ARTES
1837
SCIENTIA
VERITAS
LIBRARY
OF THE
UNIVERSITY OF MICHIGAN
„É PLURIBUS UNUM
SI
QUAERIS-PENINSULAM AMOENAM
CIRCUMSPICE
WAÐARAYADADA AJADAJAD ORI
618.2
5613
1871 a
9351
SELECTED
OBSTETRICAL AND GYNECOLOGICAL
WORKS
OF
D.C.
SIR JAMES Y. SIMPSON, BART., M.D., D. C. L.,
LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF EDINBURGH;
CONTAINING
THE SUBSTANCE OF HIS LECTURES ON MIDWIFERY.
EDITED BY
J. WATT BLACK, M. A., M.D.,
ROYAL
MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON;
PHYSICIAN-ACCOUCHEUR TO CHARING CROSS HOSPITAL, LONDON; AND LECTURER ON MIDWIFERY AND
DISEASES OF WOMEN AND CHILDREN IN THE HOSPITAL SCHOOL OF MEDICINE.
NEW
D. APPLETON
YORK:
AND COMPANY,
549 & 551 BROADWAY.
1871.
TAUB
618.2
5613
1871a
v.l
PREFACE.
HAVING lived for five years with the late Sir James Y.
Simpson as his Assistant, and having acquired, by con-
stant association with him during and since that period,
an intimate knowledge of his opinions, modes of practice,
and writings, I have been requested by his representatives
to compile and edit the present volume.
It will be found to contain all the more important of
his contributions to the study of Obstetrics and Diseases
of Women, with the exception of his Clinical Lectures
on the latter subject. These Lectures were published in
the Medical Times and Gazette (1859-61), and will
shortly appear in a separate volume.
In 1855-56 his Obstetric Memoirs and Contributions
were collected, and re-issued in two volumes, under the
editorship of Dr. Priestley of London, and Dr. H. R.
Storer of Boston, U.S., when several of the articles were
revised, and a few of them re-written by their author.
Many of the papers in the present volume are reprinted
from that work, but references to the periodicals in
which they originally appeared are given in the foot-
notes.
His Lecture Notes are now published for the first
vi
PREFACE.
time, and contain the substance of the practical part of
his Course of Midwifery. For many years it was his in-
tention to publish an outline of his Systematic Lectures,
and in 1862 I was engaged with him in incorporating
his Lecture Notes with Smellie's Treatise on the Theory
and Practice of Midwifery, which he had undertaken to
edit for the New Sydenham Society. That purpose was,
however, ultimately abandoned in consequence of the
pressure of his other engagements.
In order to keep this volume within due limits, several
articles of inferior interest or importance have been pur-
posely omitted.
In a few instances in which his practice had recently
changed, I have ventured to append a short statement
of his later views.
J. WATT BLACK.
CLARGES 'STREET, LONDON, June 1871.
CONTENTS.
PART I.
NATURAL LABOUR
Phenomena of
Management of
LABORIOUS LABOUR
LECTURE NOTES.
PAGE
1
1
3
First Order.-Tedious Labour
A. From Morbid Protraction of the First Stage by Local impeding
causes
I. Rigidity of the Lips and Neck of the Uterus
II. Rigidity of a Band of Circular Fibres of the Cervix
•
III. Wedging in of a fold of the Cervix between the Head and the
Pelvis
IV. Premature Rupture of the Membranes
V. Preternatural Toughness of the Membranes
8
∞
8
10
11
11
12
2 2 2 2
12
VI. Over-distension of the Uterus by Liquor Amnii
VII. Oblique position of the Os or Body of the Uterus
VIII. Occlusion of the Os Uteri
12
13
13
IX. Large Size of Pelvis allowing Prolapsus
13
X. Morbid Relaxation of the Soft Parts allowing Prolapsus
B. From Morbid Protraction of the Second Stage by Obstructions on
the part of the Maternal Passages
13
14
I. Rigidity and Contraction of the Vaginal Canal and Vulva
II. Distended Colon and Rectum
15
16
III. Hernia of the Intestines diminishing the Pelvic Cavity
16
IV. Distended Urinary Bladder
16
(1.) Without displacement
16
(11.) With Displacement
17
V. Calculus in the Bladder.
17
viii
CONTENTS.
VI. Tumours formed by the Ovary
PAGE
17
19
20
VII. Tumours embedded in, or attached to, the Soft Tissues
surrounding the Maternal Passages.
VIII. Diseased states of the Pelvic Bones
C. From Morbid Protraction of the Second Stage, by obstructions on
the part of the Child
I. Shortness of the Umbilical Cord
II. Death of the Child
III. Large Size of the Child
IV. Sex of the Child
V. Strong Ossification of the Head
VI. Enlargement of the Head or Body from Disease
VII. Malpositions of the Head
VIII. Malpresentations of the Head
IX. Prolapsus of the Upper or Lower Extremities with the Head.
21
21
21
22
22
23
25
≈ 2 2 2 2 2 2 2 2 *
21
21
. 22
D. From Inefficiency of the Expulsive Powers during both First and
Second Stages
26
I. Inefficiency from General Constitutional Debility
26
II. Inertia of the Accessory Expulsive Powers of the Diaphragm
and Abdominal Muscles
27
III. Inefficiency of the Expulsive Powers of the Uterus itself
27
Second Order.-Instrumental Labour
30
I. Fingers of Accoucheur
33
II. Fillet or Lac
33
III. Forceps
£4
IV. Vectis or Lever
37
Third Order.-Impracticable Labour
38
I. Craniotomy
II. Cranioclasm
III. Cephalotripsy
IV. Cæsarean Section
38
43
44
44
V. Sigaultian Section or Symphyseotomy
45
PRETERNATURAL LABOUR
45
First Order.-Pelvic Presentations
I. Footling Presentations
47
47
II. Knee Presentations
III. Breech Presentations
Second Order.-Cross-births
48
48
49
CONTENTS.
ix
PACE
COMPLEX LABOUR
4. Complications on the part of the Child
I. Shortness and Circumvolutions of the Umbilical Cord
II. Prolapsus or falling down of the Umbilical Cord
III. Plural Births
(1.) Simple twin cases
(11.) Complex twin cases
(III.) Monstrosities by excess
B. Complications on the part of the Mother
(4.) Head Complications
54
54
54
54
•
55
55
56
57
57
•
57
I. Apoplexy
57
་
VI. Syncope
I. Ascites
ง
II. Puerperal Convulsions-Eclampsia.
(B.) Chest Complications.
I. Emphysema
II. Bronchitis
III. Pneumonia
IV. Pleurisy
V. Organic Disease of the Heart and large Blood vessels
(C.) Abdominal Complications
II. Tumours
III. Hernia of the Intestines
IV. Displacements of the Uterus
(1.) Inguinal Hernia
(11.) Umbilical Hernia
57
58
58
58
59
59
59
59
59
59
59
.
60
60
60
60
(III.) Prolapsus
60
(IV.) Inversion
61
V. Lacerations of various Abdominal Viscera
61
•
VI. Rupture of the Uterus
61
VII. Lacerations in the Perineum and Vulva
65
VIII. Uterine Hemorrhage
65
(1.) Hemorrhage in the last months of Pregnancy and first two
stages of Labour
65
1. Unavoidable Hemorrhage from Presentation of the
Placenta
66
2. Accidental Hemorrhage
69
(11.) Hemorrhage in the third stage of Labour
70
(III.) Hemorrhage after delivery of Child and Placenta
72
X
CONTENTS.
PAGE
(1.) Suppression
INDUCTION OF PREMATURE LABOUR
PUERPERAL STATE AND DISEASE
Morbid Deviations during the Puerperal state
A. In the state of the Uterus
I. After pains-Hysteralgia
II. Morbid Variations in the Rapidity of Involution
III. Morbid conditions of the Lochia
(11.) Profuse Flow
(111.) Morbid Quality
B. In the state of the Bladder
I. Retention of Urine
II. Incontinence of Urine
C. Inflammation of the Vagina
74
76
76
76
76
77
76
77
77
77
77
77
77
78
D. Febrile Diseases of the Puerperal State.
73
I. Rigors
78
II. Milk Fever
III. Ephemeral Fever or Weid
IV. Puerperal Fever
78
78
79
PART II.
PREGNANCY.
Duration of Human Pregnancy
81
Therapeutic Action of the Salts of Cerium in the Vomiting of Pregnancy, etc.
Inhalation of Oil of Juniper as a Diuretic in Albuminuria
95
96
Induction of Abortion in Albuminuria
97
Treatment of Hemorrhage connected with Abortion
97
Induction of Premature Labour for Recurrent Hydrocephalus in the Foetus
Influence of the Death of the Fœtus on its Retention or Expulsion.
97
99
PART III.
THE FETUS AND ITS APPENDAGES.
Excitation of Fatal Movements by Cold
• 101
Peritonitis in the Fœtus in Utero
102
Intra-uterine Goitre or Bronchocele
125
Rudimentary Reproduction of Extremities after their Spontaneous Ampu-
tation
Vital Contractions in the Umbilical Arteries and Veins
•
129
•
133
CONTENTS.
xi
Placental Phthisis or Apnoea, as an Intra-uterine Cause of Death among
Premature Children
Chlorate of Potass in Placental Disease
Placental Hemorrhage: Changes in the Blood effused
PART IV.
PARTURITION.
PAGE
•
134
145
•
145
The Determining Cause of Parturition
Influence of the Nervous System on the Contractions of the Uterus
Sound heard during the Detachment and Expulsion of the Placenta
Frequency of Laceration of the Perineum and Cervix Uteri in Labour
Nature of Spurious Labour Pains
. 148
148
151
152
153
Indian Hemp as an Oxytocic
154
•
Complication of Labour by large Fibrous Tumours of the Uterus
Case of Malacosteon; with Practical Remarks
155
•
157
Spontaneous Expulsion and Artificial Extraction of the Placenta before the
Child, in Placental Presentations
177
Summary of Principles of Treatment in Placental Presentations
285
Special average amount of Maternal Mortality observed in cases of Turning
for Placenta Prævia
292
Treatment of Placenta Prævia by Partial Separation of the Placenta
Albuminuria in Puerperal Convulsions, etc.
295
295
•
Morbid Conditions and Injuries of the Spleen in the Pregnant and Parturi-
ent States
304
Fatal Peritonitis and Pericarditis during Labour
305
Sex of the Child as a cause of Difficulty and Danger in Human Parturition
Transverse Presentations
307
363
Spontaneous Evolution or Expulsion of the Foetus-Decapitation and
Evisceration in Transverse Presentations
379
Obstruction in Head Presentations from Dorsal Displacement of the
Arm
•
381
Danger of Rupture of the Uterus from Hydrocephalus in the Fœtus
384
State of the Foetal Pulse during Labour as an Indication of Danger to the
Child.
387
Mode of Application of the Long Forceps
387
Turning as an Alternative for Craniotomy and the Long Forceps
393
Turning as a Substitute for Craniotomy
486
Vaginal Hysterotomy, etc., in Labours obstructed by Uterine and Vaginal
Cancer
498
Spondylotomy in Cross-births
502
xii
CONTENTS.
PART V.
THE PUERPERAL STATE.
Entrance of Air into the Venous System through the Uterine Sinuses after
Delivery
PAGE
503
Communicability and Propagation of Puerperal Fever
505
Eruptive Fevers in Puerperal Patients
518
Pathological Observations on Puerperal Arterial Obstruction and Inflam-
mation
523
Case of Recovery from Puerperal Cerebral Embolism, and sudden Death
in a subsequent Pregnancy
566
Tetanus following Lesions of the Uterus, Abortion, and Parturition
569
Causation of Puerperal Mania by Albuminuria
591
Perineal Fistula left by the Transit of the Infant through the Perineum
Morbid Deficiency and Morbid Excess in the Involution of the Uterus after
592
Delivery
"
595
PART VI.
NON-PUERPERAL DISEASES OF WOMEN.
Memoir on the Uterine Sound
604
Use of the Exploring Needle in the diagnosis of doubtful forms of Pelvic
and other tumours
661
The state of Artificial Anæsthesia as a means of facilitating Uterine
Diagnosis
663
Medicated Pessaries
664
Medicated Pessaries and Suppositories
665
Direct Local Application of Remedies to the Cavity of the Uterus.
Application of solid Nitrate of Silver, etc., to the interior of the Uterus in
669
Menorrhagia
669
Gallic Acid in Menorrhagia
n
670
Imperfect Development of the Uterus, giving rise to Amenorrhoea, etc.
671
Nature of the Membrane occasionally expelled in Dysmenorrhoea.
Dilatation and Incision of the Cervix Uteri in Obstructive Dysme-
672
norrhoea
677
Retroversion of the Unimpregnated Uterus
681
Ascent of the Unimpregnated Uterus
707
Treatment of Chronic Inversion of the Uterus
710
Inflammatory Eruptions upon the Mucous Membrane of the Cervix Uteri
711
CONTENTS.
xiii
Treatment of Inflammatory Induration of the Cervix Uteri by deep Cauteri-
sation with Potassa Fusa
PAGE
712
The more common Terminations and the Treatment of Fibroid Tumours of
the Uterus
713
Artificial Removal of a large Fibroid Tumour in Posterior Wall of Uterus
Treatment of Fibroid Tumours of the Uterus
717
719
Diagnosis of Polypi growing from the Lips of the Cervix Uteri
720
Excision of large Pedunculated Uterine Polypi
722
Detection and Treatment of Intra-uterine Polypi
Cases of Removal of Intra-uterine Polypi
•
Sulphate of Zinc as a Caustic in Uterine Cancer, etc.
Occasional Latency of the Symptoms in advanced Carcinoma Uteri
Carcinomatous Disease of the Cavity, Body, and Fundus of the Uterus,
the Cervix being unaffected
Carcinoma of the Body and Fundus of the Uterus.
•
Inflammatory and Non-inflammatory Ruptures of Ovarian Dropsical Cysts
The Position of the Patient for Paracentesis in Ovarian Dropsy, and the
Place of Puncture
733
755
757
761
763
768
773
783
Treatment of Ovarian Dropsy by Injections of Iodine into the Cysts
Results of the Treatment of Ovarian Dropsy by Iodine Injections
Ovariotomy; is it, or is it not, a Justifiable Operation?
789
791
•
792
Painful Muscular and Fascial Contractions along the Vaginal Canal:
Vaginodynia.
809
Vesico-uterine, Vesico-intestinal, and Utero-intestinal Fistulæ, as results of
Pelvic Abscess .
811
•
Ball-valve Obstruction of the Rectum by Scybalous Masses
Infra-mammary Pains
816
817
Spurious Pregnancy-its Frequency and Nature
•
818
Alleged Infecundity of Females born co-twin with Males
822
1
PART I
LECTURE NOTES.
NATURAL LABOUR.
Definition. The head alone presenting. The labour termi-
nated within twenty-four hours.
Three Stages.
1. From the commencement of the process to the complete
opening up of the os uteri-The stage of Preparation and
Dilatation.
2. From the complete opening up of the os uteri to the birth
of the child—The stage of Expulsion.
3. The separation and expulsion of the placenta-The stage
of Delivery.
INDIVIDUAL PHENOMENA OF THE FIRST STAGE.
I. PRELIMINARY SYMPTOMS.
These consist of—
1. Increased moisture and relaxation of the vagina-The
'Shows."
2. Subsidence of the uterine tumour, and contractions in it.
3. More free state of respiration, digestion, etc.
4. Symptoms of pressure on the bladder, rectum, etc.
5. Often greater difficulty in progression, though greater
aptitude for it.
2
LECTURE NOTES.
The prognosis from such symptoms is good, especially from
marked subsidence of the uterine tumour.
II. UTERINE CONTRACTIONS AND PAINS.
Occasionally there are uterine contractions without pain,
and pains without perfect contractions.
Pains are divided into (I.) True and (II.) Spurious or False.
Treatment of spurious Labour-pains.
This depends on—1. The pathological state inducing them ;
2. The fact of their consisting of irregular muscular contractions.
1. Remove the pathological state exciting the pains, as
(1.) Constipation, or retention of urine, by enemata, etc.
(2.) Derangement of the stomach, or diarrhoea.
(3.) Vascular excitement and plethora, etc.
2. In all cases enforce the supine position for a time.
·
3. Afterwards suspend, if necessary, the irregular muscular
contractions by sedatives, as opium.
4. Before giving opiates have the bowels opened.
III. GRADUAL OPENING UP OF THE OS UTERI.
The os uteri may be-
1. Relaxed, moist, and equable ; or
2. Firm, dry, and irregular.
The prognosis is the more favourable the nearer the os uteri
is to the former state, and vice versû.
IV. FORMATION OF THE BAG OF MEMBRANES.
V. RUPTURE OF THE MEMBRANES.
The period of rupture varies.
The whole ovum may be expelled without rupture of the
membranes.
NATURAL LABOUR.
3
VI. FULL DILATATION OF THE OS UTERI.
Mechanism by which this is effected.
1. Contraction of the parietes of the uterus around the in-
compressible ovum.
2. Mechanical action of the fluid wedge formed by the bag
of membranes.
3. A state of dilatation and dilatability independently of
either mechanical or muscular action.
INDIVIDUAL PHENOMENA OF THE SECOND STAGE.
VII. DESCENT OF THE HEAD INTO THE PELVIS.
Its height at the commencement of labour varies.
VIII. FORMATION OF THE PERINEAL TUMOUR
(Lengthening and thinning of the perineum.)
IX. FULL DILATATION OF THE EXTERNAL PARTS.
X. EXPULSION OF THE HEAD AND BODY OF THE CHILD.
INDIVIDUAL PHENOMENA OF THE THIRD STAGE.
XI. DETACHMENT OF THE PLACENTA.
XII. EXPULSION OF THE PLACENTA AND MEMBRANES.
Management of Natural Labour.
Attend immediately when summoned.
The lying-in chamber should be large and well ventilated.
Do not obtrude hurriedly into the patient's room except
when the case is urgent.
Information is to be gained from the nurse as to the progress
of the case.
Draw the patient into some general conversation.
Avoid all notice of bad cases.
2
4
LECTURE NOTES.
Watch the character, frequency, etc., of the pains.
Prevent others, and prevent the patient herself, from injur-
ing and interrupting the process of parturition.
Communications and suggestions to the patient are to be
generally made through the nurse.
Avoid formally proposing an examination.
The
Different fingers may be employed for examining.
finger or fingers must be previously anointed with lard, poma-
tum, etc.
The finger is to be rotated in the vagina, so as to turn its
radial side forwards.
Purpose of the Examination.-To ascertain the following
points :-
1. If the patient is pregnant.
2. If she is in labour.
3. The progress or stage of the labour.
4. The presentation.
5. The state of the os uteri and passages.
Two questions are now generally to be answered-
1. Is everything right?
Tell the more immediate relative everything.
Tell the patient nothing to annoy her.
In first pregnancies do not admit too soon that the patient
is in labour.
2. When will the patient be better?
Never venture to give a direct answer unless the case is
very obvious.
General Summary of Rules regarding the Management of
the First Stage.
1. Examine to detect the existence of pregnancy and of
labour, its progress, the presentation, and the state of the
passages.
2. Repeat the examination as seldom as possible during this
stage.
NATURAL LABOUR.
5
10
3. In making the examination, introduce your finger or
fingers during a pain; but do not complete the examination till
after the pain has ceased.
4. Allow the patient to lie or walk about at pleasure till the
os uteri is dilated to a diameter of one and a half or two inches.
5. After this period, place her in bed, and upon her left side.
6. Keep the urinary bladder and lower bowel empty.
7. Give the patient nourishment of the lightest form: avoid all
stimuli, bodily and mental: endeavour to cheer and support her.
8. Keep the patient cool, and let the room be well
ventilated.
9. Prevent her from fatiguing herself or making expulsive
muscular efforts.
10. Prevent or palliate any morbid symptoms that supervene,
such as-
(1.) Rigors.
(2.) Nausea and vomiting,
(3.) Irritability and despondency.
(4.) Delirium.
General Rules regarding the Management of the Second Stage.
1. Enforce all the preceding rules in regard to ventilation,
diet, position, the state of the bladder, etc.
2. Examine as soon as possible after the rupture of the
membranes to ascertain if any part has prolapsed, as the cord
or a hand.
3. Repeat the examination occasionally, to ascertain the
progress of the head.
4. Palliate distressing symptoms, as-
(1.) Pains in the back.
(2.) Cramps or spasms in the limbs.
5. When the head is in the vulva, separate the knees, and
support the perineum.
Objections to this practice are chiefly from its abuse.
-: -,
6
LECTURE NOTES.
Advantages gained by the practice—
(1.) It gives relief to the patient.
(2.) It promotes the mechanism of parturition.
(3.) It prevents laceration from too rapid distension.
Let the head pass towards the termination of the last
expulsive pain.
Prevent the rapidity of the dilatation from being greater than
the degree of dilatability will admit of.
6. Direct the head and body out in the axis of the outlet.
7. Make the head pass in a form presenting the smallest
diameter of its ovoid cone at the outlet.
8. Leave the expulsion of the body chiefly to uterine
action.
9. Guard and support the perineum during the passage of
the shoulders and body.
Duties of the Medical Attendant immediately after the
Child is Born.
1. Draw the child from beneath the bedclothes, and imme-
diately arrange the latter, so as to prevent the access of cold
air.
2. Pass your hand over the abdomen of the mother to
feel if-
(1.) There is a second child.
(2.) The uterus is contracted.
3. Place two ligatures upon the cord, and divide it between
them, taking care—
(1.) Not to place the first ligature too near the child's
umbilicus lest it constrict an umbilical hernia.
(2.) That the ligature is sufficient when the cord is
thick.
(3.) To divide the cord always upon the palm of your
hand.
4. See if your patient requires a stimulant, and if there is
any tendency to rigors. (There is no necessity for stimulants in
common cases, unless the patient is much exhausted.)
NATURAL LABOUR.
7
General Rules for the Management of the Third Stage.
1. Wait for ten or twenty minutes to see if expulsive pains
recur to expel the placenta.
2. Then ascertain if the placenta is in the uterus or in the
vagina, by external and internal examination. If you touch the
foetal surface by tracing the cord to its root, it is in the vagina.
3. If the placenta be already in the vagina, extract it.
4. If the placenta be still in the uterus, re-excite uterine
contractions by friction, cold or warmth, slight traction at the
cord, but, above all, by compression of the uterus.
5. When these means are insufficient, at the end of an hour
pass your hand into the uterus and extract the placenta.
6. Make all tractions on the cord, and always extract the
placenta itself, in the line of the different pelvic axes.
7. Take especial care to bring away both the placenta and
membranes entire.
(If there be hemorrhage you must extract the placenta, or
expel it by compression of the uterus, immediately.)
Subsequent Duties of the Medical. Attendant in reference
to the Mother.
1. Apply immediately a warm cloth to the pudenda.
2. Place a binder upon the abdomen and pelvis.
(Use but do not abuse the binder.)
3. Remain with the patient for at least an hour.
4. Before leaving her, ascertain—
(1.) If the uterus is contracted.
(2.) If the discharge is not too profuse.
(3.) If there are no marked constitutional symptoms, and
if the circulation is neither morbidly depressed nor
excited.
5. Guard against the patient leaving the horizontal position,
or being exposed to any exciting mental or bodily stimuli.
6. Leave injunctions to be called if faintness, rigors, or con-
tinued pelvic pain supervene.
8
LECTURE NOTES.
เ
LABORIOUS LABOUR.
Definition.-Head presenting, but morbid degree of retarda-
tion and difficulty.
Pathological States inducing Laborious Labour.
1. Deficiency in the expulsive powers.
2. Morbid position, conformation or size of the body to be
expelled.
3. A morbidly undilated or contracted state of the canals
through which the body has to be expelled.
The
These states may be present singly or in combination.
degree of difficulty induced by them leads to the sub-division
into three genera or orders.
Orders of Laborious Labour.
1. Tedious.-The natural powers still sufficient, with some
accessory regulations or aids from medical art.
2. Instrumental.-Extractive mechanical aid required, but
safe in principle to both mother and child.
3. Impracticable.—Impossible to extract a full-sized or living
child through the natural passages.
FIRST ORDER OF LABORIOUS LABOURS—
TEDIOUS LABOUR.
A. TEDIOUS LABOUR FROM MORBID PROTRACTION OF
THE FIRST STAGE BY LOCAL IMPEDING CAUSES.
·Interference is to be regulated by
1. The duration of the labour. The case becomes an anxious
LABORIOUS LABOUR.
9
one if the os uteri is not opened in twelve or sixteen hours after
regular pains have set in. We may require to interfere much
earlier than ten or twelve hours.
2. The power of endurance of the patient.
3. The strength and continuous regularity of the pains.
4. The degree of morbid pressure and irritation upon the os
and cervix uteri.
5. The probability of the obstructing cause yielding to the
natural efforts.
Dangers to be dreaded from Delay.
1. Exhaustion of the contractile powers of the uterus. Hence
(1.) Powerless labour.
(2.) Irregular contraction.
(3.) Hemorrhage.
2. Irritation and inflammation, or even gangrene of the os
uteri.
3. Injury and rupture of the coats of the uterus.
4. Fever-exhaustion-depression of mind.
5. Death of the child.
Local Impeding Causes which may produce Protraction
of the First Stage.
1. Rigidity of the lips and neck of the uterus.
2. Rigidity of a band of circular fibres in the cervix.
3. Impaction of a fold of the cervix between the head and
the pelvis.
4. Premature rupture of the membranes.
5. Preternatural toughness of the membranes.
6. Over-distension of the uterus by liquor amnii.
7. Occlusion of the os uteri.
8. Oblique position of the os or body of the uterus.
9. Large size of the pelvis, leading to prolapsus.
10. Morbid relaxation of the soft parts, leading to prolapsus.
10
LECTURE NOTES.
I. RIGIDITY OF THE LIPS AND NECK OF THE UTERUS.
Varieties.
1. The natural organic state of the parts (especially in first.
cases).
2. Spasmodic contraction.
3. Induration from disease, as cicatrices, inflammation, cancer.
Constitutional-
Treatment.
1. Bloodletting. This acts by
(1.) Causing relaxation of the tissues.
(2.) Removing the tendency to morbid congestion and
inflammation, and thus restoring dilatability.
2. Nauseants, as tartar emetic and ipecacuan.
3. Warm baths.
4. Hypnotics, as opiates and chloral.
5. Chloroform.
Local-
1. Local detraction of blood??
2. Local relaxant and sedative medicines. Belladonna?
Stramonium ??
3. Unguents and oils.
Chloroform.
4. Mucilaginous injections and enemata.
5. Warm hip bath and warm douche.
6. Artificial dilatation by fingers or india-rubber bags.
7. Incision.
OPIUM IN LABOUR.
Indications to be fulfilled by Opium in Labour.
1. To suspend and control irregular and useless uterine
pains-when the pains in fact became spurious.
2. To allow the exhausted powers of the uterus to revive by
rest (as when a rigid os uteri is dilated after much suffering).
3. To allow the tissues of the os to become relaxed when
LABORIOUS LABOUR.
11
there is no fear of pressure, and the patient is not able to
bear venesection.
Rules for its Exhibition.
1. Use it only under the conviction that the pains are pro-
portionally more hurtful to the powers of the mother, than
useful in the expulsion of the child.
2. Never suspend by it the uterine contractions when they
are regular.
3. Also, never when the head is so placed as to cause in-
jurious pressure.
4. Never administer it when there is general vascular excite-
ment.
5. Always have the bowels previously opened.
6. Whatever preparation of the drug is used, and whether
it be administered by the mouth, by the rectum, or hypodermi-
cally, let the dose be large.
II. RIGIDITY OF A BAND OF CIRCULAR FIBRES OF THE CERVIX.
Diagnosis.
During a pain, the edges of the os uteri swell, but do not
become tense; and the head or the membranes are not in
contact with the edges of the os.
During the interval the stricture can be felt, one inch or
one and a half inches up the cervical canal, usually at the os
internum.
Treatment.
The same as for general rigidity. Press with the fingers
during a pain, and stretch the band.
III. WEDGING IN OF A FOLD OF THE CERVIX BETWEEN THE HEAD
AND THE PELVIS. (Almost always in front.)
Treatment.
Support and dilate the lip of the os uteri during a pain.
When the os is dilated, push up the segment above the head.
12
LECTURE NOTES.
IV. PREMATURE RUPTURE OF THE MEMBRANES.
To be specially guarded against in first pregnancies.
Treatment.
Remove all other causes of protraction so as to prevent
interference with the uterine efforts. Promote relaxation by
nauseants and unctuous applications. If necessary, dilate by
the fingers, &c., used as an artificial wedge.
V. PRETERNATURAL TOUGHNESS OF THE MEMBRANES.
This rarely retards the first stage.
Treatment.
Rupture of the membranes.
VI. OVERDISTENSION OF THE UTERUS BY LIQUOR AMNII.
(Hydramnios.)
Symptoms.
Large size and globular form of the uterus, with no irregu-
larities.
Tenseness of the abdominal parietes.
Absence of the fœtal movements.
Rapid increase of the size of the abdomen.
Pain in different parts of the uterus, especially in the
groins and pelvis.
Edema or anasarca of the lower extremities.
Difficult respiration.
On examining per vaginam, the inferior segment of the
uterus much expanded. Ballottement unusually free and dis-
tinct.
Treatment.
Rupture the membranes.
LABORIOUS LABOUR.
13
VII. OBLIQUE POSITION OF THE OS OR BODY OF THE UTERUS.
The displacement is most commonly anterior, and the abdo-
men pendulous. It is apt to lead to impaction of a segment of
the cervix uteri.
Treatment.
Place the patient on her back if the displacement be
anterior.
Keep the uterus in its proper position by a bandage.
Pull the os into the axis by the fingers?
VIII. OCCLUSION OF THE OS UTERI.
Treatment.
Formation of a small opening by the knife.
IX. LARGE SIZE OF PELVIS ALLOWING PROLAPSUS.
Treatment.
Support the cervix during the pains, so as to let the uterine
contractions open up the os fully. Assist by pushing the os over
the head if necessary.
X. MORBID RELAXATION OF THE SOFT PARTS ALLOWING
The same as for No. IX.
PROLAPSUS.
Treatment.
GENERAL RULES OF TREATMENT FOR THE VARIOUS CASES OF MORBID
PROTRACTION OF THE FIRST STAGE BY LOCAL IMPEDING CAUSES.
1. In all cases of morbid protraction of the first stage-
(1.) Preserve most carefully the patient's strength and
spirits.
(2.) Prevent, as much as possible, all tendency to febrile
excitement by attention to diet, ventilation, etc.
(3.) Keep the rectum and bladder empty.
14
LECTURE NOTES.
(In short, ward off all causes likely to interfere with
the progress of labour).
2. When the os and body of the uterus are not placed re-
latively in the proper axis of the brim of the pelvis, rectify the
position of the organ by—
(1.) The position of the patient. Place her on her back
when the uterus is displaced anteriorly.
(2.) A bandage.
3. In cases of morbid protraction from-(1.) General or par-
tial rigidity of the labia or cervix uteri; or (2.) premature rup-
ture of the membranes, rely principally on-
(1.) Venesection, if there be marked plethora.
(2.) Relaxants and nauseants.
(3.) If necessary, artificial dilatation.
4. When the rigidity is conjoined with general debility, or
with spasmodic irritability of the os and cervix, and the pains
are hence more hurtful than useful, exhibit opiates.
5. When morbid relaxation of the soft parts, and prolapsus
of the uterus exist, support the os and cervix uteri during the
pains.
6. When a portion of the cervix uteri is wedged between the
head and the pelvis, support it, and push it over the head.
7. When the membranes are preternaturally strong, or the
liquor amnii superabundant, perforate the bag.
8. When the os uteri is entirely obliterated, or the labia are
so very rigid and diseased as actually to endanger the laceration
of the uterus itself, form or enlarge the os by incisions.
B. TEDIOUS LABOUR FROM MORBID PROTRACTION
OF THE SECOND STAGE BY OBSTRUCTIONS ON
THE PART OF THE MATERNAL PASSAGES.
Obstructions to the Second Stage on the Part of the Maternal
Passages.
1. Rigidity and contraction of the vaginal canal and vulva.
2. Distended colon and rectum.
LABORIOUS LABOUR.
15
3. Hernia of the intestines within the pelvic cavity.
4. Distended urinary bladder, with or without displacement.
5. Calculus in the urinary bladder.
6. Ovarian tumours.
7. Tumours embedded in the soft tissues of the pelvis.
8. Diseased states of the hard or bony textures of the pelvis.
I. RIGIDITY AND CONTRACTION OF THE VAGINAL CANAL AND
VULVA.
Varieties.
1. Simple undilatability of their structures. (As from ad-
vanced age, particular constitutions, or premature labours.)
2. Congestion, tumefaction, and inflammation.
3. Contraction from original malformation.
4. Contraction from acquired cicatrices, adhesions, oblitera-
tions, etc.
5. A strong or double hymen.
Diagnosis.
1. Local Examination-Feeling contraction, stricture, cica-
trices, heat, dryness.
2. Studying the Effects-Arrested progress of the labour.
3. The anterior history-Previous bad confinements.
Rules of Treatment.
1. In contraction from congestion and inflammation, employ
venesection if indicated, unguents, etc.
(N.B.—In all forms inflammation is apt to supervene.
Hence watch to prevent it.)
2. In all others trust much to nature.
3. When absolutely essential divide the obstructing struc-
ture by the knife.
4. Make the required incisions during a pain.
5. Avoid frequent examination, or artificial distension by
the fingers.
16
LECTURE NOTES.
6. In all cases use abundance of local emollients and un-
guents.
7. Prevent the head from passing, in cases of rigid vulva
and perineum, till the parts are fully dilated.
II. DISTENDED COLON AND RECTUM.
Diagnosis.
1. Examination per vaginam. (The tumour is compressible
and inelastic, and retains the impression of the finger.)
2. The history of the case.
slight diarrhoea.)
3. Examination per rectum.
1
(Constipation—perhaps also
1. Enemata.
Treatment,
2. Breaking down scybalous masses by a metallic scoop and
removing them piecemeal.
III. HERNIA OF THE INTESTINES DIMINISHING THE PELVIC
CAVITY. (Pelvic and perineal herniæ.)
Treatment.
1. Taxis, while the foetal head is held up and the patient is
in a proper position.
2. If the hernia be irreducible by taxis, the early use of
forceps is indicated.
IV. DISTENDED URINARY BLADDER.
(1.) WITHOUT DISPLACEMENT.
Diagnosis.
The form of the tumour. Introduction of the catheter.
LABORIOUS LABOUR.
17
Treatment.
The use of the catheter. Very rarely puncture of the
bladder.
(II.) WITH DISPLACEMENT.
1. Backwards into the vagina.
2. More or less laterally.
3. Between the rectum and the vagina.
4. Forming a perineal hernia.
Diagnosis.
Fluctuation, etc. Use the catheter here and in all cases of
tumours obstructing labour. (The bladder has been mistaken
for the membranes, the head, the impacted lip of the cervix, or
tumours.)
Treatment.
1. Use of a flexible male catheter.
2. Reduction of the displacement of the bladder.
3. Hastening of the labour if the bladder cannot be kept
from pressure.
V. CALCULUS IN THE BLadder.
Treatment.
1. Push it above the brim if possible.
2. If this be impossible, and nature insufficient, remove the
calculus.
(1.) By extraction, through rapidly dilated urethra.
(2.) By lithotomy.
VI. TUMOURS FORMED BY THE OVARY.
Pathological character.
1. Cystic and multilocular.
18
LECTURE NOTES.
2. Cystic and unilocular.
3. Solid-malignant or non-malignant.
Time of the occurrence of prolapsus into the pelvis.
1. Before impregnation.
2. At the fourth month, when the uterus leaves the pelvis.
3. During the commencement of labour, when the parts are
relaxed.
Diagnosis.
1. Feeling a tumour in the recto-vaginal space-movable,
generally fluctuating, and hard during the pains and when much
compressed.
2. The employment of rectal and vaginal examination.
3. The use of an exploring needle.
4. Anterior history of a tumour on one side.
Rules of Treatment.
1. If the tumour be sufficiently loose, push it upwards above
the brim.
2. If this be impossible, and yet the tumour be small and
compressible, leave the case to nature, avoiding long delay or
pressure.
3. If instrumental aid be required, and the tumour be not
very large, use the forceps.
4. If there be not space for the forceps, evacuate the tumour
(if there be any fluid in it) by puncture or incision, and then
trust to the natural efforts, or to forceps.
5. If the tumour be still too large, or if originally solid, per-
form embryulcia.
Other alternatives proposed-
(1.) Version of the fœtus.
(2.) Cæsarean section.
6. Induce premature labour in subsequent pregnancies.
LABORIOUS LABOUR.
19
VII. TUMOURS EMBEDDED IN, OR ATTACHED TO, THE SOFT
TISSUES SURROUNDING THE MATERNAL PASSAGES.
Pathological Varieties.
1. Fibrous tumours in the lower segment of the uterus.
2. Polypi of the labia and cervix uteri.
3. Polypi of the vaginal walls.
4. Follicular tumours of the vagina.
5. Cystic tumours and abscesses in the cellular tissue of the
pelvis.
6. Solid non-malignant tumours in the same locality.
7. Carcinomatous tumours of the vagina and bladder.
8. Varicose, condylomatous, and other tumours of the labia
pudendi.
Diagnosis.
1. Minute examination of the situation, etc.
2. Use of an exploring needle.
3. In every case empty first the bladder and rectum.
Treatment.
Rules nearly the same as for ovarian tumours.
1. Wait the efforts of nature, and aid them, if necessary, by
relaxants, and by compressing and altering the position of the
tumour.
2. If the obstruction cannot be thus overcome, gain space—
(1.) By opening the tumour if there be any chance what-
ever of its containing fluid.
(2.) If the tumour consist of recently effused blood, either
do not open it until the blood is coagulated, or apply
the forceps immediately after incising it.
(3.) If the tumour be solid and removable, extirpate it.
(4.) If it be a polypus, use ligature and knife.
3. If the obstruction cannot be thus removed, use forceps,
vectis, version, embryulcia, or even Cæsarean section, according
to existing circumstances.
3
20
LECTURE NOTES.
VIII. DISEASED STATES OF THE PELVIC BONES.
Morbid Conformation and Morbid Anatomy of the Pelvis.
1. Varieties in its general size in different races.
2. Varieties in its size and form in individuals.
(1.) General large size of the pelvis.
(2.) General small size of the pelvis.
(3.) Funnel-shaped pelvis-two kinds.
(4.) The brim of the pelvis cordiform, round or elliptical.
(5.) Varieties in the depth of the pelvis.
3. Varieties in the inclination and axes of the pelvis.
4. Deformities from mechanical injuries, as fractures or dis-
locations.
5. Deformities from local disease.
(1.) Inflammatory hyperostosis.
(2.) Exostosis.
(3.) Osteo-sarcomatous tumours.
6. Ossification of the sacro-iliac synchondrosis, and oblique
distortion.
7. General disease of the skeleton-
(1.) Rickets.
(2.) Malacosteon.
Two general types of deformity-
(1.) Elliptical.
(2.) Triangular.
Treatment.

Measures Employed.
Forceps,
Embryulcia,
Cæsarean section,
Premature labour,
If Conjugate Diameter.
31 inches.
12 to 31
""
12
""
21 to 31
""
The labour is natural but lingering when the antero-posterior
diameter is not under four inches.
LABORIOUS LABOUR.
21
C. TEDIOUS LABOUR FROM MORBID PROTRACTION OF
THE SECOND STAGE, BY OBSTRUCTIONS ON THE
PART OF THE CHILD.
Obstructions to the Second Stage on the part of the Child.
1. Shortness of the umbilical cord.
2. Death of the child.
3. Large size of the child.
4. Sex of the child.
5. Strong ossification of the head.
6. Enlargement of the head or body from malformation or
disease.
7. Malpositions of the head.
8. Malpresentations of the head.
9. Prolapsus of the upper or lower extremities with the
head.
I. SHORTNESS OF THE UMBILICAL CORD.
1. Absolute shortness. (It is very rarely below ten or twelve
inches.)
2. From convolutions around the child.
It will not interfere with the passage of the head if it be six
or seven inches long.
It may prevent the complete extrusion of the body.
If so, divide it.
II. DEATH OF THE CHILD.
This is only a cause of delay when the child is enlarged from
putrefaction.
Its bulk, not its death, is the cause in such cases.
III. LARGE SIZE OF THE Child.
IV. SEX OF THE CHILD.
22
LECTURE NOTES.
V. STRONG OSSIFICATION OF the Head.
Management of III. IV. and V.
1. Trust as long as possible to nature, using all appropriate
means to relax the passages, and ward off accidental complica-
tions.
2. If nature be insufficient, you must have recourse to in-
struments.
VI. ENLARGEMENT OF THE HEAD OR BODY FROM DISEASE: AS
1. Hydrocephalus.
2. Hydrorachis.
3. Hydrothorax.
4. Ascites.
5. Tympanites in dead children.
6. Tumours.
Treatment.
1. Let nature complete the case if her efforts be sufficient
for it.
2. If danger threaten, and the head be not born, open any
tumour upon it, or perforate if there be hydrocephalus.
3. If the head be born, and the body retained, assist by
pulling; or, if necessary, by incision or perforation of the
enlarged part.
VII. MALPOSITIONS OF THE HEAD.
(1.) THE FOREHEAD PLACED ANTERIORLY TO EITHER GROIN.
(Occipito-posterior positions.)
These cases were formerly considered morbid.
The usual rotation is occasionally absent or imperfect.
(II.) THE LONG DIAMETER OF THE HEAD IN THE LEFT OBLIQUE
DIAMETER OF THE PELVIS.
It is useless and dangerous to alter the position.
LABORIOUS LABOUR.
23
(III.) THE LONG DIAMETER OF THE HEAD IN THE CONJUGATE
DIAMETER OF THE BRIM.
Occasionally the conformation of the pelvis is such as to
permit it.
Management.
Generally no interference is required. If absolutely neces-
sary, the position may be changed by the hand or by forceps.
VIII. MALPRESENTATIONS OF THE HEAD,
(1.) PRESENTATION OF THE SIDE OF THE HEAD.
(II.) PRESENTATION OF THE OCCIPUT.
Diagnosis.
It is recognised by the triangular shape of the occipital
bone, the lambdoidal suture, and the posterior fontanelle.
Rectify it if necessary.
Treatment.
(III.) PRESENTATION OF THE EAR.
It is rare.
Two conditions under which it occurs.
1. When the pelvis is very large.
2. When the fœtus is small.
Management.
Rectify the position, if necessary, by the fingers or the hand.
(IV.) PRESENTATION OF THE FOREHEAD.
The chin is too early separated from the chest. The case
becomes morbid when the separation is too great, or replacement.
prevented. It may change into a face presentation.
2.4
LECTURE NOTES.
Causes.
Hitching of the head on the pelvis. The hands or arms lying
in front of the neck.
Diagnosis.
The anterior fontanelle is too central. Parts of the face can
be felt.
Treatment
Keep your finger in contact with the
uterine efforts may rectify the position.
cases, require instruments as the lever
(v.) FACE PRESENTATIONS.
Varieties.
1. Primitive position before labour.
2. Secondary, from—
forehead, so that the
You may, in rare
(1.) Superabundance of liquor amnii.
(2.) Obliquity of the uterus.
(3.) The occiput hitching against a part of the pelvis.
Two principal positions at the brim.
1. The chin towards the right ilium. The right cheek
presents.
2. The chin towards the left ilium. The left cheek
presents.
In all cases, as the head descends, the chin turns forwards,
and emerges under the pubic arch.
eyos.
1. Negative characters.
Diagnosis.
2. Positive characters-Frontal suture, nose, mouth, cheek,
Causes of Delay.
1. Dilatation is not so easily effected.
2. The bones and soft parts do not yield so rapidly.
і
LABORIOUS LABOUR.
25
3. The uterus acts at a disadvantage.
4. The diameters presented are greater-
From the chin to the commencement of the hair, 3½ inches.
>>
دو
middle of the sagittal suture, 4
""
>>
>>
end
>>
>>
>>
From the root of the neck, near the sternum, to
the vertex when the head is bent back
Management.
1. No active interference is in general required.
34
"3
4/1/
"
2. In very difficult cases attempt rectification, or treat as a
difficult cranial presentation.
GENERAL RULES OF MANAGEMENT IN CASES OF MALPOSITION AND
MALPRESENTATION OF THE HEAD.
1. Avoid rupturing the membranes.
2. Have the passages as dilated as possible, by relaxants,
etc., if necessary, and particularly by preventing the descent of
a fold of the cervix uteri.
3. Keep the urinary bladder and the rectum empty.
4. Avert all causes likely to diminish the powers of the
uterus.
5. Guard carefully the perineum if the head emerge in an
unusual position.
6. As a general rule, leave the process in all deviations of
the head to nature; except in
(1.) Forehead and face cases not entering the brim.
(2.) Imperfect rotation in occipito-posterior positions.
(3.) Mento-sacral face cases?
7. In difficult face cases treat as in difficult cranial cases.
IX. PROLAPSUS OF THE UPPER OR LOWER EXTREMITIES WITH THE
HEAD.
(1.) SIMPLE PROLAPSE OF ONE OR MORE EXTREMITIES ALONG-
SIDE THE HEAD.
26
LECTURE NOTES.
Treatment.
You can generally push the prolapsed part to one side, and
thus find space for it by the side of the head.
(II.) MALPOSITION OF THE FOREARM, SO THAT IT LIES ACROSS
THE BACK OF THE NECK OF THE FETUS.
Diagnosis.
1. The head is pushed down by each pain, but is retracted
as soon as the pain passes away.
2. The head can be felt to be neither large nor impacted in
the pelvic brim.
3. Pass up your fingers and feel the obstructing arm. (You
may mark it with a stick of nitrate of silver, for identification
afterwards.)
Treatment.
1. If nature be insufficient, endeavour to bring down the
arm by the side of the head, so as to convert the case into one
of simple presentation of the head and arm.
2. If that be impossible, turn the child.
D. INEFFICIENCY OF THE EXPULSIVE POWERS OF
PARTURITION AS A CAUSE OF TEDIOUS LABOUR
DURING BOTH FIRST AND SECOND STAGES.
The expulsive powers consist of—
1. Uterine contractions.
2. Assistant contractions of the diaphragm and abdominal
muscles.
I. INEFFICIENCY FROM GENERAL CONSTITUTIONAL DEBILITY.
It seldom produces this effect when original or pre-existing
-often when secondary or acquired.
Actual general exhaustion is almost always secondary, and
the result of mismanagement.
LABORIOUS LABOUR.
27
II. INERTIA OF THE ACCESSORY EXPULSIVE POWERS OF THE
DIAPHRAGM AND ABDOMINAL MUSCLES.
1. It is principally influential during the second stage.
2. It may be caused by exhaustion from over-exertion
during the first stage, states of the abdominal organs, as the
bladder or bowels, diseases of the heart or lungs, paraplegia,
the state of the abdominal parietes, overdistension of the abdomi-
nal cavity from ascites, etc.
III. INEFFICIENCY OF THE EXPULSIVE POWERS OF THE UTERUS
ITSELF.
(1.) FROM PARTIAL, IRREGULAR, OR SPASMODIC CONTRACTIONS
OF THE UTERUS.
Causes.
1. The state of the intestinal canal, as tenesmus, etc.
2. The state of the bladder.
3. Interference with the os uteri when irritable.
4. Sudden relaxation of the uterus from the escape of a
large quantity of liquor amnii.
Diagnosis.
1. Sensations of the mother-
The pains severe and general, or crampish and local.
The intermission incomplete.
The pains often leave distressing uneasiness in the back.
The patient irritable, desponding, or even delirious.
2. Internal examination-
No effect on the progress of the head in proportion to
the suffering or apparent uterine contraction.
The os uteri sometimes contracts instead of dilating.
The os uteri is sometimes hot and sensitive.
28
LECTURE NOTES.
3. External examination-
You may feel the uterus divided by a band.
soft at one part, hard elsewhere.
not entirely relaxed in the in-
tervals between the pains.
(II.) FROM GENERAL INERTIA OR ATONY OF THE UTERUS.
Varieties.
1. The uterine action may be languid, feeble, and sluggish
from the very first commencement of labour, in consequence
of-
(1.) Constitutional inertia of the organ (in leuco-phleg-
matic persons).
(2.) Morbid local inertia of it from too frequent repetition
of parturition or miscarriage.
(3.) Organic disease in its parietes.
(4.) Overdistension in cases of twins and hydraminos.
2. The inertia may be superinduced during the progress of
the labour by-
(1.) Sudden relaxation from escape of liquor amnii.
(2.) Exhaustion of the uterine fibres from too long action,
as e.g. from a protracted first stage in the weak (in
phthisis, etc.)
(3.) Exhaustion from too strong action induced by obstruc-
tions on the part of the foetus or the passages.
(4.) The supervention of congestion in the uterine vessels.
The uterus feels thick and tender; the labia uteri
are swollen; the foetus is very restless, and its
movements are painful; the pains are short and
ineffective; there are general symptoms of plethora
-the face, eyes, skin, etc., red, and pulsations every-
where; there is heat of surface, but little thirst; the
patient is restless; there is a tendency to hæmor-
rhoids, varices, constipation, etc.
(5.) The supervention of inflammation.
LABORIOUS LABOUR.
29
(6.) Mental emotions and fears.
(7.) Secondary or acquired constitutional debility and
fever. Its danger is greater in the second than in
the first stage.
RULES OF TREATMENT IN LINGERING LABOUR DEPENDENT ON INEFFICIENCY
OF THE EXPULSIVE POWERS.
1. Avoid and avert the general or constitutional causes that
may lead to it.
2. Remove any local mechanical causes that may produce or
maintain it.
3. Be careful to husband the patient's strength and spirits.
4. If the accessory expulsive powers be at fault, use an ab-
dominal bandage, and change of position.
5. If there be symptoms of uterine congestion or inflamma-
tion present, use venesection, etc., if necessary.
6. If the contractions be irregular and spasmodic, use fric-
tion. In the first stage give opium.
7. If the inertia be simple or uncomplicated, excite the organ.
Proposed Means of exciting Uterine Action.
1. The warm bath.
2. Sternutatories.
3. Raising the foetal head so as to allow the waters to
escape.
4. Electricity and galvanism.
5. Abdominal compression.
6. Abdominal friction and bandage.
7. Emetics.
8. Stimulating clysters.
9. Purgatives.
10. Cold applications to the abdomen.
11. Irritation of the breasts.
12. Irritating the os uteri or vagina.
13. Oxytocic medicines.
(1.) Borax.
30
LECTURE NOTES.
(2.) Cinnamon.
(3.) Tanacetum vulgare—tansy.
(4.) Gossypii radix-cotton plant.
(5.) Cannabis Indica-Indian hemp.
(6.) Secale cornutum-ergot of rye.
Rules for the Exhibition of Ergot in Lingering Labours.
(1.) Never exhibit it till the first stage is over, or at least
the os uteri perfectly dilatable.
(2.) Do not give it even in the second stage if the vagina
and external parts be in any degree rigid. Hence
it is to be rarely used in first labours.
(3.) Only give it when the passages are fully prepared,
and merely some additional expulsive power re-
quired.
(4.) If the waters have fully escaped for some time, avoid
giving it if there be any probability of delay.
SECOND ORDER OF LABORIOUS LABOURS-
INSTRUMENTAL LABOUR.
Pathological Causes.
The same in principle and detail as those of Lingering
Labour, viz.:-
1. Deficiency in the expulsive powers.
2. Obstructions on the part of the passages.
3. Obstructions on the part of the child.
In all such cases we allow nature to try her efforts, and only
interfere when convinced that she is inadequate.
Circumstances by which we judge of the Propriety or Non-
propriety of Instrumental Interference.
1. The duration of the labour, and of its stages.
2. The patient's natural constitution and age, and her state
of health at the supervention of labour.
LABORIOUS LABOUR.
31
3. The former obstetric history of the patient.
4. Her conduct during the labour, and her state of cheer-
fulness or depression of mind.
5. The situation, size, etc., of the foetal head, and the degree
of pressure exerted by it upon the passages.
6. The degree of dilatation and dilatability of the passages.
7. Their condition in reference to threatened congestion
and inflammation, as shewn by the discharges, etc.
8. The strength of the uterine contractions, and their effects
upon the advancement of the head.
9. The local condition of the abdomen and of the uterus.
10. The effects of the labour upon the constitutional state and
strength of the patient.
11. The state of the child as shown by auscultation, etc.
General Rules for Non-interference.
Trust to Nature, provided-
1. The uterine contractions still advance the head.
2. There is no injurious pressure from the head, and no
marked symptom of irritation, etc. in the passages.
3. The mother's system is not morbidly disturbed.
4. There is no immediate danger to the infant.
Interference is required under a reverse combination of
circumstances,
Time for Interference.
As soon as it is certain that interference is necessary, and
the passages are in a fit state.
Wait to see what nature can effect, not what she can endure.
Propositions regarding the Duration of Labour.
1. The maternal mortality attendant upon parturition in-
creases in a ratio progressive with the increased duration of
labour.
!
32
LECTURE NOTES.
2. The infantile mortality attendant upon parturition in-
creases in a ratio progressive with the increased duration of
labour.
3. The mortality to the mother and infant is tenfold greater
in labours prolonged beyond, than in labours terminated within,
twenty-four hours; and the mortality to the mother and infant
is fifty-fold greater in labours prolonged beyond thirty-six hours,
than in labours terminated within the first two hours.
4. The liability to most of the morbid complications con-
nected with labour becomes increased in proportion as the labour
is increased in its duration.
5. The liability to febrile and inflammatory affections in
the puerperal state increases in proportion as the previous
labour has been prolonged in its duration.
6. Individual parturient, and puerperal complications not
only thus become more frequent as the labour becomes more
prolonged, but in a similar ratio they also become more dangerous
and fatal.
7. The mother is more liable to suffer under diseases of the
uterine system after long than after short labours.
8. The child, for some time after birth, is more liable to
disease and death, in proportion as the labour has been longer
in its duration.
9. Some obstetric complications, which in their causation are
independent of the length of the labour, are equally liable to
occur with short as with long labours.
10. First labours are longer in duration than subsequent
labours, and in a proportionate degree more complicated and
fatal in their effects to mother and child.
11. Male births are longer in duration than female births,
and in a proportionate degree more complicated and fatal in their
effects to mother and child.
12. The danger of instrumental delivery depends more upon
the previous length and duration of the labour, than upon the
operation employed.
LABORIOUS LABOUR.
33
Practical Deductions.
1. After a tedious labour mother and infant require more
care and watching than usual.
2. During labour, the danger increasing with the duration,
we should remove as far as possible any interfering causes.
3. If instrumental delivery be absolutely required, resort to
it early.
4. Endeavour to find means to prevent delay.
INSTRUMENTS USED IN CASES IN WHICH THERE IS
NO ACTUAL DISPROPORTION BETWEEN INFANT
AND PASSAGES.
I. FINGERS OF ACCOUCHEUR.
When the child's head lies long on the perineum, you may
help it forwards by one or two fingers inserted into the rectum,
and pressing on the head during the pains.
II. FILLET OR LAC.
Mode of its application and use.
1. Over the occiput or chin in head cases.
2. Over the body in preternatural presentations.
Objections to its employment and manner of action.
1. It is difficult of application. It requires a considerable
space to slip it up by the fingers or by an instrument.
2. We cannot by it accommodate the head to the passages,
and thus we may lock the head or produce malpresentation or
malposition of it.
•
3. It acts on one part. It may pull down that part alone,
and thus double and cut the neck.
34
LECTURE NOTES.
III. FORCEPS.
Modes of action of the Forceps.
1. By direct traction.
2. By an alternate lateral lever motion.
3. By compression of the foetal head.
4. By stimulating uterine action.
5. By changing the position of the fœtal head.
Indications for the use of Short Forceps.
1. When, for the safety of the mother, the head in its rela-
tion to the passages requires―
(1.) From its size, an additional compressing and extrac-
tive force applied to it; or
(2.) From malposition, these combined with a rectifying
power.
2. When the uterine action is insufficient safely to complete
the case.
3. When immediate delivery is required, from some compli-
cation threatening the life of the mother.
4. When there is immediate danger to the child, and the
passages are sufficiently dilated and dilatable.
N.B.-The foetal head must have entirely, or nearly entirely,
entered the pelvic cavity, before short forceps can be em-
ployed. In all cases long forceps may be used instead of short
or, in other words, one instrument may be used for both long
forceps and short forceps cases.
General Preliminary Rules regarding the use of Forceps.
1. Be perfectly assured of their necessity.
2. Tell the relatives always; the patient generally.
3. Be cautious in your prognosis regarding the infant.
;
LABORIOUS LABOUR.
35
4. Beware of ever employing them before the os uteri is
fully dilated, and the first stage undoubtedly completed.
5. Always empty the rectum and the bladder before forceps
or other obstetric operations.
6. Place the patient on her left side, her body across the
bed, and her nates at the edge of it.
7. Warm and grease the instrument, and if necessary lubri-
cate the maternal passages.
8. Assure yourself of the precise position and locality of the
head of the foetus.
Rules regarding Introduction of Forceps.
1. Insinuate, do not force on the instrument, and withdraw
it partially when any resistance offers.
2. Keep its point always in contact with the fœtal head.
3. Introduce each blade so that its concavity adapts itself to
the convexity of the foetal head.
4. Enter and apply each in the proper axis of the pelvis.
5. Introduce the instrument in the intervals between the
pains, and always suspend the attempt during the continuance
of the pains.
6. Introduce as the first blade-
(1.) The single blade of Ziegler's forceps, and place it
superiorly.
(2.) The blade whose lock looks anteriorly, of Smellie's
short and curved forceps, and place it inferiorly.
7. Hold the first blade in the right hand, using the left hand
as a guide.
8. When it is fully introduced, keep it in situ with the
thumb and last two fingers of the left hand, and again use the
first two fingers as a guide.
9. Introduce the second blade so that it comes into complete
antagonism with the first.
10. Withdraw the second blade and re-introduce it, if it be
found to be not so adapted to the first.
4
36
LECTURE NOTES.
Rules for Extraction by Short Forceps.
1. Only act during the pains; and if no pains be present,
imitate nature by working only at intervals.
2. Give the instrument an extractive power, combined with
a lateral pendulum motion.
3. Examine the instrument after every traction, and replace
it if it have in any degree slipped.
4. Change the direction of the extractive power in accord-
ance with the axes of the pelvis.
5. Bring the head down always according to the natural
mechanism of the particular position
6. If the head be impacted you may require first to free it
by elevating it slightly.
7. Support the perineum very carefully with the left hand.
8. Make the head distend, and pass over it very slowly:
allow the uterus itself to complete, as often as possible, the
expulsion of the head, and always that of the body.
Indications for the use of Long Forceps.
1. When the fœtal head is arrested at the brim of the pelvis,
from-
(1.) Slight narrowing of the brim.
(2.) Large size of the head.
(3.) Malposition of the head.
2. When the head is still at the brim, the membranes burst,
and immediate delivery required in consequence of-
(1.) Deficiency of uterine action.
(2.) Sudden complications on the part of the mother.
Differences between Long and Short Forceps.
1. In their construction.
2. In their manner of action.
3. In their place of application.
4. In their mode of application.
1
LABORIOUS LABOUR.
37
Short forceps are applied in relation to the foetal head.
Long forceps are applied in relation to the mother's pelvis.
Cautions in regard to the Introduction of Long Forceps.
1. Direct the instrument in relation to the axis of the brim.
2. Guard carefully the os uteri.
Cautions in regard to the Mode of Extracting by Long Forceps.
1. Employ them principally as a tractor.
2. Be certain to pull at first backwards, as nearly as possible
in the direction of the axis of the brim.
3. In contraction of the pelvic brim and in malposition of the
head, take off the instrument after the head is in the pelvis.
4. If the head cannot be moved, the instrument may be
left on for an extractor after perforation.
5. Where speedy delivery is required, and no uterine con-
tractions are present, the same hold may be retained till the
child is born, unless in occipito-posterior positions.
IV. VECTIS OR LEVER.
Different modes of using the Vectis.
1. As a true lever of the first-class, with the operator's left
hand as a fulcrum.
2. As an extractor, and worked as a lever of the third kind.
(The instrument should be curved if used as an extractor.)
3. As a single blade of forceps, with the operator's hand
serving as a second blade.
Proposed Cases for the Use of the Vectis.
1. All common forceps cases?
·
2. Cases of slight contraction of the brim.
3. Cases of malposition of the head, especially-
(1.) Forehead presentations.
(2.) Face presentations?
38
LECTURE NOTES.
Rules in regard to the Employment of the Vectis.
1. Attend to the same preliminary measures as in forceps
cases with regard to position, etc., etc. (p. 34).
2. Introduce the instrument by the same rules as the
forceps (p. 34).
3. When the head has not entered the brim, and in fontan-
elle and face (?) cases, place the instrument over the occiput
or the mastoid process.
4. You may place it over the forehead, face, or chin, when
it is used as forceps, and the head is on the perineum.
5. Hold the instrument in situ by one hand applied to its
handle, and use traction with the other hand applied to its
shank.
6. Carefully avoid ever using the mother's parts as a
fulcrum.
7. Act only during a pain. The vectis is not to be used
when pains are entirely absent.
THIRD ORDER OF LABORIOUS LABOURS —
IMPRACTICABLE LABOUR.
1. Craniotomy.
2. Cranioclasm.
3. Cephalotripsy.
Operations Proposed.
4. Cæsarean section,
5. Sigaultian operation.
I. CRANIOTOMY.
Indications.
1. When there is such disproportion between the passages
LABORIOUS LABOUR.
39
and the child that the latter cannot be passed through safely for
the mother, unless it be diminished in size.
2. When in a difficult case the maternal parts have become
too swelled and inflamed for the safe use of forceps.
3. When the short or long forceps might be used, but em-
bryulcia is preferred, because the child is dead?
4. When delivery is required, and cannot be readily accom-
plished by forceps or turning.
N.B. In all cases where forceps can be at all used, try them
first cautiously, and if they prove insufficient, you may leave
them on the head, perforate, and then use them as a crotchet.
Signs of the Death of the Fœtus.
Many are detailed: most of them more or less dubious.
1. Sensations on the part of the mother—
(1.) Cessation of the motions of the fœtus.
(2.) A sense of coldness and weight in the uterus.
2. The state of the maternal discharges, as the escape of
(1.) Meconium.
(2.) Fœtid discharges.
(3.) Flatus from the uterus.
3. The state of the foetus as marked by-
Uncertain ((1.) Want of cerebral pulsation.
signs. (2.) Desquamation of the cuticle of the scalp, etc.
(1.) Emphysema and disintegration of the bones,
Certain
signs.
etc. of the head.
(2.) Loss of pulse in the funis. There may be a
fallacy from twins.
(3.) Absence of action of the foetal heart.
Preliminary Measures for Craniotomy.
1. Those regarding the position of the patient, the state of
the bladder, the heating of instruments, etc., are the same as for
forceps (p. 34).
40
LECTURE NOTES.
2. Anesthetise the patient.
3. Have the uterus fixed by the hand or a bandage.
4. Have a basin and sand to receive bones and brain.
5. Have napkins placed below the patient for brain.
Two Stages in the Operation of Craniotomy.
1. Perforation and breaking up of the cranium.
2. Extraction of the dead infant.
(1.) PERFORATION AND BREAKING UP OF THE CRANIUM.
General Rules regarding it.
1. Use the left hand as a guide and guard for the perfora-
tor in the female passages, and work the instrument with the
right.
2. Perforate the presenting parietal bone rather than a
suture, because-
(1.) The suture may close from compression of the head
afterwards.
(2.) We are anxious to break up the bones as much as
possible.
3. Take care to place the perforator directly against the part
(at right angles), not obliquely, or it will slip up between the
scalp and the skull.
4. Effect the perforation by a semi-rotatory boring motion.
5. After the perforator is introduced up to the stop, open it
widely and crucially. Repeat this opening, if necessary, again
and again.
6. Advance the instrument into the encephalon, and break
up fully and well the membranes, brain, and cerebellum-par-
ticularly the ganglia at the base.
7. Remove, and always with extreme care, the projecting
portions of fractured bone.
8. According as the disproportion between the pelvis and
LABORIOUS LABOUR.
41
the head is greater, break down and remove more and more of
the arch of the cranium.
9. In breaking down, separating, and removing the bones,
do not tear the scalp, but leave it as a protection for the maternal
soft parts against the sharp edges of the bones.
(II.) EXTRACTION OF THE FŒTUS.
This is not required in the very simplest cases, the mere
diminution by perforation being enough to enable the uterus to
finish delivery.
Should we proceed immediately to extraction?
In simpler cases we need not wait.
Advantages, in very deformed cases, from delay, if there be no
pains, and if all pressure be removed (Osborne, Hamilton,
Meigs, etc.)—
1. The patient's strength recruits
2. The power of the uterine contractions becomes restored.
3. Incipient swelling and inflammation of the passages
abate.
4. The fœtus becomes softened by putrefaction.
5. The presenting part is driven downwards within reach.
In such cases we may wait in general till pains recur.
borne's thirty hours is mostly too long to wait.
Os-
If there be much inflammation of the passages we may wait,
if the perforated head do not press injuriously on them.
General Rules for Extraction.
1. See that the bones are as well defended as possible by the
scalp.
2. Use the left hand again as a guide and guard, and work
the crotchet with the right.
3. Fix the double crotchet like a pair of forceps.
The double crotchet is probably not applicable where the
42
LECTURE NOTES.
head is above the brim and the pelvis narrow (as usual) in the
conjugate diameter
(1.) It is not applicable antero-posteriorly, because
(a.) That space is fully occupied (being the narrowest)
by the head.
(b.) It is impossible to apply the anterior blade if the
promontory of the sacrum, and hence the
foetal head projects far forwards.
(2.) If applied transversely, it does not grasp the head
(which could move forwards) when the sacral pro-
montory is projecting.
4. Fix the single and guarded crotchet wherever you have
a sufficient and proper hold-
(1.) In simple cases, on the parietal or occipital bones if
possible.
(2.) In more difficult cases, in the foramen magnum, or
behind the orbit.
5. Test the firmness of the hold before using great extractive
power.
6. In extracting, work only during a pain, or if there be no
pains, work only at intervals.
7. Endeavour always to extract so as to accommodate the
head as much as possible to the form and axes of the pelvis.
8. In the most difficult cases make the occiput or face
present.
9. After the head is born apply a towel round it and the
neck to pull by.
10. In such cases you may require to perforate also the
thorax and abdomen.
SUBSEQUENT STEPS.
1. Prepare the child by stuffing out and sewing up the scalp.
2. Attend carefully to the mother.
LABORIOUS LABOUR.
43
(1.) Guard against the shock of the operation, if long, by
opiates and stimulants.
(2.) Guard against inflammation and fever following.
(3.) Attend to the state of the bladder and genital canals.
Ask after the state of the bladder for a week or two.
(4.) Examine the vagina and see if there are no spicula
nor lacerations.
II. CRANIOCLASM.
Its advantages as compared with Craniotomy.
1. It is speedier and simpler.
2. It saves the passages from the danger of laceration by
fragments of the skull.
3. It diminishes the size of the foetal head more effectually.
4. It fractures and reduces the size of the base of the skull.
5. The extraction of the head, reduced by cranioclasm, is
more easy for the practitioner and more safe for the patient.
Rules for the Operation.
1. Perforate, according to the rules for Perforation of
the Cranium (p. 40).
2. Introduce the solid blade into the interior of the skull,
and pass the fenestrated blade outside over the occipital bone,
so as to grasp the bone closely behind the foramen magnum.
3. By a twisting movement, first to one side and then to the
other, fracture the occipital bone, and loosen its attachments to
the parietal bones.
4. If necessary, pass the blades of the instrument over the
two sides of the head successively, so as to fracture and loosen
the parietal bones.
5. In some cases apply the blades over the frontal bones,
and by the same twisting movement fracture and loosen them.
6. Use the cranioclast as an extractor, according to the rules
given for Extraction in Craniotomy (p. 41).
44
LECTURE NOTES.
III. CEPHALOTRIPSY.
Rules for performing the Operation.
1. First perforate as for craniotomy (p. 40).
2. Pass, apply, and lock the blades of the cephalotribe
according to the rules for the Introduction of Forceps (p. 35).
3. Let the blades of the cephalotribe grasp the fœtal head
well forwards towards the pubes of the mother.
4. Work the screw so as to approximate the blades of the
instrument, and compress and break up the head and face of the
child; and continue the screwing action until the handles of the
cephalotribe are brought together.
5. If there be great disproportion between the head and the
pelvis, take off the cephalotribe, and re-apply it, so as to seize
the head in a different diameter, and again compress and crush
by the screw. Repeat this process a third time should extraction
be still impossible.
6. After sufficient compression has been effected, retain the
hold of the head by the cephalotribe, and use it for completing
delivery according to the rules for Extraction by Forceps (p. 36).
7. After the head is born, make traction on the body, so as
to deliver it.
8. If the extractive efforts fail, perforate and eviscerate the
thorax, and, if necessary, the abdomen; or crush the thorax
and pelvis of the child with the cephalotribe after perforation.
9. When delivery is completed, adopt the same subsequent
measures as after Craniotomy (p. 42).
IV. CÆSAREAN SECTION.
Indication.
Only when the brim is below 1 or 12 inches in the con-
jugate, by 3 inches in the transverse diameter, or when the
cavity or outlet is much contracted. (This may be from disease
of the bones, or from tumours).
Period for performing the operation.
Before the mother's strength is exhausted.
PRETERNATURAL LABOUR.
45
Principal circumstances in the operation.
1. A heated room.
2. The locality of the incision in the abdominal parietes—in
the linea alba.
3. The locality of the incision in the uterus-in the body,
not in the cervix. Avoid the lateral large vessels.
4. The avoidance of the escape of liquor amnii or blood into
the peritoneal cavity.
5. Speedy extraction of the child. Take out its head first.
6. Before removing the hand, open up the os uteri, and
7. Force the uterus into full contraction.
CÆSAREAN OPERATION AFTER THE DEATH OF THE MOTHER.
1. Perform it, if possible, immediately.
2. If practicable, and any doubt exist as to death having
occurred, prefer delivery by turning.
V. SIGAULTIAN SECTION, OR SYMPHYSEOTOMY.
Objections.
It is not sufficient in bad cases; for to increase the conjugate
diameter 1 inch, the symphysis pubis must separate 3 inches.
14
>>
3 lines,
>>
""
2
>>
1
ور
It is of no use in the common triangular deformed pelvis.
PRETERNATURAL LABOUR.
Definition. Any part presenting except the head.
Two great orders or subdivisions.
1. Presentations of the breech and lower extremities-pelvic
presentations.
2. Presentations of the trunk and upper extremities-
cross-births.
46
LECTURE NOTES.
These two are very different in regard to their difficulty,
danger, and treatment.
Pathological Causes of Preternatural Presentations.
1. Prematurity of Parturition.
2. Death of the child.
3. Intra-uterine diseases of the foetus altering its form.
4. Malformations and monstrosities altering the form of the
fœtus.
5. Twins.
6. Hydramnios or excess of liquor amnii.
7. Spasmodic contraction in the uterine parietes.
8. Organic diseases of the uterine parietes.
9. Placenta Prævia.
10. Distortion and contraction of the brim of the pelvis.
11. Irregularity in the conformation of the uterus.
12. Mechanical and casual displacements of the foetus.
Diagnosis of Preternatural Presentations.
1. Indications during pregnancy-
(1.) The presence of local spasms in the uterus.
(2.) The shape and size of the uterus.
(3.) Feeling parts of the fœtus.
(4.) Sensations of the mother.
(5.) Stethoscopic signs.
2. Suspicious symptoms during early labour-
(1.) The os and cervix uteri high in the pelvis.
(2.) The os uteri dilatable, but dilating slowly and imper-
fectly.
(3.) The membranous bag conical and elongated.
(4.) The presentation not to be felt through the os.
(5.) Escape of a large quantity of liquor amnii and cessa-
tion of the pains.
(6.) Early rupture of the membranes.
3. The only definite test is feeling the presentation.
PRETERNATURAL LABOUR.
47
FIRST ORDER OF PRETERNATURAL LABOURS –
PELVIC PRESENTATIONS.
Definition.-Presentations of feet, knees, and nates.
Effects of extractive interference on the mechanism of Pelvic
Presentations.
1. Diminution of the requisite expulsive efforts.
2. Forcible dilatation of the passages.
3. Displacement of the arms upwards.
4. Malposition of the head.
I. FOOTLING PRESENTATIONS.
General Rules of Management.
1. In none attempt to ameliorate the presentation.
2. Preserve the membranes as long as possible.
3. Promote, if necessary (as in first labours), the dilatability
of the passages.
4. Allow the uterine efforts to expel the lower extremities
and nates.
5. When the child is protruded as far as the umbilicus, pull
down a short loop of the cord.
6. If the cord be pulsating well, beware of interfering till
the child is expelled as far as the armpits. You may free the
hands.
7. If the pulsations of the cord be feeble, or there be spasms
of the child, hasten the delivery by traction, but always have
the uterine tumour at the same time well compressed through
the abdominal parietes.
8. Envelop the protruded parts in a warm cloth, more
particularly before using any extractive force.
9. If the arms have slipped up by the sides of the head
48
LECTURE NOTES.
bring them down, disengaging first the one which is least
difficult.
10. In relieving the arms, pass your fingers as far as the
bend of the elbow of the child. Be sure to bring the elbow
down over the face and the anterior part of the child.
11. Rectify, if necessary, the position and presentation of
the head so as to allow it to pass the brim.
12. In passing the head through the outlet, bring always
the chin and nose by one side of the coccyx, and keep the chin
depressed on the chest.
13. In assisting the extraction of the head, grasp the neck.
between the first fingers of the right hand; place the two first
fingers of the left hand along the sides of the nose or in the
mouth, inclining the body towards the pubes; and rotate the
head out in the axis of the outlet
MORBID IMPACTION OF THE HEAD IN THE BRIM OR THE OUTLET
OF THE PELVIS.
Treatment.
1. Endeavour to rectify its position and relations by depres-
sion of the chin and rotation.
2. Allow access of air to the mouth.
3. Use the forceps or lever.
4. If the child be dead you may perform craniotomy or
cephalotripsy.
II, KNEE PRESENTATIONS.
Diagnosis.
If in any doubt bring down the foot or hand.
Treatment.
The same as in footling presentations.
III. BREECH PRESENTATIONS.
They are more favourable to the child, and at the same time
more difficult for the mother.
PRETERNATURAL LABOUR.
49
Diagnosis.
1. Evacuation of meconium.
2. Negative characters to distinguish the breech from the
head.
3. Softness of the breech.
4. The cleft between the nates.
5. The anus.
6. The sacrum and os coccygis-particularly if the parts be
swelled.
7. Putting up the finger to feel the thighs of the child.
Treatment.
The same principles to be followed as in footling cases.
Let the breech dilate the external passages slowly.
Carefully support the perineum during the passage of the
shoulders and head,
LINGERING OR DIFFICULT BREECH CASES.
The causes and the treatment are nearly the same as in
lingering head cases.
Special Rules of Treatment.
1. If the breech have not yet entered the brim, you may
bring down the feet.
2. If the breech be already in the pelvis, assist with
(1.) Fingers.
(2.) Lac.
(3.) Blunt hook.
(4.) Forceps.
SECOND ORDER OF PRETERNATURAL LABOURS—
CROSS-BIRTHS.
Definition.—Presentations of shoulder, arm, hand, neck,·
breast, back, abdomen. The last four are extremely rare.
50
LECTURE NOTES.
Diagnosis of Shoulder Presentations.
The shoulder is not so large and hard as the
head.
Negative. It wants sutures.
Positive.
It is not so round and fleshy as the nates.
It wants the anus and parts of generation.
The Acromion pointed process.
The clavicle leading from it before.
The spine of the scapula leading from it behind.
The triangular form and mobility of the scapula.
Placing a finger in the axilla and feeling the ribs,
but neither anus nor parts of generation.
Natural terminations of this order of Preternatural Labours.
1. Death of the mother from rupture or exhaustion.
2. Spontaneous evolution or expulsion.
TREATMENT OF CROSS-BIRTHS.
The established rule is to improve and rectify the position,
by turning or version.
The only exception to this is when spontaneous evolution
or expulsion is fairly in progress.
Different kinds of Version.
1. Cephalic version,
2. Breech version.
3. Podalic version.
I. PODALIC VERSION BY INTRODUCING THE HAND INTO THE
UTERUS.
Modifications of Podalic Version, as seizing
1. Both feet.
2. One foot only.
3. One or both knees.
PRETERNATURAL LABOUR.
51
Period of Turning.
When the os uteri and passages are so dilated and dilatable
as to allow the hand to pass inwards safely.
Operate if possible before the uterus has contracted around
the child.
If the uterus be thus contracted, first relax it.
Preliminary Measures.
1. The same as for forceps as regards the position of the
patient, ascertaining accurately the position of the child, empty-
ing of the bladder and rectum, etc. (p. 34).
2. Anæsthetise the patient deeply, especially if the waters
have long escaped.
3. Choice of hand to operate with.
4. Preparation of the arm by anointing it, and of the hand
by anointing the dorsal surface of it.
5. Fixing of the uterus.
Three Stages of the Operation.
(1.) Introduction of theh and.
(2.) Changing the position
of the child. (3.) Extraction of the child.
(I.) INTRODUCTION OF THE HAND.
1. Pass it through the vulva as a flattened cone, and (if
pains be present) during a pain.
2. Direct it forwards in the axes of the outlet, cavity, and
brim.
3. If the os uteri be still small, introduce the fingers through
it gradually, and with a dilating motion.
4. Rupture the membranes at or near the os uteri.
5. Advance the hand along the anterior surface of the child.
Hence advance it along the front of the child's arm, if an arm
be down. If the position of the child be not accurately known,
advance the hand where there is least resistance, as this is gene-
rally on the anterior surface of the child.
5
52
LECTURE NOTES.
6. If any pushing force be required let the pressure be
made on the child, not on the uterus.
7. Always lay the hand flat during a pain.
(II.) CHANGING THE POSITION OF THE CHILD.
1. Apply one hand outside to fix the uterus and assist the
version.
2. Seize one or both feet or knees between your fingers.
3. Move the part seized downwards with a slight waving
motion, and be sure to bring it over the front of the child.
4. Make these efforts only during the intervals between the
pains.
Should we push up the presenting part?
(III.) EXTRACTION OF THE CHILD.
1. Leave the case to nature after the breech of the child has
entered the pelvis.
2. Conduct the case now as a footling presentation (p. 47).
3. If it be necessary to hasten the delivery, be sure to keep
the contracting uterus in contact with the child's head.
4. Effect the extraction of the head from the pelvis—
(1.) With the hands-by rotating the head out under the
arch of the pubes.
(2.) With forceps.
5. We may endeavour to save the child in some cases by
admitting air to the mouth. (Bigelow, Meigs, etc.)
SUBSEQUENT DUTIES.
1. Examine the child for any fractures or injury.
2. Watch the state of the mother.
II. PODALIC VERSION WITHOUT INTRODUCING THE HAND
INTO THE UTERUS.
Cases for attempting it.
All cases where turning is required and the membranes
PRETERNATURAL LABOUR.
53
are unbroken, or at least the waters have only partially
escaped.
Rules.
1. Pass two fingers of one hand through the os uteri so as
to feel the presenting part, and place the other hand on the
fundus uteri.
2. With the fingers in the os uteri gradually push the pre-
senting part to one side, while the other extremity of the foetus
is pushed in the opposite direction by the hand placed on the
fundus uteri.
3. Apply the pressure to both poles of the foetus in the in-
tervals between the pains, and during the uterine contractions
endeavour simply to keep it in its new position.
4. Push and tilt the fœtus over in such a direction that its
body is flexed and the podalic extremity is bent towards the
face.
5. Continue the turning process as part after part comes to
the os uteri, until the knees of the child are within reach of the
fingers, the breech being at the same time well pushed down
towards the maternal pelvis by the hand placed externally.
6. If the membranes be still unruptured, rupture them now.
7. Shift the external hand from the fundus uteri and apply
it to the lower segment of the uterus, so as to push the foetal
head upwards.
8. Seize one knee between the fingers, or hook it down with
one of them, and draw it through the os uteri.
9. Conduct the rest of the case as one of Turning by the
Introduction of the Hand into the Uterus (p. 52).
III. TURNING AFTER THE MEMBRANES ARE RUPTURED AND THE
UTERUS CONTRACTED AROUND THE CHILD.
1. Before operating, relax the uterine contraction by-
(1.) Anesthesia.
(2.) Venesection?
(3.) Large opiates.
54
LECTURE NOTES.
2. Use greater caution than usual.
3. Never remove the child's arm to facilitate the operation.
IV. IF TURNING BE IMPOSSIBLE-
1. Clip through the spine, and double up the fœtus, or
2. Eviscerate the thorax and abdomen, and initiate spon-
taneous evolution, or
3. Decapitate the infant.
COMPLEX LABOUR.
A. COMPLICATIONS ON THE PART OF THE CHILD.
COMP
I. SHORTNESS AND CIRCUMVOLUTIONS OF THE UMBILICAL CORD.
(See p. 21.)
II. PROLAPSUS OR FALLING DOWN OF THE UMBILICAL CORD.
Causes.
1. Relaxation or over-distension of the cervix.
2. Large quantity of liquor amnii.
3. Sudden and profuse escape of liquor amnii.
4. Malposition and malpresentation of the child.
5. Slight malformation of the brim.
6 Low insertion of the cord.
7. A certain length of the cord is necessary, but is not a
direct cause of prolapsus.
Rules of Management.
1. If pulsation of the cord be wholly stopped do not interfere.
2. If you discover the prolapsus before the membranes
burst-
(1.) Endeavour to return the cord above the head.
(2) If this attempt fail, and the passages be well dilated,
turn the child. You may do this without rupturing
the membranes.
(3.) Turning must never be attempted if there be any
evident danger or difficulty to the mother.
COMPLEX LABOUR.
55
3. If the membranes have already ruptured, and the head
be entering, or have entered the pelvis-
(1.) Endeavour to return and retain the cord above the
head-
(a.) With the fingers.
(b.) With a sponge.
(c.) With some rough body.
(d.) With an appropriate instrument.
(e.) By hooking it over a limb of the fœtus.
(f) By placing the patient on her knees and
elbows.
(2.) If you cannot return and retain the cord, place it in
the most empty sacro-iliac space.
(3.) If necessary, hasten the labour by relaxants, for-
ceps, etc.
(4) Never venture to turn the child unless the presenta-
tion be preternatural.
III. PLURAL BIRTHS.
(1.) SIMPLE TWIN CASES.
Signs of the Existence of Twins before Labour.
1. The form, size, etc., of the abdomen.
2. Stethoscopic signs.
Detection during Parturition.
1. Parts of two fœtuses or sets of membranes in the os uteri.
2. The size of the uterine tumour after the first child is born.
We can rarely be sure till the first child is born.
Management of Twin Cases.
1. Conduct the labour of the first child as if a single birth.
2. On detection of the second child tell the attendants—not
the mother. Secure the cord. Mark the first child. Apply a
binder.
3. If the second child present by the head or by the pelvis,
wait one half-hour to see if pains return.
56
LECTURE NOTES.
4. If the uterus still remain inactive endeavour now to re-
excite it.
5. If there be no return of uterine action in one hour,
deliver by the feet.
6. Deliver the second child by turning as soon as the
patient's state permits, if—
(1.) The child present by the trunk or upper extremity.
(2.) There be strong indications of hæmorrhage, convul-
sions, etc.
(3.) The patient have suffered much in the birth of the
first child? ??
7. Re-examine for an additional child.
8. Withdraw the two placenta as one mass.
(II.) COMPLEX TWIN CASES.
1. TWO SETS OF MEMBRANES IN THE OS UTERI AT THE SAME TIME.
Treatment. Carefully preserve that least protruding.
2. PARTS OF TWO CHILDREN AT THE SAME TIME IN THE PASSAGES.
(1.) Both heads at the brim.
(2.) The feet of both at the brim.
(3.) The head of one child and the feet of the other at the
brim.
There may be impaction in this case.
Treatment.
If nature be insufficient-
(1.) Remove the first child from the passages (by de-
capitation, etc.) if it be dead.
(2.) Reduce the head of the second child if the first be
still alive.
3. ONE FETUS EXTRUDED BEFORE THE PERIOD OF VIALIBILITY.
Treatment.-Allow the pregnancy to go on if the placenta of
the extruded child have come away, but not otherwise.
COMPLEX LABOUR.
57
(III.) MONSTROSITIES BY EXCESS.
Treatment.
1. See what nature can effect.
2. If necessary amputate the protruded part, and turn.
Make a very careful examination before doing this.
B. COMPLICATIONS ON THE PART OF THE MOTHER.
(4.) HEAD COMPLICATIONS.
I. APOPLEXY.
It rarely occurs in parturient females.
II. PUERPERAL CONVULSIONS—ECLAMPSIA.
May occur (1) before, (2) during, or (3) after labour.
Before the seventh month they are almost always hysterical.
Supposed Causes of Convulsions.
1. Plethoric condition of pregnancy
2. Difficult labour.
3. State of the atmosphere.
4. Dropsical diathesis.
5. Albuminuria.
6. Toxæmia.
(1.) Blood charged with urea.
(2.)
>>
""
(3.)
(4.)
""
""
>>
"">
carbonate of ammonia.
kreatine and extractive matters.
alkaloidal poisons.
7. Hydræmia leading to oedema of the brain under increased
blood-pressure in the arteries.
Premonitory Symptoms.-Those of Albuminuria.
1. Dropsy of the hands and face.
2. Headache and other pains.
58
LECTURE NOTES.
3. Lesions of the senses, and paralyses.
4. Nausea, vomiting, diarrhoea, cramps, etc.
General Rules of Treatment.
1. Loosen the patient's dress, raise her head, prevent self-
injury, and allow access of fresh air.
2. Bleed largely, and again if necessary ? ?
3. Apply cold to the head.
•
4. Open the bowels freely and speedily.
5. Act, if possible, on the kidneys.
6. Keep the circulation depressed by tartar emetic if it be in
any degree excited.
7. Avoid antispasmodics and opiates in general.
8. Subdue the excitability of the nervous system by chloro-
form.
9. If the passages be in a fit state use forceps, especially if
there be repeated paroxysms.
10. If the foetal head be high, and the passages unprepared,
rely on time and relaxants; but if there be imminent danger,
deliver by long forceps, turning, embryulcia, or incision of the
cervix. Should ergot be given?
11. When there is albuminuria before labour, induce labour
if the symptoms be very marked and severe.
12. In the after-treatment keep the patient low and quiet
(by tartrate of antimony, etc.), and the bowels and bladder free.
Counter-irritate in some inflammatory cases.
13. In subsequent pregnancies, on the first attack threatening,
avert it by keeping down the circulation, and by alkaline salts.
14. Use purgatives and antispasmodics in hysterical convul-
sions; and stimulants in those arising from loss of blood.
(B.) CHEST COMPLICATIONS.
I. EMPHYSEMA.
II. BRONCHITIS.
COMPLEX LABOUR.
59
III. PNEUMONIA.
IV. PLEURISY.
V. ORGANIC DISEASE OF THE HEART AND LARGE BLOODVESSELS.
VI. SYNCOPE.
General Rules of Treatment in Chest Complications.
1. Avoid everything specially which would heat, fatigue, or
oppress the patient.
2. Prevent her using any muscular exertion to promote labour.
3. If the symptoms be at all urgent, have the passages dilated,
and deliver by forceps.
4. Do not empty the uterus too suddenly.
5. Apply a binder previously, and tighten it as the uterus is
evacuated.
6. When thoracic congestion or inflammation is threatened,
avert or subdue it by venesection, or by vascular sedatives.
7. In double bronchitis you may require to keep the air tubes
free by an emetic.
(C.) ABDOMINAL COMPLICATIONS.
I. ASCITES.
It generally affords no great impediment to delivery. It may
necessitate the induction of labour in the last months.
II. TUMOURS.
They may be situated in various organs. Most frequently
they are ovarian.
Treatment.
1. If they obstruct the brim of the pelvis, or if they induce
dangerous dyspnoea by their size (conjoined with the enlarge-
ment of the uterus), you may require to induce premature labour.
2. If not, allow nature to proceed.
60
LECTURE NOTES.
3. Avert inflammation in them during gestation, labour, and
the puerperal state by appropriate means.
4. Hasten the labour if the tissues of the tumour be too much
compressed or irritated during labour.
III. HERNIA OF THE INTESTINES.
Treatment.
1. If the hernia be reducible, keep it up by your own hand,
or by that of an assistant, during the whole process, and particu-
larly at the moment of delivery.
2. If it be irreducible, prevent by the same means a greater
protrusion.
3. If it offer to become strangulated hasten delivery by
appropriate means.
IV. DISPLACEMENTS OF THE UTERUS.
(1.) INGUINAL HERNIA OF THE UTERUS.
(II.) UMBILICAL HERNIA OF THE UTERUS.
Treatment-Alternatives.
1. Reduce the hernia if possible.
2. Hold the uterus up in the proper axis of the brim.
3. Turn...
4. Perform Cæsarean section.
(III.) PROLAPSUS OF THE UTERUS.
Treatment.
1. Empty the bladder, and if possible reduce the pro-
lapsus.
2. Support the os uteri during the pains.
3. If the os uteri do not at length open, incise it.
COMPLEX LABOUR.
61
(IV.) INVERSION OF THE UTERUS.
Symptoms.
1. Great constitutional shock-Pulse small and weak-face
pallid, etc.-faintness or syncope.
2. Pain.
Diagnosis.
From the symptoms, and a conjoined examination above the
pubes, and per vaginam.
1. Danger from shock.
2. Hæmorrhage.
Results.
3. Inflammation and sloughing.
4. Chronic prolapsus and discharge.
Treatment.
1. Always reduce the inverted organ as speedily as possible.
Should we first remove the placenta or not?
2. To retain the reduced organ excite the os uteri into full
contraction before removing the hand.
3. If the first attempt at reduction fail, repeat it cautiously
from time to time.
4. If all attempts fail, treat the case as one of common
prolapsus.
5. If, afterwards, the health become ruined by the discharge,
you may have to remove the prolapsed organ.
V. LACERATIONS OF VARIOUS ABDOMINAL VISCERA.
(1.) Spleen. (2.) Liver. (3.) Cæcum. (4.) Hypogastric
vessels. (5.) Internal iliac vein. (6.) Urinary bladder.
VI. RUPTURE OF THE UTERUS.
Period of its Occurrence.
1. During pregnancy.
It may be mistaken for extra-uterine pregnancy.
62
LECTURE NOTES.
2. During labour.
It occurs most generally during the first twelve hours.
It may take place even before the membranes burst.
Causes.
During pregnancy-
1. Injury.
2. Diseases of the uterus.
During labour—
1. Direct injury from instruments or turning.
•
2. Inordinate action of the uterus, particularly when arising
from obstructions to the passage of the child.
3. Previous disease of the uterine parietes.
Its effects are heightened by inordinate uterine action, by
obstructions on the part of the passages, or by malposition of
the child.
We can never predict the degree of action a diseased uterus
will sustain.
Seat of the Rupture.
Any part of the uterus. Generally it is in the cervix and the
top of the vagina, and on the posterior or the anterior part,
opposite the promontory of the sacrum and the symphysis
pubis.
The cervix is the most frequent seat, because the part most
pressed upon and distended by the head. It is naturally the
thinnest, and forms an angle to receive the force of the uterine
contractions.
Direction of the Rupture.
Longitudinal-oblique-often transverse.
Extent of the Rupture.
Complete; or incomplete, as involving the mucous and
muscular coats only, or as involving the peritoneum only.
COMPLEX LABOUR.
63
Before labour-
Premonitory Symptoms.
1. Metritis (ramollissement) during pregnancy, and especially
if opposite the promontory of the sacrum or the pubes.
2. Injury of the uterus in previous labours (as Cæsarean
section or laceration), or during the present pregnancy or
labour.
3. The present labour not a first; and former labours difficult
from slight contraction of the brim.
During labour—
4. The labour obstructed and tedious (as from pelvic
contraction, cicatrices, hydrocephalus, arm-presentation, etc.),
especially if not so in previous labours.
5. The pains severe in character, but not in their effect upon
the advance of the head.
6. Crampish, and great pain opposite the promontory of the
sacrum or the pubes.
7. Co-existent cramps in the lower extremities.
Symptoms.
They are varied by the extent of the laceration (complete or
incomplete), by the rapidity of the laceration (sudden or slow),
and by the seat of it (in neck or fundus, interior or exterior).
When the laceration is complete and rapid-
1. Pain and a feeling of laceration in the part lacerated.
2. Abdominal pain and tenderness; and distension after a
time.
3. The shape of the child and of the uterus to be felt.
4. Recession of the presentation.
5. Diminution or arrestment of uterine action.
6. Hæmorrhage from the vagina.
7. Death of the child.
8. Constitutional symptoms.
(1.) Shock, small pulse, cold skin, etc.
(2.) Sympathetic vomiting (dark coloured).
G
..
64
LECTURE NOTES.
When the laceration is slighter and slower-——
1. Existence of predisposing and exciting causes.
2. Constitutional effects.
Diagnosis.
1. The above-mentioned symptoms.
2. Feeling the laceration by vaginal examination.
Treatment.
1. When there are any suspicious premonitory symptoms
promote delivery; or, if necessary, diminish or suspend the
violence of the labour-pains.
2. Effect immediate delivery as soon as a rupture occurs.
(1.) If the child's head be in the pelvic cavity or brim,
fix the uterus, and use forceps (long or short), or
crotchet.
(2.) If the head be too mobile for forceps or crotchet per-
form version.
(3.) In turning in cases of rupture of the uterus, secure
if possible both feet.
(4.) Empty the uterus with the hand to prevent the in-
testines from being strangulated in the rent, or the
escape of the lochia, etc. Contract the uterus well
by irritation with the hand.
(5.) Afterwards use sedatives, stimulants, and anti-
phlogistics, according to circumstances.
3. Should we ever use gastrotomy instead of turning?
Turning as a general rule is improper or impossible—
(1.) In accidental rupture during pregnancy.
(2.) During labour when the os uteri is not open.
(3.) During labour when the pelvis is too much contracted
for turning.
(4.) When the child has escaped into the abdominal
cavity.
Exceptions exist when the diagnosis is uncertain or the
passages can be forced.
•
COMPLEX LABOUR.
65
VII. LACERATIONS IN THE PERINEUM AND VULVA.
1. Longitudinal.
2. Oblique.
3. Central.
Varieties.
Treatment.
1. In slighter cases use cleanliness and quiet, and keep the
limbs together by a binder round the knees.
2. In more severe cases-
(1.) Place the patient so that the discharges, etc., do not
run into the wound.
(2.) Keep the edges in contact by metallic sutures.
(3.) Keep the bladder empty by the catheter.
(4.) Regulate the bowels according to the constitution of
the patient. Generally give opiates.
(5.) If these means fail, effect re-union by subsequent re-
vivification and suture.
VIII. UTERINE HEMORRIIAGE.
Periods at which it may occur.
1. During the first six months (abortion).
2. During the last three months.
3. During the first two stages of labour.
4. Between birth and "deliverance."
5. After the expulsion of the placenta.
(I.) HEMORRHAGE IN THE LAST MONTIIS OF PREGNANCY AND
FIRST TWO STAGES OF LABOUR.
1. Unavoidable.
2. Accidental.
Varieties.
66
LECTURE NOTES.
(I.) Unavoidable Hemorrhage from Presentation of the
Placenta.
Synonyms. Placenta Prævia-Placental Presentation.
Local Symptom.
Hemorrhage at the 6th, 7th, or 8th month, or at the full
time, unpreceded by accident, and greatest with each pain.
Constitutional Effects of the Discharge.
In moderate Hemorrhage-
1. In the heart and arteries.-The pulse feeble and quick
-a feeling of faintishness and languor.
2. In the capillaries.-Paleness of the face and lips-coldness
of the surface.
3. In the encephalon.-Vertigo-tinnitus aurium-impaired
vision.
4. In the stomach.-Sympathetic sickness and retching.
5. In the respiration.—Sighing.
In more severe Hemorrhage-
1. In the heart.-Faintness repeated.
2. In the arteries.-The pulse very feeble, quick, imper-
ceptible.
3. In the capillaries.-Pallor of the lips and face-rigors.
4. In the encephalon.-Noises-flashes of light-incoherence
-convulsions.
5. In the stomach.-Repeated vomiting.
6. In the respiration.-Jactitation-dyspnoea.
TREATMENT OF UNAVOIDABLE HEMORRHAGE.
PALLIATIVE TREATMENT.
This is to be employed if the hemorrhage be slight, and
pregnancy not completed.
1. Recumbent position.
COMPLEX LABOUR.
67
2. Quietude and removal of all stimuli.
3. Free ventilation-coolness-few bedclothes.
4. Refrigerants and astringents-ice-acetate of lead—anti-
mony? (if great vascular excitement).
5. Allay the uterine contractions-give opium with the lead.
6. Local means-plug?-cold-styptic injections
7. Watch or be within call.
RADICAL TREATMENT.
This is to be resorted to if the hemorrhage be severe, or
the full time arrived.
1. Evacuation of Liquor Amnii.
This is principally successful in partial presentations; not
often when the presentation is complete.
2. Artificial Delivery of the Child.
(1.) Artificial Delivery by Turning.
The operation is more easily performed when-
(a.) There is a relaxed state of the os and passages.
(b.) The child is alive.
The time of Turning is regulated by circumstances-
(a.) It is not to be regulated by the pains. The pains are
no guide they are often wanting in the worst
cases.
(b.) It is to be regulated by the state of the passages.
(c.) It is to be regulated by the strength and danger of
the mother.
(d.) It is to be regulated by the previous amount of flood-
ing. It is the loss of the last few ounces which
proves fatal
Cautions.-
(a.) Do not operate too early lest laceration of
the os take place.
(b) Perform the operation if possible without in-
troducing the hand into the uterus.
6
68
LECTURE NOTES.
(c.) In introducing the fingers or hand pass by the
side of the placenta, not in general through
it.
(d.) Force the uterus into subsequent full contraction.
(2.) Artificial Delivery by Embryulcia.
In partial presentation cases, where the os is too small for
turning.
(3.) Artificial Delivery by Forceps.
If the head be down, and hemorrhage still go on, forceps.
should be used.
3. Complete Separation of the Placenta.
This is the principle of practice attempted by nature.
It is performed artificially by the finger or by the uterine
sound.
To insure complete separation the placenta should be
extracted.
Separation of the placenta is safe compared with turning.
The proportion of deaths in turning is 1 in 24.
Causes of this high mortality-
(1.) Waiting till the os is relaxed.
(2.) Laceration of the os and cervix.
Hence-
(1.) Death from hemorrhage.
(2.) Death from phlebitis.
Cases in which Separation and Extraction may and should
be followed.
(1.) When the child is dead.
(2.) When the child is not yet viable.
(3.) When the hemorrhage is great, and the os uteri
is not yet sufficiently dilated for safe turning.
This was the state in 11 out of 35 cases. (Lee.)
COMPLEX LABOUR.
69
(4.) When the pelvic passages are too small for safe and
easy turning.
(5.) When the mother is too exhausted to bear turning.
(6.) When evacuation of the liquor amnii fails.
(7.) When the uterus is too firmly contracted for turning.
4. Partial Separation of the Placenta.
This is to be adopted as a minor measure in all cases before
complete separation is had recourse to, unless when the child
is certainly dead, and much blood has been already lost.
Rules for Partial Separation.
(1.) Pass the finger or a sound through the os uteri, and sepa-
rate a little of the placenta all along the line of its detachment
from the uterus.
(2.) Separate especially any portion where the placental tis-
sue can be felt to be on the stretch.
(3.) If the hemorrhage return after having been repressed
for a time by partial separation of the placenta, again endeavour
to repress it by separating an additional portion.
(4.) If partial separation of the placenta fail to arrest the
hemorrhage, proceed to complete separation.
(II.) Accidental Hemorrhage.
TREATMENT.
Repress it if possible by the usual palliative measures. If
these prove insufficient have recourse to-
1. Plug??
2. Rupture of the Membranes.
Objections
(1.) In some cases it is insufficient, as where a portion
of the child is not opposite the bleeding part to
act as a compress.
(2.) The delay till the uterus contracts is dangerous to
the mother.
70
LECTURE NOTES.
(3.) It increases the difficulty and danger of turning.
3. Artificial delivery.
Rules of Treatment.
(1.) Whenever the hemorrhage is very
severe, and the
danger great, dilate the os uteri, and deliver if the state of parts
at all allow it. In very bad cases incision of the os may be
required for immediate turning.
(2.) If the hemorrhage be more slight, or the os uteri and
passages rigid, rupture the membranes.
(II.) HEMORRHAGE IN THE THIRD STAGE OF LABOUR.
(RETENTION OF THE PLACENTA.)
Causes of Morbid Retention of the Placenta.
1. Morbid adhesion of the placenta to the uterus.
2. Hypertrophy of the placental mass.
3. Irregular contraction of the uterus.
4. Inertia of the uterus.
(1.) MORBID ADHESION OF THE PLACENTA TO THE UTERUS.
Treatment.
1. Always empty and contract the uterus as speedily as pos-
sible whenever there is hemorrhage in the third stage.
2. Pass your hand, under the same rules as in turning
(p. 51), and cautiously separate the placenta from the uterus.
3. Extract the placenta when separated, and before removing
the hand force the uterus into contraction.
4. If it be impossible to remove the whole placenta, re-
move carefully all that can be got.
COMPLEX LABOUR.
71
(II.) HYPERTROPHY OF THE PLACENTAL MASS.
Enlargement of the placenta to such an extent as to produce
retention is extremely rare.
Treatment.
If any treatment be required a little pressure or traction will
generally suffice. Should it be necessary, introduce the hand
and extract.
(III.) IRREGULAR OR HOUR-GLASS CONTRACTION OF THE UTERUS.
Causes.
It generally arises from mismanagement in the previous
stages, as from allowing the first stage to be too prolonged, or
from extracting the body of the child too rapidly after the
birth of the head.
Diagnosis.
1. Pains are present, but the umbilical cord does not
lengthen.
2. The cord yields on pulling, and again springs back.
3. The shape of the uterus may be felt externally.
4. The contraction can be felt by examination per vaginam.
Treatment.
1. If the stricture be easily dilatable and the placenta half
out, extract immediately.
2. If the stricture be not thus dilatable, chloroform the
patient deeply, and dilate it by introducing the fingers one
after another. Instead of relaxing by chloroform, you may
give an opiate enema, and then extract after half-an-hour.
3. Push down the fundus uteri by the one hand placed
externally, while the other hand is used to dilate the stricture.
4. As you extract the placenta, irritate the uterus with your
hand, so as to force it into complete contraction, and keep up
steady compression with the hand placed externally.
72
LECTURE NOTES.
*
(IV.) INERTIA OR ATONY OF THE UTERUS.
This is the most common source of retention of the placenta.
Causes.
Protraction of the labour, pulling out the child, etc.
Diagnosis.
The uterus felt large and relaxed, though regular, and no
pains present.
Treatment.
1. General and local stimulants are usually sufficient, as
wine or brandy, ergot, external friction and compression of
the uterus, tractions on the cord, the shock of a cold cloth, or
the alternate application of heat and cold.
2. Sometimes the placenta requires to be removed by the
hand.
Occasionally the placenta is retained at the os uteri by
atmospheric pressure, and cannot be readily extracted till an
edge is drawn down.
(III.) HEMORRHAGE AFTER DELIVERY OF THE CHILD AND
PLACENTA.
It generally occurs within the first hour.
It may be accompanied or not by external discharge.
The contraction of the uterus is generally slight, but irre-
gular.
Causes giving Liability to this form of Hemorrhage.
1. Tedious or instrumental labour.
2. Relaxed state of habit.
3. Plural births.
4. Peculiar conformation or morbid adhesion of the pla-
centa.
COMPLEX LABOUR.
73
5. Disease in the walls of the uterus.
6. Peculiarity of constitution.
1. By gushes.
Modes of Discharge.
2. By slow draining.
Rules of Treatment.
1. Force the uterus into full contraction by-
(1.) External stimulation and compression through the
abdominal parietes. The uterus may sometimes be
grasped between the two hands, one placed behind
and the other in front of it.
(2.) Internal irritation, by the introduction of the hand.
(3.) Compression from within and without.
(4.) Sudden shock from cold-externally or internally.
2. Keep the uterus contracted by-
(1.) Hand, or firm binder and compress.
(2.) Ergot of rye.
3. If it become necessary apply hæmostatic remedies to the
interior of the uterus by means of a syringe or a sponge.
4. If the foregoing measures fail, compress the aorta. This
is especially indicated in organic diseases of the uterus, as
fibroid tumours.
5. Carefully remove all coagula from the vagina and cervix
uteri, as well as from the cavity of the uterus.
6. In extreme cases have recourse to transfusion of blood.
7. Adhere in this and in other cases of severe hemorrhage
to the following rules of treatment.
AFTER TREATMENT IN ALL CASES OF SEVERE HEMORRHAGE.
1. Keep up the uterine contraction by hand or pad, and if there
be any tendency to relaxation, by ergot or uterine injections.
2. Carefully prevent the patient from moving, raising her
head, or using any muscular exertion.
3. Keep her cool, quiet, and perfectly free from all excite-
ment.
74
LECTURE NOTES.
4. If she be restless and irritable exhibit opium, so as to act
as a general sedative.
5. Employ cordials and stimulants if her state of exhaustion
require them.
6. Watch her sedulously for hours, and ascertain at intervals
if there is any recurrence of hemorrhage.
INDUCTION OF PREMATURE LABOUR.
Nature of the Cases requiring the Operation.
1. When the bony pelvis measures from 2 to 3 or 31
inches in one diameter.
2. When dangerous maternal affections are present, as car-
diac disease, ascites, etc., aggravated by pregnancy.
3. When dangerous disease arises during pregnancy and is
aggravated by it, as
(1.) Severe and intractable vomiting, especially in the
latter months.
(2.) Albuminuria and its consequences, both with first
and with other children.
(3.) Various acute inflammations, and other diseases?
4. When the infant is habitually too large-
(1.) From recurrent prolonged pregnancy.
(2.) From recurrent hydrocephalus.
5. When the infant is liable to die in the last months—
(1.) From placental disease.
(2.) From other causes.
6. In cases of fibrous tumours of the body of the uterus
encroaching on the pelvis.
7. In some tumours of the ovary and soft parts.
8. At four or five months, when the pelvis is too small to
pass a viable child.
Advantages of the Operation as facilitating Delivery.
1. The small size of the foetal head.
2. Its greater compressibility.
INDUCTION OF PREMATURE LABOUR.
75
Means of Operating.
1. Abdominal frictions and compression.
2. Ergot of rye.
3. Rupture of the membranes-directly or obliquely.
4. Separation of the membranes from around the os uteri.
5. Dilatation of the os uteri by sponge tents or elastic bags.
6. Dilatation of the vagina by sponge or bag.
7. Injection of warm water-
(1.) Into the vagina.
(2.) Into the uterus.
8. Injection of carbonic acid or common air.
9. Separation of the ovum from the interior of the uterus by
the uterine sound or by a bougie.
10. Insertion of a long gum-elastic catheter between the
membranes and the middle of the uterus.
General Rules and Cautions.
1. Assure yourself well of the necessity for the opera-
tion-
(1.) By pelvimeters (?) or by measuring with the fingers.
(2.) From the results of previous labours.
(3.) By a consultation if there be any doubt whatever.
2. Be careful in calculating the proper period of preg-
nancy.
3. Prepare the patient by purgatives, medicated pessaries, etc.
4. Watch her diligently from the time of the operation till
the labour.
5. Promote the facility, and if necessary the rapidity of the
labour, by supporting the os uteri from the time of the rupture
of the membranes till the head passes through it, and by dilata-
tion of the os uteri if required.
6. Use long forceps when necessary, and in transverse pre-
sentations turn.
76
LECTURE NOTES.
7. Have a warm bath and other means for resuscitating the
child at hand.
8. Previously secure a wet nurse.
PUERPERAL STATE AND DISEASE.
GENERAL PHENOMENA OF THE PUERPERAL STATE.
1. Temporary collapse and exhaustion.
2. Reaction.
3. Contraction and involution of the uterus and vagina.
4. Uterine discharge―The lochia.
5. Mammary secretion.
GENERAL MANAGEMENT OF THE PUERPERAL STATE.
Enforcement for a time of the supine position, of abstinence
from muscular exertion, and of quietude.
Ascertaining the state of the pulse, of the uterus, of the
vagina, and of the uterine discharges.
The use of napkins and of a binder.
Attention to diet, drink, temperature, ventilation, bowels,
bladder, lochia, and breasts.
MORBID DEVIATIONS DURING THE PUERPERAL
STATE.
A. IN THE STATE OF THE UTERUS.
I. AFTER PAINS-HYSTERALGIA.
Treatment.
Remove the cause- as clots or membranes in the uterus or
vagina, or the state of the rectum or bladder. Give a sedative,
PUERPERAL STATE AND DISEASE.
77
II. MORBID VARIATIONS IN THE RAPIDITY OF INVOLUTION.
1. Subinvolution.
2. Superinvolution.
III. MORBID CONDITIONS OF THE LOCHIA.
(1.) SUPPRESSION.
1. Mechanical, as from clots in the os uteri.
2. The effect of constitutional disturbances.
Treatment.
According to the cause, as the use of hot fomentations,
purgatives, antimony, etc.
(II.) PROFUSE FLOW.
Treatment.
Induce sufficient contraction of the uterus. Use astringents,
as ergot, gallic acid, or acetate of lead; and in chronic cases
tonics and external counter-irritation.
(III.) MORBID QUALITY.
Treatment.
Use disinfecting vaginal or uterine injections, as perman-
ganate of potash, chloride of zinc, or chloride of lime.
B. IN THE STATE OF THE BLADDER.
I. RETENTION OF URINE.
Treatment.
A warm sponge or cloth to the pudenda, or a cold cloth or
hand to the abdomen, or the use of spirits of nitric ether.
the catheter if necessary.
II. INCONTINENCE OF URINE.
Use
Make sure that it is not a case of retention and overflowing,
nor one of vesico-vaginal fistula.
78
LECTURE NOTES.
C. INFLAMMATION OF THE VAGINA.
1. Use fomentations.
Treatment.
2. Give opium and ipecacuan if there be much pain.
3. Give antimony if there be much fever.
D. FEBRILE DISEASES OF THE PUERPERAL STATE.
I. RIGORS.
Treatment.
Check them by diffusible stimulants.
II. MILK FEVER.
Diagnosis.
1. The mammæ are distended.
2. There is headache.
Treatment.
1. Preventative by attention to the breasts, etc.
2. Curative by the same means, administering a smart
purgative, giving febrifuge medicines, and applying leeches if
necessary.
III. EPHEMERAL FEVER OR Weid.
Symptoms.
Those of a quotidian intermittent fever, presenting three
stages: chill, dry heat, and perspiration.
Treatment.
1. Diminish the violence and duration of each stage.
2. Keep up the perspiratory stage till the headache is
removed.
3. Beware of cold in bringing the patient out of that stage.
4. Endeavour to prevent return by providing against the ex-
PUERPERAL STATE AND DISEASE.
79
citing causes, as gastric or intestinal irritation, exposure to cold,
etc.
5. Give anti-periodics, as quinine, in the intervals, if the
paroxysms recur.
6. Attempt to suspend the paroxysm in the first stage by
diffusible stimulants, etc.
IV. PUERPERAL FEVER.
Forms.
1. Simple inflammatory.
2. Bilious or gastro-enteric.
3. Typhoid or adynamic.
Symptoms.
Rigors-in about half the cases.
Abdominal pain-sometimes none.
character, and intensity in different cases.
Frontal headache-often absent.
It varies in its seat,
Rapid pulse-usually 110 to 140. A constant phenomenon.
Great diminution or arrest of lactation, and flabbiness of the
mammæ-a most important symptom.
Diminution, arrest, or fetor of the lochial discharge. The
state of the lochia varies in different epidemics.
Disorders of the tongue, stomach, and intestines-inconstant
phenomena.
Delirium-occasionally.
Abdominal tympanites-common after the fever has lasted
some time.
Hippocratic expression of face-in many cases.
Varying condition of the skin from hour to hour as to heat
and moisture-in prolonged cases. The skin sometimes becomes
of a yellowish hue.
Evidences of secondary affections of the chest, joints, and
cellular tissue--if the case last some days.
80
LECTURE NOTES.
Prophylactic
Treatment.
1. Preparatory dieting, medicine, etc.
arsenic, perchloride of iron, etc?
2. Best possible air and ventilation.
Use of quinine,
3. Avoidance of contagion, and of inoculation.
Use of
chloride of lime, cyanide of potassium, etc., to disinfect the
accoucheur's fingers.
Curative-
1. Venesection??
2. Leeches.
3. Fomentations.
4. Rapid counter-irritation-as by turpentine or blisters.
5. Enemata or purgatives.
6. Opium with calomel.
7. Ipecacuanha or tartrate of antimony.
8. Turpentine internally.
9. Colchicum.
10. Veratrum viride.
11. Digitalis.
12. Stimulants and tonics.
13. Washing out the uterus when the discharges are fetid.
Adapt the remedies to individual cases and epidemics.
Give emetics, purgatives, sudorifics, diuretics, etc., according to
the indication of nature.
PART II
PREGNANCY.
DURATION OF HUMAN PREGNANCY;
ITS FREQUENT IRREGULARITY AND OCCASIONAL PROTRACTION.¹
"I HAVE never," declared Sir Charles Clarke, "yet seen a single
instance in which the laws of nature have been changed, believing
the law of nature to be, that parturition should take place forty
weeks after conception."
The preceding statement was made by Sir Charles Clarke when
giving his evidence on the famous Gardner peerage case, before the
House of Lords, in 1816.
On the same occasion, four other London medical practitioners-
viz. Dr. Gooch, Professor Davis, Dr. Blegborough, and Mr. Penning-
ton—averred it was their belief that women never passed the normal
period of pregnancy; or, at least, never passed it beyond two or three
days at the utmost. These various witnesses, however, against the
protraction of pregnancy beyond its normal period, were by no means
agreed among themselves as to what the normal period of pregnancy
actually was. For, while Sir Charles Clarke stated it as forty weeks,
that is, 280 days, or ten lunar months, or nine calendar months and
a week on the other hand, Dr. Gooch observed, in relation to the
period of pregnancy, that "its normal duration is nine calendar
months, or rather less than nine calendar months," or from 273 to
275 days. "It is," he observed, "generally stated in the books to
be forty weeks, but I believe forty weeks to exceed the usual term
of pregnancy. The writers," Dr. Gooch added, "say nine calendar
months or forty weeks; now the fact is, that nine calendar months
is scarcely more than thirty-nine weeks." Dr. Blegborough
declared it as his opinion, that "the period of gestation is thirty-
¹ See Edinburgh Monthly Journal of Medical Science, July 1853, p. 59.
82
PREGNANCY.
nine weeks or 273 days; but," he adds, " forty weeks I consider as
the ultimatum." ¹
1
While these gentlemen thus varied as to what they considered
the normal period of pregnancy-some stating that period to be
thirty-nine weeks, others forty weeks-all of them agreed, to quote
again Sir Charles Clarke, that "forty weeks is the ultimum tempus
pariendi mulieribus constitutum." Some physicians of the present
day still hold that the law of nature is quite fixed in this respect,
and that human pregnancy never exceeds the term in question.
We have now, I believe, however, sufficient physiological and
obstetric evidence accumulated to prove-1. That this doctrine
regarding the ultimate length of gestation is incorrect; 2. That
the term of human pregnancy is not, as a general law, so very
definite and precise as many practitioners think it to be; and 3.
That deviations from it, both in the way of diminution and of
excess of time, are perhaps far more common than is generally sup-
posed among the members of the profession at large. On the
present occasion, I leave out of view the subject of abridged or
shortened gestation; and I will chiefly confine my remarks to the
much more vexed and debateable question of its occasional pro-
longation or protraction.
Most practitioners, from time to time, meet with cases in which
there is apparently every reason to believe, that the term of preg-
nancy has exceeded the usual normal duration of 274 to 280 days.
During the course of the last year or two, after setting aside some
less remarkable instances, I have taken notes of two or three cases
in my practice, in which, after making the common calculation of
280 days, or nine months and a week from the cessation of the
catamenial discharge, pregnancy exceeded this period by several
weeks, keeping the patients and their friends in a state of anxious
waiting; and in all of the instances inflicting the unnecessary, as it
proved, presence of a nurse in the house for a considerable time
before labour actually occurred. The obstetric history of the first
of these cases is interesting in more than this one respect.
CASE I. This patient was married in September 1845, and was supposed by
her medical attendant to be pregnant in the earlier months of 1846.
The case,
however, proved one of that common affection, "spurious pregnancy;" and the
catamenia, after being eight months obstructed, returned regularly. I first saw
her in the course of the following year, in consequence of her suffering under
leucorrhoea, and symptoms of chronic inflammation of the cervix uteri. The
1 See Lyall's Medical Evidence in the Gardner peerage case, pp. 4-9, etc.
ITS DURATION.
83
cervix uteri was enlarged and ulcerated, and the fundus greatly anteverted. The
uterine inflammatory symptoms yielded under appropriate treatment; but the
anteversion remained. In July 1848, an intra-uterine pessary was introduced
with the view of rectifying this displacement. The instrument remained in the
uterine cavity till the end of October following. Immediately after its removal,
pregnancy occurred, and she was delivered of a daughter in July 1849, the labour
being rendered very severe and tedious, by extrerae rigidity of the tissues of the
cervix uteri. From this cause the patient was, during parturition, fourteen hours
continuously under chloroform. It was in her next or second pregnancy, that
there was the apparent prolongation of utero-gestation. In the first week of
January 1851, the menses were present, and disappeared on the 4th or 5th of the
month. On the 20th of the same month, January, there occurred a return of
menstrual discharge for six days, in consequence of great mental distress at the
death of a favourite brother. No menstrual discharge appeared from this date,
and she was confined on the 28th of December, that is, 336 days after the last
appearance of the catamenia. From the patient wishing to go abroad, I was
asked to ascertain if she were in the family way, towards the end of April. In
consequence of the size and shape of the uterus, etc., I had no hesitation in con-
cluding at the time, that she was then at least two months advanced in
pregnancy; and I calculated for her that she would be confined about the middle
of November. Parturition, however, as I have already stated, did not occur till
the 28th of December.
CASE II. Mrs.
the mother of two children, and always quite
regular in her catamenial periods, except when pregnant and nursing, began to
menstruate about the 20th of September 1851, and the discharge ceased on the
24th. Shortly after this date, she had feverish symptoms, and from the cata-
menia not returning, she considered herself pregnant. She was not delivered,
however, till August 3d, that is, 332 days from the last day on which the
catamenial discharge appeared.
This lady's case was interesting in another point of view. In the middle of
December, while in London, in consequence of a long walk, she was threatened
with symptoms of miscarriage, requiring rest and treatment. On the 3d, or
rather morning of the 4th of January, a large steamer in which she was, caught
fire when two or three days out at sea, and only a small number of the passengers
and crew escaped. After making almost superhuman exertions to save herself
and a young son seventeen months old, whom she held in her arms, and after
having her body severely bruised and contused, she was exposed for seventeen
hours in an open boat, with little or no clothing, and sitting immersed several
inches deep in water, during the whole of that long and anxious period. Yet, all
the fearful mental excitement and bodily exertion to which she was thus subjected
were accompanied by no tendency to miscarriage, though, as I have already said,
two or three weeks previously a long walk had nearly brought on abortion. Could
the protracted mental agitation and trial have in any way led to the unusual
prolongation of her pregnancy?
CASE III.-A patient had the usual menstrual discharge in March 1852, and
it left her on the 23d day of that month. She was not delivered till the 5th of
February 1853, or till 319 days after the last appearance of the catamenia. That
the patient became pregnant very shortly, if not immediately, after her last men-
struation, I have every ground for believing; for, in May, I was asked to see her
before she left Edinburgh for the country, in order to determine whether the
cbstruction which had occurred was the result of pregnancy or not, as various
F
84
PREGNANCY.
arrangements depended upon this. On examination, I found the uterus so
enlarged, as to leave no doubt whatever that she was then about two months
pregnant. The patient was, like myself, distrustful of the obstructed menstrua-
tion being a sufficient test, from one point in her previous history. She had
been married several years, and without any family, when she first came under
my care.
The uterus was retroflexed, and for this she wore for some time an
intra-uterine pessary. Within the first half-year after its removal, menstruation
was absent for three months, and she had various symptoms of pregnancy;
among others, the areolæ became dark, and their glandulæ enlarged. The uterus,
however, did not increase in size-showing the symptoms to be those merely of
spurious pregnancy. The areola were altogether so dark and marked, that a
drawing of them was made about the third month. These sketches presented all
the usual changes as distinctly as those figured by my friend Dr. Montgomery in
his plate of the true areola at that period-and being preserved, they were found
on comparison as marked as the patient's own breasts were at the saine date a
short time subsequently, when actual pregnancy had supervened. The prolonged
pregnancy mentioned above occurred with this lady's fourth child.
When lately conversing with my friend Dr. Young, upon the
possible prolongation of pregnancy, he stated to me a case which
some time ago had occurred in his own practice; and of which the
following is a note of the date and circumstances :—
CASE IV. The patient was always regular in her menstrual life, and had the
catamenia present from the 9th to the 14th of July. This was the last appear-
ance of the menses. She felt sickness towards the end of the same month, which
continued more or less for four months, or till the end of November. Foetal
movements were distinctly felt on the 17th of November. She was delivered on
the 3d of June, or in ten months and eighteen days; being 324 days after, the
last appearance of the catamenial discharge, and six months and sixteen days, or
198 days, after the first symptoms of quickening.
In the preceding cases, the durations of pregnancy, as calculated
from the date of the last appearance of the last menstruation up to
the date of delivery, were respectively 336, 332, 319, and 324
days. But, of course, it does not necessarily follow that the preg-
nancy in these instances actually extended to the preceding dura-
tions. For, it may be objected that none of the patients became
pregnant till immediately before the return of the next menstrual
period; or, on an average, till twenty-three days later than the
date of the day of the last catamenial discharge. Even, however,
if, for this reason, we thus subtract twenty-three days from each of
these cases, the duration of gestation would still considerably exceed
the normal limits; for twenty-three days thus subtracted from the
first case would still leave a pregnancy of the duration of 313 days ;
from the second case, of 309 days; from the third, of 296 days;
and from the fourth, of 301 days. Or the cases would stand
thus:-
ITS DURATION.
85
Case I. No. of Days from last Menstruation
336-23=313
II.
""
"
332-23=309
III.
31923296
""
""
""
324-23=301
IV.
There is another and greater source of fallacy to which such ob-
servations are liable, viz. that the catamenia are sometimes arrested
from other causes than impregnation, for a month or two before
conception actually occurs; and that hence, if we date the duration
of gestation from the last appearance of the catamenia, we may fall
into a serious error of calculation. I have specially recorded Cases
I. and III., because in these instances where gestation happened to
be so much prolonged, this source of error was fortuitously avoided;
in both, the actual existence of pregnancy having been ascertained
within eight or nine weeks after conception, by the most certain of
all tests at that time, viz. the regularly marked enlargement and
altered shape of the uterus."
Three authors-Dr. Merriman, Dr. Murphy, and Dr. Reid—
have each published a long series of observations from their own
practice, to show the date of delivery as calculated from the last
day of the catamenial discharge. Dr. Merriman gives as data for
making this calculation the dates of the birth of 114 mature child-
ren, calculated from the day on which the catamenia were last dis-
tinguishable, but not including that day. Dr. Murphy's analogous
cases amount to 163; and Dr. Reid's to 500. In the following
table I have attempted to bring into a comparative view the results.
obtained by these three physicians in the 782 cases upon which
their observations are founded. The table shows, in divisions of
weekly periods, the date of delivery of these 782 patients, as calcu-
8
2
1 It has sometimes seemed to me also not improbable, that some cases of ap-
parently prolonged gestation can be accounted for by another explanation. All
our latest and best anatomists seem now to agree that the decidua of impregna-
tion is merely an altered and hypertrophied state of the mucous membrane of the
cavity of the uterus; and that, consequently, the decidua is not at first a shut
sac, but has the orifices of the Fallopian tubes and os uteri for a time opening
into it. And it seems not entirely impossible that the ovulum of one impregna-
tion dying without the decidua being immediately cast off, the cavity of the
decidua—or, in other words, of the uterus-remaining permeable, a second im-
pregnation may possibly take place within a short time, and the decidua of the
first impregnation serve as the decidua of the second conception. If ever such an
occurrence takes place, a catamenial period might be passed without any cata-
menial discharge-and hence an unavoidable error in calculation be fallen into.
2 Medico-Chir. Trans. vol. xiii. p. 340.
3 Report of the Obstetric Practice of University College Hospital, p. 9.
4 Lancet for July 20, 1850, p. 81.
86
PREGNANCY.
lated from the last day of the appearance of the last catamenial
discharge in each individual:-
TABLE I.
Dates of Delivery, calculated from last Day of Catamenia.
Weeks.
Days.
Merriman.
Murphy.
Reid.
37th
From 252d to 259th
3
12
23
38th
260th to 265th
13
14
48
...
39th
267th to 273d
14
27
81
40th
274th to 280th
33
28
131
...
41st
281st to 287th
22
39
112
42d
288th to 294th
15
21
63
481
295th to 301st
10
25
28
...
44th
and
upwards.
302d to 326th
4.
2
14
114
168
500
The result of the preceding observations of Dr. Merriman, Dr.
Murphy, and Dr. Reid, may, perhaps, however, be shown still more
accurately by reducing the facts mentioned by them into another
form, and calculating the weekly percentage of deliveries from the
last day of the catamenial discharge, as brought out in the observa-
tions of each of these authors. The following table is intended to
give this view of the subject:-
TABLE II.
Percentage of Weekly Deliveries from last Day of Catamenia.

Weeks.
Days.
Merriman.
Murphy.
Reid
. 37th
From 252d to 259th
2.65
7.14
4.60
38th
260th to 266th
11.40
8.33
9.60
39th
267th to 273d
12.28
16.07
16.20
40th
274th to 280th
29.00
16.66
26.20
41st
281st to 287th
19.30
23.21
22.40
42d
288th to 294th
13.16
12.50
...
12.60
43d
295th to 301st
8.77
14.86
...
5.60
44th
and
upwards.
...
302d to 324th
3.50
1.20
2.80
07
100.
100.
100.
The preceding facts show, that if we take as the starting-point
or commencement of our calculations regarding the duration of preg-
nancy, the last day of the last catamenia, the date of delivery is far
less decided and determinate than is generally believed by the
medical profession; the cases registered in these tables showing
very great irregularities and deviations in this respect. It is further
ITS DURATION.
87
deserving of especial remark, that a large proportion of all the cases,
from 12 to 16 per cent, terminated as early as during the course of
the 39th week, or from 267 to 273 days after the last day of the
last menstruation. On any one individual day, only a small propor-
tion of deliveries occurred. The largest actual number of mothers
delivered on individual days was in Dr. Murphy's series of 186 cases,
10, or 6 in every 100, on the 285th day after menstruation; 7 on
the 273d, 279th, and 283d days; and 6 on the 270th, 278th,
284th, 287th, and 297th days after the same date. In Dr. Reid's
series of 500 cases, the greatest number of mothers delivered on
individual days was 25, or 5 per cent, on the 282d day after the
last catamenia; 22 on the 278th day; and 21 on the 274th and
279th, etc. Out of Dr. Merriman's 114 cases, 9 were delivered on
the 280th day; 8 on the 277th; 6 on the 283d; 5 on the 281st
and 288th day; 4 on the 264th, 274th, 285th, 298th, etc.
One circumstance accounting, no doubt, for much of the apparent
irregularity or instability in the duration of pregnancy, as shown in
the above tables, in the cases prolonged to the 40th week, or beyond
it, is the fact, that though impregnation usually takes place within a
very few days after the last catamenial discharge, it may not neces-
sarily do so. For conception may in fact occur at any date pre-
vious to the recurrence of the next menstrual period. This gives an
uncertain limit for the actual date of impregnation, of twenty-two or
twenty-three days-the average interval between two menstrual
periods. But the possibility of variation from this circumstance will
by no means account for the great amount of variation in gestation
which is so frequently observed. For there has now been recorded a
long comparative series of observations upon the duration of preg-
nancy among our domestic animals, and particularly upon the cow,
in which these sources of variation and fallacy with regard to
the length of gestation, were avoided by the fact that the exact day
and date of impregnation in these experiments, from a single inter-
course with the male, were in each instance accurately noted and
fixed. Thus Lord Spencer has reported the date of delivery in 754
cows, in which the day of impregnation from a single coitus with the
bull had been carefully registered.¹ M. Tessier had previously pub-
lished 572 observations of a similar kind upon the same animal. If
we omit a number of cases in each of these two series of observations,
in which delivery supervened earlier than the thirty-seventh week, we
1 Journal of the English Agricultural Society, Part ii., 1839.
2 Mémoires de l'Académie Royale des Sciences, 1819, Tom. ii. p. 1.
88
PREGNANCY.
have the result of Lord Spencer's and M. Tessier's observations pre-
sented in the following table-
TABLE III.
Periods of Gestation in Cows.
Weeks.
Day's.
Spencer.
Tessier.
37th
From 2521 to 259th
12
6
38th
260th to 266th
4
S
...
39th
267th to 273d
24
51

40th
274th to 280th
121
166
41st
281st to 287th
392
202
42d
288th to 294th
175
105
43d
295th to 301st
16
27
44th
and
upwards
302d to 321st
7
7
...
751
572
This table shows that in the cow, even when the day of
impregnation was fixed and ascertained, the period of delivery was
still very far indeed from being quite stable and determinate.
in
But to make the comparisons between these observations on
the cow, and those reported above on the human subject, more
complete, let us reduce the experiments on the gestation of the cow
to a percentage form, as we have already done in Table II.,
relation to the cases in the human subject, recorded by Drs. Merri-
man, Murphy, and Reid. The following table shows the actual pro-
portion of weekly deliveries in Lord Spencer's and M. Tessier's
observations on the cow, as calculated from the known date of im-
pregnation of the animal; or, in other words, the proportion of
cases in every 100 in which the gestation was normal, abridged, or
prolonged :-
TABLE IV.
Percentage of Different Periods of Gestation in Cows.
Weeks.
Days.
Spencer.
Tessier.
37th
From 2524 to 259th
1.60
1.05
38th
260th to 266th
0.55
1.40
•
39th
267th to 273d
2.80
8.91
40th
274th to 280th
16.53
29.02
...
41st
281st to 287th
52.27
35.31
42d
288th to 294th
23.18
18.36
43d
293d to 301st
2.12
4.72
...
44th
and
upwards
302d to 321st
0.93
1.22
•
ITS DURATION.
89
In making any comparison between the results of the period of
gestation in the cow, as shown in Table IV., and the period of
gestation in the human female, as shown in Table II., it is necessary
to remember, that, while the normal period of gestation in the
human female is probably from 274 or 280 days, that of the cow
extends, according to Lord Spencer, to 284 or 285 days. And
hence, while we find that the largest percentage of deliveries in
the cow takes place from the 281st to the 287th day of gestation,
the largest percentage of deliveries in the human female, as calcu-
lated even from the last day of the catamenial discharge, occurred
in Dr. Merriman's and in Dr. Reid's observations from the 274th
to the 280th day; though in Dr. Murphy's series of cases, his
largest weekly percentage occurred in the week following the 280th
day from the last catamenia—an occurrence probably to be explained
by the circumstance of impregnation not following till two, three,
or more days after the last menstruation.
Amongst the various observations which might be elicited by
a comparison of these tables, let me state one more :---That though
the period of gestation in the cow is found liable to considerable
variations, and is by no means so precise and determined as many
authorities have supposed it to be, yet the period of pregnancy in
the human mother is not even so regular as the period of gesta-
tion in the cow. This greater apparent variation of the duration
of pregnancy in the human subject in these tables, doubtless de-
pends upon the fact already adverted to, that the last day of the
catamenia does not by any means, in the human mother, fix deter-
minately the actual day of conception.
Occasionally, however, in the human mother, pregnancy occurs
under circumstances which fix the date of conception to a precise
day. Dr. Reid, for example, has collected from the observations of
various authors, and from his own practice, the history of forty
cases in the human female, where impregnation was the result of a
single intercourse, the date of which was accurately known; the
cases being all of them "instances of single women who dated from
one coitus, or of married females whose husbands had been absent
for a considerable time before the last intercourse," and all of them
being selected with a view to avoid as far as possible every source
of deception. Below I have thrown these forty cases of gestation
into a tabular form. This table demonstrates the varying duration
of pregnancy, and consequently the variable date of parturition and
delivery in the human female, even when the date of impregnation is
90
PREGNANCY.
previously accurately established and known. The last column in
the table presents in the percentage form, so far as can be calcu-
lated from so small a number, the relative proportion delivered at
different dates from the day on which conception occurred.
TABLE V.
Periods of Forty Deliveries in Human Mothers-Impregnation being calculated
from a single Intercourse.

Weeks.
Total Number
Days.
Percentage.
of Cases.
38th
From 260th to 266th,
5
12.50
39th
267th to 273d
7
17.50
40th
274th to 280th
18
45.00
""
41st
42d
281st to 287th
6
15.00
288th to 294th
4
10.00
""
This table shows that in the human subject, and with the day
of impregnation known, pregnancy in nearly one-half, or in 45 per
cent, extended from 274 to 280 days; that in 15 per cent it was
protracted from the 281st to the 287th day; and in 10 per cent'
it was prolonged from the 288th to the 294th day. Three only out
of these 40 cases, or 1 in 13, were delivered on the 280th day
after conception. Seven, or 1 in 6, were delivered on the 274th
day.
Admitting then the possibility of the occasional protraction of
human gestation beyond its common normal period, another ques-
tion has sometimes been asked, viz. What is the extreme limit of
this protraction, or, in other words, to how many days beyond the
normal period of gestation is it possible for a woman to carry a
child? I confess that some of the late cases recorded, particularly
by our American brethren, appear to me to be beyond the bounds
of this possibility. Thus, Dr. Meigs of Philadelphia has reported a
case on "facts" which he conceives to be "trustworthy," where a
patient supposed herself pregnant in July 1839, quickened on the
20th of November, had spurious labour pains on the 10th of April,
but her child was not born till "the 13th of September 1840,
about daylight;" the pregnancy thus, according to Dr. Meigs,
having "endured nearly fourteen months or 420 days.'
112
1 Perhaps this proportion is male larger than it should be, by some of the
published cases which Dr. Reid has collated having been possibly recorded
merely because they were marked instances of protraction.
2 Obstetrics, the Science and the Art, 1852, p. 230.
ITS DURATION.
91
Professor Atlee of Philadelphia has published two cases of pro-
tracted gestation occurring under his own observation. In the first
of these, the patient lost her catamenia on March 22d, 1832-
quickened August 5th of the same year-and was delivered with
forceps March 22d, 1833. It was her fourth pregnancy. In Dr.
Atlee's second case, the patient saw appearance of menstruation for
the last time on August 6th, 1832-quickened on December 25th
-but was not delivered till August 13th, 1833. Dr. Atlee, who
states that he has not "the least doubt of the truthfulness of the
evidence in the above cases," imagines, from the date of the quick-
ening in each, that both mothers became pregnant shortly after
their last catamenial periods, and that consequently, in both
instances, the patient went pregnant nearly the entire circle of the
calendar, or 365 days.¹
Without stopping to inquire as to the various sources of
fallacy in these and similar observations, let me merely add, that
I believe our best criterion for fixing the "legal limit," or ulti-
mate possible period of gestation in the human female, will be
derived from careful and repeated observations upon the ultimate
period of gestation in the cow; allowing always for the difference
of four or five days of excess in the normal period of pregnancy in
the cow, as compared with the human mother. Lord Spencer, in
one instance, found the period of gestation in the cow to extend
to 313 days from the date of impregnation; and in one of his
observations on the same animal, M. Tessier states, that parturition
did not supervene till 321 days from the date of conception.
Such direct experiments and observations upon the lower
animals afford evidence, which necessarily, I think, forces us to
admit, that in exceptional cases in the cow-and hence also, as
1 Tucker's Elements of Midwifery, p. 149.-Dr. Tucker records at some length
the opinion of the American Court regarding the possible protraction of preg-
nancy, as elicited at a trial for bastardy at the Lancaster Quarter Session. In
this case the prosecutrix swore that her child was begotten on the 23d of March
1845, and was born on the 30th of January 1846-making the period of gestation.
313 days—or two days longer than the alleged term of gestation, 311 days, in the
Gardner peerage case. In the American trial, six medical practitioners testified,
with more or less positiveness, against the possibility of the protraction of preg-
nancy. On the other side, five medical practitioners declared their belief in the
occasional extension of gestation beyond the normal period, and in the possibility
of its protraction to 313 days. In charging the jury, the President of the Court
held, that protracted gestation for a period of 313 days, "although unusual and
improbable, was not impossible ;" and in accordance with this charge the jury
found the defendant guilty.
92
PREGNANCY.
+
we certainly may fairly infer, in the human female-the period
of gestation may be prolonged 30 or 35 days beyond its normal
and usual duration. And it is not impossible that further accu-
rate and repeated experiments, of the nature of those performed
by Lord Spencer and M. Tessier, may yet establish, by the same
kind of proof, even a more extended limit as the ultimum tempus
pariendi.
Those obstetricians who maintain that the period of human
gestation is a fixed period, and can never by any possibility
exceed the fortieth week (as was sworn to by the five London
accoucheurs who gave evidence in the Gardner peerage cause,
and by the six medical practitioners who more lately gave
similar evidence in an analogous cause before the American Court
at Lancaster') have none of them adduced any reason why the
period of pregnancy should be thus stable and invariable, while all
other periodic processes in the human body-as dentition, puberty,
menstruation, the date of quickening, etc., are universally known
and acknowledged to be apt to vary extremely. These obstetricians.
have offered no reasons, so far as I know, for holding that similar
variations could not take place in the duration of pregnancy.
Indeed, it would be against all analogies from other actions and
processes in the animal kingdom to suppose that such variations
did not occur in regard to the function of gestation.
Cases of protraction of utero-gestation beyond the usual
average period have been attempted to be accounted for by some
physiologists, by tardiness in the escape of the ovulum from the
ovary after impregnation, by delay in its transit through the
Fallopian tube, and by other deviations in time connected with the
earlier history of development. These explanations, however, are
at the best mere assumptions and hypotheses. There are, however,
one or two known circumstances which seem to have an occasional,
though not very marked, influence on the prolongation of preg-
nancy.
In the individual cases of protraction which I have detailed
towards the commencement of the present communication, the pro-
traction was limited to individual pregnancies in the mothers.
With other children, these mothers had not exceeded the normal
term. Occasionally, however, a disposition to prolongation appears
to be peculiar to some mothers in all their pregnancies. Dr.
Dewees states, that he had occasion to observe the anormal pro-
¹ See preceding footnote from Dr. Tucker's work.
ITS DURATION.
93
longation of pregnancy to upwards of ten calendar months, or above
300 days, as an habitual arrangement in at least four females whom
he had attended.' Dr. Hamilton has recorded the protraction of
pregnancy as a marked individual peculiarity in one of his patients.
In this case the lady lost her two first children from what was sup-
posed to be prolonged gestation to the eleventh menstrual period.
In her three next pregnancies Dr. Hamilton induced labour with
success a week after the tenth menstrual period; in all of these
pregnancies, the patient seeming to show the same tendency to the
prolongation of gestation. My friend, Professor Retzius of Stock-
holm, has informed me of a still more strange example that has
occurred in his practice of extreme protraction of pregnancy, not as
a peculiarity in an individual mother, nor as attending individual
pregnancies only, but as an hereditary peculiarity in a mother and
her two daughters.
+
It is a common idea among agriculturists in this country, that
pregnancy is more apt to be protracted in cows, etc., in proportion
to the frequency of their previous pregnancies. I am not aware
of any collected facts calculated to prove or disprove this idea.
The sex of the calf is also very usually supposed by farmers to have
some influence upon the duration of pregnancy-cows when they
pass beyond the normal period being averred to produce more fre-
quently a male than a female calf. In Lord Spencer's experiments
—if we omit the cases of twin births-among all the cows delivered
up to the 284th day after impregnation, there were 53 per cent of
female, and 47 per cent of male calves born; while among 381
cows whose period of gestation lasted from 285 to 313 days, as
many as 61 per cent of the calves produced were males, and only
39 per cent females. In the table which Dr. Murphy has published
of the duration of pregnancy in 184 human females, the sex of the
child is stated in each with a few exceptions. I find that out of
90 cases noted in which the mothers were not delivered till upwards
of 280 days after menstruation, 57 per cent of the children born
were boys, and 43 per cent were girls.
Perhaps the state of health and activity of the uterus as an indi-
vidual organ of the body, may sometimes have the effect of leading
on to prolongation of gestation. In two of the cases, viz. Cases I.
and III., which I have detailed, it is not impossible that this condi-
tion may have been the cause of the protraction.
The cause why parturition generally comes on in the human
1 Compendium of Midwifery, p. 465. 2 Practical Obscrvations, p. 106.
94
PREGNANCY.
female from the 274th to the 280th day has been much debated
among physiologists and accoucheurs; and perhaps a knowledge of
it may be necessary before we can understand all the circumstances
which lead to the frequent irregularities and occasional prolongation
of pregnancy. All the explanations which, so far as I know, have
been hitherto offered on this subject, such as those that refer the
excitation or supervention of labour to the development of the body
of the uterus, to the state of the cervix, to the state of the ovary, to
the state of the foetus, etc., will, I believe, be found untenable. And
I would venture to suggest that, in the human female, the exciting
cause of parturition is to be traced to changes going on, or rather
accomplished, between the uterus and its deciduous lining;—which
changes lead to parturition, when they have proceeded so far as to
effect the necessary amount of disintegration and separation between
the relatively attached surfaces of the uterus and decidua. In these
communications, I may take another opportunity of stating the
different facts which seem to me to bear on this view of the ques-
tion, and show more particularly the changes in the structure of the
decidua—both vera and serotina, but especially the former-and in
particular of its outer or attached surface, to which I allude. Let
me, in the meantime, merely observe, that these changes, in the
connection between the decidua and uterus, seem of a nature analo-
gous to the so-called fatty degeneration, which occurs in effete and
worn-out structures in other parts of the body; and that we artifi-
cially imitate these changes and their effects in inducing premature
labour, when we separate the membranes from the interior of the
uterus with the finger, or the sound, or when we inject water into
the uterine cavity, etc. These changes of textural degeneration and
detachment are not necessarily accomplished with precision to a
certain fixed day; and hence, I believe, the very great irregularity
which we have seen in the preceding tables to exist in relation to the
time at which parturition supervenes after impregnation. In Lord
Spencer's and M. Tessier's tables, we have evidence of the extreme
irregularity of the period of utero-gestation, and the comparative.
frequency with which anormal protraction of gestation occurred in a
series of experiments, which, it must be remembered, were limited to
about 1300 cases only;-and when we call to mind, at the same
time, that in Great Britain alone, some 600,000 cases of human
gestation and parturition take place annually, we cannot avoid con-
cluding, that irregularities and anormal protractions in human
gestation might be found in obstetric practice far more frequently
CERIUM IN VOMITING.
95
than the profession generally suppose, provided the circumstances
bearing upon this point were always duly and properly investigated.
NOTE ON THE THERAPEUTIC ACTION OF THE SALTS
OF CERIUM,
IN THE VOMITING OF PREGNANCY, ETC.¹
Chemists are at present acquainted with forty-nine different.
metals. Preparations, in the form of oxides and salts, from seven-
teen of these metals, are to be found in our British pharmacopoeias.
Most of the remaining thirty-two metals are of comparatively late
discovery, and few, or almost none, have been tried medicinally.
But, betimes, the oxides or salts of some, at least, of these newer
metals will, in all probability, be found to possess therapeutic qualities
as marked as the preparations, that have been so long used, of the
older known metallic bodies.
In attempting to make some observations on the therapeutic
character of the untried metals, I have been especially gratified by
the results which I have found to be produced by the medicinal use
of the salts of cerium.
This metal, cerium, or cererium, was first discovered in 1803,
and almost simultaneously by Hisinger and Berzelius, and by Klap-
roth. It has been found by these and other chemists to exist in a
variety of minerals, as the Edwardsite, Cerite, Euxenite, Gadolinite,
etc.
The Greenland Allanite is said to contain thirty-four per cent
of cerium.
It is usually found in nature combined with two other metals,
lanthanum, or lantanium, and didymium. In the complex process of
separating the cerium from these two other metallic bodies, oxalic
acid, or rather oxalate of ammonia, is employed in the last stage;
and in the markets cerium is thus most readily procured in the form
of an oxalate of the protoxide. In using cerium medicinally, I have
generally employed the oxalate in the form of small pills, and in the
dose of one to two grains, or a solution of the nitrate in water, and
in the same proportionate doses.*
2
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, November 15,
1854, in Edinburgh Monthly Journal of Medical Science, December 1854, p. 564.
2 For the last few years Sir James Simpson was in the habit of giving oxalate of
cerium in doses three or four times larger than those stated in the text.-J. W. B.
96
PREGNANCY.
The principal therapeutic action of the salts of cerium appears
to me to be that of a useful sedative and tonic, or, if we may use
such an expression, "sedative-tonic,”—like the pharmaceutical oxide
and salts of silver and bismuth. I have employed it pretty exten-
sively in the treatment of the class of cases described in the preceding
paper, chronic intestinal eruptions, and occasionally with the most
marked good effect in them, in instances that had resisted all other
forms of treatment. It is often useful also in common cases of
irritable dyspepsia, gastrodynia, etc. In my own practice and in
that of others, I have seen the above preparations of cerium succeed
in at once allaying irritable and obstinate vomiting after all other
means had failed. Sometimes I have observed it fail, like all other
remedies, in giving relief in the sickness and vomiting of pregnancy;
but far more frequently I have found its employment accompanied
by direct beneficial effects; and I have now repeatedly had occasion
to see it both immediately and perfectly successful in some instances
where the usual succession of medicines,—prussic acid, naphtha,
opium, bismuth, ice, etc.,—had all been previously and perseveringly
tried in vain.
INHALATION OF OIL OF JUNIPER AS A DIURETIC IN
ALBUMINURIA.'
Professor Simpson said he might take this opportunity of men-
tioning a case he had lately seen with Dr. T. Balfour. The patient,
very near her full time, suffered from oedema of the whole body, to a
greater extent than he had ever seen before. Her mind was wan-
dering. All diuretics, etc., had failed; and her stomach was so
irritable that it was impossible to administer medicine in the
ordinary way.
Premature labour could not be induced on account
of the excessive oedema of the labia. He recommended the inha-
lation of the oil of juniper. A profuse flow of urine soon followed,
and the enormous oedema rapidly subsided. The medicine had
soon to be stopped, to prevent too great irritation of the bladder.
The patient was shortly after delivered of a dead child, and made
a good recovery.
1 See Proceedings of Edinburgh Obstetrical Society, April 27, 1864, in Edin-
burgh Medical Journal, August 1864, p. 178. See also Edinburgh Medical
Journal, January 1864, p. 668.
PROPOSED INDUCTION OF LABOUR.
97
INDUCTION OF ABORTION IN ALBUMINURIA.'
Dr. Simpson stated that he had been induced to bring on abor-
tion in a case of pregnancy, on account of the presence of extreme
dropsy and dyspnoea from albuminuria. The patient, who was
apparently dying at the time, recovered speedily and entirely after
the abortion.
TREATMENT OF HEMORRHAGE CONNECTED WITH
ABORTION.2
Dr. Simpson offered some observations on the introduction of
the sponge-tent into the os of the pregnant uterus, in certain con-
ditions connected with abortion, as well as a means of inducing
premature labour. When abortion was inevitable, and the hemor-
rhage great, a small expanding sponge-tent passed into the os uteri
was, he stated, more effectual than a large vaginal plug. It at the
same time opened up the os uteri, so as to allow of the more easy
escape of the contents, whilst uterine contractions were, in most
instances, ultimately induced by its presence. For the same reasons
it was often a valuable means both of opening up the os uteri, and
exciting the necessary degree of uterine action in those occasionally
perplexing cases where, in abortion, the embryo escapes, but the
secundines are long retained. He found that the tent, when made
and introduced in the mode already stated, required no vaginal
plug, or other means to hold it in situ. By its use the first stage
of labour, or the dilatation of the os uteri, could, in a great degree,
be advanced, before the labour itself actually began.
INDUCTION OF PREMATURE LABOUR FOR RECURRENT
HYDROCEPHALUS IN THE FETUS.³
Professor Simpson said that he had brought on labour prema-
turely, about four years ago, in a case where he believed that he
had met with a new indication for the performance of the opera-
¹ See Proceedings of Edinburgh Obstetrical Society, Session xiii., in Edinburgh
Medical Journal, August 1855, p. 184.
2 See Proceedings of Medico-Chirurgical Society of Edinburgh, July 3, 1844, in
London and Edinburgh Monthly Journal of Medical Science, August 1844, p. 735.
* See Proceedings of Edinburgh Obstetrical Society, May 9, 1860, in Edinburgh
Medical Journal, September 1861, p. 289.
3
98
PREGNANCY.
•
tion. Mrs. L., the patient who was the subject of the operation,
had fallen in labour of her first child in 1851. Her labour had
lasted two days, and was terminated by the head of the child,
which was in a hydrocephalic condition, being perforated by Dr.
Jamieson of Peterhead. Her second labour, in 1853, was also
terminated by means of the same operation, by Dr. Johnston of
Stirling, because of the same morbid condition of the foetal head.
In 1856 he (Dr. S.) first saw the patient, in consultation with Dr.
Johnston, at a time when she had arrived at the eighth month of
her third pregnancy. There was every probability that in this
instance again the child would become hydrocephalic, and be de-
stroyed at birth; and the probability was increased by the circum-
stance that the only sister of the lady in question had given birth
to but one child, which had likewise been hydrocephalic, and had
been delivered by means of craniotomy. The likelihood of the
recurrence of the disease in the third foetus was still further im-
pressed on his (Dr. Simpson's) mind, by a letter which he received.
about that time from Dr. Embleton of Embleton, in which that
gentleman related how he had just delivered a woman of a child
that presented by the breech, and was very difficult of extraction,
because of the head being distended to twice the natural size from
hydrocephalus. And Dr. Embleton had stated, further, that the
first and third children of the same patient had been born hydro-
cephalic, and had been delivered by means of the forceps. Regarding
it, therefore, as in the highest degree probable, in the case of Mrs.
L., that if her third pregnancy were allowed to run its full course,
her third child would become the subject of intra-uterine hydroce-
phalus like its predecessors, he (Dr. S.) had two reasons to lead him
to induce premature labour at once; viz., 1st, it was a matter of
great importance for the lady to have a living child, and there was
little prospect of her hopes being fulfilled if her progeny were all
born hydrocephalic; and, 2dly, it was fairly to be expected, that if
the child could be brought into the world at once, and the condi-
tions of its existence changed, it would have a better chance of
escaping the dangers of the disease which had proved fatal to the
first two children. The result justified his (Dr. S.'s) expectations.
Labour was induced, and a living child was born, which he had
seen a few weeks ago in the enjoyment of the most perfect health.
INFLUENCE OF THE DEATH OF THE FŒTUS.
99
OBSERVATIONS ON THE INFLUENCE OF THE DEATH
OF THE FOETUS
IN RELATION TO ITS RETENTION IN, OR EXPULSION FROM,
THE UTERUS.¹
Dr. Simpson, in exhibiting some "secondary " fœtuses from the
University Museum, stated the following general propositions re-
garding them. The general law which regulated the occurrence of
labour in relation to the death of the foetus was well known to be
this:
1. That usually, in from one to three weeks after the fœtus dies,
uterine contractions supervene, and effect its expulsion. But to this
very general law there are various exceptions. For-
2. If the embryo die in early embryonic life, and the fœtal
appendages continue to live and vegetate, expulsion may not super-
vene for months. He showed a case of hydatiginous ovum, where
the embryo was not larger than an embryo of the sixth week, but
the placenta, or rather the chorion, was the seat of hydatiginous
hypertrophy and degeneration; and the mother, a patient of Mr.
Girdwood's of Falkirk, calculated that she had passed the usual
term of utero-gestation, not having menstruated for eleven months
previously to the expulsion of this diseased ovum.
3. When the fœtus dies from the third month onwards, in con-
sequence either of disease in its own organisation, in its umbilical
cord, or in its placenta, and a second twin living fœtus exists at the
same time in utero, and this second foetus continues to grow and
keeps up a correspondence of development between the organ and
its contents, the dead and undeveloped twin may be retained up to
the full term of pregnancy, and be then born along with the other
living and full-sized child.
4. When the dead foetus is thus retained, it is preserved free
from the decomposition usually following death, by all access of air
to it being prevented. Sometimes it retains its usual rounded
appearance and form, if it continues to be surrounded by a sufficient
quantity of liquor amnii; but in other cases where this protecting
1 See Proceedings of Edinburgh Obstetric Society, February 9, 1848, in Edin-
burgh Monthly Journal of Medical Science, May 1848, p. 836.
Wor M
8
100
PREGNANCY.
medium of liquor amnii is defective, the foetus becomes gradually
more and more squeezed between two forces, viz. the parietes of
the uterus on one side of it, and the other living twin or its mem-
branes on the opposite side; and at last, when born, it is found
compressed and flattened in form. Two such flattened fœtuses are
in the University Museum; and many such cases are on record.
5. The birth of such undeveloped dead twins has sometimes
given rise to most groundless and erroneous ideas of the existence
of superfotation.
6. Occasionally when one of twins dies early in pregnancy, it is
after a time expelled, when it happens to be situated near or over
the os uteri; afterwards the uterus closes, and pregnancy goes on
to the full time with the remaining living child. He mentioned
the case of a lady aborting of a foetus about the third month, going
on in pregnancy to the full time, and then being delivered of twins;
having originally conceived of triplets.
7. This last circumstance evidently led to the practical deduc-
tion-that when a dead fœtus in its envelopes is expelled during the
currency of pregnancy, and the uterus notwithstanding still remains.
large and apparently distended, its further contents should not be
in any way interfered with; but rest and other means employed to
avert the excitement of any additional uterine contraction, under
the hope that a living twin may still be retained, and be carried
onwards to the full term of utero-gestation.
PART III.
THE FETUS AND ITS APPENDAGES.
ON THE EXCITATION OF FŒTAL MOVEMENTS BY COLD.'
It is very generally believed by accoucheurs that the sudden applica-
tion of a cold hand, or other similar body, to the cutaneous surface
of the abdomen of a woman advanced in utero-gestation, is capable of
exciting movements on the part of the foetus; and such application
has been often recommended as one of the simplest and best means
of ascertaining, in doubtful cases of pregnancy, both the existence
and the vitality of the child.2
But as there is no direct organic communication between the
abdominal walls of the mother and the body of the fœtus, or between
the nervous system of the mother and that of the child in utero, the
power of exciting muscular movements in the latter, by a sudden
impression of cold upon any part of the abdominal maternal skin,
seems, physiologically considered, an impossibility, and clinical ob-
servation and direct experiment seem to me to prove the whole idea
to be fallacious.
If the hand, whether cold or hot, is so much pressed inwards, as
it inadvertently often is, so as either to indent, or alter the shape of,
the uterine walls, or to push and irritate the body of the fœtus, then
foetal movements will be liable to follow.
If, on the contrary, the hand, however cold, be applied so as
merely to touch the skin, and not make pressure upon it and the
uterus beneath, the impression of cold thus produced will never, I
believe, be found to excite fœtal movements.
Such at least is the result of numerous clinical observations
¹ See Proceedings of Edinburgh Obstetrical Society, Session ix., in Edinburgh
Monthly Journal of Medical Science, July 1850, p. 90.
2 See, for example, Montgomery's Exposition of the Signs of Pregnancy, p. 89;
Dr. Gooch on Diseases of Women, p. 203; Dr. A. Hamilton's Letters to Dr.
Osborne, p. 147 ; Dr. J. Hamilton's Practical Observations, p. 151, etc. etc.
102
DISEASES OF THE FŒTUS.
which I have tried to make upon the subject. In some direct
experiments in regard to it, I touched the surface of the abdomen
with metallic bodies, both larger and colder than the human hand,
without exciting any movements in the foetus. In a number of in-
stances, with Dr. Weir, I applied large pieces of smooth ice to the
surface of the abdomen, without in any one instance finding foetal
movements to follow. And yet, in these same cases, comparatively
slight pressure with the hand upon the abdominal parietes and
uterus, excited foetal movements, whenever in any way the fœtus
was irritated or displaced by that pressure.
PERITONITIS IN THE FETUS IN UTERO.'
In the recent progress of pathology it has been amply proved
that the foetus in utero is liable to a considerable variety of morbid
states. Of its diseases, some, we have reason to believe, are
altogether of a functional nature; but in regard to this class of
foetal affections we as yet possess comparatively little information,
because, excluded as the foetus is, during its abode in utero, from
any of our present means of observation, it is only when its morbid
derangements produce symptoms of a very aggravated character, that
we are enabled to recognise their existence during the continuance
of intra-uterine life. Indeed, for nearly all the limited knowledge
which we as yet possess of the diseased conditions of the foetal
system, we are indebted principally, if not entirely, to pathological
anatomy; and consequently the diseases of that system with which
we are chiefly acquainted are either such as are organic in their
nature, or that lead to an organic result.
Of all the various morbid actions which are liable to occur in the
foetus, inflammation, with the different pathological changes which it
produces, seems to be one of the most important, both as regards the
frequency of its occurrence, and the nature of the effects to which it
gives rise. In the present communication, it is my intention to
bring forward a series of cases to prove, that one species of inflam-
matory action, namely peritonitis, forms a common variety of foetal
disease, and probably constitutes one of the more frequent causes of
death of the foetus during the latter months of pregnancy.
It may be necessary, however, to premise, that the investigation,
by pathological anatomy, of the presence and effects of inflammatory
al, October 1838, p. 390.
1 See Edinburgh Medical and Surgical
PERITONITIS.
103
action, and indeed of all other morbid changes in the foetus, is beset
with unusual difficulties. When the foetus labours under any mor-
bid state which happens to prove fatal during its abode in utero,
there generally elapses an interval of from five to twenty days before
the uterine contractions, necessary for its expulsion, supervene.
During this period a number of changes are liable to occur, which
are calculated to mask or destroy the usual morbid appearances left
by inflammation. Pathologists are now becoming fully aware that
various injections, colorations, serous and sero-sanguinolent effusions.
and softenings of different tissues and organs, more or less porfectly
resembling the corresponding alterations produced in the same parts
by inflammation, are liable to be met with in the dead body of the
adult, as the effects of merely chemical and physical causes acting
during the latter hours of life, or after death. In the case of the
dead fœtus retained in utero, we have not only the same causes pro-
ducing the same results, but these results increased considerably in
their degree and intensity by the longer period during which their
causes are generally allowed to operate; and, besides, we have
further to take into account the additional effects of the endosmosis
of the liquor amnii, and of the blood and other fluids of the fœtus,
through the dead tissues of its body, and the continued maceration
of these tissues in the effused and transuded fluids in which they
are placed. In consequence of the operation of these and other
causes, we have constantly found, in our examinations of foetuses
that had died several days before birth, the heart and large blood-
vessels almost entirely emptied of blood, the different serous cavities
of the body filled by an abundant sero-sanguinolent fluid, and the
same fluid often collected in the general course of the cellular tissue,
but more particularly in that of the scalp, while at the same time
the different solid tissues are reduced more or less in consistence,
and altered in colour and physical appearance. We have seen
tissues and membranes which, from the morbid secretions existing
upon them, we knew to have been the seats of acute morbid action
immediately previous to death, macerated and blanched, and some-
times variously discoloured from the imbibed bilious, intestinal, and
other secretions; whilst, on the other hand, we have found other
membranes and tissues of the body, that had in all probability not
been the seat of any morbid state during life, more or less deeply
reddened, injected, tumefied, and softened. Indeed, we had not
been long engaged in this field of pathological inquiry, before we
became fully convinced that we were not entitled to consider any
104
DISEASES OF THE FOETUS.
tissue or organ in the dead foetus as having been the seat of inflam-
mation during life, unless we could detect in that tissue or organ
one or other of those characteristic morbid secretions, or more dis-
tinct permanent changes of structure, which are recognised as the
distinctive organic results of inflammatory action, such as the
deposition of coagulable lymph, and the indurations, thickenings,
etc., to which this deposit gives rise, the effusion of more or less
serous or sero-albuminous fluids, or of true purulent matter, ulcera-
tion, etc. Accordingly, in the details of the following cases, it will
be observed that we have only entered as genuine examples of
inflammation of the peritoneum, those instances in which there
existed upon that membrane, or in its cavity, one or other of the
organic products of inflammation to which we have just alluded;
but more particularly, effused coagulable lymph, and the adhesions
and pseudo-membranes which such lymph so readily produces, when
thrown out upon serous surfaces.
CASES OF ACUTE PERITONITIS.
CASE I. On the morning of the 15th October 1836, my attendance was
requested at the Lying-in Hospital in a case of twins. The first child had been
born after a natural and easy labour. On examination, I found the second child
presenting by the head, and labour pains having spontaneously recurred, it was
expelled in about forty minutes after the birth of the first. The first-born
child was living, healthy, and well formed. The second had apparently been
dead for some days; its cuticle could be easily peeled off, and was raised into
bullæ at various parts by a sero-sanguinolent effusion beneath it. Its body, how-
ever, was by no means emaciated, but as plump and fat as that of the first child.
Being unable to discover in the portion of the double placenta belonging to the
second child any disease that could account for its death, I opened its body twelve
hours after birth, in presence of Mr. Scott, house-surgeon to the hospital, and Dr.
Pollexfen. Besides the subcuticular effusions already alluded to, there was a
considerable accumulation of serous and sero-sanguinolent effusion in the cellular
tissue in different parts of the body, and in the cavities of the pleuræ, pericardium,
and peritoneum. Over the surface of the last-mentioned membrane (the perito-
neum) there were also deposited several isolated patches of soft coagulable lymphı,
which had produced at various points adhesion of the folds of the intestines to one
another, and to the internal serous surface of the abdominal parietes.
In this case, the consistence and other characters of the effused coagulable
lymph were such as sufficiently indicated that it was the result of recent and
acute peritoneal inflammation. That the child had perished of an acute disease
was still further attested by the general plump condition of its body, and by the
large deposit of fat in the subcutaneous tissue and other parts, which was observed
on dissection.
The mother, Ellen C
was a healthy young woman, of 22 years of
age. It was her first pregnancy. She was not aware of having received any
physical injury, or of having experienced any particular mental emotion, that
PERITONITIS.
105
could enable her in the least degree to account for the death of the second child ;
and her feelings had never led her to suspect that any change had occurred in the
contents of the uterus in the last periods of pregnancy.
CASE II.-I was sent for, April 3, 1837, by Dr. Allan, house-surgeon to the
Lying-in Hospital, to a case of difficult labour which he was attending in Black-
friars Wynd. The left arm was presenting, and, the membranes being entire and
the passages well dilated, I at once passed up my hand into the uterus, turned,
and delivered the child by the feet. It had been evidently dead for some time,
as shown by the detachment of the cuticle from the abdomen and other parts.
From the appearance of the child and the calculations of the mother, it seemed
to have been born a few days before the seventh month.
On opening the body next day, Tuesday the 4th, along with Dr. Allan, Dr.
Charles Bell, and Dr. R. Paterson, we found an effusion of reddish serum within
the sacs of the pleuræ and pericardium; but the lungs and heart were healthy.
There was a similar effusion within the abdominal cavity; and on the peritoneum
covering the convex surface of the liver we observed various distinct patches of
coagulable lymph, with corresponding points of a similar effusion upon the serous
membrane lining the abdominal parietes and diaphragm. The adhesions formed
between the opposed surfaces of the peritoneum at the points of the deposit were
so slight, and the coagulable lymph forming them so soft in consistence, that they
readily gave way under the manipulations required for exposing the contents of
the abdomen. The mesenteric glands were large, some of them equalling in size
the half of a small split pea.
The mother of the child was 36 years of age, and had borne six living child-
ren, besides having had a miscarriage several years previously, and another on the
13th of June last (1836). In this last abortion the child was expelled about the
sixth or seventh month, and she herself attributes its death, and that of the fœtus
whose history I have given, to an excess of hard labour, and more particularly to
the exertion required in carrying loads of water up a long stair of three storeys.
In her first pregnancies she had not been exposed to such toil.
In her last preg-
nancy, the motions of the fœtus had continued from the first of January, when
they were first felt, till eleven days before she was delivered. For two or three
days previous to this last date, it moved "a great deal more," to use her own ex-
pression, than usual."
CASE III. - December 23, 1837.
23, 1837. I examined, with Dr. Banks and Mr.
Stewart, the body of a dead-born child, which had been sent to me for dis-
section on the previous day by Mr. Brown. It was a foetus of about the
seventh month; and the state of the cuticle and tissues in general showed that it
had been dead for some time before birth.
The thoracic organs were healthy, though there was the usual quantity of
pseudo-morbid reddish serous fluid in its serous cavities. On laying back the
abdominal parietes, a patch of soft coagulable lymph was seen on the abdominal
peritoneum near the right iliac region, and on further examination this was found
to have formed a portion of a quantity of the same deposit, effused around the
caput cœcum and its vermiform appendage. The peritoneum covering the liver
and other remaining parts of the intestinal tube seemed healthy; but the peri-
toneal coat of the spleen was covered, more particularly on its outer or convex
surface, with a thickish layer of coagulable lymph, which united it to the corre-
sponding portion of the abdominal parietes by a large web of false membrane.
Mary C- the mother of this child, is a strong and healthy young
woman of 22 years of age. She had previously borne one living child. About a
106
DISEASES OF THE FETUS.
fortnight before the birth of the dead-born fœtus above described, she had a fall
down stairs; and to this accident she at the time ascribed the death of the
infant, as it ceased to move in a day or two afterwards. At the present date,
July 15th, she cannot recollect if the motions of the foetus were greater than
natural after the fall, previously to their final cessation.
CASE IV.—On dissecting, January 8, 1838, the body of a dead-born male
fœtus which had been for two or three months in my possession, I found the
most marked effects of inflammation in almost all parts of the peritoneal cavity.¹
The upper or convex surface of the liver, but more particularly of its right
lobe, adhered to the corresponding surface of the diaphragm. The left edge of its
left lobe was united by effused lymph to the spleen, and this latter organ was
further morbidly adherent along its external surface, partly to the large intestine,
and partly to the abdominal peritoneum. The omentum was connected at one or
two points by coagulable lymph to the concave surface of the liver, and to the
inferior part of the spleen. The small and large intestines were agglomerated
together into a mass, and their corresponding surfaces intimately united at
numerous points by effused lymph. In consequence of these adhesions the
jejunum was intimately united to the sigmoid flexure of the colon. Both the
tunica vaginales of the testes still communicated with the cavity of the peritoneum,
and the serous surface of the left one was partially coated by a layer of coagulable
lymph, or thin false membrane. The other cavities of the body were healthy.
The child was not in an emaciated state.
I regret that I have not any notes of the history of the mother of this child.
CASE V.- July 28, 1838. I examined in the Lock Hospital, with Drs. G.
Weir and Allan, and Messrs. Scott and Bannatine, the body of a child of which
one of the patients in the house had been delivered on the preceding evening.
The cuticle was loose and easily separated. The cavities of the pleura and
pericardium were filled with a reddish serous effusion; but these membranes,
with the exception of numerous points of purpurous effusion beneath them, were
otherwise quite healthy: The purpurous spots were seen under both the pleura
pulmonalis and costalis. The cavity of the peritoneum contained upwards of an
ounce of a still deeper coloured reddish serous effusion, along with one or two clots
of blood, which appeared to have come from a ruptured point in the lower surface
of the right lobe of the liver. The edges of the laceration were partly reunited by
coagulable lymph. A considerable portion of the liver in the neighbourhood of
this part was much congested, more deeply coloured, and softer than the remainder
of the viscus. The gall-bladder was filled with a quantity of viscid bile, and its
coats were thickened, to about a line and a half or two lines, by a serous effusion
into its cellular tissue. The surface of the abdominal peritoneum was coated by a
beautiful lace-like and adherent layer of tough coagulable lymph, which was of
considerable thickness at some points, and threw out long lines or films that were
in contact with the surface of several of the abdominal viscera, but not apparently
in any place adherent to them. This layer of lymph was particularly abundant
in the left hypochondriac, and in the iliac regions. Several loose long films and
masses of it were seen also among the intestines and upon the mesentery. The
mesenteric glands were large. All the other abdominal and pelvic organs were
healthy, with the exception of one of those small pediculated serous cysts adhering
1 Recent preparations of the abdominal viscera, showing the particular morbid
appearances described in Cases III. and IV., were shown at a meeting of the Medico-
Chirurgical Society, and are still preserved.
PERITONITIS.
107
to the right broad ligament of the uterus, which are so common in this part of the
body of the adult female.
Helen G, the mother of the child, is 19 years of age, and naturally of a
healthy constitution, but she has now suffered under four different attacks of
venereal disease. About fifteen months ago she had severe ulcerated sore throat
and other secondary symptoms. During the course of the present pregnancy she
entered, April 5th, the Lock Hospital under my care, affected with an ulcer and
gonorrhoea of five days' standing. She was dismissed, cured, on the 20th of the
same month. She re-entered the hospital 12th July, suffering under another
recent attack of gonorrhoea, and with two slight ulcers; but was nearly well again
when labour pains supervened on the 27th. The liquor amnii was in great quan-
tity. The placenta was pretty firm and healthy, and had not the bleached anæmic
appearance which it usually presents in cases in which the child has been dead for
a week or two. The motions of the fœtus were not very sensibly felt by the mother
after the 13th of July, but subsequently to that period they were repeatedly dis-
covered by applying the hand to the abdomen, and the fœtal heart was most
distinctly heard by myself and several of the pupils of the hospital, only five or
six days before delivery. I counted its beats at that time at 25 in the 10 seconds.
The mother was not aware of having been exposed, during the later periods of
pregnancy, in any such way as could account for the death of the foetus. She had
an abortion about eighteen months ago, when passing through an attack of typhus
fever.
CASE VI.—On opening a dead-born male fœtus of the seventh month, which
had presented by the breech and been delivered by Dr. Allan, I found, with that
gentleman and Messrs. Scott and Bannatine, the following morbid appearances, on
inspecting the body the day after birth, July 29th, 1838.
The cuticle was separated in many parts, and could be easily removed. The
face of the fœtus was swollen and deformed with oedema; and the upper ex-
tremities, but particularly the hands, were also anasarcous. The feet and legs
were likewise dropsical, though in a less marked degree, and there was a consider-
able amount of hydrocele. The cellular tissue of the scalp and loins was infiltrated
with the usual reddish serous effusion. The cavities of the pleure and pericardium
contained a similar fluid, but these serous membranes themselves, as well as the
lungs and heart, were perfectly healthy. The cavity of the peritoneum was filled
with a considerable quantity of the same effusion, and the surface of the abdominal
peritoneum, more particularly on the right side, was covered with a lace-like layer
of adherent coagulable lymph, which presented appearances and characters very
exactly resembling those seen in the preceding case. Several masses and filaments
of lymph were also seen among the convolutions of the intestine, and produced a
pretty strong adhesion between them at one or two points. The spleen was large,
and four drachms thirty-five grains in weight; its surface had several patches of
lymph upon it, and the inferior portion of the organ was intimately and exten-
sively united by morbid adhesions to the larger omentum. The mesenteric glands
were large and well developed. The other abdominal organs were healthy.
The mother, Elizabeth H-, is a robust woman of 42 years of age. The
present is her fourth child. The first was alive and at the full time. The second
was believed to be at the full time, but was born dead. The third, like the
present, was at the seventh month, and also dead at birth. She confesses to
having been affected with venereal disease, but would not afford such information.
as to enable us to judge of the form of the affection, or the particular period at
which she suffered from it. She attributes the death of the present child to her
108
DISEASES OF THE FOETUS.
having fallen down a flight of stairs about a fortnight before delivery. The
placenta was adherent.
CASE VII.—I had an opportunity of examining, February 21st, 1838, the
following case of fœtal peritonitis with Dr. Fisher, under whose care the mother
was delivered.
The appearance of the body of the infant was such as indicated that it had
been dead for some time in utero.
The epidermis was peeling off in various parts. The muscles of the limbs
were soft and flabby, and the periosteum was separated from the bones at various
points. There was no serous effusion into the subcutaneous cellular tissue of the
trunk and extremities, but the sero-sanguineous extravasation beneath the scalp,
so frequent in dead and retained fœtuses, was strongly marked. Some effusion
existed in the thoracic serous cavities, but the lungs and heart were healthy in
structure. In the cavity of the peritoneum there existed a turbid effusion, with
large flakes of coagulable lymph in it. On the upper or convex surface of the
liver a few non-adherent patches of lymph were observable; and there was the
same morbid effusion on the lower surface, particularly along the edge of the left
lobe, where the lymph was firmer and adherent. The spleen had numerous
patches of slightly adherent lymph scattered over its peritoneal surface. Similar
patches were seen on the peritoneum of the colon, and produced at one point,
near the sigmoid flexure, adhesion of two of the contiguous folds of that bowel.
The peritoneal surfaces of the small intestines, mesentery, and abdominal parietes,
had numerous flakes of coagulable lymph deposited upon them. Patches of
lymph were adhering to the right Fallopian tube. The mesenteric glands were
large. The mucous membrane of the stomach and intestines appeared healthy.
Ellen S, the mother of this infant, is a stout young woman of 20 years of
age; and had three years before a dead-born child at about the seventh month.
It was believed to have been dead for some time before its expulsion from the
uterus. In the present pregnancy the mother calculated that she was between the
sixth and seventh month of utero-gestation when labour came on. She had not
felt the child move for about twenty-three or twenty-four days before delivery;
but during the two days preceding the cessation of its motions, these motions, she
alleges, were distinctly much greater than usual. She cannot account in any
way for the death of the child, except it be that she had a fall upon her right side
the day on which its motions ceased; but the increased and morbid movements of
the fœtus had been sensibly felt during the whole day preceding this accident.
Her general health was good during pregnancy, with the exception of occa-
sional nausea, vomiting, and pain in the back. She denies that she ever suffered
under any form of venereal complaint.
CASE VIII. I inspected, January 10, 1838, with Dr. Fairbairn and Dr. John
Reid, the body of a fœtus that had died some time before birth. Its cuticle was
separating in different parts, but its cellular texture was not much infiltrated.
The pleure and pericardium contained a reddish serous fluid, but the thoracic
organs themselves were healthy. On opening the abdomen a considerable quantity
of sero-sanguinolent liquid escaped, having numerous flocculi and large shreds of
coagulable lymph floating in it. Similar shreds of loose coagulable lymph were
found lying upon the peritoneal surface of the intestines at various points, but
nowhere did this lymph seem to be adherent to that surface. On passing the
handle of the scalpel among the loose intestines, it came out covered with patches
and shreds of the substance in question.
The mother of the child, Mrs. M-, aged 26, had been exposed to much.
PERITONITIS.
109
fatigue and hardship during pregnancy, and her health had been very infirm
during the whole period. The movements of the child ceased altogether fifteen
days before its birth. On the day of their cessation it had moved with great and
unusual violence, as if, to use the patient's own expression, "the infant were
coming out at her side." Two days previously to this occurrence, the mother had
been obliged to sleep in wet clothes after a long day's travelling on foot. She had
borne two living children previously.
CASE IX. In a male foetus between the fourth and fifth month, which I
examined, July 7, 1838, with Dr. Allan and Mr. Bannatine, a few hours after its
expulsion from the uterus, the peritoneal cavity contained a quantity of serous
effusion, having numerous flocculi and shreds of coagulable lymph floating in it.
Patches and small masses of this lymph were deposited in considerable abundance
upon the peritoneum, covering the abdominal parietes and different abdominal
viscera, but nowhere did we find any of this exudation adherent to the serous
surface. The left pleura contained a quantity of clear, limpid, reddish-coloured
serosity, without any flocculi floating in it, or deposited upon the surface of the,
membrane. The fluid in the cavity of the right pleura was turbid, and contained
numerous minute masses of animal matter, the source of which was readily traced
to a softened and pulpy condition of the corresponding lung, and to part of the
broken down substance of the organ having escaped through a rupture in the
pleura. Whether this state was the effect of intra-uterine disease, or of physical
injury during or after birth, seemed to us impossible to be determined.
The mother, Frances G a healthy young woman of 18 years of age, had
been under my care in the Lock Hospital from the 12th of April 1838 to the 26th
of May. She was then suflering under a recent and severe attack of gonorrhea,
and had the remains of a chronic syphilitic eruption upon the skin. During her
pregnancy she had been comparatively well in her general health till about a
fortnight ago, when she had several attacks of chilliness and slight fever, with
pain in the uterine tumour, increased by stooping. These symptoms lasted for three
or four days, but were not so severe as to confine her to bed. Her last menstruation
occurred five months and a few days ago. The fetus was six ounces and two
drachms in weight, and exactly six inches and a half in length. It had seemingly
been dead for some days. The placenta was healthy, but in that white anæmic
state which is generally seen in those cases of abortion and premature labour in
which the infant has been for some time dead in utero.
CASE X.-A case of peritonitis, similar in its anatomical character to the two
last, is mentioned by Cruveilhier as having been met with by him in the instance
of a child that was born with the abdomen large, and evidently containing a
quantity of liquid. Death occurred about three hours after birth. On opening
the abdomen there was found a great quantity of yellowish serosity, with some
pseudo-membranous flocculi in the cavity of the peritoneum. The intestines and
stomach were extremely contracted. The large and small intestines were filled
with meconium. The stomach contained thick white mucus, like coagulated
milk) but the child had not swallowed a drop of that fluid), and this appearance
of the gastric mucus may, perhaps, M. Cruveilhier suggests as a query, be the
effect of inflammatory action in the organ. The internal surface of the stomach
presented a very marked punctated redness, in some parts of an irregular form,
in others disposed in lines. The liver was large, and the spleen also increased in
size, and dark coloured. The gall-bladder contained only some colourless mucus.
Indurated and enlarged lymphatic glands surrounded the hepatic duct.
The lungs contained numerous small, but unequally-sized, red, spheroidal
110
DISEASES OF THE FETUS.
*
masses of inflammatory induration like crude tubercle, both on their surface and
in their substance.¹
CASE XI. For the details of the following interesting case of congenital
peritonitis, I am indebted to my friend Mr. Scott, who had an opportunity of
seeing the child during life, and of examining its body after death, with Mr.
Logan.
During the act of parturition, after the birth of the head, the expulsion of
the body of the infant was prevented for some time by the distension of the
abdomen. On examining the child shortly after birth, Mr. Scott found the belly
marked with spots of purpurous or hemorrhagic effusion, especially at the sides;
it was very tense, and fluctuation was indistinctly felt. Both hands were æde-
matous, the left more so than the right. There was no dema of the lower
extremities. The child was plump and fat, but cried only in the feeblest man-
ner, and kept its legs firmly drawn up. It survived for twenty-eight hours only
after birth; and, before death, oedema of the scrotum and penis took place, with
an erysipelatous blush extending to the lower part of the abdomen. The bowels
of the child had never been opened, though castor-oil had been twice adminis-
tered to it; and little, if any, urine whatever had been evacuated, The infant
was large, and had evidently reached the full term of utero-gestation.
On opening the body after death, some air and a quantity of fluid escaped,
when an incision was made into the cavity of the abdomen. "Marks of inflam-
mation," as Mr. Scott observes in the notes with which he has favoured me,
were obvious on the surfaces both of the abdominal and intestinal peritoneum,
and from these surfaces I collected about a tea-spoonful of flaky puriform matter,
exactly resembling that which I have found in my dissections of adult females
who have died of puerperal peritonitis." The intestinal canal was pervious
throughout, but the stomach, upper intestines, and cœcum, were much distended
with air.
The left lung was not at all inflated; the right seemed to have been fully
used. Spots of purpura were seen on the pleura of both sides. The internal
surface of the contracted urinary bladder was covered with similar spots.
Mrs. P, the mother of this infant, had previously borne three living
children. A fortnight before her confinement with the dead-born child above
described, she was exposed to cold and wet in walking from Portobello at night.
On reaching home, she was seized with shiverings, which recurred frequently
during the two following weeks. She did not feel the motions of the child after
the night on which she first had rigors, and she herself believed that it had been
killed by the exposure to which she had been that day subjected.
CASE XII. In a memoir read to the Royal Academy of Medicine in 1825,
M. Veron, among other cases proving the existence of inflammatory and other
diseases in intra-uterine life, adduced an instance of peritonitis, analogous in
several respects to the case which we have last detailed. The case was observed
in 1822, with M. Baron, on the body of an infant who had been brought dead to
the Foundling Hospital at Paris. From the state of the umbilical cord, and the
appearance of the child, it seemed scarcely to have survived a day after birth.
On opening the peritoneal cavity, it was found to contain a quantity of purulent
serosity, but not in any great abundance. There was an albuminous layer or
deposit of coagulable lymph of about a line in thickness on the surface of the
cavity, and so adherent to the membrane, that all the abdominal organs and
1 Anatomic Pathologique, livrais. xv. p. 2.
PERITONITIS.
111
intestines were glued together, and formed only one mass.
The serous membrane
itself was intensely red. The intestinal mucous membrane presented no such
colour. 1
CASE XIII. In the Journal Général de Médecine, M. Brachet has detailed
the following well-marked case of acute inflammation of the peritoneum and sub-
stance of the liver, in a fœtus which was born dead at the full term of pregnancy.
The body of the child was large and well developed, but its flesh was soft, its
abdomen large and distended, and the skin had a yellow tint.
On inspection, the contents of the cranium and thorax were found healthy.
The cavity of the peritoneum contained some reddish serosity, and its right
superior part was occupied by some filamentous shreds of coagulable lymph, form-
ing the rudiments of false membranes. The superior or convex surface of the
liver was rugous, and adhered over almost all its right lobe to the corresponding
portions of the abdominal parietes, by means of patches of pseudo-membrane that
were not yet organised. The liver itself was very red and larger than natural;
its_tissue was friable and softened in its enlarged right lobe; on dividing it, an
inodorous grey reddish fluid resembling purulent sanies, flowed from the cut
surface. The other abdominal viscera were healthy, with the exception of a
reddish state of the omentum.
The mother of this infant had, during the nine months of pregnancy, ex-
perienced only the usual indisposition attendant upon that state. Lively fœtal
motions had been felt up to the middle of the eighth month. From that period
till the supervention of the pains of labour they had become less and less sensible,
and at last had ceased altogether during the act of parturition, which was
extended to eighteen hours. It was her first pregnancy. The placenta was very
large, and slightly gorged with blood, but in other respects healthy."
CASE XIV. In 1821, a well-marked case of fœtal peritonitis and enteritis was
observed by Chaussier in the Hospice de la Maternité, and reported by him to the
Société de Médecine, 3
The subject of the case, a male child, born about the seventh month, was well
formed, and presented even a degree of plumpness. The abdomen was more dis-
tended and elastic than natural; and a glyster was given to it and returned with
little effect. In the subcutaneous cellular tissue there was a slight serous infil-
tration, more particularly in the lower extremities. Its respiration was laboured,
and it died in an hour and a half after birth.
On opening the abdomen about ten drachms of a yellowish viscid serosity,
containing some small flocculi, flowed out. The omentum appeared somewhat
thickened. The convolutions of the small intestines were so united and adherent
to one another by a tenacious layer of concrete lymph, that they were formed into
a single roundish mass, encircled by the course of the colon. On examining more
minutely the small intestines, the cellular coat was found pale, thickened, and
friable, and penetrated by a semi-fluid whitish matter or lymph, which separated
it from the peritoneal coat. The cavity of the intestine was filled with greyish
mucus; and the mucous membrane appeared thickened, and traversed here and
1 Observations sur les Maladies des Enfans, Paris, 1825, p. 17.
2 Journal Général de Médecine, tom. cii. 1828, p. 43.
3 Brilletin de la Faculté et de la Société de Médecine, tom. x. 1821, p. 242.
The same case is mentioned by Billard (p. 242), as described by Dugès in his
Recherches sur les Maladies les plus importantes, etc., des Enfans nouveau-nés.
Paris, 1821.
112
DISEASES OF THE FETUS.
there by small patches or circles of vascular injection. The other viscera of the
abdomen, and those of the head and thorax, seemed healthy.
The mother of this child was a woman of 22 years of age, and pregnant for the
first time. She had always enjoyed the best health, and had not met with any
accident, or experienced any disagreeable symptom during the whole course of
pregnancy. The labour was natural, speedy, and easy.
CASES XV.-XVII.-After quoting the foregoing case (XIV.) as given by
Dugès, M. Billard, in his excellent treatise on the Diseases of Children, adds,
that he "had found peritonitis to the same degree in three infants who died a
short time after birth, and who were all fresh and vigorous. In none of these
three cases had any symptoms of the peritonitis been observed during life, and it
was only by post-mortem inspection that the cause of death was discovered.
one of them there was an abundant sero-purulent effusion, and the intestinal con-
volutions, which were very red exteriorly, were beginning to contract adhesions
to one another." M. Billard does not state what particular morbid appearances
were presented by the other two cases.¹
In
CASE XVIII.—In the slight summary which Professor Carus of Dresden has
given, in his well-known work on Midwifery,2 of the diseases of the fœtus, he
states, “I have observed on the peritoneum of several chidren born dropsical, per-
ceptible inflammation in several places, and once even the effusion of plastic
lymph and adhesion."
CASES OF CHRONIC PERITONITIS.
CASES XIX., XX.-M. Billard, in the work already referred to, has alluded
to two cases that had fallen under his own observation, of infants who died shortly
after birth, and in whose bodies he found coagulable lymph effused upon the
peritoneum in such a solid form as to indicate the existence of an inflammatory
action, which had run through its different stages during intra-uterine life. The
first of these infants died in eighteen, and the other in twenty-four hours after
birth; and in both, solid, and apparently old, adhesions existed among the
different intestinal convolutions. In one of them, the anterior or convex surface
of the liver adhered by four very tough, although very slender, filaments to the
anterior wall of the abdomen. One of the infants was lean, small, and very pallid;
but the other had the usual plumpness of the new-born child.³
CASE XXI.—In the second volume of his Pathological Anatomy, M. Andral
mentions an instance in which he found all the intestines agglutinated together
by intimate and very firm cellular adhesions, the result, as we presume, of old
peritonitis, in an infant only two days old.*
CASE XXII.-The best-marked case, however, of chronic peritonitis in the
fœtus which we have been able to meet with, is one casually described by
Morgagni. The subject of the case was an infant, who was brought to him with
the umbilical cord not tied, and consequently that had probably not lived for any
length of time after birth. With respect to size, it seemed to be of less than the
full time. The body was not in any way decayed or putrid.
The lungs were of a red colour, degenerating into a dark brown, and parts of
them, when laid upon water, immediately sank to the bottom.
1 Traité des Maladies des Enfans, Paris, 1837, p. 479.
2 Lehrbuch der Gynækologie, Bd. ii. S. 251. s Traité, etc., 1. c.
4 Anatomic Pathologique, tom. ii. p. 737.
PERITONITIS.
113
The abdominal cavity was filled with a large quantity of black blood, which
was subsequently traced to have escaped from an erosion or laceration of consider-
able extent upon the concave surface of the liver. The whole of the upper or
convex surface of the liver adhered to the diaphragm and corresponding parts of
the abdominal parietes. At first sight, the mesentery and the intestinal tube
seemed, with the exception of the rectum and lower part of the colon alone, to be
entirely wanting; but, on further examination, these apparently deficient parts
were found agglomerated into a small mass, under the lower surface of the liver,
and covered over by a false membrane. This pseudo-membrane was of considerable
thickness, of a tenacious consistence, and rendered rough by a kind of granular
deposit. There was meconium in some of the upper intestines, but none in the
rectum.1
GENERAL SUMMARY OF RESULTS.
The various cases which I have cited in the preceding pages
will, I believe, be found to afford sufficient evidence for establishing
the pathological fact, that the fœtus in utero is occasionally the
subject of peritoneal inflammation; and by an analysis of the same
and of other additional data, I shall now endeavour to trace out
some of the leading and general circumstances regarding the morbid
appearances left by the disease-the causes which are liable to pro-
duce it the symptoms which most frequently indicate its presence
—its most common terms of duration-the periods of gestation at
which it most commonly occurs-and its effects upon the life of the
fœtus. We reserve the discussion of its more indirect effects upon
other morbid states of the abdominal organs for a future occasion.
MORBID APPEARANCES OBSERVED ON DISSECTION.
The nature of the morbid inflammatory effusions or products.
observed in the cases of foetal peritonitis which we have related,
has varied considerably.
In two cases (XVI., XVII.) the particular morbid appearances
which were met with are not specified. In three (XI., XII., XV.)
the morbid effusions into the peritoneal cavity presented more or
less of a puriform character, combined with the presence of coagulable
lymph; and in all the remaining cases, this latter morbid product
(coagulable lymph or fibrin) was found either alone, or accompanied
(as in Cases I., II., V., VI., VII., VIII., etc.) with a larger or smaller
quantity of serous effusion. The coagulable lymph again has been
seen in different cases under different forms. In three instances
(VII., IX., X.) it consisted of unadherent flocculi and membranous
shreds of various sizes, floating in the serous effusion, or lying on the
1 De Causis ct Sedibus Morborum, Ep. lxvii. sec. 17.
114
DISEASES OF THE FŒTUS.
surface of the peritoneal membrane; in others (I., II., XIII., XVI.) it
was still soft and pulpy, but was attached to the serous surfaces on
which it was deposited, and produced even slight and lacerable morbid
adhesions between some of the opposed points of these surfaces; and
in four cases (V., VI., VII., XXIII.) it was found to present both of
these characters, being in part adherent and in part still loose and
unattached to the serous membrane.
In another set of cases again (III., V., VI., XIV.) the adherent
coagulable lymph was still more advanced towards the process of
organisation, and had assumed a somewhat firmer and more mem-
branous character; in some instances being effused in such abundance
as almost to agglutinate together into one mass (IV., XII., XIV.,
XXI.) a greater or less number of the abdominal organs covered by
the peritoneum, or, where the effusion was more partial and limited,
appearing in the form of a membranous (III.) or lace-like (VI.) web,
or of threads or filaments. (XIX.) passing between some of the
morbidly attached surfaces and organs.
Lastly, in the more chronic cases, the effused coagulable lymph
may, as we have seen, pass into a still more solid and pseudo-
membranous form (XIX., XX., XXI.); or appear, as in the remark-
able case quoted from Morgagni, under the character of a false
membrane investing almost all the abdominal viscera, and containing
in its substance some morbid bodies, not improbably analogous to
those tubercular deposits which are so often observed in cases of
chronic peritonitis in the adult, whilst, at the same time, this morbid
membrane had exercised upon the included viscera that contractile
power which is possessed in a greater or less degree by all organised
lymph, whether it exist in the form of granulated cicatrices upon the
external or internal surfaces of the body, or as organised false mem-
branes, or morbidly developed fibrous tissue.
Complications with co-existent inflammatory disease in other
abdominal organs and tissues, have been observed in only a very few
of the cases. In one instance (XIV.), besides the layer of coagulable
lymph upon the free surface of the peritoneum, there was a consider-
able effusion of semifluid whitish matter (concrete albumen, Dugès),
into the cellular tissue of the smaller intestines, producing a degree
of thickening and friability in the coats of the bowel. In a second
case (XIII), the peritoneal inflammation was accompanied by hepa-
titis in the stage of softening and incipient purulent infiltration; in
another, to be presently quoted (XXIII.), the morbid changes in the
same organ were of a more chronic character, the coats of the liver
PERITONITIS.
115
being opaque and somewhat thickened, and the organ itself reduced
in size. In one instance (X.), there were found some of those small
masses of inflammatory induration in the lungs which form the most
common type of pneumonia in the fœtus and infant.
In two cases (V., XXII.), there were in the peritoneal cavity
coagula of blood, which had apparently proceeded in both instances.
from a rupture or laceration upon the concave surface of the liver.
In the first of these cases (V.), the edges of the laceration had again
become agglutinated together a fact showing that the lesion must
have occurred several days before death; and the congestion ob-
served in the surrounding hepatic tissue was so great, that it might
probably have acted as the predisponent, if not as the exciting,
cause of the laceration.
In two instances (VI., X.), the spleen was unusually large, and
in a case mentioned by Petit-Mengin,¹ which we shall have occasion
to quote in our next communication, as an instance of the com-
bination of ascites and peritonitis in the fœtus, the spleen was
enormously hypertrophied, and had its peritoneal surface morbidly
adherent.
In four of the cases (II., V., VI., VIII.), I have mentioned the
very large size of the mesenteric glands. This is an appearance
which I have now met with so often in my dissections of dead-born
children, that I should feel inclined to regard it rather as a state
natural to the foetus than otherwise. Certainly, according to my
own experience in such cases, the glands, if morbid in any way, are
simply hypertrophied, and do not, as Oehler² would seem to imply,
show some of the characters of scrofulous degeneration.
In two of the cases which I have related (V., XI.), minute
hemorrhagic effusions, similar to those seen in Purpura Hemor-
rhagica, were observed in some of the internal organs of the body.
This particular morbid appearance would, according to the experience
of Cruveilhier, seem to be not unfrequent in the bodies of fœtuses
who have died in utero.
The extent of the inflammatory action in foetal peritonitis, as
shown by the post-mortem appearances, appears in the majority of
cases to have been pretty general over the peritoneal surface; but
occasionally (as in Cases II. and III.) we find it more or less limited
to particular localities and portions of the membrane; and we shall
1 Gazette Médicale de Paris, June 1833.
2 Prolegomena in Embryonis Humani Pathologiam, pp. 34 and 44.
3 Anatomie Pathologique du Corps Humain, livr. xv.
9
116
DISEASES OF THE FOETUS.
afterwards have occasion to point out the pathological importance.
of this fact, in reference to the production of congenital hernia by
local inflammatory adhesions formed between the peritoneal surface
of the descending testicle and some of the contiguous abdominal
viscera.
EXCITING CAUSES OF FETAL PERITONITIS.
On the nature of the causes of peritonitis and other inflamma-
tions in the fœtus, we as yet possess very little accurate information.
Internal inflammatory diseases in the adult are comparatively
seldom the result of noxious agencies applied directly to the organ
or tissue which is the seat of the inflammatory action, but are
generally the result, as we think might be shown if this were a fit
opportunity for discussing such a subject, of a variety of intervening
morbid alterations which originate in the first instance in derange-
ments of the secretions and other functions of the part to which the
external exciting power is applied, and that subsequently react
through it upon the economy in general, or upon that particular
part of it in which the inflammation ultimately becomes located.
These intermediate morbid states seem further capable, in different
instances, of being produced by very different morbific agencies;
and may probably in the fœtus, as in the adult, occasionally consist
in, or be excited by, derangements in some of the natural secretory
and excretory actions of the fœtal economy, as in the non-elimination
of different matters from the fœtal circulation in the placenta of the
mother, or in the introduction through the same channel of morbific
substances previously existing in her system. We can have little
doubt but that in the latter mode, the particular poisons exciting
the specific inflammations characteristic of plague, small-pox, syphilis,
etc., are conveyed from the mother to the foetus in those cases in
which the fœtus is attacked in utero by these diseases.
Causes more particularly referable to the conditions of the Mother.
-In some of the cases of fœtal peritonitis which I have detailed,
the mother had been exposed to severe labour (II.), or fatigue and
exposure to cold and moisture (VII., XI.), or bodily injury (III.,
VI.? VII.?), during her gestation; in two cases (VIII., XXIII.),
there existed general ill health during the whole of that period; and
in one of these (XXIII.), the mother herself was twice attacked with
peritonitis during the course of pregnancy. In two of the cases
(V., IX.), the mothers had an attack of gonorrhoea during the period
of utero-gestation, along with a syphilitic eruption in the one
PERITONITIS.
117
instance (IX.), and ulcers in the other (V.) A third (VI.) confessed
that she had suffered from venereal disease; and the line of life
pursued by others of the number (III., VII., and I believe also IV.),
was such as certainly freely exposed them to syphilitic infection.
Indeed, it appears to me highly probable, from the investigations
which I have already made upon this point, that a great proportion
of those children of syphilitic mothers that die in the latter months
of pregnancy, may yet be shown to have perished under attacks of
peritoneal inflammation.
But before attributing to this, or to any of the above causes on
the part of the mother, too great and exclusive an influence in the
production of peritoneal inflammation in the foetus, it must be
recollected, that in other instances which we have brought forwards,
as, for example, in Cases I., XIII., XIV., XXIV., the mother was
not aware of being in any way exposed to any known morbific
influence, and had not been the subject of any particular indisposi-
tion, either during pregnancy, or antecedently to it. Besides, that
the disease in the foetus may occur altogether independently of any
morbid state of the maternal system, and from causes strictly
originating in, and confined to, the fœtal economy itself, would
seem to be shown by the first instance which we have related,
where, in a case of twins, one child only was affected, whilst the
other was healthy and lively, although they were connected to the
mother by one common placenta, and consequently were both
exposed equally to any morbific influence which the state of her
economy might have been capable of exerting upon them. In some
of the instances we have cited, the children born with peritonitis
were, as in the case (I.) just now referred to, the product of a first
pregnancy, and the offspring of a healthy mother (XIII., XIV.)
In three instances the mothers had previously borne one or more
living children (III., VII., XI.) But others of them (II., III., V.,
VI., VIII.) had already previously suffered from the abortion or
premature delivery of a dead foetus or foetuses. In none of these
latter instances have I as yet had an opportunity of examining two
of the dead-born children of the same parents, to ascertain whether
there may have been an identity of intra-uterine disease in them,
but it seems not improbable, from other ascertained facts relative to
intra-uterine pathology, that in certain cases such an identity of
morbid action might be traced.
Causes referable to the conditions of the Foetus.-In some instances,
peritonitis in the foetus would appear to be directly induced by
118
DISEASES OF THE FETUS.
morbid physical conditions of the abdominal viscera, and by irritant
fluids accidentally applied to the peritoneal surface itself. Legouais
and Dugès¹ are said to have met with cases in which peritonitis in
the fœtus had been apparently produced by an internal strangula-
tion of the intestines. When the urethral canal of the foetus has
been impervious, the urinary bladder has often been found greatly
distended with an accumulation of urine, as seen in numerous cases
recorded by Ruysch, Portal, Sandifort, Meckel, Vrolik, Steghlehner,
Chaussier, Billard, Howship, Wilson, Lee, Montgomery, and others.
In instances of this kind, the distended organ seems liable to give
way under the great morbid dilatation of its cavity, and the effusion
of urine into the cavity of the abdomen consequent upon the perfor-
ation of the viscus, would appear, as in the adult, to be followed by
severe and fatal peritoneal inflammation, as exemplified in the follow-
ing case recently detailed by Mr. King.
CASE XXIII.-On opening the hydropic abdominal cavity of a fœtus of the
fourth month, it was found to contain a considerable quantity of opaque viscid
fluid, having numerous soft flakes of fibrinous matter floating in it. The natural
gloss of the peritoneum was a good deal destroyed; and the surface was in parts
▲ slightly coated, as with fibrin. The liver was reduced in size, and had become
much rounded in figure; its tunic was opaque and somewhat thickened. With
this organ the bowels were collected into a bunch, in the middle of the superior
part of the abdomen. The urinary bladder extended to the umbilicus, had a
globular form, and was so distended as to be capable of containing above half-a-
pint of water; its coats were decidedly thickened. A little behind its summit a
perforation was found, around which the vesical tunics were very much reduced,
as if by absorption from the pressure of distension. This ruptured opening of
communication from the bladder into the peritoneum was a simple fissure, rather
less than half-an-inch in length, and its margins were extremely thin. The
ureters were enlarged, tortuous, and somewhat thickened. The kidneys were
small, and not materially affected by the internal pressure. The urethra was im-
perforate from the prostate gland forwards. No very decided alteration was seen
in any of the other organs.
The mother of this child, aged 27, was of a strumous appearance, and men-
struated irregularly. After having been married eighteen months, she became
pregnant with the above infant. She appeared to suffer from peritonitis at an
early period of her pregnancy, and subsequently continued more or less ailing and
delicate. The premature parturition was preceded by an attack closely resembling
peritonitis. She did not suppose herself with child until the time of her delivery.
The fœtus, a male, was born dead, with a full ascitic abdomen, and the abdominal
parietes very considerably distended and attenuated.
¹ Cyclopædia of Practical Medicine, vol. iii. p. 291; and Billard, p. 483.
2 In one recent case which I had an opportunity of examining with Dr. John
Moir, the muscular and mucous coats of the dilated bladder seemed entirely re-
moved at one circumscribed point, and the peritoneal tunic alone remained to
prevent the effusion of urine into the abdominal cavity.
3 Guy's Hospital Reports, No. v. p. 508.
PERITONITIS.
119
In two cases that we have detailed (V., XXII.), in which there
were coagula of blood in the abdominal cavity, from a partial lacer
ation of the substance of the liver, could the peritoneal inflammation
have been excited in consequence of the effused blood acting as an
irritant upon the serous membrane ?
In connection with these instances of inflammation of the peri-
toneum, originating in direct physical and chemical injury of the
membrane itself, I may here mention, as cases in all probability
referable to a somewhat similar principle, that I have repeatedly
observed an effusion of patches of coagulable lymph upon the peri-
toneal surface of the intestines and other abdominal viscera, in
instances of monstrosity consisting in the extroversion of these viscera
from a partial deficiency of the abdominal parietes; and I have seen
this both in the human foetus and in that of the lower animals.
Thus, for example, I find that among the short notes which I made
some years ago, of various cases of foetal monstrosity contained in
the Museum of Guy's Hospital, London, I have incidentally marked
the existence of an effusion of coagulable lymph upon some part of
the peritoneum, as visible in three of the cases in which there was
general extroversion or hernia of the contents of the abdomen, from
the deficiency alluded to. One case (2542 A) is described as having
"some fibres of coagulable lymph upon the peritoneal surface of the
liver and protruded intestines; the head of the foetus is much mal-
formed, and probably it was one of those instances in which this
part adhered by inflammatory false membranes to the inner surface
of the placenta or amnion. There is also a strong thread or band,
probably composed of organised lymph, attached to the skin over
the external side of the left elbow." The second case is marked as
a "fœtus with harelip and extroverted heart and abdominal viscera,
and with apparently a few patches of coagulable lymph upon the
peritoneum and pericardium :" and the third case (2550 A), a mal-
formed foetal pig, is mentioned as having, among many other
anomalies of structure, "the extroverted abdominal viscera partially
surrounded by a transparent serous-like membrane, which has strings
of coagulable lymph attached to it." I have now seen in other
pathological collections several additional instances of similar partial
effusions of coagulable lymph upon the peritoneum, and even intimate
morbid adhesions between the contiguous serous surfaces of such
abdominal viscera, as happened to be protruded in cases of fœtuses
with malformations resembling the above. We may here observe
also, that Scarpa, in his treatise on Hernia, mentions and represents¹
¹ Treatise on Hernia, Wishart's translation, p. 377, and Plate xiv. Fig. 2.
120
DISEASES OF THE FETUS.
a case of umbilical hernia in the human foetus, in which a consider-
able portion of the jejunum adhered, no doubt in consequence of
previous peritonitis, to the entrance of the hernial sac; and the
same author, in another passage of his work,' points out the firm
adhesion" contracted by the protruded abdominal viscera to the
hernial sac, in instances of congenital umbilical hernia, as one of the
causes opposing reduction, and leading to the early death of almost
all those infants that are born affected with this disease.
SYMPTOMS OF FETAL PERITONITIS.
In the prefatory observations made to the present communi-
cation, I have already taken occasion to allude to the almost in-
superable difficulties which are opposed to our arriving at any
accurate knowledge of the symptomatology of intra-uterine diseases;
and the present affection only affords too apposite an illustration of
the remark in question.
In eleven only of the preceding cases have we any account
whatever of the condition and feelings of the mother during the
period of pregnancy. In four (I., VII., XII., XXI.) out of these
eleven cases, nothing seems to have occurred that was calculated to
direct the particular attention of the mother to anything peculiar in
the condition of the foetus; in three (III., V., X.), the cessation,
about a fortnight before delivery, of the motions of the foetus as felt
by the mother, was the only circumstance remembered, and in one
of these cases (V.), the fœtus certainly continued to live for some
time after this occurrence; in another case (XI.) the motions of the
infant became less and less sensible during the last two weeks of
gestation; and in the three remaining instances (II., VII., VIII.),
these motions, after being much and morbidly increased for two or
three days, ceased entirely and rather suddenly, at a period varying
from eleven (II.) and fifteen (V.) days, to upwards of three weeks
(VI.), before delivery. This last combination of symptoms-namely,
a great, but temporary, increased degree of the foetal motions,
attended occasionally with spurious pains, and followed by the
sudden and final cessation of all perceptible movements on tlte part
of the infant-may, we believe, be not unfrequently noticed in cases
of acute and fatal peritonitis of the foetus; but, at the same time, it
must be held in recollection, that this same sequence of morbid
phenomena is common to peritonitis, with all those diseases of the
fœtus in utero which are similarly acute and fatal in their character,
1 Treatise on Hernia, p. 378, § 6.
PERITONITIS.
121
and consequently they cannot by any means be held as diagnostic
marks of peritoneal inflammation alone. We omit here, as we have
done in the detail of individual cases, the recapitulation of various.
well-known but equivocal symptoms in the maternal system, of the
death of the child, such as rigors, a sense of weight in the tumour of
the uterus, flattening of the abdomen, etc.; because these signs, when
they do occur, can only be regarded at best as probable indications
of the death of the fœtus, without leading in any way to a know-
ledge of the cause of that event.
When the child has been born alive, but affected with congenital
peritonitis, it has sometimes, in the more chronic forms of the disease,
been emaciated (XIX.), but not always so (XX.); and in the more
acute cases, when any great degree of change is observed in the con-
dition of the child in regard to its natural condition of fatness and
plumpness, we shall in general be justified in ascribing it to other
causes besides the peritoneal inflammation, as we know that this
disease may even prove fatal without bringing down the state of the
little patient in this respect (XIII., XIV.) In several cases the
abdomen was swelled and fluctuating at birth (V., X., XI., XIII.,
XIV., XVIII.); sometimes even tense and tender to the touch
(XXIV.) With the abdominal effusion a certain degree of hydrocele
generally exists in the tunicæ vaginales of male infants (as in Case
VI.); and in some there has also been observed a co-existent degree
of dropsical swelling in other parts of the body, as in the hands
(XI.), in the upper extremities and face (VI.) in particular, or in the
lower extremities, and beneath the skin of the whole body (XIV.)
In two of the cases, the children's skin presented at birth the
yellow discoloration of jaundice. In one of them, that was dead-
born (XIII.), the liver on inspection was found to be the seat of
acute inflammation, and commencing purulent infiltration.' In the
1 Baumes, in his Traité de l'Ictère des Enfans de Naissance (Paris, 1806),
mentions an interesting case (p. 45) of congenital jaundice complicated with
hepatic inflammatory disease. A mother, who was herself much affected with
jaundice during pregnancy, produced a child with both skin and conjunctiva
sensibly discoloured. The child, whose right hypochondrium was very prominent
and hard at birth, died under increased symptoms of icterus in four or five weeks
afterwards. On opening its body, the tissues of the abdominal parietes and of all
the abdominal viscera were seen to be stained yellow. The liver was very large,
particularly the left lobe, which was morbidly adherent on its surface to some
neighbouring parts, and softened in its substance. The right lobe felt indurated,
and its lower or concave surface contained a small abscess. The gall-bladder
was half-filled with a greenish, limpid, slightly bitter fluid. The ductus chole-
dochus seemed obstructed by a viscid yellowish matter. The stomach was much
contracted.
122
DISEASES OF THE FETUS.
second case (XXIV.), which will be subsequently more particularly
described, the child was born alive and survived.
Again, in other instances of congenital peritonitis, none of the
equivocal symptoms here alluded to have been remarked, and the
cause of death has only been discovered by the post-mortem dissec-
tion (XV., XVI., XVII.)
DURATION OF FOETAL PERITONITIS.
We have as yet but few data on which we can rely with any
great degree of certainty for fixing the general duration of attacks
of peritonitis in the foetus. We have enough, however, I believe,
to show that, contrary to the surmises of some pathologists, inflam-
matory action may occasionally proceed with nearly as great a
degree of acuteness and severity in intra-uterine life as after birth.
In some of the cases of peritonitis that have been related (I., II.,
XX.), the plump and unemaciated condition of the foetus after death
affords very strong evidence that the fatal morbid state under which
it had suffered had not been long in its duration. In others, those
symptoms of increased movement and restlessness in the foetus which
indicated the occurrence of acute disease in some part of its system,
were only remarked for one (VII.), two (VIII.), or three (II.) days
before its death; and in one of these cases (VII.), we have further
corroborative evidence of the occasionally very acute character of the
disease in this circumstance, that the apparent exciting cause of the
peritonitis was applied only two days previous to the death of the
fœtus, as indicated by a sudden and total cessation in its motions
subsequently to a greatly increased degree of them. In two other
cases (III., XI.) also, the fœtal movements ceased in the course of a
day or two after the supposed exciting cause of the foetal disease had
operated upon the maternal system. Besides, the inspection of the
dead body, in this and in other instances (as in I., II., VIII., IX., X.,
XII.), presented such morbid appearances as corresponded only with
those left by the more acute and rapidly fatal forms of peritonitis in
the adult. Again, in other cases, the state of emaciation, and hence,
probably, of long-continued disease (XIX.), combined with the parti-
cular appearances found on dissection (XIX. to XXII.), show in as
unequivocal a manner that in these instances the inflammatory action
must have been of a decidedly chronic character.
PERITONITIS.
123
PERIODS OF FŒTAL LIFE AT WHICH PERITONITIS OCCURS.
Velpeau, in his elaborate treatise on Midwifery, without speci-
fying any particular diseased appearances, remarks in general terms,
that he "had seen incontestible morbid alterations in the lungs,
liver, peritoneum, and other parts of the body, at the third month."
I have certainly, in several different specimens, observed unequivocal
evidence of inflammation and morbid adhesions between different
points of the cutaneous surface of the embryo, at a period as early
as, or even earlier than, that mentioned by Velpeau; and although
I have adduced no case of peritonitis at that age, we shall take occa-
sion, in our next communication, to show reasons for our belief, that
we may yet be able to trace many of the malformations of the
abdominal and pelvic viscera, as well as those of different other
parts of the body, to different diseased actions, but particularly to
inflammation occurring in some of their structures during the earlier
stages of their embryonic development and growth.
In some of the instances of foetal peritonitis brought together
in the present paper, the particular age of the foetus is not noted.
Of the remaining cases, the earliest are two (IX. and XXIII.), in
which the foetus was considered about four months old, or between
that and the fifth. In two instances (II., VII.), the child was
believed to be between the sixth and seventh month; in three
(III., VI., XIV.), about the seventh month; and in others again,
near to (V., XVIII.), or apparently at, the full time (I., V., VIII.,
XI., XIII.) Most of the children who were affected, but still alive
at the period of birth (as in Cases X., XI., XVI., XVII., XXIV.),
may also be presumed to have nearly, if not fully, reached the com-
plete term of utero-gestation, before the supervention of the disease.
EFFECTS OF PERITONITIS UPON THE LIFE OF THE FETUS.
If I might be allowed to draw any general conclusion from the
comparatively limited opportunities which I have as yet enjoyed of
investigating the diseases of the foetus, I should certainly feel in-
clined to regard peritonitis as much more frequently fatal to the
foetus during the latter months of pregnancy than any other
individual acute disease to which its economy is liable. I had occa-
sion to see nine of the cases which I have related, in dispensary and
hospital practice, within a period of twenty-three months. During
the same period I have met with other inflammatory diseases in the
¹ Traité Complet de l'Art des Accouchemens, tom. i. p. 392.
124
DISEASES OF THE FETUS.
fœtus, but certainly with no single one in so many individual
instances. According to the observations also of Professor Chaussier
and Madame Boivin, peritonitis would seem to have been not
unfrequently met with by them in their dissections of the still-born
children at the Hospice de la Maternité at Paris.¹
In a considerable number of the cases which have been narrated
in the preceding pages, the peritonitis seems to have been so acute
and severe as to prove fatal to the fœtus before birth.
In eight of the cases (I., II., III., V., VI., VII., VIII., IX.), the
children had evidently been dead for some considerable time before
their expulsion from the uterus, as shown by the decomposing state
of their bodies. In one (XIII.), the infant, though dead-born, was
thought to be alive up to the commencement of parturition. In the
first three cases of chronic peritonitis, the children were born alive,
and survived to periods varying from eighteen (Case XIX.) and
twenty-four hours (XX.), to two days (XXI.) after birth. In several
of the acute cases also, the child was born affected with the disease,
and did not die till three hours (X., XIV.), nearly a day (XII.), or
even longer (XI.), after the time of birth. In one example, indeed,
recorded by Professor Desormeaux, a child born with all the most
marked symptoms of congenital peritonitis rallied completely after
birth, and survived. The following are the interesting details of
the case as given by Desormeaux himself.
CASE XXIV.-"I had under my care," he remarks, "some years ago, an
infant whose mother's health had been excellent during the whole period of preg-
nancy. The infant at birth was extremely emaciated; the surface of its body was
of a yellowish-white colour; and it had an expression of suffering, and, as it were,
of old age, strongly imprinted on its countenance. Further, the little patient
had the abdomen swelled, hard, and tender; the intestinal convolutions could
be traced under the integuments; and all announced an intense and already
chronic enteritis. The infant was intrusted to a good nurse; and, notwithstand-
ing its feebleness, it was able first to receive some drops of milk, and after a
time to suck. It has since become," M. Desormeaux adds, "a very fine child,
and enjoys good health.” 2
From peritonitis forming so often a direct cause of death to
the fœtus, its study, as that of other fatal forms of intra-uterine
disease, becomes a matter of interesting inquiry to the practical
1 "Nous avons rencontré, avec M. le Professeur Chaussier, que nous avons
longtemps accompagné dans ses recherches sur les maladies du fœtus, un certain
nombre de cas de péritonite, avec ou sans épanchemens, et toujours accompagnés
d'adherences plus ou moins multipliées des intestins."—Mad. Boivin, Recherches
sur une des Causes de l'Avortement, p. 56. See also a note by Chaussier at pp.
34-35 of his Mémoire sur la Viabilite de l'Enfant Naissant, Paris, 1826.
2 Dictionnaire de Médecine, Art. Œuf, tom. xv. p. 403.
CONGENITAL GOITRE.
125
accoucheur, as bearing strongly upon the important question of
the various causes by which abortion and premature labour may
be induced. And certainly the attention which has of late years.
been bestowed upon intra-uterine pathology has been useful in
eliciting a higher degree of information on that subject; for the
more our knowledge of the diseases of the foetal economy has in-
creased, the more have accoucheurs become convinced of the truth
and practical importance of the fact, that the causes of abortion,
and of the death of the fœtus during the different periods of preg-
nancy, are, in many instances, not to be sought for in any diseased
condition of the general system of the mother, or in any morbid
state of her reproductive organs, but in diseased actions originating
in, and more or less strictly confined to, the foetal appendages, or to
the organs or tissues of the body of the foetus itself. Besides, I
feel much inclined to believe, that to these foetal diseases, and more
particularly to certain degrees of inflammation, and to the results
or products of that morbid action in different parts of the body of
the foetus, when it happens to be of a local and limited, and con-
sequently not of a fatal character, we may yet be able to trace the
origin of various morbid states, the true nature of which is at
present little suspected.
ON INTRA-UTERINE GOITRE, OR BRONCHOCELE.¹
Various kinds of tumour in the cervical region of the fœtus
have been found at the time of birth.
1. The cervical portion of the vertebral column is sometimes,
though not so often as the loins or back, the seat of spina bifida ;
and the resulting tumour has been seen to vary in size from the
bulk of a nut to that of the infant's head.
2. Meckel, Otto, and other pathologists, have described a
variety of congenital cystic tumour of the cellular tissue, situated
on the posterior part of the neck, and remarkable for a central
pillared division, into two lateral and symmetrical lobes, by the
ligamentum nucha. I have seen it mistaken for a spina bifida.
3. Numerous instances of intra-uterine tumours in the anterior
and lateral portions of the cervical region have been recorded of
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, February 7,
1855, in Edinburgh Monthly Journal of Medical Science, April 1855, pp. 350 and
351.
126
DISEASES OF THE FŒTUS.
late years by Berndt, Cæsar Hawkins, Beatty, Mütter, and others,
under the name of cysts, or "congenital hydrocele" of the neck.
These tumours, which sometimes grow much after birth, usually
consist of one, two, or more large serous cysts, capable of being
emptied and obliterated by puncture and the injection of iodine;
by setons, etc. Sometimes an agglomeration of small cysts enters
also into their composition.
4. A kind of large cystic tumour, the mass of which consists of
a numerous collection of small cells filled with thickish glairy
fluid, is occasionally observed at birth in the upper part of the
neck, and projects more or less into the mouth. It seems to be a
true Ranula, originating and consisting of hypertrophy and enlarge-
ment of the follicles of the salivary glands. I have seen two in-
stances of it where the children died a few days after birth, the
puncturing of one or two cells being of no use in diminishing the
mass. There is a specimen of it in the Obstetric Museum of the
University, forming a large tumour at birth. This form of apparent
cystiform tumour has, I believe, been frequently confounded with
the third variety alluded to above.
5. Among the tumours on the neck at birth, I have seen one
remarkable instance of a large flattish swelling on the posterior
cervical region, covered with skin of the usual colour and appear-
ance, and formed of a deep-seated erectile vascular tissue, which in
a great measure disappeared under pressure, and enlarged when the
child cried or strained. I treated it by various means, none of
which produced complete obliteration. Some years afterwards I
heard that it was cut into by a surgeon, and the resulting hæmor-
rhage was most excessive.
6. Few cases of congenital enlargement of the thyroid gland,
or of true intra-uterine goitre or bronchocele, have been hitherto
placed upon record. The following cases, however, will show that
goitre constitutes one form of cervical tumour, which may be occa-
sionally met with at birth. Bronchocele is sometimes hereditary,
but very few instances of it have been seen at birth in infants thus
predisposed. Usually there is no trace of it till some years subse-
quently. The following is the only exception to this general
remark which I have been able to find:-
CASE I. In an essay on goitre, published in 1824, M. Ferrus refers to a con-
genital instance of the disease, which had occurred in the practice of M. Godelle,
CONGENITAL GOITRE.
127
physician to the Hospital of Soissons, and where the mother was affected with the
same disease.¹ The child only survived for a few hours after birth.2
Lately I met with a marked instance of intra-uterine goitre in my own practice,
and had an opportunity of ascertaining its true nature by dissection.
CASE II.-The mother of the child never suffered from any symptoms of goitre,
or lived in any place where the disease was endemic. She has now borne ten
children. The first seven of these infants were still-born. They all died, I
believe, from the reports given to me, of disease of the placenta, and not from
any malady or malformation in their own bodies. During her last four pregnan-
cies she has been under my professional care, and has taken always, in the latter
periods of utero-gestation, large and continuous doses of chlorate of potass. The
four last children were born alive, and have continued to live, with the exception
of the last, namely, the one born with goitre. It survived only for about eight
hours after birth, and would have died much earlier from asphyxia, if a catheter
had not been retained in the trachea to obviate the compression of the mass of
bronchocele. The child was born two
b
or three weeks before the full term,
labour having been induced in con-
sequence of the child's heart begin-
ning to beat with morbid slowness.
The goitrous enlargement of the
thyroid gland was nearly of the
size of a hen's egg. It rendered
the labour tedious, by preventing
-as the hands or arms placed in
the hollow of the neck sometimes
do-the proper flexion of the head,
and the approach of the chin to
the sternum; the presentation in
consequence being one of the fore-
head, and not of the parietal bone.
The goitre, or bronchocele, as seen
after birth, appeared to fill up entirely the space or hollow between the chin
and sternum. On examination after death, it was found to surround almost
entirely and compress the trachea. All parts of the thyroid gland were equally
affected. The goitrous tumour was comparatively smooth on its surface, but had

d
1 Dictionnaire de Médecine, vol. x. p. 283.
Fig. 1.
a
A
2 In the Archives Générales de Médecine, vol. xiii. p. 76, Dr. Cassan speaks of
a remarkable case of hereditary goitre, where a young infant in the family died of
it; but whether it was congenital or not in this child is not precisely stated.
woman, aged 23 years, married, affected with pulmonary consumption in the
second stage, presented to us an example of the obstinate hereditary predisposition
of pulmonary phthisis and of goitre; her young infant (jeune enfant), her father,
and seven brothers of her father, had died of the former disease; one of her
paternal aunts, who showed no disposition to phthisis, carried a very large goitre;
herself (the patient) was affected with goitre, which had considerably diminished
since the first symptoms of phthisis had been developed. All her brothers and
sisters had been victims to that cruel affection; only one sister, who had a goitre
commencing, enjoyed good health at that period. One could say in that family,
that the two affections were in such relation, that the one appeared reciprocally
to supplant the other."
128
DISEASES OF THE FŒTUS.
a small irregular nodule attached anteriorly to its upper border, close to the body
of the hyoid bone. In the accompanying woodcut (Fig. 1), a represents the
hyoid bone, b the epiglottis, c the trachea, and d d the right and left sides of
the goitre respectively.
Internally, it presented a firm glanduloid structure; and under the micro-
scope it appeared to consist of the usual thyroid tissues, greatly hypertrophied.
The vesicular cavities of the gland seemed not only increased in number, but
enlarged in size also, and the septa between them were thickened. They were
distended with epithelial contents. The external surface of the brain of the child
was surrounded with a large quantity of serum, and the brain itself was consider-
ably below the usual size. The opening of the eyelids was also small.
thymus gland, supra-renal capsules, etc., were normal in size and structure; and
there was no other unusual appearance detected.
The
In his essay on the pathological anatomy of new-born infants,¹ Dr. F. Webcr
describes an example of congenital goitre, similar in several respects to the pre-
ceding instances.
CASE III.—A child was born some weeks before the ninth month, and it sur-
vived only a few minutes. The goitrous thyroid gland projected forward in the
cervical region, was about half-an-inch thick, and extended not only laterally, but
also backwards, some distance over the upper part of the trachea, though not to
such a degree that a union of both lateral lobes had occurred posteriorly. On
being cut into, the parenchyma of the bronchocele appeared dark red, and the
microscope showed within it a quantity of effused blood-globules, which were not
evident to the naked eye. In other respects, the parenchyma of the tumour pre-
sented internally the normal structure of the thyroid gland. The thymus gland
appeared also larger than usual, and particularly on one side, but without any
change of structure. There was a considerable degree of hydrocephalus present,
with contraction of the extremities.
CASE IV. When describing the case No. II. to the Medico-Chirurgical
Society, immediately after the time of its occurrence in February 1855, Dr.
Keiller stated that he had, a few months previously, met with an instance of the
same disease, where the child's head at birth offered the same unusual presentation.
I have lately examined the child, who is now about a year old, with Dr. Keiller.
There is still a large irregularly lobulated swelling in the region of the thyroid
gland, and stretching somewhat upwards on each side of the trachea. It projects
forwards, and appears to swell out when the child cries. At other times, the skin
of the neck looks flaccid, wrinkled, and empty, over the site of the tumour, in
consequence of the tumour itself having diminished and shrunk considerably since
the time of birth. The lobulated masses of the tumour feel firm and hard to
touch; and probably the intervening and connecting tissue, in which the absorp-
tion has been specially marked, was originally more cystic in its character. The
tumour does not seem to affect in any way the general health and growth of the
child. The mother was born and brought up in the county of Cumberland, where
goitre is not uncommon; but neither she nor any of her relatives were ever in the
least degree affected by it. The present goitrous infant is the first child which she
has borne. Before pregnancy occurred, she was under my care for chronic
metritis; but her general health is good.
An instance of congenital cervical tumour, under the title "Scrofula in Fœtu,'
was long ago described by Francus, 2 with characters and a site which have made
¹ Beiträge zur Path. Anatomie der Neugebornen, p. 84.
2 Ephemer. Nat. Cur. Dec. ii. An. v. Obs. 223.
RUDIMENTARY REPRODUCTION OF PARTS.
129
Graetzer and Montgomery refer it to the head of goitre. In this, as in Dr. Keiller's
case, the certainty of the tumour consisting of enlargement of the thyroid gland
was not made out by dissection.
CASE V.—The child—a boy-presented at birth a tumour on both sides of the
neck, but it was largest on the left. When the infant cried, or moved its neck
too freely, that on the left side swelled excessively, and appeared to interfere with
the power of suction and deglutition. Francus adds, that he unsuccessfully tried
to effect the removal of the swelling by various remedies, local and general, and
that notwithstanding it increased daily in size.
ON THE
RUDIMENTARY REPRODUCTION OF EXTREMITIES
AFTER THEIR SPONTANEOUS AMPUTATION.¹
On the stumps of limbs that have seemingly undergone an early
spontaneous amputation in utero, there is often seen a species of
anormal structure, which has not yet, as far as I am aware, been
described in any existing work on the subject of monstrosities. I
allude to the appearance on the end of many such stumps of a pro-
jecting mass or nodule, varying in size from a small cutaneous ridge
to the bulk of a walnut, and having protruding from its surface one,
two, or more still smaller fleshy divisions or projections, which are
provided at their extreme points with nails.
This variety of anormal structure is by no means rare. Several
years ago, when searching for instances of it, I found five or six
living examples in Edinburgh and its neighbourhood; and I have
seen some, and heard of many more, living in different parts of
Scotland and England. It is interesting, however, not so much from
the frequency with which it is met with, as from the nature of the
anormal structure itself, consisting, as I believe it does, of a tendency
in the human subject to the reproduction of a lost extremity.
As a general law, the power of repairing and reproducing lost.
parts decreases as we ascend from the lower to the higher parts of
the animal scale. In the lowest and simplest forms of animal life,
as in polypes, not only are separated parts or segments rapidly
restored, but the separated segments themselves sometimes become
developed into whole and perfect individuals. A hydra was cut at
different times into various portions by Trembley, and fifty separate
individuals of the species were developed from the segments of one.
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, May 5, 1841,
and of Edinburgh Obstetric Society, March 12, 1848, in Edinburgh Monthly Jour-
nal of Medical Science, July 1841, p. 537, and June 1848, p. 890.
i
130
DISEASES OF THE FŒŒTUS.
""
Johnstone and Dugès have shown that animals with a much higher
organisation —namely, the planariæ-could in the same way be
multiplied by artificial subdivision; and Lyonnet and Bonnet found
the same true of the Nais. As we ascend upwards in the scale of
life, all power of self-development in separated parts or segments
disappears, but the power of regenerating these lost parts or seg-
ments is retained to a greater or less degree by the general body of
the animal. When the arms or rays of a star-fish are broken off
artificially, or when they are thrown off, as they sometimes are, in
the lingthorn or lluidia, etc., by a true "spontaneous amputation
on the part of the animal, the lost arms are betimes entirely re-
stored. In crustacea a separated or amputated limb is also rapidly
renovated. The head or anterior rings of the earth-worm and other
annelida are generally regenerated after their decapitation; and the
power of reproduction is still so great in the mollusca, that the snail,
according to Schweigger, has sometimes its head and antennæ restored
after they are removed by amputation, provided the cephalic ganglion
lying above the oesophagus be left uninjured. In the lower divisions
of the vertebrata we have the salamander still capable of reproducing
an entire leg or tail, or even of forming a new under jaw; and the
triton can regenerate, as in Blumenbach's experiments, a complete
and perfect eye.
But in the higher and warm-blooded vertebrata
this power of repairing and restoring lost compound parts and organs
seems totally or almost totally wanting. In man not only are com-
plex individual parts, however small, generally held incapable of
restoration, but portions of the higher individual tissues even, as
mucous membrane, muscle, etc., when cut, removed, or destroyed,
are not usually regenerated in their entire organisation. To this
general law, however, there are the following exceptions in the
human subject:-
1st. When the part removed is primitively of a lower type of
organisation than that of the general body, restoration sometimes
occurs. Thus, in a case of a child born with an additional thumb,
or with a thumb double from the first joint, the outer or smaller
one was amputated by Mr. White of Manchester. It grew again,
and along with it the nail. Subsequently Mr. Bromfield of London
a second time carefully removed this superadded portion of thumb,
and turned the ball of it fairly out of the socket. "Notwith-
standing this," adds Mr. White, "it grew again, and a fresh nail
was formed."
Regeneration of Animal and Vegetable Substances, p. 16.
RUDIMENTARY REPRODUCTION OF PARTS.
131
2d. In those animals that possess, in the most marked degree,
the power of readily regenerating lost compound parts, this power
resides specially in the extreme points of the body, as the tail and
limbs. In the human subject we sometimes find instances of an
appearance of permanence of the same power in the extreme parts,
as the fingers and toes. I have seen a distinct but imperfect nail
grow on the end of the second phalanx of the finger, after the com-
plete amputation of the first phalanx. Similar instances of nails,
and consequently of the matrices of these nails, becoming regenerated
on the tips of fingers amputated through their first joint, have been
recorded by Corvisart, Ansiaux, Blumenbach, and others.
3dly. When, in the human subject, the removal of a compound
part-such as a portion of an extremity-is effected in early fœtal
life, and consequently at a time when the physiological powers of the
young human being are more assimilated to the reparative and other
powers of animals of a lower type in the animal scale-the lost part
seems capable of at least a partial and rudimentary restoration. In
the animal kingdom generally, we find the power of regeneration
greater in the inverse ratio of the degree of development or age of
the individual. The more perfect hexapod insects never reproduce a
lost limb; but in the larvæ of these same insects, limbs and antennæ
are restored after their removal. The experiments of Heineken show
that the arachnida, in the same way, lose the property of regenerating
their legs after they have ceased to change their skin, and have
reached their full or adult development. It is only in the young
frog that reproduction of a limb occurs; and Spallanzani found that
the rapidity with which the tail of the tadpole and the limbs of the
salamander are regenerated, was always in an inverse ratio to the
age of the animal. So, while in the human subject after birth we
never see any trace of the reproduction of a limb after amputation,
we have the contrary, as I believe, evidence of the possibility of
their rudimentary regeneration in the appearances sometimes seen
on the ends of stumps resulting from spontaneous amputation in
early foetal or embryonic life.
In most of the cases in which I have observed this appearance
of a rudimentary reparation of an extremity, the spontaneous
amputation had occurred in the upper half of the forearm; and the
general resemblance of these cases to each other is very remarkable.
Usually the rounded end of the limb has exactly the appearance of
a stump after amputation, and is well covered with soft parts.
Two points of the skin, or rather of the subcutaneous tissue, are
10
132
DISEASES OF THE FETUS.
found adherent to the ends of the ulna and radius, and present a
depressed or umbilicated form, particularly when the forearm is
flexed and moved, and the fissures of the skin run in converging
lines to these two points
as centres. Midway,
and a little in front of
these two points, the
rudiment of the re-
generated extremity is
situated in the form of
a raised cutaneous fold
or fleshy mass or tu-
bercle, and having on
its surface one, two, or
more smaller projec-

Fig. 2.
In the instance given
tions or nodules, furnished with minute nails.
for illustration in the accompanying woodcut (Fig. 2) from a young
woman of eighteen years of age, four such imperfect fingers are
seen, two of them tipped with nails. In this, as in most other
cases, the left arm is the seat of the mutilation, but I have seen the
right similarly affected.
The woodcut (Fig. 3) represents the stump of the left forearm
of a foetus of the seventh

month, preserved in the Ob-
stetric Museum of the Univer-
sity of Edinburgh. There are
five small rudimentary fingers
tipped with minute nails in
the usual position on the end
of the stump. But the case
is principally remarkable for
the circumstance, that the ci-
catrisation over the ends of
the ulna and radius is not
Fig. 3.
complete. There is an aperture at the end of the radius, through
which the end of the bone can be felt when the point of a pin is
passed through it. The ulna projects to the cutaneous surface
of the stump, and has a small wound or circle of uncovered granu-
lations still around it; or, in other words, the cicatrix of the stump
is as yet incomplete, exactly as in Schaeffer's case already figured.
¹ See Dublin Journal of Medical Science, November 1836, Plate facing p. 221.
CONTRACTIONS IN THE UMBILICAL VESSELS.
133
VITAL CONTRACTIONS IN THE UMBILICAL ARTERIES
AND VEINS.¹
It is well known that, up to a late period, some, physiologists
doubted entirely whether the larger arteries of the human body
could be made to contract at individual points by stimulants applied
at those points. Few or no satisfactory experiments have yet been
published, showing that the veins possess the property of contract-
ing locally under local stimuli. But in the umbilical cord the
medical practitioner may have daily an opportunity of repeating the
following observations and experiments, which prove both of these
important physiological facts-viz. the local contraction both of the
tubes of arteries and of the tubes of veins, under local stimuli
applied to them :-
First. After the child is born, the cord, whether tied or not, is
generally sure to become contracted at different points, in conse-
quence of the local contraction at those points of the vessels in-
cluded within it. In fact, its vessels are thrown, by the irritation
of the external atmosphere, and in consequence of their partially
empty condition, into tubes consisting of a series of dilatations and
contractions, like the peristaltic contractions of the intestines; but
with this difference, that the contractions of the vessels are per-
manent.
Secondly. By pinching a portion of the cord, immediately after
the birth of the child, between the nails of the thumb and finger,
contractions of the vessels of the cord will be seen to occur at the
point irritated. And if this mechanical irritation is confined to in-
dividual vessels, as to one of the arteries or to the vein, the effect is
equally marked.
Thirdly. If the sheath of the cord be slit up by a pair of
scissors or knife, with any of its vessels or arteries exposed, the
same experiment may be repeated upon the exposed individual
vessels with similar effect-viz. that the mechanical pinching of
them will be followed in the course of a short time by a gradual,
but very marked, contraction in the irritated part.
Fourthly. Similar local contractions of these vessels occur under
the local application to them of irritating chemical substances, or of
electricity.
1 See Proceedings of Edinburgh Obstetrical Society, March 26, 1851, in
Edinburgh Monthly Journal of Medical Science, May 1851, p. 494.
134
DISEASES OF THE PLACENTA.
Fifthly. These contractions do not instantly follow the applica-
tion of the stimulant, but a short time intervenes before the effect
is seen, and the contraction is permanent.
Sixthly. When the experiment is made upon the human umbili-
cal cord, or upon that of the lower animals, where the circulation is
still going on in the vessels of the cord, the irritated vessel will
sometimes almost entirely close its tube under such local irritation.
Seventhly. These simple experiments, illustrative of the con-
tractility and irritability of the coats of the veins and arteries, are
the more remarkable as seen in the umbilical veins and arteries, in
consequence of anatomists not being able to detect any nerves in
the umbilical cord; although probably elementary nervous tissue
may exist in some form in it. For, if it did not exist, then we
should have irritability in these vessels existing without nervous
influence. The investigation of the existence of veins in any form
in the umbilical cord and its vessels thus becomes an interesting
microscopical study, in reference to the physiological question of
the dependence or independence of the contractility of vessels on
the presence of nerves.
PLACENTAL PHTHISIS OR APNŒA,
AS AN INTRA-UTERINE CAUSE OF DEATH AMONG PREMATURE
CHILDREN-ITS VARIETIES AND TREATMENT.
1
Formerly physicians used the word phthisis as a generic term to
signify consumption and organic destruction of various kinds; and
the viscus which was the immediate seat of decay and death was
added to express the nosological seat and species of the malady.
Hence arose the terms phthisis pulmonalis, phthisis mesenterica,
phthisis hepatica, etc. The infant in utero is liable to perish—1,
in consequence of various diseased states of its own body, as peri-
tonitis, dropsy, etc.; and 2, in consequence of different morbid con-
ditions of the placenta. Under the designation of placental phthisis,
I shall attempt to point out to you, very briefly, the principal
diseased states of the placenta that are apt to lead to the intra-
uterine death of the child, and at the same time I will try to state
their proper principles of treatment.
Let me premise two observations on this subject. First, That
1 Part of a Clinical Lecture. See London and Edinburgh Monthly Journal
of Medical Science, February 1845, p. 119.
PLACENTAL PHTHISIS OR APNŒA.
135
in consonance with a very curious and interesting general law in
intra-uterine pathology, some of the morbid conditions of the
placenta and foetus are liable to recur in successive pregnancies
in the same woman; and, secondly, In actual practice you will find
few cases accompanied with greater individual distress and greater
family unhappiness, than those in which there is borne by the same
mother, two, three, or more premature children, dying regularly in
utero, as the seventh or eighth month of utero-gestation recurs.
Occasionally this distressing recurrence of foetal deaths is the
result of disease or malformation in the fœtus itself, and is in a
great measure irremediable. Much more frequently, however, such
a succession of deaths among premature children is the consequence
of placental disease or placental phthisis; and is amenable to proper
principles of treatment.
The principal pathological states of the placenta that are liable.
to produce the successive deaths of a series of premature children in
the same mother are the following:
I. Congestion and Extravasations of Blood into the Structure of the
Placenta. In practice it will, I believe, be found that placental
hemorrhages or " apoplexies,"-as they have been sometimes termed
-forming in the substance, or on the surfaces of the placenta,
masses or collections of extravasated blood in various states of
change, are lesions much more frequently connected with abortions
than with premature labours. They are found connected with the
death of the fœtus more often in the earlier than in the later
months of utero-gestation. Sometimes, however, they form, and
repeatedly in the same mother, the cause of death of the infant
from the seventh to the ninth month. a succession of limited
hemorrhagic extravasations taking place, till at last the placenta is
so extensively diseased and destroyed as to be unable to maintain
any longer the life of the child. In such instances I have usually
found the placental structure softened and broken up, within and
around the more recent and extensive extravasations.
II. Inflammation of the Placenta and its various consequences-
Hepatisation, Induration, Abscess, etc.,-constitute a second cause of
intra-uterine death among premature children. In this morbid
affection, the inflammatory action is generally confined to a limited
portion of the organ, or to a few lobules, whilst the other parts of
the organ are left sound and free. In some cases, however, we find
it invading the whole surface of the placenta-an observation which
136
DISEASES OF THE PLACENTA.
you will see confirmed by the state of the organ in many cases such
as this, which I now show you, where there has been born a
secondary fœtus, along with one at the full time-the secondary
foetus, as it is called, being merely a foetus which had been destroyed
as early as probably the fourth or fifth month, by the morbid altera-
tion which had occurred in the structure of the placenta, or portion
of the placenta, belonging to it. In inflammatory induration, the
morbid deposit and change seems generally to stretch, as shown in
this preparation of Mr. Goodsir's, from the maternal surface of the
placenta towards the foetal. The decidual membrane covering the
exterior surface of the placenta is occasionally, as here, much
thickened by the inflammatory deposit.
•
III. Gangrene of portions of the placenta sometimes, though
rarely, produces the recurrent intra-uterine death of the child in the
latter months. I have seen several examples of this variety of
placental disease. One of the most remarkable was a case which I
visited repeatedly some time ago in consultation with Dr. Gibson of
Dundee, and where the foetal heart, as heard by the stethoscope,
became irregular and occasionally intermittent for a short time be-
fore the birth of the child-an effect which we attributed to the
placental disease, as it entirely disappeared when the child assumed
an extra-uterine existence. In placental gangrene, the affected parts
give forth no gangrenous odour in consequence of the external air
not having reached them; but you will find the disease marked,
like Laennec's circumscribed gangrene of the lung, by here and there
a dark and mortified portion of placental tissue being enclosed in a
limited deliquescent mass of bloody and pasty matter. The placen-
tal surface at the site of the gangrenous slough is usually depressed
and umbilicated in the centre. Generally, the included sloughing
foetal tuft retains its adhesion to the chorial surface of the placenta,
and very exactly represents the mortified branch of pulmonary tissue
often seen attached by its arterial structure to the interior of cir-
cumscribed gangrenous cavities in the lungs. The placental tissue
around the circumscribed gangrenes is usually inflamed; very often,
also, it is the site of hemorrhagic extravasation. Perhaps, indeed, the
gangrene most frequently originates in the compression and death of
placental tufts included in apoplectic extravasations, or isolated and
obstructed by local inflammatory action.
IV. General Edema or dropsy of the structure of the placenta
occasionally destroys the infant in the latter months of utero-gesta-
PLACENTAL PHTHISIS OR APNEA.
137
tion, and is marked by a white, swollen, and serous condition of the
organ, without any other appreciable change in its tissues. Some-
times it co-exists, but by no means always, with dropsy and anasarca
in the fœtus, and in the whole umbilical cord. I have seen it con-
joined, probably as an effect, with inflammatory obstruction in the
umbilical vessels, and limited dropsy of the cord. Usually it is
diffused throughout the whole placenta, and by interfering with its
intra-uterine functions, destroys at last, and sometimes very speedily,
the life of the child. It must not be confounded with the white,
blanched, and merely anæmic state of the placenta, often observable
in cases where the child has died of peritonitis or other fœtal dis-
eases, and been retained in utero for some time subsequently; and
it is pathologically very different also from the morbid state which
I have next to mention, and which can only be fully made out by
microscopic examination, viz.-
V. Stearoid or Fatty Degeneration of the Placenta.—In the last
century, Hoboken and Haller mentioned the frequency of appear-
ances of fatty matter in the placenta. During the present century,
several continental pathologists, as Stein, D'Outrepont, Wilde,
Charante, and Brehm, have described cases of fatty degeneration of
the placenta; but the importance and frequency of this peculiar
change was not recognised till the fatty degeneration of other organs
came latterly to be studied by the microscope; and it was first
brought under the special attention of the profession in this country
by Dr. Barnes of London, in two able papers published in the 34th
and 36th volumes of the Medico-Chirurgical Transactions. It is a
morbid condition found connected with the death of the foetus, both
in the earlier and later months of utero-gestation. Its exact patho-
logical nature, however, has not been accurately determined under
all the conditions in which it is found to occur. Dr. Barnes seems
to regard this fatty degeneration as, most commonly, a primary mor-
bid state in the placental tissues, or rather in the molecular walls of
the fœtal tufts, etc., unpreceded by any other morbid change; and
some of its varieties are, there is little doubt, of this character,
particularly where the fatty metamorphosis is general and unaccom-
panied by any other morbid states. But several years ago, and
before the appearance of Dr. Barnes' essay, my friend and colleague,
Dr. Bennett, carefully examined some specimens of both general and
partial fatty degeneration of the placenta with which I furnished
him; and in most of these the co-existence of coagulable lymph,
138
DISEASES OF THE PLACENTA.
indurations, etc., showed that the fatty molecules were either
thrown out as inflammatory exudations, or were formed by in-
flammatory exudations subsequently degenerating into fat particles,
and which in other respects indicated the pre-existence of some
degree of placental inflammation. Virchow and Dr. Handfield
Jones have each noticed this mode of its production, and Dr.
