 of 2d position of vertex, 54 of 3d do do 55 of 4th do do 56 of 5th do do 57 of 6th do do 57 of face, 59 Meconium, 625 Medicine, 313 Membrana granulosa, 95 Menagoga, 135 Menstruation, 116 age of commencement of, 116 of cessation of, 116 appearances of, 121 ovary after death during, 121 doctrine of, 123 during pregnancy, 213 duration of, 117 nature of, 118, 122 period of, 1 16 precautions during, 116 retardation of, 134 synonymes of, 116 suppression of, 135 total absence of, 129 Menstrual discharge, 116 amount of, 116 Menstrual fluid, nature of, 118 Haller on, 118 Boivin on, 119 Brierre de Boismont's analysis of, 119 Rindskopf's do 120 Simon's do 120 Letheby's do 120 Merriman, Dr., 199 Method, 19 Michel on ergot, 588 Midwife, 17 Midwifery, 17 meddlesome, 278, 325 Milk, when secreted, 597 Milk fever, 594 symptoms, 597 nature of, 597 complications of, 597 case, 597 dangers of, 598 Milk fistula, 607 680 INDEX. Miscarriage, 211 Moles, 210 Mollities ossium, 17 Monsters, 1SS Serres' case, 1S8 Pfeiffer's case, 189 Clarke's case, 189 Hohrer's case, 189 nature of, 191 Mons veneris, 72 diseases of, 72 Montgomery, Dr., 108 Moreau, 108, 203 Morsus diaboli, 88 Mueuet, 631 Mulder, Dr., 480 Miiller, J., 7S, 117 Murphy, Prof. Ed. W., 476 Muscles, uterine, 202 arrangement of, 203 Chailly on, 203 Moreau on, 203 contraction of, 203 X Naegele, Prof., 17, 199, 272, 453, 454, 455 Nature, periodicity in, 123 Navel, management of, 624 pouting of, 169 Navel string, 625 division of, 275 not to be pulled, 299 tying of, 614 dressing of, 615 Needham, Walter, 183 Negrier, 118 Nipple, structure of, 596 excoriated, 599 ointment for, 600 artificial, 602 Nasud-vital, 31S Noortwyck, 179, 183 Nymphas, 76 diseases of, 77 coherent, 77 Obliquely deformed pelvis, 453 management of cases, 453 Obliquity of the uterus, 244 to correct, 28S Obstetrician, 17 Obstetricy, 17 Obstetric auscultation, 239 value and importance of, 240 case, 241 as ground for prognosis, 356 before embryotomy, 511 Occipito-posterior positions, forceps in, 501 OZdema labiorum, 73 gravidarum, 206, 420 treatment of, 420 Puzot on, 206 Oken, Prof., 140, 160, 330 Omphalo-mesenteric vessels, 1S2 Opening of the joints, 3S Opossum, 78 anatomy of genitalia of, 15S pregnancy in, 159 Organs of generation, the, 71 Os coccygis, 31 pectinis, 35 Ossa pubis, 26, 33 innominata, 32 ischia, 43 Os uteri, management of, during labor, 291 undilated, 291 to render dilatable, 372 rigid, 373 anaesthesia in, 373 rigid in placenta prsevia, 384 Dr. Collins on, 384 Ovarian follicles, 93 pregnancy, 152 Pouchet on, 154 BischofF on, 154 Martin Barry on, 154 Ovaric fecundation, 115 Ovaries, the, 93 absence of, 129 Barry on, 96 Bernhardt on, 100 Bischoffon, 101 Burdach on, 104 Coste on, 95 De Graaf on, 96 Dumas on, 100 development of, 97 effects of removal of, 130 functions of. 114 Huschke on, 104,114 influence of, on character of female, 112 office of, 114 Purkinje on, 97 Von Baer on, 98 Wagner on, 95 Wharton Jones on, 100 Ovarium, Coste's views on, 101 Oviposit,. 114 fecundation only during, 12S Ovisacs, 94 Ovulation, 126 and deposit, 144 during pregnancy, 213 Ovulum, 100 maturation of, 104 Ovum, human, 103 of the bitch, 100 Owen, Prof., 159, 173 Painless contractions of the womb, 170 Pare, 17 Patterson, Dr., 108 Pean's forceps, 481 Pelvic joints, 36 relaxation of, 38 case, 3S presentations, 344 causes of, 345 INDEX. 681 Pelvic joints, diagnosis of, 348 dangerous to the child, 346 why ? 