Priestley, who has of late very carefully examined this question in
numbers of cases, believes that the so-called fatty degeneration is
perhaps most frequently a change connected with a low form of
placentitis. In a paper which I published in 1836, on placental
inflammation and congestion, I described the chronic inflammatory
induration of the placenta as not unfrequently exhibiting "a some-
what stearoid, lardaceous, or fatty-looking structure;" and I sug-
gested also that the white masses like fat and cartilage seen in the
placenta by Stein might originate in effused coagula of blood; and
I believe that in some cases we have localised fatty deposits in the
placenta, resulting from degeneration of the blood thrown out in
placental congestion and hemorrhage. Sometimes, further, when
the child dies from disease in its own body, and is retained for
some time in utero, the placental structure presents an appearance of
fatty degeneration, as an effect and not as a cause of the foetal death.
In reference to this morbid change, it is necessary to recollect that
the placental structure may appear yellowish-white and fatty in
whole or in parts, without there being any true fat globules in it;
and to distinguish it accurately, we need the assistance of the
microscope.
VI. Hypertrophy of the Placenta sometimes leads prematurely to
the death of the child in successive pregnancies. When the placenta
presents this condition, the organ is greatly enlarged; the divisions
between its lobules and maternal surface are very marked and very
deep; and the edge of the placenta seems as it were alınost to turn
to a certain degree over the boundary or circumference of the fœtal
surface. One of the preparations on the table is a specimen of this
diseased condition, and the patient from whom it was taken had
produced six or seven dead-born premature children. Mr. Goodsir
has directed his attention particularly to this effect of hypertrophied.
placenta, and similar observations have been made by some con-
tinental accoucheurs. It is difficult to say how the hypertrophy of
the placenta destroys the functions of the organ; for in the specimen
before you, as in other similar cases, there is no special lesion in the
PLACENTAL PHTHISIS OR APNEA.
139
body of the child itself. Sometimes, however, the child presents
dropsical effusions, such as anasarca and ascites. Probably the
mutual compression and impaction of the different lobules and parts
of the hypertrophied placenta upon each other, are such as to
diminish and destroy its action as a respiratory organ, and to impede
the circulation through its vast collection of vessels, as effectually as
this is produced by the obliteration of these vessels and parts by
hemorrhage, inflammation, oedema, or other direct disease.
VII. Other Morbid Conditions of the Placenta seem sometimes to
lead to a succession of dead premature children in the same mother,
as extensive cartilaginous and calcareous degeneration, morbid ramol-
lissement, atrophy, etc.; but their action is less marked and decided
than those I have already enumerated. Neither these, nor any of
the more truly morbid states of the placenta, are apt, as a general
rule, to affect and destroy the child, unless they have invaded and
obstructed a large portion of the placental structure and vessels.
Indeed, slight and limited degrees of stearoid, cartilaginous, and
calcareous degeneration are to be seen here and there in many
placenta at the full time-more as a sign of the early senility of this
temporary organ than as a mark of disease—the child's health being,
to all appearance, unaffected by them. In the essay I have referred
to, I have spoken of these fatty and ossific degenerations of vessels
as liable, when they occur earlier in placental life, to predispose to
vascular rupture and sanguineous extravasations. Let me only
farther add, that I have never seen any instance in which the
so-called hydatiginous degeneration of the placenta recurred twice.
in the same patient, and thus produced a recurrence of fœtal death;
nor have I met with true strumous tubercle so extensively diffused
in the placenta as to destroy the child.
The Diagnosis of the pathological cause of the death of the
foetus, in one or two successive pregnancies, can only be made out,
with any precision, by having an opportunity of examining the
body of one of the foetuses and its placenta. In doing so, we
may be enabled to observe which of the causes I have mentioned is
the source of the calamity, and to direct our treatment accordingly.
Some years ago, when I was engaged in the investigation of
Peritonitis in the Foetus, I more than once asked myself the ques-
tion, in what good could such an inquiry result? I felt utterly
sceptical as to its being of any benefit, except as satisfying patholo-
gical curiosity. But often when we enter on a subject of pathological
140
DISEASES OF THE PLACENTA.
study, we really know not to what ultimate results it may lead, and
therefore never ought to condemn or eschew any pathological inves-
tigation, because we do not immediately see any practical advantage
to which it may tend. I have latterly become convinced that the
study of peritonitis in the fœtus may be made of no small practical
utility in the following respect:—
In describing peritonitis in the foetus, I have stated, when dis-
cussing the exciting causes of the disease, that in some cases the
mother has been exposed to bodily injury, etc., and after mentioning
other probable morbific circumstances, I have added, that it appeared
to me highly probable, from the investigations I had then made on
this point, that a great proportion of those children of syphilitic
mothers that die in the latter months of pregnancy, may be shown
to have perished under attacks of peritoneal inflammation. Further
observations have led me to conclude that the evidences of perito-
nitis, in several successive children of the same mother, is a pretty
certain test of one or other of the parents, especially the mother,
being tainted with syphilis.
The practical deduction in the way of treatment from this obser-
vation in the way of diagnosis is evident. It is, I believe, in these
cases of successive premature labours, where the child perishes of
peritonitis, and in these cases only, that mercury and other anti-
syphilitic modes of treatment are alone useful, though these modes
of treatment have been supposed to apply to all instances where
there is the unfortunate habit of losing the infant in the last months
of utero-gestation.
TREATMENT ;-ALKALINE SALTS, ETC.;-INDUCTION OF LABOUR.
For the Treatment of the cases in which the child dies in conse-
quence of disease, not in its own structures, but in the economy and
structure of the Placenta, I believe that totally different principles
ought to be pursued; and in a large number of instances now, I
have had the good fortune to see, in my own practice, and in that
of others, these means of treatment followed by the most happy and
successful results.
You may easily understand the principles of treatment on which
I would advise you to proceed in these last affections, if, in the first
instance, you recollect that the two great functions which the
placenta performs in the foetal economy are those-1, of nutrition
and, 2, of respiration; or probably we should properly say, that
•
PLACENTAL PHTHISIS OR APNEA.
141
this
organ
is the medium of these two functions between the mother
and the infant.
When the placenta becomes diseased, it can destroy the infant
-provided there is no morbid lesion in the foetus itself-only by
the imperfect manner in which one or both of these functions is per-
formed. Such children, however, as die in connection with diseased
placenta, do not appear to perish generally from want of nutrition,
because in many instances we find them not more lean and atrophied
than healthy children sometimes are at the time of birth; and on
opening their bodies you have often abundance of deposit of adipose
matter. I believe, for my own part, that they more frequently perish
from the diseased placenta not being able to act sufficiently as a
respiratory medium between them and the mother, especially when
the placental disease and obstruction is, as often happens, extensive
and acute, or subacute; and that the infant in consequence dies from
the morbid condition of the placenta, in the same manner as we
should die if our lungs were densely studded with tubercular
deposits, or extensively destroyed by inflammatory action. They
die from want of respiration rather than want of nutrition-from
placental apnoea rather than from placental marasmus. And when
once these infants are born, and are sustained by their own pul-
monary respiration, they rapidly thrive and grow, proving that there
is in reality no disease in their own bodies.
Now the question is-with such an imperfect placenta-or, in
other words, with such imperfect foetal lungs-what means can we
possibly adopt in order to make this diseased placenta serve as a
sufficient respiratory organ to the infant for a very few weeks
longer? For the question is in general a matter only of one, two,
or more weeks—that is to say, if we could preserve the child's life
during that period from the action of the deleterious influences of
which I speak, we should save the child till it was fit to take on
an extra-uterine existence.
I have usually-in cases in which, from the history of the
previous pregnancies, I knew the tendency to be, as most frequently
it is, to some form of Congestion and Inflammation of the Placenta
-attempted to prevent these morbid actions from going to any
considerable extent, by small venesections, or leechings from time.
to time; particularly at those periods when the woman would have
had her catamenia present, provided she were not in the family
way; because it is, I believe, at these periods that she runs most
danger—there being, during pregnancy, in many females a monthly
142
DISEASES OF THE PLACENTA.
molimen of blood in these parts, though there be no monthly dis-
charge. It is, indeed, at these recurring periods of danger, that
rest in the supine position, and freedom from muscular exertion, is
specially or alone required. But though we may moderate the
hemorrhagic or inflammatory effusions in this way, we can seldom,
I believe, entirely prevent them. Hence, our object is to make the
diseased placenta as efficient as possible as a respiratory organ; or
rather to make the respiratory change in the remaining healthy
part as active and intense as possible.
To understand how this may be done, consider for a moment
how the fœtus does respire or breathe. Its type of respiration
resembles, as I have described it to you at other times, that of
fishes. The blood of the fish is sent into the vessels of the gills
in order to undergo the respiratory change which is there effected
through the oxygen contained in the surrounding water.
blood of the foetus is sent into the tufts or terminal branches of
the foetal placenta—its gills, in other words-in order to be there
exposed to the oxygen contained in the maternal blood, by which
these tufts are washed in the cavernous structure of the placenta.
The
The respiration of the human foetus is like that of a fish, then,
with this difference, that the blood in the gills of the fish is arterial-
ised by the water in which these gills are freely immersed, whilst
the blood in the placental tufts of the foetus is arterialised by the
maternal blood in which these tufts are freely immersed. We can
influence the vitality of the fish by the quantity of oxygen in the
water applied to its gills. I believe we may do the same with the
foetus, by changing the oxygenating power of the maternal blood
applied to its tufts.
Then comes the question, By what measures could we render
the maternal blood as highly an oxygenating medium as possible,
in order that, when it is applied to the foetal placental tufts, it may
make up, by the quality or intensity of the respiratory change
which is there produces, for that loss of quantity which is a neces-
sary consequence of a portion of these placental tufts being already
destroyed by disease?
I have attempted to do this, and in a great number of cases,
apparently with perfect success, by keeping the patients constantly
on small doses of alkaline salts, such as chlorate of potass, nitrate
of potass, bicarbonate of soda, etc., given several times a day, on
an empty stomach, exactly as Dr. Stevens, some years ago, proposed
to do for the restoration and arterialisation of the un-arterialised
:
PLACENTAL PHTHISIS OR APNOEA.
143
blood in fever patients. I have most frequently employed chlorate
of potass in doses of from ten to thirty grains, taken repeatedly dur-
ing the day, in solution, and upon an empty stomach. Out of
every eight atoms of this salt, as many as six atoms consist of
oxygen.
You are aware that the addition of alkaline salts to the blood
in this way appears to promote greatly, I had almost said to im-
part, arterial changes and properties, and that in a way which phy-
siologists and chemists have not yet been able satisfactorily to
explain. If you cover a coagulum of newly drawn venous blood
with a thin layer of water, the surface of the blood continues to
retain its black colour. If you add alkaline salts to the interven-
ing layer of water, the air will very speedily act through this
medium so as to render the clot of a red arterial colour.
aquatic respiration, the animal in breathing does not decompose
the water, it merely subtracts the oxygen present in it.
The same
fact, in all probability, holds good in sanguineous respiration-if
we may use such a term; and hence the importance of supplying,
in the cases we speak of, the maternal blood with a sufficient amount
of oxygen.
In
Patients have repeatedly averred to me, that the use of the salts
I have spoken of has a perceptible influence on the strength of the
motions of the foetus-or, in other words, on its muscular power and
vigour for the time being; but the observation is liable to so many
fallacies on the part of the parent, that, probably, we should not
build much upon it. But if these salts act in the manner which I
suppose, on the maternal blood, the fœtus, under their use, is placed
in a better and purer atmosphere, to use language applied to extra-
uterine life; and in this better atmosphere is capable of living on-
wards for a few weeks longer than it otherwise would have done. I
think it might be a matter of some chemical importance to inquire,
what special salts would probably be of most use in rendering the
mother's blood as highly an arterialising medium as possible, and if
the use of iron in any form would increase its power in this or other
respects. Further, would the use of chalybeates or other means ever
so invigorate the child as to prevent those placental diseases-such
as fatty degeneration-which may possibly be connected with want
of power in the fœtal economy and circulation? Could any variety
of diet or drug render the maternal blood a more nutritious medium
for the child, where the placental disease tended to produce intra-
uterine death by marasmus or inanition? The subject is quite open
144
DISEASES OF THE PLACENTA.
for inquiry, and one in regard to which I know not any very ac-
curate existing data.
In all the series of cases which I have adverted to-that is to
say, in cases where children of the same mother have died successively
from the effects of different diseased states of the placenta—I believe
that the induction of premature labour about the seventh or eighth
month ought to be a principle of treatment prominently held in
view, and frequently had recourse to. This remark especially holds
good with regard to all cases and causes of recurrent placental disease ;
and I think that obstetric authors must add, what no one of them,
so far as I know, mentions, the diseased states of the placenta to
which I have alluded, as indications for the induction of premature
labour, both when they have recurred several times in the same
mother, and produced death of the child but a few days or weeks
previous to its birth, or even in a first pregnancy,
when very
distinct
symptoms of placental hemorrhage and inflammation have occurred
after exposure to injury, and, in addition, the stethoscope shows a
state of impending danger to the life of the child. Out of three
cases of diseased placenta which have been under my care since the
commencement of the present year (1845), in two I induced prema-
ture labour successfully, as regards both mother and child, one of
the patients having previously lost six, and the other three children.
I had thoughts of allowing the third to go on to the full period, but
fortunately, natural premature labour came on about the eighth
month, and a living child was born. The placenta was so destroyed
by inflammatory induration in this last case, that I am sure it could
not have served the purpose of a lung to the child for a much longer
period. Nature here pointed out strongly, and effected by her own
efforts, what ought to be done by art in similar instances. Allow
me to add, that the necessity for the immediate induction of pre-
mature labour is sometimes shown in these cases by the supervention
of lowness and depression, more rarely by the occurrence of irregu-
larity and intermittence in the action of the foetal heart as heard by
the stethoscope. Hence, in watching and treating these cases,
auscultation should be constantly used to ascertain the first advent
of this sign of danger to the life of the child.
PLACENTAL HEMORRHAGE.
145
CHLORATE OF POTASS IN PLACENTAL DISEASE.¹
Sir James Simpson said he had used the chlorate of potass in a
great number of cases. Sometimes it failed, but all remedies fail at
times. He had seen it succeed in many cases where rest had not
been combined with it. In one case a lady, who had had a long
succession of abortions, took the chlorate, and had two living child-
ren afterwards. It failed sometimes, he thought, because it was not
given in sufficiently large doses. He usually gave it in ten to twenty
grain doses, thrice daily, and it should not be given up.
He gave
it on account of disease of the placenta, but he believed that it was
also a means of arterialising the blood. It was necessary, however,
to watch the condition of the child, and, if necessary, bring on pre-
mature labour when the fœtus showed symptoms of weakness.
He
was led to use the chlorate in such cases by the experiments of Davy
and Stephens, who pointed out that an alkaline salt, when brought
into contact with blood, gave it an arterial appearance.
At one
time he imagined that its good effects were attributable to the
amount of oxygen which the salt contained. He had been repeatedly
told by patients that the movements of the child were stronger after
each dose. It might be given in an aerated form, by means of the
syphon-bottles now in use. Dr. Williams of London uses the
chlorate in asthma with marked success.
PLACENTAL HEMORRHA GE.
CHANGES IN THE BLOOD EFFUSED.
In internal placental hemorrhage, or ecchymosis, the blood, after
its effusion, undergoes a variety of changes, interesting in themselves,
and important in this respect, that a misconception of their nature
has, as it appears to me, led pathologists into error in regard to the
nature of some of the lesions occasionally observed in this organ.
When the blood is poured out from its containing vessels into the
substance or cells of the placenta, or between the membranes, it
gradually coagulates, and assumes a very dark purple, and sometimes,
¹ See Proceedings of Edinburgh Obstetrical Society, May 12, 1869, in Edin-
burgh Medical Journal, July 1869, p. 85.
2 Part of an article on Congestion and Inflammation of the Placenta.
See Edinburgh Medical and Surgical Journal, April 1836, p. 274.
146
DISEASES OF THE PLACENTA.
as I have seen it in two preserved specimens,' almost a melanotic
black colour. After a time, however, it begins to lose this tint, the
colouring matter gradually becomes removed, and the coagulum
successively assumes a chocolate brown, a reddish or brownish
yellow hue, and latterly, if time sufficient is allowed, it presents a
pale yellowish white or straw-coloured appearance, the fibrinous por-
tion of the coagulum being then alone left. When these fibrinous
and generally firm and indurated masses are divided, they for the
most part exhibit internally a dense uniform or homogeneous tissue;
but in some cases where the individual mass or coagulum has been
formed by several successive effusions of blood occurring at the same
point, and probably from the same vessel, its section shows a more
or less perfect concentric laminated structure. M. Cruveillier² has
represented an ecchymosed placenta, in which the structure of the
coagulum appears to be concentrically laminated in this manner, and
the more external layers are seen to be losing their colouring matter,
while the nucleus of the effusion is composed of darker and more
recently effused blood. I have not had an opportunity of observing
these changes in specimens of laminated placental coagula, but have
had repeated occasion to remark the discoloration of the more
common single or homogeneous coagula, proceeding from their cir-
cumference to their centre.
In
In the blood effused in placental hemorrhage, I have been able
to trace a change still more advanced than that of its discoloration
and conversion into a yellowish straw-coloured fibrinous mass.
four instances I have seen these fibrinous masses in different parts
of the same placenta, contracted to a size considerably less than the
space which they originally occupied, and consequently appearing, as
it were, to be contained in cavities which were only but partially
filled by them. This appearance is particularly well seen when the
¹ One of these specimens was in the rich and valuable pathological collection
of Mr. Langstaff of London, the other is contained in the Anatomical Museum
of the University of Edinburgh, and is thus described in the printed catalogue (p.
236): “Placenta about the fourth month; fœtal surface studded with numerous
irregular dark-coloured tubercles resembling melanotic depositions." The dark
appearance of the sanguineous coagula in both of these cases is such as might
render them at first sight very liable to be confounded with actual melanotic
deposits; and in the Edinburgh case this mistake in regard to their true patho-
logical nature might have been the more readily committed, from the small masses
of effused blood appearing of a beautiful bluish-black colour, as seen through the
membranes covering the fœtal surface of the placenta, owing to these membranes,
as semi-transparent whitish media, reflecting the blue rays of light transmitted
through them from the dark surfaces of the coagulated masses of blood lying
immediately beneath them.
2 Anatomic Pathol. liv. xvi. pl. i. fig. 1.
PLACENTAL HEMORRHAGE.
147
blood has been extravasated towards the foetal surface of the placenta,
or behind the chorion and amnion, and when it has protruded these
membranes forwards in the form of the eminences or nipple-like pro-
jections already alluded to. In such cases, after the colouring
matter of the effused blood has been removed, and time is given for
the fibrinous masses which are left, to contract, the folds of the
chorion and amnion, which they had carried before them, being in-
elastic membranes, remain in the position in which they were placed,
and present themselves, when the ovum is afterwards examined, in
the form of loose half-empty bags or sacs, projecting towards the
cavity of the amnion. In one of the four placentæ in which I have
observed this contraction, or diminution at least, of the fibrinous
coagula, the cavities containing these contracted coagula were filled
up with a limpid serum; but in the other three instances, I do not
find in my notes any mention of such an effusion.
In no case have I seen the complete removal of the fibrinous
coagula from their containing cavities, or any appearance whatever
indicative of the organisation of these coagula; and I have to regret
not having directed my attention more particularly to the state of
the placental tissue immediately surrounding the effusions, and
observed the changes which take place in it upon the occurrence of
these sanguineous extravasations. In some instances, as in those
represented by Cruveilhier,' the surrounding placental structure
appears to become atrophied and anæmic, after the effusion has
occurred; it seems probable that, in other cases, this state and other
diseased states of the placental tissue and vessels may precede and
indirectly give rise to effusions; but whether a cyst is ever formed
around the sanguineous coagula, and under what circumstances it is
formed, I have no data to determine, either from observations which
I have myself made, or that I can find in the works of others.
I regret, further, not having in my possession any precise facts
to determine the period of time which blood effused into the placenta,
or between the membranes, requires to undergo the several changes
that I have mentioned; but I have seen them all effected in diseased
ova which I had every reason to believe were expelled before the
fifth and sixth month. The placenta I have formerly alluded to as
presenting cavities containing at the same time contracted fibrinous
coagula and an effusion of serum, was expelled at the eighth month,
but was less in breadth, though of much greater thickness, than
placentæ at that period generally are.
1 Anatom. Patholog. livr. xvi. pl. i. figs. 1 and 2, and livr. vi. pl. vi. fig. 2.
11
PART IV.
PARTURITION.
THE DETERMINING CAUSE OF PARTURITION.¹
AFTER stating and refuting the various theories that had been sug-
gested on this point, such as the supposed origin of the act of labour
in certain states of vital development or physical expansion of the
fundus, body, or cervix uteri, in some supposed conditions of the
fœtus, liquor amnii, or placenta, etc., Dr. Simpson suggested that the
loosening or decadence of the membranes, or membranes and placenta,
from the interior of the uterus, constituted the determining cause of
parturition; and that this loosening or decadence was itself the result
of the effete degeneration of the structure of the decidua towards the
full term of pregnancy. Various circumstances in obstetric physio-
logy and pathology were stated in evidence of this view. It was so
far also proved, experimentally, for we bring on labour artificially by
imitating this process when we separate the membranes with the
fingers or catheter, or when we inject tepid water into the cavity of
the uterus, or, in other words, between the membranes and interior
of the uterus-the latter a plan which Dr. Simpson had followed in
twenty or thirty cases.
INFLUENCE OF THE NERVOUS SYSTEM ON THE
CONTRACTIONS OF THE UTERUS.2
The uterine action is perfectly involuntary. It will occur in
states of mania or epilepsy, and in syncope or coma.
It has even
been seen in the dead mother, in cases where Cæsarean section was
performed.
¹ See Proceedings of Edinburgh Obstetrical Society, Session xii., in Edinburgh
Monthly Journal of Medical Science, September 1854, p. 276.
2 Part of a Lecture in Sir James Simpson's Course of Midwifery. From notes
taken in 1856 by Dr. J. G. S. Coghill, and in 1861 by J. W. B.
INFLUENCE OF NERVES ON UTERINE ACTION.
149
But though the action of the uterus is truly involuntary, yet it
is liable to be affected by mental influences and emotions, just as the
action of our hearts is. The heart will palpitate under excitement,
and a person will faint under great fear: so all labour-pains have
suddenly ceased from fright. Advantage has sometimes been taken
of this law. Women occasionally have a varicose vein in the labium
rupturing during labour. The pains have been stopped in such a
case by telling the patient that something terrible had happened,
and that she would die unless the pains ceased. In another way
advantage has been taken of the law. When the pains are languish-
ing and weak, a little encouragement given to the patient will
sometimes restore uterine action better than any drug in the
pharmacopoeia.
Another inquiry has occasioned a good deal of discussion-Are
we to consider the ordinary excitants to uterine action as cerebral, or
spinal, or ganglionic?
It has been held that the uterine action is dependent on the
connection of the uterine nerves with the brain. Brachet supported
this opinion from a case of paraplegia in the human female and from
experiments on guinea-pigs. He cut the spinal cord in guinea-pigs
above the origin of the ovarian nerves at the commencement of
parturition. The animals he operated on all died undelivered; and
he inferred that the want of uterine action was due to the cutting
of the connection with the brain. Deductions from experiments on
such small animals do not, however, hold good, because death arises.
from rupture of the bladder when the cord is divided. I have found
that in large animals, such as the pig, where you can avoid this
difficulty by drawing off the urine by the catheter, uterine con-
tractions do come on after division of the cord as proposed by
Brachet
Dr.
It has been averred by Dr. Marshall Hall and Dr. Tyler Smith
that the uterine action is a reflex spinal one, connected with a reflex
centre in the lower part of the spinal cord, the integrity of which
organ is therefore necessary to the occurrence of uterine action.
Hall argued from a case recorded by Ollivier, where a woman had
paraplegia from hydatids in the spine high up in the dorsal region.
The woman became pregnant, and bore her children without any
instrumental assistance. This, Hall said, showed that the uterus
was not under the influence of the brain, but under that of the lower
part of the spinal cord as a reflex centre.
Many years ago, I removed the spinal cord from the first dorsal
150
PHYSIOLOGY OF PARTURITION.
vertebra downwards in several pigs a few days before labour was
due. Some of the pigs died, but in others labour came on and pro-
gressed regularly. In each case all the foetuses of the litter were
born except the last one. The whole series passed from the uterus
into the vagina, one behind the other, and each in its proper mem-
branes. The uterine contractions proceeding from fundus to cervix
were sufficient to expel the fœtuses from the uterus; and each fœtus,
as it came into the vagina, was thence extruded by the force trans-
mitted from the foetus behind it. But when the last foetus came
into the vagina it remained there, because there was nothing to
transmit to it the uterine expulsive force, while the vagina and
abdominal muscles, being under the influence of the spinal nerves,
had been rendered powerless by the removal of the cord.
These experiments show plainly that the spinal cord is by no
means a sine quâ non in the accomplishment of the expulsive func-
tion of the uterus, as declared by Drs. Hall and Smith. That the
uterus can be made to contract by reflex stimulation, we have ample
evidence in the effects of the external application of cold, etc., in
post partum hemorrhage, and in the third stage of labour.
Females have borne children without any remarkable difficulty
while suffering from paraplegia-in some the result of direct injury.
In a case related by Paget, a woman was attacked with paraplegia
in the eighth month, and had neither sensation nor motion below
the umbilicus, and no reflex movements could be excited by tickling
the feet. Labour came on at the full time, and the foetus was born
without artificial assistance. The woman was quite unconscious that
parturition was going on at all; and the foetus was found dead in
the bed. I collected for publication a number of cases of this
nature, and in almost all of them parturition was effected without
instrumental interference. The case quoted by Brachet probably
misled him. In it he thought it necessary to deliver by the for-
ceps, and yet the uterus itself had fully dilated the os.
We conclude, therefore, that though the uterine contractions
are no doubt guided or influenced by the brain and spinal cord,
they are essentially independent of these organs. The ordinary
nervous power is derived neither from the brain nor from the spinal
cord, but probably from the ganglionic system of nerves; for
although the uterus will contract even when it is cut out of the
body, we do not believe that it would contract regularly unless
governed by some nervous influence.
Another series of controlling influences is now being investigated
SOUND DURING EXPULSION OF PLACENTA.
151
by physiologists. This is the inhibitory system. Irritate certain.
ganglia, and you stop almost instantaneously the action of the heart.
Irritate the splanchnic nerves, and you stop the peristaltic action of
the intestines. The uterine nerves are isolated more than any other
nerves—perhaps in order that an inhibitory action may be sent along
them to stop the pains, perhaps to induce the intense muscular
contractions more readily.
SOUND HEARD DURING DETACHMENT AND
EXPULSION OF THE PLACENTA.'
2
M. Caillant has described a new stethoscopic sound that he
considers indicative of the separation of the placenta. "On ap-
plying the stethoscope," he alleges, "to the hypogastric region,
after the expulsion of the child, and before the expulsion of the
placenta, a sound is heard with each returning uterine contraction,
feeble at first, but the intensity of which increases in proportion as
the uterine contraction becomes more energetic, and then subse-
quently diminishes and disappears as the uterine contraction sub-
sides. The sound is composed of a series of rapid small scratching
noises, somewhat like those produced by drawing the nails at right
angles across the seat of a sofa. It returns with each uterine con-
traction till the placenta is expelled from the uterus, when it
ceases." M. Caillant believes "that it depends, not upon the
uterine contractions, but upon the mechanical disunion or separation
of the placenta ;" and hence he proposes to term the sound "bruit
de décollement placentaire."
Dr. Simpson stated the result of M. Caillant's investigations on
this supposed stethoscopic indication of the separation of the pla-
centa; but while describing and admitting the sound, he added
various reasons for dissenting altogether from the explanation
offered of it by M. Caillant. He believed the sound to be pro-
duced by the mere physical compression of the placenta, as it is
being crushed within and expelled from the uterus; and in various
experiments on the subject, he found that it could be artificially
imitated with a placenta, after its expulsion from the body, by
pressing it through such an aperture as that of the os uteri and os
vaginæ.
¹ See Proceedings of Edinburgh Obstetrical Society, January 14, 1852, in Edin-
burgh Monthly Journal of Medical Science, August 1852, p. 168.
2 See L'Union Médicale for 1850, and more lately his Thèse Inaugurale,
Paris, 1852.
152
MATERNAL DYSTOCIA.
ON THE FREQUENCY OF
FISSURING AND LACERATION OF THE STRUCTURES OF
THE PERINEUM AND CERVIX UTERI IN LABOUR.'
Dr. Simpson directed the attention of the Society to this im-
portant subject; and, as the result of a long series of observations
on the matter, he drew the following conclusions:
First, Fissuring and laceration of the cervix uteri and perineum
are not, as is generally conceived, rare lesions during labour; on
the contrary, they are very common occurrences, especially in
primiparous labours.
Secondly, These lesions are not, as has been often alleged, neces-
sarily the result of mismanagement, but they occur constantly in
practice, despite every modification of management, and in cases
also in which no kind of management has been adopted.
Thirdly, Evidence of the great frequency of laceration of the
anterior structures of the perineum is furnished by-1. Almost
every careful autopsy of women after delivery, whether assisted or
not assisted during their labour; 2. By the contracted or shortened
state in which the perineum is almost always found, when vaginal
examinations are made for uterine disease in women who have
borne a family; and, 3. By the fissuring or laceration itself being
usually traceable, under careful tactile examination, particularly in
first labours, when that examination is instituted in the interval
of pain, immediately before the passage of the child's head, or
after its birth.
Fourthly, Lacerations of the perineum may be often felt begin-
ning in the form of slight roughish rents or fissures upon the
muccus surface of the perineum, and these may extend either back-
wards or forwards; and if they extend forwards, they at last run
over the edge of the perineum, and along its cutaneous surface ;
the mucous and cutaneous structures of the perineum being thus
sometimes lacerated, while its middle, cellular, and fascial tissues
are comparatively entire, or at least not so deeply and extensively
injured.
Fifthly, The proper management and support of the perineum
no doubt modifies and diminishes this form of perineal lesion,
1 See Proceedings of Edinburgh Obstetrical Society, January 22, 1851, in
Edinburgh Monthly Journal of Medical Science, May 1851, p. 488.
NATURE OF SPURIOUS PAINS.
153
but it fails far more frequently than is generally supposed in
entirely preventing it.
Sixthly, The evidence of the frequency of fissuring of the os
and lower or vaginal portion of the cervix uteri is the same in
character, and consists principally-1. In the frequency with which
slight laceration of the edges of the os, and of the mucous and
middle coat of the cervix, is detected in autopsies after natural
labours, and particularly with first children; and 2. In the perma-
nent marks of its previous occurrence, as exhibited in those cica-
trices and irregularities of the cervix uteri, which anatomists have
long empirically, but correctly, laid down as proofs that they, in
whose bodies they are found, have been previously mothers.
Seventhly, Fissures and lacerations of the vaginal portion of
the cervix uteri not unfrequently occur to a very considerable
extent in cases in which the tissues of the cervix have been ren-
dered rigid by previous inflammation, by carcinoma, or by other
morbid causes; and in such cases this fissuring or laceration, if
limited to the lower or vaginal portion of the cervix, seems to be
accompanied with little or no danger.
ON THE NATURE OF SPURIOUS LABOUR PAINS.¹
Various opinions have been expressed regarding the nature of
spurious labour pains, some believing that they consist of morbid
contractions of the abdominal muscles, others of the intestinal canal,
and others of the walls of the uterus itself. The actual locality of
the pains, and the varying degree of hardness in the uterine tumour
during these pains, leave no doubt that the seat of spurious labour
pains is in the walls of the uterus itself, and that they are produced,
like true labour pains, by contractions in these walls. But the
peculiarity of spurious pains seems to consist chiefly in the direction
of the uterine contractions, and perhaps also to some extent in their
local or limited character. In true labour pains the muscular con-
tractions of the uterus pass from above downwards. We see this to
be the fact in experiments upon the lower animals; for when the
abdomen is opened in the sow, for example, during active parturi-
tion, the wave of peristaltic uterine contraction, constituting a true
labour pain, is seen to begin at the Fallopian tube, and to pass from
thence downwards along the uterine walls to the lower extremity
¹ See Proceedings of Edinburgh Obstetrical Society, Session xviii., in Edin-
burgh Medical Journal, October 1859, p. 371.
154
MATERNAL DYSTOCIA.
of the uterus itself. This phenomenon can be felt in the human
subject during common labour by spreading out fully the thumb and
fingers over the uterine tumour. When this observation is made, it
will be found that as each true uterine contraction recurs, there is
first a feeling of hardness, and consequently of contraction, felt
beneath the finger or thumb placed at the highest point of the
uterine tumour; and secondly, this feeling of hardness and con-
sequent contraction rapidly extends downwards in succession to the
different fingers placed below. Sometimes a short series of thrills
or vibrations in this direction is felt before the full and perfect
contraction recurs. The observation can be made in some patients
much more readily than in others, and particularly upon women in
whom the abdominal parietes are unusually thin. When the same
observation is attempted to be made in cases of well-marked spurious
pains, it will be found that the contractions, instead of running from
above downwards, proceed from below upwards, or from the os
towards the fundus uteri. Occasionally, when they are slighter,
they will be found lost on the sides of the uterus as they proceed
upwards, or even stretch across in a limited form from one point to
another. Usually, however, they consist of the peristaltic uterine
contraction running in an inverted direction from below upwards,
instead of, as in true labour pains, from above downwards.
2
INDIAN HEMP AS AN OXYTOCIC.¹
Dr. Simpson stated, that, in the early part of the winter session,
he had given Indian hemp (Cannabis Indica) in several cases of
tedious labour, with the view of ascertaining if it possessed any
oxytocic effect, like ergot of rye, in increasing and exciting the
parturient action of the uterus. He had been induced to try the
effects, if any, of Indian hemp during labour, in consequence of Dr.
Churchill stating, that it possessed powers similar to those of ergot
of rye in arresting hemorrhage, when dependent upon congested
states of the unimpregnated uterus. In the few cases of labour in
which it was tried, parturient action seemed to be very markedly
and directly increased after the exhibition of the hemp; but far
more extensive and careful experiments would be required, before
a definite opinion could be arrived at, relative to its possession of
oxytocic powers, and the amount of those powers.
¹ See Proceedings of Edinburgh Obstetrical Society, Session IX., in Edin-
burgh Monthly Journal of Medical Science, July 1850, p. 91.
* Churchill, Diseases of Women, 3d edition, p. 113.
FIBROUS TUMOURS COMPLICATING DELIVERY.
155
COMPLICATION OF LABOUR BY LARGE FIBROUS
TUMOURS.
PROPRIETY OF INDUCING PREMATURE LABOUR.¹
Dr. Simpson stated that it was well known that fibrous tumours
were very common organic changes in the unimpregnated uterus.
He had seen several cases in which they were still small, and showed
themselves in the form of nodulated irregularities on the surface of
the pregnant and puerperal uterus. He had seen also a number of
instances of pregnancy and parturition complicated with large
tumours of this kind; and he mentioned the particulars of the three
following cases in consequence of unusual circumstances connected
with each.
CASE I.A patient, after being married for 10 or 12 years without any
issue, passed two menstrual periods. A very large pelvic tumour, which had long
been present, began to increase in size. He then saw her with Mr. Dixon and
Dr. Taylor. There was a very large, hard, fibrous tumour of the uterus, and low
on the left side and in front, a soft elastic part, having much the character of a
dropsical ovary. It is well known that fibrous tumours of the uterus and multi-
locular dropsy of the ovary sometimes co-exist, but he knew no other kind of
cystic collection ever existing along with fibrous uterine tumours.
In this case,
however, the soft fluctuating part was not the ovary, for it was situated anteriorly
to the hard uterine tumour, whilst diseased ovaries lie posteriorly to the uterus.
This led him to suspect pregnancy, improbable as it otherwise was, and to hazard
a diagnosis to that effect. It proved correct. The foetal heart was heard about
the fifth month, and pregnancy went on to the full time. During labour, one
portion of the tumour filled up so much of the brim of the pelvis, that the child
required to be extracted by turning. It was still-born. The mother made a
good recovery.
CASE II. In a woman suffering from dysuria, etc., and who had not
menstruated for three months, he found the uterus retroverted, and an enormous
fibrous tumour in the walls of the organ. The case was at this time seen by Dr.
Renton, Dr. Ziegler, and others. The uterus was replaced with difficulty, and
some weeks subsequently the foetus was expelled. About a year afterwards, the
same patient again became pregnant and went to the full time. The labour was
extremely tedious-a portion of the tumour diminishing the brim of the pelvis-
and at last the child was expelled by the spontaneous efforts of the uterus, but
with the head greatly compressed and flattened. The mother recovered rapidly.
In the unimpregnated state, the fibrous tumour in this instance reached to the
umbilicus, and was as large as a uterus at the fifth or sixth month of pregnancy.
The uterine cavity was found by the uterine sound to be six inches in length.
CASE III.A patient, pregnant for the first time, who had long been delicate,
arrived at the full term of utero-gestation, and after a somewhat tedious labour
1 See Proceedings of Edinburgh Obstetrical Society, May 12, 1847, in Edin-
burgh Monthly Journal of Medical Science, August 1847, p. 138.
156
MATERNAL DYSTOCIA.
""
was delivered of a dead child. There was a slight degree of hemorrhage, but it
was easily arrested. From the time, however, of delivery onwards, the patient
continued to sink-became faint and listless, and then comatose-and died in this
state five or six hours subsequently. She seemed never to rally from the "shock
accompanying delivery. Dr. Malcolm saw her with him. On opening the body,
they found the uterine parietes thickly studded with fibrous tumours, and
counted as many as forty hanging, in a more or less pediculated form, from its
external or peritoneal surface; and of all sizes, from an orange downwards.
These were easily diagnosticated through the abdominal parietes during her life.
The cavity of the uterus contained no collection of blood.
CASE IV.-A lady, pregnant for the first time, was supposed by her medical
attendant to have an extra-uterine fœtation, from her unusual shape. There was a
fibrous tumour projecting from the anterior wall of the uterus. She died of peri-
tonitis on the second week after her confinement. Dr. S. found the fibrous tumour
adhering firmly to the peritoneum lining the anterior walls of the abdomen, while
its pedicular attachment to the uterus had stretched and lacerated during the in-
volution of the organ after delivery.
In addition, Dr. Simpson alluded to two cases of large fibrous
tumours complicating labour, published in the Dublin Medical Journal,
the one by Dr. Montgomery, the other by Dr. Beatty. In the
former, the fibrous tumour, having entered the pelvis, formed such
a complete and perfect obstruction to the maternal passages, that
the Cæsarean section was required. In Dr. Beatty's case, it was
supposed, before the commencement of parturition, that the same
proceeding would be necessary; but, in the course of the labour, the
tumour was gradually raised out of the pelvis by the uterine con-
tractions, and the child spontaneously expelled.
WHAT PRACTICE SHOULD BE FOLLOWED IN CASES OF LARGE
FIBROUS TUMOURS COMPLICATING PREGNANCY ?
Dr. Simpson adduced the opinion of Dr. Ashwell, who, in dis-
coursing on this subject, inculcates the propriety of inducing pre-
mature labour, in order to evade the danger of inflammation of the
pelvic tissues and peritoneum, and the still more hazardous evils of
unhealthy softening, suppuration, and ulceration of the tumours
themselves. But Dr. Simpson stated that he entertained very
serious doubts of the correctness of Dr. Ashwell's observation, that
fibrous tumours had a tendency to soften during the latter months.
more than at any other period of pregnancy; and he disapproved of
the induction of premature labour as a general rule of treatment in
such cases, believing that the excitement of the uterus by artificial
means to the premature expulsion of its contents, would be as likely
to induce such anticipated morbid actions, as the supervention and
CASE OF MALACOSTEON.
157
completion of a natural pregnancy and labour. He believed that
the only cases of this kind which demanded the induction of pre-
mature labour were those in which the tumour encroached, as in two
of the preceding cases, upon the brim or cavity of the pelvis, and
thus produced such mechanical contraction of the maternal passages
as rendered a natural labour impossible. Where the tumours were,
as was usually the fact, abdominal and above the brim, he did not
consider premature labour in any way called for, or a practice that
ought to be followed.
CASE OF DELIVERY WITHOUT OPERATIVE AID,
THROUGH A PELVIS EXTREMELY NARROWED BY
MALACOSTEON ;
WITH PRACTICAL REMARKS.¹
Different classifications of the morbid conditions and deformities
of the maternal pelvis have been proposed by obstetric pathologists.
Some have arranged them in relation to their causes, others in rela-
tion to their nature, seats, etc. But the most practical classification
consists in dividing the morbid states of this part of the skeleton
into several grades, according to the actual degree and amount of
physical contraction in the pelvic apertures, which is induced by
these states; and consequently, according to the kind and modifica
tion of measures required to extract through the defective apertures
a child arrived at or near the full term of utero-gestation.
Drs. Denman and Ramsbotham, and Professor Paul Dubois,
have, for instance, followed this principle of classification in discuss-
ing the effects of diseased and deformed conditions of the pelvis
upon the process of parturition. Laying aside all pelves of the
normal form and standard dimensions, as requiring no accessory aid
from art for the transit of an infant through them, these authors
have divided all varieties of pelvic contractions into the three
following gradations:-
I. Pelves somewhat diminished below the natural standard, but
still admitting of the child being expelled through them by nature,
or extracted by instruments, safe (such as the forceps and vectis)
both to the mother and infant.
II. Pelves contracted to such a degree as not to allow a child,
1 Read before Medico-Chirurgical Society of Edinburgh, June 2, 1847. See
Edinburgh Monthly Journal of Medical Science, July 1847, p. 22.
158
MATERNAL DYSTOCIA.
at or near the full term, to pass through their apertures till its
head was reduced in size by craniotomy.
III. Pelves so very small as not to admit of the extraction
through them of a child even after it was mangled and mutilated
by embryulcio, and where that last resort of the obstetric art,
Cæsarean section, constituted the only possible mode of delivery.
It is evident that the reference of individual cases of labour to
one or other of the preceding degrees of difficulty in the process of
delivery, must be often regulated by other circumstances than the
mere physical dimensions of the maternal pelvis. The strength and
powers of endurance of the patient, the activity of the uterus, and
above all the dimensions and compressibility of the infant's head, as
modified by its actual volume, and by its state of ossification, the
width of its sutures and fontanelles, the separation or not of the
bones by previous death and putrefaction, etc., are so many matters
forming important points and elements of difference in different
instances. But still, however, most of our highest authorities in
midwifery have attempted to lay down, in the form of general prin-
ciples, more or less exact and fixed pelvic admeasurements between
the several classes or gradations of pelvic deformity that I have
mentioned. In other words, they have endeavoured to reduce to
abstract arithmetical formulæ, as it were, the boundaries and limits
between morbid states of pelvic contraction, admitting respectively
of delivery at or near the full time, first, without the necessity of
embryulcio; secondly, by means of embryulcio; and thirdly, where
embryulcio is inadequate and insufficient for the purpose.
For the purpose of illustrating these points and statements, I
shall collect and throw into a condensed tabular form the opinions
of some of our most eminent British accoucheurs on the pelvic
dimensions relatively fitted for these different modes of management
and delivery. It is necessary, however, to premise one observation
in order to understand the figures and formula which I shall quote.
The apertures of the brim and outlet of the human pelvis are nor-
mally of an irregularly ovoid form, and they maintain more or less
of this configuration under all kinds of morbid contraction and de-
formity. Indeed it generally happens, more particularly in cases of
rickets and malacosteon, that when either of these pelvic apertures
is morbidly contracted in one diameter, it comes to be elongated in
the other. One of the diameters, either of the brim or outlet, how-
ever, is always contracted; and hence, in speaking of the relative
size of different deformed pelves, accoucheurs often note their dimen-
CASE OF MALACOSTEON.
159
sions by simply stating, as in the first of the following tables, the
length of their shortest or narrowest diameter.
Smallest size of pelvis through which a child may pass without
mutilation.—In the standard and normally formed pelvis, the nar-
rowest diameter of the brim (the conjugate), and the narrowest
diameter of the outlet (the transverse), are each, on an average,
about four inches in length. A child may, however, pass through
these pelvic openings, though their narrowest diameter be reduced
very considerably. The following table shows the opinion of some
of the most eminent British accoucheurs on this point.
Smallest Pelvic Diameter admitting of the Passage of a Child
without Embryulcio.
34 inches-Joseph Clarke,' Burns.2
3
23/24
""
Denman, Davis, Ramsbotham.*
Osborne, Hamilton,' Barlow."
1 66 Having examined, by dissection, the bodies of many women who died after
tedious and laborious labours, I am enabled to state, with some confidence, that
three inches and a quarter from pubis to sacrum is the least diameter through
which I have known a full-grown foetus to pass entire; but it was a very putrid
fœtus, consequently the head was soft and pliable."-Dr. Clarke, in Transactions of
the Irish College of Physicians, vol. i. p. 374.
2 Dr. Burns considers Dr. Clarke "correct when he says that the head cannot
pass entire if the diameter be under 34, and even this will generally require the
perforator."-Principles of Midwifery, 1843, p. 471.-See also p. 473.
3 "Should the capacity of the pelvis be reduced under three inches, we have no
good reason to expect a living child of its full growth, however small, to pass
through it, either naturally or by the assistance of art; though the head of one that
is dead, especially if it be putrefied, or one much below the common size, may be
pressed through a pelvis of these dimensions, even without artificial assistance.
Should the capacity of a pelvis not exceed, according to our judgment, two inches
and a half, then the head of a child, unless the contents be evacuated, cannot pass
or be extracted through it."-Denman's Introduction to Midwifery, pp. 457-58.
Edition of 1816.
4 "Pelves of somewhat less dimensions than those of a standard pelvis may
occasionally admit of children being born alive at the full period of gestation. For
example, a living child of average size at that period might be born alive, provided
the conjugate diameter of the brim of the mother's pelvis was three inches and
three quarters, and the head presented in the best possible position. But, if it
amounted to no more than three inches, a well-grown child at full period could not
be expected to pass without an operation to reduce the bulk of its head."-Davis's
Principles and Practice of Midwifery, vol. i. p. 25.
5 "Some practitioners have thought that a pelvis measuring only two inches
and three quarters in the conjugate diameter would allow of the head passing
whole, provided there was sufficient room laterally. My own conviction, derived
from clinical observations, is, that the dimensions I have just mentioned (three
160
MATERNAL DYSTOCIA.
I am not aware that any English writer on midwifery has stated
it as practicable that a child could pass, without mutilation, through
a pelvic diameter less than that mentioned in the last line of the
preceding table, namely, two inches and three-fourths. Instances,
however, in which children, at or near the full time, have been
expelled by the uterus, or extracted with forceps, through pelves
measuring only two inches and a half in their narrowest diameter,
have been mentioned by some foreign authors. Solayres, Baude-
locque, and Capuron,' each advert to cases illustrating the possibility
of this occurrence.
In an obliquely deformed pelvis in my museum, the conjugate
diameter of the brim is one or two lines below 3 inches; and yet
through it a dead full-sized child passed as a head presentation, after
a long labour, but without instruments. I extracted a second infant
by the feet through the same pelvis. Further, I believe, that when
inches in the conjugate by four in the lateral diameter) are the smallest which will
grant the passage to a full-grown foetus."-Ramsbotham's Obstetric Medicine and
Surgery, second edition, page 30.
"Whenever the capacity of the pelvis is only two inches and three quarters,
or certainly less than three inches," there is, Dr. Osborne conceives, "an utter im-
possibility for a child of ordinary size, at full time, being born alive by any means,
either of nature or art, through so small a pelvis."-Osborne's Essays on the
Practice of Midwifery, p. 223. At p. 194 he states that, "when the bones
approach much nearer than three inches, it is utterly impossible for a living child
at full maturity by any means to pass," and embryulcio should be performed early
in the labour.
7 Dr. A. Hamilton, in his Letters to Dr. Osborne, adduces several cases in which
delivery took place safely and spontaneously, "where the deformity of the pelvis
seemed to be such, that according to your (Dr. O.'s) data, the head of the child
should have been opened at the beginning of labour," p. 119. In the first case
detailed by Dr. Hamilton, a living child passed, though the pelvic brim was
ascertained, by admeasurement after death, to be "sensibly under three inches.”-
P. 101.
8 Dr. Barlow, in his Essays on Surgery and Midwifery, p. 354, gives the follow-
ing Synoptical Table of the various degrees of distortion of the pelvis, and their
appropriate treatment :—

Degrees of Deformed
Pelvis.
First degree
Conjugate Diameter of Brim.
From 4 to 3 or 2 inches.
From 2 to 23 inches
Second degree
Third degree
Fourth degree
•
From 24 to 1½ inches
From 1 to the lowest pos-
sible degree of distortion
Modes of Delivery.
Efforts of Nature, or as-
sisted by forceps or lever.
Premature delivery.
Embryulcio.
Cæsarean operation.
9 Baudelocque's Midwifery, Heath's Translation, vol. ii. p. 370. Capuron's
Cours des Accouchemens, Brussels Edit., p. 221.
CASE OF MALACOSTEON.
161
the child presents by the feet, and thus the apex, instead of the
base, of the cone formed by the head and body of the fœtus, comes
first, that it may make its transit without embryulcio through a
pelvis, the smallness of which would otherwise have necessitated
mutilation or the operation of craniotomy. In this way I have,
through a pelvis probably not above 2 inches in its narrowest
diameter, extracted a child by the operation of turning, the parietes
of the skull becoming compressed and indented to allow of its
passage.¹
Highest Pelvic Dimensions necessitating the performance of the
Cæsarean Section.-It is well known that Continental practitioners
have sometimes recourse to the Cæsarean section under degrees of
pelvic contraction that are not considered by British accoucheurs to
demand an operation of such great severity and hazard.
In one of the last and best works upon Midwifery, published in
Germany, the following observations occur in reference to the de-
gree of pelvic deformity indicating the Cæsarean operation :—
4
When the smallest diameter amounts to only 23 inches, the
termination of labour is possible only by making an artificial pass-
age, or by breaking up the child. The possibility of terminating
it in the latter manner ceases whenever the small diameter amounts
only to 21 inches or less, and the Cæsarean section is then the only
possible mode of delivery, and that to which we must have recourse
in all cases, whether the child be dead or not. If the contracted
pelvis measures from 2 to under 3 inches, then the Cæsarean sec-
tion is indicated when the child is alive, while, if it is dead, perfora-
tion is to be had recourse to."
Jacquemier, the latest French writer on Midwifery, states, that
when the pelvis is below two inches in its narrowest diameter, the
¹ I have elsewhere stated the advantages, in deformed pelves, from turning
in comparison with embryulcio to be, that-1. It gives the child a chance of
life; 2. It is more safe to the mother, because it can be performed earlier
in the labour, and more speedily; 3. It enables us to adjust and extract the
head of the child through the imperfect pelvic brim in the most advantageous
form and direction, the head flattening laterally under the traction; 4. The neck
of the child, if it be living or only lately dead, is so strong as to allow us to exert
such a degree of traction upon the obstructed head, that the sides of the cranium
may become very greatly compressed, or even indented under it, and that without
necessarily destroying the child; and, 5. It is a practice which can be followed
when proper instruments are not at hand, and the avoidance of instruments is
generally desirable when it is possible.
2 Busch and Moser's Handbuch der Geburtskunde, Berlin, 1842, vol. iii. p. 108.
162
MATERNAL DYSTOCIA.
Cæsarean section is the only justifiable mode of delivery, even when
the child is dead; and when it varies from two inches to two inches
and a half, and the child is alive, the Cæsarean operation should be
adopted in preference to embryotomy, not only for the sake of the
life of the child—but as, perhaps, not more dangerous to the mother
than a protracted and difficult delivery by embryulcio generally
proves to be.¹
So far as I am aware, Velpeau is the only author who has
hitherto attempted to collect, in a generalised form, the measure-
ments of the pelvis of patients who have been submitted to the
Cæsarean section. He tells us, that out of 80 cases in which the
cause for the operation was specified, in 62 cases it was required by
contraction of the pelvis, particularly in the antero-posterior diameter
of the brim. Thus it was—
2
in 1 case.
1
inch
1
to 1 inch
in 8
""
>>
11 to 2
in 23
""
2
to 21/2
in 25
""
""
2/1/ to 23
in 5
""
""
In a number of these cases, the Cæsarean operation was adopted
under degrees of pelvic contraction, in which delivery by means of
embryulcio would have been followed by British practitioners.
This remark especially applies to the thirty cases included in the
last two lines of the table; and it applies to them the more
strongly when we further recollect that the sizes of these pelves in
English measurements would have been somewhat more than they
appear under French measurements, the French inch being about
longer than the English inch.
16
In choosing, in any case of contracted pelvis, between the alter-
natives of craniotomy and the Cæsarean section, Continental practi-
tioners generally look upon the life of the child, as well as the pro-
bable degree of difficulty and danger likely to ensue to the mother
from a painful and protracted delivery by embryulcio, as important
points and elements in deciding between these two methods of de-
livery. In this country, little, or indeed no, attention has hitherto
been given to these considerations in forming a practical conclusion
on the question. In fact, British accoucheurs have never deemed
themselves entitled to have recourse to the Cæsarean section, unless
1 Manuel des Accouchemens, Paris, 1846, vol. ii. p. 162.
2 Traité Complet de l'Art des Accouchemens, vol. ii. p. 458.
CASE OF MALACOSTEON.
163
the pelvic apertures were so much reduced as to prohibit the prac-
ticability of the extraction of the child through them by embryulcio.
With them the propriety of delivery by the Cæsarean section begins
exactly with that degree of pelvic deformity at which the possibility
of delivery by embryulcio terminates.
Hence, in order to fix and determine the highest limit of pelvic
contraction which necessitates the performance of the Cæsarean
section, we have merely, in the first instance, to fix and determine
the lowest limit of pelvic contraction at which delivery by embry-
ulcio is capable of being effected.
The following table presents, in a condensed form, the opinions
of various British and American obstetricians upon this question,
namely, the actual degree of pelvic contraction above which it is
considered still possible to deliver by embryulcio, and below which
it is deemed proper, and absolutely necessary, to extract the infant
by the Cæsarean section.
Smallest Pelvic Diameters admitting of the passage of a Child by
Embryulcio.
3 inches by 2 inches-Dewees,' Bedford, etc.
3
""
3
"9
by 12
by 11
""
""
Burns, Hull, etc.
Barlow, Hamilton, etc.
6
During the last ten or twenty years, various improvements
1 "By a sufficient diameter I mean, where there is at least two inches in the
antero-posterior, and at least three and a half in the transverse; below this, de-
livery per vias naturales, I repeat, I believe to be impossible."-Dewees' System
of Midwifery, 1837, p. 579.
2 "I do not believe it is possible to remove a child by embryotomy, when the
antero-posterior diameter of the superior strait measures less than two inches,
without subjecting the mother to severe hazard, provided the child be of the
ordinary size. I am satisfied, that even with the space of 24 inches, all the dex-
terity which the operator can bring to his aid, will be required to protect the
mother from serious, if not fatal, injury. I, without hesitation, would prefer the
Cæsarean section, if I had certain evidence that the child lived, to any attempt to
extract it per vias naturales, if the antero-posterior diameter measured less than
2 inches."-Dr. Bedford, in his Translation of Chailly's Midwifery, note, p. 386.
3 "The crotchet cannot be used, when the head is of the full size, unless we
have a passage through the pelvis and its linings measuring fully an inch and three
quarters in the short diameter, and three inches in length; or if the child bo pre-
mature and soft, an inch and a half broad, and two inches and three quarters
long."-Dr. Burns' Principles of Midwifery, 1843, p. 508.
4 "I am of opinion that it still remains to be proved whether a mature fœtus
of the ordinary size has ever been extracted, with safety to the mother, through a
pelvis, in the superior aperture of which there was not in any point, from the fore
12
164
MATERNAL DYSTOCIA.
have been proposed in our embryulcio instruments, particularly
with the view of rendering that operation more safe and easy in
cases of unusual difficulty and deformity. Lest, with such additions.
and improvements, the preceding table be supposed to misrepresent
the existing rules and doctrines of our modern British schools of
Midwifery respecting the degree of pelvic contraction necessitating
the adoption of the Cæsarean section, I shall cite, in reference to
the indications for this operation, the opinions expressed upon the
subject in the three last obstetric text-books that have issued re-
spectively from Edinburgh, Dublin, and London.
In his Introduction to the Study and Practice of Midwifery, Edin-
burgh, 1843, Dr. Campbell observes, "Unless we have a clear space
of two inches, or nearly so, in the transverse (conjugate), and fully
three in the lateral diameter of the brim, embryotomy must be
abandoned, as not likely to ensure the safety of the parent.'
"17
In his work on the Theory and Practice of Midwifery, 1843, Dr.
Churchill of Dublin, after an elaborate investigation of the subject,
draws the following deduction :-"We may therefore," he observes,
"safely conclude, that when, from any cause, the antero-posterior
diameter of the upper outlet, or the transverse diameter of the
lower, is not more than 1 inch, there is no possibility of delivery
per vias naturales, but that we must have recourse to the Cæsarean
section."
11 8
Dr. Francis Ramsbotham of London, in his Obstetric Medicine and
Surgery, London, 1844, observes, when speaking of deformity of
the pelvis," "I am quite convinced, that unless there be at the brim
one inch and three-eighths in the conjugate, by three and a half in
the iliac (diameter), or 1½ inches in the conjugate by three in the
iliac, it would be useless to attempt delivery per vias naturales."
And again, when treating of difficult labours, he remarks, "If, upon
a measurement conducted with the utmost care, we find there is
less space at the brim than three inches and a half laterally, by one
to the hind part, a space equal to 11 inch."-Dr. Hull's Defence of the Caesarean
Section, p. 391.
5 See Dr. Barlow's Synoptical Table quoted on page 160, from his Essays on
Surgery and Midwifery, p. 354.
"Whenever the short diameter of the pelvis, either at the brim or at the
outlet, will not admit above one ordinary-sized finger, or really falls under one
inch and a half, no other means are justifiable for the delivery, if the child be
arrived at the full period of gestation, than that tremendous expedient, the
Cæsarean operation."-Dr. A. Hamilton's Letter to Dr. Osborne, p. 139.
8
7 Introduction, etc., p. 319. Midwifery, p. 314. "Ramsbotham, p. 30.
CASE OF MALACOSTEON.
165
inch and three-eighths in the conjugate diameter; or three inches
by one inch and a half; we ought to consider it our duty, however
painful and appalling that may be, at once to propose the Cæsarean
section as the only means by which it is possible to save the
mother's life; and as offering also the sole chance of safety to the
child." "" 1
+
2
Our highest, as well as latest, authorities in British Midwifery
seem thus to have fixed upon a degree of pelvic contraction, in
which the dimensions varied from 3 to 3 inches in the long dia-
meter, and from 2 to 1 in the short diameter, as the lowest limit
at which delivery by embryulcio can be performed, and below
which it is always and invariably necessary to have recourse to the
Cæsarean section, when the child has reached the full time. In
the case, which it is my object in this communication to detail, the
inferior pelvic aperture of the patient was so deformed and con-
tracted from Malacosteon, that it was considerably less in its
dimensions than the lowest limit stated in the preceding table and
extracts, as capable of permitting delivery by embryulcio, and yet
the mother, after arriving at, if not past, the full time of utero-
gestation, was delivered, not only without embryulcio, and without
the Cæsarean section, but in fact without instrumental interference
of any kind. Further, the child, after its birth, was passed through
an unyielding aperture measuring under one inch in its short, and
1 Obstetric Medicine and Surgery, p. 179.
was
2 I do not stop to discuss the question, whether, in all cases of great deformity,
embryulcio is always proper where it is possible. The difficulty attendant upon
its performance in instances of marked contraction has sometimes been extreme.
In a case where the narrowest diameter of the brim was thought to measure two
inches, Dr. Meigs required many hours to break down the cranium, and afterwards
three or four hours' pulling to extract the child with the crotchet. The mother
was altogether three or four days in labour.-Philadelphia Practice of Midwifery,
p. 322. In a woman with a pelvis, the conjugate diameter of which
estimated at little more than an inch and a half," Dr. Hamilton effected delivery
by embryulcio. The extraction alone occupied four hours, and "required such
an exertion of force, that he was literally obliged from exhaustion to be carried
home in a sedan chair."-Practical Observations, p. 263. Lately, my friend
Professor Murphy extracted a child by embryulcio through a pelvis, the brim of
which measured one and a half inches in its conjugate, and four and a half in its
lateral diameter. The operation required about seven hours' work on the part of
Dr. M. The patient was in labour from Tuesday to Friday.-Lancet for April 3,
1847. "I question much," observes Dr. Burns, "if extreme cases of embryulcio
be not as dangerous to the patient as the Cæsarean operation; certainly they are
more painful.”—Midwifery, p. 501. And he elsewhere adds (p. 509), "I shall not
be surprised, if in a few years British practitioners come to resort more tre-
quently, especially in extreme cases, to the Cæsarean section."
166
MATERNAL DYSTOCIA.
two and a half inches in its long diameter; or, in other words, this
aperture was fully half-an-inch in all its dimensions below the limits
supposed to demand the necessity of the Cæsarean section. Before
showing the solution of such a seeming obstetric enigma, I shall
briefly state the anterior history of the patient.¹
DETAILS OF THE CASE OF MALACOSTEON, AND INFERENCES FROM IT.
Mrs. D―, Cupar in Fife, now 34 years of age, was in early
life regarded as a robust and large child. She became a dressmaker
in Edinburgh at fourteen years of age. The sedentary habits of
this profession betimes rendered her catamenia very irregular, and
brought on so much general delicacy of health that she was advised
to forego the occupation. She went to Cupar, and lived there with
a relation. In 1837, when about 24 years of age, she married.
Two years subsequently to that event she began to complain of
pains in the back and sides, and stiffness about the knee-joints.
From this attack she never recovered so fully as to be able to walk
without support, and continued to suffer much with shifting pains.
In 1840 she fell, while walking with a staff across her room, and
after this the pains in the limbs were for a considerable time far
more severe, and the lameness greatly increased. Since recovering,
she has been able to walk out of doors with the assistance of
crutches. But various bones of the trunk and extremities have be-
come shortened and deformed under the effects of the malacosteon.
The spine is bent backwards and outwards in the form of a bow,
with the ribs and sternum correspondingly displaced. Some of the
phalanges of the fingers are bent; the right thigh-bone is curved
forward into a semicircular shape. And from being a handsome.
and somewhat tall woman, she has shrunk down, during the course
of the last seven or eight years, into a deformed dwarf-like figure,
measuring about four feet in height.
From the time of her marriage up to last June (1846) Mrs. D.
had never become pregnant. Some time, however, during the course
of June—but she is not certain at what precise period of the month
-the catamenia appeared for the last time. She was delivered on
the 28th of April, or ten months after the last menstruation.
For some time after pregnancy commenced, Mrs. D. feared that
the swelling and increased size of the abdomen were the result of
1 For these particulars I am much indebted to the kindness of Mr. Wiseman
of Cupar, the patient's medical attendant.
CASE OF MALACOSTEON.
167
dropsy, and did not watch her own feelings so as to be aware of the
period of quickening. At last, however, the motion of the child,
etc., became so unequivocal, that she applied to Mr. Wiseman to
attend her in her approaching confinement.
On examining into the condition of the pelvis, Mr. Wiseman at
once found that its outlet was extremely contracted, but the preg-
nancy was already so far advanced as to preclude, under such a
degree of deformity, the idea of delivery by the induction of abor
tion or premature labour. Besides, all attempts to touch the os
uteri proved ineffectual, so that none of the ordinary means of
arresting pregnancy, and exciting uterine action, could have been
put into practice.
Early in March I visited Mrs. D., with Mr. Wiseman, Dr.
Graham, and Dr. Grace. She was quite incapable of moving or
turning in bed without assistance. The uterine tumour was high,
and pressed over to the right side. On applying my stethoscope to
it, I readily detected the usual rapid pulsations of the foetal heart.
I found fully borne out the correct description which had previously
been given me of the excessive deformity and contraction of the
pelvis. The sacrum was straight above, so that its promontory did
not probably encroach on the brim; but its inferior extremity was
strongly and anormally curved forwards. In front, the walls of the
pelvis felt doubled or collapsed together; and the outlet, which was
the only part that could be very accurately examined, was exceed-
ingly deformed and diminished in size. The transverse diameter
was particularly contracted. I found it impossible to introduce two
fingers between the tuberosities of the ischia. Hence this diameter
of the outlet was evidently under an inch. Posteriorly, or opposite
the sacro-sciatic ligaments, there was transversely more space, but
the strong anterior curvature of the coccyx and lower end of the
sacrum seemed to curtail the conjugate diameter of the opening, and
to prevent the probability of its admitting, when fully dilated, more
than three, or, at most, four fingers, even in this direction.
Under these circumstances, with a living child advanced to the
eighth month, and a pelvic outlet so extremely contracted, I had no
hesitation in coming to the same conclusion as the patient's medical
advisers had all previously done, namely, that the Cæsarean section
was the only practicable mode of delivery. I was aware that
Barlow, Conradi, Sprengel, and others, had seen and published cases
of mollities ossium, in which the softened and still flexible pelvic
bones had bent and yielded during labour so as to permit the pass-
168
MATERNAL DYSTOCIA.
age of the child without operative interference; but in Mrs. D. the
osseous tissue appeared far too firm to permit us to indulge even in
this faint hope. Nature, however, provided, and was perhaps
already preparing, for the mother a mode of delivery that was still
more safe and easy.
Having agreed to operate in case the Cæsarean section was
required, I anxiously waited in the daily expectation of being called
to Mrs. D. At last, on the morning of the 28th of April, I received
from Mr. Wiseman a note, dated the previous night, intimating that
our patient had begun to complain of labour pains-that the os
uteri could be felt projected low down into the vagina-that it was
not opened more than two or three lines-and that the presenting
part of the child could not yet be detected. With some profes-
sional friends who had agreed to accompany me, I forthwith pro-
ceeded to Cupar, a distance of about thirty miles. On arriving
there, we were surprised to hear that the patient was delivered, and
our surprise was only increased by learning that no kind of instru-
mental aid had been required. A visit, however, to the room in
which the child was, readily solved the apparent riddle.
The infant had been dead for some time in utero. It looked
nearly the natural length, and as it lay extended on the table, it
measured 18 inches from the crown of the head to the heels. But
its limbs and body were thin, lank, and atrophied; and its weight
was only three pounds two ounces. Its head appeared very large.
and disproportionate in size, and indeed had been considered hydro-
cephalic. This seemingly increased volume, however, was not the
consequence of effusion, but the result of putrefaction. The ence-
phalon was in a dissolved and semi-fluid state; and as the head lay
on the table, it was extended and flattened out laterally and supe-
riorly, as if it consisted of a bag or bladder, half filled with liquid or
semi-liquid contents; and such in fact it really was. For all the
bones of the arch of the cranium were separated from their attach-
ments, and floated about in the dissolved and liquified cerebral
matter. The bones of the basis of the skull were also loosened, and
more or less separated from each other—a rarer occurrence. On
handling the vertex, the first piece of bone which I touched was the
orbital portion of one of the ossa frontis. The symphyses even of
the inferior, as well as of the superior, maxillary bones, were
loosened, and admitted of free motion. And the component parts.
of the head and face were so easily displaced and compressed that,
on placing one of my fingers in the lower occipital region behind,
Y.
CASE OF MALACOSTEON.
169
and another on the nose or cheek in front, I found that, without any
considerable degree of exertion, the two could be made to approxi-
mate to within a few lines of each other. Yet the skin of the scalp
and face was continuous and entire, the epidermis only being
separated at different parts. The chest and abdomen of the child
seemed quite soft and pliable, though not in so disintegrated a state
as the head.
Thus far the macerated and diffluent state of the foetus appeared
to afford an easy explanation of the possibility of its transit through
the very contracted pelvic outlet of the mother. But I was anxious
to have more full and complete proof that
the foetus, even in this state, was capable
of passing through an aperture, of dimen-
sions so small as we knew the pelvis to pre-
sent in the case of Mrs. D. In order to
obtain this proof, I got oblong openings of
two or three different sizes cut in plates
of white iron. The smallest of these per-
forations, however, though only 3 inches
long by broad, proved unnecessarily large
for the experiment. We diminished it by
filling it up at one end with strong, thick,
and perfectly unyielding sole leather, so that
the whole opening measured only 2 inches
in its largest, by of an inch in its shortest
diameter; and yet through this aperture, of
which the accompanying woodcut gives the
exact outline,' the child was pulled without any great degree of force
or difficulty. In dragging the infant through this aperture, no par-
ticular resistance was met with from the bones of the head and face;
but the size of the liver impeded its transit for a minute or two,'as
the lower part of the thorax was passing through the metallic open-
ing. Dr. Graham, Dr. Ziegler, Dr. Weir, Mr. Wiseman, etc., wit-
nessed these experiments with me; and, if our limited time had
allowed us to remain longer in Cupar, and to have got another
plate perforated, probably we should have found the child capable
of passing through an aperture one or two lines smaller in some of
its dimensions.

Fig. 4.
The placenta had been preserved. It was small and atrophic,
1 The perforated iron plate and superadded piece of leather are preserved in
the Obstetric Museum of the University.
170
MATERNAL DYSTOCIA.
and contained scattered through it a number of those white tuber-
cles, as they are sometimes improperly termed, which we so often
see connected with, and causing, marasmus and death of the fœtus
in utero. Some of these tubercles or fibrinous deposits were of the
size of hazel-nuts, or larger.
The history of the delivery had been this.-Slight labour pains
had come on during the afternoon of the 27th. She was seen in
the course of the evening by Drs. Graham and Grace and Mr.
Wiseman, who found the os uteri beginning to dilate, but the pains
were not severe, and the husband and attendants of Mrs. D. all
went to bed. About one o'clock in the morning of the 28th, Mr.
Wiseman was raised, the waters having escaped about an hour pre-
viously, and the uterine contractions having become strong, and
bearing down. When Mr. Wiseman reached the house of the
patient, he found the soft scalp of the child already bulging through
the external parts. Some detached bones, included in the portion
of scalp that had passed, allowed him to obtain a firm hold of the
protruded portion of the head, and thus enabled him to use some
extractive force. By thus assisting the effects of the pains, the
child was entirely born about half-an-hour after Mr. Wiseman's
arrival. The mother has made a very good recovery, and declares
that "having a child is nothing."
There are no sufficient data to determine at what precise time
the infant died. Milk had been discharging from the nipples for
three or four weeks before delivery; but whether the child had
perished about that period, it is impossible to say. Mrs. D. deceived
herself with the idea that she felt it living and moving up to the
time of delivery.
The preceding case is, I believe, unique in the annals of mid-
wifery. It will perhaps, therefore, require no apology if I add one
or two brief inferences which the history and details of it appear to
suggest.
1. It has taught me, and is, I conceive, calculated to teach
others, a strong lesson of caution in regard to our prognosis, under
apparently even the most desperate circumstances.
In such rare
forms of complication as this, we must depend for our prognosis,
etc., upon the anterior observations and recorded facts of others.
Here all such records led me to expect a very different result, and
offered no hope whatever of such a fortunate termination as actually
occurred:
CASE OF MALACOSTEON.
171
"1
2. The case affords a new and striking illustration of the just
and well-known remark of Dr. Denman, that "the resources of
nature in everything which relates to parturition are infinite, and
constantly exerted for the preservation of both the parent and child;
yet, when the two objects are incompatible, the life of the child is
almost uniformly yielded to that of the parent. And the mode
and mechanism by which nature brought about this unexpected
result in the present instance are highly worthy of special notice.
For, first, she set up a diseased condition of the placenta, which pre-
vented the full and proper nourishment of the fœtus, and thus
restrained as far as possible its development and growth. Secondly,
she carried this state of marasmus to such a degree, as at last proved
slowly fatal to the child, without superinducing that expulsive action
which generally soon follows the death of the infant. Thirdly, the
dead infant was subsequently retained for so long a time in utero,
that not only the bones of the cranium, but the bones of the basis
of the skull and face were loosened and separated from each other,
and the head and other parts of the body thus rendered readily and
easily compressible. And, lastly, the emaciated, dead, and highly
2
¹ Practice of Midwifery, p. 415.
2 No individual case in midwifery has given rise to so much discussion as
that of Elizabeth Sherwood. Her pelvis was estimated by Dr. Osborne as below
the lowest standard which I have given in a preceding page, as capable of allow-
ing of the passage of a child by embryulcio, being only about of an inch from
the sacrum to the pubis; and yet he delivered her successfully by craniotomy after
working and pulling three hours with the crotchet. Many authors have stated
that Dr. Osborne must undoubtedly have under-measured the pelvis of Sherwood;
--and Drs. Hull, Burns, Hamilton, etc, have denounced the operation of em-
bryulcio as "impracticable" if Dr. Osborne's measurements were at all true and
accurate. Dr. Campbell, for instance, observes, "It would be idle to enter largely
on the refutation of this extraordinary case, since Dr. Osborne's narrative of what
he thought he had accomplished is irreconcilable with common sense; for how
could the base of the cranium, which is 14 inch in thickness, and nearly three in
breadth, be brought through the aperture which he describes. A fair estimate,
Dr. Campbell continues, " of the utter impossibility of effecting it may be afforded
by the simple experiment of forming in a plate of hard wood, an opening, in
shape and size exactly corresponding to the pelvis of Sherwood, and attempting
to force through it the base simply, divested of the other portions of the skull."
—Midwifery, pp. 317 and 318. In the case of Mrs. D., I obtained the corrobora-
tive evidence afforded by the very experiment which Dr. Campbell here properly
suggests; and I have already stated the facility with which the child was passed
through the perforated plate. In Sherwood's case there was, I believe, the same
reason for the practicability of delivery, for the fœtus seems to have been in the
same putrid and decomposed state as Mrs. D.'s child, and perhaps the bones of
the face and basis of the cranium were in a similar way loosened and compress-
ible. "The whole body of the foetus was," to quote Dr. Osborne's own words
""
172
MATERNAL DYSTOCIA.
putrefied infant, after being thus reduced to this diffluent and com-
pressible mass, and now capable of being moulded to the contracted
apertures of the pelvis, was ultimately and without difficulty expelled
through them by the supervention of natural uterine contractions.
Each stage and step in this mechanism was necessary for the success
of that which followed it, and the imperfection or omission of any
one of them would probably have entirely subverted and prevented
very fortunate and very unlooked-for result that occurred from
the combination of the whole.
the
3. Does the mode in which the delivery was effected in this
instance by nature, suggest any measures of practice which, under
similar complications, we could induce and imitate by art? I put
this question, because, in the greater deformities of the pelvis, all
the standard operations and means which we employ for delivery
are in fact imitations of processes and operations which nature herself
employs under the same conditions. When the pelvis has been much
contracted, abortion has occasionally come on in the earlier months
and saved the mother; or premature labour has supervened about
the seventh month, and saved both the parent and child. These
natural processes we imitate successfully in the artificial induction
of abortion and premature labour. If, in morbid contraction and
deformity of the pelvis, the pregnancy goes on to the full time, nature
is still sometimes capable of delivering the mother by other and
various measures. Occasionally, during labour, the symphysis pubis
has been rent asunder under the intense and wedge-like pressure of
the infant's head; or the uterus has been lacerated, or, as has hap-
pened now in two recorded cases, both the uterus and abdominal
parietes have simultaneously ruptured and allowed the escape of the
child through this double opening; or the bones of the child's
cranium have become deeply compressed and fractured, so as at last
to allow the reduced head to pass; or the same has been effected
by the infant dying, putrefying, and at last its scalp and sutures
"in the most putrid and almost dissolved state."-See p. 101 of his Essays.—
But, besides, the brim of the pelvis in Sherwood was in reality not so small as
the measurement of its conjugate diameter would seem to indicate. During
delivery the os uteri was pulled by Dr. Osborne over to the right side, or to the
space intervening between the line of the conjugate diameter and the right ilium.
Here there was an oblong aperture 3 inches long (as measured from the ilium to
the symphysis pubis), and 14 inch broad; and hence in fact an aperture as great
as Drs. Hamilton, Burns, Churchill, Ramsbotham, etc., deem necessary for the
performance of embryulcio; and greater than that through which we pulled Mrs.
D.'s child. See drawing of the brim of Sherwood's pelvis, in Dr. Hull's Defence
of the Cæsarean Section, pl. v. fig. 1.
CASE OF MALACOSTEON.
173
bursting, so as to produce the necessary diminution in the size and
dimensions of the encephalon. These several operations of nature
are all imitated by art in the respective operations of symphyseo-
tomy, the Cæsarean section, cephalotripsy, and craniotomy. And
while art thus adopts the operative principles of nature, she attempts
to improve both upon their facility and safety, by selecting an earlier
and hence less dangerous period for their performance; and by
making the required openings and lesions by cutting instruments,
instead of submitting to the chance of their being made by nature
by means simply of an enormous and hazardous expenditure of
muscular effort and compression on her part.
But, I repeat, does the mechanism of the delivery in Mrs. D.'s
case suggest any principles for imitation? Let us consider the
answer, as it might be varied by the date of the pregnancy of the
mother; and according as she had reached the periods, first, of
artificial abortion; or, secondly, of premature labour; or, thirdly, had
already advanced to the full time.
The case shows that through an opening of very small dimensions
a child may pass, provided it be in a very compressible state. So
far it evidently suggests that the induction of abortion at the fourth
or fifth month, when the head of the fœtus is still small, soft, and
very easily reducible, would, as long ago proposed by Cooper, etc.,
succeed in such extreme deformities in saving the mother from many
of the dangers accompanying delivery at a later period of utero-
gestation. I have stated above, that Mrs. D. applied to Mr. Wise-
man at a time when it was already considered too late to have
recourse either to artificial abortion or premature labour; and
further, the high position of the os would probably have rendered
either of them impracticable.
The induction of premature labour at or about the seventh
month would not, of course, have sufficed with a pelvis of such small
dimensions, unless we could modify the operation so as both to
produce the death of the child and retain it in utero, for the purpose
of allowing its structures to become dissolved and disintegrated
before labour at last supervened. Now we have no known means
of inducing that diseased state of the placenta which produced the
attendant emaciation and death, in the case of Mrs. D.'s infant ;
nor am I acquainted with any measures which would destroy the
life of the child in the later months, without superinducing labour.
The retention, however, in utero of the infant, and its maceration or
putrefaction, would be as necessary for success as its death, under
174
MATERNAL DYSTOCIA.
such great degrees of contraction.
And the result shows, that when
the pelvis is much deformed, and labour with a dead child is threat-
ened, or the infant is destroyed by craniotomy, the longer we can
retain it in utero without danger to the mother, and the more it
thus becomes putrefied and disintegrated, the easier will its ultimate
expulsion or extraction prove.
Lastly, suppose a patient with a very diminished and deformed
pelvis to have arrived at the full time of utero-gestation, does Mrs.
D.'s case suggest any new principles or modifications of treatment
for the delivery of the mother? I believe that, under these circum-
stances, our conduct and practice should be, in a great degree, regu-
lated by the state of the child. If it be alive, as ascertained by
auscultation, etc., and the pelvis is as small as in Mrs. D.'s case, or
even half-an-inch larger in its measurements, then I am decidedly
of opinion that it is our duty to perform the Cæsarean section. We ·
have two human lives committed to our charge, and it is our duty
to try to preserve both, provided we can attain that object without
subjecting the mother to a degree of danger, much greater than she
would otherwise undergo. Let us take, however, the other alter-
native, and suppose the child already dead. With this complication
most British accoucheurs would attempt delivery by craniotomy, if
the dimensions of the pelvis permitted at all of the possibility of it.
And the case of Mrs. D. seems to me to suggest one means of
rendering it thus possible, under states of contraction, where it is
at present properly regarded as in the highest degree unsafe or
totally impracticable. The grand obstacle to the delivery of the
child by embryulcio, in greatly contracted pelves, arises from our
want of means to reduce the size, or alter the shape and compress-
ibility, of the bones of the base of the skull and face. In Mrs. D.'s
child, nature had disintegrated and separated these bones,' had
removed in fact this obstacle, and thus rendered the delivery not
only possible but easy. Could we imitate or induce this same
fortunate result by artificial means? All our present means of
reducing the size of the fœtal head in embryulcio, are limited to the
destruction of the arch of the skull. I am not aware that with any
proposed form of osteotomist' we are capable of cutting or dis-
1 The Kephalepsalis of Dr. Campbell appears to me to be an instrument pre-
ferable to, and more powerful than, any of the forms of osteotomist invented by
Dr. Davis or others. Yet, as we have already seen, Dr. Campbell believes em-
bryulcio to be impracticable, even with its assistance, in a pelvis less than 3 by 2
inches. It is almost unnecessary to add, that the French operation of Cephalo-
CASE OF MALACOSTEON.
175
integrating the base of the cranium or face, when the pelvis is
diminished to 14 or 1 inch in its shortest diameter. Yet,
probably, some modification of mechanical means would give us the
power of effecting this desirable object. The common perforator
might enable us to loosen and break up the bones of the base, in
some cases, in the same way as with it we break up the arch, of the
skull. The disjunction or fracture of these bones, without their
removal, migh prove sufficient to permit the required degree of com-
pressibility and alteration of shape. Or the common bone-forceps
of the surgeon, or a modification of such powerful pliers as are used
in dividing the needles in the operation for harelip, etc., might
answer. At all events, the object seems anything but a hopeless
one, more especially when we call to recollection that modern
surgeons are now provided with mechanical means, which sometimes
enable them to seize, break up, and extract from the cavity of the
bladder, large and solid stones-and that too, through a canal
relatively so small and elongated as the male urethra.
The subsequent history of the patient, whose case is described
in the preceding pages, was as follows:
Mrs. D. remained in much the same state of health for several
years after her delivery. The deformity of the skeleton did not.
seem to advance in any degree during that period, and was con-
sidered by herself and friends to be quite arrested in its progress.
In 1853 she again became pregnant. But she did not inform her
medical attendant, Mr. Wiseman, of her state, nor consult him in
any way in regard to it; and he was not called to see her till she
had been a considerable time in labour, under the charge of a
midwife. Parturition supervened at the supposed full term of
gestation. She was not aware of the exact date of the last cata-
menia ;
but she had felt the movements of the child for five months
before labour commenced. Mrs. Adam, the midwife, was called to
tripsy is founded on the idea of crushing and compressing the bones of the base,
as well as of the circle, of the cranium. It is used by some of the leading
accoucheurs of Paris, instead of craniotomy, particularly in cases where the child
is dead, and the pelvis below the dimensions that would admit the use of the
forceps. But the instrument with which the operation is performed-the Cepha-
lotribe--is of such enormous dimensions, its blade being of solid iron, 14 inch
wide, the whole above 2 feet long and several pounds in weight, that it could not
of course be applied in cases where the pelvis was contracted to any extreme
degree.
176
MATERNAL DYSTOCIA.
Mrs. D.'s assistance
21st of June 1854.
about ten or eleven o'clock on Wednesday, the
Mr. Wiseman was first sent for next morning,
about four o'clock. The patient continued in labour during that
and the two subsequent days. On Friday morning a summons was
sent for me to Edinburgh; but in consequence of some mal-
arrangement at the telegraph office, it was not delivered; and a
second message by railway arrived that evening. Accompanied by
my friends Drs. Malcolm and Storer, I reached Cupar early next
morning. The patient was by this time very weak and exhausted,
and, indeed, almost moribund; but the child's heart could be still
heard beating, though feebly. I performed the Cæsarean section,
more with the hope of still saving the child, than of being of any
possible use to the mother. No special difficulty occurred in the
operation, except from an artery in the divided walls of the uterus
bleeding profusely by a per-saltum stream, till it was arrested after
a time by torsion. The patient died about two hours subsequently.
The child, the care of which was entrusted to Dr. Graham, breathed
only once or twice after birth; but its heart continued to pulsate
slightly for ten or fifteen minutes. It seemed to die from cerebral
effusion.
A post-mortem examination was permitted. Mr. Wiseman has
kindly furnished me with the following notes of it :—
"The entire length of the body was found to be 4 feet 4 inches.
The left femur was curved forward, rendering that limb shorter by
an inch and a half than the right limb. The measurement from
the superior anterior spinous process to the heel, being in the one
case 31 inches, in the other 324. The ribs projected much forward
from the point of the insertion of the clavicles, which bones were
greatly twisted, and the sides of the chest were thrown down upon
the bones of the pelvis. This arched line, from the upper end of
the sternum to the scrobiculus cordis, measured 6 inches. From
the junction of the clavicles to the superior anterior spinous process
of the ilium, 10 inches.
"Posteriorly, the line of the spine from the end of the os
coccygis to the nape of the neck, measured 20 inches. The spine
projected to a considerable extent at the upper part of the back,
and again to a smaller extent in the sacral region.
"We found the length of the incision made in the operation to
be 6 inches; and, the stitches being removed, about 4 ounces of
coagulated blood were found in the abdomen.
"The distance between the two superior and anterior spinous
PLACENTA PRÆVIA.
177
processes of the ilia was nearly 10 inches, or more precisely 93.
The brim of the pelvis was triangular, or cordate, in form; the
transverse and antero-posterior diameters measuring each nearly 32
inches at their widest points. The capacity of the brim, however,
was not in proportion to the above measurement, from the great
projection forward of the sacrum and pubis, and the collapse
inwards of the sides of the ilia. The outlet of the pelvis was far
more contracted. From the symphysis pubis to the coccyx, it
measured 3 inches, but the transverse diameter, or distance between
the tuberosities of the ischia, was only half-an-inch. The depth of
the pelvis at the symphysis pubis was two inches."
ON THE
SPONTANEOUS EXPULSION AND ARTIFICIAL EXTRAC-
TION OF THE PLACENTA BEFORE THE CHILD,
IN PLACENTAL PRESENTATIONS.
I.¹
SECTION I.-DANGERS OF PLACENTAL PRESENTATIONS: OPINIONS
OF AUTHORS: STATISTICAL EVIDENCE OF THE FATALITY OF
THESE PRESENTATIONS.
All obstetric authors seem to agree on this point, that there is
no one complication in midwifery attended with more anxiety to
the practitioner, and few, if any, with more real danger to the
patient, than cases of unavoidable hemorrhage from presentation of
the placenta.*
"Placental presentations," says Dr. F. Ramsbotham," are always
1 See London and Edinburgh Monthly Journal of Medical Science, March 1845,
p. 169. The substance of the following memoir was, on the 4th of December
1844, laid before the Medico-Chirurgical Society of Edinburgh.-See Edinburgh
Monthly Journal, February 1845, pp. 158-161.
2 << During the last months of gestation, and at the commencement of labour,”
observes Dr. Churchill, “patients are exposed to two forms of hemorrhage,
differing in their causes, but depending upon the situation of the placenta. The
first has been called 'accidental hemorrhage,' because it arises from a partial and
accidental separation of the placenta, which occupies its usual situation; and the
second is justly termed 'unavoidable hemorrhage,' because the placenta being
placed partially or wholly over the os uteri, the dilatation of this will unavoidably
separate the after-birth, and give rise to hemorrhage."-Theory and Practice of
Midwifery, p. 383. Our investigations in the present memoir refer to the last of
these two forms of uterine hemorrhage.
178
MATERNAL DYSTOCIA.
1
fraught with extreme peril." "The attachment of the placenta,'
observes Dr. Collins, "to the mouth of the womb, is one of the
most dangerous complications to be met with in midwifery."
"There are few dangers," to quote the words of Dr. Edward
Rigby," "connected with the practice of midwifery, which are more
deservedly dreaded, and which are wont to come more unexpectedly,
both to the patient as well as to the practitioner, than that species
of hemorrhage which occurs in cases where the placenta is implanted,
either centrally or partially, over the os uteri." "It is," says Dr.
Dewees,* "confessed on all hands, that no accident attendant on
conception, is equally menacing, as unavoidable hemorrhage; and it
also emphatically declares to the physician, that much depends on
him, that it shall not be very often fatal. It is one," he adds, "of
those extraordinary cases, in which nature does less for the preser-
vation of the individual than in almost any other." "That form of
hemorrhage," remarks Madame Lachapelle," "which depends upon
the implantation of the placenta upon the internal orifice of the
uterus, is one of the most dangerous accidents to which pregnant
women are exposed." "It is perhaps," long ago observed Deleurye,
"of all labours, that in which the mother and the child run the
greatest danger." Still earlier, Lamotte states,' that "amongst all
the accidents of child-birth, there is not any one more perilous
(il n'y en a point un plus perileux) than that in which the after-birth
presents before the child."
5"
The actual results of practice fully bear out the observations
which I have selected from the preceding authors upon the danger
of unavoidable hemorrhage from placental presentation. My friend
Dr. Churchill, in his late excellent work upon the Theory and
Practice of Midwifery, has collected from different sources the records
of 174 cases of this complication. Amongst these 174 cases, 48
proved fatal to the mothers; or nearly one in every three of them
died. I have attempted to make a still more extensive analysis of
recorded cases of placenta prævia, or placental presentation, and the
consequences of this complication as bearing on the life of the
mother. The following Table shows the results of the inquiry :-
1 Obstetric Medicine and Surgery, 2d edition, p. 391.
8
2 Practical Observations on Midwifery, p. 90.
3 System of Midwifery, p. 248.
Pratique des Accouchemens, tom. iv. p. 362.
4 Midwifery, p. 390.
7 Traité des Accouchemens, p. 36.
• Traité Complet des Accouchemens, p. 404.
8 Printed as published in the Lancet for September 1847, p. 276, in a corrected
form, and with additional data furnished by Dr. Ramsbotham, Dr. Wilson, etc.
See also Lancet for 1847. n. 517, in reference to the correctness of the data.
PLACENTA PRÆVIA.
179
TABLE OF MATERNAL MORTALITY IN PLACENTAL PRESENTATIONS.

Reporters.
Mauriceau¹
Portal 2
Giffard 3
·
Smellie¹
Rigby 5
6
Clarke and Collins 7
Busch 8
Schweighauser
Lachapelle 10
J. Ramsbotham 11
F. Ramsbotham 12
Lever 13
Lee 14
Wilson 15
•
Total
No. of Cases. Mothers Lost.
18
3
•
14
1
•
19
5
•
18
7
•
42
10
•
16
4
13
2
•
65
16
•
•
129
ེབ་
10
41
•
189
49
34
S
•
46
14
30
10
•
654
180
From the above Table, it thus appears that out of 654 cases of
placental presentations which are collected into it, the result was
fatal to the mother in 180 instances, or, in other words, 1 in every
3 of the mothers perished in connection with this complication.
1 Observations sur la Grossesse et les Accouchemens, vol. ii. pp. 8, 48, etc. etc.;
and Edinburgh Medical and Surgical Journal, vol. li. pp. 383-84.
2 La Pratique des Accouchemens, 1785, Observ. ii.-xxix., etc. etc.
3 Cases in Midwifery, pp. 22, 36, 38, 52, 87, etc. etc.
4 Collection of Cases, etc., vol. ii. pp. 307-315; and vol. iii. pp. 141-178. I
have, with Dr. Churchill and others, here and in a subsequent table, marked all
those cases of Dr. Smellie's as recoveries, where an opposite result is not directly
stated. The context seems to warrant this.
5 An Essay on Uterine Hemorrhage, 6th edition, p. 262.
6 Transactions of King and Queen's College of Physicians, vol. i. p. 380.
7 Practical Observations in Midwifery, p. 96. The returns of Drs. Clarke and
Collins are classed together, as both coming from the Dublin Lying-in Hospital.
8 Forbes' British and Foreign Review, vol. v. p. 587.
9 La Pratique des Accouchemens, p. 224.
10 Pratique des Accouchemens, tom. ii. pp. 415-461.
11 Practical Observations in Midwifery, part ii. pp. 195-233, and MS. Notes.
12 Principles of Obstetric Medicine and Surgery, 2d edition, pp. 395-96. Dr.
F. Ramsbotham kindly drew out for this memoir, in 1847, a list of all the cases
of placenta prævia attended by his father and himself, with their results, as given
in the above table.
13 Guy's Hospital Reports, vol. vi. p. 66.
14 Lectures on the Theory and Practice of Midwifery, p. 371.
15 From MS. notes of Dr. Wilson, formerly Lecturer on Midwifery, and de-
servedly one of the most highly esteemed and distinguished obstetric practitioners
in Glasgow. Many of the fatal cases were instances which Dr. W. saw in con-
sultation.
13
180
MATERNAL DYSTOCIA.
2
2
The dangers of placental presentations to the mother may appear
stronger to some minds if I state them in other terms. Two of the
most fatal epidemics of modern times, are yellow fever and Indian
or malignant cholera. In the well-known yellow fever of Cibraltar
of 1828, the mortality among those attacked was nearly 1 in 4.'
In 1832-33, about 1 in 3 of those affected in England with the
epidemic cholera, died. Hence those mothers who are the subjects
of placental presentations are submitted to as great peril of life
from this obstetric complication, as they would be if seized with
yellow fever or malignant cholera. Further, the operation of
lithotomy is generally regarded as one of the most formidable in
surgery, and is calculated to be fatal in the proportion of 1 in
every 6 or 8 subjected to it. The occurrence of placenta prævia is
twice as dangerous and fatal as the operation of lithotomy-1 in
every 3 perishing under the first, and 1 in every 6 or 8 perishing
under the last.
Looking at these results, it will, we believe, be readily conceded,
that any attempt-such as is the professed object of the present
memoir- to diminish this fearful maternal mortality in placenta
prævia, is entitled at least to the consideration of the obstetric pro-
fession, even should it fail to be so fortunate as to secure their
concurrence and conviction.
SECTION II. RECOGNISED PRINCIPLES OF TREATMENT:-1. Eva-
CUATION OF THE LIQUOR AMNII: AND, 2. DELIVERY BY
TURNING. PROPOSAL OF A THIRD PRINCIPLE: THE COM-
PLETE SEPARATION OF THE PLACENTA; GROUNDS FOR PRo-
POSING IT: ILLUSTRATIVE CASES.
Hitherto, two great principles of treatment-if we leave out the
minor details of management-may be said to have been pursued
by obstetric practitioners in the treatment of placental presentations.
1 Out of 5383 persons attacked, 1183 died.-See Researches on the Yellow Fever
of Gibraltar, by Dr. Louis of Paris; Boston, 1839, p. 259.
2 Dr. Merriman has calculated, from official returns, that 49,594 individuals
were affected with epidemic cholera in England, and that 14,807 of them died,
giving the proportion in the text. In Scotland and Ireland the mortality was
greater. See Medico-Chirurgical Transactions, vol. xxvii. p. 416.
3The average mortality from lithotomy, on all hands, appears at present to
be about 1 in 8."-Dr. Willis' Urinary Diseases, 1838, p. 347. Mr. Inman has
calculated the mortality from lithotomy to be 1 in every 7 cases, 765 patients
having died out of 5900 operations which he had collected.—See Lancet for October
5, 1841.
PLACENTA PRÆVIA.
181
And the two modes of practice I allude to are supposed by many to
be applicable to two different stages or degrees of the complication
They consist of the two following measures :—
1. The Evacuation of the Liquor Amnii.
In some cases of placenta prævia, and under some circumstances,
the artificial evacuation of the liquor amnii is recommended to be
had recourse to, and thus the same treatment is followed for
"unavoidable" hemorrhage, as is followed by most practitioners in
instances of "accidental" hemorrhage. This mode of practice has
been especially applied of late to cases in which the presentation of
the placenta was only partial, and where, consequently, a portion of
the membranes was within reach, and to instances in which the
hemorrhage was comparatively slight in its degree and effects.
About a century and a half ago, the same treatment seems to have
been employed also by some practitioners, in instances in which the
placenta presented completely over the os uteri, the placental struc-
ture being perforated artificially by the finger or an instrument, in
order to permit the liquor amnii to escape. After recommending
that, in placenta prævia, the membranes should be pierced, or the
fingers thrust through the placenta, "that at last it be perforated,
and instead of the constant flux of blood which appeared before, the
humours will presently flow out," Daventer,' writing about the year
1700, adds, "some penetrate the secundines with a hair needle,
which I do not approve of if it can be done with the fingers, because
the infant is easily hurt." Under some conditions in placenta
prævia, Deleurye³ recommends the piercing of the placenta with a
trocar, in order to allow the liquor amnii to be drained off. Bau-
delocque¹ speaks of the same practice as probably useful in instances
of complete or central presentation of the placenta, when the cervix
will not allow of turning; and in later years the same plan has been
again proposed by the elder Dr. Ramsbotham, and successfully put
in practice by Gendrin" of Paris.
1
5
1 The Art of Midwifery Improved, London, 1715, pp. 153-54.
2
2
“Placentam vel secundinam acu crinali perfodiunt," to quote the original
Latin. See p. 138 of the second edition of Daventer's Norum Lumen, etc.
Leyden, 1733. The first edition was published in 1701.
3 Traité des Accouchemens, Paris, 1777, p. 369.
4 System of Midwifery, translated by Heath, vol. ii. p. 38.
↳ Practical Observations, part ii. p. 189.
6 Traité Philos. de Médecine Pratique, tom. ii. p. 548.
182
MATERNAL DYSTOCIA.
2. The Delivery of the Child by Turning.
In the generality of cases of unavoidable hemorrhage from
placental presentation, the practice which is adopted consists in
forcing the delivery, by passing the hand through the os uteri up
to the feet of the infant, and extracting the child by the operation
of podalic turning. This last mode of practice is the one univer-
sally followed when the hemorrhage is very severe, and whether the
artificial evacuation of the liquor amnii has preceded it or not, and
it is the plan of treatment usually pursued where the presentation.
of the placenta over the os uteri is central or entire. By some
accoucheurs indeed, as Drs. Burns and Hamilton, Baudelocque,
Capuron, and others, the forcible delivery of the woman by the
operation of turning is the only mode of treatment that is thought
advisable under any circumstances in connection with placenta prævia.
6
In
It is, according to Plenck, "nullo remedio sed solâ extractione
fotûs curanda.' "All the best practical writers are," says Dr.
Merriman, "unanimous on this point, that the case of placenta
adhering over the cervix uteri is not to be trusted to nature.
all cases of attachment of the placenta over the os uteri, it is incum-
bent upon the accoucheur to make up his mind to the operation of
turning the child, and bringing it into the world by the feet."
This is a case," Dr. Conquest remarks," "in which we ought never
to confide in the powers of nature, because expulsatory uterine
efforts only augment the peril of the patient; and therefore the
hand must be either bored through the substance, or, what is better,
passed by the edge, of the placenta, and the child turned.”
completely established," to quote the words of Dr. Dewees,' “that
the only chance the woman has for life, is by a well-timed and
well-conducted delivery, in every case of placental presentation."
"When hemorrhage," says Dr. Denman," "from this cause (placen-
tal presentation) comes on, though all women without proper assist-
ance would not die, none are free from danger till they are delivered.
As there is a very doubtful chance of the delivery by the pains of
labour, and as experience has fully proved the frequent insufficiency
of all other methods intended to suppress the hemorrhage, and how
1 Elementa Artis Obstetricæ, 1781, p. 133.
Synopsis, etc., of Difficult Parturition, 1826, pp. 126, 127.
3 Outlines of Midwifery, p. 157.
4 System of Midwifery, p. 394.
• Introduction to Midwifery, p. 527.
((
It is
PLACENTA PREVIA.
183
little reliance ought to be placed on them, though they are always
to be tried; it is a practice established by high and multiplied
authority, and sanctioned by success, to deliver women by art, in all
cases of dangerous hemorrhage, without confiding in the resources
of the constitution. This practice is no longer a matter of partial
opinion, on the propriety of which we may think ourselves at liberty
to debate; it has for near two centuries met the consent and appro-
bation of every practitioner of judgment and reputation in this and
many other countries. See Mauriceau and almost every succeeding
writer."
Cases of Placenta Prævia not unfrequently occur in practice in
which neither of the two preceding plans can be successfully
adopted-where the artificial evacuation of the liquor amnii is
insufficient to moderate the hemorrhage to a safe degree-and where
forced delivery by turning is inapplicable or extremely dangerous if
adopted. In these and other cases, I would beg to submit to my
obstetric brethren an additional principle of treatment, viz.-
3. The Complete Separation, and, if necessary, Extraction of
the Placenta before the Child.
I shall first state the grounds on which I venture to found the
propriety of this proposed addition to the treatment of the very
anxious and very dangerous cases of which we speak.
Obstetric pathologists seem unanimous in the opinion that all
the more formidable varieties of hemorrhage which occur from the
uterus in the latter months of utero-gestation, or the earlier periods
of labour, are attributable to the separation of the vascular con-
nections between the placenta and the interior of the uterus, and the
escape of blood from the vessels which are laid open in consequence
of this separation.
Paradoxical as it may appear, there are sufficient grounds and
facts for believing, that when the placenta is separated slightly and
partially, the chance of fatal hemorrhage to the mother is greater
than when the disunion of the organ is entire and complete.
Various authors have detailed cases in which the death of the
mother speedily took place, though the portion of the placenta
separated from the uterus was exceedingly small. Thus Dr. Hamilton
mentions that in several cases which had fallen under his observa-
184
MATERNAL DYSTOCIA.
tion, and where he was called too late to afford proper assistance, it
was discovered that the fatal hemorrhage had proceeded from the
separation of "a very small portion of the placenta." `In one
instance of fatal hemorrhage between the seventh and eighth month of
utero-gestation, he found on dissection that "the area of the sepa-
rated placenta was less than a square inch."'
On the other hand, I believe I have collected a sufficient number
of data to prove that, when the disjunction of the placenta from the
uterus is perfect and complete, the degree of maternal hemorrhage
that occurs is in general exceedingly slight and trifling, or it is
altogether arrested. The details of a few cases may illustrate and
impress the fact which I wish to point out.
CASE I.-Placenta expelled upwards of three hours before the child; no hemor-
rhage in the interval; child removed by decapitation and extraction.—In 1840 I
was requested by my friend Dr. Graham Weir to see a patient at about the fifth
month of pregnancy, who had been attacked with very severe hemorrhage. It
was her third or fourth pregnancy. After the flooding had continued for some
time, the placenta was expelled. From the time of its expulsion the hemorrhage
ccased. The shoulder and neck of the infant were presenting over the os uteri.
The os uteri was so contracted, and the whole organ so small, as to prevent the
possibility of the introduction of the hand for the operation of turning. At my
suggestion, Dr. Weir severed the neck of the infant. Its body was then easily
extracted by pulling at the presenting arm; and its head was immediately after-
wards expelled by the unassisted action of the uterus. From three to four hours
elapsed between the protrusion of the placenta and the complete delivery of the
woman, yet during that time she lost little or no blood, and her recovery was
speedy and perfect.2
CASE II.-Placenta expelled about two hours before the child; elbow of the child
presenting. In 1841 I was requested by Dr. Lewins of Leith to visit a case of
complicate l unavoidable hemorrhage. I saw the patient shortly after nine o'clock
in the morning. Labour pains had come on about four, and a considerable degree
of hemorrhage had accompanied them. Shortly after seven o'clock, Dr. Lewins,
on visiting the patient, found the placenta expelled through the os uteri. When
I saw the woman, nearly two hours afterwards, the placental mass was lying be-
tween her thighs, and attached to her by the umbilical cord. She was weak from
the hemorrhage that had occurred previous to the expulsion of the placenta, but
from the time that organ had been extruded, the flooding had almost entirely ceased.
I found the elbow of the child presenting; and as the os uteri was well dilated,
it was easy to bring down a lower extremity, and terminate the labour. The
patient recovered without a bad symptom.3
CASE III.-Placenta expelled some minutes before the child; no intervening
hemorrhage; child expelled by natural pains, and revived.-For the details of this
case I am indebted to Dr. Dewar of Dunfermline, and shall give the circum-
1 Practical Observations, 2d edition, p. 314.
* See subsequent General Table, No. 17.
3
Table, No. 21.
PLACENTA PREVIA.
185
stances in his own graphic words. Some blood," he says, "had been lost as
nearly as we could calculate at what would have been the seventh and eighth men-
strual periods, and several times between the eighth and ninth months, and that
in spite of an entire cessation from all exercise. Labour took place at the full
time, and, as was dreaded, was accompanied with severe hemorrhage from the
beginning. When I saw her, about an hour after pain had begun, the orifice
of the uterus was pretty well dilated, and a soft spongy mass, apparently the
centre of the placenta, protruded from it. There was no time for interference, for
almost instantly a strong pain forcibly expelled the whole of the placenta from
the vagina. To my surprise, the flooding ceased. Pains continued active, and the
child was born in less than ten minutes. After a little time the infant revived,
and the mother recovered well, though considerably exhausted."¹
CASE IV.—Great hemorrhage, and expulsion of the placenta under strong uterine
action; child cxtracted by turning some hours afterwards.—Mrs. H., during her
second pregnancy, her first child having been premature, had a slight flooding
about the seventh month. When in the eighth month, labour commenced early
on the morning of the 18th of May, with slight pains, and sanguineous discharge.
These continued more or less severely till the evening of the 19th, when, as Mrs.
H. was resting upon her knees and elbows, an immense gush took place, along
with an unusually strong pain. Immediately afterwards, on being laid down, the
placenta was found protruding from the external parts. The attendant midwife
immediately sent off to a distance of several miles for two medical gentlemen, who
arrived about half-past one o'clock on the morning of the 20th. In the meantime,
the hemorrhage was inconsiderable. The medical men attempted to turn, and
deliver the child, but encountered great difficulties in doing so, the head having
remained fixed in the pelvis for an hour or two after the body was born. The
recovery was tedious. The patient, now one of the most respected and intelli-
gent midwives in Edinburgh, has had three children since the above period.²
CASE V. - Unavoidable hemorrhage terminated by the expulsion of the placenta ;
child allowed to be delivered by the natural pains.-"About half-past six on the
morning of April 29th, 1818, a messenger," says Dr. Ramsbotham, “arrived at
my house, sent by two medical gentlemen, with a note to this purport: We are
in attendance upon Mrs. H., whose situation is involved in great uncertainty,
from a placental presentation; the bleeding is going on pretty actively, and we
wish for your immediate opinion.' On my arrival at the house of the lady, about
eight, I was told by one of the gentlemen, that since the note was sent off some
strong expulsive pains had come on, which had expelled the placenta through the
external parts before the head of the child, and that it was lying upon the bed.
That before this occurrence the hemorrhage had been violent, yet not to that
extent as apparently to endanger the woman's life; but that, since the appearance
of the placenta the flooding had very much abated.' During our conversation on
this unusual occurrence, the gentleman more immediately in attendance, who, at
my arrival, was in the bedroom of his patient, came down stairs and reported,
that the head was presenting at the brim of the pelvis, with a hand down by its
side; that there was no want of uterine action; that the flooding had ceased; and
that his patient did not seem much exhausted.' An appeal was now made to my
opinion, as to the further management of the case, to which I replied, that as
the flooding, the most dangerous symptom, had abated, as the labour-pains con-
tinued active, and especially as the woman's strength kept up, there did not
1 Table, No. 48.
2 lbid. No. 2.
186
MATERNAL DYSTOCIA.
appear to be an immediate necessity for a recourse to any means for hastening
delivery; watch your patient for a short time, and wait the result; if the flooding
should return, or any dangerous symptom make its appearance, let us know.' In
about half-an-hour after this interview, the gentleman returned with a cheerful
countenance, and stated that the child was expelled without further loss of blood,
and that his patient was promising to do extremely well," etc.¹
CASE VI.-Placenta gradually coming down, during the labour, into the os
uteri, and being at last expelled four hours before the child; with no intermediate
hemorrhage.—Mrs. C., in the eighth month of her fourth pregnancy, was taken
in labour on Sunday evening, about nine o'clock. Mr. Chapman was called to
her about twelve o'clock. He was informed that the membranes had been rup-
tured for some time. The os uteri was dilated to the size of a crown-piece, and
the head presenting, but still very high. The pains were very strong and regular..
On a second examination, an edge of the placenta was discovered “ beginning to
protrude through the os uteri," with a hemorrhage which was trifling, but in-
creased upon the return of the pains, though still so inconsiderable as not to be
directly alarming. Mr. C. did not hence conceive himself justified in proceeding
to immediate delivery. But, as upon every return of pain the placenta became
more and more protruded through the os uteri, without the head advancing, the
advice of another practitioner was sought. Previous, however, to his arrival, the
pains proved so strong that the os uteri became dilated, and the placenta was
completely expelled through the os externum, about three o'clock on Monday
morning, with very little hemorrhage. From this moment the pain entirely
ceased. The other practitioner did not arrive until five o'clock. “There had
not," to use Mr. Chapman's own words, "been the least hemorrhage since the cxpil-
sion of the placenta." It was now resolved to turn the child; but after two pro-
longed attempts the feet could not be seized, the uterus being spasmodically con-
tracted in the longitudinal direction, and the circular fibres appearing to act
without the consent of the longitudinal. During the whole of this time the
hemorrhage had not in the least increased." Twelve drops of the tincture of
opium were now administered. In a very short time the patient became easy and
comfortable; and in less than half-an-hour the natural pains returned, and
speedily expelled the child, with the head and arm presenting. Nothing remark-
able happened in the convalescence, except a trifling attack of phlegmasia dolens,
an affection from which the patient had likewise suffered after her first labour.2
66
CASE VII.—Placental and shoulder presentation; placenta expelled; turning.
The patient, in the sixth month of her fifteenth pregnancy, was attacked with
hemorrhage that was alarming in extent, but not so great in quantity as to pro-
dnce syncope. "I saw her," Dr. Ramsbotham writes, "two hours after the first
attack of flooding. The placenta was now lying completely in the vagina, and
there was not the least hemorrhage. The membranes were ruptured. The shoulder
of the child presented. The cervix uteri was unexpanded and rigid, and it was
consequently impossible to get my whole hand into the uterine cavity, but I suc-
ceeded in reaching the ham of the infant, and was by this means enabled to turn
and deliver." “An hour or more" elapsed between the complete detachment of
the placenta and the birth of the child. It had been dead for some time. The
mother recovered perfectly.3
CASE VIII.-Placental and arm presentation; placenta in the vagina, and
without hemorrhage, for about eight hours before the child was born. — In a woman
3 Ibid. No. 27.
¹ Table, No. 56.
Ibid. No. 14.
PLACENTA PRÆVIA.
187
who had completed the full time of pregnancy, Dr. Macaulay found the placenta
expelled from the uterus, and lying in the vagina. She had been flooding pre-
viously, but it had ceased about eight o'clock on the morning of the 13th of Feb-
ruary 1816.
The late distinguished Dr. Kellie of Leith visited the patient with
him. The woman peremptorily refused to allow Drs. Macaulay and Kellie to
deliver her. About four o'clock P.M. the pains quickened, the placenta was ex-
pelled from the vagina, and about half-an-hour afterwards an anencephalous
infant followed. The child was in every way well shaped, except as regarded the
head. “Dr Kellie told me,” to quote the note which Dr. Macaulay made at the
time, "that the head was the smallest he had ever seen, and remarked, that
though it was an axiom in midwifery, that when the placenta was implanted over
the os uteri, hemorrhage must continue till the uterus was emptied, yet here it
stopped as soon as the placenta came down.”l
SECTION III. TABLE OF 141 CASES OF EXPULSION AND EXTRAC-
TION OF THE PLACENTA BEFORE THE CHILD: ARRANGEMENT
AND DIVISIONS OF THE TABLE.
I have been able to find upon record fifty-six cases of Placental
Presentation in which the placental mass was expelled before the
child, as in the preceding seven or eight instances which I have
brought forward in the last section. Through the kindness of
my professional friends, I have collated the notes of seventy-four
additional unpublished instances in which the same accident hap-
pened. As the entire detail of more instances than those I have
already stated, would at the present stage of our inquiries only
swell out our pages, without any corresponding advantage, I have
deemed it better to throw the principal facts connected with all the
cases which I have collated into a tabular form, in order to present
thus, in a more concise manner, their general features and individual
peculiarities. It is only necessary to premise, in regard to the
following table, that under the heads referring to the degree of
hemorrhage before and after the separation of the placenta, and the
time or interval between the expulsion of the placenta and expul-
sion of the child, I have as nearly as possible adhered to the iden-
tical words used by the reporters themselves, in each case. The
table commences with those instances in which the interval between
the birth of the placenta and the birth of the child was longest,
and progressively proceeds to those in which this interval became
shorter and shorter, till at last we come to a set of cases in which
the placenta and infant were expelled simultaneously.
For the purpose of assisting in some subsequent deductions, the
table is split up into the four following divisions:-
1 Table, No. 10.
188
MATERNAL DYSTOCIA.
GENERAL TABULAR VIEW OF ONE HUNDRED AND
OR EXTRACTION OF THE PLACENTA
FIRST
CASES IN WHICH A CONSIDERABLE INTERVAL (FROM 10 HOURS TO 10 MINUTES)
By whom observed or
reported.
1 Dr. Collins, Dublin
2 J. Y. Simpson
•
3 Mr. Cripps, Liverpool
4 Dr. Merriman, London
5 Mr. Hewitt, Earlston
6 Dr. J. Ramsbotham
7 Dr. Newman, Glasgow
S Baudelocque
9 Walter
10 Dr. Macaulay, Edinburgh
11 Velpeau
12 Mr. Perfect
•
13 Mr. Small, Wemyss
14 Mr. Chapman
15 Dr. Radford, Manchester
17 J. Y. Simpson
18 Dr. Radford, Manchester
19 Dr. Ingleby, Birmingham
20 Mr. Bailey, Thetford
21 J. Y. Simpson
22 J. Y. Simpson
·
23 | Dr. Todd, Colinsburgh
24 Dr. Fraser, Aberdeen
25 Dr. Radford, Manchester
26 Dr. Gardiner, Glasgow
27 Dr. F. Ramsbothami
28 Professor Gendrin
Degree of hemor-
rhage after the Mode of delivery
entire separation of the child.
of the placenta.
No. of
the preg
nancy.
Period
of
delivery.
Degree of hemor
rhage before the
entire separation
of the placenta.
9th mon.
2
Sth
Excessive
Inconsiderable
Turning
•
"}
૪ર
9th
A good deal
None
Turning
•
Little or none
•
9th mon. Great
Little
None
(Almost none
(not 2 oz. in all)
None
None
•
•
•
•
Not 1st Full time Great
Very great
Profuse
Almost none
Slight
Very trifling
Very slight
Quite arrested
Ceased
None
Quite arrested
Scarcely any
Qui e arrested
None
Not the least
None during labour | None
Quite stopped
Very slight
Very little
By natural pains
By natural pains
Turning
By natural pains
Turning
By natural pains
Turning
By natural pains
By natural pains
Long Forceps
By natural pains
Decapitation
By natural pains
Turning
Turning
Turning
By natural pains
Turning
By natural pains
By natural pains
Turning
By natural pains
By natural pains
By natural pains
Naturally
Turning
Extraction
None
Slight
•
7th
7th mon.
4th
Sth
""
Very great
Slight
9th
9th
""
16 Mr. Sidebottom, do.
7th
9th
>>
3d or 4th
5th
Great
>>
7th
Several 9th
9th
>>
Very considerable
">
Not very great
None
7th
Profuse
""
7th
""
Not great
None
6th
Several Sth
7th & 8th Very great
None
Not alarming
1st 9th
Moderate
>>
3d
9th
""
Very profuse
1st
9th
"
Very great
15th
6th
•
•
""
Alarming
21
Sa mons.
Sth 9th
""
Very great
1st Sth
Little
>>
1st 7th
Moderate
1st 9th
Excessive
"}
34 Dr. Irvine, Pitlochrie
35 Dr. Young, Glasgow.
•
9th
10th
1st
5th
Great
None
""
9th
None
None
6th & 7th Very great
None
36 Dr. John Ramsbotham
37 Dr. Todd, Colinsburgh
38 Dr. Radford, Manchester
39 Dr. Wharrie, Hamilton
40 Mr. Dorrington, Manchester
Several
Violent
Not great
Soon ceased
By natural pains
By natural pains
•
5th
8th mon.
Very great
Quite arrested
By natural pains
9th
Sth to 9th
Considerable
None
By natural pains
7th
9th mon.
Great
None
41 Dr. Forbes, Kennoway
42 Dr. Millar, Kilmarnock
4th
9th
•
Very great
Noue of any
I consequence )
1st
7th
""
Great, 6 lbs. in 2 dys. Slight oozing.
By natural pains
Forceps
Turning
REMARKS.
29 Mr. Wood, Manchester
30 Dr. Campbell, Edinburgh
31 Dr. Gardiner, Dundee
32 Mr. Hay, Glasgow
33 Dr. Ingleby, Birmingham
4. See details under Section VI.
5. Mr. H. was sent for on account of the expulsion of the placenta, nothing unusual having occurred before-
hand. He was some miles distant, but arrived just before the child was born. There was little or
no hemorrhage.
8. "A midwife had extracted the placenta some hours before, and had been unable to turn the child, whose
arm presented with the head. The uterus was strongly contracted on the child, and discharged but
a few drops of blood.”
9. See details under Section VI.
10. See Case under Section II
11, See Section V.
14. "In this case, very little more blood was lost than women usually do, when the placenta is expelled in
the usual manner.
15. "In this case, the expulsatory efforts were energetic to the time of accomplishing the separation and
expulsion of the placenta, when they ceased. No hemorrhage occurring afterwards, it was deemed
advisable to wait the 4 hours.
18. "The hemorrhage being arrested, there was no need to interfere, further than to adopt those measures
which are necessary to support the vital powers.
"
19. "The placenta had been expelled nearly through the os externum. A large quantity-nine-tenths, I
should say —had been cut off with a pair of scissors. I saw the case very soon afterwards; passed my
hand, and delivered the child, and then removed the small bit of placenta and membranes.
PLACENTA PRÆVIA.
189
FORTY-ONE CASES IN WHICH THE EXPULSION
PRECEDED THE BIRTH OF THE CHILD.
DIVISION.
ELAPSED BETWEEN THE EXPULSION OF THE PLACENTA AND THE BIRTH OF THE CHILD.
Time between birth
Presentation
of
Results.
Where reported, or by whom
communicated.
of placenta
and birth of child.
the child.
To mother. To child.
Evening before
Foot
Recovered Dead
Several hours
do.
do.
10 hours
Arm
do.
do.
Many hours
Died
A considerable time
Recovered
A considerable time
Head
do.
Several hours
Head
do.
Dead
Some hours
Arm & head
do.
Probably some hours
Crossbirth
Died
Dead
About 8 hours
Arm & head
Recovered
do.
Above 6 hours
do.
do.
5 hours
Abdomen
do.
Alive
4 to 5 hours
Head
do.
Dead
4 hours
Head & arin
do.
4 hours
Head
do.
Dead
4 hours
Head
do.
do.
3 or 4 hours
Shoulder
do.
do.
3 hours
Head
do.
do.
About 3 hours
Head
do.
do.
Above 2 hours
do.
do.
Above 2 hours
Arm
do.
do.
Nearly 2 hours
Head
do.
do.
Less than 2 hours
do.
do.
13 hour
Arm
do.
do.
1 hour
Head
do.
do.
About 14 hour
Head
do.
do.
An hour or more
Shoulder
do.
Putrid
1 hour
do.
do.
Médecine Pratique, tom. ii. p. 224.
1 hour
Head
do.
Dead
Breech
do.
do.
System of Midwifery, p. 369.
About 1 hour
Brecch
do.
do.
About 1 hour
Head
Died
do.
About 1 hour
Head
Recovered
do.
About 1 hour
Feet
do.
Putrid
Practical Observations, p. 192.
See Case of Mrs. H. in Section II.
Communicated by Mr. Cripps.
Synopsis, p. 126.
Communicated by Dr. Tait, Edinburgh.
Practical Observations, vol. ii. p. 232.
Communicated by Dr. Smith, Glasgow.
Baudelocque, vol. ii. p. 37.
De Morbis Peritonei, p. 33.
Communicated by Dr. Macaulay.
Traité des Accouchemens, i. p. 356.
Cases in Midwifery, vol. ii. p. 288.
Communicated by Dr. Skae, Leven.
Annals of Medicine, vol. iv. p. 308.
Communicated by Dr. Radford.
Communicated by Dr. Radford.
Seen with Dr. Graham Weir.
Communicated by Dr. Radford.
Communicated by Dr. Ingleby.
Prov. Trans., vol. vii. p. 338.
Seen with Dr. Lewins of Leith.
Seen with Mr. Hill, Portobello.
Communicated by Dr. Todd.
Communicated by Dr. Fraser.
Communicated by Dr. Radford.
Communicated by Dr. Smith, Glasgow.
Communicated by Dr. Ramsbotham.
Communicated by Dr. Radförd.
Communicated by Dr. Gardiner.
Communicated by Dr. Ingleby.
Communicated by Dr. Irvine.
Communicated by Dr. Smith, Glasgow.
Above
hour
Head
do.
Dead
Communicated by Dr. Smith, Glasgow.
Above
hour at least
do.
Pract. Obs., Case 154, vol. ii. p. 229.
At least
hour
do.
Dead
Communicated by Dr. Todd.
hour
Head
do.
do.
Communicated by Dr. Radford.
hour
Head
do.
do.
Communicated by Dr. Thompson, Hamilton.
hour
Head
do.
do.
Communicated by Dr. Radford.
Within
hour
Head
do.
do.
Communicated by Dr. Skae, Leven.
About & hour
Shoulder
do.
do.
Communicated by Dr. Paxton.
REMARKS.
20. "I found the vagina completely filled with the placenta, and the os uteri firmly contracting upon the
funis."
25.
"The hemorrhage was very excessive, so long as the placenta was only partially separated, but was
immediately suppressed by completely detaching it."
27. Dr. R. saw her "two hours after the first attack of flooding. The placenta was then wholly in the
vagina, but there was not the least hemorrhage; the membranes were ruptured; the cervix unexpanded.”
29. "Flooding 9 hours before placenta was expelled, but was immediately suppressed on its expulsion."
30. Dr. C. kindly informs me that the woman recovered perfectly,
31. Note by Dr. G.-“There was no flooding previous to the commencement of labour pains, and it was
moderate throughout.”
32. See case given in full, in Section VI.
34. "Absolutely no more hemorrhage than in a common natural labour.'
37. Dr. T. found the placenta lying in the vagina; the pains w re st ong and effective; and the infant was
expelled in half-an-hour.
39. Dr. Wharrie found the placenta partly in the vagina, and part y in the os uteri. He extracted it by a
kind of twisting motion, and the hemorrhage immediately ĉ used.
42. "In this case, the pains entirely left her after the expulsion of the placenta; a full dose of ergot was
given, the os uteri being fully dilated, and was followed by one or two smart pains, by which the
child was expelled."
190
MATERNAL DYSTOCIA.
By whom observed or
reported.
43| Dr. Millar, Kilmarnock
44| Mr. Malcolm, Dundee
45 Lamoite
46 Dr. F. Ramsbotham.
47 Mr. Johnstone, Brompton
Degree of hemor-
rhage before the
entire separation
of the piacenta.
No. of Period
the prog-
of
nancy.
delivery.
10th
Lge. fam.
9th mon.
Very little
Great
9th
5th 9th
9th mon.
Very great
""
Very great
(FIRST DIVISION
Degree of hemor-
rhage after the
entire separation
of the placenta.
Mode of delivery
of the child.
Great, S Ibs. in 3 dy. | About a pound | Gentle traction
None
None
Turning
Turning
By natural pains
By natural pains
SECOND
CASES IN WHICH A SHORTER INTERVAL (LESS THAN 10 MINUTES) ELAPSED
48 Dr. Dewar, Dunfermline
49 Dr. Fraser, Aberdeen
50 | Mr. Nimmo, Dundee
51 | Dr. John Ramsbotham
52 Dr. John Ramsbotham
53 Dr. F. Ramsbotham
54 Dr. Smith, Lasswade
55 Dr. Maxwell Adams
56 Dr. Barlow
57 Mr. Crawford, Glasgow
58 Mr. Crawford,
59 | Dr. M'Donald,
>>
""
•
By natural pains
Turning
By natural pains
By natural pains
By natural pains
Turning
By natural pains
•
6th
Lge. fam.
9th mon.
Sth
"
Profuse
Very moderate
Considerable
Severe
None
Great
9th mon.
12th
9th
""}
Exhausting
Stopped
Nono
None
за
9th
Excessive
"
7th
Very profuse
201
9th
Profuse
Profuse
Turning
""
5th
9th
•
>>
Not great
None
Turning
4th
9th
""
Exhausting
None
Turning
7th
9th
Excessive
"A good deal" Turning
20
6 mons.
•
•
Exhausting
None
30
•
10th
8th
9th
Most violent
None
""
Fearful
None
Turning
•
·
By natural pains
·
Lge. fam.
63 mons.
Active
7th, 8th
A good deal
By natural pains
7th
9th mon.
•
Not alarming
None
By natural pains
•
By natural pains
3]
•
8th, 9th,,
Considerable
None
By natural pains
5th
Sth mon.
Very great
Slight
By natural pains
70 Dr. Francis
•
By natural pains
71 Dr. Wilson, Whitburn
4th
::
•
Slight
By natural pains
60 Dr. F. Ramsbotham
61 Dr. F. Ramsbotham.
62 Mr. Tindal, Glasgow
63 | Mr. Denny
64 Dr. Conquest, London
65 Mr. Elkington, Birmingham
66 | Mr. Rose, Swaffham
67 Reviewer
68 Dr. Menzies, Glasgow
69 | Mr. James .
Evisceration
By natural pains
THIRD
CASES IN WHICH THE PLACENTA WAS EXPELLED IMMEDIATELY

72 Mr. Greenhow, Newcastle
73 Mr. Campbell, Glasgow
74 Mr. Fleming,
75 Mr. Hardcastle, Newcastle
76 Mr. Lowe, Manchester
77 Mr. Sidebottom,
78 Dr. Smellie
Considerable
Excessive
Considerable
Very great
6th
1st
7th mon.
7th, 8th
5th
Several 7th, 8th
3d
Sth
•
Very profuse
3d
9th
•
""
""
Very copious
Several 9th
•
>>
Slight
6th Sth
Severe
•
""
•
Several 7th
"
6th
Sth
•
>>
Very profuse
5th
9th
""
9th
>"
4th
•
•
3d or 4th 9th mon.
4th Sth
>>
79 Dr. Stewart, Kelso
SO Mr. Tulloch, Newcastle
81 Mr. Wood, Manchester
82 Mr. Wood,
$3 Dr. Young, Edinburgh
84 Dr. Currie, Lanark
85 Dr. Carruthers, Dundee
S6 Dr. F. Ramsbotham.
43.
"
•
Very considerable
Very great
Violent
Considerable
Violent
REMARKS.
Extracted
Turning
Turning
By natural pains
By natural pains
By natural pains
By natural pains
By natural pains
By turning
By natural pains
By turning
By natural pains
By natural pains
By natural pains
The placenta was lying partly in the vagina, and partly in the uterus. After its extraction, the feet
presented, which were laid hold of, and, at each pain, firm but gentle traction employed, till the child
was delivered.”
45. “I found the placenta occupying wholly the vagina, and pushing almost out of it. I immediately pulled
it away, whereupon, the membranes being torn, the waters came in great plenty, and I brought away
a dead child by the feet." The flooding had been excessive.
46. Dr. R. found the membranes pressing on the perineum, and the whole of the placenta almost in the
vagina. It passed outside immediately on rupturing the membranes.
48. See Case under Section II.
49. See Case under Section VI,
52. Violent hemorrhage came on two days before delivery. It ceased entirely, however, and did not return.
53. Copious hemorrhage came on 3 hours before delivery, on the membranes spontaneously rupturing.
Dr. R. found great part of the placenta in the vagina; there was no pain nor hemorrhage; and lio
would not have turned, had the shoulder not been the presenting part. The placenta came away, as
the shoulders were passing the brim, before the head was extracted.
56. The placenta was expelled while she was on her feet. "She attempted to walk up stairs, and before
she could reach the bed, a violent pain scized her, which instantly expelled the placenta, and disparted
-continued.)
PLACENTA PRÆVIA.
Time between the
Presentation
Results.
birth of placenta and
of
Where reported, or by whom
communicated.
birth of the child.
the child.
To mother. To child.
20 minutes
Feet
Recovered
Dead
Communicated by Dr. Paxton.
Upwards of 20 min.
Arm
do.
do.
Not of an hour
do.
do.
10 minutes
Head
do.
do.
About 10 minutes
Head
do.
do.
Communicated by Dr. Keiller.
Traité des Accouchemens, p. 407.
Communicated by Dr. Ramsbotham.
Communicated by Dr. Elliot, Carlisle.
191
DIVISION.
BETWEEN THE SEPARATION OF THE PLACENTA AND THE BIRTH OF THE CHILD.
Less than 10 minutes
Recovered Alive
Communicated by Dr. Dewar.
5 or 10 minutes
Died
do.
A short time
Breech
Recovered Dead
A short time
do.
A short time
Breech
do.
Putrid
A short time
Shoulder
do.
Dead
A few pains
Head
do.
Alive
A few minutes
Foot
do.
Putrid
A few minutes
Shoulder
do.
Alive
A few minutes
Head
do.
do.
A few minutes
Heal
do.
do.
A few minutes
A few minutes
Head
do.
Dead
Shoulder
Died
do.
A few minutes
Heal
Recovered
do.
A few minutes
Head
Died
do.
Next pain
Recovered
Alive
Next pain
Soon
Quickly
5 minutes
do.
Dead
do.
do.
Head
do.
Alive
do.
Head
do.
Alive
4 minutes
Head
do.
Dead
3 minutes
do.
Alive
Less than 2 minutes IIead
do.
do.
DIVISION.
Communicated by Dr. Fraser.
Communicated by Dr. Keiller.
Pract. Obs., Case 155, vol. ii. p. 231.
Pract. Obs., Case 156, vol. ii. p. 283.
Communicated by Dr. F. Ramsbotham.
Communicated by Dr. Smith.
Monthly Journal, vol. iv. p. 936,
Essays on Midwifery, etc., p. 273.
Communicated by Dr. Sunith, Glasgow,
Communicated by Dr. Smith, Glasgow.
Communicated by Dr. Smith, Glasgow.
Communicated by Dr. F. Ramsbotham.
Communicated by Dr. F. Ramsbotham.
Communicated by Dr. Smith, Glasgow.
Lancet, 1831-32, vol. i. p. 110.
Communicated by Dr. Conquest.
Communicated by Dr. Ingleby.
Communicated by Mr. Rosz.
Med.-Chir. Review, vol. iii. p. 317.
Communicated by Dr. Smith, Glasgow.
Lond. Med. Repository, vol. vi. p. 412.
Francis's Edition of Denmam, p. 485.
Communicated by Dr. Wilson.
BEFORE THE CHILD, OR BOTH WERE EXPELLED TOGETHER.
Almost immediately
Breech
Recovered Dead
Together
Head
do.
Turned immediately
Head
do.
Alive
do.
Immediately
Head
do.
Dead
Immediately
Head
do.
do.
Communicated by Dr. Dawson, Newcastle.
Communicated by Mr. Campbell.
Communicated by Dr. Currie, Lanark.
Communicated by Dr. Dawson, Newcastle.
Communicated by Dr. Radford.
Immediately
Head
do.
do.
Communicated by Dr. Radford.
Immediately
do.
Alive
Midwifery, vol. ii. p. 310,
Immediately
Head
do.
Dead
Communicated by Dr. Stewart.
Immediately
do.
do.
Immediately
Head
Died
do.
Communicated by Dr. Dawson, Newcastle.
Communicated by Dr. Radford.
Immediately
Head
Recovered
do.
Communicated by Dr. Radford.
Immediately
do.
Communicated by Dr. Young,
Almost at same time
Head
do.
Alive
Communicated by Dr. Currie.
Almost at same time
Head
do.
do.
Communicated by Dr. Carruthers.
Not many moments
Head
do.
Dead
Communicated by Dr. Ramsbotham.
REMARKS.
the funis about six inches from the child's navel. A great effusion of blood followed, and the woman
fainted ere she could be laid down on the bed.'
"
58, 59, 73. "In these three cases the placenta was detached in introducing the hand to turn, and lay in the
vagina till the feet were brought down.' Dr. Smith's note.
60. See case at length in Section VI.
"
62. See case at length in Section VI.
64. Active hemorrliage had taken place before Dr. C.'s arrival. "On examination, the pelvis was filled with
coagula, and something like placenta. Another pain expelled an unruptured ovum, which was
instantly ruptured, but the child was dead.”
68 The placenta was born along with the head; but Dr. M. was sensible of its being wholly detached, and
lying in the vagina for fully five minutes.
70. Though not actually stated, it is clear from the context that the woman here, and in Case 143, recovered.
71. When Mr. W. saw the woman there was a little hemorrhage, but not so much as to cause any alarm,
either for the mother or child. The pains were strong and downbearing, and in about twenty minutes
the placenta was expelled. The next pain expelled the child.
72. The placenta was detached to some extent when Mr. G. was called in. He immediately separated the
remainder, and removed it.
78, 91, 92. The fact is not stated, but it is manifest from the context that the mothers recovered.
192
MATERNAL DYSTOCIA.
No. of
the preg-
nancy.
Period
of
delivery.
Degree of hemor-
rhage before the
entire separation
of the placenta.
(THIRD DIVISION
Degree of hemor-
rhage after the
entire separation
of the placenta.
Mode of delivery
of the child.
6th or 7th
7th
9th mon.
mon.
Sth
Violent
Profuse
By natural pains
By natural pains
By natural pains
>>
2d
9th
Sth
Sth
Moderate
By natural pains
By natural pains
"
Profuse
Ly natural pains
""
By natural pains
Very great
9th mon.
9th
Several Sth & 9th
inon.
"
Considerable
Considerable
Exhausting
By natural pains
By natural pains
By natural pains
Turning
4th 9th
4th 9th
""
Considerable
Considerable
By natural pains
By natural pains
7th mon.
Considerable
By whom observed or
reported.
87 Dr. Brownlee, Shotts
SS Dr. Conquest, London'
89 Dr. Dawson, Bathgate
•
90 | Professor Murphy, London Not 1st
91
Dr. Smellie
92 Dr. Smellie
93 Anonymous
94
Gendrin
•
95 Mr. Easton, Glasgow
96 Mr. Easton,
97 Dr. F. Ramsbotham
98 Mr. Rose, Swaffham
•
•
99 Mr. Rae, Edinburgh
100 Schweighauser, Strasburg
101 Dr. Robert Lee, London.
FOURTH
CASES IN WHICH THE EXACT PERIOD BETWEEN THE SEPARATION
102 Mr. Bailey, Thetford
4th
9th mon.
103 Mr. Bull
104 | Cauviere
6th
•
Profuse
Most alarming
Profuse
Turning
Turning
None
Forceps
105 Dr. Clarke
106 Dr. Hamilton, Edinburgh
107 | Dr. Hamilton,
108 Labayle, Montpellier
109 Romaine, Bagneres.
110 Lamotte
·
111 Dr. Robert Lee, London
112 Leroux
•
113 Dr. Löwenhart
114 Dr. Maunsell, Dublin
115 Mr. Milligen
116 Sir F. Ould
117 Pardigon .
•
118 Dr. F. Ramsbotham
None
None
•
Severe
Considerable
Turning
7th mon.
mon.
7th
Profuse
Great
>>
:
Profuse
Profuse
7th mon..
mon.
Almost none
Copious
None
Little
119 Dr. J. Ramsbotham
120 Dr. J. Ramsbotham
121 Mr. Elkington, Birmingh.
8th
122 Dr. Cahill, Berwick.
6th & 7th
123 Mr. Hardcastle, Newcastle
124 Dr. Moody, St. Andrews.
125 Dr. Mather, Brechin
126 Dr. Nimmo senior
127 Mr. Rose, Swaffham
Very great
Not great
Severe
Much diminished Decapitation
Little or none
Entirely ceased
Not much
Turning
By natural pains.
By natural pains
Turning
Turning
Turning
By natural pains
Turning
By natural pains
•
128 Dr. Wilson, Glasgow
129 Dr. Wilson,
130 F. Osiander, Gottingen
131 F. Osiander,
132 F. Osiander,
133 F. Osiander,
134 Dr. Trefurt,
135 Kory.
136 Loss, Dorchester
137 Giffard
138 Mercier
•
•
7th
Lge. fam.
9th mon.
Moderate
Profuse
Profuse
None
Profuse
Profuse
Naturally
Turning
Turning
7th mon.
•
•
Naturally
"
•
•
},
9th
4th
7th
9th
Naturally
""
Turning
>>
>>
•
>>
3d
Violent
Very great
None
Naturally
Turning
Lge, fam.
7th
139 Amand
140 Dr. Tennant, Falkirk
201
9th inon.
141 Dr. Morrison, Dalkeith
Several
Violent
None
Profuse
Severe
Severe
Turning
Almost none
Turning
Turning
Forceps
None
By natural pains
REMARKS.
88. On endeavouring to turn, "the os became so much irritated by the attempt to introduce the hand, that
the organ forcibly contracted, expelling the hand, placenta, and child, and an almost incredible
quantity of blood.
"}
94. The hemorrhage ceased on the waters being allowed to escape by a female catheter, passed through the
placenta four hours before the birth of the infant, which was expelled with the placenta before it,
covering the head. Slight hemorrhage followed the delivery.
95. In this case the placenta, though born along with the head of the child, was detached from the uterus
about an hour. There was no hemorrhage from the time it was separated.
96. The placenta was born with the body of the child, but it had been detached for some hours.
97. The placenta passed, during the extraction of the child, before the breech.
99. I saw the woman a fortnight after delivery carrying her child, and well.
101. See Sect. V.
103. The arm was found to present after the expulsion of the placenta, and turning was then had recourse
to.
There is no word of hemorrhage after the placenta was expelled.
104. "Professor Cauviure has told me, that in one case where he introduced the forceps, for inertia of the
-continued.)
PLACENTA PRÆVIA.
Time between the
birth of placenta and
birth of the child.
Presentation
Results.
of
the child.
To mother. To child.
One pain
Head
Recovered Alive
One pain
do.
do.
One pain
Arm
do.
Dead
One pain
do.
do.
One pain
do.
do.
One pain
do.
Same pain
do.
Together
do.
Alive
Together
Head
do.
Dead
Together
Head
do.
do.
Together
Head
do.
Alive
Together
Head
do.
do.
Together
Head
do.
do.
Together
Recovered
193

Where report, or by whom
communicated.
Communicated by Dr. Wilson, Whitburn.
Communicated by Dr. Conquest.
Communicated by Dr. Dawson,
Communicated by Dr. Murphy.
Cases in Midwifery, vol. ii. p. 311.
Cases in Midwifery, vol. ii. p. 313.
Medico-Chirurg. Review, vol. iii.
Médecine Pratique, tom. ii. p. 349.
Communicated by Dr. Smith, Glasgow.
Communicated by Dr. Smith, Glasgow.
Communicated by Dr. Ramsbotham.
Communicated by Mr. Rose.
Communicated by Dr. Campbell, Edinburgh.
Pratique des Accouchemens, p. 224.
Clinical Midwifery, p. 148, case 269.
Head
Arm
Recovered Alive
do.
Dead
Died
Recovered
do.
do.
do.
do.
do.
...
Arm
do.
....
Arm
do.
Head
do.
do.
... •
Head
do.
Shoulder
do.
Head
do.
do.
do.
do.
do.
Head
do.
DIVISION.
OF PLACENTA AND THE BIRTH OF CHILD NOT KNOWN.
....
• •
• •
....
....
London Med. Repos., vol. xvi. p. 451.
Medical Gazette, vol. xix. p. 622.
Pardigon de l'Insertion du Placenta.
Collins' Midwifery, p. 91.
Notes of Lectures and Obs., p. 313.
Notes of Lectures and Pract. Obs., p. 313.
Essai sur l'Hém. Uter., Montpellier, 1827.
Leroux sur les Pertes du Sang, p. 262.
(Neue Zeitschrift für Geburtsk., bd. vii. h. 3.
See Kleinert's Rep., 1842, vi. p. 58.
Dublin Journal, vol. v. p. 373.
Lancet, 1831-32, vol. i. p. 232.
Ould's Midwifery, p. 77.
De l'Insertion du Placente à l'Orifice Uter.
Pract. Obs., vol. ii. p. 232.
Pract. Obs., vol. ii. p. 235.
Pract. Obs., vol. ii. p. 235.
Communicated by Dr. Ingleby.
Communicated by Dr. Cahill.
Communicated by Dr. Dawson.
Alive
Traité des Accouchemens, p. 405.
Dead
Clinical Midwifery, p. 144, case 263.
do.
do.
Alive
do.
Dead
do.
do.
do.
Breathed
Communicated by Dr. Smith, St. Andrews.
do.
Alive
Communicated by Dr. Binning, Arbroath.
do.
do.
Communicated by Dr. Keiller, Dundee.
Head
do.
do.
Communicated by Mr. Rose.
do.
Dead
Communicated by Dr. Wilson,
....
do.
do.
Communicated by Dr. Wilson.
Head
do.
do.
Shoulder
do.
do.
Head
do.
do.
Kleinert's Repertorium, 1832.
ber, t. 24.
Head
do.
Putrid
Shoulder
do.
....
do.
do.
Alive
Arm
Died
do.
Dead
Head & arm Recovered
do.
Head
Head
do.
do.
April Num-
(Hannoversche Annalen, Sep. 1841, Vid. Neue.
} Zeitschrift für Geburtskunde, 1843, p. 121.
Observationes Medicinales, Lond. 1672, p. 380.
Cases in Midwifery, p. 516.
Journal Gén. de Médecine, tom. 45, p. 305.
Observations sur la Pratique, etc., p. 336.
Communicated by Dr. Tennant.
do.
do.
Communicated by Dr. Morrison.
REMARKS.
uterus, when the head was in the pelvis, he was quite astonished to see the placenta pass out of the
vagina, before the child, without the slightest hemorrhage."—Pardigon's Essay.
108, 109. "It may happen," says Labayle, “that the placenta, though attached by its centre to the os, is
pushed out before the head of the child, and the labour terminates in the most happy manner. I have
inyself witnessed such a fact; and M. Romaine, Professor of Midwifery at Bagnares, has communicated
to me also an observation of this kind."
111. Dr. Lee found the placenta protruding through the orifice of the vagina. He immediately extracted it,
and a dead child followed.
101. In this case the placenta was protruding at the os uteri; on drawing it forward gently, the whole ovum
escaped without rupture of the membranes.
113. A midwife had separated the placenta, which presented, and had drawn it out of the external parts.
119, 120. I am kindly informed by Dr. Ramsbotham that he knows "one of the mothers recovered, and he
believes the other also.
128, 129. See Section V.
137. See case in Section VI.
For details of other cases see future Sections.
138. See case in Section VI.
"
194
MATERNAL DYSTOCIA.
1st Division.-Cases in which a considerable interval-varying
from ten minutes to ten hours or upwards-elapsed between the
expulsion of the placenta and the birth of the child, including the
forty-seven instances standing at the head of the table.
2d Division.—Cases, comprehending those from No. 48 to No.
71, in which the interval was shorter.
3d Division.-Cases, running from No. 72 to No. 101, in which
the child was born immediately after the extrusion of the placenta,
or expelled with it.
4th Division.-Cases, from No. 102 onwards, in which the period
intervening between the expulsion of the placenta and child is not
specified by the reporters, though the context shows that in many
of this class the interval was evidently considerable.
SECTION IV.-GENERAL DEDUCTIONS REGARDING THE PRECEDING
141 CASES.-1. NUMBER OF THE PREGNANCY. 2. PERIOD OF
DELIVERY. 3. MODES OF PRESENTATION OF THE CHILD.
4. MODES OF DELIVERY. 5. NUMBER OF CHILDREN LOST
AND SAVED.
1
We shall now attempt to state in a generalised form some of the
more important points deducible from the consideration and exa-
mination of the preceding table. Before doing so, however, I would
take this opportunity of remarking, that the total separation and
expulsion of the placenta before the infant does not seem to be so
very rare and uncommon a circumstance as medical men generally
believe, and as authors allege it to be. Dr. Collins states that it
is "extremely rare to meet with a total separation of the placenta
in unavoidable hemorrhage." In reporting Mr. Denny's case," Mr.
Gower observes, "It is perhaps a solitary instance in the annals of
obstetric practice. The placenta was brought into the world before
the child. The uterus closed upon the body of the foetus, so as to
prevent hemorrhage, and after another pain the child was born
alive. It was a quick labour, and no ill effects followed from an
accident, from which disastrous consequences might have been
reasonably apprehended to both mother and child. Perhaps,"
adds Mr. Gower, "there is no other such case on record, and it
1 Treatise on Midwifery, p. 90.
2 Table, No. 63.
PLACENTA PRÆVIA.
195
merits notice, as an example of the competency of nature to provide
for extraordinary emergencies."¹
I
The number of cases included within the preceding table shows
the entire separation of the placenta in placental presentations to be
by no means so rare as these and other authors seem to suppose.
have no doubt that the records of medicine contain more cases than
I have had leisure or opportunity of searching out, and I feel assured
that a more extensive and industrious inquiry of private practitioners
than I have been able to institute, might have brought to light a
considerable number of additional instances.
1. Number of the Pregnancy in the cases included in the Table.—In
81 cases the number of the pregnancy is stated, or facts mentioned,
so as to enable us to infer whether the patient had previously borne
a family or not.
In 12 cases the mother had "several" children previously.
4
""
a large family."
1 case it was the 15th pregnancy.
1
12th
2
∞ Na w
3
10th
""
""
5
9th
મ
"9
"9
8th
""
""
8
7th
""
6
6th
""
"9
6
5th
""
9
4th
""
""
10
3d
99
"
5
2d
""
8
1st
"
""
Total 81
2. Periods of utero-gestation at which the Patients were delivered.—
In 89 cases out of the 141, the requisite information is supplied or
this point. The result is as follows:-
Before the 6th month
3 were delivered.
From the 6th to the 7th month
5
"}
From the 7th to the 8th month
19
""
From the 8th to the 9th month
19
From the 9th to full time
43
99
Total 89 cases.
1 Lancet for 1831-32, vol. i. p. 119.
14
196
MATERNAL DYSTOCIA.
The preceding data are so far corroborative of the well-known
fact, that in placental presentations the labour is very frequently
premature. In 28 of his 42 cases of placenta prævia, Dr. Rigby
mentions the date at which labour came on. In 13 of the 28 the
labour was more or less premature; in 15 the women are said to
have reached the full term of pregnancy. Dr. Lee has reported 36
cases of unavoidable hemorrhage;¹ in 3 instances he does not state
the date of the labour; in 2 only had the women reached their full
time; and in the remaining 31 patients, the labour was premature.
Out of 16 cases of the same complication reported by Madame
Lachapelle, 1 patient was near the seventh month of pregnancy; 6
were delivered during the seventh month; 5 during the eighth
month; 1 at the beginning of the ninth month; 1 towards the
middle of it, and 2 during the course of it. Levret discusses at
some length the question, "why some of the women who have the
placenta implanted upon the cervix uteri arrive at the full time, and
why the greater part (la plupart) of those who are in the same con-
dition do not reach that period."³
2
3. Modes of Presentation of the Child.-This is specified in 90
cases.
In 4 cases the feet presented.
In 6
In 21
In 59
""
breech presented.
99
""
trunk or upper extremity presented.
head presented.
In 4 of the head cases (Table, Nos. 8, 14, 10, and 139), an arm
presented along with the head.
In the above, as in all other statistical returns, referring to the
presentation of the child in cases of placenta prævia, the number
of preternatural presentations, and particularly of cross-births, is
remarkable.
4. Modes of Delivery of the Child.-
The means by which the
children were ultimately delivered have varied greatly, according to
the peculiarities arising from the presentation, and the supposed
necessity or non-necessity of direct instrumental or other interference.
1 Clinical Midwifery, p. 142, etc.
Pratique des Accouchemens, tom. ii. p. 415.
3 L'Art des Accouchemens, Paris, 1771, p. 367.
PLACENTA PRÆVIA.
197
1 case the child was delivered by the Long forceps.
13
""
""
In
In
In
In 2
£ £ £ £ £
In 3
1
""
""
""
""
In 40
In 66
""
"9"
""
Short forceps.
Evisceration.
Decapitation.
Simple traction.
Turning.
Natural pains.
Total 116
In the remaining 25 cases, the manner of delivery is not
specified.
5. Number of Children lost and saved.—In 113 instances in the
Table, the result as regards the life or death of the child is stated.
In 1 (No. 10) of the 113 cases, it was malformed (anencephalous)
and incapable of sustaining extra-uterine life, and in 6 others it was
putrid, or had died before labour commenced. The following state-
ment shows the result as respects the remaining 106 cases :—
In 73 cases the infant was born dead.
In 33
""
the infant was born alive.
According to these data, nearly 1 out of every 3 children sur-
vived;—or 31 per cent of the children were saved, and 69 per cent
of them were lost. I shall again have occasion to recur to this topic
in the sequel of the memoir.
SECTION V.-Degree of Hemorrhage bEFORE THE SEPARATION
OF THE PLACENTA, ITS ABSENCE THE EXCEPTION TO THE RULE ;
DEGREE OF HEMORRHAGE AFTER THE COMPLETE SEPARATION OF
THE PLACENTA, ITS PRESENCE THE EXCEPTION TO THE RULE ;
PROPORTION OF CASES; NO RELATION BETWEEN THE EXtent
OF THE HEMORRHAGE AND THE DURATION OF INTERVAL BE-
TWEEN THE DETACHMENT OF THE PLACENTA AND THE BIRTH
OF THE CHILD.
Out of the 141 cases included in the preceding Table (Sect.
III.), we have returns in 111 instances regarding the extent of the
hemorrhage that was present, previously to the perfect detachment.
and expulsion of the placenta. The preceding flooding is reported as
198
MATERNAL DYSTOCIA.
Great
in 72 cases.
Considerable in 24
""
Slight
in S
""
Little or none in 7
>>
Total 111
L
2
1
The seven cases in which there occurred little or no hemorrhage
during and anterior to the disjunction of the placenta, are those
entered in the Table as Nos. 5, 11, 14, 28, 34, 117, and 138.
Mercier has devoted a special essay' to the consideration of such
exceptional instances to the general rule of flooding occurring as an
"unavoidable" symptom in placental presentations. "The hemor-
rhage," observes Caseaux, "which they have generally considered
as inevitable in these cases (placental presentations) may, however,
not show itself even during the progress of labour, and the dilatation
of the cervix uteri may be effected without there escaping one drop
of blood." Caseaux afterwards adverts to the opinions which
Walter, Moreau, and others have offered in explanation of this
exception. The most rational idea seems to be, that in such cases
the child has been dead for some time, and the utero-placental
circulation in consequence arrested previously to the supervention
of parturition.
3
But in relation to the objects of our essay, it is a much more
interesting and important subject for us to inquire into the degree
of hemorrhage after-than the degree of hemorrhage before, the
complete separation of the placenta.
"The great and excessive losses of blood," states Mauriceau, in
one of his aphorisms,* "which happen sometimes to the pregnant
woman, proceed almost always from the detachment, in whole or in
part, of the after-birth from the uterus; and these kinds of losses
of blood never cease entirely till the female is delivered."
In criticising this aphorism, Levret observes-"The first part of
this statement is, in general, but too true, but the second part is
not so constant as Mauriceau gives it. For the daily practice of
1 "Les Accouchemens ou le Placenta se trouve opposé sur le col de la matrice,
sont-ils constamment accompagnés de l'hemorrhagie ?”—Journal de Médecine, vol.
xlv. p. 305.
2 Traité de l'Art des Accouchemens, 1841, p. 559.
* See also Velpeau's Traité Complet des Accouchemens, vol. i. p. 356, and vol.
ii. p. 81.
4 Traité des Maladies des Femmes Grosses, etc., tom. i. p. 534, Aphor. 44.
PLACENTA PREVIA.
199
accoucheurs shows, that there are occasionally women attacked with
great hemorrhage, in consequence of partial separation of the
placenta, who nevertheless arrive at the natural period of delivery;
thus the word never is too positive, as it does not allow of any
exception, and it can only apply to those cases in which the separa-
tion of the placenta is complete, and not to those where it is only
partially detached." 1
2
Levret elsewhere remarks, in his essay on placenta prævia-
"Daily practice teaches us that the placenta is never detached
spontaneously, without the contraction of the part where it was
affixed, and without the detachment of this vascular mass, whether
complete or partial, being followed by discharge of blood."
The allegations made by Mauriceau and Levret, regarding the
continuance of hemorrhage after total separation of the placenta,
and I might quote similar averments, if necessary, from later
authors, are perhaps such as the mind might be inclined to draw,
from reasoning upon the subject of complete detachment of the
mass. But if we turn from theory to fact-and from preconceived
opinions to careful observations, we shall find the above statements
perfectly and directly contradicted by the results of practical
experience. For I believe that the data which I have collected for
the present paper are amply sufficient to establish, as a great
physiological and practical fact-that when the placenta, in cases of
unavoidable hemorrhage, is once completely detached from its con-
nections with the interior of the uterus, the accompanying flooding
in general entirely ceases, or becomes quite moderate and incon-
siderable in quantity. The cases adduced in the Table (Sect. III.),
afford the strongest possible evidence in favour of the truth of this
important principle. A slight analysis of them, in reference to this
point, will sufficiently demonstrate our proposition.
From the nature of the Third Division of the Table of cases,
including, as it does, those instances in which the expulsion of the
placenta was immediately, or almost immediately, followed by the
birth of the infant, we can, from this section of our data, expect few
or no decided returns in reference to the degree of hemorrhage
existing after the total detachment of the placental mass. In the
two or three cases, however, of this division, in which the complete
detachment of the organ occurred some time before its complete
expulsion—the attendant hemorrhage was observed immediately to
cease. Thus, in reference to two instances (Nos. 95 and 96), which
1 L'Art des Accouchemens, etc., p. 395.
2 Ibid. p. 347.
200
MATERNAL DYSTOCIA.
occurred in the practice of Mr. Easton of Glasgow, it is stated in
the notes of them with which I have been favoured, that though in
both the placenta was only expelled immediately before the child,
yet it had been previously separated-in one above an hour-and
in the other for several hours, and in neither of the mothers did
any hemorrhage occur after the placenta was wholly detached from
the uterine surface. In both instances the placenta were originally
affixed close to the os uteri-but not over it—and were detached
early in the labour.
In the 111 remaining instances, the facts in regard to the
existence or non-existence of hemorrhage during the interval be-
tween the detachment or expulsion of the placenta and the birth of
the child stand as follows:-In 39 out of the 111 cases, the absence
or presence of hemorrhage after the expulsion of the placenta is not
stated or alluded to by the reporters; but it is evident, from the
other circumstances which they describe, that in most of these cases
there could have been no serious, if, indeed, any extent of flooding,
because the woman was allowed to remain undelivered, in many of
them, for a considerable time after the placenta was separated-a
state of matters which would not have been permitted if there had
been any degree of discharge calling for the immediate delivery of
the patient. Three out of these 39 mothers died-one from puer-
peral fever (Table, No. 4); a second (No. 137), apparently from
post-partum hemorrhage ;-the cause of death in the other case
(No. 104) is not stated.
In 70 of the 111 cases, the existence and degree of hemorrhage,
after the complete separation of the placenta, is distinctly stated,
and may be tabulated as follows:
In 44 cases the hemorrhage was completely arrested.
10
7
""
very slight, or almost none,
inconsiderable.
ceased.
much diminished.
1
>>
1
>>
""
1
considerable.
27
}"
1 5
""
21
"a good deal.”
profuse.
Total, 70
It thus appears, that after the complete detachment of the
placenta, the hemorrhage was totally arrested in a large majority of
PLACENTA PRÆVIA.
201
the cases; that it was not alarming in its extent in a great propor-
tion of the remaining instances; and that in 5 only out of the 70—
or rather in 5 only out of the 111 labours-did it continue so pro-
fuse under the circumstances, as to be considered alarming by the
attendant, or in such excess as to require special notice in their
reports.
Hence in 1 only out of every 22 labours does there appear to
have been a continuance of hemorrhage to a great or profuse degree
after the placenta was detached. One of the five mothers died (see
Dr. Fraser's case in Section VI.) The other four all recovered.
But it may be proper to consider more at length the five cases
in which the hemorrhage is stated to have gone on to a profuse
extent, after the separation of the placenta, in order to judge better
of the circumstances which may lead to its continuance in other
instances.
First of all, however, it seems necessary to remark, in regard to
the alleged continuance of the hemorrhage after the entire sepa-
ration of the placenta, that the observation itself-simple and easy
as it may appear-is one which is most undoubtedly liable to several
sources of fallacy. Some of the authors who have described cases
of expulsion of the placenta before the child, and not a few of the
medical gentlemen who have communicated to me instances of the
kind, have expressed the surprise which they felt at the flooding
suddenly ceasing, upon the separation of the placental mass, in con-
tradiction to what their preconceived opinions had led them to
expect. Any degree of incaution in the observation of the case
might thus easily lead the medical attendant to suppose, that the
blood effused externally, or lying in the vagina, was the result of
the continuance of the hemorrhage subsequently to the total dis-
junction of the placenta ; whilst in reality it might have been the
result of the degree of flooding existing antecedently to that event,
that is, whilst the placenta was still only partially detached. The
blood already discharged might, in other words, be readily mistaken
for bood in the act of being discharged. I am the more inclined to
"insist upon this source of error, in consequence of the strong fact,
that out of all the First Division of cases in our Table-forty-seven
in number-where there was a long interval between the expulsion
of the placenta and the birth of the child, and, consequently,
ample time allowed to confirm or correct any observation upon the
degree of existing hemorrhage, in not one single instance is the flood-
ing after the complete placental detachment alleged to have been
202
MATERNAL DYSTOCIA.
profuse, or even considerable in its extent. Again, if there had
been going on any internal accumulation of blood in the uterine
cavity, or rather between the membranes and the uterus, during the
period of the partial separation of the placenta, and before its com-
plete detachment, the escape of this blood after the expulsion of
the placenta might lead to the same error. Another occasional
source of fallacy may consist in this, that the membranes may be-
come ruptured by the same pain which expels the placenta through
the os uteri or vagina, or they may burst during a subsequent uterine
contraction, and the sudden gush of escaping liquor amnii, when
mixed with the effused blood, might be readily mistaken for a pure
hemorrhagic discharge.
Of the five cases in which the hemorrhage is alleged to have
continued to a considerable or great degree after the detachment of
the placenta, one affords an illustration of this last remark. I quote
it from Lamotte.
CASE IX.-Hemorrhage, with the placenta expelled from the vagina; excessive
discharge; turning; infant and mother recovered.-Lamotte was summoned to a
woman who had been in labour from the previous day, and who had been losing
blood for about two hours. "I went immediately," to adopt his own narrative,
though it was a good league (grande lieue) out of town. As I entered the court,
several women came out with frightful shrieks, indicating to me, better than they
could tell me, the extreme danger of my poor patient. I instantly descended from
my horse, and hurried to where she was. I found that the after-birth had just
been pushed out of the vagina by the last pain, and the discharge of blood had
come in such abundance, as to have imparted that terrible fright to the bystanders,
that had made them utter this piercing cry. I hastened to pull away the after-
birth, glided my hand into the uterus, seized the feet of the infant, drew them
into the passage, and accomplished the delivery in an instant. The infant was
sufficiently alive to be baptized, but died soon after. The mother recovered in a
sufficiently brief period, notwithstanding the fearful loss of blood." In some re-
marks which Lamotte offers upon this case, he observes, that he judged the
membranes to have been entire from the surprising evacuation that followed the
placenta when he drew it out, and which could not have been all blood, as it
came away with much greater violence than it did previously, and the woman
could not have borne the loss of such a quantity of blood without sinking.
"But
I am persuaded," he adds, "that the waters escaping from the membranes in
which they were contained, became mixed with the blood effused from the vessels,
the midwife having informed me, that the waters were ready to burst, when the
accident (the expulsion of the placenta) happened, and they flowed out from my
tearing the bag, in separating the placenta."
In the above case of Lamotte's, the evidence of a continuance of
true hemorrhage after the detachment of the placenta is by no means
decisive; but we have placed it in that category in order to avoid
1 Table, No. 110.
PLACENTA PREVIA.
203
the fear of error. The continuance of hemorrhage under the same
circumstances is probably better marked in the four following cases.
For the first two I am indebted to Dr. Wilson of Glasgow, in whose
practice they occurred. I shall give them in his own words.
CASE X.-Expulsion of placenta; hemorrhage; turning.—“ May 7, 1821.—
Mrs. G., the mother of a large family, was seized, near the termination of preg-
nancy, with profuse flooding. Dr. M. was sent for. He found the placenta pre-
senting; it very soon came away, the discharge continuing. I was called in, and
such was the profusion of the discharge and state of exhaustion, that turning was
instantly resorted to. The child was dead-there was no discharge after delivery.
The recovery was tedious, but at length complete."
"' 1
CASE XI.-Placenta lying with its fœtal surface over the os uteri; hemorrhage;
turning." April 17, 1833. This evening I was sent for by Dr. Cunningham to
see Mrs.
Portugal Street, who was flooding, and had been for several hours.
The placenta was found lying loose over the os uteri, with the fatal surface down-
ward; the finger at once touched the origin of the umbilical cord. The placenta
was turned aside, the feet laid hold of, and a dead child extracted.
good recovery.'
She made a
This last case is, so far as I know, unique, in the circumstance
of the placenta being found quite inverted over the os uteri, or with
its fœtal, instead of its maternal surface, lying in contact with that
part. It may probably so far be regarded as a proof that in this
instance there was a cause for the hemorrhage continuing, in a
most unusual and extreme degree of atony or relaxation of the
uterus—a state which would seem necessary in order to admit of
the possibility of the inversion of the placental mass. In the two
following cases of Mr. Barlow and Mr. Bailey, we have the hemor-
rhage persisting under different conditions, viz., the patient being in
the upright posture at the moment of the separation and expulsion
of the placenta; and besides, having in the first of them that dis-
position of the uterus, whatever its special nature may be, which
gives rise to post-partum hemorrhage
CASE XII.-Expulsion of the placenta preceding the delivery of the child; he-
morrhage both after the expulsion and delivery.—A woman in the last month of her
second pregnancy suffered from uterine pains and a slight discharge of blood at
intervals. The hemorrhage ceased when the horizontal position, etc., were
adopted. Next morning Mr. Barlow was summoned to see her, and found her
sitting on a chair in a state of great alarm, a profuse discharge of blood succeeding
every pain.
"On requesting her," he continues, "to be conveyed to bed, she
attempted to walk up stairs, and before she could reach the bed, a violent pain
seized her, which instantly expelled the placenta, and disparted the funis about
six inches from the child's navel. A great effusion of blood followed, and the
woman fainted ere she could be laid down on the bed." Mr. Barlow passed up
2. Ibid., No. 129.
1 Table, No. 128.
204
MATERNAL DYSTOCIA.
his hand into the uterus, found the os uteri in a lax and dilated state, with the
shoulder presenting, laid hold of the feet, and accomplished the delivery of the
child, by turning, in a few minutes. The child appeared feeble, but soon
recovered on being placed in a warm bath. A considerable hemorrhage," he adds,
"followed the birth; on perceiving which, I returned my hand into the uterus,
and by keeping it moving therein for a time, its contractions were renewed, and
the hand was then withdrawn, and the flooding abated, and though the woman
appeared much reduced through the loss of blood, she soon recovered.” 1
CASE XIII.- Unavoidable hemorrhage supervening during exertion; sudden
expulsion of the placenta; turning; mother and child saved.--The case occurred to
Mr. Bailey of Thetford. A woman, aged 32, three weeks before the time of her
expected fourth confinement, when exerting herself by washing, etc., was seized
with a sudden and violent flooding, accompanied by an extreme degree of bearing
down, which, to make use of her own expression, felt "as if the head of the child
was in the birth." In the act of stepping upon the bed, she was taken with a pain,
during which the placenta was forcibly expelled, and was suspended between the
thighs by the funis. At this moment a deluge of blood followed, and she sunk
down senseless upon the bed, to all appearance dead, the pulse being imperceptible,
and the skin covered with a cold clammy sweat. The os uteri was found to be
completely dilated, the passages were well relaxed, and the head presented in the
first position. Turning was adopted, and easily accomplished. During the opera-
tion, “the hemorrhage was alarming, and large coagula were present in the uterus,
which were expelled as soon as the child was born. When the uterus was excited
to contraction, the hemorrhage ceased. The child at first appeared to be still-
born, but was restored by the proper means. Both the mother and the infan
did well."2
In relation to the last two cases of alleged hemorrhage after the
placenta was totally separated, it deserves to be specially held in
view that, as already alluded to, in both cases the patients at the
time at which the placenta was detached were in the upright posi-
tion—a circumstance which is well known to be a very certain cause
of post-partum hemorrhage when there is any tendency to that con-
dition;-in both patients the cervix uteri was very relaxed, the
introduction of the hand in the operation of turning being performed
with great ease;-in both, the complete separation of the placenta
must have occurred a very short time before delivery, as each of the
children was born alive;—and in the last patient (Mr. Bailey's), the
discharge of blood which took place after the expulsion of the
placenta must have been to some extent the result of a previous
internal accumulation occurring during the partial separation of the
placental mass, as the blood itself had had time to coagulate. This
internal hemorrhage and accumulation of blood probably occurred
also in the remaining case upon our list of hemorrhage after the
complete separation. For the details of it, see Dr. Fraser's case in
the next section, and the remarks upon it.
¹ Table, No. 56.
2 Ibid., No. 102,
PLACENTA PRÆVIA.
205
That the extent of the hemorrhage has no direct relation to the
extent of the interval between the expulsion of the placenta and the
delivery of the child, is amply attested by the following facts :-All
the reputed instances of hemorrhage after the complete detachment
of the placenta, have occurred in cases where the interval between
the birth of the placenta and that of the child was short and uncer-
tain; or, in other words, among the patients included in the Second
and Fourth Divisions of the General Table. Among the cases
belonging to the First Division of the Table, in which the interval
between the detachment of the placenta and the delivery of the
child was longer, and varied from ten minutes to ten hours, and
where, consequently, there was more time to observe any degree of
flooding that might exist, in not a single instance was the hemorrhage
observed to be great, or even considerable in extent. On the contrary, in
one only of the forty-seven cases belonging to this division was it
in any unusual degree; in nine, it is reported as "almost none,"
"trifling," or "slight," or "very slight;" and in twenty-three cases
it was totally and completely arrested. In nine, the degree of it, if
any, is not stated.
I shall have occasion to revert to the practical bearing and im-
portance of these facts in a future section of the essay.
SECTION VI.-COMPARATIVE MORTALITY IN PLACENTA PREVIA,
FROM TURNING, ETC., AND FROM EXPULSION OR EXTRACTION
OF THE PLACENTA: TEN FATAL CASES AFTER SPONTANEOUS
EXPULSION: DETAILS OF EACH CASE; SEVEN OF THEM INDE-
PENDENT OF THE SEPARATION OF THE PLACENTA: NATURE OF
THE THREE REMAINING CASES.
In common cases of placental presentation we have already found,
from ample statistical data, that the average mortality to the mother
is about 1 in 3 (see Section I.) Among the 141 cases of expulsion
and extraction of the placenta, which we have collated into the Table
(Sect. III.), 10 mothers died, or the average mortality to the mother
was 1 in 14. The difference between the two sets of cases-namely,
1st, Those terminated according to the present recognised rules of
midwifery; and, 2d, Those terminated by the spontaneous expulsion
or extraction of the placenta is sufficiently striking when thus
simply stated. The contrast may be more easily appreciated if we
tabulate the results in the following manner :—
1 Case 43. The patient lost 8 lbs. of blood in three days, and "about a pound"
after the expulsion of the placenta,
206
MATERNAL DYSTOCIA.
Mode of Management.
Cases treated by extracting the
child before the placenta, rup-
ture of the membranes, etc.
Cases in which the placenta was
expelled or removed before
the child.
Number of
Cases.
Number of
Maternal
Deaths.
Proportion
of Maternal
Deaths.
654
180
1 in 3%
141
10 1 in 14
The evidence in favour of the safety of the termination of such
cases by the expulsion or extraction of the placenta before the child.
will become still more striking if we turn our attention specially to
the ten fatal cases themselves; for we shall find that the fatal
result in few, if any, of these cases, can be directly traced and
ascribed to the circumstance of the placenta being completely sepa-
rated, or to any possible consequence arising from that separation.
An examination of these ten fatal cases in detail will sufficiently
prove this remark.
Four of the ten mothers died several days subsequently to
delivery. I shall first describe these four cases, so far as I have
notes of them, to show more clearly the immediate cause of death
in each.
CASE XIV.-Placenta expelled an hour before the child; patient died on 10th
day, after having been up, and exposed to excitement and injury, on the 9th.—The
case occurred in the practice of Mr. Hay of Glasgow. It was a first pregnancy,
and the patient had arrived at the full period. Before the separation of the
placenta, the hemorrhage was excessive, and she was quite sunk and exhausted.
Very little blood was lost after the placenta had come away, though the infant
was not born for an hour. It was expelled by the natural pains, and was still-
born. The following is Mr. Hay's note on the case :- "This patient seemed to
sink from excitement. She and her husband quarrelled on the 9th day after the
birth of the child, and on the 10th she died." Dr. Smith of Glasgow, who has
reported this, with various other cases, to me, states more explicitly, that "she left
her bed and fought with her husband till perfectly exhausted, from which state she
never recovered.” 2
1
The fatal result in this case does not require a word of comment;
the fact of the woman being able to leave her bed, and to act in the
way described, is sufficient proof that she was in a fair way of re-
covery, and that she would in all likelihood have done well, had it
not been for her own indiscretion. In the instance which I have
next to quote, the fatal event is also ascribed by the reporter to
1 I am happy in having this opportunity of offering my best thanks to Dr.
Smith for the very great zeal and kindness with which he has assisted me in
Glasgow, in the collection of cases for the present memoir. 2 Table, No. 32
PLACENTA PREVIA.
207
imprudence on the part of the patient, and, at all events, the degree
of hemorrhage was such as in no way to endanger her life.
CASE XV. Spontaneous expulsion of the placenta; little or no hemorrhage
either before or after its separation; death on the 7th day from "purpura alba.”
"About 16 years ago, I was called," says Walter,¹ "to the assistance of the wife
of the former Castellano of the Royal Academy of Treptow. On arriving, I found
her in bed; labour had commenced at 4 A.M., seven hours before; the placenta
was already separated, and had fallen to the ground; it was still attached to the
infant by the cord. I was astonished at this very rare phenomenon, which at that
time I could not explain, as I did not then understand the structure of the uterus
as I now do. As it was a cross presentation, I had recourse to turning, and within
a few moments I delivered the woman of a dead child. I can affirm most posi-
tively," the author adds, "that before my arrival, and during the labour, the
woman did not lose above two ounces of blood. She did well till the third day,
but an improper and contentious mode of living (inordinata atque contentiosa
vivendi ratio) was the cause of her being seized with 'purpura alba,'2 of which
she died on the 7th day after delivery."3
In two of the fatal cases the mothers died from puerperal fever
or peritonitis. These two instances have been recorded by Dr.
Merriman and M. Mercier, and I shall detail them, as nearly as is
consistent with brevity, in the author's own words.
CASE XVI.-Placenta expelled long before the child, etc.-"I was once," Dr.
Merriman states, "consulted by a very careful and judicious practitioner, respect-
ing a woman, who, when I first saw her, was rapidly sinking under puerperal
fever. In this case the placenta was expelled many hours before the child was
born, and no extraordinary means were used to expedite the delivery of the child;
a physician accoucheur, who was consulted upon the occasion, having deemed it
more prudent to leave the case to nature. The fatal event, however," Dr. Merri-
man unadvisedly adds, “would lead one to doubt whether it was wise, under such
circumstances, to decline the interference of art.
115
CASE XVII. No hemorrhage with the first part of the labour; vomiting;
fever; placenta spontaneously expelled; child delivered with forceps; mother died
of peritonitis nine days after delivery.-For upwards of two days before Mercier
saw the patient, she had been attended by a midwife, and latterly by a medical
man, who, being called in during the course of the second day, and finding the
woman feverish, had bled her largely. The bleeding had lessened the pains,
which did not return till that evening. The patient had not suffered from any
discharge of blood from the uterus, but she felt extremely uneasy; was not able
1 De Morbis Peritonæi et Apoplexia; Berlin, 1785, p. 33.
2 Or "miliaria," a disease which, under the old "heating" method of treating
puerperal women, was formerly extremely fatal. The Stockholm Academy pro-
posed in 1769 as a prize question, "How the different kinds of miliary fever
should be prevented and cured, as well in lying-in women as in others." The
successful author, Schultz, showed strongly the necessity of adopting a cooling
regimen. Dr. Whyte's excellent Essay on Miliary Fever (Treatise on Lying-in
Women, pp. 25-55) did much to banish the disease from English practice.
s Table, No. 9.
4
* Synopsis of difficult Parturition, p. 126.
• Table, No. 4.
208
MATERNAL DYSTOCIA.
to rest in bed; and rejected by vomiting everything that was given to her.
About two o'clock on the morning of the third day, while she was walking about
with a person supporting her, a strong pain expelled the placenta, which fell to
the ground, followed immediately by the escape of the waters. The embarrass-
ment of the midwife was extreme. She divided, however, the cord, and waited
the arrival of M. Mercier, whom she had immediately summoned. The pains
again ceased, and the woman, having been put to bed, got a little sleep.
"The
placenta," says M. Mercier, was shown me, of a small size, and covered with
dust. The cord was implanted in its middle, and about half-a-yard of it was
attached. Only a few spoonfuls of blood had been lost in addition to the small
quantity that had escaped from the cord when it was divided." In consequence
of it being impossible to excite the uterus to sufficient action, it became necessary
to terminate the labour by the forceps. This was accomplished easily. The
child did not appear to be at the full time. Its extraction was followed with a
very moderate effusion of blood, which scarcely penetrated a cloth folded four
times. "This small quantity," observes Mercier, "joined to what had accom-
panied the falling of the placenta, did not exceed the loss of blood in ordinary
labours." 1
An hour after delivery there was sanguinolent oozing, which soon
ceased. Subsequently, however, the woman was attacked with peritonitis, and
died of this affection nine days after delivery.2
Besides the four instances of death which we have just described,
at periods more or less distant from delivery, two others of the ten
fatal cases occurred within a very short time after the birth of the
infant, and a third (Dr. Ramsbotham's) appears also to come under
this head. Yet, as will appear from the details which we shall now
give, the death in these cases was not apparently in consequence of
any hemorrhage or other cause arising from the complete separation
of the placenta, the hemorrhage in all of them having ceased when
this separation took place. All the three mothers were delivered by
operative means.
CASE XVIII.-Severe hemorrhage and presentation of the arm; child eviscerated
to permit delivery; placenta detached during the operation; no hemorrhage from
its detachment; mother died.-The case occurred in the practice of Dr. Rams-
botham, to whose kindness I am indebted for the following details. On December
24, 1839, Dr. Ramsbotham was called to see Mrs. E., who was gone 6 months in
her second pregnancy. She was in a state of exhaustion from severe hemorrhage,
having lost about two quarts of blood. "The previous attendant," to give Dr.
Ramsbotham's own words, "ruptured the membranes at 7 or 8 A. M., after which
there was no further hemorrhage. The arm now came down, which he took off.
I delivered her with great difficulty, owing to the undeveloped state of the cervix,
at 43 P. M. I could not get the hand into the uterus, but managed to perforate
the chest by a blunt hook, and to extract many of the viscera. In trying to per-
forate the chest, I hooked down the placenta, a part of which was hanging loose
in the vagina; still there was no flooding." 3
CASE XIX.—Profuse and exhausting hemorrhage, terminated by expulsion of
1 Journal Ancien de Médecine, tom. xlv.
2 Table, No. 138.
8 Ibid., No. 60.
PLACENTA PREVIA.
209
the placenta; turning; immediate death.-The woman was a patient of Mr.
Wood's of Manchester. She had borne five children previously, and had reached
the eighth month of her sixth pregnancy. The hemorrhage was very profuse
previous to the expulsion of the placenta, and had caused great exhaustion; after
this it completely ceased. Turning was immediately had recourse to, and a dead
infant was extracted by the feet. She died immediately after her delivery.¹
CASE XX.-Head presentation and unavoidable hemorrhage; placenta com-
pletety detached in the operation of turning; previous exhaustion; death.-The
woman (a patient of Mr. Tindal's of Glasgow) was at the end of her tenth preg-
nancy. The head of the child presented. There was fearful hemorrhage before
the placenta was expelled, but none after. Delivery was effected by turning, a
few minutes after the escape of the placenta. The mother died in half-an-hour.
"In this case," Dr. Smith observes, in the note which I have received with it,
"the patient was exhausted previous to turning, and that operation was adopted
to have delivery effected before she died. The placenta was accidentally sepa-
rated during the course of the operation, and Mr. Tindal was perfectly certain that
the hemorrhage ceased from that moment.”2
In the three remaining cases of maternal deaths, the fatal occur-
rence took place during labour, or immediately subsequent to deli-
very. Of two of the three cases I have only very imperfect notes,
which I give, such as they are, before offering any comment on
them.
CASE XXI.-" Flooding, with one arm and part of the placenta slipped down
below the os uteri internum ;” turning; post-partum hemorrhage; death.—October
the 17th, 1731, about ten o'clock in the morning, Mr. Giffard was sent for to the
wife of a printer, near White Fryars; "She had been seized," to use his own
words, "about an hour before with a violent flooding, and when I came, I found
she had lost a large quantity of blood; and I was told she was in about the
seventh month of her reckoning. Upon touching, I found one arm of the child
slipped out beyond the os internum, as also a large part of the placenta ; where-
fore, I gave it as my opinion, that she ought to be immediately delivered—letting
her husband and others know the great danger she was in. As it was entirely
left to my conduct, I immediately passed up my hand, well greased, into the
vagina, and so on by the side of the shoulder into the uterus, where I met with
the remaining part of the placenta, wholly separated from the uterus.
I now
passed my hand between the placenta and the body of the child, and soon met
with one foot, which I drew out beyond the labia pudendi, and then taking hold
of it with a soft cloth, with a little difficulty, I brought out the hip and the body
almost to the shoulders, when, finding it stopped at the head, 1 passed in my
hand, and brought down one arm, the other not being slipped up again from its
first falling down. I then endeavoured to draw out the head, but it would not
readily follow; whereupon I passed up one finger into the child's mouth, and
strove, by pressing upon the lower jaw, to bring the face forwards, whilst at the
same time I pulled above at the shoulders; but as it was closely locked between
the bones that form the lower part of the pelvis, I had no small trouble in bring-
ing it out; however, at last I finished the delivery by bringing away the placenta,
which, being before loosened from every part of the uterus, readily followed. I
2. Ibid. No. 62.
1 Table, No. 81.
210
MATERNAL DYSTOCIA.
was then in hopes we had surmounted our greatest difficulties, and that the
flooding would have stopped; but, to my great surprise, she continued still drain-
ing. I therefore again gently, passed up my hand, believing that either some
part of the placenta was torn off and left, or else that some coagulated blood kept
the womb distended; but I could not meet with any part of the placenta, or any
clots of blood. I then ordered cloths dipped in vinegar to be applied close to the
parts, and what else I thought necessary, yet, notwithstanding all my endeavours
to save her, amisit cum sanguine vitam." 1
CASE XXII.- Unavoidable hemorrhage, with apparent hydrothorax and cardiac
disease; death speedily after the expulsion of the placenta; living child subsequently
extracted.—The case occurred to Dr. Fraser of Aberdeen. It was the patient's
sixth pregnancy. Labour came on at the eighth month. Very moderate hemor-
rhage had been going on for two hours, when the placenta became very extensively
detached by one uterine contraction, and the mass of it was found lying in the
vagina. “The accompanying hemorrhage," Dr. Fraser states, "was great, and,
without convulsions, she expired in two minutes." A few minutes afterwards,
66 А
Dr. Fraser passed his hand into the uterus, and extracted the child alive.
post-mortem examination," Dr. Fraser adds, "was not allowed, but from a com-
bination of marked symptoms, I have a strong conviction that she laboured under
hydrothorax, depending on a diseased state of the heart."2
CASE XXIII.-Fatal detachment of the placenta. -In speaking of the complete
separation of the placenta in unavoidable hemorrhage, Dr. Collins states, "Dr.
Clarke informed me, that he had met with one case of total separation; the patient
was dying before he reached the house."3 By a private note from Dr. Collins, I
am informed that he knows no more of the case than what is stated in the above
sentence, and that in consequence of Dr. Clarke's death, it is now impossible to
obtain more details.¹
GENERAL REMARKS ON THE TEN FATAL CASES.
In all the first seven of the preceding fatal cases, the separation
of the placenta, or the degree of hemorrhage after its detachment,
had evidently little or no connection with the death of the mothers.
In the first case, No. XIV. (Mr. Hay's), the blood lost during the
hour that elapsed between the expulsion of the placenta and birth
of the child, is averred to have been "very little ;" in the second
case (Walter's), not more than two ounces of blood escaped in all
during the whole labour; in the third case (Dr. Merriman's), the
hemorrhage, after the expulsion of the placenta, was, in all proba-
bility, inconsiderable, or altogether arrested, as it was not deemed
necessary to expedite delivery, though the placenta was thrown off
several hours before the infant was born; in the fourth case, the
narrator (Mercier) distinctly attests, that the whole loss of blood
was not greater than with an ordinary labour; in the fifth case,
1 Table, No. 137.
• Practical Treatise on Midwifery, p. 91.
2 Ibid. No. 49.
4
Table, No. 105.
PLACENTA PREVIA.
211
there was, to use Dr. Ramsbotham's own expression, "no flooding"
after the placenta was detached, and there had been none for some
time previously; in the sixth case (Mr. Wood's), the hemorrhage
completely ceased after the total separation of the placenta; and in
the seventh case (Mr. Tindal's), the same fact was observed. In
these two last cases, though both patients sunk principally from the
effects of hemorrhage, yet in both of them that hemorrhage had
occurred antecedently to the detachment of the placenta; the mis-
chief, in so far as the flooding was concerned, was done before that
detachment took place; in neither of them did the peculiarity of the
complete separation of the placenta occur until the case was already
so far hopeless, from the antecedent discharge, and, indeed, so far
from being injurious, the separation of the placental mass would, on
the very contrary, by its immediately arresting flooding, seem to
have been salutary, though unfortunately in each too late to save.
On the other hand, there occurred, in the course of these seven
fatal cases, circumstances and complications amply adequate to
account for the deaths of the mothers, quite independently of the
separation of the placenta, or of any flooding or other possible
accident connected with that separation. In Mr. Hay's case, the
patient's death was evidently the result of the strong excitement
and injuries to which she was subjected on the ninth day after
delivery. Walter, as we have seen, attributes the attack of the
disease ("purpura alba," or miliary fever), of which his patient died,
to her own indiscretion. In Dr. Merriman's and Mercier's cases,
puerperal fever and peritonitis were the causes of the fatal issue-a
disease that too often occurs, independently of any morbid complica-
tion whatever, during labour. Mercier's patient had, though there
was no accompanying flooding, become so exhausted, and the expul-
sive powers so inefficient, by the time he saw her, that instrumental
delivery was deemed necessary. In Dr. Ramsbotham's case (an arm-
presentation), the child was delivered by evisceration of the chest
and abdomen, an operation in itself sufficiently dangerous, and
never employed except when even turning is impossible; and, in
the present instance, it had its difficulties much enhanced by the
rigid state of the os uteri. Lastly, in Mr. Tindal's and Mr. Wood's
cases, extraction of the infants by version was had recourse to, at a
time when the mothers were already greatly exhausted, and little
able to withstand the additional shock of such an operation. Thus,
in two of the fatal cases (Mr. Hay's and Dr. Merriman's), the de-
livery was effected by the natural pains; and the cause of death in
15
212
MATERNAL DYSTOCIA.
each was apparently independent of any circumstances connected
with the detachment of the placenta. In five of the cases (Walter's,
Mercier's, Dr. Ramsbotham's, Mr. Tindal's, and Mr. Wood's), the
delivery was accomplished by such operative means as are in them-
selves always more or less perilous to the life of the mother, parti-
cularly when, as in some of them, she had already become prostrated
and exhausted by the time they were adopted.
For the above reasons we are, I believe, quite entitled to reject,
in regard to the first seven fatal cases, the idea of the death of the
mother's being caused by the total separation of the placenta, or by
its mediate or immediate consequences.
If this be granted-and we subtract on this ground the first
seven fatal cases—we have only, out of 141 deliveries, three mater-
nal deaths left, which can be at all ascribable, directly or indirectly,
to the complete detachment of the placenta, and its results. This
would give a mortality of only one in about every forty-seven
mothers from this complication during labour, in placental pre-
sentations; a proportion which, it must be confessed, is surprisingly
small.
But it seems, indeed, even more than doubtful, whether all the
three remaining fatal cases (Mr. Giffard's, Dr. Fraser's, and Dr.
Clarke's) should be allowed to have been instances in which the
death of the mothers was attributable simply to complete separation
of the placenta, and its effects.
Mr. Giffard's patient died, if we may judge from his own account,
of post-partum hemorrhage-a complication which is known to be a
special source of danger to the mother after placental presentations,
under all modes of management.' The hemorrhage was here pro-
bably the result of the injury and laceration of the vascular and
imperfectly dilated neck of the uterus, in consequence of the force
employed in the operation of the extraction of the shoulders and
head of the infant. This view would seem to be so far corroborated
by the fact, that the post-partum discharge was not connected with
the presence of any clots of blood in the uterus, and hence, was not
the effect of atony of the body or fundus of the organ. At all events,
the fatal hemorrhage was not, in Mr. Giffard's patient, in any ap-
¹ See on this topic Dr. Hamilton's Practical Observations, second edition, p.
329. In speaking of placenta prævia, he states, in reference to flooding from the
ruptured vessels of the neck of the uterus (the body and fundus of the organ being
contracted), that for many years past he has been led to “dread this danger in
every case where he has been obliged to force delivery in consequence of uterine
hemorrhage."
PLACENTA PRÆVIA.
213
parent way, dependent upon the previous complete detachment of the
placenta during the labour; and hence, we might probably be en-
titled to remove this case also, like the preceding seven, from the
list of those in which the death of the mother could be attributed
to the contingent separation and expulsion of the placenta.
In Dr. Fraser's case, the chest-affection may have had a prin-
cipal share in the sudden demise of the patient--the presence of
heart-disease (supposing such existed) predisposing, as is well known,
the subjects of it to be greatly, and, in some instances, fatally,
affected by any rapid losses of blood, and occasionally leading, as I
have known in two instances, to sudden death, from the shock of
the delivery, when the labour was in other respects quite natural.
I would add, that the details which I have obtained through Dr.
Fraser's kindness are not by any means perfectly decisive as to the
whole placenta being completely detached in this instance. The
same remark may apply to the other remaining case of Dr. Clarke;
if we may judge from the little information that we do possess in
reference to it, and contrasting it with the results ascertained in
other well-observed instances. The account of Dr. Clarke's patient
is so brief and defective, as to furnish us with no data whatever as
to the extent and nature of the accompanying hemorrhage, the
existence or non-existence of any other complication, the delivery or
not of the child, or the immediate cause of the fatal event to the
mother.
SUMMARY OF RESULTS.
Our inquiry, so far as we have hitherto proceeded, seems legiti-
mately to admit of the following deductions :-
1. The complete separation and expulsion of the placenta before
the child, in cases of unavoidable hemorrhage, is not so rare an
occurrence as accoucheurs appear generally to believe.
2. It is not by any means so serious and dangerous a complica-
tion as might a priori be supposed.
3. In nineteen out of twenty cases in which it has happened,
the attendant hemorrhage has either been at once altogether ar-
rested, or it has become so much diminished as not to be afterwards
alarming.
4. The presence or absence of flooding after the complete separa-
tion of the placenta, does not seem in any degree to be regulated by
the duration of time intervening between the detachment of the
placenta and the birth of the child.
214
MATERNAL DYSTOCIA.
5. In ten out of one hundred and forty-one cases, or in one out
of fourteen, the mother died after the complete expulsion or extrac-
tion of the placenta before the child.
6. In seven or eight out of these ten casualties, the death of the
mother seems to have had no connection with the complete detach-
ment of the placenta, or with results arising directly from it; and if
we do admit the three remaining cases, which are doubtful, as lead-
ing by this occurrence to a fatal termination, they would still only
constitute a mortality from this complication of three in one hun-
dred and forty-one, or of about 1 in 47 cases.
7. On the other hand, under the present established rules of
practice, one hundred and eighty mothers died in six hundred and
fifty-four placental presentations, or nearly one in three.
1
II.¹
SECTION VII.-MECHANISM BY WHICH HEMORRHAGE IS PREVENTED
AFTER THE COMPLETE DETACHMENT OF THE PLACENTA; SOURCE
OF THE DISCHARGE IN PARTIAL DETACHMENTS OF THE PLA-
CENTA; MEANS BY WHICH THE HEMORRHAGE IS ARRESTED IN
PLACENTAL PRESENTATIONS WHEN THE DETACHMENT IS PAR-
TIAL AND WHEN IT IS COMPLETE; ANALOGOUS CASES IN TWIN
LABOURS; ANALOGOUS PHENOMENA IN THE THIRD STAGE OF
COMMON LABOUR; MODES BY WHICH HEMORRHAGE IS PRE-
VENTED, FROM THE VASCULAR ORIFICES LEFT EXPOSED ON THE
INTERIOR OF THE UTERUS.
In his Outlines of Midwifery, Professor A. Hamilton, after laying
down the necessity of turning in placental presentations, observes,
"In some instances, before the orificium uteri can be sufficiently
opened to admit the hand of the operator to pass, the whole cake
will actually be disengaged and protruded; but," he adds, "the
separation and expulsion of the placenta previous to the birth of the
child is, for the most part, fatal to the mother."²
"If the placenta," says Petit, when speaking of unavoidable
hemorrhage, "is entirely separated, the death of both the mother
and child is certain."
¹ First published in Obstetric Memoirs and Contributions, 1855, vol. i. p. 720,
though printed and privately circulated several years previously.
2 Outlines of Midunfery, p. 44.
3 Traité des Maladies des Femmes, etc., tom. ii. p. 22.
PLACENTA PRÆVIA.
215
"When the placental mass is thus expelled before the child, the
hemorrhage," observes Carus, "must necessarily be so considerable,
that both child and mother usually become a prey to death (eine
Beute des Todes.")¹
These three quotations express what seems to be the general
opinion of medical men in regard to the complication which we are
considering. I have already, however, taken occasion to show that
the very reverse of the above statements is more consonant with
fact and experience, and that the complete disjunction and expul-
sion of the placenta before the child, is an accident neither very
fatal to the mother, nor very frequently followed by any great or
perilous degree of hemorrhage. Let us now inquire if we can
explain the mechanism by which it happens, that generally, after
the complete separation of the placenta from the uterus has occurred,
not only does no considerable degree of hemorrhage supervene, but
the preceding and sometimes violent discharge is at once arrested,
and thus the life of the mother preserved against the impending
danger of frightful and fatal flooding. The investigation will, I
believe, lead us to entertain more decided views with regard to the
propriety of the practice to which our present Essay points.
The explanation that would occur to most minds, on first
thinking of the probable mode by which nature could arrest and
prevent hemorrhage after the total separation of the placenta before
the child, is that offered by Drs. Ramsbotham and Campbell. “I
think," says Dr. Ramsbotham, "it may be satisfactorily explained
how the woman's life is preserved. The head of the child is pushed
down upon the os uteri, which suddenly gives way. Under its
relaxation, the placenta is loosed from its previous attachment, and
falls down before the head, which now comes into immediate con-
tact with the bleeding vessels, and by mechanical compression
closes their mouths; from this moment, therefore, the loss of blood
is suspended, and the head is afterwards expelled by uterine
action." Dr. Ramsbotham here imagines that the head of the
infant acts, in such cases, as a compress or plug upon the open
uterine orifices left by the separation of the placenta from the
interior of the cervix.
²
"It may," remarks Dr. Campbell, "be presumed, that in these
cases the fatal event must have been prevented by the quick
¹ Lehrbuch der Gynecologie, tom. ii. p. 442.
2 Observations in Midwifery, Part ii. pp. 191, 192.
216
MATERNAL DYSTOCIA.
descent, and consequent pressure, of the body of the child, upon the
point whence the placenta had been detached."1
2
That the above opinion of Drs. Ramsbotham and Campbell
does not afford the correct explanation of the cessation of hemor-
rhage after the complete detachment of the placenta, appears to me
to be evident from the following facts:-1st, That in some of those
few instances in which the hemorrhage continued after the total sepa-
ration of the placenta, the infant's head did present, but did not
produce the result here attributed to it (see, for instance, Mr. Bailey's
case, Sect. V.); and 2d, On the other hand, in a considerable
number of the instances that we have collected, and in which the
placenta was entirely detached and expelled before the child, the
hemorrhage totally ceased, although the portion of the child that
presented against the cervix uteri was not the head, nor indeed any
such part as could produce the required degree of pressure upon the
open uterine orifices.
In two of the instances which I have myself seen, and already
detailed in a previous section (Sect. II.), the shoulder and neck
presented in one, and the arm of the child in another parts which
could not be applied as plugs in the way supposed by Dr. Rams-
botham and Dr. Campbell.
In a considerable proportion of cases collated into our General
Table, the child presented preternaturally with the foot, feet, arm,
or shoulder. These parts are all of such a form and size, that they
could not be applied as compresses upon the part of the uterus
which was exposed by the previous detachment of the placenta,
and yet the hemorrhage appears to have been as constantly and as
completely arrested in those instances, when once the placenta was
perfectly separated, as it was in cases in which the head or breech
of the child came afterwards to press upon the cervix uteri. The
following tabular view will demonstrate this important point, by
showing the number of instances in which a lower or upper extremity
came down after the expulsion of the placenta, and the degree of
the hemorrhage that was observed to follow in these cases.
1 System of Midwifery, p. 369.
2 Since the above was written, I find that Dr. Radford of Manchester has
published the same opinion regarding the suppression of the hemorrhage as Drs.
Ramsbotham and Campbell entertain. "On a complete separation of the pla-
centa," he remarks, "the hemorrhage is immediately and completely suppressed,
provided the uterus is in a condition to so far contract, as to force down the head,
with the placenta, upon the uterine openings."—Provincial Medical and Surgical
Journal for January 22, 1845.
PLACENTA PRÆVIA.
217
Degree of Hemorrhage after
separation of Placenta in
Great
Considerable
Slight
•
Little or none
•
Not stated.
Footling
Presentations.
Arm or Shoulder
Presentations.
Total.
11
12
2
~~~
2

22
8
10
7
9
18
23
5
These data prove, that "great" or "considerable" hemorrhage,
after the expulsion or detachment of the placenta, is not more liable
to occur when the retained foetus afterwards presents by an upper
or lower extremity, than when it comes down with the head or
breech upon the exposed surface of the cervix uteri. The propor-
tion of cases in which the hemorrhage continues is not greater
under the one set of presentations than it is under the others, as
may be seen by comparing the present table with that previously
given at p. 200. And these observations seem to me to afford
amply sufficient grounds for rejecting the idea, that the prevention
of the hemorrhage after the complete separation of the placenta is
to be explained, by the presenting part of the infant coming down,
and acting as a compress upon the exposed orifices of the uterine
vessels. It may be an auxiliary, but it is not a primary or essential
cause of the suppression of the hemorrhage. For the mechanism of
the arrestment of the flooding, in cases in which the placenta
happens to be completely detached, and the child left in utero, is, I
believe, of a totally different kind. But, in order to understand it,
let me first premise, that obstetric pathologists are in all probability
incorrect in the rationale which they currently give of the immediate
source of sanguineous discharge, in instances of flooding whether
accidental or unavoidable-from partial separation of the placenta.
Anatomical Source of the Hemorrhage in Detachment of the
Placenta
From the time of Guillemeau downwards, accoucheurs seem to
have generally believed, that in cases of unavoidable and accidental
hemorrhage, arising from the greater or less separation of the
placenta, the blood that is effused escapes from the vascular maternal
1 See the details of this case already given and commented upon at pp. 203
and 204.
2 "About a pound." Case 43. See p. 190.
218
MATERNAL DYSTOCIA.
orifices that are left uncovered, and exposed upon the internal
surface of the uterus, when the placenta is detached from that sur-
face. Thus Guillemeau, in writing on the subject, states :—
"The
surest and most proper mode of assisting a woman when the after-
birth presents at the passages, is to deliver immediately (délivrer sou-
dainement). This is the more necessary, from there being usually a
constant flow of blood, owing to the mouths of the veins that are
situated in the walls of the uterus (those, namely, to which the placenta
was united) being open, and as the uterus contracts in order to ex-
pel the infant, it squeezes out the blood that is contained in these
vessels, and which is attracted to them by the heat and pain."1
Mauriceau entertained precisely similar views. "When flood-
ing," he observes, "happens to a woman truly conceived, at whatsoever
time it be, it proceeds likewise from the opening of the vessels of
the fund of the womb, caused by some blow, slip, or other hurt, and
chiefly because the secundine in such cases, and sometimes in others,
is separated in part, if not totally, from the inside of the bottom of
the womb, to which it ought to adhere, that it might receive the
mother's blood appointed for the infant's nurture, by which sepa-
ration, it leaves open all the orifices of the vessels where it was joined, and
so follows a great flux of blood, which never ceaseth (if so caused) till
the woman be brought to bed: For the secundine being once
loosened, although but part of it, never joins again to the womb to
close those vessels, which can never shut till the womb hath voided
all that it contained: For then, compressing and closing itself, and,
as it were, entering within itself (as it happens presently after
delivery), the orifices of the vessels are closed and stopped up by
this contraction, whereby also this flooding ceaseth, which always
continues as long as the womb is distended by the child, or anything
else it contains, for the reason aforesaid.”²
In another part of his work Mauriceau again states-" But the
coming first of the burden is yet much more dangerous; for, besides
that the children are ordinarily still-born, if they be not assisted in
the very instant, the mother likewise is often in very great peril of
her life, because of her great floodings which usually happen when
it is loosened from the womb before its due time, because it leaves all
the orifices of the vessels open to which it did cleave, whence flows in-
cessantly blood, until the child be born."
"13
¹ Guillemeau, Les Ocuvres de Chirurgie, p. 320.
2 Mauriceau, Diseases of Women with Child and in Childbed, p. 87 of Cham-
berlen's trauslation.
3 Ibid., pp. 218, 219.
PLACENTA PREVIA.
219
The opinions expressed in the above quotations from Guillemeau
and Mauriceau, have been generally adopted by obstetrical authori-
ties up to the present time. Thus, the writer of the last work
published upon Midwifery in Great Britain (Dr. Lee of London)
states, when discussing the pathology of accidental and unavoidable
hemorrhage—“It is from the great semilunar, valvular-like, venous
openings in the lining membrane of the uterus, which we have seen
in various preparations, and from the arteries which are laid open
by the separation of the placenta, that the blood alone flows in
uterine hemorrhage.'
"' 1
When the placenta is partially separated from the uterus,
there are two surfaces left exposed by that separation-namely, a
portion of the internal surface of the uterus, and a portion
of the external surface of the placenta. According to the usual
explanation, such as I have above shown it to be, the hemorrhage is
supposed to proceed from the first of these exposed surfaces, namely
that of the uterus. On the contrary, I am assuredly of opinion that
it chiefly, and, in most instances, entirely, proceeds from the other
surface, namely that of the placenta. I feel quite convinced that
the pathological opinion on this point advocated by the late Professor
Hamilton is the correct explanation. After citing the opinions of
Drs. Ramsbotham, Davis, Dewees, and Ingleby, in reference to the
origin of the hemorrhage from the exposed uterine surface in un-
avoidable and accidental floodings, Dr. Hamilton observes :-“ Many
other authorities may be quoted to prove the common opinion upon
this subject; and yet the author, from the earliest period of his
professional life, has been anxious to show, that the hemorrhage in
these cases proceeds from the separated portion of the placenta more
than from the ruptured uterine vessels.'
)) 2
To understand the true source of the flooding in unavoidable
and accidental hemorrhage, the cause of its continuance when the
separation of the placenta is partial, and the mechanism of its arrest-
ment when that separation is complete, we must take into consider-
ation the following different points :-First, The maternal portion of
the placenta is of a cavernous structure; that is to say, it consists of
a series of maternal vascular cells, or dilatations, or, perhaps more
properly speaking, of one large maternal vascular bag, into which
the blood of the mother is conveyed by the utero-placental arteries,
and from which it is removed by the utero-placental veins. Secondly,
¹ Theory and Practice of Midwifery, 1844, p. 361.
2 Practical Observations, second edition, p. 312.
220
MATERNAL DYSTOCIA.
The vascular maternal cells, or immensely dilated capillaries which
contain the blood of the mother in the placenta, communicate so
freely with each other throughout all the different portions of the
organ, that the blood which has access into one part, may in this
way be rapidly diffused into the other portions of the placental
mass. And, Thirdly, The deciduous or uterine surface of the placenta
has no vital, muscular, or contractile power, by which it can constrict
the orifices of the vascular tubes which pass from the uterus into it,
when these tubes are ruptured in consequence of a greater or less
detachment of the organ from the interior of the uterus.
Cause of the Continuance of the IIemorrhage, when the Detachment of
the Placenta is partial. Explanation of its occasional Cessations.
From the consideration of these premises, it will readily appear,
that when a small portion of the placenta is detached, it occasionally
occurs, as I have already shown in the early part of the present
Essay, that the consequent hemorrhage is sometimes so great as to
be dangerous, or even fatal, in its extent. Its amount, under this
and other circumstances, may be also regulated and increased by the
occurrence, in consequence of uterine contraction,' or otherwise, of
any laceration in the detached portion of the placenta itself; for
when the substance of the organ is torn, its vascular maternal cells
will be more freely opened into and exposed, and a more profuse
discharge be allowed to issue from them. We may further easily
conceive why the discharge should sometimes be actually more
abundant when the detachment of the placenta is slight, than when
it is greater in degree. For the quantity of blood passed into the
maternal vascular structure of the organ, and consequently the
quantity liable to escape from its unattached surface, will, in some
respects, depend upon the extent of vascular placental connection
which continues between it and the uterus. In other words, the
intensity of the resulting hemorrhage will be regulated as much, or
more, by the extent of placental surface which still remains in
attachment to the mother, as by the extent of surface which is
already detached; for the freedom with which the blood is supplied
See illustrative cases in Smellie's Collection, vol. iii. p. 411 (the placenta
"split in the middle "); and Ibid. vol. ii. p. 217 ("the placenta adhered to the
os internum, near its middle, or thickest part, in which part I perceived a lacer-
ation upwards of an inch long, and penetrating almost through the substance of
the placenta "). In both these cases the mothers died of the excessive flooding
before delivery, and the condition of the placenta was ascertained on post-mortem
examination.
PLACENTA PRÆVIA.
221
to the placenta will affect the violence of the flooding, equally, or
more so, than the freedom with which that blood is allowed to
escape from the open orifices of its ruptured vessels.
Probably, in most cases, the hemorrhage will reach its maximum
when the quantity of blood which enters the placental cells by the
adherent portion is equal to what can reach, and escape from, the
open orifices of the separated portion. Any additional separation
after this will tend rather to diminish the flooding, as less blood will
be carried into the placenta, from the number of its channels of
supply being diminished. Most accoucheurs seem to believe that
the greater the degree of detachment, the greater will be the
hemorrhage, and hence, we are earnestly cautioned,' in the opera-
tion of turning in placenta prævia, not to separate more of the
placenta from the cervix uteri than is absolutely necessary to permit
of the passage of the hand. Theory as well as experience would
seem to throw the greatest doubts upon the soundness and propriety
of this rule. If at all true up to a certain extent of separation, it
certainly does not hold good in regard to the detachment when
carried to some degree farther.
There is an additional anatomical reason why the accompanying
hemorrhage should be excessive, in some cases where a very small
portion only of the edge of the placenta has been separated. I have
already quoted from Dr. Hamilton a case of this kind, which proved
fatal, and where the "area of the separated placenta was less than
a square inch."2
The largest of the maternal vessels belong-
ing to the placenta is that which Meckel, Jacquemier, and other
authors, have described under the name of the circular sinus of the
organ. It courses round the circumference of the placenta, in some
parts being of a great size, and at other points more or less con-
tracted, or even absent. I have usually found this maternal placen-
tal vessel of great dimensions in several different parts of its course.
In the cases in which excessive hemorrhages occur, when a small
portion only of the edge of the organ is detached, I believe the
danger and fatality of the result are to be ascribed to the fact, that
some portion of the course of this large circular sinus has been
1 As by Rigby, System of Midwifery, p. 262: “The less we separate the pla-
centa, the less will be the hemorrhage ;" Ramsbotham, Obstetric Medicine, p. 393 :
"The profuseness of the discharge will be principally regulated by the degree
of separation." See also Levret, Accouchemens Laborieux, p. 68; Hatin, Cours
d'Accouchemens, p. 178; Lachapelle, Pratique des Accouchemens, tom ii. p. 440,
etc. etc.
2 Practical Observations on Midwifery, 2d edition, p. 314.
222
MATERNAL DYSTOCIA.
opened, and thus a rapid and free tide of maternal blood allowed to
escape from the disrupted part of this uncontracting tube.
In all instances, then, of hemorrhage from partial separation of
the placenta, I hold that the blood issues principally, if not entirely,
from the uncontracted and uncontractible maternal orifices that
belong to the external surface of the separated portion of the organ,
and that the maternal blood is supplied more or less freely to these
orifices, in consequence of the free communication existing among
the different maternal cells, and from these cells being kept filled
with blood through the utero-placental vessels of that portion of the
placental mass which continues to remain fixed and attached to
the uterus.
Further investigations will probably show, that the greatest
quantity of blood that escapes, flows from the exposed orifices
which lie nearest to, or are actually involved in, the line of sepa-
ration between the placenta and uterus. Along this line of sepa-
ration, and in its immediate neighbourhood, these orifices-consisting
mainly of apertures in the large and torn decidual veins-will be for
a time kept more stretched and patulous than in the other portions
of the detached surface, and more especially will this hold true if
there exist any tendency in the uterus to detach itself more and
more from the placental surface along this line of junction by con-
stant contractions. Under such circumstances the placental orifices
alluded to, and those in their immediate vicinity, will afford, not
only the freest, but also the nearest, channel for the discharge of the
mother's blood flowing into its maternal cells.
In cases of partial detachment of the placenta from the interior
of the uterus, the attendant degree of hemorrhage is also, no doubt,
regulated by another important circumstance-namely, by the con-
dition of the blood itself in the separated portion of the organ. If
the blood in the maternal cells of that portion continues still to
remain fluid, it will be ready to escape from every ruptured orifice
upon the detached placental surface. Hence, when a considerable
portion of the placenta is at once and suddenly separated, the dis-
charge is sometimes excessive, until the blood in the tissue of the
detached part becomes more or less coagulated. Gradually, by its
coagulation and infiltration into the structure of the separated por-
tion of the organ, it obstructs the maternal cells of that part, and
consequently more or less completely arrests the discharge.
It is in fact to this infiltration and coagulation of blood in the
PLACENTA PRÆVIA.
223
detached portion of the organ, that we are, as Gendrin' has well
shown, to look for an explanation of the occasional temporary cessa-
tions of those floodings which are so frequently observed during the
latter periods of utero-gestation, in cases of placenta prævia. It is
well known, that when the placenta presents, hemorrhage is liable
to occur at intervals, for days and weeks, or even for months, pre-
viously to the completion of the full term of pregnancy. Each of
these hemorrhages depends upon a partial detachment of the ex-
panding surface of the cervix uteri, from the unexpanding surface of
the placenta. For the expansion of the cervix uteri, during the
last periods of pregnancy, is known to produce its detachment from
the placenta, when the placenta is implanted upon it, exactly in the
same way as the contractions, or rather retractions, of the same part
during labour, lead to a similar result.
Each partial detachment occurring during pregnancy gives rise
to the exposure of a greater or less number of vascular placental
orifices, and consequently to a greater or less degree of hemorrhage
from these orifices. Each of these hemorrhages generally ceases.
after a time, and the mechanism of their cessation is not so much
to be found in any changes in the corresponding part of the uterus,
as in the changes I have adverted to as occurring in the separated
portion of the placenta. The blood becomes infiltrated and coagu-
lated in the substance, and occasionally also upon the surface, of this
separated portion; its vascular maternal cells are thus rendered im-
permeable; and the temporary arrestment of the flooding is conse-
quently effected. The blood diffused and infiltrated into and upon
the detached portion of the placental structure, undergoes a series.
of changes which I have elsewhere attempted to trace minutely ;'
and, after a time, the separated and ecchymosed tissue of the
placenta itself becomes ,yellowish and atrophied, partly from the
alterations which occur in the blood infiltrated through it, and
partly from the obliteration of its vessels, and the consequent
degeneration and desiccation of its tissues. In cases of placenta
prævia, in which there has been a repeated recurrence of hemor-
rhage, and as frequently an arrest of it, we can occasionally trace in
the placenta, after its expulsion, different parts of it, showing a
series and gradation of pathological changes arising from successive
partial detachments, and successive apoplectic infiltrations and
¹ Médecine Pratique, tom. ii. p. 216.
2
2 See Pathological Observations on the Diseases of the Placenta, in the Edin-
burgh Medical and Surgical Journal, April 1836, p. 275.
224
MATERNAL DYSTOCIA.
obliterations of its substance from coagulated blood of different
ages lodged in its structures. These alterations are confined to the
detached portion, and the part always presenting the most recent
stage of the pathological changes in question, is that lying nearest
the line of junction between the separated and affixed divisions of
the organ. The part showing the most advanced stage of the
changes will be found situated farthest from this point; or is, in
other terms, the part which was first and earliest detached. In
cases of direct and central implantation of the placenta over the os,
the centre of the organ, having in general become first detached,
will be found to present the oldest morbid alterations; and the
newer forms and phases of it may be sometimes traced in succes-
sive departments or layers, from this to the circumference of the
detached portion-always supposing there has previously occurred
a succession of detachments and attacks of hemorrhage. If the edge
only of the placenta has presented-and several successive hemor-
rhages have in the same way taken place previously to labour-the
same series of morbid changes will be found in the organ, running,
not, as in the above instance, from the centre towards the circum-
ference, but from the presenting or earliest separated point of the
edge more or less towards the centre of the mass.
1
As affording some proof of the correctness of the view which I
have already ventured to give of the immediate source of the dis-
charge in unavoidable hemorrhage, I would beg to dwell for a
moment on one other point :-Almost all obstetric authors mention,
as a mark of diagnosis during labour, between unavoidable and
accidental hemorrhages, that in the first or unavoidable species, the
flooding is greatest during the pains, and least during the intervals;
whilst in the last, or accidental form, the discharge is least during
the pains, and greatest during the intervals. In placental presenta-
tions, "the character of the hemorrhage," says Dr. Rigby, "is also
different from that of common hemorrhage, inasmuch as it increases
during a pain, and diminishes or ceases during the intervals, whereas
in hemorrhage under ordinary circumstances it is the reverse.
am not aware that any solution has been hitherto attempted of this
peculiarity in unavoidable hemorrhage. And, whilst it seems very
inexplicable upon the idea generally received that the discharge
comes from the exposed surface of the uterus, it is a condition
which we might have a priori anticipated from the opposite opinion,
that the effusion flows from the detached surface of the placenta.
System of Midwifery, p. 255.
1
I
PLACENTA PRÆVIA.
225
For, if in placenta prævia the hemorrhage proceeded from the vas-
cular orifices laid open on the interior of the uterus, it ought to be
diminished and not increased in quantity during the pains, as these
orifices will necessarily be temporarily diminished under the contrac-
tion of the uterine fibres. If we adopt, however, the other view, that
the discharge proceeds from the open vascular orifices existing on the
outer or maternal surface of the detached portion of placenta, we
can easily understand how its amount should be temporarily aug-
mented by each labour pain. For each uterine contraction, in
pushing down the presenting part of the child against the compress-
ible placental mass, will squeeze out from its maternal cells, as from
a sponge, a portion of the fluid blood contained in them; and hence,
during the pressure, an increased flow of this blood will issue from
the vascular orifices opening upon its detached surface. During the
intervals between the pains, a re-accumulation of maternal blood will
take place in the interior of the placenta; but the quantity actually
escaping will be comparatively less, till again it is forced out in
accumulated amount by the compression to which it is subjected by
a returning pain.
Cause of the Cessation of the Hemorrhage when the detachment of the
Placenta is complete.
All the preceding remarks apply to the mechanism of unavoid-
able hemorrhage, and its arrestment, when the placenta is partially
separated. Their application to the rationale of the complete arrest-
ment of the hemorrhage, in those instances in which the placenta is
completely detached, is still more obvious and simple. For, if the
explanation which I have above given of the source of the hemor-
rhage in partial detachment of the placenta, be true-namely, that
it proceeds principally, if not entirely, from the maternal vascular
cells belonging to the separated portion of the organ being still,
more or less freely, supplied through the utero-placental vessels of the
adhering portion-we can further easily understand how it occurs,
that the attendant hemorrhage is immediately moderated, or entirely
arrested, when the placenta is once thoroughly and perfectly sepa-
rated from the interior of the uterus, as in the class of cases which
form the subject of the present memoir. If the flooding proceeds,
as I have endeavoured to show, from the detached and exposed sur-
face of the placenta, and not from the detached and exposed surface
of the uterus, the placenta must cease to yield any new or additional
quantity of maternal blood, as soon as its own vascular connections
226
MATERNAL DYSTOCIA.
with the mother are destroyed; or, in other words, the immediate
source of supply of the hemorrhage is cut off, and its continuance
consequently prevented, as soon as the placenta is entirely separated
from the interior of the uterus.
Besides the preceding anatomical considerations, we must take
some important physiological points into consideration, in investigat-
ing the mechanism of the complete cessation of unavoidable hemor-
rhage upon the complete separation of the placenta. The uterus,
during pregnancy, has, like other organs under high vital periodic
activity, both its arteries and veins, but especially the latter, enor-
mously enlarged. The immediate and final object of this great
enlargement is to supply the necessary materials for nourishment
and respiration to the included fœtus. The medium through which
these materials are supplied to the foetus is the placenta; and the
maternal cells of that organ form the more immediate locality in
which they are transmitted from the maternal to the foetal system.
We have already stated that these maternal placental cells are
merely dilated capillaries, inasmuch as they constitute the only
vascular connection between the terminations of the utero-placental
arteries and the origins of the utero-placental veins. The capillaries,
especially of those parts and organs which are liable to periodic
excesses of action, are allowed to have a power of producing, under
these excesses of action, an increased determination of blood to
themselves and their corresponding arteries and veins, and that
quite independently of any change whatever in the central organ of
the circulation. This seems to hold true to a great and remarkable
degree with regard to the maternal form of capillary circulation
carried on in the placenta, in consequence of the great and remark-
able functions which this temporary portion of capillary circulation
is destined to perform. And if the organic relations of the placenta
to the uterus are disturbed, the resulting deviations are equally
striking. If the placenta is only partially detached, the "attract-
ive" power of the maternal circulation in the organ is, with the
other moving powers of the blood, generally sufficient to keep the
cells of the detached, as well as those of the adherent, portion filled
with blood; and at the same time the circulation in the uterine
arteries and veins in the immediate neighbourhood continues to be
1
1 The capillaries possess a distributive power over the blood, so as at least
to regulate the local circulation, independently of the central organ, in obedience
to the necessities of each part."-See note in Mr. Palmer's admirable edition of the
Works of John Hunter, vol. iii. p. 332.
PLACENTA PRÆVIA.
227
more or less vigorously maintained, in consequence of their conti-
guity to the free tide of communication that is carried on between
the uterine vessels and the part of the placenta that still remains
affixed. Hence, probably, even the orifices of the congested and
enlarged uterine veins opening on the interior of the uterus, and
lying near the existing line of junction between the uterus and the
placenta, may occasionally allow of some discharge, in addition to
the freer form of flooding that we have seen to take place from the
more patulous apertures left on the exposed surface of the placenta
itself. But separate entirely and completely the placenta from the
uterus, and then you at once alter the course-as you have at once
removed the great physiological aim and object-of the utero-pla-
cental circulation. The blood in the uterine vessels being now no
longer attracted by the maternal capillary system of the placenta,
and so far the distributive influence of that system being completely
and suddenly abrogated, there is not only a less absolute tide of
blood determined towards the uterus, but that which is contained
in its vessels seeks the freest and most patent course backward to
the heart through the higher and larger communicating branches
between the uterine arteries and veins. The placental capillary
influence no longer turns aside from these channels, the direct and
onward course of the circulating current into its own set of special
uterine vessels. These special vessels, now that their function is
arrested, are comparatively empty of blood, and their collapsing or
collapsed sides may serve to keep the general vascular current in its
proper canals; for the hemorrhage, if any, is from venous orifices,
and hence easily repressed by slight impediments; and we shall
afterwards see that it is not a direct discharge, but arises from retro-
gression or regurgitation of the blood in the venous tubes.
I might add, if it were necessary, some analogous instances in
illustration of these opinions. The case of a limb suddenly and
completely avulsed by machinery, or otherwise, might be shown to
be similar in most points. Every one knows how slight the
hemorrhage generally is, which is met with in connection with this
severe accident. But another illustration may be regarded as more
apposite. The foetus has a circulation of blood to and from the
placenta through its umbilical vessels, in the same way as the
mother has a circulation to and from the placenta through its
utero-placental vessels. We have found as a general law, that when
the utero-placental vessels are entirely and totally divided by the
complete detachment of the placenta, the mother has little or no
16
228
MATERNAL DYSTOCIA.
1
tendency to lose blood from their exposed extremities. When the
umbilical vessels are divided, the foetus has as little tendency to
lose blood from their divided extremities, if once the vicarious
function of the pulmonary respiration is freely established. In the
one instance, as in the other, the circulation through the divided
vessels is stopped, and their tendency to bleed is arrested as soon
as the physiological conditions which called these vessels into exist-
ence and action is completely arrested or superseded, and that
though some anatomical conditions of its vessels, apparently favour-
able to hemorrhage-particularly the presence of a large venous
tube or tubes unprovided with valves, and admitting of regurgita-
tion-may be still found persisting.
Absence of Hemorrhage in Twin Labours, with one or both Placentæ
entirely detached before the Birth of the Second Child.
There is another series of cases which, if my present space per-
mitted, might be adduced at length, both in corroboration of the
1 In reference to this point it may be necessary to state two facts. First, It
is generally acknowledged by physiologists, as the result of various observations,
that immediately after the child is born, the umbilical vessels cease to pulsate and
carry blood, if the pulmonary respiration becomes active; and if the pulmonary
respiration is by any cause interrupted or arrested before the cord is divided, the
circulation through the umbilical vessels again becomes more or less active.
Secondly, There seems to be very little danger of hemorrhage from the umbilical
vessels after the division of the cord, if previously to that division the pulmonary
respiration be allowed to become completely established. Hence various practi-
tioners have gone so far as to aver, that it is unnecessary, as a general rule, to
place a ligature upon the fœtal extremity of the cut umbilical cord, the tendency
to bleed directly through its arteries, or indirectly by regurgitation through its
veins, being so slight as not to require it, if the cord be not cut till the child has
cried loudly, and the lungs are in full and free action. See, in support of this
opinion and practice, Dehmel, in Haller's Dissertationes Anatomicæ, tom. v. p.
607; Koltschmid, De intermissa Funiculi Umbilicalis Deligatione non absolutè
lethali, Jena, 1751; Schweikhard, De non necessarid Funiculi Umbilicalis Deliga-
tione, Argent. 1769; Carboue, Journal Général de Médecine, tom. iii. p. 334;
Van der Eem, De Artis Obstetrica Hodiernorum præ Veterum Præstantiâ, in
Schlegel's Sylloge Operum Minorum in Arte Obstetricâ, tom. i. p. 94; Ziermann,
Die na'urgemasse Geburt des Menschen, etc., Berlin, 1817. C. Martin, in a Thesis
published some years ago at Munich, De Ligaturâ Funiculi Umbilicalis, maintains
(p. 11) that the practice of tying the foetal extremity of the cord is not only use-
less, but hurtful, and denounces its adoption as a reprehensible crime propagated
down to our times, facinus damnandum ad nostra usque tempora propagatum.
"Whatever," observes Velpeau, "may be the explanation, it always happens,
that if it is left to itself and without ligature, the cord would very rarely expose
the fœtus to any hemorrhage, or to any accident, even if it were clean cut, and
not bruised or torn."-Traité des Accouchemens, tom. ii. p. 566.
PLACENTA PRÆVIA.
229
fact, that the complete separation of the placenta is not followed by
hemorrhage, and in evidence of the special explanation of the cessa-
tion of the flooding which I have above offered. I here advert to
cases of twins, in which it occasionally occurs, that, after the birth
of the first child, and before the birth of the second, one or both of
the remaining placenta are expelled, and yet no hemorrhage follows.
Such cases may be arranged under three divisions, namely-
2
1. Twins, in which, after the birth of the first child, its own placenta
is expelled or removed, the other infant and placenta remaining, without
flooding, for a greater or less length of time in utero." When a wo-
man," says Mauriceau, "has a plurality of children, we must not
deliver the placenta till after the birth of the last infant; because
there would be produced a great discharge of blood (une grande perte
de sang) if we thus detached the placenta prematurely." Dr.
Denman adverts to this subject in language implying similar theo-
retical doubts upon the point, and yet, at the same time, affording
practical confutation of it. "When," he remarks, in his observa-
tions upon twins, "the placentæ are separate, that of the first child
should not be extracted before the birth of the second child, as a
discharge of blood must necessarily follow, and perhaps a hemor-
rhage; though sometimes one placenta has been discharged before
the birth of the second child, without any material loss of blood.
In some cases of hemorrhage, when there was only one child, the
placenta has been expelled before the child, without any detriment,
though not without much apprehension of danger." "
"I have seen,"
Dr. Collins observes, "several instances where the placenta of the
first child came away without interference before the birth of the
second, and yet there was no hemorrhage of any consequence.
Several cases of a similar kind have been reported to me by different
3
1) 4
1 See Proceedings of Edinburgh Obstetric Society, December 22, 1847—
Edinburgh Monthly Journal, March 1848, p. 692.
2 Aphorismes touchant la Grossesse, etc., No. 214.
3 Introduction to the Practice of Midwifery, p. 541.
• Practical Treatise on Midwifery, p. 312. Dr. Collins adverts to two hospital
cases. The two following similar cases occurred to him in private practice :-
1. "C. S. was delivered of twins, June 21, 1823. The placenta of the first
child was expelled immediately. The feet of the second were then found in the
vagina, and brought down. There was not the slightest hemorrhage. The first
was born alive, the second putrid.”
2. "M. C. was delivered of twins, May 6, 1823. The placenta of the first
child was expelled before the birth of the second, without hemorrhage. Both
children were born alive at the full period."-Sec ibid. pp. 312, 313.
230
MATERNAL DYSTOCIA.
1
professional friends. They all tend to give a direct contradiction
to the observation of Caseaux-the author of one of the latest and
best French works on midwifery-that the complete detachment of
the afterbirth of the first child "would expose the woman to a
fatal hemorrhage (exposerait la femme à une hémorrhagie mortelle.") 2
In his work, Peu even ventured to suggest it as a proper mode of
practice, in some cases, to remove the first placenta, when ascertained
to be quite isolated, before the birth of the second child.
"When
there is," he observes, "more than one child, the method ordinarily
followed is to receive the one that presents first, the cord of which
should serve as a guide for the others. The fingers are slipped along
it to the mass of the placenta, to discover if it is absolutely sepa-
rated from the other placenta. In this case, which is sufficiently
rare, one may draw it out immediately.'
" 3
It may be objected to these twin cases, as corroborative of the
fact for which I adduce them, that the distended bag of the mem-
branes of the remaining child might prevent any hemorrhage by
acting as a sufficient compress upon the whole uterine surface laid
bare by the detachment of the placenta of the infant already
expelled. But this objection will not hold good with respect to
twin cases included under the two divisions which I have next to
speak of.
2. Twins, in which, after the birth of the first infant, the placenta of
the second child was expelled, one infant and placenta remaining still in
utero.-A case of this kind has been related to me by my friend
Dr. Andrews, Lecturer on Midwifery at the Westminster School.
One of his pupils was in attendance. A placenta was expelled after
the birth of the first child. Little or no hemorrhage occurred till
the second infant was born, some time afterwards. It was found
that the previously expelled placenta belonged to it, and the still
retained placenta belonged to the child that had been first born.
Here, in a case of twins, we had a child and a placenta remaining in
utero, but the remaining placenta was not the placenta of that
"two cases of
1 Thus, "I have seen," Dr. Dawson of Newcastle writes me,
twins, where the placenta of the first came away before the birth of the second
child. There was no hemorrhage in either case. Mr. Sang," Dr. Dawson adds,
"has met with two cases of this description, and also without hemorrhage." A
case of the same kind, and with the same result, occurred some time ago to Dr.
Dickson, one of my own pupils. Dr. Fenton, Dr. Campbell, and others, have
related to me similar instances.
2 Traité de l'Art des Accouchemens, Paris, 1841, p. 785.
3 Pratique des Accouchemens, p. 208.
PLACENTA PRÆVIA.
231
child. And the placenta which was previously detached and sepa-
rated had necessarily torn asunder the bag of membranes, leaving
the portion of uterine surface to which it was itself affixed exposed,
without that exposure leading to any marked degree of hemorrhage.
3. Twins, in which, between the birth of the first and second child, the
placentæ belonging to both were expelled.—Dr. Dewar of Dunfermline
has reported to me two cases of this kind. In one "the placentæ
were firmly united, and were discharged after the birth of the first
child. There was no unnatural discharge of blood. The mother
did well." This case occurred in the practice of Dr. Brown. The
other occurred under Dr. Dewar's own observation. "The mother
had borne several children. The first child, which was at the full
time, presented by the feet, and immediately after its birth the two
placentæ, connected by a membranous but not vascular band, were
expelled. Labour followed briskly, and in little more than five
minutes the second child, which presented naturally, was born. The
hemorrhage," Dr. Dewar adds, "was very slight, and not greater than
what occurs after some ordinary labours. The mother did well."
It may be considered that, in these two cases, the interval be-
tween the expulsion of the placenta and the birth of the child was
too brief to allow accurate observations to be made upon the degree
of existing hemorrhage. This objection is completely answered by
a third case of the same kind mentioned to me by my friend Dr.
Protheroe Smith of London. "I was," he writes to me, "called to
a patient some time since who had given birth to one child, imme-
diately after which a large double placenta followed without hemor-
rhage, leaving a second child in utero, which was expelled, dead of
course, three or four hours afterwards, without further discharge of blood."
Dr. Tyler published, two years ago, a similar case. After the birth
of the first child, a double placenta was discharged. Two hours
afterwards, the shoulder of the second child was found presenting,
and the uterus in a state of "hour-glass contraction." Many un-
successful efforts to turn the foetus were made. At last its thorax
was eviscerated, and the breech brought down. The mother made
1
a good recovery. "Here," observes Dr. Tyler, "we have a case not
merely of simple placenta prævia, but a double surface exposed-
there having been two placenta; the fibres of the womb first in a
state of rigid contraction; then the irritation consequent upon the
performance of the embryotomy; and, lastly, a state of excessive
1 American Journal of the Medical Sciences for October 1843; or, Provincial
Medical Journal, vol. vii. p. 245.
232
MATERNAL DYSTOCIA.
relaxation, and still not a drop of hemorrhage, and the female entirely
recovered."
Presence of Hemorrhage in Partial, and its absence in Complete, Detach-
ment of the Placenta, in the Third or Last Stage of Ordinary
Labour.
I have now referred, under the present section, to two separate
sets of facts, illustrative of the non-supervention of hemorrhage after
the complete detachment of the placenta from the interior of the
distended uterus. We have seen that, both in the placental pre-
sentations and in twin labours, a large portion of the internal surface
of the uterus may be left exposed by the entire separation of the
placenta, while the organ continues distended by the presence of a
remaining child, and yet the vessels of that exposed surface have
little or no tendency to bleed, if the placental mass be only once
completely detached from it. We have further seen, that if, in the
same cases, the placenta be only partially separated from its uterine
attachment, hemorrhage is generally present. The supervention of
the hemorrhage, when the detachment of the placenta is partial, is
probably not more certain than its cessation is when that detach-
ment is perfect and complete.
Though these facts have escaped the general notice of obstetric
pathologists, they have all been long familiar with a third set of
instances in which the same phenomena may be observed. I refer
to circumstances well known in connection with the last or third'
stage of common labour, and after the child is born. When, during
that period of the labour, the placenta happens to become only
partially separated from the uterus-as in cases where a portion of
it still remains firmly attached from morbid adhesion-hemorrhage
is generally present. When, on the other hand, the placenta becomes
totally separated from the interior of the uterus, either naturally or
artificially, all hemorrhage generally ceases. In other words, we have
the same consequences resulting from partial, as contrasted with
complete, detachment of the placenta, in the last stage of labour,
and when the uterus is comparatively small and contracted, as we
observe under the same conditions in the earlier stages of parturi-
tion, and when the uterine cavity is still filled and distended by the
1 In correspondence with the language of Denman, Hamilton, Ramsbotham,
etc., I here use the words "third stage,” as denoting the period intervening be-
tween the birth of the child and the expulsion of the placenta.
1
PLACENTA PRÆVIA.
233
presence of an infant. Under these, at first apparently different
circumstances, the general fact seems to be the same-namely, that
hemorrhage is almost sure to occur if the placenta be only partially
separated; it is almost as sure to cease if the placenta be once fully
and entirely detached.
Means by which Hemorrhage is prevented from the Venous Orifices left
exposed on the Interior of the Uterus.
I have no intention at present to push the present investigation.
farther, and enter upon a full inquiry into this other remaining point
—namely, by what special mechanism nature prevents the occurrence
of hemorrhage from those patulous vascular orifices that are left on
the interior of the uterus, when the placenta is, as in the instances
we are considering, completely detached from its internal surface.
The simple empirical fact of its non-occurrence is sufficient for all the
practical purposes of the present essay. And I believe that the sub-
ject, if fully discussed, would form an anatomical and pathological
problem that would require for its complete solution a much more
laborious and lengthened series of researches than I can pretend at
this time to afford to it. I have, however, but little doubt, that the
means by which, in placental presentations, hemorrhage is prevented
from the uterine vessels themselves after the detachment of the
placenta, will be found in all its essential points to be the same by
which flooding is prevented after the removal of the placenta in the
ultimate stage of common labours. The non-occurrence of hemor-
rhage from the uterine vessels in this last state, or after the complete
detachment of the placenta in ordinary parturition, is probably not
explicable, as is generally imagined, upon the sole circumstance of
the simple and absolute contraction that occurs in the uterine fibres
after delivery. We know, from the observations of Gooch,¹ Vel-
peau, Rigby, and others, that post-partum hemorrhage sometimes
2
¹ Medico-Chirurgical Transactions, vol. xii. p. 157. "The observing practi-
tioner must," Dr. Gooch observes, "have been frequently struck by the little
proportion that existed between the want of contraction and the degree of hemor-
rhage; having found the uterus bulky without any hemorrhage, and a profuse
hemorrhage without greater bulk of uterus. Nay, further, I have witnessed a
profuse hemorrhage, though the uterus had contracted in the degree which com-
monly indicates security; and I have ventured to do what is seldom justifiable,
separate the placenta before the uterus had contracted, without more hemorrhage
than after a common labour. What is this circumstance that has so great an in-
fluence that its presence can cause a moderately contracted uterus to bleed pro-
fusely, and its absence can cause an uncontracted uterus to bleed scarcely at all?"
-P. 152.
2 Traité de l'Art des Accouchemens, tom. ii. p. 539.
* London Medical Gazette, vol. xiv. p. 332; and System of Midwifery, p. 218.
234
MATERNAL DYSTOCIA.
supervenes when the uterus appears contracted and reduced to its
usual size after delivery. On the other hand, the facts that I have
adduced in the preceding pages show that there is little or no
tendency to hemorrhage after the perfect expulsion of the placenta,
when this simple and absolute contraction of the uterine fibres is so
far prevented by the presence in utero of a full-grown fœtus. When
the child is born in ordinary labour, and the placenta happens to be
retained from want of uterine contraction, hemorrhage does not
necessarily supervene. It is well known that Ruysch, William
Hunter, and others, adopted, for a time, the practice of leaving the
placenta in utero for hours and days till nature herself threw it off,
and that they were at last forced to abandon this line of treatment
—not because uterine hemorrhage was liable to supervene, but be-
cause the dead and retained organ was found to become putrid, and
to give rise to symptoms of severe irritation and fever. Again, after
the complete evacuation of the uterus in common parturition, and
the total removal of the placenta, hemorrhage does not necessarily
supervene, though the uterine fibres are not in a state of firm con-
traction. We often find them alternately relaxing and contracting
when after-pains supervene, and yet the general relaxation that is
observable between the pains may not give rise to the slightest
degree of flooding. Every practitioner has had occasion to watch,
with more or less anxiety, the uterus remaining of considerable size
and softness for some time after delivery, and consequently with its
fibres not firmly contracted, but without after-pains, and without
hemorrhage supervening. In the same way I shall afterwards have
occasion to show that in some cases of placental presentation after
the placenta had become expelled, and while the child remained in
utero, the labour-pains have ceased; and still, notwithstanding this
cessation, not only has no hemorrhage followed, but, on the con-
trary, the flooding that previously existed has immediately ceased.
Such instances prove that strong uterine contractions in the
special complication which forms the subject of our observations, are
not probably so essential a part in the mechanism of the prevention
of hemorrhage from the open orifices of the uterine veins as we
might a priori suppose. When hemorrhage does continue after the
expulsion or extraction of the placenta in placental presentations,
the determining cause of the hemorrhage is probably the same as
gives rise to this accident in the last stage of labour, and after the
complete evacuation of the uterus. In two cases, which have been
already quoted at length, and where, in placental presentations, the
PLACENTA PREVIA.
235
hemorrhage remained after the complete expulsion of the placenta,
the child being retained in utero, the flooding still continued also for
a time after the infant was extracted, and the uterus was completely
emptied. The same circumstances-whatever they may be-in all
likelihood led to its recurrence under both of these conditions.
No doubt the occurrence, after delivery, of great and decided
atony in the whole muscular system of the uterus, does assuredly
give rise to post-partum hemorrhage; and the same antecedent con-
dition may be the cause of the continuation of the flooding in some
circumstances where this happens after the expulsion of the placenta
in placenta prævia. But if I may judge from my own observations,
I would venture to remark, that the morbid condition which is most
frequently and earliest seen in connection with post-partum hemor-
rhage, is a state of irregularity and want of equability in the con-
tractile action of different parts of the uterus-and, it may be, in
different planes of the uterine fibres-as marked by one or more
points in the organ feeling hard and contracted, at the same time
that other portions of the parietes are soft and relaxed-and by the
contracting and relaxing fibres slowly but frequently changing their
relative situations."
Upon the same principle, I believe, that in attempting to prevent
or remove the morbid condition leading to post-partum hemorrhage,
when it is functional in its nature, and not connected with any
organic or traumatic causes, we ought to endeavour to produce not
merely a certain degree and amount of uterine contraction, the great
and primary practical point to which we always justly look, but
also a certain equability and uniformity of contraction. The same
may perhaps be found true, both pathologically and practically, in
regard to the state of the uterus, after expulsion or extraction of the
placenta before the child in placental presentations. At the same
time, I would repeat, that this part of the subject, like the whole
question of the manner and means by which hemorrhage is pre-
vented from the exposed uterine veins, after every case of ordinary
labour, stands, in my opinion, in need of new, careful, and extended
investigations. I have, however, at present, no desire to encounter
so wide and complicated an inquiry; and shall content myself with
stating in reference to the subject the few following suggestions:-
1 "I have rarely introduced the hand into the uterus in a case of flooding,
without meeting with it (hour-glass or irregular contraction), whether the
placenta had or had not been expelled, "-Dr. Burns' Principles of Midwifery, 9th
edition, p. 543.
1
236
MATERNAL DYSTOCIA.
First. Uterine hemorrhage, after the separation of the placenta,
in any of the stages of the labour, is not Arterial in its character.
The utero-placental arteries are numerous, but so long and slender'
as to become readily closed-1, By the tonicity of their coats; 2,
By contraction of the uterine fibres upon the course of these vessels
themselves as they pass through and amid the uterine structure;
and, 3, and principally, By the changes in their tissues produced by
the mechanical rupture of their coats-torn arteries being little, if
at all, liable to bleed-and the placenta being separated by a true
process of avulsion.
Secondly. Hemorrhage, therefore, under the conditions supposed,
is Venous in its source and nature. Further, it is especially import-
ant to mark that it is a venous hemorrhage by retrogression. The
forward course of the uterine and utero-placental venous circulation
is from the dilated maternal capillaries or cells of the placenta.
towards the periphery of the uterus, and the ovarian and hypo-
gastric venous trunks. In uterine hemorrhage, the blood that
escapes, instead of flowing onwards, regurgitates backward into the
uterine cavity.
Thirdly. The mechanism by which, after the separation of the
placenta, this retrograde course of the venous circulation towards
the cavity of the uterus, so as to lead to hemorrhage, is prevented, is
probably of a compound character, or is effected by different means.
Each of these means may be more or less efficient under different
circumstances and at different times.
Fourthly. The most powerful of these preventive measures con-
sists in the uniform and regular contraction of the uterine fibres.
By this contraction the canals of the supplying arteries are con-
stricted, and the venous tubes or sinuses which more immediately
yield the discharge are directly compressed. The facility of this
compression of the sides of the veins, and the consequent diminution
of their cavities, is promoted by the naturally thin, flattened form of
their canals, and by the fact that the proper contractile tissue of the
uterus forms their second coat-the uterine veins consisting of the
usual lining membrane of the venous system placed in direct contact
with the muscular tissue of the uterus. At the same time, it is to
be recollected that there seems to be often no direct relation between
the degree of uterine contraction and the degree of tendency to
¹ I speak of these utero-placental arteries as they are seen in the beautiful
injected preparations of them left by William Hunter and the second Munro, and
as I have myself observed them in recent specimens.
PLACENTA PRÆVIA.
237
hemorrhage, for, as we have already seen-1. No hemorrhage may
occasionally be observed after delivery, though the uterus is not
contracted to its usual degree; and, 2. It may be present when the
uterus is apparently well contracted. But, 3. There are, according
to most anatomists, few or no contracting fibres in the structure of
the os and cervix uteri, and certainly after delivery I have generally,
if not always, found it remaining open, gaping, soft, and flaccid,
even when the proper cavity of the uterus above felt shut and con-
tracted, and its parietes hard and firm. Still, when the placenta is
attached to the surface of this uncontracting portion of the uterus,
hemorrhage is not common after its separation, unless some lacera-
tion of its vessels has occurred. Here we have post-partum hemor-
rhage prevented, without the contractile mechanism, generally con-
sidered necessary for its avoidance, being almost in existence.
And lastly, in cases of spontaneous or artificial extraction of the
placenta in some placental presentations and twin labours, the
placental mass may be completely separated, and the uterus still
remain distended by the presence of a child in its cavity, so as to
prevent much contraction of its fibres, without hemorrhage occurring.
The venous trunks running to the uterus are not supplied with
valves, and under the above and other circumstances, by what means
in addition to, or in substitution of, the contraction of the uterine
fibres, does nature prevent the retrograde flow of venous blood into
the uterine cavity-or, in other words, uterine hemorrhage?
Fifthly. The structure and mutual relations of the venous sinuses
of the uterus seem calculated to obstruct and prevent such a retro-
grade flow of blood in their tubes as to cause hemorrhage. The
uterine veins are large, but of a compressed, flattened form, and
arranged in several planes or floors above one another in the uterine
walls. On examining these veins in several pregnant uteri, by
dissecting them from the outer or peritoneal surface of the organ,
downwards towards the mucous, I have found the following arrange-
ment :- Each venous tube gives off numerous communicating
branches to the veins of its own plane or floor, by a set of lateral
foramina. When, however, a venous tube of one plane comes to
communicate with a venous tube lying in the plane immediately
beneath it, the foramen between them is not in the sides, but in the
floor, of the higher or more superficial vein, and the opening itself
is of a peculiar construction. Looking down into it from above, we
see the canal of the vein below partially covered by a semilunar or
falciform projection formed by the lining membrane of the two
238
MATERNAL DYSTOCIA.
venous tubes, as they meet together at a very acute angle, the lower
tube always opening very obliquely into the upper.' In the folds
of these falciform projections, the microscope shows the common
contractile tissue of the uterus. Do these semilunar or falciform
projections, and the oblique communications of the lower with the
higher planes of veins, allow the normal flow of venous blood from
the deeper to the more superficial veins of the uterus, while, after
the placenta is separated, they prevent that anormal or retrograde
flow of it from the more superficial towards the deeper-seated
venous tubes which would produce hemorrhage? Here I suppose it
possible that these falciform processes may act upon the same prin-
ciple as the Eustachian valve, but in a less perfect manner, while by
the obliquity of the communications between the different planes of
veins it may be that blood does not so readily retrograde into the
deeper vessels, in the same manner as urine does not retrograde
into the ureters from the bladder, in consequence of the oblique
opening of the former into the latter. Do the uterine fibres seen in
the venous falciform processes tend to aid this valve-like mechanism,
by diminishing, under contraction, the apertures between the dif
ferent planes of veins?
Sixthly. I have already shown that one cause contributing to
prevent hemorrhage after the total separation of the placenta, is the
abstraction from the uterine vascular system of the derivative or
sugescent power of the maternal circulation in the placental cells,
and the consequent tendency of the blood to flow in the more
direct and freely communicating channels that exist between the
uterine arteries and veins. Besides, the general and direct forward
current of the blood along the course of these larger uterine veins
diminishes, and, in a measure, destroys, the tendency which it might
1 In the course of dissecting the veins of a pregnant uterus, in the sixth
month, from the peritoneal surface downwards, Mr. Owen states that he
"observed that where the veins of different planes communicated with each
other, in the substance of the walls of the uteras, the central portion of the
parietes of the superficial vein invariably projected in a semilunar form into the
deeper-seated one; and where (as was frequently the case, and especially at the
point of termination on the inner surface) two, or even three, of these wide
venous channels communicated with a deeper sinus at the same point, the semi-
lunar edges decussated each other, so as to allow only a very small part of the
deep-seated vein to be seen. It need scarcely be observed how admirably this
structure is adapted to ensure the arrest of the current of blood through these
passages, upon the contraction of the muscular fibres with which they are every-
where immediately surrounded."-Works of John Hunter, vol. iv. p. 68. See
also Mr. Goodsir's corroborative statement, in his admirable Anatomical and
Pathological Observations, p. 61.
PLACENTA PRÆVIA.