347 fatalities in, 34S not preternatural, 345 frequency of, 344 Bland on, 345 Boivin on, 345 Collins on, 345 Lachapelle on, 345 Merriraan on, 345 Naegele on, 345 forceps often necessary in, 355 application of, in, 506 Rainald on, 346 positions of, 70 Pelvis, 21 synonymes of, 21 axis of, 46 diameters of, 44 dimensions of, 44 mode of ascertaining, 459 deformed, 453 ligaments of, 36 measurements of, 23, 44 mechanism of, 51 nerves of, 49 recent, 48 anatomy of, 49 the whole of, 39 tumors in, 462 case, 463 vessels of, 49 Pelvimeters, 460 Pennsylvania Hospital, anaesthesia in, 322 Perineum, the, 81 structure of, 81 in labor, 82, 274, 293 to relax, 293 to support, 293 influence of on mechanism, 58 convex in the old, 49 laceration of, 83, 498 cicatrices of, 83 in forceps operations, 497 Periodicity, reproductive in nature, 123 Peritoneum, the, 49 extent of, 561 inflammation of, 558 Pfeiffer, Dr., case of monstrosity, 184 Physick, Dr., 601 Physometra, 201 Pill, Hooper's, 143 Lady Webster's, 143 Blaud's, 145 Placenta, adherent, 299, 393 circulation in, 175 connection of with uterus, 176, 178 cotyledons of, 176 delivery of, 297 description of, 180 expulsion of, 177, 267, 276 function of, 161, 174 foetal surface of, 175 maternal surface of, 175 human, entirely foetal, 172 Hunter on, 172 Placenta, Fabricius on, 174 Flourens on, 173 Owen on, 173 Seiler on, 172 Velpeau on, 172 removal of, before the child, 387 forceps, Dr. Bond's, 215 hook, Dewees', 215 Placenta praevia, 382 symptoms of, 382 cause of hemorrhage in, 383 prognosis of, 3S4 turning in, 3S4 ergot in, 386 comparative frequency of, 386 Collins on, 386 Mauriceau on, 386 Simpson's treatment of, 387 Radford's do 387 Placental souffle, 239 tufts, 174 Plane of the superior strait, 39 inclination of, 39 of the inferior strait, 43 form of, 45 Planes of the ischia, 24, 34 Plethora, 142 Position, definition of, 69 Positions of the breech, 352 of the vertex, 51, 70, 269 mechanism of, 51, 57, 272 how produced, 268 relative frequency of, 268 Baudelocque on, 269 Naagele on, 269 Simpson on, 269 Boivin on, 279 Lachapelle on, 270 Post-partum hemorrhage, 790 nature of, 390 concealed, 391 treatment of, 391 Pott, Percival, 130 Pouchet, 108, 109, 122, 128, 152, 208 Poupart's ligament, 23 Pouting of the navel, 169 Pregnancy, 147 definition of, 148 commencement of, 151 computation of, 127 duration of, 193, 249 signs of, 164, 238 diagnosis of, 168 development of womb during, 162 auscultations in, 237 vomiting of, 165 costiveness of, 169 cramps of, 169 headache of, 205 vertigo of, 205 convulsions of, 205 cough of, 205 swelled feet of, 206 varicose veins of, 206 menstruation during, 233 concealed, 241 vaccination during, 432 after inversion, 551 682 INDEX. Pregnancy, with permanent retroversion, 227 protracted, 196 Asdrubali on, 197 ovarian, 152 Bischoff on, 154 Martin Barry on, 154 Pouchet on, 154 tubal, 153 extra-uterine, 236 Premature labor, induction of, 166, 638 Presentations, 65 only two, 65 pelvic and cephalic, compared, 26 cephalic, 68 deviated, 68 pelvic, 69, 344 deviated, 69 relative frequency of, 67 face, 327 mechanism of, 69 shoulder, 363 Pressure of the womb on the vessels, 204 Preternatural labor, 361 definition, 361 causes, 361 relative frequency of, 362 from anaemia, 999 from carcinoma uteri, 427 cases, 428 from compressed loops of intestine, 426 case, 426 from convulsions, 401 from cramps, 29, 412 from deformed pelvis, 452 from depressed bladder, 462 from exhaustion, 421 from fainting, 414 from hernia, 414 from placenta prsevia, 382 from prolapse of the cord, 412 from prolapse of a mass of intestines, 462 from small-pox, 430 from tumors, 462 from twins, &c, 435 from vaginal vesicocele, 289 from want of flexion, 463 from want of rotation, 463 Prevost and Dumas, 102 Primipars, more liable to convulsions, 204, 404 Procidentia uteri, 85 Mr. Stanley's case, 85 Dr. Hains' case, 85 Professional conduct, 245 Wigand on, 247 during labor, 279 Rainald on, 279 Dr. Clarke on, 280 Profiles of the female torso, 41 Prognosis, cautious in labor, 257 auscultation as ground of, 358 Prolapse of the