239
otherwise have either to flow backwards, or to escape by any exist-
ing lateral apertures of the vessels.
I
1
Seventhly. Among the other remaining means by which hemor
rhage is more or less prevented after the detachment of the placenta,
may mention-1. The occasional presence of tufts of fœtal vessels
left in the orifices of the uterine veins, and forming not only
immediate mechanical obstacles, but nuclei for the ready coagulation
of the blood; 2. The formation of coagula in some of the collapsed
venous tubes and orifices; and 3. The presence for some hours, or
even days, after delivery, of the collapsed decidua over the apertures
seen in the veins on the interior of the uterus.
To these few and imperfect suggestions I am desirous to add one
remark. Some of the natural means of arresting uterine hemorrhage
that I have spoken of admit of extended anatomical examination
being applied to their more perfect investigation; and several of
the observations that I have ventured to offer in this section may be
yet proved or disproved, by being tested by direct experiments with
vascular injections thrown into the dead body.
SECTION VIII.—INSTANCES OF PLACENTAL PRESENTATIONS, IN
WHICH THE PLACENTA HAS BEEN ARTIFICIALLY REMOVED
BEFORE THE CHILD; WARNINGS BY AUTHORS AGAINST
ATTEMPTING THE PRACTICE; CASE OF ITS SUCCESSFUL
ADOPTION; RECORDED INSTANCES OF IT UNDER SUPPOSED
MISMANAGEMENT; CASES OF PORTAL; SUGGESTION OF CHAP-
MAN; MODERN CASES OF EXTRACTION, ETC.
We have already found that various obstetric authors (see
Section I.) have strongly declared the total inefficiency of nature in
cases of placenta prævia. Several of them have especially warned
us against attempting to imitate her in any of her modes of manage-
ment of this obstetric complication, and against taking any hints
from the principles of treatment which she seems to follow under
the circumstances. Dr. Ramsbotham has, in his admirable Observa-
tions on Midwifery, reported several cases of placental presentations
in which the placenta was expelled before the child. In comment-
ing upon these cases, he remarks, "Although it satisfactorily
appears that a spontaneous detachment of the placenta is not
1 See, on this point, the observations of Professor Reid in his excellent paper
on the Anatomical Relations of the Blood-vessels of the Mother and Fœtus-
Edinburgh Medical and Surgical Journal, vol. Iv. p. 8.
240
MATERNAL DYSTOCIA.
necessarily followed by fatal consequences, that fact can furnish no
precedent in practice for the artificial separation and removal of it.
I think," he adds, "that few practitioners, aware of the probable
consequences, would have the temerity to make the experiment."¹
"It would," he again observes in another place, "be the extreme
of hardihood in any practitioner to attempt the artificial separation
of this foetal appendage in imitation of its natural expulsion." In
a similar strain Dr. Burns, the distinguished author of the well-
known Principles of Midwifery, observes, "There are, doubtless,
examples where the patient has, by labour, been safely, and without
assistance, delivered of the child, when part of the placenta has
presented. Nay, there have been instances where the placenta has
been expelled first, and the child after it. These examples are to
be met with in collections of cases by practical writers, and some
solitary instances are likewise to be found in different journals. It
would be much to be lamented if these should ever appear without
having, at the same time, a most solemn warning sent along with
them, to the accoucheur, to pay no attention to them in his practice.
I am convinced that they may do inexpressible mischief, by afford-
ing argument for delay, and excusing the practitioner, to himself,
for procrastination.
These instances are not to be con-
verted into general rules, nor allowed to furnish any pretext for
procrastination. They happen very seldom, and never ought to be
related to a young man, without an express intimation, that he is
not to neglect delivery, when required, upon any pretence whatso-
There is scarcely any malady so very dreadful as not to
afford some examples of a cure effected by the powers of nature
alone. But ought we, thence, to tamper with the safety of those
whose lives are committed to our charge?”3
ever.
* * *
Notwithstanding the strong and decided opinions expressed by
the above authors, and others who might be cited for the purpose, I
became so convinced-from two cases which I happened to see, and
from the study of others that I found upon record—that the extrac-
tion of the placenta before the child was the proper plan of treat-
ment in some cases of placenta prævia, that, during the course of
1841, I laid before the Obstetric Society of Edinburgh the deduc-
tions derivable from thirty-nine cases that I had then collated, and
proposed that the artificial separation of the placenta ought to be
our line of practice in some instances of unavoidable hemorrhage.
1 Practical Observations on Midwifery, Part ii. p. 193. 2 Ibid. p. 286.
५ 3 Principles of Midwifery, p. 367.
PLACENTA PREVIA.
241
I was deterred at the time from publishing my investigations, under
the fear that it would be considered rash in a young member of the
profession, propounding from the data which I had, so great a revo-
lation in the usual practice of placental presentations. In the course
of the spring of 1844, I laid before the same Society an additional
number of cases, with the view of supporting the same opinion. The
data which I then had to found upon were not so extensive as those
I have now brought forward, but they were to my mind so distinct
and decided, that, notwithstanding the earnest counsels of Drs.
Ramsbotham, Burns, and others, I predetermined to have recourse
to the artificial extraction of the placenta itself, in any case that I
should happen to meet with in which the hemorrhage was very
great, and where the rupture of the membranes was insufficient, or
the operation of turning dangerous or impossible.
It was not till last autumn that I met with an instance in
point. And I hope I shall be excused for stating at length a
case, which was to me so interesting in its nature and in its results.
CASE XXIV. Great hemorrhage; rupture of the membranes insufficient; the
os uteri not so dilated as to allow of turning; the placenta artificially extracted
about two hours before the birth of the child.—I was called to see the lady who was
the subject of this observation, at about five in the afternoon of the 1st of October
1844. The gentleman who was in attendance upon her, Mr. Hill of Portobello,
informed me on arriving that she was between the seventh and eighth month of
pregnancy; that she had almost daily suffered from considerable discharges of
blood, without pain, for about a fortnight previously; and that she had been
flooding, with slight uterine contractions, for about ten or twelve hours before my
visit. I found her a weakly person, with bleached features, and much sunk and
prostrated by the preceding hemorrhage. The pulse was very small, soft, and
compressible. The abdomen seemed much distended with liquor amnii. On
examination, I found the vagina filled with coagulated blood. It was exceedingly
difficult for me at first to reach the os uteri, partly in consequence of the rigidity of
the parts, and partly from the very high situation of the os uteri itself. On
touching the os uteri, I found it still very slightly dilated, and on passing the
finger through it, it came in contact with the anterior edge of the placenta; the
presentation being one in which the placenta was attached to the posterior lip of
the cervix uteri, and so as to project over the os itself. Mr. Hill and I agreed
together to allow the escape of the liquor amnii, provided I could reach and rup-
ture the membranes. I was enabled to do so with some little additional difficulty;
and immediately upon perforating the membranes anteriorly, an immense gush of
liquor amnii took place, and the abdomen became comparatively smaller. I had
hopes that I had done enough to arrest, in all probability, the hemorrhage under
which the patient was evidently sinking. She got at the same time a large dose
of the ergot of rye, and we waited with some impatience for the result. Stronger
uterine contractions came on, and shortly afterwards I re-examined, in order to
know their effect on the os uteri. I was distressed to find the vagina again filled
with clotted blood, showing too manifestly that the rupture of the membranes,
and the supervention of more powerful pains, had been anything but sufficient to
1
242
MATERNAL DYSTOCIA.
arrest the progress of the flooding. A small portion of the anterior part of the
placenta was by this time threatening to protrude through the os uteri. I passed my
finger by the side of it posteriorly, endeavoured to detach as freely as possible the
organ, and then, seizing the protruded part between two fingers, I gradually and
steadily pulled the whole mass downwards into the vagina, and through the vulva.
After accomplishing this, I confess that for a few minutes I felt a degree of timidity
at what most of my professional brethren would have at once denounced as a most
improper line of proceeding on my part, and one in direct opposition to all the
most approved and established rules in obstetric medicine. The result, however,
was such as to answer my best expectations. All fears were dissipated, by ascer-
taining in a few minutes that there were no new clots, nor any new discharge of
blood accumulating in the vagina, and that the head of the infant was presenting
-a circumstance which could not be previously ascertained. The cervix, how-
ever, was still so undilated as to hold the head from impinging directly on the
interior of the os uteri―a band of contracted fibres high up in the cervical canal
acting as a shelf on which it rested.¹ The patient got an additional dose of ergot,
and I cut through the umbilical cord, and separated the placenta for the purpose
of ascertaining, by ocular inspection of the mass, if the whole of the organ had
been extracted. It was for this purpose placed upon a plate nearly two hours
before the labour was completed. The infant came down slowly, but without any
additional hemorrhage. The mother made a perfect recovery. Her pulse, during
convalescence, never, I believe, rose above 80.
In the preceding instance, I adopted the practice which I have
detailed as a matter of principle and choice, and as a result of obser-
vation and reasoning upon the cases which I had previously seen
and collected. In a number of other instances upon record, the
same practice has been adopted through reputed ignorance, on the
part of the attendant, of the established rules of midwifery in this
variety of obstetric complication. The details, however, of some of
these cases may both demonstrate the truth of the principle and
practice which it is my wish to establish, and the practicability and
propriety of the treatment itself. The first case I shall quote is
from Dr. Collins' Treatise. He gives it as "an instance eminently
calculated," to quote his own expression, " to show the marvellous
escapes occasionally witnessed when the gross ignorance of the at-
tendant blinds him as to the danger of his patient."
CASE XXV.-The placenta removed many hours before the birth of the child.--
“G. J., at her full time, was admitted in a state of extreme debility, her pulse
so weak and frequent as not to be counted. The foot was found in the vagina, so
putrid, that the skin peeled off on the slightest touch. The discharge was fœtid.
Stimulants and cordials were freely given, and the child brought away without
1 See an analogous and very interesting case of placental presentation, with
the os uteri largely dilated, and stricture in the upper part of the crevix, recorded
by Dr. James Reid, in the London Medical Gazette, vol. xvi. p. 145. Dr. Reid's
case was further remarkable, as being one of those instances in which the placenta
presented without any attendant hemorrhage.
*
PLACENTA PREVIA.
243
difficulty. The uterus remaining enlarged and relaxed, the hand was passed to
remove the placenta, when there was none to be discovered, nor was there any
hemorrhage. The membranes had ruptured and been discharged a fortnight pre-
vious to admission, from which time, until the evening before she was brought to
the hospital, she had had more or less hemorrhage. It was now ascertained that
the placenta had been expelled the evening before her admission, and separated
by the midwife in attendance. She had been twice visited by a medical practi-
tioner, who bled her and gave her purgatives. She left the hospital well on the
13th day."1
Dr. Ramsbotham describes graphically, in words that demon-
strate his own surprise, the following similar case :—
CASE XXVI.-Placenta extracted before the child; the flooding arrested; safety
of the mother.—“Late in the evening," observes Dr. Ramsbotham, "of Thursday,
May 7, 1818, during a temporary absence from home, a message was delivered at
my house, desiring me to see a woman at Wapping, who was said to be very ill,
but of what disease, or in what state, was not mentioned. After some conversa-
tion between my servant and the messenger, it was agreed that I should visit this
woman early the following morning. By seven o'clock on the Friday morning, a
second message was sent to countermand the first, with the intimation, that the
woman was better, and was doing well.' A few days afterwards, I accidentally
met the medical gentleman, who had sent the above verbal message, and inquired
the nature of the case upon which he wished to have my opinion a few nights be-
fore. To which he replied, 'It was the strangest case I ever saw; it was a
placenta presentation, with a most violent flooding; but I got it away.' 'Got
what away?' said I: Why, the placenta,' answered he. 'What! before the
child?' asked I: 'Yes, before the child,' said he; and the flooding ceased, and
the woman did well; the child soon followed the after-birth.'
111 2
I am indebted for the following most interesting case to the
politeness of Dr. Cripps of Liverpool, and shall relate it in his own
words. Dr. Cripps' letter to me is dated 28th of December 1844.
CASE XXVII.-Placenta extracted ten hours before the child; arm presentation;
no intervening hemorrhage.—“I was sent for a few days ago, about 8 P.M., to see
a poor woman who supposed herself to be at the early part of the last month of
pregnancy with the third child. She had had occasional flooding to no great
extent for a week previously. On the morning of the day on which I saw her, a
surgeon had been sent for in consequence of the occurrence of several labour pains,
together with a good deal of hemorrhage. This gentleman being out of town, his
assistant went; he remained with her during the day, and in the evening, finding
things not going on so favourably as he wished, he sent for a friend of his em-
ployer's, who, soon after his arrival, sent for me. On making an examination, I
found an arm down, which was much swollen, the pains very severe, I immediately
gave one drachm of laudanum, and on their subsiding, turned without much
difficulty. The funis was divided, only about four or five inches remaining, and
appeared as though it had been cut. On expressing my surprise at this circum-
stance, I was informed that it was cut when the after-birth was taken away,
1 Practical Treatise on Midwifery, p. 102.
2 Observations on Midwifery, part ii. p. 231.
3
17
244
MATERNAL DYSTOCIA.
about ten in the morning.' Not believing it possible that such could be the case,
there having been no hemorrhage whatever from that hour until the period of de-
livery, I searched for the other portion of the navel-string, but not finding it, and
being again assured that 'the after-birth had come in the morning,' I introduced
my hand into the uterus, and made a most careful examination; it was contract-
ing satisfactorily, but was perfectly empty. I watched her strictly until her com-
plete recovery.
I had every portion of discharge saved for my inspection, and am
therefore perfectly satisfied that this is a case in which the placenta presented,
and was removed ten hours previously to the birth of the child, and that, in the
meantime, there was no hemorrhage whatever."
The following brief notice of an analogous case, reported by Dr.
Löwenhardt, is extracted from Kleinert's Repertorium for 1842, tom.
vi. p. 58.
CASE XXVIII.--The placenta separated and pulled away before the child;
transverse presentation; turning." Some time ago, Dr. Löwenhardt of Prenzlaw
met with a case where an ignorant midwife had separated the placenta, which
presented all round, and removed it from the passages. She then discovered that
the child was lying transversely, and, attempting to turn it, she brought down an
arm into the pelvis instead of a foot. The uterus being fully contracted, it was
with difficulty that the author accomplished the turning of the child, and saved
the mother."
Many years ago, Baudelocque related, in a footnote, in the
second volume of his well-known System of Midwifery, an instance
of the same kind.
CASE XXIX. —Placenta extracted some hours before the child; arm and head
presentation.—“A midwife had extracted the placenta some hours before I was
called, and had not been able to turn the child, whose arm was engaged below the
head. The uterus, irritated by the manoeuvres of the midwife, was strongly con-
tracted on the child, and discharged but a few drops of blood. Astonished, after
the extraction of the child, to see the cord was torn off near the umbilicus, and
more surprised still not to find the after-birth in the uterus, I discovered that it
had been extracted a long time before my arrival, and carefully concealed.”¹
In the five cases, the particulars of which have been last given,
the placenta was artificially extracted a considerable time before the
birth of the child, in simple ignorance, and hence in defiance, on the
part of the attendant, of the established rules of management in
unavoidable hemorrhage. In the first case that I have detailed in
the present section, I pursued, as I have stated, exactly the same
practice, as a matter of election, and from the belief that, under the
dangerous circumstances in which the patient was placed, this mode
of treatment was the measure best calculated to suppress the extreme
attendant hemorrhage, to gain time for the rigid cervix uteri to
1 Baudelocque's Midwifery, Heath's Translation, vol. ii. p. 37.
PLACENTA PRÆVIA.
245
dilate, and to place the mother in the greatest relative degree of
safety.
We have already seen (p. 182), that all practical authors in
midwifery insist upon the artificial extraction of the child by turn-
ing, as the principal or only means of treatment in placental pre-
sentations, more especially when the presentation is complete.
Almost all of them take occasion also to inculcate, under some form
or other, the supposed propriety of not detaching the placenta more
than is absolutely requisite, when the operator introduces his hand
into the uterus for the purpose of grasping the foot or feet of the
infant. It is well known that, in order to follow out this principle
to its fullest extent, various authorities advise that, either as a con-
stant or occasional rule, the presenting part of the placenta should
be perforated, rather than that more of the attachments of the
placenta to the cervix should be separated during the operation;1
and at all events, if the hand is introduced between the cervix and
placenta, it is to be passed to one side only, and in such a way as
to produce as little detachment as possible between the two organs.
While all thus perfectly agree upon the general rule, that the
child should be extracted before the placenta, at the same time a
self-evident and necesssry exception to this practice is mentioned by
Guillemeau (who was himself among the first, if not the very first,
2
1 For the practice of perforating the placenta, "the obvious reason," says Dr.
Rigby, is, “that by this means not more of the placenta may be separated than
is necessary for the introduction of the hand, and consequently that as little in-
crease of bleeding as possible may be produced by the operation; but if it be im-
practicable, as I have more than once found it, and it must ever be when the
middle of the placenta presents to the hand, from the thickness of it near the
funis, it must be carefully separated from the uterus on one side, and the hand
passed, till it gets to the membranes.”—Essay on Uterine Hemorrhage, p. 61.
Dr. Foster inculcates the perforation of the placenta under all conditions as the
best method of proceeding to turn in unavoidable hemorrhage.—Principles and
Practice of Midwifery; London, 1781, pp. 231-32. In one instance, Smellie tells
us, he was obliged to employ it (vol. iii. p. 163). Richter, in his Synopsis Praxis
Medico-Obstetrica, p. 176, attributes the first recommendation of this practice to
Deleurye and Mohrenheim. Deleurye (Traité des Accouchemens, p. 368) argues,
on the contrary, strongly and sensibly against the practice. Mohrenheim did not
publish his Abhandlung über die Entbindungskunde till 1791.
2 Les Euvres de Chirurgie, p. 320; Rouen, 1649. Guillemeau's rules for the
management of cases of placenta prævia are so original, explicit, and brief, that I
shall quote them here in full.-"Il faut observer deux choses. La prémière est
de considerer si ledit arrière-fais est peu ou beaucoup advancé et sorty: car estant
peu advancé (apres avoir bien situé la mere) il sera remis et repoussé le plus dili-
gemment que faire se pourra ; et si la teste de l'enfant se presente, elle serra con-
duite droict au couronnement, pour aider à l'accouchement naturel. Mais s'il se
246
MATERNAL DYSTOCIA.
6
1
4
to inculcate the necessity of turning in placental presentations), and
by Mauricean, Daventer," Roederer," Ould, Pugh," Wallace John-
son, and other authors.' Occasionally, by the time that turning
seems required, or before the operator is called upon to pursue this
measure, the placenta has been already separated by the uterine
contractions, and is so far protruding or pushed down into the
vagina, as to fill up that canal, and prevent the easy introduction of
the hand, or the ready extraction of the infant. Under such a com-
plication, the authorities I have named unite in stating, that we
must, as a matter of necessity, first remove the detached and ob-
structing placenta, in order to have the maternal passages sufficiently
clear for the operation of turning.
The cases and circumstances under which this point of manage-
ment has been advised are totally and essentially different, and
founded upon a different principle from those in which I venture to
recommend the extraction of the placenta before the child. A
quotation or two from one or more of the authors to whom I have
referred will point this out. I shall select for this purpose tlie
observations of Mauriceau and Roederer, as being at once the
simplest and the most explicit on the matter.
trouve quelque difficulté, et que l'on apperçoive que ladite teste ne se puisse tost
avancer, ou que la mere ou l'enfant, ou tous deux ensemble soient debiles; pre-
voyant que l'accouchement soit long, sans faute le plus expedient sera de chercher
les pieds de l'enfant, comme nous avons dit, et le tirer doucement par iceux.
L'autre point a observer, est si ledit arrière-fais est fort sorty, et qu'il ne se puisse
remettre, tant pour sa grosseur qui pour le flux de sang qui l'accompagne ordi-
nairement; joinct aussi que l'enfant le suite de presse, et ne demande qu'à sortir et
venir au monde, il faudra, tirer du tout ledit arrière-fais; lequel estant tiré et
sorti sera mis à costé sans couper le boyau qui est adherant à iceluy; Car par la
guide dudit boyau l'enfant se trouvera lequel s'il est viuant ou mort sera tiré par
les pieds le plus dextrement que faire se pourra." In the Provincial Medical and
Surgical Journal, for April 2, 1845, Mr. Blenkinsop has inadvertently published
a literal translation of the above passage into old English, as a piece of original
writing, by Dr. Percival Willoughby.
1 Discases of Women with Child; Chamberlen's Translat.,
p. 220.
2 Art of Midwifery, p. 154. 3 Elemens de l'Art des Accouchemens, p. 368.
▲ Treatise on Midwifery, p. 76. 5 Ibid. p. 113. 6 System of Midwifery, p. 33.
7 Smellie (Cases, etc., in Midwifery, vol. ii. p. 307) states a case in which he
followed this practice, the head being “hindered from advancing by the placenta."
At p. 315, he observes, "I have had cases where the placenta has come down into
the vagina before the child's head, and was obliged to deliver it first." It is re-
markable that later authors should not generally mention a rule so obvious as
that spoken of in the text. Yet among the writers of the present century, Petit is
the only one, so far as I at present recollect, who even adverts to it. See his
Traité des Maladies des Femmes, tom. ii. p. 23, 1806.
PLACENTA PRÆVIA.
247
"If," observes Mauriceau-and I give as nearly as possible a
literal translation of his words-"the placenta only presents at the
os uteri without passing out, and the membranes are still entire, as
sometimes happens, the accoucheur will push aside a little the part
of the placenta that presents, till he reach the membranes, which he
will immediately rupture with his fingers, to allow the waters to
escape, and at the same time to turn the child, if it presents by any
other part than the feet; by which he ought immediately to draw
it out. For it must be observed, that the after-birth, which pre-
sents first, is now nothing more than a foreign body in the womb,
when it is entirely separated from it, as it is now; and that in this
case one ought, as it would seem, to draw it out before the infant.
Nevertheless, as it is strongly attached to the membranes surround-
ing it, one would not easily accomplish this; for we could not pull
away the body of the placenta, without at the same time pulling
away the membranes that surround the body of the child; besides,
the membranes that line the whole of the interior of the womb,
from their smooth and polished surface, allow the child to be more
easily turned, and prevent by their interposition the womb from
being easily injured during the operation; which would not succeed
so well if the placenta were just pulled away. For these reasons it
is much more sure to draw away the infant first; which is, more-
over, on these occasions, so feeble, that it would soon die, unless
promptly assisted. But if the surgeon find that the after-birth is almost
completely escaped from the womb, and that its membranes have been
almost entirely broken up and torn, in this case he ought to draw it out;
for, besides that it would now be useless to push it back into the
womb, it would very much incommode the surgeon in his operation,
and make him lose time in assisting the child."'
Roederer, according to the just and candid remark of Dr. Edward
Rigby, "stands pre-eminent as being the first author who gives a
1 Maladies des Femmes Grosses, etc., tom. i. p. 332. Speaking of Mauriceau's
opinions and practice in placental presentation, Dr. Lee observes, "The rules for
the treatment of these cases are laid down with the greatest precision. When the
placenta was entirely separated, then only did he consider it as a foreign body, and
recommend its extraction before the child; but to this practice, he states, as an
obvious objection, that the placenta is strongly attached to the membranes which
surround it, and that it cannot be drawn out without the membranes enveloping
the body of the child being drawn out also. Mauriceau has related seventeen
cases of uterine hemorrhage in the later months of pregnancy from presentation of
the placenta, and in sixteen of these, delivery was accomplished artificially by
passing the hand through the opening formed by the separation of the placenta
from the uterus, rupturing the membranes, and turning the child. Two women
248
MATERNAL DYSTOCIA.
1
distinct and complete description of this [the unavoidable] species
of hemorrhage." After stating the propriety of passing the hand
between the cervix and placenta, and promptly extracting the child
by turning, when the hemorrhage is great, he adds, in relation to
the point I refer to, "If the placenta is entirely detached, and is
arrested in the vagina, and opposes the passage of the hand, it
ought to be brought out with the clots that fill the vagina. But if
the hand can be introduced, the placenta should be left, that it may
shut up the passage by which the blood and liquor amnii which dis-
tend the womb might escape. In all cases when it is adherent to
the womb, in whole or in part, it is most advantageous both to
mother and child to leave it.":
The preceding extracts show that, as I have stated, the cases and
circumstances under which the removal of the placenta before the
child has been recommended by some of the older authorities, are
entirely different from those in which I wish in these pages to insist
upon its propriety. I advise its separation in cases in which it is
still attached to the cervix, and often still contained within the un-
dilated os uteri; they advised its removal only in cases in which it
was already separated from the cervix, and expelled through the
dilated os uteri. They began their practice of removing the placenta
at the very point at which I would generally end all interference
with it-viz. after the placental mass was completely detached.
would employ its artificial detachment as a measure of election and
choice; they resorted to its removal from the passages, after it was
detached by nature, merely as a measure of self-evident necessity
and compulsion. I recommend its separation upon the pathological
principle of arresting the existing hemorrhage, and so far cancelling
the immediate source of danger to the mother; they recommended its
abstraction on the physical principle of clearing the obstructed ma-
ternal passages, and gaining more free space for the operation of
turning. They removed the placenta in order to be able to have
recourse immediately to turning. I would remove it, in order to
prevent the necessity of having recourse at all to that operation.
After having become interested in the investigation of the pre-
died after this operation, and one who would not consent to have it performed,
died undelivered.”—An Historical Account of Uterine Hemorrhage in the latter
months of Pregnancy, by Dr. Robert Lee-Edinburgh Medical and Surgical
Journal, 1839, p. 332.
¹ System of Midwifery, p. 252,
2 Elémens de l'Art des Accouchemens, p. 368; Paris, 1765.
1
PLACENTA PREVIA.
249
sent subject, I made a somewhat extensive research among obstetric
works and essays, with the double object of ascertaining the average
mortality to the mother in placental presentations under the common
modes of management, and with the view of attempting to ascertain
if any author had previously practised, or proposed as a plan of treat-
ment, the method which had suggested itself to my mind, of artifi-
cially separating, and, if necessary, of removing the placenta instead
of the infant, and operating thus not upon the child, but upon the
after-birth. The results of the first part of the inquiry I have given
in a preceding page. In reference to the second point, I was long
under the belief, that I was original in the idea of a practice, which,
so far as I was myself concerned, was, in the first instance, the result
of simple reasoning upon the data afforded by two cases that I had
personally observed, and by the histories of a few others that I had
read of, or collected.
At the time I laid a summary of the present paper before the
Edinburgh Medico-Chirurgical Society in December last, I had not.
met with any cases or remarks which altered my opinions in this
respect. I stated at the time that I was the more surprised at such
a result, for, believing as many of the older authorities did, that
before the placenta could be found presenting at the os, it had
already become detached, and fallen down from the higher parts of
the uterus, I fully expected to meet with some of them recommend-
ing its removal at an early stage of the labour, if not upon the
principle of arresting the attendant hemorrhage, at least for the
purpose of clearing away a supposed foreign and obstructing body.
They appear to have been generally intimidated from following such
a line of practice by the dread of injuring the unruptured mem-
branes, and through them the inner surface of the uterus, as
intimated in the quotation which I have already made on this
point from Mauriceau. And hence also the removal of the pla-
centa, when it was once found completely, or almost completely,
protruded from the uterus, and obstructing the vagina so as to
impede turning, was justified, on the similar ground that before
this could happen the membranes were necessarily torn, and con-
sequently no evil effects would now ensue from this mode of
interference.
Since these observations were communicated to the Medico-
Chirurgical Society, I have fallen in with two cases recorded by
one author, and a suggestion incidentally offered by another, both
of which bear, as it appears to me, so importantly upon the history
250
MATERNAL DYSTOCIA.
of the practice which forms the immediate subject of these remarks,
that I shall make no apology for dwelling briefly upon them.
During my former researches among the older authors, I did
not examine in detail, as I certainly ought to have done, the cases
of placenta prævia detailed in the work of the celebrated Paul
Portal. In drawing up the table of maternal mortality in placental
presentation (see page 179), I had predetermined to take the
returns of which it consists from such authors or sources only as
mentioned upwards of at least ten cases, in order that I might
arrive at more certainty and statistical truth in the calculation. I
took it for granted that Portal's cases did not come within this
range, in consequence of Drs. Rigby, Lee, and others, erroneously
speaking of them as being only eight in number. On the other
hand, I knew well that this accurate and original observer was
acquainted with the fact, that in placental presentations the pla-
centa was originally fixed over the os uteri, and had not fallen
down there after its attachment to the fundus. Hence, I did not
expect to meet among his cases with any instances in which the
placenta had been artificially extracted before the child as a foreign
body, or any deviation made from the treatment usually followed.
In two cases, however, which he has described, he most distinctly
adopted the practice of detaching the whole placenta immediately
before extracting the child. As these cases appear to me to be in
various respects, not only historically, but practically, interesting, I
shall take the liberty of quoting them at full length. They afford
strong additional instances of the success of the practice which it is
my wish to inculcate.
CASE XXX.-"The Delivery of a Child with the after-burthen foremost.-
April the 7th, 1672.-I was called to a woman in St. Mederic's Street, being in
the sixth month of her reckoning, and troubled with a violent flux of blood. I
told her immediately, that without being delivered forthwith, she was in danger
1 "In Portal's cases in Midwifery there are eight in which he was under the
necessity of delivering by art, in consequence of dangerous hemorrhage, and in all
of them he found the placenta at the mouth of the womb."-Rigby's Essay on
Uterine Hemorrhage, 6th edition, p. 22.
2 "Portal's Treatise, 1685, contains an account of eight cases of uterine
hemorrhage, in which he found the placenta not merely at the mouth of the
womb, but adhering to the whole neck of the uterus.
In several of these cases,
In
he felt the placenta adhering all round to the internal orifice of the uterus.
those cases the treatment employed by Portal did not differ from that which had
been employed by Parè, Guillemcau, and Mauriceau, the propriety of artificial
delivery by turning being then as completely established as at the present time.”
Lee's Clinical Midwifery, p. 140.
PLACENTA PRÆVIA.
251
of her life. Dr. Cresse, a Paris physician, was of the same opinion, and ordered
her immediately to be let blood; however, we staid a little to see whether nature
would help itself, it happening sometimes that such fluxes cease when the child
comes to the birth well turned. But the woman, growing weaker and weaker,
her husband and friends asked my opinion once more, and I answering, that the
delivery of her was the only way to secure her life, they desired me to delay no
longer.
Whereupon I brought two of my fingers, well greased with butter, into the
inner orifice of the womb, and, finding the same opened to the bigness of a
French half-crown piece, I spread my fingers in the nature of a screw, and thus
extending it, brought in my hand, and felt the after-burthen foremost. I
separated the same to open my way to the membranes, which being opened, the
water came forth, and I drew out the after-burthen, that it might not be in the
way afterwards.¹ Then, searching after the child's feet, I took hold and pulled
out one, which I baptized; and, wrapping a cloth round the foot, I accomplished
the delivery of a daughter of six months, after my usual method. Immediately
after the woman recovered of her swooning fits, she began to breathe and speak,
telling us that she felt herself something stronger, but relapsed soon after; yet
being recovered again, by the care of Dr. Cresse, she did very well afterwards.
We applied a plaister against the flux, made of the flower of gips used by the
plaisterer, mixed with the best vinegar, laying it to the belly above the womb,
and above the hips. The next day we prescribed a clyster of barley and white
bread, boiled together, and mixed with three ounces of honey of violets; but the
nurse, mistaking the matter, took honey of roses instead thereof; whence, it is
obvious how careful women ought to be in choosing their nurses, since, by the
management of clysters only, many dangerous symptoms have ensued through
the carelessness or ignorance of the nurses. Wherefore women ought to pitch
upon such nurses as are used to attend in lyings-in, and such as they know, that
will not be employed in the small-pox and other infectious distempers, which
thus may be communicated to the woman in childbed. All nurses ought to be
cautious not to give medicines to women in childbed, without the advice of a
physician, surgeon, or expert midwife; and especially not to apply astringent
remedies in the beginning of the flooding, which, if it succeeds ill, they are sure
to lay the blame on the man-midwife, or midwife. 'Tis but lately that I knew
such an ignorant and presumptuous nurse, who, in the beginning of the flooding,
washed the gentlewoman under her care with red wine only, which, stopping the
flooding, etc., fever ensuing, the patient was forced to be let blood several times
in the arm and foot, and yet they had much ado to save her."?
CASE XXXI." The Delivery of a Woman affected with a most violent flux of
blood.-January 14, 1679.-I was called out in the morning at four o'clock, to
deliver a gentlewoman in the street called Gervais Laurent, at the foot of the
Bridge of our Lady, in the parish of the Holy Cross. This gentlewoman being
about eight months with child, was seized with a most violent flux of blood,
1 I shall quote the original French of this important passage :—Je glissay ma
main dans l'entrée de la matrice, òu je sentis l'arrière-faix qui se presentoit.
L'ayant separé afin de me frayer le chemin, je sentis les membranes des eaux que
je perçay, et les caux s'estant écoulées, je tiray l'arrière-faix le prémier, afin qu'il
ne m'incommodast point à la sortie de l'enfant."-La Pratique des Accouchemens,
par Paul Portal; Paris, 1685, p. 203.
2 Compleat Practice of Men and Women Midwives, by Paul Portal, p. 148.
Case 43. London, 1763.
252
MATERNAL DYSTOCIA.
which having continued for ten or twelve days, she was reduced to a miserable
condition. Upon search made with my fingers (well greased), I found the whole
vagina or passage filled with clods of coagulated blood, notwithstanding which the
flux continued. As soon as I had brought out the clods of blood, I conveyed my
fingers further into the orifice of the womb, which I found very thin and soft, and so
wide, that I could put in three of my fingers foremost. I searched with one finger
first, and found the after-burthen foremost, and closely joined round the inner
orifice of the womb, which was the occasion of the excessive flux of blood; and, as
it had reduced the woman to a very low condition, so this, joined to the other cir-
cumstances, made me fear the life both of the woman and child. I desiring,
therefore, the assistance of a physician, Dr. Biendisant was sent for, who, finding
the poor patient not in a condition to dispense with many remedies, prescribed her
only a mixture of purslane and plantain water, three ounces each, half a drachm
of the confection of hyacinths, without musk; prepared pearls, one scruple,
mixed with an ounce and a-half of the syrup of pomegranates. This stopped the
flux for a while, yet not quite; so that, her weakness increasing every minute, it
was resolved to have her delivered, notwithstanding the great danger which must
needs attend it; but considering her death was infallible, unless she was delivered,
I went to work; though, as I laid her across the bed, there appeared in her not
the least signs of sense or motion, so that everybody concluded she would die
under my hands. However, I found some means to convey my hands (well
greased before) into the inner orifice of the womb, where I again felt the after-
burthen fastened to it, as I had told Dr. Biendisant before. I peeled it off by
degrees, and brought it out; and then, turning my hand again in the womb, the
first thing I met with was the navel-string, along which I guided my hand first to
the child's belly, and then downwards to the thigh, and hence lower to the leg
and foot, which I brought out and baptized.¹ Whilst I was pulling this foot, the
other followed, and the whole body after it, as it has been observed frequentiy
before. The child being quite alive, the parish priest of the Holy Cross (who
had before administered the sacrament unto the mother) had the opportunity of
baptizing it, though contrary to his and all our expectations. Immediately after
the delivery, the woman recovering in some measure her senses, Dr. Biendisant
prescribed the following cordial : of succory and bugloss water, three ounces each ;
of the confection of alkermes without musk, half a drachm; of prepared pearls,
one scruple; and syrup of maidenhair, two ounces. About two hours after, she
was ordered to take half a cupful of broth only, for fear of overcharging her
stomach. She was much better the next day, yet not without some symptoms of
a fever, against which a clyster was ordered, made of the decoction of the cooling
herbs, with three ounces of honey. The second day after the flooding stopped,
she recovered again by the use of the before-mentioned cordial. However, she
complained of a tension and pain in her belly (which was much swelled), as also
in her hips, wherewith she had been affected before her delivery: she was also
afflicted with a violent pain in the head (the ordinary symptom of all excessive
fluxes of blood), which continued even after her lying-in, with an intermittent
fever: she was also troubled with frequent bilious dejections, or a looseness,
1 "Je separay tout doucement cet arriere-faix, et je tiray dehors; ensuit je
glissay ma main dans la matrice. La premiere partie qui se presenta, fut l'om-
bilic que je suivis jusques au ventre, apres lequel je suivis la cuisse jusques a la
jambe et au pied, que je tiray à l'orifice externe de la matrice sur lequel je jettay
de l'eau, pour ondoyer l'enfant sous condition."-See original French edition of
Portal's work, p. 293.
1
PLACENTA PRÆVIA.
253
against which we prescribed her clysters of the decoction of emollient herbs, with
lintseed; yet, after some time this woman recovered her health, except that three
weeks after her lying-in she lost the sight of one of her eyes by a violent defluxion,
which by all the art that could be devised, was never removed thence. The cause
of this disaster¹ I attribute to a sharp, viscid, and bilious humour, contained in
the veins, which being put in motion by the violence of the pain this woman
suffered during her labour, and the anxiety she lay under, was carried upwards and
settled in her head."
3
In addition to the two preceding cases, Portal gives a detailed
account of six other placental presentations which came under his
care, and mentions six others that he had seen, but of which he does
not give the full particulars. In one of these cases the uterus con-
tracted so strongly, as to push the child through the placenta. The
mother recovered. In all his other cases he seems to have intro-
duced his hand, and turned the infant; but in none of them, with
the exception of the two we have already quoted, does he state such
particulars as to show whether, as in them, he entirely separated the
placenta immediately before turning the child, or only partially sepa-
rated it in that position, so as to enable his hand to pass into the
uterine cavity, for the purpose of practising version of the infant.
Unfortunately, he in no passage states to us, in the way of remark,
or otherwise, what special practice, or principle of practice, he re-
commended or followed in placental presentations, and in only one
part does he throw out any hint of the reason which induced him to
separate the placenta in the two cases I have cited. The hint in
question I have already had occasion to quote, as given incidentally
in the details of the first case which I have already cited (see Case
XXX.) "I drew out," he observes, "the after-birth first, that it
might not incommode me during the passage of the infant (Je
This is perhaps the earliest case on record of that Phlebitic or Fuerperal
Ophthalmitis to which the attention of the profession has been particularly called
in our own day by Drs. Hall and Higgenbotham, Dr. Locock, Dr. M‘Kenzie,
and others. In attributing it to a "humour contained in the veins,” Portal
almost forestalls the pathology of the disease accredited at the present day. An
instance of this destructive ophthalmia occurred two years ago, in the practice of
my friend Dr. Graham Weir, after, as in Portal's case, a placental presentation.
The patient also ultimately recovered. I know of a case in which both eyes were
affected. Some years ago, in a case of placental presentation, in which I turned
the child, I saw come on in a different part-namely, the region of the parotid
gland-a secondary inflammatory deposit from "a sharp humour contained in the
veins, and carried upwards and settled in the head." I have met with one other
case of fatal Puerperal Parotitis. (For further observations on this subject, see
Section on Pathology of Puerperal State.)
2 Compleat Practice of Men and Women Midwives, p. 214, Case 69.
8 Ibid. pp. 29-105, 107, 135, 143, 166, 169, 250,
254
MATERNAL DYSTOCIA.
tiray l'arrière-faix le premier, afin qu'il ne m'incommodast point à la
sortie de l'enfant¹)." And in all probability this was his sole and
only reason for the practice. For if he had separated the placenta
with any idea whatever of the principle under which I have recom-
mended it, namely, that of totally arresting the violence of the
attendant hemorrhage, and averting the principal or only danger to
which the patient is subject in placental presentations, he certainly
would not have practised what he tells us he did-the instantaneous
extraction of the infant afterwards.
I have already (at page 186) mentioned some particulars of a
very interesting case of expulsion of the placenta before the child,
detailed by Mr. Chapman, surgeon at Ampthill, Bedfordshire, and
reported by him in the 4th volume of Dr. Duncan's Annals of
Medicine, published in the year 1800. My attention has been par-
ticularly drawn to three brief remarks that Mr. Chapman appends
to his case.
One of these remarks is specially deserving of note,
from containing, so far as I am aware, the first explicit suggestion
as to the proper principle of treatment in some placental presenta-
tions. I shall quote it in the author's own words.—“ From the
expulsion of the placenta to the birth of the child was full four
hours. She (the mother) lost little or no blood. How far does this
suggest a different practice to that in general followed I mean
that of delivering the placenta previous to delivering the child, in
those cases of alarming hemorrhage where the placenta is situated
on the side of, or over, the os uteri."
Up to the time at which I communicated the views contained
in the present memoir to the Medico-Chirurgical Society in December
last, the two cases that I have quoted from Portal, and the preced-
ing interrogatory of Mr. Chapman, contain, so far as I have been
able to learn, all that had been put upon record with reference to
extraction of the placenta before the child, in placenta prævia.
Since, however, the first part of the present paper was printed in
the Monthly Journal of Medical Science, I have obtained such infor-
mation as to convince me, that several years ago, a medical teacher
and practitioner of the highest distinction in Manchester was aware
that the total separation of the placenta in unavoidable hemorrhage
was capable of arresting the attendant flooding, and adopted this
practice as a measure of treatment in one of the classes of cases that
1 Pratique des Accouchemens, p. 209. 2 Annals of Medicine, vol. iv. p. 308.
PLACENTA PRÆVIA.
255
I shall have occasion to consider under the next section-namely,
where the woman is too exhausted to allow with safety of the opera-
tion of turning. The gentleman I allude to was the late Mr. Kinder
Wood, who for some years was lecturer on Midwifery in the Man-
chester Medical School. He died in 1830. His opinions on this
matter were never, so far as I have been able to ascertain, known or
divulged beyond the range of his own immediate friends and pupils ;
and one of his own colleagues in the Manchester Lying-in Hospital,
Mr. Wood, confesses he was unacquainted with his views till they
were mentioned to him within the last few months.
1
In a short and interesting biographical account of Mr. Kinder
Wood, published in the London Medical Gazette for 1830, it is stated
that he left behind him a volume of midwifery essays all but ready
for the press. One of the papers was entitled "An Essay on
Uterine Hemorrhage, and the best mode of Treatment in alarming
cases of this kind." It is deeply to be regretted that this volume
has never been given to the public, as the opinions of so acute and
able an observer as Mr. Kinder Wood on any points connected with
the obstetric profession, are almost certain to be sufficiently valuable
to have entitled them to a better fate. Dr. Radford, who succeeded
Mr. Kinder Wood as lecturer on midwifery in the Manchester School,
purchased, as I am informed, the manuscript volume I allude to,
after the author's death, and has lately published the following ob-
servations and cases of Mr. Kinder Wood, relative to unavoidable
hemorrhage, probably from the manuscript in question. I have very
great and sincere pleasure in inserting them here, at length, as a
piece of posthumous justice to the memory of a man of distinguished
professional attainments."
2
1 The biographer, Dr. Bardsley, states--" Mr. Wood had been employed for
some time in collecting materials for a separate volume on midwifery, embracing
the consideration of some of the most important points connected with the practice
of the art. The essays on ‘Uterine Hemorrhage, and the best mode of treatment
in alarming cases of this kind;' on 'Rupture of the Uterus during Labour;' on
'Inversion of the Uterus ;' and on 'Impracticable Labour from Distortion,' are
left in such a state of readiness for the press, as to require only a few verbal, and
other trivial alterations, before being submitted to the public eye, should this be
the intention of Mr. Wood's family.”—London Medical Gazette, vol. vii. p. 624.
2 Since I communicated the present memoir to the Medico-Chirurgical Society,
Dr. Radford has himself given and published a lecture on galvanism, in which,
among other ingenious suggestions, he proposes the detachment of the placenta to
be adopted in conjunction with galvanism, in cases of placenta prævia.-Provin-
cial Medical and Surgical Journal for December 24, 1844. In this lecture he
limited the practice in question to cases of "exhaustion "—as Mr. Kinder Wood
had done. Latterly, however, in the same journal (see Number for January 22,
256
MATERNAL DYSTOCIA.
"If we find so much exhaustion as to make us fear the effect
of further hemorrhage during artificial delivery, the first step, after
passing the hand, must be to detach the whole of the placenta; by
this, hemorrhage will be completely suppressed, for the effect of
dassing the hand through the os uteri, and throwing off the placenta,
will always be to produce so much contraction as to arrest the
bleeding from the small decidual or uterine mouths. It is satis-
factory to know that the child is rarely living in these cases of
exhaustion, its blood being poured out through branches of the
placental structure, along with that of the mother; and when
brought down, its appearance, like that of the mother, is bleached
and exsanguined. The time required to separate the placenta is
very short, and the loss of blood during the attempt exceedingly
trifling. I know, from experience, that when the placenta is wholly
detached, the hemorrhage will cease."
CASE XXXII.—“I was desired to see Mrs. Clayton, Lad Lane. The hemor-
rhage had been going on several days, under the inspection of a female mid-
wife, without any assistance or advice. The discharge had been excessively
profuse, and was coming away in gushes, with slight pain, every two or three
minutes. She was extremely exhausted; of a deadly paleness, very cold, with a
quick and feeble pulse; the os uteri was moderately dilated, the cervix obliter-
ated, and the placenta presenting. I feared the effect of hemorrhage, which must
occur during the act of delivery in the common manner. The patient was placed
in a proper position, and a little brandy and water exhibited, and the placenta
completely detached, as the hand dilated the os uteri, and before reaching the
feet of the child. No hemorrhage succeeded the separation. The patient re-
covered favourably, but slowly. October 4, 1821.”
CASE XXXIII.-"I was desired to see a poor woman in Newberry Street. I
found from the female midwife in attendance, that the discharge had been going
1845), he has adopted more fully, and published, my previous ideas of applying
the detachment of the placenta to other cases of placenta prævia, besides those in
which there is simple exhaustion-erring, however, in this, that he conceives the
practice is one which cannot be attempted until the cervix and os uteri will safely
allow the introduction of the hand. Under the next section we shall find that this
would exclude an important range of cases to which the practice is especially ap-
plicable. I had an opportunity of stating my views on the artificial detachment
of the placenta to Dr. Radford when he made a visit to Edinburgh last year. Dr.
Campbell, the well-known lecturer on midwifery in Edinburgh, and a friend of
Dr. Radford, heard the subject discussed between us. When writing lately upon
this matter, Dr. Campbell observes, "It does strike us as remarkable, that Dr.
Radford, while on a visit to this city something less than a year ago, did not, when
this subject was the topic of conversation, make known his knowledge of Mr.
Kinder Wood's views.-The Northern Journal of Medicine for July 1845, p. 90.
See further the Provincial Medical Journal for Feb. 5th, Feb. 26th, and March
19th, 1845. See also London and Edinburgh Monthly Journal of Medical Science,
Feb. 1845, p. 161.
PLACENTA PRÆVIA.
257
on long and copiously. The poor patient was extremely exhausted. Feeling that
she could not survive long if left to nature, and that she could not bear the hemor-
rhage consequent upon the common operation, I separated the placenta, brought
down the feet of the child, and delivered. The effusion produced by separating
the placenta was extremely slight, and it ceased upon effecting the complete de-
tachment. The child was dead, and tending to putrefaction. A stimulant was
given before the operation, and during its continuance, but the heart never
recovered its energy nor the skin its warmth. She died in about an hour, from
pure exhaustion. November 1, 1821."
CASE XXXIV.-"I attended Mrs. T., Newton Heath. She was very much
exhausted. It was obvious she could not bear the loss of blood consequent upon
the ordinary delivery. A cordial was now administered. The hand was intro-
duced, and the placenta, which was adherent over the os uteri, was completely
separated, the membranes ruptured, and the feet seized. The child was easily
delivered. She only survived the operation a very short time, although the
hemorrhage ceased from the moment the placenta was detached.”
CASE XXXV.—“I was called to Mrs. B., January 1822, aged 25, St. James's,
who was violently flooding. I found her cold, and her pulse scarcely perceptible;
os uteri partially dilated and soft; brandy and water given; the discharge still
continued; she was much exhausted. The hand was introduced, the placenta
detached, and the membranes ruptured. There was no further discharge; but
she died in a few hours afterwards, although stimulants were freely administered.
CASE XXXVI.—“On the morning of the 11th April 1822, I was desired by a
female midwife to see Mrs. Rawson in Little Lever Street. She was in the latter
end of the eighth month of pregnancy. She had sustained frequent and copious
discharges the two previous months, and which were very profuse during the night.
The pains were slight, but always attended with fresh discharge. The patient pre-
sented a very distressing appearance. The pulse.could not be counted; the lips
were white; she was very cold, and spoke in a whisper; she had frequent syncope.
Warm brandy was freely administered. The patient was placed with the utmost
care slowly and gently on the side, and upon making an examination, the os uteri
was found low, soft, and dilated about the size of half-a-crown, the cervix was
obliterated, the placenta was found over the os uteri, one portion was loosened.
Convinced that the patient could not bear immediate delivery, and satisfied that
the hemorrhage would be fatal very early if she was left to nature, I insinuated
the hand through the os externum and os uteri, detaching the placenta by sweep-
ing the fingers beneath it, as the hand was passed forwards. The soft parts yielded
freely, and the operation was done quickly and easily, and with very trifling
loss of blood. The presence of the hand excited uterine contraction, and seemed
to rouse the languid patient. A stimulant was given during the operation. The
head was found presenting. After the placenta was separated, the membranes
were ruptured, and the hand slowly withdrawn. She was ordered to remain in
a state of perfect and complete rest, to take light support, and a stimulant
mixture every three hours. The labour pains became stronger about six hours
afterwards, and in an hour expelled the placenta, and a dead child, tending to
putrefaction. No hemorrhage occurred when the hand was withdrawn, after
detaching the placenta. The patient regained health slowly, and had a severe
attack of phlegmasia dolens.
"In some cases I have been called to attend when the ordinary method of
delivery has been adopted, the patients died, and this led me to modify the
practice, which I adopted in some of the above cases by detaching the placenta,
}
258
MATERNAL DYSTOCIA.
rupturing the membranes, and then delivering the child; but after due considera-
tion, I was again induced to vary my plan; and in those cases where we can have
no hope of saving the patient if we proceed to delivery, however well the opera-
tion be conducted, I have no hesitation in recommending that the placenta be
separated completely, and the membranes ruptured, that the hand be withdrawn
immediately upon this being effected, leaving the child and placenta behind. By
this practice, the patient will be placed precisely in the situation which occurs in
the most favourable cases of recovery [delivery] by the natural efforts. I conceive
no fact in midwifery rests upon a more solid foundation, than that this hemor-
rhage will cease upon separating the placenta, and by this practice the patient is
placed in as favourable a situation as is possible for recovery. Time will be
gained to support her by proper means, and which can be used with greater
freedom, as the hemorrhage is infallibly suppressed by this operation."
On communicating, a few months ago, my ideas upon the subject
of this memoir to my esteemed friend Dr. Beatty of Dublin, he
favoured me with the following account of a very interesting and
illustrative case from the note-book of his late father. It is dated
July 28, 1835 (1825 ?).
CASE XXXVII.-Placenta probably entirely separated for about twenty-four
hours before delivery; hemorrhage arrested by it. "The practice I adopted in
this case was such as I never tried before, nor heard of, and from its success I
think it necessary to note it. This lady sent for me at four o'clock on the
morning of the 27th. I found that she had been flooding excessively, and, as the
nurse said, she was in a sea of blood. She was within three weeks of her full
time. I examined and found the placenta directly over the os uteri. I sent for
Dr. Duke, and on his coming, I introduced my hand into the vagina, and, find-
ing I could not turn without more difficulty than I thought necessary, it
occurred to me to separate as much of the placenta as was within my reach. This
I did to such an extent as entirely stopped the hemorrhage, except a trifling
oozing. She continued all day without pain, and about three o'clock the follow-
ing morning, labour set in, and she was delivered of a still-born child at half-past
four o'clock A. M. She had no further flooding, and is likely to do well."
Since the publication of the first part of the present essay, three
instances have been published in the Medical Journals, in which the
proposed practice was adopted-one by Mr. Wilkinson of Spalding,
another by Dr. Walker of Chesterfield, and a third by Dr. Maclean
of Edinburgh. I shall append an abridged detail of these cases.
CASE XXXVIII.-Flooding suppressed by the artificial separation of the
placenta; patient delivered in an hour and a half afterwards.-Mr. Wilkinson
was called, on the 7th June 1843, at twelve P.M., to a woman between six and
seven months advanced in pregnancy. "Three weeks previous to my being sent
for," says he, "there had been, I was informed, very great hemorrhage, which
had continued, more or less, up to the time of my seeing her. On the evening
of the 7th, it had been very considerable, and previous to my seeing her, exces-
sive. I found the os uteri dilated to the size of something less than a five-shilling
piece; the placenta presenting; the hemorrhage excessive; the pains very feeble,
PLACENTA PRÆVIA.
259
She was greatly exhausted; the pulse scarcely perceptible; the countenance
blanched, and I found that she must sink. I directed some brandy and water to
be got down immediately, and also a scruple of ergot of ryc. I passed first three
fingers, and, with as little delay as possible, the whole hand, into the uterus.
The gush of blood was at first great; the placenta, however, was quickly and
completely detached, and the hemorrhage almost at once ceased. I waited a while
with my hand in the uterus; I then brought away the placenta, and immediately
re-introduced my hand, with a view of bringing on contraction. The head of the
child presented; I turned; but feeling that my patient was not in a state to bear
immediate delivery, I waited an hour and a half. She then having somewhat
rallied, I delivered. She remained during the first two or three days in a most
exhausted state, from which, however, she gradually recovered. I feel satisfied,"
Mr. Wilkinson adds, "that had the usual plan been adopted in this case, so
great had been the hemorrhage previously to my seeing her, that she must have
sunk." 1
W,
CASE XXXIX.—Exhausting flooding; placenta extracted, and flooding sup-
pressed; arm presentation; turning.-Dr. Walker was called to see Mrs. H-
about four hours after labour with her sixth child had begun. She appeared in a
most alarming state of exhaustion, exhibiting in an extreme degree all the symp-
toms consequent upon great loss of blood. "On making an examination," writes
Dr. Walker, "I found the vagina filled with clotted blood, the os uteri fully
dilated, and a large portion of the placenta presenting, nearly closing the orifice
of the uterus. With some difficulty, I passed my finger round the anterior edge
of the placenta, to ascertain the presenting part of the child, and felt what I
thought was either a shoulder or the nates. The attempt increased the hemor-
rhage slightly; and, fearful of further reducing the already too exhausted powers
of my patient, I desisted. Having previously determined to adopt the plan of
treatment lately brought before the profession by Drs. Radford and Simpson, I
proceeded to remove the placenta. Introducing my left hand, I completely, and
in one mass, separated the placenta, which was immediately expelled with my
hand into the vagina; after its complete removal, the hemorrhage, which before
was considerable, entirely ceased. At this time, the pains were feeble, and not of
frequent occurrence. At my next examination, I found that a hand had followed
the placenta, and now presented at the os externum. With the usual precautions,
version was easily accomplished, and the woman safely delivered of a still-born
child. The uterus contracted with tolerable firmness, and no farther hemorrhage
supervened. On the day following, I found my patient comfortable, though
suffering slightly from the effects of the hemorrhage, and in a few days she was
perfectly recovered." 2
CASE XL.-The placenta extracted artificially before the child; rapid recovery
of the mother.This case I have already alluded to as having happened in the
practice of Dr. Maclean. The subject of it, Mrs. Nixon, was taken in labour with
her eighth child on the 14th of June 1845, at 4 P.M. The pains were trifling till
about three next morning, when they became more frequent and severe, and were
accompanied with a discharge of blood. The os uteri was found at this time ex-
panded to the size of a shilling, but rigid and undilatable, with the placenta pre-
senting over it, and a constant oozing of blood, which at each pain became much
increased. The pains and discharge nearly ceased after the administration of a
slight opiate, and using the ordinary means to check the hemorrhage. At 11
1 Provincial Medical and Surgical Journal for July 1845, p. 471. 2 Ibid. p. 557.
18
260
MATERNAL DYSTOCIA.
o'clock the pains and flooding returned; and an hour and a half after this, “I
found," says Dr. Maclean, "the os dilated to the size of a half-crown, the placenta
presenting, and protruding through it about one and a half inches. The hemor-
rhage, which had recurred with the pains, had caused such a degree of faintness
and collapse, that the fatal termination of the case appeared inevitable; and the
pains which now came on frequently, from the great weakness of the patient, had
but little effect in dilating the os uteri, and advancing the labour. Having ascer-
tained," he continues, "by the stethoscope, that the child was dead, and Mr.
Woodhead being again in attendance with me, it was at once agreed upon, in
consultation, the mother alone requiring our immediate attention, and the state
of collapse to which she was reduced rendering the forced delivery by turning ex-
ceedingly dangerous, while the evacuation of the liquor amnii had entirely failed
even to moderate the hemorrhage, that I should immediately endeavour to sup-
press the discharge by separating the whole body of the placenta from the uterine
parietes, when the patient might be allowed to rally a little before removing the
child, supposing the views of Dr. Simpson to be correct. Accordingly, having
administered a small quantity of spirits, with a few drops of laudanum, to the
patient, I immediately introduced my hand into the womb, so as to remove the
placenta. This I was easily enabled to do, after dilating the os uteri, by pressing
down the placenta, with the fingers introduced behind it, into the palm of the
hand. A few minutes were sufficient to effect this; and I was much gratified to
find all hemorrhage cease, as soon as the whole placental mass was detached. The
placenta being carried down into the vagina, a dose of ergot was administered,
and, in about a quarter of an hour, the natural pains expelled the child. There
was no after hemorrhage, and only slight lochial discharge. The mother recovered
without the slightest drawback, and was out of bed in a few days.”
"The above case," observes Dr. Maclean, "from the alarming
symptoms attending it, and the certain fatality which must have
ensued, had the flooding continued for a short time longer, with the
immediate suppression of all hemorrhage on the placenta being
completely detached, thus allowing time for the patient to rally,
would seem to prove the operation of turning in these cases to be
almost needless; at the same time that it affords another instance
of the accuracy of the conclusions published by Professor Simpson
in the London and Edinburgh Journal for March last, where he pro-
poses in such cases to remove artificially the placenta, and not the
child."1
After the present section was written, my attention was acci-
dentally called to some interesting remarks, bearing directly upon
the point of which it treats, and contained in the old and rare
Observations sur la Pratique des Accouchemens of Viardel, printed at
Paris in 1671. I append a literal translation of the passage in
Viardel's work.
¹ Northern Journal of Medicine for August 1845, p. 132.
1
PLACENTA PREVIA,
261
CASE XLI.—“All these labours where the placenta presents or escapes entirely
are very dangerous, as the infant often loses its life, as happened to the wife of
Monsieur le Fèvre, merchant living in the Rue de Gèvre, in whom the after-birth
presented first, and occupied all the internal orifice of the womb. Being called,
therefore, to deliver her, and finding matters in this state, as I discovered from
examination, I pushed back the after-birth with the extremity of my finger, in
order to return it into the womb, and having passed my hand into it as far as I
could, I passed it around the internal orifice in order to assure myself, and thus
discovered that it was the after-birth which was entirely separated from the womb
(entirement separé de la matrice), and that the infant presented behind it by the
umbilicus. After observing all these things, and being assured that it was the
placenta, I prepared to succour her as quickly as possible, in the following manner :
-I placed her across the bed with the thighs separated and the heels drawn up
to the hips, having first made her take a couple of eggs with a little wine, to
strengthen her. I introduced my hand into the womb (as I have said above), and
having arrived at the internal orifice, I grasped the placenta by its middle part
with my open hand, and holding it firmly, drew it out of the womb, and, the
moment it was out, I put back my hand to search for the feet of the child, and
having found them I drew it out, dead.
* ** As soon as I completed the
delivery, the loss of blood, which had persisted till then, and all the other acci-
dents, ceased; and I believe that the infallible prognosis in such a case is, that
the child must be dead, although in truth the case is not always so, for it may
happen in similar labours, that the infant being strong and vigorous, may escape
shipwreck if it be promptly and timeously succoured; and I may add here, in
confirmation of this, that I have met with a case of the same kind where the
infant lived for three days, although very weak and feeble." 1
III.2
SECTION IX.-CASES OF PLACENTA PREVIA IN WHICH IT IS PROPER,
1. TO EVACUATE THE LIQUOR AMNII; 2. TO EXTRACT THE
INFANT BY TURNING; AND, 3. TO SEPARATE AND EXTRACT THE
PLACENTA BEFORE THE CHILD.-SERIES OF CASES TO WHICH
THIS LAST PRACTICE IS APPLICABLE, VIZ. 1. WHEN THE OS
UTERI IS RIGID AND UNDILATABLE; 2. IN FIRST LABOURS; 3.
IN PREMATURE LABOURS; 4. IN LABOURS SUPERVENING
EARLIER THAN THE SEVENTH MONTH; 5. WHEN THE UTERUS
IS TOO CONTRACTED TO ALLOW OF TURNING; 6. WHEN THE
PELVIS OR PASSAGES ARE ORGANICALLY CONTRACTED; 7. IN
CASES OF EXHAUSTION; 8. WHEN THE CHILD IS DEAD; 9.
WHEN IT IS PREMATURE AND NOT VIABLE.
The various cases adduced in the last section will probably be
admitted on all hands to demonstrate sufficiently the practicability
¹ Pratique des Accouchemens, p. 90.
2 First published in Obstetric Memoirs and Contributions, 1855, vol. i. p. 774,
though printed and privately circulated several years previously.
262
MATERNAL DYSTOCIA.
of the plan of treatment in placenta prævia which it is my object to
bring before the Profession in the present Essay. In the next in-
stance, it is requisite for us to consider in what special cases of
placental presentation it will be proper to adopt the principle of
treatment in question.
I have already stated (see page 183) that I believe it would be
found the just and legitimate mode of practice in those cases of
placental presentation in which either the artificial evacuation of the
liquor amnii is unsuccessful, or forced delivery by turning is inap-
plicable and dangerous.
To understand, then, thoroughly the varieties of cases in which
we should adopt the complete separation and extraction of the pla-
centa before the child as a line of practice, it will facilitate our
inquiries if, in the first instance, we consider the class of cases in
which, first, The evacuation of the liquor amnii ought to be followed,
and, secondly, Those in which the delivery of the child by turning
constitutes the suitable mode of treatment. Having cleared the
way by considering these two points, we shall be more able to judge
of and appreciate the remaining varieties of placental complication
in which this new means of treatment ought to be adopted.
1. CASES OF PLACENTA PRÆVIA, IN WHICH THE EVACUATION OF
THE LIQUOR AMNII FORMS THE PROPER PRACTICE.
The artificial evacuation of the liquor amnii appears to be prin-
cipally followed when the placental presentation is partial only, and
consequently, when a segment of the bag of membranes, as well as
a segment of the placenta itself, is placed over the os uteri. When
this practice has the desired effect, it forms undoubtedly the simplest
and safest of all the means of treatment. But its applicability is
limited. The proportion of cases in which the placenta is observed
to present partially, would seem not to be so great as of those in
which it presents completely. Besides, when it does present parti-
ally, the rupture of the membranes and the escape of the liquor amnii
would appear to be by no means so certain a mode of arresting the
hemorrhage in this form of unavoidable as it is in accidental
flooding.
1 Out of 50 cases of placenta prævia reported by Dr. Francis Ramsbotham, the
placenta presented completely in 32, and partially in 18 instances. Principles of
Obstetric Medicine and Surgery, Appendix, p. 721.
PLACENTA PRÆVIA.
263
"The method of Puzos cannot," Baudelocque avers, "have, in
these cases of partial placental presentation, those advantages which
have been generally found in it when the source of the hemorrhage
is farther off (or of the accidental form). When the placenta is
attached to the neck of the uterus, if the hemorrhage is suspended
for a moment, when the waters are evacuated it soon appears again,
and becomes so much the more abundant as the orifice of the uterus
dilates further, and as the violence of the labour increases. I have
met," he adds, "with but one case where the flooding has entirely
ceased, after the evacuation of the waters, out of at least five-and-
twenty where the placenta was attached to the neck of the uterus.2
The practice of evacuating the liquor amnii in partial placental
presentations has generally, however, been found much more suc-
cessful than it appears to have proved in the hands of Baudelocque.
No obstetrician has probably, at the present day, had more oppor-
tunities of testing its value than Dr. Francis Ramsbotham of London.
He informs us, in his Principles and Practice of Obstetric Medicine
and Surgery, that he had attended, up to 1834, as many as forty-
four cases of partial presentation of the placenta. In forty of these
cases the membranes were ruptured some time before delivery. The
results of the treatment of the artificial evacuation of the liquor
amnii in thirty-nine of these cases were as follows:
¹ Puzos wrote a very beautiful memoir upon the artificial evacuation of the
liquor amnii, as a means of arresting and treating cases of accidental hemorrhage
(Mémoire sur les Pertes, etc., et sur la Méthode de procéder a l'Accouchement
dans les Cas de Nécessité, par une voye plus douce et plus sûre que celle qu'on a
coutume d'employer.—Traité des Accouchemens, p. 323; or Mém. de l'Acad. de
Chirurgie, 1743, tom. ii. p. 203.) Hence this practice is often spoken of, as in
the text, under the name of the method of Puzos. The honour, however, of first
proposing and adopting this particular line of treatment certainly belongs to
Mauriceau, who described and practised it half-a-century before Puzos (see his
Maladies des Femmes, etc., tom. ii. cases 307, 450, 459, 479, 480, etc.) He even
preceded Puzos in his explanation of the principle upon which the treatment acts
in suppressing the discharge. "The vessels of the uterus, which," says Mauriceau,
were open, become shut by the contraction of its proper substance, as soon as
the waters of the infant, which held it extended, are evacuated from it," tom. i.
p. 334.-Daventer (Art of Midwifery Improved, p. 153, English trans., London,
1716) and Dionis (General Treatise of Midwifery, p. 244 of English trans., Lon-
don, 1719) both also recommended the practice previously to the time of Puzos.
But if there are floodings," says Dionis, "from the separation of some part of
the after-birth, however little soever the womb is dilated, the membranes which
contain the waters must be broke, that the distension may be taken off, and that
the after-birth may not be farther loosened, which both prevents the increase of
the flooding, and makes way for the child's advancing into the passage, and being
born the sooner.”
2 System of Midwifery, Heath's Translation, vol. ii. p. 37.
1
264
MATERNAL DYSTOCIA.
In thirteen cases, or in 32 per cent of the whole, the labour was
afterwards terminated by the natural powers alone.
In twenty-six cases, or in 65 per cent of the whole, in consequence
of the hemorrhage not ceasing on the evacuation of the liquor
amnii, turning was subsequently adopted. One was terminated by
the forceps.
Eight of the forty-four patients died, four of them apparently
from the excessive loss of blood suffered before delivery was effected.
The principal arguments that have been used by obstetric
authors against the artificial evacuation of the liquor amnii in pla-
cental presentations, have been, first, Its alleged inefficiency in
arresting the hemorrhage; and, secondly, The difficulty which the
loss of the liquor amnii entailed or produced in the operation of
turning, if that operation afterwards required to be adopted in con-
sequence of the continuance of the flooding. These objections, but
particularly this last one, will probably be entirely removed, by
having the other expedient in abeyance, to which our attention is
directed in the present essay-namely, the complete detachment of
the placenta itself. The previous evacuation of the liquor amnii,
whether by puncturing the membranes or by puncturing the pla-
centa, would not interfere with any plan that it might be afterwards
considered proper to adopt for the entire detachment of the placental
The knowledge of this latter alternative will certainly entitle
us to have recourse oftener than has hitherto been done to the milder
expedient, in the first instance, of evacuating the liquor amnii. It
can be practised, when necessary, at a time when the os uteri is still
so small and contracted as not to admit easily of the adoption of
other measures. Little or no difficulty is in general encountered in
its performance. When, from the placental presentation being par-
tial, the membranes alone require to be perforated, the nail of the
fore-finger, or the end of a surgeon's probe, or of a wire or pen, will
suffice for the purpose. But, when the placental presentation is
more complete, the instrument that is employed requires to be
passed through its substance, and more care is required lest the
placental structure be too much lacerated, or the fœtus itself
wounded. The hair needle, which we have already (p. 181) found
spoken of in this case by Daventer, the small trocar recommended
for it by Deleurye, and the perforating instruments of Roederer,'
mass.
¹ Elementa Art. Obstetricia, par. 627.
PLACENTA PREVIA.
265
3
Fried,' Ritzen,² Kluge, etc., consisting of hollow tubes or canulas,
blunt or rounded at the extremity, and provided with a puncturing
lancet worked by a spiral spring, would probably none of them be
so safe as other means with which the surgeon is more likely to be
provided. The common surgical exploring needle might be used
with a blunt, instead of a sharp-pointed, wire passed through it.
Gendrin used successfully, and he states, "with facility," a common
catheter. Probably its blunted extremity would, more readily than
we might at first conceive, pass through the membranes covering the
placenta, in consequence of the resistance opposed on their foetal
side by the distension of the liquor amnii. A common quill, with
a lateral aperture like that of a catheter cut near its extremity, and
another at the opposite end of the barrel, to allow of a free escape
to the waters, would perhaps answer the purpose perfectly, could
always be easily procured, and its blunt point, like that of the
catheter, would not endanger the infant. Perforating the placenta
with the fore-finger, and rupturing the membranes with the nail,
might in the same way be used with similar results, and even with
greater certainty of effect; but from what we have said of the source
of the discharge in unavoidable flooding, it would seem a leading
object not to lacerate, to any great and unnecessary extent, the sub-
stance of the placenta itself, as its maternal vascular cells might thus
be opened up to a more dangerous degree."
If the operation, in whatever way performed, failed, by not
proving successful in sufficiently arresting the hemorrhage, it might
still at least gain for us some time for the greater dilatation of the
os uteri, and hence for the more easy separation of the placenta
subsequently, and the more safe passage of the foetus. Long ago,
Deleurye stated the objects and advantages of the practice explicitly,
in the following terms :-"There are, notwithstanding, cases of pla-
cental presentation in which the placenta must be pierced: as, when
it becomes necessary to terminate labour before the full term, with-
out uterine contractions, in consequence of profuse flooding, and the
fear of uterine inertia after this from the feebleness of the patient ;
then, with a thrust of a trocar, the evacuation of the waters is to be
1 In Knauer's Selectus Instrumentorum, Tab. xxv. fig. 4.
2 Scheibler's Dissertatio de rumpendis velamentis, etc.
3 Die Anzeigen der Mechanischen Hülfen bei Entbindungen, etc., mit Kupfern,
p. 436.
4 Sec Kilian's Operationslehre für Geburtshelfer, 1843, vol. i. p. 248; and
Siebold's Abbildungen der Geburtshülfe, p. 162.
• Médecine Pratique, tom. ii. pp. 350 and 352.
266
MATERNAL DYSTOCIA.
facilitated. The uterus, which by this evacuation ceases to be pas-
sively dilated, contracts and diminishes its volume, and we facilitate
the time of election for delivering the woman with more safety."'
1
2. CASES OF PLACENTA PRÆVIA, IN WHICH TURNING FORMS THE
PROPER PRACTICE.
2
I have already shown that several of the highest obstetric
authorities look upon turning, and the artificial extraction of the
infant, as the only advisable mode of treatment in every case of
placenta prævia, and have quoted at length the opinions of Plenck,
Denman, Merriman, Conquest, etc., to this effect. (See p. 182.)
"When the placenta," says Dr. Rigby, "is fixed to the os uteri,
nothing but turning the child will put a stop to the flooding."
"It
may be laid down as a rule," observes Dr. Lee, "admitting of no
exception, that where hemorrhage occurs from the placenta being
situated over the os uteri, artificial delivery must be performed.""
The same author, in a later publication, candidly and correctly
states, in reference to this practice-the operation of turning in
unavoidable hemorrhage :-" At the best, it is a dangerous opera-
tion, and you can never tell with certainty whether the patient will
recover after its performance, however easily it may have been
effected." +
ous.
4
The professed object of my present inquiry is to attempt to
prove that the artificial removal of the placenta is a more safe and
commendable operation in different forms of placental complication,
than the artificial removal of the infant, is not attended with such
extreme hazard to the life of the mother, and is specially applicable
in those very cases in which turning is specially difficult and danger-
There are, however, very many cases of placental presentation
in which the artificial delivery, or turning, of the foetus, will still
remain as the most proper and legitimate plan of treatment. This
remark applies, I believe, particularly-1. To those instances in
which the child is alive, and at or near the full term of utero-gesta-
tion, when labour supervenes; and 2. Where fortunately the mother
has borne a family previously, and the os uteri, by the time the
hemorrhage proceeds to a dangerous extent, is either so dilated, or
1 Traité des Accouchemens, p. 369.
2 Essay on Uterine Hemorrhage, 6th edit., p. 91.
8 Researches on the Pathology and Treatment of Diseases of Women, p. 207.
4 Lectures on the Theory and Practice of Midwifery, p. 373.
PLACENTA PRÆVIA.
267
dilatable, as to allow of the introduction of the hand of the operator
and the extraction of the foetus, without any fear of injury and
laceration. Under such a condition, turning affords a very fair
chance of life to the infant-and I presuppose the state of the os
uteri to be such, that the danger of lacerating it, and thus leading
either to subsequent hemorrhage or phlebitis, is not so great as to
endanger the mother's recovery."
1
Further, there is another set of cases of placental presentation,
in which we must continue to be driven sooner or later to the adop-
tion of turning.
I have already shown that in a considerable
portion of these presentations, the foetus presents preternaturally,
and in a number of them transversely. When the position of the
fœtus is transverse, we must of course ultimately rectify it, and
deliver by turning. But here we are driven to adopt the operation
of turning, not in consequence of the peculiar presentation of the
placenta, but in consequence of the peculiar presentation of the
child. Knowing that we can at any time safely arrest the hemor-
rhage by the complete detachment of the placenta, we shall be further
able, in such cases of cross-birth, to delay, if in other respects it is
imperatively necessary, the operation of turning, and select for it
that time which may be considered most compatible with the state
and structure of the uterus, and the safety and life of the mother;
and here also the adoption or not of the artificial detachment of the
placenta will be greatly regulated by the ascertained death or life
of the child.
3. CASES OF PLACENTA PRÆVIA IN WHICH ARTIFICIAL DETACHMENT
OF THE PLACENTA FORMS THE PROPER TREATMENT.
When our practical acquaintance with this method of treatment
becomes more extensive, and the measures for effecting it are sim-
plified and better understood, it is possible that the practice itself
may come to be applied in almost all the instances of placental pre-
sentation that I have alluded to under the two preceding heads.
1 Cases of placental presentation, thus favourable for the safe operation of
turning, are much more likely to be met with in hospital than in private prac-
tice, because hospital patients are generally near the full term of delivery before
they are admitted, but of 33 cases mentioned by Dr. Lee, only 2 seem to have
reached the full time. On the other hand, out of 11 cases which occurred in the
Dublin Hospital during Dr. Collins' mastership, all had reached the full time
except 2. If turning were applied in every case, such evident differences in the
conditions of the patients must of necessity greatly modify the resulting maternal
dangers and mortality.
268
MATERNAL DYSTOCIA.
This, however, is by no means the case during our present know-
ledge of the subject, and in the meantime I would wish to point
out here in detail the special cases of placenta prævia in which the
practice I propose seems to me to be more particularly applicable.
These cases include, 1. Some complications on the part of the
mother, especially such a degree of rigidity of the os uteri or vagina,
or such obstructions of any form in the maternal passages or uterus
itself, or such states of general constitutional exhaustion, as contra-
indicate and prevent the safe exercise of the operation of turning.
And, 2. Some complications on the part of the child, particularly its
death or prematurity, rendering the operation of version unneces-
sary, so far as any view to its safety may bear upon the question,
provided the mother can be delivered by means that afford greater
safety to her. I shall now proceed to consider somewhat in detail
each special set or division of cases to which the present mode of
practice appears to be legitimately applicable.
FIRST SERIES.
When the os and cervix uteri are too rigid or undilatable to allow of the
safe exercise of the operation of turning.
Obstetric authors appear, as we have already seen, to be gene-
rally and perfectly agreed as to the propriety of turning in all cases
of complete presentation of the placenta; they differ, however, from
one another in regard to the time and circumstances which ought to
be selected as most fit and safe for the performance of this operation.
in placenta prævia. Some strongly advise us to operate rather too
soon than too late. Others as strenuously counsel us to beware of
operating till the time that the os uteri is so dilated or dilatable as to
permit of our interference, without any chance of injuring or lacerat-
ing the cervix in the passage of our land, or the extraction of the
infant. "In recommending early delivery, I think it right," says
Dr. Rigby, the highest authority I can quote on such a subject, “to
express a caution against the premature introduction of the hand,
and the too forcible dilatation of the os uteri, before it is sufficiently
relaxed by pain or discharge; for it is undoubtedly very certain
that the turning may be performed too soon, as well as too late, and
that the consequences of the one may be as destructive to the patient
as the other. I am particularly led to observe this, as I have lately
been informed, from very good authority—namely, a gentleman to
#
PLACENTA PRÆVIA.
269
whom one of the cases occurred-of three unhappy instances of an
error of this sort, which happened some years ago to three surgeons
of established reputation, who, from the success they had met with
in delivering several who were reduced to the last extremity, were
encouraged to attempt it where but very little blood had been lost,
in hopes that their patients' constitutions would suffer less injury,
and their recovery be more speedy; which, till the experiment was
made, was a very reasonable supposition. The women died, and
they seemed convinced that their deaths were owing to the violence
of being delivered too soon, and not to the loss of blood, or any other
cause."
On the other hand, Dr. Ingleby, the author of one of the best
works that has been written on uterine hemorrhage, tells us that
"a very experienced accoucheur, in whose practice about twenty
cases of this description have occurred, informs me that those
women who were delivered at an early period of gestation, recovered,
but when delivery was postponed to a late period, the result was
fatal. Similar answers have been given to the same inquiry by
other gentlemen." 2
Two great sources of danger, in fact, require to be taken into con-
sideration in relation to the operation of turning, in each individual
case of placental presentation—namely, first, The danger of too long
a continuance of the hemorrhage, and consequently the exhaustion,
and even the death of the patient, if the operation be not performed
sufficiently early; and, secondly, The danger of contusion and laceration
of the cervix uteri and its included vessels, if the operator, afraid of
delay, and of the effects of the hemorrhage, proceeds to deliver too soon.
And it is to be especially recollected in relation to this last point,
that any degree of laceration in the tissues of the cervix uteri in a
case of placenta prævia is fraught with unusual and imminent danger.
The part of the uterine parietes to which the placenta is affixed
becomes, as is well known, most freely supplied with blood-vessels;
and there, in particular, the venous sinuses of the uterus are especi-
ally large and abundant. In placental presentations it is the cervix
uteri itself that assumes this highly vascular condition; and hence
any laceration or injury of it is much more liable to be followed,
than under other positions of the placenta, with hemorrhage im-
mediately after delivery, or with subsequent inflammation of its
included and lacerated veins, giving rise to uterine phlebitis, a
¹ Essay on Uterine Hemorrhage, p. 37.
2 Practical. Treatise on Uterine Hemorrhage, p. 147.
270
MATERNAL DYSTOCIA.
+
disease which, under one or other of its many forms, is found to be
one of the most common causes of death after the occurrence of
placental presentations.
The two preceding and opposite causes of danger and death to
which the mother is submitted under the operation of version in
placental presentations, appear to be very equally balanced in their
consequences; that is to say, amongst the number of fatal cases
which occur in practice or are to be found upon record, nearly the
same proportion appear to perish from the extent of the hemorrhage
before delivery, or its subsequent effects (the results of protracting
the delivery, and from post-partum flooding from the lacerated
vessels of the cervix uteri, with uterine phlebitis, and all the other
fatal consequences arising from injury and laceration of the vascular
structures of the cervix, when the os is injured by being forced open
too early).
As this appears a most important practical point to establish on
sufficient statistical data, I have collected into the following table
the dates of the death of the mother in 78 fatal cases of placenta
prævia, reported by the different authors whose works I have quoted
PERIOD OF DEATH OF THE MOTHER IN FATAL CASES OF
PLACENTA PREVIA.


Reporters.
No. of Fatal
Cases.
Died
undelivered.
Died within
3 hours after
delivery.
Within 48
hours.
At a later
period.
Mauriceau
Giffard
3
1
•
7
Smellie
6
3
Rigby
11
2
Collins
Lachapelle
2
9
J. Ramsbotham
F. Ramsbotham
9
1
16
Lee
15
1
162 3 2 3 775
1
...
1
1
3
3
2
4
1
1
8
[2
7
Total
78
8
36
11
23
•
•
in a former page (p. 177). The table is constructed to show, first,
The number of mothers who died undelivered; secondly, The num-
ber of those that sunk within three hours after delivery, and pro-
bably from exhaustion, under the hemorrhage preceding flooding,
or from its continuance from the lacerated vessels of the cervix, after
the emptying of the uterus; thirdly, The number that died within
48 hours after delivery, and hence, I suppose, from exhaustion under
PLACENTA PREVIA.
271
hemorrhage and the operation of delivery; and lastly, The number
of those that died at a later period, after the immediate danger from
the hemorrhage and operation had subsided, and when the fatal
result was apparently always, or almost always, the consequence of
uterine phlebitis, in some of its manifold forms.
Some authors and practitioners seem to have fallen into the
mistake of supposing that in all cases of placenta prævia the os
uteri will be found dilated or dilatable by the time that the hemor-
rhage has taken place to such an extent as to endanger the life of the
mother. It may be sufficient to quote, on such a point, the opinions
of an author who has written one of the soundest and most classical
professional works that we have in the English language: "In some
cases,"
says Dr. Denman, "in which it has been presumed to be
necessary to deliver the patient on account of the hemorrhage, in
placenta prævia, the parts have been in such a state that the opera-
tion could not, it was thought, be performed with safety. Whenever
the case demands the operation, on account of the danger of the
hemorrhage, the state of the parts will, on this account, always allow
it to be performed with safety, though not with equal facility."
must, however, be confessed with regret that the opinion here ex-
pressed by Dr. Denman rather indicates the condition which we
anxiously desire than that which we always meet with in practice.
And our best practical authors seem to be becoming more and more
agreed that cases of placenta prævia are constantly occurring, in
which the hemorrhage may proceed to such a degree as to urgently
demand artificial interference upon our part, in order to arrest its
violence or complete the delivery, without the os uteri and passages
being at the same time in such a condition as to permit of the safe
passage of the hand into the uterus, or of the safe extraction of the
infant from it.
* ** *
It
If," says Peu, “ a pregnant woman is seized with considerable
flooding, which does not cease, the secret is to deliver her as soon as
possible.
For this, I always suppose that there is a suf-
ficient opening. For to force and dilate the internal orifices of the
womb is just so many deaths, or rather lives thrown away and
sacrificed (c'est autant de morts, ou de vies plûtôt qu'on precipite et qu'on
prodigne.) If, then, the smallness of the opening, or the extreme
debility of the patient, render the thing visibly impossible, it is
better to leave the case to nature, than to irritate the blood so as to
augment the flooding without hope of alleviating it." 2
1 Introduction to the Practice of Midwifery, p. 530.
2 La Pratique des Accouchemens, p. 516.
+
272
MATERNAL DYSTOCIA.
((
""
When treating of the subject of unavoidable hemorrhage, Pro-
fessor Davis states, that he "had met with many examples even of
fatal results of profuse uterine hemorrhage unaccompanied by any
amount of dilatation of the orifice of the womb.' Dr. Hamilton,
when speaking of placental presentations, tells us that in the month
of September 1816, he was called to two cases where the patient
seemed to be in articulo from the deluge of the discharge, and, never-
theless, where the os uteri was in the state of obstinate rigidity
which Dr. Davis has described. "It has been advised," Dr. Rigby
states, never to introduce the hand till nature has shown some
disposition to relieve herself, by the dilatation of the os uteri to the
size of a shilling or a half-crown; and this rule is certainly founded
on a rational principle; for when it is so much dilated, there is no
doubt but the turning may be easily and safely effected; but from
some of the annexed cases it appears, that a dilatation to this degree
sometimes does not take place at all, and that even when the woman
is dying from the great loss of blood, the uterus is very little open.'
"There is not unfrequently," remarks Dr. Lee, "most profuse and
alarming flooding from complete placental presentation, where the
os uteri is so thick, rigid, and undilatable, that it is impossible to
introduce the hand into the uterus without producing certain
mischief." "
(6
3
112
'Again, it is by no means impossible," Dr. Ramsbotham ob-
serves, "that such alarming symptoms (the patient faint, and gasping,
and cold, etc.) may show themselves before the os uteri has acquired
the diameter of half-a-crown, as to render it extremely hazardous
for us to delay our means until that degree or dilatation is arrived
at. The blood may be gushing forth in a copious and continued
stream, or may be oozing away in a less violent though steady
draining, or coagula of considerable size may be passing from the
vagina every few minutes; and it must be evident to the least
attentive observer, that such a state of things cannot be allowed to
proceed unchecked. Two modes offer themselves for our choice:
either immediate delivery, or endeavouring to restrain the flow, and
delaying until the due degree of dilatation is effected.
Our practice
will mainly be guided by the state of the os uteri itself; if it
appear soft, lax, and distensible, offering but little resistance to our
fingers in the attempt at dilatation, we shall mostly be able, under
¹ Principles and Practice of Obstetric Medicine, p. 1040.
2 Essay on Uterine Hemorrhage, p. 38.
3 Principles and Practice of Midwifery, p. 373.
PLACENTA PRÆVIA.
273
the use of sufficient caution, to pass the hand entirely through it
without injury, even although its disc be not exceeding the diameter
of a shilling; and, indeed, I have accomplished the operation of
turning on some few occasions, under these unpromising circum-
stances, by slowly insinuating the fingers seriatim. Although, then,
such a proceeding be not desirable, if it can be avoided, inasmuch as
every minute's delay brings with it an augmentation of danger—we
are fully justified in effecting the dilatation of the os uteri thus
artificially, even when, at the commencement of our efforts, it will
scarcely admit the introduction of the tips of two fingers.'
?? 1
"I know," observes Dr. Collins, "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 desirable practice, yet the success of this
operation will mainly depend on the judgment of the practitioner in
selecting the most proper and favourable 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. We are well aware the os uteri will yield at a much
earlier period after a severe loss of blood than under other circum-
stances; we are equally well aware of the great injury the
patient sustains by delaying delivery beyond the earliest moment
that the mouth of the womb will by gentle efforts permit the intro-
duction of the hand; it is against premature measures we wish to
guard the young practitioner; as every individual of experience will
acknowledge the great embarrassment he not unfrequently has
laboured under, in deciding on the time, beyond which to defer
affording assistance were timorously to risk his patient's safety, and
previous to which, delivery would be either impracticable, or, if
effected by violent means, truly dangerous; for even a slight injury
to the mouth of the womb will prove more fatal than an increased
loss of blood, so long as the strength can possibly bear it.""
2
That the flooding in placental presentations sometimes proceeds.
to such an excess as to demand measures either for its suppression,
or for the forcible delivery of the patient, before the os uteri is in
such a dilated or dilatable state as to permit with safety to its
structures of the operation of turning, admits of being still more
1 Obstetric Medicine and Surgery, 2d edit. p. 387.
2 Practical Treatise on Midwifery, p. 93.
274
MATERNAL DYSTOCIA.
of
forcibly illustrated by an appeal to the history of individual cases
unavoidable hemorrhage. As the matter is one of most important
bearing upon the argument before us, I shall offer no apology for
enforcing and extending the evidence in favour of it, by adducing
some individual facts and instances in illustration of my present
purpose.
*
"In no case,” observes Dr. Edward Rigby, "is it proper or safe
to force delivery by artificially dilating the os uteri, when it is con-
tracted and unyielding; but where the placenta is presenting, it is
peculiarly dangerous, for even slight laceration of the os uteri will
be followed by serious consequences. Where the placenta is situated
in the upper part of the uterus, it is of very little consequence if the
edge of the os uteri has been torn somewhat during labour; but
in the present case it is very different-the os uteri now plays
the part of the fundus, its vessels are immensely dilated, and larger
ones are ruptured, which cannot be closed by the finest contraction
of the uterus.
* * Cases have occurred where the os uteri
has been artificially dilated, where the child was turned and de-
livered with perfect safety, and the uterus contracted into a hard
ball; in fact, everything seemed to have passed over favourably; a
continued dribbling of blood has remained after labour, which re-
sisted every attempt to check it; friction upon the abdomen, and
other means for stopping hemorrhage by inducing firm contraction.
of the uterus, were of no use, for the uterus was already hard and
well contracted; the patient has gradually become exhausted, and
at last died on examination after death, Professor Naegele has
invariably found the os uteri more or less torn."
:
We have sometimes proof afforded us in post-mortem examina-
tions of the fact that unavoidable hemorrhage may proceed to a
fatal extent during the first stage of labour, without the tissues of
the os and cervix uteri ever dilating to such a degree as to allow of
the introduction of the hand without laceration.
In his magnificent plates of the anatomy of the gravid uterus,
Dr. William Hunter has given two representations of the uterus of
a woman who died of unavoidable hemorrhage during the first stage
of labour. She had reached the ninth month of pregnancy. The
first plate (Tab. xi.) represents the external surface of the uterus,
with the enormous uterine veins about the cervix much enlarged
and injected. The second (Tab. xii.) shows the uterus opened, with
the placenta fixed over the os uteri, and the infant presenting in the
¹ Rigby's System of Midwifery, p. 259.
PLACENTA PRÆVIA.
275
second position of the head, or with the face looking to the left
sacro-iliac synchondrosis. The os uteri appears very small and
unopened. The preparations of the parts in this case are still con-
tained in the Hunterian Museum belonging to the University of
Glasgow. On lately examining them, I found the os uteri appar-
ently not opened to the size of a shilling, and the lips of the cervix,
particularly on one side, so thick and turgid (they are correctly
represented so in the plate) as to leave no doubt that it would
have been physically impossible to distend the uterine orifice, so as
to admit the hand without certain laceration. The placenta is par
tially detached and slightly lacerated upon its external surface op-
posite the os. In reference to this preparation, I may add one fact
bearing upon the matter discussed in a former page, relative to the
mode in which retrograde hemorrhage is prevented from the uterine
veins after the placenta is detached. The veins, as I have said, are
very large, as seen in the published plates, and are injected with
yellow wax. There is, however, no appearance whatever of any of
this wax having reached so far back as the utero-placental orifices
left by the separation of the placenta.
Long ago Dr. Smellie detailed three cases of Cæsarean operation
performed immediately after the mothers had died from unavoidable
hemorrhage. These cases are interesting in a historical point of
view, as affording some of the earliest evidence which we have on
record of the occasional implantation and organic adhesion of the
placenta to the interior of the cervix uteri being ascertained by
actual dissection. They all occurred during the two years of 1747.
and 1748.2 One of the cases is further valuable in reference to our
1 It has always appeared to me a remarkable fact that, both in this plate and
in the beautiful engraving, Tab. iv., of the natural position of the fœtus in utero,
Dr. Hunter, who is justly and deservedly celebrated for his accuracy and fidelity
of observation, has represented the fœtus as lying in utero in a position which it
very rarely occupies—so rarely, indeed, that Naegele avers he only met with it
once as an original position in twelve hundred cases. Plates xv. and xxiii. re-
present the child in the third position; none in the work shows it in the first or
most frequent position. I may add that the "reversing" the infant is not a
mistake of the engraver's, as I find it exists in the original drawings by Rymsdyk,
which are still preserved in the museum. Some casts also, taken probably from
the same preparations, show the fœtus placed in this unusual position.
2 The first case in which there was post-mortem evidence of the organic im-
plantation of the placenta over the os and cervix uteri, seems to have been that
published by Petit in the Mémoires de l'Académie for 1723. It is well known
that the general belief of accoucheurs was that the placenta was always originally
affixed to the interior of the fundus or body of the uterus; and when found at the
os, it was believed to have separated and fallen down into that position. So late
19
276
MATERNAL DYSTOCIA.
present inquiry, as showing a perfectly undilatable state of the os
uteri under fatal flooding from placental presentation. I shall ap-
pend some details of it.
CASE XLII.-Casarcan operation after death from unavoidable hemorrhage;
rigid state of os uteri as found on dissection; its laceration under the attempt to
open it." The woman was turned of forty, of a gross habit, and had never borne
a child." After a fall in the seventh month, she had repeated discharges of blood.
Two or three weeks before her full time, she was taken with slight pains, upon
which Dr. Smellie was called, and found the os uteri opened to about the size of
a sixpence, and within it a soft substance that felt like the placenta. As she had
rested but indifferently the preceding night, was faint and weak, and had some
small returns of the discharge, Dr. Sands was consulted, and gave it as his opinion
that it was still proper to support the patient's strength with broths and nourish-
ing food, and more safe to wait till the slight pains should bring on the right
labour, than to use any violence to deliver her immediately. "I was again,” says
Dr. Smellie, "called about nine o'clock the same night, when she was taken all
of a sudden with frequent faintings, in one of which she expired as I entered the
room. This sudden alteration prevented me from making any attempt at delivery;
and, indeed, had not this event happened, I should have been afraid of her dying
in the operation, because of her gross and weak habit of body. As soon as all
present were satisfied that the person was dead, I opened her abdomen, and having
taken out the child, examined the uterus. I found the placenta firmly adhering
to its interior and posterior parts; about two fingers' breadth of its lower edge
was separated from the os internum, which it covered; and this was what Dr.
Sands and I had felt in the morning. Having extracted the secundines, I tried
with my hand to open the os internum from the inside of the uterus, which with great
force I performed, not without tearing it about two inches on one side."
"By this,"
he adds, "it appears how difficult it is to dilate this part in women going with a
first child, especially when they are pretty old. Indeed, it is sometimes impossible
to be done before they come to their full time, and even then not until the parts
are thin, soft, and largely opened by previous labours.”
If, in such cases as the preceding, it were necessary, in conse-
quence of the extent of the hemorrhage, to proceed to delivery, and
as 1717, Dr. Simpson, Professor of Anatomy at St. Andrews, published in the
Edinburgh Medical Essays, vol. iv., a paper in which he attempted to prove "that
the placenta inviolably adheres to the cavity of the fundus (uteri); with which it
is ingraft, and can never again shift its place."
¹ Cases in Midwifery, vol. iii. Collection xxix. No. 1, Case ii. p. 412.-Dr.
Rigby, in commenting upon this case of Dr. Smellie's, argues that the trial being
made to open the mouth of the uterus after death, "when every strong membran-
ous part is incapable of contraction and extension, is no proof that if the most
favourable opportunity had been watched for, and a gradual and repeated endea-
vour to open it had been before made, it would not have succeeded.”—Essay on
Uterine Hemorrhage, p. 44. Dr. Rigby appears to forget that the examination of
the uterus, and the laceration of the os, upon attempting to open it, occurred
immediately after death, and as the dilatability of the part depends upon its
physical rather than its vital conditions, we cannot believe that an os uteri which
was thus found incapable of dilatation without tearing after death, could have
been found during life, a few minutes previously, capable in any degree of dilata-
PLACENTA PRÆVIA.
277
yet the os uteri were not more dilated or dilatable than it was found
in Dr. Smellie's patient after death, it is evident that the forcible
introduction of the hand into the os uteri, and the artificial extrac-
tion of the child through it, would necessarily give rise to lacerations.
of a greater or less extent in the tissues of the cervix, and such we
find to be the fact in actual practice. The simple details of some
cases may enforce this important point, by showing the difficulties
of the practitioner, and the dangers of the patient under such a com-
plication. For this purpose I shall quote verbatim the reports of two
or three instances from the valuable and practical works of Dr.
Collins and Dr. Lee.
CASE XLIII.-Profuse unavoidable hemorrhage; turning required while the
passages were badly prepared; laceration of the cervix uteri ; death.—"W. S. was
admitted, at her full time, November 12. She had been shedding occasionally
for five days before, which reduced her to a state of great debility. There was no
hemorrhage on her admission, but on examination, the placenta was found at the
mouth of the womb, which was not more dilated than the size of a half-crown,
with its edge thick, but not very rigid. As the discharge had ceased, and her
strength was much exhausted, she was ordered to be kept perfectly cool and quiet,
to have some cold chicken broth. About an hour and a half afterwards, suddenly,
the most profuse hemorrhage set in, so much so, that in two or three minutes, the
blood was running in every direction over the edge of the bed; this was conse-
quent on some slight uterine action. There being no chance of life without speedy
delivery, we determined to make the attempt, though the parts were badly pre-
pared; accordingly the hand was very slowly and cautiously introduced, and the
feet brought down with little exertion; the uterus acted strongly, and felt well
contracted after delivery. The placenta canie away with the child. Great debility
succeeded the operation, with a slight discharge of blood at intervals; and on
examining an hour after, a laceration of the neck of the uterus, anteriorly and
to the right side, was discovered, commencing at its junction with the vagina,
and extending upwards. She died shortly afterwards. It was her fourth child-
a girl (living). Dissection verified the result of the vaginal examination.”¹
tion, without the same laceration. Dr. Smellie has given an additional instance
of Cæsarcan operation, performed immediately after the death of the patient in
unavoidable hemorrhage, with the view of saving the child. The dilatability of
the os uteri was not in that instance in any way affected by the death of the mother;
it was, as he describes, thin, soft, and open to the breadth of half-a-crown. "I
dilated it with ease, which showed that if I had been sent for in the evening, she
might have been safely delivered." On Dr. Smellie being called to this case,
before he had time to put her in a position for delivery, the patient fainted away,
was thrown into couvulsions, and died instantly. Two or three years ago I had
an opportunity of seeing the dissection of a woman who had died of accidental
hemorrhage in the first stage of labour. The os uteri was dilated to nearly the
size of a half-crown, but its edges were perfectly rigid, and undilatable without
tearing.
1 Collins' Practical Treatise on Midwifery, p. 97.
278
MATERNAL DYSTOCIA.
As we have seen in a previous extract, p. 273, no author seems
to be more thoroughly impressed than Dr. Collins, with the neces-
sity of not hastening the delivery in placental presentations, if it is
at all possible to avoid it; and the above case affords an apt illus-
tration of Dr. Lee's remark, that "it is sometimes absolutely neces-
sary to deliver by turning, before the hand can possibly be introduced
into the uterus, without producing fatal contusion or laceration of
the part." The following are analogous cases from Dr. Lee's own
Clinical Reports:-
CASE XLIV.—Complete placental presentation, with exhausting hemorrhage ;
os uteri so rigid as not to allow the hand to pass; foot of the child seized through the
os; forcible extraction of infant; death of the mother.-"On the 12th of January
1839, Mr. Jones, of Carlisle Street, Soho Square, called me to see a lady in the
eighth and a half month of pregnancy, who had been attacked with uterine
hemorrhage a month before. It first took place without any accident or pain, and
the quantity lost was about half-a-pint, and it produced little effect upon the con-
stitution. She remained quiet for several days, and then got up, and only felt a
little weak. For ten days she went about, but the hemorrhage returned on the
fifteenth day after the first attack, but not to a great extent. Seven days after
this, a third and more profuse hemorrhage took place: it gradually went off, but
not so quickly as the other attacks. At one o'clock, 12th January, it was renewed
to an alarming extent without any pain; about a quart of blood was suddenly
lost, and she became extremely faint. At four A. M. the discharge still continued.
When I first saw her, at seven o'clock, she felt faint; the pulse was rapid and
feeble. The upper part of the vagina was filled with a large clot of blood, which
adhered to the os uteri. By displacing this at the back part, I could distinctly
feel the placenta adhering all round to the neck of the uterus, which was thick
and rigid, and very little dilated. The effect produced by the hemorrhage was so
great, that it was evident death would soon take place if the delivery were not speedily
completed; and the state of the orifice was such, that it was certain the hand could
not be passed, but with the greatest difficulty. At eight o'clock, Dr. Merriman saw
her with us, and agreed that immediate delivery was necessary. I passed the
right hand into the vagina, and insinuated my fingers between the uterus and
placenta at the back part, and reached the membranes. But the rigidity of the
orifice was so great, that though I employed great force for a considerable time, I
could not succeed in getting the hand into the uterus. Dr. Merriman recom-
mended rupturing the membranes, and I was proceeding to do this with the
fingers, when I felt one of the feet of the child, which I grasped and brought
down into the vagina enveloped in the membranes, which then gave way. Nearly
half-an-hour elapsed before the version could be completed, and when it was
effected, the neck of the uterus grasped the neck of the child so firmly, that I
experienced the greatest difficulty in extracting the head, and not till I had made
pressure for some time with the finger, and dilated the orifice of the uterus. A
great discharge of blood instantly followed; the placenta was removed, and every
means employed to stop the hemorrhage, but the breathing became hurried, the
extremities cold, and she died in less than an hour after delivery. Dr. Merriman
informed me, that a patient of his had actually died under similar circumstances
1 Lectures on Midwifery, p. 373.
PLACENTA PREVIA.
279
before the head could be extracted. He considers the tampon as of little or no
use in such cases. "1
CASE XLV. Exhaustion; delivery of child postponed, from rigid state of os
uteri; craniotomy; death of the mother immediately afterwards.—“Mrs. H. was
attacked with uterine hemorrhage at the beginning of February 1839, when seven
and a half months pregnant. About twelve days after, it returned a second time,
and yesterday morning a third time. About half-past twelve on the 5th of March,
Dr. Davies requested me to see her with him, as the hemorrhage had returned in
a dangerous form, and the orifice of the uterus was not in a condition to admit of
delivery. We found the placenta adhering all round to the neck of the uterus,
the orifice rigid and undilatable, and open to the extent of a crown, the head of
the child presenting. By cold applied externally and internally, the hemorrhage
was restrained till six o'clock in the morning, when it was renewed with violence.
Dr. Davies then pressed his fingers through the placenta, tore it in two parts, and
perforated the membranes. Half-past eight A. M., no hemorrhage; slight pains.
Eleven A.M., no flooding; head pressing into the orifice of the uterus.
We were
prevented at the time from perforating and extracting the head, by the rigid state of
the os uteri. She seemed to regain strength during the day; but at ten in the
evening, without any further loss of blood, she began to breathe with great diffi-
culty, the lips were livid, the hands and feet cold, and it was evident she would
soon die undelivered, if we did not interfere. I opened the head, and extracted
it with the greatest difficulty, in consequence of the firm and rigid state of the os
uteri. The operation was scarcely completed before she was dead."2
•
CASE XLVI.-Turning attempted while the os uteri was too rigid to allow the
hand to pass; two days subsequently, syncope from sudden flooding; turning ;
death of the mother." On the 26th of April 1835, I was called to a patient of the
St. Marylebone Infirmary, who was more than seven months pregnant, and had
been attacked fourteen days before with alarming uterine hemorrhage. The first
discharge of blood took place during the night, when she was at rest; it was not
preceded by a sense of uneasiness about the uterus, and could be referred to no
accident or injury of any kind.
"A considerable oozing of blood still continued, when I first saw her. The
placenta presented; the orifice of the uterus was opened to the size of a crown-
piece, but its margin was so hard and undilatable, that I found it impossible,
without employing too great force, to pass the hand into the uterus.
After a
cautious trial for about half-an-hour to get the hand insinuated through the
orifice, I was compelled to withdraw it altogether, as there was no hope of over-
coming the resistance. On the 27th, the flow of blood continued, the strength
remaining unimpaired, and the os uteri being not less unyielding. I resolved to
wait till relaxation should take place, and moderate the discharge by the recum-
bent position, and the application of cold externally and internally. 28th.—A
large quantity of blood suddenly escaped, which produced complete syncope.
The countenance was afterwards pale, the extremities cold, and the pulse rapid
and feeble. The os uteri being soft and dilatable, I immediately passed up the
hand, and delivered by turning. The child was born alive. The placenta was
removed soon after; but though no further loss of blood was experienced, sho
continued gradually to sink, and died in a few days." 3
1 Clinical Midwifery, p. 155, Case 282. 2 Ibid. p. 157, Case 283.
3 Ibid. p. 145.
280
MATERNAL DYSTOCIA.
CASE XLVII.-Severe and exhausting unavoidable hemorrhage with the os
uteri perfectly undilatable; a foot caught through the undilated os, and the child
extracted; mother in great danger, but recovered. "On the 7th of October 1835,
I was requested by Mr. Gairdner, of Foley Place, to see a patient, residing in
Frith Street, who had completed the seventh month of pregnancy, and had been
attacked with uterine hemorrhage three weeks before. A slight discharge of
blood had continued during the whole of this period, but it had produced little
effect upon the system until a few hours before I saw her, when several pints of
blood were suddenly discharged, and her whole strength seemed at once ex-
tinguished. The pulse was not perceptible; the extremities were cold, and the
respiration feeble. The blood still continued to flow in great quantities, and it
was evident death would soon take place if the uterus was not speedily emptied
of its contents. The os uteri was not dilated to the size of a crown, and it was so
rigid that I found it absolutely impossible, though I employed a degree of force
scarcely justifiable, to pass more than three fingers within it. The whole hand
could not be made to pass, though it appeared certain that death would soon take
place if delivery was not immediately accomplished. On the fingers being with-
drawn for a short time, the flooding continued. I made another effort to turn
the child, but the resistance could not be overcome. I then pressed forward the
fore and middle fingers of the right hand between the placenta and uterus, so as
to reach the membranes, which I succeeded in tearing open. Pressing the
fingers still forward, they came in contact with one of the feet, which they
grasped and brought down into the vagina. This was pulled lower and lower
till the whole extremities and nates were drawn into the os uteri; but so rigid did
it continue to be, that although I exerted all the force I dared employ in dragging
it down, half-an-hour elapsed before the pelvis of the child could be made to clear
the orifice of the uterus. At last it was extracted with the placenta, and the
hemorrhage ceased. A violent rigor followed, which threatened for a time to
destroy the patient. Bottles of hot water were applied to the feet and pit of the
stomach, the whole body was covered with hot blankets, and brandy was liberally
administered. She slowly recovered from the immense loss of blood.” 1
But if we pass from individual to general facts, and attempt,
with this view, to ascertain statistically the actual results of the
practice of turning, under the complication of dangerous unavoid-
able hemorrhage in connection with a rigid or insufficiently dilated
os uteri, the consequences are probably more disastrous than the
remarks which I have made, or the cases I have quoted, under the
present head, would lead us to suppose. Dr. Collins refers to cases
of Dr. Ramsbotham's, in which, from the extent of the hemorrhage,
and other symptoms, it was considered requisite to have recourse to
turning with the os uteri still inadequately dilated. I find in Dr.
Ramsbotham's work three additional instances of the same kind.
In his Clinical Midwifery, Dr. Robert Lee states, that out of the
thirty-five cases of placental presentation which he has recorded,
“in eleven there had been more or less rigidity of the os uteri, with
dangerous hemorrhage, and turning was performed in several of
¹ Clinical Midwifery, p. 146. Case 267.
PLACENTA PRÆVIA.
281
1
them where the whole hand could not be introduced into the
uterus." Mauriceau, Lachapelle, and Collins, give each one or two
similar instances. The following table shows an analytical view of
the results of all these cases in reference to their influence upon the
life of the mother.
MATERNAL MORTALITY IN CASES OF PROFUSE UNAVOIDABLE HEMORRHAGE
WHILE THE OS UTERI WAS STILL IMPERFECTLY DILATED.

Reporters.
Mauriceau 2
Lachapelle 3
J. Ramsbotham4
R. Lee5
Collins 6
F. Ramsbotham7
Total
•
No. of Cases. Mothers lost. Mothers saved.
2
1
8
0013-0
217∞∞ 1
8
•
11
2
1
•
25
21
4
This table sufficiently demonstrates the extreme danger which
the mother incurs when forcible delivery is required, and attempted
to be accomplished by the operation of version, with the os uteri
still imperfectly dilated or dilatable. The result is, that, calculating
from the data which the table affords, 17 per cent only of the
mothers were saved and 83 per cent of them died under the compli-
cation-a result far greater than we find in any legitimatised surgi-
cal operation, and far more fatal than even the Cæsarean section
itself. But under this complication, we believe, that the complete
¹ Clinical Midwifery, p. 164. These eleven cases seem to be those marked as
Nos. 266, 271, 272, 274, 277, 282, 283, 284, 285, 287, 289.
149.
2 Observations sur la Grossesse et l'Accouchement des Femmes, pp. 134, 363.
Pratique des Accouchemens, tom. ii. case 9.
4 Observations in Midwifery, Part. ii. Nos. 138, 139, 140, 141, 142, 144, 145,
5 Clinical Midwifery, p. 149, et seq.
• Practical Treatise on Midwifery, p. 97.
7 London Medical Gazette for 1844, p. 279.
66
8 Dr. Churchill states the following conclusions as the results of his extensive
inquiries into the mortality attendant upon the Cæsarcan operation. Among
British practitioners, in 40 cases, 11 mothers recovered and 29 died, or nearly
three-fourths. Among Continental practitioners, out of 369 cases, 217 mothers
recovered, and 152 died, or about 1 in 23. Taking the entire number, which
amounts to 409, we find that 228 mothers were saved, and 181 lost, or about 1 in
2}."-Researches in Operative Midwifery, p. 221.
Dr. Churchill has further calculated, that in the Cæsarean operation, 160
282
MATERNAL DYSTOCIA.
artificial detachment of the placenta would be perfectly practicable
in most, if not in all cases, and would consequently lead to the
saving of many maternal lives. It would at once, as we have seen,
arrest the hemorrhage which is the more immediate source of
danger to the patient, and allow time for the os uteri to become
relaxed and the labour to be completed, either by the natural pains,
or otherwise, as might be afterwards found proper or necessary.
If our statistics are sufficiently extensive to be true, we might
thus save 80 or 90 maternal lives out of every 100, by having
recourse to artificial and complete detachment of the placenta,
instead of losing 80 or 90 mothers out of every 100, by having
recourse to the operation of turning. I shall afterwards take occa-
sion to show, that in this complication the life of the child does not
interfere in any material degree with these results, because the infant
itself is almost invariably lost when turning is attempted under the
particular complication in question.
SECOND SERIES.
In Cases of First Labour.
In another place I have endeavoured to demonstrate that almost
all obstetric complications are more frequent and formidable in first
than in subsequent labours-rupture of the uterus being the principal.
exception to this general rule. Placental presentations would seem
to form another exceptional instance. I am not aware that any
author alludes to this point, but it has struck me repeatedly in
pursuing the statistical inquiries upon which the present memoir is
founded. In the Dublin Lying in Hospital, during the period of Dr.
Collins' mastership, the proportion of first labours amounted to 30
per cent of all the deliveries. During the same period, eleven cases
of placental presentation were observed in the hospital. In not one
of the eleven did this complication occur in first labour.¹ In the
various reports of cases of placenta prævia, by Giffard, Smellie, Rigby,
Clarke, Collins, Lee, and Ramsbotham, I find in all 55 instances in
which the number of the pregnancy is mentioned.2 In 3 only out
children were saved, and 64 lost out of 224. We shall sce afterwards, that on
the other hand far more children are lost than saved in turning in placental pre-
sentation, with an undilated os uteri.
¹ Practical Treatise, Table, pp. 173, 175, Cases Nos. 4, 17, 33, 84, 50, 72, 77,
83, 89, 92, 119.
2 Mauriceau does not mention the number of the pregnancy in any of his cases
of placenta prævia. Giffard mentions it in 2-See his Cases in Midwifery, PP.
PLACENTA PRÆVIA.
283
of these 55 cases, was the accident observed in a first pregnancy.
Out of 81 cases, collected from our own General Table of Cases in
Section III., with the number of the labour noted, the patient was
pregnant for the first time in 8 instances. (See p. 195.)
Thus, adding these two collections of data together, we have 136
cases of placental presentation, and 11 only of these were observed in
first labours.
1
If the rarity of placental presentations came to be fully estab-
lished in first pregnancies by more extensive data, may it not afford
us some clue to the explanation of the cause or causes leading to the
origin or production of that deviation in the site of the development
of the placenta which constitutes placenta prævia?
But though placental presentations seem to occur rarely in first
pregnancies, yet when they are met with, they are liable to exhibit
unusual difficulties in consequence of the maternal passages being less
dilated and dilatable than in women who have previously borne a
family. Hence the labour is slower, and the hemorrhage conse-
quently longer and more exhausting, before the parts are sufficiently
relaxed, to admit with safety of either the artificial or natural
delivery of the infant. In speaking upon this point, in connection
with the treatment of unavoidable hemorrhage, Dr. Smellie justly
observes, "the younger the woman is with child, the greater is the
difficulty in opening the os internum, and more so in the first child,
especially if she is past the age of thirty-five." In a previous page.
2
203, and 492; neither of them first labours. Smellie notices it in 9 cases-
-Mid-
wifery, vol. ii. pp. 308, 310, 311; and vol. iii. pp. 141, 162, 178, 409, 412, 415;
one of them a first pregnancy. Rigby states it in 9 instances-Essay on Uterine
Hemorrhage, 6th edit., pp. 203, 209, 218, 224, 232, 238, 240, 246, 253; none of
them primiparæ. Clarke, in 4 cases-Trans. of King and Queen's Coll. of Phys.,
vol. i. p. 380; one of which was a first labour. Lee, in 4 cases, reports the number
of the pregnancy—Clinical Midwifery, cases 268, 272, 285, 288; all the patients
had borne children previously. Ramsbotham records the number of the pregnancy
in 6 of his cases-Observations in Midwifery, 1st edition, pp. 195, 200, 202, 206,
216, 233; one of them only was confined for the first time.
The only evidence to the contrary, that I have been able to find, is afforded
by Madame Lachapelle. She states that in her 16 placental presentations, 6 were
labours with first children. Is this in any degree explicable by the kind of patients
resorting to the Maternité Hospital of Paris, where Madame Lachapelle's observa-
tions were made? Are the patients in a great proportion about to be confined of
illegitimate children, and pregnant for the first time ?
2 Treatise on Midwifery, vol. i. p. 332. Dr. Rigby, Essay on Hemorrhage, p.
36, and Dr. Dewees, System of Midwifery, p. 385, both advert to the difficulty
which is apt to be met with in making a proper examination even of the present-
ing part in unavoidable hemorrhage, occurring with a first child. It must be
acknowledged,” to quote Dr. Rigby, "indeed, that it may sometimes happen, that
284
MATERNAL DYSTOCIA.
(p. 276) I have already quoted from Dr. Smellie an account of the
post-mortem appearances and state of the os uteri, which he observed
in a patient that had died in her first pregnancy, of unavoidable
hemorrhage. Adverting to the force required to open the os uteri
in that instance after death, Dr. Smellie observes, "By this it appears
how difficult it is to dilate this part in women going of a first child,
especially when they are pretty old. Indeed it is sometimes im-
possible to be done before they come to their full time, and even
then, not until the parts are thin, soft, and largely opened by pre-
vious labours."
In consequence of the preceding circumstances rendering a first
labour with unavoidable hemorrhage both more tedious in its course,
before artificial delivery can be adopted, and the artificial delivery
itself more difficult of execution after it is had recourse to, placental
presentations, with this complication, would appear to be very danger-
ous and fatal to the mother. Out of 10 cases of unavoidable hemor-
rhage in connection with first labour, which I find in the reports of
Smellie, Clarke, Lachapelle, and Drs. J. and F. Ramsbotham, 7 of the
mothers died. One or two cases may serve to illustrate the diffi-
culties and dangers to which I have adverted. Dr. Francis Rams-
botham has given the following instance among his elaborate and
valuable tables and notes of the obstetric practice of the London
Maternity Charity.
CASE XLVIII.-Unavoidable hemorrhage with a first child; excessive rigidity;
turning and perforation of the infant's head; death of the mother.-The patient,
the subject of this case, was more than 40 years old, and it was her first child ;
there was excessive rigidity of the os uteri and other structures." When first ex-
amined, the os uteri was not dilated to more than the size of a shilling. A
catheter was passed into the uterus "by the side of the placenta," and the mem-
branes were thus ruptured. This proceeding did not arrest the hemorrhage, and
two hours after, delivery by turning was proceeded with. "Great difficulty"
was experienced in introducing the hand and extracting the body of the child.
The head was perforated to enable it to pass. "The placenta was immediately
expelled, and although she had spoken cheerfully the minute before, she expired
suddenly directly it was born." 2
CASE XLIX. Placental presentation in a first labour; turning, with os uteri,
etc., offering resistance; death of the mother in three days afterwards.—The caso is
detailed by Dr. Ramsbotham, in his Practical Observations. The patient was in
at the very first coming on of the complaint, if the discharge be small, and more
especially if it be the patient's first child, and the parts be close and unyielding,
the admission of the hand into the vagina, as I have directed, will be attended
with the utmost difficulty, and perhaps be almost impracticable.”
1 Midwifery, vol. iii. p. 414.
2 London Medical Gazette for 1844, p. 279.
PLACENTA PRÆVIA.
285
૬
the eighth month of pregnancy with her first child. During the preceding month
she had had repeated attacks of hemorrhage, which subsided spontaneously. Upon
making an examination, "although the os uteri was rigid and but little opened,”,
the placenta could be detected. She continued free from any discharge the whole
of the two following days, when a more violent return of hemorrhage occurred.
The operation of turning was proceeded to. "The external parts, the vagina and
the os uteri, had shown little disposition to give way. The os uteri " offered
considerable resistance" to the entrance of the hand, "binding it tightly around
like a cord." This was overcome, a foot was seized, and the breech brought down
-uterine action became strong and "expelled the rest of the child alive." After
delivery there was no farther loss; she was, however, much exhausted. On the
second day she was attacked with vomitings of a dark greenish fluid, and com-
plained of pain in the belly, which felt tender and swelled; the pulse was small and
quick. In the course of the night she expired. A post-mortem examination
was not allowed; yet I could not," observes Dr. Ramsbotham, "divest myself of
the suspicion, that some injury was inflicted upon the parts in the act of delivery,
although I was not aware of such a fact at the moment.
"1
After what I have stated under the preceding division, upon
rigidity of the os uteri in placental presentations, the practical in-
ference which I would wish to draw from the above remarks and
cases, concerning unavoidable hemorrhage in first labours, is obvious.
In the present, as in the former instance, and for the same reasons,
I am inclined to believe, that the complete separation and extraction
of the placenta will be found more safe and far more practicable in
the generality of first pregnancies with unavoidable hemorrhage,
than the forced delivery of the infant by turning. The os uteri,
however, in some such cases, may be found, at the time required,
sufficiently dilated or dilatable to allow of the artificial extraction.
of the infant, provided that plan be deemed, in other respects,
proper and preferable. I here speak of the propriety of the sepa-
ration of the placenta in first pregnancies, because I believe it will
be more frequently found the proper line of proceeding in first than
in subsequent deliveries, in which the passages yield earlier and
more speedily and readily under the relaxing effects of the labour
pains and the hemorrhage, and permit earlier and more safely of
artificial delivery.
SUMMARY OF PRINCIPLES OF TREATMENT IN
PLACENTAL PRESENTATIONS, ETC." *
In a late very interesting and very able paper on unavoidable
hemorrhage, published in the Lancet for March 27th, I observe that
1 Practical Observations, part ii. p. 206.
2 See Lancet, May 8, 1847, p. 479.
286
MATERNAL DYSTOCIA.
the author, Mr. Barnes, argues on the idea that I recommend the
complete separation and detachment of the placenta before the child
as a general rule of practice in all cases of placental presentation.
Many other members of the profession appear to have had the same
impression. I have always, however, maintained a very different
doctrine. From the first observations which I published on the
subject, up to the present time, I have upheld that the practice of
detaching the placenta before the child, in unavoidable hemorrhage,
was a method to be had recourse to in cases where the other recog-
nised modes of management were insufficient or unsafe, or altogether
impossible of application; and I have always looked upon this
new method as possessing especial value, from its thus presenting to
us a rational means of treatment in precisely those more formidable
varieties of this obstetric complication, in which all former plans of
practice were attended with extreme hazard or extreme difficulty.
As I am anxious to avoid future error and misconception on
this head, I would beg leave here to take the liberty of enumerating
briefly, and without entering into special details, the different general
principles of treatment which, in my humble opinion, ought to guide
our practice in this important and anxious class of cases.
Setting aside, then, those minor and palliative measures for
moderating the attendant flooding that are generally adopted by
practitioners in all cases of uterine hemorrhage, where time permits
of their employment (such as quietude, the supine position, cold,
etc.), I hold that our management of placental presentations,
when either labour or such severe flooding as demands interference
does at last supervene, should be regulated on the following prin-
ciples :--
I. In some cases no active interference is required.-In placental
presentations, we deem ourselves called upon to interfere operatively,
with the avowed object and purpose of saving the patient from the
dangers of the attendant hemorrhage. Hence it necessarily follows
that it would not be requisite to adopt any special form of artificial
aid or delivery, if, in any case or cases, this complication were ac-
companied with little or no flooding. Now, in some instances of
partial presentation of the placenta, the flooding ceases altogether,
or abates to a safe degree, when, during the natural progress of
labour, the membranes rupture and the head descends. And in
come rare cases of complete presentation of the placenta, where the
vascular bleeding structure of the placental mass has become ob-
structed and obliterated previously to the supervention of labour,
PLACENTA PRÆVIA.
287
little or no hemorrhage has accompanied the process of delivery.
In other instances, before any operative aid can be applied, the
hemorrhage suddenly and entirely ceases, in consequence of the pla-
centa becoming totally separated and expelled by the advancing
head of the infant. Under such circumstances, and others, where
the present or prospective dangers attendant upon operative inter-
ference would be evidently greater than the present or prospective
dangers attendant upon the existing degree of hemorrhage, any
form of forced delivery would, I believe, be improper. But cases of
placental presentation, in which we can thus leave the delivery
altogether to Nature, are rare. Generally we require to adopt some
active measures, with the special object of saving the patient from
the actual or threatened dangers of the hemorrhage. These mea-
sures should, I conceive, be one or other of the plans which I have
now to proceed to mention-viz. 1, the artificial evacuation of the
liquor amnii; or, 2, the artificial extraction of the child; or, 3, the
artificial separation of the placenta.
II. Artificial Evacuation of the Liquor Amnii.-In partial presen
tations of the placenta, rupturing the exposed portion of membranes
(according to those principles that are generally followed in accidental
floodings) is a measure which sometimes proves quite adequate to
arrest or abate the hemorrhage to such an extent, that the delivery
may be afterwards entirely committed to the efforts of Nature.
Various old authors, as Daventer, Deleurye, and Astruc, have de-
scribed this same plan of treatment as applicable to complete, as
well as to partial, presentations of the placenta, with this difference,
that in the complete variety the liquor amnii is evacuated, not by
puncturing the membranes only, but by perforating the opposing
placental structure with a trocar, catheter, or other analogous instru-
And the later records of midwifery contain several cases in
which this perforation of the placenta has, in complete presentations
of the organ, been successfully adopted, both as regards the mother
and the infant.
ment.
Several high authorities, however, in midwifery, have altogether
repudiated the evacuation of the liquor amnii, both in partial and
in complete placental presentations. They have done so principally
under the idea, that if this measure failed to suppress the flooding,
the previous escape of the waters would render any subsequent
practice that might be required, more difficult of execution. This
objection certainly applies to turning, as a subsequent practice, but
it does not apply to artificial detachment of the placenta as an
ulterior measure of treatment.
288
MATERNAL DYSTOCIA.
The artificial evacuation of the liquor amnii, by perforating either
the placenta or membranes, affords assuredly a simple, but by no
means a certain, method of restraining the flooding in placenta
prævia. It is a practice which is undoubtedly attended with less
success in unavoidable than in accidental hemorrhage. But still I
believe it to be a mode of treatment to which we may occasionally
have recourse with great advantage, especially if there is originally
a large quantity of liquor amnii present, and if the flooding is great,
while the os uteri is still small and undilatable. We must beware,
however, of trusting too much or too long to this, or to any mere
palliative measures. Whatever we do, should, if possible, be always
done before the hemorrhage is allowed to proceed to such an extent
as to induce any very marked symptoms of constitutional debility
and depression in our patient. If a decided state of exhaustion has
been allowed to supervene, either of the two remaining and ulterior
measures, extraction of the child or extraction of the placenta, will
be but too liable to prove futile and unsuccessful in their results.
III. Artificial Extraction of the Child.-This forms the general
principle of management upon which unavoidable hemorrhage has
hitherto been treated by most authors and practitioners. The pro-
fessed object of the practice is this: by forcing the delivery of the
child, and thus emptying the uterus, the organ is thrown into full
contraction, and hence further loss of blood prevented. The mode
in which the indication is fulfilled, is, in some degree, regulated by
the state of advancement of the infant, its presentation, etc. In a
great proportion of cases the accompanying hemorrhage requires
interference at so early a stage of the labour, that the only proper
and possible mode of delivery is by the operation of turning; and
various authors, as Drs. Denman, Burns, Hamilton, Conquest, and
others, speak of turning as the sole and only mode of treatment
applicable to cases of placental presentation. The great objection
to it is the imminent danger which the mother necessarily runs
from the risk of some laceration of the cervix uteri during this mode
of forcible delivery; and any degree of laceration of this part is
especially dangerous in placental presentations; for in placenta
prævia the structure of the cervix is extremely vascular, being
permeated by those numerous and enlarged vessels which are always
developed, in a high degree, in the uterine walls opposite the seat
of the placenta. The laceration of these vessels leads to immediate
danger, from draining hemorrhage after delivery, and to more
remote danger, from inflammation being liable to spring up in the
PLACENTA PRÆVIA.
289
torn and wounded sinuses of this part, and extreme uterine phle-
bitis following as a direct consequence. But still I hold turning to
be the proper mode of practice in unavoidable hemorrhages which
cannot be restrained by less active measures, and where immediate
delivery is demanded, with the os uteri well dilated, or easily
dilatable, and the child still alive, or presenting transversely.
Besides turning, other modes of artificial delivery of the infant
are occasionally resorted to in placental presentations. If the
attendant flooding is such as not to require forced delivery till after
the waters are evacuated, and the head well advanced in the
passages, then version would be dangerous and inapplicable, and
the use of the forceps offers the safest and easiest mode of extracting
the infant. Further, in original pelvic presentations, extraction
may be at any time effected, when required, by seizing and dragging
at the feet of the child.
IV. Artificial Separation of the Placenta.-The arrestment of
unavoidable flooding by total detachment of the placenta should, I
believe, be our line of practice when the combination of circum-
stances is as follows-viz. the hemorrhage is so great as to show the
necessity of interference, and is not restrained or restrainable by
milder measures, such as the evacuation of the liquor amnii; but, at
the same time, turning, or any other mode of immediate and
forcible delivery of the child, is especially hazardous or impracticable,
in consequence of the undilated or undeveloped state of the os
uteri, the contraction of the pelvic passages, etc. Or, again, the
death, prematurity, or non-viability of the infant, may not require
us to adopt modes of delivery for its sake, that are accompanied (as
turning is) with much peril to the mother, provided we have a
simpler and safer means, such as the detachment of the placenta,
for at once commanding and restraining the hemorrhage, and
guarding the life of the parent against the dangers of its continu-
ance. Hence, as I have elsewhere stated, I believe that the sup-
pression of the flooding by the total detachment of the placenta
will be found the proper line of practice in severe cases of unavoid-
able hemorrhage, complicated with an os uteri so insufficiently
dilated and undilatable as not to allow of version being performed
with perfect safety to the mother: therefore, in most primiparæ ; in
many cases in which placental presentations are, as very often
happens, connected with premature labour and imperfect develop-
ment of the cervix and os uteri; in labours supervening earlier
than the seventh month; when the uterus is too contracted to
290
MATERNAL DYSTOCIA.
allow of turning; when the pelvis or passages of the mother are
organically contracted; when the child is dead; when it is prema-
ture and not viable; and where the mother is in such an extreme
state of exhaustion as to be unable, without immediate peril of life,
to be submitted to the shock and dangers of turning, or forcible
delivery of the infant. This enumeration is far from comprehending
all the forms of placental presentations that are met with in
practice; but it certainly includes a considerable proportion of the
cases of this obstetric complication, and among them, all, or
almost all, of the most dangerous and most difficult varieties of
unavoidable hemorrhage. In adopting the practice, one error,
which I would strongly protest against, has been committed in some
instances. Besides completely detaching and extracting the pla-
centa, the child has subsequently been extracted by direct operative
interference. If the hemorrhage ceases, as it usually does, upon the
placenta being completely separated, the expulsion of the child
should be subsequently left to nature, unless it present preternatur-
ally, or the labour afterwards show any kind of complication which
of itself would require operative interference under any other cir-
cumstances. Both to detach the placenta and extract the child
would be hazarding a double instead of a single operation.
Comparative Mortality attendant upon Turning, and upon the Total
Separation of the Placenta.-One circumstance which strongly led me
to advocate, in unavoidable hemorrhage, the preference of the de-
tachment of the placenta to the operation of turning the child, was
the fact of the great mortality which followed the latter operation,
as contrasted with the few mothers that died when the placenta was
spontaneously expelled, or accidentally extracted before the infant.
In speaking of the relative maternal mortality resulting from the
two modes of practice, Mr. Barnes very properly points out that
when I spoke of the mortality attendant upon the separation of the
placenta before the child as amounting to 1 in 14 only, 10 mothers
in 141 having died, I had included cases in which the placenta was
thrown off spontaneously before the child, along with others in
which it was artificially detached; and he doubts if the results
would not be "widely different" if the statistics comprehended the
latter class of cases only, "in which the severe operation of detach-
ing the placenta by the introduction of the hand had been resorted to.”
The best answer to this objection consists in a statement of the
results hitherto obtained from the practice of artificially detaching
the placenta.
PLACENTA PRÆVIA.
291
"Seventeen cases," says Dr. West,' "have been recorded in the
English journals during the past fifteen months, of detachment of
the placenta before the birth of the child, in cases of placenta prævia.
In the case recorded by Dr. Simpson, to whom it had been com-
municated by Mr. Cripps, the placenta was removed by an ignorant
midwife, and ten hours elapsed before the child was born, during
which time, however, no hemorrhage took place. In 16 out of the
17 cases, the bleeding is said to have ceased immediately on the
detachment of the placenta; but Dr. Everitt mentions, that although
the flooding abated on the separation of the placenta, it did not
entirely cease until after the application of cold externally; and he
insists on the fact as proving, in cases of this kind, the hemorrhage
comes from the uterine as well as the placental ends of the lacerated
veins. The life of the mother was preserved in every case but one
(out of the 17), and then the previous hemorrhage had been so pro-
fuse as almost to exhaust the patient, who died three hours after
delivery. All the children were still-born, except in the case
related by Mr. Stickings."
I do not stop to inquire whether, in one and all of these 17 cases,
the artificial detachment and extraction of the placenta ought to
have been followed. At present I adduce them, not as affording
evidence of the propriety of the practice, but as affording evidence
of its safety.
In proof of the maternal mortality under the old and recognised
forms of practice being greatly higher than under the proposed plan
of the extraction of the placenta before the child, Mr. Barnes refers,
apparently with some hesitation, to the statistics collected by Dr.
Churchill and myself, as showing that 1 in every 3 mothers was
usually lost in placental presentations. Among 174 cases of un-
avoidable hemorrhage collected by Dr. Churchill, 48 mothers died.
I have now before me (see page 179) a carefully collected list of
654 cases of placental presentations reported by Mauriceau, Portal,
Giffard, Smellie, Rigby, Clarke and Collins, Schweighauser, Lacha-
pelle, Drs. John and Francis Ramsbotham, Lee, Lever, and Wilson.
Among these 654 cases, 180 mothers died, or 1 in 3. In corrobo-
ration of the correctness of the statistical view which Dr. Churchill
and I have taken of the extent of maternal mortality in un-
avoidable hemorrhage, I would further beg to refer Mr. Barnes
1 See his able Midwifery Report for 1845-46, in Dr. Forbes's Review for January
1847, p. 286.
***
20
292
MATERNAL DYSTOCIA.
to the observations of Dr. Robert Lee.¹ Dr. Lee states a number of
statistical facts regarding uterine, hemorrhage from placental pre-
sentations, and, amongst other matters, he mentions the result to
the mothers in a considerable number of cases. I shall throw all
his evidence on this last point into a tabular form :-
Maternal Mortality in 72 Cases of Placental Presentations, as noted
by Dr. Lee.
No. of Cases
Reporters.
Reported.
No. of Mothers
Lost.
Dr. Clarke
14
1
Dr. Collins
11
2
Dr. Ramsbotham
19
∞
8
Dr. Lee
38
14
72
25
Hence, according to Dr. Lee's collection of statistics, the maternal
mortality in unavoidable hemorrhage, amounting to 25 in 72 cases,
is rather more than 1 in 3. And this evidence of Dr. Lee will
probably be regarded as the stronger, seeing that it is totally un-
prejudiced in its character, for, in 1845, Dr. Lee called into doubt
the accuracy of all collections of statistical data, made by others,
which led to the idea that the general maternal mortality in un-
avoidable hemorrhage was so great as to approach 1 in 3. At that
time he was, I believe, unaware of the general result of his own
previously published collection of statistical data relative to the point
in question.
SPECIAL AVERAGE AMOUNT OF MATERNAL MORTALITY
OBSERVED IN CASES OF TURNING FOR PLACENTA
PRÆVIA.2
ON another occasion I took an opportunity of stating, and proving
by comparative statistics, that "those mothers who are the subjects
of placental presentations are submitted to as great peril of life
1
Midwifery Lectures, pp. 370, 371, published in 1844.
2 See Lancet, October 9, 1847, p. 381.
PLACENTA PREVIA.
293
from this obstetric complication as they would be if seized with
yellow fever or malignant cholera." This refers to placental pre-
sentations taken irrespectively of any special forms of treatment, or,
indeed, of any treatment at all. The table on page 179 is a proof
of this, 180 mothers dying out of 654 cases, or 1 in 3. But
though placental presentations, taken as a whole, may thus be so
very fatal, it has been repeatedly argued, that in cases of unavoid-
able hemorrhage, in which the child is extracted by the operation of
turning, the mortality must be different and less in amount. I doubt
this entirely. Out of the 654 cases forming the table previously
published, in 421 the child was extracted by turning. The follow-
ing table shows the result:-
Table of Maternal Mortality in Placental Presentations treated by the
Operation of Turning the Child.
Reporters.
Number of Cases.
Mothers lost.
Mauriceau
14
1
Portal
12
1
Giffard
18
5
Smellie
8
3
Rigby.
35
Clarke and Collins
8
94
Busch
5
2
Schweighauser
46
11
Lachapelle .
13
6
J. Ramsbotham
86
40
F. Ramsbotham
96
37 1
Lever
30
7
Lee
Wilson
28
10
22
8
421
144
1 In the controversy with Dr. Lee, the latter considered that 26 of the Drs.
Ramsbotham's cases ought not to be included in this table. If these, however, be
omitted, there will remain 156 cases; the result of which was as follows :—
Table of 156 selected Cases of Turning in Placental Presentations, the Operation
not having been over-delayed.
No. of Cases.
156
Maternal Deaths.
48
Proportion of Maternal
Deaths.
1 in 31%
See particulars in Lancet for November 1847, p. 520.
294
MATERNAL DYSTOCIA.
From the above table it appears, that out of 421 placental pre-
sentations in which the child was removed by turning, the result
was fatal to the mother in 144 instances; or, in other words, the
mothers were lost in the proportion of more than one in three (one
in two and nine-tenths). Upon the continent of Europe, the Casa-
rean operation-reputed the severest in midwifery-has been fatal
to the mothers, according to Dr. Churchill, in 154 out of 371 cases,
or in 1 in 2.
Lithotomy-generally regarded as one of the most formidable
operations in surgery-is calculated by Drs. Willis and Inman to
have an average mortality of one in every seven or eight operated
upon. The fatality attendant upon placental presentations treated
by the obstetric operation of turning, is more than twice greater
than that accompanying the surgical operation of lithotomy.
When turning is had recourse to in some of those more severe
complications of unavoidable hemorrhage, which I have proposed to
treat by the total detachment of the placenta, the maternal mortality
is still even greater and more startling. Out of eleven cases of pla-
cental presentation reported by Dr. Lee in his Clinical Midwifery,
and where there was the combination of "more or less rigidity of
the os uteri with dangerous hemorrhage," eight of the mothers died,
or seventy-two per cent; and two out of the only three who did
survive, evidently made very narrow escapes from death.
After giving a tabular view of these eleven cases on another
occasion,¹ I observed, that consequently "the operation of turning
and artificial delivery in unavoidable hemorrhage, with the os uteri
imperfectly dilated, would, from these and other cases, appear to be
more deadly than any operation that is deemed justifiable in the
whole circle of surgery." And I sincerely believe that in such cases
the simple but complete separation of the placenta without its re-
moval, which could be accomplished in circumstances under which
turning was utterly impracticable, would at once arrest the hemor-
rhage, and thus place the mother in a state of comparative safety.
"But," anxiously argues Dr. Lee, "to have attempted in those cases
to tear away" (separate) "the placenta, would have been an act of
insanity." "It would, undoubtedly," as anxiously argued Dr. Brown,
some twenty or thirty years ago, be downright madness to imagine
they will condescend to encourage vaccination.'
1 Medical Gazette for 1845, p. 1013.
112
2 Edinburgh Medical and Surgical Journal, vol xv. p. 64.
ALBUMINURIA IN PUERPERAL CONVULSIONS, ETC.
295
TREATMENT OF PLACENTA PRÆVIA BY PARTIAL
SEPARATION OF THE PLACENTA.¹
Sometimes the hemorrhage might be stopped by simply sepa-
rating a little more of the placenta than what had already been
detached; for, as the bleeding came from the line of vessels between
the placenta and the uterus which are on the stretch, the separation
relieved the tension, and by this practice there is a greater chance
of saving the child.
ALBUMINURIA IN PUERPERAL CONVULSIONS, ETC.
CO-EXISTENCE OF PUERPERAL CONVULSIONS WITH ALBUMINURIA.2
The third case alluded to in the text offered me the first oppor-
tunity of confirming, by inspection after death, an opinion that I
had been led to adopt from the examination of the symptoms during
life, and had publicly taught for the last two sessions-viz. that
patients attacked with puerperal convulsions had almost invariably
albuminous urine, and some accompanying, or rather preceding,
dropsical complications, and hence probably granular renal disease.
Pathologists are now well aware of the occasional great tendency to
convulsions and other bad symptoms in patients affected with
Bright's disease, and of the influence which that affection has over
the progress of both medical and surgical affections. The present
occasion is not a proper field to discuss its bearings in relation to
parturition and the puerperal state, or otherwise its importance
might be easily illustrated. A very able and zealous investigator
(Mr. Lever of Guy's Hospital) has already so far entered on the
inquiry, by pointing out that, as in one of the cases adverted to in
¹ See Proceedings of Edinburgh Obstetrical Society, January 28, 1870, in
Edinburgh Medical Journal, April 1870, p. 943.
2 Footnote to an article on the Uterine Sound in London and Edinburgh
Monthly Journal of Medical Science, November 1843, p. 1015.
296
MATERNAL DYSTOCIA.
the text, inertia of the uterus and hemorrhage are sometimes the
accompaniments, if not the consequences, of an albuminous state of
the urine, and granular disease of the kidney.¹
LESIONS OF THE NERVOUS SYSTEM, ETC., IN THE PARTURIENT FEMALE,
CONNECTED WITH ALBUMINURIA.?
1. Albuminuria, when present during the last periods of preg-
nancy and labour, denotes a great and marked tendency to puerperal
convulsions.
2. Albuminuria, in the pregnant and puerperal state, sometimes
gives rise to other and more anomalous derangements of the nervous
system, without proceeding to convulsions; and I have especially
observed states of local paralysis and neuralgia in the extremities,
functional lesions of sight (amaurosis, etc.) and hearing; hemiplegia
and paraplegia more or less fully developed.
3. Edema of the face and hands, going on occasionally to general
anasarca, is one of the most frequent results of albuminuria in the
pregnant female.
4. The presence of this oedema (3), or of any of the lesions of the
nervous system (2), with or without the oedema, should always make
us suspect albuminuria; and, if our suspicions are verified by the
state of the urine, we should diligently guard, by antiphlogistic
means, etc., against the supervention of puerperal convulsions.
5. Albuminuria, and its effects (1, 2, 3), are far more common
in first than in later labours, and these constitute a disease which in
general disappears entirely after delivery. But I have seen one case
commencing with slight blindness, but no oedema, and ending
gradually in hemiplegia, where the palsy partially remained after
delivery, and after the disappearance of the albuminuria. In another,
amaurosis came on with delivery, and had been present for six months
when I first saw her. She had no œdema or other symptom of al-
buminuria except the amaurosis; but, on testing the urine, it was
highly albuminous.
6. Albuminuria, with convulsions, etc., occurring in any labour
later than the first, generally results from fixed granular disease of
the kidney, and does not disappear after delivery.
1 See Guy's Hospital Reports, vol. vii. 1842, p. 325.
2 See Proceedings of Edinburgh Obstetrical Society, June 15, 1847, in Edin-
burgh Monthly Journal of Medical Science, Oct. 1847, p. 288.
1
ALBUMINURIA IN PUERPERAL CONVULSIONS, ETC.
297
7. Perhaps in puerperal convulsions, etc., produced by albu-
minuria, the immediate pathological cause of the nervous lesions is
some unascertained but poisoned state of the blood. Was there a
morbid quantity of urea in the blood? In several specimens of the
blood of patients suffering under severe puerperal convulsions, fur-
nished by me to Dr. Christison and Dr. Douglas Maclagan, these
gentlemen have been unable to detect any great traces of urea. Is
the poisoning material, caseine in morbid quantity or quality? The
dependence, shown by Gluge and others, of albuminuria upon
stearosis of the kidney, makes this connection worthy perhaps of
some inquiry.
8. In cases of severe puerperal convulsions, etc., from albuminuria,
the renal secretion is in general greatly diminished, and I have found
active diuretics apparently of great use along with or after vene-
section, antimony, etc., especially where the case was offering to
become prolonged.
9. Sometimes hemiplegia supervenes during pregnancy and labour
without albuminuria, but this form does not seem to interfere mate-
rially, or very dangerously, either with the pregnancy or labour-
the disease running its own usual course. In more than one case I
have seen the patient gradually but imperfectly recover the use of
the palsied limbs after delivery. In another no improvement
occurred.
ALBUMINURIA IN PUERPERAL AND INFANTILE CONVULSIONS AND IN
PUERPERAL AMAUROSIS, ETC.¹
2
Above fifty years ago, Hamilton and Demanet³ first stated the
important fact, that puerperal convulsions were liable to be preceded
by symptoms of anasarca in the pregnant mother. The truth of
this remark has been subsequently confirmed, in incidental observa-
1 See Edinburgh Monthly Journal of Medical Science, October 1852, p. 369.
2 Duncan's Annals of Medicine for 1800, vol. v. p. 313. "Where cedematous
swellings of the lower extremities take place to a considerable extent in the latter
months of pregnancy, in women of an unimpaired constitution, copious blood-
letting alone prevents the occurrence of convulsions either before or during
labour." See also his Practical Observations, p. 354. "The fits are preceded
most frequently by lancinating pain of the head, sometimes by crampish pain of
the stomach, and sometimes by cedematous swelling of the face and upper parts
of the person."
3 Recueil Périodique de la Société de Médecine, tom. ix., 1801-2, p. 110. He
regards “l'anasarque comme une de leurs causes essentielles.”
298
MATERNAL DYSTOCIA.
tions made by Dugès, Burns, Montgomery, Ingleby, Johns, and
others. The special pathological nature, however, of the oedema or
anasarca preceding and predisposing to puerperal eclampsia re-
mained uninvestigated, nor was any direct morbid relation attempted
to be traced between the dropsy and convulsions. Previously to my
first course of lectures on midwifery in the University of Edinburgh
in 1840-41, I had, in more than one case, ascertained the œdema or
anasarca seen in patients affected with puerperal convulsions, to be.
one of the numerous and important forms of dropsical disease which
Dr. Bright had shown to be connected with the existence of
albumen in the urine. Up to 1843 I had detected, in repeated
instances, this connection of puerperal convulsions with albuminuria,
but hitherto I had found it only by examination of the urine during
life. In the spring of 1843 I saw a fatal case of puerperal convul-
sions, in which, in addition to the detection of albuminuria during
life, I had an opportunity of observing the usual granular disease of
the kidney on post-mortem inspection.
CASE I. A woman, pregnant for the third time, and whose health had latterly
been impaired, was seized with severe puerperal convulsions, in consequence, as
her friends supposed, of strong mental excitement. I saw her, along with her
medical attendant, about twelve hours after the convulsions began. She was at
that time quite comatose in the intervals between the fits. In spite of venesec-
tion and various other measures of treatment, which were tried with the hope of
relieving and rousing the patient, the convulsions continued, the coma deepened,
the extremities became cold, the circulation began to fail, and the patient was
evidently hopelessly moribund. The child's heart, however, still continued to
beat, as was ascertained from time to time by the stethoscope; and the principal
indication left was the preservation, if possible, of its life. The os uteri had,
from the imperfect labour which had supervened from the attack of the convul-
sions, opened to about the diameter of a shilling, but its structures were rigid. In
order to extract the child, I followed the plan of turning recommended by Dr.
Hamilton, and with far more facility than I anticipated a priori-viz. I tilted and
pushed upwards and aside the presenting head with two fingers of the right hand
introduced per vaginam, while, at the same time, by manipulating upon the child
with the left hand through the abdominal and uterine parietes, a lower limb was
at last brought near the opening of the os uteri, and seized. The relaxed state of
the uterus and adjoining parts, resulting from the deep coma of the patient, no
doubt greatly facilitated this version. On attempting to drag the body of the
child through the os uteri, by pulling at the extended limb, I found the rigid
structures of the undilated cervix to resist altogether the passage of the trunk.
Under these circumstances, I made two slight incisions into the cervix, one on
each side; and on the re-application of extractive force, the breech now passed
the yielding os uteri, and the birth of the child was readily effected. The child
was born alive, and it survived and throve well. The placenta escaped without
any hemorrhage. The mother died in the course of two or three hours after the
birth of the child. A post-mortem examination of her body was made by Pro-
fessor Bennett. The lateral incisions into the lips of the undilated os, and tho
ALBUMINURIA IN PUERPERAL CONVULSIONS, ETC.
299
laceration or fissuring accompanying these incisions, were found not to extend
beyond the duplicature of tissue forming the vaginal portion or projection of the
cervix uteri; and had not been followed by any hemorrhage. There was no
blood, fluid or coagulated, in the cavity of the uterus or vagina, or around the
incisions. The kidneys presented a well-marked specimen of granular degenera-
tion, probably of some standing.
In allusion to the preceding instance (see p. 295) I stated in the
Monthly Journal for 1843, that this case "offered me the first
opportunity of confirming, by inspection after death, an opinion
that I had been led to adopt from the examination of the symptoms
during life, and had publicly taught for the two last sessions-viz.
that patients attacked with puerperal convulsions had almost invari-
ably albuminous urine, and some accompanying, or rather preceding
dropsical complication, and hence probably granular renal disease." 1
My friend Dr. Lever of London, who happened also to be direct-
ing his attention at the same time to the connection of puerperal
convulsions with albuminuria, published in the last number of Guy's
Hospital Reports for 1843, several cases of puerperal eclampsia, in
five of which he had found the urine to be albuminous; and to
these cases he appended some excellent remarks on the probable
relations between those two morbid states. Of late years, the same
subject has been investigated, and the connection between albumi-
nuria and puerperal eclampsia more or less elaborately traced and
discussed by various continental authors, particularly by Cahen and
Bouchut, Rayer, Devilliers and Regnauld, Depaul, Caseaux, etc.
Since the above date (1843), I have seen a variety of cases
of puerperal convulsions in consultation and hospital practice, and
have always (with very rare exceptions indeed) detected the exist-
ence of albuminuria in the urine of the mother. In one or two
instances I have found the kidneys presenting traces of recent acute
inflammation; as pus, etc. Sometimes, as in the case detailed above,
convulsions, or symptoms threatening them, recur in successive
labours in the same mothers in connection with established granular
disease. Usually, however, the state of albuminuria, which leads
to puerperal convulsions, is a transitory morbid condition, from
which the patient recovers within the course of a few days after
delivery; and the affection does not depend upon, or result in, any
actual change of structure in the kidney. And it may be that the
premonitory odema, headaches, etc., and the actual convulsions
themselves, do not stand in the relation of effect to albuminuria or
1 Monthly Journal of Medical Science, November 1843, p. 1015.
300
MATERNAL DYSTOCIA.
renal disease as a cause, but that all of these circumstances-the
dropsy, the convulsions, and the albuminuria- are simultaneous or
successive effects of some one common central cause-viz. a patho-
logical state of the blood, to the occurrence of which pregnancy in
some way peculiarly predisposes, probably from various acts of
secretion, nutrition, and depuration being vastly increased and
altered by the conditions of utero-gestation. Occasionally, however,
the state of albuminuria, when once induced, will continue for
several weeks after delivery. Some time ago I attended, with Dr.
Fairbairn, a case that was peculiar in this respect, as well as from
the lateness of the occurrence of fatal convulsions.
CASE II.—The lady had been confined in the country without any symptoms
of eclampsia. She came to Edinburgh about seven weeks after her accouchement.
When Dr. Fairbairn and I then saw her together, her particularly leuco-phlegmatic
colour, some lesions of the senses, her occasional fits of stupor and want of memory,
and the other undefined symptoms of which she was complaining, led me to sug-
gest the propriety of testing the urine, in order to ascertain if it contained albu-
men. It was found highly albuminous. In the course of eight or ten days
subsequently, our patient was suddenly scized with convulsions, followed by
coma, under a repetition of which she soon expired. No case has, so far as I
know, been put on record, in which eclampsia supervened so very late after
delivery.
In the instance just now referred to, the albuminuria was, there
was reason to believe, present before the termination of the patient's
pregnancy; but did not lead to any attack of convulsions during, or
immediately after, labour. And I have now seen a number of such
instances in which the urine was albuminous during the last days or
weeks of pregnancy, without convulsions, or any other special
morbid phenomena, supervening in connection with labour.
I
In several of these instances, temporary, and in one or two,
more permanent, amaurosis supervened at the time of delivery;
accompanied in most, but not in all, with intense headache. During
the course of the present year I saw one such case of puerperal
amaurosis in connection with albuminuria, in a patient at the sixth
month of pregnancy; and the albuminuria in this, as in some other
cases, tended to bring on premature labour.
¹ Drs. Bright and Barlow observed amaurosis in four instances of albuminuria ;
but these cases were not connected with pregnancy. M. Landouzy states, that he
has seen thirteen cases of weakness of vision commence, cease, and re-appear with
albuminuria, and without any appreciable change in the eye or its appendages.
And he considers some degree of amaurosis as a common complication with
albuminuria.—See Archives Générales de Médecine for November 1849, p. 370.
Hamilton and other authors incidentally mention amaurosis as a symptom con-
ALBUMINURIA IN PUERPERAL CONVULSIONS, ETC.
301
CASE III. It was the patient's second pregnancy. Her face had looked
swelled for a day or two previously. During the night she complained of intense
headache. In the morning she complained of such a degree of blindness, that she
could not distinctly see objects and persons. The urine was highly albuminous.
She was freely bled. True labour pains supervened early in the forenoon. She
was placed under the influence of chloroform for some hours, and delivered of a
premature child, which was alive, but did not survive. The amaurosis in a great
measure disappeared after the bleeding, and the patient's recovery after delivery
was speedy and perfect, the albuminuria passing off within a week subsequent to
her confinement.
Lately I have visited, with Mr. Sidey, an interesting case of
more permanent amaurosis connected with the puerperal state and
chronic albuminuria :-
CASE IV. The patient, now aged 36, is the mother of six children. In 1847,
two days after the birth of her fifth child, she became totally blind in the course
of a single night, the amaurosis being found complete when daylight came on.
The blindness, however, gradually and entirely passed off in a few days. During
the second week following the birth of her last child in July 1850, she again be-
came suddenly and completely blind, with some accompanying symptoms of
stupor, and a very slow pulse. The amaurosis has not, however, altogether dis-
appeared on this occasion as after the former attack. The patient's vision is still
(September 1851) so imperfect that she cannot read; her memory is extremely
defective; she often forgets the proper word to use in the middle of a sentence;
the iris now contracts, but for some time was dilated and immobile. The last
child died of convulsions about a week after birth. Mr. Sidey discovered the
urine to be highly albuminous upon her first attack of amaurosis, and has found
this state continuing in repeated examinations of it from that time to the
present.
•
Four years ago, I met with the following instance of the com-
plication in question :—
CASE V.-A patient who was to be under my care at her confinement, sent for
me several weeks before her expected time, to tell me that her vision had become
so imperfect, that she found she could not distinctly see the trees before her
window. There was no other special symptom present; but this degree of amau-
rosis led me to examine the urine, which I found to be highly albuminous.
During the few succeeding weeks, the amaurosis increased, and in addition, symp-
toms of hemiplegia slowly and gradually came on. Convulsions did not supervene,
as I feared they would, during the labour, which was somewhat premature. The
child survived. After delivery, the mother recovered greatly but not entirely,
from the nervous lesions, and is still suffering under a slight degree of hemi-
plegia.
nected with cases of convulsions. Dr. Ingleby has published a case in which a
patient was affected with common puerperal convulsions in her first pregnancy;
and in a subsequent accouchement was attacked with complete amaurosis, which
continued during the whole period of her labour. Vision was gradually restored.
See his Facts and Cases in Obstetric Medicine, p. 53.
302
MATERNAL DYSTOCIA.
Other lesions of the nervous system may present themselves
under the same circumstances. Some of these lesions I have
already noticed elsewhere. In fact, writers upon midwifery have
long stated to us as premonitory symptoms of puerperal convulsions,
various lesions of the nervous system, as headache, giddiness, de-
rangements of sight and hearing, etc., and have told us, that when
more or fewer of these symptoms make their appearance, an attack
of convulsions is to be feared in connection with labour, but does
not always supervene. These so-called premonitory symptoms of
convulsions, however, are only in fact so many symptoms of acute
albuminuria. They are indicative of the future probability of puer-
peral eclampsia, inasmuch as they are indicative of the actual
presence of albuminuria. And, consequently, whenever they do
present themselves, their existence should lead us to examine
accurately into the state of the urine, assured that, if they are found
to be connected with albuminuria, we may be certain of the liability
of our patient to the supervention of convulsions—a liability that,
no doubt, may be often lessened or averted by proper antiphlogistic
treatment before labour, and by using such means as excite and act
freely upon the intestinal, renal, and cutaneous secretions.
1
A few weeks ago, I saw an instance in which convulsions in a
child after birth were connected with the presence of albuminuria
in its urine-or connected, as it should be perhaps more correctly
stated, with that condition of blood-poisoning or uræmia, which is
the result of albuminuria-whether that condition consists in a
morbid accumulation of urea; or is produced, as Frerichs supposes,
by the presence of carbonate of ammonia in the blood, produced by
decomposition of the urea; or is, as is more probable, the effect
of some other morbific agent in the circulating system, capable,
like strychnia, of increasing the centric irritability or polarity of
the spinal system to such an excessive degree that, under this
super-excitability, comparatively slight eccentric causes of irrita-
tion in the stomach, intestines, uterus, bladder, etc. etc., readily
1 If the blood-poison, which in albuminuria produces convulsions and coma,
be, as Frerichs believes, carbonate of ammonia resulting from decomposition of
urea, can we account for the power of chloroform in restraining and arresting, as
it does, puerperal convulsions, upon the ground of its preventing this decomposi
tion? The inhalation of chloroform produces, as various chemists have shown, a
temporary diabetes; sugar appears in the urine, and hence probably also in the
blood. The addition of a little sugar to urine out of the body, prevents, for a
time, the common decomposition of its urea into carbonate of ammonia.
ALBUMINURIA IN PUERPERAL CONVULSIONS, ETC.
303
induce convulsive attacks of a general form, like those of puerperal
eclampsia.
CASE VI.-A lady, pregnant for the first time, was suddenly, when near the
full period of utero-gestation, attacked, when rising in the morning, with a severe
headache, faintness, and threatening of convulsions. My friend Dr. Weir, under
whose professional charge she was, saw her immediately, and bled her largely at
the arm, etc. On making a second visit about three hours subsequently, she
took, when he was present, a most severe fit of convulsions, which left her in a
state of deep coma. Two hours afterwards I saw the patient with him. She was
still comatose, and remained so for some hours subsequently. The child's heart,
when examined by Dr. Weir and myself, with the stethoscope, and while the
mother was still comatose, had only 88 beats in the minute; but in the evening
it had risen to its usual rate of 130. Next afternoon labour supervened; the
patient was put under the influence of chloroform for some hours; and a living
child was born without any recurrence of the puerperal convulsions. The mother
made a slow but perfect recovery. On the third day after birth, the child began
to suffer under a succession of convulsive attacks, which gradually increased in
severity during the next twenty-four hours, when it was placed for a considerable
time under the influence of chloroform-inhalation, and the fits ceased. After the
convulsive attacks supervened in the child, Dr. Weir and I had two opportunities
of examining its urine; and on both occasions we found the renal secretion of the
infant, like that of the mother, highly albuminous. Some time subsequently,
the infant died of inflammation of the cellular tissue of the loins and pelvis. We
were not permitted an inspection of the body.
I am not aware that any one has hitherto observed albuminuria
co-existing with infantile convulsions; but future observation may
perhaps show it to be a common pathological condition in some
forms of that disease; and probably in the Trismus Nascentium.
In such cases, indeed, the urine has hitherto seldom or never been
examined, in consequence of the trouble and difficulty connected
with obtaining specimens of it in the affections of infancy. Albu-
minuria may yet be found to play also an important part in other
diseases of infancy. The induration of the cellular tissue, or skin-
bound disease (Sclérème-"L'Endurcissement ou l'Edeme du Tissu
Cellulaire" of French authors) is an extremely rare affection in Edin-
burgh. I have only seen two cases of it; and, as was stated in the
Monthly Journal of Medical Science for 1843, page 699, in both of
these instances the urine was coagulable. Hence, at that time, I
ventured to suggest, that the skin-bound disease itself, or at least
some forms of sclerema, may be a variety or effect of Bright's disease
in early infancy; the effusion into the cellular tissue, which, consti-
tutes the marked feature of the affection, being so far analogous to
the anasarca occurring with albuminous nephritis. For the solution
of this point, affirmatively or negatively, we can only look to some
304
MATERNAL DYSTOCIA.
of those Continental pathologists who have ample opportunities of
studying the disease in question.
ON MORBID
CONDITIONS AND
INJURIES OF THE
AND PARTURIENT
SPLEEN IN THE PREGNANT
STATES.¹
Sir J. Y. Simpson referred to three cases of fatal rupture of the
spleen which had occurred respectively in the pregnant, parturient,
and puerperal states. He pointed out the circumstance that, during
pregnancy, there is often, if not generally, an increase of the white.
particles of the blood, or, in other words, a kind of normal or
physiological leucocythemia. As in states of morbid leucocythemia,
the spleen was often enlarged, so was it also occasionally in preg-
nancy. Perhaps it would be found in practice much more common
than the silence of authors on the subject might lead medical men
to suppose. It sometimes recurred in successive pregnancies. In
one patient of his, the spleen became enlarged to a very marked
degree in a series of successive pregnancies, and this splenic enlarge-
ment disappeared always after delivery. Her youngest child is now
about ten years old, and during that time there has been no recur-
rence of the splenic hypertrophy in the mother. A certain amount
of softening very frequently accompanies the hypertrophy of the
spleen, and predisposes to the laceration of the organ under strong
exertion and muscular effort, blows, etc. The first case of rupture
of the spleen in a child-bearing mother which he saw was a patient
of Dr. Husband's. She began to show symptoms of fatal sinking
shortly after premature labour set in, about the sixth or seventh
month. On opening the body after death, the enlarged spleen was
found lacerated, with effusion of blood into the peritoneal cavity.
Shortly afterwards, a patient of Dr. Wilson's, who had been de-
livered a week or two before, after making some unusual muscular
exertion, complained of abdominal pain and sinking, and died.
Rupture of the spleen and effusion of blood were found on dissec-
tion. The late Dr. Cunningham of Currie delivered a patient in
Edinburgh, using the forceps. He left very shortly afterwards to
catch the railway train. The patient sank and died within an hour
1 See Proceedings of Edinburgh Obstetrical Society, June 27, 1866, in Edin-
burgh Medical Journal, September 1866, p. 268.
PERITONITIS AND PERICARDITIS DURING LABOUR.
305
or two.
An inspection of the body was ordered by the law autho-
rities, when rupture of the spleen and consequent effusion of blood
were found to be the immediate cause of death.
FATAL PERITONITIS AND PERICARDITIS DURING
LABOUR¹
Professor Simpson showed a preparation of the lower segment of
a gravid uterus, with a portion of the placenta still in apposition
with the inner surface. The preparation had been taken from the
body of a patient who had arrived at the full term of utero-gestation,
and who died some hours after the commencement of labour, very
suddenly, and without having presented any symptoms that could
afford a clue to the cause of death. She had on one or two occa-
sions had a slight escape of blood, but was moving about and seemed
to be in the enjoyment of good health until Saturday, May 4th, when
she had a shivering fit, and began to complain of pain whenever she
moved. As she had come to her full term, and pains were recurring
from time to time, a midwife was summoned in the evening, who
remained in attendance during the night. The pains having con-
tinued for several hours, and no advance of the labour having
appeared to take place, Dr. Finlay, her usual medical attendant, was
sent for about 5 A.M. of the 5th. Dr. Finlay had found that she was
fairly in labour, and that the os, though but little relaxed, was suffi-
ciently dilated to enable him to ascertain that the breech was the
presenting part. There seemed to be no particular necessity for his
continued attendance; so he went home, intending to return about
8 o'clock, and leaving instructions with the nurse, who was a very
experienced accoucheuse, to send for him sooner if she should see fit.
He had not got back till 9 o'clock; and on arriving then at the
patient's house, he had been told that the woman had suddenly died
a few minutes previously. On laying open the abdominal cavity,
they had found it filled with a quantity of serous fluid; in which
some fibrinous flocculi were floating; the intestines were loosely
gummed together, and were covered at parts with inflammatory
deposits; similar purulent patches were scattered over the surfaces
of the liver and spleen, and on several portions of the uterus,-more
particularly at the parts where the ovaries and Fallopian tubes were
in apposition with its surface. Since he had referred to the ovaries
1 See Proceedings of Edinburgh Obstetrical Society, May 8, 1861, in Edinburgh
Medical Journal, May 1862, p. 1083.
306
MATERNAL DYSTOCIA.
and Fallopian tubes, he (Dr. S.) might be allowed to make a remark
as to the relation of these organs and of the broad ligaments to the
gravid uterus. He had always believed, and had been in the habit
of teaching his class, that, during the increase in size of the impreg-
nated uterus, the broad ligaments underwent but little change besides
that of enlargement, and, in particular, that they never became split
up in any degrce, so as to contribute to the peritoneal investment
of the enlarging organ. But the relation of parts in this case had
convinced him, that that doctrine was, to say the least, not univer-
sally true, for the layers of the broad ligaments on each side had
been found to be so far split up and separated, and so spread out
over the surface of the enlarged uterus, that the Fallopian tubes, up
to their fimbriated extremities, came to be almost in contact with the
outermost layer of its muscular coat; while the ovaries were lying
about an inch or an inch and a half farther back, along the surface
of the uterus, and attached to it by an extremely short pedicle. The
fimbriated extremities of both Fallopian tubes were very highly con-
gested, and covered and surrounded with inflammatory deposits; the
ovaries presented the same external appearances, were greatly en-
larged, and were found on section to be soft and pulpy; the right
contained a large corpus luteum. On cutting through the uterine
parietes, their substance was found to be unusually soft and friable,
giving way before the slightest touch. The foetus was found with
the breech presenting, the sacrum looking forwards to the left ace-
tabulum, and the foetal pelvis so tightly jammed down through the
maternal brim, that some degree of force was required to dislodge it
from its position. No local cause for the peritonitis could anywhere.
be discovered; nor was it possible to recognise any particular spot
as that in which it had probably commenced. The only local lesion,
independently of the results of the inflammatory action, that was
found, consisted in a slight laceration of the muscular coats of the
uterus on its inner aspect, at the level of the os internum, in front
and towards the right side; corresponding to this lesion on the
interior of the uterus there was a slight effusion of blood beneath
the peritoneum; but there was no inflammatory deposit on the sur-
face of the peritoneum at that point, and no evidence of any kind
that the general peritonitis had there arisen, and thence extended
over all the abdominal cavity; and in all probability the laceration
of the uterus had rather been the result of the inflammatory changes
in its texture than the primary cause of the wide-spread inflammatory
action. The lower portion of the placenta was found to have been
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
307
separated from the interior of the uterus to some extent; and this
had doubtless been the source of the occasional hemorrhage that had
occurred before and during labour. That the peritonitis was of idio-
pathic origin seemed to be indicated by the circumstance, that the
pericardium was found also to be the seat of some inflammatory
changes; for its cavity was found distended with serum, and there
were some small fibrinous deposits on the base of the heart and at the
root of the large blood-vessels.
Dr. Simpson was not aware that there was any such case upon
record of a patient dying of acute peritonitis during parturition, with
the exception of one related by Dr. Clarke, regarding which Dr.
Hamilton used to aver that they must have examined the body of
the wrong patient in the dissecting-room. He (Dr. S.) had once
before seen a somewhat similar case along with Dr. Graham Weir a
number of years before. The lady was well enough to have been out
shopping the day before her labour came on; she died immediately
after the labour was terminated, and the cause of death was found
to have been idiopathic pericarditis.
ON THE SEX OF THE CHILD
AS A CAUSE OF DIFFICULTY AND DANGER IN HUMAN
PARTURITION.¹
My object in the following observations is to show, that the Sex
of the child has a very marked and demonstrable influence upon the
difficulties and dangers of human parturition, in relation to the fate
both of the mother and of the infant.
Two winters ago I had occasion to undertake some investigations
into the causes of the difficulties attendant upon parturition in the
white, as compared with the black tribes of mankind; and in the
human female, as compared with the female of the lower animals.
In consequence of these investigations I was led to conclude that
the adaptation of the head of the foetus to the maternal canals is so
very close and accurate in the process of parturition, as it occurs in
the female of our own race, that deviations of a very slight degree
in the relative size of the cranium of the child, and of the pelvic
passages of the mother, should, when viewed on the large scale,
lead to differences of a very appreciable and notable extent in the
relative safety or danger of the whole process.
¹ See Edinburgh Medical and Surgical Journal, October 1844, p. 387.
21
308
FETAL DYSTOCIA.
On further considering the subject, it appeared to me, that in the
slight difference which is known to exist between the size of the
heads of the male and female child at birth-and in the effects
which this difference might or might not be traced to produce upon
the results of parturition—a criterion existed by which the truth of
the opinion in question might be fully tested. It was at the same
time manifest that the subject was one of such a nature that the
only evidence by which it could be settled obviously consisted of an
appeal to an extensive body of statistical facts. The first difficulty
was that of obtaining these required data. The numerous and
excellent reports of instances of morbid and instrumental labour
published by various authors are, however valuable in other respects,
totally useless in regard to the present subject-in consequence of
the sex of the child being rarely or never mentioned by them in the
details which they give of their individual cases. The only excep-
tion to this general remark that I am acquainted with is to be
found in the admirable Practical Treatise of Dr. Collins.' In his
invaluable record of the morbid cases which occurred in the Dublin
Lying-in Hospital during his Mastership,2 Dr. Collins gives, at the
end of the different chapters that treat of the individual difficulties
and complications attendant upon labour, a table showing, amongst
other items, the sex of the infant in each case. Dr. Collins himself
properly suggests, that "an extensive record" of the kind which he
has published might "materially assist the physician in obscure
investigations. For the data forming the grounds of the following
calculations I am, as will be seen in the sequel, principally indebted
to the facts recorded in Dr. Collins' work; and while the inferences
I am about to draw form one instance of the fulfilment of his own
suggestion regarding the utility of such data as he has collected, my
deductions will, I doubt not, be regarded as the more valuable and
trustworthy, seeing that the facts on which they are chiefly founded,
were originally collected and published by Dr. Collins, without ap-
parently any view whatever to the special inquiry upon which we
propose to enter.
113
Having made these preliminary remarks, I shall now proceed to
1 “A Practical Treatise of Midwifery, containing the result of 16,654 births
occurring in the Dublin Hospital, during a period of seven years, commencing
November 1826." London, 1836..
2 "Master is the title of the physician to whose care this hospital is entrusted
for a period not exceeding seven years."—See Dr. Collins' preface.
3 Ibid. p. 1.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
309
show that the sex of the child exerts a manifest influence upon the
general maternal mortality accompanying human parturition, upon
the frequency and fatality of its individual morbid complications,
and upon the safety and life of the infant itself, both during birth
and for some time subsequently to it. In all of these respects the
birth of male children is attended with much greater danger than
the birth of females. In proof of this, I have to adduce different
series of corroborative details. These details will probably be
exhibited with the greatest clearness, in the form of such a series of
propositions as the data which I have to bring forward may seem
to warrant. And I may further arrange these propositions into
more general heads or chapters, so as to show the effect, during
parturition, of the sex of the child as bearing-1. Upon the safety
and life of the mother; and, 2. Upon the life and safety of the
infant itself; 3. I shall enter into some investigations with the view
of developing the cause of the greater comparative dangers accom-
panying the birth of male children; and, lastly, I shall allude to
some practical inferences, and attempt to point out the extent to
which the mortality in childbirth and early infancy is influenced by
the mere sex of the offspring.
THE DANGERS AND DIFFICULTIES OF PARTURITION ARE GREATER
TO THE MOTHER IN MALE THAN IN FEMALE BIRTHS.
The greater danger and difficulties which the mother incurs in
connection with male births may be demonstrated both by an
appeal to the general mortality among parturient mothers, and by
a reference to the sex of the infant in a variety of the most formid-
able complications that are found to accompany the process of labour.
One or two propositions, and the statistical proofs on which they
are founded, will illustrate this remark.
FIRST PROPOSITION.
Of the mothers that die under parturition and its immediate consequences,
a much greater proportion have given birth to male than female
children.
During Dr. Collins' term of mastership, 16,414 women were
delivered in the Dublin Lying-in Hospital. Of these, 164 died.
Of the 164 that died, 7 had been delivered of twins, and 157 of
single children. In searching for the effect of the sex of the infants
in relation to the maternal mortality, I shall on this, as on other
310
FETAL DYSTOCIA.
occasions in the following remarks, reject from the calculations the
twin cases, because the plurality of the offspring is an element that
would obviously disturb and pervert, in different ways, the accuracy
of any investigations like the present; for the fœtuses, in compound
births, are frequently of opposite sexes-they are in general consider-
ably below the average size and weight--and the expulsion of the
second of them, when once the maternal canals are dilated, is not
attended with such obstacles, nor hence with such danger, as the
passage of the first or the transit of a single child. If we confine,
then, our attention to the 157 cases in which the mothers died in
connection with the birth of a single child, we will find that in 3
the sex of the infant was not noted; in 105 it was male; and in
49 female. The number of maternal deaths was therefore much
higher after male than after female births. But, to show with more
clearness and precision the relative excess of mothers that died after
giving birth to male, as compared with those that died after giving
birth to female children, I shall, on this as on other occasions
throughout the present essay, compute the casualties connected
with female births as equal to 100, and calculate the proportion of
those connected with male births in reference to this fixed standard.
In this manner the absolute numbers and relative proportion of
maternal deaths, after male and female births, contained in Dr.
Collins' returns, would, according to the above data, stand as
follows:

Total maternal
deaths.
154
105
In these the sex of child.
· Male.
Female.
49
Or in proportion of male
to female as
214 to 100
It is proper further to remark, that 38 out of the 157 cases
appear to have died from "
causes not the result of childbirth.” I
have not been able, from the details given by Dr. Collins, to sepa-
rate these 38 cases from the general number; but if they were so
subtracted, the remaining 119 cases would not improbably show a
greater proportion of male births in connection with those maternal
deaths that thus directly resulted from parturition or its immediate
effects.
SECOND PROPOSITION.
Among labours presenting morbid complications and difficulties, the
child is much oftener male than female.
This proposition may be proved by a reference to many of the
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
311
more formidable accidents that are found to accompany labour, as
convulsions, laceration of the uterus, post-partum hemorrhage, instru-
mental cases, etc.
Convulsions. Of 28' cases of convulsions described by Dr. Collins,
in 17 the offspring was male and in 11 female; of the male children,
8 were still-born; of the female, 4.
Rupture of the Uterus.-This formidable accident occurred in 34
instances during Dr. Collins' mastership. In 23 cases the rupture
was in connection with the birth of male children, and in 11, or in
less than the third of the whole, it occurred in connection with the
birth of female children.2
Puerperal Fever.-From November 1826 to November 1833, 88
patients were attacked with puerperal fever in the Dublin Lying-in
Hospital. Among these 88 women, 54, or five-eighths, had given
birth to male, and 34, or three-eighths, to female children.
Post-Partum Hemorrhage. This complication is known to occur
especially after those confinements in which the contractile powers
of the uterus have been unusually taxed and exhausted during the
previous stages of the labour. Dr. Collins reports 44 cases of
hemorrhage after the expulsion of the placenta. In 31 of these the
child was of the male, and in 13, or less than one-third, it was of
the female sex.
Tedious and Difficult Labours.-The duration of the labour was
noted by Dr. Collins in 15,580 cases. In 264 of these cases the
process was prolonged beyond 24 hours. Dr. Collins has not, in his
chapter on tedious labours, published the particulars of all these
264 instances, nor given such data as to enable us to ascertain the
sex of the children in them. These data would, in all probability,
have shown a great over-proportion of male infants-more especially
in that class of instances in which the delay was produced by protrac-
tion of the second stage of labour, in consequence of want of proper
relative size between the fœtal head and the maternal passages.
In another part of his work, Dr. Collins details a set of facts
that may in a great measure fill up the deficiency to which we allude.
In his chapter on "Still-born Children" he notes a variety of im-
portant circumstances, relative to 1121 cases in which the child was
1 Here, as in most other cases, our calculations include only, as already stated,
the results of uniparous births.
2 Dr. Collins adduces 20 cases of rupture of the uterus mentioned by Dr.
M'Keever, and out of these, in 15 the child was male, and female in the remain-
ing 5, or in about one-fourth of the whole.
312
FETAL DYSTOCIA.
1
dead at birth. He further observes, "In 106 of the 1121, the
labour was extremely severe, and in nearly half of these the patients
had been one, two, three, days ill, or even more, before admission into
the hospital, and most of them grossly mismanaged." He gives a
short outline of 49 of the 106 cases of tedious labour in the General
Table on Still-born Children, and marks out by asterisks 60 addi-
tional instances, which were, to use his own words, "similar in most
respects to those detailed.” These two sets of cases of protracted
labour with death of the infant, amount in all to 109 instead of
106. Out of this number the sex of the child was male in 65, and
female in 44.
Forceps Cases.-The forceps were used in 24 cases during Dr.
Collins' mastership. Of the children thus delivered, 16 were males,
and 8 females.*
Crotchet Cases." Of the 16,654 births which occurred in the
hospital, in 79," says Dr. Collins," "delivery was effected by lessen-
ing the head, on account of extreme difficulty in the labour, or
where the child was dead and interference necessary for the patient's
safety." In the section on Still-born Children, 41 of the 79 are
recorded, and references given to other 33 of the cases. Among
these 74 crotchet cases that are thus noted, the offspring was male
in 50, and female in the remaining 24 instances.
If we attempt to throw the proofs that we have collected of our
present proposition under the seven preceding heads into a tabular
form, and taking again, for the facility of comparison, the female
births at the fixed standard of 100, calculate the proportion of males
to them, we shall find the result to be as follows:-

No. Female Proportion of Males to
Children.
Females as
Nature of Complication.
Total
Cases.
No. Male
Children.
Tedious Labours
109
65
44
148 to 100
Convulsions
28
17
11
153 to 100
•
Puerperal Fever
88
54
34
161 to 100
Rupture of Uterus
34
23
11
207 to 100
Post-Partum Hemor.
44
31
13
240 to 100
Forceps Cases'.
24
16
8
200 to 100
Crotchet Cases.
74
50
24
208 to 100
Total
401
256
145
•
165 to 100
1 Practical Treatise, p. 462.
2 Ibid. p. 485.
labour, the number of hours during
Five were under 12 hours in labour;
24 to 36 hours; 27 from 36 to 48
3 In 97 of these 109 instances of tedious
which the patients were in labour is stated.
14 were from 12 to 24 hours; 19 were from
hours; 21 from 48 to 60 hours; 10 from 60 to 72 hours; and 1 was 90 hours ill,
• Ibid. p. 486. o Ibid. p. 487.
↑ Practical Treatise, pp. 11 and 15.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
313
It is unnecessary to qualify the proof which the above table
affords of the proposition that we have laid down, by venturing to
offer any comments. It is proper, however, to add that here, as
elsewhere throughout the calculations of the present essay, it should
be held in recollection that about 6 per cent ought always to be
deducted from the column of the male children, in consequence of
there having occurred, in concurrence with an acknowledged law in
human statistics, that proportion of male over female births during
Dr. Collins' term of mastership in the Dublin Hospital. He noted
8548 male births, and 8068 female births, being in the proportion
of 106 males to 100 females.
Whilst it is requisite to correct our arithmetical results and
tables to this extent, it will, at the same time, at once be seen that
the required deduction is so slight as not in any material degree to
interfere with the essential evidence of our various propositions.
THE DANGERS AND ACCIDENTS FROM PARTURITION AND ITS RESULTS
ARE GREATER TO THE CHILD IN MALE THAN IN FEMALE BIRTHS.
The increased danger to infantile life dependent upon the sex
at birth, may be demonstrated by a reference to the sex of the
children in those cases in which the mothers die from labour or its
consequences. It may be proved still more strongly and easily, by
an appeal simply to the sexes of those children that are dead at the
moment of birth, without any regard to the fate of the mother, and
by the consideration of the comparative number of accidents and
deaths among male and female infants consequent upon delivery.
We proceed to illustrate each of these points in the form of two
or three propositions and their proofs.
THIRD PROPOSITION.
Amongst the children of the mothers that die from labour or its consc-
quences, a larger proportion of those that are still-born are male
than female; and, on the contrary, of those that are born alive,
a larger proportion are female than male.
This proposition may evidently be considered under two heads.
In the first place, we shall show that a greater proportion of male
than female children are found among those infants that were
brought forth still-born, by mothers who themselves died from labour
or its consequences.
314
FOETAL DYSTOCIA.
During Dr. Collins' mastership there occurred, as we have
formerly seen, 154 cases in which the mother died after the birth
of single children. The 154 mothers produced 105 male and 49
female children.
The result of the mortality of these infants at birth, relatively
to their sex, may be reduced to the following short tabular form :—
Total male births 105; of these, born dead 50, or 49 per cent.
Total female births 49; of these, born dead 16, or 34 per cent.
In the second place, we remark, that, of those children who were
borne alive by mothers that died from labour or its consequences, a
greater proportion were females than males.
Here we must again take into our calculation the number of
mothers who died after uniparous births in connection with the
absolute number of male and female children which they produced,
when the result, as far as regards those children who were born
alive, may be stated in the following form :-
Total male births 105; of these, born alive 55, or 52 per cent.
Total female births 49; of these, born alive 33, or 67 per cent.
The general proposition may be further proved and illustrated
by throwing the results we have just given into one such common
table as the following:-

Sex.
Total
Number.
Of these,
dead.
Of these,
living.
Proportion of.dead
to living, as
Male
105
50
55
95 to 100
Female
49
16
33
48 to 100'
Or, to state it conversely :—

Sex.
Total
Number.
Of these,
living.
Of these,
dead.
Proportion of living
to dead, as
Male
Female
•
105
49
55
33
==
50
110 to 100
16
206 to 100
We thus observe, that, amongst the children of mothers dying
after uniparous labours, males are born dead in the ratio of 95 to
100 living, while with females the ratio amounts only to 48 dead to
100 living. But we find, on the other hand, under the same cir-
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
315
cumstances, that males are born living in the ratio of 110 to 100
dead, while among females the average amounts to the ratio of 206
to 100 dead.'
FOURTH PROPOSITION.
Of still-born children a larger proportion are male than female.
It has already been stated, that, including the whole births in
the Dublin Hospital, the male children born were, to the female, in
the ratio of 106 to 100. By extended statistical returns, a similar
observation has been proved to hold good as a general law in
human reproduction, at least among European females. M. Bickes
whose results are founded on seventy millions of observations, has
shown the proportion of male births to female births to vary in
European nations from 104 to 108 boys for every 100 girls."
3
All writers on human statistics seem further to acknowledge,
that, among still-born children, males occur in a much greater ratio
than females. This ratio exceeds very considerably the normal dis-
proportion between the sexes at birth, and is therefore not explicable
by it.
The excess of male still-births, and the different degrees of it in
different returns, may perhaps be exhibited most simply in the form
of a table, such as we have used in speaking on this subject in our
lectures, and which we here insert.
1 It was not till after the preceding calculations and remarks had been written
that I met with the following confirmatory statement in Dr. Clarke's able letters
to Dr. Price.-(See Philosophical Transactions for 1786, p. 349.) Speaking of
the maternal mortality in the Dublin Lying-in Hospital from 1757 to 1784, Dr.
Clarke observes-"I found that of 214 women dead of single children, 50 were
delivered of still-born males, and 15 of still-born females; 76 of living males, and
73 of living females." Hence, calculating upon these data of Dr. Clarke, it
would appear that, during the above period, male children were born dead in the
Dublin Hospital in the ratio of 66 to 100 living, while with female children
the ratio amounted only to 20 dead to 100 living; and, on the other hand, the
males were born living in the ratio of 152 to 100 dead, whilst the females were born
living in the much higher ratio of 487 to 100 dead.
2 For an exception among the free population residing at the Cape of Good
Hope, see Hawkins' Medical Statistics, p. 51. It is not unworthy of remark, that
among twin children, there seem to be more females than males born. In the
Edinburgh Medical and Surgical Journal for January 1844, p. 113, I have reported
the sexes of the children in 788 twin cases. Among these there were 756 males
and 820 females, or the males were to the females in the proportion of 92 boys to
100 girls. See a future page of this volume.
³ Die Bewegung der Bevölkerung mehrerer Europ. Staaten.
316
FETAL DYSTOCIA.

Locality.
Proportion among
Still-born Children, of
Males to Females.
120 to 100
Reporters.
In Amsterdam
Lobatto.
·
Geneva
125 100
•
Wurtemburg
Prussia
...
127 100
...
135 100
...
Mallet.
Riecke.
Hoffmann.
Halle
140 100
Guete.
London
140
...
Berlin
142
100
100
Bland.
Süssmilch.
During Dr. Collins' superintendence of the Dublin Hospital, 1121
children were born dead. The number of males to females among
these 1121 children stood as follows:—

Still-born
Males.
Still-born
Females.
614
507
Orin proportion of Males
to Females, as
122 to 100
In Dr. Collins' reports, the over-proportion of still-born males,
though strongly marked, is not so great as in some of the other
returns we have quoted. We believe that probably the variation in
this respect among the evidence adduced in the preceding table, may
be partially explained by the supposition, that, in some of the
returns, premature children, and perhaps in others those that were
putrid at birth, have not been included. At all events, whenever
these are omitted, the number of still-born males in proportion to
females will be found to increase. In other words, if we limit our
calculations to infants still-born at the full time, and if we consider
only those that die during the process of labour, we shall find among
them the ratio of males to females to be greatly higher than the
average is among still-born children taken indiscriminately, and
without reference to the time and cause of their death.
We shall devote our next proposition to the proof of this.
FIFTH PROPOSITION.
Of the children that die during the actual progress of parturition, the
number of males is much greater than the number of females.
It will easily be seen that the data required in proof of this pro-
position are very difficult to be obtained. Indeed, they could only
be accurately ascertained by a series of minute observations insti-
tuted through the medium of the stethescope. This has not yet been
done, so far as we know, by any observer. From the want of such
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
317
evidence, we are under the necessity of approaching as nearly as
possible the proper proof, by taking advantage of a mark entered in
the elaborate tables of Dr. Collins. He has placed a note of “ p"
(signifying putrid) opposite to all those children that were born in
that state. These "putrid" children had evidently all, or almost all,¹
died from causes that had operated during intra-uterine life, and
before the commencement of parturition. We may, therefore, pro-
bably reject such infants from our present calculations, inasmuch as
these calculations refer only to children dying during the continuance
and progress of the parturient process. Of the 1121 children that
were still-born, as many as 527 were found putrid at birth. The
sexes of the remaining 594 stand in the relation shown by the follow-
ing table-

Still-born Children
not putrid.
No. of
Males.
No. of
Females.
Proportion of
Males to Females, as
594
357
237
151 to 100
In the general rate of infantile mortality at birth, we have
already seen, under the previous proposition, that in Dr. Collins'
cases the proportion amounted to about 122 males for every 100
females. In the present instance, and when the children that had
died some time before labour began are excluded, the ratio rises as
high as 150 boys to every 100 still-born girls, or as 3 to 2. We
might further, from the 594, exclude 62 premature still-born children
that were not putrid-viz. 37 males and 25 females, and retain only
those that had reached the full time. This, however, would not
alter our results above 1 in the column of 151 males.
But the ratio of these male still-births would probably have been
made somewhat greater, and our present proposition still more
strongly borne out, had we been able, on the one hand, to take into
the calculation those children only who died subsequent to the com-
mencement of the process of parturition, and to exclude, on the other
hand, all those that perished, however shortly before, under the in-
fluence of other morbific agents than the effects of labour. The fact
of the still-born children being "putrid," shows generally that death
has occurred several days at least before birth. It is a condition
1 For two remarkable exceptions, see Dr. Collins' Treatise, pp. 470 and 483,
cases 461 and 1058. In a paper on Peritonitis in the Foetus (Edinburgh Medical
and Surgical Journal, October 1838, p. 390), I have attempted to show that a
large number of those children that are still-born and putrid have died of peri-
toneal inflammation.
318
FETAL DYSTOCIA.
which has enabled us therefore to exclude most, but not all, of those
who had died antecedently to the commencement of actual labour.
I repeat, that if we had possessed the power of excluding all-and
thus so far improving our data-the proportion of male to female
children who died during labour, high as we have shown it to be,
would, in all probability, have been found raised still higher.
SIXTH PROPOSITION.
Of those children that are born alive, more males than females are scen
to suffer from the morbid states and injuries resulting from
parturition.
Among the accidents and injuries to the child more immediately
resulting from parturition, no one has, of late years, been made the
subject of such minute pathological investigation as the "bloody
tumour" or "ecchymosis" of the head-the Cephalamatoma neonatorum
of Naegele, Valleix, Dubois, Walshe, and various other modern
authors. "The unequal pressure," says Velpeau, "which the cranium
experiences, and the tendency that its bones have to over-ride one.
another, during most labours, when the head is traversing the
pelvis, and whether the labour be natural or artificial, is incontestably
the most common cause of this tumour. No author, that I am
acquainted with, has given any statistics regarding the sexes of the
infants affected with cephalæmatomata, with the exception of
Burchard. The data which he adduces are not so extensive as
could be wished, but still they furnish strong and indubitable proof
of our present position. In his essay, "De tumore cranii recens-
natorum sanguineo," he mentions that out of 43 cases, which he had
observed at the Breslau Hospital, the child was male in 34 and
female in 9 of the instances, so that the relative frequency of the
disease in the two sexes stood thus:-

Male
Children.
Female
Children.
Proportion of
Males to Females.
34
9
377 to 100
I am not aware that there have been hitherto published such
data regarding serous' swellings of the infant's scalp, the caput suc-
cedaneum of the older authors, or the asphyxia or apoplexy of
children at birth, or any of the other accidents to which they are
¹ Traité Complet des Accouchemens, tom. ii. p. 594.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
319
subjected during labour, as would enable us to make similar calcu-
lations with respect to them. As they are all confessedly more or
less direct results of the physical pressure which the infant's head
suffers during parturition, the calculations derived from one would
probably apply with greater or less force to each of the others.
Since additional data from individual morbid states and injuries are
thus wanting in support of the proposition we have laid down, we
shall appeal, in confirmation of it, to some calculations we have
made from Dr. Collins' data regarding the general mortality observed
among children immediately after delivery. In his chapter on
"Children dying in the Hospital," Dr. Collins observes, "thirty-two
children born at the full period died a few minutes after birth; in
six of these, respiration could not be established, though the heart's
action continued for some time." Dr. Collins does not offer any
clue by which these 32 cases can be discovered in the table attached
to this chapter, and thus their sexes ascertained. I find, however,
in that table, that 17 single children, born at the full period, are
marked as dying within the first half-hour after birth. They hence
probably perished from morbid states the more immediate results of
labour. Of the 17 children, 9 died within five minutes after birth ;
1 in ten minutes; 4 in fifteen minutes; and 3 in thirty minutes.
One of the 17 children was female, and 16 of them males. If we
might venture to make the same form of calculation as we have
hitherto used, of the respective sexes of the children from these very
small and insufficient data, it would stand thus :-

Male Female
Children. Children.
Proportion of Males
to Females as
16
1
1600 to 100
SEVENTH PROPOSITION.
More male than female children die in the earliest periods of infancy;
and the disproportion between the mortality of the two sexes gradu-
ally diminishes from birth onwards till some time subsequently to it.
This proposition follows as almost a necessary corollary from
those that have preceded it. If, in consequence of the pressure and
greater injuries to which male children are subjected during birth,
more male than female infants perish during labour; and if, again,
1 Practical Treatise, p. 501.
320
FETAL DYSTOCIA.
among those born alive more males than females are found to suffer
under such morbid states as are the immediate results of parturition,
it might justly be a priori expected that the same causes which
produced these results during delivery and immediately after it,
would so far continue to affect the male constitution, for some time
subsequently, as to predispose it more to disease, and likewise
render the diseases which did occur in it more dangerous and fatal
in their course than those that affect the female. Further, if this
greater liability to morbid action, and its greater intensity and
fatality in the male, as compared with the female infant, were the
consequence of the male being subjected to greater physical injuries
at the time of parturition, the pathological characteristics in question
should be observed to diminish more and more in the male system
from the moment of birth onwards, because the morbific effects,
resulting from any cause or causes operating during birth, would
thus progressively diminish, and ultimately pass away. At last,
therefore, at some date in early infantile life, the mortality among
male and female children, though very different at first, should be-
come nearly or entirely equal. And such, indeed, is the actual
state of facts, when the mortality during infancy is investigated
upon a large scale. Thus in his observations regarding the "influ-
ence of sexes" upon mortality, Quetelet, in his elaborate Treatise on
Man, remarks, as a matter of statistics, that among male as compared
with female children, “the ratio of deaths before [during] birth is
as 3 males to 2 females; during the first two months after birth the
ratio is as 4 to 3; during the third, fourth, and fifth months as 5 to
4; and," he adds, "after the eighth or tenth month a difference
scarcely exists."1
I shall endeavour to bring forward some statistical evidence in
support of the preceding statements.
2
Dr. Collins has given in his Treatise, a table containing a variety
of particulars regarding 284 children that died in the Dublin Hos-
pital within a few days after their birth. Excluding twins and
premature children, the date of the death of 148 of these infants is
noted in the table referred to. Six of them died on the 8th day
after birth; two on the 9th; and one on the 10th. These nine
included 5 boys and 4 girls. With regard to the remaining 139
infants that died during the first seven days after birth, the follow-
ing table, which has been compiled with considerable care, will show
1 Treatise on Man, Chambers' English edition, p. 50.
2 Dr. Collins' Treatise, p. 519, etc.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
321
the periods of their demise, and the relative proportion which the
mortality among the male and female children presented at different
dates during the first week of life.'


Period of Death.
Males. Females. Proportion of males
to females.
Ratio of Excess
of male mortality.
Within first half-hour
Within first hour
Within first 6 hours
Within first 12 hours
Within first 18 hours
Within first day
Within first week
16
•
19
29
127
1600 to 100
1500
950 to 100
850
414 to 100
314
34
15
226 to 100
126
•
36
19
191 to 100
91
•
49
28
175 to 100
•
75
80
59
136 to 100
36
The last column in the above table shows in the most striking
manner both the great proportion of male over female deaths in the
first few hours and days of extra-uterine existence, and the rapid
diminution which takes place from the moment of birth onward in
the relative superabundance of the male over the female mortality.
The principal and strongest objection that may be urged against the
table is the small number of data which is made in it the basis of
such interesting statistical deductions. I have given it, however,
such as it stands, in consequence of the want, so far as I know, of
any more numerous or complete series of similar facts bearing upon
the relative male and female mortality in the first week of life.
Against the table which I have next to bring forward, the same objec-
tion cannot be urged, as the individual data are sufficiently ample,
and yet the results are exactly the same in their nature, and equally
confirmatory of the proposition we are discussing. For the data
upon which I have constructed the table, I am indebted to an
elaborate extract of deaths at different ages, contained in one of the
invaluable reports of the Registrar-General of England. At pp.
144 and 145 of his Fifth Annual Report, the last published, are
given, in two separate tables, the numbers, ages, and sexes of all
the individuals that died in England and Wales in the year 1841.
In that year 134,563 died who had not passed the age of five;
namely, 71,595 males and 62,968 females. In the following table
I have arranged these data regarding the male and female deaths,
and made calculations from them of such a kind as bear upon the
objects of our present proposition.
for "
1 The time the mothers remained in the institution, in most instances, was
a period of eight, nine, or ten days after delivery."-Dr. Collins' Treatise,
p. 500.
322
FETAL DYSTOCIA.
Total number and relative proportion of male and female deaths
during the year 1841, in England and Wales, within the first five
years of life.

Ages.
Proportion of
Males.
Females.
males to females.
Ratio of Excess of
male mortality.
0 to 1 month
1 to 2 months
2 to 3 months
3 to 6 months
6 to 9 months
9 to 12 months
1 to 2 years
•
13,351
9,741
137 to 100
37
•
4,858
3,703
131 to 100
31
3,313
2,676
124 to 100
24
8,008
6,451
122 to 100
22
•
6,341
5,182
110 to 100
10
•
5,573
5,013
105 to 100
5
13,987
13,281
100 to 100
0
2 to 5 years
16,164
15,941
101 to 100
1
A different arrangement of the facts included in the preceding
table may probably show still more strikingly the great propor-
tionate male mortality in the period immediately following birth.
During the second year.of life-that is, from the twelfth to the
twenty-fourth month-13,987 males and 13,281 females died, or
nearly an equal number of the two sexes, the excess on the part of
the males amounting only to about 700. During the first month of
life—that is, from birth up to the twenty-ninth day following it—
there died of male infants a number nearly similar to that of those
who perished in the whole course of the second year, namely,
13,351. But the corresponding female mortality during the same.
period was very much less, amounting only to 9741. Whilst the
difference, therefore, between the mortality of the two sexes, during
the second year, did not, in the numbers given, show an excess of
much more than 700 on the side of the males, this excess ran to
upwards of 3500 during the single first month of life, or was five
times greater in amount. A tabular arrangement of these figures
will point out this contrast more plainly.

Deaths in England
in 1841.
Of male
children.
Of female
children.
3
During first month of life
13,351
9,741
13,987
13,281
During second year of life
Excess of
male mortality.
3610
700
1 In England the proportion of living males and living females does not become
equal till about the twentieth year of life. After that period, an excess of the
living population is female; before it, a small excess of it is of the male sex, there
being originally born 105 males for every 100 females.—Fourth Report, p. 12.
Hence, other circumstances being equal, a slightly greater number of males than
of females should necessarily be found in the mortality bills in early life, as seen in
the last two lines of the table.-See the Registrar's Fifth Report, p. 23.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
323
If it were necessary, and our space permitted, it would be easy
to adduce additional tables, constructed from the Registrar's Re-
turns of other years for England and Wales, and from the reports of
the mortality in other countries, showing, in correspondence with
our proposition, the two facts-1st, that the male mortality, as com-
pared with the female, is much greater immediately after birth, and
2d, that the male excess of deaths gradually and regularly dimi-
nishes from that time onwards, to about the end of the first year of
life. The only new and remarkable circumstance that would be
proved by these additional tables is, that the rate of the decrease of
the male mortality is everywhere nearly the same.
In illustration of this last remark, I shall content myself with
giving the male as compared with the female infantile mortality
in England during 1841, and in Western Flanders from 1827-30.
The Flanders mortality is calculated upon a return of 37,203 deaths
for the first five years of life, including 21,198 males and 16,005
fernales.¹
Male mortality in
Ages.
England,
Flanders.
Female
mortality.
0 to 1 month
137
139
100
1 to 2 months
131
128
100
2 to 3
124
126
100
3 to 6
122
122
100
26 to
9
110
117
100
""
29 to 12
105
104
100
1 to 2 years
100
103
100
2 to 5
101
99
100
CAUSES OF THE GREATER MATERNAL AND INFANTILE DANGER AND
FATALITY ACCOMPANYING THE BIRTH OF MALE CHILDREN.
On this point Dr. Clarke, in his excellent "Observations on
some Causes of the Excess of the Mortality of Males above that of
Females," published in the Philosophical Transactions for 1786, justly
1 See Quetelet on the Natural History of Man, p. 30. The town and country
mortality are given separately by Quetelet. I have added both together, and
computed the proportions in the table from their conjoined sums.
2 The dates of the two original returns, from the 6th to the 12th month, do
not precisely correspond. In the English tables the returns are from the 6th to
the 9th month, and from the 9th to the 12th; in those of Flanders the corre-
sponding returns here calculated upon are from the 6th to the 8th month (not the
9th), and from the 8th to the 12th. The 8th month is not given separately in
the published returns, for if so, we should have been enabled to equalise the two
exactly.
22
324
FETAL DYSTOCIA.
remarks that it may be safely asserted, "anatomy has not hitherto
detected any internal difference between the animal economy of the
male and female, which can be supposed to account for their differ-
ence of mortality, more especially in early infancy." The same
author then suggests two sets of causes in explanation of the higher
mortality among male children—namely, first, their larger size and
consequent more difficult delivery; and, secondly, their greater lia-
bility during their intra-uterine life to disease and debility, from
their requiring, in consequence of their size, more actual nourish-
ment from the mother than smaller female children stand in need
of. We shall discuss this latter opinion before attempting to show
the greater truth and correctness of the former one.
'As the stamina of the male are naturally," says Dr. Clarke,
"constituted to grow of a greater size, a greater supply of nourish-
ment in utero will be necessary to his growth than to that of the
female. Defects in this particular (nourishment), proceeding from
delicacy of constitution or diseases of the mother, must, of course, be
more injurious to the male sex.
"It appears beyond doubt," says Quetelet, "that there is a
particular cause of mortality which attacks male children by pre-
ference, before and immediately after their birth." "It will be
interesting," he further observes, "to investigate the causes of a cir-
cumstance which is so unfavourable to the male sex." "If," he
continues, "we were desirous of guessing at this point, we might
say with those who suppose that a male conception requires a certain
excess of energy in the woman, that this excess of energy was absent
or wanting during the growth of the fœtus, and, that energy failing,
the child would suffer more from it if a boy than if a girl. Hence
the disproportion of dead births between the sexes," etc."
In a review of Dr. Collins' Treatise in the Dublin Medical Journal,
Dr. Graves makes several remarks on the same subject. After
showing that Quetelet and Caspar had found respectively in Flanders
and Prussia 'the number of still-born males to still-born females to
be 140 to 100, and that in Paris the ratio was 122 to 100, Dr.
Graves adds, "In Dublin, Dr. Collins' numbers give the proportion
very nearly the same as that of Paris, so that here we have the ad-
ditional fact corroborative of those already brought forward, to prove
that a greater mortality before birth prevails among males than
2 Ibid. p. 353.
¹ Philosophical Transactions, vol. lxxvi. p. 352.
3 Treatise on Man, English edition, pp. 25 and 30.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
325
females—a most curious result, well calculated to puzzle both phy-
siologists and philosophers."
1ܙܙ
I shall not attempt to solve, as Clarke and Quetelet have done,
the problem broached by Dr. Graves, but will content myself with
showing that the observations on which it is founded are in them-
selves erroneous, and that the tables of Dr. Collins, appealed to by
Dr. Graves, prove, when studied minutely, that, contrary to the
general opinion entertained on this point, a greater mortality does
not prevail before birth among male than female infants. With this
view, we bring forward the following as our
EIGHTH PROPOSITION.
Of the children that die in utero, and before the commencement of labour,
as large a proportion are female as male.
I have already had occasion to state that, among the 1121 still-
born children, so often already referred to as occurring during Dr.
Collins' mastership, 527 were putrid, and hence had perished before
the supervention of parturition.
If we contrast together the proportionate number of males and
females among these 527 children, as well as the sexes of the infants
among them that were born at the full time, but putrid, and the
sexes of all those that were still-born prematurely, whether putrid
or not, we shall find the result to be as follows:-
State of the Children.
Total
Cases.
Male. Female.
Proportion of
Male to Female.
No. of still-born putrid children
No. of still-born at full time and
putrid
527
257
270
95 to 100
296 148
148
100 to 100
No. of premature still-births
293 146
147
100 to 100
This table seems particularly valuable and instructive in one
respect. It demonstrates satisfactorily, that the intra-uterine mor-
bific agencies, whatever they may be, which act fatally on the fœtus
before birth, act equally on the female as on the male child; and
that it is to other agencies than these that we are to look for the
remarkable proportion of male over female deaths which is observable
among still births.
In premature births the comparative compressibility and flexi-
¹ Dublin Journal of Medical Science, vol. viii. pp. 518-19,
326
FOETAL DYSTOCIA.
bility of the bones of the cranium is so decidedly greater as to offer
no such marked difference between the size and resistance of the
male and female head, as we shall immediately see to exist at the
full time. Now the last column of the table shows, that, in this
class of still-births, the premature, the number of dead-born male
and female children was exactly equal. The second column testifies,
that the same fact holds true of children born at the full time, and
in a state of putridity. Further, in looking to the evidence afforded
by the first column, we may there observe, that of all the children
that had perished from intra-uterine causes, and before the com-
mencement of labour (as demonstrated by their putrid state), the
females were even more numerous than the males.
The whole series of facts proves, contrary to what is generally
alleged, that the proportion of male children that die before birth is
not greater than the proportion of females. Indeed, if we deducted
the usual 6 per cent for the normal over-proportion of males, the
ratio of girls dying before parturition would be found to be greater
than that of boys-a conclusion which the first column would seem
to go far to corroborate and strengthen, for in that computation the
number of the dead females distinctly and considerably exceeds that
of the dead males.
This result, with regard to the equality of the sexes among putrid
and premature still-born children, becomes only the more striking
when we couple and contrast it with the fact which we have already
brought out, that of the children who are still-born, and not putrid,
as many as two out of every three are boys. In other words, among
the infants that die before labour, the females are equal, if not greater,
in number than the males. Among the infants that die during
labour the males are raised to the high proportion of 150 boys for
every 100 girls. For this sudden and surprising increase, during
labour, of the male infantile mortality over the female, there must
be some cause or causes traceable in the conditions of the process of
parturition. Let us now see, in accordance with what we have
already proposed, whether the cause or causes in question be not
referable to the greater size of the male infant, and the effects of
this size upon the compression of the cranium and its contents.
And in order to understand more thoroughly the investigation, let
us inquire, in the first place, into the actual average difference between
the volume and weight of the male and female at birth.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
327
RELATIVE WEIGHT AND SIZE OF THE MALE AND FEMALE
AT BIRTH.
In the Dublin Hospital, Dr. Clarke long ago endeavoured to dis-
cover the relative weights of the new-born male and female child,
by observations made upon 60 children of each sex.
In his paper
in the Philosophical Transactions of 1786, to which we have re-
peatedly referred, he gives both the absolute and average weights of
these 60 male and 60 female infants.
The 60 males weighed in all 442 lbs.¹
1
The 60 females weighed in all 4041 lbs.
The average weight of the male was 7 lbs. 5 oz. 2 dr.
The average weight of the female was 6 lbs. 11 oz. 2 dr.
The average difference between the weight of the male and
female child, as calculated from these 120 instances, thus amounted
to about nine ounces.
In the Edinburgh Lying-in Hospital, 50 male and 50 female
children, born during the latter months of 1842 and the earlier part
of 1843, were weighed by my friend and assistant, Dr. Johnstone.
The 50 males weighed in all 383 lbs. 11 oz. 4 dr.
The 50 females weighed in all 342 lbs. 12 oz. 4 dr.
The average weight of the male was 7 lbs. 9 oz. 1 dr.
The average weight of the female was 6 lbs. 12 oz.
i
The difference between the weight of the male and female child,
as calculated from these 100 cases, thus amounted to about ten
ounces on the average.
The respective lengths of these 50 male and 50 female children
were also carefully ascertained in the Edinburgh Hospital.
The total length of the 50 males was 1020
The total length of the 50 females was 990
inches.
inches.
The average length of the male child was 20 inches 5 lines.
The average length of the female child was 19 inches 10 lines.
The average difference between the length of the 50 males and
50 females thus amounted to 7 lines, or somewhat upwards of half-
an-inch.
These results are sufficient to prove, that at birth, as at other
subsequent periods of life, the male is usually of a greater weight
and size than the female. The general volume, however, of the
body of the child is not, in relation to the mechanism of parturition,
a matter of such immediate importance as the size of the head itself,
1 The Troy or Apothecaries' weight is there used.
328
FETAL DYSTOCIA.
་
the facility or difficulty of the process being principally dependent
upon the relative size of the latter. The greater weight and volume
of the male than the female child at birth might, a priori, entitle us
to calculate that the head of the male would, in correspondence
with the other parts of the body, be larger than the head of the
female. In such an inquiry, however, as the present, it is better to
refer to direct arithmetical facts than indirect though probable in-
ferences, and Dr. Clarke has left us a series of measurements of the
heads of male and female children, at birth, that are valuable in
giving us more precise ideas upon this point. His observations were
made upon the 120 male and female children whose respective.
weights we have already detailed. "For measuring their heads, I
made use," he observes, "of a piece of painted or varnished linen
tape, divided into inches, halves, and quarters. I took first the
greatest circumference of the head, from the most prominent part of
the occiput, around the frontal sinuses; and, secondly, the transverse
dimensions, from the superior and anterior part of one ear across
the fontanelle to a similar part of the other ear. These data appeared
to me the most likely to afford data for determining the respective
sizes of the brain in the different sexes.”¹
The result of Dr. Clarke's measurements may be exhibited in
the following manner."
Absolute dimensions in
60 males. 60 females.
Average dimensions in
60 males.
60 females.
Inches. Lines, Inches. Lines.
Inches.
Inches.
Circumference of
head
Dimensions from
839
817
13
11/4/
13
73
ear to ear
4452
4334
7
57
4
17 23
•
The differences brought out in the preceding table, between the
male and female head, may appear more precise if we reduce them
to decimal figures.

Average circumference
of head.
Average dimensions
from ear to ear.
Inches.
Inches,
In male child
•
13.983
7.429
In female child.
13.617
7.221
Difference
0.366
0.208
1 Phil. Trans. lxxvi. p. 358.
2 Since these remarks were sent to press, I have incidentally met with tho
ollowing remark in Dr. Forbes's Quarterly Medical Review, vol. x. p. 492. “M.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
329
According to these observations upon new-born children, it
would appear that—
1. The head of the male infant, when measured across from ear
to ear, over the fontanelle, is about 2 lines, or nearly two-eighths of
an inch greater than that of the female.
2. In circumference, the head of the male is 4 lines, or almost
precisely three-eighths of an inch greater than that of the female.
Hence-
3. The transverse diameter of the male head is nearly one-eighth
of an inch greater than the transverse diameter of the head of the
female child.¹
The preceding difference between the absolute size and weight
of the male and of the female child at birth, and between the rela-
tive dimensions of the male and female infantile head, may appear
to some to be on the whole so slight, as not to afford in themselves
any sufficient explanation of the differences that we have seen to
exist, between the dangers and mortality incident respectively to
male and female births. The general greater size of the head and
body of the boy at birth may not seem adequately to account, by
any influence traceable to it alone, for the general greater peril and
fatality accompanying the birth of male as compared with female
children. The alleged cause may appear unequal to the production.
of the alleged effects. Let us state, therefore, the reasons that
induce us to hold the contrary opinion, and which impress us with
the belief that the difference between the size of the male and female
head at birth, inconsiderable as it may seem, is the true cause of
that greater danger and fatality to mother and child, which accom-
panies the birth of male infants.
Before doing so, it may be proper to premise, that under our fifth
and eighth propositions I have already shown, on the one hand, that
the explanation of the cause of the greater number of male than
female still-born infants proposed by Clarke, Quetelet, etc., as de-
Nevermann gives us the results of the measurements of the heads of 384 children
by Professor Thulstrup of Christiana, which fully bear out Dr. Clarke's statements."
¹ Calculating upon the accuracy of Dr. Clarke's linear measurements of the
foetal head, it would appear that the surface of the cranium of the male infant,
above the circumferential line of measurement, is about 27.8 square inches; that
of the female about 26.3 square inches. The arch of the male cranium, at birth,
is therefore, superficially, upwards of one square inch greater than that of the
female. To state it in other words, the proportion of the surface of the head of
the male new-born child to that of the female is nearly as 19 to 18-or the surface
of the head of the female is one-nineteenth part less than that of the male.
330.
FOETAL DYSTOCIA.
the
pending upon intra-uterine agencies, is totally incorrect, and dis-
proved by statistical facts; and, on the other hand, we have seen
that the increased mortality of children of the one sex over those
of the other at the time of birth is a result of some circumstance or
circumstances connected with, or at least only in operation during,
process
of labour. Whilst this holds true as regards the child, it
is of consequence, at the same time, to recollect that the complica-
tions and dangers on the part of the mother, which we have found
so much more frequently attendant upon male than female births,
are all of such a nature as to be confessedly the direct or indirect
consequences of causes acting during parturition. Further, it will,
we imagine, be granted by every accoucheur, that whatever circum-
stance or circumstances may, by operating as a cause of obstruction,
lead to the greater danger and fatality of the male infant during the
progress of labour, will, at the same time, in all probability, equally
explain that greater peril and fatality to the mother during the
process, which is incident to the birth of males.
For the solution of the present problem, both as regards the fate
of the mother and of the infant, we believe that we ought to look
alone to the greater size of the head of the male infant, and that for
a variety of reasons which we shall now endeavour to state seriatim,
adding such illustrative remarks and evidence as they may seem to
require, and throwing the more important deductions, that may seem
to flow from the statistical proofs brought forward, into the shape of
additional propositions.
REASONS FOR CONSIDERING THE GREATER SIZE OF THE HEAD OF THE
MALE CHILD AS THE CAUSE OF THE GREATER NUMBER OF COMPLI-
CATIONS AND CASUALTIES ACCOMPANYING MALE BIRTHS.
We shall begin our enumeration of these reasons by stating
that-
FIRST, For the very marked differences existing between the difficulties
and perils of male as compared with female births, there is no
other traceable cause in the mechanism of parturition than the
larger size of the head of the male child.
Parturition, at the completed term of pregnancy, is a process.
consisting of a combination of mechanism, intended for the extrusion
of the full-grown infant from the cavity of the uterus. For the
perfect action of this mechanism, three sets of physical conditions
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
331
are essentially necessary. First, A certain degree of mechanical
expulsive power is required, and this is supplied principally by the
vital contractions of the uterus. Secondly, An adequate degree of
capacity and dilatation is necessary on the part of those maternal
passages through which the child is to be expelled. Thirdly, The
body which is to be expelled (viz. the infant) must be of such size,
and be placed in such a position or positions, as to allow of its
sufficiently easy entrance and progress through these maternal
passages. A perfect and equitable adjustment between these three
different conditions is necessary to the constitution of natural labour;
and, on the other hand, a deviation-absolute or relative-in any one
or more of these conditions, leads on to tedious and difficult parturi-
tion, and its results. In which of these three essential conditions
could a deviation be possibly effected by the sex of the child, so as
to account for the greater dangers and complications attendant upon
male births?
The mere sex of the child, and the circumstance whether it was
a male or female, could evidently produce no primary effect upon
the vital muscular contractions of the uterus, so as to alter them in
any morbid manner. Consequently, we may exclude from our
consideration the first set of physical conditions that we have
above named.
We may do equally the same with the second, because it is
impossible to conceive that the measurements of the pelvis and
maternal passages could be directly altered in any way by the child
which has to pass through them being male rather than female.
In searching for a possible cause of deviation in the mechanism
of parturition, explanatory of the facts which we have traced, we
are thus, by a method of exclusion, compelled to look to the third
set of physical conditions of labour, viz. the position and size of
the infant.
The consideration of the position of the infant will afford us no
clue to the problem, because in most of the cases from which we
have drawn our data, the presentation and position were natural.
When it was otherwise, the deviation was as frequently on the part
of the female as of the male child.
The only item, therefore, that is left in which we may trace any
distinction whatever between the mechanism of labour in male and
in female births is the relatively greater size of the infant of the
male sex, and this relatively greater size could only influence labour
or its consequences in so far as it affected the dimensions of the head
332
TOTAL DYSTOCIA.
1
of the child-the increased volume of its body never, unless when
excessive in degree, retarding or complicating, to any extent, the
progress of the labour in cases of cephalic presentations. The differ-
ence between the male and female infant's head is indeed slight, but
we are forced, at this stage of the inquiry, to believe it to be the
probable origin of the greater dangers and more numerous compli-
cations accompanying male births, simply in consequence of our
being utterly unable to trace any other appreciable difference, or
imagine any other possible circumstance, in the conditions of partu-
rition, which could afford the most distant explanation of the series
of phenomena that we are discussing. It is the only circumstance
which we can detect as an apparent and constant antecedent to the
consequences we have described; and hence seems to be that par-
ticular condition which we ought to look upon as the cause of these
effects.
In the foregoing remarks we have arrived at the conclusion that
has just been stated by a kind of reasoning by exclusion. The
argument we have been considering is in a great measure negative.
But others of a more positive character are not wanting in confirma-
tion of the same view. For-
SECONDLY, An increase in the effects may be shown to be connected
with an increase in the alleged cause.
"When," observes Dr. Hamilton, "the head of the infant is
pushed foremost, and the labour is not completed within twenty-
four hours from its actual commencement, the case is styled labo-
rious, and it may terminate in one of three ways. Thus, the natu-
ral powers may at last complete the delivery; or, though these fail,
it may be possible for the practitioner to complete the delivery by
mechanical means, with safety both to mother and child; or it may
be impossible to draw the infant alive through the natural passages.
These three several terminations constitute three different orders of
laborious labours."
Now, if it were granted us, for the sake of argument alone, that
the greater obstacles and perils attendant upon male births are
attributable to the larger size of the male infant's head, it would
almost necessarily follow, that just in proportion as the difficulties
1 Outlines, p. 45. "It is," says Dr. Churchill, "peculiar to midwifery opera-
tions (and the same remark applies equally to the different orders of laborious
labours), that they form an ascending series, increasing in gravity from the simplest
to the most severe-no two being equal.”—Researches in Opcrative Midwifery, p. 12.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
333
connected with the above three different orders of laborious labour
progressively increased over one another in intensity, so the amount
of male children connected with these labours would, in like man-
ner, probably progressively increase in number.
Let us interrogate the data to be found in Dr. Collins' reports,
in order to test practically the truth of an opinion which is so far
merely theoretical.
Under the second proposition, we have already had occasion to
state that, during Dr. Collins' mastership in the Dublin Lying-in
Hospital, among the 16,414 labours which he has reported, the
sexes of the infants born were in the proportion of 106 males to 100
females.
Out of 109 tedious and difficult labours, in which Dr. Collins
has recorded the sex of the infant, and that occurred among these
16,414 deliveries, 65 of the children were male and 44 female.
In 24 forceps cases met with by Dr. Collins, the proportion of
male to female children was still greater, the males being 16 and
the females 8 in number.
The ratio of male infants mounts yet higher, when we turn to
the cases in which the labour was so difficult as to require cranio-
tomy. Among 74 instances in which the crotchet was used by Dr.
Collins, and where the sex of the child is mentioned, the infant was
male in 50 instances, and female in 24.
A tabular arrangement of the above results will show the pro-
portion of male to female children under these different classes of
head-presentations.
Nature of the Labour and Total
Complication.
No. of
Male
No. of
Female
Cases.
Proportion of
Males to Females.
Ratio of
Excess of
Children. Children.
Males.
Labours generally
16,654
8548
S069
106 to 100
6
Tedious labours
109
65
44
148 to 100
48
Forceps cases
24
16
8
200 to 100
100
Crotchet cases
71
50
24
208 to 100
108
•
The preceding data prominently show, that as the classes of
labours increase in severity and difficulty, the proportion of male
to female children in them increases in a corresponding degree.
Evidence of exactly the same kind, in support of this opinion, may
be gathered from a tabular extract of the cases that occurred in the
Dublin Hospital during the mastership of Dr. Clarke (viz. from 1787
to 1793), published by that gentleman in the first volume of the Trans-
actions of the King's and Queen's College of Physicians of Ireland,
334
FETAL DYSTOCIA.
p. 400.
In this abstract Dr. Clarke states the sex of those infants
that were still-born in the three classes of, 1. ordinary, 2. tedious,
and 3. laborious labours.
During Dr. Clarke's mastership there occurred 10,199 cases of
single or uniparous births. Among these, 340 children were still-
born, though the labour was natural, that is, was terminated within
24 hours, and with the head of the foetus presenting. Of these
340 still-born children, 170 were male, and 170 female. The ratio
of the sexes shows this perfect equality in consequence probably of
this list including principally putrid and premature children, among
whom we have already found (see the eighth proposition) the num-
ber of still-born boys and girls to be nearly alike, and the over-
proportion, if any, to be rather on the side of the females.
Under the term "Tedious Natural Labours," Dr. Clarke includes
those which exceeded 24 hours in duration, but where there was no
such disproportion between the head of the fœtus and the mother's
pelvis, as to render destructive instruments necessary. This class of
labours is produced either, he observes," "by causes weakening the
expelling powers of the mother, or increasing resistance to the
passage of the foetus." In Dr. Clarke's report, 134 cases are re-
ferred to this division, including 16 forceps cases. In these 134
labours, the child was still-born in 41 cases. Among these 41
still-born children, 26 were male and 15 female.
Dr. Clarke further reports the sex of the child in 48 cases of
what he terms "Laborious Natural Labours," and where, to use his
own words, "the disproportion between the head of the foetus and
the pelvis was so great that it became necessary to diminish the
bulk of the former to save the life of the latter." Among these 48
crotchet cases, 32 of the children belonged to the male, and 16 to
the female sex.
Of the 429 children that were thus still-born, in these different
classes of natural or head presentations in Dr. Clarke's practice, the
proportion of the sexes was therefore in the following ratio:-

Nature of the Labour
and Complication.
Total No. Of these, Of these,
of still-born
Children.
were
Male,
were
Female.
Proportion of
Males to Females.
Ratio of
Excess of
Males.
Ordinary Natural
340
170
170
100 to 100
0
labour
•
Tedious Natural
41
26
15
173 to 100
73
labour
Laborious Natural
labour (Crotchet
48
32
16
200 to 100
100
cases)
1 Dr. Clarke's Paper, p. 371.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
335
The preceding data, from Dr. Collins' and Dr. Clarke's returns,
will be probably admitted to be sufficient to prove the point that we
have in view, and to warrant the following inference as a
NINTH PROPOSITION.
In "laborious labours," with the head presenting, in proportion as the
order of labour rises in difficulty, the amount of male births in
them rises in number.
1
To the proof that I have just given of the truth of this proposi-
tion, from the reports of Drs. Collins and Clarke, it gives me much
satisfaction to add the following general confirmatory statement
contained in an analysis of Riecke's elaborate obstetric statistics of
the kingdom of Wurtemberg, published in the Archives Générales.¹
As one of the results of these statistics (the most extensive hitherto
published in midwifery 2), it is stated that "the proportion of boys
to girls is much greater in artificial' than in ordinary labours, for it.
includes 7 boys for every 5 girls (or 140 male children for every 100
female). There is the same fact observable among the sexes of those
children that are the products of artificial births, and who are either
dead-born or die shortly afterwards, for among them the proportion
of boys to girls is as 8 to 5 (or as 160 male to every 100 female
infants). Often enough," it is added, "it happens that the same
woman cannot, without aid, be delivered of a boy, who, at all her
other confinements, when the child was female, required no as-
sistance."
THIRDLY, A diminution of the cause leads to a diminution in the
effects ascribed to it.
We have alleged the cause of the increased casualties connected
with male births to be the greater size of the head of the male than
of the female infant.
In premature infants there does not exist so great a difference,
as in those born at the full time, between the size of the head of the
1 Archives Générales de Médecine, tom. xx. p. 76.
2
They include 219,353 deliveries which occurred in Wurtemberg, during the
four years, 1821-25. The artificial deliveries (accouchemens artificiels), or those
requiring some special aid or interference, amounted to 7949. In these 7949
cases, 630 of the mothers and 3754 of the children were lost. The generalisation
in the text seems to be founded upon the sex of the infant in these 7949 labours,
and 3754 still-births.
3 Ibid. p. 88.
336
FOETAL DYSTOCIA.
male and female child. The foetuses of the two sexes approach one
* another more and more in physical and other characters, the earlier
the period at which we compare them. Besides, the cranium of the
premature child is so compressible, from its deficiency of ossification,
as to be much more easily reduced in size under the pressure to
which it is naturally subjected in the process of parturition; and
hence the slighter difference which may actually exist between the
dimensions of the heads of male and female premature infants is
still more diminished in its effects and operation during the course
of labour.
Possessing such physical conditions, the birth of premature
children should, from the diminished size and diminished resistance
offered by their heads, give rise to fewer of those casualties in labour
that we have attempted to trace to the influence arising from the
greater size of the head of the full-grown male child.
I have no evidence to bring forward with a view of showing the
influence of the birth of premature children, or their sex, on the diffi-
culties of the labour in reference to the safety and life of the mother,
because the labours with them are seldom or never so difficult as to
induce any marked maternal complications. But we may derive
equally good evidence in illustration of the point we are discussing,
by studying the effects of the labours with premature children-not
upon the mothers but upon the infants themselves. With this view
I shall collect, from the data contained in Dr. Collins' report, the
number of male and female children expelled prematurely and not
putrid, in order to contrast them with the proportion of males and
females among still-born children expelled at the full time and not
putrid. Of the former there were born in all 62, of the latter 532.
The ratio of the sexes in each series stands thus:

still-born.
Proportion of
Males to Females.
Non-putrid Children
1
Total.
Males. Females.
At full time.
Prematurely.
532
320
212
151 to 100
•
62
34
28
121 to 100
•
The comparison of the two columns in the above table shows
that, among the children who died immediately before or during
labour, and who had reached the ninth month of utero-gestation,
the proportion of males to females lost was considerably greater
than among still-born children born prematurely-and, as we be-
lieve, for this reason, that in the latter (the premature still-births),
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
337
there is not, as we have pointed out, so great a distinction between
the male and female heads as among children at the full time. The
comparison of the proportion of males to females who died within
ten days after delivery among, 1st, children born at the full time,
and, 2d, those born prematurely, leads to the same inference-viz.
that as in the latter the alleged cause of distinction between the
relative size of the male and female head is diminished, the alleged
effect upon the differences displayed between the mortality of the
two sexes is also proportionally lessened. The following table is
intended to illustrate this point. The calculations are from the data
in Dr. Collins' chapter on children dying in the hospital.

Children dying within
10 days after birth.
Total. Males.
Females.
Proportion of
Males to Females.
Born at full time
Born prematurely
171
102
106
56
கசு
65
163 to 100
46
121 to 100
The remarks that we have made regarding the heads of pre-
mature children should apply equally to those of twins. Twin
children, like those born prematurely, are in general below the
standard size and weight, and, in the same manner, have their
heads less ossified, and hence more compressible, than those of single
infants at the full time. There is, consequently, also a less marked
difference between the relative size of the male and female head,
among twin children, than among single children at the full time ;
and for the same reason, if our views are true, there should be a
similar less marked difference between the mortality of the two
sexes among twins, at birth and for some time after it. That such
is in reality the case, I shall allow Dr. Clarke to state in his own
words. Speaking of the relative male and female infantile mortality
in the Dublin Hospital, he observes, "It is worthy of observation
that though double the number of twins die and are still-born, com-
pared to single children, yet the proportion of male twins lost to
females is less. Only one-fifth more of the male sex die than of the
female, and only one-third more is still-born. Whereas of single
children, whose proportional mortality is one-half less, one-fourth more
of the male-sex die, and near double the number is still-born. To
what, then, are we to attribute this lessened mortality in favour of
male twins? Probably to their brain and nervous system suffering
less during delivery, on account of their heads being much smaller
¹ Philosophical Transactions, vol. lxxvi. p. 354.
338
FETAL DYSTOCIA.
than those of single children." In other words, the cause of the
higher mortality, or the relative size of the male over the female
head, being diminished, the effects which we attribute to it-viz. the
higher infantile mortality among male children-are also propor-
tionately diminished.
FOURTHLY, In those morbid complications in labour in which the
cause is in abeyance, the effect is also absent.
There are some morbid complications during labour which are
independent of the presence, and hence of the sex or size, of the
infant. I allude especially to those complications which occasionally
occur during the third stage of labour, and consequently after the
total expulsion of the child. It would afford no small corroboration
of the preceding remarks and inferences, if in these cases, where all
agency from the conditions of the infant was for the time being ex-
cluded, the morbid complications which may take place were found
to occur as frequently in connection with the birth of female as of
male infants. And such, we believe, may be shown to be the fact.
The two principal complications that occur during the third stage
of labour are morbid retention of the placenta and hemorrhage.
Dr. Collins reports 70 cases of retention of the placenta, 35 of
them after male, and 35 after female births.
Hemorrhage took place during the third stage of labour, or be-
tween the birth of the child and placenta, in 71 cases during Dr.
Collins' mastership. In 36 of these 71 labours the child was of the
male, and in 35 of the female sex.
These observations, when thrown into a tabular form, would
consequently stand thus:-

Nature of
Complication.
Total
Cases.
Children.
With Male With Female Proportion of Males
Children.
to Females.
Retention of pla-
centa.
}
70
35
35
100 to 100
Hemorrhage during
71
36
35
100 to 100
third stage
¹ In the Dublin Hospital, from the year 1757 to 1784, it appears from Dr.
Clarke's tables, that among the twin-births 29 males and 20 females were still-
born, and 116 male and 91 female children died within a fortnight after delivery;
on the other hand, among the uniparous or single births, 602 males and 351
females were still-born; and 1656 males and 1247 female children died within a
fortnight after birth. These data form the ground of the inferences drawn by
Dr. Clarke in the passage quoted in the text.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
339
The evidence afforded by the above table is probably sufficient
to entitle us to add to those inferences that we have already laid
down, the following deduction as a
TENTH PROPOSITION.
Of the morbid accidents that are liable to happen in connection with
the third stage of labour, as many take place with female as
with male births.
To prove that the slight increase of size of the male over the
female infant's head is the true antecedent or cause of the greater
number of casualties accompanying male births, we may so far change
the ground of direct proof which we have been hitherto attempting
to pursue, and proceed to show, as a matter of strong though indi-
rect evidence, that-
FIFTHLY, Similar effects upon the mother and child are produced by
other causes similar in their character and amount.
If the larger dimensions of the head of the male infant be the
immediate cause of the larger number of accidents and deaths
attendant upon male births, its greater degree of size could only
possibly lead to the results in question, by offering a greater pro-
portionate degree of impediment to the passage of the fœtus through
the pelvic canals. Its effects, therefore, upon the mother and child
should be such as are produced by obstructed labour. That the
various consequences which we have previously traced are all of that
description, it is unnecessary for us to point out to the obstetric
pathologist. It might be considered, however, as confirmatory of
this fact, and, at the same time, as the strongest correlative evidence
that could be adduced of the power of slight obstructions, during
labour, to lead to these effects, if we could prove that in any other
extended series of cases, in which obstructions of the same amount
existed, the same or similar effects resulted both to the mother and
child. Our evidence would only be the stronger if, in this class of
cases, we could so far reverse the state of matters as to transfer the
existing slight obstruction from the body passing to the passages
themselves. The circumstances connected with first labours offer
the exact conditions which we seek.
In first labours, taken as a class, there is a greater obstruction
to the transit of the child than in subsequent deliveries, in conse-
quence of the maternal passages being less dilatable than afterwards.
23
340
FETAL DYSTOCIA.
The two causes of obstruction-viz. the increased size of the fœtal
head, and the diminished size of the maternal passages-though
different in their seat, are nearly analogous in the nature of their
influence, and in the amount of that influence.
In male births, the body passing (the head of the infant) is
slightly greater than in female births, whilst, cæteris paribus, the
maternal passages are the same. In first labours the capacity or
dilatability of the maternal passages is slightly less than in subse-
quent labours, whilst, cæteris paribus, the head of the infant remains
the same, there being at least an equal number amongst them of
males and females. Having stated these premises, we shall go on to
point out, as another reason for supposing the size of the male head
to be the sole cause of the danger of male births, that, in accordance
with our proposition, most of the complications and accidents, which
have been already described as arising in male, as compared with
female births, from the comparatively slight increase in the dimen-
sions of the male head, occur also in first, as compared with future
labours, in consequence of the comparatively slight diminution of the
dimensions or dilatability of the passages in these labours.
We shall give the proofs of this as an illustration of another, or
ELEVENTH PROPOSITION.
More dangers and deaths occur both to mothers and children in first
than in subsequent labours.
Among the 16,414 women delivered in the Dublin Hospital
during Dr. Collins' seven years' mastership, 4987 were confined for
the first time. First deliveries occurred, therefore, in the propor-
tion of about 30 in every 100 cases. If, however, in studying the
various morbid complications which have been statistically reported
by Dr. Collins, we find the proportion of these complications in first.
labours to be greatly above the ratio of 30 per cent, it would tend
to show that there is a stronger liability to their occurrence in first
than in future deliveries. To gain some data in this question, let
us examine into the facts which may be gathered from Dr. Collins'
returns in regard to the proportion of these morbid accidents arising
from obstruction during parturition, which were met with in first, as
compared with subsequent labours.
Convulsions. Of 30 cases of convulsions described by Dr.
Collins, 29 occurred in women who were pregnant for the first
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
341
time.' Thus they were found in connection with first pregnancies
in the ratio of 96 in 100.
2
Crotchet cases.—Of the 79 cases which Dr. Collins mentions as
requiring craniotomy, the number of the pregnancy in each can be
made out only in 75. Of these, 51 were first labours ; or out of
every 100 cases in which the crotchet was used, 68 were first
deliveries.
3
Forceps cases. The forceps were employed in 24 instances. Of
these, 18 were first labours. Hence, out of every 100 instances in
which this instrument was used, the proportion of first labours,
according to this average, would be 75.
4
Tedious labours.-Under our second proposition I have already
stated that Dr. Collins has given so far the history of 109 instances
of tedious labours. Of the 109 cases, 75 were first confinements ;*
thus giving for every 100 cases a proportion of 69 as pertaining to
first deliveries.
6
5
Puerperal fever.-Out of 88 women attacked with puerperal
fever, 44 were confined for the first time. Thus this complication
supervened upon first labours in the ratio of 50 in every 100 cases.
Maternal deaths.-We have already seen, under the first proposi-
tion, that of the 16,414 women delivered in the Dublin Hospital
during Dr. Collins' charge of it, 164 died. Of these 164 mothers,
86 had given birth to first children; or of every 100 women who
died, 53 had been confined for the first time.
7
Still-births. Under this head we exclude from our calculation
all those children who were born putrid, either prematurely or at
the full time. Of 1121 still-births in all, observed by Dr. Collins,
594 were born not putrid. Of these 594 children, 260 were the
product of first confinements; or, in other words, they were found
in connection with first pregnancies in the ratio of 45 to 100.
Infantile deaths during the first eight or ten days after birth.—
The mothers and their infants generally, as we have seen, remained
for that time in the hospital after delivery. During it 284 of the
children died. Of these, 170 were single children born at the full
time." Of the 170, 75 were the offspring of primiparæ; or infantile
deaths, during the first ten days, among single children born at the
full time, occurred in connection with first pregnancies in the ratio
of 44 in every 100.
1 Practical Treatise, p. 201.
▲ Ibid. p. 462, et seq.
7 Ibid. p. 363.
2 Ibid. Table, p. 490, et seq.
Ibid. Table, p. 490, et seq.
8 Ibid. Analysis of Table, p.
3 Ibid. p. 15.
6 Ibid. p. 284.
519, et seq.
342
FETAL DYSTOCIA.
The preceding series of facts, if arranged together into a general
tabular form, would stand as follows. In reading these arranged
results, it is to be recollected that the standard proportion of first
pregnancies, in the general sum of the labours, amounts only to 30 per
cent; whilst, as shown by the table, the proportion was much higher
in the various complications under mentioned.

Complication.
Convulsions.
Forceps cases
Crotchet cases
Tedious labours
Puerperal fever
Total Cases.
1st Pregnancies.
Proportion of 1st
pregnancies.
30
29
96 in 100
24
18
75 in 100.
75
51
68 in 100
109
75
69 in 100
88
44
50 in 100
Maternal deaths
164
86
53 in 100
Still-births, not putrid
594
260
45 in 100
Infantile deaths during 1st
་
10 days; born single
170
75
44 in 100
and at full time
The results which the above table is intended to display might
perhaps be brought out more strongly by another arrangement, if
our data for it were more complete. Dr. Collins mentions the
number out of the 16,414 patients that were delivered for the first
time, viz. 4987; of these 72 were twin births. Unfortunately,
however, for our present purpose, he has omitted to give the exact
numbers of those that were confined in their second, third, and
other subsequent labours. But an approximation, sufficiently near
for the purpose we have in view, may perhaps be made without
any probability of a very serious error. To have the required
standard of comparison, I shall take it for granted, for reasons
which it is unnecessary to dwell upon, that the percentage of first
and future labours in the Dublin Hospital was nearly as follows:
Of all the cases, about 30 per cent were first pregnancies; 22 per
cent second pregnancies; 15 per cent third pregnancies; 11 per
cent fourth pregnancies; 8 per cent fifth pregnancies; 5 per cent
sixth pregnancies; 3 per cent seventh pregnancies; 2 per cent
eighth pregnancies; 1 per cent ninth pregnancies; and 3 per cent
belong to women who were confined for the tenth time or upwards.
1
¹ This calculation of percentages proceeds on the assumed probability that, of
the 16,414 women delivered in the Dublin Hospital under Dr. Collins, 4924 were
cases of first labour; 3611 were of second labours; 2462 third labours; 1806
fourth labours; 1313 fifth labours; 826 sixth labours; 495 seventh labours; 328
eighth labours; 164 ninth labours; and 491 were instances in which the women
were delivered for a tenth or later time.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
343
If we compare with this given standard the proportion of instances
in which the different complications we have been considering
occurred in different pregnancies, we shall see in a marked degree
the great over-proportion of them in connection with first deliveries.
I have constructed the following table with this view.
Table showing the percentage of Cases of Natural and Morbid Labours
belonging to different Pregnancies.

Percentage of
pregnancies.
Total No. delivered
in Hospital
Convulsions
Tedious labours
Forceps cases.
Crotchet cases
Puerperal fever
Maternal deaths
Still-births.
•
со
03
1st. 2d. 3d. 4th. 5th. 6th. 7th. Sth. 9th.
10th and
subseq.
•
}
30 22 15 11 8 5
3
2
1
3
96 4 0
69 9
0
0 0
3 2 3
0 0
0
2 1
1
•
75 ? ?
?
?
68 10
7
3
2
4
50
8
0
2
0
5
4
1
1
3
45 17 11 8
5
5
4
3
4
8
44 15 11 s
7
2
3
1
2
Infantile deaths for
10 days after
birth
•
•
1910
53 16 7
477∞
CO LO LO
co
со со на
Post-partum hemor-
rhage
Rupture of uterus
33 16 10 9 9
10
5
4 6
3
6
21 18 18
6 615 6
со
3
3 10
In regard to the two complications which we have placed at the
bottom of the above table-viz. post-partum hemorrhage and rupture
of the uterus—it will be observed that our present proposition does
not hold out so strictly with regard to them, and that they do not
occur comparatively more frequently in first than in subsequent
labours. But this does not detract in any way from the previous
view which we took of them, as occasional results of the partial
obstruction offered by the male head. For there are sufficient
reasons why they should occur more rarely in first labours, though
these labours are more obstructed than those that occur subsequently.
In regard to rupture of the uterus, for example, it is now well
known to obstetricians that two causes may give rise to its occur-
rence-namely, first, over-action of the uterus, in consequence of
impediment to the passage of the child;' and, secondly, any such
1 "There is one fact," observes Dr. Collins, "which clearly shows dispropor-
tion to be a frequent cause, namely, its being oftener met with in the expulsion
344
FETAL DYSTOCIA.
diseased condition of a portion of the uterine parietes as renders
that portion less resistant, and hence more easily lacerated, than the
other parts of the uterine walls. The first of these two causes is in
much stronger operation in male than in female births, and in first
than in future labours; but the second cause comes more and more
into action with the frequency of the previous parturitions, the
uterine tissues being more and more liable to disease under the
strain of each successive pregnancy and labour. Hence, though
lacerations from obstruction are more common in first confinements,
the same accident, as a result of disease of the uterine structures, is
far more frequent in subsequent and later parturitions, so much so
indeed, as to cancel any argument that might be derived in favour
of its origin from mere obstruction, by the study of it in primiparous
mothers.
Again, post-partum hemorrhage, though more apt, as we have
already stated, to occur in cases in which the uterine action has
been protracted, and the contractile powers of the organ morbidly
exhausted, is not so liable to appear after tedious first labours as
after tedious subsequent labours, because it is a well-known and
acknowledged fact, that altogether the uterus contracts more per-
fectly and securely after first labours than after others. Hence the
well-known rarity of after-pains subsequently to first parturitions.
"A woman," says Dr. Power, "experiences little or no after-pain
with her first parturition, because the parietes of the uterus, not
having been weakened by previous distension, contract more per-
fectly and permanently, so as to obliterate and empty the cavity
thoroughly.""
In reference to the bearing of some of the results included in
the above tables upon the question we are discussing, it is proper
also to add, that the ratio in which some of the complications
occurred in first pregnancies, is greater in degree than can be
accounted for upon the doctrine of obstruction, and is partially
dependent upon other co-existing causes. I allude more particularly
to the case of puerperal convulsions. It is well known that in the
practice of all accoucheurs this complication is met with, principally
of male children. Thus, of thirty-four cases which I am about to state, twenty-
three of the children were males, etc. This is satisfactorily accounted for by the
greater size of the male head, as proved by accurate measurements made by Dr.
Joseph Clarke.
-Chapter on Rupture of the Uterus and Vagina, in Practical
Treatise, p. 242.
"}
1 Treatise on Midwifery, p. 190.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
345
The mere
in first, and comparatively rarely in future deliveries.
amount of obstruction present in first labours is not the sole explana-
tion of the large percentage of convulsions occurring in first con-
finements, for impediments in the maternal passages in future
deliveries are not followed in any such degree by the same conse-
quence; and further, obstetric pathologists are now well aware that,
in almost every case of puerperal convulsions, a predisposition to the
affection is given by one or more particular pre-existing morbid
states of the system. Various authors, as Demanet,² Osiander,
Chailly, Johns, etc., have correctly described the most common pre-
existing morbid condition as one marked by dropsical effusions in
the face and elsewhere. Of late years the pathology of these cases
has been advanced a step farther, and the complication of convul-
sions shown to occur only, or almost only, in women who have such
confirmed or temporary renal derangement as is marked by an
albuminous state of the urine. Dr. Lever suggests that this albu-
minous state of the urine, the common state predisposing to puer-
peral convulsions, is produced by pressure of the enlarged uterus
upon the renal veins. If this were the explanation, this complica-
tion should occur as frequently in subsequent as in first labours,
because the renal veins are not more especially compressed in the
one than in the other. But to discuss any such question at present
would be wandering from our subject. We have said enough to
show that, in regard to puerperal convulsions and their frequency
in first labours, we must take other points into consideration than
the mere degree of obstruction, in order to account for their high
over-proportion in first pregnancies.
Before we proceed farther, let us pause for a minute, and simply
1 The following Table will show this fact better than any lengthened com-
mentary:-

Reported by
Total No. of
Puerperal Convulsions.
F. Ramsbotham
59
J. Ramsbotham
Lee
•
Merriman
22
No. of these occurring
in first labours.
45, or 57 per cent.
15, or 68 ""
46
30, or 65
48
36, or 75
Clarke
Johns
Collins
Total.
19
15, or 79
9
8, or 89
30
29, or 96
233
178, or 76 per cent.
2 44 Regarde l'anasarque comme une de leurs causes essentielles,”—Recueil
Périodique de la Société de Médecine, tom. ix. for 1800-1, p. 110.
346
FETAL DYSTOCIA.
recapitulate the reasons that we have already given for considering
the greater size of the head of the male child as the cause of the
greater number of complications and casualties connected with male
births. First, I have shown that for the very marked differences
existing between the difficulties and perils of male, as compared
with female births, there is no other traceable cause, in the mechan-
ism of parturition, than the larger size of the head of the male child.
We have seen, Secondly, that an increase in the morbid effects may
be proved to be connected with an increase in this reputed morbific
cause; Thirdly, that when the alleged cause is diminished, the effects
are diminished; and Fourthly, that in those morbid complications
in labour in which the cause is in abeyance, the effect is also absent.
Lastly, we have found that similar effects upon both mother and
child are produced by other causes which are similar in their
character and amount.
Now if, in conducting any investigation into the explanation or
mode of production of a number of ascertained and acknowledged
facts, we found, amidst the assemblage of phenomena submitted to
our study, one supposed antecedent condition or probable proximate
cause perfectly answering the various reasons and tests to which, in
the preceding pages, we have already subjected the increased size of
the male over the female infant's head as the alleged cause of the
reputed greater danger and mortality attendant upon male births,
the evidence, in support of that circumstance as the vera causa of
these consequences, would be deemed of a very strong and decided
character. The evidence would become still more conclusive if it
could be shown, that though this vera causa appeared at first sight
to be in itself an agent quite inadequate for an explanation of the
various important effects traced to it, yet, when studied in its full
and proper relations, it could be proved to have necessarily sufficient
power and influence for the production of the results. Such we shall
now endeavour to prove to be the case with the slightly increased
volume of the head of the male over that of the female infant, as
the cause of the greater number of the casualties accompanying the
birth of male children.
SIXTHLY, The greater size of the male than of the female infant's head
is sufficient in itself to explain the greater dangers attendant upon
male than female births, when we consider it in relation to its
absolute and cumulative effects.
"No arguments are required," as Dr. Denman observes, "to
prove that a small body will pass through a small space with more
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
347
facility than one that is large; the size of the body being supposed
to bear any reasonable comparison to the dimensions of the space.
Of course it may be presumed that the larger the head of the child
is at the time of birth, with the greater difficulty it will be ex-
pelled." Nor does the well-known compressibility of the human
cranium at birth alter this view in regard to the effects which an
increased size of the head is calculated to produce.