cord, 412 effects of, 412 management of, 412 Prolapsus uteri, 85 in pregnancy, 164, 219 Promptness, necessity for, 444 cases, 445 Puberty, 140 age of, 116 Pubic arch, 24 deformity of, 461 Pubis, 34 arch of, 35 symphysis of, 35 ramus of, 235 faulty, 292, 461 cases, 292 Pudenda, 12 Puerperal convulsions, 401 causes, 401 Collins on, 401, 403 generally in primiparae, 404 Clarke on, 404 Collins on, 404 Merriman on, 440 prevention of, 402 symptoms of, 405 treatment of, 405 consequences of, 408 cases, 407, 408 Puerperal fever, 558 causes, 559 symptoms, 560, 567 diagnosis, 565 pathology of, 561 precautions against, 569 tympanites of, 576 angulation of intestine in, 578 prognosis of, 580 non-contagious, 567 treatment of, 578 venesection, the cure of, 568 M. Baudelocque on, 574 Dr. Collins on, 571 letter on, 581 Purkinje, 97 Purkinjean vesicle, 78 Puzos, 206, 216 Pythagoras, maxim of, 257 Quetelet, M., 248 Quevenne's iron, 145 Quickening, 167 definition, 167 causes, 167 in a medico-legal point of view, 168 as a sign, 242 Raciborski, 108, 145 Rachitis, 453 Radford, Dr., 387 Rainald, Thomas, 279, 325, 346, 366, 467 Rainard, M., 194 Randolph, Dr., 589 Recto-vaginal septum, 81 Removal of the placenta, before the child, 387 arguments for, 387 against, 388 INDEX. 683 Renauldin, Dr., 129 Reproductive periodicity in nature, 123 organs, influence of on the constitution, 164 Restitution, 53 Retained placenta, 298 Retarded labor, by obliquity, 288 by rigid os uteri, 291 perineum, 293 by faulty sacrum, 291 pubis, 292 Retroversion of the womb, 171, 220 causes, 171, 220 cases, 221, 222 treatment, 224 cured by catheter alone, 224 in the virgin, 224 case, 224 permanent, 227 with pregnancy, 227 Dr. Yardley's case, 227 Amussat's case, 227 Revaccination during pregnancy, 433 Rheumatism of the womb, 139 in labor, 260 Wigand on, 260 diagnosis of, 260 case, 262 Rigby, Dr., 272 Rindskopf, 120 Rita-Christina, 189, 437 Rohrer's case, 190 Rokitansky, 665 Rosenmuller, 94 Rotation, 52 to assist, 287 forced, 463 case, 463 to effect by forceps, 498 in breech cases, 498 Round ligaments, 49 during pregnancy, 170 in retroversion, 171, 221 Rupture of the membranes, in hemorrhage, 380 of the uterus, 464 Ruysch, 299 S Sacral nerves, 28 Sacro-iliac junction, 32 Sacro-vertebral angle, 32 sciatic notch, 34 ligament, 34 Sacrum, 27 faulty, 291, 462 deformed, 462 promontory of, 32 Scholar, influence of the, 247 Schleiden, 149 Schwann, Thomas, 107, 109 Secale cornutum, 588 Second position, of vertex, 54 of right shoulder, 448 of left shoulder, 449 of pelvic presentation, 70 Second position, of the face, 333 of the breech, 354 Seiler, 172 Serres' views, 188, 309 Sex, 112 Sharp crotchet, 526 objections to, 526 Shear-bone, 53 Shoulder presentation, 363 causes of, 363 diagnosis of, 364 turning in, 366, 447 right positions of, 448 left positions of, 449 Shoulders, mechanism of delivery of, 272, 295 Siamese twins, 188 Siebold's forceps, 183 Sigault, M., 508 Sigaultian section, 507 condemned, 508 Signs of pregnancy, 164, 238 often overlooked, 238 rational, unreliable, 239 physical, 239 Simon, Franz, 120 Simpson, Prof., 272, 369, 387, 456, 458 letter from, 319 reply to, 322 Sitting up, 314 too soon, 307 Sixth position, 57 case, 58 Skull-cap in coryza, 636 Small-pox in pregnancy, 431 Smellie, 201 forceps of, 480 Snuffles, the, 632 Solayres, 513 Sore mouth, 630 treatment, 631 nipples, 599 treatment of, 600 Dr. Physick on, 601 pommade for, 601 Spencer, Earl, 195 Spigelius, 196 Spontaneous evolution, 373 nature of, 374 Stanley, Edward, 85 Stein, 17 St. Hilaire, 190 Strait, superior, 22, 25 plane of, 39 deformed, 455 inferior, 25 Stroma, 94 Strophulus albidus, 630 intertinctus, 630 Subsidence of the womb, 251 Suckling, 313 Sue, M., 507 Suppressio mensum, 134 Swan, Dr., 