"For though
nature has, with admirable wisdom," I quote the words of Dr.
Osborne, “by means of sutures and fontanelles, so constructed the
head of the human foetus, that, in the passage through the pelvis, it
may suffer the form to be altered and the volume to be considerably
diminished without such injury to its contents as shall necessarily
destroy life; yet as there is a volume beyond which each foetal head
cannot suffer compression with safety-so there is another and still
smaller into which it cannot be compressed at all."1
No one will be inclined to doubt the fact, that when the foetal
head is much increased beyond the common size at birth, its ex-
pulsion will be attended with more than the usual degree of
difficulty. But exactly the same effect may be produced by the
infantile head exceeding the required dimensions in only the most
trifling degree, provided it happens, from the particular conformation
of the mother, that the maternal pelvis and foetal cranium are
otherwise very nearly and accurately adapted to one another. In
such instances a difference in the size of the head, of the smallest
amount, may involve and change the whole question of the physical
possibility or impossibility of the passage of the infant. Dr.
Hamilton, in his Practical Observations, when speaking of the occasional
difficulty of determining in individual cases in practice, whether the
maternal passages are or are not of such dimensions as to allow the
child to pass, and whether the infant's head may or may not require
to be diminished by craniotomy, strongly remarks, "that in this
question even a miscalculation of the sixteenth part of an inch might
be fatal to the life of an infant." "The author," he adds in a foot-
note, "has been accustomed to illustrate this practical remark to his
pupils by a very simple mechanical demonstration. He first shows
the smallest possible aperture through which the foetal head of the
ordinary size can be squeezed, and he then covers the head with a
common towel, and proves the utter impossibility of its then passing
through the same aperture. He does not believe that the addition
¹ Essays on the Practice of Midwifery, p. 188.
348
FOETAL DYSTOCIA.
of a common towel can increase the diameter of the head more than
the sixteenth part of an inch."
", 1
If Dr. Hamilton's calculation regarding the increase of the
diameter of the head in this experiment be true-viz. one-sixteenth
of an inch-then here we have the transit of the foetal head entirely
prevented by an increase of size which is not more than half of that
difference (one-eighth of an inch) which we have seen to exist
between the diameter of the standard male and the standard female
head at birth.
In relation to the question of the greater difficulties attendant
upon male births, it ought further to be always held in view, that,
when the fatal head is notably above the medium standard, the
infant is, in a great majority of instances, of the male sex. Among
the 120 infants whose heads were measured by Dr. Clarke, only six
were above 14 inches in circumference. These six were all males.
Twenty-nine of the children were as high as 8 lbs. and upwards in
weight. Of these 29, as many as 19 were of the male, and 10 only
of the female sex. Such facts require no comment.
But let us throw altogether out of consideration the more ex-
treme cases to which we have adverted, and look upon the question
of the more numerous dangers attendant upon male births as the
result merely of the average slight increase of the standard male
over the standard female head at birth. Even under this limited
view, the normal difference in size between them (about one eighth
of an inch in diameter), inconsiderable as it may at first appear,
will, we believe, afford us a perfectly sufficient explanation of the
statistical facts which we have brought forward in the preceding
pages, provided we consider what the accumulated mechanical effects
of this difference in measurement would be when operating over a
very wide and extended range of cases of parturition. A few
remarks will illustrate our meaning. We take for granted, that the
act of parturition consists of the dilatation of the female passages,
and of the expulsion of the foetus through them. Before the process
can be terminated, a very considerable amount and continuance of
expulsive and dilating force is in general required. During it, the
parietes of the maternal passages are necessarily subjected to pres-
sure from the advancing fœtal head, and in turn the wedge-like
foetal head itself is compressed by the resisting passages. The
whole process is rendered the more tedious and difficult in con-
sequence of the size of the head of the foetus being nearly pro-
¹ Hamilton's Practical Observations, second edition, p. 254.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
249
What, then,
portioned to the size of the passages of the mother.
will be the effects upon this whole process, of such a difference in
the dimensions of the fœtal head as holds good with regard to the
relative sizes of the male and female at birth, supposing the mother's
pelvis and passages to be always, cæteris paribus, the same in their
capacity? If the female infant's head, when of the standard size,
require for its transit a certain extent of dilating and expulsive force
—if it necessarily produce, during its egress through the maternal
passages, a certain amount of pressure upon their walls in order to
overcome the resistance which they offer-and if, in turn, the head
of the child be, under the same action, compressed itself to a certain
degree; then the standard male infant's head (as being an eighth
of an inch greater in diameter, and consequently demanding more.
actual space for its transit), will require proportionately a greater
extent of dilatation in the maternal passages, and a greater expendi-
ture of force to effect this greater dilatation; it will hence also
produce, during its egress through the maternal canals, a greater
amount of pressure upon their parietes, and be itself reciprocally
compressed to a greater degree. The difficulties and dangers to
child and mother entailed by this latter state of matters might well
a priori be supposed to be exactly those that we have shown them
really to be, under the various propositions that we have previously
laid down.
But that the birth of the male, as compared with the female.
child, is accompanied with more obstacles and delay, need not be an
inference resting solely, as it does above, upon abstract though
satisfactory reasoning-for it is a matter which should admit of
direct statistical and arithmetical proof. If our data were suffi-
ciently precise and extensive, we ought to be able to prove, that,
as a
TWELFTH PROPOSITION,
The average duration of labour is longer with male than with female
children.
Dr. Collins has given a table' showing the number of his patients
that were delivered in "one quarter of an hour," "in one hour,” “in
two hours," etc., from the commencement of labour.
The sexes,
however, of the children are not distinguished, so that the data are
of no avail in regard to their bearing upon the proposition we have
just stated. Nor am I aware that there has been, as yet, anywhere
published such a series of facts as would enable us to prove statisti-
cally that the birth of the male child is absolutely longer than that
¹ Practical Treatise, p. 22.
350
FETAL DYSTOCIA.
of the female, in the time required for its completion. The average
duration of labour in the European female is about four or five hours.
The average duration of male births will probably be found, when
sufficient evidence is collected, to be about a quarter of an hour or
half-an-hour longer than that of females. I venture to make this
allegation, in regard to the common run of labours, upon the evidence
afforded by an assemblage of cases, now lying before me, in which
the process was somewhat protracted beyond the usual standard.
The cases I allude to were collected under the following circum-
stances. In 1836 a separate register was begun in the Edinburgh
Lying-in Hospital of those labours in which the date of the com-
mencement of the process and the comparative length of each suc-
cessive stage conld be ascertained with sufficient accuracy. Those
cases in which the labour was very speedy, and indeed all that were
less than three or four hours ill, were not entered, because in most
of them the duration of the labour and its stages could not be noted
with the accuracy required; many of these patients only entering
the hospital a few minutes before delivery. About half of the
labours in the Dublin Hospital appear to have been terminated
within the first two or three hours, so that our Edinburgh register,
as wanting that proportion of the more rapid cases, cannot show the
average length of the process in ordinary instances. The records,
however, which it contains of the cases protracted beyond the period
mentioned have, I know, been kept with adequate care, and seem
capable of furnishing us with sound and unprejudiced evidence upon
the present topic, inasmuch as they were originally noted without
any view to such an inquiry as this into the comparative duration
of male and female births. In analysing the register, I find, that,
from 1836 to 1841 inclusive, 249 male and 178 female births are
entered, with notes of the precise length of the labour in each. The
following table will show the absolute and average duration of the
labours with male and female children in these 427 cases :—
1
2

Labours.
Absolute duration of the
whole cases.
Average duration of each
labour.
With male children
(249 in number)
Hours.
Minutes.
Hours.
2646
33
10
Minutes.
38
•
With female children
1702
29
9
34
(178 in number)
Average greater length of the male birth
1
4
•
1 Of the 15,850 cases noted by Dr. Collins, 7063 were terminated within two
hours, and 9550 within three hours, from their commencement.
2 A number of the entries were made by myself when annual pupil at the
hospital in 1836-7, and have been continued by others in that office.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
351
In those classes of labour in which the process becomes morbid
from tediousness or other complications and difficulties of a more
serious character, the difference between the duration of the male
and female births would seem to be even greater than the above
table displays. At least such an inference appears deducible from
the analysis which I have made, from Dr. Collins' tables, of the
comparative length of the male and female births in the records
which he has given of 507 still-born children (including the putrid
and premature), of 97 morbidly tedious labours, of 68 crotchet
cases, and of 130 instances in which the mother died in connection
with delivery. The preceding numbers include all the cases, under
these several heads, in which the exact duration of the labour is
mentioned in Dr. Collins' tables. The result is this:
Labours.
The average duration The average duration]
of the male births of the female births
The average greater
length of the male
births was
was
was
Hours.
Minutes. Hours.
Minutes.
Hours.
Minutes.
With still-births (310
males and 197 fe-
14
27
12
10
2
17
males)
Morbidly tedious (56
males and
41 fe-
43
18
40
12
3
6
inales)
Requiring crotchets
(44 males and 24
42
22
38
20
4
2
females)
•
Leading to death of
the mother (86 males
18
9
12
58
5
11
and 44 females).
The evidence afforded by the foregoing table appears almost
enough to warrant us in qualifying the proposition we have laid
down, to this extent, that "the average duration of labour is longer
with male than female children, and the difference in this respect,
between male and female births, becomes increased in length when
the labours become more severe and dangerous in their character."
The remarks and proofs that we have now offered may tend to
remove the difficulty which the inquirer may at first entertain
regarding the supposed inadequateness of the slightly increased
size of the male head to produce all the greater number of casual-
ties and complications that we have traced to be connected with
male births. For it will probably be allowed that the principal,
or indeed sole obstacle, which the mind has to contend with, in
allowing the very small size of the male over the female infant's
head to be the cause of the remarkable differences which we have
352
FETAL DYSTOCIA.
traced between the results of male and female births, consists in the
difficulty of at first supposing so slight an apparent cause to be the
agent by which such remarkable consequences are brought about.
But in considering this and the analogous questions, it must be held
in recollection, that in all processes, whether vital or physical, in
which, as in parturition, an established relation of mechanical condi-
tions is required, any disturbance in these conditions, however small
and trifling in itself, will ultimately, and when followed out through
numerous and extended series of observations, be found to lead to
results the magnitude of which could scarcely have been previously
surmised. These results may not be appreciable when we confine
ourselves to the study of the agency in an individual case, or in a
small number of cases merely, but they become more and more
marked in proportion as the number of our instances becomes more
and more extensive. The effects cannot be distinctly seen when we
look for them in a limited series of data; but they may be evoked
with all the force of a mathematical demonstration, when we prose-
cute our calculations for them among large and accumulated masses
of observations. From any study, however minute and accurate, of
a limited number of cases of labour, no man would probably feel
himself entitled to conclude that male are in any notable degree
more difficult and dangerous than female births; but this, as we
have seen, becomes a demonstrable and strongly-marked fact, when
we direct our inquiries after the truth of it into the records of
hundreds or thousands of carefully-reported observations, such as we
have made use of in the course of the preceding inquiry.
The remarks we have hitherto made upon the male sex of the
child as a cause of delay, difficulty, and danger during labour, have
referred principally to the larger size of the male infant's head or
cranium. In that condition, and its effects, we have so far found
a satisfactory explanation of the numerous complications and
casualties to which the mother herself is subjected in male births.
One or two additional observations may be required to show more
specifically in what manner the safety and life of the male child
during labour, and for some time after it, is endangered by the same
circumstance. We believe that the larger size of the contents of the
male, than of the female cranium, or, in other words, the larger size
of the male brain or encephalon at birth, and the consequent greater
compression and injury to which it is subjected during birth, affords
us the proper clue to the explanation of these peculiarities in the
male infantile mortality.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
353
In an
The weight, and hence the size of the brain, is now well ascer-
tained to be absolutely more in the adult male than in the adult
female. From measurements of the interior of numerous crania, Sir
William Hamilton¹ computes the male adult encephalon as weighing
3 lbs. 8 oz. troy, and that of the adult female as 3 lbs. 4 oz. Pro-
fessor Reid carefully weighed in the Edinburgh Infirmary the
encephalon of 53 adult males and 34 adult fernales. The average
weight of the male brain in these observations was 3 lbs. 2 oz. 31
drachms; that of the female, 2 lbs. 12 oz. 8 drachms; and the
average difference in favour of the male encephalon thus amounted
to 5 oz. 11 drachms." This difference in weight between the
encephalic contents in the two sexes exists also at birth.
elaborate paper on the weights of the brain in the different sexes,
etc., by Professor Tiedemann, founded on numerous observations,
that distinguished anatomist states that "the female brain weighs
on an average 8 ounces less than that of the male, and this difference
is," he adds, "already perceptible in a new-born child." In one of
his tables Tiedemann adduces the weight of the brains of two male
and two female infants at birth. The average weight of the two
male brains was 13 oz. 6 drachms 20 grains; the average weight
of the two female, 10 oz. 44 grains; and the average excess of size
of the encephalon of the male infant, as deducible from these four
observations, 3 oz. 5 drachms 36 grains. But this result is pro-
bably much higher than a more extended number of data would
give, in consequence of one of the female children in the table being
evidently below the standard size and weight of the girl at birth.
3
There is another way by which, in the present deficiency of
direct facts bearing upon this point, we may arrive at the same
conclusion with equal or greater certainty. "The weight of the
brain," says Tiedemann, " of a new-born child is relatively to the
size of the body as one to six." The male infant at birth is, as we
have seen, on an average, about nine or ten ounces heavier than the
female. If the above ratio between the brain and whole body holds
equally true (as there is every reason to believe) of the two sexes,
the male brain should, on an average, be one-sixth part of this
heavier than the female brain at the time of delivery. Hence the
1 Monro's Anatomy of the Brain, 1831, p. 12.
2 London and Edinburgh Monthly Journal for 1843, p. 322. See also Dr.
Sim's paper in the London Medico-Chirurgical Transactions, vol. xix., for similar
results.
3 London Philosophical Transactions for 1836, p. 502.
354
FETAL DYSTOCIA.
male encephalon is, in the infant at birth, about 1 ounce heavier
than the female encephalon, and the male brain and cerebellum
altogether about one-ninth or one-tenth greater in weight, and con-
sequently in size, than the brain and cerebellum of the female.
The immediate effects, during parturition, of this much greater
size of the male encephalon upon its own delicate structures are
evident. For as, cæteris paribus, the pelvic passages are always the
same in their dimensions, the larger and heavier male brain will, in
its forcible transit through the given standard space of the maternal
canal, of necessity suffer more physical compression and injury than
the smaller female head and brain.
Connected with the structural economy of the brain of the new-
born infant, there are some circumstances which are calculated to
render such degrees of injury as we have adverted to, more exten-
sive in their influence, and more permanent in their results, than
similar amounts of injury of these same parts at other later periods
of life. For, first, the brain of the infant at birth is still so soft
and almost semifluid, and its vessels so large, as to be more easily
lacerated than years afterwards under the same extent of pressure.
Secondly, the brain at that particular period of life, and for ten or
twelve months afterwards, is undergoing great and rapid normal
changes from its imperfect embryonic state to the anatomical consist-
ence, form, and organisation which it is to present during the
remainder of life. "From birth," observes Billard, "to the first
year, the brain of the infant is in a true state of transition, so that
this organ, which is scarcely formed at first, arrives, towards the
ninth month or first year, at the organisation proper to the brain of
adults. Ought we not," he adds, "to attribute to this modification
supervening in the brain of infants, the frequency of cerebral affec-
tions at the age of which we speak?"¹
But there is a third peculiarity, probably even more important
than the two others. The human brain is very much larger in
proportion to the body in the infant, than it is in the adult.
In a
full-grown adult the proportion of the brain to the body is as about
1 to 40; in the infant it is, as we have already stated, about 1 to
6, or nearly seven times greater. The influence of this immense
difference is important both physiologically and pathologically."
¹ Billard, Traité des Maladies des Enfans, p. 335, Brussels ed.
2 Tiedemann, on whose authority I have given the respective proportion,
stated in the text, of the whole brain in the infant and in the adult, observes, in
relation to this point, and his words apply equally to the morbid as to the healthy
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
355
The nervous system in the infant is thus rendered naturally much
more susceptible and sensitive of physical and sympathetic morbid
impressions than at a more advanced age ;'-pathological irritations
and disturbances of other parts are far more readily and strongly
reflected upon the nervous centres ;—and, for the same reason, any
direct lesion or disease of the brain itself comes also in turn to
exert a more potent and extended effect upon the general and
individual functions of the body, than at other later periods of life.
All these conditions are heightened and increased in the male as
compared with the female infant at birth, both, first, by the greater
absolute size of the male brain; and, secondly, by the greater lesions
and injuries to which it is subjected during the process of labour.
I have collected some statistical data to show that the particular
diseases which destroy so many more male than female children
immediately after birth and for a short time subsequent to it, and
which are therefore the evident and demonstrable causes of the
excess of the male over the female mortality at that early period of
life, are all such as are capable of receiving an explanation of their
more marked frequency, severity, and danger upon the above priu-
ciples, in conjunction with the consideration of the increased size
and increased injuries, at birth, of the male as compared with the
female encephalon. To adduce evidence of this to the amount that
might be necessary, would require us to extend this essay far
beyond the limits prescribed to it, and these it has already far
overstepped. I may, on another occasion, return to the subject ;
states of the system, "The different degrees of susceptibility and sensibility of the
nervous system seem to depend on the relative size of the brain as compared
with that of the body. Children and young people are more susceptible, irritable,
and sensitive, than adults, and have a relatively larger brain. In diseases which
affect the nourishment of the body, the susceptibility increases as the patients
grow thinner. The susceptibility and sensibility decreases, on the other hand,
with persons recovering from a long illness gradually as they regain their strength.
The degree of sensibility in animals is also in proportion to the size of the brain.
Mammalia and birds have a large brain, and are more susceptible than amphi-
bious animals and fishes."-London Philosophical Transactions, vol. cxxvi. p.
503.
1 "The nervous system in infants is naturally in a very susceptible condition;
it is consequently easily excited on the application of the slightest impressions.
This constitutional irritability is characteristic of the infant state.
The nervous sensibility is in excess at this age, and whatever be the disease with
which the infant is affected, a morbid excitability and irregularity of action in
the nervous system are more or less its attendants."-Stewart's Practical Treatise
on the Diseases of Children, New York, 1841, p. 494. See also Maunsell and
Evanson on the Diseases of Children, p. 13, etc.
24
356
FETAL DYSTOCIA.
and, in the meantime, shall only add, that the particular affections
alluded to, as producing the excess of the male over the female
mortality, which is so remarkable at birth, and progressively
decreases from that time onwards, are almost all referable in their
origin or course to morbid states and disturbances of the nervous
system,' and to functional derangements and inflammatory action in
it and other organs of the body.
PRACTICAL INFERENCES, AND EXTENT OF INFLUENCE EXERTED BY
THE MALE SEX OF THE INFANT UPON THE GENERAL MATERNAL
AND INFANTILE MORTALITY DURING PARTURITION AND FOR
SOME TIME SUBSEQUENT TO IT.
The subject of the preceding inquiry is certainly not without
interest in a physiological point of view. Nor is it devoid of im-
portance in a pathological and practical light. The results of the
whole investigation show us with demonstrative force that the adapta-
tion of the fœtus to the maternal passages in human parturition
is, in general, so close and perfect, that a deviation in their relative
size, of the slightest possible extent, is capable of altering immensely,
when the subject is viewed on a large scale, the consequences of the
process as regards both the immediate safety and life of the mother
and infant, and their subsequent welfare. We may be hence led to
see more strongly than previously the advantages attendant upon
the presentation of the head of the infant in its most natural posi-
tion, and consequently in its smallest given diameter, and the dis-
advantages accompanying any deviations in its presentation, seeing
that all these deviations offer a larger circumference than the normal
parietal case. The same inquiry illustrates well the importance of
saving, and particularly in cases in any degree tedious, or in any
slight malpresentation, the space of the pelvic passages as much as
possible, by keeping the rectum and bladder empty, by carefully
guarding against congestion and tumefaction of the soft tissues
lining the pelvis, and by promoting, by all appropriate means, the
dilatability of the maternal passages. We can easily, from the same
data, understand how greatly the dangers of the mother and child
are increased by organic contractions, however slight, in the pelvic
passages and bones themselves, and by increased volume on the
1 "The diseases of the nervous system," observes Mr. Farre, "are twenty-three
per cent more fatal to males than females, the chief difference arising from the
diseases which affect children."-Registrar-General's Second Annual Report, Appen-
dix, p. 4.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
357
part of the infant, whether that increased volume be the effect
merely of excessive growth or the result of actual disease.
The object of our investigation becomes one of still more prac-
tical moment when we consider it in relation to the extensive
character of its operation and influence.
The importance of any cause of human disease does not so much
depend upon the immediate intensity and danger of the morbid
action which it is calculated to excite in single individuals, as upon
the frequency and extent of its operation, and the consequent
amount of its effects upon the general community. In this way a
slight disease or slight cause of disease, which acts upon a great
proportion of the population, may become as important in its ulti-
mate and practical results as a malady of the most formidable
character, provided that malady is much more narrowed and limited
in its attacks. "The cholera," observes Quetelet,' "and the influ-
enza are diseases which differ greatly from each other; the one is a
dreadful scourge, which manifests itself in the most dreadful manner;
the other, in its ordinary external appearance, resembles a catarrh
or common cold; and yet the tables of mortality prove that, although
the latter disease is not so deadly, it nevertheless, in consequence of
its universality, and in consequence of the sufferings it causes, pro-
duces results nearly as extensively fatal as cholera. Facts serving
to confirm this opinion may be found in the excellent work published
by Dr. Gluge on the History of Influenza." 2
The remark which we have applied to diseases, and the causes
of disease, holds equally true with regard to morbid complications
in midwifery and their causes. Those special states which, in
obstetric practice, are seen to lead to some of the most formidable
causes of difficult labour, such as tumours in the pelvis, malpositions
of the infant, inertia of the uterus, etc., are certainly often most
disastrous in their immediate effects, but yet, upon the whole, they
are comparatively so rare in their occurrence as not individually to
lead, upon a large scale, to consequences of so severe and fatal a
character, as disturbing agencies of a far slighter, but far more
general kind, such as that inconsiderable enlargement of the male
over the female head, which we have been considering in the pre-
ceding pages. A few computations will best illustrate and enforce
the truth of this abstract remark. These computations I shall found
on the idea that the bases of calculation offered by the data of the
1 Natural History of Man, p. 112.
2 Dic Influenza oder Grippe, u. s. w. Minden, 1837, 8vo.
358
FETAL DYSTOCIA.
i
Dublin Hospital are sufficiently correct to serve for a ground of
analysis of other analogous statistical results. To avoid as far as
possible any probability of great errors, we shall keep our calcula-
tions considerably within the limits that our apparent standards.
might seem to warrant.
With this explanation, let us proceed to inquire to what extent
the cause of difficulty and danger during labour, which forms the
topic of our present essay, fatally influences each single year in
England, or during a succession of years, the results of parturition,
as respects the fate both of the mother and infant. Some facts,
recorded by Mr. Farre, in his admirable contributions to the different
annual reports of the Registrar-General, will serve as matters of
comparison on these points with the Dublin Hospital returns.
Number of maternal deaths referable annually in Great Britain to the
influence of the comparatively great size of the head of the male
infant.
In the returns of Drs. Clarke and Collins, we have reports in
the Dublin Hospital of the sex of the child in 368 cases in which
the mother died from labour or its consequences. In 231 instances
the child was male; in 137 cases it was of the female sex. The
proportion of maternal deaths, after male and female births, was
therefore as follows:-

Total deaths.
With male With female
children.
children.
Proportion of
males to females.
368
231
137
168 to 100
If we venture, then, to compute from these data, that out of 250
mothers that die in childbirth from parturition or its effects, 150
have given birth to males and 100 to females, as the above table
would seem to show, then we have in every 250 maternal deaths an
actual excess of 50 cases of loss of the mothers after male births, for
which, for reasons which we have previously stated at length, we
can find no other explanation than the greater comparative size of
the male head, and we have already attempted to prove that this
explanation is in itself logically and amply sufficient to account for
the consequences which we have attributed to it. In other words,
among every 100 parturient mothers that die, we have 40 perishing
after producing female children, other 40 perishing after producing
male children, and the remaining or additional 20 in the 100 perish-
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
359
ing also after the birth of males, but so far forming a regular and
constant excess of 20 per cent of deaths in connection with male
births, traceable to no other cause than the sex and consequent size
of the infant. One in every 5 maternal deaths, or 20 in every 100,
and 200 in every 1000, are so far the direct or indirect consequences
of the greater dimensions of the head of the male infant. Now, at
the present day in Great Britain, upwards of 3000 women die every
year from childbirth or its immediate effects. Hence, according to
the above computation, 600 of these 3000 cases,' as forming the
excess of male over female births, are more or less immediately the
results of the sex and size of the male infant. In Great Britain,
therefore, the valuable lives of 500 mothers, to speak within the
terms, are annually lost in childbirth through the influence and
agency of the cause in question.
Number of infantile deaths occurring annually in Great Britain
during labour, and referable to the sex and size of the male
infant.
We have seen, under our fourth proposition, that in the Dublin
Hospital there died, during the process of parturition, and probably
as a consequence of the injuries to which they were subjected, 151
male children for every 100 females. According to the mode of
argument followed in the preceding paragraph, there was thus an
excess of 50 male deaths among every 250 children, or 20 in every 100,
referable to the greater size of the head of the male infant. Further,
we may take it for granted that, on a low computation, 1 in every
50 children born dies during labour, about 1 in every 25 cases being
a still-birth. To be certain, however, not to overstep our limits, let
us reckon only 1 in every 75 children to die during parturition, and
1 in every 5, or 20 per cent of those that thus perish, to be formed
by that excess of the mortality of males over females which we can
trace to no other cause than the influence of the greater dimensions
¹ During the four years from 1838 to 1841, there died in childbirth in England
and Wales 11,722 mothers. In 1841, the last year of which the returns are yet
published, 3007 women died in childbed in England and Wales.—Fifth Annual
Report of the Registrar-General, p. 380. If to these we add 500 deaths as occur-
ring in childbed in Scotland, we will be much within the limits in computing
3000 maternal deaths to take place annually in Great Britain from labour or its
immediate consequences. I reckon 500 deaths as occurring annually in Scotland
in childbed on the calculation which seems to hold in regard to England, that
nearly 200 deaths happen every year from this cause in every million of the
general population.
360
FETAL DYSTOCIA.
of the male head. In England and Wales about 500,000 births
take place annually. By the above computation more than 6500
of the offspring of these births die during labour, and one-fifth of
that number are lost in consequence of the sex and size of the male
child. In Great Britain, therefore, the lives of 1500 infants are
annually lost in childbirth from the operation of this agency.
Number of infantile deaths occurring annually in Great Britain within
the first year of life, referable to the influence of the sex and size
of the male child during labour.
In 1841 there died in England and Wales, within the first year
of life, 41,444 boys and 32,766 girls. There was thus an excess of
8678 deaths of male infants within the first year, and 3610 of this
excess occurred within the first month after birth. In considering
this subject under our seventh proposition, I have already stated
our reasons for considering the excess in question of male over female
deaths, in very early infantile life, as owing to the great injury sus-
tained by the head and nervous system of the male child in its
passage through the pelvis during delivery. I have further .com-
mented on the same subject in speaking of the excess of size of the
male head and encephalon as the probable cause of the greater diffi-
culties attendant upon male births. Under these points enough has
been stated to show that a large proportion, if not the whole, of the
remarkable excess of the male over the female mortality, which is
observable for some time after birth, is traceable to the greater
dimensions of the male head and encephalon, and their consequent
greater compression and injury during delivery. Supposing these
views to be perfectly correct, there die annually in Great Britain.
upwards of 5000 children within the first year after birth, whose
death is referable to the influence of the sex and greater size of the
male head during labour.
If we add together the three series of observations that have
been stated under the preceding heads, the result is as follows:—
Upwards of 7000 deaths in all-namely, above 6500 of the deaths of
4 "In 1841, 512,158 births were registered; in 1840, 502, 203; and in 1839,
492,574.”—Registrar-General's Fifth Report, p. 8. It seems doubtful if all the
births that occurred were registered, as this, like the other branches of registra-
tion, could not at once be made perfectly efficient. Certainly it is to be greatly
lamented that there is no official return of the still-births. The omission is a
most extraordinary one, and surely ought to be corrected.
SEX OF CHILD AS A CAUSE OF DIFFICULTY.
361
infants during and after birth, and 500 of the deaths of mothers in
childbed occurring annually in Great Britain—are referable to the
direct or indirect agency of the cause that we have been discussing,
viz. the sex and larger size of the head of the male child.
In using here the term cause in reference to the slightly greater
size of the male head as the source of the results that we have above
ascribed to its influence, it may be proper to state the precise
meaning which we attach to this term. Amidst all the uncer-
tainties of medical language, there is no phrase which has had more
vague and contradictory significations attached to it. Except in the
cases in which disease and death are produced by the immediate
action upon the body of severe physical injuries, or strong chemical
agents, it rarely or never happens that serious and fatal morbid
actions are excited in the economy through the operation of one
single morbific cause. In most, if not in all, other instances, a
number of causes are found to have acted either in concourse or
succession towards the production of the disease that may be pre-
sent, and the effect to which it leads. According to the order which
these several causes may occupy in the series or chain of antecedent
sequences, and according, in some instances, to their supposed re-
lative importance and intensity in the production of the existing
morbid action, they are individually described by pathologists as
accessory or determining-remote or immediate-predisposing or
exciting-in relation to the disease that has been originated by
their combined influence. Hence a cause which may be termed
predisposing in. one case may be more properly designated exciting.
in another, or the reverse, and consequently different authors often
describe the same cause under opposite heads. Further, it seldom
occurs during the course of a fatal disease that the same cause which
had especially excited the original malady continues, by the intensity
of its own immediate action, to lead to the fatal result. An example
will illustrate our meaning. All pathologists look upon excess in
eating and drinking as a common cause of disease. If the body be
1
1 For instance, Drs. Copland and Craigie, two of the latest British writers on
practical medicine, speak of intemperance in food and drink under two different
heads. Amongst the most frequent predisposing causes to diseasc is," says Dr.
Copland, "intemperance in food and drink.”—Dictionary of Practical Medicine,
Part ii. p. 562. Dr. Craigie enumerates the same morbific agency among his .
exciting or occasional causes of disease.-Elements of the Practice of Physic, p. 18.
Dr. Williams, again, describes excess of aliment among his exciting causes of
disease, and habitual excess in stimulating drinks among his class of predisposing
causes,-Principles of Medicine, 1843, pp. 9 and 24.
362
FCETAL DYSTOCIA.
debilitated by previous morbific agencies, a fit of intemperance may
suddenly excite in it some serious and deadly morbid action, as
extensive effusions or inflammation, severe fevers, etc., and thus act
as an exciting cause of these diseases; or when the powers of the
constitution happen at any time to be impaired by intemperance,
the application of an excess of cold or heat may lead to similar
consequences, and then the cause we are considering (the intemper-
ance) would be regarded as a predisposing one. Further, it rarely
happens that intemperance in eating or drinking leads to death by
the mere excess of their own action and influence on the body.
Few men, in other words, die of direct gluttony, or direct intoxica-
tion; but many die from intemperance in eating and drinking,
leading directly or indirectly to a variety of maladies, such, ac-
cording to Dr. Copland, as "plethora, inflammatory complaints,
functional and organic diseases of the stomach, liver, and bowels,
gout, apoplexy, paralysis," etc."
The view which we have stated as generally taken by patho-
logists with regard to intemperance as a cause of disease and death,
applies exactly to the greater size of the male head as a cause of the
greater number of complications and casualties connected with male
births. In some instances this excess of size acts as a predisposing
cause to the accidents and diseases that are consequent to it, and,
without its antecedent or concurrent agency, these accidents and
diseases would not be produced. In other instances, it acts as a
determining or exciting cause of the morbid conditions and compli-
cations resulting from its operations. We will take an illustrative
example from an accident which we have already spoken of in a
previous page, viz. rupture of the uterus. When rupture of the
uterus occurs in a patient who has already borne a large family, and
where the uterine parietes are, from some pre-existing disease, much
more weak and·lacerable at one part than another, the greater delay
and difficulty of the labour in connection with the larger-sized male
head may give rise ultimately to the complication in question, when
the shorter and more easy passage of a smaller fœtal head would not
have led to the same disastrous consequence. Here the previously
diseased state of the uterus acts as the predisposing, whilst the
larger size of the male head acts as the exciting or determining cause
of the lesion. On the other hand, when rupture of the uterus occurs
in a first labour in consequence of the larger size of the male head
calling forth a morbid and inordinate degree of uterine contraction
¹ Medical Dictionary, Part ii. p. 562.
TRANSVERSE PRESENTATIONS.
363
for its expulsion, we have this inordinate uterine contraction acting
as the exciting or determining cause of the injury, and the excess
of size of the male head standing now in the relation of the predis-
posing cause to it. Further, like other pathological causes, the
excess of size of the male head does not so often lead to accidents
and death by the mere influence of its own intensity, or by the
effects of direct compression upon the maternal passages or infantile
head, as by leading to the supervention and excitement of various
other formidable and fatal complications, such as morbid delays in the
labour demanding instrumental interference, eclampsia, post-partum
hemorrhage, puerperal fever, etc., on the part of the mother-and
convulsions, nervous and inflammatory diseases, etc., on the part of
the infant.
Under the signification and reservations which we have thus
stated, we repeat that the greater size of the male foetal head is the
more or less immediate cause of a large number of those maternal
and infantile deaths that take place in connection with labour, or as
a result of that process.
In illustration of this remark, I shall
venture to add another observation—one which may at first seem
sufficiently startling to those who have not practically directed their
attention to the subject, though it is but a simple and direct deduc-
tion from the facts we have so imperfectly brought forward in the
preceding pages. It is this:-
The official returns of the mortality of England and Wales have
only, as yet (1844), been collected for somewhat upwards of seven
years, viz. from 1st July 1837 to the present date. If the calcula-
tions we have already given are accordant with truth (and we
believe them to be much within the limits), there have been lost in
Great Britain during that limited period, as a consequence of the
slightly larger size of the male than of the female head at birth
ABOUT 50,000 LIVES, INCLUDING THOSE OF ABOUT 46,000 or 47,000
INFANTS, AND OF BETWEEN 3000 AND 4000 MOTHERS WHO HAVE
DIED IN CHILDBED.
TRANSVERSE PRESENTATIONS.'
At this Meeting I propose to offer a few observations on the
instance of transverse presentation and turning, which you witnessed
in the Maternity Hospital two days ago. First of all, allow me to
1 Part of a Clinical Lecture, reported by Mr. C. D. Arnott. See London and
Edinburgh Monthly Journal of Medical Science, February 1845, p. 109.
364
FETAL DYSTOCIA.
read to you the case as it has been reported by my excellent friend
Dr. Martin Barry.
"Christina Anderson, aged 28, married-third pregnancy-last
catamenia in the beginning of March, continuing for two or three
days-time of quickening uncertain.
“On the morning of Saturday, 7th of December, had a fall, in
which the left hypochondrium was violently dashed against the
corner of a large stone; says that she did not feel the movements of
the child for longer than a day or two after this. On Tuesday the 17th
-ten days afterwards the child, when born, presented the separa-
tion of nearly the whole cuticle, with sero-sanguinolent infiltration
of the scalp, and a state of looseness of all the cranial bones. The
abdomen was swollen, and on laying it open, the spleen was found
much enlarged, and patches of coagulable lymph were seen on its
peritoneal surface; similar patches were present on the iliac and
pelvic region connecting the peritoneum of the abdomen with that
of the intestines; other portions of a similar inflammatory effusion
were scattered over the intestines, more especially in the lower part
of the abdomen.
"Labour commenced on Monday, 16th of December, and was
completed in seventeen hours. The membranes ruptured twelve
hours before the full dilatation of the os uteri.
"During the labour the patient was bled, and had an ounce of
antimonial wine exhibited in 3ss doses, to promote the dilatability
of the cervix uteri. Shortly before turning, 3i of laudanum was
exhibited, in order to moderate the uterine contractions, and facilitate
the process of turning.
"The presentation was the right shoulder with the cord, and the
child was removed by turning and extraction. This was performed
by Professor Simpson, who, observing from the feet and legs, when
they had been drawn down, that the position of the pelvic extremity
of the child corresponded to the third position of the head with the
toes pointing forwards, stated that the body as it came into the
world would present a corresponding movement of rotation-a
movement forthwith seen by the writer and several others who were
present. The head was then born in the second, or right occipito-
cotyloid position."
Most of you are aware that we cannot, except in the rarest cases,
leave instances of shoulder-presentations to nature. Experience
abundantly shows us, that if we do not offer the required aid in
TRANSVERSE PRESENTATIONS.
365
these presentations, the woman, in general, either dies exhausted
from the long-continued but fruitless efforts of the uterus to empty
itself of its contents; or the organ, by the violence of its own con-
tractions, lacerates its own structure, and thus establishes one of the
most fatal complications to be met with in the practice of midwifery,
namely, rupture of the uterine walls. In these presentations, there-
fore, interference is imperatively required, and this interference
consists in so far altering the morbid position of the infant, that,
instead of allowing it to remain with its long axis across, or at right
angles to, the long axis of the uterus, we introduce our hand, and
bring down to the os uteri one of the two extremities of the ovoid
mass of the child (the child in the latter months being, as you know,
folded up into an irregular ovoid form), in order to make the long
axis of the body of the infant and the long axis of the body of the
uterus parallel to each other. For this purpose, we may bring down
either the cephalic or the pelvic extremity of the infant.
The cases are few in which it is proper and possible to bring
down the head of the child to the os uteri, or, in other words, in
which we can and should perform what is termed cephalic turning
or version.
In almost all cases, but especially in one like Anderson's, with
the child dead, and the passages well dilated or dilatable, we bring
down the pelvic extremity of the infant, and so far change the pre-
sentation from one of the shoulder or arm into one of the breech,
feet, or knees.
Many modifications of this last operation—podalic version or
turning, as it is termed-have been proposed, and different varieties
of it are advocated by different practitioners. By some we are
advised, in all cases, to bring down both feet of the infant. Others,
again, assert that to bring down one is always sufficient. Some
advise a foot or feet; others one or both knees. Let us inquire
what method would be the most simple and most practicable in a
case like the one before us.
I would first, however, remark, that in turning, in any case,
where the membranes are still fortunately entire, the female passages
dilated, and the foetus perfectly mobile in the liquor amnii, it matters,
I believe, little whether we seize one or both feet, or one or both
knees. All these parts are, under such conditions, so easily reached,
and the whole operation of seizure and version of the child is then
so simple, that it is almost needless to lay down set and formal
rules (as some authors have done) for the exact part of the child
366
FETAL DYSTOCIA.
which you should seize, and the exact mode in which you should
seize that part. There is so much room to turn, as the child still
floats in the liquor amnii, that, if you can seize firmly almost any
part of one or both of the lower extremities with the introduced
hand, you will readily effect your purpose. The flexure of the
knees affords a firmer and better hold than the foot or feet, and is
hence probably preferable. It is, however, I repeat, sufficient to
seize firmly any of these two parts, whichever of them first comes
within your reach.
But the operation of version, in a shoulder or arm presentation,
becomes a much more difficult, delicate, and dangerous operation,
when you require to turn, as in Anderson's case, with the waters
already evacuated, and the uterus tonically contracted, and folded
around the body of the child. Under such circumstances, we require
to know, and to study beforehand, the easiest method of operating
for ourselves, and the most safe mode of operating for the mother.
Let us consider, therefore, what method of turning is the most
simple, and the most practicable, under such conditions as I have
just stated; and first of all let us inquire-
SHOULD WE SEIZE BOTH FEET OF THE INFANT?
You see this method of procedure represented in the plates
before us of Moreau, and it is a mode which is strongly inculcated
by some of our latest authorities in midwifery. "Never be content,"
says Dr. Lee, in his lately published lectures on Midwifery, "never
be content with one foot, when it is at all possible to grasp both.”
In most cases, I hold this method to be improper and unjustifiable,
because it is almost always more difficult to seize both extremities
than to seize one; because one is quite sufficient for our purpose, and
more safe for the life of the mother; and because by pulling at one
extremity, when pulling does happen to be required after the version
is accomplished, we more perfectly imitate the natural oblique position
and passage of the breech of the infant, than when we drag it down
more directly and more upon the same plane, by grasping and
dragging at both limbs equally. The infant also assuredly incurs
less risk of impaction of the head, and above all, less chance of fatal
compression of the umbilical cord, when the os uteri and maternal
canals have been dilated by the previous passage of the breech,
increased in size by one of the lower extremities being doubled up
on the abdomen, than when both extremities being seized and
j
TRANSVERSE PRESENTATIONS.
367
extended, these same passages are more imperfectly opened up by
the lesser-sized wedge of the breech alone.
Notwithstanding, however, the greater difficulties, and conse-
quently the greater dangers attendant on the operation, when we
search for and grasp both lower extremities, instead of one, it is still
so dogmatically laid down as a rule by most obstetric authorities,
that many practitioners seem to deem it a duty not to attempt to
turn the child without having previously secured both feet.
About two years ago, I was sent for by an accoucheur, enjoying
a deservedly extensive practice, in order to assist him in the opera-
tion of turning in such a case as Anderson's. He had introduced
his hand, and brought down one foot into the passages. For a long
time he had been attempting to re-introduce his hand into the
uterus, for the purpose of seizing and bringing down the remaining
foot. His continued efforts, however, had proved perfectly useless,
and he requested my attendance under this supposed difficulty.
Without endeavouring to effect what he had laboured to accomplish
-namely, the seizure and extraction of the retained extremity-I
contented myself with dragging at the one foot already protruded,
and with it alone pulled down the child without difficulty.
In few or no cases of turning is it proper or requisite to bring
down both extremities, unless in the complication of turning under
rupture of the uterus. In that case, but in that only, ought we to
follow at once this procedure-and here we follow it, because, if we
left the other extremity loose in the uterus or abdomen, it would be
apt to increase the lesion in the walls of the organ, if it happened
to get involved in the aperture, or impacted against its edges. In
some very rare instances in which, after version by one leg has been
effected, and immediate delivery is necessary, the cervix and os
internum occasionally contract so forcibly and strongly upon the
protruded limb, whenever we drag upon it, as not to allow of a
sufficient amount of traction being applied to this extremity with-
out fear of lacerating its structures. In such cases also it may be
well to attempt to repass the hand to secure the other extremity,
for then, by pulling at both extremities together, we incur less chance
of injuring them than if we applied the same required amount of
force to either of them singly.
SHOULD WE SEIZE ONE EXTREMITY ONLY?
From what I have already stated, you know my opinion, as to
this being the proper method of proceeding in almost all cases of
368
FETAL DYSTOCIA.
difficult turning. The method was long ago spoken of by Portal ;
and within the present century, Hoffmann and Joerg in Germany,
and my friend Dr. Radford in this country, have severally written
on the subject, and upheld, that in no case of turning ought we to
lay hold of more than one extremity, for the purpose of effecting
the version of the infant. I have just pointed out what I conceive
to be two-perhaps the only two-exceptional conditions to this.
general rule.
Another question meets us. Supposing we intended, in turning,
to bring down the pelvic extremity of the ovoid mass of the child,
what part of that extremity should we lay hold of in order to make it
the presenting part at the os uteri ?
Some accoucheurs have thought, that if we seized and brought
down the breech of the infant, it would be the safest mode of turn-
ing. This method, however, presents so many disadvantages, that
it seems now entirely rejected from practice as a common mode of
performing version; for it is difficult to reach up to the breech of
the child-and it is difficult to take a sufficiently firm hold of it
when you have once reached it--and it is difficult, when once you
have taken hold of it, to perform the evolution or version of the
child with such a purchase.
We may limit, then, the part which we ought to lay hold of to
the lower extremities, and I have already told you that I believe
one extremity sufficient. The remaining question, therefore, is this
-What part of that extremity should we seize upon?
SHOULD WE TAKE HOLD OF THE FOOT OR THE KNEE ?
I believe the seizure of the knee to be preferable in most, if not
in all cases, to the seizure of the foot, or rather, as it should be
more correctly stated, to the seizure of the ankle of the child. I
speak, you will recollect, of turning in cases of shoulder or arm pre-
sentation, in which the liquor amnii has been for some time evacu-
ated, as in Anderson's case, and the uterus, by its tonic contraction,
has clasped itself around the body and head of the child. Under
such circumstances, it is an object of importance not to be obliged
to introduce our hand farther than is absolutely necessary into the
cavity of the uterus, because the contraction of the organ, in many
cases, opposes its introduction, and the forced introduction of it is
apt to produce laceration.-It is an object also of equal moment to
attempt to turn by a part which produces as little change as possible
TRANSVERSE PRESENTATIONS.
369
in the figure and form of the infant; because, if we thrust any of
the angulated parts of the child against the interior of the contracted
uterus, we would also thus be still more liable to produce rupture of
that organ.-Now, holding these points in view, it appears to me that
the turning of the child by seizure of the knee presents several decided
advantages over turning of the child by seizure of the foot. For-
First, The knee is more easily reached. As we slip our hand
along the anterior surface of the protruding arm, and along the
anterior surface of the thorax of the child, we always, if the
attitude of the child has not been altered by improper attempts
at version, or very irregular uterine action, find the knees near the
region of the umbilicus of the infant-the lower extremities, as you
are aware, being folded up in utero so that the knees are brought
up to that part, and the legs flexed upon the thighs in such a man-
ner that the heels and feet lie nearly in apposition with the breech
of the child. To seize a foot, therefore, we would require to pass
our hand about three inches, or, in fact, the whole length of the
leg, farther than we required to do in order to seize a knee.
Secondly, The knee affords the hand of the operator a much
better hold than the foot. By inserting one or two fingers into the
ham or the flexure of the knee, we have a kind of hooked hold
which is not liable to betray us. Every one, on the other hand,
who has turned by the foot or feet, knows how very apt the fingers.
are to slip during the required traction, and how much in this way
the difficulties of the operation are sometimes increased.
Thirdly, We produce, I believe, the necessary version of the
body of the child more easily by our purchase upon the knee-
because thus we act more directly on the pelvic extremity of the
infant's spine, than when we have hold of a foot.
Fourthly, Turning by the foot appears to me to endanger greatly
more the laceration of the uterus than turning by the knee. The
reason of this is sufficiently evident. When we turn by the foot
we have to flex the leg round upon the thigh, and thus at one stage
of the operation, and during one part of the flexion of the leg, we
are obliged to have the leg bent to a right angle with the thigh, and
the foot of the infant thus projected and crushed against the interior
of the uterus. You see this when, on the infant before me, I seize
hold of the foot, and turn it round from its position at the breech,
till I bring it up to the shoulder, the part which we are supposing
to present at the os uteri. You can easily thus perceive (as in the
woodcut) that when the leg of the child is thus brought round, it
370
FETAL DYSTOCIA.
must rasp and scratch, if I may so speak, along the interior of the
contracted uterus, and endanger to a fearful degree the laceration

.ს
Fig. 5.
of the organ. It is needless to say how much this danger is in-
creased when, after having brought down one foot, we pass again
our hand and attempt to bring down a second foot, as is recom-
mended by some authors, for thus we only double the danger of
laceration of the uterus, from the forced and obstructed passage
along its interior of this other extremity.
One point remains for our consideration. Granting that it is
proper to seize a knee, I think it a matter of the very first moment
to know
WHICH KNEE SHOULD BE SEIZED ?
On this point you will find no directions in any of our modern
obstetric works, British or foreign, so far as I know them; and yet
I believe the secret of turning with facility and safety in such a
case as Anderson's-with the waters evacuated and the uterus con-
tracted-depends upon the knowledge of which of the two lower
extremities of the infant should be seized. If we turn with one of
the extremities—and whether the foot or the knee-it should be the
foot or knee of the limb on the opposite side of the body to that which
is presenting. Thus, if the right shoulder or arm presents, we
should take hold of the left knee or foot; and if the left arm or
shoulder presents, we should take hold of the right knee or foot. I
repeat, that I believe this point to be one of the most essential
importance; and the reasons for the rule are simple.
In bringing down the foetus in the operation of turning, we may
and should produce two kinds of alteration in its position and
figure. Thus, we may bend or flex the body forwards upon the
transverse axis of the trunk; and we may rotate or turn the body
TRANSVERSE PRESENTATIONS.
371
round upon the longitudinal axis of the trunk. If we merely flex
it, the operation of version will be one of difficulty; if we both flex
and rotate the trunk at the same time, the operation will be one of
comparative facility. By merely flexing the body upon its trans-
verse axis, we are liable to bring down one of the lower extremities,
whilst we do not displace the upper extremity, which is primarily
presenting at the os uteri. If we both rotate and flex the body-
that is, turn it both on its transverse and longitudinal axes-at the
same moment, whilst we bring down the pelvic extremity of the
child, the turning of the body of the infant carries away from the
os uteri the part originally presenting.
Many of you must be acquainted with the fact, that obstetric
authors have proposed various methods of removing away from the
cervix uteri the presenting arm or shoulder, in order to allow of
more space for the part which is brought down, and to produce the
necessary evolutions of the child. Thus some recommend the pre-
senting part to be pushed up before we seize the feet; others advise
the foot to be seized with one hand, and the presenting part to be
pushed up with the other; and others again counsel us to bring
down one or both feet, secure them with a tape (as you see in a
plate of Moreau), and, whilst pulling with this tape, to introduce
the hand, after the lower extremities are brought down, for the
purpose of pushing up the presenting portion of the upper extremity.
All these rules and complications are at once avoided by follow-
ing the principle that I have just stated to you, of bringing down,
whenever it is possible, the knee opposite that of the presenting
arm or shoulder. When we do this, by carrying the knee diago-
nally across, if I may so speak, the abdomen of the child to the os
uteri, we both, as I have said, flex and rotate at the same time the
trunk of the infant, and in doing so, the semi-rotation of the trunk
inevitably carries up the presenting arm, in proportion as the knee
which is laid hold of is pulled down by the operator. I would
add this, as another of the advantages of turning with one ex-
tremity, for if we pulled down both knees or both feet, or the foot
or knee which was nearest to us, we should produce in many
instances mere flexion of the body, without that rotation of it which
is necessary to carry up and out of the os uteri the presenting part
of the infant.
I have insisted upon the advantages of taking hold of the knee
that is highest and farthest from you, and believe this to be a
matter of the very first moment. Now, it may appear to some of
25
372
FOETAL DYSTOCIA.
you that it would be more difficult to seize this knee than the knee
of the side corresponding to the presenting arm; but if you reflect
for a moment you will see that this difficulty is more imaginary
than real. Both knees of the child, as the infant lies folded up in
utero, are generally in juxtaposition, and lying upon the abdomen
of the infant, near the umbilicus. If, therefore, in passing your
hand into the uterus, you insinuate it, as you ought to do, along
the anterior surface of the thorax and abdomen of the child, you
come in contact with both knees at the same time (see the wood-
cuts). And the rule which I would give you is this, that instead of
hooking your finger or fingers into the flexure of the lower or nearer

α
Fig. 6.
knee (a), you hook them instead into the flexure of the upper, more
distant, or opposite one (b). Both are so far, in general, equally
near, or equally distant, and you seize the one or the other, accord-
ing as you take care to turn your finger so as to hook it into the
flexure of the lower or the flexure of the upper. It has been
strongly objected by some authors to the mode of turning by the
knee or knees, that we cannot with the hand in utero make a
sufficient
DIAGNOSIS BETWEEN THE KNEE AND THE ELBOW.
It is averred that the operator is exceedingly liable to mistake
the elbow of the child for the knee, and thus to bring down the
opposite arm instead of lower extremity—a result that would cer-
tainly render the case only the more complicated. I believe, how-
ever, that we might be, and are, equally liable to confound the
TRANSVERSE PRESENTATIONS.
373
foot with the hand, and thus lead to the same consequence, while
the following simple rule will always enable you to escape the error
and danger of mistaking an elbow for a knee :-Suppose the child
to be lying, as it does, with its extremities doubled up in the uterus,
the elbow and knee may be always distinguished from each other by
the opposite directions in which they point. You have the salient
angle, convexity, or rotundity of the knee, always looking upwards
towards the upper or cephalic extremity of the child, whereas you
have the salient angle, convexity, or rotundity of the elbow, always
looking towards the lower or pelvic extremity of the infant. A
glance at the sketches will show you this. Hence, if we know the
position in which the infant is lying (and this we always do, for
other reasons, ascertain previous to commencing our operation), we
may, by attending to this single fact, easily distinguish in all cases
a knee from an elbow.
There is one point worthy of every attention in regard to the
operation we have been considering, which I have not yet alluded to.
It is this, that particularly in cases of difficulty-you require to
USE BOTH YOUR HANDS FOR THE OPERATION OF TURNING.
In making this observation, I mean that whilst we have one
hand internally in the uterus, we derive the greatest possible aid, in
most cases, from manipulating the uterus and infant with the other
hand placed externally on the surface of the abdomen. Each hand
thus assists the other to a degree which it would not be easy to
appreciate, except you yourselves were actually performing the
operation. It would be extremely difficult, if not impossible, in
some cases, to effect the operation with the single introduced hand;
and in all cases it greatly aids and facilitates the operation. The
external hand fixes the uterus and fœtus during the introduction of
the internal one ;-it holds the fœtus in situ, while we attempt to
seize the necessary limb or limbs, or it assists in moving those parts,
when required, towards the introduced hand ;—and it often aids us
vastly in promoting the version or evolution of the body of the
child, after we have seized the part which we search for. Indeed,
this power of assisting one hand with the other, in the different
steps of the operation of turning, forms the principal reason for
introducing, as I have sometimes done, the left as the operating
hand into the uterus-for thus we can, by passing the right hand
between the thighs, and over the abdominal surface of the uterus
374
FETAL DYSTOCIA.
(the woman lying on her left side), have more perfect control over
the child by our external manipulations with the latter hand. Be-
sides, the left hand, when the patient is in the position I have
described, more readily adapts itself to the configuration and axes
of the pelvis. If we introduce and turn with the right hand, it is
more awkward and difficult to manipulate the abdominal surface of
the uterus with the left.
The mode of turning which I have recommended to you was
followed in the case of Anderson. When I was first called to see
her, all things were in a condition suitable for undertaking the
operation. The membranes had burst some hours previously, when
the os uteri was still comparatively rigid. It is, no doubt, a matter
of moment to be able to turn before the waters have escaped, be-
cause, as I have already stated to you, the operation is then greatly
more simple; but when the membranes do break-as in the case
before us with the os uteri still undilated and undilatable, we must
wait with patience, and employ such measures as tend to relax that
part. In the present instance, bloodletting was had recourse to for
this purpose, and antimony exhibited. A short time before I saw
her, Dr. Barry had very properly given her a large dose of opium,
in order to moderate the spasmodic or clonic contractions of the
uterus, so as to admit of the more easy performance of the version
of the child. The os uteri was quite dilatable when I reached the
hospital, but the tonic contraction of the organ was so great that I
feared there might be some delay and difficulty in the introduction
of the hand, and evolution of the child. Such, however, was not the
case to the degree anticipated, and the version was accomplished in
two or three minutes.
The child was lying with its head towards the right iliac fossa,
and its pelvis towards the left. The face, abdomen, and extremities
of the infant were looking forwards. (See Fig. 6.) I therefore, as
we always do in such cases, passed up my hand between the anterior
or pubic surface of the uterus and the infant, in order to reach more
easily the knec which I wished to seize.
As to the place or side where we ought to pass our hand-that
is whether between the infant and the pubis, or between the infant
and the sacrum-the rule is simple and evident. We pass our hand,
as in the case before us, between the pubis and the infant, when we
know the extremities of the child are looking anteriorly. We pass
our hand between the sacrum and the infant, in those other cases in
which we know the limbs of the child to look posteriorly. We do
TRANSVERSE PRESENTATIONS.
375
so for two reasons-first, because there is always the greatest space
for the introduction of the hand on that side of the foetus to which
its face, abdomen, and angulated extremities look; and, secondly, it
is only, of course, on this side of the foetus that we can find and
secure the lower extremities in order to produce the required evo-
lution and extraction. Dr. Lee lays it down as one of his "two
most important rules" in turning, that, however the trunk and
extremities of the child may be situated—that is, whether the extre-
mities look anteriorly or posteriorly-you ought "to pass up the
hand between the anterior and shallow part of the pelvis, and the
presenting part of the child." If the back of the infant were turned,
as it sometimes is, to this "anterior or shallow part," it would be
impossible, by any search in that situation, to get hold of one or
other of the legs of the child, which are situated in the very opposite
part of the uterus, and on the opposite side of the body of the fœtus ;
-and if the feet were thus really seized, they would be brought
over the back of the child, and the spine so far greatly endangered.
But Dr. Lee's rule is so very obviously erroneous, and the result of
some misconception or disregard of the mechanism of transverse
presentation and turning, as not to require any formal refutation.
His second important rule, " that when one hand is rendered power-
less by the pressure of the uterus, you ought to withdraw this hand,
and replace it by the other," will doubtless be in many cases, I fear,
an unavoidable result of the mismanagement advocated by the first
-and is rarely if ever required when you employ the proper hand
at once. And every new and unnecessary introduction of the hand
must be reprobated, as inflicting a new and additional source of
danger upon the patient, and hence should be avoided as far as
possible.
You saw, in this instance, what are the usual preliminary mea-
sures adopted in connection with the operation of turning. We
kept, as I showed you at the time, the patient placed upon her left
side, with the trunk of her body situated across the bed. The right
knee was raised by the hand of an assistant, and the uterus kept
fixed and steady by pressure on the external surface of the abdomen.
In preparing the hand and fore-arm for the operation of turning,
these parts were perfectly uncovered, and everywhere anointed with
lard, with the exception of the palmar aspect of the hand and fingers.
These latter parts require always to be kept free, in order to secure
a proper hold of the presenting part.
After cautiously passing the hand into the uterus, along the
376
FETAL DYSTOCIA.
anterior surface of the protruded arm, I glided it between the anterior
surface of the thorax of the child, and the anterior wall of the uterus,
laying it flat during one slight pain that supervened, and insinuating
it onwards immediately afterwards, till I reached the two knees
lying in the umbilical region of the infant. I passed one finger into
the flexure of the upper knee, and thus got sufficiently firm hold of
that part, without displacing the lower extremities to any extent.
Assuring myself, as we always do in the process of version of the
child, of the complete absence of all clonic contraction of the uterus, I
easily turned it round with the purchase I had, and brought down
the left lower extremity, the infant making a complete rotation
during its evolution, as we shall see immediately from the direction
of the toes, abdomen, and face.
We thus, you observe, make the version or evolution of the child
during the absence of any uterine pain, but, after bringing down the
extremity, should any further assistance be required towards the
extraction of the child-it must, I beg you especially to remark, be
made not during the absence of uterine contractions, but during the
presence of them.
In most cases, indeed, after the version is per-
formed, we allow the uterine contractions themselves to expel the
infant, but it was not necessary to wait in such a case as Anderson's,
the pains being trifling, and the child being dead. I therefore pulled
gently at the protruding leg during each subsequent contraction, and
ultimately extracted the head from the pelvis by a purchase obtained
by passing two fingers of the right hand over the neck of the child,
and introducing two others into its mouth.
You will recollect that, in Dr. Barry's report of the case, as I
read it to you, he states an interesting and important fact with
regard to the evidence which it afforded of the
NATURAL MECHANISM OF LABOUR IN FOOTLING PRESENTATIONS.
In this instance, as occasionally happens in pelvic presentations
both spontaneous and artificial-we found the toes looking
towards the pubis, from which we knew that the face and chest of
the child must be turned in the same direction-and I stated to
the gentlemen present, that this would not interfere with the process
of extraction of the infant, for the child, during its farther transit,
would rotate round with its toes, etc., towards the nearest sacro-
iliac synchondrosis, and not require any manipulation on our part
to make it come out in that-its proper and most easy position.
TRANSVERSE PRESENTATIONS.
377
or
This is a subject I would wish particularly to impress upon your
minds, for you will find it stated in almost every text-book, that
in all pelvic presentations, whether they occur spontaneously,
whether they are artificial, as in cases of turning, it is proper and
necessary for us to rotate so far the body of the child, that its toes,
and hence its face, should be turned towards the posterior aspect of
the pelvis, or, as some more properly advise, towards the nearest
sacro-iliac synchondrosis.
We are recommended, for instance, by Dr. Hamilton, to observe,
as soon as the child is born as far as the knees, whether the toes
point forwards or not-and if they do point forwards, as they did in
Anderson's case, we are further directed immediately to turn
the child round, so that they may look to the nearest sacro-iliac
symphysis.
But no such manipulation is required as a general rule in spon-
taneous pelvic presentations, and none in artificial pelvic presentations,
especially when you bring down only one extremity. In all the
cases which I have watched, the infant, as in Anderson's, during
the passage of the trunk, rotates and assumes this position itself,
without any interference on our part, and upon the principle which
I stated to you at lecture this morning, when speaking of similar
rotations in head cases, of the mutual physical relation of the child
and pelvis, the former turning within the latter, as the helix of a
partial screw will partially turn within its nut.
In natural or spontaneous pelvic presentations, this rotation that
I allude to occurs normally and naturally during the passage of the
trunk; and that the rotation itself is a mere physical result, and
independent of any vital actions on the part either of the child or
mother, is proved to demonstration by an experiment which I have
several times taken occasion to make-namely, that of dragging by
one foot a dead foetus through the pelvis of a dead mother. If, at
the commencement of this experiment, we place the child with its
toes, abdomen, and face, looking forwards, we shall find that, as the
trunk passes through the pelvic cavity, it regularly rotates round,
so that these parts come to present at the nearest sacro-iliac
synchondrosis.
Now, what holds good in regard to the mechanism of natural
pelvic presentations, holds good also in regard to the mechanism of
artificial pelvic presentations, or of those which we make in the
process of turning. In artificial, as in natural, footling and breech
cases, we ought, I believe, to discard in a great measure from our
378
FETAL DYSTOCIA.
+
mind any necessity for interfering, so as to turn the infant from one
position to another as it passes through the pelvis; for in 9 out of
10, or in 19 out of 20 cases, it will sooner or later assume for itself
the easiest and best position for the passage of the head-namely,
with the face turned towards the nearest sacro-iliac synchondrosis.
This will almost invariably be the case if we do not hurry the
extraction of the child by pulling at the protruded extremities, or if
we pull merely by one-and that the one nearest the pubis. By
dragging, when it is required, at the limb of the child lying next the
pubis, and at this limb only, we pull down the pelvis of the infant
obliquely, so far imitating the presentation and easy transit of this
part of the body in normal pelvic cases, where the anterior ischium.
is always the lowest; and by the same means we promote the
necessary rotation of the child's body, while we should prevent it,
on the other hand, by dragging at the sacral or posterior limb—or
by grasping and dragging simultaneously at both.
All obstetric authors seem to me to err in advising direct inter-
ference, for the rotation of the child in artificial pelvic cases, to be
made by the hands of the practitioner. In speaking of the duties
required in such circumstances, even my friend Dr. Rigby (who, in
other points, inculcates such sound and excellent doctrines with
regard to the mechanism of parturition and non-interference with
it on the part of the attendant), observes, "the uterus must be
emptied as slowly as possible, and the anterior part of the child
must be directed more or less backwards." It will, as I have stated
to you, be directed more or less backwards by the physical relations
between its own trunk and the interior of the maternal pelvis, so as
to require no such adaptation to be attempted by any intermed-
dling on our part. A simple experiment will convince you that
this will occur. I have already stated to you, that in repeated
experiments made by dragging a dead child by one limb through
the pelvis of a dead mother, I have seen the rotation spontaneously
take place. But it will even take place, if I perform the same
experiment much more rudely, by attempting to drag the leather
foetus before us through the bony cavity of this dry pelvis. If I
place, thus, the foetus with the feet in the pelvis, and the toes
directed towards the pubis, or, as is the case in nature, somewhat
obliquely to one side of the pubis, say towards the right foramen
ovale, and drag the foetus through by pulling only at the anterior
or pubic limb of the child, it turns, you observe, spontaneously, as
the trunk passes through the pelvis, so that the face looks at last
SPONTANEOUS EVOLUTION OR EXPULSION.
379
to one ilium, or even backwards towards the nearest, or right, sacro-
iliac synchondrosis; and this extent of rotation will more surely occur
if the right arm chance to pass into the unoccupied space of the left
sacro-iliac symphysis, or rather if that arm be removed so as not to
prevent the rotation of the shoulders and head. The curious and
illustrative experiment I have just shown you, was first pointed out
to me by my esteemed friend Dr. Ziegler.
SPONTANEOUS EVOLUTION OR EXPULSION OF
THE FETUS.
DECAPITATION AND EVISCERATION IN TRANSVERSE PRESENTATIONS.'
CASE I.-Dr. Simpson described a case of spontaneous pelvic evolution which
he had seen in the second child of a twin case. He was called in about an hour
after the first child was born, when the arm and chest of the second child were
already protruding through the vagina, and the process of its spontaneous expul-
sion going rapidly forwards. It was born dead by the unassisted efforts of the
uterus, in the course of a few pains, and by the usual mechanism. He further
alluded to a case some years ago attended here by Dr. Cowan, the arm present-
ing, and the breech at last passing first.
CASE II.-Dr. Simpson subsequently stated another case of its occurrence.
The patient was under the charge of a midwife. Mr. Alexander, who was called
in, requested Dr. S. to see the case, with the view of turning the child.
The mother had already borne four children. The present pregnancy had advanced
to between the seventh and eighth month. When born, the child weighed 3 lbs.
9 oz., and measured 174 inches in length. The labour commenced at 8 A.M., but
made very little progress till the afternoon. At 7 P.M., when Dr. S.
arrived, the shoulder of the child was pressing deeply into the pelvis. The
rectum seemed loaded; and they left the room for a short time, in order that the
nurse might empty the bowel with an enema, before turning was practised. On
being recalled, they found the pains strong, and the body of the child begin-
ning to press down through the pelvic brim-indicating the commencement
of the usual process of spontaneous evolution. Dr. S. remarked that this
peculiarity and change in the presentation had taken place during the ten or
fifteen minutes since they had left the patient-the fœtus had made a slight
turn upon its long axis, so that it presented much more of the back, and less of
the side, than before, the shoulder still, however, maintaining its deep position in
the cavity of the pelvis. The child's body came down, in other words, not with
the spine or trunk bent and doubled up laterally, but bent and doubled up in a
great measure anteriorly. The anatomical structure of the spinal column admitted
far more easily of this anterior flexion than of lateral flexion. Was this a com-
mon turn or rotation in the mechanism of spontaneous expulsion? If so, did
the want of it delay or prevent the process of spontaneous expulsion in some
¹ See Proceedings of Edinburgh Obstetric Society, March 10, 1847, in Edin-
burgh Monthly Journal of Medical Science, May 1847, pp. 869-870; and Session
viii. in Ibid. February 1849, p. 560.
380
FETAL DYSTOCIA.
cases?
And could it be imitated by art so as to allow the process to go on în
appropriate cases? After being forced into this new position, the child was
very quickly expelled by the natural efforts, and according to the common
mechanism of spontaneous evolution. As usual, it was born dead.
He had also met with two cases of cephalic spontaneous evolu-
tion or expulsion, the arm presenting, the head and thorax becom-
ing impacted together in the pelvis, and the head ultimately passing
out before the lower part of the body. One of these cases occurred
in the Maternity Hospital; the other he saw in consultation with
Dr. Skae.
General Deductions regarding spontaneous Evolution.
1st. Spontaneous evolution in transverse presentations was not
so rare as some authors averred, and it would probably occur oftener
if proper and timely assistance were not rendered.
2d. Under some circumstances, arm and shoulder cases should
probably be left to be expelled by the mechanism of spontaneous
evolution, assisting, if necessary, this mechanism by art.
3d. This ought to be our practice, if, in an arm or shoulder
case, the chest and trunk of the child be already thrust down into
the cavity of the pelvis; for to turn under such a complication, and
with that object attempt to push back the body of the child from
the cavity of the pelvis into the cavity of the contracted uterus,
would necessitate the redilatation of the uterus, and hence, in all
probability, produce a rupture of its coats.
4th. If the process of spontaneous evolution failed, two opera-
tions had been recommended to effect delivery, viz. evisceration and
decapitation; and they had always been described as applicable to
the same set of cases; but they were individually applicable in two
different sets.
5th. Evisceration was only applicable to cases of pelvic spontaneous
evolution, demanding operative interference; and decapitation prin-
cipally applicable to cases of cephalic spontaneous evolution.
6th. Of course in all common transverse presentations seen
before the body and bulk of the infant was doubled and thrust down
into the cavity of the pelvis, and while it was still in fact in the
cavity of the uterus, turning was the proper practice, and to wait
for the prospect of spontaneous evolution would be utterly wrong;
and-
7th. A child of the common size would never, in a transverse
presentation, be forced and doubled down into the cavity of the
DORSAL DISPLACEMENT OF ARM.
381
pelvis, unless the mother's pelvis were large in its dimensions; and
hence, when the process of spontaneous evolution is found in an
advanced stage, it is almost a certain sign that the pelvis is of such
measurements as to give a chance of its completion.
Of the two preceding operations, evisceration and decapitation,
the former is generally extremely tedious, an hour or more being
usually necessary:-1. To empty the contents of the thorax and
abdomen; and 2. To drag down the breech with the crotchet.
Perhaps the division of the bony spine would facilitate the whole
matter, and allow the body more easily to double up. Decapitation,
on the contrary, is usually rapid in its execution, and far more
simple. Dr. Rainsbotham's decapitating hook (an instrument the
same as a large polyptome) enables the neck to be surrounded and
severed with little or no difficulty in cases threatening cephalic
evolution, and perhaps could be applied also, if used early, in most
cases threatening pelvic evolution. From the facility with which
we have found decapitation to be effected in two or three instances
of transverse presentation, where the child was distinctly dead, and
turning was rendered difficult either by the contraction of the uterus,
or by the actual advance of the child downwards into the pelvic
brim or cavity, we have a strong conviction that it is a mode of
delivery infinitely to be preferred, under such circumstances, to
violent and repeated efforts at version.
NEW FORM OF OBSTRUCTION IN HEAD PRESENTATIONS
FROM DORSAL DISPLACEMENT OF THE ARM.¹
Dr. Simpson stated that he considered the case to which he
wished to direct the attention of the Society an important one,
because the peculiar obstruction in head presentations which it
illustrated was, so far as he knew, hitherto undescribed. The form
of obstruction consisted in one of the arms of the infant being dis-
placed backwards across the neck or occipital region; or, more
properly speaking, it was the forearm that was thus thrown across
the back of the head and neck, the arm being thrown upwards in a
line with the body, in order to admit of this malposition of the
forearm. In this abnormal position the displaced elbow and fore-
arm of the child first increased greatly the dimensions of the basis
of the head; and secondly, these same parts formed a kind of pro-
¹ See Proceedings of Edinburgh Obstetrical Society, February 13, 1850, in
Edinburgh Monthly Journal of Medical Science, April 1850, p. 389.
382
FOETAL DYSTOCIA.
jecting obstruction, which readily hitched and caught upon the
brim of the pelvis, thus preventing the descent of the head. But
the effects might be better judged of by detailing the case itself.
The patient had previously borne nine children. All the labours
had been easy, and she had frequently been delivered so speedily,
that the labour was over before the medical attendant could reach
the house. In her last and tenth labour, pains came on about four
in the afternoon, and the os uteri was not completely opened up till
about ten o'clock. About an hour before, the membranes ruptured.
At six next morning, Dr. S. received a note from her medical
attendant, Mr. Carmichael, asking him to see her, as the head had
remained in the same position at the brim for several hours, the
uterine contractions were becoming weak, and the woman herself
exhausted. On placing the patient deeply under the influence of
chloroform, in order to make a complete ex-
amination, Dr. S. found the maternal passages
perfectly relaxed and open, and the head of the
child to be by no means large, and not even
entirely filling up the brim. The vertex presented,
and the face was directed towards the left sacro-
iliac synchondrosis-a rare enough position, but
one not in any degree calculated to account for
the delay. On passing the examining fingers far-
ther upwards, in order to trace any possible ob-
struction, he touched a projecting body (the elbow)
beyond the left ear of the child; and on now
making the examination more carefully, he traced
this body backwards across the neck of the infant,
Fig. 7.
and found it to consist of the left forearm of the
child thrown back. posteriorly behind the head. He then brought the
hand downwards and forwards, believing that if it were converted
into a head and arm presentation, the case might terminate without
farther interference. During the next half-hour, however, the
pains, which had for some time been weak, had little effect in for-
warding the presenting parts, and as the pulsation of the child's
heart had now sunk as low as 78 beats in the minute, Dr. S., in
order to preserve the child, again chloroformed the patient deeply,
and delivered the child by podalic turning. The mother made a
speedy recovery. The child soon cried strongly, and went on quite
well. Its left arm was for a day or two after delivery easily thrown
into the position described. The occipito-frontal circumference of

DORSAL DISPLACEMENT OF ARM.
383
the head was afterwards measured by Mr. Carmichael, and found to
be 141 inches; when the arm was placed in its anomalous position,
the same circumference measured 15½ inches. The circumference
of the shoulders was 13½ inches. The child was of about the usual
size, and weighed 74 lbs.
The Treatment of such a cause of obstruction, when it was once
recognised, should probably consist in bringing the hand downward.
and forward over the side of the head, so as to convert the case into
one of simple presentation of the head and arm. Perhaps it might
occasionally be possible to push the elbow forwards in the direction
of the lower end of the sternum, and thus draw back the displaced
arm into its normal position in front of the chest. If either of these
measures proved impossible, or failed, then the podalic version would
be required.
The Diagnosis of the case was the most difficult point in its man-
agement. And in this, as in other complications—as detention from
intra-uterine hydrocephalus, etc.—the assistance of anesthetics in
midwifery was invaluable as a means of enabling the accoucheur to
make a far more searching and successful manual examination and
diagnosis, in cases of obstructed labour, than it was possible to do
when the patient was awake and incapable of bearing with steadi-
ness, and without unnecessary suffering, the introduction of the hand
for the purpose.
When a labour, as in the preceding case, notwithstanding steady
and continued uterine contractions, became morbidly prolonged in
a mother who had previously borne easily a large family, there was
every probability of obstruction of some kind on the part of the
infant. Dr. S. had seen two such cases, where the detention was
the result of intra-uterine hydrocephalus. In the present instance
it was the result of the malposition of the arm. Some time since
he had mentioned to the Society two cases of tedious labour, which,
several years ago, he had seen with Dr. Ziegler: in both, the head,
despite of strong pains, remained in the pelvic brim without descend-
ing; in both, the head was evidently not disproportionately large to
the maternal passages; in both, some point of the shoulder or arm
could be touched by the finger on examination; and, perhaps, if
the examination could have been made more complete by the use of
ether or chloroform, which were then unknown, a malposition of the
arm, similar to the one above described, might have been detected.
Various cases are recorded of obstructed labour, with the head, as
usual, presenting, in mothers who had previously had natural deli-
384
FETAL DYSTOCIA.
veries, and where the forceps failed to extract the child, and where
even extraction after craniotomy was difficult. Some of these cases
were in all probability instances of obstruction from dorsal malposi-
tion of the arm, or rather of the forearm. The late Dr. Campbell,
shortly before his death, had told him of a case here there was no
pelvic or other deformity on the part of the mother, no want of
uterine contraction, and no disproportionate size of the head of the
child, and yet he and others had entirely failed in extracting the
detained infant by the forceps, and at last were obliged to open its
head.
When looked for, Dr. S. believed, therefore, that the dorsal
malposition of the forearm would be found a more frequent cause
of obstructed labour than the total silence of obstetric authors on
the subject might, a priori, lead us to suppose. Further, he con-
sidered the present case as interesting, not only as an instance of an
undescribed species of malposition and obstruction, but probably as
one of a new class of malpositions as yet unrecognised in any of our
accounts of the mechanism of labour, and the malpositions of the
child. It would probably be found that other degrees and forms of
malposition of the arm might occasionally lead to the same result.
ON THE DANGER OF RUPTURE OF THE UTERUS FROM
HYDROCEPHALUS IN THE FETUS.
MODES OF DIAGNOSIS AND TREATMENT.¹
Dr. Simpson described two cases to which he had recently been
called, and in which fatal rupture of the uterus had previously
occurred in consequence of hydrocephalus in the foetus. Both
mothers had borne large families without difficulty. In both cases.
their present labours were very prolonged, and the pains severe
before the laceration occurred. And it might perhaps be laid
down as a general principle, that when a mother who had previously
borne children with the usual facility and safety, suffered a long and
difficult labour, with the head never properly entering the brim,
dangerous enlargement of the head from hydrocephalus or other
causes should be suspected, and the most careful means instituted
in order to make out a correct diagnosis. In this, as in other im-
portant cases, if the patient were put into an anesthetic state, great
¹ See Proceedings of Edinburgh Obstetric Society, March 12, 1848, in Edin-
burgh Monthly Journal of Medical Science, June 1848, p. 885.
HYDROCEPHALUS COMPLICATING LABOUR.
385
facilities would be given for making a careful and leisurely diagnos-
tic examination of the child's head by the hand, without suffering
or resistance on the part of the mother. The unusual size and
dimensions of the head might be thus ascertained; but one source
of fallacy was to be guarded against—namely, that the sutures and
fontanelles were not, as was usually described, always preternatur-
ally open and enlarged in hydrocephalic cases; for the cranial bones
were in some instances, where the internal effusion was very great,
so largely and abnormally developed as to destroy this supposed
pathognomonic sign, and to form an almost complete osseous cover-
ing for the enlarged head. In one of the two cases described by
Dr. Simpson, the cranial bones were, in this way, as large as in a
child two or three years old. When hydrocephalus was attended
with imperfect ossification, the enlarged and fluid head sometimes
moulded itself so readily to the maternal passages as to pass without
much difficulty even when of very great size. But the danger and
difficulty was much increased when to this was added the impedi-
ment arising from enlargement of the bones themselves.
Mechanism of Rupture in Cases of Hydrocephalus.
The danger of rupture of the uterus, and consequent death of
the mother, was much greater under hydrocephalus than obstetric
authors commonly described. In a collection of cases of intra-
uterine hydrocephalus made this year by Dr. Thomas Keith for his
thesis, out of 74 instances of the disease which he had found on
record, in 16 the uterus ruptured during labour. In fact, the
diseased head of the infant, distended by the effused fluid, acted,
under the impression conveyed to it by the body and spine of the
infant during labour, like a hydraulic bag or machine, pressing
equally and in all directions on the cervix uteri, or parts with
which it was in contact, with a force under which these compressed
structures were almost certain to rend, provided the pressure was of
any great duration; because the force itself contained the sum and
concentration of the whole power of the uterine contractions bearing
on each point with which the bag of the head was in contact.
Under such compression, any weak or fissured point was almost
certain to yield. And if any hydrocephalic head or fluid bag of
this kind passed into the vagina and remained there, the kind of
universal compression of the vaginal walls to which it gave rise,
was apt, if it did not lead to direct rending and laceration, to pro-
duce, if long continued, sloughing inflammation in these parts.
386
FETAL DYSTOCIA.
Removal of Hydrocephalic Head by Trocar.
Hence labours, in which the child's head was hydrocephalic,
should not, if possible, be allowed to become prolonged; but when
the delivery was not effected by the natural efforts, it was not per-
haps necessary to destroy entirely such an infant during labour, by
using, as was universally recommended, the crotchet or other mortal
operative procedure. In some instances it was a matter of legal
importance for the parents that the child should be born alive,
though not capable of surviving. And a small trocar passed into
the hydrocephalic collection was capable of evacuating the contained
fluid as efficiently as a more extensive and fatal laceration by the
usual obstetric perforator or scissors; nor was such an evacuation
by the trocar necessarily fatal to the foetus, for we know that in
the operation for hydrocephalus on the child after birth, by Dr.
Conquest and others, the simple puncture of the head was by no
means a fatal operation. Those operated on seldom or never died
of the operation itself, but of the subsequent re-accumulations and
consequences.
Evacuation of Fluid by the Spinal Canal, when the Presentation
is Pelvic.
The hydrocephalic foetus not unfrequently presented by the feet
or breech. In a case of this kind which occurred some time ago to
Mr. Girdwood of Falkirk, and where the child was dead and putrid,
the spine and skin over it lacerated at the neck, in making the usual
tractions to bring down the head. A great quantity of water escaped
from the laceration, and the enlarged head, which had previously re-
sisted the force applied to it, was now easily extracted in its collapsed
state. This case afforded a suggestion, that under a similar compli-
cation, with the body already born, instead of passing our hand and
perforator to the brim of the pelvis, in order to puncture the head,
which was sometimes a matter of no small difficulty, we might attain
the same end, the evacuation of the hydrocephalic effusion, by the
more simple and safe measure of opening the vertebral canal in any
part of the course of the spine.
INDICATION OF DANGER FROM FOETAL PULSE.
387
ON THE STATE OF THE FŒTAL PULSE DURING LABOUR
AS AN INDICATION OF DANGER TO THE CHILD.¹
Dr. Simpson made some remarks on the indications afforded by
the stethoscope for expediting delivery, and especially directed
the attention of the Society to the fact, that while danger was
usually indicated to the mother during labour, by the increased
rapidity of her pulse, the death of the child was most frequently
threatened when the foetal pulse became slower and slower.
It was known that in cases where, during labour, pressure was
exercised upon the cord, as in presentations of the cord, the pulsa-
tions of the foetal heart became feebler, and were at length sus-
pended by the continuous pressure. This was apparently the way
in which the fœtus generally perished, during severe and protracted
labours-the aëration of the blood by the placenta being thus
rendered imperfect, or entirely suspended.
There were, however, rarer cases in which danger was indicated
to the child, by the foetal pulse becoming much more rapid than
ordinary, reaching 150 or 160 beats in the minute, and at the same
time being often very irregular or intermittent. Dr. S. believed the
danger in these latter instances did not result from pressure on the
umbilical cord, as in the cases where the pulsations became slower
and slower, but arose from pressure or some source of irritation acting
on the brain.
ON THE MODE OF APPLICATION OF THE LONG
FORCEPS.2
When the head of the child becomes fixed in the brim of the
pelvis, and the powers of the uterus fail in propelling it through that
aperture, one of two modes of instrumental delivery is usually resorted
to-namely, either, 1. Diminution of the infant's head by perforation
and craniotomy; or, 2. Extraction of it by the long forceps.
Craniotomy is the preferable operation where the child is dead,
and where the pelvic brim is much contracted, or the child's head
very much above the average size. But besides being always neces-
sarily fatal to the child, craniotomy is an operation by no means
without danger to the mother;-one in every five mothers, accord-
¹ See Proceedings of Edinburgh Obstetrical Society, Session xiii., in Edin-
burgh Monthly Journal of Medicine, April 1855, p. 346.
2 See Proceedings of Edinburgh Obstetrical Society, May 10, 1848, in Edin-
burgh Monthly Journal of Medical Science, September 1848, p. 193.
26
388
OBSTETRIC OPERATIONS.
1
ing to Dr. Churchill, dying, upon whom it is performed. And in
most schools of midwifery, it is now, consequently, much more rarely
practised than heretofore. Still many authors and practitioners, as
Drs. Collins, Johnson, Lee, etc., appear to resort to it in all cases in
which the bulk of the head is unable to pass the brim, and reject
entirely the other alternative of the long forceps.
The long forceps afford in these cases the best chance of life to
the child, and when used with proper views of their mechanism and
mode of application, their employment, as is often seen in Edinburgh
practice, is by no means so difficult and dangerous as some authori-
the woodcut.
Fig. 8. .
TOIR
ties seem to believe. Misapprehension
on these points is perhaps the cause
why they are not more frequently
used. They differ from the short
forceps in some points of construc-
tion, but more particularly in regard
to their mode of application and
working. They differ, for example,
in their length; in the shanks being
parallel for some distance beyond the
lock, an indispensable point in order
to prevent their injuring the outlet;
in their blades being curved; and in
the part intended to embrace the head
being sufficiently long and large. The
instrument which Dr. Simpson has fre-
quently and successfully used during
the last five or six years, has some
additional peculiarities, as is seen in
the same as Dr. F. Ramsbotham's,
The blades are
but scarcely so much curved. The lock is Smellie's, but with
knees or projections above it of such size as to prevent the
blades readily unlocking in the intervals between the pains, thus
giving it the fixed character of the locks of Levret and Brun-
ninghausen's instruments, without their complexity. The joints
are made so loose as to allow of their lateral motion and over-
lapping to a very considerable degree, thus facilitating their intro-
duction and application. And, lastly, the handle is that used by
Naegele and other German accoucheurs-viz. with transverse knees
or rests below the lock for one or two of the first fingers of the right
hand to drag by, the long forceps being only properly used as an
1 Operative Midwifery, p. 173.


LONG FORCEPS.
389
instrument of traction, not of compression. In addition, the handles
are grooved and marked on the anterior side, to distinguish that
from the other side when the blades are within the pelvis. The
following are some of the dimensions of Dr. Simpson's forceps :-
Length of the entire instrument, 132 inches; length of handle,
including the lock, 54 inches; length of shank, from the lock to the
commercement of the curve of the blade, 24 inches; length of the
blade, 6 inches; extreme breadth of blade at 1 inches' distance
from the point of the instrument, 13 inches; length of the fenestra,
4 inches; extreme breadth of the fenestra, 13 lines; breadth of the
groove of the lock, 3 inch; thickness of the shank to fit in the groove
of the lock, inch; extreme distance between the blades at three
inches' distance from the point of the forceps when locked, 3 inches;
distance between the points of the two blades when locked, 1 inch.
In their modes of application, the long forceps differ from the
short. The short forceps are applied always to the lateral surfaces
of the child's head, in whatever position the head may be. Gener-
ally, the long diameter of the head lies in the right diagonal diameter
of the pelvis; and, consequently, the short forceps are placed in the
opposite or left diagonal diameter; or, in other words, at right
angles to the long diameter of the head. The mode in which the
long forceps ought to be applied, and are really applied in practice,
has given rise to considerable difference of opinion.
If the long forceps are ever, for inertia, hemorrhage, or other such
complications, in any case applied while the head is passing through
the brim, and the brim and head are natural in size, the instrument
may be perhaps applied, like the short forceps, directly to the lateral
surfaces of the child's head. But the common reason for the em-
ployment of the long forceps is morbid contraction of the brim o
the pelvis in its most general form, and from its most general cause
-viz. in the conjugate or antero-posterior diameter, from projection.
forward of the promontory of the sacrum. How are the long for-
ceps applied when used in this, the case in which they are most
generally had recourse to in practice? It is first requisite to state,
that under this complication the child's head is found situated in the
brim, with its long or fronto-occipital diameter lying in the trans-
verse diameter of the brim, or with the forehead looking to one
ilium, and the occiput looking to the other. In other words, the
long diameter of the head is not placed, as usual, in the right diagonal
diameter of the brim, but more in its transverse; for where the pro-
montory of the sacrum forms a morbid projection, the transverse
390
OBSTETRIC OPERATIONS.
forms the longest diameter of the brim, and, consequently, the one
in which the child's head comes to be placed by the uterine efforts.
The face or forehead looking to the ilium, and the occiput to the
other ilium, the lateral surfaces of the child's head come to be com-
pressed between the protruding sacral promontory and the interior
of the symphysis pubis. Now, in seizing the head in this case some
authors aver, that-
2
1st. The blades of the long forceps are placed, as in applying the
short forceps, on the lateral or aural surfaces of the child's head, and
consequently with one blade in front of the sacral promontory, and
the other behind the symphysis pubis. Burns,¹ Dewees, etc., speak
of thus applying the long forceps in the conjugate diameter of the
brim; and Dr. Churchill' has published a woodcut representing this
as the actual method of their application in practice. But its appli-
cation in this position is impossible in the very cases in which the
long forceps are generally required—―viz. where the conjugate diameter
is contracted, for there is not room for the additional thickness of the
blades of the instrument; if applied, they add to the thickness of the
head in that one diameter and place in which it is already too thick
and large; their pressure would greatly endanger the urethra and
bladder in front, and the soft structures placed over the promontory
of the sacrum behind; and they could not thus be placed in the axis
of the brim in consequence of the pressure of the perineum upon the
instrument below. Other authors aver, that-
2dly. The blades of the long forceps should be placed over the occi-
put and forehead or face of the child, and consequently in the trans-
verse diameter of the brim. This is the view of their mode of
application taken by Deleurye,' Davis, etc. etc., and approaches
much nearer the reality than the former opinion; but that it is not
strictly true is shown by the marking of the place of application of
the blades of the instrument after the child is born, and by a more
attentive consideration of the mechanism of such labours. One
blade is found to have been placed behind one ear, and the point of
the other to have pressed upon the side of the forehead, temple, or
region of the eye; but these would not be the places of the mark-
ings of the blades if they were applied in the transverse diameter,
1 Burns' Midwifery, p. 488.
2 Dewees' System of Midwifery, p. 315.
3 Churchill's Midwifery, Fig. 76, p. 298.
* Deleurye, Traité des Accouchemens, p. 340.
5 Davis' Operative Midwifery, p. 242.
LONG FORCEPS.
391
upon a head placed directly transverse. Dr. Ramsbotham' has
published a beautiful plate of the mode of application of the long
forceps, and has given an excellent chapter on the subject in his
work on Midwifery. He correctly represents in the plate the
anterior blade as placed upon the side of the forehead and eyebrow;
but in order to give this view with the forceps placed in the trans-
verse diameter of the brim, he has been obliged to represent the
face as turned backwards, whilst in reality, in morbid contractions
of the conjugate diameter of the brim, it is actually turned laterally;
and he places the long diameter of the blades of the 'forceps so as
to traverse the right oblique, instead of the left oblique pelvic
diameter.
3dly. The blades of the long forceps should, I believe, be placed
obliquely upon the child's head-one, the posterior, over the side of the
occiput; and the other, or an-
terior, over the side of the brow
or temple; and consequently
they should be generally situ
ated somewhat in the oblique
diameter of the brim, as in the
woodcut. The markings on
the child's head after birth
always show this mode of
application of the instru-
ment when properly ap-
plied upon the mother, and
when their situation relative
to the pelvis is examined,
they are found to have as-
sumed this position; and in
experiments with the instru-
ment, when the head of a
dead child is fixed in a pel-
vis with a contracted brim,
this is the position and re-
lation which the instrument

Fig. 9.
will be seen to assume with relation to the infantile head and mater-
nal pelvis. Besides, in thus placing the instrument, while we incur
less danger of injuring the urethra and other important parts, we
place the blades of the instrument in exactly those parts of the
1 Ramsbotham's Obstetric Medicine, plate lvi.
392
OBSTETRIC OPERATIONS.
66
pelvic circle where there is least pressure, and consequently most.
room for them. It is apparently in consequence of misconception
on this point, that some authors have come to prefer the use of the
perforator to that of the long forceps. Dr. Collins, for example,
argues that when the head is detained in the pelvic brim, the brim.
measuring little more than three inches from pubis to sacrum,'
there cannot possibly be space for the long forceps even were the
bones denuded, seeing that the blades of the smallest-sized forceps
used in Britain, even when completely closed, measure from 31
inches to 3. "How," he adds, "is it possible with the forceps
to drag a child through a pelvis where there is not space, except
by force, to introduce, as is commonly said, a straw, or where, the
smallest flexible catheter cannot be passed in some instances into
the bladder?" These and such opinions proceed on the erroneous
idea that the long forceps are to be applied, within the pelvis, at
the parts, or in the diameter in which the pelvis is most contracted,
and they suppose that the head, when fixed in the pelvic brim, fills
completely the whole circle of the brim. The usual shape of the
morbidly contracted pelvic brim is cordate, or rather elliptico-cor-
date; but the child's head is not of this shape, it is ovoid, and con-
sequently, when applied to the cordate brim, leaves unoccupied
spaces. The most unoccupied spaces, before and behind, are at the
extremities of the oblique diameters of the brim, where sufficient
room is left for the passage of the blades of the forceps, and in these
points they are passed when properly applied.
MODIFICATION OF THE CEPHALOTRIBE.'
Professor Simpson exhibited a number of cephalotribes which

Fig. 10.
were used on the Continent, one of which he used in Dr. Bryce's
¹ See Proceedings of Edinburgh Obstetrical Society, April 27, 1864, in Edin-
burgh Medical Journal, August 1864, p. 180.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY
393
case.
They were all, however, very heavy and clumsy. He had
endeavoured to improve upon them, and had got an instrument
made (see Fig. 10), which he also showed, of a similar construction,
but of much smaller dimensions, being only the length of an ordinary
pair of forceps. He had not as yet, however, had an opportunity
of testing it in the delivery of a child, but was able to thoroughly
break up the base of the skull of a newly-born dead infant.
ON TURNING,
AS AN ALTERNATIVE FOR CRANIOTOMY AND THE LONG FORCEPS,
IN DEFORMITY OF THE BRIM OF THE PELVIS, ETC.
Dr. Simpson, presenting the following papers on this subject in
1850, in a collected form to his pupils, prefaced them with the fol-
lowing remarks:-
During a residence of a few weeks on the west coast of Scot-
land in the autumn of 1847, I wrote the following imperfect Memoir;
and it was subsequently published in different numbers of the Pro-
vincial Medical Journal. The date of absence from my duties in
Edinburgh expired before I had time to finish the Essay; and
hitherto, other avocations and inquiries have prevented me from
redirecting my attention to the subject. Four additional sections or
chapters were intended to be added—namely, one on the mechanism
of the proposed mode of delivery as influencing the steps of the prac-
tice itself; a second, on the cases of obstructed labour chiefly adapted
for delivery by turning; a third, on the best mode of conducting
the operation in these special cases; and a fourth, or last, upon the
history of the practice in ancient and in modern times.
"The Essay is placed in its present unfinished form in the hands
of my pupils, principally with the view of saving time in the dis-
cussion of the subject in the class-room; and the preceding notice
is offered to them as some apology for its many deficiencies."
SECT. I.—ILLUSTRATIVE CASE, AND INTRODUCTORY REMARKS.¹
At a meeting of the Obstetric Society of Edinburgh, held on the
20th of January 1847, I had an opportunity of showing to the
members a large infant, extracted on the preceding evening by the
operation of turning, through a pelvis, the brim of which was greatly
1 See Provincial Medical and Surgical Journal, December 14, 1847, p. 673.
394
OBSTETRIC OPERATIONS.
contracted. The following particulars were at the same time stated
regarding the history of the case.
CASE I.—The mother was very lame, with the lumbar vertebræ much distorted,
and had been twice pregnant. Her first labour had been extremely protracted,
in consequence of the promontory of the sacrum projecting forwards and down-
wards, so as to diminish much the conjugate diameter of the brim. After being
several days in labour, symptoms requiring interference supervened, and Mr.
Figg, her medical attendant, availed himself of the able advice of my friends Drs.
Malcolm and Marr. These gentlemen considered it proper to ascertain whether
the child might not be capable of being delivered, without the dire necessity of
embryuleio. After a long and cautious trial, however, of the long forceps, they
found it impossible to advance the head with them, and were at last driven to
have recourse to craniotomy. Even after the cranium was perforated, and freely
broken down, it was found a matter of much time and difficulty to drag with the
crotchet the collapsed head of the fœtus through the distorted brim, and the
patient made a very long and protracted convalescence.
She was earnestly advised to have premature labour induced, provided she
again fell in the family way; but Mr. Figg was not made aware of her state till
she was near the end of the ninth month of her second pregnancy, and when it
was too late to justify interference. Parturition supervened in a few days. I
saw her with Mr. Figg on the afternoon of the 19th of January, a few hours after
the first labour-pains had commenced. The os uteri was tolerably well dilated,
the membranes still entire; and the head, which was difficult to reach, was found
high and mobile above the brim of the pelvis; a pulsating loop of the umbilical
cord was prolapsed before it. During the course of the few following hours, no
advance being made, I proceeded shortly after nine in the evening, for the labour
had commenced in the forenoon, to make the mother inhale the vapour of sul-
phuric ether, and to extract the child, as I had previously determined to do, by
the operation of turning. The os uteri was so dilated, as not to offer any impedi-
ment to the introduction of the hand; the head was pushed aside, and a knee
seized with great ease. With this hold the infant was readily turned, and its
extremities and trunk drawn down, but the extraction of the head through the
distorted brim was a more difficult task. After the arms were brought down,
very great exertion in the direction of the axis of the brim was required before the
head was extracted; still not above two or three minutes elapsed from the first
introduction of the hand till the complete extraction of the infant.
It gasped
several times after it was born, but full respiration could not be established. Its
head was compressed laterally, the left parietal region flattened, and the anterior
part of the right parietal bone deeply indented by the pressure to which it had
been subjected against the projecting promontory of the sacrum. The transverse
or bi-temporal diameter of the head, at the seat of the indentation, was found, on
careful admeasurement, and when held compressed by the fingers, not to be above
two and a half inches. Hence the conjugate diameter of the brim did not, in any
probability, exceed this. The infant, a female, was large, and above the usual
size; it weighed exactly eight pounds, the average weight of the female infant at
birth being about six pounds and three quarters. In consequence of being placed
under the complete anaesthetic influence of the inhalation of sulphuric ether before
the operation was begun, the mother was quite unconscious of pain or suffering
during the whole process of the turning and extraction of the infant. She made
a recovery that was uninterruptedly good and rapid, and left her bed, dressed, and
walked into the next room, on the fourth day after delivery.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
395
•
The preceding case was, at the time of its occurrence, one of
intense interest to me in two points of view. For, first, it was the
first case in which I or any other accoucheur had ever tried the
effects of ether-inhalation during labour, and so far it is, I believe,
destined to form the commencement of a new and important epoch
in obstetric practice. But, secondly, the case appeared to me to be
one of great moment as an apposite illustration of views which I
· had been previously led to entertain, as to the possibility and pro-
priety of substituting, in some instances, extraction by the feet for
extraction by the crotchet-the delivery of the infant by the hand
of the accoucheur instead of its delivery by instruments-the lateral
compression of the child's head by the contracted sides of the pelvis,
instead of its more dangerous oblique or longitudinal compression
by the long forceps-and, above all, the transient and not necessarily
fatal depression of the flexible skull of the fœtus, for the destructive and
necessarily deadly perforation of it.
It is in this second or latter point of view that I propose to consider
the preceding and other analogous cases in the present memoir.
In directing the attention of the Obstetric Society in January
last to the case which I have stated above, and its relations to the
question of turning, I took occasion to state that I had practised the
same operation as an alternative for craniotomy and the long forceps,
in other instances in which the head had been morbidly detained at
the brim, from the existence of disproportion between the two; and
that I believed it to present the following advantages over em-
bryulcio :-It gave the child a chance of life; it was more safe to
the mother, because it could be performed earlier in labour and more
speedily; it enabled us to adjust and extract the head of the child
through the contracted pelvic brim in the most advantageous form
and direction, the head flattening laterally under the traction; the
neck, if the child were living or only lately dead, was so strong as
to allow us to exert such a degree of traction upon the obstructed
head, that the sides of the cranium might become very greatly com-
pressed, or even indented under it, and that without necessarily
destroying the child; and lastly, it was a practice which could be fol-
lowed when proper instruments were not at hand, and the avoidance
of instruments was generally desirable, when it was possible.
These observations were published in the March number of the
Monthly Journal of Medical Science for 1847, p. 718.' In a later
1 I had previously stated the details of the case just related at page 639, and
I again had occasion to do so at page 721 of that journal.
396
OBSTETRIC OPERATIONS.
number of the same Journal, in describing a case of delivery through
a pelvis extremely deformed by malacosteon, I took occasion to
discuss, in brief terms, the different means of treatment required in
contracted pelves of different dimensions; and I repeated in the
same words the above advantages of turning in comparison with
embryulcio. At the same time I stated, in addition, in relation to
the theory of the practice, my belief "that when the child presents
by the feet, and thus the apex, instead of the vertex or base of the
cone, formed by the head and body of the fœtus, comes first, it may
make its transit without embryulcio, through a pelvis, the smallness
of which would otherwise have necessitated mutilation or the
operation of craniotomy."
The essay from which I make this extract appeared in the
number of the Journal for the 1st of July 1847.
A few weeks subsequently—viz. in the Provincial Medical and
Surgical Journal for July 28th-Dr. Radford of Manchester engaged
in the investigation of the question, by publishing a communication
"On Turning in Labours rendered Difficult by Distortion of the
Pelvis." In this communication Dr. Radford avoids all allusion, by
name or reference at least, to the previous observations which I
had ventured to offer to the profession on the subject, and he pro-
pounds the practice to his readers as if it were a new and original
suggestion on his own part, as far as British midwifery is concerned.
At the same time, in a spirit of true humanity, which does him high
honour, he strongly declares that "whatever practice can safely
supersede the murderous operation-craniotomy-should be adopted."
"The records of operative midwifery ought not," he observes, "to
be stained with so barbarous a procedure, which, according to the
present recognised principles of practice, is so unconditionally and
so unhesitatingly performed." "And," he adds, "it cannot be a
matter of surprise that I should, entertaining opinions that cranio-
tomy ought to be considered an operation of necessity, and not of
election, hail with delight any measure which only promises to
lessen the number of these destructive operations."
Afterwards, Dr. Radford proceeds to offer some remarks which
evidently show that he has mistaken, alike in its principles and in
most of its details, the alternative operation which I had proposed
to substitute for instrumental delivery; the fault, however, is, I
believe, chiefly or entirely, my own, and is a natural result of the
brevity and imperfections of my previous notices on the subject.
Indeed, I have reason to know, that Dr. Radford's misconceptions
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
397
of the proposed practice are, on this very account, shared in by
many others. It is with the anxious view of remedying this defect
that I draw up the present communication, and I trust that the
great practical importance of the questions discussed in it will
stand as some apology for the otherwise unwarrantable prolixity
and repetitions that may possibly be observed in the discussion.
In following out the object I have indicated, I shall treat
severally and successively of the kind of cases which gave rise to
the suggestions of the proposed practice; of the theory, principles,
or mechanism of the practice; and of its advantages in relation to
the curtailment of the duration of labour. I shall then answer the
objections which I have heard raised against it, in relation to the
safety of the infant, and the safety of the mother; and lastly, I
shall consider the classes of cases best adapted for the practice, and
the conditions requisite for its success.
SECT. II.—EVIDENCE SUGGESTIVE OF THE PRACTICE.'
1
In studying, in their more minute details, the obstetric histories
of recorded cases of morbid contractions of the pelvis, I have often
been forcibly struck by the circumstance, that apparently when the
child presented preternaturally, and in consequence ultimately
passed with the feet or pelvic extremity first, the labour seemed
frequently both easier and safer to the mother and infant, than
when, in other labours in the same patients, the head of the fœtus
happened to form the presenting part. In this way, mothers who
had always suffered under very severe and instrumental labours,
when their children presented with the head foremost, were, I
found, not unfrequently fortunate enough to escape far more easily,
when, at other times, the infant chanced either to present originally
with the feet, or had the feet artificially brought down during the
labour in consequence of the infant lying transversely with the arm
or shoulder constituting the presenting part;-nay, the history of
some few cases incidentally but strongly showed, that when the
distortion and obstruction in the maternal passages were so great
as to have invariably necessitated in all the previous labours the
death of the infant by the operation of craniotomy, a living child
was occasionally at last happily born alive, when it happened to
pass, or to be brought through the contracted pelvis as an original
or artificial footling presentation In such instances the presentation
¹ See Provincial Medical and Surgical Journal, December 14, 1847, p. 675.
398
OBSTETRIC OPERATIONS.
of a hand or foot, when first discovered at the commencement of
labour, has been regarded as an undoubted source of increased
danger and difficulty, but it has at last more frequently proved a
source of increased safety to the mother, and the indirect means of
the preservation of the infant.
As an illustration of these remarks, I might appeal to the
evidence of many different cases observed and recorded by different
authors, without any view to such a question as that which forms
the subject of the present memoir. But to avoid superfluity of
proof, I will in the meantime restrict the evidence to a very abridged
statement of similar cases recorded by one or two authors; and for
this purpose, I first select the work of Dr. Smellie, believing, as I
sincerely do, that his writings are not less remarkable for the
strong thought and singular practical sagacity which they display,
than for the spirit of candour and truthfulness with which all his
facts are reported. In his volumes, Dr. Smellie has recorded an
unusual number of contracted and distorted pelves; among them I
find the following cases illustrative of the remarks which I have
ventured to offer in the preceding paragraphs. The three first cases
relate to natural pelvic presentations; the two last are instances in
which the child was extracted footling, in consequence of its present-
ing transversely, or with the upper extremity.
CASE II.-To a woman "who had suffered very much in her former labours
from the pelvis being distorted," Dr. Smellie was called, and found the breech of
the child presenting. The extraction of the head required considerable manage-
ment, but the child was saved.1
CASE III. Dr. Smellie's assistance was requested for a patient with "the
breech presenting, and the pelvis distorted." The midwife told him "that the
woman's former labours had been very difficult and tedious, but now as the breech
presented she was afraid the difficulty would be greater." He "saved this child
also, although a good deal of force was used to deliver the head, ”2
CASE IV. — A woman, with the "pelvis narrow," and "who formerly was used
to have tedious labours," had a breech presentation. Dr. Smellie brought down
the legs, as the breech did not advance with the assistance of the strong pains."
The child was delivered with difficulty, but alive."
CASE V.-A woman, with the "pelvis distorted and awry, from the right
ilium being much higher than the other," was three times pregnant. The first
labour was terminated by craniotomy. The child in the second labour was pre-
mature, and presented by the arm. It was brought away alive by turning. In
her third labour the child reached the full time, presented by the head, was
turned and lost.4
1 Collect. 32, Case 10.
2 Ibid. Case 2.
3 Ibid. Case 13.
4 Ibid. 34, No. 2, Case 1.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
399
CASE VI.-A woman, with " a narrow and distorted pelvis, from the three
lowest vertebræ of the loins bending forward," four times reached the full period
of pregnancy. In her first and third labours the child required to be mutilated
by craniotomy before delivery could be accomplished. The infant in the second
labour was small, and "with the greatest difficulty saved, by the assistance of
the forceps." At the fourth confinement the right shoulder of the child presented.
Dr. Smellie first tried cephalic version, but failed. He then seized one leg,
turned the child, brought out the body and extremities, and ultimately, after
much exertion, extracted the head. The child was alive. The mother recovered
better than in any of her preceding labours.¹
In his Clinical Midwifery, Dr. Lee reports the following case as
one probably similar to those which first suggested the propriety of
the artificial induction of premature labour :-
CASE. The patient had been five times pregnant. She was delivered of her
first child by craniotomy. Dr. Lee employed the same operation to deliver her
at her fourth confinememt. "At the end of the seventh month of her second
pregnancy, labour came on spontaneously, and the child was born alive without
artificial assistance, and has been reared." Her third pregnancy was terminated
by labour coming on at the commencement of the eighth month. "The nates
presented, and the child was also extracted alive." "Dr. H. Davies induced
premature labour at the seventh and a half month of her fifth pregnancy, and the
child was born alive, but died soon after in convulsions."
Occurrences similar to what happened in the preceding case
must, observes Dr. Lee," originally have suggested the idea of bring-
ing on premature labour artificially in cases of distorted pelvis, and
probably led, in 1756, to that consultation of the most eminent
practitioners in London, at which the practice was approved of, and
soon after successfully carried into effect by Dr. Macaulay ;"* and
by a similar study of the modes of delivery occasionally adopted by
nature in the same cases of distorted pelvis, we have, I think, sug-
gested to us likewise the propriety of artificially turning and extract-
ing the infant as a footling presentation. I shall cite only one other
case from the same writer, showing the degree of difficulty in
contracted pelvis to be less when the child passes by a pelvic or
footling presentation, than when it presents and passes by the
cephalic extremity.
CASE VII.-A patient, with the outlet and brim of the pelvis both consider-
ably contracted, was delivered of her first child by craniotomy, after being more
than forty-eight hours in labour, and extremely exhausted. "The difficulty," Dr.
Lee remarks,“experienced in extracting the head with the crotchet, after it was
opened, proved that delivery could not have been completed by any other method."
At her third labour she was again delivered by craniotomy, after the labour had
1 Collect. No. 5, Case 2. 2 Clinical Midwifery, Case 81, p. 39.
400
OBSTETRIC OPERATIONS.
endured for some time, and four fits of convulsion had supervened. "I found
her," says Dr. Lee, "completely insensible, with dilated pupils and constant con-
vulsive movements of the muscles of the face. The pains continued with such
violence, and recurred at such short intervals, that I dreaded rupture of the
uterus.
The small size of the pelvis, the impossibility of applying the
forceps to the head, the imminent risk of rupture of the uterus, with the result
of the former labour, were the circumstances which made me determine to open
the head." At her fourth confinement, the child's head was again perforated.
Labour had commenced on the 2d of December; the liquor amnii escaped soon
after; the pains continued strong and regular during the whole night. On the
morning of the 8th, six days after labour "had commenced," the head being still
wedged in the brim, the abdomen tense, the patient occasionally delirious, etc.,
craniotomy was performed. The patient was thus delivered by embryulcio in her
first, third, and fourth labours. The history of her second confinement is this-
"I proposed to induce premature labour on the 21st of July 1835, when she was
seven months and a half pregnant; but she would not consent to this. Labour
came on spontaneously at the commencement of the ninth month of pregnancy ;
a foot presented, and the child was extracted dead, without craniotomy.'
"1
These, I repeat, and similar instances (and I shall have occasion
to quote cases still more striking in the sequel), appear to me to
point evidently to this probable conclusion-that in particular forms
and instances at least, of distorted pelvis, the passage of the child by
the feet or pelvic extremity affords to it and the mother some
special facility of transit which is wanting when the head or cephalic
extremity forms the presenting part. And we have thus placed
before us this problem :-Upon what does this greater facility and
safety of footling, as compared with head presentations, in such cases,
depend? Let us proceed to the consideration of this point, and
attempt to ascertain how this result is obtained.
SECT. III.—THEORY OR PRINCIPLES OF THE PROPOSED PRACTICE."
The form of the infant at birth has often and justly been com-
pared to that of a cone; the feet serving as the apex, and the arch
or bi-parietal diameter of the head forming the basis of the cone,
and there being a gradual tapering and increase of size from the
former to the latter point. Consequently, when, in cephalic presenta-
tions, the head or broad end of the cone once dilates and passes a
given point, the narrow remainder of the cone, viz. the trunk and
extremities, afterwards pass it without impediment. In fact, both
in cranial and in footling presentations-even in instances of con-
tracted pelvis-the transit of the body is usually attended with no
special difficulty or delay. The obstruction is referable to the
¹ Clinical Midwifery, p. 62.
2 See Provincial Medical and Surgical Journal, January 12, 1848, p. 1.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
401
child's head alone; and hence the necessity of accurately studying
the obstetric configuration and relations of the foetal head, in order
to be able to overcome the obstruction offered by this part.
a
C
la
Now, besides that the whole infant is, as I have just stated, of
a conical figure, the head taken alone pre-
sents more imperfectly the same configura-
tion; for the basis of the skull is consider-
ably narrower than the arch; or, in other
words, its bi-mastoid diameter (b b, Fig. 11)
is less than its bi-parietal diameter (a a),
so that the cranium increases gradually in
breadth and size, like the whole body, from
below upwards.

b
Fig. 11.
The bi-parietal diameter of the head or
vertex is, in this way, the basis both of the cone of the whole body,
and of the cone of the head taken singly.
To understand thoroughly, however, the subject of our present.
inquiries, it is necessary to have some more precise and definite
ideas of the degree of tapering of the cranium from its broad arch
to its narrow basis; or, in other words, it is requisite to fix more
accurately the degrees of difference between the bi-parietal and bi-
mastoid diameters of the head. With this view, I made some
months ago, upon the heads of several new-born infants, a variety
of measurements relative to these two points. I arrived at nearly
the same conclusions as those which I afterwards found Mr. Tomlin-
son had previously obtained, when admeasuring the foetal head for
the purpose of assisting Dr. Hull in his inquiries as to the smallest
dimensions the skull could be possibly reduced to, by the operation
of craniotomy. And, to prevent all cavil, I will here take Mr. Tom-
linson's measurements as standard and correct, and the more
valuable on this account, that they were made and published with-
out any view to such a question as the present.
Mr. Tomlinson gives, among other measurements of the head,
the breadth of the bi-parietal and bi-mastoid diameters in six infants
at birth. I shall throw them into a tabular form, and add a column,
showing the difference between these two diameters in each case.
Fig. 11. Vertical section of a fatal skull, showing its conical form.
402
OBSTETRIC OPERATIONS.
TABLE I.
MEASUREMENTS OF THE BI-PARIETAL AND BI-MASTOID DIAMETERS OF THE
HEADS OF SIX INFANTS AT BIRTH.

Number of Case.
Bi-parietal
Diameter.
Bi-mastoid
Diameter.
Difference
between the two
In.
8ths.
I.
II.
III. (a twin)
IV.
V.
VI.
3
4
2
...
co co co co co
3
6
3
3
1
2
3
2
2
3
3
2
3
2
ÉNÛNNNN
In.
Sths.
In.
Sths.
7
5
...
2
4
6
3
6
4
...
6
6
5
6
We thus find a difference between the bi-mastoid and bi-parietal
diameters of the head, varying from three-eighths to six-eighths of an
inch, or from four and a half to nine lines. Or, if we exclude, as in
fact should properly be done, the third case, as being a twin infant,
and consequently having the head and body smaller and less re-
markable than in a single and full-sized child-then we have, in
the remainder, a difference between the bi-parietal and bi-mastoid
diameters, varying from six to nine lines-that is, from four to six
eighths of an inch; or, in other words, from half-an-inch to three
quarters of an inch.¹ And in artificially extracting an infant through
a narrow pelvis, as a footling instead of a head presentation, we may
gain, I believe, when necessary, this great difference between the size
of the body to be extracted, by varying the method of the extraction
itself. For it must be further held in view that at its base (or bi-
mastoid diameter), the cranium of the infant is so strong, and its
bones so firmly and densely united, as to render it quite incompress-
ible. On the other hand, at its arch (or bi-parietal diameter), the
cranium at birth is, in general, so thin, and its bones so loosely and
imperfectly united, as to permit of the head being much flattened
and compressed, or even depressed and indented at some point,
without necessarily destroying life.
Now, when the brim of the pelvis is morbidly contracted at one
part-let us imagine, for instance, its conjugate diameter to measure
only three inches instead of four-then the child, upon being forced
1 "From the one parietal protuberance to the other, a transverse line measures
from three inches and a quarter (34) to three inches and a half (3). From one
mastoid process to the other along the base is about two inches (2). From the one
temple to the other is two inches and a half (2§).”—Dr. Burns' Principles of Mid-
wifery, 10th edition, p. 25.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
403
down upon it as a head-presentation, meets with difficulties which,
probably, no uterine effort could possibly surmount. A round body,
the diameter of which is some lines above three inches, is attempted
to be pushed through an opening measuring only three inches. But,
turn the child, extract it footling, and let the head pass through the
contracted brim, by engaging in it first the base or bi-mastoid
diameter of the cranium, and the difficulty may possibly be over-
come; for then we have the head entering the contracted brim of
three inches as a body less in its diameter than three inches, and
capable of having its broader upper portion flattened and reduced to
the size necessary for its complete transit, by the force which we can
apply to the already protruded body of the infant, producing the
requisite degree of lateral compression of the cranium against the
opposed sides of the contracted pelvic brim.
Or, let us take another and perhaps simpler view of the subject.
Suppose, in want of a better woodcut, we take the letter A as a
round cone simulating the figure of the infant, the apex of the letter
corresponding to the feet of the infant, the base of it corresponding
to the bi-parietal diameter of the head, and the cross-bar of the letter
representing the incompressible floor or basis of the skull, and the
two divergent feet of it representing the elastic and compressible
arch of the cranium. Now, if we desired to pass this round cone A
through an oblong aperture O, the diameter of which was somewhat
less than the diameter of the basis of the cone, should we succeed
best by pushing it through the oval opening with its basis foremost,
or by dragging it through it with its apex foremost? If we extract
the cone through the aperture by bringing its narrow end foremost
—or, in other words, if we bring the child by the feet instead of the
head-then two objects are gained; for, first, we have the power of
using any justifiable degree of force that may be required, by the
command we thus obtain of the protruded and narrow end of the
cone; and, secondly, the elastic sides of the base of the cone situated
above the cross-bar-or, in other words, the sides of the cranium
itself above its basis-will yield and become compressed together to
such an extent as to enable the collapsed body to pass through the
supposed opening. If, on the other hand, we attempt to make the
broad basis of the cone, or the vertex of the head, to pass first through
an aperture less than its own diameters, then we are apt, the more
we press, to increase rather than diminish the difficulty attendant
upon its transit; for the more force we apply we are liable to render
that part which is already too broad, still broader, by flattening it
27
404
OBSTETRIC OPERATIONS.
against the sides of the aperture, and making its limbs or parietes at
one point or another diverge and widen, instead of converge and
contract. It is true that if we can insinuate, obliquely or otherwise,
the basis of the compressible cone (or the arch of the head), into the
contracted aperture, so as to get its sides compressed between the
sides of the opening, and consequently its bi-parietal diameter less-
ened by the force with which the body of the cone is pushed down-
wards, a similar object would be gained, but in a more uncertain
and imperfect degree. Besides, there is always in this way the
chance of making the two sides of the cranial arch (2 2, Fig. 12)
spur out, and diverge lower down at their basis, in proportion to the
amount of force applied to the upper surface of the arch itself (c c);
so that, while we contract the sides of the arch above by the kind of
pressure applied to it, the direction of that pressure may possibly
widen and open the limbs of the arch below, and so far increase, for
the time being, the difficulty accompanying the transit of that part.
But this transverse or lateral form of flattening and compression
a
Ъ
1
Fig. 12.
of the cranium is very far indeed from being
always obtained when the vertex is allowed
to present at the brim of a distorted pelvis ;
a for frequently the whole, or the greater
mass at least, of the head remains obsti-
nately above the brim, despite the action of
the propelling efforts upon it of labour-
pains, both dangerous in the amount of
their duration, and dangerous in the amount
of their force. By bringing, however, the
apex of our cone, or the narrow diameters of the cranium foremost,
we not only improve and simplify the mechanism of the labour by so
far converting the entrance and passage of the child's head into the
contracted pelvic brim, from a matter of comparative chance into a
matter of comparative certainty; but further, we effect thus, in the
course of minutes, by turning, what it might require the course of
hours or days to accomplish, provided the transit of the foetal head
were left as a head-presentation to nature alone, or to nature assisted
at last artificially by the long forceps or crotchet.

Fig. 12. Illustrating the effect of pressure upon the top of the arch of the
fœtal cranium, as happens when the head presents. The dotted line, cb b c, is the
vertical section of a normal foetal skull, as seen in Fig. 11. The outline, 1 2 2,
shows the disadvantageous alteration in form produced by the presentation of the
head to a contracted pelvis.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
405
Ъ
But other advantages are obtained by turning, as compared with
embryulcio and the long forceps, in the class of cases which we are
considering. We not only bring the tapering or cone-shaped fœtal
head through the distorted brim, by making its narrow extremity
enter first into the contracted aperture, and afterwards using the
sides of that aperture to compress the elastic parietes of the broader
and higher part of the cranium, but in some cases we in this way, I
believe, eschew altogether engaging the broadest part of the head
(a a, Fig. 12), in the narrowest part of the contracted pelvic open-
ing-a circumstance and adjustment that, in a head-presentation,
would be otherwise quite unavoidable. For, besides being found of
a conical form when looked at vertically,
the infantile head shows the same con-
figuration also when viewed antero-pos-
teriorly. The accompanying outline, for
instance, of the foetal head, as seen from
above, is an exact copy of that given in
Chailly's late work on Midwifery, and
shows that while the head is very broad
behind in its bi-parietal diameter (a a,
Fig. 13), it gradually tapers and diminishes.
in breadth as we proceed forward to its
bi-temporal and bi-frontal (b b) diameters;
and its bi-temporal diameter is in general fully half-an-inch less
than its bi-parietal. But, in the mechanism of head cases, the
neck, as is well known, becomes early flexed in the labour, so
that the chin is brought towards the top of the sternum, and
the vertex or upper and back portion of the head first becomes
pushed downwards into the pelvic aperture, and thus constitutes the
presenting part-in other words, the broadest part of the cone of
the whole child, because the broadest part of the head, or its bi-
parietal diameter, is thus naturally first driven downwards into the
pelvic cavity, and is first directed against the contracted brim. The
same head, when extracted as a footling presentation through the
same distorted pelvis, will in some instances entirely escape having
this, its broadest part, placed and engaged in the narrowest part of
the pelvic aperture; for, as the extremities and the body of the
child are gradually extracted in the operation of turning, the head,
in ultimately adapting itself to the shape of the pelvis, comes to
have its bi-temporal, and not its bi-parietal, diameter implicated in
Fig. 13. Outline of the foetal head as seen from above.-(From Chailly.)

Fig. 13.
406
OBSTETRIC OPERATIONS.
1
the narrowest or conjugate diameter, the parietal protuberances
passing into the wider lateral space opposite the sacro-iliac synchon-
drosis. That such is the fact, the position of the mark or indenta-
tion upon the skull, produced by compression against the protruding
promontory of the sacrum in Case I., and in other instances which
I shall afterwards quote, amply proves. The injury and depression
of the cranium, if any, seems always situated before the ear, and
consequently much before the parietal protuberance; or, in other
words, it is, as I have said, in the temporal region. The anterior
edge of the parietal bone, or the anterior edge of it and the corre-
sponding posterior edge of the frontal, are generally the osseous
points that are depressed and indented, as represented in the accom-
panying diagram.
Now, the child's head narrows greatly from behind forwards,
from the occiput towards the forehead, as seen in Figure 13; and


A
D
T
B
Fig. 14.
Fig. 15.
1
in the temporal region its diameter is generally from three to five
eighths of an inch, or from four and a half to seven and a half lines
Fig. 14. The form in which the bones of the fatal cranium are compressed in
passing through a contracted brim. A. Promontory of sacrum. B. Symphysis
pubis. C. Unoccupied space between the ilium and forehead of the child. D.
Depression in child's head corresponding to the promontory of the sacrum. E.
Anterior fontanelle. F. Posterior fontanelle.
Fig. 15. Illustrating the effect of lateral compression upon the sides of the
arch of the fœtal cranium, as happens when the child is extracted footling. The
dotted line, a bab, is the vertical section of a normal foetal skull, as seen in
Fig. 11. The outline, 1 2 1, shows the advantageous alteration in form pro-
duced upon the fatal cranium by extracting the child footling through a con-
tracted pelvis.
¹ See, for example, the figures of indented fœtal skulls given by Professor
Sandifort, in pl. xxxiv. of vol. ii. of his Museum Anatomicum.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
407
less than between the two parietal protuberances.' Hence it is
evident that a great gain is effected by the head passing through
the narrowest part of the brim, with a diameter at least several lines
less than it otherwise would offer, provided it happened that the ver-
tex of the head had been kept and retained as the presenting part.
In order that the full-sized foetal head may pass through a con-
tracted pelvic brim, we require to have the head flattened laterally,
and its sides at its anterior parietal or temporal region collapsed
and compressed. The outline, a b a b, Fig. 15, is the outline of
the vertical section of the infant's skull that I have already given.
in Fig. 11. The line, 1 2 1, marks what we may presume, for the
sake of illustration, to be the shape and degree of compression to
which the head would require to be reduced in order to pass the
contracted pelvic aperture.
Would this necessary degree of compression be effected more
easily and by less amount of force if the head were drawn through
the narrow pelvis as a footling presentation, than if it were driven
into it as a cephalic presentation? I certainly believe that less
power would be required to produce the same degree of lateral
compression and collapse in the cranial arch, provided the com-
pressing force were applied, as in cases in which the child is ex-
tracted footling, directly to the two sides or lateral surfaces (1 1,
Fig. 15) of the arch itself, than under the alternative condition
supposed. For if the child descended into the pelvic brim as a
head presentation, the uterine contractions would drive it against
the narrow points of the pelvic brim, so that the reacting compress-
ing power of these points would be applied either to the two upper
surfaces of the arch (c c, Fig. 12), or partly to one of them (c), and
partly to one of its opposite lateral surfaces (a a, Fig. 15). In such
circumstances the compressing powers would be acting much more
indirectly, and far more at a disadvantage in effecting the required
compression, than if they were applied, as in extracting the child.
footling, directly and immediately to the sides themselves (a a, Fig.
15) that are to be compressed.
"Does the head," asks Dr. Radford, "elongate more readily up-
wards than downwards? If only," he answers, "the same degree
of extractile force is used, it does not." But what I have stated
1 See preceding note from Dr. Burns' Midwifery. Chailly gives the bi-parie-
tal diameter as three inches and a quarter (34) to three inches and a half (34);
and the bi-temporal diameter as two inches and a half (24) to three inches (3).—
See his Treatise on Midwifery, 1844, translated by Dr. Bedford, p. 62.
408
OBSTETRIC OPERATIONS.
shows that the same degree of extractile force will produce the
desired effect more easily, and as we shall afterwards see, more
safely also, when the child passes with the pelvis, than when it
passes with the head first. And this I believe, affords us another
advantage in the mechanism of footling as compared with cephalic
presentations in instances of diminished pelvic brim. We are
enabled to produce by it the same amount of compression of the
foetal head by a less expenditure of compressing force, for we apply
it to the lateral surfaces or piers of the cranial arch (a a, Fig. 15),
and not to its pedentures or upper surfaces (c c, Fig. 12). We
effect a saving of force by the direction in which we apply the force.
I am well aware both that it is exceedingly difficult to state
accurately and intelligibly the opinions one may happen to entertain
on such a subject as we have been discussing in the present section,
and that I am far from having succeeded in making the demonstra-
tion so simple as I could wish. It may assist, however, our com-
prehension of the matter if, before concluding it, we try to
recapitulate and sum up the advantages which, in regard to the
mechanism of labour, are, in the contracted states of the pelvic
brim, obtained by the child passing as a footling instead of as a
cephalic presentation. These advantages, as far as I have hitherto
attempted to trace them in the preceding remarks, for we shall
trace out more of them afterwards, amount to the following:-
1. The foetal cranium is of a conical form, enlarging from below
upwards, and when the child passes as a footling presentation, the
lower and narrower part of the cone-shaped head is generally quite
small enough to enter and engage in the contracted pelvic brim.
2. The hold which we have of the protruded body of the child,
after its extremities and trunk are born, gives us the power of em-
ploying so much extractive force and traction at the engaged fœtal
head, as to make the elastic sides of the upper and broader portion
of the cone (viz. the bi-parietal diameter of the cranium) become
compressed, and, if necessary, indented, between the opposite parts
of the contracted pelvic brim, to such a degree as to allow the
transit of the entire volume of the head.
3. The head, in being dragged downwards into the distorted
pelvis, generally arranges itself, or may be artificially adjusted, so
that its narrow bi-temporal, instead of its bi-parietal, diameter, be-
comes engaged in the most contracted diameter of the pelvic brim.
4. The arch of the cranium or head is more readily compressed
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
409
to the flattened form and size required for its passage through a
contracted brim, by having the compressing power applied, as in
footling presentations and extraction, directly to its sides or lateral
surfaces, than by having it applied, as in cephalic presentations,
partly to the lateral and partly to the upper surfaces of the arch.
Lastly, I may add, as a result of the whole mechanism, that the
duration of the efforts and sufferings of the mother is greatly abridged
by turning, when used as an alternative for craniotomy and the long
forceps, and that thereby her chances of recovery and safety are
increased. But as this is itself a matter of the highest moment, in
reference to the whole question of the proposed practice, we shall
devote a special section to the consideration of it.
SECTION IV. THE DURATION, AND CONSEQUENTLY THE DANGER,
OF THE LABOUR IS DECREASED BY THE PROPOSED PRACTICE.¹
2
In the short summary which I gave in January last of the ad-
vantages of turning, over embryulcio, I stated one strong reason in
favour of delivery by the alternate operation to be this-" that it
was more safe to the mother, because it could be performed earlier in the
labour, and more speedily," than craniotomy, or the application of
the long forceps. And I have the most sincere belief that the prac-
tice I propose may be the means of saving much, both of maternal
and infantile life, by enabling us in some cases to abridge the mere
duration of a difficult labour, so that we may terminate in a few
minutes a delivery, which, under other plans of treatment, might still
be protracted onwards for hours or even for days. At the same
time I am fully aware that when I state my conviction that the mere
degree of duration and continuance of a labour is, per se, dangerous
both to the mother and child, and very often fatal even in its
influence, I venture to broach a doctrine which stands up alike
against the opinion and the practice of some of the highest authori-
ties in the obstetric profession.
About half-a-century ago, when treating of the influence of the
duration of labour in difficult and instrumental deliveries, Dr.
Osborne observed" I believe it is confirmed by general observation,
that women recover at least as well, after long, lingering, and
laborious labours, the duration of which may have been extended
to several days, as after the easiest, quickest, and most natural
1 See Provincial Medical and Surgical Journal, February 9, 1848, p. 57.
2 Monthly Journal of Medical Science, March 1847, p. 718.
410
OBSTETRIC OPERATIONS.
" 1
delivery.' In making this remark, Dr. Osborne stated not his own
opinion only, but, I believe, the general opinion of the accoucheurs
of his time; and the same doctrine, little or not at all modified,
still continues to be taught and acted upon, down to the present
day, in the great English and Irish schools of midwifery, as the able
and excellent writings of, for example, Professors Davis and Murphy
in London, and Drs. Collins and Beatty in Dublin, etc., fully
testify.
That, per se, the duration of labour has no very direct nor decisive
influence upon the degree of danger and fatality accompanying par-
turition, is a doctrine which probably originated in, and has been
perpetuated by, an erroneous system of observation. In founding
and supporting it, obstetricians have, I believe, drawn their de-
ductions, not from the whole of their practice, but from parts only of
it; they have not reckoned upon the certain results of their general
collection of facts, but depended upon the fallacious results of isolated
and individual instances; they have not, in short, counted up the
terminations and consequences of all their protracted cases, but
have relied upon the evidence of some single striking case or cases of
perfect, and it may be, rapid recovery after labour of a very pro-
longed duration. In proceeding thus, obstetric authors have not
followed a course altogether different from that pursued in the study
and investigation of many other similar questions in medical science
and practice. For confessedly, the medical mind has ever been too
apt to recollect and reason upon those facts only which are in favour
of any preconceived opinion or opinions it may chance to have
adopted; and the cases of failure are too often forgotten amid the
more agreeable remembrance of the cases of success. It is on this
account that the numerical method of reasoning and investigation,
by obliging us to count up all our cases, and all our results, whether
good or bad-whether instances of recovery or instances of death--
is no doubt destined to revolutionise, in a great degree, our modes
of inquiry, particularly in surgery and midwifery, by imparting
infinitely more precision and certainty to our present deductions.
and precepts where they are true, and showing us, in language that
cannot be misunderstood, the erroneousness of our doctrines wher
they are not true.
The question of the duration of labour in relation to its effects
upon the danger and mortality accompanying parturition will be
found, in my humble opinion, to afford an apposite example of the
Essays on the Practice of Midwifery in Natural and Difficult Labours, p. 66.
TURNING AS AN ALTERNATIVE FOR 'CRANIOTOMY.
411
truth of these remarks; for when this question is examined-as it can
alone properly be examined-by the numerical or statistical method,
the results that are thus yielded assuredly directly gainsay and contra-
dict the accredited impressions and common belief of the profession
upon the subject. With the exception of Dr. Collins of Dublin, few,
or indeed no writers have, in their obstetric reports of hospital or
private practice, furnished us with data showing the duration of labour
either in their natural or in their operative cases of midwifery. In his
Practical Treatise on Midwifery (a work, the great value and candour
of the facts contained in which it would be difficult to overpraise)
Dr. Collins has given the result of the cases which occurred in the
Dublin Lying-in Hospital during a period of seven years, commencing
November 1826, and he has published throughout the work, and
especially at the end of its individual chapters, tables and data, from
which the duration of the labour in most cases and complications
can easily be calculated and compared. I shall state briefly some of
the results regarding the influence of the duration of labour which I
have obtained by summing and counting up the individual facts and
data which Dr. Collins has published. And the results which I have
in this way obtained will, no doubt, be regarded by some as the
more valuable and trustworthy, seeing that the data from which
they are calculated have been collated by Dr. Collins, and given by
him to the world under the generally prevailing idea that the mere
length of the labour was no guide or test of its danger or mortality.
During the seven years that Dr. Collins had charge of the
Dublin Lying-in Hospital, 16,414 women were delivered in it; and
of these 164 died, or one in every hundred of the mothers was
lost. In 15,850 of these cases the duration of the labour has been
marked and published; in 1 in 29 only it was not noted. Out of
the 164 fatal cases, in 138 the duration of the labour has been
marked and published; in 1 in G it was not noted. Now if, in
relation to the duration of labour as bearing upon the maternal
mortality, we calculate the proportion of the 138 maternal to the
whole 15,850 labours, I find that the interesting result is that
which is shown in the following table. Let me merely premise that
the table reads as follows :-Out of all the women delivered within
one hour, 1 in 322 died; out of all those in whom the labour con-
tinued from two to three hours, 1 in 231 died; and so on.
412
OBSTETRIC OPERATIONS.
TABLE II.
SHOWING THE PROPORTION OF MATERNAL DEATHS IN RELATION TO THE
DURATION OF LABOUR IN 15,850 cases of Delivery.
Duration of Labour.
Within 1 hour
Proportion of Mothers Lost.
One in 322 died.
From 2 to 3 hours
in 231
""
""
4 to 6
in 134
""
""
""
7 to 12
in 80
""
""
""
""
13 to 24
in 26
""
99
""
25 to 36
""
""
in 17
""
Above 36 hours
in 6
The preceding table affords ample evidence that, contrary to the
general opinion of the obstetric profession, the mere length of the
labour is a most serious and important element in reference to the
degree of danger and fatality accompanying the process. For, in
fact, as shown by these calculations, “the mortality attendant upon
parturition increases in a ratio progressive with the increased duration of
the labour." And this does not hold true with regard to the life
of the mother alone. It equally holds true with regard to the life
of the infant. For, exactly in the same way, as proved from the
1
1 The law itself-and I believe it to be a most important one-was originally
educed by a series of calculations from Dr. Collins' cases. I formerly published
merely the results of the calculation, without publishing the data on which these
results were founded; for my object was not to overload my paper, or the pages
of the Journal, unnecessarily. As Dr. Collins believes, however, that these results
are obscure, I shall simply insert, in a tabular form, the data themselves upon
which this law and its results were founded.
TABLE showing the Proportion of 138 Maternal Deaths in Relation to the
Duration of Labour in 15,850 Cases of Delivery recorded by Dr. Collins.

Duration of Labour.
Number Number
of
Deliveries.
of
Deaths.
Proportion
of
Deaths.
Within 1 hour
3,537
11
1 in 322
From 2 to 3 hours
6,000
26
1 in 231
4 to 6
"
3,875
29
1 in 134
7 to 12
""
""
1,672
21
1 in SO
13 to 24
502
19
1 in 26
""
25 to 36
134
8
1 in 17
Above 36 hours
130
24
1 in 6
Total
15,850
138
1 in 115
Out of Dr. Collins' 16,414 cases, he noted the duration of the labour in 15,850 ;
and among these 15,850 cases, 138 maternal deaths occurred. The preceding
table contains, in its first column of figures, the total number of deliveries that
took place under each specified period of duration; in the second column is stated
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
413
same collection of data, I find also that, as a general fact, “the in-
fantile mortality attendant upon parturition increases in a ratio pro-
Dr. Collins
gressive with the increased duration of the labour."
reports 1121 children as having been still-born. In 1045 of these
cases, the duration of the labour was noted. The following table
shows the proportion of the children lost in labours of different
degrees of duration. Like the preceding table, it reads thus :-Out
of all the women delivered within two hours, one in twenty of the
children was lost; out of all the women whose labour endured
from three to six hours, one in eighteen of the children was lost;
and so on.
TABLE III.
SHOWING THE PROPORTION OF INFANTILE DEATHS IN RELATION TO THE
DURATION OF LABOUR IN 15,850 CASES OF DELIVERY.¹
1
Duration of Labour.
Number of Infants still-born.
From 1 to 2 hours
One in 20 was lost.
3 to 6
7 to 12
13 to 24
in 18
in 11
,
in 6
""
25 to 36
in 3
""
Above 36 hours
in 2
The two preceding tables refer to the proportion of maternal
and infantile deaths as regulated by the duration of the labour. But
many morbid complications and accidents may arise during parturi-
tion, without necessarily proving fatal either to the mother or infant.
The occurrence, however, of these complications and accidents is
regulated by the same law of duration as I have above shown to
regulate the actual deaths of the mother and children. For, exactly
in the same way, it may be laid down as a general proposition, that
“the liability to most of the morbid complications connected with labour
the corresponding number of deaths occurring among each set of these deliveries;
and in the third column is given the proportion which the deaths bear to the
whole deliveries in labours of each specified degree of duration. In other words,
the table reads thus: *-3537 mothers had their labours terminated within one
hour from their commencement; and of these 3537 mothers 11 died, or 1 in every
322. The labour continued from 2 to 3 hours in 6000 cases, and out of these
6000 cases 26 mothers died, or 1 in every 231; and so on.-Letter to Dr. Collins.
Prov. Med. and Surg. Journal, Nov. 1848.
1 The above rule is merely a simple generalisation of Dr. Collins' own experi-
ence and cases, as will be seen in the following table, also deduced from Dr.
Collins' own data:
The other tables that follow are constructed on the same plan, and read in the same way,
414
OBSTETRIC OPERATIONS.
increases in proportion as the labour is increased in its duration."¹
It would be easy to demonstrate, for instance, that this holds good
with regard to various obstetric complications taken individually—
such as convulsions, rupture of the uterus, retention of the placenta,
or hemorrhage before and after its removal, puerperal fevers, puer-
peral inflammations, etc. The liability to each one of these com-
plications and results certainly increases with the length of the pro-
cess of parturition. But it may be enough for my present purpose to
show that, taking these complications collectively, such is the result:
the tendency to their general occurrence becomes greater and greater
in proportion as the length of the labour is allowed to become
greater and greater.
TABLE showing the proportion of Still-births in reference to the Duration of
Labour in 15,850 Cases of Delivery.

Duration of Labour.
Number
of
Deliveries.
Number of Proportion of
Still-born
Still-born
Children.
Children.
Within 2 hours
7,050
347
1 in 23
From 3 to 6 hours
6,362
346
1 in 18
7 to 12
1,672
151
1 in 11
""
""
13 to 24
502
88
1 in 6
""
25 to 36
134
42
1 in 3
"
Above 36 hours
130
71
1 in 2
Total
•
15,850
1045
1 in 15
Dr. Collins also reported 284 cases of death of the child subsequent to birth.
If we throw out of these 284 cases the premature or twin children, as too
small in size to be influenced much in their passage during labour, and those
born imperfect or diseased, we have 155 children left, born at the full time, and
apparently perfect in formation at birth. The following table of these cases will
prove that tedious and protracted labour is also a cause of death to the child after
birth.
TABLE of Duration of Labour in 155 Deliveries where the Children died within
a few Days after Birth. (From Dr. Collins' data.)

Duration of Labour.
Number
of
Deliveries.
Number Proportion
of
Deaths.
of
Deaths.
Within 6 hours
13,412
110
1 in 122
From 7 to 12 hours.
Above 12 hours.
1,672
24
1 in 70
766
21
1 in 36
Total.
15,850
155
1 in 102
1 Dr. Collins remarks that this does not accord
cwn facts and data show the opinion to be true.
-Letter to Dr. Collins.
with his experience. But his
The following table is a brief
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
415
In his Treatise, Dr. Collins has recorded the duration of the
labour in 24 cases of puerperal convulsions; in 24 cases of rupture
of the uterus and vagina; in 62 cases of retention of the placenta ;
in 102 cases during and after the third stage of labour; in 84 cases
of puerperal fever; in 5 cases of fatal pelvic abscess; and in 5 fatal.
cases of inflammation and sloughing of the vagina; in all, 306 cases
of complication occurring in 296 patients. The following table
shows the proportion in which these 306 complications occurred in
labours of different durations. It reads thus:-Of all the women
who were delivered within one hour after the commencement of
labour, one in 114 suffered from one or other of these obstetric
complications; of all those whose labours were prolonged from one
to two hours, one in 90 suffered from one or other of these compli-
cations; and so on.
TABLE IV.
SHOWING THE PROPORTION IN WHICH 306 MORBID COMPLICATIONS OCCURRED
IN 15,850 LABOURS OF DIFFERENT DURATIONS.

Duration of Labour.
Proportion of Complications.
Within 1 hour.
From 1 to 2 hours
•
One in 114 was complicated.
in 90
""
""
2 to 3
in 69
4 to 6
in 58
19
""
7 to 12
in 32
""
99
13 to 24
in 12
""
""
25 to 36
in 9
""
Above 36
in
5
The evidence which I have adduced in the preceding tables affords.
ample proof that the proportion of maternal and infantile deaths, and
way of expressing these data in reference to the eighty-four cases of puerperal
fever, in which the previous duration of the labour was noted by him, and it
sufficiently shows that the liability to this, like other complications, increases as
the labour increases in duration :-
TABLE of Duration of Labour in 84 Cases of Puerperal Fever, in the Dublin
Hospital, during Dr. Collins' Mastership.

Duration of Labour.
Number Number Proportion
of
of
of
Deliveries. Cases.
Cases.
Within 6 hours.
•
13,412
61
1 in 219
From 7 to 12 hours.
Above 12 hours.
1,672
10
1 in 167
766
13
1 in 59
Total
•
15,850
84
1 in 186
One fundamental mistake in his statistics and calculations led Dr. Collins into
416
OBSTETRIC OPERATIONS.•
of obstetric complications, becomes, as a general law, gradually more
and more numerous as the process of labour becomes more and more
prolonged in its duration. But I have brought forward the facts
principally for the purpose of showing that out of them, and in con-
nection with them, there is deducible another all-important principle,
in reference to a practical and operative obstetric inquiry of the
present nature-viz. that when operative interference, such as the
forceps, crotchet, turning, etc., is required, in order to terminate a
difficult and morbid labour, the time of the labour at which that
interference is had recourse to, regulates the amount of attendant
danger much more than the details and effects of the operation
itself. In other words, in accordance with the general law already
illustrated, the extent of danger or fatality attendant upon operative.
and instrumental delivery is regulated in a direct and demonstrable
degree by the previous length of time allowed to elapse before the
numerous errors and inaccuracies relative to the effects arising from the morbid
protraction of labour. This error has made him repeatedly express and maintain,
as the supposed result of his own facts and experience, opinions which his own facts
and experience, when properly interpreted, totally and altogether contradict.
The error I allude to is this:-In calculating from his experience of 16,414
deliveries, the effects upon the maternal mortality of morbid prolongation of the
labour as a special or individual complication, he calculates the resulting number
of deaths in relation to the total sum of all the cases delivered (16,414), instead of
calculating them in relation to the total sum of all the cases merely that were pro-
tracted (452); he calculates the effects of the complication relatively to the whole
number of cases of delivery, instead of relatively to the whole number of cases of
this special complication (protraction). An example may illustrate niy meaning.
I shall take it from the subject of rupture of the uterus and vagina.
During Dr. Collins' seven years' mastership of the Dublin Hospital, 34 cases
of rupture of the uterus and vagina occurred, and 32 of the mothers died; 2 only
of the 34 survived. If he argued upon this special complication as he does with
regard to the special complication of protraction, he would maintain that the
mortality from rupture was strikingly small; for only 32 mothers out of 16,414,
or about 1 in every 513, died of it. This would show, certainly, the proportion of
deaths from rupture in relation to the total sum of all the cases delivered; but it
would not show what was wanted-viz. the proportion of deaths from rupture in
relation to the total sum of all the cases in which rupture happened. If he wished,
in short, to state the real risk and danger attendant upon this special complication,
rupture, he should state that 32 mothers died of it out of 34 cases in which it
occurred, instead of stating that only 1 in 513 died of it. And exactly in the
same way, if asked what was the degree of maternal risk and danger attendant
upon another special complication, viz. protraction of labour beyond twenty hours,
his answer upon the same principle should not have been 42 deaths in 16,414
labours, or in the proportion of 1 in 391; but 42 deaths in 452 labours, the whole
number protracted beyond twenty hours, or 1 death in every 11 cases of labour
prolonged to this amount of protraction.-See Letters to Dr. Collins. Prov. Med.
and Surg. Journal, Nov. and Dec. 1848, pp. 601 and 683.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
417
artificial interference is had recourse to; the resulting mortality
increasing in amount according as the period at which the operation
is performed is proportionally more distant from the date of the first
commencement of the labour.
In
It is not in my power to prove from Dr. Collins' Treatise that
this law holds true in regard to the alternative operation of delivery
by the long forceps, for his work affords no data on this point.
fact, in instances in which the head of the child is arrested at the
brim, he and the profession generally in Dublin prefer the use of the
perforator to the use of the long forceps; and during the course of
the seven years throughout which his report extends, this latter
instrument does not seem to have been employed once in the Dublin
Hospital, while craniotomy was, during the same period, employed
above eighty times. During these seven years, however, the short
forceps were used to terminate the delivery in twenty-four patients
in whom the head was sufficiently low down in the maternal pass-
ages; and perhaps the results in these twenty-four cases will be
regarded as a sufficient illustration that in forceps operations the
general law holds good, that "the operation is dangerous and fatal in
proportion to the length of labour allowed to elapse before the artificial
delivery is practised."
TABLE V.
SHOWING THE MATERNAL MORTALITY ATTENDANT UPON 24 FORCEPS
OPERATIONS TO BE REGULATED BY THE PREVIOUS DEGREE OF DURA-
TION OF THE LABOUR.

Date of Operation.
In labours terminated within 24 hours
In labours terminated in from 25 to 36 hours
In labours terminated in from 37 to 48 hours
In labours terminated in above 48 hours
Results to the Mothers.
One out of 13 died¹
6 ""
4
2
Dr. Collins' data regarding the operation of craniotomy are more
extensive, and hence more valuable. During the seven years included
in his report, perforation of the head of the infant was practised in
eighty-five cases in which there was extreme difficulty in the labour,
or where the child was dead, and interference necessary for the
1 In the single fatal case of forceps operation out of thirteen in which the
women were delivered before the labour had continued twenty-four hours, the
mother became insensible after the pains had set in for a few hours, and the
instruments were apparently used in consequence. The whole labour was only of
eight hours' duration. She died in three hours after delivery.
418
OBSTETRIC OPERATIONS.
patient's safety, or for the full completion of the delivery. In
seventy-six out of these eighty-five cases, data are afforded for ascer-
taining the duration of the labour.
Out of the seventy-six women, fourteen, or one in every five and
a half, died. The following table of the results of these seventy-six
cases of craniotomy, as influenced by the previous duration of the
labour, affords direct evidence of the proposition which I have
already stated, that the fatality attendant upon this, as upon the
other allied forms of forced or artificial delivery, is regulated by the
date or period of the labour at which the operative interference is
had recourse to.
TABLE VI.
SHOWING THE MATERNAL MORTALITY ATTENDANT UPON 76 CRANIOTOMY
OPERATIONS TO BE REGULATED BY THE PREVIOUS DEGREE of Dura-
TION OF THE LABOUR.

Date of Operation.
Results to the Mothers.
""
In labours under 24 hours
from 25 to 48 hours
above 48 hours
One out of 19 died
•
8
""
3
•
""
The preceding body of evidence might easily be rendered more
minute and detailed if it were necessary. But I hold that it affords
proofs sufficiently strong and direct for our present inquiry. And
the important relations which it has to that inquiry amount to this,
that the facts adduced demonstrate-
1st. That, as a general law, the amount and proportion of mater-
nal and infantile deaths accompanying parturition are regulated and
modified by the length and duration of the labour.
2d. That the liability to various morbid obstetric complications
during and after delivery is modified and regulated by the same
law; and,
3d. That the mortality attendant upon obstetric operations, such
as the use of the forceps and crotchet, is also strictly modified and
regulated by it-operative delivery being more and more fatal in
proportion to the lateness in the course of the labour at which it is
adopted; and, on the other hand, less and less fatal in proportion
to the earliness in the course of the labour at which it is practised.
Now, the object of the present memoir is to propose that in cases
of arrestment of the head at the brim of the pelvis, artificial delivery
should be accomplished by turning, instead of by the long forceps
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
419
or craniotomy. And the operation which I thus wish to substitute
has, as I have stated at the commencement of this section, this great
and high advantage over both the two others, for which I propose
it as an alternative, that, cæteris paribus, delivery by turning can, and
must, as a general rule, be practised far earlier in the labour, than
delivery either by the long forceps or the crotchet; and in propor-
tion as it is practised earlier, so far also will it be attended by
greater safety and greater success. A few remarks upon the time
at which the employment of the long forceps or perforator is usually
adopted will render this deduction more evident.
munication we shall consider this point, and the
tion in relation to operative delivery.
In our next com-
value of ausculta-
SECT. V. -RELATIVE PERIODS OF THE LABOUR AT WHICH THE
LONG FORCEPS, PERFORATION, AND TURNING, ARE RESPEC-
TIVELY EMPLOYED: VALUE OF AUSCULTATION IN OPERATIVE
DELIVERIES.¹
1
In the preceding section I have attempted to show the compara-
tive advantage of turning over the employment of the long forceps
or crotchet, on the ground that we could thus accomplish the delivery
much earlier in the course of the labour, and hence much more
safely for the mother. In fact, when the long forceps are used in
instances of arrestment of the head at the brim, they are in general
never applied till the cranium is thrust and wedged down into the
upper pelvic aperture to as great an extent as can possibly be effected
by the unassisted uterine efforts, and till symptoms of local irrita-
tion, or constitutional reaction or exhaustion, offer to appear. But
before all this state of matters is brought about, both much expen-
diture of muscular and vital exertion on the part of the mother, and
also much expenditure of time, is usually required; and the walls of
the maternal passages are liable to have become injured by irritation
and compression. Before the assigned conditions are produced, many
long hours commonly elapse, each one of them directly and rapidly
adding to the chances of danger to the mother.
On the other hand,
in the same set of cases, if artificial delivery by turning were adopted,
it might and would be practised as early as the passages were
adequately dilated, before the head was pushed down into the pelvic
brim, and long before any symptoms of local lesion or general irrita-
tion and exhaustion presented themselves.
1 See Provincial Medical and Surgical Journal, February 23, 1848, p. 85.
28
420
OBSTETRIC OPERATIONS.
But it is principally as a substitute for craniotomy that I venture
to suggest the operation of turning in instances of arrestment of the
head at or above the brim of the pelvis. And when we contrast
the different times, as far as regards the duration of labour, at which
these two modes of delivery (craniotomy and turning) would be
respectively followed in the same class of cases, we shall perceive
still more strongly the advantages of the alternative practice. For
turning, as I have just now stated, would necessarily be performed
early in the course of the labour, and so far at a period when the
danger would be comparatively slight, according to the law of dura-
tion which I have attempted to establish. Commit, however, the
same morbid cases to the usual rules of management, by which they
would be treated under the prospective idea that they would in all
probability ultimately become cases of craniotomy, and mark the
difference. The labour is allowed to go on from hour to hour, and
possibly for one or two long and weary days, in order to give the
child every legitimate chance of being at last expelled alive, or, at
least, expelled without operative mutilation. In the meantime,
however, as the preceding tables abundantly prove, the chance of
immediate or ultimate danger to both mother and infant increases
fearfully in proportion as the labour drags on its duration.
long, then, shall we allow it to continue before we perforate and
break up the child's head? Most modern authorities would answer
that question by earnestly inculcating the propriety of not applying
the perforator till the child were distinctly and certainly dead, un-
less, indeed, the appearances of danger to the mother were extremely
marked and imminent, for almost all eagerly and properly declare
their abhorrence at the idea of "plunging an iron instrument into
the centre of the skull of a living human being."
But how long must we probably wait before the child really dies?
We have seen (Table III.) that the infantile, like the maternal,
mortality increases in a ratio. progressive with the increased length
of the labour; and that out of all cases in which, in the Dublin
Hospital, the process of parturition was prolonged beyond thirty-six
hours, one in every two of the children was lost. But still the
labour may go on to the fortieth, fiftieth, or sixtieth hour, and yet
the child live. Out of twenty-seven cases in all, reported by Dr.
Collins, in which the labour was prolonged to sixty hours and
upwards, in sixteen the child was ultimately born dead; and in the
remaining eleven it seems to have still survived, and ultimately to
have been expelled alive. Whilst, however, we are thus waiting
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
421
and watching for the certainty of the child's death before we operate,
the chance of the mother's death increases with the lapse of every
hour. Out of these same twenty-seven cases of labour prolonged
sixty hours or upwards, seven of the mothers, or one in every four,
perished. We may thus wait with the expectation of the infant's
death, till at last we run the imminent hazard of also losing the
mother; and even then, when at last we find ourselves driven to
have recourse to craniotomy in order not to place the parent in
greater jeopardy, we may be unwillingly compelled to practise the
operation while the child still really lives, goaded on by a dire, but
now irresistible necessity, to attempt to save the life of the mother
by taking away the life of her child.
Auscultation is the criterion upon which all modern accoucheurs
properly and mainly depend for ascertaining the death of the infant,
and fixing the date at which it threatens to perish, or actually does
perish, during a protracted labour. And certainly, in the progress
of a prolonged case, auscultation is, as Dr. Collins states, of “im-
mense value in ascertaining the life or death of the child." "I
know," he remarks, "of no case where the advantage derived from
the use of the stethoscope is more fully demonstrated than in the
information it enables us to arrive at with regard to the life or
death of the fœtus, in the progress of tedious and difficult labours.
It is, in my opinion, one of the greatest improvements made in the
practice of midwifery." The whole evidence of Dr. Collins' general
remarks and individual cases shows, that in protracted parturition
the special advantage which he has found, and expects others to
find, from the employment of auscultation, is a far more precise and
certain knowledge than we could otherwise possess, of the life or
death of the infant, and of the exact time at which it does die,
with a view of fixing more exactly the time at which we should
deliver it by craniotomy. Actuated by the best and most humane
feelings, Dr. Collins believes that in tedious and difficult labours,
obstetricians should rarely or never perform craniotomy upon the
head of a living child, and that auscultation will enable us to
eschew this otherwise unavoidable error. For, in one set of cases,
it will show us the propriety of postponing the operation, by show-
ing us that the child's heart is still beating. In another set of
cases it will show us the propriety of practising it earlier than we
should otherwise do, by showing us that the child is already dead.
At the same time, we must still not use our perforator immediately
1 Practical Treatise, p. 18.
422
OBSTETRIC OPERATIONS.
after the fœtal heart ceases to be heard by the stethoscope, or indeed
for some hours afterwards, lest life be not perfectly and entirely
extinct in the child. "It is totally contrary," says Dr. Collins,1 "to
every rule of practice, to deliver the patient with the crotchet when
the fœtal heart's action first becomes inaudible. It is only after
frequent examinations, with some interval between each, that this
is ever resorted to, except where the mother's life is in very imminent
danger indeed."
Such is the use and value of auscultation in protracted labours,
according to the opinion of Dr. Collins and of the Dublin school
generally; and certainly, while for one, I most gladly and gratefully
acknowledge that it is to that school that British midwifery stands
indebted for the first introduction of auscultation into English
obstetric practice, still I cannot help declaring my conscientious
conviction here, as I have often done in lecturing upon the subject,
that the preceding application of it in tedious labours is so far
undoubtedly erroneous in two most important and fundamental points.
Errors in Practical Application of Auscultation.
For, first, according to the principles upon which the Dublin
practitioners use auscultation in tedious labour-viz. in order to fix
the fact of the death or life of the child, with a view to the im-
mediate performance or further postponement of craniotomy-they
altogether leave out of consideration the great influence which the
mere duration of the labour exerts upon the maternal constitution
and life. They forget that, whilst they are delaying for the death
of the child, the very delay is rapidly destroying the mother;—
whilst they are waiting and watching for the foetal life to become
extinct, the maternal life is every hour becoming placed in greater
and greater danger. "Under proper management," argues Dr.
Collins, "the death of the child takes place in laborious and difficult
labours before the symptoms become so alarming as to cause any
experienced physician to open its head for the sake of the safety of
the mother." But I believe his own facts totally and sternly con-
tradict this argument. When for this or other causes he waited
till the labour had continued from twenty-five to thirty-six hours.
from its first commencement, one in every seventeen of the mothers
died (see Table II.); when he waited for twelve hours longer, allow-
ing the labour to be prolonged from thirty-seven to forty-eight hours,
then one in every six of the mothers was lost; when he waited for
1 Dublin Medical Journal, vol. xiii. 1838, p. 423.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
423
twelve more hours (namely, forty-nine to sixty hours), then one in
every five of the mothers was lost; and when interference was not
adopted, or delivery completed, till the labour had gone on for sixty
hours or upwards, then one in every four of the mothers perished;
and that too, although, as we have already seen, in eleven out of
twenty-seven cases, or in about one in two and a half of these very
same protracted labours, the child was still living, and was indeed
ultimately expelled alive, thus still contra-indicating craniotomy, as
far as its life was concerned, notwithstanding that the life of the
mother was reduced to an extreme degree of danger and hazard.
But, secondly, the opinions which Dr. Collins and others of the
Dublin school profess with regard to the application of auscultation,
as a valuable aid to the management of tedious and instrumental
labours, are, I conceive, still more objectionable in another point of
view. In cases of protracted parturition they use the stethoscope,
as we have shown, in order to ascertain the life or death of the
child, and in order to decide and determine the proper time.
at which embryotomy should be performed. For this purpose
they employ it with the special object of fixing the fact that the
child is dead; and fixing, when requisite, the true time when it
does die. But I am strongly of opinion that the mighty boon which
auscultation offers us in protracted parturition is quite different and
far more important. For it is not by any means so valuable in thus
often affording us evidence that the child is dead; it is not so much
of real and practical use in showing us that we may now perform
embryotomy upon a dead infant, as in showing us when, in protracted
cases, we ought to extract the child by the forceps, turning, or other
safe means, if we wish to preserve its life, as well as the life of the
mother. In this way I have repeatedly found auscultation of incal-
culable benefit in protracted labours, and been, I believe, enabled by
its evidence alone to save several times the life of the child by the
timely application of the long and short forceps. And though the
principle upon which I have thus acted in the management of
tedious labours is not acknowledged by Dr. Collins under that
subject, yet, certainly, the very same principle of using instrumental
delivery for the sake of the safety of the child is acknowledged by
him under another head, and in dependence upon another form
of evidence of the danger of the infant. In speaking of the treat-
ment of cases of prolapsus of the umbilical cord he observes:¹
"The forceps I consider highly desirable when the child is so
1 Practical Treatise, p. 344.
424
OBSTETRIC OPERATIONS.
situated that the head can be reached with safety; but as the funis
generally descends at the commencement of labour, it is very seldom
that this instrument is applicable till fœtal life is extinct. We
should not fail, however, to apply them when practicable, should any
delay occur in the delivery likely to endanger the life of the child, or
if we find the pulsation in the cord becoming gradually slower and more
feeble." Now, exactly on the same principle, when in tedious labours
in which there is no contra-indication, we have evidence that the
life of the child is becoming endangered, when by the stethoscope we
learn that the pulsations in the foetal heart are becoming gradually
slower and more feeble, it is in my opinion equally our bounden
and solemn duty to interfere by the same means in order to attain
the same end, viz. the preservation of the infant's life. For I hold
that neither in principle nor in practice does it make any difference
whether with this view we ascertain the imminent danger of the
child, and the fact that the pulsations of its heart are becoming
slower and more feeble, by feeling the pulsations of the cord, or by
listening to the pulsations of the heart itself. The sense of hearing
affords us precisely the same evidence in the one case as the sense of
touch affords us in the other, and it indicates also precisely the
same line of treatment.
The bearing of this long discussion and digression upon the
practice of turning in contracted pelves, etc., is sufficiently evident.
Over both the operations for which I propose it as a substitute-viz.
delivery by the long forceps and crotchet-it possesses this great and
weighty advantage, that it can be practised at a far earlier, and con-
sequently at a far safer, period of the labour. But it is principally
as an alternative for craniotomy that I feel anxious tɔ introduce the
operation of turning to the consideration of my profess.onal brethren ;
and over craniotomy it possesses, in addition to the above, this other
all-important advantage, that it offers the child a chance of life,
while craniotomy implies the very certainty of death; and that
while the existence of the sounds of the foetal heart, and the con-
tinuance of the infant's life, would determine us to postpone, and
postpone almost indefinitely, the delivery by embryulcio, the ex-
istence of these sounds, and the evidence they give of the continuance
of the infant's life, would determine us to adopt, and form indeed,
cæteris paribus, the very strongest reason for adopting, delivery by
turning. In the one operation we would delay, and perhaps delay
long, and hence dangerously, the delivery of the mother, because the
child was living; in the other operation we would promote and
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
425
hasten the delivery of the mother on exactly the same grounds on
which we postponed it in the first, viz. because the infant was still
living, and might still be extracted alive.
Perhaps the detail of one or two cases may impress this view
more strongly than any more lengthened remarks. I shall select the
first two from the Clinical Report of Dr. Lee of London, who, like
Dr. Collins, rejects the employment of the long forceps when the
head is delayed at the brim, and prefers the extraction of it by the
perforator and crotchet.
CASE IX. In a woman whose pelvis and extremities were distorted by rickets,
the labour began on the 9th of February 1842.¹ The membranes," to quote
Dr. Lee's own words, "ruptured on the 10th. On the 11th, the os uteri was not
dilated to the size of half-a-crown, the head was wholly above the brim, and the
base of the sacrum easily felt. Active pains came on, and lasted during the night,
and till two P.M. of the 12th. The os uteri was still very imperfectly dilated.
The head, entirely above the brim, now much swollen. It was clearly right to
interfere, which I did (by craniotomy), and she recovered without a bad symptom,
though I now feel persuaded that she ought not to have been left so long in
labour. The danger," he adds, "of rupture and fatal contusion of the uterus
is great in all such cases, and delivery should be effected as soon as it is evident
that the head cannot pass. I knew from the first, in this case, that it would not
pass through the brim, but was prevented from interfering in consequence of hearing
the pulsations of the foetal heart."
In the preceding case Dr. Lee states his conviction that the
patient ought not, in reference to her own safety, to have been left
so long in labour. The continuance, however, of the pulsations of
the foetal heart prevented him for some time from interfering and
delivering by craniotomy. It is not stated whether the child con-
tinued alive or not till that operation was at last adopted. But
the circumstance which thus directly deterred him from earlier
delivery, viz. the life of the foetus, would have directly urged him
to the new practice which I am here venturing to propose in
such cases. The reason he had for longer postponing the operation
of craniotomy would have been the strongest of all reasons for at
once preferring the operation of turning, and giving, so far, a
chance of life to the child, and at the same time preventing the
continued duration of the labour from placing the mother in greater
danger and jeopardy.
I quote the following case from the same author for the purpose
of showing what I have omitted to insist upon in the course of the
preceding remarks, that in instances in which the brim of the pelvis
1 Clinical Midwifery, Case 113, p. 51.
426
OBSTETRIC OPERATIONS.
is contracted, the protracted duration of the labour may occasionally
lead to the most deplorable morbid consequences on the part of the
mother, even though it do not actually destroy her life. An earlier
delivery by turning would, I believe, as has been already often stated,
not only enable us to avoid these results to the mother, but offer
a chance of escape and life to the child.
1
CASE X. The patient had borne nine children; all her labours had been
difficult, and the two last so much so that artificial assistance was required, and
the children were still-born. Her tenth labour commenced on the 3d of December,
and the membranes were soon after ruptured. During the 4th the pains were
feeble and irregular. Thirty-five drops of laudanum were given. On the morning
of the 5th they returned, but again feebly and irregularly. At ten o'clock on the
evening of the 5th, two doses of the ergot were given, and soon several strong
forcing pains were experienced. "The movements of the infant were not felt
after this," and the uterine contractions appear to have ceased. When Dr. Lee
visited her next forenoon-viz. at eleven o'clock on the morning of the 6th (three
days after the labour had commenced, and the membranes had been ruptured)—the
state of the patient was as follows:-"The discharge from the parts has become
offensive; bladder filled with water; the vagina is swollen and tender; the head,
greatly swelled and compressed, is firmly fixed in the brim of the pelvis, and the
finger cannot be passed around it without giving great pain; the ear cannot be
felt, the greater portion of the head being still above the brim." Dr. Lee opened
the head, and two hours elapsed before he could complete its extraction by the
crotchet. He thus continues the report :-" December 7th. A bad night; reten-
tion of urine; great swelling and tenderness of the parts; pulse rapid; tongue
loaded; headach; rigors. Sloughing of the vagina took place, and on the 14th
a fistulous communication had been formed between it and the bladder. This
unfortunate woman," adds Dr. Lee, "was soon after deserted by her husband,
and has led a life of great indigence and misery ever since."
In offering some general concluding remarks upon this and sixty-
five other cases" of "difficult labour from distortion of the pelvis, etc.
etc., in which delivery was effected by the operation of craniotomy,"
contained in his second report, Dr. Lee observes:-"In thirty-eight
of the cases in this report, the labour continued from forty to seventy
hours."-" In a very large proportion of the cases the difficulty arose
from distortion, or a contracted state of the pelvis. Rupture of the
uterus took place in three before perforation, and the inflammation
and sloughing of the uterus, vagina, and rectum, which proved fatal
to eight others, were chiefly or solely produced by the long-continued
violent pressure on the soft parts by the head of the child before it
was opened and extracted. In those who recovered with vesico-
vaginal fistula or contractions of the vagina from cicatrices, the un-
fortunate occurrences arose from craniotomy being too long delayed.”
2 Ibid. 1842, p. 59.
¹ Clinical Midwifery, Case 84, p. 40.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
427
"In several, had the delivery been sooner effected, the fatal con-
sequences which ensued would have been wholly prevented."
In some of the following cases from Dr. Collins' report, the
delivery of the patients by craniotomy was evidently postponed till
such time as the child was ascertained by the stethoscope to have
died. The state of the foetal heart is not mentioned by Dr. Collins
in all, but the omission was probably made in order to avoid un-
necessary repetition; and, except for this counter-indicating circum-
stance (the continuance of foetal life), the mothers would probably
not have been allowed to have had their sufferings protracted, or so
much constitutional excitement created, before resorting to artificial
delivery. In the last, or last two cases, the state of the mother
probably ultimately necessitated delivery, independently of any con-
siderations relative to the life of the infant. I shall quote the cases
in Dr. Collins' own words.
CASE XI.—“Was admitted in labour of her eleventh child; uterine action
very frequent and strong; the os uteri dilated to the size of a crown, and the
fundus very much inclined to the right side. In twenty-four hours after admis-
sion (the head not having made any progress for the last eight), the fœtal heart
having ceased to act for some time, it was thought advisable to lessen the head,
and deliver with the crotchet.”1
CASE XII." Was admitted in labour of her seventh child; she had been de-
livered artificially in her previous labours, and had but one child born alive. She
had been ill a considerable time before she was brought to the hospital, and in nine
hours afterwards, there being no progress made, the pulse 132, her strength much
exhausted, and the child dead, she was delivered by the crotchet." 2
CASE XIII. "This patient was admitted in labour of her first child; uterine
action was feeble, and continued so for seventy-two hours after she came in. As
the fatal heart had ceased to act for some time, and the pulse became hurried, it
was considered advisable to deliver her. The os uteri was not fully dilated; the
head was high, and resting on the pubis; it was lessened, and cautiously brought
down with the crotchet.'
"3
CASE XIV. —“Was reported to have been in labour two days before admis-
sion; the head was high in the pelvis, and pressing strongly on the pubis. It
remained in this situation for twenty-four hours after, during which time she
suffered great distress, uterine action being almost constant. This was her tenth
child; she had been twice force-delivered in this hospital; dreading every moment
rupture of the uterus, the head was lessened and brought down by the crotchet,
as it had still remained so high as to be scarcely within reach of the finger."4
CASE XV.-"Was reported to have been twenty-four hours in labour before
admission. About twelve hours after she came in, it was discovered that the face
was turned towards the pubis, and pressing so strongly on the urethra that the
1 Collins' Practical Treatise on Midwifery, p. 480, No. 1032.
2 Ibid. p, 480, No. 1005.
3 Ibid. p. 481, No. 1038.
4 Ibid. p. 477, No. 808.
428
OBSTETRIC OPERATIONS.
catheter could with difficulty be passed. The pains continued strong for fifteen
hours from this time, yet the head did not advance. It was deemed advisable to
lessen it."1
CASE XVI.-" Was thirty-three hours in labour of her third child, without
having made the least progress for the last twelve. The bladder was forced down
before the head. Her pulse became much hurried, and strength greatly exhausted,
rendering immediate delivery necessary. The head was lessened, and the child
brought away by the crotchet. It was very large; all her former children were
still-born." 2
CASE XVII.—“S. B. was forty hours in labour; it was her fourth child; all
still-born. The head not having made any progress for the last twelve hours, and
the fœtal heart having ceased to act, the delivery was effected by the crotchet;
the face was turned towards the pubis. She had been force-delivered in this
hospital two years ago, when the face presented-(see Observations on Still-born
Children, No 441); pelvis very defective. The placenta in the present instance
had to be removed by the hand, in consequence of hemorrhage; it was firmly
adherent to the fundus of the uterus. She died on the ninth day, and on exami-
nation, extensive ulceration of the vagina was found, forming a communication
with the rectum. At one point the vagina presented the appearance as if a lacera-
tion had taken place." 3
In these cases delivery by turning, instead of by craniotomy, by
being performed earlier, would, I believe, have preserved the patients
alike from the sufferings and the dangers which the continued dura-
tion of the labour entailed upon them; and the children, instead of
being necessarily sacrificed by the operation adopted and the delay
attending upon it, might possibly have been saved by the adoption
of turning, and by the earlier period at which delivery could thus
have been practised. But it has been doubted whether the object I
have just alluded to-namely, the preservation of the infant's life—
could ever be the result of forcible extraction of the child through a
contracted pelvis by turning. I shall next, therefore, notice this and
other objections to the proposed practice, on the allegation of danger
to the mother, and disarrangement of the mechanism of parturition.
The investigation, of the objections urged on these several grounds
will, I believe, leave us only with higher and more certain ideas of
the real advantage of the proposed practice itself.
SECT. VI. THE DEPRESSION AND INDENTATION DURING LABOUR
OF THE SIDES OF THE INFANTILE CRANIUM, IS COMPATIBLE
WITH THE LIFE OF THE CHILD.*
Among the advantages of turning as compared with embryulcio,
¹ Collins' Practical Treatise on Midwifery, p. 470, No. 529.
2 Ibid. p. 470, No. 509.
3 Ibid. p. 136, No. 79.
• See Provincial Medical and Surgical Journal, March 22, 1848, p. 141.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
429
I have stated that "it gives the child a chance of life," and that the
"neck of the child, if it be living or only recently dead, is so strong
as to allow us to exert such a degree of traction upon the obstructed
head, that the sides of the cranium may become greatly compressed
or even indented under it; and that without necessarily destroying
the child." I
As a comment upon these statements, Dr. Radford observes,
"It has been said that the neck of the child, alive or recently dead,
is so strong as to allow such a degree of force to be used as to greatly
compress the sides of the cranium; but," he adds, "such a procedure
is at variance with all scientific views, and incompatible with the safety of
both mother and child.”2
The accuracy or inaccuracy of the two different, and indeed
opposite opinions, thus expressed upon the same point by Dr. Rad-
ford and myself, is one of those questions in pathology which no
mere opinion or mere reasoning could ever settle. In order to decide
it, we must have recourse to facts and experience alone. And it is
of the highest moment in relation to the whole object of the present
inquiry, that the evidence on the matter be as perfect and unequi-
vocal as possible; for, in fact, the practice proposed is based in the
main, on the fundamental idea that the required compression and
indentation of the infantile skull is not incompatible-as craniotomy
is-with the continuance of infantile life.
Now, the records of midwifery contain numerous accurately
observed cases in which the cranium of the child has become greatly
compressed or flattened, or actually depressed and indented in one
of its sides, while passing through a very contracted pelvis, and that,
too, without necessarily destroying the life of the infant. Velpeau,
for instance, the only author whom Dr. Radford quotes, tells us in
a part of his work, which has evidently escaped Dr. Radford's
observation, that the depression or "indentation (enfoncement) of the
parietal or frontal bone, with or without fracture, has been noticed.
several times at the Maternity Hospital of Paris." *
X5 And
"if," he observes, "the fracture or depression of the bones is not
accompanied with effusion, nature ordinarily suffices to restore
things to their primary state, and charges herself with the burden
of the cure.
Otherwise death is the usual consequence of them, or
*
1 Monthly Journal of Medical Science, March 1847, p. 718.
2 Provincial Medical and Surgical Journal, 1847, p. 405.
430
OBSTETRIC OPERATIONS.
at least they produce drowsiness (assoupissement) and a great tend-
ency to convulsions."
Chaussier, who tells us that he had reported some examples of
these depressions and indentations of the infantile skull in 1807 and
1810, makes the following judicious observations upon their general
pathology and effects. "Sometimes," he observes, "when the sacro-
vertebral angle projects too far forward, we find on the portion of
bone which rested on this prominence an indentation or depression
(enfoncement ou dépression), at which we often remark several small
linear fissures (fêlures) in the form of a star, proceeding from the centre
of the depression, and limited to the internal surface of the bone; at
other times the bone is fractured in all its thickness, and its frag-
ments are more or less separated, or forced in upon the brain; most
commonly the infant dies in the act of delivery, or a short time
after its birth."
* * * "These lesions, however, which
would," he adds, "be always fatal for an adult, do not always ter-
minate so badly in the new-born infant, for at this age the brain
has neither the consistence, nor the action or use, which it ought to
have subsequently; they even heal easily and spontaneously if the
infant be vigorous, and the labour has not been too prolonged.""
*
Various practical authors have left incidental notices of such
cases of depression observed in the skull of the infant at birth
without the life of the child being compromised by the injury.
Sometimes the injury has been the result of an excessive degree of
compression by the forceps; but more usually it has been produced,
as pointed out by Chaussier, by the head of the infant being strongly
crushed against the projecting promontory of the sacrum, and that
whether the infant passed as a cranial or footling presentation. Dr.
Smellie, in his " Collection of Lingering Cases from a Small, Narrow,
or Distorted Pelvis," prefaces his observations with this general
remark, “that although these labours may seem to be of the same
class, and require the same management with those that proceed
from a large head, there is an essential difference; for though they
are much the same with regard to the efforts of the woman, the
operator in these has much less room when he is obliged to assist
with his hand, and the child's head is disfigured and compressed
1 Traité des Accouchemens, tom. ii. p. 588.
2. Recueil des Mémoires, etc., sur divers Objets de Médecine Légale, Paris, 1824,
p. 436.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
431
into large indentations, occasioned by the jetting in of the upper part
of the sacrum, and of the vertebræ of the loins.”¹
In the course of his valuable volumes Dr. Smellie in different
parts casually details several instances bearing out this remark, and
at the same time showing that the injury is not necessarily fatal to
the infant. I shall abridge some of these cases.
CASE XVIII. In a woman,2 "sickly from her infancy and very much dis-
torted," Dr. Smellie effected the delivery of a living child by a double application
of the forceps.
"The forceps when first fixed had impressed the forehead, though
the mark disappeared in five or six days after birth; but they made a very con-
siderable impression when they were fixed a second time along the ears." The
pelvis was "distorted from the jetting forwards of the upper part of the sacrum,"
and this projection had produced an indentation, distinct from those produced by
the forceps;
"the head was of a lengthened form, and contorted to one side, and
there was a deep impression above the ear. "Had the child been large, its life
could not possibly have been saved.”
""
CASE XIX. The descent of the infant's "head was retarded by a jetting in
at the middle of the sacrum," and the forceps were used. "The child's head
was squeezed into a longitudinal form, flattened on the sides, with a deep impres-
sion on the cranium above the ears; and from an indentation on the os frontis by a
blade of the forceps, which had been fixed on that and the occiput, I discovered
the ears were not to the sides as I had imagined. These impressions," the author
continues, "had very much galled and inflamed the parts, but in consequence of
proper care they digested, and the child recovered, and as he grew up the marks
diminished and disappeared.
Dr. Smellie describes a case of depression and injury of the
infant's cranium at birth that is still more important than the
preceding two in reference to the subject of the present inquiry,
for in it the cranial indentation was produced in following the very
practice which I am discussing, viz. in turning the infant when the
brim of the pelvis was narrow and contracted. The following are
the principal particulars
CASE XX. A patient had a "narrow and distorted pelvis," in consequence
of "the three lowest vertebræ of the loins bending forwards." The patient was
delivered four times. At her first and third labours the infants were obliged to
be extracted by the crotchet. Dr. Smellie tells us that he "managed her second
labour from the beginning in a slow and cautious manner; but," adds he,
"although the child was small, I with the greatest difficulty saved it by the
assistance of the forceps." At her fourth accouchement the shoulder presented.
Dr. Smellie tried ineffectually to perform cephalic version, and then with some
effort seized one of the legs of the infant and turned it, and extracted it as far as
the neck, the head still remaining above the contracted part of the pelvis. After
1 Collection of Cases and Observations in Midwifery, vol. ii. p. 358. 2d Edit.
London, 1758.
3 Ibid. vol. ii. p. 461. 4 Ibid. vol. iii. p. 230.
2 Ibid. vol. ii. p. 458.
432
OBSTETRIC OPERATIONS.
as there
using considerable exertion in order to drag it through the deformed brim, Dr.
Smellie states that he began to despair of the child's life, but adds,
was still a weak pulsation in the funis, I resolved to make another effort with all
my strength, by which the head was moved a little lower; then forcing up my
fingers to the forehead, I got a firm hold of it, and finished the delivery." The
infant showed some weak signs of life, and in about ten or fifteen minutes began
to cry.
"The infant," adds Dr. Smellie, "continuing to cry incessantly while the
head was washing, I examined and perceived a large tumour above the right ear ;
I likewise found a depression of the temporal bone before the ear, and the frontal
and parietal bones pushed outwards; these formed the swelling, and were the
parts that stopped at the distorted bones of the vertebra." The child was quieted
by applying pressure on the tumour with a compress and bandage. Next day
the swelling had disappeared. The mother recovered better than in any of her
preceding labours.
Dr. Smellie relates another case,' in which the head of the child
was apparently injured in a similar manner in dragging it through
a distorted pelvis."
(6
CASE XXI. The infant presented by the breech. After the body and ex-
tremities were born, "a good deal of force was used to deliver the head." Five
minutes elapsed before the child breathed; at last it began to cry incessantly,
“till one of the women observed a large swelling betwixt the left ear and temple.
Pressure with the fingers first, and ultimately with a compress, quieted the child
in the same manner as in the preceding case. "When I examined it," says Dr.
Smellie, "next day, the swelling was gone, and it appeared to have been that
part which stopped so long at the projection of the upper part of the sacrum
before the head was delivered."
Dr. Denman has recorded one exceedingly interesting case, in
which the head of the infant was much injured during the version
and extraction of it through a deformed pelvis, and that, as in the
preceding cases of Dr. Smellie, without compromising the infant's
life. The case is altogether so pertinent to the subject of the
present remarks, and affords so much important corroborative
evidence, that I feel assured I shall be excused in giving the details
in full, and in Dr. Denman's own words:
CASE XXII.
Many years ago I attended a patient in two labours, in both
of which there was a necessity of delivering with instruments, on account of the
smallness and distortion of the pelvis, and neither of the children could be
preserved. In her next pregnancy I made a proposal to bring on premature
labour, to which she and her friends would not consent, and I was dismissed
from my attendance. In the course of twelve or fourteen years she had five more
children, not one of which was born living. In the forty-sixth year of her age
she proved with child, and again applied to me. When her labour came on, the
first stage was suffered to proceed without interruption, but when the membranes
¹ Collection of Cases and Observations in Midwifery, vol. iii. p. 95. Collect.
32, Case 11.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
433
broke, I without delay passed my hand into the uterus, and easily brought down
the feet and body of the child; but the head being stopped by the narrowness of
the superior aperture of the pelvis, I was obliged to exert and continue much
force, before it could be extracted. The child was born with very little or no
appearance of life, but by the strenuous use of the common means recommended
for this purpose, it was recovered. On the left parietal bone there was a depres-
sion of considerable extent, and to my apprehension, of full one inch in depth,
occasioned by the projection of the sacrum, but the depressed part gradually rose.
In the course of a few months the bone regained its natural form, and the child
was for several years in good health, with its faculties perfect. The woman re-
covered without any untoward circumstance.
(6
""
But," adds Dr. Denman, in a cautious and contradictory note,
"the success of such attempts to preserve the life of a child is very
precarious; and the operation of turning a child, under the cir-
cumstances before stated, is rather to be considered among those
things of which an experienced man may sometimes avail himself
in critical situations, than as submitting to the ordinary rules of
practice."
"1
In the second volume of her Pratique des Accouchemens, Madame
Lachapelle relates the following instance of footling presentation in
which the child was born with a depression of the parietal bone:-
CASE XXIII.-A woman, pregnant for the second time, had a large accumu-
lation of liquor amnii, and the child floated so easily in it, that when labour-
pains first supervened, the presentation altered from time to time. The mem-
branes at last were broken, and the left foot descended. By dragging at this
foot, the lower extremities and then the trunk passed with facility. The left arm,
however, got fixed between the head and pubis, and was disengaged with some
trouble. The head, however," to quote the author's own account, "although
directed transversely, offered still greater difficulties in its extraction, either be-
cause the pelvis was a little distorted, or because our efforts were not absolutely
directed according to the axis of the brim. At all events it is certain, that after
the birth of the foetus we found a considerable depression on the right parietal
bone, which had rested upon the sacro-vertebral angle. In despite of this lesion,
the infant, which was at first apparently still-born, not only lived, but the depres-
sion was dissipated, and indeed was scarcely visible fifteen days afterwards. The
mother did not experience the slightest bad symptom."
Dugès has recorded two cases which came under his observation,
in which the cranium was very deeply depressed and indented in the
way described in the preceding instances, and yet both children
lived and did well.
CASES XXIV. and XXV.-In one of these cases of Dugès the frontal bone was
so much depressed, that the left eye appeared as it were protruded from the orbit;
still the child neither suffered from convulsions, nor any other special symptoms.
1 Introduction to the Practice of Midwifery, p. 382.
Pratique des Accouchemens, vol. ii. p. 166.
1
434
OBSTETRIC OPERATIONS.
In the second case the child had come footling through a pelvis, the great [conju-
gate?] diameter of which was estimated at three and a quarter inches. (Dont le
grand diamètre était évalué a trois pouces un quart.) The head could not at first
be extracted by the aid even of very strong tractions on the inferior jaw and
shoulders, but scarcely were these artificial efforts momentarily suspended, when
the head passed rapidly without assistance, and was expelled by the action of the
abdominal muscles. The left parietal bone, which had pressed upon the promon-
tory of the sacrum, was depressed and indented to the depth of half-an-inch, and
throughout an extent of two inches. Two or three spoonfuls of blood were
allowed to escape from the vessels of the cord, which yet beat with sufficient force,
although the infant was apparently dead; and betimes the child became gradually
reanimated, and began to cry, and passed meconium. It was troubled with con-
stant hiccup, puckering of the lips, and torsion of the mouth to the left side;
spasmodic closure of the right eye, immobility of the left; rigidity of the hands;
fingers extended and separate, with the exception of the thumbs and the last
phalanx of one of the index fingers, which were flexed inwards; rigidity of the
arms and limbs. These symptoms were remittent, and returned in fits at intervals
of ten minutes. Two leeclies were applied to the left temple. The fits continued
during the evening and night, but gradually became less and less severe. On
the morrow the infant drank; it took the breast the following day; and in fifteen
days after birth the cranial depression had almost entirely disappeared.
In his Manual of Midwifery, the same writer (Dugès) observes—
"The bones of the cranium are often fractured with indentation, by
the sacro-vertebral angle of the mother. It is one of the frontal, or
one of the temporal regions, which is the most common seat of these
lesions. * * * These fractures often heal spontaneously; the
indentations even rise in a few days.'
""1
Jacquemier, one of the latest French writers on midwifery, and
from whose work I have quoted Dugès' cases, states that these
fractures of the foetal cranium, with depression, are not by them-
selves a cause of certain death; "the depression," he remarks,
"relieves itself by degrees, and after ten or fifteen days there
scarcely remain any vestiges of it." 2
If it were required, I might cite other cases and remarks of the
same description from other authors in evidence of the fact, that the
state of compression and indentation of the bones of the infant's
cranium at birth is not necessarily fatal to the infant's life. Some
additional proofs will be quoted in the sequel; in the meantime I
have, I believe, stated enough to show-first, that the neck of the
child, if it be living, or only lately dead, is so strong, as to allow us
to exert such a degree of traction upon the obstructed head, that the
sides of the cranium may become greatly compressed, or even in-
dented, under it; and, secondly, that Dr. Radford is truly wrong in
1 Manuel d'Obstétrique, pp. 358, 359.
2 Manuel des Accouchemens, tom. ii. p. 773.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
435
stating that such a lesion and practice is incompatible with the safety
of the child. On the contrary, the recorded experience of Velpeau,
Chaussier, Smellie, Denman, Lachapelle, Dugès, Jacquemier, etc. etc.,
proves (as we have seen) that the depression and indentation of the
child's head do not necessarily destroy the child's life. Nay, Dr.
Radford's own experience on this point is, I know, not in favour of
his own views, but of mine. In evidence of this I shall quote a case
in point, recorded by Dr. Radford himself, from his own practice.
CASE XXVI.—"I was requested," says Dr. Radford, "by Mr. Dick, to visit
a poor woman in New Blakely Street, who was suffering from protracted labour,
caused by contraction of the brim of the pelvis. The long forceps were applied,
and the child delivered alive. A depression of considerable size was produced on
the left parietal bone, from the pressure it had sustained from the promontory of
the sacrum. The signs which the child manifested were those of apoplexy. The
funis was divided, but no blood followed, as the pulsation had previously ceased.
The child continued in the same state during the day, and in the evening was
attacked with convulsions, which were frequent. Two leeches were applied to the
temples, the bowels were opened, and the child recovered.” ¹
But further, argues Dr. Radford, such a procedure as I propose
is "at variance with all scientific views." I shall not stop at present
to debate here whether the practice I suggest be "scientific" or not;
but in a medical point of view I hold that appellation to be truly
merited by any propositions and measures that tend, like the present,
to promote the great essence and object of all medical science-
namely, the preservation of human life; and in the various cases
which I have quoted in the preceding sections, while none of the
mothers were lost, the lives of the infants were at the same time all
saved. But assuredly the heads of most of these children would
have been opened by the perforator, and their lives thus destroyed,
provided, in each instance, the structure of the cranium had not
yielded, and its bony parietes become fortunately depressed and
indented, to the degree required to admit of its safe transit through
the contracted aperture of the pelvis.
SECT. VII. -PHYSIOLOGICAL AND PATHOLOGICAL REASONS FOR THE
LIFE OF THE CHILD NOT BEING NECESSARILY COMPROMISED
UNDER THE PROPOSED PRACTICE.²
1
It has been alleged that the preservation of the life of the infant
is not compatible with its forcible extraction by turning through a
¹ Essays on Various Subjects connected with Midwifery, p. 11.
2 See Provincial Medical and Surgical Journal, April 5, 1848, p. 172; and
July 26, 1848, p. 393.
29
436
OBSTETRIC OPERATIONS.
contracted pelvic brim. It must perish, it has been urged, in conse-
quence of the lesions it necessarily sustains, and especially-1st, in
consequence of the injurious compression to which its head is sub-
jected during the forced delivery; and, 2d, in consequence of the
required injurious traction upon its neck. Let us examine, in detail,
each of these alleged necessary causes of death to the child under
the practice in question.
1. IS THE COMPRESSION TO WHICH THE INFANT'S HEAD IS
SUBJECTED INCOMPATIBLE WITH ITS SAFETY AND LIFE?
In the remarks which I offered under the last section, with
regard to the question whether, in turning in contracted pelves, the
degree of injury to which the child's head is subjected is or is not
compatible with its future safety and life, I confined the observations
which I made, and the illustrative cases I adduced, to that form of
cranial lesion in which the sides of the foetal skull are both com-
pressed and indented. In some instances, however, even when the
pelvis is much distorted, one of these states only, as the lateral com-
pression alone, without the indentation of the cranium, is all that is
required in order to reduce the head to the size necessary for its
transit. On one occasion, through a pelvis, the conjugate diameter
of the brim of which was less than three inches, from projection of
the promontory of the sacrum and disease of the symphysis pubis, I
extracted a full-grown infant by turning; the head passing through
in a flattened and compressed form, but without any depression or
indentation upon it. It is, I believe, unnecessary for me to prove,
that when the extraction can be effected with this single lesion, the
child is not necessarily sacrificed; because I have already proved,
that even when the two lesions of compression and indentation
co-exist, the presence of both forms of injury is not necessarily
incompatible with the continuance of life. And sometimes, by com-
pression alone, more especially if the skull is not very fully ossified,
the fœtal head may certainly be very greatly reduced in size,
without compromising life. Dr. Denman conjectures that, to quote.
his own expression," it may be reduced one-third below its original
size, without the destruction or even injury of the child from the
compression."
It would, however, be improper to leave this subject without
attending to some anatomical and physiological circumstances, in
1 Introduction to the Practice of Midwifery, 1816, p. 352.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
437
the structure of the foetal head, that enable it to bear this great
degree of lateral compression which we have been considering,
without the necessary destruction of life. Indeed, perhaps the
very knowledge of these circumstances may impart to the mind
greater faith in the correctness of the principles of the proposed
practice.
We shall afterwards have occasion to see that by far the most
frequent form of morbid contraction of the brim of the pelvis
consists in the projection forwards of the promontory of the sacrum,
and this is a kind of distortion especially adapted for the artificial
delivery of the mother by turning, instead of craniotomy. Under
this kidney-shaped pelvic brim, and other varieties of pelvic con-
traction, when the child is delivered by turning, the direction of
the compression of the head is, as we have already found, lateral
and transverse, or, in other words, in the line of its bi-temporal or
bi-parietal diameters, these diameters being reduced and shortened
by it.
Now, of all directions, the lateral is the one in which the child's
head can endure the greatest degree of compression, with the least
degree of danger. The power of diminution of the child's head under
labour "is greatest," observes Dr. Ramsbotham, "in the lateral
diameter, and," he continues, "a full-grown foetal head may be
lessened from side to side, without endangering the child's life, one
seventh of its own extent, or from three inches and a half to three
inches.""
Dr. Ramsbotham states that this degree of compression
of the head, namely, to one seventh, may be accomplished without
the life of the child being endangered. We have just now seen
that Dr. Denman imagines that the amount of compression may be
carried much farther, namely, to one-third, without the life of the
child being necessarily injured and destroyed. No author has
pointed out more correctly than Dr. Radford, the fact that the
child's head will bear, with comparative safety, a far higher amount
of compression in its transverse or bi-parietal diameter, than in its
longitudinal or occipito-frontal diameter. When the head is com-
pressed in the first of these modes, or transversely, "the brain," he
observes, "bears this alteration in the figure of the cranium with
comparatively little inconvenience, because the pressure it sustains
is parallel with the fibres of some of those parts which lie between
the two hemispheres, and with the falx, which in its natural state
1 Obstetric Medicine and Surgery, p. 25.
2 Essays on Various Subjects connected with Midwifery, p. 7, etc.
438
OBSTETRIC OPERATIONS.
supports this organ. The pressure is also less injurious, because it
is applied upon the sides of the vessels, but not in such a degree as
considerably to influence their calibres." When, however, the
direction of the pressure happens to be in the opposite or longitu-
dinal axis of the head, the results are very different, and far more
dangerous. Then "the alteration," Dr. Radford remarks, "which
takes place in the head is as follows:-A considerable diminution
in the length of the occipito-frontal diameter is produced, in con-
sequence of approximation between the frontal and occipital bones;
the fontanelles become nearly obliterated, and the sagittal suture is
wider and more prominent. The brain is pushed into this space,
which is insufficient for its accommodation; its organisation is
injured, and the child, when born, is either dead or dies soon after
birth. The pressure applied to the fore and hind part of the head
has a tendency to change the relative situation of many parts of the
brain. It forces one hemisphere from the other, which, if carried
beyond a certain degree, will inevitably produce laceration of the
coats of the veins which pass to the longitudinal sinus; and this
danger is increased by the great congestion which exists. These
serious effects," he again states-viz. apoplectic congestion, sanguine-
ous effusion, and softening of the brain-" are produced by the brain
being compressed in a direction contrary to the course of the fibres
of some of those parts which lie between the hemispheres, and also
to the current of blood along the longitudinal sinus." Dr. Radford
adds, that injuries of this character are sometimes met with when
the head has been compressed and dragged through the pelvis by
the long forceps; and he gives two dissections of the foetal ence-
phalon to show these results, congestion, effusions of blood, etc., in
two cases in which the delivery was accomplished by this instrument.
The cause for instrumental delivery and the application of the long
forceps is not specified in one of these cases; in the other they were
used on account of distortion of the brim of the pelvis. And
certainly, if we employ the long forceps to overcome this difficulty,
and place them as Deleurye, Haighton, Davis, Ramsbotham, and
other excellent operators have recommended, with one blade over
the face or forehead and another over the occiput of the child, we,
in our extractive efforts, must compress the foetal head with the
instrument so applied, in its longitudinal or anterior-posterior axis;
and hence the actual direction of our pressure would endanger the
child more than the actual degree of it. If, in the same case, and
under the same obstruction, however, the child were extracted by
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY,
439
turning, the required reduction of its head, by being effected entirely
by lateral compression, would be effected, as we have already seen,
not only with much greater facility, but with much greater safety
to the infant; and the chance of injury to the brain, and of
congestion and sanguineous effusion upon it, would be greatly
less.
But, though the danger of cerebral congestion and its effects is
diminished in lateral as compared with longitudinal compression of
the child's head, yet it is by no means abrogated and removed; and
in those cases of lateral compression and indentation of the cranium,
which, under either footling or head presentations, prove fatal, it is
this effusion and its dangers, more than the mere compression of the
proper structure of the brain, that seems to lead to this result. At
all events, the cases I have already cited, in the last section, show
that the cerebral tissue may be compressed, or, at least, displaced, in
a lateral direction by the grooved and depressed cranium, not only
without destroying or endangering life, but without producing coma
or convulsions, or any greater lesion of function than a mere tempo-
rary asphyxia, provided always there be no serous or sanguineous
congestion and effusion accompanying and resulting from it. The
escape of the infant under this form of injury in which we are thus
interested, is favoured by other circumstances. When the foetal
skull and encephalon are decreased by pressure in one diameter,
they become lengthened and increased in others. In the form, for
instance, of lateral compression resulting from extraction through a
distorted pelvis by turning, while the head is flattened and dimi-
nished in its transverse diameter, it is temporarily lengthened to a
corresponding degree in its vertical and longitudinal diameters.
The anatomical peculiarities of the foetal skull, the existence of fon-
tanelles and sutures between its component bones, and the conse-
quent isolation and mobility of the individual bones themselves,
freely admit of this; and so far under cranial depressions, no doubt,
save the proper tissue of the brain from a deleterious and destruc-
tive amount of pressure in a way that, under the same form of injury,
would be quite unavoidable with the cerebral contents of the solid
adult cranium. Besides, the immunity of the infant at birth under
such apparently severe injuries may partly be owing to another and
a physiological cause. The embryo and foetus possess a much lower
physiological type of life than that which pertains to the adult; nor
is the transition from the one to the other abruptly and entirely
completed when the infant passes from its intra-uterine to its extra-
440
OBSTETRIC OPERATIONS.
uterine existence. It is stated by Billard,' and I could quote no
more accurate observer, that symptomatic fever seems incapable of
being excited in the constitution of the infant, by injury or other-
wise, till the time of teething; and in all probability lesions such
as these to which the crania and encephala are subjected at birth in
the class of cases we have been considering, are less dangerous and
fatal in their effects, in consequence of the general law, that the
power of resisting and repairing injuries is greater in proportion as
the type of animal life is lower. It is true, besides, that individual
infants, like individual adults, have a power of withstanding injuries
much more than others, and in a way that it is impossible to account
for on any known principles.
Speaking of the differences among children in relation to the
danger they incur, from compression of the head during labour,
Jacquemier remarks:-"One infant, of a feeble constitution, will
resist a long compression by the parts of the mother, or by the
energetic and reiterated action of the forceps; another, of a strong
constitution, whose head has not been a very long time, or very
strongly, compressed by the pelvis, or between the blades of the
forceps, readily dies, or only has a few hours' existence."
") 9
Lastly, let me observe that the kind and degree of ossification
of the bones of the foetal cranium at birth admit of their yielding
and becoming depressed in a manner that, no doubt, contributes
to the safety of the infant. The ossification is as yet, in general, so
imperfect, that the flat individual bones, such as the parietal and
frontal, are still sufficiently thin and flexible to allow of their
being partially indented and altered in shape by strong pressure.
applied to one point of their surface. They are, at the same time,
usually so elastic as easily to be made to regain their former shape.
And this indentation and restoration may occur without any appre-
ciable fracture. In the first case which I have related, the right
parietal and frontal bones, when their external surface was carefully
examined after the removal of the scalp, were found deeply de-
pressed, but apparently not fractured. They afterwards fissured,
however, at the site of the indentation when being dried and pre-
1 "L'absence de toute réaction fébrile, lors même qu'il existe des lésions
graves chez les nouveau-nés; la promptitude, au contraire, avec laquelle la fièvre
s'allume par la moindre cause chez les enfants qui ont dépassé l'âge de la denti-
tion, imprime aux maladies de ces deux époques un caractère différentiel de la
plus grande importance."-Maladies des Enfans, Preface, p. 2.
• Manuel des Accouchemens, p. 770.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
441
pared for preservation. However, if the indentation is extremely
deep, or the bones unusually ossified, no doubt fracture will take
place, but still probably without danger, if without internal or
encephalic effusion.
We have found Velpeau, and the other authors we have quoted,
generally stating that the compressed cranium, and especially de-
pressed portions of it, usually become spontaneously replaced and
restored in the course of a short time after birth. This is, however,
not always the case; nor is its occurrence absolutely necessary for
the viability of the child. In evidence of this I shall content myself
by citing a single illustrative case.
CASE XXVII.-In the course of the last winter, after lecturing on the subject
of these indentations in the foetal cranium, one of the students in my class after-
wards showed me, on his own person, two deep impressions, one on each side of
the cranium, which had been produced by the use of the forceps, and which
had afterwards continued permanently depressed. He was 20 years old. On
the right side of the head, a little above the ear, there were two pretty deep,
curved fissures or indentations, from two to three inches long. On the left side
there was a single shorter indentation above the commencement of the temporal
ridge.
2. IS THE TRACTION TO WHICH THE INFANT'S NECK IS SUBJECTED
INCOMPATIBLE WITH ITS SAFETY AND Life?
The answer to this inquiry need not detain us long; in fact,
the proper reply to it has already been virtually given, when con-
sidering whether the existing degree of cranial compression and in-
dentation was necessarily fatal or not. For if, as we have found,
children can survive after being turned and extracted through so
narrow a pelvic brim, that the sides of their crania are sufficiently
collapsed and depressed against the sides of the contracted maternal
pelvis, to admit of the complete transit of the head, then it is
evident that the neck is not fatally injured under the proposed
traction; for in all these cases the degree of traction upon it was
adequate to produce all the results wanted, without destroying the
child. In these instances the extractive force necessary to drag the
head through the contracted pelvis was applied to the neck, and the
neck was found sufficient to bear it without compromising the life.
of the child; and I believe, as I have stated previously, that this
will generally, if not always, be found to be the case, "provided
the child be living, or only lately dead." It will be very different,
however, if the child has been for some time dead, and decomposing;
442
OBSTETRIC OPERATIONS.
the structures of the neck, certainly, will not then bear such traction
as is required to extract a full-sized head through a distorted brim ;
nor is it of any practical importance that it should, for such cases.
are cases for craniotomy, the child being dead, and forming no element
for consideration in the mode or kind of delivery that is followed.
But, independently of the above decisive and conclusive testi-
mony, and even if it were wanting, it would be easy, I believe, to
adduce such cases and observations from obstetric clinical reports
and other works, as would, a priori, have rendered probable what
these cases render certain, viz. that the degree of traction to which
the child's neck is subjected under the proposed practice, is com-
patible with its safety and life. I shall, for the sake of brevity,
confine my illustrations of this remark to a note or two of some
cases recorded by Dr. Smellie, and some observations offered by the
ever-cautious Dr. Denman. Dr. Smellie gives various cases in which
he was evidently himself astonished, as other practitioners have
often been, at the excessive degree of traction which the neck of
the infant stood during delivery in natural or artificial pelvic pre-
sentations, without the life of the child being compromised by it.
For example:-
66
CASE XXVIII.--In a breech case, where the woman was long in labour with a
large child, and was suffering from some hemorrhage, Dr. Smellie brought down
one foot, extracted the body and extremities, but the progress of the delivery was
stopped at the head," and required much traction for its transit, Dr. Smellie
being "obliged to increase the force at every attempt." "I pulled," he observes,
so long, and with so great force, before the head was delivered, that I was sur-
prised to find the child alive." 1
CASE XXIX. In the next instance which he reports, one of the breech pre-
senting in a narrow and distorted pelvis, after the body of the child was born,
Dr. Smellie brought down the right arm, and "helped down the forehead; but,"
he adds, "before I could deliver the head, I was obliged to bring down the other
arm, and saved the child also, though a good deal of force was used to deliver the
head."
›› 2
CASE XXX.-A young woman, of "a small size," was in her first labour.
The thighs of the child, which was large, presented. The labour was very slow
and lingering. Dr. Smellie brought down the feet, and effected the extraction of
the infant. "I delivered," he remarks, "the head, but not without a good deal
of force. The child was alive, which I scarcely expected." 3
CASE XXXI.—The breech presented, and the pelvis was narrow, and the child
was born living. In attempting to deliver the head, Dr. Smellie tells us— -"I
imagined it was impossible the child would be alive, as I found the neck was so
overstretched," having met "with greater difficulty than any that I ever delivered
in that manner.
1 Collection 32, Case 10.
2 Ibid. Case 11.
3 Ibid, Case 18.
4 Ibid. Case 13.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
443
In his classical and highly practical introduction to midwifery,
Dr. Denman has devoted a special section to the consideration of
the practice to be followed, in order to extract the head through the
brim, in cases in which preternatural presentations happen to be
complicated with distortions of the pelvis. His observations are
most valuable in regard to the necessity of combined perseverance
and caution, but they are too long to quote in detail. He tells
us that "it has been said that children have been sometimes born
alive when the strongest efforts, and those continued for many
hours, have been made, to extract the head in this position; but I
have not been so fortunate as to meet with any such instances, a
short space of time having generally been sufficient to frustrate my
hopes, and convince me that the child was dead, though when the
head has been detained a considerable time, a few cases have ter
minated more favourably than I could have expected, and I have
been agreeably surprised with the discovery of some faint signs of
life, which, by the assiduous and careful use of the common means,
have been improved, and the life of the child at length perfectly
recovered."
"When we have," he continues, "in vain exerted all the force
which we think reasonable and proper, and which, in some cases,
must be more than any circumstance would be thought to require,
it will be expedient to rest, for the purpose of gaining all the
advantage to be attained by the compression of the head. On this
account the mother will actually suffer no more inconvenience than
would have been produced if the head had originally presented and
been locked in the pelvis. After waiting some time, we must
renew our attempts to extract, and thus proceed, alternately resting
and acting with efficacy and resolution, and if the hold we may
have of the body or extremities of the child does not suit, a silk
handkerchief or other band may be passed round its neck, and this
will be found a very handy and convenient instrument."
It must be a very great disproportion," adds Dr. Denman,
"between the head of the child and the pelvis, which is able to with~
stand this method of proceeding, if we persevere in it with prudence.
and steadiness; because the integuments of the head will burst, or
the bones be bent inwards in an extraordinary degree, or even
broken." If it fail, "it then only remains that we should lessen
the head of the child, and the operation may be as easily performed
in this as in the natural presentation of the head."
"But it will,"
he continues, "be scarcely believed, how seldom this operation is
444
OBSTETRIC OPERATIONS.
necessary under these circumstances, if we have not been in a hurry,
but have acted with prudence; nor have I ever known any ill
consequences follow the compression which the soft parts undergo
between the head of the child and the sides of the pelvis, if proper
attention were afterwards paid to the state of the bladder and
rectum."1
We have already found, that when the child is extracted by
turning through a contracted pelvic brim, its life is not necessarily
sacrificed, as has been alleged by some,- either, 1st, by the
injurious compression to which its head is consequently subjected;
or, 2d, by the degree of traction required to be made upon its
neck.
One more special objection to the proposed operation of turning
remains for our consideration, viz.—
3.—IS THE PRACTICE INCOMPATIBLE OR NOT WITH THE SAFETY AND
LIFE OF THE CHILD IN CONSEQUENCE OF THE COMPRESSION of
THE UMBILICAL CORD?
In speaking of the propriety of delivery by turning in the class.
of cases for which I have proposed it, Dr. Radford states, as an
objection to it, the danger of death to the infant from pressure upon
the funis, and consequent obstruction of the umbilical circulation.
In footling presentations, "the funis," he observes, "is subject to
fatal compression;" and he imagines this danger must be greatly
increased in cases in which the child has been turned on account of
distortion of the maternal pelvis.
Perhaps the proper and the most direct answer to this, as to the
other objections to turning, drawn from supposed dangers to the
child, is simply a reference to the actual results of the cases which
I have already quoted, and may yet have occasion to quote in the
sequel. In many of these the child will be found to have passed or
been drawn footling through a contracted pelvis, and yet, in despite
of the alleged fatal danger of compression of the funis between the
body or head of the child and the interior of the maternal passages,
the infant has been born alive. The infant has been subjected to
the alleged cause of danger and death without the alleged effects
following; and hence we are surely entitled to conclude that the
influence of the cause is not so likely to interfere with the operation
of delivery as has been theoretically presupposed.
¹ Introduction to the Practice of Midwifery, pp. 497, 498, 499.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
445
i
I by no means wish to argue
Let me not be misunderstood.
that in turning in distorted pelvis there is no danger to the child
from umbilical compression, for I believe quite the reverse; but I
imagine, at the same time, that on first thinking over this undoubted
source of danger, we are apt in our own minds to magnify its
effects. Experience, as I have just now stated, teaches us that they
are not so great as theory might lead us a priori to believe; and
when we consider the subject for a moment, we shall find, I think,
sufficient reason for seeing-1st, that the risk and occurrence of
umbilical compression in footling presentations and turning is not
so very great as to invalidate the practice, and that it is in part
averted by the very form of distortion to which the pelvic brim is
most usually subject; besides, supposing, 2d, the compression to
take place, there may still, I believe, be measures in the resources
of science, by which, if we cannot now avert the occurrence of com-
pression of the cord, we may prevent at least the more dangerous
consequences of the complication for the child. I shall speak briefly
of each of these points.
The Danger and Mortality from Compression of the Cord is not so
great as to invalidate the Practice of Turning.-Dr. Churchill has
published a table of 542 cases of turning in which the result to the
child is mentioned. In these 542 cases, 182 children were lost, or
rather less than 1 in 3. And when we recollect that, no doubt, in
many of these 182 cases the child was dead before turning was
adopted, and that in others the cause demanding the delivery, such
as presentation of the placenta, was the cause also of the infant's
death, etc., we shall see reason to believe that the chance of death
to the child from the compression of the cord would be found to be
less than the chance of death from the application, and compression,
and traction of the long forceps; for, even in the more common
form of delivery by the short forceps-an operation which is gener-
ally looked upon as less dangerous to the child than delivery by the
long forceps-the mortality among the infants is as great or greater
than by turning.
Out of 871 cases of delivery by the forceps, and almost always
the short forceps, collected by Dr. Churchill, 175 children were lost,
or 1 in every 5.
Out of twenty-four short forceps cases which occurred in the
Dublin Hospital during Dr. Collins' mastership, eight of the children
were still-born, or 1 in 3. Out of thirty-three cases of presentation
of the shoulder or arm which he treated by turning, in two the
446
OBSTETRIC OPERATIONS.
child was putrid, and in two others there was hemorrhage, in one,
of the unavoidable, and in the other, of the accidental form, and
death of the children. Among the twenty-eight remaining cases,
nine were born dead, or nearly 1 in 3. Here, suppose we admit
that the cause of death in these nine children was traceable to
compression of the umbilical cord; still the infantile mortality was
probably as little or indeed less than would be found to result from
delivery with the long forceps.
Out of forty-two forceps cases related by Dr. Lee in his Clinical
Midwifery, in thirty-one cases the child was still-born, or 3 out of
every 4 of the infants were lost. In thirty-nine instances in which
he had recourse to turning in transverse presentations, twenty-nine
of the infants were born dead, or about 3 out of every 4. His
deliveries by the forceps were fatal to the children in 3 out of every
4 cases; and his deliveries by turning were fatal to the children in
nearly the same proportion of 3 out of every 4 cases.
Out of ninety-three forceps cases related by Madame Lachapelle
in her Pratique des Accouchemens, in fifteen the children were still-
born, or 1 in every 6 of the infants was lost. In sixty instances in
which she had recourse to turning in transverse presentation, eleven
of the infants were born dead, or 1 in every 51. Her deliveries by
the forceps were fatal to the children in the proportion of 1 in 6;
her deliveries by turning were fatal also in a similar proportion,
namely, about 1 in 5. Of ninety-six forceps cases occurring in the
practice of Madame Boivin,¹ in twenty the children were born dead,
or 1 in every 5 of them was lost. In sixty-two cases in which she
resorted to turning in transverse presentations, seven of the infants
were still-born, or about 1 in 9 was lost.
To obtain with more certainty the general comparative average
mortality of forceps cases and cases of turning in transverse presen-
tation, let us combine the data above given from the practice of
Collins, Lee, Lachapelle, and Boivin.
The following table exhibits in an abridged and simplified form,
the results of this collection of cases :-
1 Mémorial de l'Art des Accouchemens, Table, p. 464.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
447
TABLE VII.
COMPARATIVE MORTALITY OF CHILDREN IN CASES OF DELIVERY BY THE
FORCEPS, AND BY TURNING IN TRANSVERSE PRESENTATION, IN THE
PRACTICE OF COLLINS, LEE, LACHAPELLE, AND BOIVIN.

Mode of Delivery.
No. of
Cases.
No. of
children
still-born.
Proportion of
Still-born Children.
Forceps cases
Turning in transverse
presentation
255
74
D
1 in every 3 died.
194
58
1 in every 3 died.
Arrangements and Means by which Compression of the Cord, and its
Effects, may be averted.-Dr. Radford believes that when the child is
extracted by turning on account of distortion of the maternal pelvis,
the danger of fatal compression of the umbilical cord is then greatly
increased by the fact of the distortion. But the common variety of
contracted pelvis requiring turning is (as I have already stated, and
shall insist more upon afterwards), the peculiar and common kidney-
shaped distortion of the pelvic brim, which is produced by the
anterior prominence and projection of the sacral promontory. When
the fœtal head enters it, as it does under extraction by turning,
with its long, or occipito-frontal diameter lying in the transverse
diameter of the brim, then we have (see Fig. 14, p. 406) a free
space left, of greater or less size, between the face or forehead of the
child, and the ilium to which it looks. In this space sufficient room
may certainly, in general, be found for the free lodgment of the cord
without injurious compression. The very narrowness of the conjugate
diameter of the brim prevents this space from being entirely filled up
and encroached upon, by preventing the great mass and breadth of
the head, from the coronal suture backwards, from further passing
over to this partially occupied side of the pelvis. Besides, this un-
compressed lateral space is the very site along or near which the
cord necessarily passes in descending from the uterus, and stretching
between the placenta and umbilicus. For the anterior surface of the
abdomen of the child, to which the lower end of the cord is attached,
always, of course, looks to that side of the pelvis to which the face
is directed; and it is on that side that we have the free and uncom-
pressed space I speak of, as fitted for the safe transit and lodgment
of the cord. In thus stating the space as free and uncompressed, I
mean in so far as the adjoining opposite surfaces of the child's head
and interior of the pelvis are concerned. The space itself may be
448
OBSTETRIC OPERATIONS.
filled up, or the cord in it pressed upon by the circle of the cervix
uteri or other soft parts, but, certainly, a little adjustment and
management may often prevent any fatal compression from these
sources; for the cord may be carried round by the accoucheur to
that point in which there appears the greatest space, and conse-
quently the greatest freedom from compression; and he may some-
times defend it from the pressure of the cervix by allowing it to pass
between two fingers, introduced either for the sole purpose of pro-
tecting it, or with the view of simultaneously assisting the extraction
of the head by applying some force to the cheeks or lower jaw. In
both natural and artificial footling presentations it has even been
proposed to defend the cord more methodically, by shielding and
enveloping it at the part liable to compression in a kind of special
protecting instrument. Dr. Joos of Schaffhausen has ingeniously
proposed an instrument for this purpose.' It consists of a tube,
from four to eight inches in length, and of calibre sufficient to con-
tain the umbilical cord, leaving a longitudinal slit or fissure equal
toth of its circumference. It is composed of caoutchouc or
leather, in which are embedded a series of steel rings three lines
broad, and at the distance of one line from each other. The slit is
opened up at one end by the finger, so as to admit the umbilical
cord, and in the same manner it is made to receive it along its whole
length, the fissure closing up as the finger is removed. A handle
may be required subsequently, to keep the instrument in its proper
place. "The application of the instrument," says Dr. Joos, "takes
place during the act of birth, by presentation of the breech or feet,
in cases where delivery is effected by version and bringing down the
feet, and in cases where the cord is prolapsed and cannot be re-
turned." But I greatly doubt whether, even if we were provided
with such an instrument as Dr. Joos describes, we should not find
the difficulties of applying it, and the time required for that purpose,
more dangerous to the infant than the extraction of the child's head
by more simple and direct means. It is always well to avoid instru-
ments when we can avoid them; and such a one as the present
might not be used without some danger to the structures of the
os uteri.
Suppose, however, that the means we used to avoid compression
of the cord, by placing it in the least occupied point at the brim, or
by preventing the soft parts from pressing upon it, by the fingers,
or otherwise, were in vain, and that at last it really became irre-
1 Medical Gazette, Oct. 22, 1847.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
449
trievably compressed, and its pulsations arrested before the head
could possibly be extracted, is the safety of the child utterly hope-
less? I believe not. Long ago, Pugh and Morlanne recommended
a practice that has been latterly followed by Bigelow and others,
and which, I believe, is calculated in some instances to enable us to
continue the life of the child, by continuing its respiratory function,
whilst we go on exerting, from time to time, those cautious yet
decided means, which we have seen Dr. Denman recommending, for
effecting the complete extraction of the obstructed head. The means
to which I allude consist in exciting pulmonary respiration in the
half-born child, now that its placental respiration is stopped, and in
making it continue that vital process by the action of the lungs,
now that it is prevented from being exercised by the medium of
the placenta and umbilical cord. "When the parts are well made,"
says Pugh,'" and the child in proportion, happy the case! It will
come then any way; the arm being brought down, the head only
remains to be extracted, which must be done with as much
expedition as possible, as indeed the arms ought to be; for, con-
sider, when the child has passed the navel, the circulation between
it and the mother is stopped from the pressure of the umbilical
rope; you must then introduce the fingers of your left hand into
the vagina, under the child's breast, and put the first and second
fingers into the child's mouth pretty far; so far, however, that you
are able to press down the child's tongue in such a manner, that by
keeping your hand hollow, and pressing it upon the mother's rectum
the air may have access to the larynx; you will soon perceive the
thorax expand, as the air gets into the lungs. By this method,” he
adds, "of giving the child air, I have saved great numbers of children's
lives, which otherwise must have died."
Acting on the plan thus suggested by Pugh, we may in som
cases be able, with a little management, to change thus the respir-
ation of the infant from its intra-uterine to its extra-uterine type,
though the head be still held and arrested at the brim; for the
mouth of the infant is always then within reach, and could, I believe,
be used for the purpose of admitting a proper quantity of air into
the pulmonary passages, even when the great bulk of the head is
still held above the brim. It is a practice, at all events, which
sometimes succeeds sufficiently well when the head is down in the
pelvis, and we have all the difficulties of a rigid outlet and perineum
1 Treatise on Midwifery, 1754, p. 49.
450
OBSTETRIC OPERATIONS.
to contend against, in our attempts either to extract the head, or to
admit a sufficiently free access of air to the mouth of the foetus.
The two following cases, which I extract from Dr. Lee's Clinical
Midwifery, will illustrate and impress the practice and the remarks
upon it, which I have just made :—
CASE XXXII.—The nates presenting, the trunk and extremities were extracted,
"but the head could not be drawn through the external parts, from the rigid state
of the perineum, and the pulsations of the cord were becoming more and more
feeble. So great was the resistance of the perineum, that it was impossible to
overcome it without destroying the child. I pressed back its edge, however, so
far, that the external air could enter the mouth of the child, and it respired in
this way fully twenty minutes after the pulsations of the cord had ceased. In
spite of all our care, the edge of the perineum gave way as the bulky part of the
head passed through the external parts, but the child sustained no injury, and
continued to live."1
CASE XXXIII.-"I attended a lady in her first labour, on the 22d of October
1837. The nates presented, and the cord ceased to pulsate after the trunk and
extremities of the child had been extracted. The perineum was so rigid, that the
head could not have been delivered without using so much force, that the parts
must have been torn, and the neck of the child injured. I held the body of the
child as far forward as possible, while Dr. H. Davies assisted me in holding back
the perineum, that the air might enter the mouth of the child. The respiration
went on for nearly half-an-hour before the head could be safely drawn into the
world, and during the whole of the time there was no pulsation in the cord.
The child is alive, and the perineum was not injured.” 2
The child may not only be able to breathe, but even heard to
cry, with the head still unborn, when this form of treatment is
adopted. In his paper on the subject, published in the American
Journal of Medical Sciences for 1829, Professor Bigelow (of Boston)
states, amongst others, the following case :-
CASE XXXIV.-In a case of arm-presentation, in which the feet were brought
down, and the body delivered, "the face turned towards the perineum, the
mouth was easily reached, and the fingers were opened to give passage to the air
as before described. No struggle nor attempt at respiration, however, occurred.
A handful of cold water was then dashed upon the body, upon which the child
immediately gave a spring, and began to cry. The head was not delivered till
some minutes afterwards.'
"3
In his observations and directions upon this modification of
practice, Dr. Bigelow observes :-" After the body is expelled, if
the head can be seasonably delivered, either by the recurrence of
1 Clinical Midwifery, Case 239, p. 129. 2 Ibid. Case 241, p. 131.
3 American Journal of Medical Science, Aug. 1829, p. 288, Case 3.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
451
pains, or by the successful efforts of the practitioner, no difficulty
ordinarily occurs. But this desirable state of things cannot always
be realised; too frequently the size of the head, and the resistance
of the pelvis or soft parts, renders the delivery difficult or hazard-
ous, and the practitioner, in the midst of his efforts, is apprised by
a convulsive jerk, or spring of the body, that a state of extreme
danger exists, and that the time has come at which the child must
breathe, or will speedily die. If at this period the fingers be intro-
duced, so as to reach the mouth of the child, it will be perceived
that each jerk of the body is attended with a gasp, and convulsive
effort at inspiration, performed by the mouth and chest of the child.
In this state of things, if air be conveyed to the mouth of the child,
it will immediately breathe, and the efforts of nature, as will here-
after be shown, may, in most cases, be safely waited for to assist in
expelling the head.”1
"The method to be pursued," he continues, " in conveying air to
the mouth, depends upon the situation of the head. If the chin has
descended low in the pelvis, so that the mouth rests upon the
perineum, or lower part of the sacrum, and can be readily reached
by the fingers, the hand of the operator alone is sufficient to give
the assistance required. But if the mouth is situated so high in
the pelvis as to be reached with difficulty, or if, from the large rela-
tive size of the head, there is much compression, the assistance of a
tube may be of use. The mode of proceeding which I have found
successful in various instances is as follows:-As soon as the body
and arms are extracted, supposing the face towards the sacrum, an
assistant supports the body, carrying it towards the pubis; or the
reverse, should the position of the face be to the pubis. The
accoucheur should then introduce the hand to which the face looks,
till the middle fingers rest upon. the mouth of the child; the hand
is then to be raised from the throat of the child, making the ends
of the fingers a fulcrum, and pushing the perineum backwards;
the air will thus pass upwards as far as the chin of the child; the
middle fingers are now to be separated about half-an-inch from each
other, and thus a complete passage will be formed between them,
by which the air will reach the mouth of the child. If the child be
in a healthy state up to this period, it will immediately breathe and
cry, and the delivery of the head may be safely postponed till the
natural pains recur. If, from any degree of asphyxia, the child does
1 American Journal of Medical Science, Aug. 1829, p. 235.
30
452
OBSTETRIC OPERATIONS.
not immediately breathe, it may often be made to do so by dashing
cold water upon the body, or by other stimulating processes.
It has
even appeared to me practicable to inflate the lungs, in some cases,
through an elastic catheter. When the mouth is so high in the
pelvis as to be reached with difficulty, or when the compression is
so great as to obliterate the cavity between the fingers, a flat tube
will be found useful, made of metal, of spiral wire covered with
leather, or of elastic gum, and having its largest diameter about
half-an-inch. If the tube be of metal, or of any incompressible
material, it should be withdrawn during a pain, to prevent contusion
of the soft parts, and immediately replaced if the pain subsides
without expelling the head. Such a tube may be considered as a
prolongation of the trachea, and is fully sufficient to sustain life by
respiration for a considerable time. The tube must be guarded and
directed by keeping it between the fingers of the inserted hand."
In addition to the above remarks on the possible means of pre-
venting fatal compression of the umbilical cord, there is one obser-
vation more which I am anxious to make. If all the preceding
measures fail to avert compression, there is always still one strong
hope left-namely, that if after complete compression of the umbili-
cal vessels has occurred, no very great length of time is lost in the
extraction of the head, the child may yet be born alive. For the
type of vitality in the unborn infant is such that it will often sur-
vive, and be capable of being resuscitated, although the placental
respiration be arrested for several minutes before its actual birth.
And with others, I have been repeatedly surprised, in such cases as
we are considering, both at the great amount of extractive force
which the structures of the infant will sometimes undergo without
life being destroyed, and at the apparently great length of time
during which, in making these extractive exertions, the infant will
still survive, and that too, although the cord was compressed during
their continuance. If the infant be perfectly viable, and its heart
sounding normally at the time that turning is adopted, there are
perhaps comparatively few cases in which it will be requisite to
expend so much time upon the forcible compression and extraction
of the head, as to destroy during that time the child's life by simple
compression of the cord alone. The following case, which occurred
within the last few days, may perhaps impress this remark. In it
the foetal heart continued to beat regularly, not only after the cord
was compressed for a considerable time, during which very strong
·
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
453
exertions were made in order to extract a large and very firm head
through a pelvis three inches in its antero-posterior diameter, but its
pulsations went on for several minutes, even after the head was
perforated, an operation that required some time for its perform-
ance, and after the cervical spine had yielded under the traction
applied.
CASE XXXV.-With Drs. Ziegler and Weir, I delivered at the 'Maternity
Hospital, on April 17th, a woman, aged 19, in labour with her first child. The
os uteri was fully dilated, and the child's head had remained at the brim during
nearly ten hours of active labour-pains. The parietal bones were riding over each
other at the sagittal suture, and the right parietal bone was somewhat indented
by the sacrum, upon which it rested. The conjugate diameter measured about
three inches. A very deep dose of chloroform was given. Turning was effected,
and the body of the child delivered. Strong traction was applied in vain to bring
the head through the contracted brim, and at last the bones of the neck threat-
ened to give way. The cranium was then perforated behind the ear, and by the
aid of a crotchet in the mouth the delivery was completed. The child did not
breathe, but the pulsations of its heart went on regularly for several minutes
after delivery. The child weighed upwards of seven pounds. It measured twenty-
one inches in length. Its head was large and firmly ossified.
CONCLUDING REMARKS REGARDING THE OBJECTIONS TO THE PRO-
POSED PRACTICE FOUNDED ON THE ALLEGED DANGER AND
DEATH OF THE CHILD.
In terminating the present section of our subject, I would again
repeat, in regard to the whole, the argument which I have used
against the alleged fatality of the individual sources of danger that
we have inquired into. It has been averred that under the pro-
posed practice of turning in distorted and contracted pelves, the
injury which the foetal head must sustain would be fatal to the
child-the injury of the neck would be fatal to it-the injury of
the cord would be fatal to it. I have shown the principal fallacies
to which these arguments are individually liable. Against the truth
. of the whole, in a combined form, I would here again simply and
strongly appeal to the evidence of facts and experience. For the
results of the cases of the practice that I have given, and of others
that I may yet have occasion to give, amply attest that in various
instances in which it has been adopted, the indentation and depres-
sion of the skull of the infant were not fatal to it, nor was the trac-
tion of the neck fatal to it, nor the pressure upon its funis. It was
submitted to one and all of these sources of supposed danger and
death, and yet escaped alive from all. And having done so when
454
OBSTETRIC OPERATIONS.
the principles and details of the practice were not at all understood
may we not expect still happier and more successful results when
these principles and details come to be better comprehended, and
more systematically acted upon
I have heard turning objected to by some, in arrestment of the
head at the brim, on the ground of its inevitably occasional, or rather
frequent, fatality to the child. But when we have any new opera-
tion proposed, with the view of replacing other operations, such as
turning in distorted pelvis, instead of delivery by the long forceps
or craniotomy, we can only properly judge of the real and relative
value of the new operation, not by looking at its own absolute and
isolated results, but by looking at its results as compared with the
results of those other operative measures for which it is suggested as
an alternative. Now, as regards the respective value of turning,
to the infant, in comparison with the two operations for which I
propose it as a substitute, the case is, of course, very different,
according as we contrast it, first, with the long forceps; or, secondly,
with craniotomy.
We have seen that the fatality to the child from the common
operation of turning in transverse and cephalic presentations, was,
in the Dublin and Parisian hospitals, nearly the same as the common
operation with the short forceps, or indeed was in favour of turning,
there having been in neither set of cases any very special state of
pelvic contraction; and perhaps, if we had any adequate data, we
should find that the same analogy in their results held good when
they were respectively applied under greater and increased degrees
of difficulty, as in morbid contractions of the pelvic brim; always, how-
ever, with this important difference in favour of turning-that it could
be employed at a much earlier, and, consequently, as respects both the
mother and child, at a much safer period of the labour than was
fitted for the adoption of delivery by the long forceps; and always
also recollecting that the comparison of the results of turning, with
the results of short forceps operations, is imperfect in this respect,
that from the direction of the compression in long forceps opera-
tions-viz. in the antero-posterior or oblique diameter of the foetal
head-the danger and mortality to the child is generally far greater
than when the short instruments merely are used, the direction of
the compression with them being transverse.
But delivery by the long forceps, under any conditions, is an
operation entirely rejected by many eminent accoucheurs, and very
•
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
455
seldom indeed adopted in country practice. And I have already
often stated, but cannot, perhaps, too often repeat, that it is princi-
pally as a substitute and alternative for craniotomy in contracted
states of the pelvic brim, that I bring forward the operation of turn-
ing. Now, as far as regards the child, the results of these two modes
of delivery, craniotomy and turning, in this special and not unfre-
quent set of cases, are easy of comparison and settlement. For the
very essence of the one operation, craniotomy, is the actual death
and instrumental destruction and mutilation of the child. The
object of the other operation, turning, is to offer the child, under
the very same circumstances, a chance of escape and of life. Cranio-
tomy implies the inevitable sacrifice of the infant. Turning implies
its possible safety and probable survival. And the distinction
between them which has latterly been always uppermost in my
own mind, is this-delivery by craniotomy consists in opening and
breaking down the skull so as thus to reduce it to such dimensions
as will allow it to pass through the contracted pelvic brim; but the
operation which I propose to substitute for it, and by which the
requisite diminution of the fœtal head may likewise be produced,
consists, not in fatal opening and emptying of the skull, but in com-
pressing, and, if necessary, depressing its flexible and elastic parietes ;
and further, I have shown that extraction by turning affords us the
means of effecting this compression and indentation without always
compromising the life of the infant. As far then as regards the
safety and life of the infant, I hold that any general comparison
between craniotomy and turning is altogether and entirely in favour
of the new practice. But how stands the comparison between the
effects of the two operations in relation to the safety and life of the
mother? To answer this question a separate section is required.
SECT. VIII.-SUPPOSED OBJECTIONS TO THE PRACTICE IN RELATION
TO THE LIFE OF THE MOTHER.¹
1
In the last section, when treating of the effect upon the infant
of the practice which I propose in distortions of the pelvis, I took
occasion to state, that the only proper test or measure of value be-
tween a novel operative measure like this, and those operative
measures for which it is suggested as a substitute, consists in ascer-
¹ See Provincial Medical and Surgical Journal, October 4, 1848, p. 533.
456
OBSTETRIC OPERATIONS.
taining, not the absolute mortality attendant upon the new operation
alone, but the comparative mortality attendant upon the new as
compared with the other and older forms of treatment. In the
same way, in the present section, the question is not-What is the
absolute maternal mortality attendant upon delivery by turning in
cases of contracted pelvis? But, What is the mortality attendant
upon that operation, as compared with the mortality accompanying
the alternative operations of delivery by the long forceps and by
craniotomy?
In the records of midwifery, there do not yet exist, so far as I am
aware, any data by which it is possible to compute either the general
or relative mortality to the mother, from the use of the long forceps?
Nor can we obtain any satisfactory approximation to the probable
results of their employment upon the mother, by studying the
maternal mortality attendant upon the use of the short forceps.
For the short forceps are employed only in cases in which the head
is already sunk down into the pelvic cavity, and when the applica-
tion of the instrument is far less difficult, and its effects less danger-
ous, than when the long forceps are had recourse to in consequence
of the child's head being arrested high up in the passages, from the
obstruction of a distorted pelvic brim.
It is principally, however, as an alternative for craniotomy that
we have to consider the propriety of turning; and there exist
numerous data by which we may compare the relative mortality
of these two operations. On this and other points in the statistics
of midwifery, the laborious and valuable investigations of Dr.
Churchill have thrown much light. The following table, which I
have drawn up from Dr. Churchill's collection of data, shows us
the general relative mortality attendant upon craniotomy and turn-
ing, in so far as regards the life of the mother.
TABLE VIII.
SHOWING THE RESULTS TO THE MOTHER IN CRANIOTOMY AND TURNING.

Operation.
Number of
Cases collected.
Number of
Mothers lost.
Proportion of
Mothers lost.
Craniotomy.
251
52
1 in 5
Turning
169
11
1 in 15
•
In some of these cases of turning, the deaths may, as Dr.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
457
Churchill points out, have been owing to the cause which de-
manded the operation, such as placenta prævia, and not owing to
the operation itself; but I believe with him that the resulting
calculations are “not very far from the truth."'
So far, such an imperfect estimate of the mere mortality of the
two operations gives a result highly in favour of turning. But there
is another element which comes into action, and which is not in-
cluded in the above comparison. Most of the turning cases were
instances in which the operation was performed in consequence of
the child presenting transversely, and with most of them compara-
tively little or no difficulty was probably encountered in getting the
head to pass the pelvic brim. In the class of cases in which it is
my object to recommend turning-viz. with the brim narrow and
distorted—would the operation, from its requiring the forcible ex-
traction and compression of the head, be attended with much increase
of peril to the mother?
On such a question being first suggested, most accoucheurs, I
believe, would be inclined, a priori, to argue that the compression,
however transitory, of the soft tissues included in the maternal
pelvis, between the interior of the maternal pelvic bones and the
solid though elastic head of the infant, would be sure to be attended
with inevitable danger and evil consequences to the maternal struc-
tures; that the practice would, in short, be, as Dr. Radford has
expressed it, "incompatible with the safety of the mother."
Prejudgments, however, even in pathological and practical
matters of this description, are often wrong. Let us lay aside
argument for experience, and supposition for fact, and examine,
quietly and without prejudice, the actual and probable results of
forced operative extraction of the infant's head in cases of obstruc-
tion of the pelvic brim.
Dr. Denman had evidently some experience of the forcible
extraction of the infant's head through contracted pelves, in preter-
natural presentations of the child. The rules of treatment, which
I have already quoted from his chapter "On the Complication of
Breech Cases with Distortion of the Pelvis," show how entirely, or
almost entirely, he trusted in these instances to the forced extraction
of the head, and how very rarely, if ever, he had occasion to assist
the delivery by craniotomy. And he states the results of all his
observations in these instances, in terms most significant of its
1 ¹ Principles of the Practice of Midwifery, p. 245.
458
OBSTETRIC OPERATIONS.
safety. "Nor have I ever known," says he, "any ill consequences
follow the compression, which the soft parts of the mother undergo,
between the head of the child and the sides of the pelvis, if proper
attention were paid to the state of the bladder and rectum.'
The cases I have cited from Dr. Denman, and the others
adduced in the preceding sections, so far afford corroborative
evidence of this important remark. Altogether, I have already
referred to twelve or thirteen cases, in which the force of extraction
or expulsion was so great, that the head was not only compressed
but indented. In none of these does the mother seem to have
suffered from the compression or contusion.
But these cases, it may
be argued, are too few to entitle us to speak over positively on the
point. Let us turn, then, to others.
•
It often enough happens, among cases of pelvic distortion, that
when the head of the child presents, and becomes obstructed at the
brim, the mere perforation of the head, or first part of the operation
of craniotomy, is not adequate to allow the operator to overcome,
with subsequent ease, all the resistance of the obstacle opposing
delivery. In many cases, the second or succeeding part of the
operation of craniotomy-viz. the extraction of the head with the
crotchet through the contracted and obstructing brim-is still
attended with difficulty, and requires for its completion more or less
prolonged exertion by pulling and force. Under such circumstances,
and though the child presents by the head and not by the feet, we
have exactly the same form of danger threatening the soft structures
of the maternal pelvis, as if the excessive traction were made, not
in craniotomy, but in turning. The two cases agree in this one
common condition, that in both, an exertion of traction and force is
required to pull the obstructed head through the contracted pelvic
brim; and in both, the soft tissues lining the pelvis of the mother
are equally liable to be contused and compressed, under this traction
and force.
Now, in cases of craniotomy, such as I here allude to, and which
require the operator to use great exertions in dragging the head with
the crotchet through the obstructing brim, is the mortality to the
mother much increased above what it is in the common run of
craniotomy cases? Or, to state the question in other terms, are
such cases of craniotomy decidedly more dangerous and fatal than
¹ Practice of Midwifery, 1816, p. 469,
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
459
other cases of the same operation, in which such excess of traction
is not required?
Dr. Lee's Clinical Midwifery presents us with a series of data
relative to craniotomy operations, that may enable us to arrive at
some accuracy of information regarding this question. In the first
and second Reports of his work, Dr. Lee details eighty-seven cases
of craniotomy. Table IX. gives a condensed view of the principal
facts and results connected with these eighty-seven cases.
460
OBSTETRIC OPERATIONS.
No. of Case.
No.
in Report.
ANALYSIS OF 87 CASES OF CRANIOTOMY, RECORDED BY DR. LEE,
Cause of Obstruction and Delay.
No. of
Pregnancy.
TABLE


Length of Labour before
Operation.
12
2
1 | Rigid os uteri; vagina swollen and tender
2 | Head never through brim-convulsions
1
1
3
4 Head jammed in brim
Three days and nights
Fifty hours
Above 48 hours
4
5
Head not passed brim. Os uteri half dilated
2
667
5
8
Head not passed brim
8
Scalp tumid; bones riding
8
Head wedged in brim
123
Two days (48 hours)
Nearly 60 hours
2 Strong, above 30 hours
...
8
9
Impacted in brim
•
9 16
Not through brim. Os uteri rigid, not fully dilated
1
About 50 hours
10 17
Head low but not through the pelvis ; anterior
lip of uterus locked; labia swollen.
1
About 48 hours
11
25
Head and arm jammed in brim
2
Above 30 hours
12 29
The greater part of the head had passed through
the brim
Forty-six hours.
13
30
Great part of the head still above brim
1
Above 20 hours
14 31
Head not completely in the cavity of pelvis
15 32
16 34
Head so low that the ear could be felt
Head sufficiently low for the forceps
11
Above 72 hours.
So long that she was
17 35
Head filled the cavity of the pelvis
1
quite exhausted
Above 41 hours
18 38 Cavity of the pelvis occupied by a tumour the
size of a cricket-ball, or larger.
Twenty-four hours
19 39 Os uteri not fully dilated, thick and rigid, and
pressed down with the head through the brim
1
Above 50 hours.
of the pelvis.
20 40 Head firmly impacted in brim of the pelvis
1
Above 30 hours
21 41
22 42
Distortion of pelvis, and hard cicatrix of vagina.
Head jammed in the brim
1
Long in labour
•
23 43
Head within reach of forceps
1
•
...
...
24 56 Pelvis distorted
25 57 Face presentation.
1
26
58 Head and arm
•
27 59
Head long fixed in the brim.
28
60
Head many hours impacted in the brim; vagina 1
Sixty-seven hours
Above 48 hours.
1 Seventy-two hours.
3 Forty hours
Thirty-six hours
•
swollen and tender.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
461
IX.
IN THE FIRST AND SECOND Reports oF HIS CLINICAL MIDWIFERY."
Difficulty or not in
Extraction.
Death or
Recovery of Inflammation, Sloughing,
Mother.
Other Results.
etc.
REMARKS.
Not stated
Not stated
Recovery
Recovery
Required 1 hr., Recovery
bones of head,
etc., much torn
Great difficulty. Recovery
Long-contd. efforts Recovery
Little difficulty
Not stated
•
Recovery
Death
Strong efforts
Death
Force required
•
Recovery
Not, except in Recovery
...
overcoming pe-
rineum
Not stated
Sloughing; fistula
Violent inflammation
of uterus
Long forceps tried first.
Long forceps tried first.
Post-partum hemor Tried first to apply forceps.
hage
Slight uterine inflam- Tried first to apply forceps;
:
mation
...
...
Inflammation
...
...
...
and
sloughing of vagina
and cicatrix.
...
No bad effect.
Perineum torn
With difficulty
•
Recovery
Recovery
...
Recovery
Recovery
Recovery
Great force
Great force
Tedious & difficult Not stated
Not without much Recovery
by
shoulders of infant
craniotomy in former labour.
Recovered rapidly.
Ergot and repeated efforts with
forceps tried previously.
Forceps tried first; vagina enor-
mously swollen.
Not able to apply the forceps. No
bad consequences followed.
Delivered of first child by forceps.
Forceps tried first.
Forceps tried first; delivered
since without asssistance.
Forceps tried first.
sentation.
Forceps tried first.
Forceps tried first.
A face pre-
difficulty
Much difficulty
•
Recovery
Difficult
Not stated
...
...
...
...
Forceps tried first.
Forceps tried first. Next child de-
livered naturally at full period.
Not able to apply the forceps.
Difficult.
Recovery
Not stated
Recovery
Not stated
Recovery
Not stated
Death
Tedious & difficult
Retention of urine
violent inflamma-
tion of vagina; fever.
Recovery Slight uterine inflam-
Not stated
Not stated
•
Recovery
Recovery
Difficult
Recovery.
Not difficult
Recovery.
mation.
Hemorrhage
Severe inflammation
of uterus
Not able to apply the forceps.
Convulsions. Forceps tried first.
Face presentation.
Many efforts made at turning.
462
OBSTETRIC OPERATIONS.

No. of Case.
No.
in Report.
Cause of Obstruction and Delay.
No. of
Pregnancy.
Length of Labour before
Operation.
29
61
30
62
Head in the pelvis, and an ear felt
Os uteri rigid and partially dilated.
...
Head
Head com-
1
Twenty-four hours.
Seventy-two hours.
pressed in the brim
31 63
Head fixed in the brim
1
Above 24 hours.
32 64
Head of child passed into the pelvis. Labia
First stage very pro-
swollen to the size of a child's head
tracted
33 65
Great distortion of the pelvis
1
•
Thirty-six hours
34 66
Head fixed in the brim; pelvis small
1
Forty-eight hours
35 67
Head above the brim
36 68
Small pelvis ; os uteri rigid
37 69
Great swelling of soft parts
•
38 70
...
...
39 71 Os uteri half dilated
...
40 72
41 73
...
...
42 74
Distortion of pelvis
43 75
Head half through brim
1
44 76
Distortion of pelvis ; head not in cavity of pelvis 1
About 72 hours.
45 77
Head scarcely entered the brim
46 78
Head firmly compressed between sacrum and
pubis
About 48 hours
Forty-eight hours
47 79 Distortion of pelvis; head in the brim
2
Above 48 hours
48 80 Distortion of pelvis ; head above the brim
1 Thirty-six hours
1
1
1
...
Great protraction
(above 24 hours)
Forty-six hours.
About 72 hours.
Twenty-four hours
2 Above twelve hours
•
After great protraction
Above thirty hours
•
49 81
Distortion of pelvis; greater part of head still
above brim
1
Above 48 hours
50 82
Head firmly jammed in the pelvis
3
Above 15 hours.
51 83
Head fixed in the brim
4
Above six days
•
52 84
Head firmly fixed in the brim
10 About 24 hours.
53 85
About 30 hours.
:.
54 86 Contraction of pelvis
•
55 87 Distorted by rickets; head above the brim
1 Nearly 60 hours
56 88
Head firmly impacted in the pelvis
57 89
Head so low in pelvis that an ear was felt; closely
surrounded by the inflamed vagina
Forty-eight hours
Seventy-two hours
•
•
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
463
Difficulty or not in
Extraction.
Death or
Recovery of
Mother.
Other Results.
Inflammation, Sloughing,
etc.
REMARKS.
Not stated
Recovery
...
Vectis and forceps tried first.
Not stated
Death
Great inflammation
Not stated
Not stated
Recovery.
Death
and sloughing.
Gangrene of vagina
and external parts.
Not stated
Great force
Not stated
Recovery.
Recovery
Recovery.
...
...
Not able to apply the forceps.
Not stated
Recovery.
Not stated
Recovery
Not stated
Recovery
Not stated
Recovery
Not stated
Recovery
First tried forceps. Twins.
Violent puerperal convulsions.
Placenta prævia.
Puerperal convulsions.
Without
much Death
...
Rupture of uterus.
difficulty
Not stated
Recovery.
Not stated
Recovery
Great force
Recovery
Difficult
•
Recovery
Great force
Recovery
...
Not stated
Recovery
Slowly.
Recovery
Difficulty
•
Recovery
Easily
Readily
Difficulty
•
Recovery
Recovery.