108 Swelled feet of pregnancy, 206 Symphyseal ligaments, 36 Symphyseotomy, 507 Syncope, 305 cause, 305 684 INDEX. Syncope, after hemorrhage, 305 danger of, 308 Tablier des Hottentots, 78 Lawrence on, 78 Merat on, 78 Cuvier on, 78 Tache embryonaire, 95 Tampon, the in abortion, 217 in hydatids, 203 when inadmissible, 218 never, 309 danger of, 219 Tenesmus, 255 to prevent, 221 Teratological fetuses, 189 Tertullian, 469 Tessier, 195 Third position of vertex, 55 mechanism of, 55 of pelvic presentation, 70, 354 Thrombus of labium, 73 Tonics, 144 Touching, or examination, 258 object of, 258 mode of proceeding, 259 Transcendental anatomy, 203 Transverse head, forceps in, 501 Tubal pregnancy, 153 Tumors in the pelvis, 463 during labor, 463 management of, 463 proposal to puncture, 463 Dr. Beesley's case, 464 Tunica granulosa, 95 Turning, 363, 386, 440 Rainald on, 366 time for, 367 preparation for, 367 mode of performing, 368, 442 Collins on, 368 Simpson on, 368 to know when completed, 369 difficulties of, 370 engagement of the head during, 442 after treatment, 370 in placenta pragvia, 385 in 2d vertex position, 446 in 3d do do 446 in 4th do do 447 in 5th do do 447 in shoulder presentations, 447 in deformed pelvis, 457 Simpson on, 458 Lee's cases, 458 Turn out the clot, 310 Twins and triplets, 434 relative frequency of, 434 Churchill on, 434 signs of, 434 delivery of, 435 placenta? of, 437 chorion of, 437 amnion of, 437 Twins and triplets, development of, 191 locking of heads of, 436 danger of hemorrhage, 451^ Tympanitis of puerperal fever, 577 U Umbilical cord, 182 length of, 183 knots in, 187 composition of, 175 ring, closure of, 625 Umbilical vesicle, 181 arteries and veins, 182 retraction of, 625 Unassisted labors, proportion of, 278 Boivin on, 278 Urachus, 181 Ureters, 49 Urethra, 79 diseases of, 80 Uterine muscles, 202 Uterus, the, 87 structure of, &c, 88 lining membrane of, 89 Coste on, 89 fibres of, 89 Chailly on, 90 spasm of, 90 absence of, 129 cases, 130, 132 dimensions, 162 at term, 170 weight of, 162 after labor, 162, 275 gravid appearance of, 201 Smellie on, 201 obliquity of, 204 pressure of, in vessels, 204 during menstruation, 125 Vaccination during pregnancy, 432 Vagina, the, 48, 84 influence in prolapsus, 85 follicles of, 86 structure of, S6 laceration of, 464 Vaginal vesicocele, in labor, 289 Vagitus uterinus, 276 Valentine, Dr., 108 Vallet's mass, 144 Valve of Botalli, 611 Varicose veins, 206 Velpeau, 17, 172, 556 Venesection, during labor, 283 Dewees on, 283 object of, 283 evils of, 283 when demanded, 283 Version, 440 by the head, 441 Vestibulum, 79 INDEX. 685 Viability, 610 Villerme, 248 Vital triangle, 416 Vitellary matter, identity of with corpus luteum, 105 nature of, 106 Carpenter on, 106 Bernhardt on, 106 Bischoff on, 108 Henle on, 107 Huschke on, 107 Schwann on, 109 Von Baer on, 108 Miiller on, 106 Vitelline aac, 1S2 Vomiting of pregnancy, 165 causes, 166 treatment, 166 cases, 165 in beginning of labor, '257 Von Baer, 98, 108 Vulva, 72 W Wagner, Rudolph, 79, 95, 101 Wakley's experiments, 325 Weaning, 622 in mammary abscess, 609 Weber, 174 Weed, 602 Whale, fetus of, 176 Wigand, Justus Henrich, 40, 247, 275 Wind pregnancy, 210 Winter, Simon, 204 Womb, the, 87 structure, &c, 81 how sustained in the pelvis, 88 rheumatism of, 139 development of, during pregnancy, 162, 200 antagonism of cervix and fundus of, 162 painless contractions of, 170 examination of, at term, 178 prolapsion of, 85 during pregnancy, 219 retroversion of, 220 with pregnancy, 227 subsidence of, 281 after delivery, 302 power of contracting, 370 laceration of, 464 inversion of, 546 Women, non-menstruating, 129 Wood, Prof, 663, 664, 665, 666 Yelk ball, 94 Yardley, Dr., case, 227 Zona pellucida, 95 THE END. E 90 6® m am