Recovery
Retention of urine;
Easily.
Recovery
Extreme difficulty Recovery
...
...
Retained placenta.
Soft parts must have been
severely contused.
Uterine inflammation Delivered by craniotomy before.
Right parietal bone of the child
depressed and fractured.
First child delivered by cranio-
tomy.
The operation lasted two hours,
and the bones of the skull were
all torn to pieces before the
head could be extracted.
Next child delivered without
aid. The breech presented.
Convulsions occurred.
Delivered by turn- Recovery
ing
Great force
Some difficulty
Recovery.
Recovery
Retention of urine;
violent inflammation
and sloughing; cica-
trix left in vagina.
sloughing of vagina ;
vesico-vaginal fistula.
Sloughing; vesico-
vaginal fistula.
A dwarf. The operation lasted
nearly five hours, and the head
of the fœtus could not be
drawn through the brim of
the pelvis, until the bones of
the base of the skull were all
torn to pieces.
Uterine inflammation Turning resorted to in conse-
quence of an arm having been
brought down by the crotchet.
464
OBSTETRIC OPERATIONS.
No. of Case.
No.
in Report.
58
Cause of Obstruction and Delay.
90 Head at the external parts
No. of
Pregnancy.
1
Length of Labour before
Operation.
Seventy-two hours.
60
8 : UNIF
59
91 Pelvis distorted; head in the brim
...
tially dilated
61
93
Head wedged in the brim
62
94
Greater part of head above the brim
63
95 Head squeezed in the brim.
64
96 | Head firmly impacted in the brim
92 Part of the head above the brim; os uteri par- 1 Very protracted
Very tedious
1 Fifty hours.
Forty-eight hours
1 Seventy-two hours.
•
8 8 28 a
65
97
Head jammed in brim; distortion of pelvis
66
98
67
99
Head far advanced into the pelvis ; vagina swollen
Head compressed in brim; os uteri partially
dilated
1
1
Fifty-three hours
Seventy-two hours
70 102
71 103
Os uteri partially dilated; head above brim
Head and right arm presenting; os uteri half
dilated
72 104
73 105
Head fixed in brim; vagina swollen and tender
Head strongly compressed in the brim; os uteri
not fully dilated
Above 30 hours
74 106 Soft parts immensely swollen
75 107 Head firmly wedged in the brim; vagina swollen
and tender
Very protracted
Above 78 hours
...
68 100 Head has scarcely entered the brim; os uteri
rigid and not half dilated
69 101 Head deep in the pelvis, great swelling of the
vagina, etc.
•
1 Thirty-eight hours.
:
12
Thirty-seven hours.
Forty hours.
About 72 hours
76 108
Head not passed brim
77 109
Head impacted in the brim
78 111
Distortion of the pelvis ; head compressed in the
pelvis
::
...
1
Forty-eight hours
Forty-one hours
Eighty-six hours
79 112
Distortion of the pelvis ; head not in brim
1
80 113
Distortion of the pelvis ; head above brim
...
81 114 Head above the brim; os uteri not completely
About 48 hours
Above 62 hours
Above 78 hours
dilated
82 115
Greater part of the head above the brim
1
Above 53 hours
83 116
The head would not pass till perforated, being
distended with fluid
...
84 117
85 118
Head above brim, and distended with fluid
Head above brim, and distended with fluid
1
Nearly 60 hours
1
Long in labour
86 119 Head distended with fluid
S7 120 Head distended with fluid
...
Above 21 hours
...
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
465

Difficulty or not in
Extraction.
Death or
Recovery of
Mother.
Other Results.
Inflammation, Sloughing,
etc.
REMARKS.
Not stated
Recovery
Not stated
Recovery
Not stated
Recovery
Retention of urine; The tumefaction of the labia and
sloughing
vagina was such that the blades
of the forceps could not be in-
troduced.
...
...
An unsuccessful effort had been
måde to deliver with the forceps.
Delirium for nearly a day.
Not stated
Death
Inflammatn. of bladder
Not stated
Recovery
Not stated
Recovery
...
Recovery
Sloughing;
vesico-
vaginal fistula.
Not stated
Recovery
Face presentation.
Bursting of
a thrombus of the vulva.
Not stated
Recovery
Not stated
•
Recovery
Not stated
Recovery
Tedious
Recovery
Great force
Recovery
Not stated
Recovery
Not stated
Recovery
Great force
Recovery
Two hours re- Recovery
Retention of urine and
quired
sloughing of vagina.
Great difficulty
Death
Uterine inflammation
Perineum slightly lacerated; rc-
tained placenta; slight hemor-
rhage.
Easy
Recovery
Much force
Recovery
Not stated
Death
Great force
Recovery
Not stated
Recovery
Not stated
Recovery
0:0
Inflammation of mus-
cular coat of uterus.
Inflammation of uterus
Disease of chest ; in-
Force required
•
Recovery
Death
Easy
Death
Easy
Death
in pelvis.
Easy
Death
Rupture of uterus
Little difficulty
Death
Rupture of uterus
flammation of veins
There was a peculiar thickening
at the upper and back part of
the vagina, which seemed to
arrest the progress of the head.
Placenta prævia. Child turned
first.
Child turned.
466
OBSTETRIC OPERATIONS.
1
In most of the eighty-seven cases in the preceding table, the
operation of embryulcio was performed while the volume of the
head was still above the brim. In the detail of many of the cases,
Dr. Lee mentions whether the operation of extraction, after the
skull was opened, was difficult or not; in thirty, however, of the
eighty-seven, he particularly notes the extraction of the perforated
head with the crotchet as having been attended with difficulty and
force. The footnote below' contains a list of these thirty cases, and
Dr. Lee's own expressions with regard to the degree of difficulty
met with in each case, in this, the second part of the operation-
viz. the extraction with the crotchet. In twenty-two of these thirty
cases it is stated that the head of the child was not through the
brim at the time craniotomy was performed, but required to be
pulled through it with the crotchet. In most of the remaining
eight cases the position of the head at the time of operating is not
mentioned.
1 Case 5.-"After perforation, great difficulty was experienced in extracting
the head with the crotchet." Case 8.—“From the long-continued efforts re-
quired to drag the head into the cavity of the pelvis, it was evident that the
delivery could have been accomplished in no other way with safety to the
mother." Case 9.-"After perforation, strong efforts were required to complete
the delivery, and she died within forty-eight hours." Case 16.-"The force
afterwards required to extract the head with the crotchet made us regret that we
had not interfered sooner." Case 29.-"After perforation, the head was extracted
with difficulty by the craniotomy forceps." Case 31.-"The head was perforated,
and the force afterwards required to extract it with the craniotomy forceps was so
great, that I regretted having endeavoured to deliver before lessening the volume
of the head." Case 32.—“After perforation, so much force was required to draw
the head through the pelvis with the craniotomy forceps, that I regretted having
attempted to save the child." Case 34.-"The extraction of the head with the
crotchet was a tedious and difficult operation." Case 35.-"I did not succeed
without much difficulty in delivering with the craniotomy forceps." Case 38.-
"I opened the head, and had much difficulty afterwards in drawing it down with
the crotchet." Case 39.-"Perforation and extraction difficult." Case 40.-
"Extraction difficult." Case 56." Extraction with the crotchet tedious and
difficult." Case 59.-"Extraction difficult." Case 66.-"Great force required
to extract." Case 76.-"The bones of the cranium were all torn away with the
crotchet before I succeeded in drawing the base of the skull through the brim of
the pelvis.
* * Great force was afterwards required to drag the shoulders into
the cavity of the pelvis." Case 77.-" The operation of craniotomy was difficult.'
Case 78.—“Great force was required to extract the head after being opened."
Case 81.-"The difficulty experienced in extracting the head with the crotchet
after it was opened, proved that delivery could not have been completed by any
other method." Case 84.-" After the head had been opened, two hours elapsed
before I could extract it with the crotchet." Case 86.-"The operation lasted
nearly five hours, and the head of the fœtus could not be drawn through the brim
of the pelvis until the bones of the base of the skull were all torn to pieces with
""
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
467
Out of the thirty cases presenting the subjoined degree of force
and difficulty in the extraction of the head, two only of the mothers
died. In the remaining fifty-seven cases, either the extraction is
noted as easy, or was not so difficult as to have been considered
worthy of being noted; and out of these fifty-seven cases, thirteen
mothers died. The following arrangement expresses these results in
a tabular form :-
TABLE X.
TABLE OF EIGHTY-SEVEN CRANIOTOMY CASES, REPORTED BY DR. LEE,
SHOWING THE NUMBERS IN WHICH EXTRACTION WITH THE CROTCHET
WAS-1, NOTED AS DIFFICULT; OR, 2, NOT NOTED AS DIFFICULT; AND
THE RESULTS OF THESE TWO CLASSES.

Extraction of the Head
after Perforation.
Number of Number of
Cases. Deaths.
Proportion
of Deaths.
30
2
Not noted as such
57
13
1 in 15
1 in 4
Noted as difficult
These interesting facts evidently point to one conclusion-viz.
that in distorted pelves, the amount of force required for the delivery
and extraction of the head of the child, in cases of craniotomy, and
hence also in cases of turning, has far less influence upon the ulti-
mate results and mortality of the operation than we could well have
anticipated. But I anxiously desire not to be misunderstood on
this point. I by no means wish to maintain that the degree of
force used in delivery has no influence upon the resulting degree of
danger and mortality to the mother. Nothing could be more differ-
ent from either my intentions or my convictions. But the above
table shows that in the ordinary forms of distorted pelvis, the degree
of force employed for effecting the transit of the head is far less an
element of danger than could have been previously imagined; and
the explanation of the apparent paradox is, I believe, twofold. For,
the crotchet." Case 88.-"After the perforation, so much force was required to
extract the head, as to make it certain that the head could never have been ex-
tracted without its size being reduced." Case 89.-"I opened the head, and had
some difficulty in extracting it." Case 102.-" Great force required to extract."
Case 105." The head required great force to extract it after perforation." Case
106.-"Two hours required to extract the head with the craniotomy forceps.'
Case 107.-"Great difficulty in extracting the head." Case 109.-"So much force
required to extract the head that it was obvious it never could have been delivered
with the forceps, or expelled by the natural efforts." Case 112.-" The extraction
required great force." Case 115.-"The force required to extract the head after
perforation rendered it obvious that the head could never have passed in the
exhausted state in which she was.
31
468
OBSTETRIC OPERATIONS.
first, temporary compression applied to two special points in the circle
of the pelvis (as in the case when the child's head is dragged, by opera-
tive measures, through a brim contracted only in one diameter) is by
no means so dangerous as more prolonged, though slighter, degrees
of compression of the maternal structures, when the compression is
equable, and diffused over the whole circle of the pelvic aperture, or
the whole interior of the pelvic cavity, as in instances in which a
hydrocephalic fœtal head is pressing like an hydraulic bag, equally,
and on all sides. But, secondly, the effect of the law of the influence
of force is counteracted by, and subsidiary to, another law of a far
higher degree of practical generalisation-viz. the law which I have
illustrated at length in a preceding section, that "the danger at-
tendant upon parturition increases in a ratio progressive with the
increased duration of the labour." And I have little doubt that if
we had proper and adequate data for conducting the inquiry, it
would be found that the safe result of those craniotomy cases in
which force is employed in the delivery is in a great measure owing
to the time of the labour at which the delivery is accomplished; and
that when the result is fatal, it is as much owing to the previous
length or duration of the labour, as to the force employed. Dr.
Collins, in his chapter on still-born children, details eight cases of
craniotomy in which, after perforation, the extraction of the head
with the crotchet required more or less severe exertion and force.'
1 These eight cases are the following:-1. "No. 49 was forty-eight hours in
labour of her first child. Having made no progress for the last twenty-four
hours, the pulse becoming extremely quick, with great general debility, the head
was lessened, and delivery effected by the crotchet. Considerable difficulty was
experienced in getting the head through the pelvis, in consequence of the hand
having descended with it."-Practical Treatise, p. 462.
2. "No. 56 was a
diminutive woman, much deformed; had been twice force-delivered in this
Hospital, as from the size of the pelvis it was impossible for a child to pass
entire; even after the bones of the head were completely broken down, much
difficulty was experienced in completing the delivery." 3. "No. 209 was admitted,
reported to have been four days in labour, and attended by a midwife; the uterus
continued to act strongly, yet after waiting eleven hours the labour made no pro-
gress, and, as there was no doubt the child was dead, the head was lessened.
Many of the bones were removed before the delivery could be completed; the
child was large and putrid." 4. "No. 210; after three days' labour, the head,
still at the brim of the pelvis, was lessened, and almost every bone removed before
it could be delivered, and even after it was brought down much exertion was
required to free the shoulders and body. The child was large, and the abdomen
somewhat distended with air. The mother seemed at this time almost lifeless,
having lost the power of swallowing. The hand was introduced into the uterus,
which was quite relaxed, the placenta was gently removed, and the patient expired
immediately. On dissection, the uterus was found healthy, but badly contracted,
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
469
One of the eight patients died, but she had been seventy-two hours
in labour when the operation was undertaken; all the other seven
recovered. In six out of these seven cases, craniotomy was
adopted earlier; in one, before the labour had reached sixteen
hours in length; in all, before it had passed forty-eight hours from
its commencement.
The manner and extent in which the laws of danger attendant
upon this and other particular obstetric operations are controlled by,
and absorbed in, the more general law of the attendant mortality,
depending upon the length or duration of the labour, have been
already illustrated (see Section IV.), in reference to delivery by the
forceps, and delivery by the crotchet, taken individually. The law
and its results, however, are so extremely important, as bearing upon
the question of the present section, that I will, in further confirma-
tion of it, and at some risk of repetition, throw into a combined
containing a small quantity of coagulated blood; the intestines were in the highest
state of congestion, and there was about a pint of fluid in the abdominal cavity,
with portions of coagulable lymph in different parts, seemingly the effects of
inflammation previous to labour. On opening the chest, the lungs were observed
to adhere so firmly as to require the knife in many places to separate them.
Nothing was discovered to account for the suddenness of death." 5. “No. 256
was thirty-two hours in labour previous to admission; her pulse was rapid, and
tongue foul. She was delivered some hours after she came in, by lessening the
head, which was greatly enlarged from hydrocephalus; there was some difficulty
in completing the delivery, even after the bulk of the head had been as much as
possible reduced." 6. "No. 303 was admitted, reported to have been three days
in labour of her first child; the head was low and firmly fixed in the pelvis ; the
bladder greatly distended with urine; it having been retained for thirty hours;
pulse 140; tongue dry and white. The catheter was passed, and three pints of
urine removed. As the abdomen was free from pain, it was thought advisable to
watch the effect of uterine action for some time. After waiting five hours, during
which the pains were pretty brisk at intervals, still the head made no advance ;
it was lessened and brought away with the crotchet. There was considerable
exertion required to bring down the shoulders; the abdomen was much distended
with air; the consequence of putrefaction. She died on the fourth day from
delivery." 7. "No. 667; the labour lasted thirty hours; the head was firmly
fixed in the pelvis, and had made no progress for twelve hours. As the heart's
action had some time ceased, and the mother's pulse was 140, the head was
lessened. Great exertion was necessary to effect delivery, in consequence of the
head being much ossified." 8. "No. 725; this patient, when admitted, was
reported to have been sixty hours in labour; the os uteri was very little dilated,
and the head high up in the pelvis. The pains continued constant for twenty-four
hours after she came in, yet the labour made little progress; the mouth of the
womb was rigid, jagged, and had the feel of cartilage. The child being dead, as
indicated by the stethoscope, the head was lessened and left in that state for some
hours, and afterwards cautiously brought down. Considerable force was necessary
to complete the delivery, though the child was putrid.”
470
OBSTETRIC OPERATIONS.
form and table all the forceps and all the craniotomy cases men-
tioned by Dr. Collins in which he specifies the duration of the
labour. In other words, we will conjoin the two tables previously
given in Section IV. into one; and examine how much the maternal
mortality was modified in tedious and laborious labours, requiring
instrumental aid, by the date of the labour at which that aid was
given. Our former tables contained 24 cases delivered by the
forceps, and 77 delivered by craniotomy; in all 101 instrumental
labours. The results were as follows:
TABLE XI.
SHOWING THE RESULTS OF 101 INSTRUMENTAL DELIVERIES IN WHICH THE
DURATION OF LABOUR AT THE TIME OF THE OPERATION WAS NOTED.

Duration of Labour.
Number of Number of
Cases.
Deaths.
Proportion of
Deaths.
Under 24 hours
From 25 to 48 hours
Above 48 hours
32
2
1 in 16 died.
•
42
6
1 in 7 died.
27
11
1 in 2 died.
Total
101
19
1 in 5 died.
•
This combined table of Dr. Collins' instrumental deliveries fully
bears out the important conclusion regarding the influence of the
antecedent duration of labour, that we have already seen to be
derivable from the study of the two operative measures, the forceps
and crotchet, taken singly and individually. The evidence of the
present table, like the evidence of those previously given (see Tables
V. and VI.) amounts to this-that the maternal mortality accom-
panying instrumental delivery is regulated more by the period of the
labour at which the artificial interference is practised, than by the
nature of the operation itself, or by any other contingent circum-
stance the general fatality being decreased in proportion as the
operation is performed early, and increased in proportion as it is
postponed and delayed longer and longer from the date of the first
commencement of parturition. But, admitting that this holds true.
in regard to instrumental delivery by the forceps and craniotomy, it
may be doubted and objected that it perhaps does not hold true in
regard to artificial delivery by the operation we propose to employ,
viz. turning. Let us interrogate Dr. Collins' facts, in order to
obtain an answer.
In his Report of the Dublin Lying-in Hospital, Dr. Collins gives
the result of thirty-three cases, in which turning was practised in
:
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
471
consequence of presentation of the shoulder or arm. In one of
these cases the placenta presented, and I exclude it as thus contain-
ing a source of danger quite independent of the turning. Among
the remaining thirty-two cases, there are two deaths, or one in six-
teen; and twenty-four in which the date of the duration of the
labour, at the time of turning, is stated as ascertainable. In only
one of these twenty-four cases is the labour noted as having ex-
ceeded thirty hours in length, and this protracted case was an
instance of twins, in which the second child presented preternatu-
rally, and required turning. In twenty-one of the cases the labour
was terminated before twenty-four hours; among these, one died—
a case complicated before delivery by severe accidental hemorrhage;
in three it was prolonged beyond twenty-four hours, and one of
these three mothers died. When arranged in a tabular form, the
results are as follows:
TABLE XII.
SHOWING THE MORTALITY ACCOMPANYING TWENTY-FOUR CASES OF TURN-
ING FOR PRESENTATION OF THE ARM AND SHoulder, as reGULATED
BY THE PREVIOUS DURATION OF LABour.

Previous Duration
of Labour.
Proportion of Deaths
of Mothers.
Below 24 hours
Above 24 hours
1 in 21 died.
1 in 3 died.
The data in the preceding table are not numerous, but still they
will probably be allowed to be sufficient evidence of the fact, that
the degree of maternal danger attendant upon turning, as upon
other modes of operative delivery, is regulated and modified by the
date of the labour at which the delivery is practised; artificial
labours, like spontaneous labours, increasing in their mortality in
proportion as the previous parturient action has been allowed to be
increased and prolonged in its duration and length. Hence, also,
necessarily follows the same deductions which I have already more
than once adduced, viz.-
1. A means of artificial delivery, such as turning, which, in cases
of pelvic contraction, would enable us to finish the labour at an
early date, should, as a general rule, add greatly to the safety and
chance of life of the mother, as compared with a means of delivery
such as the long forceps or craniotomy, which cannot be usually
and legitimately practised till a much later period after the com-
mencement of parturition.
472
OBSTETRIC OPERATIONS.
2. The facts I have adduced in the present section show that
the exertion of force in artificial delivery is attended with compara-
tively little danger, provided always the delivery is early; and that
the employment of it is by no means so hazardous as the simple long
continuance and protraction of the labour.
3. All these deductions are only corollaries to the higher and
more comprehensive law, that the degree of danger and fatality
attendant either upon natural or morbid parturition, increases in
a ratio progressive with the increased duration of the labour.
SECTION IX.-ON THE COMPARATIVE DANGER OF LOCAL LESIONS
OF THE MATERNAL ORGANS (VAGINA AND UTERUS), IN DELI-
VERY BY TURNING, AND DELIVERY BY INSTRUMENTS.
1
As far as the observations in the preceding section go, they refer
to the comparative degree of actual danger to the life of the mother
under the opposite means of treatment, by which cases of labour,
with arrestment of the head and distortion of the pelvic brim, may
be treated. They refer merely to the question of the probable
death or probable survival of the mother, under the two different
lines of practice spoken of-viz. delivery by instruments and delivery
by turning. But it is possible, that, under such a form of labour
as we have been considering, the mother may survive, that she may
escape with life, and yet the maternal passages and neighbouring
soft parts may be so much damaged and injured, as to interfere, in
a more or less dangerous or distressing manner, with the state of her
future health and future happiness. The cervix uteri, or the walls
of the vagina, are sometimes so contused, or become so inflamed,
that gangrene and sloughing supervene, and lead to the formation
of cicatrices and strictures; or, what is still more deplorable, this
resulting gangrenous inflammation may produce fistulous commu-
nications between the vaginal canal, and the rectum, or urethra,
or bladder. No consequence could be possibly more deplorable
than this last-the occurrence of recto-vaginal or vesico-vaginal
fistulæ.
Speaking of sloughing of the urethra or neck of the bladder, as
a consequence of severe labour, Dr. Collins remarks, in words
dictated by the best possible feelings:-"I do not know of any
occurrence more calculated to render the patient's life one of endless
sorrow; or, at the same time, more likely to cause the practitioner
¹ See Provincial Medical and Surgical Journal, January 10, 1849, p. 9.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
473
such lasting regret. When it unfortunately happens, as in some
instances is unavoidable, in consequence of the protracted length to
which we are at times compelled to permit the labour to proceed,
owing to great difficulty in the passage of the head, the child being
alive, here the medical attendant's mind cannot, on his own account,
feel distressed, as the only means he could adopt to guard against
the danger would be to lessen the head, which, in my opinion, no
consideration should induce him to do under such circumstances.
Are such distressing results as Dr. Collins here describes more
liable to occur under the present practices of delivery by instru-
ments, or under the new practice which I propose of delivery by
turning? In other terms, the question which I wish to consider is
this:
Are Local Lesions from Inflammation of the Vagina, such as Sloughing,
Fistula, etc., more liable, in a Contracted Pelvis, to supervene after
Delivery by Turning, or Delivery by Instruments ?
Vaginal inflammation, terminating in sloughing, cicatrices, and
fistulæ, is not unfrequently observed after protracted labours that
are terminated by the forceps or crotchet. In his Clinical Midwifery,
after detailing "the histories of fifty-five cases of difficult parturition
in which the forceps was employed," Dr. Lee remarks,2" Five of the
mothers whose cases have now been related died from puerperal
convulsions, and four from the rash and inconsiderate use of the
forceps; seven had the perineum more or less injured; one the
recto-vaginal septum torn; five were left with cicatrices of the
vagina after sloughing; and one with an incurable vesico-vaginal
fistula." After describing the histories of sixty-five cases of "diffi-
cult labours from distortion of the pelvis, swelling of the soft parts,
convulsions, hydrocephalus in the fœtus, and other causes in which
delivery was effected by the operation of craniotomy," Dr. Lee again
observes, "In thirty-eight of the cases in this report, the labour
continued from forty to seventy hours. In the cases of spontaneous
rupture of the uterus and convulsions only, was the delivery effected
before the labour had lasted upwards of thirty hours. In a very
large proportion of the cases, the difficulty arose from distortion, or
a contracted state of the pelvis. Rupture of the uterus took place
in three before perforation, and the inflammation and sloughing of
the uterus, vagina, and bladder, which proved fatal to eight others,
¹ Practical Treatise, p. 359.
2 Clinical Midwifery, p. 32. 8 Ibid. p. 59.
474
OBSTETRIC OPERATIONS.
were chiefly or solely produced by the long-continued violent pres-
sure on the soft parts by the head of the child before it was opened
and extracted. In those who recovered with vesico-vaginal fistulæ,
or contraction of the vagina from cicatrices, the unfortunate occur-
rences arose from craniotomy being too long delayed."
In the table which I have previously given from the same
author (see Table IX.) of the results of 87 cases of craniotomy, local
lesions on the part of the mother are noted as having occurred in
several instances. Out of the 87 cases, eight, or about, in every 10,
suffered from vaginal inflammation and sloughing; four, or nearly
1 in every 20, were left with vaginal fistulæ.
1
On the other hand, I am not aware of a single recorded instance
in which vaginal sloughing and fistula ever followed transverse pre-
sentations of the foetus, and where the delivery is, as a general rule,
always accomplished by turning. Two circumstances lead to this
immunity :-
1st. In presentations of the arm and shoulder, the presenting
part does not so completely fill up and compress the tissues of the
brim as in head-presentations. Hence both the tendency to, and
the occurrence of, congestion of the vessels and inflammation in the
tissues, situated below the site of the compression-viz. the vagina,
etc.-is far rarer. But-
2dly. The delivery is always, or almost always, accomplished
early in the labour, and no doubt the mere length and protraction
of the labour is one of the great, if not the greatest, predisposing
and exciting causes of gangrenous inflammation and sloughing of
the vagina.
In many cases vaginal sloughings and fistulæ have been attri-
buted to the use of instruments, when they were more truly owing
to gangrenous inflammation and sloughing, ensuing in consequence
of the delay that was allowed to occur before instrumental delivery
was adopted. In the history of most instances of vesico-vaginal and
recto-vaginal fistula following labour, there is one simple fact, prov-
ing that they are not the direct effect, as is too often supposed, of
lesions and lacerations by the forceps or crotchet. If vesico-vaginal
fistula were, in this way, the direct effect of injuries produced by
cutting with the instruments, then escape of urine through the
vagina would be observed immediately after labour. But this is
rarely the case; the general fact being, that the escape of urine
¹ See Cases 10, 20, 30, 32, 57, 58, 61, 74.
2 See Cases 1, 52, 53, 64,
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
475
through the false opening between the urinary and vaginal canals is
not seen for several days after delivery; because it is not till several
days have elapsed, that the gangrenous slough in the parietes of
these canals separates. No soft parts, any more than the maternal
canals, could stand, without endangering their vitality, the steady
pressure of a firm body upon them for twenty or thirty hours, such
as that which the detained foetal head exerts in contracted pelves
upon the two points of contraction-the symphysis pubis before,
and the promontory of the sacrum behind. It is not a matter of
wonder that the soft structures compressed at these special points
between the foetal head and maternal bones, should sometimes
inflame and slough. It is rather, perhaps, surprising, that this con-
sequence does not oftener follow. On this point Dr. Beatty of
Dublin makes one or two remarks of such importance, that I shall
offer no apology for quoting them at length. "With respect," says
he," to laceration and sloughing of the vagina, bladder, etc., stated
by some authors to be caused by the forceps, and used as an argu-
ment against their employment, I am of opinion, that in the
majority of cases, when these lamentable results occur, the blame is
unmerited; because I have seen the worst inflammation and slough-
ings of these parts follow in cases where the perforator had been
used, and even in some where no instrument whatever was em-
ployed. The truth is, the mischief is effected by the pressure of
the infant's head upon the soft parts of the mother, and after this
has been continued with sufficient intensity, for a sufficient length
of time, the inflammation caused thereby will run its course, no
matter in what way delivery is accomplished, whether by the
natural efforts or by instruments. But it frequently happens that
delivery is effected in these cases by instruments, too late to prevent
the unhappy results alluded to, and then the operation is charged
with the consequences. If an accurate account of the subsequent
condition of all women after delivery could be obtained, I much fear
that the histories of those cases in which labour had been allowed
to run too long before interference, would be anything but satis-
factory. The lamentable sloughings of the vagina, with subsequent
closure of the passage by the process of cicatrisation, or the still
more distressing sloughing of the bladder, with its attendant urinary
fistulæ, are seldom mentioned in lying-in hospital reports, because
the patients are usually removed from those institutions before such
results have become very apparent; and thus, a case left to nature
476
OBSTETRIC OPERATIONS.
in which delivery is effected by the natural efforts, is set down as a
favourable one, without any notice of its consequences.
)) 1
Dr. Beatty elsewhere soundly and correctly remarks, in regard to
the causation of gangrene and sloughing, etc., of parts of the vaginal
walls by the pressure of the child's head, "that it is the continuance
of the pressure that does the mischief rather than its intensity. We
know that the soft tissues of the body are endowed with a resiliency
-a power of resistance that enables them to bear a temporary com-
pression of great amount without injury, while inferior pressure
continued for a length of time will terminate in their disorganisa-
tion. The malingering soldier is well aware of this fact, and acts
upon it when he wishes to produce an ulcer. He straps a piece of
coin or other hard substance tightly upon the part. At first no
effect is produced, and if the apparatus is removed in a short time,
there is no evil consequence; but if the same amount of pressure is
continued for some hours, such a degree of injury is inflicted as
terminates in the destruction of the part, and a sloughing ulcer is
the result."
11 2
That the mere morbid protraction of labour is the great predis-
posing cause of gangrenous inflammation and sloughing of the vagina,
as suggested in these remarks, is shown by Dr. Collins' results. Dr.
Collins has recorded the duration of the labour in six cases where
sloughing of the vagina was detected after death. The following
table shows that the accident occurred in an immensely greater pro-
portion in prolonged than in short labours; and that, consequently,
protraction is, as I have just stated, almost a necessary antecedent
to the occurrence. The case, I may remark, in which sloughing
followed a labour less than twenty-four hours in duration, required
instrumental delivery, but the mode of delivery, whether by the
crotchet or forceps, is not specialised by Dr. Collins.³
TABLE XIII.
DURATION OF LABOUR IN SIX FATAL CASES OF SLOUGHING OF THE
VAGINA.

Length of Labour.
Number of
Deliveries.
Number of
Cases.
Proportion of
Cases.
Within 24 hours
15,586
1
1 in 15,586
Beyond 24 hours
264
5
1 in
53
1 Dublin. Journal of Medical Science, vol. xii. p. 290.
2 Dublin Quarterly Journal, vol. 21, p. 344. 3 See Practical Treatise, p. 358.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
477
If, as these data show, the protraction of labour is a main and
almost necessary element in the production of gangrenous inflamma-
tion of the vagina, it is equally evident that turning, in the class of
cases we are considering, while it frees the mother from the danger
of a fatal termination, as shown in the last section, would at the
same time free her also from the chance of suffering from these local
complications that are apt to follow upon protracted labours.
In the passage which I have quoted from Dr. Collins, at the
commencement of the present section, that experienced practitioner
laments our being occasionally compelled to subject our patients to
the chance of local dangers and complications, in consequence of our
being compelled, in some unavoidable instances, to allow the labour
to proceed onward to a protracted degree, from the child being still
alive, "for then the only means the practitioner could adopt to guard
against the danger, would," says Dr. Collins, "be to lessen the head,
which, in my opinion, no consideration should induce him to do
under such circumstances," viz, as long as the infant is still living.
The proposition which I have made of turning in such instances
resolves the difficulties attending upon them, in two ways. For, first,
it enables us to deliver the patient early and at once, and thus frees
us from the dread of these consequences of protraction; and, secondly,
the continued vitality of the infant would, under the treatment by
turning, not be a reason and incentive for our dangerously delaying
the delivery, but would form a strong reason and incentive for our
proceeding with the practice at as early a period as is proper and
possible. The details of a case or two may enforce these observa-
tions; and I shall select some from Dr. Collins, calculated both to
illustrate these remarks, and to show, that in protracted labours,
occasionally before the time that the child does at last die, the dreaded
amount of local mischief has been accomplished, so that if we waited
always for the certainty of the infant's death, in order to deliver by
craniotomy, we should wait beyond the time that was necessary, in
order to save (locally) the maternal structures from inflammation and
gangrene.
It will be remarked, that in the first of the following instances,
the foetal heart was heard six hours, and in the second case eight
hours, before delivery, and consequently ceased some time between
these periods and the period at which the perforator was used-in
short, necessarily not long before craniotomy was practised. Conse-
quently we have here cases which, in the severity of their local, and,
I may add, in the severity also of their general symptoms, show what
478
OBSTETRIC OPERATIONS.
I have before argued, that the mother may herself be assuredly
placed in the greatest possible danger and hazard from the protrac-
tion of the labour, before that protraction kills the child.
I may
add, that, in the first case, the position of the foetal heart, viz. in the
right iliac region, showed the infant to be in the occipito-posterior
position (the third position of Naegele).
ance.
CASE XXXVI.-"No 126. This woman was fifty-nine hours in labour; it
was her first child. The pains were for a considerable time very trifling, with
long intervals; however, for the last twenty-four hours, the uterus acted with
tolerable regularity, the pains being at times strong, causing the head to press
with much force against the ischia, where it remained stationary for the greater
part of that time. Her pulse was very much increased in frequency, varying
between 120 and 130; the external parts were ædematous. As the foetal heart
had ceased to act, having been distinctly audible in the right iliac region six hours
before, the head was lessened, and the crotchet applied. The placenta was expelled
in forty-five minutes, immediately after which, in consequence of hemorrhage, the
hand was introduced, and so it was arrested. Violent inflammation and sloughing
set in, resisting all treatment, and she died on the 9th day. For four days pre-
vious she had severe diarrhea, a succession of motions coming on suddenly, with
severe pain; she had also severe hiccough. On examination after death, the
vagina was found in a state of slough; the sides opposite the spines of the ischia
were broken through with the slightest force, and were completely gangrenous.
A circular opening the size of a shilling was found, forming a communication be-
tween this cavity and the rectum, the mucous surface of which, as also that of the
colon, was softened, and had, in the vicinity of the opening, a gangrenous appear-
There was no symptom of inflammation in the peritoneum or uterus."1
CASE XXXVII.-" No. 1091. Was admitted August 23d, in labour of her
first child, and was not delivered until the 25th, being a period of fifty-six
hours. Uterine action, from the commencement until within six hours of the
expulsion of the child, was extremely feeble, with long intervals. The head
remained high in the pelvis, and although the ear could not be reached, it was
evident the head had sufficient room to pass; to effect which, uterine action was
alone wanting. As soon as the pains began to be brisk, the labour proceeded
without difficulty. The foetal heart was quite audible until eight hours previous
to the birth. In three hours after the hand was passed to remove the placenta,
it was found separated, and without the slightest effort the uterus contracted and
expelled both. The perineuin had suffered considerably in the passage of the
head. The patient never seemed to rally after delivery; the pulse continued
quick; there was considerable tenderness on pressure over the uterus, with a foul
discharge from the vagina.
On the 7th and 8th, she had distinct
rigors, followed by perspiration, after which her strength became greatly reduced.
The vaginal discharges continued foul, notwithstanding the most rigid attention
to cleanliness and the use of stimulating injections. She gradually sank and died
on the 11th day, having for two days previously suffered from frequent hiccough.
On dissection, the only morbid appearances found were in the bladder and vagina.
In the bladder, the mucous surface was covered with yellow lymph, and it con-
tained a quantity of muco-purulent fluid. In the vagina, opposite the right
ischium, a portion appeared to have been destroyed by slough.'
*
* *
¹ Practical Treatise, p. 158.
112
2 Ibid. p. 483.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
479
Hitherto, under the present section, I have spoken of the dangers
which the mother may avoid by employing the operation of turning
as a substitute for instrumental delivery, in cases of contraction of
the pelvic brim. But while turning enables us, as I have shown, to
eschew some of the gravest and most imminent dangers connected
with the use of the long forceps and crotchet, it is, on the other
hand, by no means to be forgotten, that it subjects the mother to
one great form of danger, from which, in common belief, she would
be comparatively free under the adoption of instrumental delivery.
The special maternal danger attending upon turning is laceration or
rupture of the uterus, confessedly the most fatal complication that can
occur in connection with delivery. Is the liability to rupture under
turning so great as to make us avoid this practice and trust rather
to the forceps and crotchet? Or, in other words-
Is Rupture of the Uterus in Contracted Pelves much more api io be pro-
duced by Delivery by Turning than by Delivery with Instruments?
M
Most authors describe laceration of the uterus as one of the
principal hazards which the mother runs in cases of turning. But
injury and laceration of the uterus are perhaps not so liable to follow
this operation as is generally imagined. "Between the years 1823
and 1834," says Dr. Ramsbotham, "I delivered more than one
hundred and twenty women under transverse presentations; inde-
pendently of a few cases to which I was summoned where spon-
taneous evolution occurred. Many of these cases presented a
formidable appearance; for in one, the membranes had been
ruptured a whole week; in another, sixty-nine hours; in a third,
fifty-eight hours; in another, fifty-five; in another, fifty-three; and
in many, more than forty-eight; and as a general principle, we
presume that the longer the liquor amnii has been evacuated, the
more likely is the uterus to have embraced the fœtal body firmly,
and the more difficulty will there be in overcoming the resistance.
In none of these cases did I exhibit large doses of opium, and in
those few where bleeding was practised, that operation was had
recourse to, not for the purpose of relaxing the uterine fibres, but
to relieve the inflammation which the soft structures were suffering,
and to remove tumefaction. In not one of these instances was any
injury inflicted on the uterine structure; nor did any permanent evil
arise that could be attributed to the operation. In four cases only was
the uterus so powerfully contracted as to refuse admittance to the
480
OBSTETRIC OPERATIONS.
hand, and compel me to adopt the alternative of eviscerating or
decapitating the fœtus."¹
Besides that injury of the uterus is thus not so apt, as is perhaps
generally imagined, to follow upon turning when carefully and
cautiously performed, there are other considerations, which are
calculated strongly to show that the danger of laceration in the
cases of pelvic contraction most fitted for the practice we suggest,
is not much, if at all, increased by the proposed operation. I shall
state the considerations to which I refer.
In the first place, I would premise this important remark, that,
according to all our best obstetric pathologists, those degrees and
forms of morbid contraction of the brim of the pelvis which I deem
to be the cases best adapted for delivery by turning, are exactly
those cases in which, under any plan of management, whether the
patient be delivered by the natural efforts, or by the forceps or
crotchet, rupture and laceration are exceedingly apt to take place.
On this subject I am anxious to adduce full evidence, and will con-
sequently appeal to the unprejudiced testimony of Ramsbotham,
Denman, Churchill, etc.
"Laceration of the uterus," says Dr. Ramsbotham, "is most
likely to happen to a patient who has had three or four children,
who possesses a slightly distorted pelvis, and who has been in strong
labour for a number of hours. Although," he further observes,
"the same rent may take place in any portion of the organ, its most
frequent seat is at the neck, either at the posterior part opposite the
prominence of the sacrum, or anteriorly, behind the symphysis pubis.
The direction is also mostly transverse, or slightly oblique. It is
not difficult to account for this being the most usual situation of the
injury; for since, during the latter part of gestation, the neck of the
womb rests upon the pelvic brim, if the promontory of the sacrum
dip too far forward, or the ridge of the pubis be preternaturally
sharp, it is reasonable to suppose that the uterine structure may be
affected, that inflammation may occur as a consequence of pressure,
and that a thinning or softening of the substance may be induced,
and, under these circumstances, should the structure give way at all,
it is likely that the weakened part will be the first to suffer. Den-
man, indeed, says that, independently of disease, the uterus may be
worn through mechanically, in long and severe labours, by pressure
and attrition between the head of the child and the projecting bones
of a distorted pelvis, especially if they be drawn into points, or a
1 Obstetric Medicine and Surgery, p. 350.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
481
sharp edge. One or other of these causes may explain," Dr. Rams-
botham concludes, "why we more frequently meet with laceration
of the uterus, when the pelvis is slightly contracted in the conjugate
diameter of the brim, than when the distortion is excessive.”¹ And
he adds one case.
"In one of the last cases," says he, "of ruptured
uterus to which I was called, dissection showed that the linea ileo-
pectinea, where it traverses the pubis, was formed into a very sharp
ridge, that there were a number of bony prominences jutting from
the inner surface of the pubic bones towards the cavity, and one,
especially, situated above the left thyroid foramen, which was so
pointed as to pain the finger when hard pressure was made on it.
The sacro-pubic diameter was two inches and three quarters in ex-
tent. It was the woman's second. pregnancy; the first child had
been delivered by craniotomy. After a consultation was held, labour
on this occasion was induced in the eighth month by the exhibition
of four doses of ergot. The membranes broke spontaneously three
hours and a half before the accident occurred. I was sent for by
the gentleman in attendance immediately, and delivered by turn-
ing; she died on the night of the fourth day."
"2
Dr. Churchill expresses similar views in regard to contraction of
the pelvis as a cause of rupture. “A certain amount,” says he, “ of
narrowing of the upper outlet may give rise to it. This is a purely
mechanical cause. The head of the child is forced down by violent
labour-pains, but is unable to enter the pelvis from the contraction
of the upper strait. Now, if the pains continue with great power,
the head is turned to one side or the other, or posteriorly, and the
only obstacle here being the uterine or vaginal parietes, the head is
drawn through them at the weakest part. They offer the less resist-
ance, probably, from the woman having borne several children." 3
Other authorities might be adduced to the same effect-viz.,
that rupture of the uterus is especially liable to happen under
protracted labour or instrumental delivery, when the brim of the
pelvis is slightly contracted, that is, in exactly the class of cases
most likely to be adapted for delivery by turning.*
In the second place, let me observe that, while contraction of the
1 Obstetric Medicine and Surgery, p. 469.
2 Ibid. p. 469.
3 Theory and Practice of Midwifery, p. 408.
4 See, for example, Dr. Roberton, Edin. Med. and Surg. Journal, vol. xlii.
p. 61.
"In a great majority of instances," says he, “of slight contraction of the
inlet, in perhaps three cases out of four, the diminution of space is caused by the
promontory of the sacrum encroaching upon the antero-posterior diameter. On
this ground, perhaps, we may explain why, in a somewhat greater number of cases
482
OBSTETRIC OPERATIONS.
pelvic brim is thus acknowledged to be a strong predisposing and
exciting cause of rupture, it must, at the same time, be held in view
as a most important correlative fact, that it seldom does lead to
laceration of the uterus, unless the effects of its mischievous agency
are allowed to be combined with, and increased by, a morbid degree
of prolongation and protraction of the labour itself. Dr. Denman's
observation is, doubtless, so far quite true, as to the possibility that
the uterus may be worn through mechanically, in long and severe
labours, by pressure and attrition between the head of the child and
the projecting bones of a distorted pelvis, especially if they be drawn
into points, or a sharp edge." In fact, the liability to rupture, like
the liability to most other obstetric complications, increases pro-
gressively with the increased duration of the labour, as the following
table, calculated from Dr. Collins' returns,' sufficiently attests:-
1
TABLE XIV.
DURATION OF LABOUR IN 24 CASES OF RUPTURE OF THE UTERUS.

Proportion of
Cases of
Rupture.
Length of Labour.
Number
of
Deliveries.
Number of
Cases of
Rupture.
Within 6 hours
13,412
7
1 in 1916
From 7 to 24 hours
Above 24 hours
2,174
10
1 in 217
264
7
1 in 38
The principle inculcated by the evidence of this table is so im-
portant in its bearing upon the practice suggested in the present
memoir, that I shall take an opportunity of enforcing it by adducing
three instances of distorted pelvis, in which laceration of the uterus
took place after the labour had been allowed to become protracted ;
and that, though the mode of ultimate delivery in each of the three
was different, in the first, being effected spontaneously, in the second,
by instruments, and in the third, by turning.
of laceration, the rent is found in the posterior rather than the anterior part of the
uterus."
Out of 300 cases of rupture of the uterus, reported by Dr. Trask, Monthly
Journal and Retrospect for August 1848, p. 178, contraction of the brim of the
pelvis was found noted as existing in sixty cases. Drs. M'Clintock and Hardy,
in their excellent work on Midwifery, observe, in regard to the pathology of rup-
ture (p. 295), that the accident is more likely to be produced "where the deformity
of the pelvis is slight than where it is excessive"—that is, in precisely those cases
best fitted for turning.
1 Ramsbotham's Principles of Obstetric Medicine and Surgery, p. 469.
2 Dr. Collins met with 34 cases of rupture during his mastership. In 24 out
of the 34 he has given the duration of the labours in a table in his Treatise, p. 370.
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
483
CASE XXXVIII.-"No. 22. On the fifth day after delivery, without any
apparent cause, was seized with violent hemorrhage. When we saw her, which
was immediately after, no pulse could be felt, and, though most prompt and
active measures were employed, she died in less than an hour. She had been
delivered, by the natural efforts, of a living child, after a labour, not very severe,
of forty-eight hours; nor from that time was there distress of any kind perceptible.
"On dissection, the abdominal viscera appeared healthy, as did the uterus at
first sight, but on raising it out of the pelvis, about the size of a shilling of its
muscular substance, corresponding to the projection of the sacrum, was found to
have given way, the peritoneal covering remaining uninjured. There were two
spots in the vagina approaching to a state of slough."¹
CASE XXXIX.-"No. 28. The labour-pains in this case were feeble, yet the
child continued to advance. The heart's action was audible with the aid of the
stethoscope, the mother's pulse natural, and no unpleasant symptom. Suddenly,
however, the most alarming debility came on, the pulse being scarcely perceptible,
accompanied with vomiting and much pain on pressure over the uterine region.
Immediate delivery was necessary, and the perforator was used. She was a feeble,
delicate woman, was thirty-six hours in labour previous to the setting in of the
above symptoms, and had been force-delivered eleven months ago. She died in
fourteen hours.
"On dissection, an opening was found at the junction of the uterus with the
vagina (exactly opposite a projection of the last lumbar vertebra), not larger than
to admit the passage of one finger, The muscular substance of the uterus, an-
teriorly, had also given way to a considerable extent, the peritoneum being whole.
The pelvis scarcely measured three and a half inches from pubis to sacrum.
112
CASE XL.—“A patient with her spine somewhat curved, and who, in her first
confinement, had borne a dead infant after several days' suffering, was taken in
labour of her second child early on the 16th of November 1846. The pains had
been constant and strong for about thirty hours, when I saw her, with Dr. Gordon,
who had been called in, and the head had remained stationary and fixed at the
same point of the brim for the last twenty-four hours. On examination, Dr.
Gordon and I found the pelvis small, the os uteri fully dilated, and the head of
the infant imperfectly entered into the brim, and apparently uninfluenced in its
descent by the powerful uterine contractions that were present. The sutures of
the fœtal head were strongly overlapping, and a triangular portion of the fœtal
cranium, terminating in the posterior fontanelle, was driven deeply in and below
the level of the two other portions of bone that went to the formation of that
fontanelle. On first touching the head, I thought this indented bone was, as
usual, the occipital, but a more careful examination showed me that it was the
left parietal bone, and that the head presented its right side, instead of the vertex.
The head, though thus greatly compressed transversely, still filled very imper-
fectly the pelvic brim, and the right side of the pelvis was so unoccupied as to
allow a long loop of the umbilical cord to prolapse. The vessels of the cord were
beating, showing the child to be still living. The local and constitutional symp-
toms under which the patient was suffering, showed the necessity of immediate
interference and delivery; but how was the delivery to be accomplished? The
mass of the head was too high above the brim to allow of the successful use of
the long forceps, even if there were space sufficient (which was very doubtful) in
the contracted pelvis, to allow of the head passing in this form. The perforation
2 Ibid. p. 300.
1 Dr. Collins Practical Treatise, p. 287.
32
484
OBSTETRIC OPERATIONS.
and breaking up of the head by craniotomy would allow of delivery, but the cord
showed the child to be alive, and I had doubts here, as in other cases, of the
propriety of murdering the infant, when delivery by other means was possible;
the other remaining means consisted in its extraction by turning, and, with Dr.
Gordon's consent, I proceeded to deliver the patient by this operation; it was accom-
plished without much difficulty. The child was still-born, but was recovered by the
usual means of resuscitation; it survived, however, only a few hours. That part
of the scalp covering the parietal bone, which had infringed so long on the pro-
montory of the sacrum, remained depressed, and pitted like an umbilical mark ;
the left parietal bone itself remained also deeply displaced, and indented below
the corresponding edges of the occipital and right parietal, and, on dissection,
some blood was found effused beneath it. The mother continued well for a few
hours, but then began to sink, with symptoms of abdominal effusion and rupture.
She died on the following day. On dissection, the neck and lower part of the
body of the uterus were found lacerated, and at one part the oblique and valvular-
like laceration extended through the peritoneum. The pelvic brim was obliquely
ovate in form, the right side being much larger than the left, but the conjugate
diameter of the brim was very narrow. At its most contracted point, a piece of
wood wedged in between the promontory of the sacrum and the nearest point of
the pubis, measured only two inches and seven-eighths. The pelvic joints felt
loose and mobile."
The observations which I have adduced in the preceding pages
seem, then, to point to the following deductions :—
First, Morbid contraction of the pelvic brim is, whatever
mode of delivery is adopted, liable to be a cause of rupture of the
uterus.
Secondly, This morbid contraction principally, and almost only,
becomes a cause of rupture, when, in conjunction with it, the labour,
as in the three cases just now detailed, has been allowed to become
long and protracted in its duration, and the compressed tissues of
the cervix are consequently rendered preternaturally friable and
lacerable. Then
Thirdly, It necessarily follows, that this complication would in
all probability be avoided, when morbid contraction of the pelvis
exists, provided either nature or art was enabled to deliver the
patient early, and did not permit of the tissues of the lower part of
the uterus becoming wedged in, contused, inflamed, and softened,
between the presenting head of the infant and the opposing points
of contraction in the pelvic brim. Hence a power of artificially ter-
minating labours with this complication, as soon after their com-
mencement as the dilatation or dilatability of the passages would
allow, would be, so far, a means of averting this fearful accident
under these circumstances. In the delivery by the operation of
turning, we possess such a power; and by the exercise of it in these
TURNING AS AN ALTERNATIVE FOR CRANIOTOMY.
485
cases we may, I believe, not only sometimes save the mother from
danger, but the child also from death. And I have already shown
at sufficient length, that the degree of force required to extract the
head, will depress and groove the cranial bones of the child, with-
out necessarily injuring or tearing the soft pelvic tissues of the
mother; provided always these tissues have not been previously
brought into a state of congestive and inflammatory friability by the
previous duration of the labour, and by the impaction of the head
having been allowed to be prolonged to an excessive and morbid
degree. All the evidence which I have adduced in different parts
of the present memoir goes to show this fact that the danger
attendant upon turning and other modes of operative delivery is,
as a general law, regulated less by the mere performance of the
operation, than by the degree of protraction allowed to elapse before
operative interference is adopted. And, in addition, the evidence
which was brought forward in the last section appears to entitle us
to deduce, as a supplement or corollary to this important general
law, that (supposing the maternal passages are once dilated or
dilatable) when operative delivery by the forceps, or crotchet, or
turning, is accomplished with comparative force, it is safer, cæteris
paribus, to the mother when performed early, than the same or other
modes of operative delivery would be if accomplished with compara-
tive facility, but performed late;-that, in other words, force is less
dangerous than protraction ;-that the hazards of operative delivery
are more regulated by the time of its adoption than by the difficulties
of its accomplishment.
Fourthly, It must still be held constantly and prominently in
view that, in the proposed practice of turning, the great maternal
danger which the practitioner has to avoid, is injury and laceration
of the uterus, and he must use all due care and caution to avert any
chance of this accident. The preceding observations show some of
the leading points and objects which he should attend to, in order
to avoid it. These points are, principally-1, The early performance
of the operation; 2, When possible (as in Case I.) it should be
effected even before the membranes rupture, as turning is greatly
more easy and more safe before, than after, the evacuation of the
liquor amnii; 3, If the liquor amnii has escaped, and the uterus has
contracted, the uterine fibres should be previously, and perfectly,
relaxed by the use of opium or chloroform; and, 4, The part of the
operation consisting in the actual turning and version of the child
should be done with extreme caution, and only and always attempted
486
OBSTETRIC OPERATIONS.
and accomplished during a perfect interval between two uterine
contractions.
Other requisite rules and precautions are enumerated so fully in
most obstetric works, and so well known to obstetric practitioners,
that it is perhaps unnecessary to dwell here at great length upon
them.
TURNING AS A SUBSTITUTE FOR CRANIOTOMY IN
LABOUR DELAYED BY OBSTRUCTION AT
THE BRIM OF THE PELVIS.¹
Formerly, medical practitioners seem to have thought little, and
medical writers said little, regarding the very repulsive and revolt-
ing character of the operation of craniotomy, when performed, as it
frequently was, when the child was still living. Apparently, some
obstetric practitioners and writers of the present day continue to
look upon the practice of craniotomy as one that should not unfre-
quently be adopted, and one which it is quite justifiable to adopt.
Obstetric reports and collections of cases have been published
within the last few years, describing craniotomy as performed forty
or fifty times, or oftener, by the hand of the same practitioner.
But perhaps, ere long, it will become a question in professional
ethics-Whether a professional man is, under the name of a so-called
operation, justified in deliberately destroying the life of a living
human being? For one, I have a strong conviction that, in the
kind of case in which the operation is most frequently performed—
namely, where there is some obstruction from disproportion, not
very great in degree, between the maternal pelvic brim and the
foetal head, the operation is not one which is either morally or pro-
1 See Edinburgh Monthly Journal of Medical Science, February 1852, p. 135.
2 During Dr. Collins' charge of the Dublin Lying-in Hospital, craniotomy
was used in 124 cases; in 79 instances on account of tediousness or difficulty in
the labour. In only one of these cases was the conjugate diameter of the pelvis
as small as 2 inches. "This," he says, was by much the most defective pelvis
I ever met with in the hospital." "The only means," he observes, "of effecting
delivery, where the disproportion between the head of the child and the pelvis
is so great as to prevent reaching the car with the finger, is by reducing the size of
the head, and using the crotchet.
2
;)
(6
In most cases requiring craniotomy, the contraction at the brim is in the
conjugate diameter, from the projection forwards of the promontory of the sacrum
-the very kind of deformity in which turning is most likely to be the means of
saving the life of the infant.
TURNING AS A SUBSTITUTE FOR CRANIOTOMY.
487
fessionally justifiable, if the child be still living. Not many years ago,
the medical practitioner had this one plea to urge in favour of the
adoption of the operation-that perhaps the child was already dead;
inasmuch as there then existed no certain means of knowing that it was
still alive. Auscultation, however, now furnishes us with certain means
of settling this question in practice, and has consequently removed
this argument in favour of the adoption of the operation. Or
perhaps the result would be more correctly given by stating, that
in cases of lingering and difficult labour, from some disproportion
between the size of the fœtal head and maternal pelvic brim, auscul-
tation can now determine the instances in which the child is dead,
and in which, therefore, it is justifiable and right to have recourse
to delivery by craniotomy; while it shows us also, on the other
hand, the strong impropriety and illegitimacy of adopting the same
operation in other analogous instances, where the sounds of the
foetal heart indubitably prove, to the ear of the medical attendant,
that the infant continues alive and well.
Assuredly no man would consider himself justified, on any plea
whatever, in perforating, and breaking down with a pointed iron
instrument, the skull of a living child an hour after birth, and sub-
sequently scooping out its brain. But is the crime less, when per-
petrated an hour before birth? Modern physiology has fully shown
that there is no such distinction between the mental and physiolo-
gical life of an infant, an hour before labour is terminated, and an
hour after it, as to make any adequate distinction between the
enormity of the act, as perpetrated at the one or at the other of
these two periods. And, as if to add to the horrors of craniotomy,
when performed upon a living infant, some authors (and among
them even the very latest), tell us, that whatever doubts may have
existed as to the child being alive or not at the date of operating,
the results of the operation itself will decide this point; for if it be
alive at the time of the deadly perforation of its scalp, skull, and
brain, this fearful fact will be revealed to the practitioner by warm
and fluid streams of blood pouring along his fingers and hand, before
any masses of broken brain escape; or the reverse.
Unfortunately, no operation in morbid labours is more easy than
craniotomy. "Of all instrumental operations in obstetric surgery,"
says Dr. Ramsbotham, "the perforation of the skull, and extraction
of the mutilated foetus, is the easiest which could be undertaken, for
delivery in any case of compacted head; and much do I fear that
to the facility with which this operation can be accomplished,
488
OBSTETRIC OPERATIONS.
have been sacrificed the lives of many children." ¹ The operations
which midwifery possesses as substitutes for craniotomy are, how-
ever, not very difficult in performance. And no conscientious prac-
titioner would surely hold the mere difficulty of an operation, as the
criterion by which he should decide upon the act of child-murder or
not.
•
In women who, in previous labours, have had the children.
removed from them by the operation of craniotomy, nature has her-
self occasionally pointed out to us, in other labours in the same
patients, various means and resources by which that operation could
be avoided. Midwifery, as an art, has appropriated some of these
hints, and happily applied them in practice. Ever and anon, women,
who had been previously the subjects of difficult and dangerous
labours, have, when parturition came on accidentally, at the seventh
or eighth month, borne living children easily and safely. Accoucheurs
have, in similar cases, taken advantage of this suggestion, and have
had recourse to the artificial induction of premature labour. In
other instances, in which previous labours have been found difficult
or impossible without craniotomy, in consequence of the form of the
maternal pelvis, a successful termination has occasionally occurred,
when the child happened, in subsequent labours, to present with the
feet or pelvic extremity, instead of the head. In such instances,
the presentation of the feet or pelvis, or of a hand (requiring the
presentation to be ultimately made footling), has sometimes, when
first discovered at the commencement of labour, been regarded as a
source of undoubtedly increased danger and difficulty; when it has
at last in reality proved a source of increased safety to the mother,
and led indirectly to the preservation of the life of the infant.
The records of cases of difficult labour left us by Mauriceau,
Smellie, Hull, etc., show, that in particular forms of difficult labour
and deformed pelvis, the passage of the child by the feet or pelvic
extremity affords some special facility of transit, which is wanting
when the head or cephalic extremity forms the presenting part.
I believe that this apparent paradox is explicable by a reference
to the anatomical structure or form of the foetal head itself. At
birth, the whole body of the child has, in its configuration, been
justly compared to that of a cone-the arch, or bi-parietal diameter,
of the skull forming the base of the cone-the feet forming its apex;
and there being a gradual tapering and diminution of size from the
1 Obstetric Medicine and Surgery, p. 290.
TURNING AS A SUBSTITUTE FOR CRANIOTOMY.
489
former to the latter points. But the foetal head itself, when taken
alone, presents also, though more imper-
fectly, the configuration of a cone; the
base of the skull being considerably nar-

C
a
rower than the arch, or, in other words, u
when (as represented in the accompanying
woodcut) we make a vertical transverse
section of the foetal skull, we find its bi-
mastoid diameter, b b, is considerably less
than its bi-parietal diameter, a a,—the
cranium increasing gradually in breadth
and size from below upwards. The difference between these two
diameters in the child at birth generally amounts to from half-an-
inch to three quarters.
Fig. 16.
Further, it must be held in view, that at its base, or bi-mastoid
diameter, the foetal cranium is so strong, and its bones so strongly
united, as to render it quite incompressible. On the other hand,
in its arch, or bi-parietal diameter, the cranium at birth is generally
so thin and elastic in its bony parietes, and its sutures are so im-
perfectly united, as to admit of the head being in its upper parts
laterally compressed, or even depressed and indented, at some point,
without necessarily destroying the life of the child.
In consequence of the above conformation, it happens, that when
the child, in a somewhat contracted pelvis, passes as a footling pre-
sentation, the cone-shaped head of the child first enters the con-
tracted brim by its narrower, or bi-mastoid diameter; and the hold
which we have of the protruded body of the child, after its ex-
tremities and trunk are born, gives us, when necessary, the power
of employing so much extractive force and traction upon the engaged
foetal head, as to compress the elastic sides of the broader, or bi-
parietal, portion of the cone, between the opposite sides or parts of
the contracted pelvic brim, to such a degree as to allow of the
transit of the entire volume of the head. In natural labour, the
mechanism consists in passing a conical-shaped body (viz. the child)
through an aperture (the maternal pelvis) somewhat larger than the
base of the cone itself (the arch of the foetal skull); and in this case,
when once the base of the cone or head does pass, a single pain is
generally sufficient to expel the remainder of the infant-an arrange-
ment by which dangerous compression of the cord is avoided by
But when the brim of the pelvis is somewhat less than the
natural standard, or the head somewhat above that standard, either
nature.
490
OBSTETRIC OPERATIONS.
from size or malpresentation, the conditions are so far altered, that
we have now a conical-shaped body (the child) to be passed through
an aperture (the brim of the maternal pelvis) somewhat smaller than
the body that is to pass. And a little reflection is sufficient to
show, that under such circumstances, the passing body would be
more easily dragged through the contracted aperture, by bringing
the narrow apex of the cone first, than it could be pushed through
that aperture by allowing the base, or broad end of the cone, to be
presented to it; more particularly, if that broad end is, as we have
supposed, somewhat larger than the aperture through which it is to
pass.
Since writing upon this subject at considerable length a few
years back, I have repeatedly had occasion to turn the child in
difficult cases, where the head was not far entered into the brim,
and where the long forceps failed, or were contra-indicated; and in
which the alternative of craniotomy seemed the only other measure
that could be adopted. A number of my professional brethren have
reported to me the success with which they have also followed this
practice. In the way of illustration, I adduce the three following
cases which have occurred in my own practice and in that of my
friends Drs. Weir and Peddie, within the last few weeks. I have
the pleasure of detailing the cases recently met with by Dr. Weir
and Dr. Peddie in their own words.
CASE I. On the evening of January 11th, I was asked to see a case of linger-
ing labour, under the charge of Mr. Keeling and Dr. Cooper. The patient, æt.
26, and pregnant for the first time, had been in labour for about forty-eight hours.
The first stage of labour had been terminated about thirteen hours before I saw
her; and the head had remained at the brim of the pelvis, without advancing in
any degree farther down, for upwards of ten hours. On examining, I found the
vagina fully relaxed, but its mucous membrane was becoming heated and œde-
matous, in consequence, in all probability, of the lengthened obstruction of the
brim above. The infant's head was elongated, down into the cavity of the pelvis ;
but the broad part of the head had not passed the brim. The promontory of the
sacrum was so easily reached by the finger, as at once to give the idea that it
projected forwards to an extent greater than natural. The direction of the sagit-
tal suture showed that the head lay more transversely than in the usual normal
presentation. The face of the infant was directed to the right sacro-iliac synchon-
drosis, or rather to the right ilium. The patient was put fully under the influence
of chloroform, and the long forceps were easily applied. The blades of the instru-
ment were, as we found after the birth of the child, applied as usual, obliquely
over the head, and did not offer to slip in any degree under the traction that was
applied. But no amount of traction that I thought it justifiable to employ could
move the head downwards; and Mr. Drummond failed also in making any im-
pression upon the advancement of the cranium, when I gave him the instrument
I altered, in several ways, the direction of the traction, and the position
to use.
TURNING AS A SUBSTITUTE FOR CRANIOTOMY.
491
of the patient, but still without any success, and at last withdrew the forceps.
Conceiving that possibly there might be some obstruction to the advancement
and passage of the child, from some malposition of the arm about the neck, or
from some malformation, I introduced the hand by the side of the child's head,
for the purpose of ascertaining these circumstances, but found nothing that
appeared to me capable of explaining the delay, and the impossibility of advanc-
ing the head by the forceps, except it were some oblique position of the head,
relatively to the neck or trunk of the infant. A few years ago, I should perhaps
in such a case have deemed the operation of craniotomy the only remaining
resource. But the stethoscope showed that the child was still alive and well.
And, under these circumstances, I resolved to attempt to extract it by the opera-
tion of turning. The patient was deeply anesthetised, in order to relax the
uterus as much as possible; and, at a time when all uterine contraction seemed
absent, I passed up my hand and brought down one of the lower extremities of
the child. While doing so, a large loop of the umbilical cord fell down into the
vagina. I now found an obstruction to the complete version of the infant, which
I had met with previously in other cases of turning, when the head was the
originally presenting part. For, though one foot was down at the orifice of the
vagina, the version of the fœtus upon its own axis had not been complete, and
the head was still at, or near the brim. Consequently, while Mr. Drummond
held and retained the extruded foot, I passed up my right hand to the head to
push it upwards, so as to complete the version—a part of the operation which, in
this as in other cases, is always much aided by the manipulation of the left hand
upon the abdomen externally. Subsequently the trunk and arms were easily ex-
tracted, and the traction requisite to make the head pass the brim was much less
than I had seen in several similar cases. The child after birth had the heart still.
pulsating, and was readily revived by repeatedly plunging its body alternately from
a warm into a cold bath. Yesterday, 21st of January 1852, I saw both the infant,
which was, perhaps, rather above the usual size, and the mother quite well.
CASE II. "On the evening of the 2d of December 1851, I was requested,"
Dr. Weir writes me, "by my pupil Dr. Bone, to give an opinion upon a case of
protracted labour. The patient had been eighteen hours in labour of her fifth
child. She had been on previous occasions the subject of tedious and difficult
labour, except in one confinement, when the child was born below the usual size.
Her face was flushed, eyes suffused, skin hot, pulse quick, and restlessness great.
The os uteri was completely dilated, and the liquor amnii discharged. The head
was still at the brim of the pelvis, and although the pains had been for many
hours quick, strong, and expulsive, a very small portion of it penetrated the
pelvic cavity, and so much as did, receded above the brim upon the cessation of
the uterine contractions. Under these circumstances, I determined to deliver her
immediately; and as it appeared a favourable case for turning, decided upon
doing so in preference to using the long forceps. The chloroform was administered
till deep snoring was produced, and the hand introduced in the usual manner
So completely were the uterine efforts suspended, that I grasped both the feet
before the uterus contracted in the slightest degree upon my hand. No difficulty
was experienced in extracting the child till the head reached the brim, when con-
siderable force was required to draw it through, but not so much as to prevent its
being born alive. The mother did well, and in a few days was attending to her
household duties. The child presented after birth a deep depression of the cranium
on the anterior part of the left parietal bone, immediately above the ear-the
result, no doubt, of compression against the promontory of the sacrum. But this
492
OBSTETRIC OPERATIONS.
has not affected the health of the child, which now, 20th January 1852, is other-
wise thriving and well."
CASE III.-"On the 30th November 1851, I was called," writes Dr. Peddie,
"to Mrs.
aged 30, in her sixth confinement.
"At her first confinement, November 10, 1843, in consequence of contraction
at the brim of the pelvis, principally on account of an exostosis projecting from
the promontory of the sacrum, and to some extent also from an under-average
size of the pelvis, she was delivered by embryulsio. This extreme measure was
not resorted to until forcible natural pains had existed for many hours, without
effecting an entrance for the head at the brim of the pelvis; until the long forceps
had been applied, first by myself, and then by Dr. Simpson, without obtaining
any advance of the head; and until the foetal circulation had been ascertained to
have ceased. After the perforation was employed, no small difficulty was ex-
perienced in dragging the child through the pelvis.
"At her second confinement, 26th September 1844, after allowing four hours
to elapse from the time when the os uteri was fully dilated without the smallest
descent of the head, I succeeded, with the long forceps and powerful traction, in
delivering the child safely. This fortunate termination was the more satisfactory,
that the induction of premature labour had been considered and decided against
some months previously.
"At her third confinement, 20th April 1846, the labour went on naturally,
and the child was expelled without artificial assistance. The explanation of this
fortunate event appeared to be, that the child was a female one, and considerably
under the average size, the head more particularly being small.
"At her fourth confinement, 28th October 1847, the labour resembled Mrs.
's first, the first stage being short, while the second had existed for many
hours before I saw her. The pains were extremely forcible, conveying the im-
pression of danger from rupture of the uterus. After trying two different pairs of
long forceps, I sent for Dr. Simpson, who furnished me with a third pair-which,
though easily applied and powerful, did not enable me to bring forward the head
in the least degree. Dr. Simpson then proposed turning in preference to perfora-
tion—the more especially as the child was ascertained to be still alive; and this
he accomplished readily, the patient being very deeply under chloroform, and
delivered her after the employment of very powerful traction. The child was at
first as if still-born, but was brought about after the continued use of the usual
means.
"At her fifth confinement, 11th December 1848, the presentation was a foot-
ling one—as if nature was indicating the right mode of procedure; and, accord-
ingly, when the first stage was completed, I seized hold of the other foot, brought
it down, and delivered the child safely, but not without the employment of very
considerable traction in bringing the head through the pelvis.
"At her sixth and last confinement, 30th November 1851, I saw Mrs.
at eleven A. M. Pains had begun about twelve o'clock on the previous night, and
had gone on regularly, but not severely, until within two hours of the time of my
visit. I found the os completely dilated, the vagina filled with tensely distended
membranes, and the head above the brim. On passing the hand to make a proper
examination, I recognised the old exostosis, but decidedly larger, fully the size of
a small walnut, projecting from the sacrum immediately within the right sacro-
iliac symphysis. I found also that the head was lying with the occiput to the
sacram, pointing somewhat to its left iliac symphysis, and the forehead to the
right side of the symphysis pubis. I was also satisfied that the head was of large
size, while the pelvis generally was small.
TURNING AS A SUBSTITUTE FOR CRANIOTOMY.
493
me.
Considering previous experience in the case of this patient, and the remark-
able success of turning in her fourth labour, when she could not have been
delivered otherwise than by the life-sacrificing perforator; and considering that
in the present labour the peculiar position of the head would render efforts by the
long forceps-however well employed-useless, I resolved at one to turn. This
I accomplished, and brought down the body very satisfactorily, while the patient
was placed deeply under chloroform by Dr. Harper of Leith, who kindly assisted
As was to be expected, much exertion and pulling were necessary to drag
the head through the pelvis, although the most favourable respective diameters
were chosen. A towel slipt round the anterior part of the neck and chest, and
crossed over the shoulders behind, gave steady purchase, and enabled me more
readily to complete the delivery. The child was a large boy, and at first
apparently still-born; but in about twenty minutes, after unceasing attention, by
giving alternate plunges in hot and cold baths, as practised in the first and
second labours, and by the use of artificial respiration, he was completely restored.
He ultimately did well, and Mrs. made an excellent recovery. The child
weighed 9 lbs. 5 oz.
In conclusion, let me briefly recapitulate some of the principal
advantages which, as it appears to me, the operation of turning
has over the operation of craniotomy, in cases such as we have been
considering in the present communication-viz. where the pelvis is
somewhat too small, or the foetal head somewhat too large, to allow
the infant to pass by the unaided efforts of nature, or even with the
assistance of the long forceps, if that instrument is had recourse to.
1. It substitutes the delivery of the infant by the hand of the
accoucheur, for its delivery by formidable steel instruments. And,
certainly, the avoidance of instruments is, as a general principle,
desirable when it is possible.
2. The transit of the cone-shaped head of the child through a
somewhat naricw brim is facilitated by the narrow end of the conc
(or bi-mastoid diameter of the head) being made to enter and engage
first in the contracted brim; and the hold which we obtain of the
extruded body of the child enables us to employ so much extractive
force upon the engaged foetal head, as to make the elastic sides of the
upper and broader portion of the cone (or bi-parietal diameter of the
cranium) to become compressed, and if necessary indented, between
the sides of the contracted brim.
3. When the child is brought down footling, we have far more
power than when the spherical arch of the cranium presents, of
manually adapting and adjusting, when necessary, the shape of the
head to the shape of the contracted brim; the rounded form of the
cranium not affording us any sufficient hold and purchase for this
purpose in cranial presentations.
494
OBSTETRIC OPERATIONS.
4. The lateral and very temporary compression of the foetal head
by the contracted sides of the pelvis, such as we can produce and
effect on artificial turning and contraction, is less dangerous to the
life of the child than its oblique or longitudinal compression with the
long forceps, or by the long impaction of the head itself in the con-
tracted brim.
5. In cases where the narrowness is greater, and such as to
produce a depression or indentation in the elastic and flexible cranium
of the child, still this transient depression, or indentation, is not
necessarily destructive to life, as the perforation of the head in cranio-
tomy is.
Children often survive and recover, when born with the
head much distorted and even indented. See, for example, the
child in Case II., and other similar instances recorded by Smellie,
Denman, Velpeau, Dugès, Jacquemier, Radford, etc. etc.
6. On these accounts, the operation of turning affords a fair
chance of life to the child, while craniotomy affords none. And
even when the turning and extraction require some considerable
time for their performance, the resulting temporary asphyxia of the
child is not necessarily so deep and fatal but that the infant may be
revived by appropriate measures applied after birth. I can, for one,
state that in these cases, and in instances of common footling and
turning cases, I have repeatedly been astonished at the viability of
the infant after traction had been applied to it, both so strong in
degree and so long in duration as to leave apparently little hope of
its survival; and I have heard other practitioners make the same
remark as the result of their experience.
7. The operation of turning, under the circumstances we speak
of, will, I believe, be found also to be more safe to the life of the
mother than the operation of craniotomy. In every instance the
operation of craniotomy is necessarily fatal to the infant; but in a
very large proportion also, this operation is fatal to the mother.
The statistical results collected by Dr. Churchill and others show
that craniotomy is fatal to the mother in about 1 in every 5 cases
in which it is performed; while turning does not generally prove
fatal in above 1 in every 15 or 16 patients, even including compli-
cated cases. Besides, it affords this great source of safety to the
1
1 Out of 303 craniotomy operations, 60 of the mothers died, or 1 in 5.-
Churchill's Midwifery, p. 314. Out of 192 cases of turning, 12 mothers died, or
1 in 16.-Ibid. p. 250. Between," says Dr. Ramsbotham, "the years 1823 and
1834, I delivered more than 120 women under transverse presentations, independ
TURNING AS A SUBSTITUTE FOR CRANIOTOMY.
495
mother, that, cæteris paribus, delivery by turning can be, and is, as a
general rule, adopted far earlier in the labour than delivery by
craniotomy; and in proportion as it is practised earlier, so far also
will it be practised with greater safety and greater success—the
maternal mortality attendant upon parturition, whether natural or
operative, increasing always in a ratio progressive with the increased
duration of the labour.
Among the operative deliveries which occurred in the Dublin
Hospital when Dr. Collins was master of the institution, the duration
of the labours at the time of operating is stated in 125 cases.
Among these 125 instrumental and operative deliveries, only 1 in
every 17 of the mothers was lost, when the delivery was accom-
plished within twenty-four hours from the commencement of labour ;
1 in every 7 of the mothers died when the delivery was delayed
till from twenty-four to forty-eight hours; and nearly 1 in every 2
mothers perished when the delivery was delayed till the labour had
gone on above forty-eight hours. Obstetricians have often argued,
that if, in cases of obstructed labour, the delivery is delayed for a
sufficient length of time, the child will be ultimately destroyed by
the uterine action and compression, and that thus craniotomy will
be at last performed upon the dead infant-the child being killed by
an act of omission, and not of commission.
But even such very
protracted delay is not always fatal to the infant-some continuing
to survive when the labour is prolonged for sixty, or seventy, or
more hours. And it is always to be remembered, that the delay
ently of a few cases to which I was summoned, where spontaneous evolution
occurred. Many of these cases presented a formidable appearance; for in one the
membranes had been ruptured a whole week; in another, 69 hours; in a third, 58
hours; in another, 55; in another, 53; and in many, more than 48; and, as a
general principle, we presume, that the longer the liquor amnii has been evacuated,
the more likely is the uterus to have embraced the foetal body firmly, and the more
difficulty will there be in overcoming the resistance. In none of these cases did I
exhibit large doses of opium, and in those few where bleeding was practised, that
operation was had recourse to, not for the purpose of relaxing the rigidity of the
uterine fibres, but to relieve the inflammation which the soft structures were suffer-
ing, and to remove tumefaction. In not one of these instances was any injury
inflicted on the uterine structure by the hand, nor did any permanent evil arise
that could be attributed to the operation. In four cases only was the uterus so
powerfully contracted as to refuse admittance to the hand, and compel me to
adopt the alternative of eviscerating or decapitating the fœtus.”—Obstetric Medi-
cine and Surgery, p. 362.
1
¹ Out of 27 cases reported by Dr. Collins, in which labour was prolonged to
60 hours and upwards, in 16 the child was born dead; and in 11 it was still alive
at birth. Of the 27 mothers, 1 in 4 died.
2
496
OBSTETRIC OPERATIONS.
itself, if dangerous to the life of the child, is also, as the above and
other evidence shows, almost equally dangerous to the life of the
mother. In such cases of long obstruction and delay, even after the
head is perforated by craniotomy, much traction is often required to
drag the shoulders through the contracted brim, and that at a time
when the structures at the brim are so damaged by previous pressure
as to be little able to bear compression with safety. And I do
think that we have most ample grounds for believing, that the long
compression of the soft parts, such as occurs in very protracted
labour, is more truly dangerous to the structures than a short com-
pression of them, greater in amount, such as occurs in the operation
of turning when early performed.
In not a few cases, in which the operation of turning is resorted
to in consequence of the complication which we have been consider-
ing, the practitioner must be prepared to meet with such resistance
to the passage of the head through the brim as will require some.
adjustment and considerable physical exertion on his part in order
to overcome it. But if the head be so adjusted in the brim, that the
shape of the one is, as much as possible, adapted to the shape of the
other; if the chin be kept depressed towards the sternum; and if
the traction applied be made in the proper axis of the brim itself,
no small amount of extractive force may be used without compro-
mising the safety of the mother or infant. The degree of traction
which the structures of the infant's neck will, in this way, undergo,
is much greater than one would a priori suppose. And, as a very
general rule, the elastic lateral walls of the cranium of the child will
become compressed or indented, before any dangerous injury is
inflicted upon the structures of the neck. But on this subject I
most willingly substitute, for any remarks of my own, two or three
sentences from the work of an author-always practical and always
cautious-Dr. Denman, who, in speaking of the occasional difficulty
of extracting the head in common pelvic and turning cases when the
brim is somewhat contracted, gives, among others, the following
directions:
"The force with which we endeavour to bring down the head
of the child must then be gradually increased, till we are convinced
that a greater degree is inconsistent with the safety of the child, or
induces the hazard of separating the body from the head. Should
the head descend in ever so small a degree, we must not act pre-
cipitately, and increase the force in order to finish the delivery
TURNING AS A SUBSTITUTE FOR CRANIOTOMY.
497
*
suddenly; but we must proceed with circumspection, or we shall
add to the danger which the child is already in, and run the risk of
doing injury to the mother; though, when the head begins to
advance, there is seldom much remaining difficulty, the cause usually
existing at one particular part of the pelvis. It has been said that
children have sometimes been born alive, when the strongest efforts,
and these continued for many hours, have been made to extract the
head detained in this position. But I have not been so fortunate as
to meet with any such instances, a short space of time having
generally been sufficient to frustrate my hopes, and convince me
that the child was dead. Though, when the head has been detained
a considerable time, a few cases have terminated more favourably
than I could have expected, and I have been agreeably surprised
with the discovery of some faint signs of life, which, by the assiduous
and careful use of the common means, have been improved, and the
life of the child at length perfectly recovered. * * When
we have in vain exerted all the force which we think reasonable and
proper, and which, in some cases, must be more than any circum-
stance would be thought to require, it will be expedient to rest, for
the purpose of gaining all the advantage to be gained by the com-
pression of the head. On this account the mother will actually
suffer no more inconvenience than would have been purchased if the
head had originally presented, and been locked in the pelvis.
After waiting some time, we must renew our attempts to extract,
and thus proceed, alternately resting and acting with efficacy and
resolution, and if the hold we may have of the body or extremities.
of the child does not suit, a silk handkerchief or other band may be
passed round its neck, and this will be found a very handy and con-
venient instrument. It must," Dr. Denman adds, "be a very great
disproportion between the head of the child and the pelvis, which is
able to withstand this method of proceeding, if we persevere in it
with prudence and steadiness; because the integuments of the
head will burst, or the bones be bent inwards in an extraordinary
degree, or even broken.
If it fail, it then only remains
that we should lessen the head of the child; and the operation may
be as easily performed in this as in the natural presentation of the
head. When," he continues, "the perforation is made, and the
brain evacuated, the head may be readily extracted either by pull-
ing by the body of the child or by inserting a crotchet in the open-
ing made by the operator as in other cases. But it will be scarcely
believed how seldom this operation is necessary under these circum-
* * *
498
OBSTETRIC OPERATIONS.
stances, if we have not been in a hurry, but have acted with
prudence. Nor," concludes Dr. Denman, "have I ever known any
ill consequences follow the compression which the soft parts undergo
between the head of the child and the sides of the pelvis, if proper
attention were afterwards paid to the state of the bladder and
rectum."
"" 1
VAGINAL HYSTEROTOMY, ETC., IN LABOURS
OBSTRUCTED BY UTERINE AND
VAGINAL CANCER.2
Carcinoma in the walls of the cervix uteri and vagina is occa-
sionally found co-existing with pregnancy and parturition. Such
deplorable cases have been seen to terminate variously. Sometimes
the cervix has been still found so very slightly diseased and indu-
rated, at the time when labour at last supervened, that it has spon-
taneously relaxed and opened for the transit of the child. Far more
frequently its unyielding structures have fissured and torn under the
pressure of the presenting part of the infant; the labour, however,
thus terminating ultimately without artificial aid, after sufficient
space was obtained by the spontaneous lacerations.
In some
instances the patient has, some days after labour supervened, died
undelivered, in consequence either of pure exhaustion, or of lacera-
tion of the walls of the body and fundus of the uterus.
And in one
or two rare cases, the pains of parturition, after coming on regularly
at the full term of pregnancy, have after a time ceased-and as in
the "missed labours," that so often happen in the cow and sheep-
the dead foetus has been retained in utero for weeks, or even months,
beyond the normal period of delivery.³
CASE I.—In a patient pregnant, and with extensive cancer of the cervix uteri,
whom I saw at Hamilton, efforts at labour seemed to come on more than once,
when and after the mother herself calculated the term of utero-gestation to be
complete. She died at last undelivered, apparently of peritonitis. The foetus
was found decomposing in utero. There was an extensive effusion of lymph on
the peritoneal surface of the uterus; but apparently no rupture. She refused to
submit to any treatment.4
¹ Introduction to the Practice of Midwifery, p. 495, etc.
2 See Proceedings of Edinburgh Obstetric Society, February 10, 1847, in
Edinburgh Monthly Journal of Medical Science, April 1847, p. 796.
3 In a most interesting case described by Dr. Menzies, in the Glasgow Journal
for July 1843, p. 229, gestation seemed in this way prolonged to the 17th month.
4 For more details of the case, see a communication by Dr. Miller in the Lon-
don and Edinburgh Monthly Journal of Medical Science for 1844, p. 279.
VAGINAL HYSTEROTOMY IN OBSTRUCTION FROM CANCER. 499
What treatment should we pursue in cases of parturition morbidly
delayed and obstructed by cancerous disease of the cervix uteri or
vagina? It has been long laid down as a principle in British Mid-
wifery, that when in labour it is found impossible, from the amount
of obstruction which exists, that the lives of both the mother and
child can be preserved-the life of the infant should be sacrificed by
craniotomy, for the safety of the mother, provided there is space to
extract the mutilated child through the maternal passages.
In
accordance with this principle, I have known the mother, in a case
of labour obstructed by carcinoma uteri, delivered by the perforation
and breaking down of the head of the infant; and cases of delivery
by craniotomy, under the same complication, have been recorded by
Denman, Dorrington, and others.
But surely we have a true and important exception to this prin-
ciple when parturition is rendered difficult or impossible by cancer
of the cervix uteri or vagina. In consequence of the fatal disease
under which the mother is suffering, her own life is not worth more
than a few weeks', or at most a few months', purchase; while the
child, if saved and not sacrificed, may possibly grow up and become
a useful and important member of society. Under such circum-
stances, we are assuredly justified in preserving the life of the child,
even were it at the expense of some additional immediate risk to
the life of the mother. When, however, in this complication, the
unassisted efforts of nature prove insufficient, and operative measures
come to be really required, those that are best, are, I believe, of a
kind that usually do not add to the danger of the mother, while
they are calculated to preserve the child. In most cases the cancer-
ous part at last spontaneously fissures and lacerates in order to allow
the child to pass. By practising vaginal hysterotomy in these same
instances, we arrive at the same end; but more certainly and safely.
For, instead of allowing the muscular contractions of the uterus to
make, by long and exhausting efforts, the necessary lacerations, and
gain for us the necessary space, we make these lacerations or inci-
sions with the bistoury; and further, when we do so, we can select
the safest time for effecting them—namely, early, and before ex-
haustion sets in; and we can select also the safest locality for the
division of the tissues of the cervix, instead of leaving this entirely
to chance. After the incisions are made, the expulsion of the child
may be left to nature, or it may be extracted artificially by turning
or the long forceps. In the two following cases the long forceps
were used after the necessary incisions were made.
33
500
OBSTETRIC OPERATIONS.
CASE II. In a woman in the Royal Infirmary, six months pregnant, the
septum between the rectum and vagina was already perforated by carcinomatous
ulceration. She went on to the full time. As the disease did not extend to the
uterus, but affected only the vagina and surrounding textures, the first stage of
labour was completed naturally; the child was then extracted by the forceps.
But it was necessary, first, to incise freely the carcinomatous mass obstructing the
vagina; and, in bringing down the head, the perineum, which was quite indu-
rated and tuberculated, tore in its whole extent. The infant was alive and
healthy. The woman had a rapid convalescence, and lived for more than two
years afterwards: the carcinomatous ulceration gradually excavating and destroy-
ing almost the whole contents of the pelvis.
CASE III.-A patient, the subject of extensive cancerous disease of the cervix
uteri, was seized in the Infirmary with premature labour near the eighth month.
After the parturient efforts had lasted for a considerable time, without any pro-
spect of successful dilatation and delivery, I enlarged the os uteri by lateral inci-
sions, and extracted the infant with the long forceps. The child survived. The
mother suffered no special aggravation of her symptoms in consequence of de-
livery. The cancerous disease proceeded on its usual course, and proved fatal a
few months subsequently.
In the following instance the uterine efforts very speedily ex-
pelled the child, after the obstruction from the indurated cervix was
removed by incision.
CASE IV. I saw this patient with my esteemed friend Dr. Martin Barry, when
he was attached to the Maternity Hospital. The woman had been ill for three
days. She was very much exhausted, and her pulse extremely rapid. The cervix
was indurated by carcinomatous degeneration at one side, and did not seem at all
inclined to yield. Two or three small incisions were made through the indurated
portion. This allowed the head to pass, and the delivery was completed after
five pains. It was too late, however, to save the patient. Her pulse never fell,
and she sank in two or three days afterwards.
The cancerous disease at the time of labour supervening may
be found not so great or extensive as to prevent the os uteri open-
ing to nearly its full extent, and yet it may prevent the head from
entering the brim. In the following case I delivered the patient
by turning, instead of the long forceps-the head being detained so
very high up, as to suggest the former as preferable to the latter
mode of delivery.
CASE V.-A patient, under the care of Dr. Burns, who had previously borne
a large family easily, had her last labour very protracted, in consequence of car-
cinomatous induration of the posterior lip of the uterus. Symptoms demanding
artificial delivery supervened by the time the os uteri was nearly dilated. The
child was extracted by turning, and survived. The diseased cervix tore slightly
as the head passed; and perhaps it would have been better to have determined
the seat of this lacration by a previous incision. The cancerous disease proceeded
slowly onwards, and she died in about a year.
VAGINAL HYSTEROTOMY IN OBSTRUCTION FROM CANCER. 501
CASE VI. In another patient of Dr. Burns', premature labour came on spon-
taneously between the seventh and eighth month; and though the whole circle
of the cervix uteri seemed affected with the cancerous disease, the os at last dilated
and fissured sufficiently to allow a living child to pass. The disease proved fatal
to the mother a few months subsequently.
In cancer complicating pregnancy, the preservation of the life of
the child is, we have ventured to state, the great object which the
practitioner should desire to effect-especially if he can accomplish
this object by means not directly detrimental to the mother-and
such cases as this last have suggested the propriety of sometimes
attempting to attain this double end by the artificial induction of
premature labour. This mode of delivery ought probably to be
adopted, if the disease is so severe or acute as to threaten to
destroy the life of the mother before the full completion of preg-
nancy; or if we fear that the mechanical obstruction, from the rapid
growth and development of the disease, is likely to prove too great
for the possible passage or extraction of a child allowed to reach the
full term. At the same time, as our calculations are specially directed
to the preservation of the child, it would be wrong to peril its life
by bringing it with any unnecessary prematurity into the world;
and certainly the idea suggested by one or two authorities, of treat-
ing this complication by inducing artificial abortion or premature
labour, before the infant was viable, seems to us a practice indefen-
sible either on moral or professional grounds.
In almost all the known and recorded instances of cancer uteri
complicating parturition, the obstruction to delivery has arisen far
more from the induration, and consequent non-dilatability of the
structures that were the seat of the disease, than from their increased
physical volume or bulk. And hence the reason why we may hope
to overcome the difficulty, in a great majority of cases, by the divi-
sion, when necessary, of the affected tissues. But where, unfor
tunately, in the exceptional case, there exists, from the mere size of
the carcinomatous deposit, such obstruction of the maternal passages
as to prevent delivery entirely, per vias naturales, unless the child be
destroyed and mutilated, then it does certainly appear justifiable to
extract the infant, if it is still alive, by the Cæsarean section. In
this complication of labour obstructed by carcinoma uteri, craniotomy,
when adopted, besides proving of necessity directly fatal to the
child, has almost always resulted also in the very speedy death of
the mother. Few or none in the instances recorded have survived
above a few hours, or a few days at most. The Cæsarean section
502
OBSTETRIC OPERATIONS.
offers every possible chance of preservation to the life of the child,
and is scarcely more rapidly fatal to the mother. Some years ago,
my friend Dr. Oldham published a case of large carcinoma uteri
obstructing labour, in which the child was saved by this mode of
delivery, and the mother did not die in consequence of the operation,
as has happened in most instances in which the Cæsarean section
has been performed in British practice.
SPONDYLOTOMY IN CROSS-BIRTHS.'
Dr. Simpson remarked, that the two oldest operations in such
cases were mentioned by Celsus-namely, cutting through the neck,
and evisceration. He mentioned a case which he had seen with
Bailie Alexander, where he thought he could turn, in which the side
was presenting. In the course of a few minutes the position of the
child was changed, and the case terminated by spontaneous evolu-
tion. Observe, you cannot bend the spine laterally, but you can.
bend the back forwards. Dr. Simpson spoke of the advantages of
spondylotomy, where, with the aid of a strong pair of scissors, with
one blade probe-pointed, the back could be divided in cases where
turning could not be effected. In Dr. Inglis' case the condition of
the uterus could not be called "spasm," but rather what the French
call "tetanus," or continued spasm. Dr. Simpson mentioned a case
of a woman in labour of her seventh child, where the cervix uteri
contracted round the child's neck: the forceps were tried in the
ordinary way and failed; but by taking advantage of the relaxation
of the uterus during the intervals between the pains, and making
traction during those intervals only, he had managed to pull down
the head. Dr. Simpson promised to narrate the particulars of a
case of arm presentation, with deformed pelvis, at next meeting,
where he had performed the Cæsarean section. In arm presenta-
tions, where turning proves impossible, Cæsarean section is almost
the only treatment, except spondylotomy, which is a mere clipping
of the spine at the nearest presenting part, but it must be clipped
quite through. Dr. Lee has mentioned that evisceration takes two
hours to perform.
¹ See Proceedings of Edinburgh Obstetrical Society, November 29, 1865, in
Edinburgh Medical Journal, February 1866, p. 770. Sir James Simpson had
previously effected speedy delivery, without eviscerating, by what he termed
spondylotomy" (σπóvduλos a vertebra), in two cases of cross-birth in which he
could neither turn nor decapitate.
J. W. B.
PART V.
THE PUERPERAL STATE.
DOES AIR EVER BECOME INTRODUCED INTO THE
VENOUS SYSTEM THROUGH THE UTERINE SINUSES
AFTER DELIVERY ?'
A SERIES of cases that Dr. Simpson saw, in consultation, and that
occurred in rapid succession, six or eight years ago, seemed to him
to suggest the idea whether air might not become introduced into
the venous circulation of the mother after delivery, and whether one
common result of this accident was not the occurrence of a red or
scarlatinoid eruption upon the cutaneous surface of the patient.
The first case occurred in the Lying-in Hospital. The patient
had been delivered of twins. Dr. Ziegler was called to visit her, in
consequence of some difficulty connected with the birth of the second
child. Considerable post-partum hemorrhage, with alternate con-
tractions and relaxations of the uterus, supervened, and she seemed
to rally very imperfectly from the effects of the flooding. In con-
sequence of this, Dr. S. saw her an hour or two subsequently. The
pulse at that time was very rapid and weak, almost imperceptible.
The countenance extremely anxious, and here and there was an
evanescent red scarlatinoid rash over the body. The patient died
in a few hours. The body was opened a short time after death,
because it was considered desirable not to incur the fallacy of air
being present from decomposition; and Drs. Simpson and Ziegler
were anxious to ascertain if the anomalous symptoms that were pre-
sent during life could possibly arise from the entrance of air into the
veins. To make the examination the more certain, the abdomen
was opened under water. The lower vena cava, but especially the
uterine and hypogastric veins, were distended with frothy blood,
i See proceedings of Edinburgh Obstetric Society, January 10, 1849, in Edin-
burgh Monthly Journal of Medical Science, April 1849, p. 707.
504
THE PUERPERAL STATE.
and air bubbled up through the water when any of these tubes were
opened. The larger veins in the extremities were in the same state.
Some search was subsequently made into the literature of cases
in which air had been introduced into the veins during surgical
operations upon the neck, etc., in order to ascertain if the evanes-
cent patches of red or scarlatinoid rash remarked in the preceding
instance, had been observed in any of these surgical cases. Dr.
Warren of Boston, in an article on the subject in the American
Cyclopædia of Practical Medicine, relates two cases which occurred in
his own surgical practice. The first patient recovered after being
insensible for a considerable time. While still comatose, "the leaden
colour in the cheeks," says Dr. Warren, "assumed a reddish tinge, and
the alarming character of the symptoms was evidently diminished."
The second case was fatal. During the period elapsing between the
entrance of the air, and the death of the patient, Dr. Warren, in
describing the symptoms, remarks, "The livid colour of the cheeks
gave place to a suffusion of vermilion red, and no glow in the cheek
of a youthful beauty ever gave one so much pleasure as that flush.
But the flush soon passed off."
If the red or scarlatinoid rash which appeared in the preceding
obstetric case upon the surface of the skin were owing to the
entrance of air into the uterine veins, might the symptom be
accounted for on the idea, that the introduced air directly mixed
with, and oxygenated, the blood in the capillary vessels ?
After the preceding case occurred, Dr. Simpson was called to three
or four other instances in which a similar train of symptoms was
present—namely, great depression after delivery, a rapid and almost
imperceptible pulse, and patches of an erratic scarlatinoid rash upon
the surface. All the patients died within two or three days after
delivery. In one case, which he saw with Mr. Kerr, and where the '
death was much more rapid, no red rash appeared, although the other
symptoms were analogous. The first was the only case in which an
autopsy was procured. Two or three of the cases had been considered
as malignant scarlatina, a disease which was acknowledged by all our
highest obstetric authorities to be exceedingly fatal to the puerperal
female, but which may possibly in many other cases have been mistaken
for, and confounded with, the affection to which this notice refers.
Supposing the introduction of air into the venous system after
delivery to be the canse of the symptoms or affection in question, it
is not perhaps difficult to understand the mere mechanism of its
introduction. Surgical pathologists generally hold that the air,
COMMUNICABILITY OF PUERPERAL FEVER.
505
cannot be drawn into open veins, unless these veins are not very
distant from the heart. But air may perhaps be forced into open veins
when the open orifices are at a distance from the heart, and when
circumstances exist capable of causing it to enter into such orifices.
A mechanism calculated to produce the entrance of air in this
last way exists in the uterus after delivery. The interior surface of
the organ, especially opposite the late seat of the placenta, has a
number of ruptured venous orifices opening upon it. Supposing air
once introduced into the uterine cavity, which in some cases may
occur in consequence of the alternate relaxations and contractions of
the walls of the organ following delivery (as in after-pains, post-
partum hemorrhage, etc.); and supposing, further, that under the
returning contractions of the organ, the expulsion of this air from
the cavity was prevented by the presence of a clot at the os uteri,
or other such obstructing cause, it will then, under the compression
to which it is subjected, be liable to be driven into the open venous
orifices existing in the lining membrane of the uterus. A bottle of
caoutchouc of the shape of the uterus, and with tubes like the venous
tubes of the uterus opening upon its interior, would act in this way
on the principle of the force-pump, in sending any air sucked or
drawn up into its cavity along these open tubes, if, after being full,
its parietes were compressed, and the aerial contents prevented from
escaping through its mouth, as we fancied to be the case in the
uterus under the conditions mentioned.
ON THE COMMUNICABILITY AND PROPAGATION OF
PUERPERAL FEVER.'
Dr. Arneth of Vienna having read a paper on the cause of the
puerperal fever at the Lying-in-Hospital of Vienna, and Dr. Moir
having related the history of some cases which had lately occurred
in his practice, Dr. Simpson expressed a similar opinion of this last
series of cases, to what Dr. Moir himself had given-viz. that the
original focus of contagion in them was to be traced to the diseased
blood and tissues of the mother who was first delivered and first
attacked-that her blood had affected the infant which she carried
within her and that probably the vaginal secretions and discharges
from this said patient during labour had unhappily formed the
¹ See Proceedings of Medico-Chirurgical Society of Edinburgh, April 16, 1851,
in Edinburgh Monthly Journal of Medical Science, July 1851, p. 72.
506
THE PUERPERAL STATE.
1
virus or material which had been unwittingly carried by Dr. Moir,
so as to affect his other patients. It was only by careful and
searching analysis of cases of puerperal fever, like Dr. Moir's, when
they did occur, that we could hope ultimately to arrive at a know-
ledge of all the various ways and means in which the disease may
originate or be spread, and consequently of all the different means
which may be adopted to prevent its spreading. Dr. Hill of
Leuchars has described one instance which was interesting in this
respect, that, as in Dr. Moir's, both the mother and the child
seemed affected before delivery. A carpenter had his hand wounded
and poisoned by the discharge issuing from a dead body, whilst
placing the corpse in the coffin. A severe attack of erysipelas
followed. Subsequently his wife had a similar attack of erysipelas.
Their daughter living with them, and in the seventh month of preg-
nancy, was then taken with an attack of fever. In a day or two
she gave birth to a dead child, whose body had all the appearance
of being affected with erysipelas, as the arms of the mother's parents
previously were. The mother herself died within twenty-four
hours, with the symptoms of malignant puerperal fever. On his
road home from visiting this patient, Dr. Hill was called to a case
of labour, and this other was also attacked with puerperal fever.
Dr. Arneth's very valuable paper adduced what was apparently in-
controvertible evidence of puerperal fever being propagated in the
way he suggested-viz. by medical men carrying on their fingers
matter capable of producing it from bodies which they were dis-
secting, and inadvertently inoculating that matter into the mucous.
membrane of the vagina of patients in labour. In these cases, the
fingers of the accoucheur, when once dipped in the poison, might
retain it till they had again inoculated that poison into the bodies
of other healthy subjects. The vaginal mucous membrane was
generally stretched and abraded in labour; the perineum was often
slightly torn; and the whole afforded a surface in a condition easily
inoculable. But if students and practitioners, with their hands
containing some portion of morbid matter, can thus, by inoculating
that matter on the abraded surface of the vagina, produce puer-
peral fever, no doubt, under similar circumstances, surgeons could
and did inoculate into the wounds which they made or dressed,
similar matter producing the similar disease of surgical fever in
their patients: If it could be inoculated into the abraded surface of
1 For details of Dr. Moir's cases, by himself, see Edin. Monthly Journal, July
1851.
COMMUNICABILITY OF PUERPERAL FEVER.
507
the vagina, it could be inoculated into a recent wound. If it pro-
duced fever in the one set of patients, it would produce fever in the
other. And since bringing under the attention of the profession
the communicability of surgical fever, Dr. Simpson stated, that her
had heard various facts in regard to it, all of which more and more
convinced him that surgeons, like accoucheurs, were occasionally
the unhappy media of inoculating their patients with morbid matter,
producing in them surgical fever, as in puerperal patients, obstet-
ricians, by the same means, produced in their patients puerperal
fever. He had no doubt that it would take many long years fully
to convince surgeons of this fact; but still it was his conviction,
that surgeons would ultimately both believe and act upon it, and
that their doing so would be a means of preventing many of the
numerous deaths which now occur after operations, particularly in
hospital surgical practice.
Continental accoucheurs generally did not understand exactly
the kind or description of evidence upon which British practitioners
founded their belief in the contagious communicability of puerperal
fever. Some of the Continental writers on this subject seem to
imagine that British obstetricians believe that puerperal fever was
usually propagated directly from one patient to another; and not
seeing this occur, when a puerperal fever patient, in their Continental
hospitals, lay by the side of another and healthy woman, they
imagine that from this fact they had a disproof of the opinion of the
contagious communicability of the disease.
But in this country we do not believe that the disease is usually
propagated in this way, directly from individual to individual, but
indirectly, through the medium of a third person; and that person
generally the medical attendant or nurse. But that it was so pro-
pagated by the medical attendant or nurse, we further believe upon
the following species of evidence-viz. that it was, as in Dr. Moir's
late cases, and in most other instances, distinctly and precisely
limited to the practice of one or two practitioners only, out of a large
number of medical practitioners, practising in a large community.
Many examples were recorded, and many more unrecorded were
known to the profession, of the disease being thus limited to
the practice of a single practitioner in a town or city; all, or
almost all, the patients of that practitioner being affected with
it, where none of the patients of other practitioners were seized with
any attack of the disease. In these cases we could not believe it to be
owing to any morbific influence present in the air, or emanating from
508
THE PUERPERAL STATE.
the locality in these cities or towns. For if so, it would affect
indiscriminately the patients of all practitioners. But it had been
often seen, as it was just now remarked, to haunt the steps of a
single practitioner, and a single practitioner only, in a community.
Many instances of this were known and published. One would
suffice for illustration. Dr. Roberton, of Manchester, tells us, that
in 1840 upwards of 400 women were delivered by different mid-
wives in connection with the Lying-in Hospital in Manchester.
These 400 women were delivered in different parts of the town at
their own houses: 16 of them died of puerperal fever; all the others
made good recoveries. The production of this could not have
arisen from any general epidemic, or atmospheric or telluric influ-
ence; for the fatal cases occurred in no one particular district, but
were scattered through different parts of the town. Now, these 400
women and more were attended in their confinements by twelve
different midwives. Eleven of these twelve midwives had no puerperal
fever amongst their patients. The sixteen fatal cases had occurred
in the practice of one only of the twelve. The disease, in fact, was
limited entirely to her patients. There must have been something,
then, connected with that one midwife, in which she differed from
the other midwives, inasmuch as all her patients took the disease,
whilst the patients of all the other midwives escaped from it. And
in medical philosophy we cannot fancy that this something con-
sisted of aught else than some form of that morbific principle or
virus to which pathologists give the name of contagion.
Further, that the disease is really, in such instances, propagated
by this third person (the physician or the nurse) carrying to the
parturient patients a virus capable of producing the disease, is shown
by this kind of additional evidence:-That when the disease has
broken out in the practice of one accoucheur, it will spread to the
practice of others of his obstetrical brethren, provided they put
themselves in a condition to carry the contagious virus from the
patients of the first practitioner. In 1836 or 1837, Mr. Sidey of
this city had a rapid succession of five or six fatal cases of puerperal
fever in his practice, at a time when the disease was not known to
exist in the practice of any other practitioners in this locality. Dr.
Simpson, who had then no full and proper belief in the contagious.
propagation of puerperal fever, attended the dissection of two of Dr.
Sidey's patients, and freely handled the diseased parts. The next
four cases of midwifery which Dr. Simpson attended were all affected
with puerperal fever, and it was the first time that he had seen it
COMMUNICABILITY OF PUERPERAL FEVER.
509
!
in practice. Dr. Paterson of Leith examined the ovaries, etc., from
these cases in Dr. S.'s lodgings, as he was at the time collecting
facts for valuable papers on Corpora Lutea. The three next cases
which Dr. Paterson attended in that town were attacked with the
disease. It was upon evidence of this kind that British pathologists
generally rested in founding their belief on the contagious communi-
cability of puerperal fever.
And it was evidence of this kind which had intuitively driven
them to adopt those means of prevention or avoidance, which are so
highly necessary, in order to arrest the propagation of this fearful
malady. The measures proposed and so successfully adopted by Dr.
Semelweiss in the Vienna Hospital, were beautiful from their mere
simplicity; but they were full also of a great lesson to us all. They
proved, in a manner beyond all dispute, the great importance of
carefully ridding the fingers from all matters in the least degree
likely to prove hurtful if inoculated into the vagina of a puerperal
patient. And no doubt, as Dr. Arneth had remarked, such matters
were always present in the fingers as long as, despite even of common
ablutions, they emitted a disagreeable animal odour, the presence of
that odour being a perfect proof of the presence of morbid matter
capable of producing the odour. Drs. Semelweiss and Arneth re-
commended, for the purpose of ridding the fingers of this morbific
matter, the use of chloride of lime. Dr. Simpson had used for the
same object for years daily (or rather, generally often during the
day), a solution of cyanide of potass, which was more effective even
than chloride of lime, and had this other advantage, that it removed
readily and at once all such stains as the fingers of the accoucheur
were apt to receive in treating uterine diseases-with nitrate of
silver, iodine, and the like.
Dr. Semelweiss believed that animal matter, in a state of
putrefaction, was the material which constituted the inoculable virus
capable of being transmitted to puerperal patients, and of producing
puerperal fever in these patients. Dr. Simpson had strong doubts
as to the idea of this matter being necessarily putrid being correct.
We see cases in which animal substances are allowed to putrefy
within the vagina, and to be applied to the mucous membrane of
that canal, without producing puerperal fever. When a polypus,
for example, was ligatured and left in the vagina, it often was killed
and putrefied there for days before the stalk was completely cut
through by the applied ligature. And yet in these cases the patient.
had little or no liability to attacks of disease like puerperal fever.
510
THE PUERPERAL STATE.
Besides, in these cases, the other condition is present, of an abraded
surface, as well as putrid matter in contact with that surface, for the
vagina was sometimes, no doubt, more or less injured in its mucous
surface while passing the ligature; and the ligature itself always
made a raw, open, and inoculable surface, as it cut through the
pedicle of the tumour. Surgery on other parts of the body admitted
of many similar proofs against this doctrine. Dr. Simpson had
always believed and taught another theory, but not perhaps a per-
fectly correct one, in regard to the nature of the contagious material.
He believed that generally, if not always, the material which, when
carried from one subject to another, could produce puerperal or sur-
gical fever in a newly inoculable subject, was an inflammatory secretion,
just as the inoculable matter of small-pox, cow-pox, syphilis, etc., was
an inflammatory secretion. The case adduced by Dr. Arneth, of
puerperal fever breaking out in the hospital apparently in conse-
quence of matter being conveyed from cancer of the uterus to a
series of puerperal patients, was not so strong an argument against
this view as might at first sight appear. For the cancer patient was,
according to Dr. Arneth's own account, several days in labour, the
carcinomatous degeneration of the cervix preventing the opening of
the os.
And there can be very little doubt, that by the end of
several days the carcinomatous structures were in a state of inflam-
mation, and probably gangrenous decomposition, from the protraction
of parturition. At all events, if the carcinomatous cervix was really
putrid, it was in all likelihood putrid from the results of gangrenous
inflammation in its compressed and irritated structures. But be
this the case or not, it was important to remark, that obstetricians
had now very decided proof of various kinds of morbid matters
which were capable, when inoculated into the vagina, of leading on
to puerperal fever.
For, first of all, when the bodies of patients who died of puer-
peral fever were opened, the inflammatory effusions in the abdomen
and elsewhere, when brought in contact with the fingers of the
accoucheur, were capable of producing the same disease in other
healthy patients upon whom they were accidentally inoculated. In
other words, the morbid effusions of puerperal fever in one woman
were capable of producing puerperal fever in another woman when
inoculated into her system.
But, secondly, the same seems to hold true with regard to the
secretions coming from the bodies of such patients, even when they
did not die and were not dissected. Dr. Simpson alluded to the
A
COMMUNICABILITY OF PUERPERAL FEVER.
511
cases, for example, of nurses and midwives, whose fingers came into
contact with the discharges from the vagina of puerperal patients,
giving the disease to other parturient women, and who had not, of
course, in the way of post-mortem examinations, been bringing their
fingers in contact with the more internal secretions. Dr. Gordon
mentions more than one case of this kind in relation to midwives,
in his history of the Aberdeen puerperal epidemic.
Thirdly, he believed that the cases recorded by the late Mr.
Storrs, Hutchinson, Ingleby, and others, sufficiently proved that the
inflammatory secretions in some other inflammatory diseases besides
puerperal fever, when carried by the medical attendant, and inocu-
lated into the maternal canals of a parturient female, were some-
times capable of producing in such females true puerperal fever.
This seemed more particularly true with regard to the inflammatory
effusions in erysipelas and gangrenous inflammation of the limbs,
scrotum, vulva, or other part of the body. That the morbid
matters thrown out in those more subacute forms of disseminated
or phlebitic inflammation which sometimes occur after delivery,
were capable of producing puerperal fever when inoculated into
puerperal patients, was a fact of some importance to hold in view.
And the following recent case will perhaps impress the truth of it.
A short time ago, Dr. Simpson was requested to see a case of pelvic
abscess in a patient delivered four or five weeks previously. The
abscess was artificially evacuated, but only with partial relief; as
there were evidently other local inflammations going on, both in the
abdomen and chest. The patient died about six or seven weeks
after delivery. The practitioner who originally attended her, and
who had no puerperal fever cases in his practice, was not able to be
present at the dissection. Another able medical practitioner whom
he had called to the case after the inflammatory attack had begun,
opened the body. Though an excellent and well-informed physi-
cian, he rather decried any fear about the possibility of contagion,
when Dr. Simpson suggested it to him as he came into the room,
and found him opening the body. This gentleman had no puerperal
fever cases in his own practice; but within fifty hours after opening
this body, he happened to be called to five cases of midwifery.
Four of these patients were attacked with puerperal fever, three in
a very severe, and one in a mild or abortive form. The fifth
patient altogether escaped, the child having been born before the
practitioner's arrival.
Fourthly, there were one or two recorded circumstances which
512
THE PUERPERAL STATE.
would lead one to the belief that some varieties of febrile exhala-
tions received by inhalation into the blood of a newly-delivered
woman, are capable of producing in her a disease analogous to, if
not identical with, puerperal fever, the effect being the same as if
morbid matter had been introduced into her blood, not by inhalation
into the lungs, but by inoculation and imbibition into the vagina,
just as in the spreading of small-pox we see the disease liable to be
produced in two ways-first, by the direct inoculation of the morbid
inflammatory matter contained in pustules on the arm of a healthy
individual; or, secondly, by individuals inhaling the morbid effluvia
from the bodies of patients labouring under the disease, without its
being inoculated into them. Dr. Collins mentions an instance in
which a patient was admitted into the Dublin Lying-in Hospital,
labouring under a bad form of typhus fever. Two puerperal females,
who occupied the adjoining beds, were attacked with puerperal fever
and died. In another instance, in the same hospital, a similar acci-
dent happened. A patient labouring under typhus fever was
admitted into one of the small wards of the house, which contained
only some four beds-all the three other women were attacked with
puerperal fever, and two of them died. But we had no very
decided evidence, so far as Dr. Simpson knew, from hospital obser-
vation, that a woman, labouring under puerperal fever, could, by
the exhalations from her body, infect with the same disease other
patients lying near her in the same ward.
Fifthly, some accoucheurs believe in the possibility of the imbi-
bition of the effluvia from typhus or puerperal fever patients by the
clothes of the medical attendant, and that the subsequent inhalation
of such matter by the parturient female, might be a means of arti-
ficially infecting that female with the disease. Dr. Simpson could
not doubt that the saturation of the bed-clothes, etc., with the dis-
charges of a puerperal fever patient, might give the same disease to
another puerperal patient who was laid in them. This, and one or
two other circumstances, were enough to show that, for safety's
sake, it was always well to act upon the possibility of the clothes
even of the medical attendant being thus a medium of contagion.
In some observations on the subject of the contagion of puerperal
fever, Dr. Merriman states, that he once attended the dissection of
a puerperal patient, but did not touch the body or any of the parts.
The same evening he attended a lady in labour, and she was
attacked with the disease. In his account of the Aberdeen fever,
Dr. Gordon mentions that a man-servant appeared to carry the
COMMUNICABILITY OF PUERPERAL FEVER.
513
infection of the disease from his sister in Aberdeen to his wife in
the parish of Fintray, six miles from Aberdeen. The midwife who
attended this woman infected two other parturient patients in the
same parish soon afterwards, both of whom died. If a statement
of this kind could be established as a fact, by careful analysis of the
requisite evidence, it would be a matter of importance, as adding to
our knowledge of the modes in which this disease may be propa-
gated. In the instance which Dr. Moir had mentioned, of Dr.
Hamilton visiting the patient of another practitioner affected with
puerperal fever, and immediately after having several cases in his
own practice, it was not at all unlikely that he had made some
examination of the patient, or, at all events, without proof that he
had not, it would not be proper to conclude that the disease in that
instance could be carried by the clothes of the physician acting in
the way of fomites. The history of the other case adduced by Dr.
Moir, of the fever breaking out on ship-board, when bed-clothes
had been used which had been employed previously in the beds of
women who had died of puerperal fever, would be exceedingly
important in the way of proof, if it had been more substantially
reported and authenticated. One can scarcely believe that such
clothes should be shipped after being thus used, without having
been previously thoroughly washed and cleansed. Dr. Simpson had
also been informed of an instance by Professor Patterson, in which
a medical gentleman, after having lost several cases of puerperal
fever, got rid of the disease in his practice by changing his clothes,
and using chloride of lime, etc.; but it again returned to him when
he happened to deliver a patient immediately after wearing a pair
of gloves which he had used during the time of the puerperal
epidemic; and certainly, if there was any piece of dress more apt to
retain the contagion than another, it was this useless and superfluous
appendage to our attire; for it might retain the morbid secretions
that were originally on the fingers of the accoucheur, just as our
vaccinating glasses would retain the cow-pox matter.
Sixthly, in a small ward or small hospital, one could almost, as
it were, manufacture puerperal fever at will, by crowding a great
number of puerperal patients together in the same ill-ventilated
room. The discharges from the different patients in a few days.
rendered the air of such a room so loaded and morbific, as to be
oppressive to all entering it, and capable of producing febrile action
by the inspiration of it, in those puerperal patients who occupied its
beds. This, no doubt, was true when this experiment was driven,
514
THE PUERPERAL STATE.
as it sometimes accidentally had been, to an extreme.
But it was
true also in its lesser degree; for Dr. Simpson believed that one
great cause of weed, ephemera, and febrile attacks during puerperal
convalescence, was the still too slight attention that was paid to the
ventilation of the lying-in chamber. He had repeatedly, he thought,
seen more or less slight febrile action set up in a patient, from the
curtains being closely drawn around her bed for eight or ten hours
during the night, being thus obliged to breathe an air loaded and
affected with the morbid animal discharges from her own body.
Seventhly, Dr. Arneth had not alluded to the question, Whether
the disease was ever caused or not, or a predisposition at least given
to it, by epidemic influence? Dr. Simpson believed that we ought
not altogether to forget the possibility of epidemic influences acting
directly or indirectly in the causation of it. During the present
century the disease had nearly, in two or three instances, as in
1819-20 and 1829, prevailed in most of the cities and lying-in
hospitals of Europe. And it was difficult or impossible to account.
for this simultaneous existence everywhere, without believing that
everywhere there was some general epidemic cause tending to its
production. In this the history of puerperal fever did not differ
from the history of other contagious febrile diseases. During the
latter part of the last century, for instance, small-pox contagion
existed in almost every town and village in England, because
in almost every one of them there were artificial causes operating
to produce and perpetuate the disease, inoculation being very
generally practised. But it was only in particular years, and some-
times at a considerable distance of time, that the disease became
epidemic. And when it did so, it was owing to other causes being
in action in addition to the mere inoculation. Nay more, in some
conditions, as during the blowing of the Harmattan wind, we know
that small-pox and cow-pox cannot be propagated even by direct
inoculation-facts, showing us the influence of epidemic constitution
in effecting a greater or less tendency to the production and spread
of particular diseases.
One predisposing cause to attacks of puerperal fever was no
doubt the state of the constitution of the patient immediately after
delivery. Dr. Collins' cases in the Dublin Hospital showed, not
only that the disease was far more apt to attack those who were
worn out by long labours, than those women who had escaped with
parturitions short in their duration; but also, that the malady, when
it did appear, was much more fatal in the former than in the latter
COMMUNICABILITY OF PUERPERAL FEVER.
515
class of patients. The Society was aware that it had been proposed
by various pathologists of late years to give various prophylactic
medicines to puerperal patients after delivery, and to surgical patients
after operations, in order to prevent the attacks of puerperal or
surgical fever. All these measures, such as sulphate of quinine,
muriate of iron, etc., had the object in view of strengthening the
constitution of those to whom they were exhibited, so as to diminish
or destroy the predisposition to these feverish attacks. And we
could understand their proposed mode of action when we reflected
upon the fact, that a predisposition to such attacks was given by
any unusual degree of exhaustion or debility in the patient. Every
patient exposed to the contagion, and even to the inoculation, of
small-pox, for example, did not take small-pox. There were other
means by which the predisposition to that discase was reduced or
removed, than by previous variolation or previous vaccination. And
perhaps, particularly, or otherwise, by medicine, we may be able to
reduce or remove the predisposition to puerperal fever, as well as to
scarlatina, measles, etc.
Lastly, Dr. Simpson observed, that no doubt sporadic cases of
puerperal fever frequently did occur traceable to no contagion or
any other cause capable of being averted; some of them owing, as
in Dr. Moir's first case, to morbid actions going on in the constitu-
tion of the patient even before delivery; but oftener owing to
morbific agencies-capable, under other circumstances, of producing
fever or inflammation-acting upon the patient during or after
delivery.
Dr. Arneth had particularly called the attention of the Society
to the connection which was generally believed by British accouch-
eurs to exist between erysipelas and puerperal fever; and he had
stated that the relation between these two diseases had not been
observed in Vienna. Dr. Simpson, however, expressed his opinion,
that now that Dr. Arneth's attention had been directed to it, he and
his compatriots would find such relations existing between these two
diseases, as English accoucheurs spoke of. We, all of us, often over-
look such facts in pathology till our attention happens to be pro-
minently called to them. Dr. Simpson had long believed and
taught that there was a pathological connection between the two
diseases in question, as to their pathological nature, their patholo-
gical anatomy, their symptomatology, and their causation. The
two diseases had in Britain been repeatedly observed to prevail at
the same time, in the same town, in the same hospital, or even in
34
516
THE PUERPERAL STATE.
the same wards. There were various accurately recorded instances
in our British journals, which he had already alluded to as showing
this-that when the fingers of medical men were impregnated with
the morbid secretions thrown out in erysipelatous inflammation, the
inoculation of these matters into the genital canals of parturient
females produced puerperal fever in them in the same way as the
inoculation of the secretions from patients who had died of puerperal
fever itself. The effused morbid matters in the one disease, as in
the other, were capable of producing the same effect when introduced
into the vagina of a puerperal patient. In an instance recorded by
Mr. Hutchinson, two surgeons, living at ten miles' distance from each
other, met half-way to make incisions into a limb affected with
erysipelas and sloughing. Both practitioners touched and handled
the inflamed and sloughing parts; and the first parturient patients.
that both practitioners attended within thirty or forty hours after-
wards, in their own distant but respective localities, were attacked
with, and died of, puerperal fever. The late Mr. Ingleby mentions.
an instance of a practitioner making incisions into structures affected
with erysipelas, and going directly from this patient to a patient in
labour. This patient took puerperal fever and died. And within
the course of the next ten days, seven cases of puerperal fever oc-
curred in the practice of the same practitioner, almost all of them
proving fatal. And various other cases, similar to the preceding,
were well known to the profession.
Again, however, the reverse of this was equally true. Not only
was the morbid matter in erysipelas apparently sometimes capable
of producing puerperal fever, but the secretions and exhalations from
puerperal fever patients seemed, on the other hand, sometimes
capable of producing erysipelas. In the series of puerperal cases
met with by Mr. Sidey in this city about 1837, and which had
already been alluded to, the morbific matter carried from two or
three patients seemed, as has been previously stated, to produce the
disease, both in Dr. Simpson's own practice, and also in the practice
of Dr. Paterson. The morbid effusions of these patients created the
same disease of puerperal fever in other patients to whom that
matter was carried. But the morbid secretions and exhalations from
these same patients appeared to do more-viz. they produced also
erysipelas in several of the nurses, relations, and attendants upon
the patients. Four or five cases of erysipelas followed upon a single
one of these puerperal cases in Mr. Sidey's practice, and that during
the week subsequent to the puerperal patient's death. The patient's
COMMUNICABILITY OF PUERPERAL FEVER.
517
•
mother-in-law, who was in constant attendance upon her, was
attacked with fever and erysipelas of the face and head. One of
the patient's sons, a boy five years of age, was attacked with erysi-
pelas of the face; a daughter was seized with fever and sore throat,
with dusky redness, which continued for some time; and the
patient's sister-in-law was attacked with acute gastric symptoms, and
great abdominal irritation, under which she sank in a few days.
Here we have apparently the same focus of contagion producing
puerperal fever in puerperal patients, and erysipelas, inflammatory
sore throat, etc., in patients who were not in a puerperal state. Dr.
Hill of Leuchars had published in the Monthly Journal of last year
two very important series of cases, showing in a similar way the
connection between puerperal fever and erysipelas, in the identity
of the poison that was capable of producing these two diseases. We
have already seen that the inoculation of the morbid matters from
erysipelatous structures into parturient patients will occasionally
produce puerperal fever. But furthermore, the converse of this is
so far also true-viz. that the inoculation of morbid matters or
secretions from puerperal fever patients into other healthy indivi-
duals, will occasionally produce in the latter attacks of erysipelas.
A considerable number of instances have been published by Dr.
Duncan, Mr. Travers, and others, in which medical men have died
from punctures received in dissection, or rather from erysipelatous
inflammation of the arm and side following such punctures. The
history of a large proportion of these cases shows further, that the
matter thus inoculated, and which produced the fatal erysipelas and
fever, was a puerperal fever secretion; as in most instances the
disease resulted to these medical men from opening the bodies of
patients who had died of puerperal fever.
Whilst thus arguing for some pathological connection between
erysipelas and puerperal fever, Dr. Simpson further stated, that
though, in a few cases, patients labouring under puerperal fever had
been attacked with erysipelas of the skin and cellular tissues; and,
on the other hand, patients who were delivered when suffering
under erysipelas, were sometimes subsequently attacked with puer-
peral fever; yet these results were not always observed. He alluded
to cases where erysipelas had attacked women before delivery, but
was not followed by puerperal fever. And he had seen more than
one patient labouring under puerperal fever have inflammation of
the skin, but that of a pustular type, like ecthyma, and not of an
erysipelatous character. In stating this, he wished to state his belief
518
THE PUERPERAL STATE.
that the diseases were not in all respects pathologically identical,
though the morbid secretions in the one were capable of producing,
in those predisposed to it, the other disease-erysipelatous effusions
producing puerperal fever, and puerperal fever secretions producing
erysipelas.
Other febrile and inflammatory products, besides those of puer-
peral fever, when inhaled through the lungs into the blood, or inocu-
lated into the blood through the vagina, may, as already stated,
probably produce puerperal fever, in addition to those we have
principally spoken of, viz. the secretions from puerperal fever and
erysipelatous patients. And he thought the whole subject one of
extreme importance to have more thoroughly investigated; because,
in a disease like puerperal fever, it was the means of prevention
that we were to look to, and to expect success in, more than the
means of cure. It was here, as elsewhere, evident that human
life would probably be saved to a far greater extent by studying the
means of preventing the causation of disease, than by any study of
the means of treatment, after disease was once actually commenced.
And when it was remembered that about 3000 women still died in
child-birth in England and Wales alone every year, and that a large
proportion of these 3000 maternal deaths were deaths from puer-
peral fever, he thought he need not make any further observations.
on the importance of studying the means of prevention and pro-
phylaxis in such a fatal and formidable malady, nor offer any apology
for the length of the remarks which he had ventured to offer on this
important subject.
ERUPTIVE FEVERS IN PUERPERAL PATIENTS.¹
Professor Simpson said he had been led to bring this subject
under the notice of the Society at present, in consequence of having
been lately called to see, in consultation, two cases of puerperal
scarlatina, which had occurred in the practice of one of the most
able and accomplished of our country practitioners.
CASE I. The first patient was a young primipara, who, at a distance from
Edinburgh, was confined after a labour of no unusual difficulty, and remained well
till the second day after her confinement, when the pulse rose, and she became so
delirious that it was thought she was labouring under an attack of puerperal
mania. When he (Prof. S.) saw her first on the third day, the delirium had
1 See Proceedings of Edinburgh Obstetrical Society, January 14, 1863, in
Edinburgh Medical Journal, June 1863, p. 1145.
ERUPTIVE FEVERS IN PUERPERAL PATIENTS.
519
subsided; but a scarlatinal eruption had broken out over the body. The erup-
tion was of a character so indefinite, as to leave some doubt as to whether it might
not be due to the rubefacient action of the turpentine stupes that had been freely
employed. Next day, on returning to see the patient, he was told that the erup-
tion had disappeared. It reappeared after a time, and again disappeared ; and came
and went in this way for a couple of days till the patient died. She had had scar-
latina some years before. This time there was slight sore-throat, but not much;
and the diagnosis had been very difficult at first, and the case peculiar, in that
the premonitory symptoms seemed rather to point to mania than to any kind of
eruptive disease.
CASE II.-In the second case, on the second or third day after the birth of a
fourth child, the patient fevered and showed a scarlet eruption all over the face,
trunk, and limbs. The tongue and throat were clean; but the pulse was so weak
and quick, that he (Prof. S.) had been led to form but a gloomy prognosis. She
had, however, ultimately recovered. Probably all the Fellows had seen such cases;
and he would like just to make this remark, which was applicable alike to small-
pox, measles, and scarlatina, that when they occurred in a pregnant female they
very rarely proved fatal to her, whatever the date of pregnancy might be; or if they
did not attack her till ten days or a fortnight had elapsed after her confinement,
they were not specially dangerous; but whenever they appear in a woman within
six or eight days after her delivery, they are always alarming and very often fatal.
CASE III. Rather more than a year ago, a lady who had been placed under
his care, died very suddenly of measles coming on shortly after delivery. The
disease had appeared in one of the children more than a fortnight before the period
of her confinement was due, and he had her immediately separated from the family,
who were staying about two miles out in the country, and brought into town, and
no kind of direct communication was allowed to take place between the two houses.
Her labour, her thirteenth, was effected on a Wednesday, without any notable
peculiarity, and she continued well for some days thereafter. But on the Sunday
afternoon she had a tremendous rigor, which was succeeded in the evening by a
high degree of fever, and during the night by great restlessness. Copious per-
spiration and a free evacuation next forenoon greatly relieved her; but in the
afternoon the rigor returned, succeeded by a high fever, with burning hot skin
and rapid pulse. Towards morning the brow became rough and red, and it seemed
for a time as if an eruption were about to break out on the face. The pulse came
down a little during the forenoon; but the rigor having recurred in the third after-
noon, the patient sank and died, fifty-two or fifty-three hours after the occurrence
of the first shivering-fit. The post-mortem examination, which was made by Dr.
Turner, revealed no special local lesion other than those changes which are found
in the liver and other glandular organs in patients dying of rapidly destructive
fevers. It would, perhaps, have been impossible to say with absolute certainty
that this puerpera died of an attack of measles; but at the time of her death, he
(Prof. S.) had no doubt as to the nature of her attack, and his opinion was con-
firmed when, some days afterwards, an eruption of measles appeared on the baby,
although it had been kept away from the infected household.
The remarks he had made with regard to scarlatina and measles
held good with respect to small-pox also. There were many cases
on record where small-pox, having attacked a pregnant woman, had
run its course without producing any very alarming symptoms in
520
THE PUERPERAL STATE.
herself, though it caused the death of her intra-uterine offspring.
But when it came on within a short period after delivery had been
effected, it was extremely dangerous.
CASE IV.-A patient who had been delivered in the Lying-in Hospital last
month, had been seized with small-pox seven days after her confinement. There
was a distinct vaccination-scar on her arm. There was not a very profuse crop of
vesicles; but on the tenth or cleventh day, some petechiae spots appeared on the
chest, which multiplied in number and increased in size till some of them looked
like ecchymoses; and on the sixteenth day she died.
With regard to diagnosis, he might remark that it was not
always very easy at first sight to determine the nature of the case,
when a puerperal woman became the subject of an eruptive fever.
He once saw a case along with Dr. Newbigging, where some of the
symptoms looked like those of scarlatina, but no eruption whatever
could be detected. Some of the children, however, afterwards
became ill, and in them the scarlatina eruption was quite distinct.
The case was the more remarkable that a sister of this lady, who
had also been recently confined, but who was living in the country,
and had no communication with the affected household except
through the doctor, was attacked with scarlatina and died also. He
(Prof. S.) did not agree with Dr. Ramsbotham in supposing that the
poison of the special epidemic fever was retained in the system of a
puerperal woman some time before it broke out; he rather believed
that it ran in them its usual course. It was difficult to determine
the cause of the great fatality of these fevers in such patients; but
it was probably due partly to the weakened condition of the system,
but still more to the presence at that time in the blood of a quantity
of effete material, which was ready to be thrown into a kind of septic
destruction whenever the materies morbi was introduced.
CASE V. When speaking of puerperal disease, he (Prof. S.) might perhaps be
allowed to read the notes of a case of purpura, which had occurred in one of the
patients recently delivered in the Lying-in Hospital. It was the first of the
kind he remembered ever to have seen; but Dr. Lyell of Newburgh, who had
been in town, and to whom he had mentioned this case, told him that he had seen
two instances of the disease, one of them marked by this peculiarity, that delivery
was attended with severe post-partum hemorrhage. The notes which he (Prof. S.)
now begged to read, had been drawn out by Dr. Murray, House-surgeon to the
hospital
M. F., æt. 24, cook, entered the Maternity Hospital on 12th Decomber at
12 noon, in labour with her third child. She had been in labour about twelvo
hours previous, and on examination the os uteri was about the size of a shilling,
and her pains very severe and frequent, only a minute or two being between each
pain. On inquiry, it was ascertained that she was only in her seventh month of
ERUPTIVE FEVERS IN PUERPERAL PATIENTS.
521
pregnancy, and that she had always been in the enjoyment of good health, having
been engaged as cook in a gentleman's family, up to the time of entering the
hospital. She has always had the best and most nourishing food, and has not
been addicted to intemperate habits, 'in drinking' at least. From extensive in-
quiries made at her friends, her statement has been confirmed on these points, and
further, they state that, though possessing ample opportunities for observation,
they never saw any spots or cruption on the skin. The patient, however, states
that for the last few months her urine had been scanty and high coloured. On
entering the hospital, the only thing noticeable was that her eyes were somewhat
congested, and that she had a dull and stupid appearance. Nothing, however,
was to be seen on her skin. Half-an-hour after entering the delivery-100m, she
complained of a sensation of intense itchiness over her whole body, which was
immediately followed by the sudden appearance of an eruption resembling nettle-
rash. She had also intense thirst; frequent desire to pass her urine, which was
high coloured. The eyes became more congested; the pains, however, diminished
in severity. A marked feature in the case was severe vomiting, which reduced her
strength very much, and for which she was ordered a tablespoonful of brandy in
water every hour.
“13th December, 4 P.M.-The membranes ruptured, when a still-born child
was delivered immediately; the placenta came away in a few minutes, and the
discharge was as usual. The child, from its appearance, must have been dead
some time.
Evening, 11 P.M.-Sent for the nurse, complaining of severe vomiting, which
had continued at intervals since she left the delivery-room, about 5 P.M.; though
very thirsty, could not retain any fluid on the stomach.—B Acidi hydrocyanici
med., mij.; aquæ zi. Sig. Fiat haustus, to be taken immediately. Vomiting
greatly relieved. l'atient passed a very restless night, but did not complain of
any pain or any other thing. Had a peculiar action of her hands, as if she felt
some difficulty of breathing. Nothing, however, was noticeable in the chest.
Pulse 108, quick and feeble. Nothing to be seen on the skin.
"14th, 9 A. M.-Patient's face has an cedematous appearance; eyelids, espe-
cially the lower, very oedematous. Complains of severe pain in the back and
loins, which are tender on pressure. Conjunctiva very much injected. A dark
red appearance over the whole body. Intense heat over the whole surface.
Pulse 110. Respiration sighing and long drawn. Pain in the back still con-
tinues. Answers questions intelligently. Lochial discharge slightly diminished
in quantity, having rather an offensive smell.-B Tr. aconiti, mxij.; aquæ @
Ziij. A teaspoonful every half-hour. Wet cloths (cold) to be applied to the
head. Makes water frequently and in small quantity. Vespere.-Pulse 94.
Pain in the back excessive (with diminished amount of urine), causing her to
start every moment.- Pul. Doveri gr. vi.; Tales duo.
Whole body was
swollen, and foot pits slightly on pressure.
“15th.--Patient has been relieved of pain, but has not slept. The face, arms,
legs, and indeed the whole body, much swollen, pitting on pressure, and of a
dark crimson appearance. A feeling of stiffness over the whole body. Con-
junctiva greatly injected, almost distended with effused blood. Had a severe
attack of bleeding from the nose, which came on at short intervals till her death.
Tongue densely coated; pulse 120, quick and feeble. Skin intensely hot, com-
municates a burning sensation to the touch; has a universally dark-red appear-
ance. Vomiting almost gone. Stools are of a dark appearance.- Tr. ferri
muriatis, mx.; Sp. ether. nit., 5ss. M. fiat haustus.
Afternoon, 3 P.M.-Urine passed in greater abundanco.
Skin still very hot
522
THE PUERPERAL STATE.
and pungent; pulse 130. Some urine was now drawn off by the catheter, when
it was found to be very dark and thick. Tested by heat and nitric acid, it be-
came denser, but did not coagulate, and on cooling, deposited a thick dark-brown
sediment. Under the microscope it showed numerous blood-corpuscles and some
epithelial cells. Evening.—Lochia entirely suppressed. No tenderness on pres-
sure over the region of the uterus. Injected a weak solution of Condy's fluid
into the uterus, and gave a hot-air bath for one and three-quarter hour; the
latter produced a copious perspiration, relieving the swelling of the body and
causing a disposition to sleep.
“16th.-Patient passed a quiet night; swelling of the arms gone down; body
feels easier; pulse 120. Small petechiæ observable on the eyelids and cheek-
bones. Ordered hot cloths to the vulva, to restore the lochial secretion if possible.
Sudden supervention of pain over the uterus. Cold cloths to be applied to head,
and hot cloths to vulva, uninterruptedly. While this was being done, patient's
pulse suddenly fell to 90, when she felt easier and looked quieter; but if these
means were intermitted, pulse rose to 120, and she again complained of uneasiness
in the abdomen.
"11 P.M.-An abundant crop of petechia was observed on the legs. A few
being intermixed with bluish-black spots on the abdomen. The patient, however,
complained most of her throat, and said that she could hardly swallow. She spat
a considerable quantity of blood. On examination, not much was to be seen,
possibly from the difficulty of obtaining a right view of it. The upper part of the
chest on both sides was resonant on percussion, but the breathing on the posterior
part of the right side was somewhat bronchial.-R Potassæ chloratis, Di.; Acidi
hydrochlorici, mxx. Fiat gargarisma. Ordered wine.
“17th.-Patient has passed a very restless night; lips and teeth covered with
sordes; throat much worse. Patient speaks indistinctly; pulse 120, very feeble.
Complains of a sore feeling all over her body. Skin was rubbed off the left elbow ;
has bled freely at the nose. Petechiae on the face almost grown to ecchymosis.—
B Quinæ disulphatis, gr. v.; Acidi sulphurici dil. ¤iv.; Vini Xerici, Zij. To be
administered frequently.
"1.15 P.M.-Patient's breathing short and difficult, accompanied by a crepitat-
ing sound, and occasionally by a puffing out of the cheeks, as in apoplexy. Voice
almost gone; but consciousness quite retained.-Died at 3 P.M.
"The autopsy was made by Dr. T. Grainger Stewart.
Integumentary System.-Body well nourished. Over the abdomen we have
abundant striæ gravidarum. Face generally of a sallow colour; here and there
are ecchymosed spots elevated above the surface, varying in size from a pinhead
to a florin. Conjunctiva intensely reddened. On the back of the thorax the
cuticle is abraded and the epidermis extremely congested, there being a bag of
blood below.
“Epidermis.—The whole surface of the body, and particularly the legs, are
covered with purpuric spots. In the substance of the muscles, bloody spots are
also seen.
Viscera.—Sanguineous effusion into pleura. Hemorrhage into lungs. Old
pleurisy of right side, with adhesions. Heart flabby, with hemorrhagic spots on
its surface. Bloody fluid in the peritoneum. In the upper half of small, and
whole of large intestines, abundant bloody patches. Liver soft and brown-coloured.
Some hemorrhage had taken place into the capsule of Glisson. Spleen somewhat
enlarged, soft, and full of pulp. Slight effusion on the surface of brain. Hemor
rhage into the substance and pelvis of the kidneys.
"Uterus.—Walls 14 inch thick, 9 inches long. When opened up, measured
about 1 foot across, and contained a bloody decidua."
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION. 523
PATHOLOGICAL OBSERVATIONS ON PUERPERAL
ARTERIAL OBSTRUCTION AND INFLAMMATION.'
It is only within the last thirty years that the inflammation and
obstruction of veins has become a prominent subject of research.
Yet all are now ready to acknowledge the high practical importance
of phlebitis, and its effects in puerperal, in surgical, and in medical
pathology.
The inflammation, however, and obstruction of arteries has
hitherto been little attended to, especially in midwifery. They are
not subjects mentioned even, so far as I know, in any obstetric
work; and, doubtless, they are not so common as venous inflamma-
tion and obstruction. But arterial obstruction and inflammation
will be found, I believe, to be much more frequent than is sup-
posed-1. When we come to know better, and really search for,
their effects and symptoms in the living body; and 2. When we
do-what has hitherto been almost entirely neglected to be done-
namely, look properly for their existence in our dissections of the
dead body.
In the present communication, my principal object is merely to
prove the fact that arterial obstructions do occasionally occur in the
puerperal patient, and are accompanied with various important
pathological consequences. As far as our present very limited and
very imperfect investigations go, these arterial obstructions in the
puerperal female seem capable of being produced by a variety of
morbid causes, particularly-1. By the separation of old or organised
cardiac vegetations, and their subsequent transference into the
arterial canals; 2. By the passing forward into the current of the
circulation of recent fibrinous masses formed in the cavities of the
heart or larger arterial vessels; 3. By local arteritis; 4. By laceration
of the internal coats of the occluded vessels; and 5. By morbid
materials carried from the systemic venous system, and lodged in
the pulmonary artery or its branches. I propose to adduce one or
more examples illustrative of each of these pathological causes of
arterial obstruction in the puerperal female; and to add a few
1 Communicated to the Medico-Chirurgical Society of Edinburgh, January 4,
1854. The following essay is drawn up from the notes used on that occasion ;
but several more recent cases are now added to it. See abstracts of the com-
munication in Edinburgh Monthly Journal of Medical Science, February 1854,
pp. 175 and 181; and in Association Medical Journal, January 13, 1854, pp. 41
and 43.
524
THE PUERPERAL STATE.
general remarks upon the causes, and the symptoms or effects of
such obstructions.
SECTION I.-ARTERIAL OBSTRUCTION FROM SEPARATED CARDIAC
VEGETATIONS BLOCKING UP THE ARTERIES.
This pathological cause of sudden arterial obstruction was for
the first time, I believe, specially noted in a puerperal patient whom
I attended in 1842, along with Dr. Abercrombie and Dr. Beilby.
The following particulars with regard to the case are stated by me.
in the published Proceedings of the Edinburgh Obstetric Society
for 15th June 1847.'
CASE I. The lady, about a year before becoming pregnant, laboured under a
very severe attack of rheumatic endocarditis. During the later months of utero-
gestation, she suffered greatly from attacks of difficult breathing, which amounted
sometimes to orthopnoea. About the eighth month hemorrhage suddenly super-
vened, and I found that, in addition to her other complications, she had the edge
of the placenta projecting over the posterior lip of the uterus. After the os uteri
was nearly dilated, the membranes having been ruptured some hours before, with-
out entirely suppressing the very severe and exhausting hemorrhage that was
present, I extracted a child, who is still living, with the long forceps. The
mother seemed for the time to make a most perfect and satisfactory recovery.
Some symptoms of irritation, however, supervened; and, during the second week
after her confinement, I one morning found that there was no pulse to be felt in
the right arm lower than the elbow, whilst it was distinct and strong down to
that point. This forearm had felt, for some hours previously, coldish, stiff, and
benumbed. In the course of a few days, the pulsation in the right radial artery
gradually but feebly returned; but the circulation, first in one and then in the
other leg, seemed to be similarly affected. At last, unequivocal symptoms of
erratic phlebitis began to show themselves, and, five weeks after delivery, ended
in a fatal attack of phlegmasia dolens in the left arm and left side of the face.
On opening the body, the vena innominata on the left side, and its affluent
trunks, were found entirely obstructed by coagulable lymph. The humeral artery,
at the bend of the arm, was shut up by an obstructing mass or coagulum; but
the inner coat of the vessel had no appearance whatever of laceration. The valves
of the left side of the heart were profusely covered over with small wart-like ex-
The lower limbs were not examined.
crescences.
In first describing the preceding instance of puerperal disease to
the Obstetric Society, I proposed the three following questions:-1.
"Was the obstruction of the artery, or arteries, in this case, pro-
duced by any mechanical cause, as one of the vegetations separated
from the cardiac valves, carried along, in the case of the arm for
example, to the bifurcation of the humeral artery, and impacted
there?" 2. "Was it not rather the result of an original puerperal
1 See Monthly Journal of Medical Science, September 1847, p. 211.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
525
arteritis?" 3. "Or might it be the effect of an effusion of coagulable
lymph from phlebitic inflammation in the coats of the artery, a
secondary phlebitic deposit upon the lining arterial membrane ?”
friend
In the summer of 1853, I saw, in consultation with
my
Dr. Moir, a similar case, in which, from the symptoms present during
life, I made the diagnosis of arterial obstruction from separated
cardiac vegetations-an opinion that was confirmed by the results
of the autopsy.
CASE II. The patient was prematurely delivered in the country, of her first
child, and continued to recover favourably for three weeks, when remittent
feverish symptoms and diarrhoea supervened, and the lochia became slightly
hemorrhagic. Soon afterwards, pains, like those of neuralgia, were experienced
in the right leg, and then in the left, where they remained fixed and occasionally
very violent. Seven weeks after delivery, sudden pain and tenderness came on
in the left groin. At this time I heard a loud systolic bruit on listening to the
heart. No rheumatism had preceded. Some days subsequently, the pulse in the
right arm became arrested suddenly, as the evening before it had been felt by Dr.
Moir. Next day a careful examination was made of the arteries of the two lower
extremities. No pulsation could be traced in the left femoral artery or its
branches. The pulse in the right femoral and iliac was very weak, and in a day
or two entirely disappeared, so that now the arterial pulsatio" in the larger vessels
of all the extremities had ceased, with the exception of the left arm. It returned
slightly for a few days before death, in the right wrist. At last, in the left lower
extremity, where latterly there had always been excessive pain, gangrene of the
great and two next toes began, ten weeks after delivery; and the mortification
had not extended beyond these toes when the patient gradually sank, and died a
few days afterwards.
On opening the body, and examining the heart, the aortic aperture
was blocked up by a mass of valvular excrescence, which appeared
nearly as large as the whole calibre of the artery. It is represented
in the accompanying woodcut, Fig. 17. This excrescence was com-
posed of three portions, one attached to each of the three semilunar
valves. The left valve presented only a comparatively small excres-
cence on the centre of its free border. The vegetation attached to
the right valve formed by far the largest proportion of the morbid
mass; while that on the posterior valve was intermediate in size.
The whole excrescence seemed of comparatively recent formation,
being very friable and granular. In each valve, the corpus Arantii
seemed the centre of the morbid growth, and each vegetation appeared
to have been originally developed between the two serous layers of
the valves, and only secondarily to have protruded through these
layers, and become projected, as cauliflower-like growths, into the
free cavity of the vessel. The openings of the coronary arteries
were unaffected. Around the margin of the left auriculo-ventricular
526
THE PUERPERAL STATE.
orifice were a number of small red excrescences or carunculæ, about
the size of sago-grains, but evidently of the same nature as the larger
masses placed on the aortic valves. The pericardial surface of the
heart was healthy. The aorta at the fourth lumbar vertebra, and
iliac vessels, were firmly bound by exudation to the surrounding
parts. The aorta was found occluded at its lower extremity, by
a large irregular mass, composed of small portions similar in
consistence and general appearance to the vegetations formed on
the aortic valves. The mass thus situated in the aorta extended
more than two inches above its bifurcation, and was somewhat
conical in form-the apex pointing upwards, while prolongations

Fig. 17.
were sent from its base along the common iliac arteries on each side.
It was loose, and unattached to the walls of the vessels, and was
covered with a coating of dark-coloured blood, through which, at
scattered points, portions of the granular structure were seen pro-
jecting, not coloured like the rest, but bearing to the naked eye a
marked resemblance to the valvular excrescences in the heart. In
the right common iliac artery, some of the detached concretions were
found not covered with blood, but lying loose in the canal of the
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
527
vessels, and were there seen to be of a greyish colour, and granular
appearance. The external iliac arteries on both sides were occupied
by sanguineo-purulent matter, and here and there mixed with this
purulent matter were small granular concretions, similar to the

Fig. 18.
granular mass above. On the right side, this inflammatory appear-
ance of the artery extended down as far as Poupart's ligament, but
on the left side it reached two inches below Poupart's ligament; and
a small granular mass was found blocking up the origin of the pro-
528
THE PUERPERAL STATE.
funda on the left side. Two inches down the left internal iliac
artery, a pulpy mass was found blocking up the vessel, and from this
a yellowish pus extended upwards to the origin of the artery. The
mode and extent to which these concretions filled up the lower part of
the aorta is represented in the woodcut, Fig. 18. Let me add, that
the whole coats of the obstructed vessels were thickened, and the
lining membrane in contact with the occluding masses was of a deep
scarlet colour. Along the external iliacs the lining membrane
assumed a dirty red colour. The left femoral vein, for two inches
below Poupart's ligament, was occupied by a fibrinous clot. The
lower part of the right humeral artery presented an inflammatory
condition, in some respects similar to that of the iliac arteries. No
portions of excrescence were found in its cavity, but at the bifurca-
tion into the radial and ulnar branches, a pulpy mass was seen
adherent to the lining membrane of the vessel, and seemed like a
small granular portion of the valvular excrescence broken down and
mixed with pus, which occupied the vessels at this situation.
The
humeral artery, as far upwards as the pectoralis minor, and the radial
and ulnar branches for several inches downwards, were quite obliter-
ated and seemed like small cords, firmly bound by exudation to the
adjoining textures. When a portion of the mass from the aortic
valves was placed under the microscope, it was seen to be composed
of separated fatty granules, with blood corpuscles, and a few com-
pound granular cells interspersed. The sanguineo-purulent matter
in the neighbourhood of the masses deposited in the aorta and
other vessels, was seen to be crowded with pus corpuscles; while
the masses themselves were chiefly composed of fat granules, blood
corpuscles, and compound granular cells, like the excrescence present
on the cardiac valves. The uterus presented no appearance of
disease either in its cavity or walls. The spleen was pulpy and
diffluent, except at one point, where there was a small mass of a
cheesy consistence and greyish-white colour. The other viscera
were healthy.¹
For notes of the following two analogous cases, I am indebted
to the kindness of my friends, Professor Macfarlane of Glasgow, and
Dr. Lever of London.
CASE III. In this instance, the obstruction of the artery occurred suddenly
ten days after the lady was delivered naturally and easily of her fifth child. At
that time she began to complain of acute pain and numbness in her right arm,
1 The morbid parts in this case were, when still recent, shown to the Medico-
Chirurgical Society.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
529
which, with slight intermission from opiates, etc., continued till her death, which
took place at the end of three weeks. No pulsation could, from the first or sub-
sequently, be felt below the middle of the brachial artery. A week after this
arterial occlusion in the upper extremity, a similar change took place in the right
thigh, accompanied with acute pain. This ceased in a great measure four or five
days after, when unequivocal indications of gangrene showed themselves, com-
mencing at the toes and extending to the knee. On dissection, the aortic valves.
were found by Dr. Macfarlane covered with numerous vegetations, none of which
exceeded in size a grain of linseed. The aorta was dilated and studded over with
atheromatous deposits. At the points of obstruction (viz. the middle of the
brachial, and the commencement of the lower third of the femoral arteries) fibrous
clots were found, which completely closed these vessels. The upper or cardiac
end of the clots contained, and was firmly attached to, a small hard body, which,
on more careful inspection, was found to be identified in size, appearance, and
structure, with the aortic excrescences.
CASE IV. This patient suffered under an attack of acute rheumatism during
pregnancy, and died of a few days' illness after delivery. During the short illness
following the confinement, it was discovered by Dr. Lever, who attended the lady,
that there was no pulsation in the arteries of the left arm; and subsequently the
same want of pulse was observed in the left inferior extremity. The pain in both
extremities was distressing; the hand and foot were both livid in colour, and
local symptoms of gangrene were manifest in each. At the post-mortem examina-
tion, mushroom-like vegetations were discovered on the valves of the heart; and
in the arteries of both the affected extremities vegetations were found obstructing
their canal, and in the veins of both were phlebolites.
2
The first case which I have mentioned above, occurred, as I have
already stated, in 1842, and was published in 1847. During the
same year, 1847, Professor Virchow of Wurzburg, perhaps the most
original and industrious of living pathologists, published an essay on
inflammation of arteries, in which he mentioned several cases of
arterial obstruction apparently produced by cardiac vegetations.
detached and carried forward into the arterial circulation. In 1852,
Dr. Kirkes read an excellent paper before the Medico-Chirurgical
Society of London on the same subject; and Ruhle, Tuffnel, and
other pathologists have subsequently reported some additional in-
stances. The cases observed by Virchow, Kirkes, Ruhle, etc., were
not in puerperal patients. The instances detailed by Kirkes and
Ruhle referred principally to detached cardiac vegetations lodging
in the cerebral vessels, and producing death by encephalic lesions.
The following interesting case, which occurred in the wife of a very
1 "Ueber die akute Entzündung der Arterien," in Archiv für Pathologische
Anatomie, vol. i. (1847), part ii. p. 272. See cases, pp. 338, 342, etc.
2 London Medico-Chirurgical Transactions, vol. xxv. p. 285.
3 "Three cases of Hemiplegia produced by the plugging of one of the cerebral
arteries.”—Medical Times and Gazette for March 1853, p. 299.
• Dublin Quarterly Journal of Medical Science, vol. xv. (1853), p. 371.
530
THE PUERPERAL STATE.
esteemed obstetrical friend, shows that the same lesion may occur
from the same cause in the puerperal female. For the following
particulars of this case I am indebted to Dr. Burrows, who, during
the life of the patient, made a perfect diagnosis of the exact morbid
states found after death.
CASE V.—The lady was seen by Dr. Burrows about six weeks after delivery ;
she was then in that state of semi-hectic which results from over-lactation.
Besides this she had obscure pains in the limbs, resembling rheumatism, and
more particularly pain in the calf of one leg, and other symptoms, which led him
to suspect she might have abscesses forming. All these symptoms gradually
abated, under the influence of cessation of lactation, great quietude, tonics, and
change of air. While in the country, however, and after rather more exertion
than common, she became suddenly hemiplegic on the right side, but without
symptoms of cerebral congestion. Dr. Burrows saw her on the following day, and
immediately suspected the case to be one of the class detailed by Dr. Kirkes.
Auscultation confirmed these suspicions, for there was a loud rasping systolic
murmur over the valves. The hemiplegia and impaired powers of speech and
memory remained to the time of death.
At the autopsy abundant vegetations were discovered on the mitral and aortic
valves, so that they were softened and ulcerated through. The left corpus striatum
was reduced to a mere diffluent pulp, and the branch of the left middle cerebral
artery passing to this part of the brain was obliterated with a small mass of fibrin,
like a grain of wheat, implanted in the vessel at its origin from the middle cere-
bral artery. The artery beyond the obstruction looked like a pale thin string, and
was quite impervious. The arteries of the limbs, in which the patient, at an early
part of her illness, had suffered so much pain, were not examined.
The five preceding cases were all apparently of the same nature,
and there were two special circumstances true as applied to the whole
of them-1st, In all the five, vegetations were found on the aortic
valves; and 2d, Loose bodies, having the same physical appearance
and structure as the cardiac vegetations, were discovered on dissec-
tion in the obstructed arteries. That the cause of arterial obstruc-
tion in these instances was not local arteritis, is proved by the super-
vention of the symptoms of arterial obstruction being sudden and
almost instantaneous; and by the obstructed artery, in some in-
stances, as in Case V., showing no post-mortem evidence of thicken-
ing or previous inflammatory disease. In all, the vegetations were
probably the result of previous endocarditis; and in three of them,
¹ In Ruhle's first case, in a patient aged 19, the cardiac vegetation found on
the aortic valves, and the plug found in the left arteria fossæ sylvii, were both
calcareous; and the walls of the occluded artery were healthy and free from all
inflammatory changes. In a similar case reported by Dr. Burrows, both the
cardiac vegetation and the plug in the middle cerebral artery were cretaceous.
See Medical Times for 1853, pp. 136 and 299.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
531
3/4
rheumatic symptoms had been present at a preceding period of life.
Further let me observe, it seems certain, that if vegetations are once
detached from the cardiac valves, they must be carried forward in
the current of the circulation. Are there, however, any circum-
stances or reasons which render it probable that such vegetations
ever become detached? In favour of this view analogy may be
appealed to in reference to the spontaneous separation of adven-
titious structures in other parts of the body. Thus, cartilaginous.
and other pediculated bodies become detached in the interior of
joints; polypi from mucous surfaces; and polypoid or fibroid
growths, from the free surface of the peritoneum, as described by
Dr. Reid and Mr. Hodgkin. In the heart there are conditions which
render the separation of vegetations much more probable than per-
haps the detachment of polypoid growths in other parts of the body.
For, 1st. The vegetations, whether sessile or pediculated, are often
loosely attached, being easily removed, after death, with the handle
of the scalpel. 2d. The valves to which they are adherent are
parts constantly in motion. 3d. Currents of blood are ever rushing
over them with considerable force. When the vegetations are once
separated, they will be carried along, until, meeting at last with a
vessel whose calibre is smaller than their bulk, they become impacted;
or they may become arrested where a larger vessel divides into two
branches, each of which is smaller than the detached vegetation.
In the occluded artery more than one result may follow such impac-
tion. Accumulating coagula may be formed from the blood around
and behind the obstructing mass. The artery may inflame at the
site of its occlusion, and this inflammation may ultimately involve,
as in Case II., the accompanying vein. The vegetations and coagula
thus deposited may at last become disintegrated and pulpy, as
occurred in the first and second instances of the group of cases that
we have now described; and their own detritus, or the inflammatory
exudations formed around them, may pass downwards and obstruct
still smaller arteries beyond; or, if minute enough, may even
traverse the capillary circulation, vitiate the general mass of blood,
and produce, as in Case I., phlegmasia dolens, or other consequences.
And lastly, the arterial pulse may betimes become restored in the
artery below, either from gradual clearance or dilatation of the
obstructed vessel above; or, as perhaps happens more frequently,
from an increase in the collateral circulation.
35
532
THE PUERPERAL STATE.
SECTION II. — ARTERIAL OBSTRUCTION FROM THE ESCAPE OF
RECENT FIBRINOUS OR UNORGANISED COAGULA FROM THE
LEFT CAVITIES OF THE HEART, OR FROM THE LARGER INTO
THE SMALLER ARTERIES.
In the well-known experiment when recently-drawn blood is
actively stirred, or whipped with a rod, the rod forms a mechanical
nucleus around which the fibrine readily and speedily coagulates.
In the same way in the living system, under particular circumstances,
when the blood in the heart or large vessels is carried or whipped
against a fixed rod or a rough body, occasionally such obstructing
points constitute mechanical nuclei upon which coagula form, and
from which they may subsequently separate and be carried forward
with the arterial current till they are ultimately arrested in some
arterial canal too contracted and small to allow them to pass farther.
Accident has sometimes offered us a kind of crucial pathological
experiment upon the living human being demonstrative of the pre-
ceding remark. Thus, in a case shown in 1849 by M. Laugier to
the Anatomical Society of Paris, a needle happened to be thrust
through the apex of the heart into the cavity of the left ventricle.
The needle was found after death, fixed with its long axis running
vertically from the apex of the heart towards the aortic orifice of
the ventricle. • The patient, a young man, to whom this accident
happened, died with gangrene of the left leg. It became an inter-
esting pathological question, what was the relation between the
cardiac injury and the gangrene of the limb? The dissection seemed
to resolve this problem. For the whole length of the needle pro-
jecting into the cavity of the left ventricle was covered with decolor-
ised, irregular concretions, which were prolonged beyond the apex
of the needle into the cavity of the aorta. The lower end of the
aorta and the iliac arteries were filled with adhering sanguineous
concretions; and it occurred, observes Cruveilhier, to all the mem-
bers of the society who saw the preparations, that some of the clots
formed around the foreign body in the left ventricle of the heart had
been projected forward from it into the arterial canals, and become
there the nuclei of new obstructing concretions.'
In the preceding case we have a foreign body, in the interior of
the left ventricle, forming a basis around and upon which unorganised
1 See Cruveithier's Traité D'Anatomic Pathologique Générale, tom. ii. pp.
201, 296, and 388.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
533
sanguineous concretions accumulate; and these concretions, soon
after their formation, becoming detached and projected into the
arterial canals so as to close them, produce gangrene like the
similar arterial plugs resulting from the separation and transference
of old and organised valvular vegetations. But if the interior of
the same ventricle be anywhere mechanically rough and irregular—
not by a foreign body, such as a needle-but by the results of
disease, as from the presence of globular polypi in the cavity, vege-
tations on the valves, or endocarditic inflammation of its lining
membrane-similar unorganised coagula may at times form, in super-
fibrinated or other morbid states of the blood, upon these roughened
and diseased points, and subsequently shut up arterial canals in
different parts by being projected from the heart into the current of
the circulation. Thus, in a case described in 1837 to the French
Academy of Medicine by M. Legroux,'-a lady, aged 29 years,
passed through an attack of acute rheumatism. Three months sub-
sequently to her first attack there was uneasiness in the precordial
region, an irregular pulse, and a loud bellows sound; and these
symptoms were attributed to endocarditis. Antiphlogistic treatment
was employed. At the end of a month she seemed to be getting
well, when all at once violent pains came on in the legs and feet,
with coldness of the extremities. In a fortnight the arterial pul-
sations had completely ceased in the lower limbs. Eight days before
death, the same symptoms were observed in the left arm, and the
pulsations ceased there also. The pains continued to the last; no
gangrene took place. On post-mortem examination the cavities of
the heart were found to contain old and adherent fibrinous clots;
and the lining membrane of the auricles had lost its polish and
transparency. The right subclavian artery, the termination of the
aorta, and the common and external iliac arteries, were completely
obliterated by old and adherent clots. The right iliac artery was
dilated, at the level of the hypogastric, to the volume of a nut, and
contained a fibrinous, cystiform coagulum. Three of the lumbar
arteries were closed by clots, which projected into the aorta like the
heads of nails. As M. Legroux points out:-1st, This disease was
originally rheumatic endocarditis. 2d. In consequence of this
"Cette opinion est fondée sur des faits assez nombreux recueillis par lui (M.
Legroux), et dont il posséde les pieces anatomiques,-faits qui démontrent, dit il,
une coincidence presque constante entre les caillots obturateurs des artères, et des
caillots anciens dans les cavités du cœur.” In the history of the subject this pass-
age is important, as having been published in 1837.
534
THE PUERPERAL STATE.
endocardial inflammation, fibrinous coagula were formed in the
cavities of the heart. 3d. The obliteration of the arteries was com-
menced by the expulsion of these coagula from the heart into the
vessels.' 4th. The arterial obliteration, at first imperfect, was com-
pleted by successive additions of coagulum; for the structure of thy
clots indicated that they had been formed at various times. 5th.
Probably the adherence of the coagula to the walls of the artery
was the result of inflammation, caused by the presence of the clot as
a foreign body, the inner membrane of the artery being only notably
altered at points where the obliteration had existed for some time ;
that of the subclavian, for example, which was recently closed, being
only slightly injected.
In the puerperal state-with the blood, as in rheumatism, over-
charged with fibrine and otherwise anormal-recent coagula seem
sometimes to form on rough points in the interior of the heart, and
subsequently becoming projected into the arterial current, shut up
one or more arterial canals. To produce this result two elements are
perhaps necessary:-1. A chemical tendency in the blood, from
super-fibrination or other causes, to coagulate; and 2. Mechanical
facilities for the formation of coagula from the presence of rough
surfaces or projections. The two following cases of puerperal arterial
obstruction probably belong to this category. In the first of these
cases, a rough globular polypus, such as is sometimes found in the
interior of the heart as a result of phlebitis and endocarditis, seems
to have served as a nucleus for the formation of the sanguineous
coagula or concretions. In the second case, for notes of which I am
indebted to Professor Macfarlane, rough cardiac vegetations, which
did not, however, themselves separate, appear to have acted a
similar office.
CASE VI. The patient, at. 33, was admitted into St. Thomas' Hospital,
August, 2, 1853, under the care of Dr. Risdon Bennett." She had generally enjoyed
good health, but for several weeks before her last confinement, which took place
nine weeks before her admission, she had debility, dyspnoea, and oedema of the legs,
with pain in the left side and occasional palpitations. She had never suffered
from rheumatism. Her labour was difficult, and her recovery after it had been im-
perfect. A fortnight before admission, she had pain across the chest and down
the left arm. A week later there occurred apparent syncope, followed by im-
paired vision and slight cough, with frothy bloody expectoration. When she
entered the hospital she seemed extremely ill, but there was no sufficient cause
discoverable to account for her alarming symptoms.
There was, however,
1 Bulletin de l'Académie de Médecine, 1837, tom. i. p. 434.
2 This interesting case has been published by Dr. Bennett in the Provincial
Medical and Surgical Journal for 1854, p. 143.
FUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
535
tumultuous, feeble, and irregular action of the heart, attended by a variable bruit,
Besides this there was some puffiness of the ankles, and pain and tenderness
generally in the lower extremities. On the 5th, or three days after admission into
the hospital, the left leg appeared much as if affected by phlegmasia dolens. It
was painful, paler than natural, and towards the foot of a lower temperature than
the rest of the body. A day or two after this the opposite limb exhibited similar
symptoms, and then the toes of both fect became shrivelled and parchment-like.
By the 13th of August both limbs were gangrenous, some vesication appeared on
the thighs, and no pulsation could be felt in the femoral arteries, even under
Poupart's ligament. On the 3d of September she became typhoid and died on the
6th. At the autopsy no vegetations were found on the cardiac valves, but under
the attached fold of the mitral valve, a thinning of the walls of the left ventricle
existed, and a notable bulging of the cavity like a commencing, "diffuse true
aneurism." This cavity did not contain coagula, but at the apex of the ventricle
was a partially adherent globular cyst or polypus, and another very similar was
found in the right ventricle. These polypi were softened in the centre, and filled
with pus-like matter. The aorta was empty as far as the origin of the superior
mesenteric artery. From this point downwards it was filled with a clot in different
stages of change. Just at the bifurcation of the aorta the clot seemed to be very
firm, and adhered with more tenacity on the left than on the right side, where the
artery continued patent for some distance lower. The iliac arteries, common,
external, and partially internal, were blocked up, as was also the femoral, for two
inches below the groin. The clot adhered pretty firmly to the arterial walls, but
when peeled off, the internal coat was not roughened. The clot had begun to
soften in different parts, more especially along the aorta itself, and the products
under the microscope were precisely similar to the one presented by the globular
cysts or clots in the heart. All the arteries which were given off from the aorta
between the superior mesenteric and deep femoral were blocked up for a short
distance. Each of the femoral veins at the groin contained a short recent clot.
The crural nerves were implicated in the surrounding inflammatory changes and
thickening. In both kidneys there were fibrinous or purulent deposits. All the
other organs examined were healthy.
CASE VII.-A lady, aged about 38, had, after an attack of rheumatic fever
seven or eight years previously, become subject to cough and dyspnoea. Three or
four years after, when Dr. Macfarlane was first consulted, the physical signs of
endocarditis, and of disease of the aortic valves, were well marked. She became
pregnant for the first time in 1841, and was delivered with the forceps after about
thirty hours' severe labour. Six hours before delivery was effected, she complained
of violent pain in the right arm, which gradually increased, and almost appeared
to exceed in intensity the parturient action. As she could only lie on the right
side, and was obliged to do so during the whole labour, little attention was paid
for some time to this symptom, under the belief that it was the effect of position
and pressure.
The persistent severity of the pain, however, and the distress it
appeared to occasion, ultimately led to the arm being examined, when it was
found that the pulse had ceased at the wrist, and that no arterial pulsation could
be detected below the axillary end of the subclavian. The pain, especially on each
side of the elbow, at the wrist and in the fingers, was violent and incessant, and
continued for six weeks, alleviated only from time to time by opiates, anodyne
frictions, and heat. The pulsations never returned to the main vessels, but the
heat of the limb was soon restored, and the shrivelled and exsanguine appearance
of the points of the fingers and nails, at first so marked after the obstruction took
536
THE PUERPERAL STATE.
*
place, gave way to a more natural appearance as the collateral circulation became
established. She died of general dropsy three months after delivery. Dr. Mac-
farlane could only obtain permission, and that after much importunity, to
examine the state of the subclavian artery at the point of its obliteration. It
was found completely plugged up between the clavicle and axilla by a firm
fibrinous clot, consisting of several layers, and hence of successive growths, but
it did not contain any roundish or hard portion, or any appearance whatever of
an excrescence or vegetation separated from the valves of the heart.
I am not aware of any direct observations, either in the puer-
peral or non-puerperal states, showing that sanguineous concretions
or coagula may occasionally form around rough and diseased points
existing in the walls of the larger arteries of the body, and be
thence separated and carried onwards into smaller arteries, so as to
obstruct and occlude the latter. Such specimens, however, are not
rare in our pathological museums. The Museum of the University
of Edinburgh contains, for example, a specimen of this kind, unfor-
tunately without a history. There are rough, ulcerated atheroma-
tous spots on the interior of the aorta, with coagula adhering to their
edges, and the tube of the iliac artery below is completely shut up
with a mass of sanguineous coagula. In a case of gangrene of the
leg, published and delineated by Sir Robert Carswell,' the artery of
the affected limb is occluded with fibrinous concretions, and the
interior of the aorta above is full of coagula, formed around athero-
matous obstructions in the walls of the vessel, and all pointing down-
wards in the direction of the circulation.
Before leaving these two first sections, or forms of arterial
obstruction, it is, perhaps, proper to observe, that the exact position
and site of obstructions in the arterial tree, produced by detached
cardiac vegetations, and fibrinous clots, appear to be regulated by
various circumstances, some of which seem recognisable. 1st.
Where the morbid mass which leaves the heart is very large, or has
a large coagulum gathered around it, it sometimes proves of too
great a size to pass at all out of the aorta, and is then usually
carried down and lodged in the lowest part of that vessel, or imme-
diately above its bifurcation. 2d. When of less size, and capable
of entering arterial canals of the second, third, or still smaller
dimensions, the course and ultimate site of the vegetation or coagu-
lum is perhaps principally determined by the directness of the arte-
rial current into particular arterial tubes, and by the angles at which
these vessels leave their larger trunks. Thus, small solid masses
floating in the blood are more liable to be carried upward, according
¹ See his Pathological Anatomy. Article "Mortification." Plate iii, fig. 2.
•
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
537
to Ruhle, into the left than into the right carotid, because the stream
of blood, running from the heart and aorta, pours more directly into
the former than into the latter vessel; and Virchow attributes the
greater frequency of their presence in the left lower limb than in the
right to a similar cause-the left iliac artery leaving the abdominal
aorta at a less angle than the right. 3dly. The mode in which an
artery divides may regulate their seat. Cardiac vegetations have
now been very often found lodged at the mouth or in the course of
the middle cerebral artery. This, according to Dr. Kirkes, is owing
to the fact, that, after the division of the internal carotid into its
two main branches within the skull-viz. the middle and anterior
cerebral-the middle cerebral not only remains the larger vessel of
the two, and hence is more capable of receiving any floating body;
but further, it maintains also far more nearly than the anterior
cerebral, the original direction of the trunk from which they both
spring, and hence is more likely to have sent forward, into its canal,
any solid body floating in the current of blood that passes upward
through the carotid.
In all the preceding remarks, I have only spoken of organised
vegetations and unorganised fibrinous masses passing from the heart
into the arteries, of such a size as to obstruct and occlude vessels of
considerable dimensions. But vegetations and coagula of a far
smaller size are ejected from the heart perhaps still more frequently,
and ultimately obstruct and collect in some of the minuter arteries
and capillary vessels. The more or less decolorised, angular, lobu-
lated deposits, frequently seen in the spleen, kidney, liver, etc., some-
times, if not always, originate in this manner, and primarily consist
of cardiac concretions and fibrine, or occasionally of pus and fibrine,
carried into and lodged, first, in the smaller arteries and capillaries
of these parts, and subsequently accumulated in the vessels and
tissues behind and around these obstructions. In other words, these
instances of so-called "capillary phlebitis," or of yellowish "fibrin-
ous deposits" in the organs named, and in other parts distant from
the heart, appear to consist usually and primarily of solid particles
of fibrine carried from the interior of the heart or larger vessels, and
lodged and accumulated in the capillaries and smaller arteries at the
sites of the deposits. Out of twenty-one instances, in which Dr.
Kirkes observed these yellow or white masses in the spleen, kidneys,
and other parts supplied by blood directly from the left side of the
heart, he found in nineteen of the cases disease of the valves or of
the interior of the heart (in fourteen there were fibrinous endocar-
538
THE PUERPERAL STATE.
4
1
dial growths); in the twentieth, the aorta was the seat of aneurism,
with laminæ of fibrine lining it; and the twenty-first, or only excep-
tional case, was one of cholera, where a doubtful mass of capillary
phlebitis existed in the liver. In describing the secondary pheno-
mena liable to be produced by endocarditis, Professor Hasse observes,
"A considerable portion of the effused substances being carried away
in the first instance by the circulation, and another portion during
the period of softening, it is obvious that these inflammatory pro-
ducts must, just as in phlebitis, act a subordinate part within the
capillary system. The spleen and kidneys appear particularly liable
to such changes. In the spleen coagulated fibrine is found of some
breadth at the periphery, but gradually tapering towards the centre,
having mostly a tolerably sharp outline, and a brownish-yellow hue.
Smaller deposits of a similar kind are met with in the cortical sub-
stance of the kidney; sometimes even intersecting the papillæ.
According," he adds, "as the inflammatory product of the endocar-
dium partakes more of the character of fibrine or of pus, the secondary
deposit will be of a more or less consistent kind, and shrivel in the
event of recovery, or else liquefy and terminate in abscess. Though
frequent in the localities above indicated, these secondary pheno-
mena are proportionately rare, as in the liver; sometimes, however,
they occur in the serous cavities." 2
SECTION III-ARTERIAL OBSTRUCTION FROM LOCAL ARTERITIS.
In the two classes of arterial occlusion which I have already
described, there were generally found thickening, condensation, and
other evidences of inflammation in the walls of the artery at the ob-
structed points. But in these instances, the arterial inflammation
was secondary, and not primary. It was the result of the irritation
and impaction of a plug, carried from a distance and fixed in an
arterial tube, which became first obstructed, and then inflamed, by
its presence. But we come now to speak of another division of
arterial obstructions, in which the arterial occlusion is the result, and
not the origin, of arterial inflammation; its cause, and not its con-
sequence.
Without entering into the debated question of whether or not a
part possessing no vasa vasorum, like the lining membrane of arteries,
can be itself the seat of inflammatory exudations, and whether or
¹ Medico-Chirurgical Transactions, vol. xxxv. pp. 307-309.
2 Hasse on Diseases of the Organs of Circulation, etc. Swaine's Translation,
p. 133. See also p. 61, on similar deposits after aortitis, etc.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
539
not, in all cases of arteritis, the exudations thrown out are not
secreted from the vessels of the more external arterial coats, and
particularly of the cellular, it is enough for our present purpose to
grant, what pathologists all allow, that local arteritis in general
speedily ends in, if it does begin with, the formation of an obstruct-
ing fibrinous or sanguineous concretion in the tube of the inflamed
artery.
The following well-marked case of puerperal arteritis, and
arterial obstruction, terminating in gangrene, occurred to Dr. James
Duncan, when acting as surgeon to the Royal Infirmary. I am
indebted to him for the following notes of it. The preparation of
the obstructed aorta and iliacs, in this case, is contained in Mr.
Spence's surgical museum.
CASE VIII.-A patient from the neighbourhood of Dalkeith was delivered of
her first child after a protracted labour. Two weeks afterwards she was brought
into the Edinburgh Infirmary, suffering under pain and acute gangrene of both
the lower extremities. The gangrene came on rapidly, with vesication, and as-
cended before death as high as the thighs. The patient sank three or four days
after she was placed in the hospital. On dissection no disease was found in the
heart, its walls, valves, or cavities. But beginning about an inch and a half above
the bifurcation of the aorta was found a fibrinous plug, which completely occluded
the artery, and extended along the common iliacs, and, as far as one or two inches.
down the external iliac arteries on each side, a prolongation of the plug shut up
also the canal of the internal iliac artery on the left side, while on the right side,
the opening of the internal iliac was occluded by the obstructing mass occupying
the common iliac artery. The upper end of the plug in the aorta was flattened,
and some lymphy filaments passed from the arterial parietes to be attached to this
superior extremity. In the aorta the mass was firmly adherent to the coats of the
vessel, which coats were thickened; and apparently, at the most inflamed point,
the calibre of the tube was contracted. The adhesion of the obstructing concre
tions to the inner coat was less along the left iliac artery; the plug in the right
iliac artery was not adherent at all to the coats, but presented a loose cast of the
arterial canal. The inferior extremities of the plugs, in each external iliac artery,
did not terminate abruptly, but were continued as a lymphy layer, like a false
membrane, over the inner arterial coat, on the right side, for an inch downwards,
and on the left for an inch and a half. The femoral and other arteries below were
quite healthy, and the veins of the limbs presented no special morbid appear-
ances.
In relation to the preceding case of local arteritis, it is difficult
to assign any reasonable cause for the occurrence of the obstructive
inflammation. It has been suggested to me that the inflammatory
action might have been produced by great pressure upon the vessel
from the enlarged pregnant or puerperal uterus. But then arteries
do not readily inflame and become obstructed under mere external
pressure; and in every puerperal case there is a greater or less
540
THE PUERPERAL STATE.
amount of this pressure on the aorta without inflammation and
obstruction following.
Perhaps some of the arterial obstructions which I have pre-
viously described in the cases detailed under the two first sections,
particularly in Section II., may be considered by some pathologists
as referable rather to the effects of local arteritis than of plugs of
organised or inorganised fibrine carried into the arterial tube from a
distance. It is only by watching more carefully the suddenness or
slowness of the arterial obstruction as it occurs during life, and by
observing and analysing far more carefully than has been hitherto
done in our autopsies, the structure of the existing plug and the
exact condition of the arterial wall at the point of obstruction, that
such a question can be definitely settled.
SECTION IV.-ARTERIAL OBSTRUCTION FROM SPONTANEOUS LACE-
RATION AND CORRUGATION OF THE INTERNAL COAT OF THE
ARTERY.
When the internal coat of an artery is divided artificially, as in
the forced elongation of arteries under accident-or when it ruptures,
as it sometimes does, spontaneously, the divided ends of the lacerated
tunic or tunics--for the middle coat may also give way-coil and
curl up so as to occlude at once, more or less completely, the arterial
canal. The friability and softening leading to spontaneous rupture.
of the lining membrane is evidently the result of a previous state of
disease, in all likelihood of an inflammatory character; and so far,
the present group is possibly more truly referable to the last, or to
those that are indirectly, if not directly, the consequence of
Arteritis.
The first case in which the sudden arrestment of pulsation in an
artery during life was traced, by dissection after death, to obstruction
of the arterial tube from the spontaneous rupture of its internal coat,
was published by Professor John Thomson in Dr. Hodgson's excellent
work on Diseases of the Arteries, in 1815. Some years subsequently
--1829-Professor Turner read a masterly essay on the same subject
to the Medico-Chirurgical Society of Edinburgh. He cites ten cases
of arterial occlusion.
1
In one of these ten cases the arterial obstruction occurred in a
puerperal patient, but unfortunately there was no post-mortem ex-
amination instituted to show whether the arrestment of the arterial
¹ See Transactions of the Edinburgh Medico-Chirurgical Society, vol. iii. p. 105.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
541
pulsation was or was not the result of spontaneous rupture and cor-
rugation of the lining membrane of the occluded artery. The case
is quoted by Mr. Turner from Dr. Parry of Bath, who details it in
his work on the Arterial Pulse,' in the following words :-
CASE IX. “I have seen the total loss of pulse in one arm, with coldness,
but complete power of motion in that part; while the other arm was warm, and
possessed a perfectly good pulse, but had lost all power of voluntary motion.
These symptoms commenced suddenly, two or three days after parturition. The
patient soon died, but a dissection was not obtained."
In 1842, Dr. Oke of Southampton published 2 a case of sudden
arterial obstruction occurring in the humeral artery after abortion,
which he deemed referable to this "spontaneous rupture of the
inner coat of the vessel, and the projection of its edges into the
tube."
CASE X.-In the autumn of 1831, a patient, æt. 24, during the tenth week of
pregnancy had hemorrhage from the uterus. On the following day it was more
profuse, and terminated in abortion. The day after delivery she was seized with
severe headache, giddiness, dimness of vision, and vomiting. So great was the
interruption to the vision, that she could not distinguish the hands of a common
clock. The fingers of the left hand felt as though scorched, and were extremely
painful. On the following day the dimness of vision continued, and there was
intense pain and numbness in the left arm, which at length became cold and
insensible to external impression. The wrist and the tips of the fingers were
discoloured, especially the tip of the ring finger, which was turning black.
On examination no pulsation could be felt in any of the arteries of the arm
above the affected hand, but the subclavian was distinctly felt pulsating above the
clavicle. There was no perceptible disturbance of the action of the heart, and no
embarrassment of the respiration. This patient eventually recovered, with the
loss only, by gangrene, of the integument of the thumb and fingers of the left
hand. In three days the power of vision was restored. The pulsation, however,
never returned in the obliterated arteries of the left arm, but the arm itself
gradually regained its sensibility and ordinary plumpness.
As proof that in this instance the obstruction originated in the
affected vessel, and not in any morbid state or lesion of the heart,
Dr. Oke, in a letter to me, dated November 30, 1853, observes-
"No abnormal action of the heart or its valves could be detected
when the obstruction in the left axillary artery took place, nor during
my observation of the case subsequently. To make the answer (to
your inquiry on this point) more complete, I lately, along with Dr.
Lake, made a careful examination of the region of the heart of this
patient, who is still living. After listening attentively to its action
1 Experimental Enquiry into the Nature, etc., of the Arterial Pulsc, p. 139.
2 Provincial Medical and Surgical Journal for April 23, 1842, p. 51.
542
THE PUERPERAL STATE.
at different points, we could not detect any sound that would indicate
a vegetated or morbid condition of the valves, nor indeed any other
abnormal sound of the organ."
SECTION V.-OBSTRUCTION OF THE PULMONARY ARTERY AND
ITS BRANCHES, BY MORBID MATERIALS COMING FROM THE
SYSTEMIC VENOUS CIRCULATION, AND PASSING THROUGH THE
RIGHT SIDE OF THE HEART.
Hitherto I have spoken only of the puerperal obstruction of
arteries belonging to the general or systemic circulation, and
produced either by local diseases and lesions in the arteries
themselves, or by morbid masses projected into them from the
centre to the circumference of the arterial circulation, from the
trunk to the branches of the arterial tree, from the cavities of the
heart or larger arteries into the canals of the smaller arteries.
But we have now to consider an interesting group of puerperal
cases of different character, and in which the pulmonary arteries
or their branches become blocked up by morbid materials carried
forward into them from some part or parts of the systemic veins.
In this case the morbid materials, in being carried onward from
the points at which they are originally formed in the systemic
venous system, to the points in which they become ultimately
arrested and lodged in the pulmonary arterial system, necessarily
traverse the right auricle and right ventricle of the heart. In
the puerperal female two or three different kinds of morbific matter
appear thus occasionally to pass from the venous system, and
become lodged and accumulated in the divisions of the pulmonary
artery—namely, pus, or some of the materials associated with pus,
separately or serving as a nucleus for coagulated blood or fibrine;
more solid nuclei formed by loosened and detached fragments of
those fibrinous concretions that so often fill and obstruct the
systemic venous canals of the pelvis, uterus, legs, etc., in puerperal
phlebitis; or equally solid portions of fibrine or coagulable lymph,
not the result of inflammatory secretion, but made up possibly of
the natural plugs by which nature normally shuts up the open orifices
and canals of the uterine veins after delivery.
Metastatic lobular pneumonia, originating apparently from the
transference and lodgment of pus in the smaller pulmonary vessels
and capillaries, is a complication occasionally met with in the
phlebitic form of puerperal fever. In the disease, as witnessed by
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
543
him at Prague, Dr. Kiwisch tells us that in most cases where the
metastatic pneumonia was violent, he found "the pulmonary arteries
of the diseased lobe usually inflamed as far as their point of exit
from the pulmonary tissue, and filled with adherent lymph and
pus." Perhaps more minute inquiry may yet prove that such
obstructions of the pulmonary arteries are by no means uncommon
in the pulmonary inflammations, deposits, and abscesses, which occur
in connection with surgical and obstetrical phlebitis.
"1
In the two following cases, described, and one of them delineated
above twenty years ago by Professor Cruveilhier in his large work
on Morbid Anatomy, the pulmonary arteries and their branches had
pus and fibrine lodged in their canals, as a consequence of puerperal
phlebitis.2
CASE XI.-A women, recently delivered, was seized, on the 12th of July 1830,
with all the symptoms of uterine phlebitis, which were combated successfully by
leeches to the epigastrium and emollient injections. From the 25th July to the
3d of August she appeared quite convalescent, and suckled her infant without in-
convenience. An invasion of new symptoms, however, took place at the latter
date—namely, oppression, cough, anxiety, nervousness, and extreme frequence of
the pulse. She died on the 9th of August, twenty-eight days after delivery. On
post-mortem inspection, the uterus was found little above its ordinary size, but
the uterine, ovarian, and almost all the hypogastric veins, were like hard cords.
They owed this hardness to compact clots filling them, which were adherent and
decolorised. The external iliac veins, with the left crural vein and some of its
divisions, contained clots less compact and adherent, and evidently of a recent
date. At the base of the left lung were found several portions of lobular pneu-
monia, in the state of red induration, and two superficial purulent patches. There
was also œdema of both lungs in the posterior half of the two inferior lobes. Some
hard concretions filled the divisions of the pulmonary artery. The lesser branches
were filled with red and scarcely adherent clots, while the concretions in the
principal trunk were coherent and decolorised. In the centre of the principal clot
or plug was a collection of pus, which offered all the characters of phlegmonous
matter; farther on the clot or plug was decolorised, and formed a complete
cylinder. In this case uterine phlebitis occurred from the 12th to the 25th of July;
and from the 25th July to the 3d of August the patient seemed to be recovering,
when suddenly, at the latter date, symptoms of pulmonary mischief supervened,
under which she sank in six days.
CASE XII. In a woman, who died of puerperal phlebitis two weeks after
delivery, and who presented typhoid symptoms during the later days of life, the
primitive iliac vein and its divisions were found filled with adherent sanguineous
concretions, some of older, others of more recent formation. These concretions
were pale in the principal trunks, and contained pus in their centre; they were red,
and gradually less and less coherent in the smaller divisions of the vessels. The
lower extremities only presented a very slight œdema. The liver was of a yellowish
colour, and softened. The uterus was equally soft, but without any other morbid
1 Die Krankheiten der Wöchnerinnen, etc., 1840, p. 116.
2 Anatomic Pathologique, livrais. ii. tab. 1 and 2, pp. 18 and 21.
544
THE PUERPERAL STATE.
alteration. There were marks of true recent pleurisy on the posterior border of
the right lung, with a combination of ordinary or diffuse and lobular pneumonia
on the same side. The tissue of the lung, when divided, presented sections of
vessels full of fibrinous concretions. These obstructed canals or vessels were, on
further examination, found to be the divisions of the right pulmonary artery.
The concretions in the arteries were pale and full of pus at their centre, but as
they divided and subdivided with the course of the arteries, they became red and
hardly coherent. The concretions in the smaller pulmonary vessels only existed
in the neighbourhood of the parts of the lung affected with lobular pneumonia.
In the portion of lung attacked with ordinary inflammation, the tissue of the
organ was infiltrated with pus, and in the state known under the name of grey
hepatisation. The circumscribed patches of lobular pneumonia presented great
differences in respect to volume, and the attendant degree of inflammation. In
one place there was red induration; in another place marbled patches of white
and red; in a third pus, infiltrated on the tissue, or diffused in irregular patches.
A case of puerperal obstruction of the pulmonary arteries, very
similar to the two detailed by M. Cruveilhier, has been published
by Professor Levy of Copenhagen.' There were symptoms during
life and evidence after death of uterine phlebitis, though not in a
severe form; and the patient died apparently of two consecutive
attacks of lodgment of morbid materials in the pulmonary arteries.
CASE XIII. The 19th of February 1853, a primipara was easily confined, and
seemed well, with the exception of a catarrhal cough. On the 20th there was
pain over the uterus, but it disappeared after the application of leeches. On the
22d it returned with fever and tympanites. On the 24th there was less sensibility,
and the fever had diminished. In the evening, however, she had an attack of
violent dyspnea, with painful constriction of the epigastrium, anxiety, dry cough,
and a quick pulse. Auscultation discovered nothing but a moist rhonchus, and
the symptoms disappeared after bleeding. Convalescence went on favourably
until the 3d of March, when, after supper, sudden and acute pain came on in the
epigastrium, with oppression, the respiration became anxious and laborious, and
death supervened at the end of a few minutes. On dissection Dr. Levy found
the two cavities of the right side of the heart and the pulmonary artery, even to
its small divisions, filled with a quantity of blood-clots of different sizes, some
freshly formed, others older and more consistent, of a greyish red, more or less dis-
coloured; while others, again, contained a greyish mass, faintly grained, and of
a purulent appearance. The walls of the pulmonary artery were slightly tinged.
There was nothing in the left side of the heart, but the aorta had four regular
insufficient valves. The veins of the uterus contained concrete pus, more
especially towards the broad ligaments.
An instance in which puerperal obstruction of the pulmonary
artery suddenly supervened during, convalescence from phlegmasia
dolens, and where, consequently, as in the preceding examples, the
pulmonary disease was connected with, and dependent upon, pre-
vious phlebitis in the systemic venous system, was published at
1 See it quoted from the Deutsche Klinik into l'Union Médicale, Dec. 27, 1855.
!
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
545
Berlin, several years ago, by Dr. Hoogeiveg, in the Preussische
Vereinzeitung for 1852, p. 52.
CASE XIV. A young woman, three days after delivery of her first child, was
attacked with phlebitis of the left extremity which yielded to appropriate treat-
ment. But, during convalescence, she suddenly uttered a scream, fell down, and
expired. On post-mortem inspection the left crural vein and its branches were
found obstructed with phlebitic coagula, which extended upwards to the junction
of the crural and iliac veins. The pulmonary artery was filled with similar
coagula. These coagula could be traced into some of the smaller ramifications of
the pulmonary artery.
In the following instances of puerperal phlebitis, published in
the Deutsche Klinik, by Dr. Hecker of Berlin, symptoms of pulmo-
nary distress and death suddenly came on-in one case during con-
valescence from, in the other during the course of, the phlebitic
disease; in both women obstruction of the pulmonary artery or its
branches by fibrinous or sanguineous plugs was discovered on dissec-
tion; and in both, the description, as given by Dr. Hecker, of the
upper ends of the concretions found in the inflamed veins, is such
as to show that a portion of it was loose in the tube of the vein,
and hence easily capable of being detached and carried forward
towards the right side of the heart by the current of the circulation.
Virchow has found the upper and floating portions of some of these
venous plugs so loose that they were separated by succussion of the
dead body. Hence we need not feel surprised at sudden alterations
in the positions of the patient, or sudden muscular exertions appa-
rently detaching portions of them, as in the following instances.
CASE XV.-A primipara, æt. 31, on the third day after a natural labour, was
seized with phlebitis of the left crural vein, followed by cedema of the limb. She
so far recovered, however, as to be able to leave her bed on the 20th day, but
complained of feebleness and numbness of the foot. On the 29th day, in remov-
ing some article from the stove, she suddenly sank down; and although the
intellect was clear, there was great anxiety, pallor of the face, pinched nose, gasp-
ing, very frequent respiration, a small, depressed pulse, and cold extremities.
Notwithstanding all the efforts made to rally her, she sank and died at the end of
three quarters of an hour. At the autopsy Dr. Hecker found the left crural vein
entirely closed by fibrinous clots, which extended along the common iliac vein to
the vena cava. A portion of clot an inch to an inch and a half long projecting
into the cava was quite free, and terminated by a conical point. The hypogastric
vein was equally plugged on this side. On further examination, the two primary
branches of the pulmonary artery were found filled with fibrinous coagula, which
reached to their final ramifications. These clots in the pulmonary arteries were
nowhere adherent to the walls of the vessel, but had the same appearance as those
in the crural vein. There were no morbid appearances traceable in the heart or
head.
546
THE PUERPERAL STATE.
CASE XVI.—A robust woman, aged 30 years, after an easy delivery (on the
1st of October), suffered from severe hemorrhage in consequence of an adherent
placenta, which had to be extracted. Her state was satisfactory till thirty-six
hours after her accouchement, when she took a rigor, which was prolonged to the
morning of the 3d of October, and was succeeded by febrile heat. The uterus was
very tender to pressure; the skin hot and dry; the pulse 120; and there was
anxiety, feebleness, and violent headache. During the next three days the
symptoms became graver, and the pulse rose to 136 or 140. An uterine lymph-
atitis was considered as probable. On the 6th of October she seemed better, but
the great frequency of the pulse still produced serious fears. On the 8th, she
reported herself as having passed a good night and felt well. After noon, how-
ever, notwithstanding a warning to the contrary, she got up, but immediately fell
to the ground, and rose with great difficulty. At the end of an hour and a half
she was found sitting at the edge of her bed, and at 4 o'clock seemed dying. Her
pulse was thread-like, and difficult to count; her respiration very frequent, 60 to
64 a minute; the face was cold, blue, and bore the appearance of extreme
anxiety; her extremities were cold. In a short time she became insensible, and
died at half-past ten in the evening. On dissection, small portions of the pla-
centa, according to Dr. Hecker, were found still adherent to the anterior wall of
the uterus. In its walls, the lymphatics were filled with pus, and the veins with
fibrinous coagula. The left hypogastric veins were obstructed with clots, which
extended to some distance into the tubes of the common iliac veins. The heart
was normal, but the trunk of the pulmonary artery was plugged by a thrombus
or coagulum, extending into its two branches, and capable of being followed far
into their ramifications.
In all the preceding instances of obstruction of the pulmonary
artery, that obstruction occurred in connection with, and as a
sequence of the existence of phlebitis and phlebitic concretions in
the uterine, pelvic, or other systemic veins. But sometimes obstruc-
tion and occlusion of the pulmonary artery or its branches takes
place in the puerperal state, independently of any antecedent venous
inflammation in the body. The researches of Mr. Paget, Baron,
Dubini, Richelot, and other pathologists, have now accumulated a
number of instances in which, in the male and in the non-puerperal
female, death has occurred in connection with, if not as a conse-
quence of, sanguineous and fibrinous concretions in the pulmonary
arterial system, and when there was no evidence of phlebitis being
anywhere present. In two most interesting essays on "Obstruction
of the Pulmonary Arteries," published by Mr. Paget in the Medico-
Chirurgical Transactions,¹ this distinguished pathologist has reported
a variety of such cases-none of them in the puerperal female-and
has endeavoured to trace the cause of the plugging of the pulmo-
nary arteries, and the formation of coagula in them, sometimes to
impediments in front to the pulmonary circulation, as from disease
¹ London Medico-Chirurgical Transactions, vol. xxvii. p. 162, and vol. xxviii.
p. 352
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
547
*
either in the lungs themselves or in the left side of the heart;
sometimes to coagulation of the slowly moving blood in patients
`whose hearts and systems were nearly exhausted towards the close
of life; in other instances, he inclines to refer the obstruction to
inflammation and disease of the pulmonary artery itself; and, lastly,
in others again he suggests that the coagulation of blood in the pul-
monary vessels may be owing to a morbid state or states affecting
the constitution of the blood itself, so as to "increase that adhesion
of it to the walls of the vessels which constitutes, even in the
healthy state, the greatest resistance which the heart's power has
to overcome.'
Out of seventeen cases collected by Mr. Paget of obstructing
concretions found in the pulmonary arteries after death, in seven
death occurred suddenly and unexpectedly. As I have already
stated, none of the instances referred to in Mr. Paget's essays
occurred in puerperal females. Out of the six cases which I have
already given of plugging of the pulmonary arteries in the puerperal
state, in four death occurred with fearful suddenness and rapidity.
In all these instances uterine or crural phlebitis preceded the pul-
monary obstruction. In the two following cases death struck down
the patients with the same appalling abruptness; in both there was
found, on dissection, the same fatal obstruction of the pulmonary
vessels; but in neither of them was there any decided evidence of
previous phlebitis, certainly none in the first of the two cases.
Could the concretions in the pulmonary vessels be the results-as I
have ventured to suggest at the commencement of the present
section-of the detachment and transfer by the circulation of one or
more of the plugs normally formed in natural labour in the open
orifices of the uterine veins after the separation of the placenta, and
acting as nuclei for further coagulation when lodged in the pulmonary
arteries;—or were these sanguineous concretions a local coagulation
of blood produced by the morbid qualities of the blood itself—
and similar perhaps in kind to the obstructing coagula which we
sometimes find rapidly formed in the tubes of varicose veins? Let
me add that I am indebted to Mr. Paget for directing my attention
to the two following interesting cases, and I owe to his kindness the
notes which I possess of the second of them. Mr. Paget had an
opportunity of examining the recent morbid appearances in both
of these instances, and I have his authority-the greatest I could
quote on such a question-for stating that he believed the immediate
cause of death in both patients was the mechanical obstruction of
36
548
THE PUERPERAL STATE.
the pulmonary arteries, and that in both instances the concretions in
the pulmonary arteries had, as appeared from their anatomical
structure, been formed before death.
CASE XVII. The patient,' a lady æt. 34, was confined of her second child on
the 18th of August 1851. Her labour was easy and natural, and she made a toler-
ably good recovery up to the 30th; by this time moving about and apparently in
good health and spirits. On that day, however, while dressing, she fell on the
bed; the nurse observed frothiness at the mouth, and slight convulsion of the
face. She spoke feebly once, then laid herself back and died; the whole circum-
stances occupying but a few seconds.
At the post-mortem examination, the muscular structure of the heart was found
pale and thin, especially that of the right ventricle, which contained some dark
blood. Each of the pulmonary arteries contained a clot of blood, nearly filling the
calibre of the vessels. The chief clots were about an inch and a quarter in length,
mottled and firm, and in some instances slightly adherent to the side of the vessel.
In tracing the divisions of the pulmonary artery, numerous other clots were found
of the same character as the larger ones, and they extended even into the smaller
ramifications of the vessels.
The following analogous case occurred in the practice of Mr. J.
H. Hewer, and I give the account of it in that gentleman's own
words.
CASE XVIII.—Mrs.
was safely confined of her third child on July 4,
1853, and continued remarkably well until eight days after that time. On the
afternoon of the eighth day, at two o'clock, she was seen by her medical attend-
ant, who found her very well, and in excellent spirits. A little before 5 o'clock
she complained of a slight pain in one of her hips, which she attributed to having
remained rather long in one position. She obtained relief from sitting up, and
then used some little exertion in passing urine. As she was returning to the re-
cumbent posture, the nurse observed her face become suddenly pale, and she
turned her head round with a most painful expression of countenance, and said,
“O nurse, I am dying!" The nearest medical man was summoned, who arrived
in ten minutes after the first signs of danger. He found her pulseless, very pale,
and breathing with difficulty. She was quite sensible, and in this state she re-
mained to the time of her death, which took place in about 35 minutes from
the commencement of the attack.
She had always enjoyed excellent health, with the exception of
slight derangements of digestion, which were referred to a sluggish
liver; she was rather stout, and a very hearty person.
In the examination, 24 hours after death, nothing unusual was
observed about the exterior of the body. All the internal organs
were healthy, except that the liver was rather large, and a few small
gall-stones were present in the gall-bladder. The heart appeared
healthy, although its muscular tissue was thought rather pale. The
¹ This case has already been published by Mr. Havers, in the Medical Times
and Gazette for February 1852, p. 161.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
549
pulmonary arteries were distended with firm, hard, cylindrical
coagula. No other vessels contained clots. The vena cava inferior
was empty and collapsed. The pulmonary arteries were healthy in
structure; their coats smooth and without earthy deposit. The
clots in them were firm, laminated like those in an aneurismal sac,
but not closely adherent to their walls. The external layers ap-
peared most firm; the interior being darker, softer, and apparently
of a more recent date.
It was ascertained, after the examination, that before the patient's
confinement, her left thigh and leg had been greatly swollen. This
swelling had gradually subsided after her delivery, and at death there
was no apparent difference of size in her lower extremities.
The occasional occurrence of sudden and unexpected death in
the puerperal mother is a subject which has engaged the attention
and pen of various obstetrical pathologists, as Drs. Denman,
Chevalier, M'Clintock, Robert, and others. Different causes lead
to it in different cases. Sometimes it is apparently the result of the
entrance of air into the circulating system through the open orifices
of the uterine sinuses, as in the cases described at p. 503, and
in instances reported by Bessems, Wintrich, Berry, etc. I have
seen one case where hepatic abscess ruptured into the peritoneum
by the efforts of labour, and speedily destroyed the patient; and
another where abdominal bleeding from peritoneal fissures on the
uterus rapidly led to the same result. Diseased heart, especially
disease of the mitral valve, with ventricular dilatation, sometimes
seems to produce sudden death after delivery, especially upon moving;
and simple "shock," "syncope," and "idiopathic asphyxia," have
all been severally brought forward as possible or probable explana-
tions of this appalling occurrence. All such cases and causes, how-
ever, evidently require to be reinvestigated, with a view of ascer-
taining whether the more palpable condition illustrated by the
preceding instances, is not in truth the origin of many examples
of this frightful complication-viz, obstruction of the pulmonary
artery, or its larger branches.
It requires, however, to be noted, that obstruction of the pul-
monary arteries sometimes proceeds to a very great extent, without
producing any necessary tendency to sudden dissolution, particularly
if the obstructing concretions have gradually accumulated, and only
successively invaded one division of the pulmonary vessels after
another, as in Cases XI. XII. etc. Under these circumstances there
550
THE PUERPERAL STATE.
may be set up, as Mr. Paget has shown, a mutual adjustment between
the decreased quantity but increased velocity of the blood sent
through the partially occluded pulmonary circulation, and the
diminished volume and rate of the circulating fluid in the systemic
circulation. Every new amount of occlusion, however, adds to the
danger of the patient; and when at last the obstruction has become
very extensive, death in some cases supervenes suddenly, under
muscular exertion or movement, but less perhaps from true asphyxia
than from true anæmia of the left side of the heart and brain, or
want of blood in the systemic circulation; while in other instances,
dissolution very early and rapidly ensues from the obstruction in the
pulmonary artery or its larger branches being at once so great as to
produce complete and fatal arrest to the flow of blood through the
pulmonary artery or its larger subdivisions, a result which is pro-
bably also sometimes produced by large obstructing coagula forming
in and filling up the right cavities of the heart itself.
In 1849, Dr. Meigs published, in the March number of the
Philadelphia Medical Examiner, an ingenious and suggestive paper on
sudden death, after delivery, from "heart-clot." In this communi-
cation, Dr. Meigs argues that white fibrinous coagula of blood or
polypi are occasionally apt to form in the right auricle and ventricle,
in consequence merely of great hemorrhages, attended or complicated
with syncope (states, both of which predispose to sanguineous coa-
gulation), and that these coagula or polypi may afterwards augment
in size around an original small nucleus, and at last fatally obstruct
the flow of blood through the pulmonic side of the heart. He only
gives full details of one case, and in it the coagulated fibrine stretched
from the distended and obstructed right auricle and ventricle into.
the pulmonary artery and its principal branches.
CASE XIX.-A lady, after the birth of her fifth child, had post-partum
hemorrhage to the extent of about thirty ounces. On visiting her next day, her
medical attendant found her quite well in every respect, and the pulse at 75. She
was taken out of her recumbent position and placed upright in bed, when she be-
came suddenly ill; and only three hours after his morning visit, her physician
was again summoned to see her in a most distressed and apparently dying state,
with the pulse at 164, very feeble and thread-like, the hands cold, and the res-
piration violent and irregular. Auscultation of the heart disclosed a feeble im-
pulse, with great irregularity of the systolic action. There was thoracic pain or
angina on respiration; but no pain or anything anormal in the condition of the
abdomen. She continued to survive for forty-eight hours more, suffering during
that time inexpressible respiratory distress. On post-mortem examination, the
right auricle and ventricle and the auriculo-ventricular opening were found-to
use Dr. Meigs's own words-"completely tamponed with a clot, which consisted
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
551
apparently of a firm, whitish-yellow mass of fibrine, out of which every particle of
hæmatoglobulin had been washed away or expressed." The pulmonary artery, he
tells elsewhere, was in this case also obstructed or "tamponed with a cylindrical
clot, extending several inches along the vessel and its principal branches"
(p. 145).
CAUSES OF ARTERIAL OBSTRUCTION AND INFLAMMATION IN THE
PUERPERAL STATE.
If there happened to exist on the cardiac valves old pediculated
vegetations, capable of being readily separated, an increased force
in the current of the circulation may at any time detach them.
The excitement of the circulation occurring during the exertions of
parturition, might, a priori, be supposed to be calculated to accom-
plish their separation. But in only one of the preceding cases
(Case VII.) did the arterial obstruction occur during or shortly after
labour; and in that instance the obstructing agent was probably
not a detached cardiac vegetation.
The liability to arterial obstruction and inflammation in the
puerperal state must be, therefore, traced-if traceable at all-to
other conditions. These conditions will probably be found in cer-
tain peculiarities in the blood of the puerperal female, or in certain
morbid states which these peculiarities predispose to and produce.
The occurrence of endocarditis and consequently of endocar-
ditical vegetations, concretions, and coagula, is observed principally
in connection with morbid states of the system in which there
exists a vitiated condition of the blood. The two pathological states,
however, with which endocarditic as well as pericarditic lesions are
found most frequently combined,' are-1, acute rheumatism; and,
2, the more chronic forms of Bright's disease-two diseases which
all modern medical authorities acknowledge to be complicated with,
and attended by, if they do not actually consist of, certain morbid
states or alterations of the constitution of the circulating fluid. In
these two diseases acute rheumatism and chronic albuminuria, the
¹ In an admirable paper on The Causes of Pericarditis, etc., published by the
late Professor Taylor in the London Medico-Chirurgical Transactions, vol. xxviii.,
that accomplished pathologist shows, from the analysis of an elaborate series of
cases and data, that acute Endocarditis is principally seen in connection with
acute rheumatism and chronic albuminuria, and occurs in about 8 out of every
100 cases of acute rheumatism, and also in about 8 out of every 100 cases of
chronic Bright's disease (p. 559); whilst in the subjects of these two diseases,
evidence of recent as well as old Endocarditis (as indicated by valvular lesions) is
found in nearly a half of all those affected (p. 560).
552
THE PUERPERAL STATE.
morbid state of the blood is no doubt specifically different, but, at
the same time, in several respects analogous; and hence the analo-
gous tendency in both affections to the occurrence of endocarditis
and other internal inflammations. In both of these affections,
under certain conditions and stages, the blood, as taught us by chemi-
cal pathologists, contains special irritating principles in the form of
morbid matters (urea and probably lactic acid) accumulated within
the circulating system from want of due depuration or excretion.
In chronic albuminuria, as in acute rheumatism, there is generally,
also, according to Simon and others, an increase of serum and a
diminution of blood globules. Further, in acute rheumatism the
quantity of fibrine is usually much increased; and the same is true
of acute albuminuria, but not of the chronic forms of the disease,
except when some of the inflammations liable to be produced by
the disease-such as endocarditis, pleuritis, etc.-spring up when the
quantity of fibrine rapidly rises, and a temporary state of hyperi-
nosis or excess of fibrine is engendered.
1
Among the list of cases of arterial occlusion and inflammation
in the non-puerperal state which have been recorded by Virchow,
Ruhle, Paget, etc., several had been suffering previously, or at the
time of the arterial obstruction, from some form of febrile disturb-
ance, and hence of blood disease; most were the subjects either of
rheumatic complications or of chronic renal disease. Thus in two
out of Ruhle's three cases of obstruction of the cerebral arteries,
acute rheumatism existed. In three out of five cases of obstruction
of the pulmonary artery by old clots observed by Mr. Paget, the
patients had Bright's disease of the kidney.
But if such blood diseases as rheumatism and albuminuria give a
tendency in the non-puerperal condition to endocarditis and to
arterial concretions, and inflammation, we cannot wonder that
similar arterial lesions should occasionally occur in the puerperal
female-for the constitution of her blood is temporarily changed
even under normal circumstances at the time of delivery, and often
becomes much and morbidly changed under the anormal circum-
stances to which she is then liable to be exposed, so that its
characters are more or less assimilated to the characters of the
same fluid in the subjects of acute rheumatism and chronic
albuminuria.
The analyses and investigations of Becquerel, Regnauld, Kiwisch,
1 See the analyses by Drs. Andral, Gavarret, Christison, etc., in Simon's
Animal Chemistry, vol. i. pp. 273, 323, etc.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
553
Cazeaux, and others, have shown that during the last weeks of preg-
nancy there is, as in acute rheumatism and chronic albuminuria, a
diminution of the red globules of the blood, an increase of serum,
and a marked state of hyperinosis or excess of fibrine. According
to the researches of Gavarret and Delafond, this redundancy of
fibrine not only appears to remain after parturition, but tends even
for a time to increase-giving, doubtlessly, among other causes, a
predisposition to obstruction and inflammation of the containing
vessels, whether arteries or veins. Besides, the constitution of the
blood in the puerperal female is altered in other ways. The reten-
tion and accumulation of matters destined for excretion. -as urea
and lactic acid—are supposed to give that tendency to internal in-
flammations, which is possessed by rheumatic and albuminurious
blood, these retained excretory matters probably producing the in-
flammations in question, by being-by a kind of perverted secretion
-thrown out upon surfaces, or into tissues which are directly excited
into inflammation by their presence as stimulating and irritating
matters. During the puerperal condition, the blood is more loaded
with new materials, intended, some for excretion, and some for se-
cretion, than at any other term of life; and hence is specially liable.
to diseased changes under the superaddition of any exciting or septic
causes. For the uterus, during the first weeks after delivery, is becom-
ing involved and absorbed by a kind of retrograde metamorphosis,
and the effete materials resulting from its disintegration necessarily
first pass into the blood before they are ultimately discharged and
depurated from the system; there is an excretory action going on in
its interior in the form of the lochial discharge; and the elements
for the formation of a new and important secretion-the milk-
are present in the circulation.
But under various accidental causes, or by the supervention of
fever, under exposure to cold, from indiscretion in diet, etc., the
normal discharge of these natural puerperal excretions and secretions
is not unfrequently impeded or arrested; and the blood becomes
morbidly altered and diseased from their retention or non-elimina-
tion. Besides, morbid matters sometimes pass into the circulation
in the puerperal state through the uterine veins, etc., more par-
ticularly pus or some of the elements of pus, and afterwards are
carried round with the circulating mass. Some of these new or non-
eliminated materials appear occasionally to have a direct tendency
to produce coagulation or consolidation in the super-fibrinated and
diseased blood, as is seen experimentally when particular varieties
554
THE PUERPERAL STATE.
of pus are mixed with it; while others of them have a greater or
less tendency to irritate, and produce changes upon the lining mem-
brane of the vascular system, ending in obstruction and inflammation
of the veins (phlegmasia dolens); or in obstruction or inflammation
of the arteries; or, as in Cases I., II., etc., in simultaneous or suc-
cessive obstruction and inflammation of both individual arteries and
individual veins in the same patient. If the cardiac valves or
endocardial membrane has been in previous periods of life, as in
some of the other cases detailed in Section I., the seat of inflamma-
tion and consequent vegetations, such diseased parts and excrescences
will, in accordance with an acknowledged pathological law, be
more liable than any other more healthy and normal part of the
interior of the circulating system to take on a renewed inflammation
under these renewed inflammatory conditions; and when these
parts, and the pedicles by which the vegetations are attached to
them, are attacked and rendered friable by inflammatory action, the
common force of the blood-current may be sufficient at last to
detach and separate one of them, or a succession of them. There
seems some ground also for believing that, occasionally in a pro-
tracted puerperal convalescence, as in Cases II. and V., the endo-
carditis and resulting endocarditic vegetations may both form and
separate after delivery, the detached vegetations being recent, and
not of old standing; and perhaps, when obstetricians have studied
more accurately the liability of the puerperal female to endocarditis.
and pericarditis, they may come to acknowledge, with Testa, one or
more forms of puerperal carditic inflammation.'
SYMPTOMS OF PUERPERAL ARTERIAL OBSTRUCTION.
I. IN THE ARTERIES OF INTERNAL ORGANS.
The symptoms of arterial obstruction necessarily vary with the
artery obstructed, or rather, to speak more correctly, they vary with
the function of that part to which the artery belongs, and hence are
more or less severe and serious, according as the function of the
affected part is important or not in the economy. The results in
this way of arterial obstruction are very different, according as the
occluded artery belongs to organs connected with the head, chest, or
abdomen, or is an artery belonging to one of the extremities of the
body.
The immediate symptoms of arterial obstruction are occasionally
1 See his work, Della Malattie del Cuore, tom. iii. p. 178, Capo ix. "Delle
Pericarditi et delle Idropericarditi puerperali."
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
555
modified also by the slowness or suddenness with which the obstruc-
tion is produced, and by the fact whether the stoppage in the artery
or arteries perfectly or imperfectly shuts off the flow of blood to the
parts beyond, and thus perfectly, or only imperfectly, interferes with
and paralyses the function of that part. Thus, when a cardiac vegeta-
tion, displaced from the heart, is suddenly carried upwards, as hap-
pened in Case IV., and in other instances, into the middle cerebral
artery, the function of the portion of brain supplied by that artery
seems, in general, at once suddenly disturbed or totally arrested-
the part supplied by the middle cerebral artery having little or no
anastomoses with the neighbouring cerebral branches. In the
instance in question-Case IV.—there was sudden loss of innerva-
tion, or hemiplegia of the opposite side of the body, followed by the
symptoms of ramollissement or gangrene of the implicated portion of
brain; and the nature of the disease and the lesion were correctly
diagnosed by Dr. Burrows on his first visit to his patient, from his
finding, 1st, sudden hemiplegia supervening in a comparative young
patient, who presented at the same time, 2dly, auscultatory signs of
cardiac valvular disease or endocarditis.
The history of other cases of obstructed cerebral arteries shows,
however, that the resulting paralysis and other nervous symptoms.
may sometimes come on more slowly, especially when the arterial
obstruction from an impacted concretion is not complete at first, but
only becomes completed from coagula collecting round this concre-
tion as a nucleus; or when the obstruction occurs more slowly from
disease of the coats of the implicated vessels themselves.
It is possible that the complete occlusion of a single artery by
a vegetation, or concretion thrown into it, may destroy entirely the
function of an individual organ, when that organ depends for its
function on a single artery. In his large work on Diseases of the
Heart, Testa dedicates a chapter to blindness as a complication some-
times seen in cardiac diseases (tomo ii. capo ix. p. 132). Corvisart
describes a case of sudden dissolution of the right eye, without any
preceding or accompanying inflammation, or any appearance such as
we see in phlebitic ophthalmia, occurring in a patient suffering under
cardiac inflammation. "The most careful examination," observes
Dr. Stokes, when speaking of this case, “failed to detect any cerebral
disease, and the sudden dissolution of the eye remains an unex-
plained fact." The fact, however, appears not inexplicable upon
the idea that a small fibrinous concretion or plug had passed upward
1 Stokes on Diseases of the Heart and Aorta, p. 59.
556
THE PUERPERAL STATE.
out of the cavity of the inflamed heart, and lodged in and occluded
the ophthalmic artery. Of course, the truth of such an explanation
can only be ascertained by examining the state of the artery in any
similar case.
Several years ago I saw the destruction of an eye in a
puerperal patient, which I have sometimes thought might possibly
belong to this form of disease.
CASE XX-A patient, six weeks after delivery, walked some distance to my
house to show me her right eye, which was quite blind and opaque, but the case
differed from 'Corvisart's in this respect, that the eyeball was distended with puru-
lent matter. A fortnight subsequent to her accouchement, on making some
unusual muscular exertion, pain suddenly came on in this eye, which had been
weakened during an attack of measles in childhood. Inflammation speedily
followed. When I saw her, there was no constitutional disturbance, such as we
see in cases of puerperal phlebitic ophthalmia-a disease that is almost always, if
not always, fatal. I have lately seen this patient with the eye quite collapsed and
atrophied. She has an irregular pulse, and other symptoms of old disease of the
heart.
Of the symptoms of obstruction in the arteries of the abdomen.
and chest we know in pathology, as yet, little or nothing.
The cases which I have described under Section V. of obstruc-
tion of the pulmonary artery show that the patients upon whom this
obstruction is found after death suffer during life under symptoms
indicating distressing disturbance in the actions of the heart and
lungs. The first symptoms in some appear to have been sudden
pain or angina in the region of the heart, with faintness, palpitation,
and afterwards great increase in the rapidity of the pulse. The
respiratory symptoms have mostly consisted of laboured, anxious,
and irregular breathing, particularly on the least movement; with
sometimes the addition of cough and frothy or bloody expectora-
tion. There occasionally breaks out a cold perspiration on the
surface, and there is often a marked and deadly coldness of the
hands or other extreme parts of the body, with congestion of the
face. In one or two cases, temporary unconsciousness, or delirium,
or a convulsive fit, have been observed; and in others, great nausea
and vomiting have formed early symptoms. If such symptoms of
cardiac and pulmonary suffering suddenly supervene in a puerperal
patient, especially after change of position or exertion, and more.
particularly when recovering from any form of phlebitis, we might
have reason to suspect obstruction to a greater or less extent of the
circulation in the pulmonary arteries. Hitherto auscultation has not
enabled pathologists to make out any special signs indicative of the
existence of obstruction in the pulmonary artery; and indeed the
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
557
sudden supervention and presence of such severe cardiac or pulmonic
disturbance without any corresponding stethoscopic signs, forms in
itself, perhaps, one of the best tests of the lesions consisting in some
occlusion in the pulmonary vessels. These symptoms, in some
instances, have, as I have already stated, been observed to come
on slowly, in all probability from the obstruction in the pulmonary
arteries only gradually increasing and accumulating. When the
occlusion at last reaches the larger pulmonary arteries, or shuts up
their canals from the first, death, as we have previously seen, comes
on with unusual rapidity and suddenness. (See Cases XIII. XIV.
XV., etc.)
Gangrene of the lung, with its characteristic fœtor, sometimes
comes on in the puerperal, as in other states, without any adequate
amount or intensity of preceding inflammation, and sometimes,
indeed, the "inflammation," to quote the words of Lænnec,
'surrounding the gangrenous spot seems to be rather the effect
than the cause of the sphacelus." Is the gangrene in such instances
not sometimes an effect, and hence also a symptom, of the ob-
struction of the pulmonary, or rather of the bronchial arterial branch
supplying the sphacelating part, and is not pulmonary gangrene, like
the gangrene of the extremities, frequently the consequence of
arterial obstruction?
Perhaps some instances of impeded and arrested function,
gangrene, etc., in the abdominal viscera, may yet be found to admit
of a similar explanation. Dr. Abercrombie pointed out a remark-
able series of fatal cases of ileus, in which apparently there existed
merely paralysis of a limited portion of the intestinal canal, in
consequence of which loss of muscular power, that portion did not
act in concert with the other parts of the tube, and the non-
transmission of the intestinal contents was the result. In these
cases of paralytic ileus, there was usually violent pain during life;
and on dissection the paralysed portion of bowel was found in some.
instances white and discoloured, in others livid, and in one instance.
gangrenous, but without any appearances of inflammatory exuda-
tion. In the remarks which I have to make immediately upon the
symptoms of arterial obstruction as seen in the extremities of the
body, we shall find that in the limbs arterial plugging and occlusion
gives rise to these same various effects, paralysis, pain, and
occasionally gangrene. If arterial obstruction produces similar
1 Abercrombie on Diseases of the Stomach, etc., 2d. edit. pp. 143-144, Cases 25,
26, 27, 28, etc.
558
THE PUERPERAL STATE.
effects internally to those which it thus produces externally, would
not the plugging of a mesenteric artery, or of some of its branches,
give rise to the symptoms and consequences seen in the paralytic
form of ileus described by Dr. Abercrombie? The whole subject,
however, of the pathological signs and results of the obstruction of
the arteries supplying the internal organs of the body, is as yet so
unknown and uninvestigated, that speculating on the matter is mere
hypothesis.
II. SYMPTOMS OR EFFECTS OF OBSTRUCTIONS SEATED IN THE ARTERIES
OF THE EXTREMITIES.
The symptoms, however, of arterial obstruction have hitherto
been principally observed and studied as they are met with in oc-
clusion of the arteries of the extremities of the body. These
obstructions are generally preceded in the puerperal female by more
or less febrile and constitutional symptoms, and occur especially in
patients who are suffering or have suffered from rheumatic or other
diseases of the heart and cardiac valves. When arterial obstruction
at length takes place in one or more of the vessels of a limb in
patients presenting these predisposed states, the following local
symptoms are liable to occur in the obstructed limb-viz., 1st,
Arrest of the pulse below the site of obstruction; 2d, Increased
force of pulsation in the artery above this site; 3d, Change in the
temperature of the affected limb; 4th, Paralysis, or neuralgia in it;
5th, Gangrene. Let me speak briefly of some of these symptoms of
puerperal arterial obstruction and inflammation in succession.
1. Arrest of the Pulse below the site of Obstruction.—The arrest of
the pulse from a point in the course of the artery of a limb down-
wards may supervene suddenly, as when the arterial obstruction is
produced by a vegetation or coagulum carried from a distance and
impacted in the canal of the vessel; or the pulsation may cease
gradually, as when the obstruction is produced more slowly by the
presence of a local arteritis. In practice, physicians are seldom in
the habit of examining any artery, except the radial; and hence
probably the cause why arterial obstruction has been more frequently
found in the arm than in other parts during life. In any doubtful
case, especially where there are any other symptoms of obstruction
present in the lower extremities, as neuralgia or partial paralysis, it
is our duty to examine the course of the arteries in that extremity,
in order to ascertain whether at any point the pulse is obstructed
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
559
in them. It is necessary also to remember, in relation to this
symptom, that after a time the pulse may return in an artery pre-
viously obstructed, as happened in Cases I., etc.
2. Increased Force of Pulsation in the Artery above the site of Ob-
struction.-Though absent in some instances, this symptom has been
well marked in a few others. Thus, in a very important case de-
scribed by Mr. Tufnell,¹ and in which the popliteal artery was
occluded by cardiac vegetations impacted in the canal of the vessel,
there was such strong pulsatile action in the femoral artery above.
the site of obstruction, as at first to suggest the idea of the possi-
bility of aneurism, but there was no aneurismal bruit de soufflet
present. This symptom may even serve us in the diagnosis of the
obstruction of some internal arteries. In a case of puerperal hemi-
plegia, which I saw with Dr. Alexander, this symptom, with others,
led me to suspect the probable occurrence of impaction of a cardiac
vegetation or concretion in one of the cerebral arteries.
CASE XXI.-The patient was the subject of old-standing disease of the mitral
valve, and considerable hypertrophy of the heart. About the eighth month of
her pregnancy she returned home from a long walk scarcely able to articulate, and
with commencing symptoms of hemiplegia in the right side. There was no albu-
minuria. During the course of the next twenty-four hours these paralytic
symptoms increased in intensity, and the arm and leg became gradually more
powerless, so that the leg at last did not answer to the reflex irritation of tickling
the sole; the hand was spasmodically shut. At the same time the patient evi-
dently retained completely her consciousness and mental faculties, though quite
unable to give utterance to her wishes and feelings. There was no tendency
whatever to stupor, and no febrile reaction. On feeling simultaneously, with the
fingers of the two hands, the left and right carotids, the amount of pulsation in
the artery on the left side was found by Dr. Alexander and myself greatly stronger
and more marked than the pulsation of the corresponding vessel on the other side
of the neck. The patient went on in much the same state to the full time, and
was safely delivered. The hemiplegia had decreased since that period, but still—
now three years since the attack-the power of articulation remains much im-
paired, and the right leg and arm are feebler than the left.
If the hemiplegia in this instance had been the result of san-
guineous effusion into, or other lesion of, the left hemisphere of the
brain, and not the result of arterial obstruction in one of the arteries
supplying that hemisphere, would there have been this extraordinary
impulse in the left carotid artery? I am not aware that pathology
yet possesses facts and observations to answer the question definitely;
but reasoning a priori, one would expect it to be answered in the
negative. And if this case be an instance of hemiplegia from arterial
¹ Dublin Quarterly Journal of Medical Science, vol. xv. p. 371.
560
THE PUERPERAL STATE.
obstruction, it is invested with this additional interest, that it affords
us evidence of the possibility of partial recovery at least, from this
variety of encephalic lesion.
3. Fall in the Temperature of the Limb. When the artery or
arteries are obstructed in a limb, a fall in the temperature of the
extreme parts of the limb usually soon follows. A morbid feeling
of heat is sometimes complained of by the patient in the first
instance; but the application of the hand, and still more of the ther-
mometer, certifies, in general, an actual and sometimes a consider-
able fall. The extent of this diminution of temperature is regu-
lated by the extent and completeness of the obstruction to the
supply of arterial blood in the limb.
4. Lesions of the Motory and Sensory Powers in obstruction of the
Arteries of the Limb.—PARALYSIS-NEURALGIA, etc.—The functions
of sensation and motion in limbs, in which the arteries have
become obliterated, are very differently affected in different instances.
These differences depend upon the degree of arterial obstruction
that is present, and upon some collateral circumstances. The
amount of blood sent to the obstructed part may be sufficient for
maintaining the mere purposes of its vegetative or nutritive life,
but not sufficient for maintaining in it, in their normal state, the
higher functions of sensation and motion pertaining to its nerves,
or the irritability of its muscles. The production of paralysis in
the two posterior extremities in animals, by ligature of the aorta,
and in individual limbs by tying and obstructing the principal
arteries of these limbs, has been proved experimentally on the
lower animals by Stenson, Arnemann, Englehart, Segalas, and other
physiologists; and similar results are observed in operative surgery
on the human subject-the power of motion being wholly or par-
tially lost till the collateral circulation is developed. Treviranus
and Müller infer that the resulting paralysis of muscular motion in
the obstructed limbs is referable in these experiments and opera-
tions to the muscular fibres being deprived of their requisite constant
afflux of arterial blood. In some of these experiments and cases,
however, there is evidence of the arrested flow of blood influencing
directly the functions of the nerves of the limbs, as a state of cuta-
neous anesthesia is observed along with the paralysis. In many
cases of arterial obstruction, another effect, more difficult of explana-
tion, presents itself, namely, pain or neuralgia in the implicated
limb-a result sometimes temporarily seen, though seldom to a very
marked degres, after the ligature and obstruction of vessels fer
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
561
aneurism. In practice we find very various degrees and combina-
tions of these motory and sensory lesions in extremities whose
arteries are the seat of obstruction. Thus-
First, When the arterial obstruction is sudden and complete, the
limb may at once be found perfectly paralysed, both in relation to
motion and sensation, as happened in the famous case in which Sir
Astley Cooper first threw a ligature around the aorta. In a case of
arterial paralysis of the leg, mentioned by Cruveilhier, the limb was
from the first in a state of death, or, as he terms it, "cadaverisation,"
and totally without feeling or movement.
Local arterial paralysis, let me here add, differs in one or two
important diagnostic points from cerebral or nervous paralysis. In
the arterial paralysis there is a want of those head symptoms, that
generally precede or accompany all paralyses that arise from lesions.
of the central organs of the nervous system. The temperature of
the limb is commonly diminished in arterial paralysis; but not, at
least in the first instance, in cerebral or nervous paralysis. In the
former variety of paralysis, there is an arrest of pulsation in the
arteries of the affected limb; but the arterial pulsations are not
influenced or changed in the latter variety of the disease. In
arterial paralysis, gangrene sometimes speedily supervenes; in ner-
vous or cerebral paralysis, this result is unknown.
:
Secondly, In cases in which the arterial obstruction in the
extremities is not complete, the accompanying lesions of innervation
sometimes only amount to a feeling of numbness, or prinkling and
stiffness or semiparalysis in the implicated limb, like that occasion-
ally produced by pressure on the sciatic nerve in sitting. Usually
there is pain, and, at all events, tenderness on pressure, at the site
of obstruction, and more or less along the course of the occluded
artery. But-
Thirdly, In connection with arterial obstruction in a limb, there
has now been also often observed a feeling of extreme pain and
tenderness on pressure, not only at the site of occlusion, and along
the course of the obstructed vessel, but more or less throughout the
extremity; and this increased supersensibility often amounts to a
true and severe arterial neuralgia, that may be either constant or
intermittent in its type. Sometimes the pain or neuralgia accom-
panying arterial obstruction is combined with paralysis of the motory
powers of the limb; sometimes, as in a case of arterial obstruction
and gangrene in the right leg, recorded by Drs. Graves and Stokes,
the ultimate paralysis of motion and sensation in the limb is pre-
562
THE PUERPERAL STATE.
ceded by pains; and in other instances the arterial neuralgia is
excessive, and without any accompanying paralysis having at least
been remarked. This pain is occasionally the first, and throughout
the most prominent symptoms in arterial obstruction. In a case which
lately occurred in the practice of my friend Dr. Paterson of Leith,
and where at last gangrene attacked the two lower and one of the
upper extremities in a lady of thirty years of age, who was the sub-
ject of chronic valvular disease, the first symptom observed consisted
in sudden and excruciating pain or neuralgia in the leg first affected,
and which wakened her out of sleep in the middle of the night. In
any instances in which arterial obstruction is probable, this occur-
rence of sudden neuralgia is in itself a circumstance to awaken sus-
picion, and lead to a careful examination of the arteries of the limb.
M. Legroux was attending on a patient complaining of great pains
in the lower extremities. The means of relief which he had em-
ployed having totally failed, several physicians were called into con-
sultation. They all believed the pains to be rheumatic. After the
consultation was finished, M. Legroux revisited the bedroom of his
patient, examined for the first time the arteries of the affected limb,
and discovered that both femoral arteries were hard, tender, and
without pulsation. After the patient's death, the lower end of the
aorta, the iliac, and crural arteries, were found obstructed by concre-
tions.¹
The proximate cause of the pain or neuralgia accompanying
arterial obstruction in a limb, is a point which, in the present state
of our knowledge, it is difficult or impossible to determine. It is
not the result of a puerperal neuritis in the affected limb; for, in
the right leg of the patient in Case II., the neuralgia was very great
during life, but the nerves, on dissection after death, were found
quite sound. Nor is it essentially the result of arteritis; for the
pain has often developed itself before any arterial inflammation could.
be established, as immediately upon the artery being obstructed by
a vegetation or clot; or, as has been seen in surgery, sometimes
instantly after perchloride of iron, etc., was injected, and had pro-
duced coagulation of the blood in the vessel. Perhaps the proxi-
mate cause of the attendant pain may yet be traced to pressure in
some form; or to morbid over-distension of the arterial tube; or,
possibly, in some instances to a spasmodic contraction of the walls
of the vessel upon its contents.
1 Cruveilhier's Traité d'Anatomic Pathologique, tom. ii. p. 299.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION.
563
5. Gangrene below or beyond the seat of Arterial Obstruction.--In
several of the cases which we have previously detailed of puerperal
arterial obstruction and inflammation, gangrene of the parts beyond
the seat of obstruction followed to a greater or less extent. The
cerebral ramollissement and disintegration observed in Case V., in
the parts of the brain supplied by the obstructed middle cerebral
artery, is in all probability of this pathological nature. The parts of
the brain supplied by that artery are, as we have already stated, the
more likely to become dead and gangrenous, in consequence of its
occlusion, seeing there is little or no anastomosis between its branches
and those of the other cerebral vessels. The occlusion of an artery
going to some part may interfere with the function of these parts
without leading to gangrene. We can easily suppose, for instance,
the artery of the retina occluded, with the destruction of the func-
tion of vision, without the eyeball or its appendages running any
risk of destruction or gangrene, because these parts are nourished by
other vessels. When the chief artery or arteries of one of the ex-
tremities is obstructed, gangrene frequently comes on, not as a
primary, but as an ultimate symptom and result; and its superven-
tion appears to be regulated by various pathological circumstances.
It is seldom that the local obstruction of the leading artery alone of
a limb leads to gangrene in the extreme parts of that limb; the
collateral circulation, if left free, being usually sufficient to prevent
any mortification. In fact, the obliteration of the main artery of a
limb seldom, apparently, produces gangrene, unless it be combined
and co-exist with conditions that more effectually prevent the circu-
lation in the extremity; such as the simultaneous obstruction of the
usual channels of the collateral circulation above, or of the smaller
arteries of the limb below; or the simultaneous obstruction of the
principal vein or veins, as in the left limb of Case II.
Gangrene, in one or other of the extremities of a puerperal
female, is the only sign by which we know that arterial obstruc-
tion has in all probability occurred, in instances where there has
been no opportunity of making an accurate post-mortem examina-
tion. I have notes of two or three unpublished cases of gangrene
of the extremities in puerperal women, which I may here quote
both as additional evidence of the frequency of arterial obstruction,
and of this additional complication. The three following cases.
are all, besides, remarkable for the rapidity with which the
mortification supervened. For notes of the two first I am indebted
to Dr. Cowan; the third was seen by Dr. Reid of Kirkcaldy.
37
564
THE PUERPERAL STATE.
CASE XXII.-Mrs. G——, æt. 36, healthy and active, was delivered of her
fourth child some time in the spring of 1826. She was visited regularly for three
days, and during this time no bad symptoms were observed; and the lochial and
lacteal secretions were natural. Dr. Cowan was sent for early in the morning on
the fourth day, and found that his patient had suffered from a severe rigor in the
night. The countenance was anxious and distressed, the face pale, the eyes sunk
and languid, and she was screaming from excruciating pain in the left leg and
foot, but referred principally to the upper and inner portion of the calf, which was
found cold and tense, but not increased in size. This state extended to the foot,
on the fore-part of which a large spot of ecchymosis appeared most evident over
the metatarsus, and creeping upwards to the ankle-joint. The uterus was not
perceptibly larger than usual, but there was some tenderness in the left hypogas-
trium on pressure, as also in the lumbar region. The pulse was small and rapid,
the thirst urgent, and the tongue dry and coated. There was some nausea, but no
vomiting. The lochia had ceased, and the milk was scanty. On returning in the
evening, Dr. Cowan found that the pain was mitigated, but her appearance was
worse in every respect. The pulse was now very feeble, the tongue parched and
of a fiery red hue; her mind was sluggish and wandering; the discoloration had
reached the rise of the calf of the leg (having a wavy margin), and still advancing
upward with the same cold, tense, unyielding character, but with little increase of
bulk. The thigh seemed natural, but colder than the other. The bowels had been
moved with oil, but little or no urine was secreted. At seven o'clock the follow-
ing morning everything was found worse, and in addition vesication had begun on
the spot first discoloured; in short the foot was hopelessly gangrenous and the
patient sinking fast. Death put an end to her sufferings early on the fourth day
of disease, and the eighth from delivery. No decided margin of arrest in the livid
or gangrenous limb could be observed, but the foot showed marks of decomposition,
and the smell was characteristic both before and after death. The post-mortem
examination was refused.
CASE XXIII.-A patient aged 25 years, ten days after delivery with her first
child, was seized with gangrene of one of the lower extremities. Dr. Cowan saw
nothing of the case until he entered the room at the time of the operation for the
removal of the limb. He had no opportunity of making an examination of the
state of circulation in the heart and arteries. Above the site of the gangrene the
thigh seemed paler than natural, but little altered in size. The gangrene involved
the foot and leg nearly to the knee-joint; the patient was greatly exhausted and
anxious, but not suffering severely. The limb was amputated at the lower third
of the thigh, but not a drop of blood followed the knife. The patient died next
day, sinking gradually without suffering. An autopsy was refused, but the femoral
artery from the groin to its extremities in the wound were allowed to be examined.
The artery was pervious and empty, except some soft clots, adhering slightly to its
inner wall, which, when scraped off, showed the inner coat of a bright roseate
colour, gradually fading in its descent. The veins were not obstructed.
CASE XXIV. This patient had previously borne a large family. Her last
labour was easy, for it came on prematurely, and the child was dead born. On
the third or fourth day subsequent to delivery fever supervened, followed by swell-
ing of the left leg and thigh, which was attended with great pain and suffering.
In the course of two or three days gangrene showed itself, and when Dr. Reid
was called in, the whole extremity was already dark coloured, and the mortifica-
tion extensive. She died ten days after delivery. There was no dissection.
PUERPERAL ARTERIAL OBSTRUCTION AND INFLAMMATION. 565
After gangrene in an extremity occurs in a puerperal mother,
death has almost always followed, whether the disease was left to
the effects of nature, or amputation had recourse to as in Case
XXIII. An instance of puerperal gangrene in one of the legs was
published in the Lancet for 1845, by Mr. Bottomley of Croydon,
and is interesting from the circumstance that the patient recovered
after amputation of the mortified parts. Mr. Bottomley writes me,
that he has no doubt that the gangrene originated in arteritis, or
arterial obstruction. The history of the case is as follows:-
CASE XXV. The patient, æt. 39, was confined on the 8th of February 1845.
Her pregnancy was favourable until within a month of delivery, when she
suffered from cough and great debility. The labour, however, was expeditious;
the lochia were small in quantity; and the after-pains slight. The woman con-
tinued doing well for ten days, when symptoms of pleuritis, with considerable
constitutional disturbance, presented themselves. These symptoms disappeared
under the treatment employed. Two or three days after her recovery from the
pleuritic attack, she complained of pain in the heel, passing from thence to the
great toe and ankle-joint. No abnormal appearance, however, could be found
when these parts were examined. The pain was treated by Mr. Bottomley as
neuralgic, by veratrian ointment, morphia, etc., but with no good result. At
length a livid spot appeared on one of the toes, the temperature of the foot and
leg became gradually diminished, and there was impaired sensibility. This
diminished temperature and sensibility continued to increase. The toes severally
became black, and this appearance extended so as to involve the foot and ankle.
At length a line of demarcation was formed about two inches above the ankle-
joint, and amputation was thought of, but deferred until the patient's health
should be somewhat improved. On the 3d of May the leg was amputated above
the knee. It was deemed advisable to operate as high up as this; for although
the line of demarcation was just above the ankle-joint, and the skin had its
normal colour higher than this, still there was much swelling, some hardness and
pain in the calf, and the cause of the gangrene was believed to be a constitutional
one.
When the tourniquet was applied, it was noticed that the pulsation in the
femoral artery was hardly perceptible. After the removal of the limb, both the
femoral artery and vein were found plugged with a transparent semicartilaginous
substance.
The recovery of this patient was complete, and, as I am lately
informed by Mr. Bottomley, she has borne two children since the
occurrence of this attack of puerperal gangrene.
The preceding contribution gives a view of puerperal arterial
obstruction and inflammation, that is in many respects altogether
unfinished and imperfect. Of its many defects no one can be more
deeply and sincerely aware than I myself am. But imperfect and
defective as the sketch is, it will answer the principal purpose for
566
THE PUERPERAL STATE.
which it is intended, provided only it be fortunate enough to direct
the attention of my obstetrical brethren to the subject, and thus
initiates a full investigation into this new form of puerperal disease.
RECOVERY FROM PUERPERAL CEREBRAL EMBOLISM,
AND SUDDEN DEATH IN A SUBSEQUENT
PREGNANCY.
Professor Simpson said: On the same day on which we exa-
mined the body of the patient whose history I have brought under
your notice, I had occasion to assist at the autopsy of another
patient, whom I had seen several times during life, and whose case
was of a very different, and, to me, still more interesting nature.
About five years ago, immediately after the publication of an essay
on puerperal embolism, I was asked by Dr. Alexander to see a
patient who had arrived at the eighth month of her fourth preg-
nancy, and who, after walking up a stair, had been found by her
servant lying in a stupid and almost senseless state. When Dr.
Alexander saw her she was suffering from hemiplegia of the whole
of the right side of the body, and he requested me to visit her along
with him, with the view of consulting as to whether anything
should be done towards anticipating the occurrence of parturition.
Among other cases that I had published was one of the wife of a
distinguished obstetrician, himself but recently dead. That lady,
the nature of whose disease had been skilfully diagnosed by Dr.
Burrows during life, was found to have died in consequence of
softening of the corpus striatum, produced by the impaction in one
of the branches of the middle cerebral artery of a small embolus
which had become detached from some of the cardiac valves. In
Dr. Alexander's patient I suspected that the same kind of accident
might have happened, for the carotid artery was pulsating more
powerfully on the left side than on the right; and there was no
evidence of any congestive or inflammatory action having taken
place within the cranium. Moreover, after a careful examination of
the heart, Dr. Halliday Douglas discovered that the mitral orifice.
was to some extent contracted; and it seemed in every degree pro-
bable that some vegetation might have been produced on the
contracted valves during the period of pregnancy, when the blood is
1 See Proceedings of Edinburgh Obstetrical Society, May 8, 1861, in Edin-
burgh Medical Journal, May 1862, p. 1085.
RECOVERY FROM PUERPERAL CEREBRAL EMBOLISM.
567
in a hyperinotic condition, and that as a result of the increased
action of the heart, brought on by the effort of ascending the stair,
some portion of these vegetations might have got loosened, and
been carried into the cerebral vessels. Up to that time, so far as I
am aware, no case of cerebral puerperal embolism of this kind had
occurred in which the patient had made a recovery; and in this
case I formed a very gloomy prognosis. She carried her child,
however, to the full time, and was easily delivered; recovered sub-
sequently so far as to be able to move about, although she walked
lamely; had her power of speech impaired, and had only very
imperfect use of the right hand. She has since borne one or two
children without any untoward circumstances.
I had heard of her progress from time to time from Dr. Alex-
ander, but did not again see her professionally till Friday last, when
I was summoned about mid-day, as she seemed to be dying. On
my arrival at the house, I learned from Dr. Alexander that she was
in the seventh month of pregnancy: he had seen her the night
before, and thought her not quite so well as usual, having remarked,
in particular, that the left hand, which was the one she now always
used in shaking hands, was unnaturally cold, although she herself
declared there was nothing amiss with her general health. Her
husband had left her at ten A.M., apparently well, but soon after-
wards she became suddenly ill, and the servant, who was alone in
the house with her, was afraid to leave her; so that the doctor was
not sent for until after the return of her husband between twelve
and one o'clock. Dr. A. found her in bed, breathing very laboriously,
cold and collapsed, but quite sensible and capable of answering his
questions in her ordinary broken and inarticulate manner.
He suc-
ceeded in making her swallow a little brandy; so that, when I saw
her shortly afterwards, she was not altogether so sunken as when
he first saw her. But still she was evidently in a moribund con-
dition. The countenance had an anxious, alarmed expression; the
skin was cold and clammy, and strangely discoloured, being partly
livid from the stasis of blood in the superficial vessels, and partly
yellow, perhaps from the decomposition and diffusion of some of the
colouring matters of the blood (one small vein in the columnæ nasi
was especially remarkable from the excessive degree of turgidity and
the darkness of the contained blood); the pulse was small and
fluttering, hardly at times to be felt at all; the action of the heart
was tumultuous and irregular, but the loud respiratory sounds in
the patient's throat rendered it impossible to distinguish any cardiac
568
THE PUERPERAL STATE.
murmur or any distinct pulmonic sound. The fœtal movements
had ceased, and no cardiac or placental sounds were audible. Two
hours afterwards the patient died.
On making a post-mortem examination, we found the cerebral
lesion to be seated at the base of the brain on the left side, below
and to the external side of the left ventricle, where a cavity of con-
siderable size existed, which involved the lower and anterior portion
of the corpus striatum, and was lined by a very vascular serous-
looking membrane. This cavity was elongated, but contained almost
no fluid; its lateral surfaces being in mutual contact. The branches
of the middle cerebral artery running towards it from the fissure of
Sylvius were all carefully examined, but no obstruction could in any
of them be discovered. But if we reflect on the length of time that
had elapsed since the occurrence of the hemiplegic attack, we can
easily understand how all trace of the original cause of the cerebral
lesion may have become obliterated. For we know that a pretty
extensive destruction of cerebral substance may result from the im-
paction of an embolus in even a small artery; and in the lapse of
years such an artery may have degenerated into a small undistin-
guishable fibre running in the pia mater; or the small plug may
itself have become disintegrated and dissolved, and the lumen of the
artery may subsequently have become restored. In either case the
portion of brain, temporarily deprived of its vascular supply, and
perhaps otherwise damaged from the disturbance of the circulation
in the surrounding vessels, had become destroyed, and its place only
indicated by the kind of cystic cavity of which I have spoken. The
source of the embolus was easily discernible in the condition of the
mitral valves. The left auriculo-ventricular orifice was so contracted
as barely to admit the point of the forefinger; the valves, as well as
the tendinous cords attached to them, were shortened and thick-
ened, and on the free surfaces of each, towards the margins, there
were one or two warty-looking projections which were overlaid by
fresh coagula. There were firm recent clots lying behind the valves,
which had probably begun to form during life, and impeded the
heart's action. Similar coagula stretched along the pulmonary
veins. I had imagined, from the suddenness of the attack, that an
embolism might have taken place in some of the branches of one or
other pulmonary artery; but these were found, on careful examina-
tion, to be all quite free, and the pelvic veins contained only fluid
or loosely coagulated blood. The lungs presented no trace of any
recent morbid`affection, only they were slightly oedematous, and
PUERPERAL ETC. TETANUS.
569
both, but more particularly the left, had undergone to a slight
degree that kind of change which Virchow has described as brown
induration of the lungs.
TETANUS FOLLOWING LESIONS OF THE UTERUS,
ABORTION, AND PARTURITION.¹
Dr. Robert Reid, in his work On the Nature and Treatment of
Tetanus, etc., states that "injuries or derangements of internal organs
do not appear to have much tendency to produce this affection.
Indeed," he adds, "I have not been able as yet to find any case
recorded of true tetanus which arose from internal injury, whether
in the alimentary canal or elsewhere."2
The uterus is certainly an "internal organ," in the sense in which
that expression is used by Dr. Reid; and internal injuries or lesions
of it, both in the unimpregnated and puerperal states, are, without
doubt, sometimes followed by tetanus in an acute and fatal form.
This fearful complication is fortunately a rare occurrence in mid-
wifery practice. But the following series of cases is calculated to
show that traumatic tetanus does supervene occasionally as a
secondary obstetrical disease, in the same way as all medical autho-
rities acknowledge it to supervene occasionally-and still more
frequently as a secondary surgical disease.
Before, however, detailing the proofs which I wish to adduce of
this last remark, let me premise that in ancient times tetanus was
usually considered and described, for example by Aretaus, as a
disease more common among females than males. Modern statistics,
however, have amply shown the reverse to be true.
Out of 128 cases of traumatic tetanus collected by Mr. Curling,
112 were males, and 16 only were females.3 Out of 221 cases
collected in an excellent paper by Professor Lawrie of Glasgow, 185
of the patients belonged to the male sex, and 36 to the female sex.*
The Registrar-General's Official Reports afford a still greater
amount of evidence on the relative liability of the two sexes to
tetanus.
The number of fatal cases of tetanus which have occurred
annually in England and Wales during the last fifteen or sixteen
1 See Edinburgh Monthly Journal of Medical Science, February 1854, p. 97.
2 Nature and Treatment of Tetanus, p. 52.
3 Treatise on Tetanus, Table in Appendix.
* Glasgow Medical Journal for October 1853, p. 352.
570
THE PUERPERAL STATE.
years has varied from about 120 to 150; in 1847 as many as 165
died of this disease. The number of deaths from tetanus, etc., has,
unfortunately, not been published for every year of the reports; in
some of the years, those occurring in the metropolis are not given ;
and occasionally the data as to the sexes of the patients cannot be
discovered in the official returns. But from 1837 to 1842, I find
629 deaths from tetanus entered in the reports, with the numbers
of each sex stated; and from 1847 to 1849, there are 430 deaths
from tetanus similarly specified. Out of these 1069 fatal cases
of tetanus, 829 belonged to the male sex, and 240 to the
female sex. In other words, out of every 100 of these cases, 77
per cent were males, and 23 per cent females. Or the males
attacked with fatal tetanus were to the females in the proportion of
nearly 4 to 1.
In how many of the above 240 instances of fatal tetanus in the
female sex the uterus was the seat of traumatic irritation or injury
we have no means of judging. Doubtless, the proportion was but
small. The following cases, however, will tend to prove that this
dreadful malady may follow-(1) lesions of the unimpregnated
uterus; as well as the lesions left in the uterus and maternal canals,
(2) by abortion; and (3) by parturition at the full time :—
1. TETANUS AFTER LESION OF THE UNIMPREGNATED UTERUS.
Lesions and injuries of the unimpregnated uterus seem to have
little tendency to produce traumatic tetanus. But the following
instance affords a remarkable example of this formidable complica-
tion :
a
CASE I.-A widow, et. 35, who had been suffering for many months under
severe menorrhagia, came from a considerable distance for advice. The uterus
was large and heavy, and evidently contained some roundish morbid mass either
in its cavity or in its walls. The use, for a few hours, of a single sponge-tent
opened up the os uteri, and allowed a polypus to be felt in the interior of the
uterus. Menstruation supervened in a profuse degree; and any further local
treatment was in the meantime suspended. In a few days uterine contractions
came on. They were severe in character, and gradually pushed down a large cel-
lular polypus from the uterus into the vagina. No special operation was required
to detach it, as the expulsive efforts of the uterus had, in a great measure, spon-
taneously broken up the adhesions of the tumour with the interior of the uterine
cavity; and at last the polypous mass was found so loose as to be easily removed
from the vagina by slight traction with the fingers. It proved to be a cellular or
loose fibrous polypus, of the size of the closed fist. After the separation of this
mass the patient felt comparatively well. She was free from fever and local pain,
and appeared for a time quite convalescent. On the ninth evening, however,
PUERPERAL ETC. TETANUS.
571
after the polypus was detached, she sent for me, to complain of some stiff and
strange feelings about her face. At the time of my visit she was sitting up, drink-
ing tea. She herself remarked that she was almost unable to swallow it, from pain
and difficulty in opening her mouth, which she had first noticed a few hours pre-
viously. My suspicions of tetanus were not at the time excited. I believed, with
the patient herself, that she was threatened with an attack of cynanche. But early
next morning, all the symptoms of the disease were becoming far too marked to
leave any doubts of its nature. The muscles of the neck were affected with tetanic
spasms, and the jaws fixed. Deglutition was impossible. During the day, Pro-
fessor Syme saw the patient with me. In spite of all the usual remedies, the
tetanic paroxysms increased in extent, in frequency, and in severity. She bore
the terrible spasms with wonderful equanimity, and her mind seemed to remain
entire up to the very last. She died, exhausted by the disease, about fifty-five
hours after the first symptoms of tetanus were observed.
On making a post-mortem examination, no special lesions were
found in any organ examined, with the exception of the uterus; and
there the principal, or, indeed, only morbid appearance, consisted of
the shaggy and projecting attachment of the uterine extremity of
the ruptured pedicle of the polypus, marking the spot where it had
adhered to the interior of the body of the uterus.
I do not remember of having heard or read of any analogous
case in which a lesion of the unimpregnated uterus was followed by
traumatic tetanus. Mr. Curling refers to an American case, recorded
by Dr. Smart, in which the disease was supposed to have been pro-
duced by an injury of the neighbouring mucous canals-viz. "by
the passage of large, rough, angular pieces of clay from the intestinal
canal into the vagina." The case, however, is not an example
exactly in point. A French author of the sixteenth century, Mar-
tinus Akakia, states-apparently in the way of a general observation,
from one or two individual cases-the occurrence of trismus, general
tetanus, and opisthotonos, running on to a fatal termination by the
fourth day, as an occasional sequence of menorrhagia, whether that
menorrhagia, or hemorrhage, had been the result of diseased states
of the unimpregnated uterus, or of abortion, and delivery.
2
II. TETANUS AFTER ABORTION.
Several of our oldest medical authorities describe abortion as one
of the occasional causes of tetanus. "Individuals," observes Archi-
genes, are attacked with this disease in consequence of various
causes, as from wounds, and in women from abortion (in fœminis cx
1 Treatise on Tetanus, footnote, p. 197.
+
2 De Morbis Muliebribus, lib. i. cap. 6, "De fluxu rubro." See Spachius'
Gynæciorum Libri, p. 759.
572
THE PUERPERAL STATE.
1
abortu)." When speaking of the causes of tetanus, Aretaus specially
enumerates wounds of all kinds, with exposure to cold, and he adds
that "
women are sometimes, though rarely, attacked with the disease
as a result of abortion."
1) 2
In none of our modern obstetric books, nor in any of the various
essays or works devoted to the consideration of abortion or puerperal
diseases, is any illusion made, so far as I know, to the possible super-
vention of tetanus after miscarriage. It is a complication, however,
which does occasionally take place; and it is always one very for-
midable in its character, and generally very fatal in its issue. Two
deaths from tetanus after abortion occurred some years ago, almost
simultaneously, in Edinburgh. I have the kind permission of Dr.
Alexander Wood and Dr. Malcolm, in whose practice these cases
occurred, to state the following particulars regarding them :-3
CASE II.-A lady, aged about 36, and the mother of six children, after having
had the catamenia obstructed for three months, was attacked on 16th November
1845, with symptoms of abortion. On the 17th, the os uteri was open, and large
coagula were expelled. In three or four days she was so far recovered as to require
no more medical care. On November 23d, the patient suffered under some degree
of sore throat and stiffness of the jaws. Early next morning, when Dr. Wood
visited her, he found the rigidity of the jaws so considerable, and the difficulty of
opening the mouth so great, that it was impossible to get an inspection of the
throat. The pulse was 80, soft and compressible. During the day the stiffness
of the jaws increased, acute pain of the spine was complained of; the abdominal
muscles were rigid; and swallowing became difficult. General tetanic spasms
supervened in the evening, and notwithstanding the employment of turpentine,
tobacco, Indian hemp, etc., the disease contined to increase, and she died on the
evening of the 26th.
CASE III. In this case the tetanic attack was still longer in supervening
after the abortion. Nearly a fortnight after an early miscarriage, and when the
patient was considered well, she was suddenly attacked with symptoms apparently
of cynanche parotidea. On the second day, Dr. Malcolm found his patient un-
able to open the jaws. On the third day, the symptoms were all much aggra-
vated; and on the fourth day, she was seized with general tetanic spasms, which
recurred again in two hours with increased violence, and then proved fatal in the
course of a few minutes. Dr. J. Duncan, and one or two other medical gentle-
men, saw this lady in the first of these general tetanic paroxysms, during Dr.
Malcolm's unavoidable absence at an obstetric case.
In the following instance the ovum was at least partially sepa-
rated, as shown by the attendant hemorrhage and by a segment of
1 See Aetius' Tetrabibl. ii. sec. ii. cap. 39.
2 De. Causis Acutorum Morborum, lib. i. cap. 6; vol. i. p. 2, of the Latin
edition in the Medicæ Artis Principes.
3 Notes of these two cases have already appeared in the published Proceedings
of the Obstetrical Society. Edinburgh Monthly Journal, April 1850, p. 387.
{
PUERPERAL ETC. TETANUS.
573
it being felt protruding through the os uteri. In all probability it
passed-as ova in early abortions sometimes do-when the bowels
or bladder were evacuated, and unobserved by the patient's im-
mediate attendants. If not, the case must be reckoned one of fatal
tetanus, with the ovum partially separated, but not expelled. I
have been favoured with the notes of it by my friend, Dr. Hislop of
East Linton, in whose practice the case occurred.
CASE IV. The mother of a family, who had never aborted previously, had
not menstruated for nine weeks, when she was seized with a considerable loss of
blood from the vagina, which left the pulse quick and feeble. The bleeding soon
ceased, but next morning Dr. Hislop found the pulse at 120, the os uteri relaxed
and open, and a soft mass protruding through it. He introduced a sponge into
the vagina to restrain the hemorrhage, which had recurred to a slight extent, and
gave the patient some small doses of ergot of rye, to expel the ovum.
The mem-
branes were not observed in the vaginal discharge, but the convalescence of the
patient went on satisfactorily, till six days subsequently, when she first complained
of "weakness of the lower jaw." Next morning the jaw felt stiff, and could not
be opened more than half. The patient herself became anxious and alarmed. In
the evening any attempt at swallowing produced a sensation of choking; and
there was a copious secretion of viscid saliva. On the following day the jaw was
still more fixed, swallowing became impossible, tetanic spasms began to affect the
back of the neck, and subsequently they stretched to the chest, back, and ex-
tremities. By night the opisthotonos was complete, the spasms increased in
severity, the pulse rose to 160, her mind, however, remaining quite clear; and she
expired next morning, or on the third day after the tetanic symptoms began.
The treatment principally consisted of large opiates, interrupted during the
second day of the attack, till the bowels were acted on by a dose of croton oil, and
by turpentine enemata.
Tetanus, when it has taken place in obstetrical practice, has
apparently been repeatedly mistaken, in its earliest stages, for an
attack of cynanche (as in the first case I have detailed); or even
oftener, perhaps, for some irregular form of hysteria. It is only
after the tonic spasms have passed to other muscles than those of
the jaw and neck, that the actual presence of such a fearful and fatal
malady has in general been fully realised by the mind of the medical
practitioner. The notes of the following case, obtained for me by
Dr. Symonds, and drawn up by a medical gentleman, a near relative
of the patient, afford an instance in point. The case also offers
another example of the fact, that amid the mortal and agonising
struggles of the patient, the reason and intellect often remain clear
and unclouded up to the last fatal spasm-the disease being
originally and truly an affection of the reflex spinal system and not
of the brain.
CASE V.-A lady, aged 41, of a delicate and nervous temperament, and the
mother of six children, miscarried at an early period of pregnancy (17th Nov.
574
THE PUERPERAL STATE.
1849). So much hemorrhage occurred that it was necessary to use the tampon.
During the following week she suffered severely from the effects of loss of blood,
and was especially troubled with palpitation, headache, and a sensation in the
throat resembling the hysterical globus. On the morning of November 25th, or
seven days subsequent to abortion, she experienced a difficulty in deglutition and
a stiffness in the jaws and neck, which gradually increased and became paroxysmal
in their character, leaving eventually no doubt of the existence of true tetanus,
though it had been hoped previously, that hysteria, with the addition of “a stiff'
neck" from catching cold, would explain ail. The existence of complete trismus
subsequently formed a leading feature throughout. Deglutition, too, was much
impeded at an early period, and soon became almost impracticable. The muscles
of the neck, chest, and abdomen, were fully affected with the tetanic spasms; but
not those of the back or extremities. Towards the termination of the case the
larynx became involved, and the paroxysms of strangulation, several of which
occurred before death, were agonising in the extreme. The spasmodic exacerba-
tions, irrespective of these laryngeal paroxysms, were very severe. About sixty
hours from the commencement of the tetanic symptoms, death relieved the poor
patient from her sufferings, in a paroxysm of strangulation. The mind and
reason were unaffected to the very last.
There is a case of fatal tetanus after abortion mentioned by
Velpeau in his Essay on Puerperal Convulsions,' where the first
symptoms of the disease were overlooked as unimportant. The
details given by Velpeau are as follow :-
CASE VI. At the commencement of the year 1834, a young woman entered
as a patient at the Hôpital Cochin, in consequence of a miscarriage. After some
little time she was seized with trismus, to which little attention was paid. It was
thought even that she complained without reason, and that she suffered less than
she professed. A change in the service about this time occurring, she was in
some sort forgotten. Nevertheless, these convulsive movements spread little by
little, although slowly, to all the other parts of the body. Several bleedings were
employed, but nothing was able to arrest the progress of these symptoms, and the
unhappy woman died in a complete state of opisthotonos. No manifest lesion was
found upon the dead body. The uterus, the brain, the spinal cord, and the vis-
cera, appeared in a normal condition.
The symptoms of tetanus are liable to considerable variations in
different cases. The following case of fatal tetanus connected with
abortion, for the notes of which I am indebted to a very accurate
observer, Dr. Ritchie of Glasgow, is remarkable as one of the rare
instances in which the spasmodic paroxysms affected, during one
period of the disease, the muscles that open the lower jaw, instead
of, as usual, the muscles that close it :-
CASE VII. Mrs. --, aged 40; the mother of seven children; eccentric
and nervous; when in the third month of pregnancy was exposed to sudden
mental agitation. On the instant she had a flow of blood from the vagina. This
1 Observation 21, p. 232.
PUERPERAL ETC. TETANUS.
575
ceased on lying down, when the os uteri was found shut, but the cervix bulky.
Next day, on removing a tampon which had been left at the previous visit in the
vagina, it was found that the os uteri could easily admit the finger, that the mem-
branes were tense, and that there was no bleeding. The plug was re-introduced,
and, soon afterwards, the membranes gave way, the rupture being accompanied
by a loud noise and a discharge of watery blood and some clots. The tampon was
again had recourse to, but about ten in the evening, much suffering being caused
by it, the patient withdrew it. This was succeeded by profuse hemorrhage and
alarming faintings till two A. M. There was no evidence of the expulsion of the
ovum excepting the appearance of some shreds of decidual membrane, although it
was possible that such might have been passed unseen in the clots.
From this day, the discharge ceased, the os uteri closed, and there was every
symptom of convalescence, except that the neck of the womb continued to be
bulky. Some clots passed from the vagina on the 11th day; and next day, while
about to chastise a child, she was seized with locked jaw, succeeded by a sense of
suffocation in the throat, and, two days after, by tetanic spasms or cramps in the
muscles of the neck and back, and by acute shooting pains in the articulations of
the lower jaw.
She was put on a course of calomel and opium with croton oil. The mouth
became sore on the 3d day of the tetanic attack, and dysentery also set in, appa-
rently from the oil. The spasms of the neck and face continued, although rather
less intensely. Some fetid clots escaped from the uterus. She was now put on 25
drops of laudanum every three hours, the former medicine being omitted. On the
4th and 5th day of the disease the tetanic spasms ceased, and the dysentery also
had disappeared. The opium was discontinued.
But during the course of the 6th day after the commencement of the tetanus,
she was again accidentally excited, and in consequence seized with general rigidity
of the muscles of the body. The mouth was thrown violently and widely open,
the face became livid, spasmodic movements of the limbs succeeded, with complete
insensibility, lasting for about half-an-hour. These paroxysms were succeeded by
intervals in which the jaw became firmly closed, and she was affected with convul-
sive jerking movements, occasioned apparently by contraction of the extensor
muscles of the back.
During the ensuing twenty-four hours she suffered from about four or five of
the first-mentioned seizures; and in the intervals her head was violently drawn
backwards every few minutes, occasioning a sensation at the throat as if she were
about to be strangulated. The severe fits usually began with a sense of constric-
tion at the chest and of a want of air. She died at last in one of these fits, on
the evening of the 7th day from the first commencement of the tetanic symptoms.
In some of the preceding instances of tetanus following early
miscarriage, there was nothing particular in the phenomena of the
abortion, and nothing special in the treatment which the cases
required. In fact, in several of the examples adduced (as in Nos.
II. III. and VI.), no medical or obstetric treatment seems to have
been called for during or after the miscarriages-the cases being in
all respects simple and uncomplicated. But in others (as in Nos.
IV. V. and VII.), there was one special complication present-viz.
hemorrhage, and one special and effective mode of arresting it
adopted-viz. plugging the vagina. I do not allude to these
576
THE PUERPERAL STATE.
instances as any certain evidence that either this special symptom or
special treatment were connected, in the way of causation, with the
subsequent occurrence of the tetanus. The vagina is daily plugged by
obstetric practitioners, to restrain hemorrhage both from the unim-
pregnated and pregnant uterus, without any such evil consequences
following; but we have so far a certain amount of proof, in these
instances, that tetanus, after abortion, is more particularly liable to
supervene, either where the uterine surface is in such a state of
injury and lesion as to lead to the protracted continuance of hemor-
rhage, or where the maternal canals have been irritated by the
tampon, when used as a mechanical means to diminish and arrest
that hemorrhage. Dr. Adams of Lanark has furnished me with
notes of a case of fatal tetanus after abortion that occurred in his
practice when he was settled in Glasgow, which affords an illustration.
of the disease supervening upon the arrestment of the attendant
degree of puerperal flooding. The patient was, in Dr. Adams' absence,
attended by Mr. Crossken, who has drawn up notes of the symptoms
and post-mortem examination.
CASE VIII.--Mrs. the mother of several children, had a miscarriage at
the third month. A slight degree of hemorrhage followed. On the eighth day
after the abortion this discharge suddenly ceased, and a feeling of stiffness soon
after supervened in the masseter muscles. Next day the jaws were quite locked,
and the head was bent backwards with tetanic spasmns, the muscles of the jaw and
neck being fixed and rigid. The eyeballs were also sunk, and the eyelids partially
closed. The patient, however, was able to speak; but the deglutition of fluids
was impossible. The pulse was 72; the bowels constipated and flatulent; and
the urinary secretion natural. There was no discharge from the uterus, and no
uneasiness or pain in that region. The pulse betimes became weaker, and the
tetanic paroxysms more and more severe and frequent; and she sank and died in
about seventy hours after the appearance of the first symptoms of tetanus.
The body was examined by Mr. Crossken and Dr. Fleming about
thirty-six hours after death, and as the morbid appearances were in
some respects peculiar, I will state them in Mr. Crossken's own
words. "The uterus," he reports, "was about the ordinary size.
Its substance and internal lining membrane were emphysematous
throughout, full of air-vesicles, and crepitating under the fingers.
In fact it was like a piece of lung, and resembled it also by floating
in water. There was, however," he adds, "no appearance whatever
of decomposition."
In surgical pathology, inquiries have been repeatedly instituted,
with the view of ascertaining if there was any kind of settled con-
PUERPERAL ETC. TETANUS.
577
nection between the existing state of the wound and the occurrence
of tetanus, but without much success. For surgeons seem gener-
ally agreed upon the fact, that while the tetanic disease very fre-
quently supervenes when the external wound appears in all respects
perfectly healthy, in about an equal proportion of other instances
it comes on when the wound is unhealthy, or inflamed, or sloughing.
In some of the preceding examples of obstetrical tetanus superven-
ing after miscarriage, the lesion or wound, left on the interior of
the uterus by the abortion, seems to have been in a “healthy
state," as far as could be ascertained; in others it was so far un-
healthy, as to have been a source of morbid sanguineous oozing
and hemorrhage. In none of the examples of obstetrical tetanus,
included in this or in the next division, does there appear to have
been any tendency to inflammation of the uterus as an antecedent
to the occurrence of tetanus.
III. TETANUS AFTER PARTURITION.
Puerperal tetanus, when following parturition at or near the
full time of pregnancy, seems to be guided, in regard to the period
of its supervention, by the same laws as regulate the occurrence of
the disease after abortion, or after surgical operations and injuries.
Under all of these conditions the tetanic attack usually does not
commence till about a week after the occurrence of the exciting ob-
stetrical or surgical lesion. According to some statistics published
by Romberg,' in more than half of all instances of surgical tetanus—
or in 112 out of 208 cases collected by him-the attacks set in
between the 3d and 10th days after the receipt of the injury, or
the occurrence of the operation. The same period includes the
dates at which the tetanic seizure usually took place in the examples
of obstetrical tetanus which I have already detailed, as well as in
those which I have collected under the present head. In the fol-
lowing instance, which occurred in the practice of my friend, Dr.
Lyell of Dundee, the tetanic symptoms began on the sixth day
after delivery at the full time, and when there was apparently nothing
unusual in the labour itself, or in the puerperal state of the patient,
to excite the disease.
CASE IX. A patient, aged 25, was delivered of her first child at the full
term of utero-gestation, without any unusual complication, the labour being
easy, and only of seven hours' duration. On the sixth day after her accouche-
1 Manual of Nervous Diseases, vol. ii. p. 105.
578
THE PUERPERAL STATE.
ment, stiffness of the muscles of the back came on, followed by symptoms of
trismus, which daily increased. On the third day of the attack, on attempting
to swallow, strong opisthotonos at length supervened, the head being drawn back
between the shoulders. The tetanic symptoms went on increasing, till the patient
sank on the sixth day of the disease (the twelfth from delivery). The treatment
consisted principally of large opiates; but they failed either in procuring sleep or
in relieving the tetanic spasms. Venesection also, and turpentine in the form
of enema, were tried. The child (a female) was living, and afterwards throve
well. There was," adds Dr. Lyell, "no perineal laceration or other injury to be
ascertained."
In the following case of puerperal tetanus, reported to me by
Dr. Lever of Guy's Hospital, in addition to the usual lesions left by
delivery in the interior of the uterus, there existed also, as possible
traumatic causes of the disease, lesions or injuries of the maternal
passages and perineum :—
CASE X.-A mother, about seventy-two hours after delivery, was attacked
with tetanus. The disease presented all its most characteristic symptoms. In
this patient, laceration of the vagina and perineum had occurred during the pro-
cess of labour. Opium was given in large quantities; but the disease proved
fatal in three days. The child also died, affected with trismus and jaundice.
I have already alluded to the circumstance that an unusual de-
gree of hemorrhage, and the use (sometimes prolonged) of the
vaginal plug, seem to have been precedents to a considerable num-
ber of the instances in which tetanus appeared in connection with
early abortion. In the two following cases of tetanus after parturi-
tion at the full time, the same or similar causes were also antecedent
to the occurrence of the fatal attacks of this disease. For the notes
of the first example I am indebted to Dr. Mackinlay of Barrhead ;
the second has already been placed on record by Dr. Storer of
Boston.
CASE XI.-A mother, aged 27, was delivered, at the full time of pregnancy, of
her second child, on the 2d February 1852. She made for three or four weeks a
fair recovery; but suddenly, after some physical over-exertion and much mental
disquietude, she was attacked with secondary uterine hemorrhage on the 27th
February. The flooding was so great as to require the vagina to be plugged by a
surgeon, who was called in. He left the plug in the vagina for two or three days.
On the 5th March, stiffness about the face and neck came on. Early next morn-
ing the trismus was very marked; and she continued to show, in an increasing
degree, all the characteristic symptoms of tetanus, up to the 8th March, when
death put an end to her sufferings. The tetanic spasms principally showed the
opisthotonic form.
CASE XII. Mrs. C▬▬, aged 28, and the mother of two children, was de-
livered at the full time of an infant that weighed eight pounds. The umbilical
cord broke off near its origin in endeavouring to extract the placenta. After
some unsuccessful attempts to detach the afterbirth, it was considered proper to
PUERPERAL ETC. TETANUS.
579
·
desist from further efforts. The attendant hemorrhage was slight. During the
five following days the pulse remained good, and the patient free from fever or
uterine pain. Towards the commencement of the sixth, a fragment of placenta
was removed from the vagina, and after the use of ergot two other placental masses
were expelled-decomposing, and offensive in smell. On the seventh day the
pulse was, for the first time, above 100, small and wiry; and the patient com-
plained of pain in the head, considerable stiffness of the jaws, and a difficulty of
swallowing. These symptoms rapidly increased during the day, and at night the
tip of the tongue could scarcely be protruded between the teeth. The muscles of
the neck and jaws had also become much more painful; the respiration was
laborious; and, at irregular intervals, tetanic spasms were present. Next day,
the eighth after the birth of the child, the muscles of the face were so rigid that
the jaws could not be separated in the slightest degree. The merest touch seemed
to distress the patient, and to hasten on the spasmodic attacks, which recurred
every few minutes. The head was retroverted upon the pillow; and so firmly
contracted were the muscles of the neck, that when the hand was placed behind
her occiput, the whole body was brought forward, the neck not being flexed in
the slightest degree. When the spasms were present, the patient's sufferings
appeared to be extreme. The paroxysms increased in frequency until about mid-
night of this, the eighth day after parturition-when she sunk, exhausted by
opisthotonos. Throughout, there were not any symptoms of uterine or peritoneal
inflammation.¹
External injuries and lesions form certainly the most common
sources of tetanus. And next in frequency as an exciting cause of
the disease, authors usually reckon exposure to cold, or rather to
currents of cold and damp air-especially if the person has,
immediately before this exposure, been overheated or perspiring.
Wounds may lead to tetanus without any exposure to cold; and
exposure to cold sometimes leads to tetanus, without the presence
in the body of any appreciable lesion. But though these two
sources of tetanus may each confessedly lead to the production of
the disease quite independently of the other, their combined action
far more frequently leads to this result. Most of our surgical
authorities, who have seen much of tetanus in practice, agree in
stating that in surgical subjects the disease has very often been ob-
served to occur immediately after those bearing surgical lesions
upon their body have been accidentally exposed to cold currents, or
to sudden changes of temperature. The same fact seems also to
hold good with regard to puerperal tetanus. In one of the cases
already detailed (Case II.), Dr. Wood found that, a few hours before
the patient was attacked with tetanus, she had thrown her window
open, and dressed her hair, exposed to the draught of cold air
from without. In the three following cases of puerperal tetanus, all
of which occurred in the practice of one physician, Dr. Aubinais of
1 American Journal of Medical Science for January 1842, p. 97.
38
580
THE PUERPERAL STATE.
Nantes,' sudden exposure to cold seems to have been instrumental in
lighting up the tetanic attack.
CASE XIII. In a primiparous patient, the milk-fever was high on the fourth
day, when the woman, æt. 30, crossed a wet floor, with her feet naked, and while
her skin was covered with perspiration. She was speedily seized with prolonged
shivering, abdominal pain, and suppression of the lochia; and gradually the
tetanic condition, commencing with difficult deglutition, markedly prevailed,
inducing a slight degree of emprosthotonos. She died seven days after tetanic
symptoms began.
CASE XIV.-A woman, æt. 34, while in a state of perspiration, exposed
herself to wet and cold four days after her confinement, with the effect of
suppressing the lochia. Tetanic symptoms appeared twenty-four hours sub-
sequently, and soon became strongly developed. The disease obstinately resisted
the most active treatment until the tenth day, when it began to yield, and the
patient ultimately recovered. She was bled six times, 100 leeches were applied,
and musk and valerian were afterwards given.
CASE XV.-A poor woman, æt. 28, having suffered from an attack of
eclampsia, for which she was bled, was delivered a few days afterwards of a seven
months' child. She went on very well until the fifth day, when, having drunk
a large quantity of cold water, she was seized with shivering, followed by trismus
and difficult deglutition. These symptoms went on to complete tetanus. On
account of her enfeebled state, blisters were alone resorted to, and the lochia were
restored by warm baths. The spasmodic symptoms did not abate for twenty
days; and forty elapsed before she was quite restored.
The author of the article on Tetanus in the Dictionnaire des
Sciences Médicales, M. Fournier-Pescay, mentions an instance, similar
to the above, in which exposure to cold acted apparently as the
more immediate excitant of an attack of this disease in a puerperal
patient.
Ten or
CASE XVI.-A woman, sixteen days after her confinement, was for a short time
exposed to cold and cold draughts. She experienced at the time a sensation
great chilliness; and suppression of the lochia suddenly followed.
twelve hours subsequent to this exposure all the muscles of her body were
powerfully contracted (fortement contractés). She was bled with the lancet,
leeches were applied to the vulva and epigastrium, and emollient tepid drinks
and baths were employed. Under their use the patient's symptoms disappeared,
while the lochial discharge became re-established. 2
In a case of puerperal tetanus, published from the notes of the
late Mr. Colles of Dublin, exposure to cold seems also to have been
considered as an important link in the excitement of the attack.
CASE XVII.—A woman who had been delivered a fortnight before of her
sixth child, was exposed to cold. That same evening she felt tightness of her
¹ Revue Médico-Chirurgicale, tom. v. p. 149. British and Foreign Medical
Review for July 1869, p. 146.
2 Dictionnaire des Sciences Médicales, vol. lv. p. 15.
PUERPERAL ETC. TETANUS.
581
jaws, and was ordered opium, and mercurial ointment. Next day she could
open her mouth better, but during it had two or three tetanic paroxysms, and died.¹
2
In the case which I have just cited from Mr. Colles, the disease
occurred in June; and there seems to be a prevalent idea in the
profession that tetanus is more common in our own climate in the
warm than in the cold months of the year; in summer more than
in winter. But the idea is of very doubtful accuracy. In one of
the Registrar-General's Official Reports there has been published a
table showing the relative number of deaths produced by different
special diseases in London during the four different quarters of the
year, and from 1840 to 1847 inclusive. During these seven years
179 individuals died in the English metropolis of tetanus.
Of
these 179 cases, 49 occurred during the spring quarter of the year
ending with March; 37 during the summer quarter ending with
June; 34 during the autumn quarter ending with September; and
39 during the winter quarter ending with December. Such facts
show, beyond cavil, how very little influence, if any, season has
upon the frequency of tetanus in our own climate.
Traumatic tetanus is a disease which is generally alleged by
pathologists to be more common in warm than in temperate
climates, a result to which various causes may contribute, besides
the mere amount of heat. And puerperal, like surgical tetanus,
would appear to occur more frequently under the tropics than
with us.
Thus, in some remarks which Dr. Christie has pub-
lished on tetanus in Ceylon, he casually observes, that he had
occasion to treat a case of tetanus consequent on parturition,
"which," he adds, "the native practitioners of Ceylon inform
me is not an unfrequent occurrence here." Dr. Christie gives
the following particulars regarding this instance of puerperal
tetanus:
CASE XVIII.-"A healthy woman of the Portuguese caste was, two days
after delivery of her first child, seized with rigidity of the jaw, and other
symptoms of tetanus. The native doctors and midwives," continues Dr. Christie,
immediately pronounced her incurable, and their predictions were fulfilled.
She was in vain treated with mercury, opium, and the warm bath.”3
Individual examples of puerperal tetanus among the inhabitants
of tropical climates are sometimes incidentally alluded to in the
writings of those who have practised in these climates. Thus-
1 Dublin Quarterly Journal, No. xxx. p. 288.
2 Ninth Annual Report, p. 151, etc.
3 Edinburgh Medical and Surgical Journal, vol. viii. p. 415.
582
THE PUERPERAL STATE.
CASE XIX. In a communication' upon tetanus, Mr. Dickenson, surgeon in
Grenada, reports concisely the histories of thirty-three cases of the disease which
he met with during the time he was in practice in the West Indies. One of these
cases of tetanus occurred in a female after delivery. The patient-a black-was
seized with the disease soon after parturition, and died on the fifth day from the
commencement of the malady. The treatment consisted of blisters, mercurial
friction, and laudanum.
Puerperal tetanus has occasionally been observed to supervene
after cases of operative midwifery. An instance in which tetanus
succeeded delivery by turning, in a case of placental presentation,
has been recorded by Mr. Finucane of Nenagh. The case is further
remarkable in consequence of the extreme rapidity (if the reporter's
data are given correctly), with which the tetanus ran through its
brief and fatal course.
CASE XX.-A patient, in her fifth confinement, was attacked during labour
with much flooding. On examining, Mr. Finucane found the placenta attached
to the cervix uteri, and in consequence proceeded to extract the child, which was
still-born, by the operation of turning. Four days afterwards, she had a violent
rigor, followed by perspiration, which returned slightly on the following day.
On the evening of this (the fifth day after delivery), the patient began to complain
of stiffness about the articulations of the jaw, with pain in the back part of the
head and neck. Early on the following morning the lower jaw was found com-
pletely fixed, and the patient was suffering under complete opisthotonos, the
body resting on the heels and occiput. Every attempt to drink excited violent
spasms, and the patient died in a few hours. The tetanus ran throughout its
fatal course in little more than fifteen hours.
The Cæsarean operation has, from the earliest annals of French
surgery up to the present time, been performed many times in Paris.
The present distinguished Professor P. Dubois has himself, I believe,
operated on eight patients. But it is a remarkable fact, that not a
single instance of recovery from the Cæsarean section is known to
have ever occurred in the French capital. The case in which the
patient survived for the longest time, at least of late years, was one
operated upon in 1839, and where ultimately the woman died of
tetanus, seventeen days after the performance of the Cæsarean
section. The following are the principal points connected with this
instance of the disease :-
CASE XXI.-On the 22d January 1839, Professor Dubois extracted a living
child by the Cæsarean operation from a deformed dwarf. Febrile and inflamma-
tory symptons speedily set in; but by the 31st, these had, in a great measure,
disappeared; the pulse was 110, and the patient's appetite had returned. The
patient's state continued to improve still more up to the 5th February, or till the
1 London Medical Repository, vol. i. p. 192.
2 Lancet for June 2, 1838, p. 388.
PUERPERAL ETC. TETANUS.
583
fourteenth day after the operation, when general uneasiness and stiffness in the
movements of the jaw came on. The masseter muscles were soon affected with
violent contractions; the poor patient was unable to drink; and the symptoms of
tetanus became clearly established. The disease continued up to the 9th, the
tetanus affecting principally the muscles of the jaw and neck; fits of suffocation
supervened, and the patient at last sunk on the seventeenth day after delivery,
and the fourth after the first commencement of the tetanic symptoms.
At the time the tetanus began, the abdominal wound was already
completely healed, except at its lower angle. On dissection, the
original wound in the uterus was found closed, not by the union of
the edges of the cut uterus, but by their close adhesion to the
anterior wall of the abdomen, to the posterior wall of the bladder,
and to a fold of intestine. Several small abscesses existed among
the peritoneal adhesions. In the spinal marrow nothing was found
except a very slight and doubtful softening at one point.¹
In the following instance of tetanus supervening in a patient
who had been previously the subject both of a surgical operation
and of parturition, it is difficult to say whether the fatal attack of
tetanic disease belongs to the class of surgical or of obstetric cases,
or pertains to either. The disease set in at an unusual distance of
time after parturition, and at a still longer date after the surgical
operation.
CASE XXII.-In 1809, Mülder of Gröningen excised the knee-joint of an adult
female, in whom articular disease had been of long standing. Great irritative
fever followed at the end of nine days; and, later, she suffered intensely from the
knee, and from hectic fever. At the lapse of two months after the operation, she
was delivered of twins, and ultimately she died from tetanus, seven weeks after
delivery and fifteen weeks after the operation for excision.
Let me. make one further remark before closing this list of
instances of puerperal tetanus. Occasionally cases of death from
tetanus after delivery are referred to in English official and tabular
records, without any special details in regard to them being given.
The following two or three instances are examples of this remark,
and afford additional evidence of the fact that puerperal tetanus is
not so very rare as the total silence of obstetric works on this sub-
ject might lead us a priori to suppose.
CASE XXIII. The late Dr. Merriman, in his Synopsis of Difficult Parturition,
has published a table of the causes of death in childbed, among 10,190 patients
3
1 Lancet for 29th February 1840, pp. 821-852.
2 Wachter's Dissertatio de Articulis Extirpandis, Gröningen, 1810.
3 Synopsis of Difficult Parturition, p. 339.
584
THE PUERPERAL STATE.
attended by one physician. There occurred 107 maternal deaths in this long list
of deliveries. One of these puerperal deaths is noted as having been produced by
"locked jaw." But no particulars are given.
CASES XXIV. XXV.-From the Fourth Annual Report of the Registrar-
General, it appears that, in the course of the year 1840, 140 of the inhabitants of
England and Wales died of tetanus. The sex of the patients, in 116 of these cases,
is given in the report. Of these 116 patients, ninety-six were males, and twenty
were females.
The causes which led to the attacks of tetanus, in this long list of
cases, are, of course, not specified. But, incidentally, it is stated in the Report'
that two of the deaths from tetanus occurred after parturition, "lock-jaw caused
by childbirth" being reported in two cases in which the patients were aged “34
and 35 years." Thus, out of the twenty cases of fatal tetanus among females
during that year, two at least, or 1 in 10, were cases of puerperal tetanus.
The relative frequency or rarity with which tetanus occurs in
obstetrical, as compared with surgical practice, could perhaps be
properly ascertained by an analysis of the official returns given in
for a few years to the Registrar-General of all deaths from this
disease. And certainly the investigation would form an interesting
point of inquiry in puerperal pathology.
NATURE OF PUERPERAL TETANUS.
It will be granted, I believe, by all pathologists that the existence
of an injury or wound upon the external parts of the body is by far
the most common cause of tetanus. After abortion and parturition
we have the existence, upon the interior of the uterus, of a similar
state of lesion. All authorities seem now generally agreed as to the
facts-(1) that the human decidua is, as was maintained in the
last century by Krummacher, the thickened and hypertrophied
mucous membrane of the uterus; (2) that the epithelial or super-
ficial layer of it separates from its basement, or outer, layer, in
abortion and after delivery; and (3) that this separation or solution
of continuity of tissue, as well as the rupture of the organic attach-
ments of the placenta from the uterus, leaves the interior of this
organ so far in the condition of an external wound, or with a new
or raw surface for the time being exposed. Obstetrical tetanus has,
in this respect, an exciting cause essentially similar to surgical tetanus.
And perhaps the great reason why this state of lesion of the interior
of the uterus does not more frequently give rise to tetanus is simply
1 Fourth Annual Report, p. 224.
2 Membrana decidua "proprie est membrana uteri interna, quæ post concep-
tionem intumescit et crassescit, usque ad tertium circiter graviditatis mensem,
etc.”—See Krummacher's Dissertatio circa Velamenla Ovi Humani, 1790.
PUERPERAL ETC. TETANUS.
585
this, that the uterus is itself principally, or indeed almost entirely, sup-
plied by nerves from the sympathetic system, while apparently, as
stated by Mr. Curling and other pathologists, tetanus is an affection
far more easily excited by lesions of parts supplied with nerves from
the cerebro-spinal system, than by lesions of parts supplied with
nerves from the sympathetic system.
1
Tetanus is known to follow wounds very various in their degree
and severity. "Whether," says Professor Wood, "the wound is
trifling or severe seems to be of little consequence," so far as regards
the supervention of secondary tetanus. By what pathological me-
chanism a wound or lesion of a part can, under any circumstances,
lead to an attack of tetanic disease, is an inquiry regarding which
we as yet possess little information; and in this respect the pro-
duction of obstetrical tetanus is not more obscure than the produc-
tion of surgical tetanus.
The disease, when developed, essentially consists of an exalted
or super-excited state of the reflex spinal system, or of some seg
ment or portion of that system. What circumstances in midwifery
or surgery might possibly, either singly or in combination, produce.
this state, and so produce traumatic tetanus? In relation to this
question I will venture to make one or two hypothetical remarks.
1. We have in obstetric pathology evidence almost amounting
to certainty that the analogous super-excitable state of the cerebro-
spinal system of nerves which gives rise to eclampsia or puerperal
convulsions is generally produced by the existence of a morbid
poison in the blood. And it seems not impossible that the genera-
tion of a special blood-poison, at the site of the wound or elsewhere,
may sometimes in the same way give rise to obstetrical and surgical
tetanus. We know, indeed, that the introduction into the blood of
particular vegetable poisons is capable of exciting an artificial disease
quite analogous to tetanus." Brucine and strychnine have both of
them, as is well known, this effect. Abundant experiments upon
the lower animals, and cases of poisoning in the human body, have
1 Practice of Medicine, vol. ii. p. 746.
2 Backer has shown that even after the spinal cord was divided in dogs, nux
vomica, taken by the mouth, produced convulsions in the paralysed lower limbs,
which it could only affect and reach through the blood.—Commentatio, etc., p.
139. On the other hand, Stannius found in the frog, that when the lower half
of the spinal cord and its nerves was merely separated from all connection with
the vascular system, no convulsions in the hind extremities followed the use of
strychnine, while the anterior extremities were affected as usual.— Untersuchungen
über die Rückenmark, etc., p. 50.
586
THE PUERPERAL STATE.
1
amply proved this. Tetanus is a frequent disease from wounds,
etc., in the horse and lower animals. Would it not, in relation to
the possible humoral origin of the disease, be worthy of trial whether
the blood of an animal dying of tetanus is ever capable by trans-
fusion of infecting another animal with the same malady? The
experiment is said to have succeeded with a disease having many
analogies with tetanus-viz. hydrophobia. But-
2. We know further, with regard to the tetanising effects of
strychnine and brucine, that these agents do not necessarily require
to circulate in the blood in order to produce their special effects.
In the lower animals, when strychnine or brucine is applied directly
to the spinal cord, tetanic effects speedily follow; and in all pro-
bability, when they are introduced into the blood, they produce
their tetanising consequences, by being carried in the current of the
circulation to the cord-thus toxicologically influencing it, as if they
were primarily applied to it. Centric irritation, or centric morbid
conditions of the cord (and, it may be, of the cerebro-spinal system),
may lead, according to these experiments, to tetanic disease, inde-
pendently of any morbid state of the blood. And, if the observa-
tions of Sims, Harrison, and others, are correct as to the occasional
mechanical origin of Trismus Nascentium from pressure and displace-
ment of the occiput upon the medulla oblongata, we have, in this
obstetrical instance, tetanus resulting-as it certainly sometimes does
under other circumstances-from direct injuries, or affections of the
nervous centres.
3. The appropriate and specific affection of the spinal cord, or
cerebro-spinal system, constituting traumatic tetanus, would appear
to be sometimes, if not always, a condition excited by some influ-
ence propagated upwards along the nerves, from the seat of the
injury or wound to the central portions of the nervous system. In
1 See details in the works on Toxicology. Thus, in a boy poisoned by false
Angostura bark, which contains both brucine and strychnine, Professor Emmert
found that when "he touched the patient's arm, in order to feel his pulse, a
sudden and violent tetanic spasm intervened; the eyelids opened wide; the cyes
projected rigidly and immovably; the lower jaw was firmly compressed against
the upper one; both lips separated from one another, so that the front teeth
were exposed; the different muscles of the face were tense; the extremities were
extended and rigid; and the spinal column and the head were violently drawn
back."-Romberg's Manual, vol. ii. p. 129.
In a number of frogs Stilling removed the heart, and, indeed, all the other
viscera, and applied to the exposed spinal cord a drop of a solution of acetate of
strychnine. All the animals thus treated were rendered tetanic in a few minutes.
The tetanus was universal over the system.
PUERPERAL ETC. TETANUS.
587
proof of this, we have the fact that occasionally, as in cases pub-
lished by Hicks, Murray, Larrey, etc., but not often, the artificial
division of the nervous communication between the seat of the
wound and the nervous centres has arrested the disease, when per-
formed in a very early stage of the attack. What the nature of the
transmitted influence may be, we have at present no means of judg-
ing. But we have analogies for the transmission itself in some of
the phenomena of electrical induction and propagation. And, let
me further add, that the symptoms of tetanus assimilate themselves
very greatly to a rapid succession of electrical or galvanic currents.
transmitted peripherally from a nervous trunk or centre to the sets
of muscles affected.
At the present time various physiologists are busy with recondite
inquiries into the laws pertaining to the electro-motive powers of the
nervous and muscular systems of the body. When our knowledge
of these laws is more advanced, physicians will, perhaps, be able to
deduce from them a more correct and true pathology of tetanus and
other convulsive diseases.
TREATMENT OF PUERPERAL TETANUS.
According to Mr. Curling, tetanus is not only less frequent in
women than in men, but it is also "less fatal in the female than in
the male sex.'
,, 1
Out, however, of the preceding list of twenty-four cases of obste-
trical tetanus, only three recovered (Nos. XIV. XV. and XVI.);
and these under opposite modes of management. There are two other
cases on record of the successful termination of puerperal tetanus.
The two instances I allude to have been reported by Dr. Symonds
and Dr. Currie. The true tetanic character of both cases may per-
haps admit of some doubt.
In his article on Tetanus, in the Cyclopædia of Practical Medicine,²
Dr. Symonds of Bristol speaks of the first of these cases in the fol-
lowing words:-
CASE XXVI. "We remember," says Dr. Symonds, attending a young
woman, who was seized with lock-jaw soon after delivery of a still-born and pre-
mature fœtus; but the affection readily gave way to a turpentine injection, and
we looked upon it as a mere sympathetic accident."
The other case of recovery from puerperal tetanus, which I have
adverted to above, is mentioned by the late Dr. Currie of Liverpool,
1 Treatise, p. 29. 2 Cyclopædia of Practical Medicine, vol. iv. p. 874.
588
THE PUERPERAL STATE.
in an essay on the treatment of tetanus and other convulsive diseases
by the cold bath and cold affusion, which he published in the third
volume of the Memoirs of the Medical Society of London. In this
essay he details six instances of tetanus. He gives the few follow-
ing particulars regarding the puerperal case:-
CASE XXVII.-A poor woman, "in consequence of difficult labour, and, as
she imagined, of local injury in some part of the uterus, was seized with the
spasmus cynicus, locked jaw, and other symptoms of tetanus. She was imme-
diately taken to the cold bath, and thrown into it, with good effects. The spasms
disappeared, and though they afterwards returned in a slight degree, they gave
way entirely to a second immersion."
Supposing these two instances of recovery to have been instances
of genuine tetanus, it would still appear, from the evidence of all
the cases which I have collated, that puerperal tetanus is nearly as
fatal as surgical tetanus, for, out of the whole twenty-six examples
collected, twenty-one died and five recovered; or, the disease was
fatal in the proportion of four out of every five persons attacked.
Dr. Lawrie has calculated surgical tetanus to be fatal in seven out
of every eight who are seized; but, like Mr. Curling, he believes
surgical tetanus in females to be less fatal than this.
In such a communication as the present, it would be out of place
to dilate on all the means usually recommended for the treatment
of tetanus. Let me merely remark that, in obstetrical tetanus, no
kind of local treatment to the seat of the original uterine lesion
could be well applied, or would probably be of any avail, if applied.
And, as to constitutional means, perhaps the most important are-
1st, The greatest possible quietude and isolation of the patient
from all irritation, corporeal or mental, during the course, and for
some time even after the resolution, of the disease.
2d, The special avoidance of painful and generally impracticable
attempts at opening the mouth in order to swallow; but sustaining
the strength of the patient, and allaying thirst, by enemata, or by
fluids applied to the general surface of the body.
3d, If there is any well-grounded hope of irritating matters
lodged in the bowels acting as an exciting or aggravating cause, to
sweep out the intestinal canal at the commencement of the disease
with an appropriate enema.
4th, To relax the tonic spasms of the affected muscles, and
diminish the exalted reflex excitability of the spinal system by
sedatives, or antispasmodics; with the prospect of either directly
subduing this morbid reflex excitability; or of warding off the
PUERPERAL ETC. TETANUS.
589
immediate dangers of the disease, and allowing the case to pass on,
from an acute and dangerous attack, to a subacute, and far more
hopeful and tractable form of the malady.
Various sedatives and antispasmodics have been recommended
to fulfil this last most vital and important indication in the treat-
ment of tetanus-as belladonna, stramonium, hemlock, henbane,
musk, camphor, Indian hemp, hydrocyanic acid, valerian, camphor,
etc. Perhaps the two drugs of this class that have hitherto been
most used, and most relied upon, are opium by the mouth, and
tobacco by enema. But certainly we have no decided evidence of
the beneficial effects of opium, even in the most heroic doses; and
it seems doubtful even if this and other such medicines are readily
or at all absorbed from the stomach and upper part of the intestinal
canal in cases of acute tetanus. Tobacco in the form of enema has
doubtless often acted most favourably in arresting the spasms; but
it is a drug the action of which is not easily or safely kept up
with that degree of constancy which is required in acute tetanus.
Latterly, the antispasmodic action of sulphuric ether and chloro-
form has been repeatedly employed to allay that exalted state of
the reflex nervous system, and to relax that resulting tonic con-
traction of the maxillary and other muscles, which constitutes the
essence of tetanus. Medical men may yet discover therapeutic.
agents, to be introduced into the body by inhalations or otherwise,
the action of which will be as directly anti-tetanic in their effects, as
strychnine is directly tetanic in its properties; and such agents, if
they were otherwise innocuous, would form the proper remedies for
tetanus. Here, as elsewhere, in future, physicians will probably
seek for therapeutic remedies in the same way, and upon the same
principles, as toxicologists search for antidotes to poisons. Chloro-
form in sufficient doses acts as a direct sedative upon the reflex
nervous system, and upon exalted muscular contractility. In con-
sequence of this action, it affords us one of the surest and most
manageable means of allaying common convulsive attacks; and it
has now also, according to the reports in periodical medical litera-
ture, been repeatedly successful in the treatment of traumatic
tetanus,' whilst it has apparently also repeatedly failed in subduing
the more acute forms of the disease. Perhaps some of the failures
1 See, for example, Dr. Ranking's Abstract, vol. ix. p. 239 (three successful
cases); British and Foreign Medical Review for 1851, p. 464 (two succossful
cases), etc.
590
THE PUERPERAL STATE.
have arisen from the patient not being kept sufficiently deeply and
continuously under the action of the drug. If used in tetanus its
action will require to be sustained for many hours, or oftener per-
haps, for many days. And there is abundant proof of the safety
with which its continuous action may be kept up under proper care
and watching. For instance, a few months ago I saw, with Dr.
Combe, a case of convulsions of the most severe and apparently
hopeless kind in an infant of six weeks. The disease at once
yielded, and ultimately altogether disappeared, under the action of
chloroform, which required to be used almost continuously for
thirteen days; as much as 100 ounces of the drug being used
during the period. After all tendency to convulsions at last ceased,
the little patient rapidly grew, and is at the present moment a very
strong, healthy child. In a case of the successful treatment of
traumatic tetanus by Dr. Dusch, above sixty ounces of chloroform
were employed.¹ Let me close these remarks with a case of puer-
peral tetanus treated with chloroform.
CASE XXVIII. In the following letter, dated 20th January 1854, Professor
Lawrie of Glasgow has kindly communicated to me the encouraging results, so far
as they go, of an example of the disease which is at present under his care:-
"Mrs. B——, a fine young woman, æt. 24, in the third month of her third
pregnancy, miscarried on the 4th of this month (January 1854). She lost a con-
siderable quantity of blood, and required plugging, cold, and pressure, but was so
well on Sunday, the 8th, that I ceased my attendance. On Thursday, the 12th,
she complained of stiffness about the neck and lower jaw, but not suspecting the
nature of her illness, she did not send for me till late on Saturday, the 14th. I
found trismus well marked-the spasm not extending beyond the neck-and the
pulse nearly natural. Every attempt to swallow gave great pain, and produced a
spasm in the muscles of the neck and larynx, which threatened instant suffocation.
I forbade all attempts at swallowing, ordered nutritive enemata with 50 or 100
drops of laudanum every six hours, and pectra to the neck, with aconite and
chloroform. There was little change till the night of Monday, the 16th, when
the pulse had risen to 120, and the spasms had greatly increased, but had hardly
extended beyond the neck; deglutition was impossible. I immediately exhibited
chloroform, which acted admirably, and gave instant relief. I taught her husband
and mother how to use it, and she has since been more or less constantly, and
nearly continuously, under its influence. Thursday, 18th, the pulse was 96, and
she swallowed with comparative case. To-day, Friday, 20th, she is not quite so
well; the pulse is 108, and abdominal muscles rather tense, and the rectum will
not retain the enemata. For this last occurrence I was, of course, prepared ; and,
since the 15th, she has been carefully rubbed with oil, butter, and cream. She
still swallows tolerably well. My prognosis in this case was from the first serious
for although the pulse was natural, and the spasms had not extended beyond the
neck, deglutition was nearly impossible, and suffocation was often imminent. One
symptom I have forgotten, which is often one of the most distressing—a constant
¹ Ranking's Abstract, vol. xvii. p. 63.
ALBUMINURIA IN PUERPERAL MANIA.
591
cough from accumulated mucus, which cannot be raised or got rid of. In two days
it has disappeared. I now anticipate recovery. The treatment has been negative,
with the exception of the chloroform, which has been most useful. I attribute
the improvement on the 17th and 18th entirely to it; and if Mrs. B. recovers,
she will owe her life to your invaluable discovery."1
Even when not curative of tetanus, the use of chloroform has
proved of no small service in relieving the sufferings and agonies
of the patient. Thus, in a fatal case of puerperal tetanus already
detailed in a preceding page (Case V.), the medical gentleman who
drew up the case observes, "We had the just comfort of finding the
paroxysms materially alleviated by chloroform, which was used
during the last sixteen hours of the patient's life. Chloroform!
chloroform!' was the poor sufferer's anxious exclamation whenever
she felt the spasms impending, and comparative tranquillity speedily
followed its application each time." Our practical power over the
most rapid and fatal forms of tetanus perhaps amounts yet to little
more than a "meditatio mortis." But even to alleviate the suffer-
ings attendant upon such a dreadful disease, should we effect no
more, and to produce a state of euthanasia, is surely an object
worthy of the best-directed efforts of the medical art. "Physicians,"
says Bacon, “do make a kind of scruple and religion to stay with
the patient after the disease is deplored; whereas, in my judgment,
they ought both to inquire the skill, and to give the attendances
for the facilitating and the assuaging of the pains and agonies of
death.”²
ON THE CAUSATION OF PUERPERAL MANIA BY
ALBUMINURIA.³
In obstetric, as in medical practice, various cerebral and nervous
complications have of late years been traced to the previous exist-
ence of albuminuria. Thus, many cases of convulsions, coma,
amaurosis, etc., have been found to co-exist with and depend upon
those morbid states of the system which are connected with the
presence of albumen in the urine. In what exact pathological
relation the albuminuria stands to these various complications, it
¹ Subsequently to the publication of this essay in the Monthly Medical Journal
this patient sunk under the continuance of the disease.
3 Montagu's Edit. of Bacon's Works, vol. ii. p. 166.
3 See Proceedings of Edinburgh Obstetrical Society, session xvi., in Edinburgh
Medical Journal, February 1857, p. 761.
592
THE PUERPERAL STATE.
was not Dr. Simpson's present object to inquire. But he wished
to point out another morbid complication with albuminuria in the
puerperal state, in order that the subject may be fully investigated
as occasion occurs. In the last four instances of puerperal mania
which he had been called to in practice, albuminuria existed at the
commencement of the attack of each; and, when we see albuminuria
in the parturient female so often lead on to convulsions and coma,
we cannot be surprised at meeting with this other cerebral complica-
tion in connection with it. In one of these cases, puerperal
convulsions occurred before delivery, with very marked albuminuria ;
and, after a short period of convalescence and absence of the albumen,
acute puerperal mania set in, and the urine, on examination, again
proved highly albuminous. In another of the cases, there were two
sudden attacks of puerperal mania, with a week's interval between
them. At the commencement of both attacks, the urine was
charged with albumen, and in the interval was free from it.
In such cases, we shall probably only find the albuminuria in a
marked form, at or immediately after the commencement of the
attack of mania; and the co-existence of sleeplessness, and al-
buminuria or its symptoms, should always put us on our guard
against a maniacal attack. In the last case which he had seen, the
puerperal mania lasted for two or three weeks-the albuminuria,
which was at first well marked, disappearing before the restoration
of the mental powers.
PERINEAL FISTULA
LEFT BY THE TRANSIT OF THE INFANT THROUGH THE
PERINEUM.¹
The length of the perineum in the adult virgin female is usually
stated by anatomists to vary from one inch to one inch and a half ;
but it is very frequently found shortened in women who have borne
a family, from the liability of its anterior portion to become more
or less fissured and lacerated during the passage of the child's head
and shoulders.
In consequence of the natural shortness of the perineum, it looks
a priori almost impossible that the child and its appendages should
ever be propelled directly through it during labour, while the orifices
of the vulva and anus were left entire. But the state of the peri-
1 See Edinburgh Medical Journal, July 1855, p. 1.
PUERPERAL PERINEAL FISTULA.
593
neum is very different in the stage of labour immediately preceding
the expulsion of the child, from what it is in the non-parturient
condition. By the time the child's head at last fully dilates the
external parts in labour, the perineum is so stretched, that it
has become thin and lacerable, while, at the same time, it is enor-
mously increased and expanded in all its superficial dimensions.
The perineum when thus distended by the child's head has been
found to measure six inches in breadth, or from one tuberosity of
the ischium to the other; and in length three inches or more from
the posterior commissure of the vaginal orifice backward to the
anterior commissure of the dilated and elongated orifice of the rec-
tum; or as much sometimes as seven inches from the fourchette to
the point of the coccyx. When the perineum is thus attenuated
and expanded, like a thin cap placed upon the head of the child
previously to its expulsion, it is easy to conceive that a fissure occur-
ring in the centre of the stretched perineal structures would readily
enough tear and extend under the strong expulsive efforts of par-
turition, so as to allow the head of the fœtus to pass through the
accidental opening; and if the resulting lacerations assume, how-
ever irregularly, the forms of X, Y, or V, with their diverging lines.
passing somewhat on either side of, but without rupturing into, the
orifices of the rectum behind, or the vulva in front, we may have
the infant, cord, and placenta traversing the perineum, while the
rectal and vaginal canals remain entire and intact.
Instances in which the infant and its appendages were thus born
and expelled through a central aperture in the perineum, have been
published by Nedey, Coutouly, Merriman, and various other
accoucheurs; and references to most of the recorded cases of this
singular lesion are to be found in the writings of Moreau,¹ Du-
parcque, and Dr. Churchill, upon the subject.
2
3
None of these authors specially allude to any examples of a
fistulous opening remaining subsequently in the perineum, as a result
and a proof of the perforation of it in the process of parturition.
Such a result indeed appears to be very rare, in consequence of the
edges of the lacerated wound almost always perfectly uniting, under
common surgical care and treatment, subsequently to delivery. A
preparation in the Obstetric Museum of the University of Edinburgh
presents, however, an exception to this general rule, and is a well-
1 ¹ Revue Médicale for June 1830; or, Moreau's Traité des Accouchemens, vol.
ii. p. 462, etc.
2 Histoire des Ruptures de l'Utérus, p. 368, etc.
3 Diseases of Pregnancy and Childbed, p. 403.
594
THE PUERPERAL STATE.
marked instance of that rare lesion, viz. perineal fistula in the
female.
CASE I. The patient was attended during her first labour by a practitioner
in the west of Scotland. The labour
The labour-as he subsequently informed me—was
tedious, particularly during the advance of the head through the lower part of
the pelvis. After the perineum had become much stretched and distended by
the child's head, and when the artificial support of it by the hand happened
to be for a short time withdrawn, a very strong expulsive effort supervened, and
the practitioner was recalled to the patient in consequence of her loud cries. To
his surprise he found the head passing, or in fact, already nearly entirely passed
through a rent in the perineum; and the next pain expelled the body of the
child through the same opening. Through this same perineal perforation, the cord
and placenta were delivered. The sphincter ani and the anterior edge or four-
chette of the perineum remained untouched. The sides of the laceration did not
entirely unite. A year subsequently to her delivery, I saw her, along with the
late Dr. Dawson of Bathgate, under whose care she had come with symptoms of
phthisis. The perineal fistula still remained, and, as we found on a post-mortem
examination some months subsequently, it was about the size of the barrel of a
goose-quill. The opening was situated about half-an-inch behind the posterior
commissure of the vulva. The perineum was very thin at the site of the fistula,
and converging lines of old cicatrices were still visible on its mucous surface.
But its anterior edge, or fourchette, was strong and dense, and placed unusually
far forwards over the vaginal orifice.
I have only been able to find on record two other cases in any
way analogous, of perineal fistula originating in perineal perforation
during labour. They are described by Marter of Koningsberg¹ and
Halmagrand² of Paris.
CASE II.—In a primiparous woman, to whose assistance Marter was summoned
by a midwife, he found the head of the child already passing through a central
laceration in the perineum. The child was speedily pushed by the strong pains
that were present through the abnormal aperture, and the placenta afterwards
followed through the same crucial-shaped laceration. Inflammation of the lips
of the wound subsequently occurred, and, despite of the use of ligatures, a perineal
fistula remained, by which the menses escaped during the two subsequent years.
She then again became pregnant ;, and this second child was born naturally by the
vulva.
CASE III.—In 1838, a patient applied to Halmagrand, some time after delivery,
with a perineal perforation not yet cicatrised, and forming a communication with
the vagina. He cut the anterior bridle of the perineum, which was slender, made
raw the edges of the fistula, and brought them together by the apposition of the
thighs alone. Reunion and cicatrisation took place in a few days. The patient
was subsequently confined without any renewal of the perineal lesion.
To the preceding remarks, let me merely add that, as a means
of preventing central perineal laceration, and the chance, con-
sequently, of perineal fistula as a result, we have to trust to--1st.
¹ Siebold's Journal für Geburtskunde, vol. ix. p. 726.
2 Démonstrations des Accouchemens, p. 577.
DEFICIENCY AND EXCESS IN INVOLUTION OF UTERUS. 595
*
The common methodic manual support of the perineum, so as to
save excess of pressure upon it while at the same time we push the
head forward to the vaginal opening-a means which, in the practice
of Denman and Lachapelle, succeeded in preventing the child's
head from passing through the perineum, after its central structures
were split and burst; 2d. Delivery of the head, and its proper
guidance through the vulva by the forceps, as has been effected by
D'Outrepont, Hüter, and Braun, in cases in which this accident was
impending; and, 3dly. Lateral incisions, if absolutely necessary, of
the interior edge of the perineum; for in this, as in the more com-
mon longitudinal forms of ruptured perineum, it is, I believe, better
practice to make one or two slight cuts on either side of the four-
chette, so as to regulate the site and direction of the lacerations that
must occur, rather than leave their form and their character to mere
chance alone. It is always an infinitely more important matter
to save the sphincter of the anus than the sphincter of the vagina.
MORBID DEFICIENCY AND MORBID EXCESS IN THE
INVOLUTION OF THE UTERUS AFTER DELIVERY.'
For,
The enormous increase which occurs in the parietes of the uterus
during the nine short months of pregnancy has long attracted the
attention of professional observers. It is a kind of physiological
hypertrophy unequalled, either in regard to its magnitude or its
rapidity, in any other organ in the adult human body.
during the forty weeks of utero-gestation, the uterus enlarges from
nearly 3 inches in length and 13 of an inch in breadth, to 12 or 15
inches in length and 9 or 10 inches in breadth. It increases from
about 2 ounces in weight to 25 or 30 ounces. The cavity of the
uterus before impregnation is less than one cubic inch, while at the
full term of pregnancy it is extended to above 400 cubic inches;
and the surface of the organ increases from about 5 or 6 square
inches to nearly 350 square inches. Before impregnation, the
uterine cavity would not hold above a drachm or two of fluid; at
the ninth month of utero-gestation, its contents usually weigh from
120 to 150 ounces.
The rapidity, however, with which the uterus diminishes in size
after delivery, is perhaps still more marvellous than the rapidity
1 Read before Edinburgh Obstetric Society, February 11, 1852. See Edin-
burgh Monthly Journal of Medical Science, August 1852, p. 127.
39
596
THE PUERPERAL STATE.
with which it increases in size after impregnation. The celerity of
its involution in the puerperal state is in fact more striking and
remarkable than the celerity of its evolution during the pregnant
state. If the process of absorption of organs in the adult is ever
studied successfully anywhere, it will probably be by making obser-
vations on the reduction or involution of the uterus in women or in
the lower animals subsequent to parturition. Whilst the human
uterus takes forty weeks to attain the dimensions pertaining to the
fully developed state of pregnancy, it requires only, on the contrary,
from four to eight weeks to decrease from the extreme size of the
organ peculiar to pregnancy, down to the small size peculiar to the
same organ in its unimpregnated condition.
1
But in the vital mechanism of the involution or reduction of the
uterus after delivery, various pathological derangements are liable
from time to time to occur. This, like every other process in the
animal economy, is apt, for example, to fail, either in the way of
defect or of excess. Some years ago, I endeavoured to point out to
my professional brethren, that occasionally, as one of the derange-
ments in this mechanism of involution, the uterus is morbidly slow.
in regaining its original dimensions-its involution becomes impeded
or arrested-and the organ is in consequence liable to be found,
weeks or even months after parturition, still so large and unreduced,
as at first to be readily mistaken for a tumour of the uterus or ovary.
I described this peculiar condition of the puerperal uterus, under
the name of “Morbid Permanence of the State of Puerperal Hyper-
trophy," and illustrated it with the following example
CASE I. During the summer of 1842, I attended, along with Dr. Abercrombie,
a lady, who, after a premature confinement in the country, had suffered from a
smart attack of puerperal fever. After so far recovering for a few weeks, she was
sent from a considerable distance into town, to be treated for what appeared to be
a large tumour, stretching upwards from the pelvis into the right iliac region.
The tumour had not been observed before delivery, and was somewhat painful to
the touch. It seemed at first sight extremely doubtful whether the mass consisted
of an inflamed uterine fibrous tumour, or enlarged ovary, or of one of those chronic
purulent collections which are apt to form towards one or other iliac region in
1 In the Swedish Hygieia of last year, my friend, Professor M. Retzius of
Stockholm, published some interesting observations on the process by which
nature effects the reduction of the puerperal uterus. He found, in a series of
anatomical and histological observations on the subject, that the process of absorp-
tion of the walls of the puerperal uterus was preceded, as absorption of other
deposits is, by fatty transformation of its component fibres; and that the blood
during puerperal convalescence shows under the microscope a corresponding
superabundance of globules or granules of fat.
2 See Memoir on the Uterine Sound, p. 632.
DEFICIENCY AND EXCESS IN INVOLUTION OF UTERUS. 597
connection with puerperal fever or inflammation. The uterine sound, when
introduced into the os uteri, passed easily and directly upwards for several inches
to the superior end of the tumour, and its apex could be felt there by the hand
placed externally. This at once showed the supposed diseased mass to consist of
the enlarged uterus. Further examination proved that there was nothing strictly
abnormal about the uterus, except its great size. In fact, it was a case where the
organ had apparently remained nearly undiminished after delivery, probably from
the puerperal attack arresting the usual progress of its absorption and diminu-
tion. It decreased rapidly and fully under leeches and other local antiphlogistic
treatment.
In alluding to the pathological state of the uterus, of which the
preceding case is a well-marked example, Dr. Lever has adopted the
same designation which I originally applied to the affection.' More
lately (1851), Dr. Snow Beck described to the London Medical
Society a case of this malady, under the simple term of "A New
Disease of the Uterus." On examining microscopically the struc-
ture of the hypertrophied uterus in this instance, no inflammatory
or heterologous deposits could be detected; but the tissue of the
organ was, it is stated, similar in its histological characters to the
tissue of the uterus at the ninth month of pregnancy, except only
that its component muscular fibres were smaller in size, or like those
of a uterus at the middle period of utero-gestation.
Retarded involution or reduction of the uterus after delivery is
not unfrequent in its less marked degrees; especially when inflam-
matory or febrile action
action supervenes and interferes with the
phenomena of the puerperal state. It is often, for example,
observable both during life and after death, in women who are
the subjects of puerperal fever, pelvic cellulitis, and phlegmasia
dolens. Chronic hypertrophy of the uterus in any excessive degree,
from morbidly retarded or arrested involution, is more rarely met.
with. I have sometimes, however, seen it ten or twelve weeks
subsequent to delivery, in the form of an apparent tumour, twice or
more the bulk of the normal uterus. In lesser, though still
sufficiently remarkable degrees, it often persists for many long
months, or even years, after parturition; particularly when com-
bined, as I have repeatedly found it, with anteflexion or retro-
flexion of the fundus uteri, or with the state of prolapsus.
The day after (July 18) the preceding remarks were written, I
saw with Dr. Retzius the following instance of this combination of
retarded involution with retroversion of the uterus, in a lady, who
came for advice from the north of England.
¹ Guy's Hospital Reports, vol. ii. 1844, p. 17.
2 Lancet for 19th April 1851, p. 447.
598
THE PUERPERAL STATE.
¡
CASE II. The patient, aged 28, and married for three years, was delivered of
her first child two years ago.
She was so well as to be allowed to leave her
bed at the end of a fortnight. The lochia, however, were very abundant, and
continued for eight weeks. She nursed her child for seven months, and during
this period of lactation the menses recurred, as they have done since, regularly,
profusely, and each month somewhat prematurely. She complains of pain of the
back, weakness, etc. In making a vaginal examination, the body of the uterus,
which is retroverted, feels large and heavy, like a uterus at the third month of
pregnancy. Its cavity is, as appears by examination with the sound, nearly an
inch greater than the natural length. The cervix is large, and fills entirely the
extremity of the largest-sized speculum. Its surface is red and congested, but
presents no appearance whatever of abrasion or ulceration. The os is unusually
patent, and admits the tip of the finger for about half-an-inch. The lining mem-
brane of the cervical cavity feels, with the os, hypertrophied, and thrown into
prominent folds, and some of the Nabothian glands are much enlarged. The
hypertrophied body and fundus of the uterus seem quite free from fibrous tumour,
or any other heterologous disease.
Sometimes hypertrophy of the uterus, from arrested reduction.
or sub-involution of the uterus, follows upon abortion or premature
labour. I have at present the following instance under my
care:-
CASE III. The patient, æt. 35, and the mother of six living children, had a
premature labour on the 11th December 1851, under the charge of my friend, Dr.
Dickson of Bathgate. The labour came on about the fifth or sixth month of preg-
nancy, and was in itself simple and easy. The convalescence, however, proved
slow and imperfect; and she was indeed in a great measure confined to bed for
three or four months afterwards. The lochial discharge stopped on the second or
third day. Menstruation has recurred regularly, but with some degree of menor-
rhagia. There is slight leucorrhica. The uterus feels heavy and hypertrophied
when examined per vaginam, but without any organic disease in its walls. The
cervix is also much enlarged, particularly the anterior lip, which is considerably
thicker than the posterior. Immediately around the os there is a line or two of
granular ulceration. The uterine cavity measures between three inches and three
inches and a half.
The preceding instances and remarks refer to deficient, impeded,
or arrested involution. But a morbid excess of involution or reduc-
tion in the uterus after delivery (super-involution) is still more rare
than a morbid defect in it (sub-involution); and I am not aware that
hitherto any obstetric pathologist has described the former as a
diseased state of the uterus. The following remarkable instance of
such super-involution, as ascertained both during life and by dis-
section after death, has lately fallen under my notice :—
CASE IV.—The subject of this rare pathological affection began to menstruate
at the age of thirteen; and the catamenia recurred regularly every four weeks till
she became pregnant when eighteen years old. Utero-gestation went on without
any unusual phenomena to the full term; and her parturition was natural but
DEFICIENCY AND EXCESS IN INVOLUTION OF UTERUS. 599
Nothing
But sub-
tedious, a male child being born after a labour of seventeen hours.
unusual occurred during her puerperal convalescence and lactation.
sequently to delivery she never menstruated. She was, however, subject to
frequent attacks of diarrhoea, which she herself believed to be generally most
severe at recurring monthly intervals; and the dejections were then sometimes
tinged with blood.
Two years after her accouchement, she became a patient in the female ward of
the Royal Infirmary, complaining of the state of amenorrhoea, with attendant
broken health. She suffered from pain in the back and hypogastrium, with a
sensation of weight and pressure in the pelvic region; dysuria; a furred tongue ;
and a weak compressible pulse, generally beating from 80 to 90 in the minute.
She was thin, feeble, and anæmic in appearance. The mammae were shrunk and
flat. For some time before admission she had suffered much from occasional
headaches and giddiness; frequent nausea and vomiting; palpitation and
occasional rigors.
On making a vaginal examination, I found the uterus small and mobile. The
cervix uteri was much atrophied, and the vaginal portion of it scarcely made any
projection into the canal of the vagina. The os uteri was so much contracted as
to admit a surgeon's probe with difficulty. It was dilated by a slender bougie
being left in it for two or three days; and, when the uterine sound was sub-
sequently used, the uterine cavity was found to be only one and a half inch in
length, or about an inch less than normal.
A variety of means were employed with the view of benefiting the general
health of the patient, and of exciting action in the uterine system, but with little
or no effect.
Diarrhoea repeatedly occurred during the three or four weeks she remained
under my care, requiring the free use of opiates for its restraint; and as the
uterine symptoms did not at the time seem to admit of special attention and
treatment, the patient was transferred to one of the general wards of the hospital,
where she was placed under the care of my colleague, Dr. Bennett.
During the following month, the diarrhoea recurred from time to time very
severely. At last, anasarca in the lower extremities and albuminuria supervened ;
ascites followed; and shortly afterwards her face and arms became edematous.
About a month after these symptoms appeared, delirium at last came on, the fæces
passed involuntarily, and ultimately she died in a state of prolonged coma.
On post-mortem inspection, some crude tubercles were found in both lungs-
especially in the left. The liver was enlarged, and showed some fatty trans-
formation. The kidneys presented also some stearoid degeneration; and in the
right there was, in addition, a small tubercular abscess. The large intestines
were very much thickened in their parietes, and contracted in their calibre; while
their mucous membrane was ulcerated in various parts. Along the lower end of
the ileum several large ulcerations were seen running circumferentially around the
interior of the bowel. One or two ulcerations were also found in the stomach.
The uterus was very small, and atrophied in its length and breadth; its size being
diminished about a third below the natural standard in all its measurements;
and its parietes were correspondingly thin and reduced. The whole length of the
uterine cavity from the os to the fundus was not more than one inch and a half,
while the normal uterus usually measures in this direction two inches and a half.
When a section was made of the posterior wall of the organ, the thickness of its
parietes at their deepest or most developed point was not above three lines, instead
of the normal measurement of five or six lines. The tissue of the uterus appeared
dense and fibrous, and the section of it presented the orifices of numerous small
600
THE PUERPERAL STATE.

4
Fig. 19.
DEFICIENCY AND EXCESS IN INVOLUTION OF UTERUS.
601
vessels. The ovaries seemed also much atrophied, and smaller than natural.
Their tissue was dense and fibrous, and presented no appearance of Graafian
vesicles. There was no inflammatory deposit on the peritoneal surface of the
uterus or its appendages; but some thick pus, or tubercular matter, existed in the
distended cavity of the right Fallopian tube.
The woodcut on the preceding page presents the uterus and
upper part of the vagina, the broad ligaments, and ovaries, of the
exact size which they presented, and their degree of atrophy may
be easily judged of by comparing the sketch with the same parts
when of the normal size. The sketch represents the posterior
surface of the uterus and broad ligaments, with the uterine cavity
exposed, in order to show the diminished thickness of the parietes
of the viscus. The whole parts represented in the woodcut weighed
only one ounce, four drachms, twenty-five grains, in apothecaries'
weight.
In females, subsequently to the cessation of the menses, the
uterus, along with the ovaries, undergoes a slow but marked reduc-
tion in size. The uterus in this way, in some extreme instances,
recurs subsequently to menstruation nearly to the small dimensions.
appertaining to it previously to puberty; it becomes atrophied and
shrunk in all its measurements and dimensions; the vaginal portion
of the cervix can be specially felt flattened and reduced in size; and
occasionally the canal of the cervix, especially at its upper part, is
found so contracted as not to admit of the passage of a probe. This
form of senile atrophy of the uterus is doubtlessly connected with
the natural suspension of the functions of the reproductive organs ;
and in this respect is so far similar to the results which we some-
times see in other viscera, as the testes, when the functions of these
viscera are arrested in the course of nature, or when they happen
to be prematurely suspended by chronic inflammation, or other
forms of disorganising disease.
The principal peculiarities in the instance of the marasmus,
or atrophy of the uterus, which I have detailed, are twofold:-
1. The occurrence of the affection in a very young female, as a
consequence of pregnancy and parturition; and 2. The excessive
degree of that atrophy or super-involution-the uterus being, as
we have seen, reduced fully a third in size below its natural
dimensions.
During the last few years I have seen a number of cases of
permanent amenorrhea connected with an atrophied, or rather
602
THE PUERPERAL STATE.
undeveloped condition of the uterus. In these cases the cavity of
the uterus generally measures from one and a half to two inches in
length, as ascertained by the use of the uterine, sound; the shrunk
cervix usually projects but slightly into the cavity of the vagina ;
and the opening of the os is small and contracted. In these cases
the uterus has apparently not taken on its usual degree of evolution
and growth at the period of puberty. The organ, by a kind of
malformation from defective development, as teratologists would
describe it, retains after the date of puberty the type and size which
normally pertain to it in the state of girlhood. But the particular
case of undersized uterus which I have described in the preceding
paragraphs is quite different from these; for in it the uterus, after
being fully developed at puberty, and after performing normally
the several functions of menstruation, pregnancy, and parturition,
returned, as it were, suddenly to the type peculiar to the organ
antecedently to the commencement of menstrual life; or, perhaps,
we may more correctly say, it assumed, at the early age of nineteen,
by an excess of the natural involution or absorption pertaining to
the puerperal state, a degree of anatomical atrophy of its structures,
and physiological arrestment of its functions, such as does not occur
normally till the age of forty-five or fifty; and even then, at that
advanced period of life, the degree of physical reduction in the size
of the organ only rarely becomes so very great as was observed in
the case which I have detailed above.
The case itself affords no precise data for determining whether
the atrophy of the ovaries and uterus stood to each other in any
respect in the relation of cause and effect; or whether they were
both simultaneous results of one common agency.
Instances from time to time occur, in which, as in the preceding
case, permanent amenorrhoea follows parturition. It will not, of
course, be found that all such instances depend upon excess in that
process of natural absorption or involution which follows upon
delivery. But the case in question shows that this super-involution.
of the uterus may be expected to be met with, in some instances,
in connection with this type of amenorrhoea.
At present I see professionally, from time to time, a case in
which amenorrhoea has followed parturition, and in which the uterus
is also reduced below its natural size. The following are the prin-
cipal points in its history:
CASE V. The patient, now aged 30, has been married ten years. She has
borne three children. From the time of her third labour, which occurred four
DEFICIENCY AND EXCESS IN INVOLUTION OF UTERUS. 603
years ago, no menstruation has recurred. The catamenia thus ceased at the age
of twenty-six. After this third labour she made a good recovery, and left her bed
on the eighth day. She nursed the child for fourteen months. I first saw her
about two years subsequently to the birth of her last child. She then supposed
herself to be again near her confinement; but the case was only a marked example
of spurious pregnancy. The uterus, instead of being enlarged, felt looser and
smaller than natural; and the vaginal portion of the cervix was specially reduced
below the natural standard in length and breadth. The cavity of the organ was
somewhat diminished below the usual length, and did not allow the stem of the
sound to pass up to quite two inches and a half. In this patient the mammæ are
flat and atrophied; and she is thin, weak, pale, and impaired in health and strength.
Sometimes super-involution of the uterus follows abortion, or
premature labour. During the present month, I have had placed
under my care an instance of this complication, in a patient from
Canada.
CASE VI.—A mother of eight living children, now aged 35, had, on the 29th
July 1851, a dead premature child, about the sixth or seventh month, under the
charge of Dr. Campbell. Nothing occurred to impede her convalescence. Before,
however, her confinement, her health was not so good as usual, and she was dis-
appointed to find it remained so after delivery. She has only once seen the cata-
menia during the past twelve months-viz. in September. There is slight
leucorrhoea. She is anæmic and chlorotic, with palpitation, etc.
The mamma,
which, she states, were previously very full and large, are now shrunk and flaccid.
The uterus is of nearly its natural length, but the vaginal portion of the cervix
is very short and atrophied, with the lips somewhat everted. The superior portion
of the cervix, above the reflection of the vagina, can be felt small, firm, and
cylindrical; and the body and fundus of the uterus, when grasped between the
left hand placed above the pubes, and the two first fingers of the right hand intro-
duced per vaginam, appears under examination unusually mobile and slender, and
altogether reduced below the usual standard of size.
PART VI.
NON-PUERPERAL DISEASES OF WOMEN.
MEMOIR ON THE UTERINE SOUND.'
SECTION I.
2
PROPOSITIONS REGARDING UTERINE DIAGNOSIS.
THE symptoms by which the diseased states of the various in-
dividual organs of the body are detected and discriminated from
each other, are divisible into two great classes. The first class,
forming the Functional, Dynamical, or Rational symptoms of various
pathological writers, includes all the ascertainable derangements of
functions, local and sympathetic, that may be present; the second
class, constituting the Physical symptoms of the same authors, com-
prehends all the ascertainable circumstances connected with the
structure, density, form, and other anatomical conditions of the
organ which is the primary seat of disease.
Our diagnosis is always the more exact and perfect the more we
can combine the information that may be gained from both classes
or sets of symptoms-and especially the more that we can manage
to confirm or correct the knowledge derivable from our study of the
functional symptoms, by ascertaining, by the cognisance of our
own senses, the exact physical state of the affected organ with which
these symptoms happen to co-exist.
In morbid affections of the exterior parts of the body, the
Physical Diagnosis of the disease can be in general easily accom-
plished, by the direct tactile examination and visual inspection of
the affected organ. It is this facility of examination and inspection
which renders the diagnosis of these more external diseases, which
¹ Read before Medicq-Chirurgical Society of Edinburgh, April 19, 1843.
2 See London and Edinburgh Monthly Journal of Medical Science, June 1843,
p. 547.
DIAGNOSIS BY THE UTERINE SOUND.
605
belong to the province of the surgeon, so much more precise and
accurate than the discrimination of those maladies of the more
internal parts of the body, that fall under the investigation of the
physician.
Within the last half-century, however, the diagnosis of the
diseases of the deeper-seated organs has been very greatly advanced
by the application of various measures to improve our knowledge of
their existing structural states. In fact, the medical science of the
present day owes its superiority over that of an earlier date to no
circumstance more, than to the increased degree of attention that
has, for a considerable time past, been devoted to the study and
improvement of Physical Diagnosis. As the knowledge of the
structural lesions which the various organs may undergo from
disease, has of later years extended in the hands of the pathological
anatomist from his examination of the body after death, the practical
physician has, for the purposes of his diagnosis and the guidance of
his treatment, exerted himself in discovering means of detecting
these same morbid alterations during the lifetime of his patient, and
thus of studying, if I may so speak, necroscopic anatomy upon the
living body. It is true that, in the discrimination of the diseases
of some organs, as of the brain or spinal cord, we are, with some
slight exceptions, obliged to trust entirely to the functional symptoms,
because we have no means of detecting the morbid states of these
organs except in the derangements produced in their functions.
Hence arises the occult character of this class of diseases. In the
diseases, however, of other organs, as those of the chest, the fact is
different. Formerly the affections of the thoracic organs were also,
as those of the head still are, detected and distinguished by their
functional symptoms and derangements only, and their diagnosis
was consequently always more or less doubtful, and often exceedingly
obscure. Now that we can ascertain, with so much precision, the
existing anatomical state of the lungs and heart, by auscultation,
percussion, etc., and thus combine the physical with the functional
diagnosis of pulmonary and cardiac diseases, much of the difficulty
and obscurity that was formerly connected with their detection and
discrimination has entirely disappeared.
In ascertaining the Diseases of the Uterus, we have it in our
power to avail ourselves of both the classes of symptoms of which
I have spoken; or, in other words, we may form our judgment
of its morbid conditions, both by studying the vital Functional.
Derangements, local, sympathetic, and constitutional, that may be
606
DISEASES OF WOMEN.
present; and by informing ourselves, by Physical Diagnosis, of the
exact existing state or states of the organ itself. Each of these
classes of symptoms may afford us most important information; and
in all cases where both can be had recourse to, our diagnosis will be
greatly more certain under their combined evidence, than if the data
furnished by either were alone trusted to. Of the two, if we are to
make comparisons between them, the physical symptoms are
assuredly, in most cases, by far the most valuable and trustworthy;
and yet in the common course of medical practice, the testimony
which they are capable of affording, is but too frequently neglected
and overlooked-and the functional and much less faithful class of
symptoms alone relied upon, as well in forming the diagnosis, as in
directing the measures of treatment.
Thus, if we attempt to analyse the mode in which the medical
practitioner usually endeavours, in any suspected case of uterine
disease, to detect the presence and character, or ascertain the
absence of such an affection, we shall find, I believe, that he
generally proceeds by taking into consideration some or all of the
following sources and varieties of information :-
First, The local and functional state of the uterus, so far as it
is indicated by the quantity, character, periodicity, etc., of the men-
strual and mucous secretion of the organ; by the occurrence or non-
occurrence of morbid uterine or vaginal discharges, as blood, serous
fluid, pus, etc.; by the existence or not of morbid sensations in the
region of the uterus, such as different modifications of pain, inter-
mittent or continuous, feelings of heat, weight, tension, bearing down,
etc.; and, if the patient be married, by the reproductive powers of
the organ, as shown by sterility, by the recurrence of abortions, etc.
Secondly, The presence or absence of various morbid affections
of the neighbouring viscera; particularly of the rectum and bladder,
and of branches of the vessels and nerves passing through the pelvis.
-as indicative either of their sympathetic irritation or of their
mechanical compression by the enlarged or displaced uterus.
Thirdly, The existence or non-existence of secondary local
neuralgic pains in the mamma, along the lower extremities, in
the loins, and at points along the course of the spinal column, in
the parietes of the thorax or abdomen on one or other side, and
especially under the left breast, and under the margin of the ribs,
along the colon, etc., increased in their intensity by any causes
of increased action in the uterus itself, by the erect posture, by
menstruation, etc.
DIAGNOSIS BY THE UTERINE SOUND.
607
Fourthly, The state of the general constitution of the patient,
as marked by various degrees of deviation from the standard of
health-and especially by the supervention of nervous, hysterical,
dyspeptic, chlorotic, or cachectic symptoms.
The several preceding series of morbid phenomena consist of
derangements in the vital actions of the uterus-or of other parts
and organs secondarily affected-or of the constitution at large-
and so far strictly belong to the class of Functional or Dynamic
symptoms only. Up to a late date in the history of uterine
diagnosis, most practitioners remained, and some still remain,
satisfied with the degree of knowledge which is afforded by the
above sources of information. No one, however, who is practically
acquainted with the diseases of the uterus can have any hesitation
in declaring that the symptoms derivable from these sources are
utterly inadequate, in the general routine of such cases, for the
purposes of correct diagnosis, and are constantly liable to lead into.
fallacy and error when their individual evidence is alone trusted to.
In making this observation, I do not mean to allege that these
classes of symptoms are not sufficient to give us the power, in most,
though not in all, instances, of detecting the actual presence of
uterine disease. They are perfectly deficient, however, in this other
point, that, by their single unassisted aid, we cannot ascertain what
the exact character and nature of the existing disease is-nor, con-
sequently, what may be the proper line of treatment requisite for
its alleviation or removal. They may generally, in other words,
enable us to decide that the uterus is the seat of some morbid con-
dition, but are not adequate to inform us what that morbid condi-
tion really is. They may show that the organ is affected, without
showing us how it is affected.
If we attempted to throw the generalities, regarding the diagnosis
of uterine diseases, into propositions, we would, therefore, be
inclined to lay down the following as our
FIRST PROPOSITION.
The General and Local Functional Symptoms of disease of the Uterus
are such as enable us to localise, without enabling us to specialise,
the exact existing affection of the organ.
One or two instances may serve to illustrate and impress, more
strongly than any mere abstract statement, the force and truth of
the above proposition.
608
DISEASES OF WOMEN.
In the changed and changing state of the uterus during preg-
nancy, we have in all cases a constancy in the primary site and
character of the existing irritation-if we may apply a term so far
pathological, to a state which, in its object at least, is strictly phy-
siological. But though in the pregnant female the local uterine
irritation is constantly and specifically the same in its source and
nature, the local and constitutional phenomena or Functional
Symptoms to which it gives rise, are well known to vary infinitely
in different individuals, and even in the same individual in different
pregnancies. In one case, the health of the woman remains in all
respects unimpaired, notwithstanding the altered condition of the
uterus. In a second, we find her suffer from distressing local symp-
toms, such as weight, distension, and bearing-down sensations in the
interior of the pelvis, derangements in the state of the bladder and
rectum, œdema and stiffness in the lower extremities, etc. In a third,
the local affections may be slight or altogether absent, but there may
be severe and even serious sympathetic affections of the general con-
stitution, or of particular and distant organs, such as of the stomach,
with cardialgia or vomiting, or of the brain, with headache and sleep-
lessness, or even with convulsions or mania.
Again, in other instances, we occasionally find all the usual
symptoms, both local and constitutional, of pregnancy present, in so
marked a degree, as to impress both the patient and the practitioner
with the certainty of the existence of that state; and yet these
symptoms may all, after a short time, be found dependent on the
irritation produced by some subacute functional or organic disease
of the uterus that has no relation whatever to utero-gestation, except
in the identity of its primary seat, and in the similarity of the
symptoms to which it gives rise.
The few well-known facts to which I have thus adverted directly
point to the two following important deductions:-1st, That in
pregnancy we have the same identical condition of the uterus, not
always accompanied by the same identical symptoms; and 2d, That
the usual concourse and succession of functional phenomena to which
pregnancy generally gives rise, may be induced by other states of
the organ than the state of utero-gestation.
The same two important inferences are true in regard to the
various individual morbid affections of the uterus. The marked
uncertainty which exists regarding the effects produced by the con-
dition of the organ`in pregnancy, holds equally good regarding the
effects produced by it in its different states of actual disease. In
DIAGNOSIS BY THE UTERINE SOUND.
609
uterine disease, as in pregnancy, the same specific affection of the
organ excites sometimes very different phenomena in different cases;
and the same specific phenomena frequently result from affections of
the organ that are entirely at variance with each other in their
pathological character, in their course, and in their treatment.
But
Probably the most common organic disease of the uterus consists
in the development of those fibrous tumours which are so frequent
in the tissues of the body and fundus, and so rare in those of the
cervix of the organ. These tumours do not, in some cases, occasion
any very decided symptoms, and are often, as I have repeatedly
known, only accidentally discovered in the living subject, after
reaching a very large size; or, as frequently happens, they are not
suspected or detected before they are found on the post-mortem
examination of the body. I have one such tumour in my museum,
which weighed fourteen pounds, and where the principal or only
symptom during life was the mere enlargement of the lower portion
of the abdomen, produced by the presence of this great mass.
in other cases, these fibrous tumours of the uterus, even when still
small, often produce distressing irritation among the pelvic viscera,
and derange in various ways the physiological function of the organ
-producing sometimes diminution or suppression of the menstrual
secretion, or again, especially when they are situated near the mucous
surface, inducing leucorrhoea and attacks of menorrhagia, that are
occasionally most formidable, both from their severity and per-
manency. But the remarkable circumstance with regard to this,
and almost all other structural diseases of the uterus, is, that though
the walls of the organ be the seat of extensive morbid transformations
and deposits, the menstrual secretion frequently remains so regular
and normal as to deceive both the patient and her medical attendant;
and I have known conception-the principal physiological function
of the uterus-to take place, not only where fibrous tumours were
present, but, in more than one case, where the cervix of the organ
was the seat of malignant disease, that destroyed the patient shortly
after her abortion or delivery.
Let us consider for a moment one other instance, illustrative of
the important practical fact that the same organic disease of the
uterus is often attended by the most varied, and even apparently
opposite, sets of external symptoms.
Scirrhous degeneration of the cervix uteri is an affection con-
stantly occurring in the course of practice. This disease sometimes
gives rise, at an early period of its progress, to severe pains and
610
DISEASES OF WOMEN.
sufferings in the uterine region; to great local irritation of the
bladder and neighbouring parts; and to the supervention of marked
sympathetic and constitutional phenomena. In other numerous
instances, however, it marches onwards to an advanced stage with-
out occasioning almost one single symptom in the way of local
pains, discharges, or otherwise, calculated to rouse the attention of
the patient to the impending work of destruction that is, with slow
but fatal steps, going on within her. I have repeatedly seen cases
of the kind where the disease was under assiduous treatment for
simple leucorrhoea or menorrhagia, merely because no examination.
had been instituted in order to learn upon what local states the
leucorrhoea or menorrhagia depended. In other cases the intensity
of the sympathetic or secondary symptoms may be such as to con-
ceal and disguise entirely the primary disease. In an instance of
fatal carcinoma uteri that occurred lately in this city, the symptoms
complained of during the lifetime of the patient were entirely referred
to the urinary, and not to the uterinė organs. I have known the
mammæ most actively treated by leeching, etc., for the sympathetic
pains present in them, while the state of the uterus itself (the
primary cause of the pains) was altogether held out of view, until at
last, when attention was ultimately called to it, its whole cervix was
found utterly destroyed by cancerous ulceration.
While we thus not unfrequently find the most malignant organic
diseases of the uterus more or less latent or marked in their symp-
toms, we have, on the other hand, sometimes the most severe local
and constitutional symptoms of uterine disease developed in instances
of slight and remediable organic affections of the part, as in cases of
simple Ulcerative and Granular Inflammation of the cervix; and
these symptoms may be all present in their most aggravated forms
for months and even for years, where the local examination and
final result show us that there is certainly no organic disease what-
ever, as in cases of "irritable uterus," or hysteralgia. Indeed, in
some females, we have all these symptoms strongly but temporarily
excited at every recurrence of the catamenial discharge, in connec-
tion merely with that congestion and increased vital activity of the
organ which accompanies its natural menstrual secretion.
We may meet, in short, with the same train of local and
secondary functional symptoms indicative of uterine disease, in
neuralgic, in congestive, in inflammatory, and in malignant diseases
of the organ; and whether we explain it by the slowness with which
morbid depositions are apt to develop themselves in this organ-by
DIAGNOSIS BY THE UTERINE SOUND.
611
the slight sensibility of the component tissues of the viscus-or by
the intermittent and latent nature of its vital actions-there can be
no doubt of the fact, that there seems to be no organ in which there
is a less strict relation observable between the intensity and character
of the existing pathological disease, and the intensity and character
of the accompanying symptoms, or between the exact nature of the
structural lesions that are present, and the exact combination and
succession of functional derangements to which they give rise.
Hence, in order to form in any case a correct diagnosis in regard to
the existing state of the uterus, it is necessary to ascertain, as far as
possible, if any anatomical alterations may be present in the struc-
ture and organisation of the organ-as well as in its physiological
functions-and what these alterations are. In other words, we
must institute a local examination of the organ itself, by the sense
of touch, and, if necessary, by the use of the speculum. It is
assuredly only by doing so, that we can hope with any certainty to
decide upon the specific nature of the uterine disease that may be
present. We may make the general diagnosis of the existence of
uterine disease, by the consideration of the functional derange-
ments to which such disease gives rise. We can only make the
differential diagnosis of what the specific disease really is, by aiding
this by the examination of the structural condition of the organ
itself.
In deciding upon the existence or non-existence of pregnancy,
especially in any cases of importance or doubt, no medical man,
who valued his own professional character, would deem himself
justified in offering a final and dogmatic opinion, from the mere
functional symptoms only, which we have already seen to be some-
times very equivocal-nor would he venture to form a definite
judgment until he had made a sufficiently accurate physical exami-
nation of the state of the uterus itself. In deciding in the same way
upon the pathological nature, and consequently upon the line of
treatment which any marked uterine disease may require, we believe
exactly the same caution to be necessary, and the same local exami-
nation to be demanded, where there exists any doubt, and where the
examination is not otherwise counter-indicated. The local exami-
nation of the uterus is had recourse to, in the case of pregnancy, to
settle a point which time itself would alone ultimately decide. The
local examination is had recourse to in the case of uterine disease,
for an object of much more immediate and practical moment-
namely, to obtain that information which can alone enable us to
40
612
DISEASES OF WOMEN.
form a proper and precise judgment of the nature of the case before
us, and to select the proper remedial measures for its mitigation,
arrestment, or timely removal. We have seen some unfortunate
cases, where its unwarrantable omission in the earlier and curable
stages of disease has allowed the morbid action to make so extensive
and fatal progress before sufficient alarm was excited, as to be utterly
beyond the reach of treatment. Consequently, it appears to us,
that in uterine diagnosis it may be most safely and justly laid
down as a
SECOND PROPOSITION.
In almost all instances of diseases of the Uterus, it is only by the Physi-
cal Examination of the organ itself that we can distinguish the precise
nature of the existing affection, and fix its character, extent, etc.
The information thus obtained may be merely negative, but it is
not the less useful either in a diagnostic or in a practical point of
view. In a case of morbid discharge of blood from the vagina, for
example, we may only ascertain that there is no appreciable organic
disease of the uterus. Our prognosis and treatment, however, of a
case of menorrhagia would, under such circumstances, be very differ-
ent from those which we should adopt, if, by the same examination,
we discovered a state of simple ulceration of the cervix, or conges-
tive enlargement of the uterus, or the presence of a polypus, or the
existence of a cauliflower excrescence or carcinomatous degene-
ration.
Local examination, however, usually affords us much positive and
direct information with regard to the seat and character of the
existing disease, by informing us of all those changes that have
taken place in the vagina and uterus, which can be recognised by
touch or sight. By it we are thus often enabled to detect the
different morbid conditions of the cervix, whether congestive, in-
flammatory, or more strictly organic. We can generally distinguish,
by the same means, these states from each other, and discriminate
between the equally enlarged and dark-coloured congestion of the
cervix, and the different forms of inflammation to which its struc-
tures are liable, whether that inflammation has assumed the granular,
ulcerative, aphthous, or pustular type;-between simple, syphilitic,
corroding, and carcinomatous ulcers of this part ;-between granular
enlargements, cauliflower excrescence, and cancerous degeneration of
the cervix ;-between the vaginal tumours formed by prolapsus, or
DIAGNOSIS BY THE UTERINE SOUND.
613
by inversion of the uterus, and those formed by the presence of a
simply hypertrophied cervix, or of a true polypus;—and between
the general diffused enlargement of the organ produced by hyper-
trophy of its walls, or distension of its cavity, and that irregular,
roundish, knobbed form which it almost invariably assumes in cases
of fibrous tumours, and in such cases only.
THIRD PROPOSITION.
The Physical Examination, as hitherto practised, seldom enables
us to ascertain accurately the organic condition of more than
the cervix and lower part of the body of the Uterus.
If the uterus be large, and the woman of a spare and lax habit,
we may indeed be able to feel the fundus of the organ through the
walls of the abdomen, by the hand pressed in above the pubes. It
generally, however, lies so low in the pelvis, and usually moves
away so readily under the touch and pressure of the fingers, that,
even in such persons, this means of examination is of no great avail.
In all persons of an opposite habit, and in most cases where the
uterus is misplaced without enlargement, the hypogastric examina-
tion is of little or no use whatever.
By examination per vaginam with the finger, we can only, ex-
cept when the uterus is prolapsed, feel the cervix, and the parts
resting on the roof of the vagina. Hence, diseased states of the
cervix, having been far more easily ascertained than diseased states
of the body and fundus of the organ, have, probably, been very
much over-rated, both in frequency and importance, at least since
the speculum has come into more general use. In regard to the
parts that are felt through the roof of the vagina, the touch alone
does not, in many instances, give us information at all sufficiently
satisfactory and decisive. We can, no doubt, when the tumour is
large, often ascertain with considerable accuracy its size and form,
by combining the vaginal examination with the aid derived from
examination by the rectum, and above the pubis.
in many cases, left entirely in the dark as to whether the existing
tumour is an enlargement of the whole mass of the uterus, or a dis-
tension of its cavity, or a morbid growth; and, if the latter, whether
the growth is seated in the uterus itself, or in one of the ovaries or
other neighbouring parts. If the tumour is small, and cannot be
felt above the brim, we then have it not even in our power to ascer-
tain its size and form, as we can examine it only on one side, namely,
But we are still,
614
DISEASES OF WOMEN.
on that next the vagina. Under these circumstances we are unable
to tell whether it arises from a new morbid structure attached to
the uterine parietes, or from a simple displacement or flexion of the
fundus of the uterus itself.
To meet these and other difficulties in uterine diagnosis, I have
for some time past been in the habit of using a metallic Uterine
Sound or Bougie of nearly the size and shape of a small male.
catheter, which, when introduced, as it can easily be done, into the
interior of the uterus, and manipulated there in different ways, has
proved to me of great service in rendering the diagnosis of the
diseases in question, and more particularly those of the fundus, body,
and cavity of the organ, parts usually considered beyond the reach
of examination, much more accurate and precise than can be effected
by any other means with which I am acquainted. I am induced to
bring this means before the notice of the profession, under the
strong hope that the instrument will be found of equal service in
the hands of others; and the results which have been obtained by it
seem already sufficient to enable us to place, among the generalities
of uterine diagnosis, the following as a
FOURTH PROPOSITION.
It is possible, by the use of a Uterine Sound or Bougie introduced into
the uterine cavity, to ascertain the exact position and direction of
the body and fundus of the organ-to bring these higher parts of
the uterus, in most instances, within the reach of tactile examina-
tion, and to ascertain various important circumstances regarding
the os, cavity, lining membrane, and walls of the viscus.
Having already exhausted my present limits by these preliminary
observations, I must reserve the particular description of the instru-
ment-the modes of introducing and using it-and the different
diagnostic indications which it is capable of fulfilling, for a second
communication.
SECTION II.'
PROPOSALS FOR THE IMPROVEMENT AND ELUCIDATION OF UTERINE
DIAGNOSIS, BY MEANS OF A SOUND OR BOUGIE PASSED INTO THE
UTERINE CAVITY.
In my former paper I took occasion to speak of the uncertainty
of those symptoms of Uterine Disease that consist merely of de-
¹ See London and Edinburgh Monthly Journal of Medical Science, August
1843, p. 701.
DIAGNOSIS BY THE UTERINE SOUND.
615
rangements in the functions of the uterus itself, and of other con-
tiguous and sympathising parts. Some facts were adduced to show,
that, in uterine pathology, this uncertainty was so marked, that
frequently the same affection of the organ was accompanied in
different cases by different trains of functional symptoms; while it
held equally true, that occasionally the same train of symptoms was
found indiscriminately in connection with a number of morbid con-
ditions of the uterus, that were essentially and practically dissimilar
from one another both in their nature and treatment. From this
frequent want of relation between morbid states of the uterus and
their functional effects-from finding identical lesions combined, in
a variety of instances, with very diversified symptoms-and identical
symptoms connected with very different lesions-it followed, that in
order to form a sure and perfect diagnosis in this class of affections,
it is generally requisite to take into consideration the exact structural
state of the uterus itself, and hence to institute, for the ascertainment
of this point, a careful local examination of the organ. In urging
the necessity of such a physical examination of the uterus in uterine
diseases, I endeavoured only to claim for that organ a means of
diagnosis, which, when practicable, is regarded as indispensable in
the case of every other part of the system. In discriminating from
each other, for example, the various kinds of morbid affections of
the eye, no medical man would trust merely to the knowledge that
he might acquire regarding the derangements of vision that might
be present, the degree and character of the local and sympathetic
pains, the quality and nature of the lachrymal and conjunctival
secretions, the accompanying state of the system in general, etc.—
he would farther, in order to arrive at such an accurate diagnosis as
would enable him to institute a rational course of treatment, ex-
amine as thoroughly as possible the local structural condition of the
organ itself, as the only means of determining in what individual
texture or textures, whether the conjunctiva, cornea, lens, etc., the
disease was specially localised, and what the precise nature of the
morbid action really was in the texture that was affected. In the
same way, in a case of excessive morbid irritation of the urinary
passages, no surgeon would venture to decide precisely what the
extent, seat, and nature of the affection was-and whether renal,
vesical, or urethral-until he had made a strict local or physical
examination of the urinary organs themselves. He might, by the
kind of functional derangements present, be led to suppose that the
morbid irritation was connected with a stone in the bladder, or an
616
DISEASES OF WOMEN.
enlargement of the prostate, or a stricture of the urethra, etc.;
but he could never be perfectly certain that one or other of these
was the cause, until he had instituted, with the finger, sound, etc.,
a local examination of the parts implicated. It is exactly the same
with uterine diseases. The external symptoms may show the
presence of disease in the uterine organs, and occasionally may be
such as to lead us to adopt some opinion as to its nature; but we
can never, in any case of the slightest doubt, be certain of its exact
character and extent, to such a degree as to serve for guides to our
diagnosis, prognosis, and treatment, unless we have the aid of the
knowledge of the local structural state of the viscus itself.
A portion of my former communication was further taken up in
showing, that the methods of uterine diagnosis as hitherto practised,
whether by touch, or the speculum, or both, were, except where the
patient was of a spare and relaxed form, calculated principally or
only to distinguish the various morbid states of the cervix uteri.
Lastly, I ventured to suggest, as an addition to our other means of
uterine diagnosis, that the higher and more interior parts of the
uterus should be examined by a Sound or Bougie introduced into
the uterine cavity, and stated that various points of great im-
portance, and otherwise unascertainable, could be made out by its
assistance.
In the present chapter I intend briefly to state the kind of
instrument I have used, and the modes of introducing and mani-
pulating it, with some of the points of information which we can
obtain through its employment.
DESCRIPTION OF THE UTERINE SOUND.
I have already stated that the instrument which I employ is
somewhat similar to a small male catheter. It is, moreover, pro-
vided, like the common male sound, with a flat handle, to facilitate
its manipulation; and terminates at its other extremity in a rounded
knob or bulb, to prevent injury to the uterine textures. The inter-
vening stem tapers gradually from the handle to the knob, the
thickest part being nearly one-fifth of an inch in diameter, equal to
the size of a catheter No. 8, and the thinnest part about one-tenth
of an inch, or equal to a catheter No. 3. The greater thickness of
the attached extremity is necessary to give that portion of the in-
strument the requisite degree of strength and resistance; it is more
slender towards its other extremity, to allow of its easily entering
DIAGNOSIS BY THE UTERINE SOUND.
617
The
The
into, and being moved in, the orifice and canal of the uterus.
terminating bulb is about one-eighth of an inch in diameter.
stem is about nine inches in length, and graduated so as to render
its employment, and some of its indications with regard to the mea-
surement of the uterus, more precise. Different modes may be had
recourse to in marking it, but the marks, whatever they may be,
must be such that they can be easily felt with the finger while the
instrument is within the vagina. For this purpose, they must be
placed on the convex or posterior surface of the instrument, the
surface, namely, with which the directing finger is in contact. The
mode of graduation adopted in the instrument I have myself used,
and which is figured in the engraving, is as follows:-At two inches
and a half from the extremity of the instrument, this measurement
being the usual length of the uterine cavity, there is placed a slight
elevation or knob, which, in the employment of the Bougie, at once
serves to show that it is introduced to the full extent into the

Fig. 20.
interior of the organ, and at the same time forms a fixed or standard
point from which the instrument may be farther graduated towards.
either of its two extremities. This farther graduation is marked by
shallow grooves, which may be placed at the distance of either half-an-
inch or an inch from each other, and, by their assistance, it becomes an
easy matter to measure the exact length of the uterine cavity, when
either it is diminished, or, as much more frequently happens, when it
is prolonged to different degrees beyond its usual dimensions. The
alternate groove may be double, to facilitate the measurement by the
finger. The form of curvature at the extremity of the instrument is
nearly that of a common catheter, and, like it, begins about three or
four inches from its point; but the degree and extent of this curvature
require to be varied according to the necessities of individual cases,
and according to the indications which it is wished to bring out. Hence
the stem of the Bougie requires to be formed of a metal that admits of
being pretty freely and frequently bent without the risk of fracture,
and at the same time is capable of adequately maintaining any form
that may be temporarily given to it. These objects are fully attained
when the stem is made of solid silver, but probably some composition
618
DISEASES OF WOMEN.
of the inferior metals may also be found to have the necessary com-
bination of pliability and strength. The handle of the Bougie is
made of wood or ivory, is about three inches long, three-fourths of
an inch at its broadest part, and rather more than a quarter of an
inch in thickness. The posterior surface of it is smooth, whilst its
anterior surface, or that corresponding to the concave aspect of the
Bougie, is roughened, in order to make the operator constantly aware
of the direction of the point of the instrument when it is hid in the
uterine cavity—a circumstance which we shall afterwards see to be
of great importance in reference to some of its diagnostic uses.
Mode of Introduction.—In introducing the Bougie or Sound into
the uterine cavity, the patient may be placed either on her back or
left side. If on her back, the fore-finger of the right hand is intro-
duced into the vagina, and its extremity brought in contact with
the indentation formed in the cervix uteri by the os tincæ, so as to
act as a guide to the point of the instrument. The instrument
itself is held in the left hand, and its point slipped along the palmar
surface of the finger in the vagina, and directed by it into the
uterine orifice. If the patient is placed on her side, she must lie.
with her body directly across the bed-a position which facilitates
greatly the manipulations required both for common tactile exami-
nation, and for examination by the Sound and Speculum. In this
case the fore-finger of the left hand is used as a guide to the os
uteri, and the instrument is held in and directed by the right. In
some instances where the parts are very lax, and the cervix uteri in
any way displaced, the introduction of the Bougie is facilitated by
passing both the fore and middle fingers into the vagina, fixing
the cervix with them in the axis of the passages, and gliding the in-
strument along the groove between the two up to the os. In
whichever of these ways the Sound is guided up to and passed
within the os uteri, it generally afterwards glides easily, under a
slight propulsive force, along the canal of the cervix and body, till,
as shown by the elevated mark already alluded to as placed on
the stem, its extremity has passed onward to the fundus of the
organ. Sometimes the extremity of the instrument is slightly
obstructed about an inch or less within the os tincæ, by the natural
contraction existing there between the cavity of the cervix and
cavity of the body. This obstacle is easily overcome by a little
additional impulse, or, if that fail, by slightly retracting and alter-
ing the direction of the point of the Sound. The direction which
the instrument should naturally follow in passing along the uterine
b
DIAGNOSIS BY THE UTERINE SOUND.
619
canal, must always be held in view. In the normal condition of
the parts, the uterus and vagina meet at a considerable angle, the
former passing upwards and at the same time considerably forwards,
and varying somewhat its inclination with the varying degrees of
distension of the bladder and rectum. In using the Bougie, there-
fore, supposing the organ to be in the natural position, its concavity
should be directed forwards towards the walls of the abdomen; or,
in other words, it should be passed in the same direction as in most
other manipulations in this part of the body, namely, in the line of
the axis of the brim of the pelvis.
The degree of uneasiness felt by the patient during the passage
of the instrument is in general very trifling, and not more, if so much,
as is felt on passing the catheter along the urethra of the female, and
certainly not by any means nearly so great as in using the Sound or
Bougie in the male. In a few cases, I have seen it, like the passing
of the sound in the male, produce a feeling of sickness and nausea.
In the healthy state, however, of the organ, the lining membrane of
the uterus does not in fact appear to be more sensitive than that of
the vagina, so that the existence of any true and actual pain in making
the examination with the Bougie is to be considered so far anormal,
that it is generally, as we shall afterwards see, indicative of the exist-
ence of some morbid state or other of the part or parts with which
the extremity of the instrument is at the time in contact.
In the average run of cases, the introduction of the Sound into
the uterine cavity is probably not more difficult to accomplish than
the introduction of the catheter into the bladder of the female. The
os uteri is, in fact, usually much more easily and certainly detected
by the finger, than the orifice of the urethra; and generally the one
and the other instrument passes readily along its appropriate canal
after it has once entered it. If it is otherwise, the very difficulty
may be in itself important, as marking the existence of some anormal
and probably diseased state. It is almost unnecessary to add, that
the power of passing either instrument with perfect facility and cer-
tainty, is only to be gained by a little perseverance in the practical
employment of them.
The manner in which the instrument should be manipulated,
after it is fully introduced into the uterine cavity, varies according
to the object or objects which we wish to ascertain. The mode of
using it with these views will be best explained by now pointing out
individually, and at some length, the different diagnostic indications
which it is capable of fulfilling.
620
DISEASES OF WOMEN.
USES OF THE UTERINE SOUND.
I. The Sound increases to a great degree our power of making a perfect
and precise tactile examination of the Fundus, Body, and Cervix
of the Uterus.
I have already stated, that the body and fundus of the uterus
are so deeply included in the cavity of the pelvis, and at the same
time are generally so mobile under the pressure of the fingers,
whether applied to the organ from above or below, that it is difficult
to ascertain anything precise with regard to the condition of these
parts, either by a common vaginal, or by a hypogastric examination.
The obstacles which thus so effectually oppose an accurate and
complete tactile investigation of the surfaces and walls of the body
and fundus of the uterus, may be, in most cases, in a great measure,
overcome by the aid of the Uterine Sound, if we employ it for the
double purpose-first, Of giving sufficient resistance to the organ for
its exploration by the fingers; and, secondly, Of altering the position
of its parts, so as to bring them each successively within the reach of
tactile examination.
When the pliable and mobile uterus is held steady by the sound
being placed in its cavity, and the central axis of the organ is for the
time being thus rendered, as it were, firm and solid—the examination
of its external surface and of its walls becomes a matter of far more
certainty and accuracy than if we had the organ indefinitely yielding
and receding before each slight touch of the fingers.
But besides thus rendering the organ fixed and resistant for our
examination, the Uterine Sound will, as a diagnostic means, be found
of still greater use and importance, by the control which its presence
in the uterine cavity gives us over the position of the whole organ,
and by its enabling us to alter at will the situation of the viscus to
such a degree, that we can in succession bring within the range of a
tactile investigation different parts of its external surface and parietes,
that are generally considered to be entirely beyond our reach. In
reference to this remark, it must be specially kept in mind that in
the healthy state the uterus is so loosely fixed in its situation in the
pelvic cavity, that its position is capable of being changed to a very
considerable extent, without incommodity or injury, by such exterior
influences as may naturally or accidentally act upon it. Its position ist
so far constantly changed by the varying states of distension of the
bladder and rectum. Under voluntary efforts of straining, it can in
DIAGNOSIS BY THE UTERINE SOUND.
621
general be readily pushed down half-an-inch or an inch in the cavity
of the vagina. It may be drawn down by instruments till the cervix
reaches the external parts themselves, or even protrudes beyond
them—a circumstance which facilitates immensely the operation of
excision of this part of the organ. In consequence of the same
anatomical peculiarity, we are able, through the use of the Uterine
Bougie, to move the organ upwards, forwards, etc., to such degrees
as are requisite for a complete hypogastric examination, without in
general causing any marked inconvenience or pain to the patient.¹
If, after the Bougie is introduced into the uterine cavity, we
carry the handle backwards towards the perineum, the upper
extremity of the instrument-and consequently the fundus uteri
placed upon that extremity-will be proportionally moved forwards
into the hypogastric region. One hand placed above the pubes
will now feel the fundus uteri, with the central and thinnest part
only of the abdominal parietes intervening between the fingers and
the surface of the uterus. Provided the woman be not of a full
habit, and the abdominal muscles sufficiently relaxed by position,
we can now pretty accurately examine, with the hand placed on the
hypogastric region, the state of the uterus as it is held forwards on
the end of the Bougie, and we may always make ourselves still
more certain of its condition by retracting and otherwise moving
1 In corroboration of the statements in the text with regard to the natural
mobility of the uterus, I would beg to fortify the remarks I have there made, by
quoting upon the subject the opinions of two of the latest authors who have ad-
verted to this particular point-Cruveilhier and Lisfranc. When speaking of the
uterus in his excellent System of Descriptive Anatomy, Cruveilhier observes, "The
looseness and extensibility of its connections enable it to float, as it were, in the
cavity of the pelvis, and to be moved to a greater or less extent.
The facility
with which it can be drawn towards the vulva in certain surgical operations, and
its displacement during pregnancy, when it rises into the abdomen, are proofs of
its great mobility."-Vol. i. p. 618, of Dr. Madden's translation. Lisfrane's
observations are still stronger. "There is," he remarks, "a physiological fact of
importance but little known, and which hitherto has scarcely been alluded to by
any writer. The uterus in the normal condition, and even when affected with en-
gorgement, has a truly extraordinary mobility. To prove this, a very simple
experiment will suffice. Let a speculum be introduced as high up the vagina as
possible, so as to embrace the cervix uteri within its upper extremity; then bid
the patient bear down as if at stool; and you will perceive that as the instrument
descends, the uterus follows it to the extent of one, or even of two inches; an im-
mense advantage when the surgeon wishes to bring down the uterus to near the
vulva. In cases requiring operation about the cervix, all that the surgeon has to
do is, to lay hold of the os uteri with a hook, and draw it gently down, until it
comes fairly within sight; this may be effected without difficulty, and with very
little inconvenience to the patient."--Translated from the second volume of the
Clinique de la Pitié, into the Medico-Chirurgical Review for April 1843, p. 360,
622
DISEASES OF WOMEN.
the handle of the instrument so as to bring the different parts of
the superior and anterior surfaces of the uterine tumour under the
touch of the fingers. By a slight turn of the instrument to either
side, the lateral surfaces of the upper part of the viscus may, in the
same way, be brought under our tactile examination; and in spare
subjects, I have occasionally found it possible, when the fundus was
pushed against the abdominal parietes, to extend the manual exami-
nation to some distance along the posterior wall of the organ.
In those cases where this cannot be effected, the sound still
enables us to make a more perfect tactile examination of this-the
posterior, part of the uterus, than we could otherwise effect, [by
giving us the power of temporarily depressing and reflecting its
posterior wall, so that it may be felt by a rectal examination. The
vaginal examination of the lower part of its anterior surface may
be in general rendered more complete by a similar aid from the
instrument.
In these different steps of examination, the degree and accuracy
of the information obtained is varied in different individuals by the
differences which exist in the thickness of the tissues placed between
the uterine surface and the fingers; but in most instances the
presence of any marked irregularity in the uterine structures—such
as the presence of one or more small fibrous tumours—their hyper-
trophic thickness, etc., may be readily made out-and, under still more
favourable circumstances, the exact physical conditions of the organ,
in relation to its volume and dimensions, the morbid tenderness of
individual parts of it, etc., may be precisely determined.
When we employ the sound for the purposes alluded to in the
preceding sentences-namely, for enabling us to make hypogastric
examinations of the fundus and body of the uterus-the instrument,
before its introduction, should have its extremity bent upon its
stem at as nearly a right angle as the conformation of the genital
canals admits, and, after being introduced, its handle should be well
retracted towards the perineum. By attending to these circum-
stances, the fundus and body of the uterus will be more easily and
fully turned forwards, and our examination of them very much
facilitated. The same object will also be much promoted by retain-
ing the directing finger at the cervix during the course of the exami-
nation, both to steady the instrument and to serve as a fulcrum to
it. In that case the handle may be retracted or pushed backwards
to any required degree by the forearm, while the other hand is
employed in the hypogastric examination.
DIAGNOSIS BY THE UTERINE SOUND.
623
The preceding remarks apply to the examination of the fundus
and body of the uterus, parts which-unless when much enlarged,
or the patient very thin-are generally looked upon as beyond
reach of any physical diagnosis.
The physical states and relations of the cervix uteri are gener-
ally ascertainable by the finger alone. Still, in various morbid
conditions of the cervix, our tactile examination of the organ may
be much promoted by the assistance of the bougie introduced into
the uterine cavity. For instance, in chronic enlargement, cauli-
flower excrescence, and other organic diseases of that part, it is
sometimes a matter of moment, both as regards our prognosis and
our treatment, to ascertain if the existing diseased state stretches
upwards so far as to involve or not the lower portion of the body of
the uterus. In several such cases, I have found much assistance in
determining this point by gently depressing the uterus by the
bougie introduced into it, and having the power thus of examining
the organ, immediately above the cervix, by compressing the struc-
tures of that part between a finger or two in the vagina, and the
resistant sound placed in the uterine cavity, and consequently in
the very axis of the viscus. In this way, each point in the circum-
ference of this portion of the organ may be successively examined.
These observations apply generally to such indications as can
be made out through the use of the bougie, when the uterus still
retains that freedom of motion which we have seen it to possess,
when it is itself in a healthy condition, and when there are no
obstructions or impediments to its mobility in the surrounding
parts. But there are cases where, from the organ having become
more or less fixed and immobile, no advantage can be taken of those
facilities which the power of partially displacing it in general allows
us. In these instances, the very circumstance, however, of the
mobility of the organ being lost, and still more the degree and
extent of its immobility, often materially assists in pointing out the
true nature of the affection that is present. Thus in scirrhus of the
cervix, the early immobility of that part, in consequence of the
morbid degeneration invading the contiguous tissues from almost
the very commencement of the disease, is often one of the first and
best characteristics of that dreaded malady. In this instance, the
fixed state of the cervix of the organ is detected by the direct
application of the finger. In other states of disease, the cervix
remaining comparatively free and unaffected, the body and fundus
may be immobile from various pathological causes, as from morbid
624
DISEASES OF WOMEN.
adhesions, the consequence of inflammation of its peritoneal surface,
from the pressure of tumours or abscesses, etc. Or, again, both
cervix and fundus may be immobile at the same time, from general
carcinoma of the organ, etc. In all these cases the immobility of
the body and fundus, its degree, extent, and seat, can only be
discovered by the bougie; and its use, along with other considera-
tions, may further lead us to detect the special pathological state
that may be the cause of the morbid attachment or fixture of these
parts of the organ.
II. The previous introduction of the Sound facilitates and simplifies the
subsequent Visual examination of the Cervix Uteri with the Spec-
ulum.
In employing the speculum uteri, the principal obstacle which
we have to contend with is the impossibility of always catching
easily and accurately the os and cervix uteri in the upper or internal
extremity of the instrument, so that these parts may be brought at
once and completely within the range of sight. Indeed the search
after the cervix uteri, when it is not at first caught in the open end
of the speculum, is sometimes so painful to the patient, and this
part of the manipulation is occasionally so difficult to the operator,
that every one who has made much use of the speculum will, I
believe, be ready to confess that in some cases where the uterus is
situated obliquely, or where the cervix is high and displaced, the
object is almost impossible of attainment. The previous introduc-
tion and use of the uterine sound offers a simple and certain means,
both of overcoming the difficulty in question, and of facilitating the
employment of the speculum in our ordinary cases of examination
with that instrument. After making such tactile examination as
may be required with the sound, leave it in the uterine cavity,
and using it as a general guide, slip the uterine extremity of the
speculum, whether tubular or bladed, over its handle and along its
stem, till the instrument be fully introduced. The upper or uterine
extremity of the speculum is thus guided with almost unerring
certainty along the stem of the sound, till the cervix uteri is touched
1
1 Thus, in their excellent Treatise on Diseases of the Uterus, Boivin and Dugès
state that "The cervix uteri is sometimes so inclined backward that the speculum
cannot show it by any movement."-Heming's Translation, p. 33. See also
Lisfranc's Lectures as reported by Pauly, Maladies de l'Utérus d'après les Leçons
Cliniques de M. Lisfranc-Paris, 1836, pp. 59, 60; and Téallier, Du Cancer de la
Matrice, pp. 70, 71, etc.
DIAGNOSIS BY THE UTERINE SOUND.
625
and included in its opening. Further, if we still keep the sound in
the uterus, we have in it a means of turning the cervix to one or
other side at will, so as to give ourselves a complete view of the
mucous membrane covering the whole vaginal surface of this part of
the organ. This last step in the examination is much facilitated by
first drawing aside the stem of the bougie into the cleft between
the two blades of the speculum-provided we are using a double-
bladed instrument.
In making these remarks, I presuppose that the patient, during
the employment of the sound and speculum, is placed upon the
left side in bed, in the position already pointed out as most favour-
able for making a common tactile examination. When occupying
this position, with, as previously recommended, the body laid across
the bed, the speculum can be employed with perfect ease and suc-
cess, and, at the same time, without any of that revolting exposure
of the person of the patient, which is unavoidable when she is
turned, as is so commonly practised, upon her back during this
operation. The instrument can be introduced readily without the
assistance of sight, and if the bed and body clothes be placed with
a little care in contact with the surface of the patient, and the latter
be closely arranged around the tube of the instrument, the mouth
of the speculum is the only part which actually requires to be un-
covered in order to enable us to examine the cervix uteri and canal
of the vagina, and there ascertain those changes of colour, superficial
alterations of structure, etc., that the speculum is occasionally of so
great service in divulging, and by which we may have an oppor-
tunity, in doubtful instances, of either confirming or correcting the
previous evidence afforded by the sense of touch.
III. By the use of the Uterine Sound we may, in many instances of
Pelvic and Hypogastric or Abdominal Tumours, ascertain the con-
nection or non-connection of these Tumours with the Uterus.
We have already seen the advantages of having the uterus fixed
upon the bougie in facilitating the tactile examination of the outer
surface of the organ. This use of the sound is of still greater im-
portance, when a chronic pelvic or hypogastric tumour is present,
and we wish to ascertain whether this additional structure has its
origin in, or any connection with, the tissues of the uterus, or is
attached to some of the neighbouring parts or organs. The power
of making such a distinction leads, in some instances, to practical
626
DISEASES OF WOMEN.
distinctions in the treatment, and in almost all cases to differences
with regard to our opinion of the future progress of the disease.
The prognosis, for example, is very different in ovarian dropsy, and
in enlargement of the uterus from the presence of a large mass of
fibrous tumours in its walls. I have found, however, no mistake
to be more common in practice, than to suppose a tumour in the
hypogastric or iliac region to be an enlarged and dropsical ovary,
when it actually consisted of the other much less formidable dis-
ease of a great mass of fibrous tumours in the uterine structures.
When these fibrous tumours "attain," to quote the words of Dr.
Lee, "a large size, and come to occupy a great part of the abdo-
minal cavity, they produce all the injurious consequences of enlarged
ovaria, from which indeed, during life, they are distinguished with
the greatest difficulty." "It is often," says Dr. Ashwell, "exceed-
ingly difficult, where a growth, occupying the abdominal cavity, is
large, filling perhaps its greater portion, to determine whether the
uterus or ovary, or both, may not be diseased." This difficulty is,
in some cases, more or less removed by the evidence afforded by the
use of the uterine sound.
When the tumour which is present is uterine, and consists of
either some general or partial enlargement of that organ, I have.
usually been able to gain satisfactory evidence of the fact by the
bougie, when passed into the uterine cavity, entering, as it were,
more or less directly into the very structure of the morbid mass,
and by the tumour and instrument afterwards reciprocally moving
in exact correspondence with all the possible motions imparted re-
spectively to each of them.
In other instances, where the tumour is not uterine, I have
repeatedly made myself and others certain of the fact, by first
introducing the bougie, and so far giving us at once a knowledge
of the exact position of the uterus, and a control over its move-
ments, and then proceeding in one of three ways:-1. The uterus
may be retained in its situation with the bougie, and then, by
the assistance of the hand above the pubis, or by some fingers
in the vagina, the tumour, if unattached to the uterine tissues, may
be moved away from the fixed uterus. 2. The tumour being left
in its situation, it may be possible to move away the uterus from
it to such a degree as to show them to be unconnected. Or, 3.
Instead of keeping the uterus fixed and moving the tumour-or
Cyclopædia of Medicine, vol. iv. p. 388.
2 Practical Treatise on the Diseases peculiar to Women, Part ii. p. 291.
DIAGNOSIS BY THE UTERINE SOUND.
627
fixing the tumour and moving the uterus-both may be moved.
simultaneously, the uterus by the bougie, and the tumour by the
hand or fingers, to opposite sides of the pelvis, to such an extent
as to give still more conclusive evidence of the same fact. In a
case, for example, which I saw during the last winter, there were
two distinct, firm, defined tumours to be felt at the brim of the
pelvis when the hand was placed above the pubes. The smaller of
these tumours was placed to the left, and somewhat anterior to
the other. The two tumours lay so close as to seem to be con-
nected with each other, and this, with their semiglobular form,
impressed the physician who had charge of the case with the belief
that his patient had one of those masses of roundish fibrous
growths affixed to the uterine walls that I have already spoken.
of as not unfrequently met with in this part of the body. The
hypogastric examination of the swelling induced me at first to
adopt the same opinion, but the employment of the bougie readily
showed us to be both in error. The instrument, when introduced
through the os into the uterine cavity, passed directly upwards to
the top of that tumour which lay towards the left side, and the
apex of the sound could be felt through the intervening tissues, at
once demonstrating that this apparent tumour was formed by the
fundus of the somewhat enlarged and displaced uterus. Retaining
the instrument in this position, the uterus was next moved by
means of the bougie still farther to the left, whilst the other
tumour was at the same time pushed still farther to the right or
opposite side, by the pressure of the hand, with such ease and to
such an extent as to prove that it had no immediate organic
connection with the uterus. The farther examination of the
tumour on the right side-its rounded form and other physical
characters-its position behind the broad ligament, etc.-showed it
to be ovarian. Without, however, the aid of the bougie, the two
hypogastric swellings in this case would assuredly have passed for
uterine fibrous tumours, instead of the one being formed by the
fundus of the uterus, and the other by an enlarged ovary.
The rules of diagnosis which I have been stating, evidently
apply only to those cases in which the uterus and pelvic or.
hypogastric tumour are neither organically adherent to each
other, nor so closely wedged together as to render them mutually
immovable. But it often happens that, in consequence of the
existence of one or more of these last-mentioned conditions, none
of the tests that I have just now spoken of can be applied, and in
41
628
DISEASES OF WOMEN.
such instances the bougie affords no very affirmative evidence.
Still, however, the knowledge which we can gain by it, and by it
alone, of the state of the uterine cavity, of the increased or
diminished length of that cavity, and especially of its relative
situation and direction in regard to the existing morbid mass, are
calculated in some of these more difficult and complicated instances
to afford no small degree of assistance in the diagnosis.
In one
common set of cases, the knowledge of the exact
situation of the uterine cavity, and hence of the uterus itself, in
relation to the tumour that is present, even when both were
immobile, has in repeated instances appeared to me especially
important. The ovary normally lies behind the uterus, being
attached to the posterior surface of the broad ligament. If, there-
fore, in a case of chronic tumour situated in the pelvis, the sound
shows the tumour to lie on the anterior surface of the uterus; or,
in other words, if the uterine cavity runs up the posterior surface
of the morbid mass, the disease may be considered as certainly not
ovarian, and the further difficulties of the diagnosis will thus be so far
very much simplified by way of exclusion. This remark particu-
larly applies to those cases in which the tumour, of whatever nature
it may be, is still not so large as to have passed out of the pelvic
cavity and become abdominal.
I have found, however, advantage from the negative infor-
mation given in other ways by the bougie, even when the
tumour was abdominal in its seat. An example will best illus-
trate my meaning. In a case sent to Edinburgh a few months
ago, for the purpose of having some opinion given in regard to its
nature, an immense abdominal swelling that was present, and which
had been supposed by some medical gentlemen who had seen the
patient to be ovarian, was shown not to be so, by sufficient evidence
of the following nature. The uterus was displaced obliquely back-
wards, and the fundus of the bladder was displaced towards the
right iliac region by the abdominal enlargement-circumstances
which were easily ascertained by introducing the uterine sound into
the cavities of both of these organs. Further, the uterus, though
. displaced, was quite mobile; and when its fundus was turned by
the bougie towards the site of either ovary, and the abdominal
tumour lifted at the same time as high as possible towards the
epigastrium, no obstruction was met with, nor was this great change
upwards in the direction of the tumour found to produce any drag-
ging effects whatever upon the uterus as held by the bougie, or upon its
DIAGNOSIS BY THE UTERINE SOUND.
629
connections-effects which, unless under the improbable supposition
of a pedicle several inches long, would have inevitably occurred if
the diseased mass had originated in or was connected with the
ovaries or uterine appendages. So far, the evidence was negative,
but still, nevertheless, important. I may add, that other characters
of a more positive nature-the history, particular form, and consist-
ence of the tumour-its position in front of the intestines as ascer-
tained by percussion, etc. etc.—seemed to show it, seeing that it was
not ovarian, to be in all probability one of those hydatigenous
tumours that sometimes form in the tissue of the omentum, and
whose physical symptoms during life in many respects correspond
with those of ovarian dropsy.
In a case, in which a very large hard and solid tumour was
situated in the mesial line of the abdomen, and had been growing
for years, the aid of the uterine bougie assisted us greatly in
making a diagnosis of its pathological seat and character, by a kind
of evidence which was exactly the reverse of that stated in the
preceding instance. In the case we speak of, the os uteri was in its
usual situation in the pelvis; the bougie, however, after passing
through it, glided onwards, obliquely forwards, and towards the left,
showing the body of the uterus to be displaced in that direction,
Farther, it was ascertained, by moving the bougie in the uterine
cavity, that the progress of the uterus towards the right side was
entirely prevented by the presence of the opposing morbid mass,
whilst it could be moved to the left side to a slight extent, but still
so much so as to show that its surface was not immediately
adherent to the tumour. Holding the bougie in the uterus, with a
finger in contact with the cervix uteri, the body of the growth was
next strongly pushed both upwards and to the right, with the other
hand placed upon the lower part of the abdomen. When so moved,
the tumour distinctly pulled upwards along with it the uterine
bougie, and consequently the uterus itself. The whole examination
by the bougie thus showed that, first, The tumour was not a
fibrous growth developed in the uterine structure, or intimately
attached to its exterior surface, because the body of the uterus,
though displaced by the presence of the growth, was still movable
to a certain degree independently of it; secondly, It was probably
an enlarged ovary, or tumour connected with the ovary or uterine
appendages, because, when moved upwards or to the right, it dragged
the uterus along with it; thirdly, Though mesial in its position, it
was attached to the side of the right ovary, or to the posterior sur-
:
A
630
DISEASES OF WOMEN.
ace of the right broad ligament, because the body and fundus of
the uterus were displaced forwards and towards the left, and had
some remaining mobility in that direction, but could not be moved
by the bougie in any degree backwards or towards the right side,
in consequence of the presence of the opposing mass of the tumour.
These circumstances in the physical diagnosis of the tumour, as
ascertained by the bougie, were confirmed by the other symptoms
of the case; but these other symptoms would certainly, in conse-
quence of the equivocal character and position of the tumour, have
been in themselves insufficient to have fixed its true pathological
seat and character.
In the preceding remarks, I have pointed out the uses of the
uterine bougie, in so far as they aid our examination of the exterior
of the uterus, or of the outer surface of the Fundus, Body, and
Cervix, and enable us to distinguish between tumours of the
uterus itself, and those situated in structures altogether external
to it.
In continuing the subject in my next communication, I shall
attempt to state the still more important uses to which the instru-
ment can be put, in examining the interior of the organ, and the
state of its walls, and in determining the presence of those common
but hitherto little known forms of displacement that pass under the
names of retroflexion, anteflexion, etc.
I shall take the same oppor-
tunity of showing the circumstances which counter-indicate the use
of the sound, and the cautions required in its employment.
SECTION III.'
ON THE MEASUREMENT OF THE CAVITY OF THE UTERUS AS A MEANS
OF DIAGNOSIS IN SOME OF THE MORBID STATES OF THAT ORGAN.
No organ of the body is, in its normal and physiological state,
more subject than the uterus to great and striking alterations of
volume. Witness its rapid increase during pregnancy, and its still
more rapid diminution in the puerperal female. In some of its
anormal and pathological conditions, the same organ strongly dis-
plays the same tendency to enlarge in different directions and
dimensions. "No tissue," observes Cruveilhier, "is more extensible,
more malleable (plus extensible, plus malléable), than the tissue of the
1 See London and Edinburgh Monthly Journal of Medical Science, November
1843, p. 1009.
DIAGNOSIS BY THE UTERINE SOUND.
631
1
uterus, when it has undergone the softening which constantly accom-
panies its hypertrophy. It becomes elongated and extended in all
directions; and it is only when its distension is carried beyond
measure, that upon its hypertrophy supervenes atrophy." Again,
on the other hand, the cavity of the unimpregnated uterus is so
small, and its canal of communication with the vagina is so narrow,
that they are liable to be found more or less obliterated by malcon-
formation or disease; while the uterine walls themselves are some-
times observed, by their partial displacement and inversion, to
shorten, and even to efface, the internal cavity of the viscus.
The changes in the capacity and dimensions of the uterus, which
are thus so often produced by disease, have been long well known
to the pathological anatomist. They have hitherto, however, in a
great measure, escaped the observation of the medical practitioner,
because, though frequently discovered by him upon the dead body,
he possessed no certain means of detecting their presence during the
lifetime of his patient. In the following communication, it is my
purpose to show, that this blank in uterine pathology may be filled
up, and that we can ascertain, by means of the bougie, with suffi-
cient facility and precision, upon the living subject, the varying sizes
of the uterine cavity. And here, as in all other cases in which
physical signs have enabled us to determine pathological lesions
during life, we shall find that the knowledge of them may be
rendered of the highest avail in diagnosis and practice.
With these views, we shall attempt to illustrate as our next
proposition, with regard to the uses of the instrument which we are
describing, that
IV. The Uterine Bougie is capable of affording valuable diagnostic
information, by enabling us to measure the Length of the Uterine
Cavity.
The uterus varies in its dimensions, and consequently in its
length, in different persons, independently both of pregnancy and
disease. In the unimpregnated state, and in its normal and healthy
condition, I have found the cavity of the organ to measure, on an
average of a pretty extensive number of observations made both
upon the living and dead body, about two inches and a half from
the os to the fundus. The bougie has, as already stated, an elevated
mark upon its stem at this distance, two inches and a half, from its
¹ Anatomic Pathologique, livr. xiii.
632
DISEASES OF WOMEN.
point, for the purpose of showing whether or not the instrument is
completely introduced into the uterine cavity. The cavity is, in its
normal varieties, more often above than below the standard. Fur-
ther, the instrument, as previously mentioned in the description that
has been given of it, is so graduated by inch or half-inch marks upon
its stem, as to indicate, when it is introduced up to the fundus
uteri, the exact degree of elongation, or of shortening of the interior
of the organ. In illustrating its utility in this respect, I propose to
demonstrate its application to the discovery, first, Of some morbid
states in which the uterine cavity is preternaturally increased; and,
secondly, Of others in which it is preternaturally diminished in length.
In the present communication, we shall limit our attention to the
first of these divisions, or to
INSTANCES OF INCREASED LENGTH OF THE UTERINE CAVITY.
The cavity of the uterus may be found elongated under a variety
of circumstances which we shall consider somewhat in detail.
1. Morbid Permanence of the State of Puerperal Hypertrophy.—This
peculiar condition does not appear to have as yet attracted the
attention of obstetric pathologists, as the cause of one of those forms
of chronic hypogastric tumours that are occasionally met with during
the first weeks and months after delivery. The want of any deci-
sive means of recognising it has doubtlessly led to this omission.
The notes of a case will show, better than any comment, the nature
of the affection to which we allude, and the facility and certainty
with which it may be recognised by means of the uterine bougie.
During the summer of 1842 I attended, along with Dr. Aber-
crombie, a lady, who, after a premature confinement in the country,
had suffered from a smart attack of puerperal fever. After so far
recovering for a few weeks she was sent from a considerable distance
into town, to be treated for what appeared to be a large tumour,
stretching upwards from the pelvis into the right iliac region. The
tumour had not been observed before delivery, and was somewhat
painful to the touch. It seemed at first sight extremely doubtful
whether the mass consisted of an inflamed uterine fibrous tumour,
or enlarged ovary, or of one of those chronic purulent collections
which are apt to form towards one or other iliac region in connection
with puerperal fever or inflammation. The sound, when introduced
into the os uteri, passed easily and directly upwards for several
inches to the superior end of the tumour, and its apex could be
DIAGNOSIS BY THE UTERINE SOUND.
633
felt there by the hand placed externally. This at once showed the
supposed diseased mass to consist of the enlarged uterus. Further
examination proved that there was nothing strictly anormal about
the uterus except its great size. In fact it was a case where the
organ had apparently remained nearly undiminished after delivery,
probably from the puerperal attack arresting the usual progress of
its absorption and diminution. It decreased rapidly and fully under
leeches and other local antiphlogistic treatment."
May not some of the instances of pelvic or hypogastric swellings
after delivery, which have been recorded by Puzos and others² as
lacteal collections (dépôts laiteux) or inflammatory effusions, and that
ultimately yielded without suppuration, be of the above nature? The
lateral position of the swelling is, as shown by the preceding case,
not a sufficient criterion.
In one of those cases of subacute inflammatory tumours that
occasionally form in the pelvis of the puerperal female, and that
lately came under our care, the information afforded by the sound
was perfectly the reverse of that obtained in the preceding instance,
and yet still of considerable importance. I did not see the patient
till nearly two months after her confinement. She had not regained
much strength, and there were symptoms present which indicated a
degree of subacute inflammation in the region of the uterus. A
rounded and circumscribed tumour could be readily felt rising from
the pelvis to the height of an inch or two above the brim of the
pelvis. Was this a swelling resulting from some limited inflam-
matory effusion among the pelvic viscerá? was it the uterus itself,
or some neighbouring organ, enlarged and diseased? or what was
its nature? On passing the bougie through the os uteri, which was
1 Long after the above case and the observations preceding it were written, I
met with the following passage in Dr. Hooper's work, showing that the diseased
state that I had recognised during life was known to him as a post-mortem ap-
pearance :—“When a fœtus has been recently expelled, it is, in some instances,
a long time before the uterus returns to its original state; and it is larger and
softer during the period. I have examined uteri four times their natural size from
this cause, two months, and even more, after the foetus was expelled.”—Morbid
Anatomy of the Human Uterus, p. 5. Is this the disease alluded to in Kleinert's
Repertorium, bd. ii. 1838, s. 51, as described by Kopp under the name of Hyster-
anesis in the first volume of his Denkwürdigkeiten, p. 235? I regret that I have
no access to this work.
2 See Levret's Art des Accouchemens, p. 168. Des Engorgemens Laiteux dans
le Bassin, etc. Deleurye's Traité des Accouchemens, p. 509. Des dépôts laiteux
dans les ligamens larges, etc. etc. In a MS. copy of William Hunter's Lectures,
belonging to the College of Physicians, Edinburgh, among the remarks on puer-
peral diseases, is a short chapter on "the iliac abscess."
634
DISEASES OF WOMEN.
a matter of some difficulty, in consequence of its distance from the
vulva, it slipped easily upwards to the top of the hypogastric swelling,
and showed the apparent tumour to be the uterus itself, situated
much higher, and more anteriorly than usual. It showed further
that the uterine cavity was of its usual length, and consequently
that, though displaced, the organ was not enlarged. It was, how-
ever, found to be firmly fixed in its anormal position by some
morbid cause, which prevented its fundus and body from being
moved by the bougie either backwards or laterally. On searching
further into the nature of the morbid cause which could thus anor-
mally displace and fix the organ, I found a large swelling situated at
the upper part of the vagina, and between the uterus and rectum.
It pressed downwards upon the roof of the vagina, and backwards
upon the rectum, and pushed upwards the uterus in front. Its ex-
tent and situation in the pelvis were made out by a combined rectal
and vaginal examination. Its nature was more obscure, and the
feeling of fluctuation, if any, was very indistinct. In the presence
of Mr. Ziegler, Dr. Keith, and Dr. Murray, a very slender exploring
needle was passed from the rectum through the dense walls of the
tumour, in order to ascertain whether it contained fluid, and if so,
the nature of that fluid. A drop or two of thin pus escaped along
the tube of the instrument. This at once satisfied us of the nature
of the tumour. I immediately made a larger perforation into it
from the bowel with Pouteau's trocar. A quantity of pus escaped,
and continued to do so for a considerable time. The local and
general symptoms under which the patient was suffering speedily
abated, and she has since entirely recovered her general health and
strength. The catamenia have returned. The uterus, however,
still remains preternaturally fixed and immobile.
In the case which I have just detailed, the results were to me
the more gratifying, inasmuch as some months previously I had seen,
in the Lying-in Hospital, an instance of the same disease, in which
the affection proved fatal, from the collection of matter bursting
into the general cavity of the peritoneum. On the post-mortem.
inspection of the body, it was evident that from the thinness of the
partition intervening between the purulent collection and the cavity
of the rectum, the abscess would have soon burst into the bowel, if
it had not given way superiorly into the peritoneum itself; and it
was equally evident that an artificial opening, made from the
rectum into the purulent sac before the period of its rupture, might
have saved the life of the patient.
DIAGNOSIS BY THE UTERINE SOUND.
635
M. Martin of Montpellier, who has written one of the best
memoirs extant upon this subject,' under the title of Des dépôts des
annexes de la Matrice qui surviennent a la suite des Couches, recommends,
in the treatment of the purulent collection, that, in order both to open
it externally, and to produce previous adhesions of the containing sac
to the abdominal parietes, caustic potass should be applied to that
part of the hypogastrium which forms the most prominent point (le
point le plus saillant) of the swelling. This rule of practice, which
seems to have been very successful in M. Martin's own hands,
would, if universally followed out as a mode of evacuating the col-
lection, sometimes lead to an irreparable and fatal blunder. In the
case that I have detailed, the most prominent hypogastric point of
the swelling was, as we have seen, formed by the uterus itself, as
demonstrated by the bougie. The use of the instrument would
easily guard against such a mistake as applying-as might have
happened in such an instance--the caustic or knife over the uterus,
instead of over the purulent cyst itself.
In these cases of subacute or chronic purulent collection in the
pelvis after delivery, the pus seems to be in the first instance effused
beneath the peritoneum of the uterine appendages, and between it
and the pelvic fascia. The original inflammation appears to be
seated in the structures intervening between these two membranes.
I have seen several cases in the female of chronic "pelvic inflamma-
tory tumours" of the same seat and nature, unconnected with the
puerperal state, and where the fixed state of the body of the uterus,
the surrounding tumefaction, and the apparent, almost ebony indura-
tion produced in the roof of the vagina at one stage of the disease,
by the tenseness and distension of the pelvic fascia, gave rise to the
idea that the affection was organic and carcinomatous, and not
simply inflammatory. I may revert to this subject in a future part.
Already the present digression on it is much too long.
1 See also among the more recent descriptions of the disease, the observations
of Dance and Husson in Breschet's Répertoire d'Anatomie, tom. iv. p. 172 (Sro
edit.); Meniere in Archives Génér. de Médecine, tom. xvi. p. 529. Grisolle in
ib., tom. xlix. p. 37; Kyll in Rust's Magazin für die ges. Heilkunde, bd. xli. s.
311; Imbert in his Traité des Maladies des Femmes, tom. i. p. 160; Dupuytren
in his Leçons Orales, tom. iii. p. 347; Meissner in Kleinert's Repertorium, bd. vi.
1842, s. 38; Charlton in the Edinburgh Monthly Journal for 1841, p. 329;
Doherty in the Dublin Journal for 1842, p. 199. I observe that in the last or
September number of the Dublin Journal, my friend Dr. Churchill has published
an excellent memoir on this affection, but does not seem to be aware that the
disease has already attracted the attention of many modern writers.
2 Mémoires de Médecine et de Chirurgie Pratique, p. 312.
636
DISEASES OF WOMEN.
2. Normal Elongation of the Puerperal Uterus as a Sign of Delivery.
-Immediately after delivery, the uterine cavity is in general from
six to eight inches in length. I have seen it measure between
eight and nine inches in three women, who each died within
twenty-four hours after delivery, with the organ imperfectly con-
tracted. In one of these cases death apparently resulted from the
introduction of air into the venous circulation through the free
openings of the uterine sinuses; the second sank after a twin
labour and severe hemorrhage; the third died about six hours.
after delivery, having laboured under convulsions and deep coma
during the whole previous day; and in both these last cases ex-
tensive and well-marked granular disease of the kidney was found
on dissection.¹ In the course of the natural changes of the puerperal
state, the uterus gradually diminishes and regains its natural size in
the course of four or five weeks, and, in some, not till a longer
period after parturition. In two cases which I have lately seen,
where it was requisite for the purposes of criminal law to ascertain
the existence of the signs of delivery, the uterine cavity was, about
the seventh day after the accouchement, still between four and five
inches in length. In a third case, in which the date of the parturi-
tion is still uncertain, two most intelligent medical men gave in a
report, certifying the existence of all the ordinary signs of delivery
upon the body of a woman nearly fifty years old, with the single
but important exception, that no uterine tumour could be felt by
them above the pubis, probably in consequence of the organ being
so flaccid or so low in the pelvis, as not to be felt by the common
hypogastric examination. Eight days subsequently, I saw the
accused along with one of the medical reporters, and at that time
found that the uterine cavity still measured fully four inches in
length, and that the fundus of the organ could be pressed easily
forwards by the end of the introduced bougie, so as to make us
both perfectly certain of the existence of enlarged uterine tumour.
This completion of the evidence was the more satisfactory, as the
person still pertinaciously denied the crime of concealment in con-
nection with child-murder, on an accusation for which she was at
the time incarcerated, and the proof, independently of the facts
ascertained by the medical witnesses, was very vague and uncertain.
In this last case, the use of the bougie proved the presence of
the enlarged uterus, when, as long as a week previously, it could not
be felt above the pubes by an abdominal examination carefully con-
1 The footnote proper to this place will be found as text at p. 295.—J. W. B.
DIAGNOSIS BY THE UTERINE SOUND.
637
ducted in the ordinary mode. It showed the uterine tumour to
exist when it could not be felt by the usual means of examination.
In other instances of the same kind, it may prove useful in the con-
verse way, by demonstrating the tumour that may be felt, not to be
formed by the enlarged uterus. Dr. Montgomery, in his essay
On the Signs of Delivery, justly states, that "the chief points of
attention ought to be the state of the uterus, of the external parts,
and of the breasts. "' 1
But in regard to the first of these, as felt
above the pubes, he properly remarks, "a tumour may be felt so
situated, and yet may not be the uterus." 2 The introduction of the
bougie into the uterine cavity would at once decide this point.
In any doubtful case, the evidence derivable from the measure-
ment of the uterus might be made the more complete by repeating
it from time to time, so as to note the gradual diminution of the
length of the organ, till it ultimately returned to its natural size.
This sign, like all the other proofs of delivery, can never be
relied upon alone, but must always be taken in connection with the
other data that are present. It may be considered, however, as an
addition to their number, which is the more valuable in this respect,
that it can be ascertained at a date later than most of them. To
render its evidence still more certain and precise, it would be
necessary to know the general rate of diminution in the length of
the uterine cavity after delivery, and its variations. An extensive
series of observations, both upon the living and dead subjects after
delivery, could alone fully determine these points. The examina-
tions of puerperal uteri after death, which have been recorded by
Ruysch, Roederer, Montgomery, etc., will aid in such an inquiry."
In cases of feigned delivery, the sign that we have pointed
out from the measurement of the uterus, might be equally useful
in demonstrating the organ to be of its normal length and
dimensions.
1 P. 317.
2 P. 307.
s I may add, that in one of the women above alluded to, and whom I saw in
prison, along with Dr. Graham Weir, we detected another sign of delivery, not
hitherto pointed out, as far as I know, by any medical jurist. All of them men-
tion the value of the evidence afforded by the tactile examination of the os uteri.
The visual examination of this part with the speculum afforded in the instances
alluded to a still stronger proof. The swollen, ecchymosed, and gaping state of
the labia and os uteri presented such striking peculiarities, as made it almost im-
possible to confound it with any other morbid condition of the parts, such as the
inequalities, ulcers, etc., attendant on syphilis, and against the similarity to
which as ascertained by touch, Gardien (Traité d'Accouchemens, tom. i. p. 132) so
particularly guards us.
638
DISEASES OF WOMEN.
3. Increased Length in Metritic and Congestive Hypertrophy of
the Body of the Uterus.-When the body and fundus of the uterus
are the seat of any continued morbid irritation, the walls of the
organ become hypertrophied in the same manner, though by no
means to the same degree, or with the same uniformity, as under
the continued normal irritation of pregnancy. The most common
pathological cause of uterine hypertrophy, when uncomplicated with
organic disease, is chronic congestion or metritis. It happens in
hypertrophy from this source, that, as in cases of excentric hyper-
trophy of the heart, the cavity of the organ becomes in general
enlarged, along with the enlarged state of the parietes. This en-
largement of the cavity generally takes place in all directions, so
that it is increased in its length, as well as in its other dimensions.
The increase of length or elongation of the uterine cavity may be
ascertained and measured by the bougie. There are as yet few or
no precise data which can be referred to, to indicate the degree of
hypertrophy, and consequent elongation in such cases. In an excel-
lent specimen of simple hypertrophy of the uterus, contained in
Dr. William Hunter's museum, the length of the cavity of the organ,
from the os to the fundus, is exactly three inches and one-fourth.
It is set down in the catalogue, as a Uterus slit open from before ;
it is the size of the impregnated uterus at two months; the woman,
however, was not pregnant, but had the furor uterinus."¹ The
hypertrophy and accompanying elongation may be occasionally
greater. I have repeatedly found the uterine cavity measuring as
much as three and a half inches. When speaking of hypertrophy
as a result of chronic metritis, Boivin and Dugès observe, that in
this state “the uterus is often distended throughout, and its volume
assumes the dimensions presented in the second month of pregnancy."
And they add, "In some cases it enlarges so as to fill the hypogas-
trium, and reach the umbilicus." "With this state (of simple
hypertrophy)," says Dr. Hooper, "the whole of the uterus is of a
preternatural size, more especially the body of the uterus, without
any other morbid or unnatural appearance; and this increase of
size is caused by an unusual formation of the healthy structure of
the organ. With regard to the extent of this unnatural occurrence,
I have found the uterus more than twice the usual size; and this
may be considered as the mean, or most common size in hyper-
trophy; but it is sometimes much larger. "I have known,'
2
2
66
113
¹ Printed Catalogue, p. 147, No. 97, s. Chapter on Chronic Metritis, p. 352
3 Morbid Anatomy of the Human Uterus, p. 5.
""
DIAGNOSIS BY THE UTERINE SOUND.
639
"11
observes Dr. Burns, "the cervix thicker, the body evidently swollen,
and, if not deluded, the fundus rising above the pubis, and yet the
tumour disappear.' Dr. Hamilton says he has seen the “uterine
tumour as large as the womb in the fifth month, and yet it was
removed."2
We would qualify these remarks upon the increased admeasure-
ment of the uterus in congestive or inflammatory hypertrophy, by
adding that, judging from our own experience of it, probably this
mode of physical diagnosis will, in the morbid condition under con-
sideration, be found of more use practically in showing us with
sufficient precision the gradual diminution of the organ, and hence
the rate of progress towards recovery, under the treatment that we
may be following, than in forming by itself, in the first instance, a
perfect diagnostic criterion of the original existence of the disease.
For we must hold in view, that the length of the cavity of the
organ is, from natural conformation, liable in different persons to
exceed the usual standard by a few lines, even when no disease is
present; and in chronic hypertrophy the increase of the longitudinal
dimensions of the uterus will not be to any very marked or notable
extent, unless the affection has proceeded to a considerable degree.
Besides, there may exist, although we cannot call to our recollection
any example of it, a form of metritic enlargement, in which, as
sometimes occurs in the heart, the hypertrophy is concentric, and
not excentric, to borrow the cardiac nomenclature of Bertin, and
where the length of the uterine cavity would consequently not be
increased by the presence of the disease.
In employing the bougie in the diagnosis of simple hypertrophy
of the uterus, the instrument is of use in other respects than by
merely enabling us to measure the length of the uterine cavity. It
gives us at the same time the power of examining, in the mode that
we have already shown, much more accurately than we could other-
wise do, the condition of the fundus and anterior and posterior
walls of the uterus, through the abdominal parietes and rectum-so
that we can at the same time ascertain, that while the organ is in-
creased in length, its external surface is quite regular, and presents
none of the inequalities which indicate the existence of any more
fixed or formidable organic change.
4. Longitudinal Hypertrophy of the Uterus, and especially of
the Cervix.In that form of simple or metritic hypertrophy which
we have last described, the morbid enlargement of the organ affects
¹ Burns' Principles of Midwifery, p. 122, 10th edit. 2 Pract. Observ. p. 65.
640
DISEASES OF WOMEN.
equally all its dimensions, and increases its breadth as well as its
length. Occasionally, however, it happens, that in hypertrophy of
the uterus, the increase in the dimensions. of the organ is princi-
pally, or even entirely, in its longitudinal direction, and that in
consequence the uterine cavity becomes so elongated, as to afford
us a much more decisive physical sign of its morbid state when
submitted to the measurement of the Uterine Sound. One of the
most remarkable examples of this type of uterine hypertrophy
hitherto placed on record is that mentioned by Dr. Kennedy, in
an excellent paper' in the Dublin Journal, as having occurred in a
case of extra-uterine gestation. The uterus was "developed in its
length, with very little increase of breadth, to the extent of twelve
inches."2
When this longitudinal hypertrophy takes place in the unim-
pregnated uterus, it almost always results from morbid elongation
of the cervix. The body and lips of the organ are natural in size
and dimensions; but the intervening part, or cervix, appears as if
its tissues had become ductile, and been extended and drawn out to
a greater or less degree. The elongated cervix may either retain
its normal diameter, or, as more rarely happens, it is attenuated in
thickness nearly in proportion to its increase in length.
Two different varieties of the morbid hypertrophy that we are
considering seem to occur, and have not been sufficiently distin-
guished by authors. In one, the elongated portion of cervix is
placed altogether above the reflection of the roof of the vagina; in
the other, the hypertrophy is situated below that reflection, or affects
only the vaginal cervix, as it has been termed. In the former
variety, the altered uterus is reduced in form to the shape and type
of the organ in infancy. We have seen this variety in some cases
of complete procidentia of the uterus," and found the uterine canal,
as measured by the bougie, to be stretched out to four and five inches
in length. Mr. Heming supposes that this form of cervical elongation
is most apt to take place in connection with prolapsus of the uterus,
"complicated with hernia at its posterior part," whilst the cervix
remains unchanged in prolapsus "complicated with hernia at its
anterior part."* I have examined one case where the reverse holds
1 "On Hypertrophy of the Os Uteri."-Dublin Journal of Med. Science,
vol. xiv.
2 P. 321.
3 See good illustrative sketches of this form of the neck of the uterus in the
case of prolapsus uteri figured in Cloquet's Pathologie Chirurgicale, 1831, pl. viii.
fig. 3, and Froriep's Chirurgische Kupfertafeln, t. 417, figs. 1 and 4.
4 Med. and Phys. Journal, vol. lxviii. p. 107.
DIAGNOSIS BY THE UTERINE SOUND.
641
true; the os uteri is prolapsed an inch or two beyond the vulva,
and the cervix much elongated; but the posterior wall of the
vagina remains in situ, forming a deep reflection behind the pro-
truding tumour; and the anterior wall of it with the bladder forms
part of the external swelling. I may add that this variety of
hypertrophy is met with also in instances in which the elongation
of the body of the organ takes place in connection with the presence
of fibrous or other tumours, when they happen to drag and raise
upwards into the abdomen the fundus uteri, while the cervix remains
fixed. Cruveilhier has represented an example of this complication,
in which the canal of the cervix alone is stretched out to the length
of five or six inches.¹
When the portion of cervix which is below the vaginal reflection
is hypertrophied, the elongated structure projects downwards from
the vaginal roof, like the cylindroid finger of a glove or a cow-teat.
I have had occasion to excise one, in consequence of the constant
discomfort which it produced. In another case of this kind, in
which the patient has suffered often from recurrent attacks of
severe uterine irritation, and has the os uteri almost projecting
through the vulva, the neck of the organ is about two inches in
length, and the body of the uterus is, as I have ascertained by the
sound, acutely bent or retroflected backwards and to the right;
and it has its fundus firmly adhering in this anormal position to
the pelvic peritoneum, covering a firm solid tumour lodged behind
the rectum, and filling up the upper part of the hollow of the
sacrum. The shape and consistence of the tumour at first gave me
the idea that it was one of those osteo-sarcomatous masses that are
sometimes seen in this locality; but the use of the exploring needle
showed that the induration was not from any bony deposit. When
of still greater size than in these instances, the hypertrophied
cervix has prolapsed externally, and by its shape and configuration.
has been mistaken for the male penis. Some of the cases of
spurious hermaphroditism in the human female, as those described
by Saviard, Valentin, and Home, appear to have been merely
examples of this disease. Its presence generally prevents impreg-
nation; and in fact, the tapering, conical form of the cervix uteri,
which is so commonly found in women long married without
becoming mothers, is a minor degree of this same diseased state.
Ollivier, Lisfranc, and others, have mentioned the frequent connec-
¹ Anat. Path., livrais. xiii. pl. 2.
1
2
2 Dr. Todd's Cyclopædia of Anatomy, vol. i. p. 690.
642
DISEASES OF WOMEN.
tion of this state with sterility; and I have repeatedly had occasion
to verify it. In a case that came under the care of Dupuytren, the
elongated cervix was reduced to its natural length by the knife.
The patient had been previously eight years married, and asked
medical advice on account of her want of family. Two months
after the operation she became pregnant.¹
3
The morbid elongation of the cervix uteri is spoken of by Roux
as "a pretty frequent condition (état assez fréquent), and one that
has been hitherto mistaken for procidentia or prolapsus by the
greater number of practitioners." Roux ascribes the first notice of
this morbid state to Lallemand and Bichat. It was, however, long
before described by Morgagni,' Levret, and Hoin," and has since.
been commented upon at greater or less length by Desormeaux,'
Murat, Gardien," Dance,10 Heming," Boivin and Dugès," Lobstein,"
Cruveilhier,¹¹ Davis," Kennedy, etc. etc.
8
The longitudinal hypertrophy of the cervix uteri is liable to be
confounded with other morbid states of the organ. "This disease,"
says Dr. Kennedy, "has been mistaken for polypus, and its removal
has been attended with fatal results. In the hypertrophy of the
neck, from the os remaining open, with the exception of its altered
position, it is, however, most likely to be mistaken for prolapsus.
The detecting, by a carefully conducted examination per vaginam,
and, if necessary, by the rectum, the elongated or outstretched neck
of the uterus, whilst the fundus of the organ is perceptible of its
natural size, and in its usual position in the pelvis, will sufficiently
establish the diagnosis." The exact height and position of the
fundus uteri, which are thus requisite for the diagnosis in some
cases, can only, as we have already shown, be ascertained by the aid
of the bougie, when the abdominal parietes are sufficiently dense to
oppose a perfect tactile examination at the hypogastrium. In hyper-
trophy of the cervix, the use, however, of the bougie is still greater
17
¹ Dumont's Thèse sur l'Agénésie, l'Impuissance, et la Dysgénésie-Paris, 1830.
No. 2231; and Archives Gén. de Médecine, t. xxv. p. 266.
2 Preface to Bichat's Anatomie Descriptive, t. v. p. 7.
Epist. xlv. obs. 11.
• Journal de Médecine, tom. xl. p. 352.
8 Dict. des Sciences Méd., tom. xxxi. p. 186.
3 Ib. t. v. p. 282.
5 Jour. Ancien de Méd. tom. xl.
7 Dict. de Médecine, tom. ii. p. 12.
• Traité d'Accouchemens, etc., tom. i. p. 118.
10 Archives Générales, tom. xx. p. 524, 1829.
11 Medical and Physical Journal, vol. lxviii. p. 107.
13 Path. Anat. tom. i. p. 57.
14 Anat. Path. livraison xxxiv. pl. 2.
16 Dublin Journal, vol. xiv. p. 322.
12 Tom. i. p. 193, etc.
15 Obstetric Medicine, p. 208.
17 Ibid.
1
DIAGNOSIS BY THE UTERINE SOUND.
643
in another view. "A sound," says Desormeaux, in his article on
Allongement du col de l'Utérus, "carried into the os tinca pene-
trates to the depth of five, six, seven inches, or even more.” This
last circumstance," he observes, "is primarily important in fixing
the diagnosis." Desormeaux is at the same time certainly wrong
when he adds that we may thus "easily distinguish elongation of
the cervix from complete prolapsus of the uterus, inasmuch as, that
in the latter a sound would scarcely penetrate above two inches in
depth." In complete prolapsus, the uterus, it is true, does occasion-
ally retain its normal length; but as I have already stated, the
reverse is much more generally the case, and the prolapsus is usually
accompanied with cervical elongation of the organ, more especially
if its fundus, as it very often happens, has become morbidly adhe-
rent to some of the neighbouring portions of pelvic peritoneum,
during the course and increase of the displacement. Even in simple
and incomplete prolapsus, the uterine cavity is not unfrequently
somewhat elongated; because that prolapsus in recent and subacute
cases is very often the result merely of the general hypertrophy and
increased weight of the organ; and here its increased length may
so far form a valuable sign, in showing that in the treatment we
must act against the hypertrophy, as the pathological cause, before
we can hope to ameliorate the prolapsus, which is simply its me-
chanical effect.
2
When the cervix is elongated downwards from the upper part
of the vagina, we may easily measure by the uterine sound, and by
a finger in the vagina, the exact extent of its morbid prolongation ;
and, on the other hand, when the hypertrophied portion is situated
above the vaginal roof, we may attain the same object by tracing
with a finger, in the posterior reflection of the vagina, or in the
rectum, the progress of the sound as it passes upwards through the
elongated and tapering cervix, until it reaches the entrance (and
there the canal is generally contracted) of the cavity of the broader
1 Dictionnaire de Médecine, tom. ii. p. 13.
2 The partial prolapsus, which often takes place in metritic hypertrophy,
furnishes," observes Duparcque, "the means of assuring ourselves more
directly of the state of the uterus. Unfortunately, practitioners rarely know
how to profit by it. They consider solely the prolapsus, and apply a pessary,
and they are astonished when it cannot be borne, or that, so far from putting an
end to the various pains and uneasinesses which they attributed to the prolapsus,
the presence of the instrument exasperates them, or becomes even the exciting
cause of more serious alterations."-Traité sur les Altérations Organiques de la
Matrice, p. 201.
42
644
DISEASES OF WOMEN.
and bulging out body of the uterus itself. In making such an ex-
amination, we must guard against the error of supposing the instru-
ment to be fully introduced into the cavity of the body of the uterus,
when it has only reached the upper part of the occasionally dilated
cavity of the cervix. Lobstein describes an instance of the disease
in which the error might have been easily fallen into. "The
museum," he observes, "of our faculty (at Strasburg) contains a
very interesting example. The neck of the uterus has a length of
three inches and one line, its thickness at its superior part is six
lines; in descending it becomes enlarged, and its cavity dilated so
as to give it a size of an inch and seven lines. At first view it looks
like a piece composed of two uteri touching each other by their
necks; no change of tissue is discoverable." 1
5. Hypertrophy of the Uterus and Uterine Cavity, from the growth
of Fibrous Tumours in the Parietes of the Organ.— When fibrous
tumours, the most common of all the organic diseases of the uterus,
grow in the walls of the viscus, they are generally accompanied
with a hypertrophied condition of the uterine parietes, exactly
resembling in its nature and appearance their hypertrophied state
in pregnancy. Under the irritation of an isolated fibrous tumour
or tumours the surrounding hypertrophy is usually local in its seat,
and confined to the uterine walls in its immediate vicinity; when
the fibrous masses are larger or more numerous, the uterine hyper-
trophy becomes more general. I have a preparation of a case of
this kind, in which the organ resembled in size, and in the thickness
and characters of its parietes, the uterus of the female a day or two
after delivery. "The natural substance of the uterus," observes.
Dr. Hooper, in which this tumour is imbedded, is almost always
found to have undergone a decided change, having become more
distinctly fibrous, and the fibres more obviously fasciculated. The
2
¹ Traité d'Anat. Pathologique, tom. i. p. 57.
2 "The hypertrophy of the uterus is," observes Cruveilhier, general when the
fibrous tumour directs itself towards the side of the uterine cavity; it is partial
when the tumour follows an opposite course; if it occupies the fundus it is the
fundus alone which becomes developed, and the rest is moulded upon it; if the
anterior wall is its seat, it is the anterior wall which becomes developed; if it
approaches the peritoneum, the fibres intérvening between it and that membrane
undergo the change. In the cases of partial hypertrophy of the uterus, the remain-
der of the organ may be in its natural state; but this is rare, because if the uterus
is not solicited to development in the direction of its thickness, it is so in the
direction of its height, in consequence of the slow or rapid increase of the fibrous
bodies. Now a development in height or length is still always a hypertrophy."-
Anat. Pathol. livr. xix. pl. 1, 2.
DIAGNOSIS BY THE UTERINE SOUND.
645
quantity of these fibres, that is of the natural fleshy fibres of the
uterus, is very much increased, so that the diseased structure is often
surrounded by walls much thicker than those of a healthy uterus."
"In these instances," he remarks in another page, "the uterus very
much exceeds its natural bulk and weight after the morbid structure
has been completely removed. I have found the uterus in many of
these cases weigh two pounds, after having dissected out masses of
subcartilaginous (fibrous tumours) or other substances." 1
In cases of fibrous tumours leading to uterine hypertrophy in
the manner just described, the cavity of the uterus is frequently
enlarged, as well as its parietes. "When fibrous tumours," says
Bayle, in his admirable essay on this disease, “are numerous or very
large, they deform altogether the body of the uterus. Almost
always when they become so large as a man's head, they enlarge
(aggrandissent) the uterus in every direction, and dilate considerably
its cavity (dilatent considérablement sa cavité)."
)) 2
The cavity of the uterus, however, is not always enlarged, even
when the fibrous tumours are both large and numerous. This
result, in regard to the cavity, seems to be regulated by the seat and
relations of the tumours. We have observed in the disease the three
following conditions of the uterine cavity:-
First, The cavity is elongated and enlarged with the enlarging
state of the tumour and uterine parietes, when the morbid mass
grows from any point towards the interior of the organ, or when
it is originally situated in the lateral walls of the body of the uterus,
and so during its development tends to stretch out these walls, and
consequently the contiguous cavity along with them, in a longitudinal
direction.
3
"I have
In cases in which the fibrous tumour is seated on one side or
wall of the organ, and becomes of a great size, the lengthened
uterus sometimes comes to be wrapped and welded for some dis-
tance around the exterior surface of the fibrous growth.
seen," says Cruveilhier, "in these cases the uterus considerably
elongated, and form a kind of a half-belt (demi-cintre) around the
tumour." The degree of elongation and dilatation of the uterine
cavity under these circumstances is very various. I have repeatedly
found it, both upon the living and dead subject, measuring three,
four, and five inches in depth. Madame Boivin describes and
represents a uterus of a conical shape, containing in its parietes
¹ Morbid Anatomy, pp. 11 and 6. 2 Dict. des Scien. Méd. tom. vii. p. 72.
3 Anat. Path. livr. xiv. pl. 1, 2.
646
DISEASES OF WOMEN.
several fibrous tumours, and having its cavity prolonged in the form
of a narrow canal, to the length of nine inches.' I have in my
museum a preparation of this kind, in which the uterine canal
measures above ten inches.
The greatest elongations of the uterine
cavity that I have as yet ascertained by the bougie in cases of
fibrous tumours in the living subject, are two instances where the
canal was, in the one six inches in length from the os uteri to the
fundus, and in the other seven and a half inches. Dr. Beilby saw
with me the former, and Dr. Girdwood of Paddington the latter
case, and both of these gentlemen assured themselves, by personal
examination with the uterine bougie, of the accuracy of the measure-
ments that I have stated. This hypertrophy of the walls and cavity
of the uterus seems liable to occur in its greatest degree when the
tumour or tumours are rapid in their growth, and make their
appearance during the child-bearing periods of life. In using the
bougie in these cases the instrument sometimes requires to be so
much unbent as to be nearly straight before it can be introduced ;
and where the elongated uterus curves around the exterior of the
fibrous mass, the apex of the sound must be passed so as to follow
the particular direction of the uterine cavity.
Secondly, The uterine cavity may retain nearly its natural
dimensions and depth, or be only very slightly increased, even
when the fibrous tumours are both large and numerous, provided
they grow from any part towards the exterior surface of the organ,
or are originally seated in the fundus uteri and not in its lateral
parietes. I have seen a mass of uterine fibrous tumours so large
as to have been mistaken by one practitioner for an enormous
hepatic growth, where the uterine cavity was only about three
inches in depth. In this instance the tumours were evidently all
growing from the peritoneal surface of the uterus, and could be felt
through the thin abdominal walls adhering to it with pedicles of
varying sizes, like a number of exterior polypi.
Thirdly, In connection with the existence of fibrous tumours in
the uterus, the uterine cavity may be found apparently shortened in
consequence of some portion of it being obliterated by adhesive
inflammation from the pressure together of its opposing surfaces by
the presence of the tumours. I shall state afterwards a case of this
kind, where the uterine canal, as examined from the vagina,
appeared only an inch in depth. In this, as in most other such
cases, the cavity of the body was found concealed higher up,
¹ Heming's Boivin and Dugès, p. 179, pl. 14.
DIAGNOSIS BY THE UTERINE SOUND.
647
enlarged to some degree, but forming a short cavity from the
obliteration of its inferior part. This result, as the effect of the
presence of fibrous tumours, is principally observed when the
tumours have been of very long standing, and when the hypertrophy
of the uterine tissues that accompanied their earlier development
has at last been followed by a state of atrophy of the included and
compressed walls of the organ.
The practical deductions that may be drawn from the preceding
remarks regarding the length of the cavity of the uterus in fibrous
tumours of the organ, are so evident as to require little or no
comment. I have already stated my opinion, and would repeat it
here in the strongest terms, that no error is more common in practice
than to mistake a fibrous tumour of the uterus for a dropsical ovary,
or a dropsical ovary for a fibrous tumour.¹ I shall take another
opportunity, in these contributions, of offering some suggestions for
the more perfect diagnosis of ovarian tumours, and their connections.
In the meantime I may merely state that in the lengthened state of
the uterine cavity, as easily ascertained by the bougie during life,
we have, in many instances, an additional physical sign between the
two classes of diseases alluded to, subject to exceptions which I will
subsequently mention; and if the elongated uterine cavity is dis-
covered by the bougie to run behind the tumour that is present, it is
another and still more decisive reason for concluding that the
affection is uterine and not ovarian. At the same time it is to be
held in recollection that if the uterine cavity is of its natural depth,
it is no sufficient reason that the hypogastric or abdominal growth
is not a fibrous uterine tumour, and more careful examination under
such circumstances will often show the tumour or tumours to be
such, and to have either a more or less pediculated form, and
attachments to the external uterine surface, or to be imbedded in
the walls of the fundus. Lastly, the uterine canal is sometimes
greatly shortened in the way described, in connection with the
existence of fibrous tumours in the uterine walls. I am not aware
that it is ever in this way diminished in depth from the presence
of ovarian disease.
1 In illustration of this remark, I shall content myself with adducing one fact.
Few men in England seem to have attended more zealously to the subject of ovarian
tumours, and no one has laboured so much to reintroduce the excision of them, as
Mr. Clay of Manchester. Yet out of five cases which he has lately recorded, of
operations for the extirpation of enlarged ovaries, in two it was found, after the
abdomen had been laid open, that the disease was not ovarian, but consisted "of
anomalous and uterine tumours."-See his Cases of Peritoneal Section for the
Extirpation of Diseased Ovaria, p. 18.
648
DISEASES OF WOMEN.
In
6. Enlargement and Distension of the Uterus, from Polypi, etc., in its
Cavity. When polypi or other morbid structures form in the cavity
of the uterus, they act like the presence of an ovum, enlarge the
interior of the organ in proportion to their growth and size, and
generally at the same time induce, as in pregnancy, a corresponding
degree of thickening and hypertrophy in the uterine parietes.
such cases the uterine bougie shows an increased depth of the uterine
cavity. The degree of increase will necessarily vary in every
different instance. I have seen a retained polypus enlarging the
uterus to the size of the organ at the fourth month of pregnancy.
Cruveilhier has represented a large fibrous polypus as included
within and distending the uterine cavity, so that the organ measured
above eight inches from the os to the fundus. We shall see after-
wards that it is not the mere length to which the bougie may pass
that forms the diagnostic mark under such circumstances, but that
it is by the possibility of passing it on more than one side between
the surface of the tumour and the interior of the uterus, or by the
power of so far revolving it round, and isolating, as it were, the
contained mass, that we draw the distinction between tumours
situated in the cavity and those which, as described under the last
head, are still imbedded in the parietes of the organ.
1
7. Elongation of the Uterus in Hernia of the Organ.-Hernia of
the unimpregnated uterus is a disease of very rare occurrence. The
organ, however, has been found protruding into the tumours formed
by different varieties of abdominal hernia. It had passed through
the crural ring in cases met with by Lallemand and Cruveilhier;"
through the inguinal canal, in instances detailed by Desault and
Chopart, and Lallemand. Most of the cases of hernia of the im-
pregnated uterus which have been recorded by Sennertus, Hildanus,
Ruysch, Ladesma, Fisher, etc., were instances in which the uterus
seems to have become displaced after conception took place.
3
1
5
When the unimpregnated uterus forms the subject of hernia it
seems in general to be considerably elongated. In Chopart's case
the organ is described as smaller than usual, rounded and lengthened
in form (arrondie, allongée); in Cruveilhier's plate the displaced
1 Bulletins de la Faculté de Médecine, 1816, tom. i. p. 1.
2 Anat. Pathologique, livr. xxxiv. pl. vi.
3 Traité des Maladies Chirurgicales, tom. ii.
p. 305.
• Mémoires de la Soc. Méd. d'Emulation, 3me année, p. 323.
5 See the details of them collected by Dr. Cormack, in Edinburgh Monthly
Journal for 1841, p. 491, and ibid, for 1842, p. 28.
DIAGNOSIS BY THE UTERINE SOUND.
649
•
viscus is represented as drawn out to the length of five or six inches.
In fact, the uterus itself must in all such cases be either much drawn
out in length, in order to allow its fundus to be the subject of such
great displacement, or the vaginal canal must be extended into the
neck of the hernial sac, as happened in the example already referred
to, as recorded in the Bulletins de la Faculté de Médecine.
In one of the cases of hernia of the uterus described by Lalle-
mand, the patient applied for advice in consequence of the superven-
tion of symptoms of strangulation. The sac, on examination, was
supposed to contain a portion of intestine; but the age of the patient,
etc., prevented an operation being attempted. On examination after
death, the hernial tumour was found to be composed of two folds of
omentum, two hydatic cysts, the ovaries, Fallopian tubes, and uterus.
In relation to the difficulty of the diagnosis in this and similar cases,
Murat observes, that "hernia of the unimpregnated uterus is most
frequently confounded with that of other parts of the abdomen, and
there are no pathognomic signs by which we can recognise it."¹ We
may, as Nauche advises, so far overcome the difficulty, by finding,
on vaginal examination, "the uterus situated high in that canal
more or less devious, the orifice turned to the side opposite that of
the hernia, and on pressing it with the finger, we impart a certain
mobility to the hernial tumour.” 2 A much more decisive means of
solving the problem will be afforded by the use of the uterine
bougie. If, instead of trusting to the preceding points as ascer-
tainable by the examination of the os and cervix with the finger, we
pass the bougie into the uterine orifice and its elongated cavity,
both the direction which the instrument will, during the course of
its introduction, take towards and into the mass of the tumour, and
the power of feeling its apex in the fundus uteri, through the hernial
walls, after it is fully introduced, will at once place the matter beyond
the possibility of doubt. In this procedure it will be proper to
recollect, that in some cases a slender, and it may be even a flexible
bougie will be required, in order to overcome the contractions and
irregularities of the uterine cavity that may be present.
¹ Dict. des Sc. Méd. vol. xxxi. p. 228.
2 Maladies de l'Utérus, p. 114.
1
650
DISEASES OF WOMEN.
SECTION IV.¹
ON THE MEASUREMENT OF THE CAVITY OF THE UTERUS AS A MEANS
OF DIAGNOSIS IN SOME OF THE MORBID STATES OF THAT ORGAN
-continued.
In our last communication we described a number of morbid
conditions of the uterus, in which the cavity of that organ is more
or less elongated. We showed that the diagnosis of these affections.
could be greatly advanced by ascertaining, through the use of the
uterine bougie, the exact extent and degree of the existing elonga-
tion. It was at the same time remarked that in some pathological
states of the uterus its cavity is shortened and diminished in depth.
On the present occasion, we purpose to describe briefly this latter
set of cases, and will point out in what respects their discrimination
during life may be promoted by the employment of the uterine
sound.
INSTANCES OF DIMINISHED LENGTH OF THE UTERINE CAVITY.
The cavity of the uterus, when shorter than natural, may have
its depth diminished as the result of malformation, of disease, or of
displacement.
1. Preternatural shortness of the Uterus from original malformation
of the organ.-Few of the malformations of the uterus, with the ex-
ception of the duplicity and absolute deficiency of the organ, have
as yet attracted much attention. It would, however, be easy, we
believe, to bring together, by a little patient research, a considerable
series of cases, in which the organ was found less than its normal
length by an inch or an inch and a half." In some instances, in fact,
the cervix of the uterus is alone present, and the body and fundus
of the organ are imperfectly or totally undeveloped. In more strict
terms, the lower extremities of the Fallopian tubes, instead of coa-
lescing and becoming evolved into the body and fundus of the uterus,
remain separate, retain their tubal character, and open into the
superior part of the single cavity of the cervix. Such appears to us
to be the explanation of the case, for example, described by Lauth,
in which the cervix was sufficiently well formed, with the tubes
1 See London and Edinburgh Monthly Journal of Medical Science, March 1844,
2 For further remarks on this subject, see p. 601.
p. 208.
DIAGNOSIS BY THE UTERINE SOUND.
651
opening into it almost directly, and only separated by a small cavity.'
Morgagni speaks of a uterus in which the distance from the os to
the fundus was not so much as the breadth of the thumb. The
genital organs were in other respects malformed. Dr. Dewees
mentions an instance of amenorrhoea, in which the uterus was of
a size not exceeding the thumb of a man.
66
113
In that particular variety of malformation which various patho-
logists have described under the name of "oblique uterus," and
where the organ originally lies with its fundus directed to one side
of the pelvis, and has one set of its lateral ligaments shorter than
another, the organ is sometimes, though not always, shorter than
natural. Tiedemann describes an oblique uterus two inches and a
line in length, and in which the cavity would measure considerably
under two inches.4
In all cases in which the uterus is malformed and shortened in
the modes we have alluded to, the uterine sound will probably
afford us important diagnostic information, by enabling us to
measure the exact degree of diminution in the length of the cavity
of the organ. To make the information more certain and precise, it
will be necessary at the same time to ascertain, by a hypogastric or
rectal examination, that the apex of the instrument has really
reached the superior end of the uterine body, and hence, that it is
not arrested in its progress by any structure in the cavity, or by any
flexion in the walls of the viscus, such as we shall afterwards fully
describe.
2. Uterine canal shortened from stricture or partial obliteration.-
"A stricture," says Dr. Baillie, "is sometimes formed within the
cavity of the uterus, so that its cavity at one part is obliterated
entirely. This," he adds, “I believe almost always to take place
at one part, namely, where the cavity of the fundus uteri terminates,
and that of the cervix begins, for in this place the cavity of the
uterus is narrowest. As the sides of the cavity round this place lie
very near each other, and form naturally a small aperture, it is
probable that some slight inflammation may unite the parts together,
and shut up the aperture; or the parts may gradually approach
each other without this cause, as in the stricture of the urethra.”
1 Andral's Anatomic Pathologique, tom. i.
p. 677.
2 Epist. xlvi. 20, Alexander's Translation, vol. ii. p. 661.
* System of Midwifery, p. 69, ed. of 1837.
▲ Von den Cowperschen Drüsen des IVeibs, etc., p. 26.
5 Morbid Anatomy, edit. of 1812, p. 379.
652
DISEASES OF WOMEN.
The morbid state which Dr. Baillie has so accurately described
in the above quotation, as the result of his observations upon the
dead body, could only be detected upon the living subject, by
examination with a uterine probe or bougie. Nor would the dia-
gnosis be difficult, for at the same time that it was found that the
bougie was completely arrested in its progress upwards, at the
distance of an inch, or an inch and a half, from the os tincæ, it
might be ascertained by a hypogastric examination, that it was still
far from having reached the fundus uteri.
1
Since the time that Dr. Baillie wrote, Professor Mayer of Bonn
has shown that in old persons, the os internum or cervico-uterine
orifice is so often obliterated, that it may be almost looked upon as
a normal condition, connected with the general atrophy of the viscus
that takes place in very advanced life. In one or two aged patients
I have found it impossible, during life, to pass the smallest probe
through the os internum, probably owing to the contraction in
question. The cases I allude to were those of females who in earlier
life had produced children, and where there was therefore no original
stricture or malformation.
Stricture of the os internum is, like diminution in the size of the
os tincæ, not unfrequent in females affected with dysmenorrhoea,
and who, though married, have never had children. In several cases
I have met with difficulty and obstruction in passing through the
opening between the cavities of the neck and body of the uterus, a
sound or probe that had already passed easily and freely through
the os tincæ. I have at present under my care a case of this kind,
in which there is a most remarkable degree of antroversion of the
whole uterus. Jahn, in his Essay on the Oblique Uterus, mentions an
instance of that malconformation where, after death, the os internum
was found so narrow that a fine probe could not be passed through
it (ut subtillissimo stilo transitum denegaret); and yet the os tince was
well formed.2 In Ruysch's Catalogue a uterus is mentioned, with
the os internum so small as not even to admit the head of a small
needle (ne caput quidem acicule minoris admittere posset).³
3
Occasionally the whole cavity of the body of the uterus is
obliterated, from the os internum to the fundus, and yet the cavity
of the cervix continues patent. Cruveilhier speaks of having seen
a case of this kind, "in which there was no trace of a cavity in the
1 Beschreibung einer Graviditas Interstitialis Uteri, p. 14.
2 De Situ Uteri Obliquo, in Schlegel's Sylloge Operum Obstetr. tom. i. p. 268.
3 Thesaurus Anatomicus, vi. No. 85.
DIAGNOSIS BY THE UTERINE SOUND.
653
body of the organ, although the cavity of the neck remained." An
example of the same kind has been represented by Madame Boivin
in the plates attached to her treatise on diseases of the uterus.²
The cavity of the uterus is, in some rare cases, partially obli-
terated, in consequence, as has been already stated, of the develop-
ment of fibrous tumours in the walls of the organ. Under such
circumstances, the obliteration is the result of inflammatory adhe-
sions, formed between those portions of the opposed surfaces of the
lining membrane of the uterus, that happened to be maintained in
a state of close and morbid apposition, by the presence and pressure
of the neighbouring tumours. The adhesive inflammation thus ex-
cited occasionally extends to some distance from its original seat.
In all cases, however, the cavity of the cervix seems to escape, and
the portion of the cavity of the body that is placed above the stric-
ture frequently becomes distended and enlarged, from the accumula-
tion of morbid mucous secretions within it. Cruveilhier has
described a very illustrative case of this kind.³ A preparation was
presented to the Anatomical Society of Paris, as a morbid ovary.
In external appearance, it had much more resemblance to an ovarian
than an uterine disease. On more minute examination and dissec-
tion, however, it was found to consist of an agglomerated mass of
fibrous and fibro-calcareous tumours, the whole forming a shapeless
body, with an irregular, tuberculated surface. The tumours varied
in size from a pea to a large compound one weighing by itself about
1 pound. On cutting into the midst of the mass, a cavity was
found, filled with reddish serum, which it was easy to see was the
cavity of the body of the uterus. This cavity was a shut sac, there
being no opening from it. Inferiorly, its communication with the
cervix uteri was entirely obliterated. When examined as to its
vaginal relations, the uterus, or uterine canal, seemed to terminate
at an inch above the os tince. A blunt stilet, adds Cruveilhier,
passed in all directions, could not discover above this point any
opening into the uterine cavity. If the same means had been em-
ployed, as a matter of diagnosis during life, the same result would
have been obtained as in the post-mortem examination, and that
result would have afforded pretty conclusive evidence that the
disease was not ovarian, because the uterus does not seem to be
liable to become occluded in the course of its cavity, in connection
1 Descriptive Anatomy, vol. i. p. 621 of Dr. Madden's translation.
2 See plate xiii. fig. 3.
3 Anatomic Pathologique, livrais. xiv.
654
DISEASES OF WOMEN.
with ovarian growths; and besides, the use of the bougie would
have shown the uterus imbedded in the tumour, and probably the
partial canal of the cervix running in such a direction in relation.
to the tumour as to add further testimony to its non-ovarian
character.
3. Diminished depth and effacing of the Uterine Cavity in Inversion
of the Uterus. We believe that the diminution in depth, and, in
extreme cases, the total obliteration which the canal of the uterus
undergoes in inversion of the organ, will generally give us the
power of distinguishing this morbid state from all others to which
it is symptomatically allied; and more especially from those forms
of polypus that occasionally so strictly resemble it, and with which
it has been frequently and sometimes fatally confounded.
When inversion of the uterus occurs immediately after delivery,
it can, in general, be easily distinguished from a polypus that has
passed through the os uteri after the expulsion of the child, or
placenta, or both, because, omitting other considerations, though
in each we may find in the vulva or vagina, if we are led to
make an examination by the severity of the symptoms, a large
fleshy tumour, yet this tumour, in the case of polypus, can be proved
not to be the displaced uterus, as the fundus uteri can still be felt
above the pubis, whilst the reverse is true of inversion.
If any
doubt remained, in consequence of difficulties in the way of the
hypogastric examination, or otherwise,' a bougie cautiously passed
by the stalk of the vaginal tumour, would, if it were a polypus,
prove at once the uterine cavity to extend upwards to the length.
of six or seven inches, and if desired, would enable us further to
feel more distinctly through the hypogastrium the fundus uteri
still remaining in situ. If the tumour were the inverted fundus of
the uterus, the cavity of the organ would, on the contrary, be found
shortened to an inch or two on all sides, and it would be found
difficult, or impossible, to bring, as usual, any part fully within the
reach of an abdominal examination. In those rare instances in which
the inversion was complete, the orifice and cavity of the uterus would
be found entirely effaced.
The difficulty, however, of distinguishing between polypus and
inversio uteri is greatly increased when the diagnosis is attempted
1 For cases of polypus of the vagina after delivery mistaken for inversion, see
Ramsbotham's Practical Observations, vol. ii. p. 473, and Gooch's Account of
Diseases of Women, p. 282; and for cases of inversion under the same circum-
stances, mistaken for polypus, see Gazette Médicale for 1822, p. 422.
DIAGNOSIS BY THE UTERINE SOUND.
655
after the puerperal uterus has diminished to its normal volume, or
when the patient applies for advice at a distance from the period of
confinement, and the inversion is only partial. Under such circum-
stances it has repeatedly happened that a polypus has been mis-
taken for an inverted uterus,' or the still more dangerous error
committed of considering an inverted uterus to be a polypus, and
treating it accordingly. Such errors involve not only the comfort
but the life of the patient.
2
It is true that a diagnosis can generally be established with con-
siderable certainty between polypus of the uterus and partial chronic
inversion of the organ, by attending, amongst other points, particu-
larly to the two circumstances, that however similar in other respects
the tumour formed by inversion is, 1st,-in its history, traceable
to having appeared immediately after delivery; and, 2d, in its
character, it differs from polypus in being sensitive to a greater or
less degree to the touch, while the polypus is not so.
We must,
however, at the same time, hold in view that some fibrous polypi,
when they carry down before them, and are covered with a layer of
true uterine tissue, or when temporarily inflamed, are found to be
sensitive, and that the inverted uterus becomes almost insensible when
long exposed; and again the fact, that the tumour first appeared
¹ See cases in Ansiaux Clinique Chirurgicale, p. 207; Acta Harniensia, 1818,
tom. v. p. 51.
3
4
2 On cases of inverted uteri mistaken for polypi, see Morgagni, de Sedibus, etc.,
Epist. xlv. No. 4. Palletas' Exercitationes Pathologica, pp. 17, 18. Gooch, in his
Diseases of Women (1831), p. 265, gives an instance where Dr. Hunter applied
by mistake a ligature to an inverted uterus. A preparation illustrative of this
error was in the museum of the late Dr. Hamilton; the patient, as in Dr. Hunter's
having died with the uterus partially cut through with the ligature. Occa-
sionally the uterus has been included without fatal effects: see numerous quota-
tions in Dr. Burns' Principles of Midwifery, 1837, p. 128.
case,
3 'It is said that an inverted uterus is sensible to the touch, while polypi, on
the contrary, are void of feeling. This can never be an accurate mode of forming
a diagnosis, as we can only judge of the sensibility of the tumour by the expres-
sions of the patient, which are regulated more by disposition than by the extent
of her sufferings. I lately attended a lady with uterine polypus, and had I
judged solely by the complaints of my patient, I should have pronounced the
polypus to have been more sensible than an inverted uterus usually is."-Dr.
Chas. Johnstone in Dublin Med. Reports, vol. iii. p. 488.
"We shall always find it difficult to distinguish between the sensibility of the
tumour and sensation occurring in neighbouring viscera, which are irritated by
the process of examination; while, too, it must be remembered, that the sensi-
bility of the inverted uterus is greatly diminished in its chronic stage, and that
the sensibility of polypus may be increased by the presence of inflammatory
action."- Newnham on Inversio Uteri, p. 83.
4 "It is said that the polypus is usually indolent, and that the fundus of the
656
DISEASES OF WOMEN.
2
immediately after delivery, is not itself conclusive, because in some.
cases of inversion the accident has not caused such severe symptoms
as to be recognised at that moment,' and again, the first time a
polypus passes from the uterus to the vagina is occasionally immedi-
ately after labour. In their physical character, the two diseases
often very nearly resemble one another. "When the uterus," says
Dr. Gooch, "is only partially inverted, that is, when its fundus only
is drawn down through its orifice into the vagina, and the patient
has survived for many months, the tumour feels exactly like a poly-
pus of the fundus. :
In the smoothness of its surface, the
roundness of its body, the narrowness of its neck, and its being
encircled by the orifice of the uterus, it sometimes exactly resembles
polypus of the fundus."*
To show still more strongly the difficulties which occasionally
intervene in the distinction between chronic inversion of the uterus
and polypus, I will adduce the testimony of one or two writers,
whose authorities on this point are such as to command all con-
fidence.
Mr. Newnham in his learned essay on Inversion of the Uterus,
after having brought together the opinions of many authors-ancient
and modern-British and foreign-upon this question in diagnosis,
adds, “On reviewing the foregoing testimony we shall be induced
to conclude that it is always difficult, and sometimes impossible, with
our present knowledge, to distinguish partial and chronic inversion
of the uterus from polypus.""
uterus has an exquisite sensibility, but very often one meets with painful polypi ;
and it must be so, since they are very often covered with the tissue of the uterus.
Their lower part may be insensible, because this envelope is too thin, or it may
be perforated. On the other hand, it is certain that the sensibility of the inverted
uterus gets duller after a time."—Lisfranc, Clinique de la Pitié, tom. vii. p. 133.
"In time, the surface of an inverted uterus becomes less sensible to external
impressions.”—Jourdin, Dict. des Sciences Médicales, tom. xxxiii. p. 288.
'Dr. Montgomery has in his museum a preparation of inverted uterus which
had during life been quite insensible to the application of the needle."-Dr.
Burns' Midwifery, p. 561.
1 "
The nature and even the facts of the accident have often not been dis-
covered till after the lapse of many days, weeks, or months subsequently; and in
a smaller number of cases not till after the death of the subject.”—Davis' Obstetric
Medicine, p. 1088.
2 Two cases of this nature are given by Levret in his paper on uterine polypi,
n the Mémoires de l'Académie Royale de Chirurgie, tom. iii. pp. 543, 545.—See
also Gardien's Traité des Accouchemens, tom. iii. p. 316; Delpech's Précis des
Maladies Chirurgicales, tom. ii p. 586 ; three cases in the Journal Hebdomadaire
de Médecine, No. 44 Ramsbotham's Observations, vol. ii. p. 473.
I have seen
one come down after a premature labour.
3 P. 255.
4 Essay on the Symptoms, etc., of Inversio Uteri.—London, 1818, p. 82.
DIAGNOSIS BY THE UTERINE SOUND.
657
In his elaborate work on Operative Midwifery, Professor Kilian
offers a nearly similar observation-"An inverted uterus may so
deceitfully (täuschend) resemble a polypus that the diagnosis is
scarcely possible.
" 1
In a clinical lecture on inversion of the uterus, Velpeau, in
alluding to the diagnosis of that disease from polypus in some very
difficult instances, adds, "There are cases in which doubt is the only
rational opinion (le doute est la seule opinion rationelle).”
3
4 ((
), 2
"When," observes Lisfranc, "the polypus or inversion has only
partially opened the os uteri, we are assured that the diagnosis is
impossible-authors do not even consider the case." "From the
facts we have adduced," he adds, one may easily conceive the
immense difficulties met with in cases of this nature; thus, under a
great number of circumstances, the most distinguished practitioners
have believed that they had tied polypi, when they had included
the organ of generation itself in the ligature; and in other cases
they have supposed they had removed the uterus either wholly
or in part, when they had only relieved their patients of polypous
tumours."
5
In order to resolve the difficult problem in uterine diagnosis to
which these remarks refer, Malgaigne some time ago proposed a
means which is thus described: "A curved catheter is introduced
into the bladder; it is then carried backwards, and its concavity
directed downwards, so as to bring the point of the instrument
into the bottom of the uterine sac; the index finger is then intro-
duced into the vagina, where the point of the catheter is as easily
felt as it is in the hypogastrium in ordinary catheterism." Thus
the diagnosis is established; "but there are circumstances,"
continues Lisfranc, "in which the catheter, in consequence of the
adhesion of the organs, cannot penetrate into the sac of the inverted
uterus; then it might be erroneously believed that we had to do
with a polypus." Setting this last objection aside, we doubt entirely
the applicability of such a means of diagnosis in this case as that
proposed by Malgaigne. The urethra of the female is placed in
such a direction in relation to the other pelvic contents, that if the
stem of an ordinary male catheter be held in it, the apex of the
instrument, when turned backwards, will look posteriorly to the
hollow of the sacrum, and cannot, without lacerating the urethral
2 Clinique Chirurgicale, Paris, 1841, tom. ii. p. 425.
3 Clinique, tom. iii. p. 135.
+ P. 136.
5 Lisfranc, Clinique de la Pitié, tom. iii. p. 137.
1 ¹ B. ii. p. 280.
658
DISEASES OF WOMEN.
connections, be made to return downwards towards the vagina. To
enable it to do so, the instrument would require to be curved at an
acute angle, and not at an obtuse-and if of the former shape, it
could not be made to pass into the bladder, and even if passed,
could not probably be used with safety. We make these remarks
after having tried repeatedly the experiment upon the dead
subject.
A more safe and easy means of distinguishing a polypus from
a partially inverted uterus, will be found in the measurement of the
uterine cavity, by the introduction of the sound. In some doubtful
instances its aid will afford us a certain mode of completing the
diagnosis in this, a class of uterine cases in which, above all others,
the prognosis and treatment are almost entirely dependent upon the
accuracy of our diagnosis.
To avail ourselves of the information afforded by the measure-
ment of the bougie, it is to be held in view that in polypus the
depth of the uterine cavity is not necessarily diminished, but some-
times the reverse, while in inversion it is always diminished to a
great and notable degree.
In four cases of polypi of considerable size, projecting through
the os uteri, and which I have had occasion to remove within the
last three months, the bougie in all, when passed by the side of
their pedicles into the interior of the uterus, showed its cavity to be
of the natural depth. In some preparations, I have seen the cavity
elongated, in consequence probably of its distension by the polypus.
previous to the protrusion of the latter. On the other hand, in
partial chronic inversion of the uterus, with the fundus uteri passed
downwards, and projecting through the os, the uterine cavity must
be necessarily diminished on all sides in depth by this doubling up
of the organ; and further, this diminution of its depth must be pro-
portionate in its degree to the degree of the inversion, so that
ultimately, if the inversion becomes, as sometimes happens, complete,
the cavity will, of course, be entirely obliterated. In a common case
of such partial inversion and protrusion of the fundus as is liable to
be confounded with a polypus projecting through the os, the depth
of the interior cavity would be found diminished at least by more
than a half, or might measure on all sides about an inch or less in
depth, instead of the usual length of two and a half inches.¹ In
1 In a case in which the inverted uterus was tied in the Lyons Hospital, under
the idea that it was a polypus, the patient died on the fifth day. On the post-
mortem examination, the vagina and uterus were of the natural size, and the
DIAGNOSIS BY THE UTERINE SOUND.
659
making this measurement with the bougie, it will always be re-
quisite to ascertain accurately that the depth of the uterus is
lessened in the same way at every point around the stem of the
tumour, otherwise we might mistake a polypus, which, by adhering
to one side of the cavity, diminishes by the presence of its pedicle
the depth of that one side merely, for an inversion of the uterus
which diminishes the depth of the cavity equally on all sides. It is
for this reason that we believe the employment of the finger alone,
to ascertain this shortening of the uterine cavity, as recommended
by Boyer¹ and Dupuytren, is quite insufficient. In most cases it is
too large a body to be passed without force and pain, if at all, into
the contracted cervical cul-de-sac; and even if passed to its full depth,
it could never leave us perfectly sure that there was not a narrow
communication at some point with the uterine cavity beyond.
2
As a general rule, then, it will, we believe, be found that, in cases
of tumours projecting through the os uteri, and when the other
symptoms leave any doubt as to whether the tumour be a true
polypus or merely the fundus of the organ chronically inverted, the
employment of the uterine bougie will enable us to decide the
diagnosis, and hence also, in a great measure, the prognosis and
treatment, by the positive or negative information which it affords
with regard to the shortening or non-shortening of the uterine
cavity. For-
1. If the bougie passes into the uterine cavity to its usual depth
of two inches and a half or more, the disease is not inversion of the
fundus a fact, the certainty of which may, while the bougie is still
in utero, be farther corroborated, by the fundus in situ being
actually felt through the hypogastric walls whilst it is pushed
forward on the apex of the instrument, or through the rectum,
whilst by the same means it is retroflected in the mode already
described upon the front wall of the bowel. In this case the tumour
is one which is in general safely and easily removable. But―
2. If the uterine bougie cannot pass at any point around the
stem of the tumour to a greater extent than about one inch, the
uterine cavity may be considered as shortened by inversion, and the
protruding mass cannot be interfered with, without imminent danger
uterine cavity was on all sides reduced to seven or eight lines in depth (dans tous
les points de son étendue sept ou huit lignes de profondeur). Petit, in whose
practice the case occurred, relates that four "Maîtres de l'Art," after a careful
tactile examination, all pronounced the inverted uterus in this instance to be a
polypus.-Recueil des Actes de la Société de Santé de Lyon, 1798, p. 103.
2
¹ Maladies Chirurgicales, tom. x. p. 583. Leçons Orales, tom. iii. p. 535
43
660
DISEASES OF WOMEN.
»
to the patient. When in any case this last point is positively ascer-
tained, another consideration may arise. Is the general shortening
of the uterine canal the result of simple inversion of the uterus, or
of inversion complicated with, and produced by, the attachment of
a polypus to the interior of the fundus uteri? The decision of this
point may be of the first importance, both as regards the propriety
and the safety of any further interference. If the disease be simple
inversion, no operation would be attempted, unless under the call of
very anxious and urgent reasons. If the inversion be the result of
the weight and dragging of a polypus, then, by removing the latter,
the uterus may itself become replaced, and the patient be restored.
to the enjoyment of perfect health. In making this additional
diagnosis between simple and complicated inversion, the previous
history of the patient, and the characters of the tumour, may be
sufficient to guide us, but both again may be liable, in particular
instances, to lead us into error. The length of the whole interior
of the uterus, as made up by the double measurement, first of the
depth of the cul-de-sac of the cervix, and, secondly, of the inverted
portion from the roof of this cul-de-sac to the apex of the inverted
tumour, may afford us more positive information. When added
together, the two measurements will, in a case of simple inversio
uteri, not exceed much, if at all, the normal length of the cavity
of the organ; in a case of inversion complicated with polypus, they
will exceed this standard in a ratio proportioned to the size of the
polypus and the probable elongation of the uterine tissues which it
has produced.
"'1
"The only danger," says Dr. Gooch, "attendant on the operation
en polypus is, that the ligature may include a portion of the
uterus.' This danger, which has led to a fatal result in many
master-hands, will be easily avoided by the previous use of the
bougie in the way we have suggested, so as to ascertain the pres-
ence or absence of any co-existent degree of inversion. If the
polypus be found complicated with inversion, but yet has a suffi-
ciently marked narrower part or pedicle connecting it with the
fundus uteri, its removal in the usual way, by the ligature or knife,
may be safely accomplished, if great caution be employed. If the
polypus, however, adheres by a broad base, and is decidedly fibrous.
1 P. 264.
2 See, for example, a case of Dr. Denman's, in his Introduction to Midwifery,
p. 106, ed. of 1816. Herbiniaux, Traité sur divers Accouchemens, etc., tom. ii. p.
35, and Obs. xvii. etc.
DIAGNOSIS BY THE EXPLORING NEEDLE.
661
or cartilaginous in its structure, the case would probably form an
appropriate one for the operation that has been had recourse to
in several instances of late for the removal of fibrous tumours on
the wall of the uterus-namely, dividing by a longitudinal or crucial
incision the thin layer of uterine tissue, covering the projecting part
of the tumour, and afterwards enucleating the mass of which it
consists. In this way the source of danger pointed out in the
quotation from Dr. Gooch would be so far avoided.
In the preceding observations I have not adverted to the dis-
tinction between complete chronic inversion of the uterus, where
the cavity is entirely effaced, and polypus of the neck or lips of the
uterus.
ON THE USE OF THE EXPLORING NEEDLE
IN THE DIAGNOSIS OF DOUBTFUL FORMS OF PELVIC AND
OTHER TUMOURS.1
Those authors who, some years ago, wrote at great length upon
acupuncture, as Beclard, Cloquet, Carraro, etc., all spoke of the im-
punity with which they found that acupuncture needles could be
introduced into the muscles, vessels, and even the viscera of the
living body. It was well known that small punctured wounds did
not bleed, and the parts punctured generally closed immediately,
and left little or no trace of the separation of their tissues by the
puncturing instrument, provided it were small.

a
op


ф
Fig. 21.
Taking advantage of the knowledge of these facts, it has been
found that using a small grooved needle, or very slender trocar, we
can introduce it into various morbid parts, so as to ascertain the
¹ See Proceedings of Edinburgh Obstetric Society, December 12, 1849, in
Edinburgh Monthly Journal of Medical Science, February 1850, p. 196.
662
DISEASES OF WOMEN.
nature of their contents. Surgeons had used such exploring needles
for this purpose, in cases of doubtful tumours, in order to ascertain
whether they were abscesses, or cysts, or aneurisms, etc. They have
been used to explore even large aneurisms without any dangerous
result. Dr. Simpson alluded to a case in which a celebrated surgeon
was showing to his pupils the use of the exploring needle, in detect-
ing matter in what was supposed to be an inflamed bubo, before
laying it open. Air, however, rushed out, instead of pus, showing
the swelling to be formed by the skin inflamed over a hernial sac.
พ
Dr. S. mentioned that he had repeatedly used the exploring
needle to detect the nature and contents of various kinds of pelvic
tumour, when no other means of diagnosis were sufficient for that
purpose. He especially adverted to its advantages as a means of
diagnosis in some doubtful cases of pelvic abscess and ovarian tum-
ours, and in cases in which tumours existed about the cervix uteri,
the cystic or other nature of which it was otherwise impossible to
determine. Would it serve to diagnosticate cases of extra-uterine
pregnancy, either by the instrument striking against bone, or by any
contents that might pass through the tube?
The instrument which he employed was that figured in the ac-
companying woodcut. It was simply a very slender silver trocar
and canula, the former tipped with a short steel point of the form
of that of a graving instrument. The tube of the trocar is open for
nearly an inch along one side at its point, as is seen in the cut, so as
to admit more easily of the escape through the canal of the tube, of
any fluid in which its point may be placed. Sometimes he had ap-
plied an exhausting syringe to the outer end of the instrument, in
order to procure the flow along its tube of any more viscid fluid.
a Shows the canula, or tube of the instrument; b, the trocar; and
c, the canula, with the trocar introduced as ready for use. Thin
fluids, like those of most ovarian cysts, flow readily along the tube,
and can be recognised by their microscopic and other characters.
When introduced into a sac containing pus, generally a few drops
only of the fluid enter the tube of the instrument, from which, how-
ever, it can be readily forced, after withdrawing the instrument, by
blowing through the tube. If our microscopic characters of specific
tumours and morbid structures were more exact than they are at
present, the pathologist might ascertain the nature of most morbid
tumours that appear in the living body, by the use of such an instru-
ment, for he could remove by it a sufficient amount of its structure
or contents for histological purposes.
ARTIFICIAL ANESTHESIA IN UTERINE DIAGNOSIS.
663
ON THE STATE OF ARTIFICIAL ANESTHESIA
AS A MEANS OF FACILITATING UTERINE DIAGNOSIS.¹
Since the first introduction of ether and chloroform into obste-
tric practice in 1847, Dr. Simpson stated that he had annually en-
deavoured to point out in his lectures the great advantages that
were occasionally derivable from their employment, in the way of
facilitating obstetric diagnosis. The production of a state of anæs-
thesia has been found specially useful as a means of physical dia-
gnosis, under the following circumstances:-
1. In cases of difficult parturition, the state of anesthesia
enables the accoucheur to ascertain more easily and exactly, by his
tactile examination, any peculiarities in the position or presenta-
tion of the child, or in the nature and amount of any impediments
existing in the pelvic bones or maternal passages.
2. In instances of uterine or ovarian disease, connected with
neuralgic tenderness of the abdominal walls and pelvis, it is often
impossible to make a complete and useful tactile examination, unless
the patient be previously anesthetised.
3. In spurious pregnancy, with its usual characteristic, abdominal
distension, the use of chloroform at once, as is now well known,
enables the practitioner to decide the nature of the case; the abdo-
minal enlargement disappearing as the state of deep anesthesia
supervenes.
4. In the two preceding morbid states, and in any other cases
of uterine or ovarian disease, requiring a very accurate tactile exa-
mination, the previous production of anæsthesia not only allows the
tactile examination to be gone through without suffering, but
further, it very greatly facilitates the examination by the state of
local and general relaxation which it induces. Under such relaxa-
tion, the physical examination of the uterine organs by touch is
rendered infinitely more perfect.
5. In instances where a required examination is objected to
from motives of delicacy, the state of anesthesia saves the feelings
of the patient—a matter of no slight moment in the practice of the
obstetric profession.
¹ From MS. Proceedings of Edinburgh Obstetrical Society, March 14, 1855.
664
DISEASES OF WOMEN.
MEDICATED PESSARIES.¹
In diseased states of the cervix uteri and vagina, medicinal sub-
stances have been applied locally to those parts under various forms,
but principally either in a solid state, as nitrate of silver, potassa,
etc., or in a liquid form, as in the great varieties of medicated injec-
tions in common use in leucorrhoea, etc. When thus used, the local
application is temporary, and applied for a few minutes only. But
in various forms of disease it seems an indication of no small import-
ance to have the medicated substance applied continuously, and not
temporarily. Medicated pessaries, which Dr. Simpson first intro-
duced into practice several years ago, and which have since been
extensively adopted by various practitioners in London and else-
where (see descriptions of them published by Dr. Safford Lee, Dr.
Oldham, etc.), enable us to fulfil this indication. By their use, for
instance, we can keep the cervix uteri, when ulcerated and indurated,
constantly embedded in mercurial or iodine ointment for weeks, and
sometimes with the most marked benefit and success. They fulfil
another indication in cases of irritation and inflammation of the
mucous membrane of the cervix uteri and vagina. They keep
the opposed diseased surfaces from coming in contact, and it is well
known how important a matter this is in the pathology of mucous
and cutaneous surfaces.
Dr. Simpson has been in the habit of applying a variety of
substances in the form of medicated pessaries, particularly zinc and
lead ointment, etc., as simple emollients; mercury and iodine as
discutients, and particularly the iodide of lead; tannin, alum, and
catechu, as astringents; opium, belladonna, etc., as anodynes. The
pessaries are made of the size of walnuts, and can be easily intro-
duced by the patients themselves; one or two in the twenty-four
hours. They are composed of the medicine used mixed up in the
form of an ointment, and brought to a requisite degree of consistence
with one or two drachms of yellow wax to the ounce of ointment.
Messrs. Duncan and Flockhart, druggists, have found the following
proportions requisite in the subjoined forms, those in most frequent
use in Edinburgh; and they might serve as models for the others.
1 See Proceedings of Edinburgh Obstetric Society, March 12, 1848, in Edin-
burgh Monthly Journal of Medical Science, Juno 1848, p. 886.
2 On Tumours of the Uterus, p. 25.
3 Guy's Hospital Reports, vol. vi. pt. i. p. 193.
USE OF MEDICATED PESSARIES AND SUPPOSITORIES.
665
After being made up in the proper form, they are usually coated by
the druggists with a firmer covering, by dipping them in an ointment
made up with wax and resin, kept liquid by heat. About an ounce
of the different ointments makes four balls.
1. Zinc Pessaries.-R Oxydi Zinci 5j, Cera Albæ 5j, Axungia
5vj. Misce, et divide in pessos quatuor.
2. Lead Pessaries.-R Acet. Plumbi 3ss, Cera Albæ 5iss, Axun- ·
giæ 5vj. Misce
3. Mercurial Pessaries.- Unguent. Hydrarg. Fort. 5ij, Cera
Flava 3ij, Axungiæ 3ss. Misce.
4. Iodide of Lead Pessaries.- Iodidi Plumbi 9j, Ceræ Flavæ
›v, Axungiæ 3vj. Misce.
5. Tannin Pessaries.—B Tanninæ ij, Cera Albæ ✪v, Axungiæ
3vj. Misce.
6. Alum and Catechu Pessaries.-R Sulph. Aluminis 5j, Pulv.
Catechu 3j, Ceræ Flavæ 5i, Axungiæ 3vss. Misce.
7. Belladonna, Pessaries.-B Extr. Belladonna Dij, Cera Flavæ
3iss, Axungiæ 3vi. Misce.
ON MEDICATED PESSARIES AND SUPPOSITORIES.¹
Professor Simpson wished to bring under the notice of the
Society some changes that had been made in the form and compo-
sition of medicated pessaries, and to throw out some suggestions as
to the more extended employment in practice of various kinds of
suppositories. He had been in the habit for many years past of
applying different kinds of medicated pessaries to the cervix uteri
in the treatment of uterine disorders; having been led to their use
by finding that bromide and iodide of potassium, and many other
substances, could thus be administered locally, which were of no
avail in the form of a lotion. As a medium for the administration
of drugs the ointment-pessary was not new, for Daremberg, in his
late translation and commentary of Oribasius, has pointed out that
a form of it was made use of long ago in Rome. Pessaries had not
yet found an acknowledged place in the Pharmacopoeia; but that did
not interfere with their usefulness. Up to a recent date, he (Pro-
fessor Simpson) had been in the habit of using pessaries composed of
simple ointment, with the special drug rubbed up in it, made into a
globular shape, and stiffened on the surface by being dipped in some
¹ See Proceedings of Edinburgh Obstetrical Society, February 8, 1865, in
Edinburgh Medical Journal, May 1865, p. 1042.
666
DISEASES OF WOMEN.
warm melted ointment in which the proportion of wax largely pre-
dominated. But, latterly, Messrs. Duncan, Flockhart, and Co., of
this city, had made them for him of cocceine, which presented this
great advantage over the old ointment, that it was much more con-
sistent and firm when cold, whilst it melted at a lower temperature,
and with greater rapidity. In consequence of this greater solidity
of the cocceine, it was found that pessaries made of that substance
were more easily employed by the patients themselves than the
softer and more yielding ointment-balls; and the facility of intro-
duction was still further promoted by having them made, not spheri-
cal, but conical,—almost precisely of the shape of a Minié bullet.
Professor Simpson had brought with him specimens of some of
these pessaries; but their various constitution and uses would be
most easily seen by reference to the following list of them, which
had been recently published by the chemical firm to which he
had alluded:
Atropine (Belladonna)
•
Opium
Morphia
Bismuth, Oxide
•
Borax
Zinc, Oxide
·
Sedative
do.
1-20 grain.
2
grains.
do.
grain.
Cicatrising and Emollient 15
grains.
do.
do.
do.
do.
15
do.
•
15
do.
•
Tannin
•
Alum
•
Astringent
. 10
do.
do.
Do.
Matico.
Alum and Catechu
Acetate of Lead
Do. do. and Opium
Sulphate of Iron (dried).
Gallic Acid
do.
Iron
do.
do.
do.
do.
은은 ​은은 ​은 ​은은
​· 15
do.
15
•
10
do.
•
•
73
5
10
do.
•
do.
10
•
do.
Perchloride of Iron
Hemostatic
10
5
do.
do.
Persulphate of Iron
Sulphate of Zinc (dried).
do.
5
•
Caustic .
..10
Carbonate of Soda.
Antacid.
15
do.
Carbolate of Lime.
Deodorant
5
은은 ​음​은 ​은 ​은은 ​은은 ​은은 ​응응
​do. of each.
do.
do. 2 gr. Opium.
do.
do.
do.
do.
•
Iodide of Lead
Alterative and Resolvent
5
do.
Do. do. and Atropine
do.
do.
5
do. 1-20 Atropine.
Do. Potassium.
do.
do.
10
do.
Bromide of Potassium
do.
do.
10
do.
Mercurial
do.
do.
30
do. (Ung. Hydrarg.)
Many of the pessaries are made with morphia (½, 1, or 2 grains)
in them, to suit cases where a sedative is also required. They are
also sometimes made hollow in the centre, to allow of a few drops
of chloroform liniment being introduced along with them. Various
other kinds of pessaries are made.
USE OF MEDICATED PESSARIES AND SUPPOSITORIES. 667
Besides being useful in the manufacture of pessaries, cocceine
would be found invaluable as a medium for the administration of
medicinal substances by the rectum. The ordinary suppository mass
was apt to be either so soft as to be difficult of introduction through
the anus, or so firm in its consistence as to be very slow of solution ;
and the result in some cases was, that either the medicine was im-
perfectly applied, or the suppository was so long of dissolving, that
the drug had not the opportunity of exerting its specific action at a
sufficiently early period. These drawbacks to the use of sup-
positories were quite done away with when they were made of
cocceine, which is at once firm and fusible; and he (Prof. S.)
believed that the advantages attached on its use would now probably
lead to the more frequent application of medicines through this
channel. We had long been in the habit of administering opiates
in this way, especially the muriate of morphia in doses varying with
each particular case. For many years the suppositories he had most
frequently employed contained half-a-grain of morphia in each; but
latterly, for ordinary uses, he had had them made with only a
third of a grain, because in a few exceptional cases the half-grain
exhibited by the rectum seemed to act too powerfully. Dupuytren
had pointed out that sometimes opium seemed to affect patients
more powerfully when administered per anum, than in the ordinary
way; and this case was one of those where the individual appeared
to be unusually susceptible of the influence of the dose. But
besides morphia and the opiates, there was a great variety of other
remedies that might be usefully applied in this way, as would be seen
from this list of suppositories :-
Aloine (with Soap)
Belladonna
Bismuth, Oxide .
Borax
Copper, Acetate of
Elaterium
Ergot of Rye
Gall and Opium
Gamboge
•
1 grain, 5 grains Dry Soap.
1, 1, and 2 grains (Ext. Bellad.)
10 grains.
5 do.
2 do.
grain.
2 drops oil.
5 grains and 1 grain.
5 do.
5 do. (Ext. Hyoscy.)
3 do.
2 do.
6 do. (Ung. Hydrarg.)
Henbane
Iron, Alum
Do. Persulphate
Murcurial
Morphia
Opium
Podophyllin
Santonine
1 grain.
5 grains.
1, §, §, 1, 14, and 2 grains.
2 grains.
668
DISEASES OF WOMEN.
Soda, Hyposulphite of
Tannin
5 grains.
5 do.
Zinc, Oxide
10 do.
•
Do. Sulphate (dried)
3 do.
Thus, there were, first, a number of cathartics which might be
introduced into the rectum, and thus often afford relief to patients,
without their being subjected to the disagreeable ordeal of swallow-
ing some nauseous medicine. We had all known that nurses were
occasionally in the habit of introducing a bit of soap into the bowels
of children, with the view of inducing a motion, and the result was
thus probably due to the physical irritation that ensued. But the
question was, whether we could not introduce some substance into the
rectum in the form of a suppository, which would exert such an
action on the mucous or muscular coats of the bowel as to lead to
a full evacuation. He (Prof. S.) had employed the gamboge sup-
pository in some instances, with a satisfactory result. When
introduced into a rectum which was distended with fecal matter, it
almost always acted comfortably within an hour; but if introduced
into an empty bowel it gave rise to severe griping. He had under
his care a lady from Liverpool, who told him the other day, with an
air of much surprise, that her bowels had acted the night before.
She had been habitually constipated, and for many years had had
no relief except from the use of an enema, which she used to employ
in the morning; and the evening evacuation which had so
astonished her resulted from the action of a gamboge suppository
which had been introduced. He was not, of course, prepared to say
what the precise doses of the different drugs, when thus employed,
ought to be; certainly the half-grain of elaterium noted in the list
was too large a dose, and in one case had produced some dysenteric
symptoms. He sometimes saw, along with Dr. Maclagan, a young
lady in whom half-a-grain of podophyllin in a suppository acted very
easily and well; but, in some other patients, the use of a podo-
phyllin suppository had been followed by a very prolonged diarrhoea.
Again, mercury could be administered in the suppository form
in cases where it was deemed necessary to salivate, for its specific
action was sometimes very rapidly developed when it was thus em-
ployed. In this form, moreover, it was one of the most effectual
means at our command for the destruction of ascarides; an object
which in other instances might probably be attended by the use of
suppositories containing santonin or hyposulphite of soda as their
active ingredients.
DIRECT APPLICATIONS TO CAVITY OF UTERUS.
669
Besides the drugs of the aperient class, we might employ others
of a more sedative or tonic character. Thus, the acetate of copper
suppository had been found useful in case of bleeding piles, and he
had seen a patient who was suffering from fissure of the anus, and
who rebelled against the use of morphia, greatly relieved by em-
ploying suppositories containing the dried sulphate of zinc. Ergot
might be administered in this manner in appropriate cases; and
quinine and iron might be similarly administered,—especially with
patients whose stomach resented the use of chaly beates. Astringents,
too, of every variety, could be employed with the greatest benefit ;
and, indeed, one could hardly predicate how many kinds of medicines
we may yet learn usefully to administer in the form of a simple
suppository.
DIRECT LOCAL APPLICATION OF REMEDIES TO THE
CAVITY OF THE UTERUS.¹
Dr. Simpson stated to the Society that he had of late applied
nitrate of silver, etc., to the lining membrane of the cavity of the
uterus, in cases of uterine leucorrhoea, and of dysmenorrhoea, con-
nected with a morbidly sensitive state of portions of the inner
surface of the organ, as ascertained by the bougie, and with mem-
branous, sub-inflammatory effusions; in chronic suppression of the
menstrual discharge, etc. The results proved, that while direct
local applications could thus be made with perfect ease and safety
to the diseased lining membrane of the uterine cavity, the effects
were such as to lead to the hope of a successful issue in some cases
of uterine disease, otherwise almost or indeed totally unmanageable.
APPLICATION OF SOLID NITRATE OF SILVER, ETC., TO
THE INTERIOR OF THE UTERUS IN MENORRHAGIA.Ⓡ
Sir James Y. Simpson spoke of the success which sometimes
attended the introduction of a solid piece of nitrate of silver into
the uterine cavity, in cases of obstinate menorrhagia that were
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, April 19,
1843, in London and Edinburgh Monthly Journal of Medical Science, July 1843,
p. 661.
2 See Proceedings of Edinburgh Obstetrical Society, February 27, 1867, in
Edinburgh Medical Journal, June 1867, p. 1142.
670
DISEASES OF WOMEN.
independent of the presence of polypi or of fibroid tumours in the
walls of the uterus. For this purpose he had generally used a short
piece of solid nitrate of silver, made half the thickness of the usual
stick, and introduced and lodged in the uterine cavity by a hollowed
or tubular instrument, of the size of the common uterine sound. In
some cases the hemorrhage was arrested by this treatment, as it is
in internal rectal hemorrhoids by the application of slight caustics.
The powder of the persulphate of iron may be lodged in the uterus
for the same purpose.
He considered solid substances and powders
as much more safe applications to the interior of the uterus than
any forms of fluid injections. The occasional danger arising from
the latter was not, he believed, so much from their passing along
the Fallopian tubes into the peritoneal cavity, as from their some-
times over-distending the uterus, and fissuring and tearing through
its mucous surface, thus getting fatal access to the circulation.
GALLIC ACID IN MENORRHAGIA.'
Professor Simpson stated that for the last year he had employed
gallic acid in some cases of menorrhagia, with the most successful
results. Like all the other remedies directed against that disease,
it had also occasionally failed in his hands. Some of the cases,
which had completely yielded under its use, were of an old standing
and aggravated description. He gave it during the intervals, as
well as during the discharge, in doses of from ten to twenty grains
per day made into pills. It had this advantage over most other
anti-hemorrhagic medicines, that it had no constipating effect upon
the bowels. He was first induced to use it, by finding a case of
very obstinate menorrhagia get well under the use of Ruspini's
styptic, after many other 'remedies had utterly failed, and from it
being alleged that gallic acid was the active ingredient in that
styptic. He suggested whether the anti-hemorrhagic properties of
some of our common astringent drugs may not depend upon the
gallic acid as much or more than upon the tannin which they con-
tain, or upon the tannin becoming changed into gallic acid within
the body.
At a subsequent meeting of the Society, February 7, 1855, Dr.
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, April 19, 1843,
and February 7, 1855, in London and Edinburgh Monthly Journal of Medical
Science, July 1843, p. 661; and Association Medical Journal, February 1855,
p. 186.
IMPERFECT DEVELOPMENT OF UTERUS CAUSING AMENORRHOEA. 671
Simpson stated, as the result of his experience in cases of hemor-
rhage, that gallic acid was only occasionally successful. Some ten
or twelve years ago he had had occasion to treat a case of severe
menorrhagia where all kinds of medicines had been used without
effect. From the recommendation given by Sir Benjamin Brodie
in his chapter on Hæmaturia, he prescribed Ruspini's styptic; and
relief speedily followed. The disease recurred, however, and the
patent medicine was found to be too expensive. Acting on the hint
of Dr. Anthony Todd Thomson, that Ruspini's styptic contained it,
he gave gallic acid, and similar benefit was obtained. Dr. Gairdner
said that tannin had greater effect as an astringent in the treatment
of hemoptysis; but this it was difficult to reconcile with the obser-
vation of Wöhler, that tannin was converted into gallic acid in its
passage through the circulation, and consequently before it reached
the lungs. He believed in fact that rhatany, krameria, and other
vegetable astringents containing tannin, acted as secondary hemo-
statics upon the lungs, kidneys, and uterus, by being carried in the
blood of these parts as gallic acid; and that their efficacy in
restraining hemorrhage was thus to be explained. Dr. Andrew
Wood had stated his experience of the efficacy of the acid in pur-
pura; while it was well known that Garrod had as strongly recom-
mended alkalies in that disease. Such statements he thought could
be reconciled by supposing that there might be several forms of
purpura, each with their stronger affinity to particular remedies;
and he believed that the uncertainty in the treatment of menor-
rhagia admitted of a similar explanation. After such astringents
were given by the stomach, just as after gallic acid, gallic acid, as
stated by Liebig, was found in the urine; and consequently was
present in the blood.
IMPERFECT DEVELOPMENT OF THE UTERUS, GIVING
RISE TO AMENORRHOEA, ETC.'
Dr. Simpson mentioned that he had seen a considerable number
of cases of short or imperfectly developed uteri in the living subject.
The imperfect development of the organ was ascertained, on exa-
mination by the finger, by the small and atrophied cervix uteri, and
by actual admeasurement of the length of the cavity by the uterine
¹ See Proceedings of Edinburgh Obstetrical Society, Session xii. in Edinburgh
Monthly Journal of Medical Science, September 1854, p. 275.
672
DISEASES OF WOMEN.
sound. Instead of being 2 inches in length, the cavity in such
cases was only 2 inches, or more frequently only 1 or 1 inch long.
The subjects of this imperfect development were often well made
and formed in other respects. But the malformation led to various
functional defects, especially amenorrhoea and sterility. The
amenorrhoea was usually persistent, and when a patient applied for
medical relief who was already twenty-five or thirty years of age,
this malformation would in a large proportion of cases be found to
be the organic cause. In some such cases of amenorrhoea, there
was great vascularity of the face, and occasionally a most uncon-
querable form of acne. He had seen in some of these instances
the wearing of an intra-uterine galvanic, or zinc and copper, pessary
-gradually increased in size-followed by the best results, and even
occasionally by cure of the amenorrhoea. The uterus developed
itself around such a foreign body, when it filled its cavity, as it did
around a fibrous tumour or an ovum.¹
ON THE NATURE OF THE MEMBRANE OCCASIONALLY
EXPELLED IN DYSMENORRHOEA.2
It is well known that in some cases of dysmenorrhoea an organ-
ised membrane is expelled, with much pain, from the uterus during
the course of the catamenial discharge, and that this happens either
occasionally only, or, what is far more common, during a long suc-
cession of menstrual periods.
All authors who have expressed an opinion regarding the nature
of this dysmenorrhoeal membrane have, so far as I am aware, re-
garded it as a morbid structure formed by the exudation of coagu-
lable lymph or fibrin upon the free surface of the mucous membrane
of the uterus.
"It is composed," says Dr. Churchill," of plastic lymph, such as
we see secreted by the mucous membrane of the trachea in croup,
thrown off by the lining membrane of the uterus, and taking gener-
ally the form of the cavity of that organ, although it may be dis-
charged in shreds."*
"We shall probably be correct," Dr. Montgomery observes, "in
referring such productions [dysmenorrhoeal membranes] to any
cause capable of exciting a certain degree of irritation, or perhaps
1 See pages 601 and 650.
2 See Edinburgh Monthly Journal of Medical Science, September 1846, p. 161.
3 Diseases of Females, p. 102; edition of 1844.
NATURE OF DYSMENORRHOEAL MEMBRANE.
673
of inflammation, by which fibrin is poured out on the internal sur-
face of the cavity of the uterus, and assumes a membranous texturc,
as we find occurring in other hollow organs lined with a mucous
membrane, as, for instance, in the intestines in cases of diarrhoea
tubularis, and in the trachea and air-tubes."
"The membranous shreds passed in some of these cases [of
dysmenorrhoea] evidently," remarks Dr. Copland, "consist of
plastic lymph thrown out in the cavity of the womb.
That a degree of inflammatory irritation exists in the internal sur-
face of the uterus, even in the neuralgic form of the disease, is
proved by the formation and expulsion of a false membrane in many
cases of that form. That this membrane is induced by the similar
state of inflammatory action to that which sometimes occurs in
other mucous surfaces, and gives rise to a similar exudation, is
most probable, notwithstanding the absence of other inflammatory
phenomena and the neuralgic character of the pain.'
112
In a number of cases, I have had an opportunity of examining
from time to time the form and structure of these dysmenorrhoeal
membranes. Two or three years ago, my observations upon them
led me to believe that they were not new or false membranes
formed of coagulable lymph, and secreted by the mucous surface of
the uterus, but that they in reality consisted of the superficial layer
of the mucous membrane of the uterus itself, hypertrophied and
separated. All my later observations have gone to confirm me in
the same opinion-viz. that the productions in question are not the
results, as is generally supposed, of fibrinous or plastic exudations
upon the free surface of the mucous membrane of the uterus, but
that they consist of actual exfoliations of that membrane itself.
The proof of this opinion rests upon different grounds :
First, The dysmenorrhoeal membrane presents anatomical pecu-
liarities that are never seen in any simple fibrinous or inflammatory
exudation; and these anatomical peculiarities, on the other hand,
specially pertain to, and are characteristic of, the structure of some
mucous tissues, such as that of the uterus. One special illustration
¹ Signs of Pregnancy, p. 147.
2 Dictionary of Practical Medicine, vol. ii. pp. 844, 845. See also Dr. Fergusson
in the Library of Medicine, vol. iv. p. 311: "A not uncommon effect of dysmenor-
rhoea is the formation of coagulable lymph modelled to the shape of the inner sur-
face of the uterus." Dr. Rigby's Essay on Dysmenorrhæa, p. 39 : “ Fibrinous exu-
dations every now and then attend these cases of dysmenorrhoea.' Dr. Ashwell's
Treatise on Female Diseases, pp. 105 and 107, etc.
""
674
DISEASES OF WOMEN.
may suffice. Professor Reid, Krauss, and others, have shown that
the surface of the mucous membrane of the uterus is marked by
numerous orifices of small tubular glands, crypts, or follicles, opening
upon it (the uterine glands of some modern authors). This struc-
ture I have distinctly traced in different specimens of dysmenorrhoeal
membrane from different individuals.
Secondly, The general configuration and character of the surfaces
of the dysmenorrhoeal membrane are such as would result from the
origin which I have attributed to it-namely, the exfoliation or
detachment of the mucous membrane of the uterus. In those
instances in which the membrane is thrown off in one piece, and
without disintegration, it presents exactly the flattened triangular
appearance of the uterine cavity. Its sides may be so compressed
that the expelled mass at first appears solid; but a little careful
dissection or maceration will readily show that it consists of two
layers, and that there are the remains of a cavity between them.
The interior of the cavity is smooth, and marked by the orifices of
the uterine mucous crypts that I have above alluded to. Occasion-
ally we can easily trace three large openings at its three angles,
corresponding to the openings of the two Fallopian tubes and
cervix uteri. But the external surface of the mass is rough and
shaggy, marking the effects of dilaceration from the tissue of the
uterus. Sometimes we see a piece discharged quite smooth on one
surface, and rough on the other. When this is the case, we may
be perfectly certain that it is a portion only of the membrane which
has been expelled, or, at least, preserved for inspection. For, if the
portion of mucous membrane lining the anterior wall of the uterus
alone, or lining its posterior wall alone, be discharged and examined,
and not that of the whole cavity, it will necessarily display the
apparent anomaly alluded to. If the membrane is thrown off in
broken or disintegrated fragments, as sometimes happens, it will be
more difficult to trace the structural characteristics that I have
mentioned. Another form of difficulty is occasionally produced by
blood being infiltrated into or upon the dysmenorrhoeal membrane.
In some instances the membrane is found encased in one or more
layers of coagulated blood; and if that blood has already become
decolorised, and assumed a fibrinous appearance, mistakes might easily
occur, provided the inquirer were not aware of this source of fallacy.
One of the earliest descriptions of the dysmenorrhoeal membrane
upon record is given by Morgagni. He gives an exact account of
the appearances which it presented in the case of a "noble matron,"
NATURE OF DYSMENORRHOEAL MEMBRANE.
675
long afflicted at the menstrual period with "pains like those of child-
birth." Morgagni's description of the dysmenorrhoeal membrane
expelled on these occasions is so exact and excellent, that I shall
perhaps be excused quoting it. "In almost the middle," as he
states, "of the membranous flux, a membranous body, as it appeared,
was discharged from the uterus; and that in such a form, and of
such a magnitude, as perfectly corresponded to the triangular form
of the uterus; being moderately convex externally; on which sur-
face it was unequal and not without many filaments that seemed to
have been broken off from the parts to which they had adhered,
but internally hollow; on which surface it was smooth and moist,
as if from an aqueous humour, which it had before contained, but
had discharged, at its own exit, by an ample opening, which was at
one of its angles, that had been readily opened by rupture."
"1
Thirdly, The dysmenorrhoeal membrane exactly resembles the
decidual membrane, the decidua vera; and all our highest authorities
in anatomy are, I believe, now willing to grant that, as pointed out
by the researches of Sharpey, Weber, Goodsir, and others, the
decidua vera is not a new membrane formed in the uterus after
conception, but merely the normal mucous membrane of the
uterus, hypertrophied, with its mucous crypts or follicles increased
in size, and the cells of its interstitial tissue greatly developed
and multiplied. In the dysmenorrhoeal membrane the mucous
follicles or crypts are perhaps not enlarged and developed to the
same proportionate degree as they are in the decidual membrane.
In other respects the two membranes are identical. They have the
same triangular form. There is the same appearance in both, of
openings at their three angles, and in both, these openings are
occasionally more or less perfectly sealed up when the tissue of the
membrane, in their immediate neighbourhood, is developed in an
unusual degree. The external surface of each membrane has the
same shaggy, ragged form. In each we have the same cribriform
appearance upon their smooth internal surface, marking the orifices
of the mucous follicles. When examined under the microscope, the
interstitial or interfollicular tissue of both membranes shows a
similar structure, namely, one wholly composed of an agglomeration
or superposition of simple nucleated cells. And altogether, if, on
the one hand, it be allowed that the structure of the decidua proves
it to be the mucous membrane of the uterus in a state of high de-
velopment and hypertrophy, then, on the other hand, the structure
¹ Morgagni, The Seats and Causes of Diseases, etc., vol. ii. p. 706.
44
676
DISEASES OF WOMEN.
of the dysmenorrhoeal membrane is so similar to that of the decidua,
as to prove a perfect identity with the decidua in its characters, and,
consequently, also in its origin.
In some respects the evidence which we have in favour of the
decidual membrane being merely a hypertrophied state of the
mucous membrane of the uterus, is still wanting, in so far as regards.
the dysmenorrhoeal membrane. For, first, in cases of patients dying
at different periods of early pregnancy, a regular progression of
observations has now been made, showing the gradual transforma-
tion of the true mucous into the true decidual membrane; and,
secondly, in patients dying after delivery, and, consequently, after the
separation of the decidual or lining membrane of the uterus, the
actual absence of the mucous surface of the uterus has been often
ascertained on dissection. I lately saw a case where the patient
died six weeks after delivery, and still, at that late date after con-
finement, the mucous lining of the uterus was not yet regenerated.
No corresponding series of observations has hitherto been made
upon the actual formation of the dysmenorrhoeal membrane before
menstruation, or upon its actual absence after that period. But a
more careful investigation of the state of the uterus after death, in
patients who have happened to be suffering under membranous
dysmenorrhoea during life, will, I have no doubt, afford the requisite
data. It may not be uninteresting to add, that the absence of the
mucous lining of the uterus in persons who have died after delivery,
or who have been previously subject to membranous dysmenorrhoea,
may have given rise to the strong opinions expressed in former
times by several anatomists, and particularly by Morgagni, Chaussier,
and Gordon, in regard to the human uterus not being normally pro-
vided with a mucous membrane. Not meeting with that membrane
under some circumstances and in some cases, they were induced to
doubt its presence under any circumstances or in any cases.
Modern physiology has made us sufficiently acquainted with the
curious fact, that a portion of the epithelial layer of the mucous
surface of various organs exfoliates constantly and normally during
the performance of the special functions of these organs. For in-
stance, this holds true with regard to the epithelium of the stomach
during digestion, and that of the uterus during menstruation. But
there are few circumstances, either in healthy or morbid anatomy,
so strange as that which I have attempted to prove in the preced-
ing remarks--namely, that the proper mucous tissue of the uterus
INCISION OF CERVIX FOR DYSMENORRHEA.
677
itself may, within the compass of a menstrual period, form, enlarge,
separate, and again be reproduced; and further, that all this may
occur and continue regularly for a succession of months, or, as some-
times happens, for a succession of years.
I have no intention, however, at present of dwelling either upon
the various pathological or practical views to which the opinion that
I have above propounded, regarding the origin and nature of the
dysmenorrhoeal membrane, very evidently points. It is enough,
perhaps, to remark, that the observations which I have made go to
demonstrate that the dysmenorrhoeal membrane is not formed, as is
generally believed, by a simply inflammatory effusion of plastic or
coagulable lymph, and hence is not to be successfully prevented and
combated by simple anti-inflammatory treatment. The action giving
rise to it may in some cases be combined or complicated with in-
flammation. I have seen, for example, the membranous dysmenor-
rhoea in several instances co-existing with inflammatory induration
and ulceration of the cervix uteri. But essentially, the normal
action of the uterus or ovaries giving rise to the formation of the
dysmenorrhoeal membrane is not a state identical with inflammation,
but a state identical with the condition of these organs after impreg-
nation and during the earlier weeks of pregnancy. It is so far a
state and product natural to one special condition of the uterus, but
here occurring at an unnatural time, under unnatural circumstances,
and with unnatural frequency.
DILATATION AND INCISION OF THE CERVIX UTERI
IN CASES OF OBSTRUCTIVE DYSMENORRHOEA.
Dr. Simpson, in speaking of dilatation of the os and cervix uteri
as a means of treatment,' pointed out the results of this practice in
the hands of the late Dr. Mackintosh in the cure of dysmenorrhœa
and sterility, connected with normal and inflammatory strictures of
the os uteri. His own results had not been so successful as those of
Dr. Mackintosh; but he had now seen a considerable number of
severe cases in which dysmenorrhoea that had previously resisted all
other kinds of treatment, had at once yielded to the mechanical
dilatation. Dr. Simpson had found the stricture occasionally at the
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, July 3, 1844,
in London and Edinburgh Monthly Journal of Medical Science, August 1844, p.
734.
678
DISEASES OF WOMEN.
os internum, or opening between the cavities of the cervix and body,
and not at the os tincæ. Dr. Mackintosh had effected the dilata-
tion by long straight bougies of different sizes. Dr. Simpson had
found them more easily used when slightly curved.
He also showed
other instruments, one of them like the dilator for the female
urethra, which he had occasionally employed for this purpose. These
instruments were all of them intended to be left in the os uteri for
only a short period, and their introduction repeated from time to
time, as in the usual treatment of stricture of the urethra in the
male. Latterly Dr. Simpson had in his practice thrown these aside,
and used another, a form of permanent bougie, for this purpose,
which he considered to be greatly preferable. These permanent
bougies (Fig. 25, p. 701) were made of Berlin silver; the stem or
part included in the uterine cavity was two inches and a quarter in
length, the lower end which rested in the vagina was bulbed and
enlarged to the size of a large almond, and was perforated below for
the purpose of being placed on a temporary handle, used in the in-
troduction. One of the instruments was left in the uterine cavity
for three or four days, and by that time the part was so much
relaxed, that another of a much larger size could, in general, be
readily introduced. They could easily be borne without the slight-
est inconvenience, and, indeed, without the patient being aware of
their presence: Dr. Simpson pointed out that this permanent form
of bougie gave altogether much less pain to the patient and less
trouble to the practitioner; was more certain and expeditious in its
effects, and was especially useful when the surrounding tissues of the
lips and cervix were in any degree indurated. Obstructive dysme-
norrhoea sometimes depends on other circumstances than ordinary
strictures of the os. It is sometimes seen in connection with the
conical hypertrophy and elongation of the cervix. He had found it
in several instances accompanied with much morbid thickening of
the anterior lip of the os uteri, the posterior lip being thin and
healthy, and the os stretched out between them of an irregular
crescentic shape. In such, and other instances, he had divided the
os uteri on each side to the extent of a few lines with a very
narrow knife or "lithotome caché," and subsequently kept the part
temporarily dilated by the sponge-tent. He quoted cases of the
perfect success of this simple and safe measure; it placed the parts
in somewhat the same condition as that which they present subse-
quent to miscarriage; and this latter occurrence is known in general
to leave without dysmenorrhoea those who have previously been
INCISION OF CERVIX FOR QYSMENORRHOEA.
679
labouring under that affection, whilst, at the same time, women after
aborting usually soon again become pregnant, there being no such
great lacteal determination to the mammæ as occurs after parturition
at the full period, and which seems then usually to interfere with the
early repetition of conception.
At a meeting of the Edinburgh Obstetric Society, March 10,
1847,¹ Dr. Simpson stated that he had now been in the habit for
three or four years past of performing the operation of incision of
the cervix uteri for obstructive dysmenorrhoea. He first described
the operation to the Medico-Chirurgical Society in 1844, and it had
latterly been adopted by Dr. Rigby, Dr. Protheroe Smith, Dr.
Oldham, and other accoucheurs in London and elsewhere. He had
frequently been asked if he had occasion to perform the operation
often. Certainly he had. In the last week he had operated in
seven cases. He was in the first instance led to incise, instead of
dilating the os uteri with bougies, by meeting several years ago with
a patient suffering from dysmenorrhoea, who could only remain a
few days under his charge. The incisions had in this instance the
desired effect; and the lady was delivered of a son within a twelve-
month. She had been previously six or seven years married, but
had never been pregnant.
He further explained that he believed the sufferings in obstruc-
tive dysmenorrhoea to arise from the uterus being driven into con-
tractions, like those of abortion, to expel its own retained menstrual
secretions. Now, the menstrual secretion need not necessarily be
retained when the os uteri is small; for the secretion might form
very slowly, and so escape without accumulation and distension.
On the other hand, it might be secreted so abundantly by the lining
membrane of the uterus, as not to escape sufficiently freely even
when the os was of the natural size, and thus, under that condition,
lead to retention, accumulation, and expulsive pains. In fact, in
order to produce obstructive dysmenorrhoea, there must be a want
of relation between the quantity of fluid secreted, and the quantity
allowed to escape, so that a greater or less degree of retention is
the result. It was of course most apt to occur with a small and
contracted os uteri, and these were the cases most frequently requir-
ing the operation.
The instrument which he makes use of is a kind of lithotome
1 See Proceedings of the Society in Edinburgh Monthly Journal of Medical
Science, May 1847, p. 870.
680
DISEASES OF WOMEN.
caché, manufactured by Mr. Young, cutler. The end of the instru-
ment is passed up through the cavity of the cervix, and within the
os internum. It is then slightly opened laterally, first on one side.
and then on the other, so as to divide any fibres that may be causing
constriction of the internal orifice. The principal incision is then
made in withdrawing the instrument. This incision commences at
the union of the cervix with the body of the uterus, and passing
gradually more and more into the substance of the cervix as it
descends, the blade is brought out at the outer and lower edge of
the cervix, at the point of reflection of the mucous membrane upon
the wall of the vagina. The instrument is then turned, and a

Fig. 22.
similar cut made on the other side; or the incisions may be made
antero-posteriorly instead of laterally. The incision is thus of a
conical form, and at its lower part includes the whole thickness
of the cervix. Care must be taken that it does not pass beyond
the substance of the cervix, as it is closely surrounded by a plexus
of veins, which, if cut, would certainly cause severe hemorrhage.
If care be taken to regulate the incision in this way, the hemorrhage
is usually very trifling. The operation causes little or no pain. The
lips of the wound generally get everted, and have very little tendency
to cohere. If they offer to do so, it is necessary to touch the raw
surface, more especially the angles of the wound, every three or four
days, with nitrate of silver.
[In consequence of the gratifying results sometimes produced by
incision of the cervix uteri in obstructive dysmenorrhoea and sterility,
that operation became an extremely favourite one with Simpson.
Certain risks connected with it, however-and in particular its
liability to be followed by pelvic inflammation-inclined him ulti-
mately to a rigorous selection of cases, and to the enjoining of re-
cumbency for several days after the performance of the operation.--
J. W. B.]
RETROVERSION OF THE UNIMPREGNATED UTERUS.
681
ON RETROVERSION OF THE UNIMPREGNATED UTERUS.
PRELIMINARY REMARKS AND DEFINITION.
Diseases are sometimes regarded as rare, merely in consequence
of a deficiency on our part of a proper and easy means of detecting
them during life, or from our overlooking their existence in the
dead body. Not many years ago, for instance, emphysema of the
lung and granular degeneration of the kidney were supposed to be
affections that were very seldom met with in practice. After, how-
ever, Laennec and Bright pointed out simple and ready modes
of diagnosticating these diseases, they were speedily found to be
morbid affections that were extremely common instead of extremely
rare in their occurrence; and every physician at the present day
is now ready to acknowledge their great frequency.
With some of the displacements of the unimpregnated uterus
practitioners have long been familiar. In particular, the displace-
ments of the organ downwards, in the form of prolapsus and
procidentia, are recognised and acknowledged by all, and elabo-
rately described in every work on female diseases. But displace-
ments of the unimpregnated uterus, in the form of versions or
flexions, either of the whole or of the upper part of the uterus,
posteriorly, anteriorly, or laterally, have hitherto been looked upon
as rare; and this, far more however from our past want of power of
diagnosticating them, than from their own infrequency.
In the present communication, it is my object to describe
briefly some new and simple means that I have practised for the
last four or five years for detecting and treating these displace-
ments.
Let me premise that, in the normal and healthy state, the long
axis of the uterus is situated in a line parallel with the line of the
axis of the brim of the pelvis, or in the relative direction repre-
sented in the accompanying diagram (Fig. 23, b.) But the fundus
of the uterus, instead of looking upwards, may be turned down-
wards and forwards, or downwards and backwards. In c it is
represented as directed downwards and forwards, constituting
anteversion. In a, d, e, it is directed downwards and backwards,
constituting retroversion. These three figures of retroversion re-
present different forms or degrees of this displacement. The dia-
gram, a, represents an aggravated degree of retroversion, taken
¹ See Dublin Quarterly Journal of Medical Science, May 1848, p. 371.
682
DISEASES OF WOMEN.
from a drawing of a case of this displacement by Frank. The
mode in which the rectum is impressed by the retroverted uterus is
here shown. He found this instance of displacement in the body
of a patient who had died of chest disease, but he does not give her
previous history.'
Some authors have attempted to draw a specific line of distinc-
tion between the forms of posterior displacement of the uterus
portrayed in d and e, and have described the form given in e as
α
b
с

d
Fig. 23.
retroflexion, and that given in d as retroversion. In other words, by
retroversion, properly so called, they would understand a displace-
ment backwards of the entire organ, d-the flexion taking place in
the upper part of the vagina, and the uterus itself not being neces-
sarily changed in form. On the other hand, retroflexion, e, is a term
proposed to designate the displacement backwards of the fundus
only, along with more or less of the body of the uterus; the lower
part of the cervix uteri retaining, in some degree, its natural posi-
tion, and the flexion taking place in the substance of the body, or
upper part of the cervix of the organ. But, in reality, in the living
subject, we meet with all possible intermediate shades and degrees
of these posterior displacements; and I believe it to be an incorrect
and unnecessary refinement to draw such theoretical nosological dis-
Fig. 23. These diagrams are intended to represent vertical or antero-posterior
sections of the uterus, and upper part of the vagina. In b the uterus is supposed
to be placed in its normal position, and the other four figures represent different
deviations of the organ from this position.
1
Opuscula posthuma, p. 78.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
683
!
tinctions between them. Practically and pathologically there is no
true difference between these modifications or degrees of this morbid
position of the uterus; and I shall in my subsequent remarks include.
them, and all other varieties of posterior displacement, under the
generic term of Retroversion. Farther, in order to avoid repeti-
tion, I shall in the present communication treat only of retroversion
of the uterus. It will be found that the same principles of dia-
gnosis and treatment apply, mutatis mutandis, to the almost equally
common displacement of the uterus which I have defined above as
Anteversion.
ALLEGED RARITY OF RETROVERSION OF THE UNIMPREGNATED
UTERUS.
In all our English systematic books on midwifery and female
diseases, down to the very latest works, retroversion of the unim-
pregnated uterus is described as an exceedingly rare disease.
In his work on the Diseases peculiar to Women (1846), Dr.
Ashwell tells us that he has "been long in the habit of observing
uterine organic disease;" but he states "the published cases of
retroversion are nearly silent on any other cause than pregnancy;"
and he speaks of this as the result also of his own observations.'
Dr. Burns (1844) says: "Mr. Pearson relates a case where the
uterus was retroverted in consequence of being scirrhous. Dr.
Marcet gives an instance where the uterus was retroverted without
pregnancy, producing constipation and vomiting. Dr. Alken of
Bergheim relates a case where a woman, after suffering from difficulty
of passing the urine and stools, had in fourteen days complete
retention of both. The bladder reached to the umbilicus; the
extremities were cold, the pulse small, vomiting, etc.: the urine was
drawn off. After bleeding and the warm bath, force was employed
in opposite directions, both from the rectum and vagina, and in an
hour the uterus was replaced. It was, however, displaced again
next day, but was reduced, and the retroversion did not return.
The uterus was unimpregnated." Dr. Burns himself quotes these
cases in illustration of his own opinion, that retroversion, besides
occurring during pregnancy, "may also be produced when, the womb
is enlarged to a certain degree by disease.""
Writing in 1844, Dr. Churchill observes: "I have known retro-
1 Practical Treatise on the Diseases peculiar to Women, p. 598.
2 Principles of Midwifery, p. 288.
684
DISEASES OF WOMEN.
version to happen the first day of a menstrual period, when the
weight of the uterus was increased by afflux of blood. Mr. Pearson
and Dr. Blundell met with cases of retroversion caused by scirrhus.
Callisen and Blundell mention cases where this accident followed
delivery, but such must be exceedingly rare.”¹
2
The experience of the few last years has amply convinced me
that these opinions regarding the supposed rarity of retroversion of
the unimpregnated uterus are entirely wrong. Since discovering
an easy method of detecting its existence, I have found it one of
the most common and frequent displacements and affections of the
unimpregnated uterus. My observations, in this respect, have
been fully confirmed by several of my professional brethren in
Edinburgh. Three or four years ago I pointed out its frequency,
mode of diagnosis, and treatment, to my friends, Drs. Rigby and
Protheroe Smith, of London; and I have much pleasure in adding,
that their extensive opportunities at the London Hospital for
Uterine Diseases have enabled them and the pupils of that useful
institution to confirm amply the justness of my previous deductions,
with regard to the great frequency of fetroversion, and the advan-
tages of my proposed methods of detecting and treating it.
SYMPTOMS AND DIAGNOSIS OF RETROVERSION.
General Remarks. The morbid conditions of the uterus are
recognised in practice by two classes of symptoms-viz. the functional
and physical. The evidence derived from these two different classes
is different in its nature and value.
All accoucheurs will, I believe, readily admit that the two fol-
lowing observations hold good with regard to the symptoms and
diagnosis of utero-gestation-viz. 1. That the state of the uterus in
pregnancy, one and identical as it is, is liable to be accompanied, in
different women, or in the same woman in different pregnancies,
with very different local, sympathetic, and general effects or func-
tional symptoms; and, 2. That the usual concourse and succession
of functional phenomena, to which pregnancy generally gives rise,
may be induced by other states and irritations of the organ than
utero-gestation.
1 On the Principal Diseases of Females, p. 267.
2 In April 1843, I stated these results in a communication to the Medico-
Chirurgical Society of Edinburgh; showed the frequency of retroversion of the
unimpregnated uterus, and its means of detection and cure.
Journal of Medical Science for July 1843, p. 660.
See Monthly
RETROVERSION OF THE UNIMPREGNATED UTERUS.
685
The same two important inferences are true in regard to the
various individual morbid affections of the uterus. The marked
uncertainty which exists respecting the local and constitutional
effects produced by the condition of the organ in pregnancy, holds
equally good regarding the effects produced by it in its different
states of actual disease. In uterine disease, as in pregnancy, the
same specific affection of the organ excites sometimes very different
phenomena in different cases; and the same specific phenomena
frequently result from affections of the organ that are entirely at
variance with each other in their pathological character, in their
course, and in the treatment required.
In deciding upon the existence or non-existence of pregnancy,
especially in any case of importance or doubt, no medical man who
valued his own professional character would deem himself justified
in offering a final and decisive opinion from the study of the mere
functional symptoms only; nor would he venture to form a definito
judgment, until he had made a sufficiently accurate local or physical
examination of the state of the uterus itself. In deciding, in the
same way, upon the pathological nature, and consequently upon the
line of treatment which any marked uterine disease may require, we
believe exactly the same caution to be necessary, and the same local
or physical examination to be demanded, where there exists any
doubt, and where the examination is not otherwise counter-indicated.
It is assuredly only by doing so that we can hope, with any cer-
tainty, to decide upon the specific nature of the uterine disease that
may be present. We may make the general diagnosis of the exist-
ence of uterine disease by the consideration of the functional de-
rangements to which such diseases give rise. We can only make
the differential diagnosis of what the specific disease of the uterus
really is, by aiding this by the physical examination of the structural
condition of the organ itself. The study of the rational or functional
symptoms may show that the organ is affected, without showing us
how it is affected. They point out the fact of the uterus being the
seat of some diseased state or action, without pointing out what is
the specific nature of that diseased state or action. To gain this
last most important information, we must have recourse to the study
of the physical signs or symptoms of uterine disease, in addition to
the functional. In other words, we must attempt to ascertain the
actual, physical, or structural condition of the uterus by the tactile
and visual examination of the affected organ itself. We must en-
deavour to decipher and read its morbid anatomy in the living body,
686
DISEASES OF WOMEN.
by the careful employment of the senses of touch and sight. Hence,
then, I attach far less importance to the functional symptoms of
retroversion which I have first to enumerate, than to the physical
signs, which I shall afterwards consider.
FUNCTIONAL SYMPTOMS OR DERANGEMENTS.
In some cases of retroversion of the unimpregnated uterus, more
especially when the displacement is chronic and the pelvis large, as
in some other forms of serious uterine disease and of pregnancy, few
or no marked functional or sympathetic symptoms, either local or
general, are present; while in other instances the attendant func-
tional derangements and irritations are excessively severe and dis-
tressing. And in this, as in other uterine affections, between these
two extremes we may meet with every shade of difference.
In retroversion, as in other morbid conditions and diseases of
the unimpregnated uterus, the accompanying sympathetic derange-
ments or symptoms are, when they are well and highly marked,
more or less perfect imitations of the secondary phenomena of preg-
nancy. Dyspeptic and hysterical symptoms are sometimes present,
with local neuralgic pains in the mamma; in some portions of the
vertebral column; or, what is still more frequent, in the parietes of
the abdomen or chest, and more especially in a limited spot beneath
the left mamma. The displaced position of the uterus often gives
rise to mechanical irritations and symptoms of the same kind as if
the organ were actually morbidly enlarged. Constipation and im-
peded defecation are frequent results, partly from the fundus of the
displaced uterus physically compressing the calibre of the rectum,
and partly from its producing a functional inability to expel the
feculent contents of the bowel through the lowest part of the canal.
Occasionally the bowel is irritated, and there are discharged from it,
from time to time, quantities of mucous or fibrinous-like effusions.
The bladder frequently suffers from dysuria or retention; and, much
more rarely, I have seen a degree of incontinence, especially where
the urine has become phosphatic, from the want of power in some
cases of completely emptying the bladder. Symptoms of weight,
tension, and bearing down in the regions of the uterus and rectum,
with dragging at the loins and in the regions of the uterine liga-
ments, are very common. Pains often stretch down one or both of
the lower extremities. Occasionally there is an inability to bear
carriage exercise, and walking and standing speedily produce fatigue.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
687
In a few rare cases I have known the patients to find themselves
forced to remain almost constantly in the horizontal position, from
the intense and overpowering feeling of pressure and malaise which
the erect posture always brought on, and the power of standing and
progression restored by the spontaneous or artificial reposition of the
uterus. In general, all the symptoms, local and constitutional,
which I have alluded to, are aggravated more or less by exercise in
the erect position; and they are more particularly liable to be in-
creased in their intensity when the uterus becomes periodically
congested and heavier, at the recurrence of each menstrual period.
In some cases of retroversion the menstrual function is not
morbidly altered. In other cases, however, I have seen the cata-
menial discharge affected, but affected most oppositely and variously
-occasionally in the way of amenorrhoea, sometimes of dysmenor-
rhoea, and not unfrequently of menorrhagia, particularly after mis-
carriage.
The mucous secretion of the uterus is not altered by retrover-
sion, unless congestion or inflammation supervene; it may then
change into leucorrhoea. Occasionally there is a sudden temporary
increase of discharge, once or oftener during the intervals between
the catamenial periods, as if it had collected in the cavity of the
retroverted organ, and escaped, or become expelled, only from time
to time.
When a patient with a retroverted uterus becomes pregnant,
abortion is apt to take place. But I have seen various instances
in which the uterus became spontaneously rectified in position as it
became larger, and utero-gestation went on to the full time.
Usually the existence of retroversion interferes with the function of
conception. Often it is a cause of sterility, as shown by impregna-
tion taking place after the displacement is rectified. In women who
have borne children at distances of several years between each, I
have several times found the uterus permanently retroverted in the
unimpregnated state.
The functional symptoms that I have enumerated may make us
suspect the existence of retroversion of the uterus. But retrover·
sion may be present without most, or almost any of them; and they
may be present with other diseases besides retroversion. Hence the
necessity here, as elsewhere-in this, as in other uterine affections-
of having recourse to the physical examination of the uterus, in
order to decide and determine its actual morbid state.
688
DISEASES OF WOMEN.
PHYSICAL SIGNS OF RETRO VERSION.
The usual physical means of diagnosis of uterine disease are
reducible to the observation of phenomena by the senses of sight
and touch.
Speculum. The employment of sight, by means of the speculum,
assists us in no respect in the diagnosis of retroversion.
Tactile Examination.-On an accurate vaginal examination we
feel an apparent projection of a solid tumour between the uterus
and rectum, when applying our finger, or fingers, behind the cervix
uteri to the posterior part of the upper reflection, or roof of the
vagina. (At a, Fig. 23.) The same firm mass is felt through the
anterior wall of the bowel in making an anal examination. The
tumour or mass feels smooth and roundish on its surface; is often
sensitive on pressure, more especially if the retroversion is recent,
or when the posterior wall is, as often happens, congested and
engorged; is generally capable of being moved more or less easily
by the finger; and varies in size according to the degree of dis-
placement, and the morbid or healthy state of the uterine walls.
The os and cervix uteri may be displaced forwards, or they may
maintain their usual position. The whole body of the uterus is often
prolapsed and lower than its natural situation; but occasionally it
is quite normal in these respects.
How are we to determine that the solid tumour lying upon the
back part of the roof of the vagina, and between the rectum and
uterus, is the displaced fundus and body of the uterus.
If the patient be unusually thin and emaciated, and we examine
simultaneously with one or two fingers of the right hand placed in
the vagina, and those of the left hand placed above the pubes, we
can almost feel the uterus between the two hands, and ascertain
the whole position and relations of the organ; but this, however,
can very rarely be accomplished.
Generally, we have by tactile examination no other means of
¹ In a few cases the sense of hearing is also had recourse to. I have repeatedly
heard with the stethoscope a sound like the placental souffle in large fibrous
tumours of the uterus. The uterine walls around these tumours are sometimes
hypertrophied and thickened, exactly like the walls of the uterus in pregnancy,
and their vascular structure undergoes a similar increase and mutation. Hence,
probably, the origin of the sound in question. When present, I believe it to
serve among others, as a diagnostic mark between fibrous tumours of the uterus
and ovarian tumours.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
689
knowing the probability of the apparent tumour being formed by
the displaced fundus and body of the uterus, than by tracing along
with the finger, between the tumour and cervix uteri, a direct con-
tinuity of structure, and this may be done either per vaginam or per
rectum. But this physical sign is in itself apt to lead into error, if
alone depended on. If the uterus is retroflected more than retro-
verted, the continuity cannot be traced at the point or angle of
flexion; while, on the other hand, a fibrous or other tumour attached
to the back wall of the uterus sometimes may be distinctly traced
to be in continuity with the uterine structure, and moves with all
motions imparted to the cervix. Nor is the position of the os uteri
any more certain guide, for sometimes it is not displaced when the
fundus is so; and it may be thrown forwards by a tumour, when
the fundus retains its normal position.
Other and additional means, therefore, of diagnosis become neces-
sary. M. Pereyra, of Bordeaux, suggested, a few years ago, to attempt
to obtain a more correct physical diagnosis for retroversion, by con-
ducting the examination by the rectum or bladder. "The diffi-
culty," he observes, "of distinguishing diseased growths from retro-
version of the uterus is greater than might at first be supposed; the
only way of attaining a correct diagnosis is to ascertain if the uterus
be or not in its normal situation. Two methods are proposed for
this end; either the forefinger is introduced into the rectum, or a
male catheter into the bladder, by the extremity of which instru-
ment an exploratory process is conducted. The latter mode, treated
of by Malgaigne,' requires, of course, some tact, but to the experi-
enced surgeon it will give the more certain indication."
"12
The determination of the case by an examination per rectum
is impossible; and I have elsewhere shown that Malgaigne's method
of diagnosis is attended with difficulties and uncertainties that
render it quite useless in practice.³
A far more simple and certain method is to determine the
precise situation of the fundus and body of the uterus, not through
either the intestinal canal behind, or the urinary canal in front,
but through the intermediate genital canal itself. The proper
canal of the uterus is, of course, too narrow to allow us to introduce
our finger into it; but by passing into it a slender metallic finger,
if we may so speak, we can easily by it ascertain, amongst other
1 Thèse du Concours, 1833.
2 American Journal of Medical Sciences, April 1843, p. 483.
3
See
P. 657.
690
DISEASES OF WOMEN.
The
matters, any change in the direction of its cavity, and consequently
in the direction of the body and fundus of the uterus itself.
employment of the uterine bougie readily enables us to do this.
Examination by the Uterine Sound or Bougie.-The form, etc., of
the uterine bougie is represented in Fig. 20, and consequently requires
little or no description. Some years ago I gave a full account of
the instrument and the mode of using it.¹ It has the configuration
of a slender male catheter; tapering in form; knobbed at the
extremity; divided into sections, so as to measure, when required,
the length of the uterine cavity; and provided with a handle,
smooth on its posterior surface and roughened on its anterior, that
surface represented in the woodcut, in order to make the operator
constantly aware of the position and direction of the point and
concavity of the instrument, when it is passed into and hid in the
uterine cavity.
This instrument can be easily and readily passed into the uterine
cavity, so as to enable us to measure its depth; to examine, more
distinctly than we have otherwise the power of doing, its fundus,
body, and cervix ; to ascertain the presence of strictures in the
canal; diseased states of the cavity and walls of the organ, etc. I
have used it daily for five or six years past, and have never, in any
instance, seen any serious irritation, or any bad result to the uterus,
follow its employment; whilst it has enabled myself and others to
detect and discriminate morbid conditions of this organ, that
were, by any other means, entirely beyond the reach of correct
diagnosis.
Its power of detecting retroversion of the unimpregnated
uterus depends, as I have already stated, upon its directly and
easily enabling us to ascertain the direction of the uterine cavity, and
hence of the body and fundus of the uterus, which form the walls
of that cavity.
When the uterus is in its normal position, and is placed with
the long axis of the organ, and consequently the long axis of its
cavity, in a line parallel with the axis of the pelvic brim, the point
of the bougie, when introduced into the uterus, passes upwards and
forwards in the direction of the umbilicus; and the concavity of
the instrument, or the rough side of its handle, is directed towards
the symphysis pubis. When, however, the uterus is retroverted,
the point of the instrument, instead of passing up vertically and
forwards, is resisted in that direction, and can only be passed
1 See p. 616.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
691
horizontally and backwards towards the hollow of the sacrum ; its
concavity and the rough side of its handle thus looking towards the
sacrum instead of towards the pubes, and at once showing the
altered position of the cavity, body, and fundus of the uterus.
But the diagnosis may be made out still more completely and
accurately by the further use of the bougie. For—
1. Besides showing, in the manner stated, the direction of the
uterine cavity, and hence of the body and fundus of the uterus, by
the direction in which the instrument itself
passes-
2. We can ascertain by a vaginal or anal examination of the
supposed tumour, that the extremity of the uterine bougie is lodged
in its centre, showing the swelling to be produced merely by the
displaced fundus of the uterus; and—
3. After this, by turning the bougie gently round, so as to bring
the concavity, or the rough side of its handle, to look to the pubes.
instead of looking, as at first, to the sacrum, we can replace the
uterus, and feel it upon the bougie if required, through the abdominal
parietes in front. We can thus certify to our own minds that we
have nothing on the point of the instrument except the fundus
uteri. And again, if necessary, by introducing a finger into the
rectum or vagina, and then retroverting or replacing the uterus at
will, we can as it were make and unmake, as often as required, the
apparent tumour lying between the uterus and rectum, and thus
further prove this tumour to be nothing whatever but the retroverted
fundus uteri.
DIFFERENTIAL DIAGNOSIS OF RETROVERSION.
I have seen retroversion of the unimpregnated uterus not only
very frequently and entirely overlooked, but also very often mistaken
for other morbid states and lesions of the uterus. I shall point out
the principal morbid conditions with which I have known it to be
confounded, and the modes of distinguishing retroversion from
them.
1. From Pregnancy.-In a considerable number of instances I
have had occasion to see the feeling of fulness and apparently in-
creased size of the uterus in retroversion mistaken for the earlier
periods of utero gestation. A few weeks ago I was called to a case
at a distance from Edinburgh, where this error of diagnosis had
led to much distress: from an unmarried lady, suffering severely
from dysmenorrhoea and menorrhagia, being supposed by her medical
45
692
DISEASES OF WOMEN.
attendant to be pregnant and aborting, by his mistaking the retro-
verted fundus and body of the uterus for general enlargement of the
organ. This error is still more liable to be committed when the
retroversion is accompanied, as it sometimes is, with occasional
amenorrhoea. Two or three years ago, I had under my care a
patient with retroversion of the uterus and temporary amenorrhoea,
who had been pronounced as undoubtedly pregnant, by her usual
medical attendant, an excellent practitioner and lecturer on mid-
wifery in another medical school. About the same time I had a
patient under my own care with retroversion, who passed three
successive menstrual periods; but I was certain, from no corre-
sponding increase in the size of the retroverted uterus, that she was
not pregnant. In this case the difficulty of the diagnosis was ren-
dered the greater in consequence of the areolae becoming darker and
their follicles enlarged as in pregnancy. A drawing was made of
the areolae at the time; and afterwards, when the uterus was re-
placed, and the patient at last became pregnant, the areola were
most certainly not deeper marked at the same period in the true,
than they had been in the spurious pregnancy.
2. From Fibrous and other Tumours in the posterior IVall, etc., of
the Uterus.-This is one of the most frequent errors of diagnosis
which I have met with, and one into which, in former times, I
myself frequently fell.
The attendant functional symptoms are in all respects the same;
and on examination there is the same continuity of structure felt
between the cervix uteri and the body lying between it and the
rectum. In this way retroversion of the uterus has very often been
mistaken for a morbid growth upon the back part of the uterus,
and even described as such. But the introduction and direction
¹ Dr. Hamilton, in his Outlines of Midwifery, describes retroversion as an
unequal projection on the posterior part of the uterus. I have seen one or
two patients whom he had pronounced in writing to be labouring under these
projections,” and where the apparent tumour was the retroverted fundus uteri.
In the work quoted he observes :-"An unequal projection of different sizes is
occasionally discovered on the posterior part of the uterus, resembling in shape
the tubera which form upon the surface of the liver, but differing from tubera in
being of a more resisting texture, and in being pained on pressure. From the
cases which have fallen under the author's notice, it appears to him that the fol-
lowing is the progress of this fortunately rare disease. At first there is a slight
enlargement of the uterus, with a little thickening and tenderness of its posterior
surface, occasioning a sense of bearing-down on making any unusual exertion, and
an obscure gnawing pain towards the back part of the pelvis. In the progress of the
disease the posterior surface of the uterus becomes more and more unequal, till at
RETROVERSION OF THE UNIMPREGNATED UTERUS.
693
of the uterine bougie at once enables us to solve the difficulty. The
bougie passes backwards into the very body and centre of the ap-
parent tumour, at once showing it to be the retroverted fundus
uteri. It may be proper, however, to add that instances are by no
means rare in practice of the presence of small fibrous tumours at-
tached to the posterior wall of the uterus being conjoined with
retroversion.
I have known the retroverted fundus uteri to be pronounced a
carcinomatous tumour, local thickening of the back walls, etc. The
differential diagnosis is readily made, in the way I have just men-
tioned. When it has occurred after delivery, I have seen it mistaken
for the common puerperal hypertrophy of the uterus. The means
of differential diagnosis are the same. And cases, in which the
apparent swelling formed by the back wall of the deflected uterus
have been, out of the pregnant and puerperal states, mistaken for
simple general hypertrophy of the uterus, and assiduously treated
by mercury, iodine, etc., have frequently come under my notice.
3. From Ovarian Tumours in their earlier Stages. When the
ovary enlarges from multilocular degeneration, or other causes, it
almost always first grows downwards into the space lying between
the back wall of the uterus and the anterior part of the rectum,
resting thus upon the roof of the vagina behind. In its enlarge-
ment it almost invariably pushes the uterus anteriorly, and before
it; and this relative position of the uterus to ovarian tumours is
often an important matter in the diagnosis of ovarian disease in its
latter and more advanced stages. At first the body of the enlarged
ovary may be mistaken for the retroverted fundus uteri, more
especially as the os uteri is generally displaced forwards. But the
introduction of the bougie shows the uterus to be in its normal
situation, and at the same time generally enables us to draw the
uterus so far forwards as to make us certain that it is not attached
to the existing tumour, and does not form one continuous structure
with it. So far the evidence is merely negative. If further
last a distinct projection like a walnut, or even larger, can be felt on examination
per anum.
At this stage of the disease the patient can neither stand nor sit
upright, such is the continued uneasiness in the back part of the pelvis. It is
remarkable that in this, as well as in several other of the local diseases of the
uterus, the catamenia continue to flow as usual. In the early stages of this
disease the progress has been generally checked by the means employed in cases
of chronic enlargement of the uterus; but in the latter stages-that is, after the
circumscribed projection has taken place-no other means of treatment have
hitherto proved successful."—Outlines of Midwifery, p. 134.
694
DISEASES OF WOMEN.
evidence of a positive kind, of the nature of the tumour, is required,
we may obtain it by the use of a fine exploring needle, a means of
diagnosis of great value in this as in other complications.
4. From Pelvic Cellulitis.—Inflammation of the cellular tissue of
the pelvis, limited or more diffuse, is certainly a frequent disease,
both after delivery and in the unimpregnated state. I have seen it
now at many different periods of life, from six years up to sixty.
It is generally spoken of as "pelvic abscess," but improperly so, for
it does not always necessarily terminate in abscess, any more than
pleurisy necessarily terminates in empyema. When the inflamma-
tory effusion seems limited, as it sometimes is, to the space between
the uterus and rectum, the firm tumour, or swelling formed by it,
may be mistaken for retroversion. The direction of the bougie,
when introduced into the uterus, will show us, however, that the
uterus is not retroverted; and the accompanying symptoms, and, if
necessary, the use of the exploring needle, will enable us to complete
the diagnosis.
5. From Extra-uterine Conceptions lodged between the Uterus and
Rectum.-Nauche¹ mentions a case in which an extra-uterine concep-
tion was mistaken for a retroverted uterus. I lately met with an
instance where it was a matter at first of great doubt and difficulty,
whether a tumour lying on the anterior wall of the rectum, and
accompanied with sudden symptoms of rupture into the peritoneum,
was an enlarged and retroverted uterus, or an extra-uterine concep-
tion. Examinations with the bougie at once showed the uterus to
be both normal in its size and in its position.
6. From Organic Disease in the Anterior Wall of the Rectum.—In
a case of Dr. Marnoch's, the tactile examination of a tumour lying
between the uterus and rectum gave me the idea that it was a
retroverted uterus. The employment of the bougie, however,
showed the uterus 'to be normally placed. On more minutely ex-
amining per anum, the anterior wall of the rectum was found much
thickened and indurated; the patient died some months subsequently
of carcinomatous stricture and disease of the rectum.
7. From Stricture of the Rectum.-The diagram of retroversion in
Fig. 24 shows how readily this disease may be mistaken for stric-
ture in the rectum; the deflected fundus uteri pressing in upon, and
sometimes diminishing greatly, the calibre of the bowel. But the
use of the bougie always readily dispels the difficulty, by showing
first the direction of the fundus, and secondly, when the instrument
1 Maladies des Femmes, p. 108.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
695
is turned round, by at once removing the fundus and the supposed
stricture. But I know that the mistake of confounding a retro-
verted uterus with stricture of the rectum is by no means infrequent
in practice. Sir Charles Bell states that he had found a surgeon
employing rectum bougies for years, on account of an obstruction
from displaced uterus.¹ A case of retroversion of the unimpregnated
uterus some time ago came under the care of a medical friend of
mine in Edinburgh. He discovered the displacement, introduced
the wire pessary (Fig. 27), which I shall afterwards describe, and at
once rendered his patient comfortable, and capable of taking exer-
cise. She returned to her own distant home, with a line to her
physician, who declared he knew the instrument well, but thought

e
f
6
a
Fig. 24.
it necessary to take it out at the menstrual period, and could not
again replace it. Another distinguished obstetrician was called in
his place. He said the uterus was enlarged, and not displaced;
used leeches, etc. Not finding the desired benefit from this treat-
ment, the lady placed herself under the care of an eminent surgeon,
who pronounced all the previous opinions wrong, and that the real
disease was stricture of the rectum. The last time I heard of the
patient she was submitting to the frequent use of bougies for the cure
of this imaginary affection.
Fig. 24 is a diagram of the position of the retroverted uterus, b; and its
replacement to c by the sound, d; f being the sacrum; e the rectum ; and a the
vagina.
¹ Institutes of Surgery, vol. ii. p. 216.
696
DISEASES OF WOMEN.
RETROVERSION LIABLE TO ESCAPE NOTICE EVEN IN POST-
MORTEM EXAMINATIONS.
In the preceding pages I have spoken of retroversion of the
unimpregnated uterus being with extreme frequency entirely mis-
taken in practice, and overlooked during life. But even after death
the same error is liable to occur. Dr. Robertson details¹ a case
most illustrative of this remark. A woman died of tenesmus, con-
stipation, and symptoms of obstructed bowel, ending in enteritis.
Before death the rectum was examined for the obstruction, and the
gut was found "encroached on by a tumour which, per vaginam,
was discovered to be the uterus.” But," adds Dr. R., " on the post-
mortem examination, to our surprise, no uterine tumour was found to
encroach on the rectum." In this, as in other cases in which retro-
version of the uterus has existed, the morbid displacement has, on
the inspection of the body after death, escaped notice, from the form
and structure, and not the mere position, of the uterus being looked
to. In our common post-mortem method of examining the pelvic
contents from above, the attention of the morbid anatomist is rarely
or never directed to the observation of any mere deflection of the
fundus and body of the uterus; and when once the parts are dragged
out of their situation, it is impossible to ascertain the amount and
degree of retroversion.
ORGANIC STATE OF THE UTERUS IN RETROVERSION.
This is very variable. I have seen it several times co-existing
with the presence of fibrous tumours in the uterine parietes. More
frequently the uterus is hypertrophied merely from chronic metritis,
and the enlargement more especially marked in the posterior walls.
The organ is at the same time elongated as well as hypertrophied;
and its cavity, instead of measuring two and a half inches in length,
will measure three or three and a half inches. Many authors seem
to think that enlargement of the uterus, under some form or another,
is a necessary preliminary to retroversion taking place, and that we
never meet with the displacement, without finding it combined with
some increase in the size of the organ. Such, however, is assuredly
not the fact. In a large proportion of cases the retroverted uterus
is in no degree enlarged or increased in volume, but natural in size.
¹ Edinburgh Medical and Surgical Journal for 1822, p. 525.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
697
Nay, I have on more than one occasion seen the uterus retroverted,
when it was less than normal in its length and dimensions. Latterly
I have happened to be consulted in several instances of amenorrhoea
in women advanced beyond twenty or thirty years of life, in whom
the menstrual secretion had never appeared, and where, on examina-
tion, the uterus was found imperfectly developed, and the length of
its cavity, as measured by the uterine bougie, was not above one,
one and a half, or at most two inches. In one of these instances,
in which the cavity of the uterus was only one and a half inches long,
the fundus of the preternaturally small organ was, at the same time,
distinctly retroverted, and felt like a small roundish tumour through
the vagina and rectum. Some time ago I saw, with my friend
Dr. Girdwood of Paddington, a case still more rare. The uterus
was retroverted, as he had ascertained by examination and the use
of the bougie. There was a second orifice in the cervix uteri. On
introducing a second bougie into this additional orifice, I found it
pass into a second uterine cavity, quite separated and distinct from
the first, and with the fundus of each diverging from the other. In
fact, the uterus was not only retroverted, but double. It is, as far
as I am aware, the first case in which a double uterus has been dis-
tinctly diagnosticated upon the living subject.
TREATMENT OF RETROVERSION OF THE UNIMPREGNATED UTERUS.
When recent, and occurring after some straining effort, or from
congestion and inflammation of the uterus, or subsequent to delivery,
mere replacement of the organ by the bougie or finger will some-
times suffice, provided, along with it, we enforce for a length of
time the horizontal position, or rather lying on the side or face,
prevent over-distension of the rectum and bladder, reduce any local
congestive or inflammatory state that may be present, and restore.
the local tone of the relaxed soft structures of the pelvis by
astringent vaginal injections, or by the use of medicated pessaries
made with ointment containing extract of oak-bark, or tannin, or
iodide of lead, etc.
But such simple treatment rarely succeeds, even when the retro-
version is recent; and still more seldom when, as is almost always
the case in practice, the displacement is already chronic and
confirmed. Under these circumstances we have three principal
indications to perform:-1. To remove, if necessary and possible,
any morbid action in the uterine structures that may exist along
698
DISEASES OF WOMEN.
with the displacement. 2. To restore the uterus to its normal
situation. 3. To use means to retain it in its replaced and natural
position. I shall speak separately of these several indications.
1. Removal of any Morbid State of the Uterus that may co-exist with
the Retroversion.—Not unfrequently, along with retroversion, the
uterus is congested and hypertrophied, and the uterine bougie shows
it to be elongated half-an-inch or more. Sometimes chronic inflam-
mation of the body of the organ is present, and more especially in
its posterior wall, which often feels tumefied and tender to the
touch; or the cervix is enlarged, condensed, and ulcerated, especially
in its posterior lip. The os uteri, or the uterine canal, an inch or
so above the os, is not unfrequently contracted and strictured, and
may have been giving rise to retention of the menses and congestion.
Occasionally one or both ovaries can be felt through the roof of the
vagina, enlarged and painful from congestive or inflammatory irrita-
tion. As a general rule, all these morbid states should, when
possible, be reduced and removed, or at least moderated by their
appropriate means of treatment, before engaging with the other
indications to be fulfilled, particularly when they are apparently in
any respect the cause of the retroversion. More frequently, how-
ever, they are the effects of the retroversion; and in this latter case
our means of combating them, will usually fail, or only partially
succeed, till we have first restored the organ to its natural form and
situation, by our fulfilling the second and third indications which I
have laid down, before we fulfil the first. When the retroversion is
combined with and produced by the presence of fibrous tumours in
the posterior wall or fundus of the uterus, the first indication can-
not, of course, be accomplished, as we as yet possess no certain
power of removing and discussing these tumours.
2. Restoration of the Uterus to its Normal Situation.—Most
authors who have treated of retroversion of the unimpregnated
uterus have spoken as if its replacement could generally be fully
effected by the fingers alone. In practice, however, its complete
replacement by this means is almost always found to be impossible.
By pushing up the retroverted fundus, or by pulling down the
cervix, or by combining simultaneously both measures, the replace-
ment can sometimes be effected by the fingers alone; but rarely.
For it is scarcely ever possible, by any pressure which we can make
with the fingers upon the posterior surface of the uterus, either
through the vagina or through the rectum, to push the fundus uteri
upwards and forwards to a sufficient degree. Some authors, finding
RETROVERSION OF THE UNIMPREGNATED UTERUS.
699
their fingers to fail, from their shortness, etc., have proposed in-
struments for the purpose. Richter and Evrat suggested a species
of vectis or probang, to be used through the rectum. Bellanger,
Lallemand, and Dugès, have spoken of introducing a strong sound
into the urethra and bladder, to act as a lever upon the os uteri.
Siebold and Drejer attempted to replace the uterus by instruments
made of whalebone, introduced into the vagina, and made to press
by their upper and blunted extremities upon the fundus uteri
through the upper and back portion of the vaginal parietes.
The simplest and most easy method of temporarily replacing the
retroverted uterus is by introducing an instrument into the cavity of
the organ itself, and using it as a mechanical means or lever, for the
purpose. In treating of the physical diagnosis of retroversion, I have
shown how the uterine bougie can be readily used for this purpose.
The very means of diagnosis are thus, at the same time, the very
means of replacement.
2
3. Retention of the Replaced Uterus in its Normal Situation.-This
is necessary to effect a cure. Some, as Schmitt and Schweighauser,
have supposed that it could be accomplished by the mere position
of the patient, and that lying on the side or face, with the pelvis
somewhat elevated, would be sufficient. I have already stated that
in few—exceedingly few cases, indeed—will it be found to succeed,
and these only of recent origin. Instruments for the purpose of
supporting and retaining the uterus in situ are therefore necessary.
They have been proposed to be worn in the rectum,' and in the
vagina. Various forms and modifications of vaginal pessaries have
been invented by Hervez, Drejer, Sander, etc. They are all intended
either to press principally, by guarded stems or otherwise, through
the roof of the vagina, upon the tumour formed by the fundus uteri ;
or to keep the cervix uteri pushed back, with the view of throwing
the fundus forwards. I have used sponges for this last purpose;
and Siebold and Kilian state, that they believe they form the best
pessaries for retroversion, modified according to the necessities of
each case.
Moreau conceives that the principle of treatment should
be to fill up the space between the uterus and rectum, so as to take
away any room for the retroversion to recur: he uses a kind of
caoutchouc pessary for this purpose. Two years ago I removed from
a patient one which had been worn for some months, and which
Moreau himself had introduced. It had not in any degree benefited
the retroversion.
1 Ætius, Vernandois, Desault.
2 Colombat, Dugès, etc.
*
700
DISEASES OF WOMEN.
After detecting the ease and certainty with which the uterine
bougie could be used for the discovery of retroversion, and for the
temporary restitution of the organ, it appeared to me that the most
direct and perfect method of retaining the replaced uterus in situ
would consist in some means of retaining and fixing, as it were, the
end of the bougie for a time in the uterine cavity. I soon found
that the restoration of the uterus temporarily, from day to day, with
the bougie, was insufficient, and that some more permanent means
of keeping the organ replaced and retained were necessary. But
one primary and important point required to be solved-Would
the uterus bear with impunity the presence of such a body for a
length of time in its own cavity? My first experiment on the sub-
ject I made with extreme anxiety, and great misgivings as to the
result. I watched the case from hour to hour, and from day to day,
and was delighted to find that the presence of the instrument was
borne by the uterus without irritation or annoyance. The patient was
almost entirely incapacitated from walking, by retroversion of the
uterus, before it was used. After thus wearing for some months a
wire pessary in the cavity of the uterus, she so far recovered as to
bear two children, one in this country, and subsequently another in
India. I soon found in other cases, that, when the instrument was
once properly fitted and adjusted, it could be borne with perfect
safety, and without any pain or inconvenience. Occasionally I have
since met with cases in which the uterine pessary has created so
much irritation as to render its withdrawal necessary in a few days
after it was introduced. But these cases have been exceptions, and
by no means common or frequent exceptions, to the general rule ;
and I have allowed the instrument sometimes to remain in the
uterus for two, four, six months, or longer. Within the last few
weeks I have removed two uterine pessaries, one of which I had
introduced eight, and the other nearly ten months previously. They
are not to be interfered with at the menstrual periods. Sometimes,
though by no means always, a slight menorrhagia follows their use,
particularly for the first period or two after their introduction.
It is unnecessary to detail the changes of form which were tried,
and the difficulties I met with, in first attempting to construct a
proper uterine pessary. The three forms which I have been in the
habit of using for the last three or four years are those depicted in
the woodcuts.¹
1 Mr. Young, our cutler in Edinburgh, makes them of German silver; some-
times he has electrotyped them for me, but this addition is unnecessary,
RETROVERSION OF THE UNIMPREGNATED UTERUS.
701
First Form of Uterine Pessary, Fig. 25, a, b, d.—The stem of the
instrument, d, 2 inches long, is introduced into the uterine cavity;
the lips of the cervix uteri rest upon the flattened ovoid bulb or
ball; a shows the lower surface of the bulb or ball, with an orifice
in it to allow of the end of a staff, c, about 8 inches in length, to
be fixed in it, for facilitating its introduction into the uterus. This
form of pessary generally answers much better for anteversion than
for retroversion. Occasionally I have had the bulb made of lead,


α
d
万
​त
α
Fig. 25.
e
Fig. 26.
that it might serve as a counterpoise to hold the os uteri in situ.
The instrument, however, is imperfect, from the impossibility usually
of retaining it in the uterus above a few days, the canal relaxing and
dilating, and allowing of its escape. In fact it is exactly the form of
bougie which I generally use to dilate the os and canal of the uterus
in cases of stricture, in any cases in which I do not employ the knife
or hysterotome for that purpose.
Second Form of Pessary, Fig. 26, has a similar uterine stem and
bulb, and in addition a large ovoid disc, 2ğ inches in length, 14
inch broad, and an inch in depth, to retain the instrument in
situ. The bulb, b, for the cervix uteri to rest upon, is fixed in the
middle of the disc, and the uterine stem, d, is movable to a certain
extent upon it. This is necessary in consequence of the size of the
retaining disc, and the impossibility of introducing the instrument
into the uterus and genital passages, with the stem fixed upright,
and at right angles to the plane of the disc. The dotted line re-
presents the stem laid down, as is required in the introduction and
withdrawal of the instrument. On the lower surface of the instru-
ment, which is not seen in the figure, there is a spring-catch to hold
the stem fixed and upright after the instrument is introduced, and
capable of being unlocked by the nail when the instrument requires
to be again withdrawn. The expanded disc, by pressing on the sides
702
DISEASES OF WOMEN.
of the vagina, enables the uterine portion of the pessary to keep its
situation. In some cases this instrument answers well in retaining
the replaced uterus. But occasionally, when the tendency to dis-
placement is great, this form of pessary is altogether inadequate, and
will be moved about by the changes of position which the uterus
itself undergoes. The remaining form, which I most frequently
employ, is free from these disadvantages. The two first forms are,
when used, altogether concealed within the genital passages.
In
this third form a portion of the instrument is placed externally, and
another internally.
Third Form of Pessary, Fig. 27.'-It is made up of two parts:-
1. An internal part, provided, like the two preceding pessaries, with
a stem, ƒ, to pass into the uterine cavity; a bulb or ball, g, for the
cervix to rest upon; and, in addition, a vaginal portion, or curvilinear
tube, h. 2. An external part, consisting of a wire frame-work, a, b, c,
to maintain and hold the internal portion in situ. This external
part, or wire frame, is about 5 inches long; at its lowest or vaginal
portion it is about an inch broad; and towards its upper or pubic
portion, it suddenly swells out to 3 inches in breadth. From the
vaginal extremity of this frame projects, at nearly right angles to
it, a flat tubular portion, c, 2 inches long, closed at its farther ex-
tremity, like the point of a female catheter, and fitted to slide into
and fix in the corresponding open tube, h, attached to the bulb of
the internal half of the instrument, g."
2
In the woodcut the uterine stem of the instrument is represented
as placed in the cavity, e, of the uterus, a section of the organ, d,
being outlined around it. In introducing the instrument, the in-
ternal portion, f, is first passed into the uterus and vagina, in the
same way as the uterine bougie is passed for the purpose of dia-
gnosis. The retroverted uterus is then replaced by raising it up
upon this portion of the instrument, which is turned round for that
purpose. After the organ is replaced, the solid vaginal portion
attached to the external frame of the pessary is slid into the corre-
¹ The different parts of the pessaries are represented in the woodcuts as some-
what below their actual size. The bulb or ball is, in general, made an inch and
a half long, one inch broad, and about half-an-inch thick. I have sometimes used
a larger bulb. When smaller, it is apt to produce dilatation of the os uteri, and
even to pass partially into it.
2 I have a patient at present wearing one of these pessaries with a stem three
and a half inches long. The retroverted uterus is enlarged and elongated by
fibrous tumours in its walls, and one of the ordinary pessaries did not suffice to
hold it replaced.
RETROVERSION OF THE UNIMPREGNATED UTERUS.
703
sponding vaginal tube, h, of the internal half of the instrument,
locking into it on the same principle as the stilet locks into the
canula of a curved trocar. Thus the instrument is, as it were,
rendered at once completely solid and fixed. In order to have room
to lock the two portions together, it is necessary, in general, first to
bend back the pubic portion of the external frame-work to a very
considerable extent, for the purpose of avoiding its being caught
and impeded by the anterior part of the pelvis or pubes. After the

a
f
d
g
h
Fig. 27.
locking is accomplished, this pubic portion of the instrument is bent,
and moulded upon the anterior portion of the pelvis, so as to fit it
as exactly as possible. Formerly I was in the habit of attempting
to keep the instrument more permanently fixed, by having elastic
tapes fixed posteriorly into the apertures, b, and anteriorly into those
still represented in the upper part of the pubic portion of the instru-
ment; and both attached to a band encircling the trunk of the body.
This arrangement I always now dispense with as unnecessary. If
the pubic portion of the pessary is properly bent in over the pubes,
it generally takes a sufficient hold; and if aught more is found neces-
sary, all that is required, in addition, is, that the patient wear a
common napkin, or understrap, to pass between the limbs and over
the instrument. Latterly I have had the instrument made without
the part, b, projecting posteriorly.
It is, perhaps, almost unnecessary to add that, if the instrument
is found to press disagreeably on any part, it may be easily bent
without removing it, so as to take off that pressure; and it may
thus require to be remodelled and adjusted again and again in
704
DISEASES OF WOMEN.
various parts, in order that it may be ultimately worn without
annoyance and inconvenience.
When required to be withdrawn, the pubic portion is first bent
back, so as to be clear of the pubes; then the vaginal pieces are
unlocked; and, lastly, the internal part is extracted.
The time during which it requires to be worn, in order to effect
a cure, varies in different cases from one or two weeks to many
months. The recent or chronic character of the case, and parti-
cularly the degree of tendency to the recurrence of the retroversion,
are our principal guides on this head.
The employment of these uterine pessaries will cure many, but
by no means all cases of retroversion of the unimpregnated uterus.
And even when not sufficient to cure, they will generally relieve the
patient, and palliate her annoyances and sufferings.
If the retroversion were causing no unpleasant symptoms, nor
interfering with the functions of the uterus, I have always recom-
mended the avoidance instead of the adoption of local measures and
remedies, either mechanical or others. When the reverse was the
case, I have employed the means I have mentioned, with the effect
of curing many and of relieving others. In the few exceptional
cases in which no pessary could be borne, in consequence of the
irritable state of the uterus, or where they failed to produce a cure,
I have contented myself with reducing this morbid state of the parts
by leeching, external counter-irritation, the application of belladonna
ointment pessaries, etc., and rest, in the first instance, followed after-
wards by the employment of local and general tonic measures. The
patient often derives much relief from wearing an abdominal band-
age, as those of Hamilton and Hull, with a supporting perineal pad.
I have not entered into the consideration of the Causes of retro-
version of the unimpregnated uterus. An explanation of these
causes, and, indeed, of uterine displacement in general, is only to be
found, I believe, in a complete study of the forms, relations, and
functions of the different parts and layers of the pelvic fascia. In
retroversion, those portions of this fascia which unite the back part
of the uterus to the rectum and pelvic cavity behind, partially yield
and give way. To restrengthen this support, and allow of its reno-
vation, retention of the uterus for a length of time in the position
and mode I have described often suffices. The simultaneous use of
local injections and baths aids further the same view. But I allude
here to the subject principally to observe that we may yet find
further means of strengthening the weakened tissues, by indurating
RETROVERSION OF THE UNIMPREGNATED UTERUS.
705
•
and contracting the upper and posterior portion of the vagina, as by
the use of caustics, thus taking advantage of that contracting and
strengthening power of the new tissue of cicatrices which burned
surfaces particularly have. I think I have seen the application of
nitric acid and potassa to the posterior lip of the uterus produce
replacement.
BIBLIOGRAPHICAL NOTE.
In the fifth century Etius treated definitely and at length of
retroversion of the unimpregnated uterus (Tetrabillos, sermo iv.
cap. 77); Moschion has left us some notices of it (Spachius' Gynæcia,
p. 24); and in his work on female diseases, Roderic a Castro has
some observations upon it (De Universâ Muliebrium Morborum
Medicina, p. 274). In modern medical literature, the first indi-
vidual case of retroversion of the unimpregnated uterus that was
put upon record was reported by Saxtorph, in 1775 (Collectanea
Hauvniensia, vol. ii. p. 129). In 1779, Willich described a second
case (Richter's Bibliothek, vol. v.) In 1786, in a woman who died
of pulmonary disease, Peter Frank found the uterus greatly retro-
verted, and published a notice and drawing of the displacement
(Opuscula Posthuma, p. 78). In 1787, Jahn noticed its occasional
occurrence in the unimpregnated uterus, but considered it “too
obscure and too unimportant to deserve the name of a disease,"
(Dissertatio de Utero Retroflexo, in Schlegel's Sylloge Operum Minorum
Præstantiorum ad Artem Obstetricam, etc., p. 612). A few years.
subsequently, Schneider (Richter's Bibliothek, vol. xi.) and Kirschner
(Stark's Archives, vol. iv.) published each a case of this affection.
In 1817, Schweighauser of Strasburg pointed out that retroversion
of the unimpregnated uterus was far from being rare, and he
asserted it to occur much more frequently than in the gravid uterus
(Aufsätze über einige physiologische und praktische Gegenstände der
Geburtshilfe). In 1820, Schmitt published at Vienna an essay taking
the same view (Uber die Zurückbeugung de Gebärmutter bei Nicht-
schwangeren, etc.) Subsequently individual cases of retroversion of
the unimpregnated uterus, or more general remarks regarding it,
have been published by D'Outrepont (Zeitschrift für Geburtskunde,
1827), Denman (Introduction to the Practice of Midwifery, p. 138),
Cooper (Anatomy and Surgical Treatment of Abdominal Hernia, part
ii. p. 59, 1827), Robertson (Edinburgh Medical and Surgical Journal,
1822, vol. xviii. p. 520), Velpeau (Traité de l'Art des Accouchemens,
vol. ii. p. 622), Bazin de Basseneville (Mémoire sur la Rétroversion de
706
DISEASES OF WOMEN.
l'Utérus, 1837), Moreau (Traité Pratique des Accouchemens, vol. i.
1838), etc. etc. I have referred in a preceding page to the first
observations which I published on the matter, in the Abstract of
the Proceedings of the Medico-Chirurgical Society of Edinburgh. I
shall extract these remarks from the Monthly Journal of Medical
Science, for July 1843, p. 660:—“ As one of the most important of
all these applications of the uterine bougie, Dr. Simpson demon-
strated that, by showing the direction of the uterine cavity, and
hence of the uterus itself, and by its enabling us, when it is intro-
duced, to change at will the position of the organ, it afforded a
simple means of detecting those displacements of the unimpregnated
uterus known by the names of retroversion and retroflexion, ante-
version and anteflexion-states that Dr. Simpson further showed
were very common, and which, from the want of proper means of
diagnosis, had been almost constantly mistaken for fibrous, carcino-
matous, and other tumours situated between the uterus and rectum,
or between the uterus and bladder. In cases of retroflexion and
anteflexion of the unimpregnated uterus, the organ can with facility
be temporarily restored to its normal position and relations, by
turning the uterine bougie, when used as a means of diagnosis. Dr.
Simpson proposed to maintain and fix the bougie in the uterine
cavity for a length of time as a means of cure. He laid before the
Society a number of utero-vaginal pessaries, which had been used
by him for this purpose. They were constructed of nickel and
silver wire, and had each attached to them a part which passed up
to the fundus uteri. Some of them had been worn for weeks and
months in the uterine cavity, and had produced little or no irrita-
tion." In 1846, Dr. Rigby published some excellent and accurate
observations on the disease (Medical Times, p. 292, etc.); and more
lately Dr. Protheroe Smith has written on the subject (Obstetric
Record, p. 35, etc.); see also Mr. Hensley (Provincial Medical and
Surgical Journal for January 1848); and Dr. Beatty (Dublin Journal
for November 1847); etc.
[Of late years Simpson did not often employ the above instru-
ments in the treatment of retroversion of the uterus.
In the great
majority of cases of retroversion requiring mechanical replacement,
he simply used vaginal pessaries made of gutta percha or of vul-
canite, and shaped like a horse-collar, or like some of Hodge's
patterns. The intra-uterine stem he continued to have recourse to
occasionally in retroversion, and in anteversion, when vaginal sup-
ports failed to give relief.—J. W. B.]
#
ASCENT OF THE UNIMPREGNATED UTERUS.
707
ASCENT OF THE UNIMPREGNATED UTERUS.
(ELEVATIO UTERI).'
2
No subject in uterine pathology is better known to the prac-
titioner than the displacement of the uterus downwards, or the
so-called Prolapsus Uteri. But the occurrence of the ascent, or
displacement of the uterus upwards, has been left comparatively
unnoticed. In my observations on paracentesis, I have alluded to
its elevation and position upwards in front of an enlarged ovarian
tumour, as occasionally rendering it liable to be injured by the trocar
of the surgeon. Voison has published a case in which the elevated
uterus was fatally wounded from this cause, in the operation of
tapping an ovarian dropsy. I have seen several instances of
multilocular dropsy of the ovary, in which the uterus was drawn up
and elevated more or less in front of the ovarian tumour, but only
very rarely so as to be beyond the reach of the finger. The same
upward displacement, or Elevatio Uteri, occasionally happens in
connection with the presence of fibrous uterine tumours.
In cases
of fibrous tumours, I have known this displacement so great that the
os and cervix uteri could not be readily or at all reached by a
vaginal examination with the first finger or fingers of the right hand,
till the mass of the tumour was pressed downward, and, at the same
time, somewhat rotated forwards upon its transverse axis by the
left hand placed externally upon the abdomen. Within the last two
weeks I have met with an instance of this elevation of the uterus
to a higher degree than I remember to have previously observed.
The displacement in this instance has occurred in connection with
the
presence of several large fibrous tumours in the uterine parietes.
CASE I. The patient, aged forty, had been married twenty years, had borne
one child about a year after marriage, but had never been again pregnant. The
abdominal cavity is now distended by a mass of dense, firm, fibrous uterine
tumours, which stretch upwards to nearly the scrobiculus cordis, and are alto-
gether as large as the uterus in the eighth month of pregnancy. The mass con-
sists of one great tumour stretching upwards above the umbilicus, and superadded
to this are several comparatively smaller masses above and laterally, forming
tuberose elevations and projections upon the sides of the larger central tumour.
One of these smaller tumours, situated towards the left side, of a flattish form,
and about two and a half inches broad, is pediculated and mobile, like a peritoneal
polypus. On examination per vaginam, a rounded elongated portion of the largest
tumour is felt pressing low down into the pelvis, and filling up the space in front
¹ See Edinburgh Monthly Journal of Medical Science, October 1852, p. 366.
2 Recueil Périodique de Médecine, vol. vii. p. 362.
46
708
DISEASES OF WOMEN.
of the rectum. The vagina, from the lowest point of the tumour upward, is
narrowed and flattened between the tumour and the pubes; but the finger, when
passed along this contracted canal, cannot reach the os or cervix uteri. In fact,
a sound passed into this canal runs a considerable distance upward from the vulva
before it touches the upper extremity of the vagina, and consequently before it
reaches the cervical portion of the elevated uterus; and the end of the sound
arrested at the junction of the vagina and uterus can be felt through the abdo-
minal parietes as high as two and a half inches above the upper edge of the sym-
physis pubis. The body of the uterus can be felt as a flattened projecting mass
above this part.
This patient, who has come for medical advice from Australia,
was there considered to be labouring under ovarian dropsy; and it
was supposed to be a case admitting of removal by operation. But
that it is a fibrous tumour, and not a multilocular cyst of the ovary,
is certain from its slow growth, from the density of the tissue of the
tumour, from the arrangement alluded to of superadded external
tumours, and from one of these superadded tumours having become
pediculated like an external polypus-a morbid arrangement which
we never see in ovarian disease. Besides, there is this common, and,
as I believe, pathognomonic sign present, that in various parts of the
larger tumour, and particularly on its right side, a loud souffle is
heard synchronous with the pulse, when the stethoscope is used
a phenomenon very common in fibrous tumours embedded in
the substance of the parietes of the uterus, but which I have
never met with in any instance of dropsical disease of the ovary.
The affirmative evidence of the enlargement being a fibrous uterine
tumour, which can be usually derived from the simultaneous move-
ment and union of the mass of the tumour with the body and
cervix uteri, under a combined abdominal and vaginal examination,
is here of course wanting; in consequence of it being impossible to
reach the elevated uterus. Nor, for the same reason, can we take
advantage of those other means of diagnosis between fibrous tumours
of the uterus and cystic degeneration of the ovary, which depend
upon the respective measurements of the length of the cavity of the
uterus in these two diseases, as ascertained by the employment of
the uterine sound.
At present I have under my care, from Berwickshire, a case of
very large fibrous tumour of the uterus, in which the os uteri is
elevated above the pubes; though not to the great height mentioned
in the preceding instance.
CASE II. The patient, æt 38, has been married seventeen years, but has had
no family. Menstruation has been regular; and only lately somewhat menor-
hagic. Her general health is good. About ten years ago she first noticed an
ASCENT OF THE UNIMPREGNATED UTERUS.
709
abdominal enlargement, which has gradually and slowly increased. The tumour is
now of as great size as the uterus at the ninth month of pregnancy. It touches
the lower edge of the ribs upon the right side. Its external form, however, is
somewhat irregular, particularly from a large projection upon it towards the right
iliac region. The tumour is not so firm in consistence as fibrous tumours gener-
ally are; and towards its centre, and near the umbilicus, it feels comparatively
so soft as to give a deceitful idea of fluctuation, like that sometimes imparted by
subcutaneous adipose tumours. Three months ago a trocar was passed in this
situation, without drawing off any fluid whatever. There is a deep musical
souffle, synchronous with the pulse, to be heard on the sides of the tumour, par-
ticularly on the left side. On making a vaginal examination, the os uteri cannot
be reached, but a decreasing, conical-shaped cavity may be felt, passing up in
front of the tumour, and somewhat towards the left side. When the patient is
placed upon her face, and the finger deeply passed along and behind the symphysis
pubis, the os uteri can with considerable difficulty be touched, lying above the
upper edge of the pubes. The uterine bougie, when introduced into the os,
passes readily for several inches, showing the uterus to be elongated and hyper-
trophied upon the side of the tumour. In this instance, there is no projection.
downwards of the tumour, as in the preceding case, into the pelvic excavation.
The pelvic cavity is, in fact, quite free, and the roof of the vagina is altogether
higher than usual.
It does not seem difficult to understand the mechanism by which
the uterus becomes morbidly elevated in such cases of ovarian and
uterine disease as I have alluded to in the preceding remarks. If
an ovarian or fibrous tumour, attached organically to the back wall
of the uterus, grow downward upon the roof of the vagina, or, in
other words, into the reflection of peritoneum between the rectum
and uterus, and develop itself steadily in this its lower segment, the
extension of the tumour in this downward direction, upon the resist-
ing roof of the vagina, forces the tumour to lift the uterus, which is
attached to the anterior surface or body of the tumour, higher and
higher with it during the longitudinal development of the mass to
which it is united. The tumour, in its downward longitudinal.
development, necessarily carries upward more and more the uterus
affixed to its anterior part; in the same way as the uterus, in its
own enlargement during pregnancy, carries and elevates upwards the
Fallopian tubes and ovaries attached to its two sides. Or the
enlarging uterine or ovarian tumour may, as in the second case
detailed above, obtain a similar elevating influence upon the uterus,
by resting its lower and growing segment upon the pubes or sides.
of the brim of the pelvis, instead of upon the roof of the vagina ;
thus ultimately displacing the uterus upwards by somewhat the
same kind of mechanism, as the os and cervix uteri are often, in
common pregnancy, raised upwards and backwards above their usual
level for some time after the uterus expands into the cavity of the
710
DISEASES OF WOMEN.
abdomen, and rests, during its enlargement, upon the anterior circle
of the pelvis.
Morbid ascent or elevation of the uterus sometimes occurs in
connection with other morbid states besides the two mentioned-
ovarian dropsy and fibrous uterine tumours. Occasionally, indeed,
the cervix uteri, and, consequently, the whole organ, is found placed
at an unusual height from the vaginal orifice as a natural conforma-
tion; and in advanced life, when the uterus becomes atrophied, it
sometimes is situated higher than natural, with the vagina drawn.
upwards in a funnel shape. I have seen it displaced upwards from
diseased action in connection with, and as a result of, pelvic cellulitis
or pelvic abscess; as well as from the effects of simple pelvic peri-
toneal inflammation and adhesions (Perimetritis).
TREATMENT OF CHRONIC INVERSION OF
THE UTERUS.¹
Sir J. Y. Simpson had seen several cases of inverted uterus,
days, weeks, and months after the accident had happened. He
had, in some of the instances, succeeded in re-inverting the in-
verted uterus, by steady pressure upwards upon the fundus of the
displaced organ, the patient at the same time being chloroformed.
He was certain that in some, if not in all cases where a chronically
inverted uterus was thus replaced, a fissuring or split occurred in
the cervix uteri, or at the point of inversion. In one instance he
felt the fissuring with the finger, and it seemed to extend through
all the coats of the organ; but in this, as in other instances, the
patient made an uninterrupted and perfect recovery. In one case,
which he saw with Dr. Keiller, where inversion occurred in con-
sequence of disease, and not of the puerperal state, both Dr. Keiller
and he failed in reducing the organ, and in that instance it had be-
come a question whether an incision of the cervix to imitate the
fissuring would not allow of the replacement of the displaced fundus
uteri. Possibly, in such chronic cases, it may yet also be found
that an instrument can be passed through the inverted fundus or
body of the uterus, so as to reach the site of the peritoneal contrac-
tion at the point of inversion, and mechanically and straightway
dilate it so as to admit of the return of the fundus of the organ.
¹ See Proceedings of Edinburgh Obstetrical Society, March 13, 1867, in Edin-
burgh Medical Journal, July 1867, p. 67.
INFLAMMATORY ERUPTIONS ON CERVIX UTERI.
711
Any dilator would need to be a metallic one, without any cutting
edge, and might be passed through an orifice in the fundus or walls.
made by a trocar or knife. Perhaps it would be found safer than
the removal of the inverted fundus by the ligature or knife, as if it
were a polypus, an operation which had been successful in the
hands of Dr. Johnson and others.
INFLAMMATORY ERUPTIONS UPON THE MUCOUS
MEMBRANE OF THE CERVIX UTERI.'
The common forms and effects of inflammation of the cervix
uteri-viz. ulceration, hypertrophy, and induration of the cervix—
were now well known to the profession. But the surface of the
cervix was liable to other types of inflammation of an eruptive
character, which apparently had hitherto been little, or not at all,
studied by obstetricians; and were not yet described in works upon
the pathology of uterine diseases. Among these special inflam-
mations of the cervix uteri and top of the vagina, Dr. Simpson had
observed eruptions referable to the vesicular, pustular, tubercular,
papular, and erythematic orders of the classification of Willan and
Bateman. Herpes (herpes uterinus) he had seen following the usual
course of herpes labialis in two or three instances, in patients who
had months previously been under treatment for common ulceration
of the cervix; and Dr. S. suggested that perhaps this and other
eruptions were occasionally the origin and basis of the common
variety of granular cervical ulcer. Acne, in the form of chronic hard
tubercles and pustules, was by no means uncommon, and often co-
existed with common ulceration. A papular form of eruption some-
times supervened in chronic cases of uterine disease, and was usually
diffused over both the cervix uteri and interior of the vagina; some-
times having the characters of Lichen; in other instances presenting
the appearances and severe itching symptoms of Prurigo. Eczema
and patches of Aphthee also occurred. The treatment required to be
varied according to the nature and character of the eruption, and
consisted of the application of nitrate of silver, of medicated washes
and medicated pessaries, etc. In severe and distressing cases of
prurigo of the cervix, vagina, and vulva, brushing the affected
surface often with hydrocyanic acid (the strength of that of the
¹ See Proceedings of Medico-Chirurgical Society of Edinburgh, March 6, 1850,
in Edinburgh Monthly Journal of Medical Science, April 1850, p. 386.
712
DISEASES OF WOMEN.
Edinburgh Pharmacopoeia), was mentioned as frequently giving the
greatest relief.
TREATMENT OF INFLAMMATORY INDURATION OF THE
CERVIX UTERI BY DEEP CAUTERISATION WITH
POTASSA FUSA.¹
Dr. Simpson stated that his own observations fully confirmed
the recorded opinions of Dr. Bennett and others regarding the
general dependence of leucorrhoea upon inflammatory ulceration and
induration of the cervix uteri. He had found inflammatory enlarge-
ment and induration of the tissues of the cervix very frequent in
practice, and existing, in fact, in most cases of very chronic and
aggravated leucorrhoea. In practice he had seen it mistaken for the
induration and ulceration of carcinoma, etc. Formerly, in the treat-
ment of these common cases, he had employed the frequent local
application of leeches, and counter-irritation to the sacrum,-etc., with
the use of pessaries of mercurial and iodine ointment, keeping the
indurated tissues imbedded in these applications, etc. The cure in
this way is tedious, and months are often required before the in-
durated parts become reduced. Various local escharotics, partly to
destroy the indurated tissues by direct decomposition, and partly to
soften down the remainder by new inflammatory action, had been
in modern times employed for the same purpose, and with much
more certain and expeditious effect. He had in this way employed
in a number of cases nitrate of silver often applied, Vienna paste
(potassa cum calce), and nitric acid. He stated the particulars of a
case which he had treated successfully four years ago with nitric
acid, and he had lately seen the patient in perfect health; it was at
the time supposed that she had cancer uteri. Latterly, he had
abandoned these and other escharotics, and now always used the
common potassa fusa. He had found it far more manageable, speedy,
and certain, than any other method. He used it of course through
the speculum, applying a stick of it freely with a proper caustic-
holder to the ulcerated and indurated tissues. It required to be
rubbed or held strongly for a time against the part which was to be
destroyed. In general a piece three-quarters of an inch, or an inch
long, was melted down. The decomposition produced by it often
-
1 See Proceedings of Edinburgh Obstetrical Society, April 13, 1847, in
Edinburgh Monthly Journal of Medical Science, July 1847, p. 71.
TREATMENT OF FIBROID TUMOURS OF UTERUS.
713
caused a hissing sound. If the induration is extensive, and the
whole cannot be removed at once, increased action and absorption
are set up in what remains, and the parts adjacent become softened
and diminished in size. Absorption in this way is truly one of the
results or consequences of inflammation, though still an undescribed
termination. In some aggravated cases two or more applications of
the caustic are required, at intervals of eight or ten days. He had
never seen pelvic cellulitis, or any other bad result, follow. The
appearance after the operation is as if a portion had been clean cut
out with the knife. A large quantity of vinegar and water is im-
mediately thrown up through the speculum to neutralise the potassa,
and prevent it from injuring the sound parts. A copious purulent
discharge usually follows for several days, requiring the use of
astringent washes, or zinc ointment pessaries. When the whole of
the induration is once removed, the remaining ulcer heals rapidly
and permanently. An ulcer over an indurated part may be cica-
trised, but it is almost certain to break out again and again till the
induration itself is reduced.
[Simpson used potassa fusa as a caustic far less frequently than
might be inferred from the foregoing article. Latterly, at least, he
reserved it for unusually obstinate and troublesome inflammatory in-
duration, and for nodular projections on the surface, of the cervix.
uteri.-J. W. B.]
ON THE MORE COMMON TERMINATIONS, AND ON THE
TREATMENT OF FIBROID TUMOURS OF THE UTERUS.¹
uterine tumour.
By far the most frequent form of organic disease met with in
the body and fundus of the uterus, is that species of growth which
usually passes under the name of the " fleshy," "fibrous," or "fibroid"
These tumours, which generally affect a roundish
form, and are almost always gregarious, vary greatly in size. They
are sometimes not larger than peas or hazel-nuts, and occasionally
they acquire, singly or gregariously, the size of a uterus at the sixth
month, or even at the full term of pregnancy. Their anatomical
relations and characters, their symptoms and general treatment, I
have dwelt upon at some length in another work."
¹ See Obstetric Memoirs and Contributions, vol. i. p. 114.
2 See Essays on the Diseases of the Uterus, in the Library of Medicine, vol. iv.
p. 332.
714
DISEASES OF WOMEN.
In former times, the common fibrous or fibroid tumours of the
uterus were generally considered as malignant in their type, and too
often confounded with cancer. Some obstetric writers of the
present day even look upon these fibrous uterine growths as having
a kind of scirrhous or carcinomatous nature. And no doubt the
texture of a chronic fibroid tumour may, like any other tissue,
natural or morbid, become occasionally, though rarely, the seat of
carcinomatous deposit. But primarily and essentially, they have
nothing carcinomatous in their character, nor any tendency to
undergo the changes to which carcinomatous structures are liable.'
On the contrary, the changes to which they are subject are patho-
logically very different, and vary in different instances.
1. Fibroid uterine tumours sometimes go on growing-usually
very slowly-sometimes intermittingly-and retain throughout life
their original fibrous character, increasing merely in volume, with-
out any specific change in their structure.
2. Often, after increasing for years, they entirely cease from
further growth, without any further marked change in their size or
structure. This termination appears to occur principally when the
tumours are imbedded in the uterine walls, or are intramural in their
seat, and when they are restrained in their development by the
strength and denseness of the tissues surrounding them.
3. When they cease growing, however, the fibroid structure of
the tumour is frequently found to become changed into cartilaginous
tissue, and subsequently to become more or less the seat of osseous
or calcareous degeneration; a transformation observed equally in
the smallest fibrous tumours as in those of a larger volume. This
calcareous degeneration in uterine fibroids seems to indicate the
death, and consequently the cessation of the reproductive action, of
those cells which form the essential growing constituent in these
tumours.2
1 I have now several times seen the uterine tissue with which a pediculated
fibrous tumour or polypus was long in contact, become in those predisposed to
cancer the seat of carcinomatous degeneration and ulceration, apparently from
the constant irritation of the tumour as a foreign body upon the contiguous
uterine tissue. Carcinoma of the cervix as well as of the cavity of the uterus is
sometimes induced indirectly in this way, without the fibroid tumour or polypus
itself degenerating into cancer.
2 I have elsewhere tried to show (see Proceedings of Obstetric Society, in Edin-
burgh Monthly Journal for August 1847, p. 140), that we have a similar change
and deposit in the case of some human entozoa-for example, the trichina and
TREATMENT OF FIBROID TUMOURS OF UTERUS.
715
4. In a few cases observed by Clarke and other pathologists,
fibroid tumours of the uterus have appeared to undergo another and
most important change, viz. they have gradually atrophied and
become diminished both in volume and density.
If we looked upon fibrous uterine tumours as purely heterolo-
gous structures, it would be difficult indeed to believe in the possi-
bility of their atrophy and involution—either spontaneously or
under any form of treatment. But the more I have examined
these structures of late years, the more have I become convinced
that they are essentially and primarily homologous structures only,
and that they essentially consist, in fact, of local masses, nodose col-
lections, or hypertrophies, if I may so speak, of the normal fleshy or
fibrous tissue of the uterus. Most physicians further are, we believe,
ready to acknowledge that mere hypertrophies of the natural struc-
tures of organs sometimes diminish and are amenable to treatment ;
and we all know that the uterus, immediately after delivery, is in a
state of great physiological hypertrophy, from which it is rapidly
reduced by a normal process of involution or atrophy. During the
process of puerperal involution the uterine structures undergo a fatty
form of degeneration. Occasionally on dissection we have observed
uterine fibroid tumours presenting what we conceived to be an
analogous white fatty-like transformation. And during the last
few years I have watched upon the living subject the progress of a
number of cases of uterine fibroids that have appeared to me gradu-
ally to involve and atrophy to a greater or less extent under
treatment.
In Germany, the waters of Kreuznach have obtained some repute
for their supposed efficiency in the reduction of tumours, and espe-
cially of fibroid tumours, in the walls of the uterus.
I have seen a
considerable number of such cases after they had been subjected to
full courses of this water drank internally, and applied locally. In
most of them, this treatment had most completely failed; but one
or two have appeared to benefit by it. I have seen a far larger pro-
portion of cases do well under a long-continued course of bromide
of potassium given in doses of from three to five grains taken thrice
cysticercus-the cyst belonging to and enclosing these entozoa ossifying or becom-
ing calcareous after their death. At the same time I mentioned the interesting
experiments of Rayer, in which that pathologist induced the artificial transforma-
tion of normal fibrous tissue, such as the ear of the rabbit, into cartilaginous and
osseous substance, by the repeated or continued irritation of it. And as a result
of these remarks, the possible artificial induction of osseous transformation, as an
indication of treatment in fibrous uterine tumours, was suggested.
716
DISEASES OF WOMEN.
etc.
a-day; and sometimes combined with its local application, leeching,
The Kreuznach waters contain bromine; but only in very
small quantity. If the bromine is, as it is supposed to be, the chief
deobstruent in these waters, the methodic exhibition of this in-
gredient artificially in more powerful and continuous doses ought to
be followed, as I believe it is, by more beneficial and decisive effects
than the waters themselves. It stands thus in the same relation to
the Kreuznach waters, as quinine does to cinchona. One of the first
patients who used the bromine alone, with this view, I saw along
with my friend Dr. Wyse. The lady had been at Kreuznach, and
taken full courses of the waters there without any benefit whatever.
The uterine fibrous tumour was of large size, and incommoded her
much from its weight and pressure. Under a course of bromide of
potassium and local leeching, continued in perseveringly for many
long months, the tumour involved and decreased in a most marked
manner; and her health and power of walking and exertion became
quite restored. I have found the same remedy succeed in several
similar cases, in arresting, and more or less reducing, uterine fibroids,
and again, in others I have seen it fail. But to most persons the
bromide of potassium can be given for a great length of time without
any interference with the general health. In fact, it usually serves
apparently as a tonic as well as a deobstruent, in this respect having
a marked advantage over iodide of potassium.
5. When fibroid tumours are situated more immediately under
the serous or mucous coats of the uterus, they usually become
gradually more or less pediculated, forming fibroid polypi. Some-
times the pedicle becomes more and more attenuated, and at last
gives way, allowing the tumour, when subperitoneal, to fall into the
cavity of the abdomen (of which I have seen several instances); or,
when it is submucous, the tumour or polypus drops into the cavity
of the uterus and vagina, and thence escapes. The accoucheur
imitates this latter process in the surgical removal of uterine polypi.
6. When the tumour is non-pediculated and intra-mural, another
termination is occasionally observed. The tumour sometimes in-
flames, and sloughs, and the intervening uterine tissues ulcerating, it
is ultimately eliminated from the genital canals in smaller or larger
masses. I have seen several instances in which nature thus reduced,
and threw off successfully by ulceration and gangrene, large portions
and masses of intramural fibroid tumours. Attempts have been
ENUCLEATION OF LARGE FIBROID TUMOUR OF UTERUS. 717
made by Amussat, Maisonneuve, Atlee, and others, to imitate by the
knife this process of spontaneous or natural elimination; but we
believe it to be, from the cases which we have seen, an operation
that, as at present practised, will very rarely indeed succeed, and
which ought to be very rarely, if ever, undertaken.
ARTIFICIAL REMOVAL OF A LARGE FIBROUS TUMOUR
IMBEDDED IN THE POSTERIOR WALL OF
THE UTERUS.¹
Dr. Simpson explained to the Society the mode in which he had
lately removed a large fibrous tumour from the posterior wall of the
uterus. The patient was forty-six years of age; she had borne ten
children, the youngest being six years old, naturally strong and
healthy. During the last two years she had been subject to severe
floodings, which recurred every fortnight, and had reduced her exces-
sively. Her general health had become quite broken up, and for
several months she had suffered much from sore throat, and general
irritation of the mucous membranes. He found, on examination, a
large fibrous tumour imbedded in the back wall of the uterus, and
protruding downwards upon the top of the vagina in a rounded
form, the os uteri and uterine cavity lying in front of it-as ascer-
tained by the uterine sound.
Accompanied by Drs. Malcolm, Ziegler, Weir, and Keith, he
made an opening, by means of caustic potass, into the most pro-
minent part of the tumour, about one inch behind the os uteri. It
extended through the layer of uterine substance, and into the mass
of the tumour itself. On inserting the finger into the hole thus
made, it was found that it could be passed easily between the sub-
stance of the tumour and the uterine wall. The tumour, in fact,
seemed to be very loosely connected with its uterine envelope, and
could be separated from it with great ease as far as the finger could
pass between them. Two days after the caustic was used, he found
the artificial opening enlarging like the os uteri in labour, and the
tumour beginning to protrude through it. It opened up gradually,
the patient taking some ergot, and on the fifth day a large piece of
the tumour was found pushed low down into the vagina, while the
edge of the uterine wall could barely be felt, encircling it like the
1 See Proceedings of Edinburgh Obstetric Society, December 22, 1847, in
Edinburgh Monthly Journal of Medical Science, March 1848, p. 695.
718
DISEASES OF WOMEN.
rim of the os uteri when fully dilated. The abdominal tumour had
subsided considerably. On the eighth day he attempted to pass a
ligature round the mass, but found it could not possibly be made to
include more than a very small portion. He separated, however, and
brought away a small fragment, not without giving a good deal of pain.
The tumour now gradually and more completely filled the vagina.
The uterus, however, seemed unable to throw it off entirely, and the
patient was getting exhausted from the quantity of the discharge,
which was very fetid and offensive. On the twelfth day, Dr. Simpson,
while she was completely under the influence of chloroform, passed up
his hand by the side of the tumour, completed the separation of the
remaining adhesion, like an adherent placenta, and brought away
the tumour in one mass. This was done in a very few minutes.
The patient awoke quietly, and said she had felt no pain whatever ;
nor did she complain at all of pain in the region of the uterus subse-
quently. She proceeded very well for three days, her pulse not above
eighty; when, in consequence of her nurse having taken unwarrant-
able liberties with her in making her get out of bed, washing, etc.,
she was seized with rigors, followed by severe sore throat and
irritative fever. This completely exhausted her remaining strength,
and she died six days after the tumour was removed.
The body
was examined by Drs. Bennett, Scott, Simpson, and Keith. The
peritoneal surface of the uterus was perfectly healthy, and showed no
trace whatever of inflammatory action. The cavity in the back
wall, in which the tumour had been imbedded, was much reduced
in size, and appeared to be tending to a healthy cicatrisation.
The tumour weighed three pounds eight ounces when removed.
It must have previously been somewhat heavier, as the great dis-
charge for several days was no doubt from partial softening and
decomposition of the tumour. Various French surgeons had cut
down upon such tumours, and enucleated them by instruments, or
by the hand. In the above case, Dr. S. had merely formed an
artificial opening into the uterine cyst, as it were, containing the
tumour, and then allowed the uterine walls, which are hypertro-
phied around such masses, exactly like the uterus in pregnancy, to
push down and expel the foreign body. It was, he believed, the
first time this new operation had been performed, and the largest
fibrous tumour ever yet enucleated. The tumour, on division, was
shown to be the common fibrous tumour of the uterus.
TREATMENT OF FIBROID TUMOURS OF THE UTERUS. 719
TREATMENT OF FIBROID TUMOURS OF THE UTERUS.¹
Professor Simpson exhibited a uterus containing a large number
of fibroid tumours of various sizes, in different situations, and in
various stages of degeneration and development. Some were as
small as peas, one was as large as the foetal head, and there were
others of every intervening size. Some lay immediately beneath the
peritoneum, others were imbedded in the uterine walls, whilst a
third set projected into the cavity of the uterus, invested with a
more or less complete covering of mucous membrane. The largest
of the tumours projected forward in this manner the mucous mem-
brane, and its surface was considerably ulcerated. On being cut
into, it was found to be very much softened and friable, and of a
pinkish hue, from an increase in its vascularity. It had evidently
been the seat of an inflammatory attack, which had led to this
alteration in its texture, and which, had the patient survived, would
probably have ended in the destruction and separation of the morbid
inass. Most of the other nodules and nodular masses presented the
ordinary characters of fibroid tumours still vital and progressive ;
but one of them, a sub-peritoneal one of medium size, was firm and
gristly, and at one part of its circumference contained a thin calcareous
or osseous layer. The patient had been the subject of many attacks of
excessive menorrhagia, which he (Professor Simpson) had repeatedly
checked by applying perchloride of iron to the mucous lining of the
organ. Under the use of bromide of potass, etc., the patient seemed
to improve in health, and thought, as he himself believed, that the
mass had shrunk somewhat. She had returned to him, however,
some months ago, suffering from pain and a recurrence of the
menorrhagia. Inflammation set in in the peritoneum, probably
spreading from the already inflamed tumour, and the patient sank.
He (Professor Simpson) had had in his ward last session a
patient with an enormous fibroid tumour, which he had attempted to
remove partially by means of the écraseur. The chain had given
way, but the strangulated part sloughed; the mass contracted con-
siderably; and the patient—who had been reduced to the last stage
of weakness before, so that for a time her life was almost despaired
of-was now going about in the enjoyment of tolerably good health.
Where such tumours were not so large he had sometimes removed
it by enucleation, but the operation was usually accompanied with
¹ See Proceedings of Edinburgh Obstetrical Society, November 26, 1862, in
Edinburgh Medical Journal, February 1863, p. 766.
1
720
DISEASES OF WOMEN.
much danger, and was never perhaps justified, except when the
hemorrhage was so great as to threaten life. Lately he saw a lady
from Ireland, who for some years suffered from excessive menor-
rhagia, and from whom he removed a fibroid tumour of the size of a
swan's egg, which was projecting in the form of a sessile polypus
from the inner surface of the uterus. The patient was in a low
and critical state for a few days after the operation, but she was
now the picture of health.
ON THE DIAGNOSIS OF POLYPI GROWING FROM THE
LIPS OF THE CERVIX UTERI.¹
1
In polypi arising from any part of the interior of the uterus, and
projecting into the vaginal cavity, the stalk of the tumour is always.
found more or less encircled by the lips of the dilated os and cervix
of the organ. The tracing, with the finger, of this circle of the
cervix, round the pedicle of the polypus, forms always an important
diagnostic mark in such forms of the disease. Thus Dupuytren
remarks, "The essence of diagnosis is always the exploration of the
neck-of its central orifice, and of the circular cul-de-sac which
separates it from the vagina."
When, however, a polypus arises from the edge of the os uteri
or vaginal surface of the cervix, the above important diagnostic
mark is wanting; and the case in consequence becomes one, the
nature of which is often much more difficult to determine. Speak-
ing of this form of the disease, Dr. Gooch states strongly the
difficulty of diagnosis in such cases. "I have seen," he observes in
regard to them, "the most experienced practitioners in London
puzzled to tell what was the nature of the tumour in the vagina,
and what ought to be done for it ;" and Lefaucheux describes the
appearances on dissection of a case of this form of polypus, which
during life could not be discriminated from complete inversion of
the uterus.
The difficulty of diagnosis of polypi of this kind, arising from the
edge of the os uteri, or from the vaginal surface of the cervix, does
not depend merely upon our not finding the pedicle of the tumour
encircled, as usual in other, forms of uterine polypi, by the dilated
orifice of the uterus, but also from this still more fallacious circum-
stance, that the os uteri, though traceable in the stalk of the tumour,
1 Part of a Clinical Lecture. See London and Edinburgh Monthly Journal of
Medical Science, April 1845, p. 319.
DIAGNOSIS OF POLYPI GROWING FROM CERVIX UTERI.
721
is generally so displaced in situation, and altered in form, as to
render its identity doubtful. "In these cases," remarks Lefaucheux,
"the orifice of the uterus has always lost its natural form. It is
found situated obliquely, and the lip of the cervix which is not the
seat of the pedicle is the most elevated, the pedicle elongating, on
the other hand, that lip to which it is attached. When the pedicle,"
he adds, "has taken its rise in the cellular tissue of the greater part
of the circumference of the orifice of the uterus, it is sometimes
very difficult to distinguish between such a polypus and inversion of
the organ, for the remainder of the orifice forms only a kind of
fissure, which is detected with difficulty, and through which it is
impossible to introduce the finger." The difficulties attending the
diagnosis of the form of polypus to which these remarks refer,
would in most, if not in all cases, be perfectly removed, if we could
assure ourselves that the body of the uterus itself was of the natural
size, and in its natural position, and that the opening or imperfect
cleft that may be traceable on the inside of the tumour was in
reality the os uteri. If these points could be fixed with certainty,
the attachment and nature of the tumour would become at once
evident the question of the propriety of its removal would be
resolved—and the exact point of its removal more safely and cer-
tainly determined, than it otherwise could be; in those cases where
the stalk grows from the cervix, the rule being, as laid down by
Gooch, that the knife or ligature ought to be applied a little below
the orifice, if it can be distinguished. These important points in
diagnosis and practice we would, in future cases, propose to fix by
introducing the sound into the uterine cavity, so as to determine the
real situation of the os, and the position and state of the uterus
itself, as ascertained by the direction and length of its cavity. The
introduction of the instrument in particular cases of this compli-
cation will require unusual care and patience, in order to pass it
through the displaced and altered uterine orifice, and a sound of 2
smaller size than usual may in some instances be necessary.
the clear information afforded by the examination in a set of cases
that are so often doubtful and perplexing in their character, will
amply repay the mastering of any such difficulties as I have presup-
posed in the employment of the means.
But
722
DISEASES OF WOMEN.
OF THE EXCISION OF LARGE PEDUNCULATED
UTERINE POLYPI,
AND ITS ADVANTAGES OVER DELIGATION.¹
A variety of operative means have been proposed and practised
for the removal of uterine polypi, after they have once passed the
os uteri and come within the reach of surgical interference. The
means usually followed differ according to the size and consistence
of the polypus.
In the removal of small and soft uterine polypi of the mucous
or cellular type, practitioners employ-1, Simple avulsion with
proper forceps, or with the fingers; or 2, Avulsion by torsion;
or 3, Compression or crushing of the neck or body of the polypoid
growth; or 4, Scooping out its attachment with the nail, if the
cervix is opened, or with the scraping or gouging instruments in-
vented by Recamier and Dr. Locock; and 5, The introduction
and application of a stick of potassa fusa inside the os, followed by
the free application of vinegar, is sometimes most advantageously
had recourse to, where, as is often seen in practice, several small
sessile or pediculated polypi-formed by dilatation of the Nabo-
thian follicles—are attached to the lips of the os and along the
interior of the cavity of the cervix uteri.
In the present communication, however, I wish only to speak of
the larger and firmer forms of pediculated uterine polypi. These
are usually fibroid or cellulo-fibroid in their structure, and vary
from the size of a small walnut to that of a new-born child's head.
In the removal of them one or other of the following operations is
generally had recourse to-viz. either,
I. The slow and gradual division of the pedicle of the polypus
by Deligation, or by the constriction of ligatures of silk, cat-
gut, silver-wire, etc., applied by means of various forms of
canulæ ; or,
II. The instantaneous division of the pedicle by Excision with
the scissors, scalpel, or bistoury, and the consequent imme-
diate removal of the amputated polypus.
Some practitioners combine together these two methods-
1 See Edinburgh Monthly Journal of Medicine, January 1855, p. 10.
EXCISION OF LARGE UTERINE POLYPI.
723
applying deligation first, and then-either immediately or some
days subsequently-using excision or resection in addition.
In this country the operation by deligation alone has been
the plan usually adopted. In England," as Dr. Ashwell states,
"the ligature has always had a decided preference."1 "British prac-
titioners have," says Dr. Hamilton, "universally agreed that the safe
mode of operating is by ligature. "I shall," observes Dr. Rams
botham," consider this as a point settled, at least in our island.'
12
113
The removal, however, of large uterine polypi by excision, has
long appeared to me to be in many respects a simpler and a safer
operation than their removal by ligature. It is, on the whole, more
easily accomplished; the cure of the disease by it is infinitely
quicker; it is accomplished with far less restraint and annoyance to
the patient; with less risk of local irritation; and, as I believe,
with less ultimate chance of actual peril to health and life.
Two objections have usually been urged by accoucheurs against
the removal of large uterine polypi by excision. The first of these
objections, viz. the danger of hemorrhage, has been particularly
insisted on by those practitioners who have written in favour of
deligation. But the fact is, that excessive hemorrhage is not
common after division of the peduncle of the polypus; and
however great that or any other traumatic hemorrhage from the
unimpregnated uterus may be, it can always be arrested by properly
filling the vagina for a few hours with pieces of sponge or other
appropriate plug. Dupuytren, though using no plug or other
means to prevent bleeding, only met with two cases of severe
hemorrhage out of some two hundred instances in which he
removed uterine polypi by excision; and Lisfranc only observed
it twice out of one hundred and sixty-five similar operations
practised by himself. I believe, however, from what I have myself
seen, that the practitioner, in employing excision, must expect
considerable hemorrhage in a proportion of cases much greater
than this; but at the same time he can, I repeat, always readily
arrest it, when it does occur, with proper plugging; and it is
perhaps best as a general rule-to prevent and forestall its
occurrence by introducing, for ten or twelve hours after every case
of resection, a proper tampon of fine sponge into the vagina. Let
me add, that it is well to have each piece of sponge which is used
1 Diseases Peculiar to IVomen, p. 485.
4
3
2 Practical Observations on Midwifery, p. 40. Medical Gazette for 1835, p. 433.
4 Lisfranc's Clinique Chirurgicale, vol. iii. p. 210.
47
724
DISEASES OF WOMEN.
previously transfixed by a strong thread, the end of which should be
left out of the vagina, in order to permit of the more easy with-
drawal of the plug.
The second objection usually urged against excision is of greater
weight, viz. that more or less injury is always liable to occur to the
pelvic attachments of the uterus, if it and the polypus are forcibly
dragged down by Museux's forceps, or by hooked vulsella, so as to
bring the peduncle of the tumour into view before dividing it,¹ a
plan followed by most operators; or, on the other hand, if the
peduncle is divided, while the polypus and uterus are in situ, the
scissors or knife employed are, it is averred, apt to injure and cut
the vaginal walls and neighbouring tissues, while worked within the
vaginal cavity."
2
Of late years I have used a means of excising large uterine
polypi, that seems to me to obviate entirely this last class of
objections, and by which, as I have been led to believe, the whole
operation is much simplified, and rendered both greatly more easy
to the practitioner, and more safe to the patient. By the means or
instrument in question, the peduncle of the polypus is divided in
situ, and without any chance of its cutting portion injuring the
structures of the vagina or vulva.
The instrument, or polypus-knife, to which I refer, is sketched
in Fig. 28. It is of the form of the usual midwifery hook; with
the concavity, however, of the hook not blunt, but turned into a
cutting surface by the insertion of a small piece of well-tempered
steel blade into it. A transverse section of the curved or cutting
portion of the instrument, and of its included knife-blade, is also
shown in the woodcut. The entire length of the instrument which
I have hitherto employed in my own practice is ten inches-the
length of the wooden handle being four inches, and that of the
metallic shaft six inches. A shorter instrument might, perhaps,
suffice equally well. The cut represents the curved portion, or
hook at the extremity, as somewhat wider and larger than in the
¹ Dr. Heming's Translation of Mad. Boivin's Treatise on Discases of the Uterus,
pp. 210, 211.
2 When the texture of the polypus is too soft to allow, without tearing, of the
mass being drawn downwards by vulsella, Lisfranc even advises the hooks of the
forceps to be fixed in the cervix uteri itself, to get a sufficient hold for dragging
down it, and the polypus with it, to the vulva.-Gazette Médicale, 1834, p. 149.
3 Quia secantia instrumenta ægre in vaginam immitti possunt, ne partes
vicinas lædent, et facile lethales hæmorrhagias gignant.-Nissen De Polypis Uteri,
1789, p. 34.
EXCISION OF LARGE UTERINE POLYPI.
725
polyptome made for me in the first instance, and which I have
generally employed in practice. Perhaps an increased or a
diminished size and width, in the curved hook at the
extremity of the instrument, would render the opera-
tion of division by it more easy, according as the stalk
of the polypus is very thick, or comparatively slender.
The extreme point of the instrument is blunt and
rounded; and the cutting portion or blade is so pro-
tected and concealed by it, and by the back wall of the
curve, that it can be introduced into and withdrawn
from the vagina, without any chance of its edge injuring
or dividing the vaginal structures themselves. To be
always able to discover the direction to which its hooked
extremity points after it is introduced into the vagina,
the front aspect of the handle is distinguished by having
a slight knob or other mark upon it.'
In employing this polyptome, the stalk of the poly-
puts is first to be reached by the apex of the first finger
of the right hand, introduced along the short anterior
or pubic surface of the vagina; the instrument is then
pushed by the left hand along this finger as a guide,
and passed over or above the peduncle of the tumour,
in such a direction that the concavity of the hook will
come down upon and embrace this peduncle, as the
instrument is pulled again downwards. The next
Fig. 28.
step is to make the blade of the polypus-knife cut through the
stalk of the tumour. For this purpose, a little simple traction,
with a slight rolling or sawing motion, is all that is generally
required. If the tissue of the peduncle is dense and strong, the
dividing force of the instrument may be increased by the fore-
finger of one hand being applied with a tractive power to the blunt
extremity of the instrument, while the handle is dragged down and
moved in a sawing direction, by the other hand of the operator.
Sometimes, when the polypus is round and loose, after the curve or
hook is applied to its pedicle, the cutting portion of the polyptome
will divide this stalk most readily, by merely doubling backwards
with the fingers the body of the polypus upon its own stalk, and
pulling the knife against the bent peduncle. In such a case, the
1 The use of the polyptome was first proposed to the Obstetrical Society of
Edinburgh at its meeting of June 25, 1851. See Edinburgh Monthiy Journal of
Medical Science, Nov. 1851, p. 492.

726
DISEASES OF WOMEN.
peduncle is divided as much by pressing it against the knife, as by
pulling the knife through the peduncle.
During the last few years, I have removed a very considerable
number of uterine polypi of different sizes, and some of them of large
dimensions, with this curved polyptome; and I can now speak from
somewhat extensive experience of the perfect facility and safety of
its employment.
Sometimes soft and slender cellular and canaliculated polypi,
usually of an elongated form, are met with in practice, which afford
no sufficient resistance for a knife to divide them or their peduncles.
In such cases, the peduncle of the polypus is, perhaps, most easily
severed, by the careful clip of a pair of blunt-pointed, curved
scissors. In all other forms of the disease, where the tumour was
large and pedunculated, I have of late employed the polyptome. In
using it, the patient is placed in bed, in the common position on the
left side; and generally the whole operation is accomplished so
readily and easily, that she is often not aware that more than a
common digital examination has been made. I have several times
seen more difficulty attend the removal of the amputated polypus
itself from the vagina, after its stalk was divided, in consequence
of the great size of the tumour; and in order to effect extraction, I
have occasionally been obliged to transfix it with the teeth of a
large vulsellum. But hitherto I have met with no special difficulty
in at once and easily dividing the peduncles themselves of the
polypi with this polypus-knife.
The whole operation is simple and safe, expeditious and pain-
less, and approaches, perhaps, more than any other in practice, to
the Asclepiadean character of the object of the physician: "ut tuto, ut
celeriter, ut jucunde curet."
In conclusion, let us compare and contrast, in a few points, the
operation of the excision of a common or large-sized uterine polypus,
by the method I have described, and its removal by the ordinary
operation of deligation.
I. Relative difficulty of the Excision and Deligation of
Uterine Polypi.
No practitioner can ever be perfectly certain that any large
growth detected in the vagina is a uterine polypus, until his
finger touches and traces the peduncle itself of the tumour. And
wherever the finger can thus be made to pass and detect the
EXCISION OF LARGE UTERINE POLYPI.
727
stalk of the polypus, the polyptome may certainly be guided to,
and applied so as to divide that stalk. I refer here to cases of
considerable difficulty, from the unusual shape or size of the
polypus. In such instances, one cannot but conceive it easier
a
b
Fig. 29.
to pass upwards a solid curved instrument directly around the mere
stalk of the tumour, than to pass a piece of whip-cord or other
ligature behind and over the whole body and mass of the polypus
itself, till, in being retracted, it comes indirectly and ultimately to
embrace the stalk. For example; in Fig. 29, there is a sketch of a
large uterine polypus, which I some time ago amputated with the
polyptome. The figure represents the polypus diminished two-
thirds—a marking the upper, and b the inferior extremity of the
polypus, while e denotes the site and thickness of the peduncle of
the tumour, as divided by the polyptome. In this instance the
polypus is of an elongated form, its peduncle being attached to its
middle, and not to its upper extremity. The tumour had evidently
grown into this form after being expelled from the uterus into the
vagina. It had developed upwards towards the roof of the vagina,
as much or more than downwards. In this case, the peduncle of
the tumour was readily caught and divided by the polyptome; but
it would evidently have been a matter of great difficulty to have
C
1

728
DISEASES OF WOMEN.
passed a ligature over the back and top of such a polypus, so as to
embrace with it the peduncle from above.
When, however, a polypus is smaller, round, or oblong, and its
peduncle is attached to its upper part, there is not more difficulty
in applying the ligature, than in applying the knife to the stalk of
it. Some, however, of the practitioners who have had most expe-
rience with the ligature, confess to the occasional difficulty of its
application with even the best kind of canula. "By practice and
dexterity," says Dr. Burns, "this instrument (the double fixed
canula) may doubtless be adequate to the object in view, but with-
out these requisites the operator will be foiled-the ligature twisting,
or going past the tumour; every attempt giving much uneasiness to
the patient; and not unfrequently, after many trials and much
irritation, the patient is left exhausted with fatigue, vexation, and
loss of blood." This is very likely to happen if the polypus be so
large as to fill the vagina. "Dr. Hunter," adds Dr. Burns, " after
repeated trials, failed in a case where the polypus filled the vagina :
the pedicle in the preparation is long, and as thick as the finger.
The application of a ligature to a large uterine polypus is, "in
many cases," Dr. Hamilton" testifies, one of the most difficult and
dangerous operations in surgery;" and he tells us that "he has seen
some of the most eminent practical surgeons of this part of the king-
dom foiled in their endeavours to apply the ligature."
"1
I quote, in preference, such opinions from the writings of Pro-
fessors Burns and Hamilton, because both of these gentlemen were
strongly in favour of the operation of deligation.
II.-Relative Duration of the Operation of Deligation and Excision.
The process of excision is generally accomplished in the course
of two or three minutes at most, sometimes in a shorter period. On
the contrary, the deligation of a uterine polypus consists of a succes-
sion of operations rather than of one; and is usually protracted
through a period varying from two or three days to two or three
weeks. The application itself of the ligature and canula, in the first
instance, requires as much, or indeed more time and pains than the
act of excision. But, after its first application, the ligature requires
to be tightened and adjusted from time to time.
"Twice a-day,"
as Dr. Gooch directs, "the ligature is to be untwisted from the
1 Burns' Principles of Midwifery, p. 130.
2 Hamilton's Practical Observations, p. 40.
EXCISION OF LARGE UTERINE POLYPI.
729
(6
""
shoulder of the canula, drawn tighter, and then fixed again round
the projecting part; and this is to be done morning and night.
Every day," observes Sir Charles Clarke, another advocate, like Dr.
Gooch, for this mode of treatment-" every day the practitioner is
to examine the state of the ligature, and as often as it is found to
be at all slack, it is to be tightened. The mode of tightening it,"
he continues," requires particular attention. If the canula should
happen to be long, the practitioner should not hold the end of it
whilst he tightens the ligature, lest with the force used the ligature
should cut through the neck of the tumour, and the other extremity
of the canula should be suddenly and forcibly pushed against the
internal parts of the woman. The time," he adds, "at which the
ligature will come away will depend upon the thickness and firm-
ness of the neck of the tumour, and the tightness with which the
ligature is at first applied. The neck of the tumour sometimes is
cut through in four days, sometimes ten or twelve days will elapse
between the application of the ligature and the removal of the
tumour, and occasionally the separation of the tumour will take up
three weeks; but this is an uncommon occurrence.”
"After an
interval," observes Dr. Churchill, "varying from six days to three
weeks, the canula will be found loose in the vagina, and the stalk of
the polypus severed." 2
III.-Relative Care and Management after the two Operations.
After the operation of excision, the only special treatment in
general required is the introduction of a sufficient plug, of sponge or
other soft material, into the vagina, to prevent the chance of bleed-
ing; and the withdrawal of this plug after ten or twenty hours.
After, however, the application of the ligature in deligation of a
uterine polypus, a considerable amount of continuous care and
caution is necessary up to the time at which the pedicle is ultimately
divided. "The patient is," says Sir Charles Clarke, "to be desired
to remain constantly upon her side, and should not be allowed
to move from one side to another unless when the practitioner is
present." For want of attention to this caution, there is," he adds,
"reason to believe that the canula has been inadvertently pressed
against, and its extremity pushed through the uterus of the patient,
so as to occasion her death. "The woman,” as Dr. Ramsbotham
3
1 Observations on the Discases of Females, p. 263.
2 On the Diseases of Females, p. 220.
3 Observations, etc., p. 262.
730
DISEASES OF WOMEN.
"" 1
states, "will be obliged to keep her bed during the sloughing pro-
cess; and she ought to be cautioned, upon attending to her natural
calls, to beware of any accidental occurrence which might push the
point of the instruments against the internal surface of the uterus.
"As the instrument," Dr. Gooch remarks, "projects out of the
vagina, if the patient was, whilst turning from side to side, to sit
down upon it, she might impale herself on it-an accident which I
have heard once took place, and terminated fatally."
1) 2
IV. Relative chance of Local Irritation of the Vagina and Uterus.
Local lesion and irritation of the vagina and cervix uteri are not
liable to follow upon the practice of excision, unless some local injury
has resulted in the operation from very incautious manipulation.
But in addition to this danger, there are after deligation other sources
of local disease in the sloughing and putrefaction of the polypus
before its complete separation; in the presence of the very fetid and
excoriating fluid with which the surface of the vagina and vulva is
in consequence constantly bathed; and in the irritation by the
ligature itself, as a foreign body, upon the constricted and ulcerating.
stalk of the tumour-not to speak of the constant application to
this ulcerated surface of the foul and acrid discharges that issue from
the dead and decomposing polypoid structure. The polypus usually
swells after the first application of the ligature. "On account,"
observes Chelius, " of the increasing bulk of the polyp, it is gener-
ally necessary, for the first few days after deligation, to empty the
bladder with the catheter, and the rectum by clysters. The symp-
toms," he further states, "which may occur after the tie has been
made, are, violent inflammation and fever, pain, spasms, bleeding,
and other symptoms, from the pressure of the swelling polyp. To
prevent," he adds, "the effect of the stinking ichor, repeated injec-
tions of decoctions of aromatic herbs must be employed." After
the ligature is applied, "When putrefaction has commenced, the
discharge from the vagina," to quote the words of Dr. Ramsbotham,
"becomes fetid and highly offensive.
It is, indeed, the best
sign we can observe, as it proves that decay is going on, that the
stem is sufficiently compressed to strangulate the vessels which
nourished the diseased growth. If ever," he adds, " such a discharge
1 Dr. John Ramsbotham's Practical Observations, vol. ii. p. 468.
2 On some of the most important Discases peculiar to Woman, p. 264.
3 System of Surgery, South's Edition, vol. ii. p. 752.
EXCISION OF LARGE UTERINE POLYPI.
731
did not take place in a day or two, I should be suspicious that the
operation would not succeed."
V.-Relative danger of the two Operations to the Health and Life of the
Patient.
Those authors who have written in favour of deligation usually
quote one solitary case of death from hemorrhage after excision,
recorded by Zacutus Luzitanus, in the seventeenth century. It was
an instance of the fact that the amount of attendant hemorrhage is
not regulated by the mere size of the polypus; for in the case in
question it is stated that the amputated polypus was not larger
than an almond." In this instance the operation was performed by
an empiric, and no plug or other means for arresting the hemorrhage
appear to have been employed. The patient died, not so much
from the operation, as from neglect of all proper means to restrain
the hemorrhage resulting from it. At the same time let me remark,
in passing, that the operation of deligation itself is not free from the
risk of hemorrhage, both from the abrasion of the surface of the
tumour in working with the canula and ligature, and from the
division of the vessels of the stalk, as they are cut through in the
process of deligation. "I think," maintains Dr. Meigs of Phila-
delphia, "the ligature is to be preferred to all other modes of extir-
pation. It is not in every case to be effected without hemorrhage.
I know," he adds, "of two cases here in which the hemorrhage was
terrible.” 3
But the principal danger to health and life in this, as after other
surgical operations, is the danger of phlebitis and surgical fever. Is
such a consequence more liable to follow upon the instantaneous
resection of the peduncle of a polypus, and the subsequent immediate
removal of the amputated polypus itself-or is it more likely to
supervene upon the slow process of disjunctive ulceration being set
up in the stalk of the polypus by the ligature, while the gangrenous
and putrefying polypus itself is left decomposing in the cavity of the
vagina?
I believe that no physician or surgeon acquainted with modern
pathology will have any difficulty in answering, that the danger of
phlebitis is much greater under the latter circumstances than under
2 Praxis Medica, lib. ii. Obs. 86.
See also Examples in Colombat
1 London Medical Gazette for 1835, p. 435.
3 Meigs' Females and their Diseases, p. 255.
de l'Isère's Traité des Maladies des Femmes, p. 817.
732
DISEASES OF WOMEN.
the former. The recorded experience of some of those who have
written in favour of the ligature, shows strongly enough the occa-
sional liability under deligation to the occurrence of irritative fever
and internal inflammations, from phlebitis and the absorption of
putrid and purulent matter from the vagina. Dr. Hamilton' men-
tions three cases of death which he had seen follow the removal of
uterine polypi by ligature. "On a close inquiry," observes Mr.
Arnott, "I find that even those who use it (the ligature) acknowledge
that occasionally cases have been met with, where the ligature, in
cutting its way through, has excited irritation and fever, and even
death. Two cases have been described to me by the practitioners
concerned where this occurred, and in casually referring to the
interesting works of Boivin and Dugès I find two similar ones."2
In his lectures on fibrous tumours of the uterus, Dupuytren³ states,
"I possess eight or ten observations of women who have perished,
from veritable poisoning and absorption of pus, after the application
of the ligature for uterine polypus."
I have myself seen a woman die with a ligature still fixed
around the partially divided neck of a uterine polypus; and other
cases where severe but not fatal attacks of phlegmasia dolens and
phlebitis followed deligation. Twelve or thirteen years ago, on a
patient of Dr. Edgar's of Berwick, I applied a silver wire ligature to
the neck of a large polypus, and tightened it from time to time,
according to the usual rules. In the course of a few days the
polypus was dead and putrefying; there was much heat and irrita-
tion in the vagina; and the patient's pulse became rapid under the
irritative fever that followed. On strongly tightening the ligature,
to expedite as much as possible the total amputation of the polypus,
the wire broke, and the canula and wire slipped off. I immediately
proceeded to remove the polypus by excision, instead of making any
renewed attempt at deligation; and the result was to me very
striking and satisfactory. Within twenty-four hours the local irri-
tation had greatly subsided, and the constitutional disturbance
entirely disappeared. From that time to this I have operated on
many uterine polypi, but never again by the process of slow deliga-
tion. And the more that I have seen of the practice of removing
1 Hamilton's Pract. Observ. p. 37.
2 Arnott in Lond. Med. Gazette, 1836, p. 412. See also notices of two other
cases of death from uterine phlebitis after deligation, in Cyclopædia of Practical
Medicine, vol. iv. p. 393.
3 Leçons Orales. Brussels ed. 1826, p. 237.
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 733
large pediculated uterine polypi by excision, the more deeply has
the conviction grown upon my mind, that this method is very
superior to the usual method followed in this country, of the
removal of them by the canula and ligature.
ON THE DETECTION AND TREATMENT OF INTRA-
UTERINE POLYPI.¹
After a polypus, or pediculated tumour, arising from any part of
the interior of the uterus, has once passed downwards into the
vagina, the diagnosis of the disease is, generally speaking, very easy,
the operation for its removal comparatively simple, and the result
of the treatment in the highest degree successful and satisfactory.
112
"When
66 So
But before a uterine polypus has passed through the os uteri—
in other words, as long as it is still intra-uterine, or shut up and
contained within the uterine cavity-the disease has hitherto been
usually regarded and described as entirely beyond the reach of legi-
timate diagnosis and treatment. "It very frequently happens,"
observes Dupuytren, "that polypi concealed in the uterine cavity,
inaccessible to our senses and instruments, give rise to severe symp-
toms, the true cause of which cannot be determined."
polypi," he again states, "are entirely included within the uterus,
the rational symptoms afford room only for conjecture; and exami-
nation by the finger or speculum are both alike insufficient."*
long," remarks Madame Boivin, " as the polypus is concealed within
the uterus, all that can be ascertained is the increased size of that
organ. "If the polypus," says Dr. Ramsbotham, "be still in-
cluded within the uterine cavity, and if the mouth of the organ be
closely shut, it is impossible to reach it by the finger, and conse-
quently quite out of our power to ascertain its presence.'
"So
long," according to Mende, " as a polypus is
cavity, its diagnosis is scarcely possible.""
while they remain enclosed in the uterine cavity, furnish," observe
Roche and Sanson, "none but equivocal symptoms, which may be
194
115
enclosed in the uterine
"True uterine polypi,
¹ Extended from a Paper read before the Medico-Chirurgical Society of Edin-
burgh, November 21, 1849. See Edinburgh Monthly Journal of Medical Science,
January 1850, p. 3.
2 Leçons Orales, vol. iii. p. 542.
→ Practical Treatise on Diseases of the Uterus.
Medical Gazette, vol. xvi. p. 406.
3 Ibid. p. 490.
Heming's Translation, p. 200.
6 Krankheiten des IVeibes, p. 591.
734
DISEASES OF WOMEN.
confounded with those of pregnancy. These different symptoms
may also depend on chronic inflammation of the womb; and it is
often impossible to distinguish this affection from polypus. In the
actual state of the science, there is but one case in which a certain
diagnosis may be formed, viz. when, the neck being effaced, and
partly opened, it is possible to feel the rounded tumour within.'
These, and other passages that might be cited, show that intra-
uterine polypi are generally considered at the present day as placed
beyond the pale of any certain means of detection, or any possible
means of operative removal. And some of the older pathologists,
indeed, would seem to have believed that there was no necessity for
devising such means, inasmuch as, in their opinion, no danger was
connected with the disease as long as the polypus remained intra-
uterine. They held that the great source of prostration and peril
attendant upon uterine polypi—namely, the hemorrhage or menor-
rhagia which accompanies them-is not liable to supervene till the
polypus has passed through the os uteri. Levret, for instance, was
of opinion that, as long as a polypus remained within the uterine
cavity, there was no accompanying hemorrhage, and that floodings
appeared only after the tumour had left the uterine cavity."
Several years ago, I saw, with Dr. Alexander Wood, a case, the
result of which was distressingly opposed to this doctrine.
She
CASE I. The patient was about fifty-five years of age, and unmarried.
I.—The
had been suffering long under severe menorrhagia. The face was pale and anæmic,
and her health and strength broken down. On examining, per vaginam, the os
uteri was found closed; but the uterus felt somewhat large and distended; and
Dr. Wood, believing, with me, that the hemorrhagic drain which was present
might be the result of an intra-uterine polypus, the mechanical dilatation of the
uterine cavity was advised, but given up in consequence of local treatment being
objected to. In a few weeks the patient sank, under the continuance of the
hemorrhage. On opening the body, Dr. Wood and I found the lower part of the
cavity of the uterus diştended by a polypus, of the size of a small plum, and
attached to the back wall of the uterus by a narrow half-broken stalk. The lining
membrane of the uterus was white and bloodless; but the polypus was red, from
engorgement and effusion of blood in its tissues. Its structure was fibrous; and
there was another small fibrous tumour imbedded in the walls of the uterus, near
the uterine extremity of the right Fallopian tube. It had descended lower down
than at the time we examined, so as to have already dilated the cavity of the
cervix; and the os, at the time of death, had begun to open. It was evident
that, if the cavity of the os and cervix could have been artificially dilated during
life, the polypus would have come within reach, and the patient's life been
saved.3
1 Nouveaux Elémens de Pathol. Méd. Chir. tom. iii. p. 284.
2 Levret, Sur la Cure Radicale de Plusieurs Polypes de la Matrice, p. 25, etc. etc.
3 The uterus and its included polypus, from this patient, are in the University
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 735
I have seen several other cases of intra-uterine polypus, where
the hemorrhage was both long in continuance and great in quantity.
Some years ago, along with the late Dr. Henderson of Corstorphine,
I excised a slender pendulous polypus, hanging from the os uteri,
in a patient who, some time previously, had nearly died of exces-

Fig. 30.
sive uterine hemorrhage of several days' duration, at Leamington;
but at the period of that dangerous attack the attendant physicians
had been unable to discover any uterine organic disease, to account
for the discharge. The polypus had not yet passed the os uteri.'
When nature, in cases of intra-uterine polypi, begins to expel
the tumour, and open up the os uteri, we may, at that stage, as
stated in a preceding quotation from the work of Roche and Sanson,
find it possible to make a diagnosis of the disease by being able to
'feel the rounded tumour within." If art could furnish us with any
means of producing, at will, the same extent of opening of the os
66
Fig. 30. Polypus fatal by continued hemorrhage, while still included in the
uterine cavity.
Museum; and the above woodcut presents a faithful sketch of them, diminished
two-thirds, made from the preparation, and showing the size and site of the poly-
pus, its place and mode of attachment, and the slight dilatation of the os that had
taken place before death.
In this, and in one or two other instances in which I have seen extreme
degrees of flooding attendant upon small polypi, the narrow elongated polypus was
of a cellular structure internally, and externally spotted and roughened over by
numerous small linear-placed elevations, like those on the shell of the echinus.
736
DISEASES OF WOMEN.
uteri, it would enable us in the same way to "feel the rounded
tumour within" with our finger; and it is evident that, by this
means, we would possess a power of detecting, with all the certainty
of physical diagnosis, the existence or not of the disease within the
cavity of the uterus, in cases in which the attendant rational symp-
toms-as the menorrhagia, uterine leucorrhoea, and perhaps the
swelled state of the neck or body of the uterus-might lead us to
conjecture the probable presence of an intra-uterine polypus.
In 1844, in a communication¹ laid before the Medico-Chirurgical
Society of Edinburgh, I proposed a means of safely opening up the
cavity of the cervix and body of the uterus, to such an extent as
might enable us to introduce a finger into the uterine cavity, for the
purposes of diagnosis and operation in this and other diseased states
of the organ. The means described consisted in the introduction
of sponge-tents into the os and cavity of the uterus, so as gradually
to dilate these parts to the degree required. For several years past

บ
Fig. 31.
I have been constantly employing this means of dilatation of the
uterine os and cavity, for a variety of purposes and indications.
The sponge-tents used by myself and my professional brethren in
Edinburgh are manufactured by Duncan, Flockhart, and Co. They
are of a narrow conical or pyramidal form; and used of many differ-
ent sizes and lengths, according to the object in view. One of nearly
the medium size is represented in Fig. 31. These tents are
made by dipping a piece of sponge in a strong solution of gum-
arabic, tying and compressing this sponge around a central wire, as
its axis, into the required conical form, by a continuous layer of
whip-cord, drying it thoroughly, removing the cord, and subsequently
slightly coating the surface of the tent with tallow, or axunge and
1 "Mechanical Dilatation of the Cavity of the Os and Cervix of the uterus, as
a means of Diagnosis and Treatment in some Affections of that Organ.”—See
abstract of it in the Monthly Journal of Medical Science, August 1844, p. 734.
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 737
wax, to facilitate its introduction. The central wire passes only for
half-an-inch or an inch into the base of the cone (see section of one
above); and the opening left by it serves as an aperture to transfix the
tent with the tip of the metallic director (Figs. 31 and 32), used for
guiding and introducing the tents through the os uteri. This metallic

Fig. 32.
director, which, at the distance of nearly two inches from its ex-
tremity, is bent at an obtuse angle, thence tapering to a blunt point,
is introduced like the uterine sound or the catheter; its handle, with
the sponge affixed to it, is held and manipulated by the left hand,
while the forefinger of the right hand touches the os uteri, in order
to guide and direct the apex of the tent into that opening. The
old forms of sponge-tent used by surgeons, and made of sponge
steeped in preparations of wax, required for their expansion and
development the aid of heat, in order to dissolve their retaining
ingredient. The tent I have described, made by steeping sponge
in a solution of gum, requires moisture, and not heat, for the
solution of its retaining material, and for the expansion of the
sponge. Very generally the secretions of the surrounding mucous
canal afford a sufficient quantity of moisture for these two purposes ;
but if not, a small quantity of tepid water may be injected from
time to time into the vagina. Usually a well-made tent takes
twenty or thirty hours to expand to its full extent in the os uteri ;
and dilates to four or five times the diameter it presented in its
original compressed state. Generally the first tent opens up the os
and cavity of the cervix, and allows the finger ample space to ex-
amine sufficiently its contents, and the state of its parietes. If it is
necessary to open the uterine cavity higher, to enable the finger to
pass into the cavity of the body of the organ, a succession of tents
is usually required; and they must be passed completely through
the os internum or narrow portion, lying between the cavity of the
cervix and cavity of the body of the organ. The use of the tent for
a day, generally, as I have already stated, dilates the os uteri and
cavity of the cervix sufficiently; and the employment of the sponge
is accompanied with little or no feeling of uneasiness. When it is
necessary to examine the state and conditions of the interior of the
cavity of the body of the organ, the persevering use of a series of
738
DISEASES OF WOMEN.
larger and larger tents for several days is usually requisite; and the
dilatation of the os internum and body of the organ sometimes, but
not always, causes a feeling of uneasiness and pain, that may require
the use of an opiate. I have omitted to state that the tent is always
prepared with a string affixed to its base, to allow of its easy removal.
(See Fig. 31.) In using sponge-tents, it should be remembered that,
when sponge is in contact with the maternal passages for some hours,
it always exhales, when removed, a very fetid odour.
For dilatation of the unimpregnated os uteri, the tent should be
selected as regularly conical as possible; and with the apex neither
too blunt and rounded to pass the os, nor too slender and flexible,
so as to double back in the attempt. The spirally-grooved surface of
the tent, resulting from the compression of it by the whip-cord
during its manufacture, tends to retain it in situ till its expansion
commences. It perhaps ought to be added, that the introduction.
of the sponge-tent into the os and cavity of the uterus should be
effected without the use of the speculum. The sense of touch
serves, in this and some other analogous operations, infinitely better
than the sense of sight.
By the use of sponge-tents introduced daily, and of increasing
size and length, we may reach a polypus when affixed and sessile
even upon the fundus uteri. One of the first cases in which I
dilated the uterine cavity to its extreme height was the following:-
CASE II.-In 1844, a patient, æt. thirty-six, under the care of Dr. Graham of
Dalkeith, had a miscarriage, from the effects of which she never satisfactorily re-
covered. Previously she had borne four children. When I first saw her, two or
three years afterwards, she was emaciated and extremely pallid from the excessive
loss of blood which she had been sustaining for some time; and her weakness was
such, that it was with difficulty she could rise and walk across her bedroom. In
August 1847 I dilated fully the interior of the cervix and body of the uterus by a
succession of sponge-tents, and at last felt a hard round fibrous polypus seated at
the very fundus of the uterus, and projecting, of the size of a walnut, into the
upper part of the cavity of the organ. Dr. Ziegler, Dr. Toogood of Torquay, and
other professional friends, confirmed this diagnosis. It was impossible to ascer-
tain how it was pediculated, or to operate upon the pedicle. We could only reach
the round body of the tumour; and that I compressed strongly and repeatedly in
the blades of a lithotomy forceps, with the view of breaking down its tissue, so as
to destroy the vitality of the polypus. A purulent discharge followed, and three
largish pieces of organised structure were subsequently cast off. Her recovery of
health, after these discharges ceased, was gradual but perfect. There has been no
return of menorrhagia. About a year ago she called upon me, and the change
from excessive pallor and emaciation of the face, to the hue and ruddiness of
health, was so great, that I had difficulty in being convinced of the identity of
my former patient.
The Symptoms which might, a priori, induce a practitioner to
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 739
conjecture the probable existence of an intra-uterine polypus, are, as
we have seen in the quotations I have already given, of a very un-
certain and equivocal character. The polypus, while still included
within the uterus, is principally liable to give rise to the following
groups of symptoms :—
1st. Menorrhagia, in consequence of the discharge of blood from
the surface of the tumour. The attendant hemorrhages take place
particularly at the menstrual periods, but are apt to recur also at
other times; and the blood is sometimes fluid, sometimes coagulated;
occasionally there is an almost constant red stained discharge. The
effects of these repeated floodings upon the constitution of the
patient vary with their amount; but if they go on increasing, as
they usually do, in quantity and frequency, the patient's constitution
becomes gradually more and more shattered and broken down by
the amount of hemorrhagic discharge; and all the symptoms of
anæmia, in their most marked degree, at last supervene, as pallor of
the face and lips, great muscular debility, vertigo, palpitation, dys-
pepsia, œdema, etc.
2dly. The discharge of mucous, purulent, or serous matter from
the cavity of the uterus in consequence of the mucous membrane
of the organ becoming often irritated, inflamed, and even ulcerated,•
by the presence and pressure of the polypus. If a severe leucor-
rhoeal discharge is present, and we ascertain by the speculum that it
does not originate in ulceration or other morbid state of the external
surface of the cervix, or of the vagina; and if we further detect,
with the speculum, the discharge issuing from the cavity itself
of the uterus, the probabilities of it originating in some pathological
irritation within the uterus will be necessarily increased. Some-
times the discharge, in cases of polypi, is fetid, especially if it be
retained, or mixed with decomposing blood.
3dly. Increased size of the cervix and body of the uterus, in
consequence of its interior being distended by the presence of the
polypus, is traceable in those cases in which the polypus is of any
great size. Not unfrequently intra-uterine, like vaginal polypi, are
found combined with the presence of fibrous tumours in the walls
of the uterus; and by these tumours the magnitude of the organ is
increased, and its shape rendered more or less irregular. Fibrous
tumours of the uterus are seldom or never situated in the walls of
the cervix; and if the swelling and distension affect the cervix,
there is consequently much more chance of its being a polypus and
not an interstitial fibrous tumour, than when we have similar symp-
48
740
DISEASES OF WOMEN.
toms attendant upon a similarly augmented state of the body of the
organ. Further, the probability of the disease being intra-uterine
polypus would be increased, if, on successive examinations, we had
an opportunity of ascertaining that the enlarged and distended
state of the cervix was descending gradually lower and lower down
towards the os; for polypi in their progress and descent, as seen in
Case I., gradually dilate the cervix from above downwards in the
same way as happens in pregnancy or abortion. They are born by
a kind of chronic labour.
4thly. There may be symptoms of irritation and pressure upon the
bladder, rectum, etc., if the polypus happen to be so large as to
exert mechanical compression upon these or other parts, or dysme-
norrhoea if it fills up the cavity of the cervix. And sympathetic
pains may be present in the loins, limbs, etc.; or there may be sym-
pathetic disturbance of the stomach, heart, etc., if the uterus is
much irritated and excited by the presence and distension of the
polypus.
But one or more of the preceding groups of symptoms may be
altogether absent, though the uterus contain an intra-uterine polypus.
The mechanical and sympathetic symptoms last alluded to are the
most uncertain of all. For while almost all uterine diseases, how-
ever intrinsically different, give rise to similar secondary and sym-
pathetic symptoms, we have often, in other instances of the very
same diseases, these same symptoms entirely wanting; just as in
one woman during pregnancy we sometimes see severe, even serious,
local, and constitutional symptoms; and in another woman, or even
in the same woman in another pregnancy, we see the same condition
of-the uterus unattended by any special local or constitutional dis-
turbance. Again, there may be no ascertainable increased volume
of the uterus, as the polypus, especially if it is vesicular, and origin-
ates in the interior of the cervix, may be far too small to lead to
any appreciable augmentation in the size of the organ, although,
notwithstanding, the menorrhagia may be great; for the extent of
flooding does not depend on the size of the polypus--small polypi,
like small hemorrhoidal excrescences, often being the source of severe
and repeated hemorrhages. Further, the leucorrhoeal discharge,
which is sometimes attendant, may be entirely absent, as the polypus
may not be irritating the mucous surface of the cavity in which it
is inclosed. And lastly polypi occasionally, though not very fre-
quently, are present for a long series of years without producing
any degree of hemorrhage or menorrhagia. In the following case,
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 741
for example, there was a state of long-standing amenorrhoea, instead
of menorrhagia, co-existent with the presence of a polypus, though
the two conditions, the amenorrhoea and polypus, had probably no
causal relation to each other.
CASE III.-A poor woman, from East Lothian, aged about 35, and of a weak
and debilitated frame, came, some three or four years ago, to ask for advice re-
garding the state of her health. She described her case as one of long-standing
amenorrhoea. For five or six years the catamenia had been entirely absent; and
she ascribed her broken health to this cause. On examining the uterus and
ovaries, in order to ascertain if there was any organic change to account for the
amenorrhoea, I found, with the uterine bougie, the cavity of the os and cervix
uteri very small, and the latter apparently obstructed, about three-quarters of an
inch from the orifice. I introduced a long thin sponge-tent, with the view of
determining more correctly the state of the cervical cavity. On removing the
sponge, two days subsequently, I found the lower part of the cervix natural, but
a flattened polypus, of the size of a small cherry, attached by a short pedicle to
the interior of the higher portion of the cervical cavity. The pedicle was easily
seized with a pair of long slender polypus forceps, and separated by torsion or
avulsion. For some time subsequently to this little operation, menstruation re-
curred—the irritation of the sponge-tent having probably so far roused the uterus
to a restoration of its secreting functions; but a patient, from the same neigh-
bourhood, about half-a-year ago, informed me that her health had relapsed again
into its former unsatisfactory state.
The polypus, in the preceding case, was intra-uterine. During
the past autumn I removed a uterine polypus, which had long
passed down into the vagina, and yet had never given rise to
menorrhagia.
CASE IV. The patient, 55 years of age, had, for at least twenty-five years,
been aware of the occasional protrusion, between the labia, of a portion of what
she supposed a fold of thickened and insensible skin. When she first noticed it,
she had called the attention of her medical attendant to it, an eminent London
obstetrician, under whose kind care she was for many years placed. He examined
the tumour and its relations; but advised her to let it alone. Two or three years
ago a little sanious discharge began to appear, and continued to recur almost
daily. On examining the projecting body, I found it an elongated polypus, of
the size and figure of the fruit of the date, and depending by a long slender
stalk, which passed upwards through the os uteri. I divided the stalk with a
pair of blunt-pointed scissors, immediately below the os uteri, and in four days
afterwards the patient set off on a long journey. The polypus was of a dense
cellular structure. At one point, near its fundus, its surface was ulcerated. The
ulcer was of about the size of a sixpence, and, no doubt, the source of the dis-
charge that had latterly appeared. Perhaps the removal of this polypus, when it
was first discovered, would have enabled the patient to become a mother, and
saved from extinction one of the highest and oldest titles in the kingdom.
Cases, however, like the above, of uterine polypi, of long dura-
tion, without attendant hemorrhage, are exceptions, and not very
742
DISEASES OF WOMEN.
common exceptions, to the general rule. And certainly the exist-
ence and return of attacks of menorrhagia, draining and undermin-
ing the powers of the constitution-without the presence of any
ascertainable organic disease in the vagina, or around the os uteri,
to account for the floodings, and the persistence of this discharge, in
despite of all constitutional care and treatment-forms always the
most frequent and principal symptom that would induce the prac-
titioner to use means to ascertain if there existed an intra-uterine
polypus, or any other intra-uterine lesion, that was the probable
source of the hemorrhage. He would, a priori, have more expecta-
tions of detecting, in his investigation, an intra-uterine polypus,
provided, along with the menorrhagia, there was an occasional leu-
corrhoeal or sanious discharge, coming-as proved by the speculum
-from the cavity itself of the uterus, and not from the surface of
the cervix; and provided also there was an increased size or mis-
shapen state of the cervix or body of the uterus, such as might result
from the inclosure and distension of a polypus.
To convert, however, the probability derivable from such symp-
toms into a certainty, we must endeavour to read the true value of
these rational symptoms by obtaining access to the cavity of the
uterus itself, and ascertaining, by a digital examination, if a polypus
be present in that cavity or not, or if there be any other co-existent
uterine lesion, capable of accounting for the symptoms. It is be-
coming every day more and more acknowledged, that we can alone
discover uterine diseases, and discriminate them from each other, by
appealing in this way to the evidence of physical diagnosis. And
no remark could be, pathologically and practically speaking, more
sound and true than that which Sir Charles Clarke many years ago
made: "The true character of any disease of the internal female
organs can only be ascertained by examination." With this view,
in order to enable the finger to reach and examine the cavity of the
uterus, the os and cervix must be opened up by a succession of
sponge-tents in the way already described. When an adequate
degree of dilatation is obtained, the finger will be enabled to touch
the tip of the polypus; and then the pediculated or polypous
character of the tumour may be farther made out by passing either
the finger or a uterine sound between its body and the containing
cavity of the uterus. In making this examination, as in making
most other examinations of the uterus, a rule requires to be followed
which is too often forgot, namely, to use both hands for the purpose.
1 Discases of Females, vol. i. p. 250.
1
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 743
For if we are examining the uterus internally with the forefinger, or
fingers of the right hand, the facility and precision of this examina-
tion will be found to be immensely promoted by placing the left
hand externally over the hypogastric region, so as to enable us by
it to steady, or depress, or otherwise operate upon, the fundus uteri.
The external hand greatly assists the operations of that which is
introduced internally; and farther, we can generally measure, be-
tween them, the size, relations, etc., of the included uterus.
If without, or before, using sponge-tents, we are desirous to
examine at the time when the os uteri is naturally most relaxed, we
shall find that time to be either immediately after a menstrual dis-
charge, or immediately subsequent to any severe attack of inter-
current hemorrhage. Under such circumstances, we can sometimes.
introduce the finger partially into the os uteri, and ascertain the
presence of any morbid body in the lower segment of the cervix;
when in the same patient, at other times, this orifice is so completely
shut as to prevent entirely such a proceeding. Sometimes, indeed,
a small or elongated intra-uterine polypus will pass through the os
uteri at these times, so as to be felt by the usual vaginal examina-
tion, but it will become retracted into the cavity of the cervix during
the interval between the hemorrhagic discharges. In the following
case' this occurrence was observed:
CASE V.-About eight years ago, I occasionally saw a patient who suffered
much from leucorrhoea and menorrhagia. At last her health became so much
broken in consequence of these discharges, and the pallor of the face and
lips, and other symptoms of anæmia, so alarmed the patient, that she agreed re-
luctantly to submit to a vaginal examination. She had an objection, however, to
me, on the score or youth; and the late Dr. Beilby was so good as to make the
examination, and found a polypus, of the size of an almond, projecting from the
lips of the os uteri. On Dr. Beilby returning, two or three days subsequently, to
put a ligature around the neck of the polypus, none could be found, and the os
uteri was shut. The other symptoms, however, did not change; and, on the re-
currence of a new hemorrhage, Dr. Beilby made another examination, again found
the polypus protruding, ligatured, and removed it.
In this instance, as in many others, the passage of the polypust
through the os uteri did not produce any appreciable degree of pain.
In enumerating the symptoms of intra-uterine polypus, I have
omitted to state that, like polypi which have passed through the os
uteri, they very rarely are attended with feelings of pain; and too
often, both by the patient and the practitioner, the absence of pain
1 See notice of an analogous case, by Dr. Ramsbotham, in the Medical Gazetle
for 1835, p. 406.
744
DISEASES OF WOMEN.
1
In a
is erroneously supposed to be a proof of the absence of organic
disease. Sometimes, however, as they are pressing upon the lower
part of the cervix and os uteri, or distending and passing through these
parts, uterine contractions and pains temporarily supervene, similar
to those of miscarriage; and, if there is any difficulty in the passage
of the tumour, these pains may become exceedingly severe.
case in which a fibrous tumour of the uterus had undergone the
calcareous degeneration, and part of it had assumed a semi-
pediculated or polypous form, the recurrent pains, when the mass
came down upon the os uteri, appeared at times as extreme as those
of the last stage of labour.
CASE VI. The patient, now 69 years of age, the mother of several child-
ren, had for several years suffered from recurring slight attacks of uterine
hemorrhage. In February 1848, I saw her with Dr. Hunter. The os uteri was
drawn up so high, that it was with great difficulty I could reach and touch it;
the top of the vagina stretched up in the form of an inverted funnel, the apex
being placed at its upper or narrow extremity, and hence it was impossible to
introduce or use a speculum. At the same time, the abdominal parietes were so
thick and full, that it was impracticable to ascertain in any way the state of the
uterus by an external examination. Not feeling a polypus, however, I left with
the idea that the cause of the menorrhagia was some form of carcinomatous disease
of the uterus. Subsequently, in the month of July, all her symptoms became
aggravated, and very severe bearing-down pains were superadded. These pains
recurred regularly once a-day, lasted in paroxysms for several long hours, and
always left the patient weakened and prostrated. In consequence of their per-
sistence, Dr. Hunter made another examination of the vagina, and found the os
uteri, which was now pressed lower down, filled with an apparently irregular bony
mass. I saw her again, and removed the calcareous mass, filling up the os uteri,
with a portion also of fibro-calcareous tumour, which we found above it, and dis-
tending the lower part of the cervix. The irregular calcareous portion protruded
through the os uteri, was about the size of a hazel-nut, and the portion of fibro-
calcareous tumour above it nearly four times that volume. The daily fearful pain
which the patient had been lately enduring immediately ceased, and everything
looked so favourable that we had every hope that the whole of the fibro-calcareous
tumour, or polypus, had been removed. Last February, however, after some
unusual exertion, the pains again recurred more severely, if possible, than before;
and with this difference, that the attacks of them were now twice a-day, instead
of being only once, as on the first occasion. Opiates and sedatives had little or
no effect towards their alleviation. On examining the os uteri, no new foreign
body could be found anywhere within reach. As the patient's strength and
spirits, however, were rapidly giving way, I dilated the os fully, by a succession
of sponge-tents, and found the cavity of the cervix occupied by another fibro-cal-
careous mass, larger than the first. After an ineffectual attempt to break it down
and remove it, by strong lithotomy and other forceps, I dilated the os still
farther with tents, with the view of, if possible, getting two or three fingers up
to seize the tumour, and assist in its detritus and extraction. To allow the hand
to pass into the vagina for this object, I was obliged to incise its orifice; and,
after no small difficulty, I was enabled to break off, by the fingers and forceps,
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 745
•
four or five fibro-calcareous pieces from the mass in the cervix; and these pieces,
when afterwards conjoined together, were found to form a roundish semi-pedicu-
lated tumour, of the size of an orange. In order to enable her to sustain the pain
of these proceedings, the patient was kept, during this tedious operation, under
the influence of chloroform. The pains again ceased from the date of the removal
of this second intra-uterine tumour; and under the kind care of her son, himself
a physician, our patient made a good and steady recovery, and her health was
restored by spending some of the autumn in the country. There still, however,
remains in the uterine parietes some fibro-calcareous structure, as I lately ascer-
tained by passing a uterine bougie into the elongated cavity of the uterus, and
striking it against its hard stony surface.
The Treatment of intra-uterine polypi requires to be varied ac-
cording to different circumstances, but particularly by the tendency
or probability of the tumour passing downwards or not through the
os; by the effects of the symptoms or the urgency of the case; and
by the size and site of the polypus.
Two plans of procedure may be followed according to the nature
and necessities of the case-viz. first to wait till the polypus descends
farther; or, secondly, to remove it immediately. It is a generally
acknowledged principle in obstetric surgery, that a polypus of the
uterus should be extirpated as early after its discovery as possible."
But when such a tumour is discovered still included within the
uterine cavity, and the polypus seems gradually but certainly mak-
ing its way downwards through the cervical cavity, and the hemor-
rhage and other symptoms are not urgent, it will assuredly be better
to wait for its descent through the os; for after that its removal
becomes much more easy and simple. The dilatation of the os and
cervix by the sponge-tents will promote and facilitate its descent;
and perhaps the internal use of the ergot of rye may aid it. But
the degree of attendant hemorrhage and debility may be too great.
to entitle us to postpone the removal of the polypus; or the tumour
may be attached by such a short pedicle as not to be capable of
leaving the uterine cavity without dragging down with it, or invert-
1 "In the treatment of this disease (uterine polypus) the first principle, undis-
puted, I suppose, by those who are possessed of experience in the management of
these morbid growths, is, that it ought by all means to be extirpated; for unless
it be removed, it will continue to grow larger and larger, till it utterly wears out
life, and this especially if it be shooting from the upper part of the uterus, or even
from the neck. It is, moreover, of vast importance in polypus, not only that it
should be extirpated, but that this extirpation should be accomplished as early as
possible. Lay this down, then, as a most important part of your practice, that
polypi are not only to be taken away, but that they are to be extirpated early, as
soon as they are discovered, and as soon as it is practicable."-Blundell's Observa-
tions on Discases of Women, p. 126.
746
DISEASES OF WOMEN.
ing, the fundus or some part of the parietes of the uterus; or it
may be retained in its descent by adhesions formed between the
surface of the uterus and the surface of the polypus. I once wit-
nessed the dissection of a case of large fibrous polypus included in
the cavity of the uterus, and where inflammation had been present
before death; the surface of the polypus was adherent to the
surface of the uterus through the medium of a recently-effused
false membrane. Even when an intra-uterine polypus has descended
so far as even partially to open up the os uteri, it may remain in
that situation for such a length of time, and with such results, as to
place the patient in no small degree of danger. I shall quote, in
illustration of this remark, an interesting case reported by Dr. Meigs
of Philadelphia, in his work on Female Diseases. Dr. Meigs, who
quotes Dr. Lee, to the effect, that "it would be folly to attempt the
removal" of a polypus still retained in utero, details the case referred
to in the following words :-
3
CASE VII.-"Some months ago a lady came to me from New Jersey. She had
been for some years labouring under a uterine discase, accompanied with violent
and exhausting floodings. Upon arriving here, she was wholly unable to walk or
sit up in her chair. I discovered a hard polypus, whose apex was lying just
within the os uteri, which was a circular opening as large as a half-dollar. The
os uteri was pretty low down in the pelvis, it was very hard, and completely un-
dilatable. The fundus uteri was half-way up to the umbilicus, and the uterus
hard and solid, so as to allow me to trace its outlines very clearly in my hypogas-
tric palpation. I assure you I have rarely met with a more extreme case of
anæmia than in this person. This anæmia was evinced not only in the pallor of
her surface, and its flabbiness, and in her irregular breathing, the frequent palpi-
tation of the heart, and the anæmiacal throb of her pulses, but in the state of all
her innervations, which were most miserable indeed, except when lying pro-
foundly still in a low recumbency.
"After a few days' refreshment from the journey, I attempted to do what I
thought I should fail to do—namely, to get a ligature on the tumour. But I soon
found how vain was such an attempt, for I never found the uterus a moment
relax, nor open beyond the size of a half-dollar. My attempt caused an attack of
hemorrhage to come on, that I was glad to suppress by cold, by rest, and by
opium.
"I kept her here many months, in hopes of seeing the uterus enter into
powerful contractions to throw off the morbid mass. I gave her large doses of
ergot. I thought the ergotism that was produced might expel the polypus, but I
was disappointed, and subsequently had reason to believe the tumour had formed
1 Cases of intra-uterine and vaginal polypi tending thus to invert the uterus at
the site of the pedicles are detailed by Denman, Introduction to Midwifery, p. 106;
Davis, Obstetric Medicine, p. 618; Dr. Oldham, Guy's Hospital Reports, New
Series, vol. ii. p. 105; Scoutetten, Gazette Médicale for August 1839; Crosse,
Transactions of Provincial Medical Association for 1845, p. 321, etc.
2 Library of Medicine, vol. iv. p. 335.
3 Females and their Diseases, p. 255. Philadelphia, 1848.
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI.
747
strong attachments to the inside of the uterine walls, so low down, that I could
reach them with my finger, but could not break them up.¹
During her residence here, I thought to see her bleed to death before my
eyes; her life was hardly saved by the tampon, so perverse was the hemorrhage.
At length I sent her home, with directions as to her health, and a request to be
informed if the tumour descended into the vagina. It will never descend into the
vagina, if the adhesions I supposed to exist are truly there."
But, secondly, the severity of the attendant hemorrhages, or the
improbabilities of the speedy and entire descent of the intra-uterine
polypus, may induce us to remove the tumour at once; and cer-
tainly this may be effected in most cases, though with greater
difficulties than in cases where the polypus has passed down into
the vagina. To admit at all of the removal of an intra-uterine
polypus of any considerable size, the os uteri must be previously
very fully dilated by sponge-tents; and perhaps it will sometimes be
found necessary, at the time of operating, to gain additional freedom,
by dividing any obstructing band of the os or cervix that may not
have been fully dilated by the tents. Afterwards, we shall require
to proceed differently in different cases, in order to destroy or
remove the polypus. We may only be able to accomplish this
object by contusing and crushing the tumour, as I have described in
a case already detailed. See Case II. In the instance in question,
I grasped the polypus, for this purpose, with strong lithotomy for-
In another similar case, after fully dilating the os and cervix,
I seized a large intra-uterine polypus between the jaws of a screw-
propelled lithotripsy instrument-invented for the purpose of crush-
ing vesical calculi-and was enabled, by it, to crush and destroy
readily the structure and vitality of the included tumour. Occa-
sionally, we may be enabled to divide the stalk of the polypus with
a silver wire or ligature, acting on the principle of the chain-saw ;
or we may reach it with very curved blunt-pointed scissors. The
two following cases may serve to illustrate these two last-mentioned
methods of operating :-
ceps.
CASE VIII. A patient, æt. 36, about three years ago began to suffer under
menorrhagia and dysmenorrhoea. The catamenia became both too frequent in
their return, as well as much too great in quantity; but there was little or no
leucorrhoeal discharge. Latterly coagula of blood accompanied the menstrual
periods, and the patient felt much weakened by each attack. The dysmenorrhæa
generally supervened on the second day of menstruation, and confined the patient for
1
The use of the uterine bougie would probably have determined this point;
or the mechanical dilatation of the os by tents would have enabled the finger fully
to reach and break the adhesions.
748
DISEASES OF WOMEN.
a couple of days, the third day being usually one of much sickness as well as pain,
particularly if the patient tried to assume the erect posture. I first saw this lady
in July of the present year, and found the uterus somewhat enlarged, and exter-
nally irregular in form, from the presence of one or two small fibrous tumours in
its body and fundus. But the os uteri was shut, and I could not ascertain if the
debilitating hemorrhage was the result merely of the irritation of these tumours
in the parietes of the uterus; or whether one of them, forming a polypus in the
cavity of the organ, was its source. I wrote her medical attendant to dilate the
os in order to determine this point; and she returned home to England. In
September she came back to Edinburgh; but, in consequence of the state of her
health, I did not venture to dilate fully the os and uterine cavity till towards the
end of October. On doing so, I was enabled to detect the rounded extremity of
a polypus hanging down into the cervical cavity. During two or three days it
descended somewhat lower, but ultimately remained fixed and stationary above
and within the os. I found I could not move it farther downwards by fixing a
vulsellum into it, and applying some dragging force. On the 6th November,
assisted by Dr. Duncan, I applied a silver wire above the body, and around the
neck of the tumour, by means of an instrument presently to be described. After
the instrument was fixed and adjusted, a few turns of the screw made the wire
cut through the pedicle of the polypus, and without any pain or suffering on the
part of the patient. The separated tumour was then pulled by the vulsellum
through the os uteri. The polypus was of the size and shape of a plum, with a
small portion of the pedicle attached. It was fibrous in its internal structure.
The patient's recovery was slow, but uninterrupted. She has menstruated once
since the operation, but without the discharge being excessive, as formerly, either
in quantity or duration (it lasted only three days); and also without her former
distressing dysmenorrhoeal pains.
The instrument employed in the preceding case was a modifica-
tion of one kindly sent to me by my friend Dr. Sabine, of New
York. I am told it has been successfully used by various American
practitioners for the removal of polypi in the vagina. The advan-
tage which it possesses over the instruments of Niessens, Gooch,
Davis, and others, in the removal of intra-uterine polypi, is, that the
screw-power with which it is furnished enables us to use it with the
power of a small chain-saw, for the immediate division of the
pedicles of the polypi. And it is almost superfluous to observe,
that if we can finish our operation at once, it will be much safer for
our patient than leaving a rough instrument within the cavity of
the uterus. The instrument itself consists of two parts, viz. two
hollow canule, like those pertaining to the instruments of Niessens
and Gooch; and of a second part, resembling the polypus instru-
ment of Graefe of Berlin, with this difference, that it has a ring
affixed to its top, of a heart-shaped figure, and intended, first, to
receive the two canule, with their contained ligatures, and after-
wards to serve as a point of resistance during the cutting action of
the ligature upon the pedicle of the tumour. The canula and
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 749
ligatures are first applied in the same way, and according to the
same rules, as those of Niessens and Gooch. After the pedicle is
encircled by the ligature, the two lower extremities of the canula
and included ligatures are passed through the ring of the second
portion of the instrument. This second portion of the instrument
is then run up, with its ring surrounding the included canulæ, till
it reaches the pedicle of the tumour; the projecting side of the
ring being turned towards the pedicle. The canula are then
slipped off and withdrawn, leaving the wires or ligatures alone
in the terminal ring of the instrument. Subsequently, these wires
are twisted around, and fixed upon, the knob attached to the
screw. Lastly, by moving the knob downwards, by the operation
of the screw, the ligature is made to cut into and through the
pedicle.
In the following case, I was enabled to divide the pedicle of a
large intra-uterine polypus with a pair of well curved blunt-pointed
scissors.
CASE IX. The patient was 48, and unmarried. About fourteen years ago
she was first seized, when in service, with a severe flooding. It returned at short
intervals, and reduced her strength so much that she was obliged to leave her
situation, and has never been able to take another. The hemorrhage she de-
scribes as having been almost constant for many years; that is, there was always
some red oozing, and fluid blood and clots often escaped when she made any
exertion. She had been treated by various medical gentlemen during this
period, chiefly with iron, styptics, and astringents. A vaginal examination had
never been made, in order to ascertain the source of the hemorrhage. During
last autumn she presented herself for advice at my house. She was blanched,
thin, and debilitated, and scarcely able to walk. On examination per vaginam,
the uterus felt enlarged, more particularly in its cervical region. A sponge-tent
was introduced, and on her returning, two days afterwards, I found a polypus
descended upon the distended os. Dr. Ziegler, Mr. Carmichael, and Dr. Duncan,
were present at the removal of the polypus. In order to reach, if possible, with
the scissors, the pedicle of the polypus, I required to make a slight incision into
the thin lips of the os. I was enabled at last, after some difficulty, and by seiz-
ing the polypus with a vulselluin on one of its sides, to turn the polypus laterally,
and obtain access, with the scissors, to its pedicle, which was small and easily
divided. After the polypus was completely separated, it took no inconsiderable
amount of traction to drag it through the os uteri. The polypus was round, of
the size of a small orange, and of a fibrous structure. The patient was rendered
anæsthetic during the operation. The vagina was plugged with sponge, and the
woman sent home. Next day the plug was removed. The patient has ever since
kept free from any return of the flooding, and a degree of leucorrhoea, which
followed, as often happens, the removal of polypi, is subsiding under the use of
medicated pessaries. A month subsequent to the operation, she stated her
strength to be greatly improved beyond what it had been for many years.
The preceding remarks, relative to the treatment of intra-uterine
750
DISEASES OF WOMEN.
polypi, principally refer to these tumours when they happen to be
of a large size. But uterine polypi are often too small to be re-
moved by the knife, scissors, or ligatures; and yet these small
polypi not unfrequently lead to severe and long-continued menor-
rhagia. From the analogy of hemorrhoidal tumours, we know that
the mere size of a polypus is not to be taken as any measure of its
capability of producing hemorrhage. Small vesicular, mucous, or
cellular polypi sometimes grow from the fundus uteri, giving rise to
considerable and long-continued hemorrhagic discharge. I have
preserved specimens of them from the dead subject, and have met
with them in the living. They can hardly be properly termed
polypi, as they are scarcely pediculated at their attachment, and
sometimes short, but in other cases long and slender, in their body.
The following case may be cited as an illustration of this form
of the disease :-
CASE X.-A lady, the mother of ten children, became irregular in her men-
strual discharge during her 44th year. At times it was wanting at the usual
monthly periods, at others it amounted to menorrhagia. About a year after this
irregularity commenced, such an amount of fluid blood and coagula escaped as at
first to lead on her part to some suspicion of miscarriage; but it continued to go
on profusely for two or three weeks. At the end of that time I visited her, with
Mr. B. Bell and Dr. Malcolm. On examining the uterus, we found a small vesi-
cular polypus attached to the inner surface of one of the lips of the os, and it was
easily removed by avulsion. The discharge, however, was not abated in conse-
quence, as we expected. A series of sponge-tents was then introduced, so as to
open up, first, the cavity of the cervix, which was found free from additional
polypi, and ultimately the cavity of the body of the uterus. When the distension
of the whole uterine cavity was at last completely effected, both Dr. Malcolm and
myself found that we could touch two or three small slender polypoid bodies,
hanging from the very fundus of the uterus. I removed them cautiously, from
the surface to which they were attached, with the nail of the first finger. After
this the hemorrhage ceased, but some local treatment was required to cure the
ulcerated state of the cervix. The polypi were removed in April. The patient
went soon afterwards to spend the summer in the country, where she soon gained
strength, and enjoyed much improved health. I saw her lately. The menor-
rhagia had not recurred, but she still looked anæmic, having never recovered her
colour since the hemorrhages in spring.
Dr. Malcolm informs me that, since meeting with the above case,
he has seen another similar one, and treated it successfully in the
same way. I may add, that in several cases of chronic and severe
menorrhagia, in which I have been induced to open up the cavity
of the uterus with sponge-tents, in order to ascertain whether there
was any small intra-uterine polypus present or not, I have merely
found the interior of the uterine cavity rough and granulated at
particular points, which I have generally tried to remove and scratch
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI.
751
off with the nail. Whether owing to their removal or not, or owing
to the irritation resulting from the pressure and distension of the
sponge, I know not, but certainly, in two or three cases, the menor-
rhagia has subsequently abated and ceased.
By far, however, the most common site for the origin of small
vesicular polypi, is the interior of the cervix uteri. In fact, the

Fig. 33.
small cellular or vesicular form of cervical polypus is infinitely the
most common form of polypous disease of the uterus. Several
specimens of them are represented in the woodcuts. These cervical

Fig. 34.
vesicular polypi are generally of a small size, like a pea or orange-
pip, and vary from this size to the size of a hazel-nut. Sometimes
they are sessile; and sometimes pediculated, as represented in the
sketch from Cruveilhier (Fig. 33). Occasionally they are single
(Fig. 34), or they form a single complex cluster; but more fre-
quently they are gregarious, as represented in Madame Boivin's
Fig. 33. From Cruveilhier's plates of Pathological Anatomy, fasc. xiii. pl. vi.
fig. 1.
The cut shows some small pediculated polypi of the cervix uteri. Here,
as often happens, there was co-existent disease in the body and fundus of the
uterus.
Fig. 34. Taken from a plate appended to a paper by Dr. Lee in the nineteenth
volume of the London Medico-Chirurgical Transactions.
752
DISEASES OF WOMEN.
drawing of them, copied in Fig. 35. Indeed it is, I believe, the
rule rather than the exception to it, that when we find one perhaps
protruding at the os uteri, as in Fig. 36, we shall find, on further
search, that there are others, sometimes to the number of four, five,
or six, springing from other points of the interior of the cervix, and
not discoverable till the cavity of the cervix is dilated by a sponge-

I
Fig. 35.
tent. When hanging from the os uteri, their stalk is sometimes so
loose and long, and the small depending polypus is itself so small
and soft, that it moves away before the finger in making a tactile

Fig. 36.
examination, and one unaccustomed to this peculiarity will not feel
perfectly sure of the presence of such a polypus till the speculum is
used, when the polypous body will be easily seen, generally of a
cherry-red or purplish colour. Such polypi, though small, are often
apparently the source of much menorrhagia and leucorrhoea, for they
In the latter a pisiform
Figs. 35 and 36 are representations of a single uterus.
cystic polypus is shown projecting from the os, in the former the cervix is opened
up, and three small cystic polypi seen on its walls. They are from Madame
Boivin's work on Diseases of the Uterus, plate xviii. figs. 1 and 2.
DETECTION AND TREATMENT OF INTRA-UTERINE POLYPI. 753
almost always co-exist with, and probably produce, some degree of
ulcerative inflammation of the contiguous surface of the cervix.'
In trying to remove these small vesicular polypi of the cervix, it
is, therefore, to be held in recollection, that there are generally more
than one present, and that, to ascertain this point with any precision,
it is necessary to dilate and expand the cavity of the cervix with a
sponge-tent.
In more than one instance I have found these polypi, when their
pedicles were perhaps long and easily broken, come away, imbedded
in the surface and foramina of the sponge, which had torn them off
during its expansion. But in twenty-nine out of thirty cases, more
methodic measures are required for their removal—as scratching
them off with the sharp finger-nail, seizing and tearing them off with
polypus forceps, or dividing their stalks with a pair of scissors. If
we can use the speculum, these modes of removal are greatly facili-
tated by the sense of sight. Indeed, if we require to use the polypus
forceps or scissors, for the removal of these small polypi, and are
guided by touch alone, we shall generally find the operation, though
apparently simple in principle, one which is tedious and difficult to
perform in practice.
In a considerable number of instances of obstinate slight
menorrhagia and leucorrhoea, I have been enabled to detect the
presence of vesicular polypi attached to the interior of the walls of
the cervix uteri, by opening up the cavity of the os and cervix with
sponge-tents, and have afterwards removed them by the methods
alluded to. The following was one of the first instances in which I
pursued this practice :-
CASE XI.-A lady was confined of a premature child in early married life, and
afterwards her health remained broken and wretched. She did not again conceive;
and was unable to take walking exercise. There was a constant feeling of drag-
ging and pressure about the pelvis. Betimes menorrhagia, and some degree of
leucorrhoea, supervened. She was seen by many medical men in different parts of
Europe. It was generally considered that there was a tumour on the back wall of
1 A small cervical polypus may even produce death by the extent of hemor-
rhage to which it gives rise. In an excellent practical paper on polypi, published
by Dr. Locock, in the London Medico-Chirurgical Transactions for 1848, he states
(p. 171), "Upwards of twenty years ago, the late Dr. Robert Hooper showed me
a preparation of a uterus laid open, having a polypus not larger than a pea, with
a short and narrow peduncle attached within the cervix, high up, considerably
within the os uteri, and not perceptible till the cervix was slit open. All the
history which he could give me was, that the uterus was removed from the body
of a young woman, who had died in the Marylebone Infirmary from long-continued
uterine hemorrhage.”
754
DISEASES OF WOMEN.
the uterus; and for some years previous to my first seeing her, in 1842, she had
been undergoing a course of local leeching, and other treatment, under the idea that
the enlargement of the uterus was hypertrophic, and that her irregular menstruation
was the result of congestion. I found the apparent tumour or hypertrophy of the
uterus was formed by a complete retroversion of the organ. The cervix uteri was
ulcerated, and I thought I could touch a small vesicular polypus, on pressing my
finger against the os. I distended the cervical cavity with a sponge-tent; and,
on removing it next day, I was easily able to trace three or four small cystic
polypi attached to the interior of the cervix. I removed them, by picking each
individual polypus carefully off with small forceps. An amelioration in the
irregular menstruation immediately followed; and other means were subsequently
adopted for the treatment of the other complications.
The small vesicular polypi of the cervix have sometimes, as we
have already seen, long pedicles. Occasionally, however, we find,
co-existing with these pediculated polypi, others that are non-pedi-
culated or sessile; and occasionally, after the cervix is dilated, we
find others not raised yet above the level of the general surface of
the mucous membrane of the part, but feeling imbedded like shot or
peas in or beneath that membrane. In other words, we find, in
some cases, these vesicular polypi th all their stages of formation,
from small shut cysts up to pediculated vesicular tumours. When
such is the state of matters, we can only remove those that are more
fully formed, by the nails, scissors, or forceps. To effect a complete
cure, we require other means; and for this purpose the application
of caustics to the mucous membrane of the cervix answers every
indication. Nitrate of silver generally proves too weak for this
purpose, unless repeated very often, and combined with scarification
of the mucous surface. We possess a far more potent and certain
caustic for the purpose, and one that is perfectly manageable, in
potassa fusa.
The surface of the os and cervix, when small vesi-
cular polypi exist, are often found to be the seat of chronic inflam-
matory ulceration; and sometimes the submucous tissue, and the
structure of the cervix, is also the seat of chronic inflammatory
hypertrophy and induration. When such a combination exists, the
potassa fusa is doubly useful, as its application at once destroys the
polypi, and sets up a new and healthy action in the affected and
morbid tissues of the cervix. I have described elsewhere its great
value and mode of application in inflammatory induration of the
cervix,' and the power we have of immediately arresting and limiting
its action by the neutralising effects of acetic acid. I need only add
here, that I have now repeatedly found this caustic of the greatest
possible use in obstinate and complicated cases of vesicular polypi of
1 See page 712 of this volume.
REMOVAL OF INTRA-UTERINE POLYPI.
755
the cervix, such as I have above alluded to. In illustration of its
effects, I shall cite only one instance, and that because it was a case
which was peculiar in several respects.
CASE XII. On the 1st October last I was called into Roxburghshire by Dr.
Anderson of Jedburgh, to see a lady who had been losing large quantities of blood
for three weeks previously, and in whom the hemorrhage had continued to go on
profusely, day after day, in despite of all the means which he had tried for its
suppression. The patient's strength had, in consequence, become greatly ex-
hausted. She was between forty and fifty years of age, was the mother of a
family, and for some years past had suffered under occasional menorrhagia. Three
years ago a uterine polypus had been detected at Brussels, and afterwards re-
moved in London, apparently with some difficulty, as the first physician who
attempted it failed. Her present attack of hemorrhage was much more long-
continued and severe than those that had occurred previously. Before being able
to make a tactile examination of the uterus, I had to remove several large clots of
blood lying in the vagina. I found the anterior lip of the os uteri very much
enlarged, indurated, and roughened on the surface. By the speculum we saw this
lip greatly enlarged and dotted over with small pediculated red-coloured polypi,
like red currants; and the use of the mop showed them to be the source of the
flooding. About a dozen of these small red polypi were within the field of the
speculum, but others could be felt on the internal aspect of the enlarged lip. As
it seemed hopeless to attempt to detach them all one after another by the forceps,
and as doing so would not remove the suspiciously indurated and enlarged an-
terior lip of the cervix, I at once had recourse to the application of potassa fusa to
the diseased lip itself, and melted it down, with the polypi attached, by decom-
posing upon it a couple of sticks of potassa, of above an inch in length each, and
followed this immediately by the free and abundant injection of vinegar to
neutralise the alkali. Subsequently, under the use of astringent injections and
medicated pessaries, the surface took on a healthy cicatrisation, and her health
greatly improved under Dr. Anderson's kind and able care. I saw the patient in
Edinburgh two months afterwards, on her way home to London. There were no
remains of the induration or polypi. The uterus felt natural in size, and the
surface of the cervix was entirely cicatrised. There has been no recurrence of
the menorrhagia. The menses have been present once, but not in unnatural
quantity.
CASES OF REMOVAL OF INTRA-UTERINE POLYPI.¹
Sir James Simpson showed the Society four intra-uterine fibroid
polypi, which he had removed from three different patients within
the last eight or nine days.
The first of these cases was an unmarried lady from England,
who had suffered from hemorrhage for twelve years, and sometimes
had been so greatly reduced by the discharge as to be invalided and
bedridden for weeks. She was very white and blanched. The os
¹ See Proceedings of Edinburgh Obstetrical Society, February 13, 1867, in
Edinburgh Medical Journal, June 1867, p. 1134.
49
756
DISEASES OF WOMEN.
uteri was opened up with sponge-tents, a polypus found in the
uterine cavity, and its neck divided without difficulty with a small
polyptome. The removal of the polypus from the uterine cavity
after its detachment was by no means easy, as it escaped readily
from the vulselle and polypus forceps that were used to catch and
extract it.
In the second case, an unmarried lady from Glasgow, the
hemorrhage had only lasted fourteen months, but had been some-
times very excessive. The same means of diagnosis and treatment
were used, and the same difficulty met with in attempting to remove
the free polypus, which was of the size of a large filbert, through
the small os. Ultimately the os was divided to allow of the possi-
bility of extraction.
The third case occurred in a married patient in Inverness-shire,
who had had great intercurrent menorrhagia for nearly eighteen
months. Sir J. Y. Simpson visited her at her own home in
Inverness-shire, and thought he detected the presence of polypi with
the uterine sound; but as a long diagnosis with dilatation was
required, she was removed to Edinburgh when her strength was
sufficiently recovered. In this instance, after the os uteri was
opened, first one semi-pediculated polypus was felt and removed, and
then the presence of a second similar one was discovered high up in
the uterine cavity, and detached by partially cutting through its
pedicle, and then dragging it down with vulsellæ. In regard to
these cases of intra-uterine polypi, Sir J. Y. S. added the following
inferences :-
1st, In such cases of intra-uterine polypi, the presence of the
disease may be guessed by the increased size of the uterus, and
particularly its cervix, which sometimes expands above as it does in
a threatened abortion, and by a persistent and sometimes a great
menorrhagia. Occasionally it can be felt by the uterine sound, used
like a metallic finger, but usually not with any great certainty. The
only certain mode of diagnosis consists in dilating the cervix uteri
so as to feel the interior of the uterine cavity with the finger, and
touch the polypoid body. He adverted to a case which he saw with
Dr. Wood, many years ago, of a patient who died of hemorrhage
from intra-uterine polypi. The autopsy in this case first suggested
the idea of reaching and diagnosing the intra-uterine tumour by
opening the cervix with some dilating body.
2d, For this purpose, sponge-tents were suggested and used by
him; and more lately Dr. Sloan proposed tangle-tents. He believes
SULPHATE OF ZINC AS A CAUSTIC.
757
that tangle-tents are to be preferred when a slight dilatation, as for
dysmenorrhoea, was required; but for a greater degree of dilatation,
when we require to introduce the finger and remove a polypus,
sponge-tents are preferable.
3d, In making the diagnosis, it is usually necessary to push down
the fundus uteri with one hand pressed against the abdominal
parietes, and by the forefinger of the other hand search the interior
of the uterus.
4th, In removing intra-uterine polypi, he had sometimes found
torsion an easy plan, but the forceps must be strong in blade and
joint to give the necessary power. Torsion succeeded best when the
pedicle was small. When the pedicle was large and thicker, and
when the tumour was only of a polypoid character, division, with
the tenotomy knife, of the tissue-covering of the thick neck, or even
of the body of the polypus, greatly facilitated its extraction. A
small polyptome, as in two of these cases, was sometimes the
simplest method of dividing the pedicle; and perhaps a loop of a
wire écraseur might be passed over it to separate it, but usually not
without much difficulty.
5th, But our armamentarium was chiefly deficient at the present
time in proper means to seize and extract the polypus after it was
separated. Fibroid polypi are elastic, and readily jump out of the
catch of any form of polypus forceps. Sir J. Y. Simpson had tried
an improved form of lithotrite to lay hold of them, but it had also
failed. Vulsellæ with very long teeth were difficult to open in the
narrow uterine cavity, and the teeth were apt to catch hold of the
uterine walls. The best instrument which he had yet found was a
vulsella provided in each blade with three small and short teeth ;
but he suggested to the society whether some of the members could
not invent a more fit and useful instrument for the purpose.
SULPHATE OF ZINC AS A CAUSTIC IN UTERINE
CANCER, ETC.¹
Sulphate of zinc is a drug extensively and daily employed by
medical men in solution, in the form of collyria, of lotions, of injec-
tions, etc. No writer, however, has, as far as I am aware, hitherto
pointed out that when applied as a fine powder to an open and
diseased surface, sulphate of zinc acts as one of our most powerful
1 See Medical Times and Gazette, January 17, 1857, pp. 56 and 78.
758
DISEASES OF WOMEN.
and manageable caustics. In using it for this purpose I have always
employed it dried or anhydrous, and finely levigated. Sometimes I
have applied it in the form of a simple powder, sometimes in the form
of a paste made with glycerine, and sometimes as a strong ointment.
To work it into a paste, about one drachm of glycerine to an ounce
of the dried powder is required; and in this form it keeps for any
length of time ready for use. A caustic ointment may be formed
by pounding together two drachms of axunge with an ounce of the
dried sulphate of zinc.
When used in the form of a powder, paste, or ointment, to an
open or ulcerated surface, the part to which it is applied is rapidly
destroyed to a depth corresponding to the thickness of the super-
imposed layer. The slough, eschar, or devitalised part, is of a white
colour, and usually separates on the fifth or sixth day, leaving behind
it (if the whole morbid tissue is removed) a red, granulating, healthy,
and rapidly cicatrising wound. I have sometimes seen the edges of
the wound already more or less puckered and contracted at the
time of the separation of the eschar. The white slough or eschar
itself shows no tendency to chemical or putrefactive decomposition,
but is firm in texture and free from taint or odour. If we apply
the sulphate of zinc in any case of malignant or semi-malignant
ulcer or deposit, it will require to be repeated immediately after the
first or preceding eschar separates, provided any yellow or unhealthy
tissue remain at the bottom or in the sides of the wound, or if the
surrounding hardness is not yet quite dispelled. After the last
eschar is removed the remaining wound or sore will rapidly heal up
under any common applications, as black wash, astringent lotions,
water-dressing, etc.
Sulphate of zinc, like chloride of zinc, will not act as a caustic
where the epithelium is entire, or unless it be applied to a broken
or open surface. This is at once an advantage and a disadvantage;
an advantage in so far that it prevents all fear of the caustic ever
unnecessarily affecting any of the healthy contiguous surfaces and
parts, and renders its application and use far more simple and cer-
tain; and a disadvantage, because when we wish to apply it to a
non-ulcerated structure, we must first remove the intervening epithe-
lium by a small blister, or more effectually by the application of an
alkaline or acid caustic. A paste made with sulphuric acid and
powder of sulphate of zinc will both, perhaps, at once remove the
epidermis, and give at the same time the action of the mineral
caustic. If too liquid it may be prevented from spreading beyond
SULPHATE OF ZINC AS A CAUSTIC.
759
the desired spot by enclosing that spot within a circle of oxide of
zinc powder, or within a ring made with an oxide of zinc paste.
The local inflammatory reaction around a sulphate of zinc eschar
is generally slight and transient. I have never witnessed any very
marked effusion or swelling in the surrounding parts, except where
the caustic was used in the neighbourhood of parts containing a
large quantity of loose cellular tissue. Nor have I ever seen the
general system affected by any absorption of it, or any special con-
stitutional symptoms or disorder follow the topical application of
sulphate of zinc, however freely and lavishly used. Like other
strong caustics, its action is usually, but not always, attended for a
few hours with considerable local pain and burning. This local
suffering, however, generally disappears more rapidly with sulphate
of zinc than with arsenic or chloride of zinc, and may always be
relieved when necessary by the temporary use of anaesthetics or
opiates, or by applying locally along with it, or before it, a very
small quantity of sulphate of morphia. The devitalised part or
eschar also produced by sulphate of zinc separates sooner than after
most other caustics. The eschar made by arsenious acid seldom
separates before the sixteenth or eighteenth day; that made by the
chloride of zinc usually separates from the tenth to the twelfth day.
I have generally found the eschar made by sulphate of zinc to
separate as early as the fifth or sixth day.
The advantages of the sulphate of zinc, as compared with other
caustics, are, therefore, in general terms:-1. Its powerful escharotic
action; 2. The rapidity of its action; 3. Its great simplicity and
manageableness; 4. Its facility of application; 5. Its non-tendency
to deliquesce or spread; 6. Its perfect safety; and 7, I believe I
may add, its efficacy.
On this last point, however, more experience will require to be
accumulated than I can yet offer. But I have seen not only the
surface of cancroid or cancerous ulcers speedily and perfectly ex-
cavated by its application, but the surrounding characteristic in-
duration become at the sarne time rapidly absorbed, and the
remaining wound very speedily cicatrise. I have seen, more than
once, ulcers with irregular everted edges, dirty cavities, and indurated
bases and sides, and which had been open for years, become quite
softened, closed, and healed over, within five or six weeks after the
first application.of the caustic. In spreading epithelial or cancroid
ulcer of the cervix uteri, I have found in as brief time, under the
free local application of powdered sulphate of zinc, the ulcerated
760
DISEASES OF WOMEN.
surface exfoliated, the sanguineous and sero-purulent discharges
arrested, the parts temporarily, at least, if not permanently,
cicatrised, and healed, and the patient's health, strength, and spirits
restored, though, when first inserting the caustic, I believed the
disease to be altogether beyond the reach of any remedial measures.
Let me add here, that I have tried as caustics other metallic
sulphates besides the sulphate of zinc. The sulphates of iron, nickel,
etc., have a similar escharotic action, without presenting, as far as I
know, any special claims or advantages.
In a preceding paragraph it has already been remarked that
many of the most famed secret pastes and applications that have at
different times and in different countries been in fashion for the cure
of cancer, contain arsenical preparations as their essential and
efficient base. Perhaps it may be found that sulphate of zinc is the
principal ingredient in other secret caustic remedies. A few days
ago, after showing some examples of the caustic properties of
sulphate of zinc to Dr. Johnston of Worcester, Massachusetts, during
a brief visit which he paid to Edinburgh, that gentleman stated to
me, that from accidental information which he had obtained from
a druggist, he believed sulphate of zinc to form the basis of one, if
not more, celebrated secret American applications for the cure of
cancerous disease.
Caustics are often used in practice for other purposes than the
extirpation of cancerous and cancroid malignant and semi-malignant
ulcerations and deposits; and I have successfully employed sulphate
of zinc in fulfilling most of the indications for which escharotics are
resorted to, as for example-
1. In the treatment of indurated inflammatory ulcers of the
cervix uteri. To this part it can be readily applied, either through
a speculum, or still more easily by means of a small ivory or wooden
cylinder and piston, like the common leeching tube, or like Dr.
Locock's glass tube for carrying silver solution; or in the form of a
medicated pessary, made up with a small quantity of axunge or
glycerine.
2. In cases of lupus and rodent non-malignant ulcers of the nose
and face, and other integumental parts. Here we must not forget
Rayer's rule, that not one, but a succession of applications of any
caustic, is generally necessary for ultimate success.
3. In the annoying and intractable ulcerous forms sometimes
assumed by certain cutaneous affections. Thus, I have seen it arrest
a case of Impetigo Rodens, which, in despite of various applications,
had gone on progressing for two years.
LATENCY OF SYMPTOMS IN CANCER OF UTERUS.
761
4. In eating down the small red sensitive tumours so common
at the orifice of the female urethra, and in the neighbouring vulvar
mucous surfaces.
5. In destroying ulcerated condylomata and warty excrescences.
6. In several cases I have easily introduced the sulphate of zinc
and glycerine paste, by means of a small catheter-like tube and
piston, into the proper cavity of the uterus, to cauterise the open
surfaces and diseased structures leading to obstinate menorrhagia ;
and which deep points it is, I believe, sometimes difficult, or indeed
impossible, to reach with any other efficient caustic. In the uterine
cavity, as elsewhere, sulphate of zinc acts only upon any abraded and
diseased surfaces that exist, and not to any extent upon the parts
covered with healthy mucous membrane
7. I have tried to take advantage of the highly contracting
power of the cicatrices left by sulphate of zinc in the replacement
and sustentation of chronic prolapsus of the uterus and bladder.
It will, perhaps, be found also adapted to the treatment of some
obstinate ulcers of the limbs, and to the early cauterisation and
destruction of syphilitic chancres and pustule maligne.
Other practical applications of sulphate of zinc as a caustic will,
no doubt, betimes suggest themselves to the minds of the clinical
surgeon and physician.
To obtain the fullest caustic action of the salt, the part or surface
to which it is applied should be previously dried, or at least free
from much moisture.
OCCASIONAL LATENCY OF THE SYMPTOMS IN
ADVANCED CARCINOMA UTERI.'
In the earlier stages of cancer of the uterus, the disease is, as a
general rule, accompanied by few, or indeed no, well-marked dynamic
symptoms. Patients themselves, and sometimes also the members
of the profession, seem to expect that the advent and presence of
this fatal malady should be very constantly accompanied with local
pain and suffering. The reverse, however, of all this seems to be
the general rule. In fact, it rarely happens that a patient affected
with uterine cancer applies at all for medical advice till the disease
has advanced beyond the stage of deposit, and has already made
more or less progress in the stage of ulceration. Even then the
› See Edinburgh Monthly Journal of Medical Science, January 1852, p. 41.
762
DISEASES OF WOMEN.
local symptoms which excite the patient's attention are usually not
the expected pathognomonic pain, but occasional attacks of hemcr-
rhage, attended with leucorrhoeal discharge. Or, if the pain is pre-
sent, it often as yet only amounts to a sensation of discomfort and
uneasiness, and not to a feeling of actual suffering Nay, sometimes
any feeling of pain in the uterus or uterine region itself never super-
venes at all, or not till the very last period of the affection. In the
course of practice I have happened to see a number of cases to
which this remark applies. Instances also occasionally occur where
the patient suffers more or less severely from pain; but that
symptom is in the form of a sympathetic or reflex pain, situated,
not in the uterus, but in the limbs, loins, or some other distant part.
Several years ago I had occasion to examine a case in which the
cervix uteri was entirely eaten away by extensive cancerous ulcera-
tion; but without any marked local pain. The patient, however,
had complained so much of pain in the mamma, that local anodyne
and other applications had been applied to that part of the body.
Dr. Davidson told me the particulars of a case in which the patient
complained to her medical attendant of nothing during life, except
a series of severe urinary symptoms, for which she had ineffectually
undergone a variety of treatment. On opening her body after death
the coats of the bladder were found deeply implicated in a mass of
ulcerated uterine carcinoma. The following case, which I saw within
the last few weeks with Dr. Cowan, in a patient who came from a
distance in the country, is one of the most striking illustrations
which I have met with of the occasional latency of the local symp-
toms of cancer of the uterus, even in a very advanced and ulcerated
stage, and of the transference, as it were, of the principal suffering
and symptoms to another organ :
CASE.-A lady, æt. 43, married at a very early age, and the mother of six
children, had enjoyed the most robust health until twelve months ago. About
that period she first observed a white discharge from the vagina, which she
believed to be common leucorrhoea. There likewise occurred repeated discharges
of blood, sometimes in large coagulated masses and shreds. At the same time the
catamenia recurred with regularity and without pain. About three months since
she first complained of such prostration as prevented her taking her usual amount
of exercise; difficulty and pain also in passing water; and latterly, incontinence
of urine supervened. During all this period she experienced no feeling of uneasi-
ness referable to the uterus itself; nor was the leucorrhoea or menorrhagia of a
nature or extent calculated to excite in the mind of the patient any feelings of
alarm. In fact the principal, and, according to her own account, her almost sole
symptoms, were the debility already mentioned, and the painful dysuria, which
had, however, been relieved by alkalies.
CANCER OF CAVITY, BODY, AND FUNDUS OF UTERUS.
763
On making a vaginal examination, I found the cervix uteri, with the upper
and anterior part of the vagina, the seat of extensive carcinomatous induration
and ulceration. The disease in its ulcerative process had in fact proceeded so
far at one point, that it had implicated and already perforated the neck of the
bladder—thus leading first to the dysuria, and subsequently to the incontinence
of urine, of which the patient so much complained.
In a note from Dr. Cowan, dated December 20th, he states :—
"At present our patient's appetite is good; bowels regular. She
sleeps well, and the general appearance is improved rather than
otherwise since you saw her. All she complains of is, general
debility, incontinence of urine, with a thin white non-acrid dis-
charge, and occasionally, but not constantly, heat in the region of ·
the uterus, unaccompanied with pain. All other symptoms of exten-
sive uterine disease are absent."
6
Dr. Cowan has further stated to me, in a recent communication :
Mrs. C. died ten months after you and I visited her together in
Edinburgh. She gradually sank under the extension of the can-
cerous disease. Some time after you and I saw her, the symptoms
were still so slight and trivial, that another medical man whom she
saw declared that it was impossible she could have such a serious
malady as cancer. She died in Paris, and the French physicians
whom she consulted for a time doubted the correctness of your
diagnosis and prognosis, her symptoms looking still so slight. But the
subsequent course of the affection showed them the true cancerous
nature of her disease."
ON CARCINOMATOUS DISEASE OF THE
CAVITY, BODY, AND FUNDUS OF THE UTERUS,
THE CERVIX BEING UNAFFECTED.'
Most pathologists and practitioners have laid it down that the
cervix uteri is always, or almost always, the portion of the uterus
that is first and principally affected in cases of cancer.
3
In a preceding page, we have seen Rokitansky stating that cancer
of the uterus always attacks the cervix in the first instance." ~
"Cancer of the uterus," observes Dr. Walshe, "almost invariably
originates in the cervix." In describing carcinoma uteri in his work
on the Diseases of Females, Sir Charles Clarke remarks, "This disease
1 See Obstetric Memoirs and Contributions, vol. i. p. 193.
2 Manual of Pathological Anatomy, vol. ii. p. 300.
3 The Nature and Treatment of Cancer, p. 96.
764
DISEASES OF WOMEN.
"" 1
attacks only in the first instance the cervix of the uterus, and the
author," he adds, "lays great stress on this observation.
"The
cancerous action," according to Dr. Francis Ramsbotham, "first
assails the tissues of the os and cervix uteri. I believe," he con-
tinues, "this is invariably the case.'
11 2
Such strong statements are liable to mislead the practitioner,
and to cause, ever and anon, errors in diagnosis and prognosis. No
doubt, the cervix of the uterus is much more frequently the seat of
carcinomatous disease than the cavity of the organ, or the tissues of
the body and fundus. But I have been myself deceived, and have
seen others deceived, by the common belief that cancerous affections
never originate in the cavity, body, or fundus of the uterus, and
without the cervix being primarily or contemporaneously attacked.
In the course of practice, I have seen, on the contrary, a very con-
siderable number of instances in which carcinomatous disease, when
affecting the uterus, has primarily sprung up in the cavity of the
organ, or in the walls of the fundus or body, and in which the
tissues of the cervix have remained sound to the last, or at most
been only affected secondarily.
Carcinoma, when it attacks the cavity, body, or fundus of the
uterus, may appear under different types or forms. The principal
varieties of it which I have had occasion to observe in practice are
the following:-
1. When carcinomatous disease attacks the cavity of the uterus,
it sometimes presents the form of an irregular, flat, or roundish
fungoid excrescence, attached by a broad basis to a greater or less
extent of the interior of the organ.
CASE I. The first decided instance of this kind which I had an opportunity
of seeing was in an unmarried lady, forty years of age, the sister of a distinguished
English physician. For many months she had suffered under a constant and
copious discharge of watery fluid from the genital canals, with occasional slight
hemorrhage, and gradual emaciation; but there was no local pelvic pain or suffer-
ing. She was for some time under the care of an esteemed obstetric practitioner
here-a friend of her brother's-and a great variety of applications were employed
by him to arrest the profuse serous discharge. These applications had been all
made to the surfaces of the vagina and cervix uteri; but without any effect on
the copious morbid secretion. When I saw the patient with her physician and
relative—as there was apparently no diseased state of the vaginal canal or cervix
uteri, I suggested the introduction of a sponge-tent into the os uteri, with a view
1 Observations on the Diseases of Females, p. 207.
2 London Medical Gazette for 1835, p. 466.
CANCER OF CAVITY, BODY, AND FUNDUS OF UTERUS.
765
of shutting up that aperture for a time, and thus ascertaining if the abundant
watery secretion did not proceed from the cavity of the uterus itself. As long as
the tent remained in the os uteri the discharge was arrested-a phenomenon not
observed for many months before; and on withdrawing it there was a copious
rush of the characteristic clear fluid. The morbid source of it was thus proved to
be some point or points in the interior of the uterine cavity. On opening up the
os and cavity of the cervix more fully with sponge-tents, we were able to reach
the edge of a rough tuberose excrescence, attached by a broad basis to the interior
of apparently a great part of the cavity of the uterus. Small granular portions of
it were easily detached by the finger or nail. It seemed to all of us a sessile car-
cinomatous or cauliflower growth growing in the cavity of the uterus. The dis-
charge continued and increased; and the patient ultimately sank under the usual
course of cancer about eighteen months subsequently.
CASE II. A short time afterwards I was sent for to the Highlands to see, a
week or two before her death, a patient who had long suffered under the same
kind of profuse watery discharge; but in her the local disease was much farther
advanced. The os uteri was dilated to the size of a two-shilling piece; the orifice
was round, and its lips thin and healthy-exactly like the uterine orifice in the first
stage of natural labour. There projected, however, through this opening, not any
part of an ovum or fœtus, but a rough irregular mass, granular on its surface, and
very friable and lacerable in its structure. It bled profusely when touched. On
passing the finger over the edge of the dilated os, and within its interior, the
fungating structure protruding from the uterine opening was found springing, as
it were, from the interior of the cervix uteri all around, at a height varying from
a few lines to about an inch. In the centre of the protruding excrescence there
was an opening leading up, as shown by the uterine sound, into the cavity of the
The uterus itself was enlarged, and could be felt midway between the
pubes and umbilicus. Its whole interior seemed to be filled by an accumulation
of this epithelial cancer. This patient was about 33 years of age. She had been
long married without having any children.
uterus.
Since the above period I have seen several cases of the same
nature as the above at different stages of their progress. Occa-
sionally, as in the last case I have described, the os uteri was so
open as to allow the carcinomatous structure springing up from the
interior of the cavity to be felt at once by the finger. In one or
two instances, I have seen the carcinomatous fungus protruding
through the os, sloughing and gangrenous from the stricture and
compression of the circle of the os upon it. But in most instances
the disease has been in an earlier stage; the patient complaining of
watery and bloody discharge from the cavity of the uterus; and the
true nature of the malady was not ascertained till the canal of the
cervix was artificially dilated for the purpose of a more accurate
diagnosis by the finger.
In some of these instances of carcinoma affecting the interior of
the uterus, the whole bulk of the organ is little, if at all, increased
beyond its natural dimensions, and the discharge is bloody rather
766
DISEASES OF WOMEN.
than serous ; but towards the termination of the disease, it begins
to present the odour peculiar to cancer, with shreds and fragments
of the cancerous tissue passing along with it.
CASE III.—In a patient, aged 50, I saw the disease of the uterus followed by
cancerous disease of the mamma. A few years after the regular catamenia had
ceased, this lady observed from time to time a slight bloody or sero-sanguineous
discharge from the vagina. On examination, the cervix uteri felt normal and
healthy, and the whole uterus was of the natural size. After suffering in this way
for a couple of years, carcinomatous disease appeared in the right mamma, and
she died in the course of a twelvemonth, without, however, the affected mamnia.
ulcerating or fungating. A few weeks before her death, portions of cancerous
excrescence protruded from the os uteri; but up to the last the cervix uteri
remained unaffected.
2. Occasionally, cancer affects the cavity of the body and fundus
of the uterus, in the form of carcinomatous ulceration, and without
any appearance of excrescence and fungation.
I have seen this form of uterine cancer destroy life without any
other complication. But more frequently, I have seen it result
apparently as the effect of the long-continued irritation of a pedi-
culated fibroid polypus upon the interior of the uterus.
CASE IV.—In a case of long-standing menorrhagia, after dilating the uterine
canals with sponge-tents, I removed, in the presence of Dr. Arneth of Vienna, a
small hard intra-uterine polypus, attached by a short pedicle to the fundus uteri.¹
The menorrhagia, however, shortly afterwards returned, and the patient died with
the usual symptoms of uterine cancer about eight months afterwards, the cervix
remaining, however, still unaffected.
CASE V. Three years ago, I saw repeatedly, during the last twelvemonth of
her life, a patient of Dr. Brotherston of Alloa, who complained of bloody and fetid
discharges from the vagina, with the os and cervix uteri, however, apparently
quite healthy. She was about sixty years of age, had borne a large family, and
menstruation had ceased thirteen years before the morbid discharge appeared.
The discharge was from the first offensive in smell, and of a greenish colour.
There was a feeling of weight and uneasiness which never amounted to pain. At
last, a fibroid polypus, which was in the interior of the uterus, sloughed and
separated, and was removed artificially in a succession of pieces. For some time
the patient's health seemed to be comparatively restored, and the discharges
diminished; but again they became greater in quantity, very offensive, and occa-
sionally mixed with blood. After one severe attack of hemorrhage ten days before
death, all discharge whatever ceased, as if the canal into the cavity of the uterus
had become occluded. Shortly afterwards, great collapse supervened; tho alcer-
ated uterine walls having become lacerated or perforated by the retained and dis-
tending secretion. On dissection, the cervix of the uterus, from the os externum to
the os internum, presented a perfectly healthy appearance. The body of the organ
¹ Dr. Arneth has recorded the case in his Geburtshülfe und Gynækologie in
Frankreich, Grossbritannien, und Irland.
CANCER OF CAVITY, BODY, AND FUNDUS OF UTERUS. 767
was distended into a large cavity, about five inches long, containing a semi-putrid
fluid, and with its surface in several parts excavated by cancerous ulcerations, one
of which had completely perforated or broken through the back wall of the uterus.
The os internum uteri seemed to form a complete line of demarcation between the
diseased and healthy parts. There was an abundance of pus and lymph in the
peritoneal cavity.
CASE VI. Last year I showed to the Medico-Chirurgical Society¹ the drawing
and preparation of a case of cancerous ulceration and perforation of the fundus
uteri, where there still existed, attached by a short pedicle to the interior of the
uterus, the remains of a fibroid polypus. The cervix uteri was unaffected with the
cancerous disease. The patient had long suffered from menorrhagia and fetid dis-
charges from the genital passages. But as in most other cases of carcinoma of the
cavity of the uterus, she complained of little or no local pain during the course of
the malady.
Let me observe in passing, that I have seen two or three well-
marked instances of carcinoma of the cervix uteri follow apparently
the irritation of a polypus when allowed to remain long without
removal, even after the body of it had passed from the cavity of the
uterus to the cavity of the vagina.
3. The soft or encephaloid variety of cancer sometimes affects
the structures of the fundus and body of the uterus, without impli-
cating the tissues of the cervix. In this variety of the disease the
cancerous structure is seated in the walls of the fundus and body,
and not in the cavity of the uterus. Sometimes the tumour reaches
rapidly the size of a uterus at the fourth or fifth month of pregnancy.
In this form there is not usually any menorrhagia or any peculiar dis-
charge from the vagina. In the following instance, while the patient
was under my care, hemorrhage accompanied it, but the hemorrhage
was from the urinary, and not from the genital canals.
CASE VII.-An unmarried lady, 40 years of age, suffered for some time from
pains in the back and lower extremities, particularly after exertion. When at last
an examination was instituted by her physician in Dublin in 1851, a large tumour
was found in the uterine region. Early in 1854 the tumour increased much and
rapidly in size, and when I saw her soon after, it already reached half-way between
the pubes and umbilicus. But still there was no appearance of general cachexia
observable. After a few weeks the morbid structure again suddenly assumed a
rapid growth; a dark, sanious, and bloody discharge was passed from the bladder ;
and the patient sank exhausted in the course of a few days.
On laying open the abdominal cavity, the omentum was found adherent to a
morbid mass, reaching from the pelvis to a point higher than the umbilicus. This
mass or tumour was covered by large tortuous vessels; had a soft general con-
sistence; and near the summit it was broken down and pulpy, and had evidently
all but burst into the cavity of the peritoneum. The whole fundus and anterior
wall of the uterus were implicated in the structure; but the cervix and tissues im-
1 See Edinburgh Monthly Journal of Medical Science, March 1854, p. 285.
768
DISEASES OF WOMEN.
mediately surrounding it were free from morbid deposit, except in the form of two
or three minute nodules. The bladder, however, was perforated posteriorly, and
a portion of dark fungus from the uterine tumour projected into its cavity. The
tumour, which was carefully examined, had all the characteristics of the Ence-
phaloid or Hæmatoid variety of cancer. The cavity of the uterus presented no
appearance of the disease, while the structure of the anterior wall and fundus of
the organ was lost and merged in the encephaloid mass itself.
ON CARCINOMA OF THE BODY AND FUNDUS OF
THE UTERUS.¹
Professor Simpson said he had once or twice already called the
attention of the Society to the occurrence of carcinomatous disease
in the body and fundus of the uterus; and he had been induced to
do so because of the allegation of Ramsbotham and others, that
malignant disease of the uterus always commenced in the cervix,
and only extended secondarily to the rest of the organ. He (Pro-
fessor S.) had already demonstrated the fallacy of this observation,
and had related the history of several cases where the disease had
originated in the higher segments of the uterus; but he had thought
it advisable to bring another illustrative preparation under the
notice of the Society, the more especially as he was desirous of
directing attention to a symptom which was very distinctly observ-
able in the patient, at whose autopsy the preparation had been
obtained, and which had been very marked in most of the cases
that have come under his observation. The symptom he referred to
was the daily recurrence—usually at a regular hour-of intense
paroxysms of pain, beginning, perhaps, slight and intermittent, but
soon reaching a high pitch of intensity, at which it continued for an
hour or two, and then gradually subsided. Sudden and severe
spells of pain of a shooting, lancinating, or "coruscating" character,
such as were seen in cases of cancer of the mamma or other organs,
and in the more ordinary forms of carcinoma uteri, were often
observable also in the cases under discussion, where the disease had
its seat high up in the organ; but what he wished to insist on in
connection with the latter class of cases, was this, that in addition
to the more indefinite and sometimes merely momentary pangs, the
patient at some period or other of her history was also subject to
the daily recurrence of the intermittent paroxysms of pain, which
¹ See Proceedings of Edinburgh Obstetrical Society, November 25, 1863, in
Edinburgh Medical Journal, April 1864, p. 945.
CANCER OF BODY AND FUNDUS OF UTERUS.
769
sometimes lasted for hours, and might be so intense as to cause the
patient to groan continuously, or scream aloud. As to the recogni-
tion of such cases, he might state that it had been doubted whether
a true diagnosis could be made out during life; and a few months
ago, when the two patients, whose history he was about to relate,
were lying in his ward in the Royal Infirmary, and he was bringing
them under the notice of a distinguished English obstetrician, who
had kindly come to make the visit with him, that gentleman, after
having examined the cervix uteri with his finger, and found it per-
fectly healthy, said, "But how do you know that there's cancerous
disease inside the uterus in those women?" Well, it was commonly
observed in these cases that there was-1st, a disagreeable watery
discharge going on almost constantly, and to an unusual extent.
Then, 2dly, there was frequent, and sometimes profuse menorrhagia,
which was incapable of being arrested by any of the ordinary medi-
cines or applications and injections into the vagina. With regard
to this special symptom, he might state, that on the first occasion
when he (Dr. Simpson) saw and recognised a case of the kind under
consideration, this was the most prominent and distressing of the
patient's symptoms. The lady was the sister of a medical man, and
he (Professor S.) was called to see her in consultation with the late
Dr. Thatcher, who showed the cervix through the speculum free
from disease, and was inclined to think there could be no malignant
formation present. A sponge-tent, however, having been introduced
into the uterus, the discharge for the first time for many months.
had been arrested. On the withdrawal of the tent the pent-up
fluid had gushed out, and the finger passed through the dilated
cervix had felt the interior of the uterine cavity containing a mass
of malignant tubercular granulations. In another patient whom he
(Professor S.) had seen in the hospital that day, the bleeding had
been going on almost daily for twelve months. Then, 3dly, by
means of the sound we could feel the foreign body in the interior of
the uterus; and by dilating the cervix with sponge-tents, we could
introduce the finger and feel the diseased portion, hard, rough, and
irregular, or more soft, fungoid, and friable. 4thly, Pieces of the
morbid texture sometimes passed off and could be scraped off for
microscopical examination. And, lastly, there was often, but by no
means in every case, the periodic recurrence of the characteristic
pains to which he had been calling their attention. The cases
whose histories he (Professor S.) wished to relate, had been entered
in the Infirmary Journal as follows:—
770
DISEASES OF WOMEN.
CASE I.-E. W., aged 29, from Whitekirk, Haddington, admitted to the
hospital 20th December 1862.
Patient states that, in September 1862, she found her menses increase greatly
in quantity, and continue from one period to another, the discharge being
sometimes greater, at other times less, according as she employed means to check
it or not. To check the flow, she used cloths dipped in vinegar; but, finding it
continue, she was obliged to give up her situation. She was sent to the ward
from the Servants' Home as a case of menorrhagia.
On admission, patient complained of a fixed pain in the left side of the belly,
as well as of the discharge already mentioned. The sound, when passed into the
uterus, entered the full distance, no more. Ordered of tr. cannabis Indicæ, 10
drops in water, twice daily.
23d December.-Pain and discharge much increased. Dose of the medicine as
above, doubled; and to be repeated thrice daily, which checked the flow.
5th January.—Sore throat, which was treated with infusion of hæmatoxylon
as a gargle.
8th.-Throat better; gargle discontinued.
12th.-Abdominal pain severe as ever, but discharge ceased. Patient is
taking no medicine.
19th.—Patient states that pain comes on periodically at 9 A. M., continues
more or less severe through the day, and disappears at night.
22d. It was supposed some irritating cause was within the uterus; so two
sponge-tents were introduced, to dilate the os. When they were both withdrawn,
there was separated by means of the finger a small irregular mass of fatty-like
matter, some parts of which were tough, and other parts soft, having in it a
patch of soft, cheese-like matter. This was pronounced by Professor Simpson to
be carcinomatous. Under the microscope, it presented compound granular cor-
puscles, and others filled with fat.
28th. Since the last date (22d), patient has felt the sharp stinging pain in
the left side of the abdomen and left iliac region much increased. It has been
treated by painting with iodine, by liniments of belladonna and glycerine, and
by opiates given both by the mouth and rectum.
30th.-Ordered of the following :-R Ext. cannabis Indicæ, gr.i.; Quinæ
sulph., gr.iij., ft. pil.,-one pill, twice daily.
1st February.—Began using belladonna pessaries containing a few drops of
chloroform.
2d.-Complained of disordered digestion and vomiting, and was ordered the
following:-R Bismuth. albi, gr.iv.; Pulv. ipecac., gr.ss. M.-Ft. pulv. Sig.
One, twice daily.
11th. The uterus having been again dilated by sponge-tents, Professor
Simpson scraped away some portion of the growth.
16th.-Patient has been relieved of the severe cutting pain ever since the
operation. She experiences now only a feeling of uneasiness, and does not require
opiates, pessaries, or draughts. She has been taking for the last three days the
following:- Quinæ sulph., gr.i.; Cerii oxalatis, gr.i.; Conf. rosæ, q. s. M.-
Ft. pil. tales xii. Sig. One, thrice daily.
2d March.—Patient continued much relieved till this date, when the cutting
pains recommenced.
5th.-A sponge-tent re-introduced with some difficulty, as the anterior wall
of the uterus is enlarged, and the uterus itself anteverted.
13th.-Complains of great pain, relieved by the use of brandy.
25th.—The cervix having been dilated by two sponge-tents, Professor Simpson
removed a portion of a carcinomatous growth.
CANCER OF BODY AND FUNDUS OF UTERUS.
771
6th April.-Patient has been relieved of her severe pains by the last opera-
tion, and has only complained of uneasiness since. For the last eight days,
however, she has not been able to make water without the use of the catheter.
Nothing like the former growth is to be found within the os. The hard base,
however, on which it was implanted seems to have developed itself into a small
tumour in the anterior wall of the cervix, about the size of a small egg.
on the left of the
17th. There is a flat growth, as large as the tip of the finger, at the upper
end of the vagina, on the left of the cervix. There are also two nodular growths
cervix, the size of small shot. The growth, when touched,
gives rise to pain. She suffers great pain, which has told lately upon her strength
and appetite. Ordered to use min. x. of chloroform in a bottle of soda-water.
This gave relief once or twice, but soon lost its effect. Her urine not passing
freely through the catheter she is obliged to use, ordered, —
Spt. ætheris nit., 3i. M.-Sig. Forty drops, thrice daily.
Tr. ferri mur., Ziss.;
4th May.-Patient finds that nothing relieves the paroxysms of pain so much
as the injection of a teaspoonful of undiluted solution of the muriate of morphia into
the rectum, and the internal use of brandy. The anterior wall of the uterus felt
from the vagina is enlarged and tender. The os is open, and its lip has a nodu-
lated feel on its right and posterior side.
Ward 12 was closed on the 8th of August 1863, and patient was removed in
consequence to Ward 18, where she died on 20th September 1863.
Post-mortem Examination (extracted from Pathologist's Case-book).—On the
21st September 1863, E. W.'s body was examined. The lungs were emphy-
sematous, and the left lung partially adherent. Both contained numerous
cancerous nodules, the largest about the size of a bean. The membranes were
fatty; spleen natural; liver fatty, and the kidneys natural. Intestines were not
examined. The sigmoid flexure was adherent to the fundus uteri, and, in adhe-
sion to it, a large cancerous mass. The bladder was healthy. At orifice of the
urethra there was a nodule of cancerous matter. The uterus was much thickened,
and its interior was ulcerated, and there was found attached to the fundus a
polypus about the size of an almond. The vagina was a mass of cancerous ulcers,
and there was a deep excavation in the posterior wall, which was almost perforated.
The pelvic and lumbar glands were enlarged, and in them there were deposits of
cancer. The mesenteric glands were free from disease.
CASE II.—M. R., aged 50, admitted 29th January 1863. Patient states that
she has been ailing since May 1861. For eight or nine months previous to that
date she had had little menstrual discharge, till one day, after lifting a heavy
weight, a bleeding came on,' which was repressed by means of wet cloths in four
or five days. In January 1862, the bleeding commenced again without any
apparent cause. After having used a wet compress to stem the bleeding, for a
fortnight, she felt pain in the hypogastric region, extending from one side of the
abdomen to the other, and striking through the body to the back. This pain has
continued ever since, and now begins at 12, 1, or 2 o'clock in the day, culminates
between 3 and 5 o'clock, and leaves her entirely about 6 or 7 o'clock, unless a
second attack is going to come on, in which case she has a remission till 10
o'clock, when the pain returns for two hours. Patient has had no bearing-down
pains. The discharge, which, for a fortnight in January 1862, consisted of pure
blood, is now water, with a little blood. It has no odour, and is sufficient in
quantity to wet four napkins in the day. The patient is yellow in complexion,
and has an anxious look. Her disease has been treated, but without success, by
the wet compress, sponging with acids, quinine, and Donovan's solution.
50
772
DISEASES OF WOMEN.
On examination, the uterus was felt to be enlarged both anteriorly and
posteriorly, but more especially in the latter direction. The sound passes into
the uterus three inches. After dilatation by sponge-tents, a slender, long, soft
polypus was felt distinctly, depending from the fundus, with another short growth,
either part of itself or a distinct polypus, attached anteriorly also on the fundus.
On the posterior wall, a good way up, there is a small nodule, which appeared to
be about the size of a pin's head.
2d February.-Ordered, R Ext. belladonnæ, gr.ss.; Pulv. magnesiæ, q. s.
M.-Ft. pil. tales xii. Sig. One, twice daily.
12th. The uterus was dilated by two sponge-tents, and Professor Simpson, on
making an examination, was led to consider this a case of malignant disease.
Ordered patient twenty-five drops, thrice daily, of liq. secal. cornuti.
5th March. Two more sponge-tents have been introduced, and Professor
Simpson thinks that the uterus is somewhat swollen, and ordered,—B Tr.
cannabis Indicæ, 3ii.-Sig. Twenty-five drops, thrice daily. Two days after the
sponge-tents were introduced, the pain began to abate, and it has been less since.
25th.-Two sponge-tents having been introduced, and the parts well dilated,
there was felt at the fundus of the uterus a growth resembling half a marble, at
the side of which there were some ragged tufts. This mass Professor Simpson
scraped away.
6th April.-Patient has suffered a great deal of pain lately. It comes on, as
before, periodically, about the middle of the day, and lasts through the afternoon,
and more or less through the night also. Chloroform had been used to lull the
pain for two or three days, but, as it made her sick, and interfered with her
appetite, it was discontinued.
16th.-Ordered to use chloroform in a bottle of soda-water (min. x.) This
caused some relief, but was followed by sickness.
17th.-Dismissed to-day, as her cries were injurious to the other patients, and
as there was no prospect of giving her relief.
Three or four other cases of a precisely similar nature, and
presenting the same train of symptoms, had come under his (Pro-
fessor Simpson's) observation in private practice within the last six
months, and if he had had time to look over the pages of the
Infirmary Journal, he believed there would be found a record of
some other cases besides those he had cited. But he thought the
histories he had related brought out distinctly enough the general
characters and course of the disease, and would serve to indicate the
importance of the special symptom to which at the outset he had
alluded. He had seen similar intermittent, periodic pains in one
single case, where the patient was not affected with cancer of the
interior of the uterus, and in that instance there was a hard foreign
body in the cavity of the organ, resulting from the calcareous
degeneration of a fibroid tumour of the submucous variety. He
had also seen paroxysms of pain, approaching in character to those
seen in cases of internal cancer of the uterus, in two or three
instances of retention of fluid in the cavity of the uterus from
occlusion of the os,-in fact, in dropsy of the organ; but, except in
EFFECTS OF RUPTURE OF OVARIAN CYSTS.
773
those rare and isolated cases, the symptom he had tried to describe
was only to be met with, so far as his observation went, in patients
who were suffering from carcinoma of the body and fundus of the
uterus.
ON INFLAMMATORY AND NON-INFLAMMATORY RUP-
TURES OF OVARIAN DROPSICAL CYSTS.'
The common multilocular dropsy of the ovary may terminate
fatally in various ways when left altogether uninterfered with by
art.
In some cases, when the tumour at last reaches those enormous
dimensions which it sometimes acquires, the mere strong compres-
sion laterally, backwards, and forwards, of the diseased mass upon
the various abdominal viscera, vessels, and walls, and upwards upon
the diaphragm and thoracic organs, proves sufficient in itself to lead
gradually on to a fatal termination, preceded by marasmus, exhaus-
tion, dyspnoa, etc. In such instances there is a slow but increasing
physical clog set to the machinery of various organs that are neces-
sary to the continuance of life-more particularly to the processes.
of nutrition and assimilation; but latterly, even respiration and
circulation come to be more and more interfered with; till at last
the impaired and obstructed mechanism of the body is fatally
arrested. Very often, however, before such a termination occurs,
oedema, particularly of the lower extremities, and ascites, come to be
superadded, hastening the fatal result by their presence; and almost
always it is also hurried onward by the supervention, during the
last stages of the disease, of a greater or less amount of irritative
fever.
But patients suffering under dropsy of the ovary do not always
die from the mere mechanical increase of the tumour, and its mere
mechanical pressure and irritation. Much more frequently inflam-
matory action attacks the walls or dissepiments of the diseased mass
during the latter stages of its growth, and expedites the progress of
the malady towards a fatal termination. Occasionally the inflam-
matory action recurs from time to time in the same cyst or in dif-
ferent cysts, accompanied with fever and local pains, generally of a
slight and obscure kind. Under repetitions of such attacks, the
cysts rapidly increase in size, inflammatory effusions being poured
¹ Sce Edinburgh Monthly Journal of Medical Science, December 1852, p. 521.
774
DISEASES OF WOMEN.
into their cavities or deposited upon their lining membranes; and
sometimes the intervening septa and walls of the tumour become
diseased and broken down under them. Its external or peritoneal
surface is frequently also the seat of inflammatory effusions, and of
consequent local adhesions between it and the neighbouring viscera
and surfaces. One or more cysts, left with purulent effusions in
their cavities, or with the structure of their walls disintegrated,
often enough remain as permanent sources of local and constantly
recurrent inflammatory action in the tumour.
Hectic fever gener-
ally comes to be set up in the system as a consequence; and under
the repeated recurrence of such local and constitutional irritation,
the powers of life gradually give way.
Again, occasionally, when inflammatory action, whether acute or
sub-acute in its course, is present in an ovarian multilocular tumour,
it proves fearfully more rapid in its course, and leads to speedy
death by a different mode. For when the tumour, in one or more
of its cysts, is the seat of acute inflammation, such cyst or cysts
sometimes become so over-distended by inflammatory effusions, as
ultimately to rupture, and allow of the escape of their contents into
the peritoneum. In these cases the walls of the over-dilated cysts
are occasionally rendered friable and lacerable in their structure by
the inflammatory action of which they are the seat, and in conse-
quence of this morbid softening of tissues, the rupture in question
the more readily occurs. In one or two cases I have seen the walls
of the inflamed and ruptured cyst present ulcerations upon its in-
terior, the perforation of the cyst in such instances being begun by
ulceration of the lining membrane and tissues of the cyst, and
per-
fected by mechanical laceration of its exterior or peritoneal coat.
During the last two months I have met with two cases of rapid
death from the rupture of inflamed multilocular tumours of the
ovary, and the consequent effusion of their morbid contents into
the cavity of the abdomen. The first of these cases occurred in a
patient under my care in the ward set aside for female diseases in
the Royal Infirmary. She had been previously under the care of
Dr. Brown of Carronshore.
CASE I.-Mary W., æt. 34, married, was admitted October 6, 1852. She
had borne three children, the youngest of them now four years old. In May last
she first observed a small rounded tumour in the lower part of the abdomen. The
tumour was then of firm consistence, painful on pressure, and slightly movable.
At the date of admission, the abdominal tumour was nearly as large as the uterus
EFFECTS OF RUPTURE OF OVARIAN CYSTS.
775
It
at the full term of utero-gestation, and unequal and bosselated on its surface.
was tense and painful under pressure, and a distinct fluctuation could be traced
in it. The os uteri was situated very high in the pelvis (elevatio uteri), and the
vagina was much narrowed and stretched at its upper extremity.
During the week subsequent to her admission, the patient was merely confined
to bed for the sake of rest, and placed under some simple antiphlogistic treatment.
On the morning of October 13th, seven days after she entered the hospital, she
was suddenly attacked with severe pain in the right hypochondriac region, pre-
ceded by a feeling as if something had burst in the abdomen. This pain in-
creased in intensity during the forenoon, with great and general tenderness of the
abdomen on pressure. In the after part of the day, nausea and vomiting super-
vened, and the pulse rose in frequency and sank in strength.
On the following day, at the time of visit, she expressed herself, however,
much easier; the abdomen was tense, and increased in size, but scarcely now
painful on pressure. The face, however, was very pinched and anxious, the sur-
face cold, and the pulse so small that it could not be counted, and she was
altogether so collapsed that there seemed little hope of her surviving the attack.
That night, however, and during the subsequent day, she rallied considerably.
The pulse became stronger and reduced in frequency, and she improved gradually
for the next fifty or sixty hours. Five days, however, after this first rupture and
attack of peritonitis another and more fatal one supervened. For, early in the
morning of the 18th, when attempting to raise herself in bed, she was suddenly
seized with great renewed pain in the epigastrium, followed by vomiting of
greenish-coloured fluid, extreme coldness of the surface, and other symptoms of
sinking and collapse. The pulse became imperceptible; and she died within
twelve hours.
On a post-mortem examination, the abdomen was found to contain two or three
quarts of turbid serum, while thick layers of unorganised and recently secreted
coagulable lymph covered the peritoneal surface of the ovarian tumour and the
more exposed parts of the abdominal viscera. At some parts, this layer of lymph
was fully an inch in thickness, but quite soft and easily broken down. The left
ovary was small and slightly indurated. The enormous ovarian tumour which
was present, was attached to the site of the right ovary by a pedicle measuring
about two fingers in breadth and thickness.
On removing the tumour out of the abdomen, a quantity of dirty, fetid, puru-
lent fluid made its escape from an opening at the upper and back part of its right
side. The aperture was of such size as to admit the forefinger. Its edges were
ragged and ulcerated; and it exactly corresponded in position to the seat of pain,
when the symptoms of sinking first appeared. On cutting into the cyst with
which the opening communicated, it was found to contain upwards of a pint of
fluid such as has been described. The wall of the cyst, for about an inch around
the point of rupture, was much thinned and softened, and presented a black
colour.
The remaining portion of the lining membrane of the cyst was covered with
patches of recent lymph, and red spots, having the granulated appearance of the
intestinal canal in acute dysentery. At the lower and anterior part of the left
side of the ovarian tumour, there existed another largish cyst, presenting similar
characters when cut into. Several of the smaller cysts of the tumour showed
strong signs of recent acute inflammatory action; and pus oozed out in various
parts when the large multilocular mass was bisected. The intervening septa
were at some parts found to vary from half-an-inch to an inch in thickness, and
presented on division a fibro-cystic structure. No other opening could be found
in the external or peritoneal coat of the tumour, except the one already noticed.
776
DISEASES OF WOMEN.
The following analogous case of fatal inflammatory laceration of
an ovarian dropsical tumour has occurred still more lately in my
private practice. In this, as in the preceding instance, the tumour
was unusually rapid in its general growth.
CASE II. The patient, aged 43, was married in 1836, and had been for
two years a widow. She was the mother of three children. Up to the middle
of last year she enjoyed uninterrupted good health. At that time she began to
complain of pain in the right side; and at the commencement of the present year
the presence of an abdominal swelling was detected by her medical attendants at
Boulogne, where she was residing. In May last she came to Edinburgh, and a
large ovarian tumour was then easily diagnosed. It continued to increase and
soften with extreme rapidity; and in despite of antiphlogistic measures, iodine,
etc., the abdominal swelling and distension were so very great by the first week
of September, that tapping became necessary. Twelve imperial pints of a clear
glairy fluid were withdrawn, but the bulk of the tumour seemed not much reduced
in size by this evacuation; and it was evident that an enormous mass of cysts re-
mained untouched, while a single and comparatively small one only had been
opened. She speedily recovered from this paracentesis. By the 16th of October
the re-accumulation of fluid was already so great, that tapping was again had re-
The fluid now evacuated was of a dark colour, and was evidently
commixed with pus and inflammatory secretions from the lining membrane of the
perforated cyst. During the few following weeks she complained occasionally of
more or less pain and tenderness in the tumour, but was able to take some out-
door exercise. On November 17th, she walked to my house, a distance of about
half-a-mile, to ask if I would allow her again to begin the use of some iodine which
she had formerly taken. She became sick and vomited on her return home, and
subsequently complained of some abdominal pain. Next day vomiting again
recurred, and the pain became far more severe and diffused over the whole
abdomen. By evening the pulse was very rapid, and almost imperceptible at the
wrist, the extremities cold, and the vomiting almost incessant. The symptoms of
sinking increased during the night, and she died on the following day about two
o'clock, retaining her consciousness to the last, and expressing herself, for some
hours previously, as free from all pain.
course to.
On making a post-mortem examination, a very large multilocular tumour of
the right ovary was found adhering, in different parts, to the abdominal parietes.
A quantity of yellow glairy fluid, mixed with coagulable lymph, was effused into
the cavity of the peritoneum. Upon the right side of the tumour, immediately
below the liver, two small apertures, in two different but neighbouring cysts, were
observed; and from these, fluid similar to that in the abdomen welled out upon
pressure.
At that part of the tumour the cysts were exceedingly numerous, and
their walls, at various points, so transparent and attenuated, that under slight
pressure they burst, and had their contents evacuated.
Most of the larger cysts in the tumour, and several of the smaller, showed signs
of high preceding inflammatory action in their parietes. Many of them contained
pus in their cavities, and their injected lining membrane was coated freely, in
various parts, with particles and layers of yellowish coagulable lymph. There
were perforations in the walls of most of the larger cysts, allowing of free com-
munication between their cavities and the cysts adjoining them.
In few or none of our accounts of the pathology of ovarian
EFFECTS OF RUPTURE OF OVARIAN CYSTS.
777
tumours, are those morbid appearances described which are pro-
duced by inflammation in ovarian multilocular cysts. But when the
lining membrane of a compound ovarian cyst is the seat of inflam-
matory action, it generally presents, as in the preceding instances,
morbid appearances similar to those that we see upon inflamed
normal serous surfaces, such as the pleura and pericardium. When
the effusion from the inflamed membrane is limited to serum merely,
this alone is scarcely traceable; because it becomes at once com-
mixed with, and lost among, the normal serous or gelatinous con-
tents of the cyst. But pus is very often a result of inflammation of
an ovarian cyst, more particularly if the inflammation has been sub-
acute rather than acute in its type. The purulent matter is usually
not seen on tapping or dissection, till the very lowest part of the
cyst is emptied, for it is generally observed to have gravitated down-
wards to the more dependent parts of it. Flakes and masses of loose
coagulable lymph are also often present in the contents of the inflamed
cyst; or the lymph is attached to the lining surface of it, in the form
of granulated spots, or larger patches and layers, or as an organised
false membrane covering the interior of the cyst. When the coagu-
lable lymph effused on the interior of an ovarian cyst becomes
organised,' and the walls of the cyst again happen to be the seat of
renewed inflammation, blood is frequently poured out to a greater
or less extent into the cavity of the cyst, as in hemorrhagic pleurisy;
and this termination is perhaps more frequently the result of inflam-
mation of the ovarian cyst, than the result of inflammation of any
natural serous membrane. Occasionally the organised lymph de-
posited by inflammation upon the interior of an ovarian cyst, becomes
highly injected under sub-acute or chronic inflammation; and I have
seen it give an appearance of roughness to the interior of the cyst, as
if it had been lined by mucous membrane, beset with numerous
elongated injected villi. In a few instances the interior of an in-
flamed ovarian cyst becomes ulcerated, the ulcerated spots being
sometimes round, in other cases irregular. The perforation of the
walls of continuous cysts seem sometimes to be the result of ulcer-
ation; but more frequently, perhaps, they are ruptures produced by
mechanical or inflammatory distension. And now and again portions
of the walls of a cyst, or of several cysts, are found dead and gan-
grenous, either as the result of destructive inflammatory action in
1 In the Anatomical Museum of the University there are some specimens of
ovarian cysts beautifully injected by Professor Goodsir, and the lymph on their
interior is seen to be highly vascular.
1
778
DISEASES OF WOMEN.
their tissues, or from the circulation through them being mechanically
arrested by the compression and obliteration of the vessels which
supplied them with blood.
In both the cases which I have above described, the effusion of
the contents of the lacerated ovarian cyst into the cavity of the
peritoneum, was followed by rapid and fatal peritonitis. But many
cases are on record, and I have myself seen several, in which the
rupture of ovarian cysts into the cavity of the abdomen led to no
such pathological result. And it becomes not only an interesting,
but an important practical question to consider-
Under what circumstances is the rupture of an ovarian cyst followed
by inflammatory action in the peritoneum ? and under what cir-
cumstances does this dangerous consequence not supervene ?
I believe the proper answer to this question consists in a refer-
ence to the condition and contents of the cyst at the time of its
laceration. If the walls of the cyst, previous to laceration, have
been the seat of inflammatory action, and its contents consist of
inflammatory secretions, or perhaps of some other forms of morbid
irritating matter, the escape of such morbific fluids into the cavity
of the peritoneum, will be found, I imagine, to give rise invariably
to inflammatory action in the peritoneum itself; and hence, to be
always accompanied with danger to the life of the patient. But if,
on the other hand, the cyst does not lacerate under inflammatory
distension, but has either given way in consequence merely of the
gradual thinning and attenuation of its own over-distended walls-
or has ruptured under external mechanical injury, as falls, etc.-and
the fluid which escapes through the laceration into the cavity of the
peritoneum is of the mild unirritating character which naturally
belongs to ovarian cysts in an uninflamed condition, then inflam-
mation of the peritoneum has little or no tendency to supervene.
The bland fluid which, under these last conditions, becomes discharged
into the cavity of the peritoneum, is not a morbific irritant to that
serous membrane, such as a fluid commixed with inflammatory
secretions is. Nay, the lacerations of multilocular uninflamed ovarian
cysts, instead of leading to imminent danger and probably speedy
death, have frequently, though accidentally, led to the actual pre-
servation, or at least to the prolongation, of the life of the patient.
The explanation of this result perhaps merits one or two remarks.
EFFECTS OF RUPTURE OF OVARIAN CYSTS.
779
The interior of an ovarian cyst has no power whatever of ab-
sorption; and consequently no diuretics, or deobstruents of any
kind, have any therapeutic influence on the reduction of an ovarian
tumour by removal of its fluid contents by the tissues of the tumour
itself. But if the bland uninflamed contents of an ovarian cyst
become evacuated by accidental rupture into the cavity of the peri-
toneum, they may be, and often are, readily absorbed from that
position; the peritoneum being normally provided with abundant
absorbing powers, and these powers being generally capable of being
excited, when required, by the action of diuretics, etc. Consequently,
when an escape of innocuous unirritating fluid takes place from the
sac of an ovarian cyst into the sac of the peritoneum, it may be, and
often is, rapidly absorbed and removed from the peritoneal cavity.
Cases occasionally occur where nature in this way from time to time
spontaneously taps, if we may so speak, an ovarian dropsy into the
cavity of the peritoneum; thus ever and anon relieving the patient
of the recurrent accumulations of fluid. But another and still
happier result has sometimes followed the mechanical laceration of
an ovarian cyst into the peritoneal cavity. In fact, in repeated in-
stances it has been observed that in this way a cure which may be
termed a permanent, though a palliative one, has taken place. For,
when the laceration in the walls of the ovarian cyst has been
originally large—or, though originally small, has remained permanently
open—so as to allow of the continuous escape of the fluid secreted
by the ovarian sac into the cavity of the peritoneum itself, the peri-
toneum, under these circumstances, has sometimes acted as a per-
manent absorbing surface, removing constantly the fluid eliminated.
by the lining membrane of the ovarian cyst as a permanent secreting
surface. In these fortunate, but rare cases, another result appears
sometimes to follow-namely, the ovarian tumour, if it has happened
to contain one large and preponderating cyst, becomes collapsed, the
fluids which have originally escaped from its own cavity surrounding
and compressing its walls externally; and the interior of the cyst,
thus kept with its walls in apposition, at last secretes little or no
fluid; and possibly perhaps its sides may ultimately adhere together
in some very rare cases.
I am acquainted with the history of two cases in which the first
tapping of an ovarian dropsy has never been followed by any re-
accumulation, the operation in both having now been performed
several years ago. And I believe that the secret of this very un-
usual termination in the two cases in question, is ascribable to the
780
DISEASES OF WOMEN.
circumstance, that the perforation formed in the walls of the ovarian
cyst by the trocar has remained permanently open like a fistula,
allowing of the continuous drain of the ovarian fluid into the cavity
of the peritoneum.
Perhaps art will yet be able to imitate both successfully and
with certainty, in an appropriate set of ovarian cases, this fortunate
accidental termination.
Occasionally, after a patient has been often submitted to the
operation of paracentesis, an accidental rupture of the ovarian cyst
has produced a comparatively permanent cure, as in the following
instance :—
CASE III.-A patient, now aged 56, the mother of five children, and naturally
of a very robust and strong constitution, had up to the end of last year been
tapped for ovarian dropsy 44 times by myself and others. Latterly, the paracen-
tesis was required every few weeks, and an enormous amount of fluid was always
evacuated. I have repeatedly seen above four gallons of fluid drawn off at a
single tapping. Last winter this patient slipped in walking upon a frozen path,
and so violently struck the abdomen and ovarian tumour against the ground in
her fall as to rupture the cyst. Since that time, however, no new tapping has
been required. The abdominal swelling, though still large, is considerably less
than it was at the time of the fall, and does not increase in size. For a time the
fluid of the cyst evidently escaped freely into the cavity of the peritoneum, and
was as regularly absorbed from it. Latterly there has been apparently much less,
or, indeed, no perceptible amount of fluid in the cavity of the peritoneum. For
several months the patient's skin was in an almost constant state of diaphoresis
-a result which to her appeared the more strange, as for years previously she
had never been able to excite any perceptible degree of perspiration. This tend-
ency to spontaneous diaphoresis has latterly decreased. The urinary secretion was
often previously affected, and greatly diminished as the ovarian tumour enlarged.
Since the fall and rupture of the cyst, the kidneys have continued to act very
freely and uninterruptedly, the urine secreted being now, always clear and limpid.
In the course of the preceding remarks, I have referred to the
rupture of ovarian cysts into the cavity of the peritoneum only;
but they rupture, occasionally also into the intestinal, genital, or
urinary canals, or upon the external surface of the abdomen. When
ovarian cysts rupture, not into the peritoneum, but into these
mucous canals, or on the external cutaneous surface, it is a matter
of little moment, in relation to the life and safety of the mother,
whether the cysts, before bursting, have been inflamed or not in-
flamed, and whether their contents be of an acrid and irritating, or
of a bland and unirritating character; for there is no danger to the
mother from the mere nature of the contents of the cysts when these
contents have once escaped into a free mucous canal, or upon the free
cutaneous surface of the body. And whatever may be the character
EFFECTS OF RUPTURE OF OVARIAN CYSTS.
781
of the escaped or escaping fluid, we may equally hope for a tempo-
rary or more permanent amelioration of the disease. If the opening
is slight and valvular, the fluid accumulating in the cyst may only
escape intermittingly or imperfectly; if the opening is larger and
more permanent, the contents of the cyst are sometimes kept con-
stantly draining off from the morbid cavity of the ovarian tumour ;
and this cavity has in consequence, in some cases, diminished and
collapsed to a degree amounting to a kind of perfect cure.
I have seen two or three instances in which ovarian cysts have
ruptured externally, or into the adjoining mucous canals. The case
which I have had an opportunity of watching the longest is the
following:-
CASE IV. This patient felt a movable tumour in the abdomen, of the size
of the fist, about the age of sixteen or seventeen. I first saw her about eight
years afterwards, when the abdomen was greatly distended by a dropsical ovary,
larger than the uterus at the full period of pregnancy. She was complaining
greatly of the symptoms of over-distension. I removed the fluid by tapping in
1840. Fifteen months afterwards the same operation was repeated, in conse-
quence of the re-accumulation of the fluid. But no paracentesis has been required
since that time; and at the present date, November 1852, she enjoys good health.
A few months after the second tapping, the patient had a tedious attack of typhus
fever, accompanied and followed by peritoneal inflammation. She was confined
for many long weeks to bed. Some time after her recovery, and when the tumour
was again increased to a great size, there suddenly supervened, one night on going
to bed, much soreness in the tumour; and this was followed ere morning by an
abundant and large escape of thickish clouded fluid from the genital canals.
The
tumour subsided much in size under this discharge, which only, however, lasted
for a few days. Again, after this discharge ceased, the tumour increased to an
exceeding size; and, on the patient one day twisting herself round on the sofa,
she felt, as she herself described it, "something tear" in the right side. In the
course of that day a clear limpid fluid again began to pour profusely from the
vagina, and the tumour immediately softened and decreased in size. This
discharge has since that time continued, and has now gone on for several years.
The discharge is always greatest when the patient is lying or walking, but its
total daily amount is at present not great. The ovarian tumour is, she herself
believes, now much less in size than after its last rupture, though it is still larger
in volume than the adult head. It moves readily under pressure. The patient's
menstrual life is regular and normal in all respects; she now enjoys, as I have
already stated, the most excellent health; daily performs active house duties;
and has latterly become so stout as to weigh upwards of fourteen stone.
The seat of the opening between the ovarian cyst and the genital
tubes in the preceding case, it is of course impossible to ascertain.
But judging from the dissections which have been made in analo-
gous cases of ovarian cysts emptying themselves by the genital
canals, the seat of communication is, in all likelihood, between the
ovarian cyst and the Fallopian tube. Lately, Richard has shown,
782
DISEASES OF WOMEN.
that ovarian cysts do not so unfrequently as was formerly supposed
communicate with the Fallopian tube, and that the cavity of the
tube in consequence often becomes distended with the fluid of the
adjoining cyst. But though thus distended, the tube is not in many
cases sufficiently open at its uterine extremity to allow of the
escape through the uterus of the contained fluid. Several cases,
however, have now been observed by Morgagni, Boivin, Robertson,
and others, in which, after death, ovarian cysts have been found to
have such a free communication along the canal of the Fallopian
tube, and this tube again with the cavity of the uterus, that the
contents of the cyst escaped freely outward along the course of the
genital canals.
The desultory observations offered in the preceding remarks
may, perhaps, be all briefly recapitulated in the form of the follow-
ing conclusions :—
1. The cysts forming an ovarian dropsy occasionally rupture,
first, from inflammatory effusion into and distension of their cavities;
or, secondly, the contents of the cysts being only the common bland
secretion of such cysts, and unmixed with any inflammatory matter,
they may rupture from mere over-dilatation and gradual attenuation
of their coats, or under sudden mechanical pressure and injury.
2. When a cyst ruptures from the effects of inflammation, or
contains within it at the time of rupture inflammatory secretions
and materials, the escaping fluid, if effused into the cavity of the
peritoneum, is always liable to be followed by dangerous, and
generally fatal, peritonitis.
3. If, however, a cyst bursts into the peritoneum under mecha-
nical injury, or in consequence of simple laceration from over-dis-
tension of its cavity, and the fluid effused into the sac of the peri-
toneum is consequently not commixed with inflammatory secretion,
there is little or no great tendency to peritonitis.
4. Sometimes, indeed, when a non-inflamed ovarian cyst thus
ruptures into the cavity of the peritoneum, the life of the patient is
preserved, or at least prolonged, by this accident.
5. When an ovarian cyst ruptures into a mucous canal, or upon
the cutaneous surface, the safety or danger attendant on the lacera-
tion is not regulated by the inflamed or non-inflamed character of
the effused fluid.
OPERATION OF TAPPING IN OVARIAN DROPSY.
783
6. In cases in which the fluid of an ovarian cyst obtains an outlet
by a mucous canal, or by the skin, a temporary or more permanent
reduction of the tumour and comparative cure of it may be the con-
sequence.
Lastly, let me add that, as in many cases and points the surgery
of art is an imitation of the surgery of nature, possibly the artificial
repetition and establishment of the above modes of relief, if they
could be imitated safely and certainly, may yet be found capable of
temporarily arresting, if not curing, ovarian dropsies in some appro-
priate cases; and more particularly in instances in which the great
bulk of the tumour is formed by one original large preponderating
cyst, or by several cysts broken up and conjoined into one common
cavity or cell.
ON THE POSITION OF THE PATIENT FOR PARACEN-
TESIS IN OVARIAN DROPSY, AND ON THE
PLACE OF PUNCTURE.'
When paracentesis is resorted to for the relief of ovarian
dropsy, the method in which the operation is performed among us,
is generally, if not invariably, the following:-The patient is seated
more or less upright upon the edge of the bed, or upon a chair,-a
broad bandage is placed around the lower part of the trunk, and the
two ends of it, crossed behind, are each entrusted to an assistant,
with the view of pulling and tightening it as an abdominal compress,
in proportion as the fluid is evacuated,-and a small opening is cut
in the anterior part of the bandage, as an aperture by which a trocar
of sufficient size is introduced through the abdominal parietes into
the ovarian cyst.
The bandage or compress encircling the trunk is generally al-
leged to be used with two objects-first, To aid by abdominal pres-
sure in the evacuation of the ovarian fluid; and secondly, To secure
the patient against the chances of faintness and syncope upon the
sudden withdrawal of such a large quantity of fluid from a person
seated in the upright position. Different kinds of compressing
bandages, as linen, flannel, caoutchouc-cloth, etc. etc., have been
recommended to be employed; and the ends of them are sometimes
slit or perforated, with the view both of making the compression
1 See Edinburgh Monthly Journal of Medical Science, October 1852, p. 361.
784
DISEASES OF WOMEN.
exerted by them more complete, and of allowing the bandage to be
run and applied more easily and accurately in proportion as the
abdomen diminishes in size, during the evacuation of the contained
fluid through the trocar. I have seen the operation of paracentesis
in ovarian dropsy performed often, and by many different hands;
but I have rarely seen the bandage run correctly, even when in the
first instance it was most carefully applied, and afterwards as care-
fully pulled by the two assistants in charge of the two ends of it.
As the fluid is gradually evacuated, the bandage, in fact, is ever
liable to lose its proper adaptation to the diminishing shape of the
abdomen; or it becomes oblique in its position, and, pressing upon
the canula of the trocar, threatens to displace it; or, as sometimes
happens, it rolls up, and strongly compresses one circle or portion of
the abdomen, leaving the other parts of the abdominal tumour com-
paratively uncompressed and unsupported. Besides, any one who
has acted as an assistant in a case of tedious tapping knows that
the mere pulling at the end of the bandage is a task sufficiently
irksome and fatiguing.
Latterly, when performing the operation of tapping in ovarian
dropsy, I have placed the patient in the horizontal position, and
dispensed entirely with the use of the compressing bandage during
the operation, with, I think, no small advantage and relief to the
patient, to myself, and to my assistants. If the patient be placed
in the supine position, there need be no dread of the tendency to
fainting and syncope, for the prevention of which the bandage is
specially recommended; and, at the same time, the contents of the
dropsical cyst or cysts are, it appears to me, even more easily, and
certainly more completely evacuated, than when the operation is per-
formed with the patient placed in the upright position.
In tapping an ovarian cyst in the horizontal position, the patient
requires to lie as near the front of her bed or couch as possible, with
the face, of course, turned towards it, and, indeed, with the distended
ovarian sac projecting, if possible, over the edge of the bed. If it
is previously and accurately known that it is the right or left ovary
which is affected, and that there is a prospect of the tumour being
very completely evacuated of its contents by the operation, the
patient should lie upon the right side if it be the right ovary, and
upon the left side if it be the left ovary that is diseased. The
trocar is then introduced into the distended cyst at the usual part
in the abdominal parietes, and with the usual precautions. Towards
the termination of the operation, the most complete evacuation of
OPERATION OF TAPPING IN OVARIAN DROPSY.
785
the cyst may be secured when necessary by turning the patient
somewhat upon her breast, so as to make the puncture as dependent
as possible-and, when necessary, by compressing the abdominal
parietes with the hands-the latter a proceeding which requires to
be followed in most cases of paracentesis in the upright position.
One great danger attendant upon tapping an ovarian cyst consists
in the liability of air to go backwards into the emptied cavity
towards the latter part of the operation, when the stream through
the trocar becomes imperfect, or actually intermits, in consequence
of the irregularity of the abdominal compression. I believe that
this accident, and its consequences, inflammation of the walls of the
cyst from decomposition of its remaining contents, will be found to
be much less liable to occur when the patient is tapped in the hori-
zontal position, and the parietes of the abdomen are allowed to
compress the cyst merely by their own elasticity, and by the ex-
ternal pressure of the atmosphere, than when the operation is per-
formed with the patient sitting upright, and with the compression
in a special degree entrusted to the proper adaptation and action of
a bandage, the mechanism of which is not easily regulated. Let
me further add, that the preparations for the operation are far less
formidable to the patient when the tapping is performed in the
horizontal position, and without bandages; and, besides, the neces-
sity of assistants to manage the bandage is dispensed with. The
compression itself of the bandage amounts to a feeling of distress
and suffering with some patients; and I have been strongly assured
by those who have been tapped at different times in both ways,
that the absence of the bandage, combined with the horizontal
position, were great advantages to them, as far as their feelings and
comfort were concerned. It is almost unnecessary to add, that the
edge of the bed requires to be protected by several plies of sheeting
or towels; and, if deemed necessary, a bandage may be placed
round the abdomen, when the patient lies back in bed, subsequent
to the operation, particularly if the abdominal parietes are greatly
relaxed, and the remaining mass of ovarian tumour feels very loose
and mobile in the cavity of the abdomen. Sometimes, however, I
have dispensed even with this secondary bandage.
In performing paracentesis for the evacuation of an ovarian cyst,
the trocar is usually introduced in one of two situations-viz. either
centrally, in the course of the linea alba; or laterally, in the course
of the linea semilunaris. It perhaps is of little moment which of
these two places is adopted, provided only the trocar is introduced
786
DISEASES OF WOMEN.
in a situation in which the fluctuation is very distinct, and the
parietes of the cyst thin and equal, and in which, therefore, the
instrument easily reaches the cavity of the cyst.
In selecting the place of the puncture, it must be held in re-
membrance that various causes may render the introduction of the
trocar at particular sites difficult and dangerous; and that the pre-
sence of one or other of these causes should induce us to select
another situation. For example:-First, The chance of wounding
the urinary bladder must be avoided. The evacuation of the organ
immediately before the operation, is our best security against this.
Secondly, The uterus is sometimes elevated and drawn upwards in
front of an ovarian tumour, and has been fatally wounded by the
trocar in the operation of paracentesis. This ascent and displace-
ment of the uterus can be ascertained before the operation; and all
chance of injuring it would be avoided, if, as I have already stated,
a point in the cyst sufficiently fluctuating and thin in its parietes
be selected as the site of the puncture. Thirdly, Ovarian cysts have
been occasionally found so turned upon their axes, that the elongated
Fallopian tube has stretched across the front of the diseased ovary,
and interfered with the introduction of the trocar; and a dense
fibrous state of the cyst at particular parts has led to the same mis-
chance—the cyst thus becoming merely displaced and not perforated
by the pressure of the point of the instrument. A case of obstruc-
tion to tapping from this cause is detailed by Dr. Bright in the
Guy's Hospital Reports. The puncture, in consequence, must not be
made over a point which feels unequal and condensed in its structure.
Fourthly, In the later stages of ovarian dropsy, the tumour often so
compresses the contents and parietes of the abdomen, that the cir-
culation of the blood through the abdominal portion of the vena
cava is much interfered with. I have twice, in dissections of ovarian
dropsy, seen the cavity of the vena cava obstructed from this cause.
In consequence, a vicarious venous circulation is set up in many cases
through the superficial veins of the abdominal parietes; which hence
become greatly enlarged. These veins are often seen of the size of
goose-quills or larger, and running immediately beneath the skin.
In paracentesis, the wounding of one of these large veins with the
trocar must be carefully avoided. Lastly, The epigastric artery has
been opened by the instrument in ovarian paracentesis. It is on
this account that some authors have advised us to select the linea
alba in preference to the linea semilunaris, as the site of puncture.
Mr. South relates a case, however, in which this artery was fatally
OPERATION OF TAPPING IN OVARIAN DROPSY.
787
wounded when the tapping was made in the first of these sites-the
linea alba. Common care, and a little examination beforehand for
the seat of a pulsating artery in the thin and distended abdominal
parietes, should enable us to avoid this source of danger. And if we
avoid this difficulty, and at the same time select as our proper site
for the operation the part where the fluctuation is most distinct,
and the parietes of the sac most thin and equable, it matters not
whether that be in the course of the linea alba or of the linea semi-
lunaris. The latter is perhaps the best, because the most dependent
site, if we have our patient lying, during the operation, in the hori-
zontal position.
It has been suggested by Callisen, Macarn, Delpech, Recamier,
Arnott, and others, that dropsical ovaries should be tapped through
the roof of the vagina in preference to the abdominal walls. If the
so-called ovarian cyst is unilocular, its contents may certainly be
evacuated by this means, as well as by tapping through the parietes
of the abdomen; and I have more than once evacuated the contents
of a dropsy of the Fallopian tube, by introducing the small trocar
which forms the usual exploring needle in this position. In one of
these cases the elongated sac formed by the distended Fallopian tube
inflamed after its evacuation, and, in consequence, seemed to become
entirely obliterated. The patient, a lady from New York, had pre-
viously been almost incapacitated from taking exercise, and had
been in bad health for several years. Since her return home she
has been pregnant, and borne a dead child. But it is excessively
rare that a true ovarian dropsy, so distended as to require tapping,
is unilocular. In forty-nine cases out of fifty, or perhaps in a larger
proportion, the enlarged ovarian dropsy requiring the operation of
paracentesis, consists of the multilocular form of degeneration of the
organ; and in this compound or multilocular cystic dropsy of the
ovary, paracentesis by the vagina can very seldom readily or safely
evacuate the contents of the diseased mass. For, in the opera-
tion of paracentesis in the common multilocular form of ovarian
dropsy, we evacuate merely the contents of the largest cell or cells
in the mass; and we reach this largest cell or cells easily through
the abdomen, but cannot usually reach them readily through the
vagina. This important circumstance depends upon a simple patho-
logical law, which has not been adverted to, as far as I know, in
any of the numerous essays or observations which have been
published on ovarian disease. Cystic tumours of the ovary, like
other morbid tumours and collections, increase always most readily
51
788
DISEASES OF WOMEN.
and rapidly towards that direction in which there exists the least
physical resistance to their growth; and, on the other hand, most
slowly and imperfectly towards that side or sides on which they
meet with most opposition to their mechanical development and
increase of size. Ovarian tumours do not usually grow readily, or
largely, towards their inferior or pelvic sides, because the resistance
of the floor of the abdomen and pelvic parietes offers in that direc-
tion sufficient impediment to their development. But they increase
and develop readily in an upward direction towards the abdomen,
because in that direction they meet with comparatively little resist-
ance or opposition to their growth. And while the cells in the
pelvic portion of the remaining multilocular tumour are, as far as I
have examined them in a considerable number of preparations and
dissections, usually very small in size, however great in number,
we have, on the contrary, in consequence of the above pathological
law, the largest cyst or cysts in the mass generally, if not always,
placed, first, at the upper or abdominal extremity of the tumour ;
and, secondly, on the anterior part of the abdominal tumour, rather
than on its lateral or posterior parts-the cyst or cysts in front
growing more readily, because they are less resisted in their growth.
by the abdominal parietes in front, than the cyst or cysts placed
towards the sides or back of the tumour, inasmuch as these latter
are repressed by the denser fabric of the lateral and posterior walls
of the abdominal cavity of the patient. It is, I repeat, in conse-
quence of this pathological arrangement, that, fortunately, by the
operation of abdominal paracentesis, we are usually able to evacuate
the largest cyst or cysts in the mass; and in consonance also with
the same law, the contents of such more prominent cyst or cysts are
usually far more fluid, and hence more easily capable of being eva-
cuated through the trocar, than are the contents of the more con-
densed and undeveloped cysts of the tumour. In fact, the larger
and more anterior cyst or cysts have often their contents sufficiently
fluid for evacuation by paracentesis, at the very time that the more
undeveloped and more compressed cysts still contain a thick gela-
tiniform matter quite incapable of being evacuated through any trocar.
It is almost unnecessary to add, that the horizontal position of
the patient answers as well for paracentesis in ascites as for para-
centesis in ovarian dropsy. It sometimes happens that the two are
combined in a greater or less degree. A few days ago I saw, with
Mr. Goodsir, a case of this combination-viz. a very large multi-
locular ovarian tumour floating in and surrounded by a quantity of
INJECTIONS OF IODINE INTO OVARIAN CYSTS.
789
ascitic fluid. On placing the patient in a horizontal position, the
ovarian cyst was first evacuated of its contents, which were of a very
dark brown colour, and mixed with old-effused blood. After the
ovarian cyst was completely emptied, a second puncture of the
abdominal parietes was necessary while the patient was still lying
in the horizontal position, to remove the collection of ascitic fluid.
ON THE TREATMENT OF OVARIAN DROPSY BY
INJECTIONS OF IODINE INTO THE CYSTS.'
It has been often proposed to treat dropsy of the ovary upon
the same principles as hydrocele or dropsy of the tunica vaginalis.
In accordance with this view, Drs. Hamilton, Scudamore, and others,
have in former times injected ovarian cysts with irritating solutions
of sulphate of zinc, etc.; but the results have in general proved so
unfortunate and disastrous as to prevent a repetition of the practice.
In 1832, Mr. Martin first recommended the use of tincture of
iodine as the surest and safest injection for the cure of hydrocele ;
and this drug seems now almost universally adopted by surgeons in
the obliterative treatment of this variety of local dropsy in the male
subject.
Latterly, various surgeons, particularly Velpeau, Bonnet, Bel-
luerimi, etc., have extended the practice of iodine injections to the
treatment of other local dropsies and cysts; to chronic abscesses ;
diseases of the joints, etc. And the past experience of surgeons on
the subject would certainly seem to show that while the local and
direct application of iodine to morbid secreting surfaces has a great
power of modifying, altering, and arresting even the secretory action
of these surfaces, and often changes suppurative into adhesive
inflammation, it shows at the same time wonderfully little aptitude
to excite any excess of local irritation and pain. Hence naturally
arose the question whether it could be safely and successfully in-
jected into such large cysts as those of the common form of dropsical
Ovary.
In 1846, Dr. Alison of Indiana recorded the history of a chronic
case of ovarian dropsy that had been repeatedly tapped, and which
he injected at last with a solution of iodine.
Severe symptoms
followed, but the ultimate result seems to have been favourable.
1 See Proceedings of Edinburgh Obstetrical Society, Session XII. 1852-3, in
Edinburgh Monthly Journal of Medical Science, May 1854, p. 467.
790
DISEASES OF WOMEN.
In 1851, Dr. Simpson assisted Mr. Syme in injecting a cyst in the
neighbourhood of the ovaries, but not a common cystiform ovary.
The symptoms which ensued were those of considerable excitement;
but the original cyst apparently became obliterated. Another one
in its vicinity has lately shown itself in this patient.
Within the last year Dr. Simpson has, subsequently to tapping,
injected into dropsical ovarian cysts the tincture of iodine in seven
or eight cases. For this purpose he has employed the common
tincture of iodine of the Edinburgh Pharmacopoeia, undiluted. He
has usually thrown into the cyst two or three ounces of the tinc-
ture. In some cases he has allowed a portion of the injected fluid
to re-escape; in others has retained the whole of it in the sac
of the cyst that was tapped. From these cases he drew the follow-
ing conclusions:-
1. In none of the cases of ovarian dropsy treated with iodine
injections after tapping has he yet seen any considerable amount of
local pain follow the injection, with one exception; in most instances
no pain at all is felt; and in none has constitutional irritation or
fever ensued. In the one exceptional case, considerable local irrita-
tion followed; and the pulse rose to 110; but the same phenomena
occurred in the same patient after previous tappings, without iodine
being used.
2. While the practice seems thus so far perfectly safe in itself, it
has by no means proved always as successful as in hydrocele, in
preventing a re-accumulation of the dropsical fluid; for in several
instances the effusion into the sac seems to have gone on as rapidly
as after a simple tapping without iodine injection.
3. But, in two or three of the cases, the iodine injection appears
to have quite arrested, for the time being, the progress of the disease,
and to have produced obliteration of the tapped cyst, as there is no
sign whatever of any re-accumulation, though several months have
now elapsed since the date of the operation.
Lastly. Accumulated experience will be required to point out.
more precisely the special varieties of ovarian dropsy most likely to
benefit from iodine injections, the proper times of operating, the
quantities of the tincture to be injected, and other correlative points.
Perhaps the want of success in some cases has arisen from an in-
sufficient quantity of iodine being used, and from the whole interior
of the cyst not being touched by it. The greatest advantage would
of course be expected from it in the rare form of unilocular ovarian
cysts. In the common compound cyst, the largest or most pre-
INJECTIONS OF IODINE INTO OVARIAN CYSTS.
791
ponderating cyst is usually alone opened in paracentesis; and though
it were obliterated, it would not necessarily prevent some of the other
smaller cysts from afterwards enlarging and developing into the usual
aggravated form of the disease.
?
RESULTS OF THE TREATMENT OF OVARIAN DROPSY
BY IODINE INJECTIONS.¹
Professor Simpson said he had now employed these injections in
twenty or thirty cases, with varying results. In the first operation,
the first, he supposed, in which it had been used in Great Britain,
the tumour is still present, but never has again increased to any
great size. Sometimes the injection in his hands had proved quite
successful. Lately he saw two patients on whom he had operated
three years ago.
In one of these cases, a young person of twenty or
twenty-two, who had been once or twice tapped before, the dropsical
tumour was of very great size, and the patient's health and strength
were rapidly breaking down when the iodine injection was had re-
course to. There has been no return of the dropsy, and the patient
is now quite well and strong. He lately saw an elderly patient,
upon whom he had operated about the same time, with a similar
successful, and apparently permanent result. In other cases the
iodine injection had been completely or partially successful-partially
in several, inasmuch as it had obliterated the largest cyst in the
multilocular tumour, but had not prevented the remaining smaller
cysts from growing and developing. In some, on the other hand,
it had so far entirely failed, that the cyst, operated on and injected,
had again refilled; but perhaps, as a general rule, not so rapidly as
when no injection was used. The failures were, in special instances,
perhaps traceable to the iodine being too much diluted by the fluid
left in the cyst; to the quantity of iodine used being too small, or
too weak; to care not being taken to bring it in contact with the
whole interior of the cyst, and other possibly avoidable causes. No
doubt it was a valuable means in some cases, especially where the
dropsy was principally limited to one or two large cysts; and no
doubt it would fail in others, especially where the tumour had
several large cysts developing simultaneously. The iodine injection
was seldom attended with much pain, or with any severe local or
¹ See Proceedings of Medico-Chirurgical Society of Edinburgh, December 17,
1856, in Edinburgh Medical Journal, February 1857, p. 754.
792
DISEASES OF WOMEN.
constitutional irritation. Out of the twenty or thirty cases in which
he had injected ovarian cysts with iodine, in only one instance had
death subsequently occurred, namely, in a patient to whom he was
called by Dr. Monroe, of Dundee. The dropsical distension of the
abdomen in this patient was, before tapping, greater, he believed,
than he had ever before witnessed, and the iodine injection was used
at the first tapping. Was the fatal result attributable to the tap-
ping or the injection? He had now used the iodine injection so
often, without any marked local suffering or constitutional reaction,
that he was inclined to doubt if the iodine were in any degree blame-
able; while he had so frequently seen danger and death follow first
tappings, and where nothing but tapping was used, that he believed
the result was to be ascribed to the paracentesis, rather than the
injection.
OVARIOTOMY;
IS IT OR IS IT NOT-AN OPERATION JUSTIFIABLE UPON
THE COMMON PRINCIPLES OF SURGERY?
ARE-OR ARE NOT-CAPITAL OPERATIONS IN SURGERY JUSTIFIABLE
TO THE EXTENT GENERALLY PRACTISED ?¹
"In truth there are Brothers who will brag of the many they have dismem-
bered;
but they that truly understand Amputation and their Trade, well know
how villainous a thing it is to glory in such a Work—it being more for your credit
to save one Member than to cut off many.”—Richard Wiseman's 6th Chirurgical
Treatise.
"Cut off-
Unshriven, unanointed, unaneeled :—
If thou hast nature in thee, bear it not."
Complaint of the Ghost in IIamlet.
DR. BENNETT 'having communicated to the Medico-Chirurgical
Society of Edinburgh, on the 3d of December 1845, a case in which
ovariotomy had been performed, Professor Simpson stated, that he
believed ovariotomy quite unjustifiable in many of the cases in
which it had been had recourse to, but in a few rare instances, like
that of Dr. Bennett's patient, quite as justifiable as most of the
operations performed in surgery for chronic affections. And it
appeared to him that two circumstances prevented ovariotomy from
obtaining a fair consideration and fair trial, especially with professed
1 See Proceedings of Medico-Chirurgical Society of Edinburgh, December 17,
1845, in Edinburgh Monthly Journal of Medical Science, January 1846, p. 56.
OVARIOTOMY.
793
surgeons. First, the diagnosis and the operation were, under the
existing divisions and arrangements of practice, undertaken by two
different sets of practitioners-the former by the obstetric physician,
and the latter by the operating surgeon. It was, perhaps, the only
capital operation in which the surgeon was now required to proceed
upon the diagnostic knowledge of another party; and no one was
to be blamed if he felt a natural repugnance to incur so serious a
responsibility on such grounds. Secondly, surgeons, as a class, still
confessedly allowed themselves to be greatly bound and swayed by
the trammels of authority, and the mere fact that some of the
highest names in surgery had once declared, with or without due
investigation, against ovariotomy, is with most others an ample and
satisfactory reason for totally rejecting the operation. In the same
way, but in an opposite direction, the leading authorities in the
surgical world having agreed to consider ligature of the arteria inno-
minata as a legitimate operation, it has now been repeatedly per-
formed. But what has been the result? Why, the vessel has been
tied some twelve times, according to Mr. Phillips-it might be
oftener, or it might not be so often-but, at all events, as often as
the operation had been performed, it had proved fatal; and yet,
because it had been decreed proper and justifiable by authority, we
find it in the very last text-books on surgery still commented on as
such; whilst ovariotomy, as proving fatal in one out of every two
or three cases, was loudly denounced as improper and unjustifiable.
In the important department of surgery, such inconsistency would
doubtlessly betimes become rectified-when, as had been long the
case in medicine and midwifery, the dogmatism of mere facts and
experience came to be more respected than the dogmatism of mere
opinion and authority.
The diseased condition of the ovary, to which the operation of
ovariotomy was particularly applicable, if applicable at all, was, in
Dr. S.'s opinion, that form of ovarian dropsy which was by far the
most frequent of all, and consisted in multilocular cystic degeneration
of the organ-the gelatiniform or areolar cancer of some authors.
All other forms of ovarian dropsy, as they were called, were rare in
comparison to this; and to it all remarks, in such a discussion as
this, principally or entirely applied. In most instances-in nine
cases out of ten-this species of ovarian dropsy pursued, he believed,
a regular progress onward, towards greater or less enlargement,
insufferable distension, more or less repeated palliative tappings,
frequently disintegration of the morbid structure, local irritation,
794
DISEASES OF WOMEN.
constitutional exhaustion, and death. Generally, it took a series of
years to run its course, but sometimes it passed through its phases
and progress more rapidly. We want a sufficient body of well-
observed facts to know the average duration and simple natural
history of this, as of most other diseases. Some authorities averred
that the disease occasionally went on for twenty, thirty, forty, or
fifty years. He doubted entirely the truth of such alleged cases,
and believed that abdominal tumours, with this history, were not
affections of the ovary at all, certainly not its cystic multilocular
disease, but fibrous tumours of the uterus, which were often exceed-
ingly chronic in their progress, and, as he had repeatedly seen, were
very frequently mistaken for the ovarian affection under dispute.
Again, it had been as strongly averred that cases of multilocular
dropsy of the ovary had been absorbed and cured. He equally
and entirely doubted the validity of this observation. Errors in
diagnosis would, he believed, account readily for all such therapeuti-
cal incredibilities. He had seen hysterical tympanitic distension of
a portion of bowel, and collections of fæces, mistaken for ovarian
tumours; and these were certainly quite curable. He had, in several
instances, seen also ovarian dropsy very perfectly simulated in form,
figure, situation, etc., by large chronic inflammatory effusions into
the cellular tissue of the pelvis and broad ligament, always com-
mencing with and accompanied by inflammatory phenomena; and
these, like similar inflammatory effusions elsewhere, were always
more or less completely amenable to medical treatment. But he
had no belief whatever that iodine, or mercury, or muriate of lime,
or aqua potassæ, or diuretics, or deobstruents, or aught else, were
capable of absorbing and removing the complicated structure and
contents of a multilocular cystic tumour of the ovary. He would
almost as soon believe that the head could be absorbed and removed
by medicine. When the disease was accompanied with much local
vascular action and congestion, the occasional loss of blood was cer-
tainly sometimes beneficial. But in the general run of cases of this
malady, he had long come to the conclusion that we did all that was
possible with medicine, when we kept the individual functions of the
economy as near as possible to their individual standards of health.
Break down the activity and vigour of the system by mercury or
other debilitating medicines, and then the ovarian disease only too
often progressed with double strides.
Seeing medicine was of so little direct use--what measures had
surgery to propose? The cystic structure of the tumour had been
OVARIOTOMY.
795
In some
tapped and injected in imitation of the treatment of hydrocele-
setons had been passed into it, and through it-incisions had been
made into its walls, etc. etc.; but all such operations were now, he
believed, abandoned by general consent, as useless in their effects,
and far too often fatal in their practice to admit at all of repetition.
In fact, two measures only were at the present day applied to the
surgical treatment of the disease-namely, 1. Tapping; and, 2.
Total extirpation. The first of these operations-tapping-was
professedly adopted merely as a palliative measure-for the present.
relief of the patient-not for the cure of the disease. In a very few
instances the tumour appears to become bound down by adhesions
after tapping, and no re-accumulation takes place; but these cases
are so very rare, that in practising the operation we scarcely even
venture to reckon upon the possibility of this occurrence.
cases where the tumour is very large, but the cells small, and con-
taining gelatiniform matter, tapping is of no use, and cannot in any
degree evacuate or diminish its contents. Fortunately for the success
of this operative procedure, the anterior and superior cell or series of
cells were generally large, and dilated more than the others, in
consequence of least resistance being opposed to their growth and
distension in this direction. And tapping, when adopted, though a
palliative measure only, was by no means so free from danger as some
practitioners think, and some writers would seem to allege. We
had as yet no sufficient collection of data to show its actual results.
But Mr. Southam had commenced the inquiry, by tabulating the
results of twenty cases of the operation. Fifteen of these cases had
been recorded by Drs. Bright and Barlow, without apparently any
view to such an investigation, and hence afforded the more valuable
and unprejudiced evidence. Four of the twenty patients, or one in
five, died of the effects of the first tapping. Four patients died of
inflammation within a few days after the operation; three more
died in one month; fourteen in all died within nine months after
the first tapping. Of the remaining six, two died in eighteen
months, and four lived from periods varying from four to nine
years.
Paracentesis, whilst thus merely a means of palliation, was still
a proceeding in which no inconsiderable amount of danger appeared
to be incurred. Ovariotomy, on the other hand, was an operation
which, if successful, was professedly a means for the perfect and
radical cure of the disease. But it was undoubtedly a most serious
and dangerous operation; was it therefore warrantable or unwar-
796
DISEASES OF WOMEN.
rantable, when judged of by the principles applied by surgeons to the
determination of the propriety of other capital operations in chronic
diseases? Let us consider ovariotomy and the objections to it in
this point of view; for by such a comparative test will the propriety
or the impropriety of the operation be best ascertained and deter-
mined. The principal objections which Dr. Simpson had heard
urged against ovariotomy were as follows:-
1. It was an operation accompanied with great danger and mortality.
All parties are ready fully to admit this point. But it is by no
means a matter decisive, as some think, of the impropriety of the
operation. At all events, if ovariotomy is to be condemned and
suppressed on this account, several of the legitimatised capital opera-
tions in surgery must be equally, or still more strongly, condemned
on exactly the same charge; for it is in reality not more fatal than
many of these operations, and even not so fatal as some of them.
On this subject, the mortality accompanying capital operations in
general, very erroneous views seem to be entertained by many
members of the profession. The statement of a few simple statis-
tical facts will serve to prove the position assumed, and may,
perhaps, surprise those who have not directed particular attention
to the subject. Dr. Churchill, Mr. Phillips, Dr. Atlee, and Dr.
Cormack (see his Journal for May last), had each calculated the
mortality in ovariotomy, from the cases on record, and came to
nearly the same conclusion. Dr. Simpson took Dr. Cormack's
results as being those of a writer against the operation, and hence.
his tables could not be suspected of any unfair leaning towards
ovariotomy.
Out of 89 cases in which ovariotomy had been either performed
or attempted, 34 sunk, or nearly 4 in every 10 patients died.
Out of 65 cases, collected by Dr. Cormack, in which the opera-
tion had been perfected, 25 died, or between 3 and 4 out of every
10 patients were lost.
Now Malgaigne has shown, that out of 852 amputations of the
extremities of all kinds, including those of the fingers and toes,
which were performed in the Parisian hospitals from 1836 to 1841,
332 died, or about 4 out of every 10 proved fatal.
Among these, out of 201 amputations of the thigh, 126 died, or 6 in every 10
"
192
91
""
leg,
106 died, or 5
10
arm,
41 died, or 44
10
OVARIOTOMY.
797
Of the amputations of the thigh, in 46 cases the operation was per-
formed for severe injury of the limb: of these 34 died, or more than
7 out of every 10.
When we looked to the results of amputation nearer home, the
results were not much more encouraging. In the Glasgow Infir-
mary, from 1795 to 1840, Dr. Lawrie has shown that out of 276
amputations performed, 101 proved fatal, or nearly 4 in 10 died.
Among these, out of 128 amputations of the thigh, 46 died, or 34 in every 10
30 died, or 5
21 died, or 44
""
""
62
53
""
leg,
arm,
10
10
In the Edinburgh Infirmary, during the four years commenc-
ing July 1839, there occurred 72 amputations of the thigh, leg,
shoulder-joint, arm, and forearm. Of the 72 patients, 37 recovered
and 35 died—or nearly 5 in every 10. Of these amputations, 18
were primary. Out of 4 primary amputations of the leg, one patient
recovered and 3 died. Out of 4 similar amputations at the shoulder-
There was one primary amputation
There were eight primary amputa-
joint, 1 recovered, and 3 died.
of the arm; the patient died.
tions of the thigh; all the eight patients died.¹
Mr. Phillips has collected the histories of 171 cases in which
the larger arteries of the body were tied; of these 57 died, or
about 3 in every 10. Dr. Inman has collected
199 cases of these
Out of 40 cases of
operations; 66 died, or about 33 in every 10.
ligature of the subclavian artery which he has tabulated, 18 proved
fatal, or nearly 5 in every 10 died.
In his work on hernia Sir A. Cooper records 36 deaths among
77 operations for that disease, or nearly 5 in every 10 died. Dr.
Inman has collated 545 cases of operation for hernia; 260 proved
fatal, or nearly 5 in every 10 of the patients died.
In the earlier years of life, lithotomy is comparatively a safe and
legitimate operation, and few die. But it is quite different when
the operation is submitted to at forty years of age, and upwards.
At and above this term of life, Dr. Willis has shown, from numerous
statistical returns, that from 2 to 5 out of every 10 operated upon
die.
Even what we deem slighter operations are sometimes attended
in the absolute by no inconsiderable danger to life. Out of 95
cases of excision of the mamma, referred to in Dr. Cormack's Journal
for February 1843, 20 died, or 2 in every 10. In how many cases
¹ See Dr. Peacock's Official Reports.
798
DISEASES OF WOMEN.
of the remaining 75 would the disease inevitably return, and ulti-
mately destroy the patient?
Ovariotomy, then, is fatal in the proportion of about 35 or 40
in every 100 operated upon; but in most capital operations we
have singly as high or even a higher mortality than 35 or 40 per
cent. Amputation of the thigh has a higher mortality. So has
amputation of the arm. So has ligature of the subclavian, for
aneurism. Tying the innominata is fatal in every case. The
operation for hernia has a higher mortality. Lithotomy is as fatal
in most hands after the middle term of life. Even amputation of
the leg below the knee is scarcely more safe, or at all events as
many, or more, die after amputation of the leg, in the hospital prac-
tice of Paris and Glasgow, as die after ovariotomy.
It had been foolishly objected to the statistics of ovariotomy,
that we did not know all the unsuccessful cases. Dr. S. believed
that the ascertained statistics regarding it were as full and complete
as the statistics regarding any other capital operation. It was too
serious and too startling an operation for any cases of it to remain
easily hid. On the other hand, it could be readily shown that the
statistics of our major surgical operations were not always reported
in the most faithful manner, and so as to give the most accurate
results. Malgaigne candidly confesses as much in regard to the
elaborate statistics which he has collected of various surgical opera-
tions from different hospitals.
In
The existing results regarding ovariotomy would, probably, be on
all hands allowed to demonstrate one point, namely, that exposure of
the cavity of the peritoneum was not so dangerous a proceeding as
was formerly thought by pathologists. Surgeons have exposed it
often in hernial operations, and even left ligatures upon its omental
vessels when necessary, and not unfrequently with impunity.
1842-43 a portion of the omentum was removed in six operations
for hernia at St. George's Hospital, London. "In some of the cases,
two ligatures, each embracing one-half of the omental mass, were
applied; in the other cases, ligatures were applied to all the bleeding
vessels." Five of the six patients recovered. One died comatose, a
few hours after the operation, from disease of the brain. But still,
it must be confessed, extreme dread of all such abdominal surgery
was, and probably is, the prevailing idea. The comparative success
of the Cæsarean section in the hands of Continental accoucheurs
might almost have taught us a different lesson, the peritoneal cavity
1 Hewett in Medico-Chirurgical Transactions, vol. xxvii.
1
OVARIOTOMY.
799
in that operation being of necessity freely opened up; and we may
daily see the same done upon the females of some of our domestic
animals, with remarkable impunity, in the coarse operation of
spaying.
2. The ultimate results of cases of Ovariotomy were alleged to be unknown
and unfavourable.
It was urged that the reports of cases had been published with
too great haste, and before the final effects could be known months
and years afterwards. Great weight had been attached to this
argument in the question of ovariotomy. But it probably would be
found to tell against other capital operations with much more truth
and effect than against ovariotomy. In how few instances were the
published reports of capital surgical operations carried beyond a few
weeks? And what a large proportion did die within a short period
after escaping from the more immediate consequences of the opera-
tion for aneurism, and stone, and cancer, and amputation—and that
with very broken and imperfect health, too, during the interval.
The primary history of cases of these operations was given, yet not
their ultimate history. Dr. Simpson at the same time adduced various
facts, to show that, as far as regarded ovariotomy, the allegation did
not in reality hold good. The process of reparation after ovariotomy
is, say some, too great to be accomplished with health and safety.
Theory may argue so-but facts here give a direct and practical
denial to theory, by demonstrating the reverse to be true. In one
of the first cases operated on, Emiliani's in 1816, the patient has
since become the mother of five living children-an ample proof of
the completeness of the cure. Dr. Simpson read a note from Dr.
Clay of Manchester, stating the present condition, on 14th December
1845, of the patients that he had operated upon two or three years.
back. His first patient, operated on 12th September 1842, "con-
tinues quite well, and follows her household duties with ease and
comfort." A patient, subjected to ovariotomy on the 25th Septem-
ber 1842, "is at this time perfectly well, and capable of greater
exertion than most women of her age-viz. 60." Regarding a third
patient, operated upon in November 1842, Dr. Clay states, "I saw
this case a few days ago on account of a polypus of the nose-in
every other respect she is quite well." A patient operated upon
in August 1843 "is at this time perfectly well-saw her a few days
ago." Dr. Clay operated on two cases in October 1843: "the first
800
DISEASES OF WOMEN.
remains at this time quite well"-the second reports herself "in
better health now than in any part of her former life." A case was
operated upon in November 1843: "I have," says Dr. Clay, “seen
this woman frequently of late whilst attending other branches of the
family-she is quite well;"—and so on with regard to some others.
3. It was argued that the extirpation of the affected ovary would not
necessarily effect a perfect cure of the disease, or secure the patient
against its return.
This certainly holds true of the diseases for which several of the
major operations in surgery were performed, but as certainly it did
not hold true of multilocular dropsy of the ovary. The surgeon
amputates a limb, or excises a tumour for some form of carcinoma-
tous disease, hazarding more or less the life of his patient for the
temporary removal of a diseased action which is almost perfectly
certain to recur.
He ties the subclavian for aneurism-but is it not
a disease which is very liable to co-exist in different vessels at the
same time, or to form consecutively in different parts-and if the
patient escapes the great and immediate dangers of the operation, has
he any surety against its re-appearance elsewhere? You amputate
the thigh to get rid of a scrofulous or tubercular knee-joint. But in
how many cases is local tubercular disease the mere result of a general
diathesis, that ere long will betray itself in some other part or organ?
Dr. Simpson thought it a point of the highest practical moment to
consider that, on the contrary, the pathological nature of multilocu-
lar disease of the ovary was such that it had no tendency to recur
after its complete removal. From the character of its morbid
structure, and its clinical history, it was certain that it presented no
liability to spring up again, like malignant or tubercular disease, in
the same locality-or in distant and in different organs of the body.
The other ovary might be partially affected, and if so, might require
removal along with the first-a step which at the time would pro-
bably not add much to the absolute danger of the operation-seeing
the abdomen was once opened. Do not surgeons operate for popli-
teal aneurism, when it is present in both limbs, even with the
additional chances of an analogous diseased condition of the vessels
existing internally? Probably it will be found that a surgeon would
more rarely require to repeat ovariotomy, in consequence of the re-
maining ovary subsequently becoming diseased, than he now requires
to repeat lithotomy, in consequence of a second or a third stone
forming after a time in the bladder.
OVARIOTOMY.
801
4. Ovarian disease, it was averred, does not produce such dangerous
and urgent symptoms as to demand an operation.
Dr. Simpson said that he had already adverted sufficiently to the
dangerous and ultimately fatal tendency of the common multilocular
dropsy of the ovary. He had at present charge of one case, where
an enormous ovarian tumour produced occasional most intense suffer-
ing, in the form of severe abdominal pains and spasms resembling
the agonies of labour. In many cases where it had reached a large
size, it more or less incapacitated the patient, by its simple weight
and volume, from following the ordinary duties belonging to her
station; and if poor, threw her upon the bounty and charity of
others. In most it was, after a time, liable to be attended with
local attacks of irritation and inflammation, fever, etc., or produced
dyspnoea, difficult progression, etc.
He doubted if, in many cases operated upon, of aneurism or necrosis,
or ulcers, etc., supposed to demand amputation, etc., the suffering or
the incapacity from the duties of life were greater than in a large
proportion of ovarian cases. But, argue the surgeons, we operate
early in aneurisms, etc., because they continue to increase-the
same is true of ovarian tumours; because the aneurismal swell-
ing is, after a time, liable to affect the structure of neighbouring
parts, and render late operative interference less successful—the same
is true of ovarian tumours; because with the aneurismal disease
the constitution will sympathise and become debilitated-the same
is true of the ovarian tumour; because the aneurism may burst
and endanger life—the same is true of ovarian tumours.
He had,
two years ago, seen one burst into the peritoneum, and prove fatal;
its parietes were eroded by small internal ulcerations at several points,
and at last had given way. Any argument urging haste in the one
case, would, he feared, equally apply to the other. On the contrary,
would proper palliative treatment applied to local aneurisms not stay
their progress, and make them as chronic, if not more so, in their
course, than multilocular tumours? Mr. Fergusson has lately stated
that he has watched one case of axillary aneurism "for several years"
without its increasing. And aneurisms sometimes are, at last,
spontaneously cured; much oftener, he believed, than ovarian
dropsies. Take another case that happened in the Hospital practice
this morning. A man applied with stricture, and symptoms of stric-
ture only. On passing a small bougie, a stone is struck in the
•
802
DISEASES OF WOMEN.
bladder, and the patient is forthwith advised to submit his life to
all the perils and consequences of lithotomy, though he has no
suffering traceable to the calculus. Would it be justifiable to advise
a patient with an ovarian dropsy, giving her no trouble, to submit
in the same way to ovariotomy? He most assuredly thought it
would be utterly unwarrantable. And the palliative treatment for
urinary deposits and calculus was, it must further be recollected, now
far more advanced than the palliative treatment of ovarian dropsy.
A calculus of this kind would not be likely to increase so rapidly as
to destroy the patient in five or ten years. An ovarian tumour very
likely would do so. And sometimes, as in this case, a urinary
calculus does not really give rise to such uneasiness as to demand
any very active palliative treatment. Do we not sometimes see
calculi in the bladder after death, which have never given rise to any
marked symptoms during life? Again, does not the operation for
the obliteration of the varicose veins of a limb sometimes prove
speedily fatal, and yet the disease itself is one easily palliated by
rest and bandages? Besides, this recognised legitimate surgical
operation for varicose enlargement was not only dangerous to life
but, he feared, useless in its effects. In most cases, at least, the
disease was as bad again in a few months as it was before surgical
interference was adopted. Did we not sometimes see surgeons
amputate the limb, when it was merely the seat of simple and
benign, but untractable ulceration? And ulceration might be a
very serious inconvenience to a labouring man; but here we have a
dangerous and often fatal operation performed for a disease which
was not fatal nor dangerous in its own character, and that easily
admitted of palliative treatment. Altogether, it appeared to him,
that the question of when we should conscientiously deem ourselves
entitled to practise ovariotomy, or any other dangerous operation,
for a chronic disease, was one that had hitherto received no sufficient
attention. It was a question that probably must always be decided
much upon the merits of each individual case, and in regard to which
different minds may come to opposite and yet conscientious conclusions.
It always embraced a difficult moral and professional problem, in
cases where the required operation was, as in ovariotomy, ligature
of the larger vessels, amputation, lithotomy, etc., directly and
immediately dangerous to the life of our patient. It resolved itself
in such a case into a question of this kind :-Am I conscientiously
ENTITLED to inflict deliberately upon my own fellow-creature, with my
own hands, the imminent and immediate chance of DEATH, for the proble-
{
OVARIOTOMY.
803
matical and prospective chance of his future improved HEALTH and pro-
longed LIFE? In calculating what amount of danger of present death
ought to be incurred for the hazard of future good, many secondary
elements necessarily entered into the problem-such as the existing
chance of otherwise palliating the disease and prolonging life with
certainty for months or years-the extent of attendant suffering —
the probability of the affection recurring-or already existing else-
where, etc. etc. In such a calculation, the ideal glory of a successful
operative result has probably been too often allowed to dazzle the
calm judgment of both the operator and his patient, and the darker
but equally truthful shades of the picture have been, for the moment,
so far obscured and unseen. With the patient the stern reality of
danger and death too frequently vanishes, here as elsewhere, before
the strong hope of life. And the surgeon, like the soldier, is, in the
computation of his successes, perhaps too liable to forget the actual
amount of human suffering and human fatality through which these
successes are obtained.
5. It has often been argued against ovariotomy, that the operation, when
begun, could not sometimes be completed, from adhesions, etc.; or no
tumour could be found.
These circumstances were the results of imperfect diagnosis ;
and he adverted to the occasional difficulties connected with the
discrimination of ovarian tumours, and admitted them to their
full extent. He explained that he could scarcely conceive the
repetition of some of these errors if due caution were adopted.
If other means failed, an exploring needle would always certify the
presence of a tumour, and its structure or nature; the uterine bougie
would show if the tumour were situated in the uterus or ovary, etc.
The chief and ruling difficulty at this moment was assuredly that of
discovering the existence or not of adhesions of the tumour by false
membranes, their extent, etc. If this point could by any measures
be cleared up, it would remove one of the great, perhaps the greatest
existing objection to ovariotomy. Nor was it totally hopeless. One of
the most sure and solid advances made by modern pathology was our
gradual but great improvement in the physical diagnosis of the
diseased states of different organs. Probably the next marked step
in this path would be the detection of some measure or measures
for improving our knowledge of the physical diagnosis o. diseases of
the abdominal viscera. It was not more extravagant to expect
52
804
DISEASES OF WOMEN.
this, than thirty years ago it would have been extravagant to expect
all the vast aid and certainty which we now derive from ausculta-
tion in the physical diagnosis of diseases of the chest; and he
believed some important steps had been already made regarding the
detection of ovarian adhesions by Dr. Frederick Bird of London
and others. Dr. Bennett's contribution was, under this head, of the
highest pathological and practical value. As soon as the ovarian
tumour in the case described by him was exposed, it was evident to
all who had taken an interest in the question, that the accompany-
ing ascitic effusion oozed by apertures from the interior of the
ovarian tumour, and was a secondary result. But if, as Dr. Bennett
would, he doubted not, be able ultimately to show, it was possible
to distinguish, by microscopic characters, between the fluid of
common ascites and the fluid of ascites thrown into the peritoneum
through small ulcerated apertures in the walls of an ovarian tumour,
it would clear up various points in a set of cases formerly sur-
rounded with perplexing difficulties. It would enable us to detect
the pathological cause and source of the great ascitic collections
sometimes attendant upon comparatively small ovarian tumours.
Cases with this complication—that is, ovarian tumours with aper-
tures allowing their secretions to pass into the general peritoneal
cavity—evidently in general ran a very rapid and fatal course.
these secretions were acrid and irritating, as when mixed with
inflammatory effusions from the walls of the cyst or cysts, they might
at once excite fatal peritonitis. This, however, was rare, and the
exception to the rule. Usually the secreted fluid appeared to be
blander, distilled slowly through the morbid openings in the parietes
of the tumour, and, accumulating in the peritoneum, required ever
and anon to be removed from that cavity by tappings, which soon
became more and more frequent, and more and more exhausting.
This variety was probably, he suggested, of all ovarian cases, that
most surely justifying the adoption of extirpation. And besides, in
these very cases, it was generally ascertainable whether there were
adhesions or not, for the tumour was surrounded by a fluid medium,
and hence admitted more easily of this point of diagnosis being
made out by its mobility in that medium. Perhaps it was, on the
other hand, unjustifiable in our present state of knowledge to
operate where there were many adhesions, or any great want of
certainty about the existence and extent of them; as it was, where
the tappings, though many and frequent, did not, as was seen in a
few exceptional cases on record, exhaust rapidly the powers of the
If
OVARIOTOMY.
805
patient, or threaten her life with any prospect of urgent or imme-
diate danger.
But, admitting to their fullest extent the occasional difficulties
which have been found to beset the diagnosis of ovarian tumours
for operation, do we not meet with occasional difficulties of exactly
the same kind in other surgical operations, and which do not yet
deter surgeons from interfering? Is the trephine never used with-
out detecting any effused blood, or pus, or depressed and fractured
fragments of bone? In tying the carotid and subclavian and iliac
arteries for aneurism, it has now repeatedly happened that all the
great dangers of these operations had been submitted to most use-
lessly, the disease, during the operation or after death, being found
not to be aneurismal at all,' and hence not at all curable by such a
procedure; and when aneurismal, the operation has been sometimes
left incompleted-the vessel searched for either not being secured,
or, as has happened with Dupuytren and others, it has been reached
and fatally transfixed with the ligature, instead of being surrounded
by it. Have not the antrum, and the mamma, and the testicle, etc.,
been sometimes found to be the seat of simple inflammatory and
curable effusion, after all the usual operative measures for the
removal of supposed malignant tumours from these localities had
been commenced, or even completed? A surgeon had excised ten
scirrhous mammæ, and in every case with perfect success. In not
one was there any return of the disease. Sir Benjamin Brodie was
requested by this active operator to see a new case of scirrhus
which he had determined to remove. "It was nothing more," says
Sir Benjamin, "than a chronic abscess of the breast, which he deno-
minated scirrhus." Dr. S. had seen amputation of the thigh per-
formed by a celebrated surgeon for supposed scrofulous disease of
the knee-joint, and where, on examining afterwards the amputated
limb, no traces of such a disease could be found. Most of them had
seen cases of diseased limbs threatened with, or actually condemned
to, the knife, and which yet afterwards got quite well, when surgical
interference would not be submitted to by the patient. In some
cases of hernia, is it not occasionally found impossible, as in some
1 ¹ During the discussion Dr. Spittal mentioned, that out of fifty-nine cases,
collected by Dr. Norris, of ligature of the subclavian artery for aneurism, “in
three no aneurism existed, and in two the tumour was mistaken for aneurism and
punctured." Hence, in one out of every twelve of these cases, the diagnosis was
perfectly wrong.
2 Medical Gazette, 1844.
806
DISEASES OF WOMEN.
cases of ovariotomy, to finish the operation, and return the bowel, in
consequence of extensive morbid adhesions or other causes ? Is not
the stone sometimes found encysted in lithotomy, and for that or
other causes its removal rendered impossible after the bladder is cut
into? Is the operation for the removal of an incarcerated piece of
necrosed bone not sometimes found impossible after it is begun?
Grave errors have been committed in diagnosis in ovariotomy cases,
in relation to the propriety and practicability of the operation, but
he doubted if as grave errors were not as frequently committed in
some other recognised capital operations. A much greater amount
of caution was undoubtedly requisite on this head.
In summing up his statement, Dr. Simpson allowed that ovario-
tomy was a most serious and dangerous operation; but at the same
time he maintained, that surgeons in declaiming against it had used
a series of arguments, all, or almost all, of which would equally, and
some of them still more strongly, apply against those capital opera-
tions for chronic maladies, regarding the propriety of which they did
not affect to entertain one single doubt, and which they every day
performed without the slightest scruple. For his own part, how-
ever, he entirely doubted whether surgeons should resort to many of
these operations, under the circumstances in which they often adopted
them. He doubted whether, for example, they should at once subject
a man to all the immediate and fearful perils of lithotomy and
lithotrity, because he had a stone in the bladder which gave him
little or no uneasiness, and which might allow him, under proper
regimen and treatment, to live and perform the duties of life for a
long series of years. He doubted whether, in a case of axillary, or
carotid, or popliteal aneurism, slowly increasing, or not increasing at
all, having some small chance of spontaneous cure, and having no
inconsiderable chance of being followed or accompanied with the
same disease in other parts of the arterial system, all the dangers of
the ligature of the vessel nearer the heart should be at once reck-
lessly encountered. He doubted whether, in malignant or carcino-
matous disease of the forearm or leg, amputation of the arm or thigh
should be at once resorted to, with the hazard of death in a few
hours or days in one out of every two operations, and the almost
perfect certainty of the same morbid action reappearing sooner or
later in the stump, or in some other part, if the patient did happen
to. survive. And, on the same principle, he doubted whether
ovariotomy had not been employed in some cases under perfectly
unjustifiable conditions, when the health and life of the patient were
OVARIOTOMY.
807
not immediately threatened by the stage and progress of the malady,
when the tumour was a source of inconvenience and deformity, rather
than a source of danger, and when the evils of the disease were as
yet prospective rather than real. But if the health of the patient
were becoming rapidly undermined by the disease-if the progress
of the affection showed that ere long it would inevitably prove fatal
if the question were thus reduced to one of certain and not distant
death from the course of the malady, or possibly an entire escape
from the affection, with prolonged life and health from the operation
-and if, in addition, the ascertained or apparent freedom of the
tumour from adhesions and other circumstances were such as to
present no counter-indication-then he believed that ovariotomy
might be undertaken under conditions far more justifiable and legi-
timate than the surgeon could possibly urge in favour of some of his
stone, and aneurism, and other capital operations for pathological
lesions of a similarly chronic character and course.
Lastly, he stated, that if betimes ovariotomy came to be recog-
nised as a surgical operation, fit and proper in such cases of ovarian
disease as he adverted to, or in others, he had no doubt the steps of
the operation itself would meet with improvements. Such im-
provements were almost always wrought out by experience. How
different is amputation now, from what it was formerly with the
hot iron, or boiling pitch, to seal up the cut vessels.
How com-
paratively safe and simple is the tying of an artery now from what
it was half-a-century ago, with the flat double ligatures, and liga-
tures of reserve, etc. One great source of danger in ovariotomy
was the irritation and injury inflicted on the intestinal canal and
peritoneum from the strong ligature which was required for the
stalk of the tumour being passed through the abdominal cavity,
and out at the external wound-remaining there for days or weeks,
and keeping a portion of the wound in the abdomen necessarily
open by its presence, and, consequently, so far still more hazarding
the occurrence of peritonitis. Probably it might be possible to
devise some other measures of securing the large vessels, principally
veins, be it remarked, of the pedicle, and thus save the several dan-
gers arising, 1st, From leaving the ligature to irritate there; 2d,
From the ligature, by its constriction of the stalk, producing stran-
gulation; and 3d, From its exciting phlebitis. And if the ligature
still continues to be employed, it would, he believed, be found a
great improvement, as had been suggested to him by his excellent
friend and assistant, Dr. Keith, to pass it down, perforate the very
1
808
DISEASES OF WOMEN.
thin layer of serous and mucous membranes dividing the utero-rectal
reflection of the peritoneum from the upper and back part of the
vagina, and bring it out along the vaginal canal. He knew that on
the dead subject this could be done with the greatest facility. It would
have several advantages. 1. It would enable the surgeon to close at
once the whole length of the incision in the abdominal parietes; 2.
The sides of the vaginal canal, being in contact, would act as a valve
sufficient to prevent that dangerous access and egress of air to and
from the peritoneum under strong respiration, vomiting, etc., which
had sometimes occurred through the aperture kept open by the
ligature, in the old form of operating; 3. The ligature would not
pass through the same extent of the peritoneal cavity, and would
scarcely, if at all, touch or irritate the folds of the intestinal canal;
and 4. If the uterus happened to be displaced backwards upon
the rectum, the ligature applied to the posterior surface of its broad
ligament would be included and imbedded in a cavity almost divided
and separated from the general cavity of the peritoneum, and where
the process of reparation and adhesion might often go on without
fatally extending upwards into the general peritoneal sac. Farther,
the cases already published recounted some errors which the experi-
ence derived from them showed might be avoided in future. We
were thus warned to take great care to close, as accurately as pos-
sible, the peritoneal side of the wound, to prevent strangulation of
a fold of intestine in its edges; to adopt precautions with the same
view, of not allowing a similar effect from the portion of ligature
passing through the abdomen; not to allow the bladder to become
distended, lest it drag upon the uterus, or disturb the reparative
process; not to excite inflammation by dragging at the ligatures,
etc. etc.
Dr. Simpson subsequently added a few observations in reply to
some remarks made by Mr. Spence. According to Mr. Spence, tre-
phining for the discovery of effused blood, and tying the arteria
innominata, were not now looked upon by surgeons as justifiable
operations. Probably, the Society would allow that the lately pub-
lished text-books by Professors Fergusson and Syme were fair stand-
ards of the existing state of British surgery. Now, Mr. Fergusson
not only in his work advises trepanning for effused blood, but even
speaks of cutting through the dura mater in search of it. Mr.
Syme, in treating of the ligature of the innominata, states that it is
a dangerous operation, but he does not give the most remote hint
as to its being regarded by him or others as an unjustifiable one ;
PAINFUL MUSCULAR AND FASCIAL CONTRACTIONS IN VAGINA. 809
and, on the contrary, he describes the steps of the operation, and
suggests means for rendering it safer. Mr. Spence had alluded to
the spontaneous cure of aneurism, and thought him wrong in his
ideas about its frequency. Dr. S. did not know of any data calcu-
lated to show how often, or how seldom, the spontaneous cure of a
local circumscribed aneurism-such as surgeons operated for-might
be expected; but of eight or ten cases of popliteal aneurism, seen
in the hospital within as many years, nature set up inflammatory
action in the sac or vessel, or both, and cured one case, a patient of
Dr. Cunningham, before art had an opportunity of interfering.
all events, he felt assured, that if local external aneurisms were
treated by common palliative measures, their spontaneous cure would
be found not to be so rare as the spontaneous cure of ovarian dropsy ;
and he feared that all Mr. Spence's arguments for early operation in
the one case, most unwittingly applied with similar appropriateness
to the other.
At
PAINFUL MUSCULAR AND FASCIAL CONTRACTIONS
ALONG THE VAGINAL CANAL-VAGINODYNIA.'
Professor Simpson said that he had lately seen a number of cases,
and he had seen them from time to time for years, where painful
muscular or fascial contractile bands existed in the sides or along
the course of the vagina. He had known some of these cases to
have been mistaken and treated for various alleged affections of the
uterus or its appendages. The pains complained of were, sometimes,
principally sympathetic or reflex, and referred to the uterus or other
parts, and often aggravated by all movements calling the pelvic
muscles into action. He had under his care at present a patient
whose chief complaint was a constant disagreeable pain in the sacral
region; another who had the same severe kind of pain in the left
iliac region; while a third could not walk because of the pain which
she felt in the pelvis whenever progression was attempted. In this
class of cases the uterus and ovaries would, on careful examination,
be found healthy, but a tense, corded, transverse band could be felt
at some part of the vaginal wall, and usually, if not always, on one
side of it, and placed, as it were, more or less deeply beneath or
1 See Proceedings of Edinburgh Obstetrical Society, November 14, 1860, in
Edinburgh Medical Journal, December 1861, p. 594.
810
DISEASES OF WOMEN.
below the mucous membrane. The band or cord was most com-
monly placed about an inch above the vaginal orifice. It varied
considerably both in thickness and tenseness in different cases.
When the cord was touched and stretched with the finger, the
patient complained of more or less severe suffering; and this was
the pathognomonic mark of the disease. Sometimes the patient only
experienced pain at all when the vagina was touched; and these
cases usually came under treatment in consequence of being unable
to submit to marital intercourse. He had one patient under treat-
ment who could not bear at first to allow herself to be examined
vaginally without chloroform, because of the pain experienced from
the touch of the finger. Painful and distressing as these cases were,
they were very amenable to treatment,-division or rupture of the
tight and contracted band being usually sufficient to afford complete,
and often instantaneous, relief; and in the milder form of cases,
sedative applications were sometimes sufficient. The method he
had usually adopted for the cure of very severe cases of this kind
was, after chloroforming the patient, to divide the tight band by
means of a tenotomy - knife introduced underneath the vaginal
mucous membrane. It was a bloodless operation, and had never
been attended with any worse consequences than the formation of
a thrombus, which had taken place in one patient and had delayed
her recovery. He had tried also to effect the object of stretching or
rupturing the band by dilating the vagina forcibly with the fingers,
whilst the patient was asleep with chloroform. The principle of
cure was the same as that employed for the relief of fissure and
spasmodic contraction of the orifice of the rectum. But less severe
means were occasionally successful. Patients afflicted with this
complaint were usually relieved, and sometimes cured, by the daily
introduction into the vagina, for a length of time, of local sedatives,
such as belladonna ointment and chloroform. A small cup-like
indentation was made with the finger in an ordinary belladonna
pessary; a few drops of chloroform having been poured in, and then
shut in by putting a piece of ointment over the orifice, and then the
whole was introduced into the vagina, where the ointment slowly
dissolved, and became absorbed along with the chloroform. As to
the probable nature of these painful contractions, he (Dr. Simpson)
could not supply any very definite answer, but he thought they
depended in different cases either, first, on a kind of permanent
spasm of some of the muscular fibres around the vagina, of the same
nature as the spasm of the sternocleido-mastoid muscle, which pro-
VARIOUS FISTULE RESULTING FROM PELVIC ABSCESS.
811
duces torticollis ; or, secondly, they were due to contractions going
on slowly in some portions of the pelvic fascia, perhaps resulting
from a kind of subacute inflammation, and resembling those often
painful contractions of the palmar fascia, which are the acknowledged
cause of "crooked-in fingers." Dr. S. believed that the common
anatomical seats of these painful vaginal contractions were either in
the bundle of muscular fibres forming the anterior border of the
levator ani, or in the duplicatures or edges of the pelvic or recto-
vesical fascia at the points where the vaginal canal perforates the
fascia and receives insertions and prolongations from it. These
contractions sometimes appeared in patients in whom no previous
disorder of any of the pelvic organs could be ascertained to have.
existed; and he had lately seen one patient who was the subject of
it, and who had never been able to allow her husband to approach
her, so that in her the morbid condition must have been present
before marriage, although she had never been in a position to be
made aware of its existence. Instances, however, like this last
oftener belonged to a class of cases where apparently the stricture
was not, as in the preceding class, in the course of the vaginal canal,
but was situated at its very orifice, independently apparently, in
most, of all disease there except supersensibility and spasm of the
sphincter of the vagina, but traceable in others to hyperesthesia of
the mucous surfaces of the vulva or vagina, resulting from irritable
eruptions or other morbid states of these mucous surfaces.
ON VESICO-UTERINE, VESICO-INTESTINAL, AND
UTERO-INTESTINAL FISTULÆ,
AS RESULTS OF PELVIC ABSCESS.¹
Cellular tissue exists abundantly within the pelvis, along the
lining of the walls of the pelvic cavity, within the layers of the broad
ligament, and between the intestinal, genital, and urinary canals, at
all those points in which they come into organic coherence. Inflam-
mation of this tissue, or Pelvic Cellulitis, is a common affection,
particularly as a consequence of parturition, etc. Pelvic cellulitis,
after giving rise to great swelling and induration, by the effusion of
serum, coagulable lymph, etc., into the inflamed portion of the
cellular tissue, very often terminates sooner or later in resolution ;-
1 Sec Edinburgh Monthly Journal of Medical Science, December 1852, p. 532.
812
DISEASES OF WOMEN.
he disease not unfrequently assuming a subacute or chronic type.
In other instances, however, the inflammatory action runs on towards.
suppuration, and forms a so-called Pelvic Abscess. When this ter-
mination occurs, the collected purulent matter is found to obtain
egress by different outlets. The abscess sometimes bursts into the
intestinal canal, or into the genital canal, or into the urinary bladder.
Occasionally it discharges externally upon the cutaneous surface;
and in a few rare instances it opens into the cavity of the peri-
toneum. Sometimes the collected pus is found to make its escape
simultaneously, or rather consecutively, by two different exits. Thus
we may have the cavity of the same abscess opening into two differ-
ent pelvic mucous canals. Where such double perforations, originat-
ing in the escape of matter from a pelvic abscess, become chronic in
their character, they lead to the formation of several species of deep
pelvic fistula, which have not, so far as I am aware, been hitherto
described by obstetric pathologists.
Very few instances of the existence of fistula of any kind between
the bladder and uterus have hitherto been put upon record. Indeed,
the number of vesico-uterine fistula hitherto recorded seems to be
limited to three instances, reported severally by Mad. Lachapelle,
Professor Stoltz, and M. Jobert; and in all of these three cases, the
perforation which existed between the bladder and cavity of the
neck of the uterus was the result of injury during parturition.
In the following case this rare form of lesion was produced as a
consequence of pelvic cellulitis; or, to speak more definitely, it was
produced by a purulent collection formed in the cellular tissue lying
between the bladder and the neck of the uterus, and which ulti-
mately ruptured-on one side into the bladder, and on the other
side into the cavity of the uterus, or rather the cavity of the cervix
uteri.
--
CASE I. The patient, aged 22, and the mother of two children, was admitted
into the female ward of the Royal Infirmary in June last. Her youngest child
was then eleven months old; and she had made a perfect recovery after her con-
finement with it. About six months, however, subsequently to her delivery, she
was seized with local pelvic pain, dysuria, and the usual symptoms of pelvic cel-
lular inflammation. Three or four weeks after the commencement of this attack
she had shiverings and perspirations, and other symptoms of hectic fever. These
symptoms were shortly followed by evidence of the escape of purulent matter;
and subsequently complete incontinence of urine came on. After this the urine
continued to be discharged per vaginam up to the date of her admission into the
hospital, four months after the commencement of the inflammatory symptoms.
The urine contained a considerable quantity of pus. On examination, the urethra
was found perfectly patent, although the urinary secretion was not discharged
VARIOUS FISTULA RESULTING FROM PELVIC ABSCESS. 813
through it. There was still a considerable mass of fixed inflammatory deposit in
front of the cervix uteri, or in the cellular tissue between it and the posterior wall
of the bladder. The cervix uteri itself was considerably hypertrophied, par-
ticularly its anterior lip. That the urine passed from the bladder through the os
and cervix uteri, was ascertained by the simple experiment of filling up the os
uteri for a day with a small sponge-tent. During the time the cavity of the os
uteri was stopped up with this plug, the urinary discharge was evacuated through
the urethra; but immediately began again, and continued, to pass through the
artificial vesico-uterine opening as soon as the sponge plug was withdrawn. After
withdrawing the plug, the cervical cavity, which had been dilated by its presence,
was examined by the finger, and two apertures were found passing into it, or
rather leading from it-the normal aperture leading upwards into the cavity of
the uterus, as ascertained by the uterine sound-the other, tending obliquely for-
wards towards the cavity of the bladder. This latter artificial opening was freely
cauterised by solid nitrate of silver. Subsequently, local and general measures were
employed, as external counter-irritation, iodine, etc., to promote the absorption of
the inflammatory deposit. In the course of a few weeks the swelling from the de-
posit between the bladder and cervix uteri diminished, the incontinence of urine
became gradually lessened, and was ultimately totally arrested; the cure being,
as I believe, the result of the natural contraction of the parts, following upon
the absorption of the original inflammatory deposit. Subsequently this poor
patient was attacked with symptoms of acute pulmonary phthisis, and died a
short time ago at a distance in the country, but without any return whatever of
the incontinence of urine.
I have seen other cases of pelvic cellulitis which had run on to
suppuration, leave other forms of fistulous perforation, perhaps still
more strange and singular in their anatomical relations.
Two years ago, I had under my care a case in which there was
produced, as the result of this disease, a utero-intestinal fistula.
CASE II.-A lady, a few days after her first confinement, was attacked with
symptoms of fever, and local pelvic inflammation. These terminated in a very
tedious pelvic abscess. About a year subsequent to her accouchement, she was
brought to Edinburgh, and placed for some time under my care. She still had
considerable thickening and pain on pressure in the left side of the pelvis, which
had been the seat of the pelvic cellulitis. The cervix uteri, and indeed the whole
uterus was elevated upwards, and drawn considerably to the same side. On ex-
amining simultaneously, with the fingers of the right hand on the roof of the
vagina, and with those of the left hand placed externally over the left iliac region,
much thickening and agglutination of the uterus and intestines could be readily
ascertained in the left pelvic and iliac regions. Discharges of slight accumulations
of pus recurred from time to time through the os uteri; and, occasionally, after
these discharges, small quantities of feculent matter were found in the vagina-
showing a communication to exist between the intestinal canal, at some part,
perhaps the sigmoid flexure, and the cavity of the uterus. When the canal of the
cervix uteri was gently examined by a slender probe or sound, a fistulous com-
munication could be traced, passing up from the cavity of the cervix laterally
towards the left iliac region; but this sinus could not be followed for any great
length.
814
DISEASES OF WOMEN.
In this case there was a constant tendency to the recurrence of
inflammatory attacks in the original seat of the pelvic inflammation,
some of which were extremely severe. The patient subsequently
removed to the south of England, where she died under, I believe,
one of these renewed inflammatory attacks. My friend, Professor
Lawrie of Glasgow, saw this case repeatedly.
Some time since, I was consulted by a patient, in whom there
existed a still more rare and curious form of fistula, the result of a
pelvic abscess under which she had suffered. Professor Macfarlane
of Glasgow, and Dr. Miller of London, also saw the case.
Its pecu-
liarity consisted in this-that, as a result of pelvic abscess, a fistula
was formed between the bladder and rectum-a recto-vesical fistula
and yet the intermediate uterine and vaginal canals were not
implicated in it. The principal particulars regarding the case are as
follow:-
CASE III. The patient, when about twenty-three years of age, and unmarried,
was attacked with fever and severe local inflammatory pain in the pelvis and left
groin. After these symptoms had continued for some weeks, she was at length
relieved by the discharge of a large quantity of purulent matter from the rectum.
About twelve months after the occurrence of this pelvic abscess, she was con-
sidered so well as to be allowed to be married. But from that time she suffered
from repeated attacks of pelvic irritation and inflammation, with leucorrhoea,
irregular menstruation, etc. She never became pregnant. Several years subse-
quent to marriage, during one of these recurrent pelvic attacks, the bladder
became greatly irritated; and, after this painful dysuria had lasted for some time,
purulent matter was discharged along with the urine. Subsequently to this
period, and on to the time of her death, four years afterwards, small portions of
feculent matter and flatus passed from time to time by the urethra, along with
the urine-showing a communication to exist between the intestinal and urinary
canals. As high up the rectum as could be reached with the finger, a fistulous
opening was traceable in the anterior and lateral part of the bowel, and a probe
could be passed forwards to some extent through it. There was much thickening
and agglutination of the pelvic tissues at that part. No treatment was of
avail in relieving the patient from her distressing symptoms. She died ultimately
of a short illness, from, as reported to me by Dr. Miller, some affection of the
brain.
any
In the preceding and in other cases of pelvic abscess, the different
openings through which the matter becomes discharged do not, as I
have already remarked, always occur simultaneously, but generally
consecutively. After the purulent matter has escaped, apparently
with sufficient freedom, by one opening, it will occasionally, in
consequence either of its temporary obstruction and retention in the
sac of the abscess, or in consequence of the walls of the abscess
VARIOUS FISTULE RESULTING FROM PELVIC ABSCESS. 815
themselves ulcerating, again open at a subsequent period into
another canal. The following case, which I had occasion to see
often under the kind and able care of Dr. Johnson of Stirling, will
serve to illustrate this remark:-
CASE IV.—A patient in the country was seized with acute symptoms of pelvic
cellulitis; and a large inflammatory tumour speedily formed in the cellular tissue
of the left broad ligament, and in the left iliac fossa. In despite of the active
antiphlogistic treatment that was adopted, the disease ran on towards suppuration,
and dangerous symptoms of irritative fever and exhaustion supervened, with great
local tenderness in the affected part. An exploring needle, introduced by the
spine of the ilium into the inflammatory swelling, lying in the iliac fossa, showed
the presence of a deep collection of pus. I evacuated it twice by a trocar, with
great relief to the patient. Pus continued to be freely discharged for a considerable
time through this artificial opening on the edge of the left iliac fossa. After this
discharge had gone on for some weeks, the opening from time to time offering to
become nearly closed, a new and distressing symptom supervened. For, along
with a discharge of matter through the artificial opening, there passed from time
to time some flatus, and occasionally a slight appearance of feculent matter-
showing that the abscess had ulcerated into the bowel, probably the sigmoid
flexure of the colon.
In this instance, the spontaneous opening of the abscess into the
intestinal canal did not, as I have said, occur till weeks subsequent
to the discharge of the matter through the external opening. After
this occurrence, the external fistula was attempted to be shut up by
various means, but for some time without avail. At last, by altering
the position of the external orifice by a new incision, the whole
external aperture was happily obliterated, and the patient has made
a perfect recovery.
In the preceding cases, the fistulous communications resulting
from the pelvic abscess were probably valvular in their form, inas-
much as apparently the fluids and air escaped through the track of
the fistula only occasionally, and not constantly. Perhaps, in some,
the transit of these matters was only effected when the canal of the
fistula was preternaturally distended by an accumulation within and
behind it of the morbid matters that passed; the walls of the canal
at other times being so much in contact as not to allow of the
passage of any foreign body.
In the case of vesico-intestinal fistula which I have mentioned—
(see Case III.)-feculent matter and flatus appeared to pass from
the bowel into the bladder; but the patient was never aware of the
urine passing from the bladder backward into the bowel. It is
quite possible, however, that it may occasionally have done so in
ห
816
DISEASES OF WOMEN.
small quantity, without her being able to recognise it distinctly. If
it were not so, then, in that case, the fistulous communication was
of such a valvular structure as to allow of the transit of matters in
one direction, and not in another-a point in its anatomy which it
is not difficult to conceive.
Since the preceding notes were written, I have received a com-
munication from an old pupil, Dr. Heslop, directing my attention to
a case published by him,' in which the left ovary was found after
death of the size of an orange, adhering intimately to the rectum
and bladder. The cavity of the enlarged ovary contained "a soft,
pultaceous, half fæcal, half caseous-looking matter;" and communi-
cated posteriorly with the lower portion of the sigmoid flexure of
the colon, and anteriorly with the urinary bladder. In this case a
fistulous communication seemed to be formed between the intestinal
and urinary canals, through the cavity of this diseased ovary; and
air, and probably feculent matter, are said to have passed occasion-
ally from the bladder for twelve months before death. The patient
had, in addition, a calculus in the left kidney, enlargement of the
liver, etc.
BALL-VALVE OBSTRUCTION OF THE RECTUM BY
SCYBALOUS MASSES.2
Dr. Simpson described a recent case of this not uncommon com-
plication which he had seen with Dr. Husband. The patient, when
Dr. Simpson visited her, was suffering from intermitting paroxysms
of abdominal muscular effort, like those of labour. Dr. H., on making
a vaginal examination, had detected the impacted and distended state
of the rectum. A large, hard, oblong scybalous mass filled up the
canal of the rectum. It was incrusted with phosphatic deposit on
its external surface. The rectum was in consequence irritated by it,
and tender under examination. The patient was chloroformed, the
mass broken down by an iron instrument, and with some difficulty
removed piecemeal. Subsequently, some smaller and higher-placed
masses were expelled by the action of aperients, and the patient was
relieved from her sufferings.
¹ Dublin Quarterly Journal for 1850, p. 220.
2 See Proceedings of Edinburgh Obstetric Society, January 10, 1849, in Edin-
burgh Monthly Journal of Medical Science, April 1849, p. 705.
INFRA-MAMMARY PAINS.
817
Dr. Simpson alluded to some other cases of the same kind which
he had seen. Such ball-valve obstructions often caused great distress
to the patient; and the disease was occasionally altogether over-
looked for a time, and its nature mistaken. This was more parti-
cularly liable to happen in consequence of the circumstance, that a
small quantity of thin feculent matter often escaped from day to
day in these cases, leading to the idea that the uneasy sensations of
the patient, and ultimately the paroxysmal and expulsive pains,
could not be the result of obstruction in the bowel. Thin feculent
matter in this way escaped, in consequence of the scybalous mass
not necessarily occupying and shutting up the whole calibre of the
bowel, but allowing the more fluid matter to pass between its sur-
face and the sides of the intestinal canal. When, however, the
patient used, as was instinctively done, any straining effort to make
the expulsion more complete, the scybalous mass was by this means
pushed down upon the lower and more contracted portion of the
rectum, and acted exactly like a ball-valve, so far temporarily closing
the bowel, and preventing any further evacuation from it for the
time. Such patients could sometimes partially evacuate the bowel
in a lying, when they could not effect it in a sitting, posture, a
result easily understood when we consider the mechanical character
of the disease. It was an affection liable to recur from time to
time in those who had been once subject to it.
ON INFRA-MAMMARY PAINS.'
A local limited pain under the left mamma, more rarely under
the right, is a species of suffering which is not unfrequently seen in
the female sex, and it has been alluded to and described by various
authors. Usually the seat of the pain is limited to a part not more
extensive than a crown-piece. Sometimes it spreads further, and
circularly around the side. It is apparently seated in the soft parts
covering the ribs, and principally in the integumental coverings.
Often it co-exists with uterine disease. Sometimes it persists for
weeks, months, and years, occasionally recurring in fits, more
generally of a chronic and more permanent nature. Many means
have been suggested for its relief and treatment; as cupping and
1 See Proceedings of Edinburgh Obstetrical Society, Session XVI., in Edinburgh
Medical Journal, April 1857, p. 965.
818
DISEASES OF WOMEN.
counter-irritating the corresponding portion of the vertebral column ;
applying leeches, blisters, sedatives, etc., to the affected part.
Latterly, in a considerable number of instances, I have injected the
subcutaneous tissue at the pained part with ten or twenty drops of
the common solution of the muriate of morphia, or with a watery
solution of the bimeconate of morphia, of the same strength, accord-
ing to the plan ingeniously suggested by Dr. Alex. Wood for the
cure of neuralgia. The results have been in most cases successful
beyond my previous hopes. I have seen the pain at once disappear
in a number of instances in which it had previously persisted for
various lengths of time. In most a single morphia injection has
sufficed; in some it required to be repeated twice or oftener. The
instances which have not yielded to this treatment have been
relatively very few in number, compared to those in which it has
succeeded; and the measure is so simple and so generally effectual
as, I believe, to deserve the attention of the Society.
SPURIOUS PREGNANCY-ITS FREQUENCY AND
NATURE.¹
A case of hysteria and spurious pregnancy having been read by
Dr. Keiller before the Medico-Chirurgical Society of Edinburgh, the
president, Dr. Simpson, observed that he believed cases of spurious.
pregnancy were often met with in practice; for many a married
lady would acknowledge, when questioned, that she had once or
twice thought herself pregnant when, as the result showed, she was
not. He had in his own practice seen several cases in which ladies
had removed into town with their entire establishments, in the full
belief of their approaching confinement, and where he had had the
disagreeable duty of informing them that they were not in the family
way. Shortly before his predecessor, Dr. Hamilton, died, one lady,
in her anxiety to reach Edinburgh, had had the roads cleared of
snow for a long series of miles, to enable her to accomplish the journey,
which proved after all a useless one, as Dr. Hamilton pronounced
her not pregnant. These were instances in which patients progressed
onwards to near the full term of pregnancy, suffering all the usual
symptoms and discomforts of that state. Sometimes phenomena.
exactly like those of labour came on at the full term.
This seemed
¹ See Proceedings of Medico-Chirurgical Society of Edinburgh, April 5, 1854,
in Association Medical Journal, April 21, 1854, p. 357.
SPURIOUS PREGNANCY.
819
to have occurred in Dr. Keiller's patient. He had seen several analo-
gous instances of spurious pregnancy terminating in spurious partu-
rition. In one of the first cases of this kind which he had witnessed,
and which occurred in the Maternity Hospital of Edinburgh, he had
been suddenly called from lecture to see it; the case being reported
by the house-surgeon, a man of remarkable acuteness, to be one of
placenta prævia, and requiring the operation of turning. The
patient had the phenomena of labour present, with severe menor-
rhagia; but there was no child to turn, as she was not pregnant.
Besides the cases of pseudo-pregnancy in which, as in the above,
the patient went on with the usual symptoms of pregnancy till near
or up to the full period of labour, there were other varieties of this
curious morbid state. In some, for example, the affection lasted
only for a few months; in others, it occasionally continued far
beyond nine months, and became, as it were, chronic in its character.
As to the symptoms themselves, they consisted of the presence of
more or fewer of all the usual sympathetic symptoms of pregnancy,
as swelling of the abdomen, nausea and sickness, a feeling of quick-
ening and motion of the child, etc. Dr. Keiller had stated that the
mammary signs were not well marked in his patient. Sometimes,
however, they were; and he had sketches illustrative of this fact,
executed by the patient herself during a state of spurious pregnancy,
and in whom, in a subsequent veritable pregnancy, her first, the
areolæ did not present a deeper tint than they had done during her
pseudo-pregnancy. As to the sensations which had been described
in such cases, they were very frequent, and sometimes there were
true motory contractions in the abdominal walls. He saw, about a
year ago, with Drs. Moir and Weir, a patient who had been sent
from the country on account of a supposed difficulty in the delivery,
the woman having, according to her statement, been in labour for
three days. In this case there were very strong motions visible in
the abdominal walls; so much so that the husband, who was present
during the consultation, declared, on their affirming that there was
no child, that then there must be an animal inside his wife. Dr.
Simpson was inclined to believe that the malady was connected with
the ovary. In one aggravated case which had fallen under his
observation, there was marked ovaritis, and the ovary subsequently
suppurated. Again, it was observed that, although menstruation
did occur in the cases which had been noticed, yet that it was much
scantier than usual, and sometimes the catamenia were wanting for
several months. It was well known that the complaint was not
53
820
18
DISEASES OF WOMEN.
peculiar to the human female. Harvey had long ago remarked
that in hounds who were well fed, many of the phenomena of preg-
nancy, such as swelling of the abdomen, and the presence of
milk in the mamma, occurred both subsequently to unsuccessful
sexual intercourse, and also frequently after seasons of heat, during
which there was no intercourse with the male; kittens and other
young animals were frequently stolen by the animal, to make the
semblance of a litter. The curious observation had also been made by
Harvey, that the animals were liable to the diseases of bitches which
had recently been delivered. Dr. Simpson stated some similar facts
in the case of the domestic cow. The symptoms of spurious pregnancy
often occurred in the virgin female dog. And he believed that,
when some of the cases of the so-called hysteria in unmarried
females were inquired into, they would be found, as he thought
he had repeatedly seen, to be really symptoms only of spurious
pregnancy. Dr. Keiller had alluded to retraction of the limb as
having been a well-marked symptom in his patient. He himself
had seen a case many years before the introduction of chloroform,
in which the symptom was a prominent one. The lady had been
under treatment in Paris, and, on her return to Scotland, a surgeon
examined her, and recognised, as he supposed, the presence of a
large ovarian tumour not an uncommon mistake, as, in the
records of ovariotomy, six cases are detailed in which no tumour
could be found after the abdomen was opened. Dr. Simpson was
consulted, and, on percussing, he found the abdomen quite tym-
panitic, and of course negatived the tapping, and the presence of
any ovarian tumour. The leg in this case was much drawn up, and
he was informed that, while in Paris, the heel was for a time closely
applied to the back of the neck. About two years ago, he saw a
lady, with Mr. Syme, whose limb was strongly and permanently
retracted, and presented the appearance of hip-disease.
·
He
was uncertain whether there was abdominal fulness in this case,
or not. The appearances were so deceptive, that a practitioner
had used the exploring needle for the purpose of evacuating matter.
As soon as the patient was brought under the influence of chloro-
form, however, the limb was readily straightened for the first time
for many long months, and the case was at once ascertained to be
one of "hysterical disease" of the joint. With regard to the nature
of the abdominal swelling in spurious pregnancy, he had tried various
experiments to ascertain its cause, but in vain; and as yet he could
come to no decided conclusion on the subject. It had been sug-
་
SPURIOUS PREGNANCY.
821
gested that, while the patient was deeply under the influence of
chloroform, contained air escaped unobserved; but, in one very
marked case in the hospital, he had passed a tube per anum, its
nozzle being kept under water; but not a bubble of air escaped.
The diaphragm he was inclined to suspect to be a chief agent in the
production of the swelling. One patient who had a small fibrous
tumour of the uterus, and a rounded tympanitic abdomen, could
greatly diminish the prominence of the abdomen by drawing herself
up, and, on allowing the diaphragm to fall, the fulness and the
appearance of pregnancy returned. The chloroform, he believed,
here acted by relieving the muscles, diaphragmatic and abdominal,
from the influence of reflex action, and permitting their relaxation.
In one case, he had also seen the Cæsarean section proposed, though
in somewhat different circumstances from the case of Dr. Keiller.
The patient was dying from another disease, but spurious pregnancy
was present; she was positive about the child's being alive, and he
had been asked to operate after the mother's death to save the child.
On a vaginal examination, etc., the uterus was found small and un-
impregnated. The idea of some living animal being contained within
the abdomen, in such cases as in Dr. Keiller's patient, was not un-
frequent. On two or three occasions such a belief had been
expressed to himself. Dr. Keiller had classed the interesting case
which he had communicated under the head of hysteria; but some
of the cases to which he himself had alluded could scarcely be
properly included under that designation. The phenomena were
common to the females of our domestic quadrupeds, and in them
would not be designated hysteria. Dr. Simpson suggested that a series
of experiments should be made on the bitch during the occurrence
of the anomalous pregnancy, to ascertain, by examination of the
state of the ovaries and uterus, the true nature of the cause. He
thought that some cases of membranous dysmenorrhoea might be
referred to the same category as the one under consideration; for in
some patients, besides the throwing off of a membranous structure or
maternal decidua, the other constitutional symptoms were also
present. In some cases, the similarity to true pregnancy was very
marked even in special and minor details. In a case from Ayr-
shire, which he had lately seen with Dr. Taylor, a peculiar
eruption of intense prurigo was present, which the patient declared
had hitherto only appeared when she was really pregnant. He
concluded by asking if any member could suggest a rationale of the
occurrence of the abdominal swelling, or explain the peculiar effect
produced upon it by the inhalation of chloroform.
822
DISEASES OF WOMEN.
Dr. Simpson had made some experiments on the subject in the
wards of the hospital, and had satisfactorily ascertained that, in the
cases he had examined, the prominence of the abdomen did not de-
pend upon any arching of the spine.
ON THE ALLEGED INFECUNDITY OF FEMALES BORN
CO-TWIN WITH MALES.
WITH SOME NOTES ON THE AVERAGE PROPORTION OF MARRIAGES
WITHOUT ISSUE IN GENERAL SOCIETY.'
"It is," says Dr. Burns, “a popular opinion, and I do not know
any instance to discountenance it, that if twins be of different sexes
the female is sterile."--"I have never," he adds, "had an oppor-
tunity of examining the state of the uterus and its appendages after
death.
1, 2
Some years ago I took considerable pains to collect a series of
data for the purpose of testing the validity of the opinion alluded
to by Dr. Burns in the preceding paragraph. The results of the
inquiry were, in 1839, laid before the Edinburgh Medico-Chirurgical
Society in the following form." I venture to publish the observa-
tions now, with a few additions and corrections, under the idea
that the subject is not devoid of interest in relation to physiology
and legal medicine, and involves one or two correlative questions
worthy of some degree of investigation. Besides, I know well the
many difficulties connected with a statistical inquiry like the present,
however brief and simple it may appear when condensed into its
ultimate results; and the publication of the evidence that I have
obtained upon the topics in view may probably be fortunate
enough to save others from expending time and trouble upon the
same research.
ON THE REPRODUCTIVE POWERS OF FEMALES BORN CO-TWIN WITH
MALES AMONG OUR DOMESTIC UNIPAROUS ANIMALS, AND IN
THE HUMAN SUBJECT.
Mr. John Hunter, in an essay read before the Royal Society of
London in 1779, and afterwards published both in the Philosophical
1 See Edinburgh Medical and Surgical Journal, January 1844, p. 107.
2 See the last edition (1843) of his well-known Principles of Midwifery, p. 236.
3 In an article on Hermaphroditism in Dr. Todd's Cyclopædia of Anatomy,
part xvi. (1839), p. 736, I have stated some of the results of the earlier part of this
inquiry.
INFECUNDITY OF FEMALES CO-TWIN WITH MALES.
823
Transactions for that year, and in his work on the Animal Economy,
showed that, when among black cattle the cow brings forth a male
and female at the same birth, the male is a perfect bull calf, but the
apparent female is almost always imperfect in its sexual organisa-
tion. Female cattle of this kind, born co-twin with males, have long
been distinguished in this country under the name of free-martins.
In external appearance and form of body they usually resemble the
ox and spayed heifer more than either the entire male or entire
female of the species. They commonly grow to a larger size than
either the bull or the cow, and have horns like those of an ox, and
a tone of bellowing similar to his, with the same marked disposition
to become fat under the use of nourishing food. In general they
do not show any sexual desire for the bull, or the bull for them.
The defective sexual conformation of free-martin cattle is
attested, not only by the observation of their sterility during life,
but also by the anatomical examination of their reproductive organs.
Mr. Hunter had an opportunity of dissecting several free-martin
Cows. In all of them the external sexual organs were of the female
type the vulva and os vagine being in general well developed.
The vaginal canal, however, was contracted at its upper part, and the
internal female organs, the uterus, Fallopian tubes, and ovaries, were
altogether rudimentary and imperfect in their structure.
In some
there was an apparent superaddition of male organs, testes and vasa
deferentia, probably from a permanence of the Wolffian bodies and
ducts of the early embryo; and in one case the ovaries were replaced
by bodies having all the external characters of male testicles.
Mr. Hunter's observations have been since corroborated by addi-
tional cases and dissections made by Scarpa,' Gurlt," and Allnatt.³
I have myself had an opportunity of dissecting the sexual parts of
two adults and a third young free-martin, killed in the shambles of
this city, and have found all of them formed after the anormal and
imperfect sexual type pointed out by Mr. Hunter. My friend Dr.
Allen Thomson made some years ago a similar observation upon a
free-martin twin foetal calf.
The butchers in Edinburgh and its neighbourhood, of a number
1 Mem. della Societa Italiana, tom. ii. p. 846.
2 Lehrbuch der Pathologischen Anatomie der Häus-Saugethiere, Bd. ii. s. 188.
Tab. xxi. Fig. 2, 3, and 4.
3 London Medical Gazette, vol. xviii. p. 528.
4 I have described at length the particular anatomical appearances met with
in these cases in Dr. Todd's Cyclopædia of Anatomy, vol. i. pp. 702 and 707.
$24
DISEASES OF WOMEN.
of whom I have made inquiries upon the subject, seem to be per-
fectly familiar with the fact, that in the free-martin, whose flesh
they usually reckon of a superior quality, the womb, or calf-bed, as
they term it, is in almost all cases apparently wanting; and all our
intelligent agriculturists in the Lothians are acquainted with the
sterile character of these animals.
Though we are certainly indebted to the sagacity of Mr. Hunter
for first fully appreciating the value of the physiological sexual
anomaly observed in free-martins, and for confirming the fact by
accurate anatomical investigation, yet it is but proper to mention
that the circumstance itself of the infecundity of the free-martin
cow has long, as was indeed pointed out by Mr. Hunter himself,
been notorious among agriculturists in Great Britain, and is promi-
nently mentioned by Leslie, and some of the older authors on
husbandry.
Indeed, the Roman agriculturists seem not to have been un-
acquainted with the variety of barren female cattle under considera-
tion; or at least their attention appears to have been so often
attracted by cases of sterility in the cow, that they found it a matter
of convenience to employ, as we do, for their designation and dis-
tinction, a specific noun, and named them Taure. Thus Varro in
his work De Re Rustica, tells us "Quæ sterilis est vacca taura appel-
latur;"¹ and Columella, in speaking of the sorting (delectus) of the
flock, directs that "those which have brought forth, and the old
cows which have ceased to breed are to be removed, and so also the
tauræ, which occupy the place of fertile cattle, are to be set aside, or
to be trained to the plough, since they are not by their sterility
rendered less fit for labour than the common heifer." "
There is no
direct evidence, however, to show that the Romans were aware of
the particular circumstances, in respect of plural births, under which
such taura were' produced.
Though the infecundity of free-martin cows be a very general.
fact, still it is by no means a universal one. Mr. Hunter, in his
original essay on the subject, mentions that in one instance, in ex-
amining a free-martin that died when about a month old, he found
all the organs of generation well formed. After stating this case,
¹ Libri de Rustica Catonis, Varronis, Columellæ, etc., Paris Edit. (Liber ii.)
p. 82.
2 Enixæ et vetustæ quæ gignere desierint summovendæ sunt, et utique tauræ,
quæ locum fœcundarum occupant, ablegandæ, vel aratro domandæ, quoniam laboris
et operis non minus quam juvencæ, propter uteri sterilitatem patientes sunt.—Ibid.
lib. vi. cap. xxii. p. 232.
INFECUNDITY OF FEMALES CO-TWIN WITH MALES. 825
he adds, "I have heard of other twin cows breeding; but as I can-
not call to mind the names of the individuals who communicated
the circumstances to me, I have only mentioned one of undoubted
authority."
An anonymous author in the Farmers' Magazine for November
1806,' has described such an instance in a free-martin belonging to
Mr. Buchan of Killintringham. This cow was well made and a good
milker; she produced one calf. The same gentleman, Mr. Buchan,
had a second free-martin which never bred. Another writer in the
same Magazine for November 1807, makes the following state-
ments :—“ On the 11th of November 1804, a cow of mine brought
forth two calves, one a bull, and the other a cow calf; and in spring
last the female twin produced a very good male calf; yet a neigh-
bour of mine assures me that a female twin belonging to him
would never take the bull, and was sold on that account to the
butcher at the age of four or five." Dr. Moulson of Halifax men-
tions, in Loudon's Magazine, the case of a free-martin cow reared by
Joseph Holroyd, Esq., of Withers, near Leeds, which copulated
with its own twin bull. "In due time," he adds, "the heifer
brought forth a bull calf, and she regularly had calves for six or
seven years afterwards."
In the course of making some inquiries in West Lothian after
cases of free-martin cows, I have become acquainted with two well-
authenticated instances in which these animals proved capable of
propagating. One of these cases occurred some years ago at Newton,
near Queensferry. The second was reared by Mrs. Cochran of
Stewartsfield, Broxburn, and produced several calves. Such excep-
tional cases, however, as those to which I have alluded, appear, on
the whole, to be comparatively so rare in their occurrence, as not to
invalidate the generality of the fact with regard to the sterility of
the free-martin twin cow, and render it a question of interesting
inquiry, whether this law of infecundity in the female of male and
female co-twins be confined only to plural conceptions among
black-cattle, or extends also to twins among other species of uni-
parous animals.
In reference to the females of opposite-sexed twins among
sheep, I have been assured from different quarters that the law of
the sexual imperfection and infecundity of the free-martin cow does
not hold good with respect to them. Several varieties of sheep,
particularly some of those belonging to the white-faced breeds,
1 See Youatt On Cattle, p. 539.
n
Magazine of Natural History, vol. v. p. 765.
826
DISEASES OF WOMEN.
produce twins with such constancy that we may truly consider this
as one of their occasional hereditary characters. These twins are
not unfrequently of different sexes, and yet instances of sterility are
rarely if ever observed among such flocks.¹
I have not been able to learn how the matter stands with
regard to twins among goats, not having access in this district of
the country to any information or direct observation upon the sub-
ject in that animal.
I have hitherto been equally unsuccessful in tracing out any
instance of a twin mare or she-ass, born under the circumstance
already pointed out, being reared to maturity. The mare, indeed,
appears only in extremely rare cases to produce twins, and these
twins are almost always endowed with such feeble powers of life as
seldom to survive for any length of time after birth.
Sir Everard Home, in a paper "On Animals preternaturally
formed at the time of birth," inserted in the Philosophical Transactions
for 1799, and in the third volume of his Comparative Anatomy, after
assuming that certain sexual organs in the male and female are
originally identical or neuter in their character, and are only after-
wards changed to the male or female type according to ulterior cir-
cumstances, adds the following observations:-"If it is allowed
that the sex is impressed upon the ovum at the time of impregna-
tion, it may in some measure account for the free-martins occurring
when two young are to be impressed with different sexes at one
impregnation, which must be a less simple operation, and, therefore,
more liable to a partial failure, than when two or any greater
number of ova are impressed with the same sex."
It may also account," he remarks in reference to the human
subject, "for twins being most commonly of the same sex; and when
they are of different sexes, it leads us to inquire whether the female,
when grown up, has not, in some instances, less of the true female
character than other women, and is not incapable of having child-
ren."
"In warm countries," Sir Everard adds, "nurses and mid
wives have a prejudice that such twins seldom breed.""
In reference to this last remark, it is not unimportant to observe,
that, as I have repeatedly found during the course of my inquiries
The tendency to the production of twins in the human subject is sometimes
so marked in particular families as to entitle it to be considered as almost a here-
ditary peculiarity. I know of one family, in the different branches of which
twelve pair of twins have been born within three generations.
2 Comparative Anatomy, vol. iii. pp. 333-4.
INFECUNDITY OF FEMALES CO-TWIN WITH MALES. 827
upon this subject, a similar prejudice in reference to the infecundity
of human females born co-twin with males exists to a considerable
extent among the peasantry of the Lothians, and has very probably
been derived from the analogy of the free-martin cow. "The mis-
chief," justly observes a late physiological author, "to which the
opinion might give rise, in causing a girl to be rejected as a wife for
a defect, or taken for an excellence, according as sterility might be
regarded, which she did not possess, is incalculable.""
The truth or falsity of the opinion itself can only be satisfactorily
settled by an appeal to a sufficient number of accurately ascertained
histories of cases in which women born co-twin with males have
reached an adult age and become married.
I have collected what may probably be considered as a sufficient
number of such cases for forming some just conclusions upon this
subject.
Before, however, bringing forwards the results derivable from
these collected cases, as bearing upon the question of the fecundity
or sterility of human females born under the circumstances in ques-
tion, I may, in the first place, mention that instances of twins in
the human subject, of whom one child is male and the other female,
seem not to be at all rare in their occurrence, though the contrary
position is generally believed, and, as we have seen, was assumed
by Home, and made by him at one and the same time a deduction
from, and an argument in favour of, the particular theory which he
held in respect to sexual development. In proof of this statement,
I have analysed the records of all the labours that occurred in the
Edinburgh General Lying-in Hospital from 1823 to 1836, both
years included, as well as the published returns of all the cases oc-
curring in the Dublin Lying-in Hospital from 1787 to 1793 as
given by Dr. Clarke, and from 1826 to 1833 as given by Dr.
Collins, as also those occurring in the London Maternity Charity
from 1828 to 1840, which are the only returns that I am aware
of in which the average number of twin labours and the sexes
of the different co-twins have been noted. The three following
tables have been constructed from these reports. The first of
them shows the average number of twin labours as they occurred in
these institutions respectively; the second presents the sexes of the
9
¹ See footnote at page 74 of Dr. Fletcher's Rudiments of Physiology.
2 Dr. Collins' Practical Treatise on Midwifery, table beginning p. 331.
³ Dr. Ramsbotham's Principles and Practice of Obstetric Medicine and Surgery,
p. 621, footnote.
828
DISEASES OF WOMEN.
different pairs of twins as they occurred in each; and the third
illustrates the proportion in which the differently-sexed co-twins
were to the general number of labours.
I. Total number and proportion of twin-labours.
Total number
of Labours.
Number of
Twin Labours.
Proportion of
Twin Labours.
Edinburgh Hospital
2,888
46
1 in 63
Dublin Hospital (Clarke)
10,337
184
1 „ 56
Dublin Hospital (Collins)
16,414
240
1 65
19
London Maternity Charity
29,489
318
1 93
""
59,178
788
1 in 75
II. Sexes of the different co-twins in the above 788 cases.
Two
Two Male and Tot. number
males.
females.
female.
of twins.
Edinburgh Hospital
16
17
13
46
Dublin Hospital (Clarke)
47
66
71
184
Dublin Hospital (Collins)
73
67
100
240
London Maternity Charity 93
111
114
318
•
229
261
298
788
III. Proportion in which the differently-sexed co-twins occurred
to the whole 59,178 cases of labour :-
Male and female twins once in every 199 labours.
Two female twins once in every 226 labours.
Two male twins once in 258 labours.
The result of these two last tables goes to show, in opposition to
the opinion of Sir Everard Home, that twins of opposite sexes are
not by any means uncommon.' And this circumstance, of co-twins
of opposite sexes occurring so proportionally frequent, may, perhaps,
be adduced as bearing somewhat against the opinion of M. Girou,
that the sex of the offspring is determined by the sex of that parent
whose reproductive power or organism (puissance prolifique) is at the
time of conception either absolutely or relatively in the greatest de-
gree of vigour.
But to return from this digression.
The only data hitherto
1 As far as the data of these tables go, they would seem also to show that,
among twin births as a whole, more female than male children are produced.
Out of the 1576 children born in the above 788 twin cases, 756 were male, and
820 female.
INFECUNDITY OF FEMALES CO-TWIN WITH MALES.
829
published, so far, at least, as I am aware, containing an appeal to
actual facts for the determination of the question of the fecundity or
infecundity of the human female, when born co-twin with a male,
are to be found in a short paper published by Mr. Cribb, in the
Medical Repository for 1823, and in the notice of a single case of
this kind brought forward by the late Professor Meckel, in his essay
on Hermaphrodites in Reil's Archives.²
1
In the paper referred to, Mr. Cribb has adduced the histories
of seven married women, who were born co-twin with males, of
which the following is the result:-six had a family; one had no
children, though married several years; or one in six was without
issue.
The woman mentioned by Meckel was a mother.
I have endeavoured to obtain as accurate and authentic reports
as possible of the married history of various females born co-twin
with males, and have so far been successful in gaining such infor-
mation as I could implicitly rely upon in relation to 113 females
born under such circumstances. Of these 113 female co-twins,
103 had a family; 10 had none; or about one in ten was without
issue. Of the ten cases in which there was no family, 1 had been
married above five years; 9 from ten to forty years.
3
The history of the male co-twin in the 103 cases in which the
female was productive was as follows:-in 53 he was the father of a
family; in 24, he died in early life, or unmarried; in 8 he remained
unmarried; in 2, he was married, but had no issue; and in 14, his
history could not be accurately ascertained.
In addition to the above cases of twins of opposite sexes; I have
traced the married history of the female in four instances of triplets,
in which there were born either two males and one female, or two
females and one male. In all of these four cases the female, whose
history I ascertained, had a family. In a case of quadruplets, re-
corded in the Medical Repository for 1827, there were three males
1 London Med. Repos. vol. xx. pp. 213-16.
2 Reil's Archives für die Physiologie, Bd. xi. p. 282.
3 For assistance in the collection of these cases, I am much indebted to various.
professional friends, and particularly to Mr. Angus of Holytown, Mr. Girdwood
of Falkirk, Dr. Gilchrist of Leith, and Dr. Cowan and Mr. Carmichael of Edin-
burgh. Tables, containing the name, address, and other particulars of each case,
are in the hands of the Secretary of the Medico-Chirurgical Society.
4 In one of these cases of triplets the three, two males and one female, all
reached adult life. Dr. Merriman (Synopsis of the various kinds of Difficult
Parturition, 4th edition) observes, p. 260, "So many years had elapsed, notwith-
830
DISEASES OF WOMEN.
and one female. The males were all reared, and the female be-
came herself the mother of triplets.
If we unite together all the various facts I have alluded to, we
shall have the married history of 123 females born co-twin with
males. The results, so far as they refer to the question we are dis-
cussing, may be stated in the following form: Of 123 females born
co-twin with males, 112 had a family; and 11 had no issue, though
married for several years. In other words, the marriages of the
females, born under the circumstances we are considering, were
unproductive in the proportion of one in ten.
It may at first sight be supposed that this result, though not
fully bearing out, yet supports rather than otherwise the popular
opinion and the statement of Sir E. Home, with regard to the infe-
cundity of the female in twins of opposite sexes. Before, however,
assenting to such a modification of the view, it is incumbent on us
to inquire—
1
WHAT IS THE AVERAGE PROPORTION OF PRODUCTIVE AND UNPRO-
DUCTIVE MARRIAGES IN GENERAL SOCIETY ?
1
On this point I have been able to gain but little precise informa-
tion from the statistical or physiological works that I have had an
opportunity of consulting. I have made personal inquiry on the
same matter of several of our most eminent statisticians, without
being able to obtain any accurate facts bearing on the subject. In
the Dictionnaire des Sciences Médicales, it is stated that Hédin, a
Swedish minister, had noticed that in his parish, composed of 800
souls, one barren woman is not met with for ten fertile. It is
further stated, that Frank asserted, but from what data is not men-
tioned, that it would be found on investigation, that in most com-
munities containing 300 to 400 couples, at least 6 or 7 would be
sterile, without anything in their physical condition to explain the
fact. It seems to have been from this assertion of Frank's, that
Burdach, who is almost the only author who even alludes to the
standing repeated inquiries, before I could meet with a well-authenticated instance
of three children at a birth being all reared, that I began very much to doubt the
fact." Besides the above, three other well-authenticated instances have been re-
ported to me of triplets being viable and reared to maturity. Most certainly,
however, one or more generally die shortly after birth.
1 Vol. vi. p. 215. See also Neue Abhandlungen der Schwedischen Akademie
der Wissenschaften, vol. xi. p. 70
INFECUNDITY OF FEMALES CO-TWIN WITH MALES. 831
matter, has given the general statement that one marriage only in 50
is unproductive.'
For the purpose of ascertaining the point by numerical data, I
had a census taken of two villages of considerable size-viz. Grange-
mouth in Stirlingshire, and Bathgate in West Lothian,-the one
consisting principally of a seafaring population, and the other of
persons engaged in agriculture and manufacture.
The following form the results in these two places:
Of 210 marriages in Grangemouth, 182 had offspring; 27 had
none; or about one marriage in 10 was without issue.
Of the 27 unproductive marriages, all the subjects had lived in
wedlock upwards of five years, and in all the female had been
married that period before she reached the age of 45.
Again, of 402 marriages in Bathgate, 365 had offspring; 37 had
none; or about one marriage in 11 was unproductive. There were
at the same time living in the village 122 relicts of marriages, and
of these 102 were mothers; 20 were not mothers; or about one in
six had no family. In all, of 467 wives and widows, 410 had off-
spring; 57 had none; or about one marriage in 8 was unproductive.
Of these last 57, six had not been five years married, and there were
other six above the age of 45 when married. If we subtract these
twelve, we have, of 455 marriages, 410 productive, 45 unproduc-
tive; or one in 10 without issue.
Returns such as I have just now adduced are exceedingly diffi-
cult to obtain, in consequence of no registers being anywhere kept,
so far as I know, that could be brought to bear upon the question.
If it had been otherwise, I would here, if possible, have gladly
appealed to a larger body of statistical facts, in order to arrive at a
more certain and determinate average of the proportion of unpro-
ductive marriages in the general community. For the purpose,
however, of extending this basis of data, I have analysed with some
care and trouble the history of 503 marriages detailed by Sharpe in
his work on the British Peerage for 1833.
Among British Peers there were 401 marriages with issue;
102 without issue; or of
503 existing marriages among British Peers in 1833,
1 Dr. Allen Thomson's excellent Essay on Generation, in Todd's Cyclopædia,
vol. i. p. 478, footnote.
2 My young friend, Mr. Thomas Girdwood of Falkirk, was so good as make
the census of Grangemouth for me. For the data relative to Bathgate, I am
indebted to the kindness of Mr. William Dick of that place.
832
DISEASES OF WOMEN.
74 were without issue after a period of five years. Of those who
had not yet lived in the married state for five years, 28 were
still without family; and in Burke's Peerage for 1842, there
still remained among these 28 marriages,
7 without issue, making
81 as the total number of unproductive marriages among the
original 503; or the proportion of the unproductive to the produc-
tive marriages among this number is, as nearly as possible, 1 in 64.
In the above calculation I have excluded eight unproductive
marriages, in which the age of the husband at the date of marriage
exceeded 56. These eight, however, ought to be deducted from the
original sum of total marriages that were included, or, in other
words, the 503 should be reduced to 495, and then the whole result
would stand thus:-Among 495 marriages in the British Peerage, 81
were unproductive, or 1 in 63 were without any family.
The total result of the three series of facts that I have brought
forward with regard to the average number of unfruitful marriages
may be tabulated, then, as follows:-
Proportion of
unprod. marriages.
1 in 101
1, 101/
Total
marriages.
Marriages
without issue.
In Grangemouth
202
20
In Bathgate
455
45
In British Peerage
495
81
•
1252
146
or 1 in 84
1 "
6 31/3/
We thus see that if the marriages of females born co-twin with
males are, as we have found them, unproductive in the proportion
of 1 in 10, they do not in this respect exceed the degree of unpro-
ductiveness of marriages in other portions of the general community.
Nor would I be inclined to forego this deduction, even if the average
of unproductive marriages in society should be found, on a broader
and more extensive basis of data, to be less than the above facts
would seem to show. For certainly my own impression is, that
probably I have had reported to me, and have entered among my
notes and calculations, a greater proportional number of unproductive
females among opposite-sexed twins than may actually exist. In
relation to such a question as the present, all minds are too liable to
be impressed with and recollect instances illustrative of the supposed
rule and common opinion, whilst the apparent exceptions to it are
INFECUNDITY OF FEMALES CO-TWIN WITH MALES.
833
unattended to or forgotten. In the earlier part of the inquiry I
happened to take notes of several cases that had, in this way, been
long stored up, by those that reported them to me, as evidence of
the infecundity of the female co-twin, and who deemed them so far
to afford sufficient proof of the popular opinion. The latter part of
the investigation has, in a great measure, if not entirely, escaped
this source of fallacy.
Before finally attempting to draw all the conclusions that are
deducible from the facts we have collected, let us consider for a
moment the question under another point of view, and inquire-
WHAT IS THE AVERAGE PRODUCTIVENESS OF MARRIAGES IN GENERAL,
AND DOES THAT OF THE FEMALE IN OPPOSITE-SEXED TWINS
COME UP TO THE COMMON STANDARD ?
5.
6
7
Various authors, in treating of statistics and population, have
calculated the average degree of fecundity of marriages in different
climates and districts, as Malthus,' Macculloch," Hawkins,³ Saddler,*
Sussmilch, Quetelet, and others. Their observations show this
average to vary from the number of 3 children to each marriage as
a minimum, to 5 or 5 as a maximum. In an elaborate investi-
gation into the subject made by Benoiston de Châteauneuf, that
eminent statistician states, as average results upon a large series of
observations, the following general conclusions :—
10
In southern Europe, 457 births result from every 100 marriages,
or about 4 from each; in northern Europe, 430 births result from
every 100 marriages, or about 4 from each.
3
1
Mr. Farre calculates the mean fruitfulness of marriages in Eng-
land in ordinary periods to be in every
Marriages.
100
No. of children.
420
Prop. of children to each mar.
41%
1 Essay on the Principle of Population (1803), p. 224.
2 Statistics of the British Empire, vol. ii. p. 413.
3 Elements of Medical Statistics, p. 221.
4 The Law of Population, vol. ii. p. 380, etc.
Göttliche Ordnung, Th. iii. s. 64.
• Sur l'Homme, ou Essai de Physique Sociale (1836), Tome i.
7 See a collection of evidence on this point in the Report from His Majesty's
Commissioners for inquiring into the Poor Laws (1834).
Communications, and table in Preface, p. xcix. etc.
8 Annales des Sciences Naturelles, Tome ix. p. 431.
Appendix F of Foreign
"Notice sur l'Intensité
de la Fécondité en Europe au commencement du dix-neuvième siècle."
See Maculloch's British Empire, 1. c.
834
DISEASES OF WOMEN.
In relation to Scotland, Benoiston de Châteauneuf states,' that
he had the patience to go over the tables of population in seventeen
out of the twenty-one volumes of Sir John Sinclair's Statistical
Account of this kingdom, and found in every
Marriages.
100
No. of children.
430
Prop. of children to each mar.
41%
3
10
What is the usual degree of fruitfulness in married life of females
born co-twin with males? To make as near an approximation as
possible to the solution of this question, I have added together the
total number of children produced by 94 of those female co-twins,
whose history I have collected. We omit the others remaining on
the list, merely because we have no notes taken of the exact extent
of their families. The total number of children produced by the 94
mothers alluded to amounts to 409; or the result, when stated in
relation to the standard of every 100 marriages of them, would be
as follows:-In
Marriages.
100
No. of children.
424
Prop. of children to each mar.
410
But in 15 of the 94 cases, the mother had as yet only one child
at the time her case was noted, having either only lived in wedlock
for a year or two previously, or the single child being the result of
illegitimate intercourse. If we deduct these 15 cases only, though
other mothers with a young and increasing family of two or three
children might be excepted from the calculation in the same way,
and on the same grounds, we shall then have 79 mothers producing
364 children; or, again, to state it in reference to the supposed
standard of 100 marriages, we have this result as the degree of
fruitfulness of such co-twin females:-In every
Marriageg
100
No. of children.
460
Prop. of children to each mar.
41%
The whole inquiry detailed in the few preceding pages forms an
apt illustration of an old remark, that in medicine it often requires
a much greater extent of observation and research to disprove satis-
factorily an alleged and accredited fact, than was ever expended,
either upon the original development or subsequent confirmation of
it. In the present instance, the results have turned out to be per-
fectly contradictory of the opinion which I, in common with others,
held regarding the infecundity of the female in double-sexed twins,
¹ Annales des Sciences Naturelles, Tome ix. p. 447.
INFECUNDITY OF FEMALES CO-TWIN WITH MALES. 835
when I commenced looking into the subject; and instead of finding
my preconceived ideas confirmed by the investigation, they have, on
the other hand, been completely confuted by it. For the data that
I have adduced do, so far as they go, evidently prove-
1. That, in the human subject, females born co-twin with males
are, when married, as likely to have children as any other females
belonging to the general community.
2. That, when they are married and become mothers, they are,
in respect to the number of their children, as productive as other
females.
3. That the same law of the fecundity of the female in opposite-
sexed twins seems to hold good among all our uniparous domestic
animals, with the exception of the cow alone.
Indeed, the strong confirmatory evidence which the preceding
inquiry affords of this last exceptional point constitutes one of its
most interesting results. For certainly it cannot but be considered
as an extraordinary circumstance, that, in the cow, the twin exist-
ence in utero of a male along with a female should, as a general
principle, lead-
1. To so great a degree of malformation as we have described,
in the sexual organs, and in the sexual organs only.
2. That this malformation should be limited entirely to the re-
productive organs of the female twin, while those of the male twin
are perfectly and fully developed.
3. That this sexual malformation should, apparently so far as we
yet know, occur in the case of twins in the cow only, and in this
species of uniparous animal alone. The curiosity of the fact be-
comes heightened and increased when we recollect that when the
cow has both twins of the same sex, as two males or two females,
these animals are always both perfectly formed in their sexual
organisation, and both capable of propagating. The whole series of
circumstances, when considered in conjunction with each other,
seems to form, in relation to the origin of malformations, one of the
strangest and most inexplicable facts to be met with in the study of
anormal development.
54
INDEX.
ABDOMINAL tumours
complicating | Arteritis, local, causing arterial obstruction
in the puerperal state, 538.
labour, treatment of, 59.
Abortion induction of, in albuminuria,
97; treatment of hemorrhage from, 97;
apt to result in cases of retroversion of
uterus, 687.
Abscess, pelvic. See under Pelvic abscess.
Accidental hemorrhage, uterine treatment
of, 69; anatomical source of, 217.
Adhesion, morbid, of the placenta, treat-
ment in, 70.
After-pains, treatment of, 76.
Air, entrance of, into venous system through
uterine sinuses after delivery, 503.
Albuminuria-oil of juniper as a diuretic
in, 96; induction of abortion in, 97; in
puerperal convulsions, 295; lesions of
nervous system in parturient female con-
nected with, 296; in puerperal and
infantile convulsions, and in puerperal
amaurosis, etc., 297; causation of puer-
peral mania by, 591.
Alkaline salts in treatment of placental
disease, 142.
Amenorrhoea from superinvolution of
uterus after delivery, 599, 602; from
imperfect development of uterus, 601,
671; treatment of, by use of intra-uterine
pessaries, 672; treatment of, by applica-
tion of remedies to interior of uterus, 669.
American Court, on protracted pregnancy,
91, footnote.
Amputation, spontaneous, rudimentary re-
production of fœtal extremities after, 129.
Anesthesia, artificial, state of, as a means
of facilitating uterine diagnosis, 663, 821.
Aortic valves, vegetations of, separated,
blocking up arteries in puerperal state,
524.
Arm, obstruction from dorsal displacement
of, in head presentations-case of, 381;
diagnosis of, 26, 383; treatment of, 26,
383.
Arterial obstruction.
See under Puerperal
arterial obstruction and inflammation.
Arteries, obstruction of, in puerperal state.
See under Puerperal arterial obstruction
and inflammation.
|
Ascent of unimpregnated uterus-in some
cases of ovarian tumours and of fibroid
tumours of uterus, 707; mechanism by
which it is produced, 709; in old age,
in pelvic cellulitis, and in perimetritis,
710.
Ascites-complicating labour, 59; from
rupture of ovarian cysts, 804.
Atony of uterus in first two stages of
labour, varieties and treatment of, 28,
29; in third stage of labour, causes,
diagnosis, and treatment of, 72.
Auscultation--errors in practical applica-
tion of, in relation to craniotomy, 422;
value of, in indicating necessity for
operative interference in labour to save
life of child, 423, 487.
BLADDER, urinary-distension of, in la-
bour, diagnosis and treatment of, 16;
calculus in, in labour, treatment of, 17;
displacements of, in labour, varieties,
diagnosis, and treatment of, 17; morbid
affections of, after labour, 77.
Blood-effused in placental hemorrhage,
changes in, 145; in the puerperal state,
state of the, 552.
Bougie, uterine. See under Sound, uterine.
Brain, comparison of fœtal, infantile, and
adult, 353.
Breech, presentations of-diagnosis and
treatment of, 49; special rules of treat-
ment in lingering or difficult, 49
natural mechanism of labour in, 376.
Broad ligaments of uterus, changes in,
during pregnancy, 306.
Bronchocele in the foetus, 125.
CÆSAREAN section-indication for, 44;
period for performing, 44; mode of
operating in, 45; after death of mother,
45; highest pelvic dimensions necessitat-
ing, 161; difference between Continental
and English views on the subject of,
162; case of, 176; measurements of
pelvis in case of, 177.
Arteries, umbilical, vital contractions in, Calculus in the bladder impeding labour,
133.
treatment of, 17.
838
INDEX.
sound in diagnosing from inversion
of uterus, 721; small and soft,
menorrhagia and leucorrhoea from,
752; removal of small and soft, by
dilatation with sponge-tents, scrap-
ing, avulsion, torsion, scooping out,
excision, crushing, potassa fusa, etc.,
722, 753.
Cancer of uterus-propriety of vaginal Cervix uteri :
hysterotomy in labours obstructed by,
498; propriety of Cæsarean section
in some cases of labour obstructed by,
501; occasional absence of symptoms
in, 610, 761; use of dried sulphate of
zinc as a caustic in, 757.
Cancer of body and fundus of uterus not
involving the cervix-cases and forms of,
763; daily paroxysms of intense pain as
a symptom of, 768; diagnosis of, from
discharges and periodic pain, and from
use of sponge-tents, uterine sound, and
microscope, 769.
Cause, determining, of parturition, 94, 148.
Cellulitis, pelvic-differential diagnosis of,
Enlargement of, and expansion of
canal of, as a diagnostic mark in
intra-uterine polypus, 756.
Cancer of occasional absence of symp-
toms in, 610, 761; use of dried
sulphate of zinc as a caustic in,
757.
from retroversion of unimpregnated | Chest-complications in labour, rules of
uterus, 694; causing ascent of uterus,
710.
Cephalhæmatoma, greater frequency of, in
male than in female children, 318.
Cephalotribe-bulk and weight of French,
175, footnote; Simpson's modification
of, 392.
Cephalotripsy, rules for performing, 44.
Cerium, use of, in the vomiting of preg-
nancy, 95.
Cervix uteri :
In labour-rigidity of, varieties and
treatment of, 10, 11; wedging in of
a fold of, between head of foetus
and pelvis, treatment of, 11; ob-
liquity of, effects and treatment of,
13; frequency of laceration of,
152; occasional rigidity of, in
placenta prævia, 271; great danger of
rigidity of, in placenta prævia, 281.
Exploration of, aided by use of uterine
sound, 623.
Longitudinal hypertrophy of-in pro-
lapsus of organ, 640; apt to be
mistaken for prolapsus, or polypus,
642; use of uterine sound in dia-
gnosis of, 642.
Stricture of canal of-normal, at os
internum in the aged, 652; as a
cause of dysmenorrhoea and sterility,
652, 677; dilatation and incision of
cervix for cure of dysmenorrhoea, etc.,
caused by, 677; cause of suffering
in dysmenorrhoea, etc., from, 679;
instrument for incision of cervix in
dysmenorrhoea, etc., from, 680;
from retroversion of uterus, 698.
Inflammatory eruptions on mucous
membrane of, 711.
Inflammatory induration of treat-
ment of, by deep cauterisation with
potassa fusa, 712; treatment of,
by application of dried sulphate of
zinc, 760.
Polypi growing from-use of uterine
|
|
treatment in, 59.
Child. See under Foetus.
Chlorate of potash, use of, in placental
disease, 142, 145.
Chloroform-use of, in puerperal tetanus,
589; use of, in facilitating uterine
diagnosis, 663, 821.
Coagula-recent, of left side of heart pro-
ducing arterial obstruction in puerperal
state, 532; from uterine sinuses obstruct-
ing pulmonary artery in puerperal state,
542, 547.
M
Cold as an excitant of foetal movements, 101.
Colon, distended, impeding labour, diagnosis
and treatment of, 16.
Complex labour from complications on
part of child, kinds, diagnosis, and
management of, 54; from complications
on part of mother, kinds, diagnosis, and
management of, 57, 155.
Condylomata, use of dried sulphate of zinc
for destruction of, 761.
Constitutional debility causing inefficiency
of expulsive powers in labour, 26.
Contractions, vital, in the umbilical vessels,
133.
Convulsions, puerperal. See under Puerperal
convulsions.
Cord, umbilical. See under Umbilical cord.
Cow-periods of gestation in the, 88; in-
fecundity of females born co-twin with
males in the, 823.
Cranioclasm - advantages of, over cranio-
tomy, 43; rules for performing, 43.
Craniotomy-indication for, 38; prelimi-
nary measures for, 39; perforation and
breaking up of cranium in, 40; extrac-
tion of fœtus in, 41; subsequent steps
after performance of, 42; smallest size
of pelvis admitting delivery without,
159; smallest size of pelvis admitting
delivery by, 163; comparative frequency
of, in male and female births, 312, 333,
334; comparative frequency of, in first
and subsequent labours, 341; when pre-
INDEX.
839
ferable to use of long forceps, 387; de-
lay in performing, in consequence of life
of child, 421; relative maternal mor-
tality in delivery by turning and by,
456; analysis of 87 cases of, recorded by
Dr. Lee, 460; mortality of, as influenced
by difficulty of operation, 467.
Cranium of foetus. See under Head of foetus.
Cross-births. See under Presentations,
transverse.
Crotchet-comparative frequency of use of,
in male and female births, 312, 333,
334; comparative frequency of use of,
in first and subsequent labours, 341.
See also under Craniotomy.
Cystic tumours in the neck of the fœtus,
125.
Cysts, ovarian.
See under Ovarian.
DEATH OF FŒTUS. See under Fœtus,
and under Mortality.'
Death, sudden-case of, in pregnancy from
supposed cerebral embolism, 567; from
entrance of air into venous system
through uterine sinuses in puerperal
state, 503; from obstruction of pul-
monary artery in puerperal state, 547,
etc.
Decapitation in transverse presentations,
54, 380, 381.
Decidua-fatty degeneration of the, as the
determining cause of parturition, 94,
148; analogy to, of membrane occasion
ally expelled in dysmenorrhoea, 675.
Delay in labour, dangers of, 9, 31, 409, 495.
Delivery, normal elongation of puerperal
uterus as a sign of recent, 636.
Diagnosis, uterine-insufficiency of func-
tional symptoms alone, for exact, 607;
necessity of physical examination for
exact, 612; physical examination with-
out uterine sound insufficient for, in
many cases, 613; proposals for improve-
ment of, by means of a sound passed
into uterine cavity, 614; state of arti-
ficial anæsthesia as a means of facilitat-
ing, 663; use of sponge-tents in, 736,
742, 756, 769.
Dropsy, ovarian. See under Ovarian.
Duration of labour-dangers of prolonged,
9; propositions regarding effects of,
31; longer with male than with female
children, 349; in contracted pelvis di-
minished by substituting turning for
craniotomy, 409; the maternal mortality
attendant on parturition increases with
the increased, 412; the infantile mor-
tality attendant on parturition increases
with the increased, 413; the liability to
most morbid complications connected
with labour increases with increased,
413; maternal mortality attendant on
forceps operations increases with in-
creased, 417; maternal mortality attend-
ant on craniotomy increases with in-
creased, 418; as influencing maternal
mortality from turning, 471; liability to
rupture of uterus increases with increased,
482, 484.
Duration of pregnancy, 81.
Dysmenorrhoea, treatment of some forms
of, by direct applications of remedies to
cavity of uterus, 669.
Dysmenorrhoea from stricture of cervical
canal-frequency of, 652; treatment of,
by dilatation and incision, 677; cause of
sufferings in, 679; instrument for incis-
ing cervix in, 670.
Dysmenorrhoeal membrane-consists of ex-
foliation of mucous membrane of uterus,
673; analogy of, to decidua vera, 675.
EAR, presentations of, impeding labour,
causes and management of, 23.
Eclampsia in labour. See under Puerperal
Convulsions.
Elbow, diagnosis between, and knee in
transverse presentations, 372.
Embolism. See under Puerperal arterial
obstruction and inflammation, etc.
Embryulcia-smallest size of pelvis admit-
ting delivery without, 159; smallest
pelvis admitting delivery by, 163. See
also under Craniotomy.
Endocarditis, liability to, in puerperal state,
552.
Ephenieral fever, symptoms of, 78; treat-
ment of, 78.
Erectile tumour in neck of foetus, case of,
126.
Ergot of rye, rules for exhibition of, in
lingering labour, 30; use of, in intra-
uterine polypus, 745.
Eruptions, inflammatory, on mucous mem-
branes of cervix uteri, 711.
Eruptive fevers in puerperal patients, cases
of, 518; difficulties of diagnosing, 520.
Erysipelas, connection between, and puer-
peral fever, 515.
Evisceration in transverse presentations, 54,
380, 381.
Evolution, spontaneous, or expulsion of
fœtus in transverse presentations—cases
of, 379; general deductions regarding,
380.
Exploring needle-use of, in diagnosis of
pelvic abscess, ovarian tumours, etc.,
661; description of, 662.
Expulsive powers, inefficiency of-in first
two stages of labour, 26; in third stage
of labour, 71.
Extra-uterine pregnancy, differential dia-
gnosis of, from retroversion of unimpreg
nated uterus, 694.
840
INDEX.
FACE, presentations of, impeding labour-
varieties, positions, and diagnosis of, and
causes of delay in, 24; management of,
25.
Fascia, pelvic, relation of, to displacements
of uterus, 704.
Fecundity, average, in general society, 830,
833.
Feet, presentations of-management of, 47;
morbid impaction of fetal head in, treat-
ment of, 48; natural mechanism of labour
in, 376.
ments, in contracted pelvis, 473; vesico-
uterine, vesico-intestinal, and utero-intes-
tinal, as results of pelvic abscess, 811.
Foetal appendages, growth of, after death of
fœtus, 99.
Foetal mortality. See under Mortality.
Fætal movements, cold as an excitant of,
101.
Foetal neck-tumours in region of, 125;
degree of traction capable of being borne
by, in delivery by turning, without de-
struction of life of foetus, 441, 496.
Female births, excess of male births over, Foetal pulse, state of, in labour-indication
315, 333.
See also under Sex.
Fever, ephemeral-symptoms of, 78; treat-
ment of, 78.
Fever, milk-diagnosis of, 78; treatment
of, 78.
Fever, puerperal-forms of, 79; symptoms
of, 79; treatment of, 80; relative fre-
quency of, after male and female births,
311; relative frequency of, after first and
subsequent labours, 341; communica-
bility and propagation of, 505; possi-
bility of epidemic influence producing,
514; connection between erysipelas and,
515.
Fevers, eruptive, in puerperal patients-
cases of, 518; difficulties of diagnosing,
520.
Fibroid tumours of uterus-complicating
labour, 155; great variety in local and
constitutional effects produced by, 609;
use of uterine sound in diagnosis of, 626;
increased length of cavity of uterus from,
644; partial obliteration of uterine canal
from, 653; differential diagnosis of, from
retroversion of unimpregnated uterus,
692; co-existence of, with uterine cancer,
714; natural terminations of, 714; waters
of Kreuznach and bromine, in treatment
of, 715; artificial removal of, by enuclea-
tion, 717, 719; menorrhagia caused by,
treatment of, by application of per-
chloride of iron to interior of uterus, 719.
Fillet, objections to use of, 33.
of danger to child from, 387; importance
of ascertaining, as indicating necessity for
operative interference to save life of
child, 423.
Foetus, configuration of, general, 400.
Foetus, death of-signs of, 39; influence of,
on retention of fœtus in or expulsion from
uterus, 99; post-mortem appearances in
cases of, 103; as common in females as
in males, 325.
Fœtus, diseases of-hydrocephalus, recur-
rent, induction of premature labour for,
97; peritonitis, 102; goitre and other
tumours in cervical region, 125.
Foetus, obstructions on part of, impeding
labour-death and large size, 21; sex, 21,
307; strong ossification of head, and en-
largement of head or body from disease,
22; malpositions of head, 22; malpre-
sentations of head, 23; prolapsus of ex-
tremities in head presentations, 25;
transverse presentations, 363, 379; dorsal
displacement of armı, 381; hydrocephalus,
384. See also under Sex.
Footling presentations-management of, 47;
morbid impaction of foetal head in pelvis
in, treatment of, 48; natural mechanism
of labour in, 376.
Forearm, dorsal malposition of, in labour,
diagnosis and treatment of, 26, 381.
Forehead, presentations of, impeding
labour, causes, diagnosis, and treatment
of, 23, 24.
Fingers of accoucheur, use of, to aid birth Forceps-modes of action of, 34; indica-
of foetal head, 33.
First labours, mortality in, greater than in
subsequent labours, 340.
First stage-phenomena of, in natural labour,
1; management of, in natural labour, 4 ;
local impeding causes protracting, 9 ;
general rules of treatment of, when pro-
tracted by local causes, 13; inefficiency
of expulsive powers protracting, 26.
Fissuring of perineum and cervix uteri in
labour, frequency of, 152.
Fistula, perineal, left by transit of infant
through perineum, 592.
Fistula-vaginal, comparative danger of,
after delivery by turning and by instru-
tions for use of short, 34; preliminary
rules for use of, 34; rules for introduc-
tion of, 35; rules for extracting by short,
36; indications for use of long, 36; dif-
ferences between long and short, 36;
cautions regarding introduction of long,
37; cautions regarding extraction by
long, 37; comparative frequency of use
of, in male and female births, 312, 333;
comparative frequency of use of, in first
and subsequent labours, 341; when use
of long, preferable to craniotomy, 387;
description of Simpson's long, 388; mode
of application of long, 389; long, to lie
obliquely on child's head, 391; compara-
INDEX.
841
tive fœtal mortality in delivery by, | Hemorrhage, uterine, in third stage of
and by turning, 447.
Free-martins, 823.
Funis. See Umbilical cord.
labour-causes, diagnosis, and treatment
of, 70; presence of, in partial, and ab-
sence of, in complete separation of pla-
centa, 232.
GALLIC ACID, use of, in menorrhagia, Hemorrhage, uterine, post partum-causes
670.
Gangrene from arterial obstruction, 563.
Goitre in the fœtus, 125.
HEAD-COMPLICATIONS in labour, 57.
Head offœtus-enlargement of, from disease,
impeding labour, 22; malpositions of,
impeding labour, 22; malpresentations
of, impeding labour, 23; rules for per-
foration of, in craniotomy, 40; morbid
impaction of, in footling presentations,
treatment of, 48; comparative size of, in
males and females, 328; reasons for con-
sidering greater size of male, the cause of
the greater number of complications and
casualties attending male births, 330;
shortness of bi-mastoid as compared with
bi-parietal diameter of, as facilitating its
passage through a narrow pelvis with its
base first, 402, 489, 493; shortness of
bi-frontal as compared with bi-parietal
diameters of, as facilitating its passage
through a narrow pelvis with its base
first, 405; compression and adaptation
of, more easily effected when it passes
through the pelvis with its base first,
407, 493; lateral depression and inden-
tation of, during labour, compatible with
life of child, 428, 436, 494, 496.
Heart-vegetations formed in, obstruction
of arteries in puerperal state from, 524;
recent coagula formed in left side of,
obstruction of arteries in puerperal state
from, 532.
Hemiplegia, from puerperal obstruction of
middle cerebral artery, 530, 555.
Hemorrhage, absence of, after division of
umbilical cord, 228.
Hemorrhage, uterine, unconnected with
pregnancy. See under Menorrhagia.
Hemorrhage, uterine, from abortion, treat-
ment of, 97.
Hemorrhage, uterine, accidental-treatment
of, 69; anatomical source of, 217.
Hemorrhage, uterine, unavoidable-effects
and treatment of, 66; relative degrees
of, before and after separation of pla-
centa, 197; anatomical source of, 217;
causes of continuance of, when separation
of placenta is partial, 220; cause of
cessation of, when separation of placenta
is complete, 225; great danger of, when
os uteri is rigid, 281.
Hemorrhage, uterine, in twin labours,
absence of, between birth of first and
second child, 228.
of, 72; treatment of, 73; nature's means
of preventing, 233; relative frequency of,
after male and after female births, 311,
338; relative frequency of, after first and
after subsequent labours, 343, 344.
Hemorrhage, uterine, during and after de-
livery, after-treatment of, 73.
Hemp, Indian, as an oxytocic, 154.
Hernia of intestines complicating labour,
treatment of, 16, 60.
Hernia of uterus-in labour, treatment of,
60; increased length of cavity of uterus.
in, diagnosis of, by means of uterine
sound, 648.
Hour-glass contraction of uterus in third
stage of labour, causes, diagnosis, and
treatment of, 71.
Hydramnios, symptoms and treatment of,
12.
Hydrocephalus in the foetus-induction of
labour for, 97; danger of rupture of
uterus from, 384; mechanism of rupture
of uterus in, 385; removal of fluid by
trocar in, 386; evacuation of fluid in, by
spinal canal, 386.
Hypertrophy of placenta impeding delivery,
treatment in, 71.
Hypertrophy of uterus-morbid perma-
nence of puerperal, 596, 632; normal, as
a sign of recent delivery, 636; from
inflammation and congestion of organ,
638; longitudinal, 639; from fibrous
tumours in its parietes, 644; from
polypi in its cavity, 648; in hernia of
organ, 648.
Hysteralgia, treatment of, 76.
Hysterotome, figure and description of,
680.
Hysterotomy, vaginal-propriety of, in
labour obstructed by uterine and vaginal
cancer, 498; for cure of obstructive
dysmenorrhoea, 677.
IMPACTION of head, morbid, in footling
presentations, treatment of, 48.
Impracticable labour, 38.
Incontinence of urine after labour, dia-
gnosis of, 77.
Indian hemp as an oxytocic, 154.
Induction of premature labour-cases re-
quiring, 74; means of effecting, 75;
rules for, 75; for recurrent hydrocepha
lus in the foetus, 97; for placental
disease, 144; propriety of, in pregnancy
complicated by fibroid tumours of uterus,
156.
842
INDEX.
|
inducing, 8; first order of, 8; second
order of, 30; third order of, 38.
Inefficiency of expulsive powers-in first LABORIOUS labour-pathological states
two stages of labour, causes, diagnosis,
and treatment of, 26; in third stage of
labour, causes, diagnosis, and treatment
of, 71.
Inertia of accessory expulsive powers in
labour-causes of, 27; treatment of, 29.
Inertia of uterus in first two stages of
labour-varieties of, 28; treatment of,
29.
Inertia of uterus in third stage of labour,
causes, diagnosis, and treatment of, 72.
Infant, susceptibility of nervous system of,
to morbid impressions, 355.
Infecundity--alleged, of females born co-
twin with males, 822; of free-martins,
823.
Infra-mammary pains, treatment of, by
hypodermic injection of morphia, 817.
Instrumental delivery-maternal mortality
attendant on, depends more on previous
duration of labour than on nature or
details of operation itself, 416, 470, 495;
comparative danger of inflammation,
sloughing, and fistula of vagina after
turning and after, in contracted pelvis,
473; comparative danger of rupture of
uterus after turning and after, in con-
tracted pelvis, 479.
Instrumental interference in labour-cir-
cumstances for judging of propriety of,
8, 30; time for, 31.
Instrumental labour, 30.
Interference in difficult labour-circum-
stances regulating, 8, 30; time for, 31.
Intestines, hernia of, complicating labour,
treatment of, 16, 60.
Inversion of uterus-treatment, etc., of, 61;
simulating polypus of uterus, 654; uterus
apt to become insensible in chronic cases
of, 655; use of uterine sound in dia-
gnosing between, and polypi growing from
cervix uteri, 658, 721; chronic, treat-
ment of, 710.
Involution of uterus after delivery-morbid
deficiency in, 596, 632; causes of mor-
bid deficiency in, 597;, morbid excess
in, 598.
Iodine, injections of, into ovarian cysts,
treatment of ovarian dropsy by, 789, 791.
Irregular contraction of uterus-in first two
stages of labour, causes, diagnosis, and
treatment of, 27, 29; in third stage of
labour, causes, diagnosis, and treatment
of, 71.
JUNIPER, oil of, inhalation of, as a diu-
retic in albuminuria, 96.
KNEE--presentations of, diagnosis and
treatment of, 48; diagnosis between, and
elbow in transverse presentations, 372.
Labour:
Natural-phenomena of first stage of,
1; phenomena of second stage of,
3; phenomena of third stage of, ;
management of, 3.
Tedious-froin morbid protraction of
first stage by local impeding causes,
8; from morbid protraction of second
stage by obstructions on part of ma-
ternal passages, 14; from morbid
protraction of second stage by ob-
structions on part of child, 21; from
inefficiency of expulsive powers in
first two stages, 26; relative fre-
quency of, in male and female births,
311, 333, 334; relative frequency of,
in first and subsequent labours, 341.
Instrumental--circumstances for judg-
ing of propriety of, 8, 30; time for,
31; use of fingers of accoucheur in,
33; fillet or lac in, objections to,
33; forceps in, modes of action of,
indications for, and mode of using,
34; vectis or lever in, mode of
using and cases for, 37; craniotomy
in, indications for and mode of per-
forming, 38; cranioclasm in, advan-
tages of, over craniotomy, and mode
of performing, 43; cephalotripsy in,
rules for performing, 44; Cæsarean
section in, indication for and princi-
pal circumstances in, 44; symphyse-
otomy in, objections to, 45. See
also under Instrumental delivery.
Preternatural first order of (pelvic
presentations), diagnosis and manage-
ment of, 47; second order of (cross-
births), diagnosis and management
of, 49. See also under Presentations.
Complex-from complications on part
of child, kinds, diagnosis, and ma-
nagement of, 54; from complica-
tions on part of mother, kinds,
causes, diagnosis, and management
of, 57, 155.
Induction of premature nature of
cases for, 74; modes of effecting and
rules and cautions for, 75; for re-
current hydrocephalus in the fœtus,
97; for placental disease, 144; pro-
priety of, in pregnancy complicated
by fibroid tumours of uterus, 156.
Duration of. See under Duration of
labour.
Laceration of perineum and cervix
uteri in, frequency of, 152.
Sex of child, effects of, on difficulty of.
See under Sex.
Determining cause of, 94, 148.
INDEX.
843
Lac, objections to use of, 33.
Laceration of internal coat of arteries giving
rise to arterial obstruction in the puer-
peral state, 540.
Laceration of perineum, central, means of
preventing, 594.
Laceration of perineum and cervix uteri in
labour, frequency of, 152.
Laceration of perineum and vulva in la-
bour, varieties and treatment of, 65.
Leucorrhoea, uterine-treatment of, by ap-
plication of remedies to interior of uterus,
669; from intra-uterine polypi, 739,
752.
Lever-different modes of using, 37; pro-
posed cases for use of, 37; rules for
employment of, 38.
Ligaments, broad, of uterus, changes in
during pregnancy, 306.
Liquor amnii, superabundance of, in la-
bour, symptoms and treatment of, 12;
evacuation of, in placenta prævia fre-
quently resorted to, 181; cases in which
evacuation of, forms the proper practice
in placenta prævia, 262, 287.
Lochia-suppression of, treatment of, 77;
profuse flow of, treatment of, 77; mor-
bid quality of, treatment of, 77.
Long forceps-indications for use of, 36;
differences between, and short, 36; cau-
tions regarding introduction of, 37;
cautions regarding extraction by, 37;
when use of, preferable to craniotomy,
387; description of Simpson's, 388;
mode of application of, 389; to lie ob-
liquely on child's head, 391.
MALACOSTEON, case of unaided de-
livery through a pelvis extremely nar-
rowed by, 157, 166.
Male births, excess of, over female births,
315, 333. See also under Sex.
Malignant disease. See under Cancer.
Malpositions of head of fœtus, impeding
labour-varieties of, 22; general rules of
management of, 25.
Malpresentations of head of foetus, im-
peding labour-varieties of, 23; general
rules of management of, 25.
Management of natural labour, 3.
Mania, puerperal, causation of, by albumi-
nuria, 591.
Marriages-average proportion of produc-
tive and non-productive, in general
society, 830; average productiveness of,
in general, 833.
Maternal mortality. See under Mortality.
Maternal passages, protraction of second
stage of labour from obstructions on part
of, varieties, diagnosis, and treatment of,
14.
Measles, puerperal, case of, 519.
Membranes - premature rupture of, in
labour, treatment of, 12; unnatural
toughness of, in labour, treatment of,
12; degeneration of, as determining
cause of parturition, 94, 148.
Menorrhagia from fibroid tumours of uterus,
arrest of, by application of perchloride of
iron to interior of uterus, 719; from
intra-uterine polypi, 734, 739, 750, 752,
755; application of solid nitrate of
silver to interior of uterus in obstinate,
669; gallic acid in, 670; application of
dried sulphate of zinc to interior of
uterus in obstinate, 761; as a symptom
of cancer of body and fundus of uterus,
769.
Metritis, increased length of uterine cavity
in, 638.
Microscope, use of, in diagnosis of cancer of
body and fundus of uterus, 769.
Milk fever-diagnosis of, 78; treatment
of, 78.
"Missed labour," due sometimes to ob-
struction from cancer of cervix uteri,
498.
Monstrosities by excess, management of
birth of, 57.
Mortality, fœtal-greater in male than in
female births, 313, 315, 316; causes of
greater, in male than in female births,
323; before labour, as great in females
as in males, 325; excess of male over
female, less in premature births than
at term, 336; excess of male over fe-
male, less in twin than in single births,
337; greater in first than in subsequent
labours, 341; amount of, referable in
Great Britain annually to greater size of
head of male foetus, 359; from compres-
sion of funis in turning, 445; compara-
tive extent of, in delivery by turning and
by forceps, 445, 447. See also p. 32.
Mortality, infantile-greater in males than in
females in earliest infancy, 319, 337,341;
amount of, referable annually in Great
Britain to male sex of infant during
labour, 360; resulting from parturition
increases with increased duration of
labour, 414, footnote. See also p. 32.
Mortality, maternal-greater in male than
in female births, 309; greater in first
than in subsequent labours, 341; amount
of, referable in Great Britain to compara-
tively greater size of male foetal head,
358; increases with the increased dura-
tion of labour, 412; attendant on for-
ceps operations increases with increased
duration of labour, 417; attendant on
craniotomy increases with increased dura-
tion of labour, 418; comparative, in
delivery by craniotomy and by turning,
456; in craniotomy, as influenced by
844
INDEX.
difficulty of operation, 467. See also
p. 31.
Mortality, maternal, in placental presenta-
tions-general, 179; comparative, from
turning, etc., and from expulsion or
extraction of placenta before child, 205,
290; in cases where os uteri rigid, 281;
special average, from turning, 292.
Multiparity, a supposed cause of protrac-
tion of pregnancy in cows, 93.
NATURAL LABOUR-phenomena of the
first stage of, 1; phenomena of the
second stage of, 3; phenomena of the
third stage of, 3; management of, 3.
Neck of fœtus-goitre and other tumours
in region of, 125; degree of traction.
capable of being borne by, in delivery by
turning, without destroying life of fœtus,
441, 496.
Needle, exploring-use of, in diagnosis of
pelvic abscess, ovarian tumours, etc., 661;
description of, 662.
Nervous system, influence of the, on the
uterine contractions, 148.
Neuralgia- from arterial obstruction, 560;
infra-mammary, hypodermic injection of
morphia for, 818.
Non-interference, rules for, in labour, 31.
OBLIQUITY of os or body of uterus in
labour, effects and treatment of, 13.
Occiput, presentation of, impeding labour,
diagnosis and treatment of, 23.
Occlusion of the os uteri in labour, treat-
ment of, 13.
Opium in labour-indications for, 10; rules
for exhibition of, 11.
Os externum uteri, stricture of, causing dys-
menorrhea, treatment of, by dilatation
and incision, 677.
Os internum uteri-normal contraction of,
in the aged, 652; morbid contraction of,
causing dysmenorrhoea, 652, 677.
Os uteri-occlusion of, in labour, treatment
of, 13; obliquity of, in labour, effects
and treatment of, 13; occasional rigidity
of, in placenta prævia, 271; great danger
from rigidity of, in placenta prævia, 281.
Ossification, strong, of head of fœtus, im-
peding labour, management in, 22.
Ovarian cysts their modes of producing a
fatal termination, 773; inflammation of,
frequency of, 773; causes of rupture of,
774, 777, 782; production of pus in,
774; ulceration, rupture, etc., from in-
flammation of, 774, 777; absence of
peritonitis from rupture of, when contents
bland, 778; danger of peritonitis from
rupture of, into peritoneum, when in-
flamed, 778, 782, 804; beneficial effects
of rupture of, in some cases, 779, 782;
rupture of, into genital canals, 781; as-
cites from rupture of, 804.
Ovarian dropsy-treatment of, by injections
of iodine, 789, 791; fatality of, 794.
Ovarian tumours-impeding labour, patho-
logical varieties of, 17; diagnosis and
treatment of, when impeding labour, 18 ;
use of exploring needle in diagnosis of,
662; differential diagnosis of, from re-
troversion of unimpregnated uterus, 693;
uppermost cysts in, the largest, 787.
Ovariotomy-opposition to, 793; special
applicability to multilocular cystic de-
generation of ovary, 793; comparison of,
with tapping, 795; comparison of mor-
tality of, with that of other surgical
operations, 796; ultimate results of,
799; necessity for, because of fatality of
ovarian dropsy, 795, 801; difficulties in
performing, from adhesions, etc., not
greater than difficulties in performing
other surgical operations, 805; argu-
ments against, apply in principle to other
surgical operations, 806; desirability of
improvements in mode of performing,
807.
Oxytocic, Indian hemp as an, 154.
Oxytocics, 29, 72, 73.
PAINS-nature of spurious, in labour, 153;
infra-mammary, treatment of, by hypo-
dermic injection of inorphia, 817.
Paracentesis. See under Tapping.
Paralysis from arterial obstruction, 560.
Paraplegia, labour in cases of, 149, 150.
Parturition, the determining cause of, 93,
148.
Passages, maternal, obstructions on part of,
protracting labour, forms, diagnosis, and
treatment of, 14.
Pelvic abscess-use of exploring needle in
diagnosis of, 662; sites of opening of,
812; vesico-uterine fistula from, 812;
utero-intestinal fistula from, 813; recto-
vesical fistula from, 814; intestinal fis-
tulæ from, 815.
Pelvic cellulitis-differential diagnosis of,
from retroversion of unimpregnated
uterus, 694; ascent of uterus from, 710.
Pelvic fascia, relation of, to displacements
of uterus, 704.
Pelvic presentations-evil effects of ex-
tractive interference in, 47; diagnosis
and management of, 47-49; morbid im-
paction of fœtal head in pelvis in, treat-
ment of, 48; difficult, treatment of, 49;
natural mechanism of labour in, 376.
Pelvis-large size of, allowing prolapsus in
labour, treatment in, 13; morbid condi-
tions of, impeding labour, varieties of,
and treatment in, 20; smallest, admitting
passage of child without embryulcia,
INDEX.
845
159; largest, requiring Cæsarean section,
161; smallest, admitting delivery by
embryulcia, 163; extremely narrowed by
malacosteon, unaided delivery through,
157, 166; contracted, proposal to reduce
base of skull and face of fœtus in, 174
measurements of, in a case of Cæsarean
section, 177; turning as a substitute for
craniotomy and long forceps, in contrac-
tion of brim of, 393, 486; dangers of delay- |
ing delivery in contraction of, 417, 418,
495; comparative danger of inflammation,
sloughing, and fistula of vagina after
delivery by turning and by instruments.
in contracted, 473; comparative danger
of rupture of uterus in delivery by turn-
ing and by instruments in contracted,
479; slight degrees of contraction of the,
most liable to induce rupture of uterus,
480; means of extracting fœtal head
after turning in contracted, 496.
Perforation of foetal head in craniotomy,
rules for, 40.
Pericarditis during labour, fatal case of,
305.
Perineal fistula, left by transit of infant
through perineum, 592.
Perineum laceration of, in labour, varieties
and treatment of, 65; frequency of
laceration of, in labour, 152; transit of
infant through, in labour, 592; means
of preventing central laceration of, in
labour, 594.
Peristaltic action of the uterus, in labour,
153.
Peritonitis during labour, fatal case of,
305.
Peritonitis in the foetus in utero-cases of
acute, 104; cases of chronic, 112; mor-
bid appearances in, 113; exciting causes.
of, 116; symptoms of, 120; duration of,
122; periods of fatal life at which it
occurs, 123; effects of, on life of foetus,
123.
Pessaries, intra-uterine-use of, in amenor-
rhæa, etc., from imperfect development
of uterus, 672; use of, in dysmenorrhoea
from stricture of cervical canal, 678;
use of, in treatment of retroversion of
unimpregnated uterus, 700.
Pessaries, medicated-uses of, 664, 697,
712; varieties and composition of, 665,
666.
Phthisis, placental, varieties and treatment
of, 134, 145.
Phlebitis, puerperal, leading to obstruction
of the pulmonary artery, 542.
Placental hemorrhage, changes in the blood
effused in, 145.
Placental phthisis, varieties and treatment
of, 134, 145.
Placenta, diseases of the-congestion and
hemorrhage, 135; inflammation, 135;
gangrene, 136; general edema, 136;
fatty degeneration, 137; hypertrophy,
138; treatment in, 140, 145.
Placenta, expulsion of, sound heard during,
151.
Placenta, perforation of-for evacuation of
liquor amuii in placenta prævia, 181;
for facilitating turning, 245.
Placenta prævia-constitutional effects of
hemorrhage in, 66; treatment of, 66;
separation of placenta in, 68; dangers
of, 177; recognised principles of treat-
ment in, 180; evacuation of liquor
aminii in, 181; delivery by turning in,
182; complete separation of placenta in,
before birth of child, 68, 183; table of
141 cases of expulsion and extraction of
placenta before child in, 188; general
deductions regarding these 141 cases of,
194; relative degrees of hemorrhage be-
fore and after separation of the placenta
in, 197; comparative mortality of, un-
der different modes of treatment, 205;
general remarks on ten fatal cases of,
after separation of placenta before child,
210; summary of results of separation
and expulsion of placenta before child in,
213; anatomical source of hemorrhage
in, 217; cause of continuance of henior-
rhage in, when detachment of placenta
is partial, and explanation of occasional
cessation of hemorrhage, 220; cause of
cessation of hemorrhage in, when detach-
ment of placenta is complete, 225;
warnings of authors against attempting
separation of placenta in, 239; cases of,
in which placenta has been artificially
extracted before child, 241; practice of
perforating placenta to effect turning in,
245; practice of removing placenta when
separated for facilitating turning in, 246;
Portal's cases of, 250; Kinder Wood's
proposal and practice of artificial separa-
tion of placenta in, 255; cases of, in
which evacuation of liquor anni forms.
the proper practice, 262, 287; cases of,
in which turning forms the proper prac-
tice, 266, 288; cases of, in which artifi-
cial detachment of the placenta forms
the proper practice, 68, 267, 289;
period of death of mother in fatal cases
of, 270; rigidity of os uteri in, 271,
281; rarity of, in first labours, 282;
special applicability of artificial separa-
tion of placenta to first labours in, 285;
summary of principles of treatment in,
285; sometimes no interference required
in, 286; comparative mortality attendant
upon turning and upon total separation
of placenta in, 290; maternal mortality
under old forms of practice in, 292;
846
INDEX.
treatment of, by partial separation of
placenta, 69, 295.
Placenta, removal of, when separated in
placenta prævia-to ensure its complete
separation, 68; to facilitate turning, 246.
Placenta, retention of, in labour-from
morbid adhesion of, to uterus, treatment
of, 70; from hypertrophy of itself,
treatment of, 71; from irregular con-
traction of uterus, causes, diagnosis, and
trentment of, 71; from atony of uterus,
causes, diagnosis, and treatment of, 72;
as common after female as after male
births, 338.
Placenta, separation of, complete, before
birth of child, in placenta prævia-cases
in which it forms the proper practice,
68, 267, 289; removal of placenta after,
to insure complete separation, 68;
grounds for propriety of, 183; summary
of results of, 213; warnings of authors
against attempting, 239; cases of artifi-
cial, 241; removal of placenta after, to
facilitate turning, 246.
Placenta, separation of, partial, in treat-
ment of placenta prævia, 69, 295.
Plural births, varieties, detection, manage-
ment, etc., of, 55.
Podalic version. See under Turning.
Polypi of uterus—increased length of cavity
of uterus from, diagnosis of, by means
of uterine sound, 648; sometimes sensi-
tive to touch, 655; diagnosis between,
and inversion of uterus, by uterine sound,
658, 721.
diagnosis of, 736, 742, 756; menorrha-
gia, leucorrhœa, enlargement of cervix
and body of uterus, signs of pressure on
bladder and rectum, and sympathetic
phenomena, as symptoms of, 739; occa-
sional absence of such symptoms in, 740;
tendency of, to descend through os uteri
during hemorrhage, 743; pai.iful uterine
contractions in some cases of, 744; use
of dilatation of cervix and administration
of ergot of rye to encourage descent of,
into vagina, in simple cases, 745; dilata-
tion of cervix and removal of, by wire
loop or scissors when hemorrhage, etc.,
severe, 747; small mucous, menorrhagia
and leucorrhoea from, 750, 752; removal
of small mucous, of cervix uteri, by dila-
tation with sponge-tents, scratching off
with finger-nail, avulsion, torsion, exci-
sion, use of potassa fusa, etc., 722, 753;
state of cervix uteri, and use of uterine
sound in diagnosis of, 756; advantage
of pressing down fundus uteri for dia-
gnosis of, 757; use of torsion, of teno-
tomy-knife, of small polyptome, of wire
écraseur and of vulsella with short teeth,
in removal of, 757.
Polyptome-description of, 724; use of, in
excision of large pedunculated uterine
polypi, 725; use of, in excision of intra-
uterine polypi, 757.
Post-partum hemorrhage.
morrhage.
| See under He-
Polypi, small and soft, of cervix uteri-me-
norrhagia and leucorrhoea from, 750, 752;
removal of, by dilatation with sponge-
tents, scraping, avulsion, torsion, excision,
scooping out, crushing, potassa fusa,
etc., 722, 753.
Polypi, large pedunculated uterine-ad-
vantages of excision of, over deligation of,
722; hemorrhage after excision of, usu-
ally moderate, and easily arrested, 723;
injury to attachments of uterus in ordi-
nary methods of excising, 724; use of
polyptome in excising, 725; use of scis-
sors for excising when soft, 726; relative
difficulty of excision and deligation of,
726; relative duration of operation of
deligation and excision of, 728; relative
care and management after deligation
and excision of, 729; relative chance of
local irritation of vagina and uterus by
deligation and excision of, 730; relative
danger to life and health of patient, of
deligation and excision of, 731.
Polypi, intra-uterine-difficulties of dia-
gnosis of, 733; fatal case of, with os
uteri still unopened, 734; use of dilata-
tion of cervical canal by sponge-tents in
Potash, chlorate of, use of, in placental
disease, 142, 145.
Potassa fusa-treatment of inflammatory
induration of cervix uteri by deep cau-
terisation with, 712; use of, in destroy-
ing small and soft polypi of cervix uteri,
722, 754.
Pregnancy-duration of, 81; cases of pro-
tracted, 82; great variety in functional
symptoms of, 608, 684; simulation of,
by uterine disease, 608, 684; differential
diagnosis of, from retroversion of unim-
pregnated uterus, 691.
Pregnancy, extra-uterine, differential dia-
gnosis of, from retroversion of unimpreg-
nated uterus, 694.
Pregnancy, spurious — use of artificial
anææsthesia for diagnosis of, 663, 821;
frequency of, 818; occasionally followed
by a spurious labour, 818; symptoms
of, 819; nature of, 820.
Preliminary symptoms of labour, 1.
Premature births, excess of male over fe-
male mortality in, less than in births at
term, 336.
Premature labour, induction of-cases for,
74; modes of effecting, and rules and
cautions for, 75; for recurrent hydroce-
phalus in the fœtus, 97; for placental
INDEX.
847
disease, 144; propriety of, in uterine
fibroid tumours, 156.
Premature rupture of membranes in labour,
treatment of, 12.
Presentations, footling-evil effects of ex-
tractive interference in, 47; management
of, 47; morbid impaction of fetal head
in pelvis in, treatment of, 48; natural
mechanism of labour in, 376.
Presentations, preternatural, causes and
diagnosis of, 46.
Presentations, transverse-diagnosis of, 46,
50; different forms of version in, 50-54;
necessity for turning in, 365; one knee
-the farthest-to be seized in turning
in, 370; diagnosis between knee and
elbow in, 372; use of both hands in
turning in, 373; spontaneous evolution
or expulsion of fœtus in, 379; decapita-
tion and evisceration in, 381; spondy-
lotomy in, when turning impossible, 54,
502.
Preternatural labour-first order of (pelvic
presentations), diagnosis and manage-
ment of, 47; second order of (cross-
births), diagnosis and management of,
49.
Preternatural presentations, causes and
diagnosis of, 46.
Prolapsus of arm of foetus behind head in
labour-case of, 381; diagnosis of, 26,
383; treatment of, 26, 383.
Prolapsus of extremities of fœtus with head
of fœtus, in labour, varieties and treat-
ment of, 25.
|
Prolapsus of uterus-in labour, causes and
treatment of, 13, 60; with longitudinal |
hypertrophy of organ, 640.
Puerperal arterial obstruction and inflam-
mation, pathological observations on, 523.
Arterial obstruction from separated
cardiac vegetations, 524; arterial ob-
struction from recent coagula from heart
or from larger arteries, 532; arterial ob-
struction from local arteritis, 538;
arterial obstruction from spontaneous
laceration of internal coat of artery, 540;
obstruction of pulmonary artery and its
branches by morbid materials from sys-
temic venous circulation, 542; causes of,
551; symptoms of, in arteries of internal
organs, 554; symptoms of, in arteries
of extremities, 558,; case of re-
covery from, in a cerebral vessel, and
sudden death in a subsequent pregnancy,
566.
Fuerperal convulsions-supposed causes of,
57; premonitory symptoms of, 57, 302;
rules of treatment of, 58; co-existence
of albuminuria with, 295; cases of, as-
sociated with albuminuria, 298; con-
dition of kidneys in, 298, 299; use of
chloroform in, 302; relative frequency
of, in male and female births, 311; re-
lative frequency of, in first and subse-
quent labours, 340, 344.
Puerperal fever-forms of, 79; symptoms
of, 79; treatment of, 80; relative fre-
quency of, after male and female births,
311; relative frequency of, after first
and subsequent labours, 341; liability
to, increases with increased duration of
labour, 415, footnote; communicability
and propagation of, 505; possibility of
epidemic influence producing, 514; con-
nection between erysipelas and, 515.
Puerperal mania, causation of, by albumi-
nuria, 591.
Puerperal measles, case of, 519.
Puerperal phlebitis, leading to obstruction
of the pulmonary artery, 542.
Puerperal purpura, case of, 520.
Puerperal scarlatina, cases of, 518.
Puerperal state-general phenomena of, 76;
general management of, 76; morbid de-
viations during treatment, etc., of, 76.
Pulmonary artery, obstruction of, in puer-
peral state-by morbid materials result-
ing from phlebitis, 542; by coagula from
uterine sinuses, 542, 547.
Pulse, fœtal, state of, in labour-indication
of danger to child from, 387; import-
ance of ascertaining, as indicating neces-
sity for operative interference, to save
life of child, 423.
Purpura, puerperal, case of, 520.
;
RANULA in the fœtus, 126.
Rectum-distended, impeding labour, dia-
gnosis and treatment of, 16; organic
disease of, differential diagnosis of re-
troversion of unimpregnated uterus from,
694; stricture of, simulated by retro-
version of uterus, 694; ball-valve ob-
struction of, by scybalous masses, 816.
Reproduction, rudimentary, of amputated
extremities-in the human fœtus, 129
in the lower animals, 129.
Respiration, intra-uterine, means of estab-
lishing, to save life of foetus in operation
of turning in contracted pelvis, 449.
Retention of placenta in labour-from mor-
bid adhesion cf, to uterus, treatment of,
70; from hypertrophy of itself, treat
ment of, 71; from irregular contraction
of uterus, causes, diagnosis, and treat-
ment of, 71; from atony of uterus,
causes, diagnosis, and treatment of, 72;
as common after female as after male
births, 338.
Retention of urine after labour, treatment
of, 77.
Retroflexion of uterus. See under Retro-
version of unimpregnated uterus.
848
INDEX.
Retroversion of unimpregnated uterus
forms of, 681; frequency of, 684; causes
no symptoms in some cases and severe
symptoms in others, 686; state of men-
struation in, 687; often leads to sterility,
and to abortion, 687; symptoms of, never
sufficient for diagnosis, 687; tactile ex-
amination insufficient for diagnosis of,
688; use of uterine sound in diagnosis
of, 690; diagnosis between, and preg
nancy, 691; diagnosis between, and
tumours in posterior wall of uterus, 692;
diagnosis between, and small ovarian
tumours, 693; diagnosis between, and
pelvic cellulitis, 694; diagnosis between,
and extra-uterine pregnancy, 694; dia-
gnosis between, and organic disease of
anterior wall of rectum, 694; diagnosis
between, and stricture of rectum, 694;
liable to escape notice in post-mortem
examination, 696; organic state of uterus
in, 696; removal of morbid states co-ex-
isting with, in treatment of, 698; restora-
tion of uterus to its normal position, in
treatment of, 698; retention of uterus in
its normal position by intra - uterine
pessaries in treatment of, 699; no treat-
ment required in cases of, causing no un-
pleasant symptoms, 704; causes of, 704;
caustics to vagina and cervix uteri as a
means of treating, 704; bibliographical
note on, 705.
Rigidity of cervix uteri in labour-varieties
and treatment of, 10, 11; occasional, in
placenta prævia, 271; great danger of,
in placenta prævia, 281.
Rigidity of a band of circular fibres of the
cervix in labour, diagnosis and treatment
of, 11.
Rigidity of vaginal canal and vulva in
labour, varieties, diagnosis, and treatment
of, 15.
Rudimentary reproduction of amputated
extremities-in the human foetus, 129;
in the lower animals, 129.
Scybalæ, obstructing rectum like a ball-
valve, 816.
Secale cornutum-rules for exhibition of,
in lingering labour, 30; use of, in intra-
uterine polypus, 745.
Of
Second stage of labour-phenomena of, in
natural labour, 3; management of, in
natural labour, 5; protraction of, from
obstructions formed by maternal passages,
14; protraction of, from obstructions on
the part of the child, 21; protraction of,
from inefficiency of expulsive powers, 26.
Sex of foetus, impeding labour, 21, 22; as
influencing the duration of pregnancy, 93.
Sex of child as a cause of difficulty and
danger in human parturition, 307.
mothers dying from parturition, a much
greater proportion have given birth to
male than female children, 309; in com-
plex and difficult labours the child is
much oftener male than female, 310; of
the still-born children of mothers that
die from parturition, a larger proportion
are male than female, and of those born
alive a larger proportion are female than
male, 313; of still-born children a larger
proportion are male than female, 315;
of children dying during parturition, the
number of males is much greater than
the number of females, 316; of children
born alive, more males than females suffer
from the effects of parturition, 318; more
males than females die in early infancy,
319; causes of greater maternal and in-
fantile mortality in male births, 323; of
children dying in utero, before labour, as
many are female as male, 325; relative
weight and size of male and female
at birth, 327; reasons for considering
greater size of head of male child the
cause of greater difficulty of male births,
330; in laborious labours, the amount
of male births increases as the labours
rise in difficulty, 335; in third stage of
labour, as many accidents take place with
female as with male births, 339; more
dangers and deaths occur to mothers and
children in first than in subsequent
labours, 340; average duration of labour
is longer with male than with female
children, 349; practical inferences, 356.
Sex of twins, 828.
་
Rupture of spleen in pregnant, parturient,
and puerperal states, 304.
Rupture of the uterus-causes of, 62; seat
of, 62; premonitory symptoms of, 63;
symptoms of, 63; diagnosis of, 64; treat-
ment of, 64; relative frequency of, in
male and female births, 311; relative |
frequency of, in first and subsequent Sherwood, Elizabeth, case of, 171, footnote.
pregnancies, 343; danger of, from hydro- Short forceps-indications for use of, 34;
cephalus in the fœtus, 384; mechanism rules for extracting by, 36; differences
of, in hydrocephalus, 385; most apt to between, and long, 36.
occur under slight contractions of the Shoulder presentations. See under Pre-
pelvis, 480; liability to, increases with
increased duration of labour, 482; means
of averting, in contracted pelvis, 485.
SCARLATINA, puerperal, cases of, 518.
sentations, transverse.
Sigaultian section, objections to, 45.
Sinuses, uterine-entrance of air into venous
system through, after delivery, 503;
coagula from, plugging up pulmonary
INDEX.
849
artery in puerperal state, 542, 547;
inflammation of, leading to arterial ob-
struction in puerperal state, 543.
Souffle heard in fibroid tumours of uterus,
value of, as a diagnostic mark, 688 foot-
note, 708.
Sound heard during detachment and expul-
sion of placenta, 151.
Sound, uterine-proposal for improvement
of uterine diagnosis by means of, 614;
description of, 616; mode of introduction
of, 618; increases, to a great degree, our
power of making a perfect examination
of fundus, body, and neck of uterus,
620; previous introduction of, facilitates
subsequent visual examination of cervix
uteri with the speculum, 624; enables us
in many instances of pelvic and abdominal
tumours to ascertain the connection or
non-connection of those tumours with
the uterus, 625; capable of affording
valuable diagnostic information by enab-
ling us to measure length of uterine
cavity, 631; use of, in diagnosing subin-
volution of uterus, 632; use of, in dia-
gnosing normal elongation of puerperal
uterus as a sign of delivery, 636; use of,
in diagnosing increased length of uterus
in metritic and congestive hypertrophy,
638; use of, in diagnosis of longitudinal
hypertrophy of uterus, and especially of
cervix, 639; use of, in diagnosing hyper-
trophy of uterus from growth of fibrous |
tumours in parietes of organ, 644; use
of, in diagnosing enlargement and disten-
sion of uterus from polypi, etc., in its
cavity, 648; use of, in diagnosing elonga-
tion of uterus in hernia of organ, 648;
use of, in diagnosing unnatural shortness
of uterus from original malformation of
organ, 650; use of, in diagnosing shorten-
ing of uterine canal from stricture or
partial obliteration, 651; use of, in dia-
gnosing diminished depth of cavity of
uterus, and differential diagnosis from
polypus, in inversion of organ, 654,
721; use of, in diagnosing retroversion of
unimpregnated uterus, 690; use of, in
diagnosing direction of uterine cavity,
690; use of, in diagnosis of intra-uterine
polypi, 756; use of, in diagnosis of
cancer of body and fundus of uterus, 769.
Speculum uteri, use of, sometimes simplified
by previous introduction of uterine
sound, 624.
Spina bifida, in the cervical region, 125.
Spinal cord, parturition after removal of,
in pigs, 149.
Spleen, morbid conditions and injuries of,
in the pregnant and parturient states, 304.
Spondylotomy in cross-births, when turning
impossible, 54, 502.
|
Sponge-tents-use of, in arresting hemor-
rhage in abortion, 97; mode of forming,
736; mode of using, 738; use of, to
dilate cervical canal for diagnosis of
intra-uterine polypi, 736, 742, 756; use
of, to dilate cervix uteri in cases of intra-
uterine polypus, to encourage descent of
polypus into vagina, 745; use of, for
removal of small mucous polypi of
interior of cervix uteri, 753; use of, in
diagnosis of cancer of body and fundus
of uterus, 769.
Spontaneous amputation, rudimentary re-
production of fetal extremities after,
129.
Spontaneous evolution or expulsion of
fœtus in transverse presentations-cases
of, 379; general deductions regarding, 380.
Spurious labour pains-treatment of, 2
nature of, 153.
Spurious pregnancy use of artificial
anæsthesia for diagnosis of, 663, 821;
frequency of, 818; occasionally followed
by spurious labour, 818; symptoms of,
819; nature of, 820.
Stage, first, of labour-phenomena of, in na-
tural labour, 1; management of, in na-
tural labour, 4; local impeding causes
protracting, 9; rules of treatment of,
when protracted by local causes, 13;
inefficiency of expulsive powers protract-
ing, 26.
Stage, second, of labour-phenomena of, in
natural labour, 3; management of, in
natural labour, 5; protraction of, from
obstructions formed by maternal passages,
14; protraction of, from obstructions on
part of child, 21; protraction of, from
inefficiency of expulsive powers, 26.
Stage, third, of labour-phenomena of, in na-
tural labour, 3; management of, in na-
tural labour, 7; hemorrhage in, causes,
diagnosis, and treatment of, 70; hemor-
rhage in, presence of, in partial, and ab-
sence of, in complete, separation of pla-
centa, cause of, 232.
Sterility from imperfect development
of uterus, 672; from stricture of
canal of cervix uteri, 677; often caused
by retroversion of uterus, 687; average
proportion of, in general society, $30.
Still-born children. See under Mortality.
Stricture of canal of cervix uteri-diagnosis
of, by the uterine sound, 652; normal,
at os internum in the aged, 652; as a
cause of dysmenorrhoea, etc., 652, 677;
dilatation and incision of cervix for cure
of dysmenorrhoea, etc., caused by, 677;
cause of suffering in dysmenorrhœa from,
679; instrument for incision of cervix in
dysmenorrhoea, etc., from, 680; from re-
troversion of uterus,, 698.
850
INDEX.
Stricture of rectum simulated by retrover-
sion of unimpregnated uterus, 694.
Subinvolution of uterus after delivery-
cases of, 596, 632; causes of, 597, 598;
use of uterine sound in diagnosis of, 632.
Superinvolution of uterus after delivery-
case of, etc., 598.
Suppositories, medicated-list of, 667; uses
of, as cathartics, opiates, mercurials, etc.,
668.
Symphyseotomy, objections to, 45.
TANGLE-TENTS, use of, for dilatation of
cervix uteri in obstructive dysmenorrhea,
757.
Tapping in ovarian dropsy-inconveniences
of using an abdominal bandage in, 784;
advantages of placing patient in hori-
zontal position for, 784; selection of
place of puncture for, 785; risk of wound-
ing bladder, uterus, Fallopian tubes, or
bloodvessels in, 786; disadvantages of per-
forming through roof of vagina, 787;
danger of first, 795; merely palliative,
795.
Tedious labour-from morbid protraction
of first stage by local impeding causes,
8; from morbid protraction of second
stage by obstructions on part of maternal
passages, 14; from morbid protraction
of second stage by obstructions on part
of child, 21; from inefficiency of expulsive
powers in first two stages, 26; relative
frequency of, in male and female births,
311, 333, 334; relative frequency of, in
first and subsequent labours, 341.
Temperature, fall in, of limb, in arterial
obstruction, 560.
Tents, sponge. See under Sponge-tents.
Tents, tangle, use of, for dilatation of cervix
uteri in obstructive dysmenorrhoea, 757.
Tetanus after lesion of unimpregnated
uterus, 570; after abortion, 571; apt
to be mistaken for cynanche or hysteria,
at outset, 573; after plugging for he-
morrhage in abortion, 575; after partu-
rition, 577; exposure to cold favourable |
to production of, after delivery, 579;
nature of puerperal, 584; treatment of
puerperal, 587.
3
Third stage of labour-phenomena of, in
natural labour, 3; management of, in
natural labour, 7; hemorrhage in, causes,
diagnosis, and treatment of, 70; hemor
rhage in, presence of, in partial, and
absence of, in complete, separation of
placenta, cause of, 232.
Transverse presentations. See under Pre-
sentations, transverse.
Trocar, exploring-use of, in diagnosis of
pelvic abscess, ovarian tumours, etc.,
661; description of, 662.
Tumours, abdominal, connection or non-
connection of, with uterus, use of uterine
sound in diagnosing, 625.
Tumours, complicating parturition-ovari-
an, pathological varieties of, 17; ovarian,
diagnosis and treatment of, 18; of soft
tissues surrounding maternal passages,
varieties, diagnosis, and treatment of, 19;
abdominal, treatment in, 59; fibroid, of
uterus, effects and treatment of, 155.
Tumours, fibroid, of uterus-souffle heard
in, value of, in diagnosing them from
ovarian tumours, 688 footnote, 708.
See also under Fibroid.
Tumours, ovarian. See under Ovarian.
Tumours, pelvic, connection or non-con-
nection of, with uterus, use of uterine
sound in diagnosing, 625.
Tumours in cervical region of fœtus, 125.
Turning-relative maternal mortality, in
delivery by craniotomy and by, 456;
maternal mortality connected with, as
influenced by previous duration of la-
bour, 471; comparative danger of inflam-
mation and sloughing of vagina and of
fistulæ after delivery by instruments and
by, in contracted pelvis, 473; compara-
tive danger of rupture of the uterus in
delivery by instruments and by, in con-
tracted pelvis, 479; means of extracting
foetal head in, in contracted pelvis, 496.
Turning in transverse presentations-by
introducing hand into uterus, period of,
preliminary measures for, and method of
performing, 50; without introduction of
hand into uterus, cases for, and mode of
performing, 52; when uterus strongly
contracted, means of producing relaxa-
tion for, 53; one knee-the farthest-
to be seized in performing, 370 dia-
gnosis between knee and elbow for, 372;
use of both hands in, 373; hand, in being
introduced into uterus for, to be passed
along anterior surface of child, 374;
direct interference for rotating fœtus in
pelvis in, not required, 378.
Turning in placenta prævia time and
cautions for, 67; the common practice,
182, 288; cases in which it forms the
proper practice, 266, 289; comparative
mortality of, and of total separation of
placenta, 290.
Turning as a substitute for craniotomy and
the long forceps in deformity of pelvic
brim-illustrative case of, and remarks on,
393; evidence suggestive of the practice,
397; theory or principles of the pro-
posed practice, 400, 488; duration and
danger of the labour is decreased by
the proposed practice, 409; relative
periods of the labour at which long
forceps, perforation, and turning are
INDEX.
851
employed, 419; value of auscultation
in, 419; depression and indentation of
fœtal cranium during labour is compa-
tible with life of child in, 428; physio-
logical and pathological reasons for the
life of the child not being necessarily
compromised under the proposed prac-
tice, 435; concluding remarks on objec-
tions to proposed practice, founded on
alleged danger to child, 453; supposed
objections to the practice in relation
to life of mother, 455; comparative
danger of local lesions of maternal or-
gans in delivery by, and delivery by
instruments, 472; cases illustrating ad-
vantages of, 490; recapitulation of ad-
vantages of, 493; course to be pursued
in cases of, where unusual resistance
experienced, 496.
Twin, co-, with males, alleged infecundity
of females born, 822.
Twin births, excess of male over female
mortality in, less than in single births,
337.
Twin labours-simple, diagnosis and man-
agement of, 55; complex, forms and man-
agement of, 56; absence of hemorrhage
in cases of, with one or both placenta
detached before birth of second child,
228; number and proportion of, 828.
Twins, sex of, 828.
UMBILICAL CORD-shortness of, im-
peding labour, 21; prolapsus of, causes
and management of, 54; absence of
bleeding from, after division of, 228;
compatibility of pressure on, with life of
child, in turning in contracted pelvis,
444; degree of mortality from pressure
on, in turning, 445; means for averting
pressure on, in turning, 447.
Umbilical vessels, vital contractions in the,
133.
Unavoidable hemorrhage. See under He-
morrhage.
Urinary bladder-distension of, in labour,
diagnosis and treatment of, 16; calculus
in, in labour, treatment of, 17; displace-
ments of, in labour, varieties, diagnosis,
and treatment of, 17; morbid affections
of, in puerperal state. 77.
Urine-retention of, after labour, treatment
of, 77; incontinence of, after labour,
diagnosis of, 77.
Uterine action-inefficiency of, in first
two stages of labour, from partial irregu-
lar or spasmodic contractions, causes,
diagnosis, and treatment of, 27, 29;
inefficiency of, in first two stages of
labour, from general inertia or atony,
varieties and treatment of, 28, 29; in-
efficiency of, in third stage of labour,
from irregular contraction, causes, dia-
gnosis, and treatment of, 71; inefficiency
of, in third stage of labour, from inertia
or atony, causes, diagnosis, and treat-
ment of, 72; inefficiency of, after de-
livery, leading to hemorrhage, causes
and treatment of, 72; influence of ner-
vous system on, 148.
Uterine bougie. See under Sound, uterine.
Uterine diagnosis. See under Diagnosis,
uterine.
Uterine disease-same, excites very differ-
ent phenomena in different cases, and
same specific phenomena result from
different kinds of, 608, 685.
Uterine hemorrhage. See under Hemor-
rhage, uterine.
Uterine phlebitis, giving rise to obstruc-
tion of pulmonary artery in puerperal
state, 543.
Uterine sinuses-entrance of air into venous
system through, after delivery, 503;
coagula, etc., from, after delivery, giving
rise to obstruction of pulmonary artery,
542, 547.
Uterine sound. See under Sound, uterine.
Uterus, ascent of unimpregnated-in some
cases of ovarian tumours, and in fibroid
tumours of uterus, 707; mechanism by
which it is produced, 709; in old age, in
pelvic cellulitis, and in perimetritis,
710.
Uterus, atrophy of, senile, 601, 652.
Uterus, cancer of. See under Cancer.
Uterus, cavity of-measurement of, by
uterine sound, in diagnosis of morbid
states of organ, 630; increased length of,
in morbid permanence of puerperal hy-
pertrophy, 597, 632; normal elongation
of, in puerperal state, as a sign of de-
livery, 636; increased length of, in me-
tritic and congestive hypertrophy of body
of uterus, 638; increased length of, in
longitudinal hypertrophy of uterus, 639
increased length of, in hypertrophy of
uterus from growth of fibrous tumours
in its parietes, 644; increased length of,
in enlargement and distension from polypi,
648,658; elongation of, in hernia of organ,
648; diminished length of, from original
malformation of organ, 602, 650; short-
ening of, from stricture or partial obliter-
ation, 651; diminished length in inver-
sion of organ, 654; direct local applica-
tion of remedies to, 669; application of
solid nitrate of silver and of dried sul-
phate of zinc to, in menorrhagia, 669,
761; direction of, use of uterine sound
in diagnosing, 690.
Uterus, contractions of
vous system on, 148.
Uterine action.
influence of ner-
See also under
55
852
INDEX.
Uterus, development of, imperfect-caus- | Vagina, painful muscular and fascial con-
ing amenorrhoea and sterility, 601, 650,
671; treatment of, by use of intra-uter-
ine pessaries, 672.
Uterus, displaced-use of uterine sound in
replacing, 691, 699. See also under
Retroversion.
Uterus, hernia of-treatment of, in labour,
60; increased length of cavity of uterus
in, 648.
Uterus, hypertrophy of morbid perma-
nence of puerperal, 596, 632; normal, as
a sign of recent delivery, 636; from in-
flammation and congestion of organ, 638; |
longitudinal, 639; from fibrous tumours
in its parietes, 644; from polypi in its
cavity, 648; in hernia of organ, 648.
Uterus, immobility of, in cancer, etc., 623.
Uterus, inertia of. See under Uterine action.
Uterus, inversion of-symptoms, diagnosis,
results, and treatment of, 61; simulating
polypus of uterus, 654; uterus apt to be-
come insensible in chronic cases of, 655;
use of uterine sound in diagnosing between,
and polypi growing from cervix uteri,
658, 721; chronic, treatment of, 710.
Uterus, involution of, after delivery-mor-
bid deficiency in, 596, 632; causes of
morbid deficiency in, 597, 598; morbid
access in, 598.
Uterus, mobility of, degree of natural, 620.
Uterus, obliquity of, in labour, effects and
treatment of, 13.
Uterus, polypi of. See under Polypi.
Uterus, prolapsus of treatment of, in
labour, 60; with elongation and hyper-
trophy of organ, 640.
Uterus, rupture of. See under Rupture.
Uterus, retroversion of. See under Retro-
version of unimpregnated uterus.
Uterus, tumours of. See under Fibroid.
VAGINA, cancer of, propriety of vaginal
hysterotomy in labours obstructed by, 498.
Vagina, inflammation of, after labour-
treatment of, 78; comparative frequency
of, after delivery by turning and by in-
struments, 473.
tractions in-morbid effects of, 809;
treatment of, 810.
Vagina, rigidity and contraction of, in
labour, varieties, diagnosis, and treatment
of, 15.
Vagina, sloughing of, after labour-com-
parative frequency of, after delivery by
turning and by instruments, 473; dura-
tion of labour in six fatal cases of, 476.
Vaginal examination
purposes of, in
labour, 4; use of both hands in making,
742, 757.
Vaginodynia from painful muscular and
fascial contractions in vagina-morbid
effects of, 809; treatment of, 810.
Valves, aortic, vegetations of, separating and
blocking up arteries in puerperal state,
524.
Vectis-different modes of using, 37; pro-
posed cases for use of, 37; rules for em-
ployment of, 38.
Vegetations, cardiac, blocking up arteries in
puerperal state, 524.
Veins, umbilical, vital contractions in, 133.
Version. See under Turning.
Vomiting of pregnancy, cerium in the, 95.
Vulva-rigidity and contraction of, in labour,
varieties, diagnosis, and treatment of, 15;
laceration of, in labour, varieties and
treatment of, 65.
WEDGING of a fold of cervix uteri be-
tween the head and the pelvis in labour,
treatment of, 11.
Weight, relative, of male and female
children at birth, 327.
ZINC, dried sulphate of, as a caustic-mode
of using, 758; advantages of, 759; use
of, in cancer of cervix uteri, 759; use of,
in indurated inflammatory ulcers of cervix
uteri, 760; use of, in destroying vascular
tumours of orifice of urethra, condylomata,
etc., in cauterising interior of uterus for
cure of obstinate menorrhagia, and in
treatment of chronic prolapsus uteri,
761.
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extended discussion of disputed points."- Boston Medical and Surgical Journal.
"To those who desire to get a concise, clear, but at the same time sufficiently full ré-
sumé of the existing state of physiological science, we heartily recommend Dr. Flint's work.
Moreover, as a work of typographical art, it deserves a prominent place upon our library
shelves."-Medical Gazette, N. Y.
D. APPLETON & CO.'S MEDICAL PUBLICATIONS.
Elliot's Obstetric Clinic.
A Practical Contribution to the Study of Obstetrics and the Dis-
eases of Women and Children. By GEORGE T. ELLIOT, Jr.,
A. M., M. D., Prof. of Obstetrics and the Discases of Women
and Children in the Bellevue IIospital Medical College, Physi-
cian to Bellevue IIospital and to the New York Lying-in Hos-
pital, etc., etc. 8vo, pp. 458.
Cloth, $4.50
This volume, by Dr. Elliot, is based upon a large experience, including fourteen
years of service in the lying-in department of Bellevue Hospital of this city. The
book has attracted marked attention, and has elicited from the medical press, both
of this country and Europe, the most flattering commendations. It is justly be-
lieved that the work is one of the most valuable contributions to obstetric literature
that has appeared for many years, and, being eminently practical in its character,
cannot fail to be of great service to obstetricians.
"The volume by Dr. Elliot has scarcely less value, although in a different direction, than
that of the Edinburgh physician (Dr. Duncan, Researches in Obstetrics). The materials com-
prising it have been principally gathered through a service of fourteen years in the Bellevue
Hospital, New York, during the whole of which time the author has been engaged in clini-
cal teaching. The cases now collected into a handsome volume illustrate faithfully the anx-
ieties and disappointments, as well as the fatigues and successes, which are inseparable
from the responsible practice of obstetrics-a line of practice which, under difficulties, e-
mands the greatest moral courage, the highest skill, and the power of acting promptly on a
sudden emergency. Dr. Elliot's favorite subject appears to be operative midwifery; but
the chapters on the relations of albuminuria to pregnancy, ante-partum hemorrhage, the in-
duction of labor, and the dangers which arise from compression of the funis, are all deserving
of careful perusal. The pleasure we feel at being able to speak so favorably of Dr. Elliot's
volume is enhanced by the circumstance that he was a pupil at the Dublin Lying-in Hospital
when Dr. Shekelton was master. We can certainly say that his teachings reflect great credit
upon his Alma Mater."-London Lancet, April 11, 1868.
"This may be said to belong to a class of books after the practitioner's own heart.' In
them he finds a wider range of cases than comes under his observation in ordinary practice ;
in them be learns the application of the most recent improvements of his art; in them he
finds the counterpart of cases which have caused him the deepest anxiety; in them, too, he
may find consolation, for the regret-the offspring of limited experience, which has always
cast a shadow on the remembrance of some of his fatal cases-will pass away as he reads of
similar ones in which far greater resources of every kind failed to avert a fatal termination.
There are not many books of this kind in our language: they can probably all be num-
bered on the fingers of a single hand. *** Many circumstances concur, therefore, to influ-
ence us to extend to this work a cheerful welcome, and to commend it as fully as possible.
We do thus welcome it; as the production of a gentleman of great experience, acknowledged
ability, and high position-as an emanation from one of the leading schools of our country
and as an honorable addition to our national medical literature.”—American Journal of
Medical Science, April, 1868.
"As the book now stands, it is invaluable for the practitioner of obstetrics, for he will
hardly ever in practice find himself in a tight place, the counterpart of which he will not
find in Dr. Elliot's book."-New York Medical Journal, February, 1868.
"The book has the freshness of hospital practice throughout, in reference to diagnosis,
pathology, therapeutical and operative proceedings. It will be found to possess a great
amount of valuable information in the department of obstetrics, in an attractive and easy
style, according to the most modern and improved views of the profession."- Cincinnati
Lancet and Observer, April, 1868.
"As a whole, we know of no similar work which has issued from the American press,
which can be compared with it. It ought to be in the hands of every practitioner of mid
wifery in the country."-Boston Medical and Surgical Journal.
"One of the most attractive as well as forcibly instructive works we have had the
pleasure of reading. In conclusion, we recommend it as one having no equal in the English
fanguage, as regards clinical instruction in obstetrics."-Am. Jour. of Obstetrics, Aug., 1863.
Many ripe, elderly practitioners might, but few young could, write a book so distin-
guished by candor, want of prejudice, kindly feeling, soundness of judgment, and extent of
erudition. While we do not say the book is faultless, we say there is no book in American
obstetrical literature that surpasses this one. ***** *The work now under review is
his first-born book or volume, and shows how fine opportunities he has had, chiefly at Belle-
vuc Hospital, for acquiring experience, and how diligently he has availed himself of them.
But his book shows much more. It is the work of a physician of high education, a qualifi-
cation in which obstetric authors are often deficient-it shows qualities of mind and skill
of hand rarely attained by so young a man."-Edinburgh Medical Journal, Feb., 1868.
:
DESCRIPTIVE CATALOGUE
OF
MEDICAL WORKS.

PUR SUMUOVE
D. APPLETON & CO.,
PUBLISHERS AND IMPORTERS,
549 & 551 BROADWAY, NEW YORK.
1873.
"It is unvaryingly a pleasure to take up a medical work pub-
lished by this house, if for nothing else than the elegance with
which the publishers' work is done. Type and paper are alike
fitly chosen, and proof-errors rare.' DETROIT REVIEW OF
MEDICINE,
""
"Messrs. Appleton & Co. deserve the thanks of the profes
sion for the very handsome style in which they issue medical
works. They give us hope of a time when it will be very gen-
erally believed by publishers that physicians' eyes are worth
saving."-MEDICAL GAZETTE.
2
>
CATALOGUE
OF
MEDICAL WORKS.
ANSTIE.
Neuralgia, and Diseases which resemble it.
By FRANCIS E. ANSTIE, M. D., F. R. C. P.,
Senior Assistant Physician to Westminster Hospital; Lecturer on Materia Medica in West-
minster Hospital School; and Physician to the Belgrave Hospital for Children: Editor
of "The Practitioner" (London), etc.
1 vol., 12mo. Cloth, $2.50.
"It is a valuable contribution to scientific medicine.”—The Lancet (London).
"His work upon Neuralgia is one of the most interesting, instructive, and practical,
we have seen for a long time. We have given it careful reading and thoughtful study.
and, for a treatise of its size, we are free to say that we have never met one that gives
more practical information and is fuller of useful suggestions."-Medical Record.
BARKER.
On Sea-sickness.
By FORDYCE BARKER, M. D.,
Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital
Medical College, etc.
1 vol., 16mo. 36 pp. Flexible Cloth, 75 cents.
Reprinted from the NEW YORK MEDICAL JOURNAL. By reason of the great demand
for the number of that journal containing the paper, it is now presented in book form,
with such prescriptions added as the author has found useful in relieving the suffering
from sea-sickness.
BARNES.
Obstetric Operations, including the Treatment
of Hæmorrhage.
By ROBERT BARNES, M. D., F. R. C. P., LONDON,
Obstetric Physician to and Lecturer on Midwifery and the Diseases of Women and Chil-
dren at St. Thomas's Hospital; Examiner on Midwifery to the Royal College of Phy-
sicians and to the Royal College of Surgeons; formerly Obstetric Physician to the
London Hospital, and late Physician to the Eastern Division of the Royal Maternity
Charity.
WITH ADDITIONS, by BENJAMIN F. DAWSON, M. D.,
Late Lecturer on Uterine Pathology in the Medical Department of the University of New
York; Assistant to the Clinical Professor of Diseases of Children in the College of
Physicians and Surgeons, New York; Physician for the Diseases of Children to the
New York Dispensary; Member of the New York Obstetrical Society, of the Medical
Society of the County of New York, etc., etc.
Second American Edition. 1 vol., 8vo. 503 pp. Cloth, $4.50.
To the student and practitioner this work will prove of the greatest value, being, as it
is, a most perfect text-book on "Obstetric Operations," by one who has fairly earned the
right to assume the position of a teacher.
66 Such a work as Dr. Barnes's was greatly needed. It is calculated to elevate the
practice of the obstetric art in this country, and to be of great service to the practitioner."
-Lancet.
D. Appleton & Co.'s Medical Publications.
Bellevue and Charity Hospital Reports.
The volume of Bellevue and Charity Hospital Reports
for 1870, containing valuable contributions from
ISAAC E. TAYLOR, M. D.,
AUSTIN FLINT, M. D.,
LEWIS A. SAYRE, M. D.,
WILLIAM A. HAMMOND, M. D.,
T. GAILLARD THOMAS, M. D.,
FRANK H. HAMILTON, M. D.,
and others.
1 vol., 8vo. Cloth, $4.00.
"These institutions are the most important, as regards accommodations for
patients and variety of cases treated, of any on this continent, and are surpassed
by but few in the world. The gentlemen connected with them are acknowledged
to be among the first in their profession, and the volume is an important addition
to the professional literature of this country."-Psychological Journal.
BENNET
Winter and Spring on the Shores of
the Mediterranean; or, the Riviera, Mentone, Italy,
Corsica, Sicily, Algeria, Spain, and Biarritz, as Win-
ter Climates.
By J. HENRY BENNET, M. D.,
Member of the Royal College of Physicians, London; late Physician-Accoucher to the
Royal Free Hospital; Doctor of Medicine of the University of Paris; formerly Resi-
dent Physician to the Paris Hospitals (ex-Interne des Hôpitaux de Paris), etc.
This work embodies the experience of ten winters and springs passed by Dr. Bennet
on the shores of the Mediterranean, and contains much valuable information for physi-
cians in relation to the health-restoring climate of the regions described.
""
1 vol., 12mo. 621 pp. Cloth, $3.50.
Exceedingly readable, apart from its special purposes, and well illustrated."-Even-
ing Commercial.
"It has a more substantial value for the physician, perhaps, than for any other class or
profession.
We commend this book to our readers as a volume presenting two
capital qualifications-it is at once entertaining and instructive."-N. Y. Medical Journal.
On the Treatment of Pulmonary Con-
sumption, by Hygiene, Climate, and Medicine, in its
Connection with Modern Doctrines.
By JAMES HENRY BENNET, M. D.,
Member of the Royal College of Physicians, London; Doctor of Medicine of the University
of Paris, etc., etc.
1 vol., thin 8vo. Cloth, $1.50.
An interesting and instructive work, written in the strong, clear, and lucid manner
which appears in all the contributions of Dr. Bennet to medical or general literature.
"We cordially commend this book to the attention of all, for its practical common.
sense views of the nature and treatment of the scourge of all temperate climates, pulmo-
nary consumption."-Detroit Review of Medicine.
D. Appleton & Co.'s Medical Publications.
BILLROTH.
General Surgical Pathology and The-
rapeutics, in Fifty Lectures. A Text-book for Stu-
dents and Physicians.
By Dr. THEODOR BILLROTH,
Professor of Surgery in Vienna.
Translated from the Fifth German Edition, with the special permission
of the Author, by
CHARLES E. HACKLEY, A. M., M. D.,
Surgeon to the New York Eye and Ear Infirmary; Physician to the New York Hospital;
Fellow of the New York Academy of Medicine, etc.
1 vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, $6.00.
Professor Theodor Billroth, one of the most noted authorities on
Surgical Pathology, gives in this volume a complete résumé of the ex-
isting state of knowledge in this branch of medical science. The fact
of this publication going through four editions in Germany, and hav-
ing been translated into French, Italian, Russian, and Hungarian, should
be some guarantee for its standing.
"The want of a book in the English language, presenting in a concise form the views of the
German pathologists, has long been felt; and we venture to say no book could more perfectly
supply that want than the present volume. . . . We would strongly recommend it to all who
take any interest in the progress of thought and observation in surgical pathology and sur-
gery." The Lancet.
"We can assure our readers that they will consider neither money wasted in its purchase,
nor time in its perusal."-The Medical Investigator.
COMBE.
The Management of Infancy, Physiologi-
cal and Moral. Intended chiefly for the Use of
Parents.
By ANDREW COMBE, M. D.
REVISED AND EDITED
By SIR JAMES CLARK, K. C. B., M. D., F. R. S.,
Physician-in-ordinary to the Queen.
First American from the Tenth London Edition. I vol., 12mo. 302 pp.
Cloth, $1.50.
"This excellent little book should be in the hand of every mother of a family; and, if some
of our lady friends would master its contents, and either bring up their children by the light
of its teachings, or communicate the truths it contains to the poor by whom they are surround-
ed, we are convinced that they would effect infinitely more good than by the distribution of any
number of tracts whatever. We consider this work to be one of the few popular medical
treatises that any practitioner may recommend to his patients; and, though, if its precepts are
followed, he will probably lose a few guineas, he will not begrudge them if he sees his friend's
children grow up healthy, active, strong, and both mentally and physically capable."-Tho
Lancet.
•
D. Appleton & Co.'s Medical Publications.
DAVIS,
Conservative Surgery, as exhibited in remedying
some of the Mechanical Causes that operate injuri-
ously both in Health and Disease. With Illustrations.
By HENRY G. DAVIS, M. D.,
Member of the American Medical Association, eto., etc.
1 vol., 8vo. 315 pp. Cloth, $3.00.
The author has enjoyed rare facilities for the study and treatment
of certain classes of disease, and the records here presented to the pro-
fession are the gradual accumulation of over thirty years' investigation.
"Dr. Davis, bringing, as he does to his specialty, a great aptitude for the
solution of mechanical problems, takes a high rank as an orthopedic surgeon,
and his very practical contribution to the literature of the subject is both valu-
able and opportune. We deem it worthy of a place in every physician's library.
The style is unpretending, but trenchant, graphic, and, best of all, quite intelli-
gible."-Medical Record.
ECKER.
The Cerebral Convolutions of Man,
represented according to Personal Investigations, es-
pecially on their Development in the Fœtus, and with
reference to the Use of Physicians.
By ALEXANDER ECKER,
Professor of Anatomy and Comparative Anatomy in the University of Freiburg.
Translated from the German by Robert T. Edes, M. D.
1 vol., 8vo. 87 pp. $1.25.
"The work of Prof. Ecker is noticeable principally for its succinctness and
clearness, avoiding long discussions on undecided points, and yet sufficiently
furnished with references to make easy its comparison with the labors of oth-
ers in the same direction.
"Entire originality in descriptive anatomy is out of the question, but the
facts verified by our author are here presented in a more intelligible manner
than in any other easily-accessible work.
"The knowledge to be derived from this work is not furnished by any other
text-book in the English language."-Boston Medical and Surgical Journal,
January 20, 1873.
D. Appleton & Co.'s Medical Publications.
ELLIOT.
Obstetric Clinic. A Practical Contribution to the
study of Obstetrics, and the Diseases of Women and
Children.
By the late GEORGE T. ELLIOT, M. D.,
Late Professor of Obstetrics and the Diseases of Women and Children in the Bellevue Hospital
Medical College; Physician to Bellevue Hospital, and to the New York Lying-in Asylum;
Consulting Physician to the Nursery and Child's Hospital; Consulting Surgeon to the State
Woman's Hospital; Corresponding Member of the Edinburgh Obstetrical Society and of the
Royal Academy of Havana; Fellow of the N. Y. Academy of Medicine; Member of the
County Medical Society, of the Pathological Society, etc., etc.
1 vol., 8vo. 458 pp. Cloth, $4.50.
This work is, in a measure, a résumé of separate papers previously pre-
pared by the late Dr. Elliot; and contains, besides, a record of nearly
two hundred important and difficult cases in midwifery, selected from
his own practice. It has met with a hearty reception, and has received
the highest encomiums both in this country and in Europe. It is justly
believed that the work is one of the most valuable contributions to
obstetric literature that has appeared for many years, and, being emi-
nently practical in its character, cannot fail to be of great service to
obstetricians.
"The volume by Dr. Elliot has scarcely less value, though in a different di-
rection, than that of the Edinburgh physician (Dr. Duncan, 'Researches in Ob-
stetrics')."-Lancet.
"This may be said to belong to a class of books' after the practitioner's own
heart,' and many circumstances concur to influence us to extend to this work a
cheerful welcome, and to commend it as fully as possible. And we do thus
welcome it as the production of a gentleman of great experience, acknowledged
ability, and high position-as an emanation from one of the leading schools of
our country-and as an honorable addition to our national medical literaturė.”.
American Journal of Medical Sciences.
"There is no book in American obstetrical literature that surpasses this
one."-Edinburgh Medical Journal.
"It ought to be in the hands of every practitioner of midwifery in the coun-
try."-Boston Medical and Surgical Journal.
"It has no equal in the English language, as regards clinical instruction in
obstetrics."-American Journal of Obstetrics.
"The book has the freshness of hospital practice throughout in reference to
diagnosis, pathology, therapeutical and operative proceedings. It will be found
to possess a great amount of valuable information in the department of obstet-
rics in an attractive and easy style, according to the most modern and improved.
views of the profession.”—Cincinnati Lancet and Observer.
"It is invaluable for the practitioner of obstetrics."-N. Y. Medical Journal.
D. Appleton & Co.'s Medical Publications.
FLINT.
The Physiology of Man. Designed to rep-
resent the Existing State of Physiological Science as
applied to the Functions of the Human Body.
By AUSTIN FLINT, JR., M. D.,
Professor of Physiology and Microscopy in the Bellevue Hospital Medical College, and in the
Long Island College Hospital; Fellow of the New York Academy of Medicine; Microscopist
to Bellevue Hospital
In Five Volumes. 8vo. Tinted Paper.
Volume I.-The Blood; Circulation; Respiration.
8vo. 502 pp. Cloth, $4.50.
"If the remaining portions of this work are compiled with the same care and
accuracy, the whole may vie with any of those that have of late years been pro-
duced in our own or in foreign languages."-British and Foreign Medico-Chirurgi-
cal Review.
"As a book of general information it will be found useful to the practitioner,
and, as a book of reference, invaluable in the hands of the anatomist and physi-
ologist."-Dublin Quarterly Journal of Medical Science.
"The complete work will prove a valuable addition to our systematic treatises
on human physiology."-The Lancet.
"To those who desire to get in one volume a concise and clear, and at the
same time sufficiently full résumé of 'the existing state of physiological science,'
we can heartily recommend Dr. Flint's work. Moreover, as a work of typographi-
cal art it deserves a prominent place upon our library-shelves. Messrs. Appleton
& Co. deserve the thanks of the profession for the very handsome style in which
they issue medical works. They give us hope of a time when it will be very
generally believed by publishers that physicians' eyes are worth saving."-Medi-
cal Gazette.
Volume
II. —
- Alimentation; Digestion; Absorption;
Lymph and Chyle.
•
8vo. 556 pp. Cloth, 84.50.
"The second instalment of this work fulfils all the expectations raised by the
perusal of the first.
The author's explanations and deductions bear
evidence of much careful reflection and study.
The entire work is one
of rare interest. The author's style is as clear and concise as his method is
studious, careful, and elaborate.”—Philadelphia Inquirer.
"We regard the two treatises already issued as the very best on human physi-
ology which the English or any other language affords, and we recommend them
with thorough confidence to students, practitioners, and laymen, as models of
literary and scientific ability."-N. Y. Medical Journal.
"We have found the style easy, lucid, and at the same time terse.
The prac-
tical and positive results of physiological investigation are succinctly stated,
without, it would seem, extended discussion of disputed points."-Boston Medical
and Surgical Journal.
"It is a volume which will be welcome to the advanced student, and as a
work of reference."-The Lancet.
"The leading subjects treated of are presented in distinct parts, each of which
is designed to be an exhaustive essay on that to which it refers.". Western Jour-
nal of Medicine.
D. Appleton & Co.'s Medical Publications.
Flint's Physiology. Volume III. - Secretion ;
Excretion; Ductless Glands; Nutrition; Animal
Heat; Movements; Voice and Speech.
8vo. 526 pp. Cloth, $4.50.
"Dr. Flint's reputation is sufficient to give a character to the book among the
profession, where it will chiefly circulate, and many of the facts given have been
verified by the author in his laboratory and in public demonstrations."- Chicago
Courier.
"The author bestows judicious care and labor. Facts are selected with dis-
crimination, theories critically examined, and conclusions enunciated with com-
mendable clearness and precision."-American Journal of the Medical Sciences.
"The work is calculated to attract other than professional readers, and is
written with sufficient clearness and freedom from technical pedantry to be per-
fectly intelligible to any well-informed man."-London Saturday Review.
"From the extent of the author's investigations into the best theory and prac
tice of the present day, the world over, and the candor and good judgment which
he brings to bear upon the discussion of each subject, we are justified in regard-
ing his treatises as standard and authoritative, so far as in this disputed subject
authority is admissible."-New York Times.
Volume IV.-The Nervous System.
8vo. Cloth, $4.50.
This volume is now ready. It is a work of great interest, and, in
conjunction with the "Treatise on Diseases of the Nervous System," by
Dr. Wm. A. Hammond, constitutes a complete work on "The Physiology
and Pathology of the Nervous System."
"}
Volume V.-Generation. (In press.)
Manual of Chemical Examination of
the Urine in Disease. With Brief Directions for the
Examination of the most Common Varieties of Uri-
nary Calculi.
By AUSTIN FLINT, JR., M. D.,
Professor of Physiology and Microscopy in the Bellevue Hospital Medical College; Fellow of the
New York Academy of Medicine; Member of the Medical Society of the County of New
York; Resident Member of the Lyceum of Natural History in the City of New York, etc.
Third Edition, revised and corrected. 1 vol., 12mo. 77 pp. Cloth, $1.00.
The chief aim of this little work is to enable the busy practitioner to
make for himself, rapidly and easily, all ordinary examinations of Urine;
to give him the benefit of the author's experience in eliminating little
difficulties in the manipulations, and in reducing processes of analysis
to the utmost simplicity that is consistent with accuracy.
"We do not know of any work in English so complete and handy as the
Manual now offered to the profession by Dr. Flint, and the high scientific reputa-
tion of the author is a sufficient guarantee of the accuracy of all the directions
given."―Journal of Applied Chemistry.
"We can unhesitatingly recommend this Manual."-Psychological Journal.
"Eminently practical."-Detroit Review of Medicine.
D. Appleton & Co.'s Medical Publications.
FLINT.
On the Physiological Effects of Severe
and Protracted Muscular Exercise. With Special ref-
erence to its Influence upon the Execretion of Nitrogen.
By AUSTIN FLINT, Jr., M. D.,
Professor of Physiology in the Bellevue Hospital Medical College, New York, etc., etc.
1 vol., 8vo. 91 pp. Cloth, $2.00.
This monograph on the relations of Urea to Exercise is the result of a thorough and careful
investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian.
The chemical analyses were made under the direction of R. O. Doremus, M. D., Professor of
Chemistry and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his
assistant. The observations were made with the coöperation of J. C. Dalton, M. D., Professor
of Physiology in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Profess-
or of Surgical Anatomy; W. H. Van Buren, M. D., Professor of Principles of Surgery; Austin
Flint, M. D., Professor of the Principles and Practice of Medicine; W. A. Hammond, M. D.,
Professor of Diseases of the Mind and Nervous System-all of the Bellevue Hospital Medical
College.
"This work will be found interesting to every physician. A number of important results
were obtained valuable to the physiologist."-Cincinnati Medical Repertory.
HAMILTON.
Clinical Electro-Therapeutics. (Medical
and Surgical.) A Manual for Physicians for the
Treatment more especially of Nervous Diseases.
By ALLAN MOLANE HAMILTON, M. D.,
Physician in charge of the New York State Hospital for Diseases of the Nervous System;
Member of the New York Neurological and County Medical Societies, etc., etc.
With Numerous Illustrations. 1 vol., 8vo. Cloth. Price, $2.00.
This work is the compilation of well-tried measures and reported cases, and is intended as
a simple guide for the general practitioner. It is as free from confusing theories, technical
terms, and unproved statements, as possible. Electricity is indorsed as a very valuable remedy
in certain diseases, and as an invaluable therapeutical means in nearly all forms of NERVOUS
DISEASE; but not as a specific for every human ill, mental and physical.
HAMMOND.
Insanity in its Relations to Crime.
A Text and a Commentary.
By WILLIAM A. HAMMOND, M. D.
1 vol. 8vo. 77 pp. Cloth, $1.00.
"A part of this essay, under the title 'Society versus Insanity,' was contributed to Put-
nam's Magazine, for September, 1870. The greater portion is now first published. The im-
portance of the subject considered can scarcely be over-estimated, whether we rogard it from
the stand-point of science or social economy; and, if I have aided in its elucidation, my object
will have been attained."-From Author's Preface.
D. Appleton & Co.'s Medical Publications.
HAMMOND.
A Treatise on Diseases of the Nervous
System.
By WILLIAM A. HAMMOND, M. D.,
Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, in the Bellevue
Hospital Medical College; Physician-in-Chief to the New York State Hospital for Diseases
of the Nervous System, etc., etc.
FOURTH EDITION, REVISED AND CORRECTED.
With Forty-five Illustrations. 1 vol., 8vo. 750 pp. Cloth, $5.00.
The treatise embraces an introductory chapter, which relates to the
instruments and apparatus employed in the diagnosis and treatment of
diseases of the nervous system, and five sections. Of these, the first
treats of diseases of the brain; the second, diseases of the spinal cord;
the third, cerebro-spinal diseases; the fourth, diseases of nerve-cells;
and the fifth, diseases of the peripheral nerves. One feature which may
be claimed for the work is, that it rests, to a great extent, upon the per-
sonal observation and experience of the author, and is therefore no mere
compilation.
This work is already universally popular with the profession; their
appreciation of it may be evidenced by the fact that within two years
it has reached the fourth edition.
"That a treatise by Prof. Hammond would be one of a high order was what we anticipated,
and it affords us pleasure to state that our anticipations have been realized."-Cincinnati
Medical Repertory.
"This is unquestionably the most complete treatise on the diseases to which it is devoted
that has yet appeared in the English language; and its value is much increased by the fact that
Dr. Hammond has mainly based it on his own experience and practice, which, we need hardly
remind our readers, have been very extensive.”—London Medical Times and Gazette,
"Free from useless verbiage and obscurity, it is evidently the work of a man who knows
what he is writing about, and knows how to write about it.”—Chicago Medical Journal.
"This is a valuable and comprehensive book; it embraces many topics, and extends over a
wide sphere. One of the most valuable parts of it relates to the Diseases of the Brain; while
the remaining portion of the volume treats of the Diseases of the Spinal Cord, the Cerebro-
spinal System, the Nerve-Cells, and the Peripheral Nerves."-British Medical Journal.
"The work before us is unquestionably the most exhaustive treatise, on the diseases to
which it is devoted, that has yet appeared in English. And its distinctive value arises from
the fact that the work is no mere rafficiamento of old observations, but rests on his own ex-
perience and practice, which, as we have before observed, have been very extensive."—Ameri-
can Journal of Syphilography.
"The author of this work has attained a high rank among our brethren across the Atlantic
from previous labors in connection with the disorders of the nervous system, as well as from
various other contributions to medical literature, and he now holds the official appointments of
Physician to the New York State Hospital for Diseases of the Nervous System, and Professor
of the same department in the Bellevue Hospital Medical College. The present treatise is the
fruit of the experience thus acquired, and we have no hesitation in pronouncing it a most valu-
able addition to our systematic literature."-Glasgow Medical Journal.
D. Appleton & Co.'s Medical Publications.
HOFFMANN.
Manual of Chemical Analysis, as applied
to the Examination of Medicinal Chemicals and their
Preparations. A Guide for the Determination of
their Identity and Quality, and for the Detection of Im-
purities and Adulterations. For the use of Pharma-
ceutists, Physicians, Druggists, and Manufacturing
Chemists, and Pharmaceutical and Medical Students.
By FRED. HOFFMANN, PHIL. D.
One vol., 8vo. Richly illustrated. Cloth. Price, $3.
The preparation of the chemicals used in medicine and pharmacy has largely
passed from the hands of the pharmaceutist into those of the manufacturer ;
yet legal responsibility and professional duty require all who compound, dis-
pense, or sell medicines, as well as the manufacturer, to determine, by correct
tests, the identity, quality, and purity of every article dispensed or sold for med-
ication. A work embracing the most approved methods of examinations, and
forming a critical and useful guide for such tests, has as yet been a desideratum.
This want has now been successfully met by the present work.
The book is divided into two parts, the first of which treats of operations
and reagents, and gives a general account of the principles and methods of
chemical analysis. The second, or main part, gives, in an alphabetical order,
a complete account of the medicinal chemicals, their physical and chemical
characteristics, and directions for the establishment of their quality and purity,
selected and arranged with care and judgment; each compound is fully de-
scribed according to its aspect and properties, its solubility in the usual sol-
vents, simple and chemical, and its deportment with reagents (tests of Identity);
this is followed by the Examination, under which heading the defects, or the
accidental impurities, resulting from the processes employed in the manufacture
of the chemicals, or from insufficient purification, and also the adulterations and
substitutions, are considered, and their detection clearly and precisely described,
so that they are readily understood by those having an average knowledge of
chemistry, and ordinary chemical manipulations, many of which, as well as the
more important apparatus, are illustrated by excellent engravings. A number
of very useful tables is scattered through the text; and the volume concludes
with comparative tables of the thermometric scales, the troy and metric weights,
and a complete index, embracing the common English terms and the Latin
names and synonymes in use.
The work has been brought up to the latest results of scientific research,
within the briefest possible compass; and forms a thoroughly practical and
trustworthy guide, combining easy operations, simple apparatus, and economy
of time, with the greatest attainable accuracy.
D. Appleton & Co.'s Medical Publications.
In America it has already met with general and unqualified approval; and
in Europe is now being welcomed as one of the best and most important addi-
tions to modern pharmaceutical literature. To give a better idea of the real
merits and popularity of the book, we would call attention to the following:
"A work of this kind has long been needed, and for this reason alone this volume would be
heartily welcomed, even if it had been less complete than it is. . . . This brief outline of the
contents of this valuable work is scarcely sufficient to convey a correct idea of all the informa-
tion presented in it. The descriptions and directions are clear and precise, and we feel sure
that those whose vocation requires the examination of medicinal chemicals will find this valua-
ble work what the author designed it to be-a trustworthy guide for the determination of their
identity and quality.”—American Journal of Pharmacy.
"A work of this character has long been a desideratum, and we may now truly say that the
void has been well filled by this excellent treatise, which will be cordially welcomed by every
pharmacist and by all others to whom it is especially directed. In all the departments of the
work Dr. Hoffmann displays extended research, and a critical familiarity with the subject, while
at the same time he has placed the matter before the student with system, and in a language
at once clear and concise. Not only is the author to be congratulated upon the excellent result
of his labor, but every pharmaceutist also upon this most opportune addition to the literature
of his art, and most valuable assistant in his daily work."-The Pharmacist (Chicago).
"In this excellent work, the author, a thorough practical pharmaceutist, eminently fitted to
the task, has successfully endeavored to crystallize into a single volume all that is essential to
form a reliable and practical guide.”—New York Medical Review.
"The object for which this book has been written has been successfully accomplished; it is
an eminently practical work throughout; its style and descriptions are clear and accurate, and
it will prove very valuable to those who have occasion to examine drugs and chemicals."——
Boston Medical and Surgical Journal.
"This book has long been a desideratum, and will be well received. It treats of subjects of
vital importance to the physician and druggist in a clear and concise manner. We do most
heartily recommend this work as the best aid in the examination of medicinal chemicals."--
Nashville Journal of Medicine and Surgery.
"This volume is a carefully-prepared work, and well up to the existing state of both the
science and art of modern pharmacy. It is a book which will find its place in every medical
and pharmaceutical laboratory and library, and is a safe and instructive guide to medical stu-
dents and practitioners of medicine.”—American Journal of Science and Arts.
"The appearance of this work must be regarded as very timely. That the physician and the
pharmaceutist may have it in their power to examine by the most approved methods the arti-
cles they prescribe and dispense, the author has, carefully and with a mature judgment and
sound discretion, collected and arranged in accessible form the most trusty tests of purity in
medicinal chemicals."-Medical and Surgical Reporter.
"In this volume Dr. Hoffmann has supplied a want in the literature of his profession, by
having gathered together the widely-scattered fragments of information relating to the exami
nation of chemicals, and has arranged them into a systematic and ready hand-book of especial
interest and value, which certainly is entitled to a wide circulation. ... With regard to indices,
the work is a model; it contains a number of valuable tables, and is largely illustrated with ex-
cellent engravings, which serve to elucidate very much the descriptions of apparatus and ma-
nipulations. The work is issued in Messrs. Appletons' best style, and presents not only an at-
tractive appearance, but an unusual freedom from typographical defects and errors."—Ameri-
can Chemist.
"The reputation of the author of this book is the best guarantee of its accuracy and value.
Dr. Hoffinaun is well known as a highly-valued contributor to scientific journals, as a popular
lecturer, and as an original investigator. He has himself practically applied the leading meth-
ods set forth in the book, and has proved most of the tests recommended by him. . . . The
book is a valuable addition to our pharmaceutical literature, and ought to have the effect of
securing a still more extended knowledge of the medicinal chemicals most in use."—Journal
of Applied Chemistry.
"This excellent volume carries out fully the prefatory promises, and fills a void which has
heretofore existed in American pharmaceutical literature. It is not only a valuable acquisition
to the library of the average pharmaceutist, but also an invaluable aid to those better qualified
and practically familiar with the subject, and there is no doubt that this work will be regarded
as a standard among works on pharmacy."-Prof. C. Lewis Diehl, Louisville, Kentucky.
"It is with great satisfaction that we note the appearance of this manual, especially adapted
to the pharmaceutical chemist and manufacturer of medicinal chemicals. The processes recom-
mended have been judiciously and carefully selected, and the instructions are full and trust-
worthy; and we hope that the circulation of this elaborate work, on both sides of the Atlantic,
may tend to accomplish its objects.”—Chemical News (London).
D. Appleton & Co.'s Medical Publications.
HOLLAND.
Recollections of Past Life,
By SIR HENRY HOLLAND, Bart., M. D., F. R. S., K. C. B., etc.,
President of the Royal Institution of Great Britain, Physician-in-Ordinary to the Queen,
etc., etc.
1 vol., 12mo, 351 pp. Price, Cloth, $2.00.
A very entertaining and instructive narrative, partaking somewhat of the nature of
autobiography and yet distinct from it, in this, that its chief object, as alleged by the
writer, is not so much to recount the events of his own life, as to perform the office of
chronicler for others with whom he came in contact and was long associated.
The "Life of Sir Henry Holland" is one to be recollected, and he has not erred in giv-
ing an outline of it to the public."-The Lancet.
"His memory was-is, we may say, for he is still alive and in possession of all his
faculties-stored with recollections of the most eminent men and women of this cen-
tury. . . . A life extending over a period of eighty-four years, and passed in the most
active manner, in the midst of the best society, which the world has to offer, must neces-
sarily be full of singular interest; and Sir Henry Holland has fortunately not waited until
his memory lost its freshness before recalling some of the incidents in it."-The New
York Times.
HOWE.
•
Emergencies, and How to Treat Them.
The Etiology, Pathology, and Treatment of Accidents,
Diseases, and Cases of Poisoning, which demand
Prompt Attention. Designed for Students and Prac-
titioners of Medicine.
By JOSEPH W. HOWE, M. D.,
Visiting Surgeon to Charity Hospital; Lecturer on Surgery in the Medical Department of
the University of New York, etc.
1 vol., 8vo. 265 pp. Cloth, $3.00.
This volume is designed as a guide in the treatment of cases of emergency occurring in
medical, surgical, or obstetrical practice. It combines all the important subjects, giving
special prominence to points of practical interest in preference to theoretical considera-
tions, and uniting, with the results of personal observation, the latest views of European
and American authorities.
"The style is concise, perspicuous, and definite. Each article is written as though that
particular emergency were present; there is no waste of words, nor temporizing with
remedies of doubtful efficacy. The articles on cedema glottidis, asphyxia, and strangulated
hernia, are particularly clear and practical, and furnish all the information required in the
management of those urgent cases.
"It will be found invaluable to students and young practitioners, in supplying them
with an epitome of useful knowledge obtainable from no other single work; while to the
older members of the profession it will serve as a reliable and 'ready remembrancer.'"-
The Medical Record.
D. Appleton & Co.'s Medical Publications.
HUXLEY AND YOUMANS.
The Elements of Physiology and
Hygiene. With Numerous Illustrations.
BY THOMAS H. HUXLEY, LL. D., F. R. S., and
WILLIAM JAY YOUMANS, M. D.
New and Revised Edition. 1 vol., 12mo. 420 pp. 81.75.
A text-book for educational institutions, and a valuable elementary
work for students of medicine. The greater portion is from the pen of
Professor Huxley, adapted by Dr. Youmans to the circumstances and
requirements of American education. The eminent claim of Professor
Huxley's “Elementary Physiology" is, that, while up to the times, it
is trustworthy in its presentation of the subject; while rejecting dis-
credited doctrines and doubtful speculations, it embodies the latest
results that are established, and represents the present actual state of
physiological knowledge.
"A valuable contribution to anatomical and physiological science."-Religious Telescope.
"A clear and well-arranged work, embracing the latest discoveries and accepted theories."
-Buffalo Commercial.
nal.
"Teeming with information concerning the human physical enconomy."-Evening Jour-
HUXLEY.
The Anatomy of Vertebrated Animals.
BY THOMAS HENRY HUXLEY, LL. D., F. R. S.,
Author of "Man's Place in Nature," "On the Origin of Species," "Lay Sermons and
Addresses," etc.
1 vol., 12mo. Cloth, $2.50.
The former works of Prof. Huxley leave no room for doubt as to the impor-
tance and value of his new volume. It is one which will be very acceptable to
all who are interested in the subject of which it treats.
"This long-expected work will be cordially welcomed by all students and teachers of Com-
parative Anatomy as a compendious, reliable, and, notwithstanding its small dimensions, most
comprehensive guide on the subject of which it treats. To praise or to criticise the work of so
accomplished a master of his favorite science would be equally out of place. It is enough to
say that it realizes, in a remarkable degree, the anticipations which have been formed of it;
and that it presents an extraordinary combination of wide, general views, with the clear, accu-
rate, and succinct statement of a prodigious number of individual facts.”—Nature.
D. Appleton & Co.'s Medical Publications.
JOHNSON.
The Chemistry of Common
Common Life.
Illustrated with numerous Wood Engravings.
By JAMES F. JOHNSON, M. A., F. R. S., F. G. S., ETO., ETO.,
Author of "Lectures on Agricultural Chemistry and Geology," "A Catechism of Agricultural
Chemistry and Geology," etc.
2 vols., 12mo. Cloth, $3.00.
It has been the object of the author in this work to exhibit the
present condition of chemical knowledge, and of matured scientific
opinion, upon the subjects to which it is devoted. The reader will not
be surprised, therefore, should he find in it some things which differ
from what is to be found in other popular works already in his hands or
on the shelves of his library.
LETTERMAN.
Medical Recoilections of the Army of
the Potomac.
By JONATHAN LETTERMAN, M. D.,
Late Surgeon U. S. A., and Medical Director of the Army of the Potomac.
1 vol., 8vo. 194 pp. Cloth, $1.00.
"This account of the medical department of the Army of the Poto-
mac has been prepared, amid pressing engagements, in the hope that
the labors of the medical officers of that army may be known to an in-
telligent people, with whom to know is to appreciate; and as an affec
tionate tribute to many, long my zealous and efficient colleagues, who,
in days of trial and danger, which have passed, let us hope never to re-
turn, evinced their devotion to their country and to the cause of hu-
manity, without hope of promotion or expectation of reward."-Preface.
"We venture to assert that but few who open this volume of medical annals,
pregnant as they are with instruction, will care to do otherwise than finish them
at a sitting."-Medical Record..
ས
"A graceful and affectionate tribute."-N. Y. Medical Journal.
LEWES.
The Physiology of Common Life.
By GEORGE HENRY LEWES,
Author of "Seaside Studies," "Life of Goethe,” etc.
2 vols., 12mo. Cloth, $3.00.
The object of this work differs from that of all others on popular
science in its attempt to meet the wants of the student, while meeting
those of the general reader, who is supposed to be wholly unacquainted
with anatomy and physiology.
D. Appleton & Co.'s Medical Publications.
MAUDSLEY.
The Physiology and Pathology of the
Mind.
By HENRY MAUDSLEY, M. D., LONDON,
Physician to the West London Hospital; Honorary Member of the Medico-Psychological Society
of Paris; formerly Resident Physician of the Manchester Royal Lunatic Hospital, etc.
1 vol., 8vo. 442 pp. Cloth, $3.00.
This work aims, in the first place, to treat of mental phenomena from
a physiological rather than from a metaphysical point of view; and,
secondly, to bring the manifold instructive instances presented by the
unsound mind to bear upon the interpretation of the obscure problems
of mental science.
"Dr. Maudsley has had the courage to undertake, and the skill to execute,
what is, at least in English, an original enterprise."-London Saturday Review.
"It is so full of sensible reflections and sound truths that their wide dissemi-
nation could not but be of benefit to all thinking persons."-Psychological Journal.
"Unquestionably one of the ablest and most important works on the subject
of which it treats that has ever appeared, and does credit to his philosophical
acumen and accurate observation."—Medical Record.
"We lay down the book with admiration, and we commend it most earnestly
to our readers as a work of extraordinary merit and originality-one of those
productions that are evolved only occasionally in the lapse of years, and that
serve to mark actual and very decided advances in knowledge and science."-
N. Y. Medical Journal.
Body and Mind: An Inquiry into their Con
nection and Mutual Influence, specially in reference
to Mental Disorders; being the Gulstonian Lectures
for 1870, delivered before the Royal College of
Physicians. With Appendix.
By HENRY MAUDSLEY, M. D., LONDON,
Fellow of the Royal College of Physicians; Professor of Medical Jurisprudence in University Col-
lege, London; President-elect of the Medico-Psychological Association; Honorary Member of
the Medico-Psychological Society of Paris, of the Imperial Society of Physicians of Vienna,
and of the Society for the Promotion of Psychiatry and Forensic Psychology of Vienna;
formerly Resident Physician of the Manchester Royal Lunatic Asylum, etc., etc.
1 vol., 12mo. 155 pp. Cloth, $1.00.
The general plan of this work may be described as being to bring
man, both in his physical and mental relations, as much as possible with-
in the scope of scientific inquiry.
"A representative work, which every one must study who desires to know
what is doing in the way of real progress, and not mere chatter, about mental
physiology and pathology."-The Lancet.
"It distinctly marks a step in the progress of scientific psychology.”—The
Practitioner.
D. Appleton & Co.'s Medical Publications.
MARKOE.
A Treatise on Diseases of the Bones.
By THOMAS M. MARKOE, M. D.,
Professor of Surgery in the College of Physicians and Surgeons, New York, etc.
WITH NUMEROUS ILLUSTRATIONS.
1 vol. 8vo. Cloth, $4.50.
SPECIMEN OF ILLUSTRATIONS.

This valuable work is a treatise on Diseases of the Bones, embracing their
structural changes as affected by disease, their clinical history and treatment, in-
cluding also an account of the various tumors which grow in or upon them.
None of the injuries of bone are included in its scope, and no joint diseases, ex-
cepting where the condition of the bone is a prime factor in the problem of
disease. As the work of an eminent surgeon of large and varied experience, it
may be regarded as the best on the subject, and a valuable contribution to medi-
cal literature.
"The book which I now offer to my professional brethren contains the substance of
the lectures which I have delivered during the past twelve years at the college. . . . I
have followed the leadings of my own studies and observations, dwelling more on those
branches where I had seen and studied most, and perhaps too much neglecting others
where my own experience was more barren, and therefore to me less interesting. I have
endeavored, however, to make up the deficiencies of my own knowledge by the free use of
the materials scattered so richly through our periodical literature, which scattered
leaves it is the right and the duty of the systematic writer to collect and to embody in
any account he may offer of the state of a science at any given period."—Extract from
Author's Preface.
D. Appleton & Co.'s Medical Publications.
MEYER.
Electricity in its Relations to Practical
Medicine.
By DR. MORITZ MEYER,
Royal Counsellor of Health, etc.
Translated from the Third German Edition, with Notes and Additions,
A New and Revised Edition,
By WILLIAM A. HAMMOND, M. D.,
Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, in the Bellevue
Hospital Medical College; Vice-President of the Academy of Mental Sciences, National
Institute of Letters, Arts, and Sciences; late Surgeon-General U. S. A., etc.
1 vol., 8vo. 497 pp. Cloth, $4.50.
"It is the duty of every physician to study the action of electricity,
to become acquainted with its value in therapeutics, and to follow the
improvements that are being made in the apparatus for its application in
medicine, that he may be able to choose the one best adapted to the
treatment of individual cases, and to test a remedy fairly and without
prejudice, which already, especially in nervous diseases, has been used
with the best results, and which promises to yield an abundant harvest
in a still broader domain."-From Author's Preface.
SPECIMEN OF ILLUSTRATIONS.

Saxton-Ettinghausen Apparatus.
"Those who do not read German are under great obligations to William A
Hammond, who has given them not only an excellent translation of a most ex-
cellent work, but has given us much valuable information and many suggestions
from his own personal experience."-Medical Record.
"Dr. Moritz Meyer, of Berlin, has been for more than twenty years a laborious
and conscientious student of the application of electricity to practical medicine,
and the results of his labors are given in this volume. Dr. Hammond, in making
a translation of the third German edition, has done a real service to the profession
of this country and of Great Britain. Plainly and concisely written, and simply
and clearly arranged, it contains just what the physician wants to know on the
subject."-N. Y. Medical Journal.
"It is destined to fill a want long felt by physicians in this country."-Journal
of Obstetrics.
D. Appleton & Co.'s Medical Publications.
•
NIEMEYER.
A Text-Book of Practical Medicine.
With Particular Reference to Physiology and Patho-
logical Anatomy.
By the late Dr. FELIX VON NIEMEYER,
Professor of Pathology and Therapeutics; Director of the Medical Clinic of the University of
Tübingen.
Translated from the Eighth German Edition, by special permission of
the Author,
By GEORGE H. HUMPHREYS, M. D.,
Late one of the Physicians to the Bureau of Medical and Surgical Relief at Bellevue Hospital for
the Out-door Poor; Fellow of the New York Academy of Medicine, etc.,
and
CHARLES E. HACKLEY, M. D.,
One of the Physicians to the New York Hospital; one of the Surgeons to the New York Eye
and Ear Infirmary; Fellow of the New York Academy of Medicine, etc.
Revised Edition. 2 vols., 8vo. 1,528 pp. Cloth, $9.00; Sheep, $11.00.
The author undertakes, first, to give a picture of disease which shall
be as lifelike and faithful to nature as possible, instead of being a mere
theoretical scheme; secondly, so to utilize the more recent advances
of pathological anatomy, physiology, and physiological chemistry, as to
furnish a clearer insight into the various processes of disease.
The work has met with the most flattering reception and deserved
success; has been adopted as a text-book in many of the medical colleges
both in this country and in Europe; and has received the very highest
encomiums from the medical and secular press.
"It is comprehensive and concise, and is characterized by clearness and
originality."-Dublin Quarterly Journal of Medicine.
"Its author is learned in medical literature; he has arranged his materials
with care and judgment, and has thought over them."-The Lancet.
"As a full, systematic, and thoroughly practical guide for the student and
physician, it is not excelled by any similar treatise in any language."—Appletons'
Tournal.
"The author is an accomplished pathologist and practical physician; he is not
only capable of appreciating the new discoveries, which during the last ten years
have been unusually numerous and important in scientific and practical medicine,
but, by his clinical experience, he can put these new views to a practical test, and
give judgment regarding them."-Edinburgh Medical Journal.
"From its general excellence, we are disposed to think that it will soon take
its place among the recognized text-books.”—American Quarterly Journal of
Medical Sciences.
"The first inquiry in this country regarding a German book generally is, 'Is
it a work of practical value?" Without stopping to consider the justness of the
American idea of the 'practical,' we can unhesitatingly answer, 'It is!'"-New
York Medical Journal.
"The author has the power of sifting the tares from the wheat-a matter of
the greatest importance in a text-book for students."-British Medical Journal.
"Whatever exalted opinion our countrymen may have of the author's talents
of observation and his practical good sense, his text-book will not disappoint
them, while those who are so unfortunate as to know him only by name, have in
store a rich treat."-New York Medical Record,
D. Appleton & Co.'s Medical Publications.
d
b
11
NEUMANN.
Hand-Book of Skin Diseases.
By DR. ISIDOR NEUMANN,
Lecturer on Skin Diseases in the Royal University of Vienna.
Translated from advanced sheets of the second edition, furnished by the
Author; with Notes,
By LUCIUS D. BULKLEY, A. M., M. D.,
Surgeon to the New York Dispensary, Department of Venereal and Skin Diseases; Assist-
ant to the Skin Clinic of the College of Physicians and Surgeons, New York; Mem-
ber of the New York Dermatological Society, etc., etc.
1 vol., 8vo. About 450 pages and 66 Woodcuts. Cloth, $4.00.
SPECIMEN OF ILLUSTRATIONS.
e

Section of skin from a bald head.
Prof. Neumann ranks second only to Hebra, whose assistant he was for many years,
and his work may be considered as a fair exponent of the German practice of Dermatolo-
gy. The book is abundantly illustrated with plates of the histology and pathology of the
skin. The translator has endeavored, by means of notes from French, English, and Ameri-
can sources, to make the work valuable to the student as well as to the practitioner.
"It is a work which I shall heartily recommend to my class of students at the Univer
sity of Pennsylvania, and one which I feel sure will do much toward enlightening the pro-
fession on this subject."-Louis A. Duhring.
"I know it to be a good book, and I am sure that it is well translated; and it is inter-
esting to find it illustrated by references to the views of co-laborers in the same field.”—-
Erasmus Wilson.
"So complete as to render it a most useful book of reference."-T. McCall Anderson.
"There certainly is no work extant which deals so thoroughly with the Pathological
Anatomy of the Skin as does this hand-book."—N. Y. Medical Record.
"The original notes by Dr. Bulkley are very practical, and are an important adjunct to
the text.
I anticipate for it a wide circulation."-Silas Durkee, Boston.
•
"I have already twice expressed my favorable opinion of the book in print, and am
glad that it is given to the public at last."-James C. White, Boston.
"More than two years ago we noticed Dr. Neumann's admirable work in its original
shape; and we are therefore absolved from the necessity of saying more than to repeat
our strong recommendation of it to English readers."-Practitioner.
D. Appleton & Co.'s Medical Publications.
NEFTEL.
Galvano-Therapeutics. The Physiological and
Therapeutical Action of the Galvanic Current upon
the Acoustic, Optic, Sympathetic, and Pneumogastric
Nerves.
By WILLIAM B. NEFTEL.
1 vol., 12mo. 161 pp. Cloth, $1.50.
This book has been published at the request of several aural sur-
geons and other professional gentlemen, and is a valuable treatise on
the subjects of which it treats. Its author, formerly visiting physician
to the largest hospital of St. Petersburg, has had the very best facili-
ties for investigation.
"This little work shows, as far as it goes, full knowledge of what has been
done on the subjects treated of, and the author's practical acquaintance with
them."-New York Medical Journal.
"Those who use electricity should get this work, and those who do not
should peruse it to learn that there is one more therapeutical agent that they
could and should possess."-The Medical Investigator.
NIGHTINGALE.
Notes on Nursing: What it is, and what it is not.
By FLORENCE NIGHTINGALE.
1 vol., 12mo. 140 pp. Cloth, 75 cents.
Every-day sanitary knowledge, or the knowledge of nursing, or, in
other words, of how to put the constitution in such a state as that it will
have no disease or that it can recover from disease, takes a higher place.
It is recognized as the knowledge which every one ought to have-dis-
tinct from medical knowledge, which only a profession can have.
PEREIRA,
Dr. Pereira's Elements of Materia
Medica and Therapeutics. Abridged and adapted
for the Use of Medical and Pharmaceutical Practi-
tioners and Students, and comprising all the Medi-
cines of the British Pharmacopoeia, with such others
as are frequently ordered in Prescriptions, or re-
quired by the Physician.
Edited by ROBERT BENTLEY and THEOPHILUS REDWOOD.
New Edition. Brought down to 1872. 1 vol., Royal 8vo. Cloth, $7.00;
Sheep, $8.00.
D. Appleton & Co.'s Medical Publications.
PEASLEE.
Ovarian Tumors; Their Pathology, Diagnosis,
and Treatment, with reference especially to Ovariotomy.
By E. R. PEASLEE, M. D.,
Professor of Diseases of Women in Dartmouth College; one of the Consulting Physicians to
the New York State Woman's Hospital; formerly Professor of Obstetrics and Diseases of
Women in the New York Medical College; Corresponding Member of the Obstetrical
Society of Berlin, etc.
1 vol., 8vo. Illustrated with many Woodcuts, and a Steel Engraving of Dr.
E. McDowell, the "Father of Ovariotomy." Price, Cloth, $5.00.
This valuable work, embracing the results of many years of successful experience in the
department of which it treats, will prove most acceptable to the entire profession; while the
high standing of the author and his knowledge of the subject combine to make the book the
best in the language. It is divided into two parts: the first treating of Ovarian Tumors, their
anatomy, pathology, diagnosis, and treatment, except by extirpation; the second of Ovariot-
omy, its history and statistics, and of the operation. Fully illustrated, and abounding with
information the result of a prolonged study of the subject, the work should be in the hands of
every physician in the country.
The following are some of the opinions of the press, at home and abroad, of this great
work, which has been justly styled, by an eminent critic, "the most complete medical mono-
graph on a practical subject ever produced in this country."
"His opinions upon what others have advised are clearly set forth, and are as interesting
and important as are the propositions he has himself to advance; while there are a freshness,
a vigor, an authority about his writing, which great practical knowledge alone can confer."-
The Lancet.
"Both Wells's and Peaslee's works will be received with the respect due to the great repu-
tation and skill of their authors. Both exist not only as masters of their art, but as clear and
graceful writers. In either work the student and practitioner will find the fruits of rich expe-
rience, of earnest thought, and of steady, well-balanced judgment. As England is proud of
Wells, so may America well be proud of Peaslee, and the great world of science may be proud
of both."-British Medical Journal,
"This is an excellent work, and does great credit to the industry, ability, science, and
learning of Dr. Peaslee. Few works issue from the medical press so complete, so exhaustive-
ly learned, so imbued with a practical tone, without losing other substantial good qualities."
-Edinburgh Medical Journal.
"In closing our review of this work, we cannot avoid again expressing our appreciation of
the thorough study, the careful and honest statements, and candid spirit, which characterize it.
AFor the use of the student we should give the preference to Dr. Peaslee's work, not only
from its completeness, but from its more methodical arrangement.”—American Journal
of Medical Sciences.
"Dr. Penslee brings to the work a thoroughness of study, a familiarity with the whole
field of histology, physiology, pathology, and practical gynecology, not excelled, perhaps, by
those of any man who ever performs the operation."-Medical Record.
"If we were to select a single word to express what we regard as the highest excellence of
this book, it would be its thoroughness.”—New York Medical Journal.
"We deem its careful perusal indispensable to all who would treat ovarian tumors with a
good conscience."-American Journal of Obstetrics.
"It shows prodigal industry, and embodies within its five hundred and odd pages pretty
much all that seems worth knowing on the subject of ovarian diseases."-Philadelphia Medi-
cal Times.
“Great thoroughness is shown in Dr. Peaslee's treatment of all the details of this very ad-
mirable work.”—Boston Medical and Surgical Journal.
"It is a necessity to every surgeon who expects to treat this disease."-Leavenworth
Medical Herald.
"Indispensable to the American student of gynecology."-Pacific Medical and Surgical
Journal.
"There is not a doubtful point that could occur to any one that is not explained and an-
swered in the most satisfactory manner."- Virginia Clinical Record.
"The work is one the profession should prize; one that every earnest practitioner should
possess.”—Georgia Medical Companion.
"Dr. Peaslee has achieved a success, and the work is one which no practical surgeon can
afford to be without."-Medical Investigator.
D. Appleton & Co.'s Medical Publications.
SAYRE.
A Practical Manual on the Treatment
of Club-Foot.
By LEWIS A. SAYRE, M. D.,
Professor of Orthopedic Surgery in Bellevue Hospital Medical College; Surgeon to Bellevue
and Charity Hospitals, etc.
1 vol., 12mo. New and Enlarged Edition. Cloth.
"The object of this work is to convey, in as concise a manner as possible,
all the practical information and instruction necessary to enable the general
practitioner to apply that plan of treatment which has been so successful in my
own hands."-Preface.
"The book will very well satisfy the wants of the majority of general practitioners, for
whose use, as stated, it is intended."-New York Medical Journal.
On Foods.
SMITH.
By EDWARD SMITH, M. D., LL. B., F. R. S.,
Fellow of the Royal College of Physicians of London, etc., etc.
1 vol., 12mo. Cloth. Price, $1.75.
Since the issue of the author's work on " Practical Dietary," he has
felt the want of another, which would embrace all the generally-known
and less-known foods, and contain the latest scientific knowledge re-
specting them. The present volume is intended to meet this want, and
will be found useful for reference, to both scientific and general read-
ers. The author extends the ordinary view of foods, and includes
water and air, since they are important both in their food and sanitary
aspects.
STROUD.
The Physical Cause of the Death of
Christ, and its Relations to the Principles and Prac
tice of Christianity.
By WILLIAM STROUD, M. D.
With a Letter on the Subject,
By SIR JAMES Y. SIMPSON, BArt.,
1 vol., 12mo. 422 pp. Cloth, $2.00.
M. D.
This important and remarkable book is, in its own place, a masterpiece, and
will be considered as a standard work for many years to come.
The principal point insisted upon is, that the death of Christ was caused by rupture or lacor-
ation of the heart. Sir James Y. Simpson, who had read the author's treatise and various com-
ments on it, expressed himself very positively in favor of the views maintained by Dr. Stroud.
-Psychological Journal.
D. Appleton & Co.'s Medical Publications.
SIMPSON.
The Posthumous Works of Sir James
Young Simpson, Bart., M. D. In Three Volumes.
Volume I.-Selected Obstetrical and Gynaecological Works of
Sir James Y. Simpson, Bart., M. D., D. C. L., late Professor of Midwifery
in the University of Edinburgh. Containing the substance of his Lect-
ures on Midwifery. Edited by J. WATT BLACK, A. M., M. D., Member of
the Royal College of Physicians, London; Physician-Accoucheur to Char-
ing Cross Hospital, London; and Lecturer on Midwifery and Diseases of
Women and Children in the Hospital School of Medicine.
1 vol., 8vo. 852 pp. Cloth, $3.00.
This volume contains all the more important of the contributions of
Sir James Y. Simpson to the study of obstetrics and diseases of women,
with the exception of his clinical lectures on the latter subject, which
will shortly appear in a separate volume. This first volume contains
many of the papers reprinted from his Obstetric Memoirs and Contri-
butions, and also his Lecture Notes, now published for the first time,
containing the substance of the practical part of his course of mid-
wifery. It is a volume of great interest to the profession, and a fitting
memorial of its renowned and talented author.
"To many of our readers, doubtless, the chief of the papers it contains are familiar. To
others, although probably they may be aware that Sir James Simpson has written on the sub-
jects, the papers themselves will be new and fresh. To the first class we would recommend
this edition of Sir James Simpson's works, as a valuable volume of reference; to the latter, as
a collection of the works of a great master and improver of his art, the study of which cannot
fail to make them better prepared to meet and overcome its difficulties."-Medical Times and
Gazette.
Volume II.-Anaesthesia, Hospitalism, etc.
WALTER SIMPSON, Bart.
1 vol., 8vo. 560 pp. Cloth, $3.00.
Edited by Sir
"We say of this, as of the first volume, that it should find a place on the table of every
practitioner; for, though it is patchwork, each piece may be picked out and studied with pleas-
ure and profit."-The Lancet (London).
Volume III.—The Diseases of Women. Edited by ALEX. SIMP-
SON, M. D., Professor of Midwifery in the University of Edinburgh.
1 vol., 8vo. Cloth, $3.00.
One of the best works on the subject extant. Of inestimable value to every physician.
SWETT.
A Treatise on the Diseases of the Chest.
Being a Course of Lectures delivered at the New
York Hospital.
By JOHN A. SWETT, M. D.,
Professor of the Institutes and Practice of Medicine in the New York University; Physician
to the New York Hospital; Member of the New York Pathological Society.
1 vol., 8vo. 587 pp. $3.50.
Einbodied in this volume of lectures is the experience of ten years in hospital and private
practice.
D. Appleton & Co.'s Medical Publications.
SCHROEDER.
A Manual of Midwifery. Including the
Pathology of Pregnancy and the Puerperal State.
By Dr. KARL SCHROEDER.
Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen.
Translated from the Third German Edition,
By CHAS. H. CARTER, B. A., M. D., B. S. Lond.,
Member of the Royal College of Physicians, London, and Physician Accoucheur to St. George's,
Hanover Square, Dispensary.
With Twenty-six Engravings on Wood. 1 vol., 8vo. Cloth.
"The translator feels that no apology is needed in offering to the profession a translation
of Schroeder's Manual of Midwifery. The work is well known in Germany and extensively
used as a text-book; it has already reached a third edition within the short space of two years.
It is hoped that the present translation will meet the want, long felt in this country, of a man-
ual of midwifery embracing the latest scientific researches on the subject."
TILT.
A Hand-Book of Uterine Therapeu-
tics and of Diseases of Women.
By EDWARD JOHN TILT, M. D.,
Member of the Royal College of Physicians; Consulting Physician to the Farringdon General
Dispensary; Fellow of the Royal Medical and Chirurgical Society, and of several British
and foreign societies.
1 vol., 8vo. 345 pp. Cloth, $3.50.
Second American edition, thoroughly revised and amended.
"In giving the result of his labors to the profession the author has done a great work. Our
readers will find its pages very interesting, and, at the end of their task, will feel grateful to
the author for many very valuable suggestions as to the treatment of uterine diseases."-The
Lancet.
"Dr. Tilt's 'Hand-Book of Uterine Therapeutics' supplies a want which has often been
felt.
It may, therefore, be read not only with pleasure and instruction, but will also be
useful as a book of reference.”—The Medical Mirror.
found very
"Second to none on the therapeutics of uterine disease."—Journal of Obstetrics.
VAN BUREN.
Lectures upon Diseases of the Rectum.
Delivered at the Bellevue Hospital Medical College.
Session of 1869–270.
By W. H. VAN BUREN, M. D.,
Professor of the Principles of Surgery with Diseases of the Genito-Urinary Organs, etc., in the
Bellevue Hospital Medical College; one of the Consulting Surgeons of the New York Hos-
pital, of the Bellevue Hospital; Member of the New York Academy of Medicine, of the
Pathological Society of New York, etc., etc.
1 vol., 12mo. 164 pp. Cloth, $1.50.
"It seems hardly necessary to more than mention the name of the author of this admirable
uttle volume in order to insure the character of his book. No one in this country has enjoyed
greater advantages, and had a more extensive field of observation in this specialty, than Dr.
Van Buren, and no one has paid the same amount of attention to the subject.. Here is the
experience of years summed up and given to the professional world in a plain and practical
manner."-Psychological Journal.
D. Appleton & Co.'s Medical Publications.
VOGEL.
A Practical Treatise on the Diseases
of Children. Second American from the Fourth
German Edition. Illustrated by Six Lithographic
Plates.
By ALFRED VOGEL, M. D.,
Professor of Clinical Medicine in the University of Dorpat, Russia.
TRANSLATED AND EDITED BY
H. RAPHAEL, M. D.,
Late House Surgeon to Bellevue Hospital; Physician to the Eastern Dispensary for the Diseases
of Children, etc., etc.
1 vol., 8vo. 611 pp. Cloth, $4.50.
The work is well up to the present state of pathological knowledge;
complete without unnecessary prolixity; its symptomatology accurate,
evidently the result of careful observation of a competent and experi-
enced clinical practitioner. The diagnosis and differential relations of
diseases to each other are accurately described, and the therapeutics
judicious and discriminating. All polypharmacy is discarded, and only
the remedies which appeared useful to the author commended.
It contains much that must gain for it the merited praise of all im-
partial judges, and prove it to be an invaluable text-book for the stu-
dent and practitioner, and a safe and useful guide in the difficult but all-
important department of Pædiatrica.
"Rapidly passing to a fourth edition in Germany, and translated into three
other languages, America now has the credit of presenting the first English ver-
sion of a book which must take a prominent, if not the leading, position among
works devoted to this class of disease."-N. Y. Medical Journal.
"The profession of this country are under many obligations to Dr. Raphael
for bringing, as he has done, this truly valuable work to their notice."-Medical
Record.
"The translator has been more than ordinarily successful, and his labors
have resulted in what, in every sense, is a valuable contribution to medica.
science."-Psychological Journal.
"We do not know of a compact text-book on the diseases of children more
complete, more comprehensive, more replete with practical remarks and scientific
facts, more in keeping with the development of modern medicine, and more
worthy of the attention of the profession, than that which has been the subject
of our remarks."—Journal of Obstetrics.
D. Appleton & Co.'s Medical Publications.
WALTON.
The Mineral
Mineral Springs of
Springs of the United
States and Canada, with Analyses and Notes on the
Prominent Spas of Europe, and a List of Sea-side
Resorts.
By GEORGE E. WALTON, M.D.,
Lecturer on Materia Medica in the Miami Medical College, Cincinnati.
1 vol., 12mo. 390 pages, with Maps. Price, $2.00.
The author has given the analyses of all the springs in this country and
those of the principal European spas, reduced to a uniform standard of
one wine-pint, so that they may readily be compared. He has arranged
the springs of America and Europe in seven distinct classes, and de-
scribed the diseases to which mineral waters are adapted, with refer-
ences to the class of waters applicable to the treatment, and the pecul-
iar characteristics of each spring as near as known are given-also, the
location, mode of access, and post-office address of every spring are men-
tioned. In addition, he has described the various kinds of baths and
the appropriate use of them in the treatment of disease.
"In this volume the author has endeavored to arrange all the known facts
concerning mineral waters, in such a manner that they shall be readily acces-
sible. For this purpose he has consulted the best European authors, their con-
clusions being drawn from hundreds of years of laborious investigation of the
spas of Germany, France, Switzerland, and Italy. It has been interesting, in
the course of this study, to note how closely the conclusions drawn by them
concerning the action of different classes of waters agree with the observations
made at springs in this country, independent of any knowledge of foreign re-
search. The portion relating to the springs of the United States is the result
of a selection of credible evidence regarding them, gained by correspondence
and personal observation."-Extract from Preface.
UNIVERSITY OF VIRGINIA, June 9, 1878.
GENTLEMEN: I have received by mail a copy of Dr. Walton's work on the
Mineral Springs of the United States and Canada. Be pleased to accept my
thanks for a work which I have been eagerly looking for ever since I had the
pleasure of meeting the author in the summer of 1871. He satisfied me that
he was well qualified to write a reliable work on this subject, and I doubt not
he has met my expectations. Such a work was greatly needed, and, if offered
for sale at the principal mineral springs of the country, will, I believe, com-
mand a ready sale. Very respectfully yours,
J. L. CABELL, M. D.
D. Appleton & Co.'s Medical Publications.
WELLS.
Diseases of the Ovaries; Their Diagnosis
and Treatment.
By T. SPENCER WELLS,
Fellow and Member of Council of the Royal College of Surgeons of England; Honorary Fellow
of the King and Queen's College of Physicians in Ireland; Surgeon in Ordinary to the
Queen's Household; Surgeon to the Samaritan Hospital for Women; Member of the Im-
perial Society of Surgery of Paris, of the Medical Society of Paris, and of the Medical Soci-
ety of Sweden; Honorary Member of the Royal Society of Medical and Natural Science
of Brussels, and of the Medical Societies of Pesth and Helsingfors; Honorary Fellow of
the Obstetrical Societies of Berlin and Leipzig.
1 vol., 8vo. 478 pp. Illustrated. Cloth, Price, $4.50.
In 1865 the author issued a volume containing reports of one hundred and
fourteen cases of Ovariotomy, which was little more than a simple record of
facts. The book was soon out of print, and, though repeatedly asked for a
new edition, the author was unable to do more than prepare papers for the
Royal Medical and Chirurgical Society, as series after series of a hundred cases
accumulated. On the completion of five hundred cases he embodied the results
in the present volume, an entirely new work, for the student and practitioner,
and trusts it may prove acceptable to them and useful to suffering women.
Arrangements have been made for the publication of this volume in Lon-
don on the day of its publication in New York." French and German trausla-
tions are already in press.
(C
WAGNER.
A Hand
Handbook of Chemical Tech-
nology.
By RUDOLPH WAGNER, Ph. D.,
Professor of Chemical Technology at the University of Wurtzburg.
Translated and edited, from the eighth German edition, with extensive
additions,
By WILLIAM CROOKES, F. R. S.
With 336 Illustrations. 1 vol., 8vo. 761 pages. Cloth, $5.00.
Under the head of Metallurgic Chemistry, the latest methods of preparing Iron, Cobalt,
Nickel, Copper, Copper Salts, Lead and Tin, and their Salts, Bismuth, Zinc, Zinc Salts, Cad-
mium, Antimony, Arsenic, Mercury, Platinum, Silver, Gold, Manganates, Aluminum, and
Magnésium, are described. The various applications of the Voltaic Current to Electro-Metal-
lurgy follow under this division. The preparation of Potash and Soda Salts, the manufacture
of Sulphuric Acid, and the recovery of Sulphur from Soda Waste, of course occupy prominent
places in the consideration of chemical manufactures. It is difficult to over-estimate the mer-
cantile value of Mond's process, as well as the many new and important applications of Bisul-
phide of Carbon. The manufacture of Soap will be found to include much detail. The Tech-
nology of Glass, Stone-ware, Limes, and Mortars, will present much of interest to the Builder
and Engineer. The Technology of Vegetable Fibres has been considered to include the prep-
aration of Flax, Hemp, Cotton, as well as Paper-making; while the applications of Vegetable
Products will be found to include Sugar-boiling, Wine and Beer Brewing, the Distillation of
Spirits, the Baking of Bread, the Preparation of Vinegar, the Preservation of Wood, etc.
Dr. Wagner gives much information in reference to the production of Potash from Sugar-
residues. The use of Baryta Salts is also fully described, as well as the preparation of Sugar
from Beet-roots. Tanning, the Preservation of Meat, Milk, etc., the Preparation of Phospho-
rus and Animal Charcoal, are considered as belonging to the Technology of Animal Products.
The Preparation of Materials for Dyeing has necessarily required much space; while the final
sections of the book have been devoted to the Technology of Heating and Illumination.
THE NEW YORK MEDICAL JOURNAL.
WM. T. LUSK, M. D.,
JAS. B. HUNTER, M. D.,
D., }
} Editors.
Published Monthly. Volumes begin in January and July.
((
Among the numerous records of Medicine and the collateral sciences pub-
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On Puerperal Diseases. Clinical Lectures delivered at
Bellevue Hospital. By FORDYCE BARKER, M. D., Clinical Professor of Mid-
wifery and Diseases of Women in the Bellevue Hospital Medical College;
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New York State Woman's Hospital, and to the New York State Hospital
for Diseases of the Nervous System; Honorary Member of the Edinburgh
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A course of lectures valuable alike to the student and the practitioner.
Hand-Book of the Histology and Histo-
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WM. A. HAMMOND, M. D. Edited, with Notes, by T. M. B. Cross, M. D.
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2
UNIVERSITY OF MICHIGAN
3 9015 05785 3148

WORKS
OF
SIR J.Y. SIMPSON
OBSTETRICS
AND
GYNECOLOGY
618.2
5613
1871a